*Piotr Rożniatowski1, Emil Korporowicz1, Dariusz Gozdowski2, Dorota Olczak-Kowalczyk1
The impact of oral hygiene, the intensity and increase of caries on the condition of Equia Fil glass ionomer and Tetric EvoCeram composite proximal restorations in permanent teeth
Wpływ stanu higieny jamy ustnej, intensywności i przyrostu próchnicy na stan wypełnień ubytków na powierzchniach proksymalnych w zębach stałych wykonanych z materiału szkło-jonomerowego Equia Fil i złożonego Tetric EvoCeram
1Department of Paediatric Dentistry, Medical University of Warsaw
Head of Department: Professor Dorota Olczak-Kowalczyk, MD, PhD
2Department of Experimental Design and Bioinformatics, Warsaw University of Life Sciences
Head of Department: Professor Wiesław Mądry
Wstęp. Cementy szkło-jonomerowe i materiały złożone są powszechnie wykorzystywane do bezpośredniej odbudowy ubytków próchnicowych, także w młodych zębach stałych. Niewystarczająca jest jednak wiedza o wpływie czynników sprzyjających rozwojowi próchnicy na jakość wypełnień z tych materiałów, zwłaszcza wykonanych na powierzchniach proksymalnych, częściej narażonych na działanie płytki bakteryjnej.
Cel pracy. Ocena wpływu stanu higieny jamy ustnej i przyrostu próchnicy na stan wypełnień ubytków na powierzchniach proksymalnych młodych zębów stałych wykonanych z materiału kompozytowego i cementu szkło-jonomerowego po 2 latach użytkowania.
Materiał i metody. U pacjentów w wieku 12-20 lat z ubytkami próchnicowymi na powierzchniach proksymalnych w zębach przedtrzonowych i trzonowych założono wypełnienia wykonane z materiału szkło-jonomerowego Equia Fil i złożonego Tetric EvoCeram. Na wizycie wstępnej i kontrolnych po 6, 12, 18 i 24 miesiącach oceniono stan wypełnień oraz obliczono wskaźniki: OHI-S, DPUWZ, a także ich przyrost. Określono powiązania pomiędzy oceną kliniczną wypełnień a wartościami wskaźników: higieny, intensywności próchnicy, ich przyrostem oraz przyrostem liczby zębów z plamami próchnicowymi.
Uzyskano zgodę Komisji Bioetycznej Warszawskiego Uniwersytetu Medycznego nr KB/157/2013.
Wyniki. U 49 pacjentów wykonano 100 wypełnień na powierzchniach proksymalnych. Po 24 miesiącach skontrolowano 98: 50 z materiału Equia Fil i 48 z Tetric EvoCeram. Średnie wartości OHI-S i DPUWZ w badaniu wstępnym u pacjentów z wypełnieniami Equia Fil wyniosły odpowiednio: 1,37 i 12,04, z wypełnieniami Tetric: 1,27 i 10,38, natomiast w badaniu kontrolnym: 1,80 i 15,41 oraz 1,63, i 12,38. Odnotowano istotne statystycznie zalez?nos?ci pomie?dzy wskaz?nikiem OHI-S a wartos?ciami okres?laja?cymi ocene? materiało?w. Wartos?ci te wzrastały wraz ze wzrostem OHI-S i DPUWZ.
Wnioski. Zaro?wno wypełnienia wykonane z materiału Tetric Evo Ceram, jak i Equia Fil sa? wraz?liwe na działanie czynniko?w kariogennych.
Introduction. Glass-ionomer cements and composite materials are widely used for direct restoration of carious lesions, also in young permanent teeth. However, knowledge on the effects of cariogenic factors on the quality of restorations performed using these materials, especially those covering proximal surfaces, which are more often exposed to bacterial plaque, is insufficient.
Aim. The aim of the study was to assess the impact of oral hygiene and increased intensity of caries on proximal composite and glass ionomer restorations in young permanent teeth after 2 years of usage.
Material and methods. Equia Fil glass-ionomer and Tetric EvoCeram composite restorations were performed in patients aged between 12 and 20 years with proximal carious lesions in premolars and molars. The clinical condition of restorations was assessed and indices such as OHI-S and D1-2DMFT (along with their increased values) were calculated at baseline, as well as during follow-up visits at 6, 12, 18 and 24 months. Correlations between clinical assessment of restorations and indices for oral hygiene and caries intensity, their increase and increased number of teeth with carious spots were evaluated.
