Article_6_4_2-stoleriu
CARIOLOGY
THE INFLUENCE OF SALIVA CONTAMINATION ON UNIVERSAL ADHESIVE BONDING
Original Articles
TO ENAMEL AND DENTIN
Simona Stoleriu1a* , Gianina Iovan1b, Irina Nica1c, Galina Pancu1d, Sorin Andrian1c
1
Odontology-Periodontology and Fixed Prosthesis Department, Faculty of Dental Medicine,„Grigore T. Popa” University of Medicine and Pharmacy Iași,
Iași, Romania
a
DMD, PhD, Associate Professor
b
DMD, PhD, Professor
c
DMD, PhD, Assistant Professor
d
DMD, PhD, Lecturer
e
DMD, PhD, Professor
ABSTRACT DOI: https://doi.org/10.25241/stomaeduj.2019.6(4).art.2 OPEN ACCESS This is an Open Access
article under the CC BY-NC 4.0 license.
Introduction: The aims of the study were to investigate the enamel and dentin Peer-Reviewed Article
marginal seal of a universal adhesive system applied with etch and rinse and self-
Citation: Stoleriu S, Iovan G, Nica I, Pancu G, Andrian
etch strategy and to evaluate the enamel and dentin marginal microleakage in S. The influence of saliva contamination on universal
case of saliva contamination on different steps of the adhesive application by dye adhesive bonding to enamel and dentin. Stoma Edu J.
2019;6(4):230-236
penetration assessment.
Received: November 10, 2019
Methodology: Thirty class V cavities were prepared on the buccal face (group Revised November 18, 2019
I- etch and rinse application of universal adhesive system) and the lingual face Accepted: November 27, 2019
Published: December 16, 2019
(group II- self-etch application of universal adhesive system) of molars and
*Corresponding author:
bicuspids. In each group 3 subgroups were created according to the moment of the Associate Professor Simona Stoleriu, DMD, PhD
saliva contamination: subgroup 1- no contamination, subgroup 2- contamination Odontology-Periodontology and Fixed Prosthesis
Department, Faculty of Dental Medicine, „Grigore T.
before light curing the adhesive, subgroup 3- contamination after light curing the Popa” University of Medicina and Pharmacy Iași,
16 Universității Street, 700115-Iași, Romania
adhesive. The dye penetration at the adhesive interface was evaluated according Tel/Fax: 0040745106066,
to a 4-score scale. e-mail: stoleriu_simona@yahoo.com
Results: In both groups increased enamel and dentin microleakage was Copyright: © 2019
the Editorial Council for the Stomatology Edu Journal.
recorded in subgroups 2 and 3 when comparing to subgroup 1. In group I saliva
contamination before and after light curing the adhesive resin led to similar mean
value of dentin microleakage. Increased values of microleakage were recorded in
group II when comparing to group I in the subgroups where contamination with
saliva was done before light curing the adhesive resin.
Conclusions: Saliva contamination of the adhesive system after light curing
increased enamel microleakage only when the adhesive system was applied with
etch and rinse strategy. Increased dentin microleakage after contamination was
recorded with both strategies of universal adhesive system application.
Keywords: Universal Adhesive System; Adhesion; Saliva Contamination;
Etch and Rinse; Self-Etch.
1. Introduction dipol-dipol forces, by hydrogen or covalent bonds);
Adhesion is the attraction of two different surfaces 3. adhesion by diffusion (substances precipitation
placed into direct tight contact determined by on the tooth surface to which resin monomers can
intermolecular forces that act at a relatively low bond mechanically or chemically); 4. combination of
distance [1]. The name adhesive indicates a material, the three mechanisms mentioned above [3,4]. The
most frequently a viscous fluid that joins (bonds) adhesion mechanism of bonding systems represents
together two substrates and favours the transfer the replacement of removed tooth minerals with
of forces from one surface to another [2]. There resin monomers in order that the polymers could
are many mechanisms implicated in the bonding be micromechanically integrated into the dental
process, four mechanisms being implicated in structure [5,6]. There are some conditions to obtain a
bonding to the tooth structure: 1. mechanical good adhesion: the surface substrate should be clean,
adhesion (resin penetration into the dental structure the adhesive should perfectly wet the substrate,
and resin tags formation); 2. adhesion by sorption there should be a good intimal adaptation of the
(chemical adhesion to the inorganic part of the adhesive to the adherent, and the bond strength
tooth structure – hydroxyapatite – or to the organic should be high enough to resist to debonding forces
part – mostly to type I collagen by Van der Waals or [7]. Acid etching was recommended more than sixty
230 Stoma Edu J. 2019;6(4): 230-236 www.stomaeduj.com
THE INFLUENCE OF SALIVA CONTAMINATION ON UNIVERSAL ADHESIVE BONDING
TO ENAMEL AND DENTIN
Table 1. Details regarding the restoration protocol in sugroups 1-5 of groups I and II.
