The effect of chlorhexidine primer application on the clinical performance of composite restorations: a literature review

Assessment of colour modifications in two different composite resins induced by the influence of chlorhexidine mouthwashes and gels, with and without anti-staining properties: An in vitro study

OBJECTIVES

Chlorhexidine (CHX)-based products are the most effective chemical agents used in plaque control and oral disinfection. One of their side effects is tooth and restoration staining. For this reason, CHX products with anti-discolouration systems (ADS) have been developed. The aim of this in vitro study was to compare different CHX-based products (gel and mouthwash) with or without ADS in composite colour modification.

METHODS

Two hundred specimens were created, 100 of which were made of packable composite and 100 of flowable composite. After 24 h, colour coordinates (L*, a*, b*, C*, h°) were recorded using a spectrophotometer (T0). Then, all samples were subjected to a CHX/tea staining model and immersed in human saliva for 2 min. Composite specimens were divided in 10 groups (N = 20). Control groups (PC, FC) were soaked in distilled water and test groups (PG, PGads, FG, FGads, PM, PMads, FM and FMads) were immersed in CHX-based solutions or brushed with CHX gel. Then the cycle was repeated 6 times, and colour differences (ΔEab and ΔE00) were finally calculated.

RESULTS

Through flowable composites, FC and FG showed the highest colour differences, respectively ΔEab = 3.48 ± 1.0, ΔE00 = 2.24 ± 0.6 and ΔEab = 2.95 ± 1.3, ΔE00 = 1.53 ± 0.6. In the composite groups instead, PM and PMads showed the highest colour differences, respectively ΔEab = 2.78 ± 1.3, ΔE00 = 1.94 ± 0.8 and ΔEab = 2.71 ± 1.4, ΔE00 = 1.84 ± 0.9.

CONCLUSIONS

CHX-containing products are able to cause stains on restorative composite materials. Discolouration is more likely to occur in flowable composites than packable composites, and ADS-containing products cause fewer pigmentations than CHX products without ADS. Packable composites showed more staining after mouthwash treatment, whereas flowable composites underwent higher discolouration after treatment with gels.

Effect of Nisin-based pretreatment solution on dentin bond strength, antibacterial property, and MMP activity of the adhesive interface

OBJECTIVE

To evaluate the effect of a Nisin-based dentin pretreatment solution on microtensile bond strength, antibacterial activity, and matrix metalloproteinase (MMP) activity of the adhesive interface.

MATERIALS AND METHODS

100 human molars were sectioned to expose dentin. The teeth were assigned to five groups (n = 20), according to the dentin pretreatment: 0.5%, 1.0%, or 1.5% Nisin; 0.12% chlorhexidine (positive control), and no solution (negative control), and divided into 2 subgroups: no aging, and thermomechanical aging. Specimens were etched with 37% H3PO4 for 15 s and submitted to the dentin pretreatment. Then, they were bonded with an adhesive (Adper Single Bond 2) and a resin composite for microtensile bond strength (μTBS) evaluation. Antibacterial activity against Streptococcus mutans was qualitatively examined using an agar diffusion test. Anti-MMP activity within hybrid layers was examined using in-situ zymography. Data were analyzed with two-factor ANOVA and post-hoc Tukey's test (α = 0.050).

RESULTS

For μTBS, significant differences were identified for the factors "solutions" (p = 0.002), "aging" (p = 0.017), and interaction of the two factors (p = 0.002). In the absence of aging, higher μTBS was observed for the group 0.5% Nisin. In the presence of aging, all groups showed similar μTBS values. All Nisin concentrations were effective in inhibiting the growth of S. mutans. Endogenous MMP activity was more significantly inhibited using 0.5% and 1.0% Nisin (p < 0.050).

CONCLUSION

0.5% and 1.0% Nisin solutions do not adversely affect resin-dentin bond strength and exhibit a potential bactericidal effect against S. mutans. Both concentrations effectively reduce endogenous gelatinolytic activity within the hybrid layer.