The study was approved by the Bioethics Committee of the Medical University of Warsaw (No. KB/157/2013).
Results. A total of 100 proximal restorations were performed in 49 patients. After 24 months, 98 restorations (50 Equia Fil and 48 Tetric EvoCeram) were evaluated. Mean baseline OHI-S and D1-2DMFT were 1.37 and 12.04, respectively, for Equia Fil restorations, and 1.27 and 10.38 for Tetric restorations, with the following values reported during follow-up: 1.80 and 15.4; 1.63 and 12.38. Statistically significant relationships were found between OHI-S and values describing the state of materials. These values increased with increasing OHI-S and D1-2DMFT.
Conclusions. Both Tetric Evo Ceram and Equia Fil restorations are susceptible to cariogenic factors.
The current guidelines of minimally invasive dentistry recommend selective removal of carious dentin, i.e. leaving residual demineralised dentin on the intrachamber wall followed by its sealing, preferably using materials that accelerate remineralisation of demineralised dentin to protect the pulp (1). Restoration of large two-surface lesions in lateral teeth requires an additional use of materials with high mechanical strength. For this reason, composite materials, which ensure stability and aesthetics, are very popular. However, these materials are not recommended for patients at high risk of caries, i.e. exposed to cariogenic factors. It was found that patients with high intensity of caries are more likely to develop secondary caries and present with the loss of marginal adhesion of composite materials (2).
Temporary restorations using glass-ionomer cements are recommended for high-risk patients. Owing to their remineralisation properties, these materials are commonly used for restoring carious lesions, deep ones in particular. Insufficient mechanical strength is a factor limiting the use of conventional glass-ionomer cements for long-term restoration of proximal cavities in permanent teeth. Sensitivity to acids and worse aesthetics compared to composite materials are also important disadvantages. Currently available high-viscosity glass-ionomer cements show improved aesthetics and resistance to abrasion, as well as low solubility in the oral cavity (3-9). Covering these materials with a protective varnish containing nanofiller increases their smoothness, resistance to abrasion and hardness (10-13). At the same time, high-viscosity glass-ionomer cements show biocompatibility and the ability to release fluoride comparable to those of conventional ones. These properties suggest both longer use of restorations made of these materials, also when covering more than one surface, as well as benefits of their use in young permanent teeth showing higher dentin permeability, as well as in patients at high risk of caries. However, there is no sufficient evidence supporting this hypothesis in literature.
Dental plaque, new cavities and carious spots are objective indicators of restoration exposure to cariogenic factors (14). Very few studies assessed the effects of cariogenic factors or caries intensity on the performance of restorations made of different materials (2, 15).
The aim of the study was to assess the impact of oral hygiene and increased intensity of caries on proximal composite and glass ionomer restorations in young permanent teeth after 2 years of usage.
Material and methods
A randomised clinical study involving two types of intervention was conducted between 2013 and 2015. The interventions included a preliminary clinical and radiological assessment, follow-up examinations at 6-month intervals for 2 years, as well as Tetric EvoCeram (Ivoclar Vivadent, Schaan, Liechtenstein) composite (intervention A) or Equia Fil (GC, Tokyo, Japan) glass-ionomer (intervention B) proximal restorations in molars and premolars. The examinations were performed by two specialists in paediatric dentistry, each with more than 5 years of clinical experience, after appropriate training and calibration (Kappa coefficient: 0.89). The study was approved by the Bioethics Committee of the Medical University of Warsaw (No. KB/157/2013).
Recruitment was performed among patients reporting to the Department of Paediatric Dentistry of the Medical University of Warsaw. Inclusion criteria were as follows: age 12-20 years, proximal carious lesions in premolars or molars (Black class II; ICDAS II code 4 or 5, radiographic caries depth D1, D2 or D3 according to Manji et al.), and a written consent from the patient/parent or legal guardian to participate in the study. Exclusion criteria were as follows: secondary caries, signs of pulpitis in a tooth with a proximal cavity (pain, inappropriate response to dental pulp tests), parafunctional tooth-clenching (bruxism), malocclusion, ongoing or planned orthodontic treatment, history of chronic disease requiring specialist medical care, planned change of residence during the year.
According to the principle of randomisation, a block-size of 6 was used to allocate patients for two types of interventions. The codes for interventions (A, B) were assigned to the numbers of teeth (n), in accordance with the order of reporting. If more than one tooth was qualified in a given patient, the order of intervention was determined by the location of the tooth in the oral cavity – tooth 16 first, then teeth 26, 36 and 46. Blinding of the intervention was achieved by placing randomisation results in opaque envelopes. The use of allocation concealment allowed for the protection of randomisation and prevented access to information about the group to which the patient was allocated before inclusion in the study.
