Joint Illnesses and Diseases: Causes and Treatments

Joint Illnesses and Diseases: Causes and Treatments Herniated Disc Herniated (slipped) disc happens when all or only a portion of an intervertebral disc is forced through the weak part of the disc thus exerting pressure to the adjacent nerves or spinal cord. Intrinsic degeneration of the intervertebral disc or extrinsic compression of the neural structures in the spinal canal can cause radicular pain. The loss of disc height, which can alter the mechanics of the axial skeleton, may result to disc degeneration. The said changes might produce in other structures such as the zygapophyseal (facet) joints and may result to spinal stenosis. Radicular pain is defined as pain radiating in the distribution of spinal nerve caused by the irritation of the dorsal root ganglion while discogenic pain is an axial pain originating in a degenerative disc. [39] [40] [41] [45] Considered to be a critical part of the load-bearing structures of the spinal column, the structural component of the invertebral disc make it capable of changing shape and absorbing shock thus allowing movement. The dysfunction of the intervertebral disc is brought about by multiple factors namely trauma, aging or the degenerative disorders of the spine. [46] The boundary between nucleus and annulus become less evident as a person ages, furthermore as a person grow older the nucleus of the intervertebral disc becomes less gel-like and more fibrotic. Trauma results from activities such as slipping, lifiting while in a flexed position, suppressing a sneeze or falling on the buttocks. Degeneration like in osteoarthritis or ankylosing spondylitis predisposes the misalignment of the vertebral column of the client. [46] A research on the mechanism of intervertebral disc pointed out several pathophysiologic processes. It includes the changes that occur in aging, loss of proteoglycan which is mentioned as the most significant biochemical change that occurs in disc degeneration. It is inferred that the loss of proteoglycan leads to loss of hydration. Another mechanism is the loss of collagen fiber. Unlike with the proteoglycan, the loss of collagen is not that evident. Furthermore, it is deduced that the biochemistry of disc degeneration do not just include increase fragmentation of collagen and proteoglycans but also it includes the increase fragmentation of fibronectin populations. The said mechanisms contribute to the functional changes of the intervertebral disc. [6] The cervical and lumbar portion of the vertebrae is commonly affected by the dysfunction because it is the most flexible areas of the spine where bending of the vertebral column and support of the mass are greatest. Around 90 to 95% of herniations in the lumbar vertebrae occur in L5 or L% to S1 regions respectively. With regards to the herniation at the cervical spine, the most often affected portion is C1 to C7 and C6 to C6. The protrusion usually happens posteriorly toward the intervertebral foramen where the annulus fibrosus is thin and poorly supported by the anterior or posterior ligaments. Pain is the first and the most usual symptom of herniated disc. The nerve roots namely L4, L5, S1, S2 and S3 give rise to back pain that radiates down back of the leg and over the sole of the foot. Major weakness is rare but slight weakness may occur. Also the most common sensory deficits are paresthesia and numbness, specifically of the leg and foot. There are instances also that knee and ankle reflex may also be absent or decreased. [46] Osteoarthritis Osteoarthritis is a disease in the joints that usually affects middle-age to elderly people. The disease is commonly referred as OA or as the wear and tear of the joints although it also involves the cartilage, joint lining, ligaments, and bone. Osteoarthritis is undoubtedly the most usual type of arthritis. [47] Almost 27 million Americans are living with osteoarthritis and almost 1 million people consults medical professional because osteoarthritis. [47] Perhaps, it is the most cause of disability and pain among elderly people. [48] [49] Among the risk factor in the development of osteoarthritis are old age and obesity, in fact in the United States it is concluded that by the year 2020, the prevalence of osteoarthritis is already 66 to 100%. [49] Epidemiologic data shows that age, gender and race interact in the development of osteoarthritis. Men is said to be affected at a younger age compare to women however the prevalence of women affected with osteoarthritis exceeded men by mi ddle age. [50] Heredity influences the occurrence of osteoarthritis. There is a lower prevalence of hip osteoarthritis among Chinese than Europeans, perhaps representing the influence of other factors such as occupation, obesity