CLINICAL RELEVANCE

The use of 0.5% and 1.0% Nisin solutions for dentin pretreatment potentially contributes to preserving the adhesive interface, increasing the longevity of composite restorations.

Antibacterial Agents for Composite Resin Restorative Materials: Current Knowledge and Future Prospects

Resin composites became the material of choice for direct restorations in anterior and posterior teeth. Despite the revolutionary improvement in the material, restoration failure is still a major drawback due to the material's inherent negative properties, including a lack of antibacterial effects. Therefore, many attempts have been made to incorporate antibacterial agents into resin composite materials to improve their antimicrobial properties and prevent secondary caries formation. Multiple laboratory studies have been conducted using different antibacterial agents, such as quaternary ammonium compounds, methacryloyloxydodecylpyridinium bromide, magnesium oxide nanoparticles, chlorhexidine, and chitosan. This review provides a glance at the current status of these materials and the research directions needed in the future.

Synthesis, monomer conversion, and mechanical properties of polylysine based dental composites

OBJECTIVE

The aim of this study was to synthesize a new bioactive and antibacterial composite by incorporating reactive calcium phosphate and antibacterial polylysine into a resin matrix and evaluate the effect of these fillers on structural analysis, degree of monomer conversion, mechanical properties, and bioactivity of these newly developed polypropylene based dental composites.

METHODOLOGY

Stock monomers were prepared by mixing urethane dimethacrylate and polypropylene glycol dimethacrylate and combined with 40 wt% silica to make experimental control (E-C). The other three experimental groups contained a fixed percentage of silica (40 wt%), monocalcium phosphate monohydrate, and β-tri calcium phosphate (5 wt% each) with varying amounts of polylysine (PL). These groups include E-CCP0 (0 wt% PL), E-CCP5 (5 wt% PL) and E-CCP10 (10 wt% PL). The commercial control used was Filtek™ Z250 3M ESPE. The degree of conversion was assessed by using Fourier transform infrared spectroscopy (FTIR). Compressive strength and Vicker's micro hardness testing were evaluated after 24 h of curing the samples. For bioactivity, prepared samples were placed in simulated body fluid for 0, 1, 7, and 28 days and were analyzed using a scanning electron microscope (SEM). SPSS 23 was used to analyze the data and one-way ANOVA and post hoc tukey's test were done, where the significant level was set ≤0.05.

RESULTS

Group E-C showed better mechanical properties than other experimental and commercial control groups. Group E-C showed the highest degree of conversion (72.72 ± 1.69%) followed by E-CCP0 (72.43 ± 1.47%), Z250 (72.26 ± 1.75%), E-CCP10 (71.07 ± 0.19%), and lowest value was shown by E-CCP5 (68.85 ± 7.23%). In shear bond testing the maximum value was obtained by E-C. The order in decreasing value of bond strength is E-C (8.13 ± 3.5 MPa) > Z250 (2.15 ± 1.1 MPa) > E-CCP10 (2.08 ± 2.1 MPa) > E-CCP5 (0.94 ± 0.8 MPa) > E-CCP0 (0.66 ± 0.2 MPa). In compressive testing, the maximum strength was observed by commercial control i.e., Z250 (210.36 ± 18 MPa) and E-C (206.55 ± 23 MPa), followed by E-CCP0 (108.06 ± 19 MPa), E-CCP5 (94.16 ± 9 MPa), and E-CCP10 (80.80 ± 13 MPa). The maximum number of hardness was shown by E-C (93.04 ± 8.23) followed by E-CCP0 (38.93 ± 9.21) > E-CCP10 (35.21 ± 12.31) > E-CCP5 (34.34 ± 12.49) > Z250 (25 ± 2.61). SEM images showed that the maximum apatite layer as shown by E-CCP10 and the order followed as E-CCP10 > E-CCP5 > E-CCP0 >Z250> E-C.

CONCLUSION

The experimental formulation showed an optimal degree of conversion with compromised mechanical properties when the polylysine percentage was increased. Apatite layer formation and polylysine at the interface may result in remineralization and ultimately lead to the prevention of secondary caries formation.

