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. 2016 Dec 30;25(4):259–266. doi: 10.5978/islsm.16-OR-20

Microleakage in Class V Composite Restorations after Desensitizing Surface Treatment with Er:YAG and CO2 Lasers

Hamid Reza Mozaffari 1, Alireza Ehteshami 2, Farshad Zallaghi 2, Nasim Chiniforush 3, Zohreh Moradi 4,✉
PMCID: PMC5532164  PMID: 28765670

Abstract

Aims: Glutaraldehyde, CO2 and Er:YAG lasers can be used for treatment of dentin hypersensitivity. However, their application may have adverse effects on the clinical service of restorations. This study aimed to assess the microleakage in composite restorations following surface treatment with Glutaraldehyde desensitizer, CO2 and Er:YAG laser irradiation for treatment of dentin hypersensitivity.

Materials and methods: This experimental study was conducted on 60 extracted sound human teeth. Class V cavities were prepared measuring 3×3 mm using a diamond bur. Specimens were randomly divided into 4 groups of 15. Group one:no surface treatment, Group two:applying Glutaraldehyde desensitizer, Groups of three and four were irradiated with CO2 and Er:YAG lasers, respectively. Surfaces were restored with bonding agent (Single Bond 2, 3M, USA) and Z250 composite (3M, USA). Specimens were thermocycled and immersed in 1% methylene blue solution for 24 hours. Microleakage scores were assessed under a stereomicroscope at ×20 magnification. Data were analyzed using SPSS and the Kruskal Wallis test (P=0.05).

Results: There was no significant difference between microleakage of groups in enamel margins (P=0.694). The difference in microleakage at the dentin margin was significant between groups (P=0.018).

Conclusions: Application of Glutaraldehyde-desensitizer and CO2 laser irradiation of surfaces prior to composite restoration do not increase microleakage at the enamel or dentin margins but tooth surface treatment with Er:YAG laser significantly increased the microleakage at the dentin margins.

Keywords: Dentin hypersensitivity, CO2 laser, Er:YAG laser, Glutaraldehyde desensitizer, Microleakage

Introduction

Dentin hypersensitivity is the most common patient complaints and is defined as pain and discomfort in response to cold, hot, chemical and osmotic stimuli due to exposed cervical dentin 1, 2). The prevalence of dentin hypersensitivity ranges from 3.8 to 57% 3, 4). To relieve mild dentin hypersensitivity, toothpastes containing strontium salts chloride or acetate) or potassium salts (chloride and nitrate) are often recommended 5). In case of severe dentin hypersensitivity affecting the quality of life, application of glass ionomers or photopolymerized sealants may be required to obstruct the dentinal tubules. In very severe cases of dentin hypersensitivity, more invasive procedures such as crown placement or root canal therapy may be indicated 6). The efficacy of some desensitizing agents containing glutaraldehyde has been confirmed in vitro and in vivo. Glutaraldehyde reacts with serum albumin in dentinal tubules and stimulates the polymerization of HEMA (2-hydroxyethyl-methacrylate) 7).

Microleakage has also been reported to cause dentin hypersensitivity. Microleakage is defined as passage of bacteria and their products through the restoration- tooth interface and is one of the main reasons for replacement of restorations. Microleakage results in formation of marginal gaps and leads to development of secondary caries, post-operative tooth hypersensitivity or pulp involvement. Thus, it is extremely important for dental restorative materials to efficiently seal the margins 8). Considering the advances in dental materials and introduction of new materials with more favorable characteristics as well as high patient expectations, researchers investigate for ideal dental materials to achieve high patient satisfaction 9). Despite some reports of success in relieving dentin hypersensitivity, the success of most treatments is short-term, lasting for less than 6 months 10). Moreover, some desensitizing materials have a delayed effect and cause a late response in patients 11). Introduction of laser technology contributes to some fields of dentistry 2, 12, 13). In 1980, laser was used as an anti-inflammatory tool and stimulating neurons in clinical setting 14). Several studies have evaluated the application of different types of lasers to relieve dentin hypersensitivity. Lasers used for desensitization are divided into two main groups of low energy lasers and high energy lasers. The mechanism of action of low energy lasers is via blocking the nerve ends and affecting the inflammatory mediators, meanwhile mechanism of action of high energy lasers is via changing the structure of dentin to obstruct dentinal tubules 2). CO2 and Er:YAG lasers are highly popular in dentistry. Evidence shows that the smear layer is completely melted and evaporated following Er:YAG laser irradiation and results in deposition of insoluble salts at the orifice of the open dentinal tubules leading to their obstruction 15, 16). Studies have shown that Er:YAG laser irradiation results in insignificant thermal injury to the pulpal tissue, which is an advantage for this type of laser 17–19). On the other hand, CO2 laser concentrates high levels of energy in a small area. Energy is converted to heat and results in burning, melting or vaporization of the respective area in dentin. Melting and re-crystallization of dentin result in obstruction of dentinal tubules and dentin hypersensitivity may be relieved 8). This study aimed to assess the effect of three different desensitization treatments on marginal microleakage of composite restorations bonded with a two-step, etch and rinse adhesive. The null hypothesis is the application of desensitizing agents/methods prior to restoration do not affect the marginal seal of bonded composite restorations.

