Calcium Silicate-Based Versus Conventional Sealers in Nonsurgical Endodontic Retreatment: A Systematic Review and Meta-Analysis

This is the authors' abstract. We don't add key points for this paper.

This systematic review and meta-analysis aimed to determine whether obturation with a calcium silicatebased sealer alters periapical healing, postoperative pain, analgesic consumption, apical sealer extrusion, or tooth survival compared with a conventional sealer in permanent teeth undergoing orthograde nonsurgical retreatment; to establish whether any effect on healing is stable across loose and strict success criteria; and to determine whether the published evidence permits a causal statement about sealer chemistry independent of obturation technique.Seven databases, two trial registries, and two grey literature sources were searched from inception to August 2026, with citation chasing and hand-searching.Randomized and non-randomized comparative studies of orthograde nonsurgical retreatment comparing a calcium silicate-based sealer with any non-calcium-silicate sealer were eligible.Loose (healed plus healing) and strict (complete resolution) radiographic success at ≥ 12 months were co-primary.The designs were synthesized separately.In two studies, pooling was conditional on a prespecified heterogeneity screen (I² < 50% and p Q ≥ 0.10); outcomes failing the screen were reported under Synthesis Without Meta-analysis (SWiM).Risk of bias was assessed with Revised Cochrane Risk-of-Bias tool for randomized trials (RoB 2) and Risk of Bias in Non-randomized Studies -of Interventions (ROBINS-I), and certainty with Grading of Recommendations, Assessment, Development and Evaluation (GRADE).Nine studies were included; five contributed data (276 teeth).Under loose criteria, the two randomized trials disagreed (risk ratio (RR) 1.14, 95% confidence interval (CI) 0.90-1.43 and 0.93, 0.82-1.07;I² = 51.4%) and were not pooled.Under strict criteria, both favored the conventional sealer and were consistent (I² = 0%), giving a pooled RR of 0.56 (0.27-1.15; 67 teeth), equivalent to 189 fewer complete resolutions per 1,000 teeth (310 fewer to 62 more).The exploratory ratio of RRs between criteria was 1.87 (0.89-3.90), an interval that includes 1. Postoperative pain did not differ at 24 hours (0.93, 0.53-1.64)or 48 hours (0.85, 0.43-1.67;165 teeth).No sealer extrusion occurred in either arm of the only trial reporting it.No retreatment-specific survival data exist.The prespecified subgroup analysis of obturation technique could not be performed: no study contributing healing data matched the technique between arms.Available evidence represented 35% of the optimal information size for strict healing, 4% for loose healing and 0.8% for pain at 24 hours.Certainty was very low for all healing outcomes and low for pain.In nonsurgical retreatment, the direction of the estimated effect of sealer chemistry differed between definitions of success: no difference under loose criteria, and a point estimate favoring conventional sealers under strict criteria that the data are too imprecise to confirm or exclude.Because the ratio of RRs includes 1, this difference is exploratory and does not establish that the effect depends on the criterion.Because sealer chemistry is confounded with obturation technique in every study reporting healing, the contrast measured is between obturation strategies rather than between sealers.The field is far from an answer, and a trial of approximately 192 teeth using strict criteria would be decisive.