|Year : 2023 | Volume
| Issue : 1 | Page : 88-93
|Influence of varying dry air temperatures on postoperative sensitivity, penetration depth, and push-out bond strength of an ethanol/water-based adhesive: An in vivo double-blind clinical trial and in vitro analysis
Sachin Kumar1, Palmoor Santosh Kumar2, Sampath Vidhya2, Sekar Mahalaxmi2, Pranav Vanajassun Purushothaman3
1 Private Practitioner, Patna, Bihar, India
2 Department of Conservative Dentistry and Endodontics, SRM Dental College, SRM Institute of Science and Technology, Bharathi Salai, Ramapuram, Chennai - 600 089, Tamil Nadu, India
3 Specialist Endodontist, Bahrain Specialist Hospital, Juffair, Kingdom of Bahrain
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|Date of Submission||11-Aug-2022|
|Date of Decision||05-Sep-2022|
|Date of Acceptance||29-Sep-2022|
|Date of Web Publication||08-Dec-2022|
| Abstract|| |
Background: Incomplete monomer infiltration into the etched dentin causes postoperative sensitivity (POS) with total-etch adhesives. Increasing the temperature of the air to dry the adhesive has shown to improve its infiltration into the dentin.
Aims: The aim of this research is to evaluate the effectiveness of dry air temperatures of 15°C ± 5°C and 50°C ± 5°C on the POS, depth of penetration, and bond strength of an ethanol/water-based etch-and-rinse (ER) adhesive under in vivo and in vitro conditions.
Methods: Forty-four premolars from 11 patients scheduled for orthodontic extraction were allocated into cold air (Group 1) and warm air (Group 2) groups using a split-mouth design. A 2 mm × 2 mm × 2 mm cavity was prepared on the middle third of the buccal surface of the teeth, acid etched, and two coats of an ethanol/water-based adhesive resin mixed with 0.1% rhodamine B was applied for 10 s. A dental air gun customized to deliver warm and cold air was used to dry the adhesive prior to its light polymerization. The cavities were restored with resin composite incrementally. POS was assessed using visual analog scale at 24 and 72 h using cold test. The teeth were atraumatically extracted and analyzed for depth of adhesive penetration using confocal laser scanning microscope (n = 11) and push-out bond strength (n = 11).
Statistical Analysis Used: The data were analyzed using sample t-test and Wilcoxon signed-rank test (P < 0.05).
Results: A significantly lower POS and greater adhesive penetration into the dentin was observed in the warm air group compared to cold air (P < 0.05). No significant difference could be elicited between the push-out bond strength of both the groups (P > 0.05).
Conclusions: Warm air alleviated POS and improved the penetration of an ethanol/water-based ER adhesive into the dentin.
Keywords: Bond strength; cold air; composite resin; dentin bonding agent; postoperative sensitivity; visual analog scale; warm air
|How to cite this article:|
Kumar S, Kumar PS, Vidhya S, Mahalaxmi S, Purushothaman PV. Influence of varying dry air temperatures on postoperative sensitivity, penetration depth, and push-out bond strength of an ethanol/water-based adhesive: An in vivo double-blind clinical trial and in vitro analysis. J Conserv Dent 2023;26:88-93
|How to cite this URL:|
Kumar S, Kumar PS, Vidhya S, Mahalaxmi S, Purushothaman PV. Influence of varying dry air temperatures on postoperative sensitivity, penetration depth, and push-out bond strength of an ethanol/water-based adhesive: An in vivo double-blind clinical trial and in vitro analysis. J Conserv Dent [serial online] 2023 [cited 2023 Dec 8];26:88-93. Available from: https://www.jcd.org.in/text.asp?2023/26/1/88/362923
| Introduction|| |
The quality of the adhesive interface determines the longevity and performance of resin composites. Various strategies have been tested over the years to minimize degradation of this interface. Ensuring a complete coverage of the denuded collagen fibrils by the resin monomer is a fundamental requirement to achieve a stable hybrid layer (HL) with structural and functional integrity. Self-etch (SE) adhesives were introduced to overcome the disadvantages of the critical drying step associated with etch-and-rinse (ER) adhesives. Owing to their limited conditioning ability, SE adhesives form shorter resin tags and thinner HL compared to the ER adhesives. It is proven that bond durability is dependent on the quality of the HL and not on its thickness. Even though the length of the resin tags is not critical for the mechanical strength of the HL, the wider anastomoses and lateral branches that might form between them greatly strengthens the adhesive interface. Such an anastomoses can only be brought about by an acid etchant used in conjunction with ER adhesives.