Material and methods

A total of 60 sound extracted human molars were collected. The teeth were cleaned from debris using a periodontal curette and were then immersed in 0.1% thymol solution (Merck, NY, USA) for one week. The teeth were evaluated under a stereomicroscope at ×10 magnification to ensure absence of cracks and structural anomalies and were then stored in distilled water at 4°C. Class V cavities measuring 3mm in width, 2mm in depth and 3 mm in height were prepared in such way that 1.5 mm of the cavity height was above and 1.5 mm was below the cementoenamel (CEJ) junction using 008 diamond bur and a high-speed handpiece under water and air spray. All cavities were prepared by the same clinician. Materials were used in this study are shown in Table 1. The specimens were randomly divided into 4 groups (n=15) based on the desensitizing technique as follows:

Table 1: Products used in this study.

Brand name Chemical composition Manufacturer
Gluma® Desensitizer HEMA, Glutaraldehyde, Water HeraeusKulzer South America Ltd.
Ultraetch Phosphoric acid 37% Ultradent, USA
SingleBond2 Bis-GMA, HEMA, Silanized silica, Glycerol 1,3 dimethacrylate, Diurethane Dimethacrylate, water, ethanol, polyalkenoic acid copolymer, photoinitiator 3M ESPE, MN, USA
Z250 UDMA, BisGMA, BisEMA, TEGDMA, zirconia/silica filler 3M ESPE, MN, USA
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Group one (control group): No surface treatment

Group two: Cavity surfaces were treated with Gluma® desensitizer (HeraeusKulzer Ltd., South America) according to the manufacturer's instructions.

Group three: Cavity surfaces were lased with CO2 laser (US-20D, Deka Dental Laser system, Florence, Italy) with settings of 1.5 W, 85 J/cm2, 10 Hz and 300 µs pulse width.

Group four: Cavity surfaces were lased with Er:YAG laser (USD20, Deka Dental Laser system, Florence, Italy) with settings of 10 Hz, 50 mJ and 470 µs pulse width.

One week after desensitizing treatment, specimens in all four groups were similarly etched with 37% phosphoric acid (Ultraetch, Ultradent, USA) for 15 seconds. The bonding agent (Single Bond 2, 3M ESPE, MN, USA) was then applied and light cured for 20 seconds, the cavities were restored with Z250 composite (3M ESPE, MN, USA) in 2mm increments according to the manufacturer's instructions and cured for 20 seconds. All specimens were then thermocycled (3500 cycles) between 5–55°C for 30 seconds at each temperature with 15 seconds of transfer time. Root apices in all specimens was sealed with utility wax and the surfaces of specimens were coated with two layers of nail varnish except for 1mm around the restoration margins. The specimens were then immersed in 1% methylene blue solution for 24 hours. The specimens were then rinsed with water, dried and buccolingually sectioned in the middle of the cavity. The microleakage was scored under a stereomicroscope at × 20 magnification by one blind researcher using the following scoring system (figures 1–4):

Figure 1:

Figure 1:

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Grade zero

Figure 4:

Figure 4:

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Grade 3

Figure 2:

Figure 2:

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Grade 1 at enamel margin

Figure 3:

Figure 3:

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Grade 2

Grade zero: No dye penetration through the cavity margins.

Grade one: Dye penetration to more than half of the cavity depth

Grade two: Dye penetration through the entire length of the cavity wall but not reaching to the axial wall

Grade three: Dye penetration through the entire length of the cavity wall and into the axial wall

Data were analyzed using SPSS version 20. The difference in the microleakage among groups was analyzed using the Kruskal Wallis test.

Results

Data were analyzed using SPSS version 20. The difference in the microleakage between groups was analyzed using the Kruskal Wallis test. Pairwise comparisons were made using Dunn's test. P<0.05 was considered statistically significant. The Kruskal Wallis test showed that there was no significant difference in the frequency of microleakage at the enamel margin between groups (P=0.694). Table 2 shows predominance of score 0 (no microleakage) for all groups (G1: 73.3%; G2: 80%; G3: 73.3%; G4: 86.7%).

Table 2: Frequency distribution of microleakage in the enamel margin.