The Role of Duration of Chlorhexidine Gluconate 2% Application on the Shear Bond Strength of a Total Etch Bonding Agent: A Comparative Study

Introduction

Matrix metalloproteinases enzymes (MMPs) can degrade the hybrid layer which can cause failure of composite restorations. Chlorhexidine gluconate 2% can reduce MMPs activity and increase the bond strength of the resin to dentin.

Purpose

This study aims to determine the role of the duration of chlorhexidine gluconate 2% application on shear bond strength of a total-etch bonding agent.

Methods

A total of 36 freshly extracted maxillary premolars were removed occlusally by one-third of the crown using a carborundum disc until the dentin was exposed. Specimens were divided into four groups n(9). The dentin surfaces were etched for 5s. Group A is the control group. In group B, chlorhexidine gluconate 2% was applied for 30s. In group C, chlorhexidine gluconate 2% was applied for 60s. In group D, chlorhexidine gluconate 2% was applied for 90s. The universal adhesive was applied afterwards and then followed by composite to the dentin surface. All specimens were stored in artificial saliva at 37°C for 24 hours. The shear bond strength was tested using a universal testing machine.

Results

There was an increase in the shear bond strength of the bonding agent along with the additional application duration of chlorhexidine gluconate 2%. All groups gave higher MPa values than the control group. The shear bond strength in group A (control) was 12.64 MPa; Group B (30s of chlorhexidine) was 16.93 MPa; Group C (60s chlorhexidine) was 18.23 MPa; group D (90s of chlorhexidine) was 18.47MPa.

Conclusion

Duration of chlorhexidine gluconate 2% application affects the shear bond strength of the bonding agent with the total-etch system. The effective duration of chlorhexidine gluconate 2% for the restorative procedure is 60 seconds.

Selective adhesive luting: A novel technique for improving adhesion achieved by universal resin cements

OBJECTIVE

We aimed to introduce the concept of "Selective adhesive luting-SAL" which is explained through clinical steps and supported by preliminary laboratory evidence.

CLINICAL CONSIDERATIONS

Cementation with rubber dam is difficult to perform in case of short abutment teeth and/or subgingival crown margins. By means of universal resin cements/universal adhesive systems, which can be employed in self-adhesive as well as adhesive luting procedures, this paper presents a novel technique allowing clinicians to perform reliable cementation where rubber dam isolation is difficult. The SAL technique entails the application of a universal adhesive system only on easily accessible abutment surfaces, enabling simultaneous adhesive and self-adhesive luting in different portions of the abutment. The SAL clinical workflow is explained through prosthodontic rehabilitation of maxillary right central incisor affected by microdontia and restored with a lithium-disilicate crown. Furthermore, our laboratory microshear bond strength study supports the rationale behind SAL application demonstrating higher bond strength even when the adhesive resin is placed only on one portion of the cementation substrate.

CLINICAL SIGNIFICANCE

This article advocates the application of SAL technique in clinical situations where effective adhesive luting is uncertain, since it can improve the adhesion between the tooth and universal resin cements.

The effect of carbodiimide on push-out bond strength of fiber posts and endogenous enzymatic activity

BACKGROUND

To investigate the effect of 0.3 M 1-ethyl-3(3-dimethylaminopropyl) carbodiimide (EDC) aqueous solution pretreatment on push-out bond strength (PBS) and matrix-metalloproteinases (MMPs) activity within radicular dentin when different post cementation strategies were employed.

METHODS

One hundred and twenty monoradicular human teeth were endodontically treated and randomly divided into six groups, depending on the cementation strategy and root dentin pretreatment (n = 20): EAR: cementation with an etch-and-rinse adhesive (LuxaBond Total Etch, DMG) and resin cement (LuxaCore Z Dual, DMG); EAR/EDC: 1 min EDC pretreatment after etching + EAR; SE: cementation with a self-etch primer (Multilink Primer, Ivoclar Vivadent) and corresponding cement (Multilink Automix, Ivoclar Vivadent); SE/EDC: self-etch primer + EDC pretreatment + SE; SA: cementation with a universal self-adhesive cement (RelyX Universal, 3 M); SA/EDC: EDC pretreatment + SA. Slices were submitted to PBS test and interfacial nanoleakage evaluation 24 h after cementation or after thermocycling (40.000 cycles, 5-55 °C). To investigate the effect of EDC on MMPs activity, 4 additional first maxillary premolars per group were processed for in situ zymography analysis. Multivariate ANOVA and post hoc Tukey tests were used to analyze PBS values. The data from in situ zymography were analyzed with Kruskal-Wallis test and Dunn's pairwise multiple comparison procedures (α = 0.05).