Original Articles
Group I
Subgroup 1 Phosphoric acid application for 15 seconds on enamel and dentin; washing
(control) with water; drying with a brush applicator; scrubbing the surface with
adhesive resin for 20 seconds, air drying for 5 seconds, lightcure for 20
seconds; composite resin restoration
Subgroup 2 Phosphoric acid application for 15 seconds on enamel and dentin; washing
with water; drying with a brush applicator; scrubbing the surface with
adhesive resinfor 20 seconds; saliva contamination for 5 seconds, air drying
for 5 seconds, lightcure for 20 seconds; composite resin restoration
Subgroup 3 Phosphoric acid application for 15 seconds on enamel and dentin; washing
with water; drying with a brush applicator; scrubbing the surface with
adhesive resin for 20 seconds; air drying for 5 seconds; lightcure for 20
seconds; saliva contamination for 5 seconds; air drying for 5 seconds,
composite resin restoration
Group II
Subgroup 1 Scrubbing the surface with the adhesive resin for 20 seconds; air drying for 5
seconds; lightcure for 20 seconds; composite resin restoration
Subgroup 2 Scrubbing the surface with the adhesive resin for 20 seconds; saliva
contamination for 5 seconds; air drying for 5 seconds; lightcure for 20
seconds; composite resin restoration
Subgroup 3 Scrubbing the surface with the adhesive resin for 20 seconds; air drying for
5 seconds; lightcure for 20 seconds; saliva contamination for 5 seconds; air
drying for 5 seconds; composite resin restoration
years ago by Buonocuore to facilitate the adhesion two-step self-etch adhesives and 73.3% of the one-
of composite resin to the tooth structure [8]. By step self-etch adhesives adversely influence their
etching the smooth surface of enamel is changed bond quality [14]. Universal adhesive systems are the
into an irregular surface and the surface energy latest category of bonding agents released on the
increases. The resin will penetrate the rough surface market. Here are some of their characteristics: they
by capillary action and resin tags will result. This is can be used for direct and indirect restorations, they
the fundamental mechanism of bonding to enamel can react with different substrates, they can be used
[9]. Bonding to dentin relies mostly on monomers on etch and rinse, self-etch or selective etch strategy
penetration within the collagen fibers exposed after according to the clinical situation and the personal
acid etching. The dentin fluid presence on the cut preference of the practitioner [15]. They should be
dentin surface and the smear layer formation by hydrophilic in order to wet the dentin surface well,
fragments of hydroxyapatite crystals and denatured they should be hydrophobic not to allow water
collagen might complicate the adhesion to dentin sorption and hydrolysis after polymerization, they
[10 ]. Optimal adhesion is obtained by completely should be acid enough to etch well, but not so acid
removing the smear layer (etch and rinse strategy) in order not to destroy some of the initiators [7].
or incorporating it into the adhesive layer (self-etch There are only few data in the literature regarding
strategy) [11]. The technique of restoration using the bonding of universal adhesive systems in case
composite resins is very sensitive to moist, so good of substrate contamination [16,17]. The aims of the
isolation of the operating field is mandatory to obtain study were to investigate the enamel and dentin
a good adhesion. The clean and high energy state of marginal seal of a universal adhesive system applied
the surface is mandatory to obtain strong bonding. in etch and rinse and self-etch strategy, to evaluate
In some particular clinical situation ideal isolation the enamel and dentin marginal microleakage in
cannot be achieved and oral biofilms, saliva, other case of saliva contamination on different steps of
oral fluids, and organic debris might contaminate the adhesive application by dye penetration assessment.
tooth surface prepared for adhesion [12].