or heredity. White women will most likely experience hand osteoarthritis on the other hand knee osteoarthritis is more common on black women. [49] In addition, excess fat may have might have a direct metabolic effect on cartilage beyond the effects of excess joint stress; hence weight loss reduces the risk of developing knee arthritis. The disease is defined as a breakdown of joint cartilage brought about by mechanical strees or biochemical alteration, resulting to the failure of the bone underneath. Osteoarthritis used to affect various joints in the body which includes hip, knee, first metatarsal pharyngeal joint and, cervical and lumbosacral spine. [47] [48] With regard to hands, the base of the thumb and, the proximal and distal interphalangeal joints are most commonly affected. Osteoarthritis is a joint failure wherein all structures of the joint have undergone structural change which is pathological. [49] As mentioned earlier, osteoarthritis is popularly known as wear-and-tear arhthritis. Osteoarthritis undergoes substantial mechanical and composition change in the properties of cartilage. [48] The first structural change happens in the cartilage followed by the soft tissue. The progressive wear and tear of the cartage leads into thinning of the surface of the joint and bone ulceration. Later on, inflammation of the joint, increased in the blood flow and hypertrophy of subchondral bone will occur. Consequently, new cartilage and bone will be formed at joint margins resulting to osteophytosis or bone spurs which cause alteration in the shape and size of the bone. The primary manifestation of osteoarthritis is a long-standing pain in one or more joints that aggravate with weight bearing or joint use. There is also a presence of morning stiffness usually for 30 minutes and bone deformity (osteophyte) or enlargement of the joint. In some cases there are crepitation and effusion. [51] Spondylolisthesis Spondylolisthesis is a bone condition wherein a vertebral body in the spine slips out of the proper position onto the bone below it. It can be associated with spondylosis, infection, lumbosacral junction congenital anomalies, osteoporosis, trauma, tumor, degenerative spine or prior surgery. It is most common to women than men. The slippage of the vertebral body may be asymptomatic or may cause low back pain, hamstring tightness, nerve root injury which is more frequent in L5, or spinal stenosis. The tenderness of spondylolisthesis can be produced near the segment that has slipped forward. There might be a protrusion of the abdomen and shortened trunk because of the extreme forward displacement of L4 on L5. Surgery is usually recommended for patients who are not recovering through rest and physical therapy. [33] In children spondylolisthesis usually happens between the L5 and S1. It is sometimes because of a birth defect in the spine area or an acute injury in the portion of the spine. In adults, the most often reason behind the development of spondylolisthesis is the abnormal wearing off of the bones and cartilage such as in arthritis. Individuals playing sports such as gymnastics, football and weight lifting is at risk in developing the disease. [52] Anteroposterior and lateral plain radiographs of the lumbar spine should be obtained in patients complaining of back pain. The lateral view of plain radiograph is useful in identifying spondylolithesis for it can demonstrate the pars interarticularis. Pars interarticularis is the region of junction of the lamina and the pedicle. Incases wherein there is an absence of nerve involvement, computed tomography (CT) scanning of the lumbar spine provides necessary information with regards to spondylolithesis and its possible cause. CT myelography can give information regarding nerve impingement to patients with radiculopathy. Magnetic Resonance Imaging is advantageous for it protects the patient from being exposed to radiation while imaging is being done. Typically sagittal and axial planes are used. [52] Fibromyalgia Fibromyalgia is a poorly understood type of myofascial pain syndrome. Patients with fibromyalgia usually have severe muscle pain and tenderness having specific trigger points, easy fatigability and disturbances in sleep. People with fibromyalgia have â€Å"tender points† such as on neck, shoulders, hips, arms, legs and back. These areas hurt if pressure is exerted to them. In the United States, fibromyalgia has a prevalence rate of 3 to 5 % in females and 0.5 to 1.6% in males. Fibromyalgia is the second most common disease that experts in rheumatology encounter with 15% among those who are evaluated. It is also ascertained that around 8% of patients cared in primary care clinics have fibromyalgia. In 2005, the United State spend 10, 199 dollars per patient