Acid etching exposes adequate collagen meshwork for subsequent bonding. But achieving monomer infiltration to the fullest extent of demineralization under clinical conditions is challenging. It has been proven that bond integrity deteriorates in the presence of residual solvents and unpolymerized monomer in the adhesive after polymerization. These may generate porosities within the bonded interface causing inward diffusion of oral fluids leading to increase in water sorption, thereby resulting in lower mechanical properties and hydrolysis of resin and collagen fibrils., Researchers worldwide have advocated several procedural changes to accomplish monomer infiltration to the fullest extent by using multiple adhesive layer coatings and increasing the interaction time between dentin and adhesive resin allowing longer polymerization time. Increasing the temperature of the bonding resin and the water used for rinsing the resin has also been shown to improve bond strength., Reduced adhesive viscosity, improved wettability, enhanced solvent evaporation and limited residual solvent are the advantages obtained by increasing adhesive temperature.,, In addition, using warm air up to a temperature of 60°C has been shown to increase the rate of polymerization of adhesive resins. The most adopted method to achieve solvent evaporation is the use of dental air syringe. However, this leads to an increase in the concentration of nonvolatile monomers which in turn decreases the vapor pressure of the remaining solvents, making it impossible to evaporate the solvent completely under clinical conditions. Yiu et al. stated that ethanol and acetone-based adhesives retain 5%–10% of the solvent, even after air blowing for 120 s, which is 10 times longer than manufacturer's recommendations. Klein-Júnior et al. suggested a more focused approach towards solvent evaporation by increasing the temperature of the air used for drying. Reis et al. hypothesized that the use of warm air to evaporate solvent before polymerization of the resin produces an adhesive interface that is less prone to water degradation and leads to the formation of a highly cross-linked polymer with reduced water sorption and solubility. A thorough literature search revealed that no study has evaluated the effect of elevated dry air temperature on postoperative sensitivity (POS) following the use of ER adhesives under in vivo conditions. Controversial reports are found regarding the effect of warm air on the bond strength and depth of penetration of ER adhesives into dentin.,, Hence, the aim of this study is to evaluate POS, bond strength, and depth of penetration of an ethanol/water-based ER adhesive by using dry air temperatures of 15°C ± 5°C and 50°C ± 5°C on adhesive applied dentin adopting a split-mouth design under in vivo and in vitro conditions. The null hypothesis was that the temperature of air used to dry the adhesive will not have any influence on the above-mentioned parameters. Most of the published reports have used hair dryer as a heat source to generate warm air under in vitro conditions. As this technique is not feasible for clinical chairside use, a customized dental air gun was designed and used in this study.
| Methods|| |
Fabrication of customized dental air gun
A customized dental air gun was devised according to previously reported specifications for obtaining optimum moisture-free warm and cold air at a constant speed of 5 m/s. It comprised of an air compressor to generate condensed air into pressure control unit and a vortex device to generate the required air pressure and temperature. A 20 μ desiccant type moisture condenser with pressure control gauze was installed to generate dry air and to maintain the velocity of airflow. Ranque-Hilsch vortex tube, a mechanical device that works on the concept of thermo-fluid dynamics was used to separate compressed air into hot and cold streams at two different ends of the tube. The warm and cold air emerging from the vortex tube can reach up to 200°C (392°F) and −50°C (−58°F) respectively. A digital thermometer was incorporated into the setup to measure the temperature of dry air released from the vortex tube. A three-way syringe was incorporated to the custom-made device to deliver the dry air to the tooth with appropriate temperature.