An acid conditioned enamel surface rapidly absorbs 2. Materials and methods
salivary components, which decreases the surface Thirty molars and bicuspids having buccal and lingual
energy and impairs the surface for adhesion [13]. cervical third of the crown with no caries lesions, no
A review of the literature regarding the influence wear lesions or other defects after the extraction
of saliva contamination on adhesive dentistry has were chosen for this study. Class V cavities having
shown that 77% of the three-step adhesive systems, a depth of 3 mm and the cervical margin placed
46% of the two-step adhesive systems, 81.5% of the 2 mm apically to the enamel-cementum junction
Stomatology Edu Journal 231
THE INFLUENCE OF SALIVA CONTAMINATION ON UNIVERSAL ADHESIVE BONDING
TO ENAMEL AND DENTIN
Table 2. Microleakage scores on enamel and dentin margins in group I.
Original Articles
Mean scores
Score 0 Score 1 Score 2 Score 3
value
Grup I - enamel
Subgroup 1 10 - - - 0
Subgroup 2 8 2 - - 0.2
Subgroup 3 6 4 - - 0.4
Grup I - dentin
Subgroup 1 10 - - - 0
Subgroup 2 6 2 2 - 0.6
Subgroup 3 6 2 2 - 0.6
were prepared on these areas. The buccal cavities dye penetration less than half of the wall; 2 – dye
were included in group I and the lingual cavities in penetration more than half but less than the entire
group II. All the cavities were restored using the same wall; 3 – complete dye penetration on the wall until
composite resin (Ceram X sphere TEC one, Dentsply the axial wall of the cavity.
Sirona – batch number 0894) and a universal adhesive
system (Prime and Bond Active, Dentsply Sirona – 3. Results
batch number 1810000151) applied in two different The scores of dye penetration in subgroups 1-3 of
strategies: etch and rinse (group I) and self-etch groups I and II are presented in tables 2 and 3. In both
(group II). In each group 3 subgroups were created groups increased enamel microleakage was recorded
according to the moment of saliva contamination in groups 2 and 3 when comparing to subgroup 1.
during the adhesive system application (table 1). Contamination with saliva after polymerization of the
Human stimulated saliva was used for contamination. adhesive resine led to the highest microleakage mean
The saliva was collected from a single person in two value. In group II increased values of microleakage
different days, at the same hour, after a diet break were recorded in all subgroups when comparing to
of 5 hours. The same quantity of saliva (0.1 mL) was group I and the highest microleakage mean value
applied in contamination session using a syringe. The was obtained when saliva contamination was made
composite resin used for restoration was applied in after light curing the adhesive resin.
two layers of 1.5 mm, each one being polymerized At the dentin margins increased values of micro-
using a LED lamp (LED B, Guilin Woodpecker Medical leakage were recorded in groups 2 and 3 when
Instrument Co., Ltd., Guilin, China) with a light comparing to control in both groups. In group I
intensity of 850-1000mW/cm2 and a wavelength of saliva contamination before and after light curing
420-480 nm. A constant light intensity of 1000mW/ the adhesive resin led to similar mean values of
cm2 was used during the experiment and the light microleakage. Increased values of microleakage were
intensity was tested before the beginning of the recorded in group II when comparing to group I in
test using Demetron® LED radiometer (Kerr Dental, the subgroups where contamination with saliva of
Bioggio, Switzerland). After restoration the teeth the adhesive resin was done before light curing.
