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ORIGINAL ARTICLE
Year : 2018  |  Volume : 7  |  Issue : 1  |  Page : 19-22

A novel method to reduce postoperative sensitivity after composite restoration: A triple-blinded in-vivo study


Department of Conservative Dentistry and Endodontics, SRM Kattankulathur Dental College and Hospital, Tamil Nadu, India

Date of Web Publication22-Mar-2018

Correspondence Address:
Dr. Chitra Janardhanan Vejai Vekaash
Department of Conservative Dentistry and Endodontics, SRM Kattankulathur Dental College and Hospital, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_37_17

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  Abstract 


Objective: To evaluate the efficacy of Zinc-carbonated hydroxyapatite in the reduction of postoperative sensitivity during composite placement.
Context: Postoperative sensitivity after composite restoration still remains a major clinical challenge.
Materials and Methods: Sixty class I cavities were prepared in 60 patients by the same operator with the following inclusion and exclusion criteria: The patients selected for the study were between 20–45 years with vital pulp and having remaining dentin thickness of 1mm. Previously restored, nonvital and tooth with periodical changes were excluded. Patients were randomly divided into two groups of 30 each—Group I self-etch and Group II selective-etch with Subgroup A- zinc-carbonated hydroxyapatite applied and Subgroup B- zinc-carbonated hydroxyapatite not applied. After the surface treatment, the teeth were restored with composite resin. The patients were evaluated with visual analogue scale (VAS) at the end of one week and one month.
Statistical Analysis: Data were analyzed using Kruskal–Wallis one-way analysis.
Results: Comparing within groups, Group I self-etch mean values showed statistically significant lower values compared with Group II selective-etch (P < 0.01). Zinc-carbonated hydroxyapatite Subgroup A showed statistically significant lower values compared with Subgroup B where zinc-carbonated hydroxyapatite was not applied (P < 0.01).
Conclusion: Application of zinc-carbonated hydroxyapatite showed significant reduction in postoperative sensitivity after composite placement.

Keywords: Composite, postoperative sensitivity, selective etch, self-etch, zinc-carbonated hydroxyapatite


How to cite this article:
Vejai Vekaash CJ, Venkatesh KV, Kumar Reddy TV, Devaraj K. A novel method to reduce postoperative sensitivity after composite restoration: A triple-blinded in-vivo study. J NTR Univ Health Sci 2018;7:19-22

How to cite this URL:
Vejai Vekaash CJ, Venkatesh KV, Kumar Reddy TV, Devaraj K. A novel method to reduce postoperative sensitivity after composite restoration: A triple-blinded in-vivo study. J NTR Univ Health Sci [serial online] 2018 [cited 2018 Jul 18];7:19-22. Available from: http://www.jdrntruhs.org/text.asp?2018/7/1/19/228148




  Introduction Top


Today's dental practice revolves around the concept of minimal intervention and composite resin restoration has made this possible.[1] Composite has gained a lot of importance by means of greater changes in the technical perspective and material science. Despite the significant improvement in the material science and adhesive techniques, this restoration may still present a few clinical complications, such as microleakage and postoperative sensitivity.[2]

Many techniques have been introduced to overcome most of these drawbacks and have been managed, except post-op sensitivity, which still remains the biggest challenge. Due to technique-sensitive procedures, class I and class II composite restoration showed more failure rate than other restorations.[3] Previous clinical studies have reported that 30% of patients present with post-op sensitivity after composite restoration.[4],[5],[6],[7]

Enamel remineralization has gained a lot of popularity in our practice since 1990s after the use of CCP-ACP (Casein phosphopeptide-amorphous calcium phosphate).[8],[9],[10] With the advent of nanotechnology, this is the era of dentin remineralization. One such dentin remineralizing agent is zinc-carbonated hydroxyapatite.[11],[12],[13] We developed a novel method to remineralize the cavities before any surface treatment for composite placement.

The aim of the study is to evaluate the role of dentin remineralization in the reduction of post-op sensitivity in composite placement.


  Materials and Methods Top


The ethical approval was obtained to perform this study from SRM Medical Ethical Committee. Class I cavities from 60 patients were taken for the study with the following inclusion and exclusion criteria: The patients selected for the study were between 20–45 years with vital pulp and having remaining dentin thickness of 1mm. Previously restored, nonvital and tooth with periodical changes were excluded. The remineralizing agent selected for the study was zinc-carbonated hydroxyapatite (Stomysens, Biorepair). The sample was randomly divided into two groups based on self-etch application and selective-etch application, which was further divided into two subgroups on the basis of application of zinc-carbonated hydroxyapatite.

Group I = self-etch (n = 30)

Group II = selective-etch (n = 30)

Subgroup A = zinc-carbonated hydroxyapatite applied (n = 15)

Subgroup B = zinc- carbonated hydroxyapatite not applied (n = 15)

Personnel blinded in the study were operator, evaluator, and patients.

Remaining dentin thickness was assessed using direct digital radiography, and also it was made sure that there was no pulp involvement or periapical pathology.