Study group Number Degree of microleakage
Grade zero Number (%) Grade one Number (%) Grade two Number (%) Grade three Number (%)
Control 15 11 (73.3%) 2 (13.3%) 2 (13.3%) 0 (0%)
Gluma® 15 12 (80%) 3 (20%) 0 (0%) 0 (0%)
CO2 laser 15 11 (73.3%) 2 (13.3%) 1 (6.7%) 1 (6.7%)
Er:YAG laser 15 13 (86.7%) 2 (13.3%) 0 (0%) 0 (0%)
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At the dentin margin, it was shown significant differences between groups (p=0.018). The Dunn's test showed that Er:YAG laser group presented significantly higher microleakage than the other groups (p<0.05). There was no significant diferences between other groups. Control and Gluma® showed predominance of score 0 (53.2% and 60%, respectively). CO2 showed predominance of scores 0 and 4 (46.7% for each score) while Er:YAG showed predominance of score 4 (53.3%). Table 3 shows the frequency distribution of microleakage at the dentin margin.

Table 3: Frequency distribution of microleakage in the dentin margin.

Study group Number Degree of microleakage
Grade zero Number (%) Grade one Number (%) Grade two Number (%) Grade three Number (%)
Control 15 8 (53.3%) 1 (6.7%) 4 (26.7%) 2 (13.3%)
Gluma® 15 9 (60%) 3 (20%) 2 (13.3%) 1 (6.7%)
CO2 laser 15 7 (46.7%) 0 (0%) 1 (6.7%) 7 (46.7%)
Er:YAG laser 15 3 (20%) 0 (0%) 4 (26.7%) 8 (53.3%)
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Discussion

Clinical trials have confirmed the efficacy of Gluma® desensitizer and CO2 and Er:YAG laser irradiation for treatment of dentin hypersensitivity 20–28). However, changes in dental substrate due to the application of Gluma® or laser irradiation may affect the quality and clinical service of restorations. Thus, some studies have evaluated the effect of Gluma® application and laser irradiation on some characteristics of restorations such as composite bond strength or retention of cemented crowns 29). However, limited reports are available on the effects of these two techniques on marginal seal of composite restorations 8).

In this study, all specimens were restored using the same method and materials. The only difference between groups was the type of surface treatment of dental substrates (Gluma®, laser or no surface treatment). All restored teeth were subjected to 3500 thermal cycles at 5–55°C for 30 seconds at each temperature and 15 seconds of transfer time, which corresponds to one year of clinical service. Thermocycling simulates maximum and minimum oral temperatures and its results indicate the similarity between the coefficient of thermal expansion of tooth structure and the restorative material 30). Reports on the effects of thermocycling on microleakage are controversial. Pazinatto et al. showed that increasing the number of thermal cycles (500, 1000, 2500 and 5000 cycles) had no significant effect on the microleakage of composite restorations 31).

In the current study, the effect of three treatment modalities for dentin hypersensitivity (Gluma® application, CO2 and Er:YAG laser) on the quality of marginal seal of composite restorations was evaluated by assessment of microleakage. Oral environment has adverse effects on composite bond to tooth structure. These effects may result in formation of a gap at the tooth-restoration interface enabling the passage of liquids, molecules, ions and bacteria. This process is known as microleakage 32).

Methylene blue dye was used for assessment of microleakage in this study, which is one of the several methods used for this purpose. Methylene blue dye has molecules with 1.2 nm diameter, which can pass through microscopic gaps 33).

Results of this study rejected the null hypothesis. There was no significant difference in the frequency of microleakage at the enamel margin between the two groups of Gluma® and control. Similarly, Sahin et al. compared the sealing ability of several etch and rinse and self-etch adhesives as well as Gluma® desensitizer using the fluid transport model and found that Gluma® had no effect on microleakage. This finding is explained by the fact that Gluma® does not bond to tooth structure and cannot provide marginal seal in cavities 34). The mechanism of action of Gluma® desensitizer is via the coagulation of plasma proteins and formation of septa within the dentinal tubules, which decrease the flow of intra-tubular fluid 6, 35). It appears that Gluma® has no significant effect on the bond between the dental substrate and restorative materials. Sabatini and Wu evaluated the effect of initial surface treatment with Gluma® desensitizer on bond strength of adhesive systems and reported that Gluma® did not cause a significant change compared to the control (no Gluma®) group which confirms our results 36). Johnson et al. found that treatment of tooth surfaces with a Gluma® -base material as desensitize had no significant effect on retention of crowns cemented with zinc phosphate, glass ionomer or resin 37). Based on the above-mentioned results and our findings, it may be concluded that Gluma® desensitizer has no adverse effect on marginal seal of restorations. However, further studies are required to confirm it.

