Quintessence Journals - Sandra Kalil Bussadori

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Influence of Cavity Lining and Remaining Dentin
Thickness on the Occurrence of Postoperative
Hypersensitivity of Composite Restorations
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Florian Wegehaupt a /Herbert Betke b /Nicole Solloch c /Ulrike Musch a,b /Annette Wiegand a,b /
Thomas Attin d,e
Purpose: To investigate the influence of the remaining dentin thickness after cavity preparation, calcium hydroxide
lining, and two restorative systems on the occurrence of postoperative pain or hypersensitivity.
Materials and Methods: One hundred twenty-three fillings were placed in 123 healthy patients. The remaining
dentin thickness after caries excavation was measured with the Prepometer device at the deepest area of the cavity.
The cavities were allocated to three different groups (shallow, medium, and deep) on the basis of the Prepometer results.
The decision to use a calcium hydroxide liner or not was made by tossing a coin. Cavities which were to be later
treated with an indirect restoration were restored with a buildup material. The other cavities were treated with a hybrid
composite. After 6 months, the patients were re-examined and interviewed concerning postoperative pain incidents
or hypersensitivity. A logistic regression was performed for the statistical analysis.
Results: Logistic regression showed no statistically significant influence of any of the three different variables “cavity
depth”, “calcium hydroxide liner” and “restorative material” on the occurrence of pain or hypersensitivity.
Conclusion: The occurrence of pain or hypersensitivity does not depend on the remaining dentin thickness, calcium
hydroxide lining, or the restorative system used in the present study.
Keywords: dentin thickness, calcium hydroxide liner, postoperative pain, hypersensitivity, composite, adhesive.
J Adhes Dent 2009; 11: 137-141. Submitted for publication: 14.12.07; accepted for publication: 05.03.08.
In the last 50 years, different studies have shown that
caries-linked dental hard tissue loss is directly related to
the presence and fermentation processes of oral bacteria.
15,25 The aim of caries treatment is the removal of bacteria
and softened hard tissue. When caries has progressed
a Assistant Professor, Clinic for Preventive Dentistry, Periodontology and Cariology,
University of Zürich, Zürich, Switzerland.
b Assistant Professor, Department of Operative Dentistry, Preventive Dentistry
and Periodontology, Georg August University of Göttingen, Göttingen, Germany.
c Dentist in Private Practice; Department of Operative Dentistry, Preventive
Dentistry and Periodontology, Georg August University of Göttingen, Göttingen,
Germany.
d Professor, Department of Operative Dentistry, Preventive Dentistry and Periodontology,
Georg August University of Göttingen, Göttingen, Germany.
e Professor and Chair, Clinic for Preventive Dentistry, Periodontology and Cariology,
University of Zürich, Zürich, Switzerland.
Correspondence: Dr. F. Wegehaupt, Clinic for Preventive Dentistry, Periodontology
and Cariology, University of Zürich, Plattenstr. 11, CH-8032 Zürich,
Switzerland. Tel: +41-44-634-3439, Fax: +41-44-634-4308. e-mail:
florian.wegehaupt@zzmk.uzh.ch
into deep dentin areas, the remaining dentin thickness after
excavation can be distinctly reduced. The remaining
dentin thickness estimated to be necessary for protection of
the dental pulp against injury or inflammation has changed
over the years. Stanley 31 suggested that the remaining
dentin under the cavity preparation should be at least 2 mm
thick to guarantee protection of the pulp. Other investigations
found a minimum thickness of 1 mm or even 0.5 mm
to be necessary for pulp protection. 21,26 During treatment,
it is often difficult for the dentist to decide how much dentin
is left over the pulp. The dentist can perform only a rough estimation
of the remaining dentin thickness, since the variability
of different teeth and different calcification degrees
of the pulp chambers render a clear estimation difficult. 22,28
Hypersensitivity after adhesive restorations is observed
with a frequency of 5% to 26%. 5 This phenomenon might
be caused by penetration of components of the adhesive
systems into the pulp, or by micro-/nanoleakage, allowing
movement of the dentin liquid in those dentin areas where
optimal adhesion and sealing of the dentin was not accomplished.