The research protocol was duly submitted to the university's Institutional Review Board and Ethical Committee Approval was Obtained (No. 308). The experimental protocol was in accordance with the CONSORT guidelines. This double-blind clinical trial was registered in the (Clinical Trial Registry of India/2018/05/014076). A split-mouth design was followed in this study to eliminate bias among the groups. Patients aged 16–25 years with completely erupted first and second premolar teeth with fully formed roots, intended for all four premolars extraction under orthodontic treatment plan were recruited from the outpatient wing of department of orthodontics. The nature of the study was explained to all the participants and a written informed consent was obtained. Patients with poor oral hygiene, those with premolars which were impacted or partially erupted, or having incompletely formed root apices and those with orthodontic extraction scheduled for one arch only were excluded from the study.
Sample size calculation was based on power analysis. With a power of the study at 90% and an alpha error of 0.05, a total of 44 teeth were required for the study. Forty-four teeth from 11 patients were divided into 2 groups based on the temperature of air used for drying the adhesives. Following split-mouth design, premolars of 1st and 4th quadrants were assigned to cold air (Group 1, n = 22) and those of the 2nd and 3rd quadrants were assigned to warm air (Group 2, n = 22).
Cavity preparation and restoration
One operator (SK) recruited the patients and carried out the restorative procedure. Patients were asked to rinse their mouth with 0.2% chlorhexidine mouthwash (Hexidine, ICPA Health Products, Ankleshwar, India) followed by disinfection of the tooth using 5% betadine solution (Prolidon, Ajanta Pharma Ltd., Mumbai, India) prior to local anesthesia and rubber dam (GDC Fine Craft Dental Pvt. Ltd, Hoshiarpur, India) application. A standardized 2 mm × 2 mm × 2 mm box-shaped cavity was prepared in the middle third of the buccal surface of the tooth using a No. 245 bur (Mani Inc, Tochigi, Japan) in high-speed airotor handpiece. The prepared cavities were etched with 37% phosphoric acid (Eazetch, Anabond Stedman, Chennai, India) for 15 s followed by rinsing and blot drying. Two coats of bonding agent (Tetric-N-Bond, Ivoclar Vivadent, AG Schaan, Liechtenstein) mixed with 0.1% rhodamine B (Chenchems, Chennai, India) were applied with slight agitation for 10 s using a disposable brush. The bonding agent was air dried for 10 s using the customized dental air gun held at a distance of 10 cm from the target surface at temperatures based on the grouping and then light cured Bluephase N (Ivoclar Vivadent, AG Schaan, Liechtenstein) for 20 s. Later, the cavities were restored with light cure resin composite (Te-Econom Plus, Ivoclar Vivadent, AG Schaan, Liechtenstein) incrementally and cured for 40 s. All composite restorations were finished with abrasives (Super-Snap polishing system, Shofu INC. Kyoto, Japan) and polished using pumice paste and the occlusion was checked before the patient was relieved.
Postoperative sensitivity assessment
One examiner (PV) who was blinded to the patient recruitment and restorative procedure carried out the assessment of POS. All treated patients were evaluated for POS at 24 and 72 h, by applying cold (Endo-Frost, Coltene, Germany) and running an explorer tip on the superficial surface of the composite restoration to elucidate sensitivity. The patients were asked to note their sensitivity response on visual analog scale (VAS) with a rating from 0 to 10.
In vitro analysis
After the completion of in vivo analysis at 72 h, the teeth were atraumatically extracted. Twenty two teeth under each group were randomly distributed for evaluation of depth of adhesive penetration into dentin (n = 11) and push-out bond strength (n = 11).
Evaluation of depth of adhesive penetration
The teeth were sectioned at the level of the cementoenamel junction and the roots were discarded. A 1-mm thick transverse section was obtained along the dentin-resin composite region using a slow-speed water-cooled 0.3 mm microtome saw. The prepared specimens were mounted onto glass slides and examined with a confocal laser scanning microscope (CLSM) (LSM 700, Carl Zeiss, Germany) at ×10 to measure the depth of penetration of the dentin bonding agent into the dentin. The images were acquired and analyzed by an in-built image examiner software.