Class II cavities were treated according to the principles of minimally invasive dentistry, i.e. leaving residual demineralised dentin. Matrix bands 0.045 mm were used for tooth shape restoration, and lignin rolls were used for treatment site isolation (13, 16-20). The materials were applied in accordance with manufacturers’ instructions. Tetric EvoCeram was applied using the layered technique, while a single-layer method was used for Equia Fil. In the case of composite materials, surface finishing was done immediately after application. For Equia Fil, surface finishing was done 2.5 minutes after the beginning of mixing. The surface was covered with Equia Coat and light-cured for 20 seconds.
Clinical examinations were performed in a dental office setting (21, 22). Baseline and follow-up examinations were performed to assess both oral hygiene using oral hygiene index simplified (OHI-S) for dental plaque according to Green and Vermillion (1964), and dentition – the presence of caries on all tooth surfaces according to the International Caries Detection and Assessment System (ICDAS-II). D1-2DMFT was calculated, with ICDAS II code 1 and 2 taken as D1 and ICDAS II ≥ 3 taken as D.
Restorations were assessed after a month and during follow-up, using a 5-point scale, as in accordance with the criteria developed by Hickel et al., and recommended by the World Dental Federation (FDI) (23, 24) (tab. 1).
Tab. 1. Hickel’s criteria for the assessment of dental restorations
|Clinical condition||Excellent, very good||Good||Sufficient, satisfactory||Unsatisfactory||Poor|
|Surface discolouration||none||mild, easily removable discolouration||moderate surface discolouration, including other teeth, aesthetically acceptable||unacceptable surface discoloration, greater intervention needed||severe unrepairable discoloration|
|Retention and cracking||none||hairline fractures||larger cracks with no effects on marginal sealing or the contact point||cracks affecting sealing or the contact point, massive cracks with the loss of more than 50% of filling ||partial or total loss of filling|
|Marginal adaptation||no gaps or discolouration||marginal gap removable by polishing||marginal gap cannot be removed by polishing, minor cracks in the enamel or dentin||exposed dentin, fracture gap compromising marginal sealing and exposing dentin||loose restoration|
|Post-operative hypersensitivity/tooth vitality||viable tooth, no hypersensitivity||mild, transient hypersensitivity, viability maintained||no subjective symptoms, reduced or delayed response to stimuli, no need for treatment||increased, longer-lasting response, symptoms reported||symptomatic pulpitis, pulp necrosis, endodontic treatment needed|
|Secondary caries, erosion, abfraction||none||very mild, in situ; demineralisation, abfraction, correction not needed||large surfaces of demineralization, erosion, abfraction, no dentin exposure, no need for intervention||undermining caries, erosions, abfraction, dentin abrasion, repairable||deep secondary caries, exposed dentin, unrepairable|
Patients were provided with dietary and hygiene advice, as well as had fluoride varnish applied during visits.
Statistica 12 (StatSoft) for Windows (Microsoft) was used for statistical analysis. A p ≤ 0.05 was considered significant for all calculations. Data for statistical evaluations was obtained from previously prepared Excel spreadsheets (Microsoft). T-student test was used to compare mean OHI-S, D1-2DMFT, increased D1-2T and the number of patients with an increased number of carious spots for interventions A and B, as well as mean D1-2DMFT, D1-2T, OHI-S and their increase for the individual materials rated excellent within 24 months. The U-Mann-Whitney test was used to compare the mean values from the assessment of materials in the individual categories, while chi-square test was used to compare the numbers of restorations with Hickel’s score of less than 1 for a given category. Spearman’s rank correlation coefficients were determined to assess the correlations between clinical findings for the tested materials (mean scores) and mean OHI-S for each patient throughout the study period, baseline D1-2DMFT, as well as an increase in OHI-S, D1-2DMFT and D1-2T.
A total of 49 patients aged between 12.08 to 19.58 years (mean age 15.87 ± 1.80), in whom 100 proximal restorations in 46 premolars and 54 molars (64 maxillary and 46 mandibular) were performed, were included in the study. A follow-up of 98 restorations, including 50 Equia Fil and 48 EvoCeram restorations, was performed after 24 months. The lower number of restorations assessed during follow-up was due to patient failure to report.
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