Surface treatment protocols

Group I Subgroup A: After cavity preparation, the pulpal floor was coated with EDTA (Ethylenediaminetetraac etic acid) solution (Septodont), and after 2 min, the solution was washed away. This procedure helped in removing the smear layer formed during the cavity preparation and in enhancing the subsequent remineralizing procedure. Later, the remineralizing agent, zinc-carbonated hydroxyapatite, was applied to the pulpal floor with an applicator tip. After 5 min, the cavity was gently air-dried using chip blower to remove the excess agent. The entire cavity was then coated with self-etch (Tetric N self-etch, Ivoclar Vivadent) and scrubbed for 10 s and then excess was removed and light cured. The cavity was restored with bulk fill composite (Tetric N bulk fill, Ivoclar Vivadent).

Group I Subgroup B: After cavity preparation, the entire cavity was then coated with self-etch (Tetric N self-etch, Ivoclar Vivadent) and scrubbed for 10 s and then excess was removed and light cured. The cavity was restored with bulk fill composite (Tetric N bulk fill, Ivoclar Vivadent).

Group II Subgroup A: After cavity preparation, the pulpal floor was coated with EDTA solution (Septodont), and after 2 min, the solution was washed away. This procedure helped in removing the smear layer formed during the cavity preparation and in enhancing the subsequent remineralizing procedure. Later, the remineralizing agent, zinc-carbonated hydroxyapatite was applied to the pulpal floor with an applicator tip. After 5 min, the cavity was gently air-dried using chip blower to remove the excess agent. In this group, selective-etch technique was followed. Then 37% phosphoric acid (Total-etch, Ivoclar Vivadent) was applied on to the cavosurface enamel first and after 10 s, the etchant was applied to the remaining cavity. Within 2 s, the cavity was washed thoroughly for 1 min with water. The entire cavity was gently air-dried to remove the surface moisture. Two coats of bonding agent (Tetric N bond, Ivoclar Vivadent) were then applied to the cavity. After 15 s, the excess was removed and light cured. The cavity was restored with bulk fill composite (Tetric N bulk fill, Ivoclar Vivadent).

Group II Subgroup B: After cavity preparation, 37% phosphoric acid (Total-etch, Ivoclar Vivadent) was applied on to the cavosurface enamel first and after 10 s, the etchant was applied to the remaining cavity. Within 2 s, the cavity was washed thoroughly for 1 min with water. The entire cavity was gently air-dried to remove the surface moisture. Two coats of bonding agent (Tetric N bond, Ivoclar Vivadent) were then applied to the cavity. After 15s, the excess was removed and light cured. The cavity was restored with bulk fill composite (Tetric N bulk fill, Ivoclar Vivadent).

To maintain standardization of procedures mentioned, the entire process starting from cavity preparation to restoration was performed by a single operator.

Then, the patients were analyzed using visual analogue scale (VAS). VAS had a score of 0 to 10, 0 and 1 - no sensitivity; 2 and 3 - mild, annoying sensitivity; 4 and 5 - nagging, uncomfortable and troublesome sensitivity; 6 and 7 - distressing and miserable sensitivity; 8 and 9 - intense, dreadful and horrible sensitivity; 10 - worst possible, unbearable sensitivity.

The patients were recalled at one week and one month for evaluation and VAS score was taken. Data were analysed using Kruskal–Wallis one-way analysis.


  Results Top


The results of this in vivo study are given in [Table 1]. In all the groups evaluated, the mean value obtained with the use of zinc-carbonated hydroxyapatite Subgroup A showed statistically significant lower values compared to Subgroup B where zinc-carbonated hydroxyapatite was not applied (P < 0.01). Comparing within groups, Group I self-etch mean values showed statistically significant lower values compared to Group II selective-etch (P < 0.01). The mean value of one month Group IA showed statistically significant lower values compared to one week Group IA (P < 0.01).
Table 1: 1 Week and 1 month post-op results obtained

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  Discussion Top


The advent of newer techniques and concepts in adhesive dentistry has increased the number of composite restorations done. The associated complications of composite restorations are yet to be solved, such as marginal discoloration and post-op sensitivity, which directly attributes to polymerization shrinkage and related stress at the bonded interface.[2]

Etching dentin and formation of hybrid layer introduced by Nakabyashi in 1992 were promising theoretically, but the related complications of etching created quite a few complications practically, one of which being the post-op sensitivity. Hence, the self-etch concept came into practice but still never gave a complete solution.