Evaluation of push-out bond strength
The teeth were sectioned at the level of the cementoenamel junction and the roots were discarded. Two millimetre mm thick longitudinal section comprising of residual dentin with the resin composite were obtained using a slow speed water-cooled 0.3 mm microtome saw. The prepared specimens were mounted on a custom-made jig that facilitated placement in a universal testing machine (Instron, Canton, USA). Push-out bond strength testing was carried out using a cylindrical plunger at a cross head speed of 1 mm/min until bond failure occurred.
Sample t-test was used to analyze the data of POS, depth of adhesive penetration into dentin, and push-out bond strength. Wilcoxon signed-rank test was used for comparing the POS values at 24 and 72 h using IBM Statistical Package for Social Sciences (SPSS) for Windows V17.0 (IBM Corporation, Armonk, New York) for Microsoft windows with a significance set at P < 0.05.
| Results|| |
Eleven patients (5 male and 6 female) received the intended treatments, and all 44 teeth were assessed for outcome. Both the cold (Group 1) and warm (Group 2) air groups recorded a significantly higher POS at 24 h compared to evaluation at 72 h (P < 0.05). Warm air group showed a mean VAS score of 0.18 at 24 h which is significantly lesser compared to the VAS score recorded in cold air group (1.64) (P < 0.05). At 72 h follow-up, patients treated under warm air group had no POS, while patients treated with cold air showed a VAS score of 0.23 (P < 0.05). The graphical representation comparing the percentage of POS recorded in both the groups at both the time intervals is shown in [Figure 1].
|Figure 1: Graphical representation comparing the percentage of postoperative sensitivity in Group 1 (cold air) and Group 2 (warm air) at 24 and 72 h|
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CLSM images showing penetration of the adhesive into the dentin is given in [Figure 2]a and [Figure 2]b. Warm air group showed a uniform HL and a significantly greater depth of adhesive penetration into the dentin (354.77 μm) compared to that of cold air (148.52 μm) (P < 0.05) [Figure 2]c. There is no significant difference in the push-out bond strength values of both cold air (53.14 N) and warm air (53.97 N) groups [P > 0.05, [Table 1]].
|Figure 2: CLSM images showing adhesive penetration into the dentin in cold (a) and warm air (b) groups graphical representation (c) comparing the depth of adhesive penetration into the dentin in Group 1 (cold air) and Group 2 (warm air). CLSM: Confocal laser scanning microscope|
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|Table 1: Mean push-out bond strength values (N) of cold and warm air groups|
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| Discussion|| |
The split-mouth design used in this study removes inter-subject variabilities, as the patient serves as his/her own control providing an increased statistical efficiency. Buccal surface was chosen for cavity preparation rather than the occlusal surface in order to maintain a uniform minimum remaining dentin thickness of 1 mm without interferences from variations arising due to cuspal eminences.
Unlike enamel, the structural and compositional heterogeneity associated with dentin, renders the resin-dentin interface enigmatic. Complete displacement of water from the demineralized dentin and replacement with the solvated monomers from the adhesive resin is a primary requirement for a durable resin-dentin bond as resin-entombed collagen is less prone for proteolytic degradation. The solvents present in the adhesives act as a transport medium by displacing water from the moist collagen network and allowing infiltration of monomers into the nanospaces. However, resin polymerization before optimal solvent evaporation could leave behind residual solvent and water resulting in areas of incomplete monomer polymerization and reduced degree of monomer conversion. This results in porosities within the resin-dentin interface, making it vulnerable to inward diffusion of oral fluids. Hydrolytic degradation of resins weakens the resin-dentin interface. The presence of hydrophilic monomers and outward movement of the dentinal fluid potentiate this process. It is further accelerated by the presence of residual monomer which can have an additional plasticizing effect on the polymer.
Dentin bonding agents consist of solvents such as acetone, ethanol and water. Unlike acetone-based adhesives in which the solvent can volatilize too quickly after being dispensed and water-based adhesives that are more prone for phase separation, ethanol-based adhesives evaporate less quickly and are less sensitive to dentin wetness., On the other hand, it has low volatile rate that may lead to improper polymerization and hydrogel formation. These hydrogels can imbibe water leading to hydrolytic degradation.