per year and it has been also estimated that overall, fibromyalgia costs the United State economy over 9 billion dollars every year. [53] With respect to gender, epidemiologic data reveals that fibromyalgia is more common to women than in men with a female-to-male ratio of around 9:1. Furthermore, it can occur to patients at any age of either sex. It can occur to pediatric patients, especially the adolescents. [54] The current understanding about fibromyalgia is that it is a disorder of central pain processing or a syndrome of central sensitivity. It is described as a problem with pain threshold. Researchers suggests that patients with fibromyalgia have a lower threshold to pain and other stimuli namely noise, heat and strong odor. It is also believed that neurobiologic changes causes hypersensitivity of patients. These neurobiologic changes are related to psychological factors in that this change affects the person’s perception to pain, expectancy or vigilance. Disturbed sleep has been linked to the pathogenesis of fibromyalgia. Studies have ascertained that awakening unfreshed or nonrestorative sleep has been observed in most of the patients with fibromyalgia. Sleep electroencephalographic studies have shown disruption of normal stage 4 of sleep (non-rapid eye movement). Deprivation in stage 4 sleep has a role in causing fibromyalgia as supported by the observation that symptoms of fibromyalgia developed to normal individuals with disrupted sleep in stage 4. Decreased serotonin metabolites are seen in the cerebrospinal fluid of patients with fibromyalgia. Since serotonin is known to be a neurotransmitter that regulates NREM sleep and pain, it is believed that it might also be involved in the pathogenesis of fibromyalgia. Autonomic dysfunction is also suspected to be involved in the development of fibromyalgia. Individuals with the said disorder were observed to have low levels of cortisol. Low level of urinary free cortisol decreased respo nse to corticotrophin-releasing hormone suggest abnormal hypothalamic-pituitary-adrenal axis. There is also low level of growth hormones. Growth hormone is released during stage 4 or NREM sleep. Many patients have accompanying psychological abnormalities. Almost 30% of patients fit the diagnostic criteria of anxiety, depression, somatization and hypochodriasis. There is also high prevalence of physical and sexual abuse, and eating disorder. [55] The goal of treatment for patient with fibromyalgia is to relieve pain and other symptoms, and to help a person cope with the said symptoms. It includes: physical therapy, stress relief methods, exercise and fitness program, antidepressants, muscle relaxants and cognitive behavioral therapy. The Haunting Of Hill House | Analysis The Haunting Of Hill House | Analysis Eleanor life is characterized by numerous challenges that happen because of her mother. She has a difficult responsibility of taking care of her ailing mother without any help from the society. She leads a strange life blending with people that sees her outcast in the society as she has grown with the attitude that people hate them because they do not mix with them. She later learns that her mother defied the society norms, and that is the reason that the society abandoned her. Others believe that perhaps that is the reason that she is ailing. Even though, Eleanor is aware of the existence of the social norms, she never knew their significance because she was never into them. After she drives into the Hill House, at first, she is not certain about her identity in the society, and she thinks that in the Hill house, she might experience some difference. She enters the house and her life changes, she starts seeing things in a completely different way and after contemplating on her relationship with the society, and she has no option, but to become a witch. Her death is mysterious as other character restores their lives back. It is true that many critics and readers believe that, in the end, Hill House consumes Eleanor and she willingly allows this to happen. Hill House consumes Eleanor Eleanor mothers poor health deprived Eleanor more than just her precious moment. The main reason that Eleanor rides forth to the house is an event that happened when she was young that certainly integrated some kind of supernatural manifestations. Despite of the situation, Eleanor tells Dr. Montague afterward in the story that she cannot clearly recall her mother claimed that the neighbors never appreciated them, and that was the reason that she would never mix with them (Jackson 73). The reader learns that, Eleanor and her sister had supposed at the time that the other was responsible for the supernatural incident (Jackson 7). This incident although, Dr. Montague reassures Eleanor that the