Quintessence Journals - Sandra Kalil Bussadori

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Copyright 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 Not for Publication Quintessence 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 Not by 140 The Journal of Adhesive Dentistry
Copyright 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. REFERENCES 1. Akimoto N, Momoi Y, Kohno A, Suzuki S, Otsuki M, Suzuki S, Cox CF. Biocompatibility of Clearfil Liner Bond 2 and Clearfil AP-X system on nonexposed and exposed primate teeth. Quintessence Int 1998;29:177-188. 2. Bergenholtz G. Evidence for bacterial causation of adverse pulpal responses in resin-based dental restorations. Crit Rev Oral Biol Med 2000;11:467-480. 3. Brännström M, Linden LA, Astrom A. The hydrodynamics of the dental tubule and of pulp fluid. A discussion of its significance in relation to dentinal sensitivity. Caries Res 1967;1:310-317. 4. Brännström M, Nordenvall KJ. Bacterial penetration, pulpal reaction and the inner surface of Concise enamel bond. Composite fillings in etched and unetched cavities. J Dent Res 1978;57:3-10. 5. Briso ALF, Mestrener SR, Delicio G, Sundfeld RH, Bedran-Russo AK. Clinical assessment of postoperative sensitivity in posterior composite restorations. Oper Dent 2007;32:421-426. 6. Camps J, Dejou J, Remusat M, About I. Factors influencing pulpal response to cavity restorations. Dent Mater 2000;16:432-440. 7. Cox CF. Effects of adhesive resins and various dental cements on the pulp. Oper Dent 1992;(suppl 5):165-176. 8. Cox CF. Evaluation and treatment of bacterial microleakage. Am J Dent 1994;7:293-295. 9. Cox CF, Felton D, Bergenholtz G. Histopathological response of infected cavities treated with Gluma and Scotchbond dentin bonding agents. Am J Dent 1988;1(special issue):189-194. 10 . Cox CF, Hafez AA, Akimoto N, Otsuki M, Suzuki S, Tarim B. Biocompatibility of primer, adhesive and resin composite systems on non-exposed and exposed pulps of non-human primate teeth. Am J Dent 1998;11(special issue):S55-63. 11. Darvell BW. Effect of dentine thickness on pulpal changes beneath restorative materials. Aust Dent J 1981;26:80-81. 12. Gente M. Begrenzung der Präparationstiefe durch elektrische Widerstandsmessungen. Dtsch Zahnarztl Z 1995;50:658-660. Not for Publication Wegehaupt et al Quintessence 13. Gente M. Untersuchung zur Begrenzung der Präparationstiefe bei der Kronenpräparation durch elektrische Widerstandsmessung. Marburg, Germany: Thesis, 1992 14. Gente M, Becker-Detert D. Studies on the specific electric resistance of the dentin of human teeth [in German]. Dtsch Zahnarztl Z 1991;46:803-806. 15. Keyes PH. The infectious and transmissible nature of experimental dental caries. Findings and implications. Arch Oral Biol 1960;1:304-320. 16. Koliniotou-Koumpia E, Papadimitriou S, Tziafas D. Pulpal responses after application of current adhesive systems to deep cavities. Clin Oral Investig 2007;11:313-320. 17. Lee SJ, Walton RE, Osborne JW. Pulp response to bases and cavity depths. Am J Dent 1992;5:64-68. 18. Loguercio AD, Reis A, Hernandez PA, Macedo RP, Busato AL. 3-Year clinical evaluation of posterior packable composite resin restorations. J Oral Rehabil 2006;33:144-151. 19. Mjör IA, Ferrari M. Pulp-dentin biology in restorative dentistry. Part 6: Reactions to restorative materials, tooth-restoration interfaces, and adhesive techniques. Quintessence Int 2002;33:35-63. 20. Murray PE, Hafez AA, Smith AJ, Cox CF. Bacterial microleakage and pulp inflammation associated with various restorative materials. Dent Mater 2002;18:470-478. 21. Murray PE, Smith AJ, Windsor LJ, Mjör IA. Remaining dentine thickness and human pulp responses. Int Endod J 2003;36:33-43. 22. Murray PE, Stanley HR, Matthews JB, Sloan AJ, Smith AJ. Age-related odontometric changes of human teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:474-482. 23. Nakabayashi N. Importance of mini-dumbbell specimen to access tensile strength of restored dentine: historical background and the future perspective in dentistry. J Dent 2004;32:431-442. 24. Nayyar S, Tewari S, Arora B. Comparison of human pulp response to totaletch and self-etch bonding agents. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;104:45-52. 25. Orland FJ, Blayney JR, Harrison RW, Reyniers JA, Trexler PC, Ervin RF, Gordon HA, Wagner M. Experimental caries in germfree rats inoculated with enterococci. J Am Dent Assoc 1955;50:259-272. 26. Pameijer CH, Stanley HR, Ecker G. Biocompatibility of a glass ionomer luting agent. 2. Crown cementation. Am J Dent 1991;4:134-141. 27. Perry RD, Kugel G, Habib CM, McGarry P, Settembrini L. A two-year clinical evaluation of TPH for restoration of Class II carious lesions in permanent teeth. Gen Dent 1997;45:344-349. 28. Polansky R, Reichhold C, Lorenzoni M. Die Topographie der Pulpa im Seitenzahnbereich nach Stufenpräparation für Vollkeramische Kronen. Eine experimentelle Untersuchung. Dtsch Zahnarztl Z 1998;53:643-647. 29. Schmalz G, Hiller KA, Nunez LJ, Stoll J, Weis K. Permeability characteristics of bovine and human dentin under different pretreatment conditions. J Endod 2001;27:23-30. 30. Snuggs HM, Cox CF, Powell CS, White KC. Pulpal healing and dentinal bridge formation in an acidic environment. Quintessence Int 1993;24:501- 510. 31. Stanley HR. Dental iatrogenesis. Int Dent J 1994;44:3-18. 32. Tielemans S, Bergmans L, Duyck J, Naert I. Evaluation of a preparation depth controlling device: a pilot study. Quintessence Int 2007;38:135-142. 33. Türkün LS, Aktener BO. Twenty-four-month clinical evaluation of different posterior composite resin materials. J Am Dent Assoc 2001;132:196-203. 34. Wendt SLJ, Leinfelder KF. Clinical evaluation of a posterior resin composite: 3-year results. Am J Dent 1994;7:207-211. 35. Whitworth JM, Myers PM, Smith J, Walls AW, McCabe JF. Endodontic complications after plastic restorations in general practice. Int Endod J 2005;38:409-416. 36. Wiegand A, Caspar C, Becker K, Werner C, Attin T. In vitro cytotoxicity of different self-etching dental adhesive systems. Schweiz Monatsschr Zahnmed 2006;116:614-621. 37. Wisithphrom K, Murray PE, About I, Windsor LJ. Interactions between cavity preparation and restoration events and their effects on pulp vitality. Int J Periodontics Restorative Dent 2006;26:596-605. 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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