A simple approach to improve bonding efficacy and stability of HL is by enhancing substantial interfacial water and solvent evaporation to avoid phase separation within the adhesives. Giannini et al. advocated the use of compressed air to accelerate the evaporation of solvent. But prolonged air drying of the adhesive could increase the monomer density resulting in a monomer concentration gradient that would retard further evaporation of the solvent. Thus the benefits of solvent evaporation obtained by extending the drying time is negated. An alternate technique supported by previous reports was to increase the temperature of air used to dry the solvent.,
Studies have reported that warm air ranging from 40°C to 60°C could alter the amount of residual solvent concentration. Hence, to enable effective solvent removal, a dental air gun that could deliver warm moisture-free air with a temperature of 50°C ± 5°C was devised and used. Silva et al. has investigated the effect of warm air on the pulp chamber temperature under in vitro conditions. The authors have concluded that a 10 s application of warm air stream at a distance of 10 cm from the substrate surface resulted in the lowest temperature increase in the pulp chamber. Hence these parameters were adopted in the present study.
POS is one among the many reasons cited for the failure of nearly 15%–50% of the resin composite restorations. Discrepancy between the depth of demineralization brought on by acid etching and resin permeation leads to hydrolytic degradation in the base of the HL. Accelerated hydrolysis of the polymer makes it to behave as a semi-permeable membrane and allows water movement through the bonded interface even after adhesive polymerization. This gap formation between the adhesive and the dentin can lead to microleakage and POS clinically.
In the present study, a significantly reduced POS in the warm air group can be attributed to an accelerated solvent evaporation, apparently resulting in better resin penetration. Warm air improves the wettability of the dentin resulting in a good quality resin-dentin interface with less residual solvents. The observations made in previous studies that the use of warm air to dry an ethanol/water-based adhesive diminished nanoleakage compared to the use of cold air corroborates to the findings of this study., However, factors such as trauma inflicted during cavity preparation, the number of surfaces involved in a restoration and the methods used to assess sensitivity can influence the outcome of clinical studies assessing POS.
The POS results of the current study also corroborate with the in vitro depth of penetration of the adhesive resin. Warm air is found to propel the monomer deeper into the dentinal tubules to a depth of 354.77 μm. It is hypothesized that heat increases the surface free energy of dentin, resulting in a lesser resin-dentin contact angle and better wettability. Increased temperature also decreases the viscosity and increases the spreading velocity of the adhesive resin. These phenomena result in an improved resin diffusion and infiltration into the demineralized collagen network, resulting in its increased depth of penetration.
In the present study, both the drying protocols produced a bond strength value which is more than the optimal bond strength that is required for satisfactory clinical performance of a resin composite restoration. But no significant increase in bond strength can be appreciated with the use of warm air over cold air similar to a study by Carvalho et al. However, these results are contradictory to the findings of Malekipour et al. who observed that rinsing the dentin surface with distilled water warmed up to 50°C prior to the application of ER adhesive significantly increased the bond strength compared to the use of distilled water at 5°C. The authors have hypothesized that heat could have changed the physical properties of the bonding agent and the etched dentin surface, thereby resulting in diminished degradation changes at the resin-dentin interface. When heat is delivered to a substance, the kinetic energy and vapor pressure of the molecule are increased thereby causing changes in the state of adhesives leading to better penetration. Though the difference in immediate push-out bond strength between the groups in the current study is insignificant, long-term bond strength analysis is required to evaluate the effect of warm air on the durability and integrity of resin-dentin bonds. Future study designs should also include SE adhesives and the newer universal adhesive systems.
| Conclusions|| |
Within the limitations of the present study, it can be concluded that drying an ethanol/water-based ER adhesive using warm air shows minimal POS and enables a deeper adhesive penetration into the dentin compared to cold air. The different temperatures have no influence on the push-out bond strength of the adhesive to dentin.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Sampath Vidhya
Department of Conservative Dentistry and Endodontics, SRM Dental College, SRM Institute of Science and Technology, Bharathi Salai, Ramapuram, Chennai - 600 089, Tamil Nadu
Source of Support: None, Conflict of Interest: None
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