event is long forgotten, means the incident must have had a negative impact on Eleanors family and, certainly did not affect Eleanors personality (Jackson 74). She is still uncertain whether she will ever be accepted in the society after her mother defying the social norms. It is difficult to face the reality in order to fight the stigma from the society. However, that is the only way out if she has to survive in the society. From the start, Eleanor grew up with a mother who was against the societys norms. Perhaps the ailing mother suffered out of her ignorance to the societal norms, and Eleanor suffers because of her mother. The journey to the Hill House is move that Eleanor fails tom resist. At one point, he thinks it is the right call for her to make, considering her relationship with the society and at another point, he wrestles with that spirit that pushes her to accept the invitation into the house. It becomes almost impossible for her to make a decision. From the onset of the book, Eleanor is in a dilemma. Even though, there are some characters in the Hill House that accepts to be part of the Hill house that does not mean that Eleanor should be inclusive. As opposed to Eleanor, the four characters have weird characters and perhaps that is the reason they feel comfortable being part of the Hill House. For instance Luke, despite being an heir of the house, steals from his aunt. Theodora too, an artist by profession is a lesbian. Doctor Montague, although a scholar, has an interest in the occult. This shows that, even though it is difficult to accept these characters within the social culture, they are better off than Eleanor, who cannot face the society. To worsen the matter, Eleanor is homeless, and this secludes her from the rests of Jacksons characters. Theodora engages into a conflict in the Hill House, but she cannot return, she remains there. The house has already consumed her. In depicting a homestead setting far from the Hill House, Jackson reveals to the reader that Dr. Montague is a family man and in the later chapters, we see his wife cleaning dishes together with Mrs. Dudley in Hill House, and this shows a kind of familiarity. Similarly, Dudley and her family own a house in town (Jackson 39) which keeps them safe from the house during late night hours. Moreover, Luke Sanderson could say that he owned the house, but he never took care of it. Luke is an affluent man, and he could buy the house, but it is not clear why he does not have one. Instead of accepting her situation and predicaments in life, for instance, being homeless, Eleanor says that she has a home. She is aware of the social values, even though she has never been deep into them. Hill house is a strange house as depicted in the previous discussions. When Eleanor accepts to be consumed by the house, she turns out to be an outsider. The House consumes Eleanor, and it blends both her fear and attraction of the House. She is lured into mysterious place, and she becomes interstitial that her pas life when she enters the house. Eleanor fits neither with her friends, nor in the society, and she turns out to be outrageous. The society rejects her , she turns to be a fringe member, and she does not have an option, but to fit into the skin of a witch. The five characters in the house have their differences, but Eleanor believes that with time they will adopt tom each others behavior (Jackson 58). She anticipates that sooner they will be a friend, and Theodora, affectionately refers to her as a cousin. They lived in the house as one family and even shared meals together. However, some scholars look at this situation in a different perspective, for instance, Tricia Lootens, in Whose Hand I Was holding, says that the characters live together as one family. However, Lootens is not certain about the continuity of this group and she cites this as terror of [Jacksons] entire culture: the brutal, inexorable visionà ¢Ã¢â€š ¬Ã‚ ¦of nuclear families that kill what they are supposed to nurture (151). Even though, Lootens believes that the group has a hidden agenda of ruining each others life, I refute with her perception. The characters are in harmony with one another, and there is no sense or fear between them. Eleanor is the one who is undisputed and seems rejected and deserted. This is evidenced at the novel closes its chapters, whereby Theo, Luke, and Dr. Montague observe Eleanor and she distances herself from the Hill House. Jackson mentions about the death of Eleanor and the other characters going back to their normal lives. Novel Dental Materials for Root-end Applications: A Review Novel Dental Materials for Root-end Applications: A Review Abstract Achieving a good apical seal is crucial for ensuring successful endodontics; especially in cases