It can also be speculated that parts of the adhesive
systems might enter the pulp via a thin dentin
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Wegehaupt et al
Table 1 Application protocols for the two kinds of adhesives and restorative materials
used in the study
Definitive filling:
Prime & Bond NT and Spectrum
Buildup filling:
Clearfil Liner Bond 2V and LuxaCore
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Enamel etching for 40 s, dentin etching
for 20 s with 37% phosphoric acid
↓
Rinsing with water for 30 s and
gently drying with oil-free air
↓
Application of Prime&Bond NT
on the cavity surface for 20 s
↓
Gentle air drying for 5 s
↓
Light curing of the adhesive for 20 s
↓
Application of small increments
of Spectrum
↓
Light curing of the composite for 20 s
each increment
Mixing primer liquid A+B
↓
Application of the primer liquid mixture for
30 s on the cavity surface
↓
Gentle air drying for 30 s
↓
Mixing bond liquid A+B
↓
Application of the bond liquid mixture on
the cavity surface and gentle air drying
↓
Light curing for 20 s
↓
Filling of cavities with LuxaCore in bulk technique
bridge, 29,36 thus provoking some postoperative pain sensations.
To avoid penetration of components of adhesive
systems into the pulp, a calcium hydroxide liner can be
placed onto the dentin at the deepest points of the cavity.
This procedure was previously recommended especially
for nonadhesive restoration and was referred to as indirect
pulp capping. Thus, a calcium hydroxide liner may prove
effective in reducing postoperative hypersensitivity occurring
after application of an adhesive restoration.
Various formulations of calcium hydroxide have been investigated
over the years. 4,30 Calcium hydroxide has
demonstrated its potential for inducing pulp healing and
dentin bridging. Despite a certain degree of controversy,
some recent studies have also reported the possibility of
pulp healing and dentin bridging by the use of adhesive
systems for pulp capping. 1,10
Thus, the aim of the present study was to identify the
influence of the use of a calcium hydroxide liner in cavities
with different remaining dentin thicknesses and two different
adhesive restorative materials on the occurrence of
pain or postoperative hypersensitivity.
MATERIALS AND METHODS
Approval (No. 5/11/02) was issued prior to the study by
the Ethics Committee of the University of Göttingen. A total
of 123 fillings was placed in 123 patients, after they
signed an informed consent form prior to their participation
in the study. Exclusion criteria were: patients under 18
years, pregnancy, breastfeeding, immunosuppressed or
addicted patients.
Only teeth fulfilling the following criteria were included
in the study: caries media or caries profunda (according to
bitewing radiographs), insufficient fillings, positive reaction
to a vitality test (cold test), no signs of pulp inflammation,
no spontaneous pain attacks before treatment, only premolars
and molars, only one filling per tooth, and a minimum
extension of the cavity of 1 mm in width. This cavity
size was necessary, since the probe of the Prepometer device
(Hager & Werken; Duisburg, Germany) described
below has a diameter of 1 mm.
Treatment was performed under local anesthesia (Ultracain
D-S, Hoechst Marion Roussel Deutschland; Frankfurt
am Main, Germany) and the use of rubber-dam. Caries removal
was performed with tungsten burs until CariesDetector
(Kuraray Dental; Frankfurt am Main, Germany)
induced no further staining of the cavity. After total caries
removal, the cavity was rinsed with 0.2% chlorhexidine solution.
After cavity preparation, the remaining dentin thickness
in the deepest cavity area was measured with a remaining
dentin thickness measuring device, hereafter referred to
as RDTMD (Prepometer, Hager & Werken). Before measuring,
the RDTMD was calibrated by touching the dentin surface
with the calibration and sensor electrode at the same
time. During measurement, the reference electrode was
placed in the buccal vestibule. For measuring the remaining
dentin thickness, the sensor electrode was gently
moved over the cavity floor.
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Table 2 Number of teeth according to allocation to the different cavity depth groups, the use of
calcium hydroxide liner, and the kind of restorative material
Calcium hydroxide liner Restorative material Cavity depth group
shallow medium deep
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Yes buildup 6 8 9
definitive filling 14 21 17
No buildup 5 5 7
definitive filling 16 5 10
Table 3 Percentages (absolute number) of pain incidence or hypersensitivity of the buildup and definitive
restorations placed in either shallow, medium or deep cavities after use of a calcium hydroxide lining
or not
Calcium hydroxide liner Restorative material Cavity depth group
shallow medium deep
yes buildup 17% (1) 0% (0) 11% (1)
definitive filling 14% (2) 14% (3) 11% (2)
no buildup 40% (2) 0% (0) 29% (2)
definitive filling 13% (2) 40% (2) 40% (4)
On the basis of the RDTMD results, the cavities were divided
into three different groups (shallow, medium, or
deep cavity) of 40 teeth each. Cavities with RDTMD scores
1 to 5 (1.5 to 3.0 mm, green or yellow LEDs) were allocated
to group “shallow”, cavity scores 6 and 7 (0.9 to 1.5
mm, orange LEDs) were allocated to group “medium”, and
with results 8 to 10 (< 0.9 mm, red LEDs) to group “deep”.