were submersed in distilled water for 24 hours, then The Mann-Whitney statistical test was used to com-
the external surfaces of the buccal and lingual tooth pare the results in groups and subgroups. No statistic
faces were covered with water resistant varnish, significant results were obtained when comparing
except a 1 mm area around the restorations, then enamel microleakage in subgroups 1 and 2 from
they were submersed in methylene blue solution group I (p=0.145>0.05) and subgroups 2 and 3
2% (pH=7) for 24 hours. The teeth were sectioned with subgroup 1 from group II (p=0.075>0.05 and
in a buccal-lingual direction using diamond disks p=0.056>0.05, respectively). A significant statis-
at low speed, under water cooling (Komet Dental, tical result was obtained when comparing enamel
Brasseler GmbH & Co., Lemgo, Germany). The tooth microleakage subgroups 1 and 3 from group I
sections were evaluated using an optic microscope (p=0.029<0.05). At the dentin margins statistically
(Carl-Zeiss AXIO Imager A1m) at 10X magnification significant results were obtained when comparing
and the dye penetration at the enamel (occlusal) and subgroups 2 and 3 with subgroups 1 in groups I
dentin (cervical) margins of the cavity was assessed and II (p=0.030<0.05, p=0.030<0.05, p=0.004<0.05,
using a 4-score scale: 0 – no dye penetration; 1 – and p=0.005<0.05 respectively). Irrespective of the
232 Stoma Edu J. 2019;6(4): 230-236 www.stomaeduj.com
THE INFLUENCE OF SALIVA CONTAMINATION ON UNIVERSAL ADHESIVE BONDING
TO ENAMEL AND DENTIN
Table 3. Microleakage scores on enamel and dentin margins in group II.
Original Articles
Score 0 Score 1 Score 2 Score 3 Mean scores
value
Grup II- enamel
Subgroup 1 8 2 - - 0.2
Subgroup 2 4 6 - - 0.6
Subgroup 3 4 4 2 - 0.8
Grup II - dentin
Subgroup 1 10 0 - - 0
Subgroup 2 4 6 - - 0.6
Subgroup 3 4 4 2 - 0.8
moment of saliva contamination, the microleakage dentin and a possible closure of the spaces between
values at the dentin margins in etch and rinse the collagen fibers with reactive products [22].
strategy of adhesive application were not higher than The bond strength of the newer adhesive systems
those at enamel margins (subgroup 2 p=0.260>0.05, has been permanently improved, so the mild two-
subgroup 3 p=0.342>0.05, subgroup 4 p=0.728>0.05, step self-etching systems are a viable alternative to
and subgroup 5 p=1.00>0.05). In the self-etch stra- the three or two-step etch and rinse systems [23]. This
tegy of the adhesive application similar values of performance relies on their pH of 2, acidic monomers
microleakage were recorded at enamel and dentin being capable to create enough microretention in
margins. (in all subgroups p value was 1.00>0.05) enamel. Regarding dentin, the self-etch adhesive
systems have also demonstrated similar adhesion to
4. Discussion the total etch systems [24]. Unfortunately one-step
Composite resins are the most frequently used self-etch adhesive systems did not show the same
materials for direct restoration due to their good adhesion to enamel when comparing to total
mechanical and optical properties and to the cons- etch adhesive systems and additional step of selective
ervative preparation of the teeth needed [18]. A lot etching is needed to improve enamel bonding [25-
of factors can contribute to the marginal leakage 27]. One of the advantages of universal bonding
of composite resins into the oral cavity: the size systems is their possibility of application in etch and
and the shape of the cavity, the type of the dental rinse and self-etch strategies, but the major goal of
substrate, the type and the placement of the their released on the practice was the one-step self-
prepared cavity margins, and the technique of etch application. Functional monomers, like 10-MDP
restoration [19]. Marginal adaptation of the adhesive (10-methacryloyl oxide decyl hydrogenphosphate)
system to the tooth structure should prevent the molecule that chemically bond to hydroxyapatite
microleakage onset and future caries lesion adjacent simultaneously with the etching and adhesive resin
to the restoration, saliva infiltration, pulp irritation or penetration into the tooth structure are responsible
fracture of the restoration [20,21]. Progress was made for this particular behavior [25,27-29].
in time to improve the composite resins bonding to Studies have shown a similar bonding performance
enamel and dentin. Phosphoric acid was the first acid of universal adhesives when comparing to the self-
used for tooth etching, but the newer generations of etch adhesives and etch and rinse adhesives [16].
bonding agents contain acidic primers that etch and Previous studies that investigated the adhesion of
prime simultaneously. Simplifying the clinical steps a universal bonding system used in class V cavities
of bonding application led to the release of all-in-one restoration showed similar values of bond strength
adhesive systems that can etch, prime and bond in irrespective the strategy of application [27].