that involve a wide apex (e.g. immature apices, apical resorption, and fracture involving the tooth apex). An efficient root-end material is an absolute requisite towards achieving this goal. The recent years have witnessed a decent outflow of new products for root-end applications. However, their merits, and claims of superiority over MTA, have to be ascertained via sustained research. Keywords: Apical seal, bioactive, MTA, novel root-end materials, review. Introduction The quest for an ideal material for root-end applications has produced a plethora of products that are based on different compositions and exhibit varied setting reactions. Though many of them have been proven to be effective, none of them can be described as ideal yet, thus generating scope for further development. MTA as the gold standard Since its introduction by Torabinejad in 1993, MTA has been extensively studied and used. Over the years, it has emerged as the time-tested and attested material. MTA is essentially Portland cement (Sio2, CaO, Al2O3, MgO, and Fe2O3), to which a radioopacifier (Bi2O3), and dehydrated(anhydrous) calcium sulphate have been added. MTA is biocompatible and osteogenic. It is bioactive: i.e. MTA is capable of interacting with living tissues and allows deposition of apatite crystals in the MTA-tissue interface. This material is capable of inducting hard tissue formation.1 Apart from exhibiting excellent sealing properties, it also has the capacity to set and also remain steady in the presence of moisture. Hence, a recent review has described it as ‘hydraulic silicate cement’.2 However, this material is not devoid of disadvantages. Re-entering MTA-treated teeth is difficult. High acidity and alkalinity (beyond a pH of 8.4) can unfavorably influence the surface hardness of set MTA. MTA is shown to expand uncontrollably.3 Grey MTA has been found to discolor tooth and the neighboring gingival tissues. Both grey and white MTA contain toxic substances and impurities. The material is fairly difficult to manipulate owing to its sandy consistency; though the small particle size of white MTA may aid in producing a thicker mix; hence, better workability.4 MTA exhibits low washout resistance during initial set especially when a setting accelerator is not incorporated into the MTA mixture. Its initial solubility is undesirable when used as a root-end filling material.5 In lieu of MTA’s potential drawbacks, the search for superior materials has resulted in the emergence of newer materials in the market; the majority of which, bear resemblance to MTA with minor alterations in their composition. Bioaggregate This novel water-based, hydraulic cement, consists of tricalcium silicate as its primary component. Tantalum oxide imparts radioopacity; hydroxyapatite and amorphous silicon oxide have been added to reduce the level of formation of the weak phase- calcium hydroxide.6 Purity is ensured via elimination of aluminum. Though the manufacturer states that trace amounts of naturally occurring contaminants may be detected during chemical analysis, the lack of detection of heavy metal contamination is noteworthy. The material is bioactive.7 Sayeed et al. suggested that Bioaggregate be considered as an alternative to MTA owing to the former’s better sealing ability. The authors attributed the hermetic seal associated with bioaggregate to: (1) Its nano-sized particles that exhibit excellent adhesion to the dentinal walls of the root canal, (2) Its hydrophilicity.The presence of a gel-like calcium silicate hydrate as the main component, resulted in improved strength, hardness, and sealing characteristics to the set material.8 Bioaggregate also exhibited excellent biocompatibility and induced periodontal regeneration.9 Biodentin Biodentine, marketed by Septodont is available as a powder and liquid formulation. Tricalcium silicate and dicalcium silicate form the core materials of the powder. Purity of calcium silicate is enhanced by eliminating the contaminants namely aluminates. Calcium carbonate and calcium oxide, and zirconium oxide have been added as the fillers and as the radioofacifier respectively. Liquid comprises of calcium chloride as the accelerator. Hydrosoluble polymer and water reducing agents are also present. Biodentine can be used as a root repair material but is not indicated for root amputation and hemisection. The working time is over 1 minute and the setting time ranges between 9 and 12 minutes. The final hardness of Biodentine approximates that of the dentin, thus rendering retreatment difficult if not impossible. 