Adhesive Dentistry and Endodontics

7/31/2019 Adhesive Dentistry and Endodontics

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Adhesive Dentistry and Endodontics: Materials, Clinical Strategies and Procedures for

Restoration of Access Cavities: A Review

Schwartz and Fransman, 2005 - Adhesive Dentistry and Endodontics: Materials, Clinical Strategies and Procedures forRestoration of Access Cavities: A Review

Contamination of the Root Canal System

One of the primary goals of root canal treatment is to eliminate bacteria from the root canal system to the greatest possible extent (2and3). Siqueira, 2000 - Bacterial leakage in coronally unsealed root canals obturated with 3 different techniques and

Siqueira, 2001 - Aetiology of root canal treatment failure and why well-treated teeth can fail

Bacteria have been shown to be the etiology for apical periodontitis (4) Kakehashi, 1965 - The effects of surgical exposures of dentalpulps in germ-free and conventional laboratory rats

and to be the cause of endodontic failure (2,3and5). Siqueira, 2000 - Bacterial leakage in coronally unsealed root canals obturated with 3different techniques and

Siqueira, 2001 - Aetiology of root canal treatment failure and why well-treated teeth can fail and

Lin, 1992 - Factors associated with endodontic treatment failures

One of the goals in restoring of the tooth after root canal treatment should be to prevent recontamination of the root canal system.Gross contamination can occur during the restorative process from poor isolation or poor aseptic technique. Contamination canalso occur from loss of a temporary restoration or if leakage occurs. The same things can occur with a permanent restoration,but permanent materials tend to leak less than temporary materials (6).

Exposure of gutta-percha to saliva in the pulp chamber results in migration of bacteria to the apex in a matter of days (2,7,8and9).

Siqueira, 2000 - Bacterial leakage in coronally unsealed root canals obturated with 3 different techniques

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Swanson, Madison,1997 - An evaluation of coronal microleakage in endodontically treated teeth. Part 1. Time periods,

Magura, Newton, 1991 - Human saliva coronal microleakage in obturated root canals: an in vitro study,

Saunders & Saunders, 1994 - Coronal leakage as a cause of failure in root canal therapy: a review

Endotoxin reaches the apex even faster (10).Alves, 1998 - Coronal leakage: endotoxin penetration from mixed bacterial communitiesthrough obturated, post-prepared root canals,

The importance of the coronal restoration in successful endodontic outcomes is widely accepted and has been supported by studies

by Ray and Trope (11), Ray &Trope, 1995 - Periapical status of endodontically treated teeth in relation to the technical quality of the root

filling and the coronal restoration

Hommez et al. (12), Hommez, 2002, Periapical health related to the quality of coronal restorations and root Fillings

Tronstad et al. (13), Tronstad, 2000 - Influence of coronal restorations on the periapical health of endodontically treated teeth,

Iqbal et al. (14), Igbal, 2003 - A retrospective analysis of factors associated with the periapical status of restored, endodontically treatedteeth

and Siqueira et al. (2). Siqueira, 2000 - Bacterial leakage in coronally unsealed root canals obturated with 3 different techniques

However, studies by Riccuci et al. (15), Ricucci, Bergenholtz, 2000 - Periapical status of root-filled teeth exposed to the oralenvironment by loss of restoration or caries,

Ricucci and Bergenholz (16), Ricucci & Bergenholtz, 2003 - Bacterial status in root-filled teeth exposed to the oral environment by loss ofrestoration and fracture or caries: a histobacteriological study of treated cases

Heling et al. (17), Heling, 2002 - Endodontic failure caused by inadequate restorative procedures: review and treatmentrecommendations

and Malone et al. (18) Malone, 1997 - An in vitro evaluation of coronal microleakage in obturated root canals without coronalrestorations,

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indicate that contamination may not as important a factor in failure as is commonly believed.

Therefore, it must be concluded that the significance of bacterial contamination as a cause of endodontic failure is not fully understood.Because there is clearly no benefit to introducing bacterial contamination into the root canal system, and since it may be acontributing factor in endodontic failure, a basic premise of this review will be that every effort should be made to prevent contamination.

Temporization

To minimize the likelihood of contamination, immediate restoration is recommended upon completion of root canal treatment (19,20and21).

When immediate restoration is not possible, and the tooth must be temporized, a thick layer of temporary material should be used,preferably filling the whole chamber. The majority of restorative dentists prefer a cotton pellet in the chamber, however (22)

If a cotton pellet or sponge is to be use, orifice barriers are recommended, to provide a second layer of protection againstcontamination in addition to the temporary material at the occlusal surface.

Recommended procedure for placing orifice barriers:

1. Countersink the orifice with a round bur.

2. Clean the orifices and floor of the pulp chamber thoroughly with alcohol or a detergent to remove excess cement and debris. Airabrasion provides a dentin surface that is free of films and debris.

3. Place a temporary or permanent restorative material in the orifices and over the floor of the chamber.

A bonded material such as composite resin or glass ionomer cement is preferred

:Results varied in studies that evaluated temporary materials for the access cavities (21,30,31,32, 33,34,35and36).

The most common materials tested were zinc oxide eugenol (such as IRM, Dentsply Int.), zinc oxide/calcium sulfate (Cavit, PremierCorp.) or resin based materials including composite resin and resin modified glass ionomer materials.