RESULTS

The variables "EDC pretreatment", "root region" and "thermocycling" significantly influenced PBS (p < 0.05), while the variable "cementation strategy" had no influence (p > 0.05). Thermocycling significantly reduced PBS in SE and SA groups (p < 0.05). EDC was effective in preserving PBS after artificial aging. EDC pretreatment significantly reduced enzymatic activity at baseline in EAR and SE groups, and in SA group after thermocycling (p < 0.05).

CONCLUSIONS

The use of EDC prevents the reduction of bond-strength values after artificial aging and silences endogenous enzymatic activity within radicular dentin when different cementation strategies were employed.

Some Myths in Dentin Bonding: An Evidence-Based Perspective

Laboratory investigations are essential models responsible for science development. However, laboratory discoveries must be confirmed in a clinical environment where many known and unknown variables and complex mechanisms are involved. Using conclusions from laboratory studies to make clinical recommendations can lead to widespread "unreliable truths" or so-called myths in any field of knowledge. These myths may increase the costs (financial and time) or even cause harm (side effects) that would be unnecessary, given that the current protocol or conduct was previously evaluated in a more complex and complete clinical setting. This article will discuss certain myths in dentin bonding that may influence clinical decision-making, bringing some principles of evidence-based practice to allow a more critical evaluation of the literature findings.

An Insight into Enamel Resin Infiltrants with Experimental Compositions

Resin infiltration is a conservative treatment of initial enamel carious lesions. Only one infiltrant material is available on the market (Icon, DMG), and research is now investigating new chemical compositions so as to further exploit the benefits of the resin infiltration technique. A literature search of the articles testing the effects of different formulations on mechanical properties, resin penetration ability, remineralizing, and antibacterial activities was conducted. Of 238 articles, 29 resulted in being eligible for the literature review. The formulations investigated were all different and consisted in the inclusion of hydrophobic monomers (i.e., BisEMA, UDMA), solvents (ethanol, HEMA), alternative etchants (PAM) or molecules with antibacterial or bioactivity features (i.e., AgNP, YbF_3, MTZ, chitosan, DMAMM, HAp, MC-IL, NACP, PUA, CHX) and microfilled resins. Information on the long-term performances of the tested experimental materials were scarce. The combination of TEGDMA with hydrophobic monomers and the inclusion of a solvent alternative to ethanol reinforced mechanical properties of the materials. Hybrid-glass materials demonstrated an enhanced remineralization capacity. Techniques such as tunnelization increased the penetration depth and preserved the recourse to less-conservative treatments. Combining the min-invasive infiltrant approach with remineralizing and bacteriostatic properties would be beneficial for therapeutic and economical aspects, according to the principles of minimally invasive dentistry.

Novel Dental Restorative Solutions for Natural Teeth and Implants

The long-term survival of restorations in the oral cavity has always been one of the most significant challenges in modern dental practice [...].

The comparative evaluation of the effects of quercetin, α-tocopherol, and chlorhexidine dentin pretreatments on the durability of universal adhesives

OBJECTIVE

The aim of this study was to evaluate and compare the effects of chlorhexidine, quercetin, and α-tocopherol on the shear bond strength of universal adhesives in the short (24h) and long term (6 months).