10 On performing cytotoxicity assay and cell growth on set materials, human gingival fibroblasts responded similarly to Biodentine and MTA extracts.11 EndoSequence Root Repair Material EndoSequence Root Repair Material (Brasseler USA) is based on bioceramic technology and is essentially composed of nanoparticles of tricalcium silicate, dicalcium silicate, calcium phosphate monobasic, amorphous silicon dioxide, and tantalum pentoxide.12 It differs from white MTA mainly in that it is aluminium free and contains calcium phosphate monobasic and tantalum pentoxide (radioopacifier).13 It is marketed as a pre-mixed formulation in two different consistencies: syringeable paste, and condensable putty. `The former has bendable tips to facilitate intra-canal material placement. 14 According to the manufacturer, the material exhibits superior handling properties owing to its pre-mixed formulations, short setting time (~2 hours), and high resistance to washout. The material is radiopaque, hydrophilic, and highly alkaline (+12 pH), thus bactericidal. Its setting reaction is initiated by dentinal moisture. 15 Endo sequence is bioactive. 16 Hirschberg et al. compared the sealing a bility of ERRM with MTA, and concluded that leakage was greater in samples restored with ERRM when compared to that of MTA-restored samples.17 In simulated root resorption defects, intracanal placement of white MTA resulted in greater and sustained release of hydroxyl ions, and thus a higher pH when compared to EndoSequence. This, the authors attributed to the quicker set of ES as compared with MTA. But, few MTA samples exhibited discoloration, while none of the ES samples did. This may be esthetically relevant.18 Top of Form Bottom of Form iRoot BP Plus These bioceramic materials are primarily composed of calcium silicate, and require the presence of moisture to set and harden. They also contain zirconium oxide, tantalum pentoxide, calcium phosphate monobasic, and filler agents They are available in three forms: (1) iRoot ® BP Plus putty root canal filling andrepair material- white hydraulic premixed puttyintended to be used for root canal repair and restorative applications, (2) iRoot ® BP Injectable Root Canal RepairFilling Material- white hydraulic premixed injectable paste intended to be used for root canal repair and restorative applications, and (3) iRoot ® SP Injectable Root Canal Sealer- injectable white hydraulic cement paste intended to be used for permanentroot canal filling and sealing applications. 19 According to the manufacturer, these materials are insoluble, radiopaque, aluminum-free, possess excellent physical properties, and do not contract on setting.20 iRoot ®BP Plus was biocompatible and did not elicit critical cytotoxic effect. However, its long-term performance was inferior as compared to White MTA.21 Another study observed that both materials i.e. iRoot BP Plus and iRoot FS exhibited negligible cytotoxicity. Under simulated clinical conditions, iRoot FS was able to completely solidify within an hour, whereas iRoot BP Plus set only after seven days.22 Ceramicrete Developed at Argonne National laboratory, Ceramicrete is essentially a chemically bonded phosphate ceramic (CBPC), which was developed to function as a binder for waste management. The material was inducted into dentistry owing to its inherent strength, biocompatibility, and bioactivity. Radioopacity is achieved by incorporation of radio opacifiers (bismuth oxide, cerium oxide). Wagh and Primus found Ceramicrete to be a strong material exhibiting lower porosity and permeability due to the formation of potassium-magnesium phosphate hexahydrate ceramic matrix phase. The decreased porosity also contributes to Ceramicrete’s superior sealing capacity.23 The use of an acid conditioner prior to application of ceramicrete may result in better adaption due to removal of smear layer, thus improving the seal. Incorporation of calcium silicate whiskers resulted in the formation of a brushite phase, which improves mechanical properties. Though, initially, the material tends to be acidic, set Ceremicrete-D is alkaline (pH of 11 after 72 hours). However, the acidic pH (2.2) of a fresh mix may exacerbate the acidic condition of an already inflamed tissue. 24 The low pH may be the reason why ceramicrete D caused initial death of primary osteoblasts and failed to support further cell growth, since low pH is shown to inhibit osteoblast activity. 