Based on the results of the current study, no significant difference existed between the specimens in the Gluma® and control groups with respect to the frequency of different microleakage at the dentin margin. In contrast to our results, Fu et al. reported that although formation of intra-tubular septa due to the deposition of plasma proteins can decrease tooth hypersensitivity, dentin specimens treated with Gluma® showed the least desirable seal 38). Such controversy between our findings and those of Fu et al. may be due to different methodologies of the two studies.

The results of this study showed no significant difference between specimens treated with CO2 laser and the control group in terms of the frequency of microleakage at the enamel and dentin margins. Similarly, Shafiei et al. assessed the microleakage in surfaces of Class V cavities treated with CO2 laser and restored with composite and an etch and rinse adhesive and found no significant difference between the lased and non-lased groups. They concluded that application of CO2 laser had no adverse effect on the sealing ability of enamel and dentin surfaces in composite restorations 8).

Results of current study revealed no significant difference between the control and Er:YAG laser groups in terms of microleakage at the enamel margin. This finding was in agreement with the results of Arami et al and Esteves-Oliveira et al. They found no significant difference in microleakage at the enamel margins between specimens treated with Er:YAG laser and controls 39, 40). Lack of a significant difference between the control and lased groups in terms of microleakage may be attributed to the similarity of enamel structure in the two groups. In agreement with this theory, scanning electron microscopic analysis showed that the structure of enamel treated with phosphoric acid and Er:YAG laser was quite similar to the structure of enamel etched with phosphoric acid only. In both techniques, the enamel had a chalky white appearance; the only difference was that the porosities were greater when acid etching was combined with laser irradiation compared to the application of etchant alone 41).

In contrast to findings of this study, Chinelatti et al. reported greater microleakage at the enamel margins of restorations following surface treatment with Er:YAG laser compared to the control (no treatment) group; this indicated the negative effect of surface treatment with Er:YAG laser on the marginal seal of restorations 42). Such controversy may be attributed to the laser energy, exposure time and other laser parameters. Although the exact mechanism of action of laser has yet to be known, it appears that laser irradiation destructs enamel prisms. Moreover, there is a possibility that laser irradiation causes irregularities in the cavity walls, internal angles and margins and therefore, compromises the bond of the restorative material to tooth structure and subsequently compromises the marginal seal and increases the risk of marginal leakage 43).

Based on the results of the current study, microleakage at the dentin margin in Er:YAG laser group was significantly higher than that in the control group; which is in line with the findings of Fattah et al. They evaluated the effect of different surface treatments on microleakage of restorations and reported higher microleakage at the dentin margins of surfaces treated with Er:YAG laser 44). Over-drying of dentin surface caused by the heat generated during laser irradiation followed by acid etching can dehydrate dentin and result in collapse of demineralized dentin. This decreases the penetration of resin monomers into the etched area. As the result, resin tags and hybrid layer cannot form completely and the bond strength consequently decreases. This increases the risk of gap formation at the tooth-restoration interface and subsequently increases the risk of microleakage 45).

Single Bond 2® was used in this study, which is an etch and rinse adhesive. In this system, bonding depends on the formation of a hybrid layer, comprising of the remaining hydroxyapatite crystals, exposed collagen and resin tags. After etching, resin monomers penetrate into the collagen porosities previously occupied by hydroxyapatite. This yields the most efficient bonding to sound dentin surface. If the thickness of the layer containing exposed collagen increases or the water content of the dentin structure changes, resin penetration may not occur adequately or resin monomers may not polymerize well 46). Laser irradiation changes the structure of dentin and can impair the function of Single Bond 2® and increase microleakage at the dentin margins. Moreover, Apel et al. showed that subablative erbium laser irradiation can result in formation of different organic and non-organiccompounds such as melted collagen fibrils, calcium pyrophosphate, calcium metaphosphate, and alpha and beta tri-calcium phosphate with variable degrees of acidic solubility 47). Therefore, lased dentin probably cannot be etched completely and resultantly, the quality of micromechanical interlocking and penetration of bonding agent into dentin decrease 48).

Within the limitations of this study, it was concluded that application of Gluma® desensitizer and CO2 laser irradiation of tooth surfaces prior to composite restoration did not increase microleakage at the enamel or dentin margins. These two desensitization techniques do not seem to have an adverse effect on marginal seal of composite restorations.

Conclusion

Tooth surface treatment with Er:YAG laser as desensitizer did not increase the microleakage at the enamel margins but significantly increased the microleakage at the dentin margins and had an adverse effect on marginal seal of restorations. Therefore, Er:YAG laser irradiation as a desensitizer is not recommended for teeth that need to be restored.

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