MATERIAL AND METHODS

Ninety-six extracted sound molars were collected and divided randomly into four groups: control (no treatment), 2% chlorhexidine, 10% α-tocopherol, and 1% quercetin. The solutions were prepared and applied to the teeth for 60 s, followed by application of All-Bond universal adhesive and composite build-up. Half of the specimens in each group (n = 12) were tested for shear bond strength (SBS) after 24 h of storage and the other half were kept in distilled water for 6 months and then tested for shear bond strength. The shear bond strength test was performed and the failure modes were determined using a stereomicroscope. The data were analyzed using two-way analysis of variance and Tukey's post hoc tests with p ˂ .05 as the significance level.

RESULTS

The results of the two-way analysis of variance test showed that there was no significant difference in immediate SBS, and after 6 months, α-tocopherol had the lowest SBS in comparison to the control and CHX subgroups (p < .05). The t-test showed that the shear bond strength in the α-tocopherol and quercetin groups was significantly decreased after 6 months.

CONCLUSION

It can be concluded that the solutions used in this study had no adverse effect on immediate SBS. After 6 months, the CHX could preserve SBS in comparison to other groups.

Effect of Endodontic Irrigating Solutions on Radicular Dentine Structure and Matrix Metalloproteinases-A Comprehensive Review

Irrigating solutions play an important role in the eradication of intracanal microbes and debris dissolution during endodontic treatment. Different combinations of solutions and protocols have been advocated, with sodium hypochlorite (NaOCl), ethylenediamine tetra acetic acid (EDTA), and chlorhexidine (CHX) remaining the most widely used ones by many clinicians. Although these solutions provide efficient inorganic dissolution and antimicrobial capacity, their use has also been reported to cause undesired effects on root dentin composition and mechanical and biomechanical properties, such as microhardness, surface roughness, bond strength, and matrix metalloproteinase (MMP) activity. Several corroborating studies attribute these changes in mechanical properties of dentine to the use of irrigating solutions, and there are limited reports on how the solutions affect the expression of MMPs, which may be a correlating link to understanding the role of these enzymes in dentin collagen and changes in the mechanical properties of dentin. Hence, using the basis of several studies from the literature, the objective is to comprehensively review the influence of individual and combined irrigating solutions on root dentine structure and the activity of the MMPs.

Biofilm in Endodontics: In Vitro Cultivation Possibilities, Sonic-, Ultrasonic- and Laser-Assisted Removal Techniques and Evaluation of the Cleaning Efficacy

Incomplete and inadequate removal of endodontic biofilm during root canal treatment often leads to the clinical failure. Over the past decade, biofilm eradication techniques, such as sonication of irrigant solutions, ultrasonic and laser devices have been investigated in laboratory settings. This review aimed to give an overview of endodontic biofilm cultivation methods described in papers which investigated sonic-, ultrasonic- and Er:Yag laser-assisted biofilm removal techniques. Furthermore, the effectiveness of these removal techniques was discussed, as well as methods used for the evaluation of the cleaning efficacy. In general, laser assisted agitation, as well as ultrasonic and sonic activation of the irrigants provide a more efficient biofilm removal compared to conventional irrigation conducted by syringe/needle. The choice of irrigant is an important factor for reducing the bacterial contamination inside the root canal, with water and saline being the least effective. Due to heterogeneity in methods among the reviewed studies, it is difficult to compare sonic-, ultrasonic- and Er:Yag laser-assisted techniques among each other and give recommendations for the most efficient method in biofilm removal. Future studies should standardize the methodology regarding biofilm cultivation and cleaning methods, root canals with complex morphology should be introduced in research, with the aim of simulating the clinical scenario more closely.

Does immediate dentin sealing influence postoperative sensitivity in teeth restored with indirect restorations? A systematic review and meta-analysis

Objective

This study comprehensively reviewed clinical trials that investigated the effect of immediate dentin sealing (IDS) technique on postoperative sensitivity (POS) and clinical performance of indirect restorations.

Materials and methods

The systematic review was conducted according to the preferred reporting items for systematic reviews and meta‐analyses statement, and was guided by the PICOS strategy. Clinical trials in which adult patients received at least one indirect restoration cemented with IDS approach and one restoration cemented following the delayed dentin sealing (DDS) were considered.