25 The radioopacity of ceremicrete was substantially less (3.2mm of aluminium) than white MTA (8.5mm of aluminium). Handling properties and resistance to washout were superior. According to porter et al, Ceremicrete-D retained a weak chalk like consistency even after seven days of setting. They suggested the original formula be modified to effect increase in the strength of the material.26 Capasio Capasio (Primus Consulting, Bradenton, FL) is an experimental calcium-phospho-aluminosilicate–based cement that is mixed with a water based gel. Bismuth oxide has been added as a radiopacifier.27 When mixed, Capasio develops dough like consistency and can be rolled into a rope which enables better handling. Ceremicrete-D and Generex A also demonstrate this desirable property. Capasio displays good washout resistance, and improved physical characteristics such as setting time (9 minutes), compressive strength, and washout resistance.26 It exhibited slightly less basic pH (10.9) when compared with white MTA. 28 The radiopacity of Capasio was significantly less as compared to MTA but marginally greater than Ceremicrete-D.26 Capasio is also bioactive. It has the ability to precipitate apatite crystals on its surface. The smaller particle size of Capasio (a mean particle size of 5.3 µm as compared to 10 µm of MTA) may be perceived as an advantage. Materials that demonstrate the capability of penetrating dentinal tubules exhibit improved marginal adaptation, retention, and also entomb the residual bacteria. The material was shown to penetrate dentinal tubules up to a depth of 18-26  µm; much greater than that of MTA.29 Penetration of an endodontic material into the dentinal tubules results in improved marginal adaptation, increase mechanical retention, entombs residual bacteria and improved antibacterial effects owing to closer proximity of the material to the bacteria.30 Quick-set Capasio (Primus Consulting, Bradenton, FL) has been further developed and has been renamed as Quick-Set (Primus Consulting). The refinement has been performed via removal of the cationic surfactant from the liquid gel component, which was thought to affect its biocompatibility. Using murine dental papilla-derived odontoblast-like cell line (MDPC-23), Wei et al. observed that the in vitro cytotoxicity of Quick-Set was similar to that of WMTA.31 Ashraf et al. concluded that the in vitro osteogenic/dentinogenic differentiation potential of Quick-Set was favorable. 32 Generex A and B Generex A (Dentsply Tulsa Dental Specialities, Tulsa, Usa) and B are calcium-silicate-based materials with novel setting reactions. Generex A contains tricalcium silicate, dicalcium silicate, and tricalcium alumunate. Its composition is similar to that of MTA but for the fact that the powder is finer, and unique gels are used for mixing instead of water as is the case with MTA.25 Usage of the gel results in: improved handling characteristics and reduced setting time.26 Among the materials evaluated for their osteogenic potential (Generex A, Capasio, Ceramicrete, and MTA), only Generex A and MTA allowed primary osteoblast growth.25 In a study conducted by Porter et al, Generex A exhibited the shortest setting time (1.25 hrs) as compared to Capasio and Ceramicrete, which set in 2.5 hours. Generex A also emerged as the strongest among the other materials tested. 26 Endobinder Endobinder differs from MTA in that, MgO and CaO (cause undesirable expansion of the material), and Fe2O3 (causes tooth darkening) are eliminated from its composition. Al2O3 and CaCO3 are calcined at temperatures between 1315deg C and 1425d C, and are ground following which, Bismuth oxide is added to obtain radioopacity. Purity is ensured by eliminating traces of MgO, CaO, and Fe2O3.32, 33 Endobinder assisted early differentiation of a higher osteoblastic cell population in comparison to MTA. this, the authors attributed to the lower calcium hydroxide release from endobinder when compared with MTA.34 While slightly higher concentration of extracellular calcium can stimulate osteoblast cell viability, proliferation, differentiation, and function, an overload can be cytotoxic. 35 According to Oliveira et al., Endobinder exhibited better fluidity, improved handling properties, higher mechanical strength, and reduced porosity (with lower pore size) when compared with MTA.36 The material was biocompatible when tested in subcutaneous tissue of rats.37 Conclusion The past few years have witnessed the development of novel materials with a purpose of overcoming the disadvantages of MTA. Some are primarily composed of calcium silicate (Endobinder, Endosequence, Generex A and B, and iRoot BP Plus), some are primarily tricalciumsilicate-based (Bioaggregate, and Biodentine) or calcium-alumino-silicate based (Capasio and quickset), and one is a chemically bonded phosphate ceramic (Ceramicrete). The focus behind developing these materials has mainly been- improved physical and biological properties over the present gold standard i.e. MTA. While some of these novel materials have exhibited improved characteristics, more research in the form of in vivo and in vitro studies are required in this direction, in order to ascertain the same. Also, newer materials with a composition differing from that of MTA, may bring a fresh approach with regard to this application. 1