In each group, cavities were treated either with or without
use of calcium hydroxide liner (Kerr Life, KerrHawe; Bioggio,
Switzerland). The decision to use a calcium hydroxide
liner or not was made by tossing a coin. This resulted in
20 liners being placed in the shallow group, 29 in the
medium-depth group, and 26 in the group of deep cavities
(Table 2).
To make the calcium hydroxide liner, a small drop of
Kerr Life was placed on the deepest part of the cavity and
allowed to set until its surface was hard upon probing.
The restoration of the teeth was performed either with a
buildup composite (n = 40) (LuxaCore, DMG; Hamburg,
Germany) or a hybrid composite (n = 83) (Spectrum,
Dentsply DeTrey; Konstanz, Germany). For the buildup
composite restorations, a self-etching nonrinse adhesive
system was used (Clearfil Liner Bond 2V, Kuraray Dental).
The buildup composite was used when a large amount of
dental hard tissue was lost and an indirect restoration was
required (crown or partial crown) later to stabilize the integrity
of the tooth or when the cervical margin was located
subgingivally. An etch-and-rinse adhesive
(Prime&Bond NT, Dentsply) was used in the remaining cavities
that were restored with the hybrid composite Spectrum.
These were Class I and II restorations (O, OM/OD,
and MOD) with the cervical margin located para- or
supragingivally. During the restoration, steel matrices were
used and fixed with wooden wedges. The hybrid composite
for the definitive restorations was applied in the cavities in
small horizontal increments with a maximum height of 1
mm. Application protocols for the two kinds of adhesives
and restorative materials are given in Table 1.
The patients were not told to which cavity-depth group
their tooth was allocated and if calcium hydroxide was
used or not. The patients were asked to record whether
any hypersensitivity, pain, or discomfort occurred following
treatment.
During a second appointment 6 months later, the patients
were re-examined by one dentist evaluating the following
criteria:
• Vitality test (yes/no): vitality testing was performed with
a cold foam pellet pressed on the buccal surface of the
tooth. The patients were asked to report whether they
felt the cold.
• Occurrence of hypersensitivity (yes/no): the patients
were asked if they had noticed any pain, hypersensitivity,
or discomfort in the teeth after the application of
the filling.
Reacting negative to the vitality test and reported pain
or hypersensitivity were ranked as failure.
To evaluate the influence of the three different variables
“cavity depth”, “calcium hydroxide liner”, and “resto-
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Wegehaupt et al
ration material” a logistic regression was carried out. The
significance level was set at p ≤ 0.05.
The allocation of the tooth to the cavity groups, use of
calcium hydroxide lining, and the kind of restorative material
is shown in Table 2.
RESULTS
All patients were re-examined after 6 months; all 123 fillings
were still in situ. No fractures or any other distinctive
features were visible in the clinical examination. All teeth
exhibited a positive reaction in the vitality test. Percentage
distribution of pain incidents or hypersensitivity according
to the cavity groups, calcium hydroxide lining use, and the
kind of restorative material are shown in Table 3.
The logistic regression showed no statistically significant
influence of any of the three different variables “cavity
depth” (p = 0.65), “calcium hydroxide liner” (p = 0.086),
and “restoration material” (p = 0.71) on the occurrence of
pain or hypersensitivity.
DISCUSSION
The present study aimed to investigate the influence of different
thickness of remaining dentin on pain occurrence of
adhesively luted restorations under in vivo conditions.
Since the treated teeth were not extracted afterwards, no
histological examination was possible to determine dentin
thickness. Thus, for determining dentin thickness and to
allow the allocation of the teeth to different categories of
remaining dentin thickness, the RDTMD was used. The
measurement with the RDTMD depends on the electrical
resistance of the dentin. 14
Studies performing histological examination of restored
teeth mostly use teeth planned to be extracted for orthodontic
reasons. 6,21 This procedure has the disadvantage
that these teeth are often free of caries, thus not mirroring
the usual clinical situation. An advantage of using the
RDTMD in the present study was that teeth with clinically
common carious lesions could be included in the study.