Results

Following title screening and full‐text reading, four studies met the inclusion criteria and were included for qualitative synthesis, while two studies were selected for quantitative synthesis. According to Risk of bias‐2 tool, two studies were classified as “some concerns” for the outcome POS. No statistically significant differences were found between teeth restored with indirect restorations using the IDS and DDS approach for POS (p > 0.05), neither at the baseline (very low certainty of evidence according to GRADE) nor after 2 years of follow‐up (low certainty of evidence according to GRADE).

Conclusion

There is low‐certainty evidence that IDS does not reduce POS in teeth restored with indirect restorations.

Clinical significance

There is no clinical evidence to favor IDS over DDS when restoring teeth with indirect restorations.

An 18-month clinical evaluation of prolonged polymerization of a universal adhesive in non-carious cervical lesions: A double-blind randomized clinical trial

OBJECTIVE

This study aimed to evaluate the effect of prolonging polymerization time on the 18 months clinical performance of a universal adhesive system used as etch-and-rinse (ER) and self-etch (SE).

METHODS

140 restorations were randomly placed in 35 subjects according to the following groups: ER10 (light-curing for 10 s); ER40 (light-curing for 40 s); SE10 (light-curing for 10 s) and; SE40 (light-curing for 40 s/1200 mW/cm²). A resin composite was placed incrementally. The restorations were evaluated at baseline and after 18 months by using the FDI criteria. The following outcomes were evaluated: marginal staining, marginal adaptation, spontaneous post-operative sensitivity and recurrence of caries. The differences among the groups were calculated using Friedman repeated measures analysis of variance rank (α = 0.05).

RESULTS

After 18 months the retention/fracture rates were 88.9% (95%CI 74.1-95.6%) for ER10, 94.3% (95%CI 91.4-98.5%) for ER40, 77.2% (95%CI 60.1-87.9) for SE10 and 97.2% (95%CI 85.5-99.9%) for SE40. A significant difference was detected in the retention rate when SE10 was compared to the SE40 (p = 0.01). Also, ER40 showed a significant improvement of the marginal adaptation when compared to ER10 (p = 0.01).

SIGNIFICANCE

This is the first study that demonstrates an improvement in the clinical performance of universal adhesive systems in non-carious cervical lesions when prolonged light-cured was applied.

Is clinical behavior of composite restorations placed in non-carious cervical lesions influenced by the application mode of universal adhesives? A systematic review and meta-analysis

OBJECTIVE

To answer the following PICOS question: "Is the risk of retention loss, marginal discoloration, marginal adaptation and postoperative sensitivity (POS) equal for etch-and-rinse (EAR) compared to self-etch (SE) or selective-enamel etch (SEE) mode when restoring non carious cervical lesions (NCCLs) with universal adhesives?".

METHODS

PubMed, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, Scientific Electronic Library Online, LILACS, OpenGrey and Google Scholar™ were searched. Randomized controlled clinical trials in which resin composites and universal adhesives were used for restoration of NCCLs were considered. Cochrane Risk of Bias Tool was used to assess the risk of bias. Meta-analyses were performed using Revman; random-effects models were applied, and heterogeneity was tested using the I² index. The significance level was set at p < 0.05. Certainty of evidence was assessed by GRADE tool.

RESULTS

After screening, 20 articles were included in qualitative, while 14 articles were used for quantitative synthesis. Twelve studies ranked as "low", while 8 studies scored as "unclear" for risk of bias. At 12- and 18/24-months the risk for retention loss was higher for SE than for EAR groups (p = 0.005; RR = 0.22, 95% CI [0.08, 0.63],[moderate certainty of evidence and p = 0.0002; RR = 0.32, 95% CI [0.17, 0.58], moderate certainty of evidence, respectively). No significant differences were observed for marginal discoloration and adaptation (p > 0.05). The probability of POS occurrence was less in SE than in EAR groups (RR = 2.12, 95% CI [1.23, 3.64], moderate certainty of evidence). The certainty of evidence for other outcomes was scored as "low" or "moderate", depending on the follow-up period.

SIGNIFICANCE

Using universal adhesives in EAR or SEE mode provides more predictable retention, while SE strategy reduces the risk of POS occurrence.