just one step. Unfortunately, one-step self-adhesive In the present study, the universal adhesive system
systems do not etch the enamel as efficiently as etch application led to similar microleakage at enamel
and rinse systems and as a consequence the marginal and dentin margins irrespective of the strategy of
seal might be incomplete. For multiple steps etch application. Some previous studies have shown
and rinse adhesive systems increased risk for dentin increased dentin microleakage when comparing
dehydration after drying might occur and also the to enamel for etch and rinse and self-etch adhesive
subsequent collapse of the collagen fibers. Also, systems [30,31]. Due to increased mineral content and
residual unremoved acid after an incorrect washing to a more homogenous structure, a better adhesion
might lead to prolonged demineralization of the and a lower marginal leakage to enamel are achieved
Stomatology Edu Journal 233
THE INFLUENCE OF SALIVA CONTAMINATION ON UNIVERSAL ADHESIVE BONDING
TO ENAMEL AND DENTIN
when comparing to dentin. Dentin has a significantly resin [27]. Also, water incorporation in incompletly
Original Articles lower mineral content and is mainly composed of polymerized resin might interfere with future co-
a dense network of type I collagen fibers and it has polimerization with the next resin layer. In a literature
dentin tubules. Branches of these tubules are denser review of the adverse effects of contamination
on root dentin than on crown dentin. Etching with in adhesive dentistry the authors reported that
phosphoric acid or with acidic primers changes the contamination had a deleterious effect on 73.3%
surface morphology and chemical composition. of the 30 evaluated one-step self-etch adhesive
Moreover, the tubules orientation can change the systems. The negative effects occurred either when
hybrid layer formation [32]. The results of some contamination was simulated before and after
other studies also showed that the enamel marginal adhesive polymerization; it always affected the
leakage when universal bonding systems were used enamel and in 66.6% of the cases it affected the
in the etch and rinse or self-etch strategy was similar, dentin [17]. Nair et al. reported different results than
which led to the conclusion that an additional step our study, but in their paper both 7th generation of
of selective enamel etching is not necessary [16]. adhesives and the universal adhesives were included
The same study showed similar bonding to dentin in the category of one-step self-etch adhesives, so we
for the universal bonding systems applied in both do not know for sure how many of the investigated
strategies. That might be explained by the particular adhesive systems were really universal adhesive
chemical composition of the bonding agent that was systems. The limitations of this study are represented
tested in the study (Scotchbond Universal Adhesive, by the low number of the samples, the microleakage
3M, St. Paul, MN, USA). 10-MDP molecule creates evaluation immediately after restoration, and the
stable chemical bond and VitreBond copolymer standardized time for contamination (which is rele-
ensures the long-term adhesion on wet or dry dentin vant only in fewer clinical situations). The present
[25,28]. Studies that investigated the adhesion of study simulated clinical conditions that are likely
a universal bonding system used in class V cavities to rarely appear. Probably that is the reason why
restoration showed similar values of bond strength the producers do not include in the indication for
irrespective of the strategy of application [27]. One use a procedure to improve the adhesion in critical
of the advantages of universal bonding systems condition of adhesive application.
is the possibility of application in both strategies,
but the major goal of their release on the practice 5. Conclusions
was the one-step self-etch application. Functional Given the conditions of this study, saliva
monomers, like MDP molecule, that chemically bond contamination after the adhesive system light cure
to hydroxyapatite simultaneously with the etching increased the enamel microleakage only when
and adhesive resin penetration into the tooth the adhesive system was applied in etch and rinse
structure are responsible of this particular behavior strategy, but increased the microleakage in dentin in
[25,27-29]. In class V restorations when the gingival etch and rinse and self-etch strategies. Contamination
margin is located apically as to the enamel-dentin with saliva before the adhesive system light cure did
junction the moisture control is difficult to achieve. not change the enamel microleakage irrespective of
Sulcular fluid and saliva (when a proper isolation the strategy of adhesive application, but increased
is not possible) can contaminate the surface. The the dentin microleakage in both strategies.