Another issue with bonded interface during polymerization is excessive stress that leads to dentin crack formation on the pulpal floor and sensitivity while chewing. Despite modifications of surface treating the tooth, incremental placement of composite and changes in polymerization techniques, the problem of post-op sensitivity still remains.[7]

Dentin remineralization happens when zinc-carbonated hydroxyapatite reacts with inorganic component of dentin and forms hydroxyapatite crystals covering dentinal tubules, making the patient less susceptible to post-op sensitivity. So, after etching either with self or selective method, less damage to dentin happens. Studies show that remineralization happens within 2 min on application and progresses gradually.[13],[14],[15]

Therefore, we thought about a novel idea of remineralizing the dentin before surface treating it for adhesive protocols. Age group of 25–45 was selected; thus dentin is not too young or old and has a good remineralizing potential. EDTA was used to disturb the smear layer and make the surface active for dentin remineralization.[16],[17]

In this study, it was found that there was significant reduction in post-op sensitivity in the patients where dentin remineralizing agent was applied before adhesive protocols. The remineralized pulpal floor would definitely be resistant to the surface treatment employed (self-etch, selective-etch) for adhesive restorations. Hence, the hybridization of remineralized area will not be as effective as the non-remineralized area. But clinically what is more important is the cavosurface seal. This has been perfectly obtained in this study. Further studies in this regard would give a perfect insight about the issues of hybridization in the remineralized areas.

The reason for the reduction of post-op sensitivity is probably due to the effect of dentin remineralization, as explained above.


  Conclusion Top


Under the limitations of the study, it was found that there was significant reduction in post-op sensitivity in patients who underwent surface treatment before adhesive protocols. Further, long-term studies and evaluation of bond strength will make this procedure possible in class II restoration.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Anand VS, Kavitha C, Subbarao CV. Effect of Cavity Design on the Strength of Direct Posterior Composite Restorations: An Empirical and FEM Analysis. Int J Dent 2011;2011:214751.  Back to cited text no. 1
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Hayashi M, Wilson NH. Failure risk of posterior composites with post-operative sensitivity. Oper Dent 2003;28:681-8.  Back to cited text no. 2
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Al-Nahlawi T, Altaki Z, Abbood D. Post-operative sensitivity of Class I, II amalgam and composite resin restorations: Clinical evaluation in an undergraduate program. Int Dent Med J Adv Res 2015;1:1-4.  Back to cited text no. 3
    
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Brännström M. The cause of postrestorative sensitivity and its prevention. J Endod 1986;12:475-81.  Back to cited text no. 4
    
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Pashley DH, Carvalho RM. Dentine permeability and dentine adhesion. J Dent 1997;25:355-72.  Back to cited text no. 5
    
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Cochrane NJ, Saranathan S, Cai F, Cross KJ, Reynolds EC. Enamel subsurface lesion remineralisation with casein phosphopeptide stabilised solutions of calcium, phosphate and fluoride. Caries Res 2008;42:88-97.  Back to cited text no. 6
    
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Baratieri LN, Ritter AV. Four-year clinical evaluation of posterior resin-based composite restorations placed using the total-etch technique. J Esthet Restor Dent 2001;13:50-7.  Back to cited text no. 7
    
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Cury JA, Tenuta LM. Enamel remineralization: Controlling the caries disease or treating early caries lesions?. Braz Oral Res 2009;23(Suppl 1):23-30.  Back to cited text no. 8
    
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Jayarajan J, Janardhanam P, Jayakumar P. Efficacy of CPP-ACP and CPP-ACPF on enamel remineralization-an in vitro study using scanning electron microscope and DIAGNOdent. Indian J Dent Res 2011;22:77-82.  Back to cited text no. 9
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Bertassoni LE, Habelitz S, Marshall SJ, Marshall GW. Mechanical recovery of dentin following remineralization in vitro – An indentation study. J Biomech 2011;44:176-81.  Back to cited text no. 10
    
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Frankenberger R, Lohbauer U. Selective enamel etching reconsidered: Better than etch-and-rinse and self-etch?. J Adhes Dent 2008;10:339-44.  Back to cited text no. 11
    
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Total-etch versus selfetch adhesive: effect on postoperative sensitivity. Jorge Perdigão, Saulo Geraldeli, James S. Hodges J Am Dent Assoc. 2003;134: 1621-9.  Back to cited text no. 12
    
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Lelli M, Putignano A, Marchetti M, Foltran I, Mangani F, Procaccini M, et al. Remineralization and repair of enamel surface by biomimetic Zn-carbonate hydroxyapatite containing toothpaste: A comparative in vivo study. Front Physiol 2014;5:333.  Back to cited text no. 13
    
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Goldberg M, Kulkarni AB, Young M, Boskey A. Dentin: Structure, Composition and Mineralization: The role of dentin ECM in dentin formation and mineralization. Frontiers in Bioscience (Elite Edition). 2011;3:711-35.  Back to cited text no. 14
    
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Tschoppe P, Zandim DL, Martus P, Kielbassa AM. Enamel and dentine remineralization by nano-hydroxyapatite toothpastes. J Dent 2011;39:430-7.  Back to cited text no. 15
    
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Nakabayashi N, Ashizawa M, Nakamura M. Identification of a resin-dentine hybrid layer in vital human dentine created in vivo: Durable bonding to dentine. Quintessence Int 1992;23:135-41.  Back to cited text no. 16
    
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Pashley DH. Smear layer: Overview of structure and function. Proc Finn Dent Soc 1992;88:215-24.  Back to cited text no. 17
    



 
 
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