Quintessence Journals - Sandra Kalil Bussadori

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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used in the study Definitive filling: Prime & Bond NT and Spectrum Buildup filling: Clearfil Liner Bond 2V and LuxaCore Not for Publication Copyright <strong>Quintessence</strong> for Not by 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. 138 The Journal of Adhesive Dentistry
Copyright 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 Not for Publication Wegehaupt et al <strong>Quintessence</strong> for Not by 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- Vol 11, No 2, 2009 139
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