Generally, all of the temporary materials were adequate if placed in a thickness of 3 mm or greater (21,33, 34,35and36).

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Resin modified glass ionomer materials are also a good choice for long term temporization, because they provide a bond to dentin andenamel, and many have antimicrobial properties (44).

Restoring Access Openings

If the existing restoration is a crown or onlay that appears to be clinically satisfactory and replacement is not planned, the chamber andinternal restorative materials should be examined carefully with magnification. Caries detector should be painted on the internal toothsurfaces. Any areas stained by the caries detector, particularly adjacent to restorations, should be examined carefully for softness orgaps. Caries detector may also stain sound areas of dentin that have decreased mineral content (49). The key to the presence of cariesis determined by whether the stained areas are hard or soft. Many times caries can be identified internally, necessitating replacement ofthe crown.

Bonding to Enamel

Enamel is often present along the margins of access preparations of anterior teeth. The resin bond to etched enamel is strong anddurable. The technique dates back to 1955 (58).

Etching of enamel with an acid such as 30 to 40% phosphoric acid results in selective dissolution of the enamel prisms and creates asurface with a high surface energy that allows effective wetting by a low viscosity resin. Microporosities are created within and aroundthe enamel prisms that can be infiltrated with resin and polymerized in-situ (59).

These resin tags provide micro-mechanical retention. Bond strengths are typically in the range of 20 megapascals (Mpa) (60).

Megapascals are a measure of the force per unit area that is required to break the bond. Self-etching adhesive systems, which will bediscussed in the section on bonding to dentin, etch ground enamel fairly well, but do not etch unground, aprismatic enamel effectively(61,62 and63).

Therefore, enamel margins should be beveled when using self-etching adhesive systems. It is critical to prevent contamination ofetched enamel with blood, saliva or moisture (64).

Poorly etched enamel leads to staining at the margins of the restoration (65).

4
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A good enamel bond protects the underlying dentin bond which is less durable (66).

Bonding to Metal-Ceramic and All-Ceramic Restorations

Access cavities are often made through metal-ceramic or all-ceramic materials, so attaining an effective, durable bond is importantwhen restoring them. The literature is unambiguous that the best method to bond to porcelain is to first roughen the surface by acidetching and then apply a silane coupling agent, followed by the resin (67,68,69and 70).

Bond strengths of 13 to 17 Mpa have been reported, and failure is often cohesive within the porcelain, meaning that the interfacial bondstrength exceeds the strength of the porcelain itself (71,72and73).Bonding to porcelain was initially developed as a method for repair of fractured metal-ceramic crowns. Improvements in the technique

allowed porcelain veneers to become a common clinical procedure. Etched ceramic materials form a strong, durable bond with resin(74).

Micro mechanical bonding can be attained by roughening the porcelain with a bur, air-abrasion or etching with hydrofluoric acid.However, acid etching is the most effective method (73,75and76).

The first to introduce acid etching of porcelain was Calamia in 1983 (77).

Adhesion between the resin and porcelain may be enhanced by the use of a silane-coupling agent. Silane acts as a surfactant tolower surface tension and forms double bonds with OH groups in the porcelain, forming a siloxane bond. At the other end of the silane

molecule is a methacrylate group that copolymerizes with resin. The use of a silane-coupling agent with porcelain was first described byRochette in 1975 (78).

Cosmetics

Several products are available that may be used to mask the underlying metal before the restorative composite is placed. Most of theseare composite resins that contain opaquers. They may be covered with more translucent composite materials. Several composites areavailable that are quite opaque and work well when restoring access cavities in metal-ceramic crowns. Composite stains can be used toaccentuate pits and fissures to further enhance the cosmetic result

5
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Endodontic Issues in Dentin Bonding

Some of the materials used in endodontics may have a significant impact on the bonding process. These issues apply not only torestoration of access cavities, but also to the obturating materials that utilize adhesive resin technology, which will be discussed in asubsequent article.

EugenolIn endodontics, eugenol containing materials are widely used in sealers and temporary filling materials. Eugenol is one of manysubstances that can prevent or stop the polymerization reaction of resins (138) and can interfere with bonding (139).

If resin bonding is planned for a dentin surface that is contaminated with eugenol, additional clinical steps are needed to minimize the

effects of the eugenol. The surface should be cleaned with alcohol or a detergent to remove visible signs of sealer. Many temporarycements, whether they contain eugenol or not, leave behind an oily layer of debris that must be removed before bonding procedures (140and141).Air abrasion is an effective method for cleaning the dentin surface .

Once it is clean, the dentin should be etched with an acid, such as phosphoric acid and then rinsed. The acid demineralizes the dentinsurface to a depth of about 5 m and removes the eugenol rich layer. Several studies have shown that the total etch (three step)procedure allows effective bonding to eugenol contaminated dentin surfaces (24and142).

An etch and rinse adhesive system should be used, because the self etching systems incorporate the eugenol rich smear layer into

the hybrid layer, rather than removing it.

Eugenol has no effect on glass ionomer cements (143).

Sodium HypochloriteSodium hypochlorite is commonly used as an endodontic irrigant because of its antimicrobial and tissue dissolving properties (144).

Sodium hypochlorite causes alterations in cellular metabolism and phospholipid destruction. It has oxidative actions that causedeactivation of bacterial enzymes and causes lipid and fatty acid degradation (144).

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