However, the use of the RDTMD for allocation of the teeth
to different categories of remaining dentin thickness is a
topic of some discussion. Gente 13 observed a higher electrical
resistance with longer dentin tubules and greater
remaining dentin thickness. 12,14 The same author 13
reported the remaining dentin thickness as being 2.1 to
3.0 mm for the green LEDs, 1.5 to 2.1 mm for the yellow
LEDs, 0.9 to 1.5 mm for the orange LEDs, and less than
0.9 mm for the red LEDs. Thus, our definition of shallow,
medium, and deep corresponds to 1.5 to 3.0 mm, 0.9 to
1.5 mm, and less than 0.9 mm remaining dentin thickness,
respectively. In contrast, Tielemans et al 32 found the
use of RDTMD to be reproducible, but in their study, the
electrical resistance showed no statistically significant correlation
with the histologically determined dentin
thickness. It should be mentioned that in the study by
Tielemans et al, 32 only two patients with a total of 12
teeth were examined. Moreover, the present study using
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the RDTMD was started before the discrepant findings by
Tielemans et al 32 were published. To clarify the contradictory
findings regarding the RDTMD, a comprehensive in
vivo study with an appropriate number of test teeth must
be performed.
In the present study, two different kinds of restorative
materials were used to reflect different treatment requirements.
The definitive fillings were made with the hybrid
composite in an incremental technique. This material has
shown good clinical performance in various previous clinical
studies. 18,27,33,34 The buildup composite in combination
with the self-etching adhesive system was applied in
bulk in the cavities with greater extension. This procedure
presents a fast, economical, and less technique-sensitive
approach, and is often used to build up teeth prior to indirect
restorations.
The overall occurrence of postoperative pain in the present
study amounted to 17%. This corresponds well with
the findings of another recent study, 5 showing postoperative
pain incidence of 5% to 26% after adhesive restorations
with different cavity sizes.
Our finding that there was no statistically significant influence
of use of a calcium hydroxide liner on hypersensitivity
corresponded with the results of Whitworth et al. 35
They also found no difference in the protection of the pulp
by calcium hydroxide lining or conditioning and sealing
with adhesive resins only. This might be explained with the
precipitation of crystalline salts in the dentin tubules after
the use of calcium hydroxide liner 19 or the sealing of the
dentin with light- or self-curing resin after the use of a hydrophilic
adhesive, creating a continuous resin-dentin hybrid
layer. 23 Both may lead to a reduction of the dentin
permeability for potential cytotoxic components of restorative
materials or bacteria, 8 thus protecting the pulp tissue.
Moreover, with respect to the hydrodynamic theory of
Brännström, 3 which states that movement of dentinal liquid
is responsible for hypersensitivity, both precipitation of
calcium salts and formation of the hybrid layer might be
able to counteract hypersensitivity.
In the present study, no statistically significant influence
of the cavity depth on the occurrence of pain was observed.
Murray et al 21 also did not find the remaining
dentin thickness to be statistically correlated to signs of
pulp inflammation as histologically proven. In contrast,
Whitworth et al 35 estimated the residual dentin thickness
to be a key determinant for the pulp reaction. It should be
mentioned that in that study, 35 teeth with pulp exposure
were also included in the group of deep cavities; furthermore,
there was no requirement for the dentists to use
rubber-dam during treatment. The use of rubber-dam
might have an impact on the pulp response after cavity
preparation, as shown by Camps et al 6 , who found remaining
dentin thickness to be of only minor importance in the
reaction of the pulp, as compared to bacteria left in the
cavity prior to filling. It might be assumed that lesser
amounts of bacteria are still present on the cavity walls
when rubber-dam is used during treatment.
The effect of restorative materials on the vitality of the
pulp and the occurrence of postoperative pain is a contentious
issue in the literature. 9,16,24,37 In the present
for
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study, no statistically significant influence of the restorative
material was found. This finding agrees with prior findings
that even a thin layer of residual dentin may protect
the pulp against both material and bonding system toxicity,
2,20 so that different restorative materials or adhesives
will not have a significant influence on the pulp tissue. 24
Cox 7 also showed the restorative materials to have a minimal
influence on postoperative pulp reactions. In contrast
to these findings, a recent study by Whitworth et al 35 observed
a correlation between restorative materials and
pulp breakdown only in the deep cavities and cavities with
pulp exposure. This finding may be explained with previous
investigations which showed that odontoblasts are already
injured by cavity preparations with a depth close to or into
the pulp tissue, 11,17 which may lead to pulp inflammation
and pulp breakdown.
We suggest that the layer formed by the adhesive systems
acts as a barrier to filling material contents reaching
the pulp. Similar to our finding that the materials used
here had no influence on the pulp vitality, Nayyar et al 24
also observed no difference in the pulp response between
a self-etching adhesive and an etch-and-rinse adhesive.
CONCLUSION
The results of the present study showed that neither the
thickness of the remaining dentin, the use of calcium hydroxide
liner, nor the adhesive and restorative system
used in the study have an impact on the incidence of postoperative
pain.
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for
Clinical relevance: Neither the thickness of the remaining
dentin, the use of calcium hydroxide liner, or the adhesive
and restorative systems have an impact on the
incidence of postoperative pain.
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