multiple step adhesive systems are more prone to
failure due to high risk of substrate contamination Author Contributions
when comparing to simplified adhesive systems. The SS: concept, experimental design, data gathering
adhesion of some self-etch bonding systems seems and analysis, manuscript writing, GI: concept, ana-
to be less efficient in dentin due to moisture that lysis and interpretation of the results, IN: protocol,
blocks the complete diffusion of the adhesive resin data collection, analysis and interpretation of the
in the collagen network. Water sorption also leads to results, PG: experimental design, data gathering and
phase separation between hydrophobic resins and analysis, SA: interpretation of the results, manuscript
hydrophilic primers in the chemical composition of proofreading.
the bonding agent. Saliva glycoproteins adsorbed
into the unpolymerized adhesive layer may act as a Acknowledgments
barrier that lowers the humectant character of the Not applicable. The study was self-funded.
234 Stoma Edu J. 2019;6(4): 230-236 www.stomaeduj.com
THE INFLUENCE OF SALIVA CONTAMINATION ON UNIVERSAL ADHESIVE BONDING
TO ENAMEL AND DENTIN
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Stomatology Edu Journal 235
THE INFLUENCE OF SALIVA CONTAMINATION ON UNIVERSAL ADHESIVE BONDING
TO ENAMEL AND DENTIN
Original Articles Simona STOLERIU
DMD, PhD, Associate Professor
Odontology-Periodontology and Fixed Prosthesis Department
Faculty of Dental Medicine
„Grigore T. Popa” University of Medicine and Pharmacy Iaşi
Iaşi, Romania
CV
Simona Stoleriu graduated from the Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine
and Pharmacy Iaşi, Iaşi, Romania in 1997. Since 1999 to present she has been assistant professor, lecturer and
now associated professor teaching Cariology, at the Department of Odontology, Periodontology and Fixed
Prosthodontics, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and Pharmacy Iaşi, Iaşi
Romania. As of 1998 she has been a dentist with a private practice. Major research interests: 1. restorative materials
behavior in oral environment; 2. clinical and in vitro studies regarding the etiology, and the preventive and
restorative treatment of tooth wear lesions; 3. dental hard tissues remineralization of carious lesions and erosive
wear.
Questions
1. The mechanisms implicated in bonding to the tooth structure include three
mechanisms, with ONE EXCEPTION:
qa. Mechanical adhesion;
qb. Adhesion by sorption;
qc. Electrostatic bonding;
qd. Adhesion by diffusion.
2. A review of the literature regarding the influence of saliva contamination on adhesive
dentistry has shown that:
qa. 17% of three-step adhesive systems adversely influence their bond quality;
qb. 26% of two-step adhesive systems adversely influence their bond quality;
qc. 81.5% of two-step self-etch adhesives adversely influence their bond quality;
qd. 3.3% of one-step self-etch adhesives adversely influence their bond quality.
3. The results of the present study demonstrated that:
qa. Saliva contamination after adhesive system lightcure increased enamel microleakage only when the
adhesive system was applied in etch and rinse strategy;
qb. Saliva contamination after adhesive system lightcure increased enamel microleakage only when the
ICOI
adhesive system was applied in self-etch strategy;
qc. Saliva contamination after adhesive system lightcure increased enamel microleakage only when the
adhesive system was applied in selective etch strategy;
qd. Saliva contamination after adhesive system lightcure increased enamel microleakage both etch and
rinse and self-etch strategies.
4. Irrespective of the strategy of universal bonding application saliva contamination
significantly increased the microleakage in:
qa. Enamel;
qb. Dentin;
COLOMBO
qc. Enamel and dentin;
qd. None of the answers are correct.SRI LANKA
January 23-25, 2020
ICOI COLOMBO
ICOI ASEAN CONGRESS
GALADARI HOTEL COLOMBO
64 LOTUS RD, COLOMBO 00100, SRI LANKA
www.icoi.org
SRI LANKA DIGITAL IMPLANT DENTISTRY -
January 23-25, 2020 REDEFINING TREATMENT CONCEPTS
ICOI ASEAN CONGRESS
GALADARI HOTEL COLOMBO
236 64 LOTUS RD, COLOMBO 00100, SRI LANKA
Stoma Edu J. 2019;6(4): 230-236 www.stomaeduj.com
DIGITAL IMPLANT DENTISTRY -