Flávio Fernando Demarco

Longevity of posterior composite restorations: Not only a matter of materials

Resin composites have become the first choice for direct posterior restorations and are increasingly popular among clinicians and patients. Meanwhile, a number of clinical reports in the literature have discussed the durability of these restorations over long periods. In this review, we have searched the dental literature looking for clinical trials investigating posterior composite restorations over periods of at least 5 years of follow-up published between 1996 and 2011. The search resulted in 34 selected studies. 90% of the clinical studies indicated that annual failure rates between 1% and 3% can be achieved with Class I and II posterior composite restorations depending on several factors such as tooth type and location, operator, and socioeconomic, demographic, and behavioral elements. The material properties showed a minor effect on longevity. The main reasons for failure in the long term are secondary caries, related to the individual caries risk, and fracture, related to the presence of a lining or the strength of the material used as well as patient factors such as bruxism. Repair is a viable alternative to replacement, and it can increase significantly the lifetime of restorations. As observed in the literature reviewed, a long survival rate for posterior composite restorations can be expected provided that patient, operator and materials factors are taken into account when the restorations are performed.

22-Year clinical evaluation of the performance of two posterior composites with different filler characteristics

OBJECTIVES This retrospective longitudinal study investigated the longevity of posterior restorations placed in a single general practice using 2 different composites in filler characteristics and material properties: P-50 APC (3M ESPE) with 70vol.% inorganic filler loading (midfilled) and Herculite XR (Kerr) with 55vol.% filler loading (minifilled). METHODS Patient records were used for collecting data. Patients with at least 2 posterior composite restorations placed between 1986 and 1990, and still in the practice for regular check-up visits, were selected. 61 patients (20 male, 41 female, age 31.2-65.1) presenting 362 restorations (121 Class I, 241 Class II) placed using a closed sandwich technique were evaluated by 2 operators using the FDI criteria. Data were analyzed with Fishers exact test, Kaplan-Meier statistics, and Cox regression analysis (p<0.05). RESULTS 110 failures were detected. Similar survival rates for both composites were observed considering the full period of observation; better performance for the midfilled was detected considering the last 12 years. There was higher probability of failure in molars and for multi-surface restorations. SIGNIFICANCE Both evaluated composites showed good clinical performance over 22 years with 1.5% (midfilled) and 2.2% (minifilled) annual failure rate. Superior longevity for the higher filler loaded composite (midfilled) was observed in the second part of the observation period with constant annual failure rate between 10 years and 20 years, whereas the minifilled material showed an increase in annual failure rate between 10 years and 20 years, suggesting that physical properties of the composite may have some impact on restoration longevity.

Dentin-derived BMP-2 and Odontoblast Differentiation

It is known that stem cells from exfoliated deciduous teeth (SHED) can be induced to differentiate into odontoblasts. However, the nature of dentin-derived morphogenic signals required for dental pulp stem cell differentiation remains unclear. The hypothesis underlying this work is that dentin-derived Bone Morphogenetic Proteins (BMP) are necessary for the differentiation of SHED into odontoblasts. We observed that SHED express markers of odontoblastic differentiation (DSPP, DMP-1, MEPE) when seeded in human tooth slice/scaffolds and cultured in vitro, or implanted subcutaneously into immunodeficient mice. In contrast, SHED cultured in deproteinized tooth slice/scaffolds, or scaffolds without a tooth slice, do not express these markers. SHED express the BMP receptors BMPR-IA, BMPR-IB, and BMPR-II. Notably, blockade of BMP-2 signaling inhibited the expression of markers of odontoblastic differentiation by SHED cultured in tooth slice/scaffolds. Collectively, this work demonstrates that dentin-derived BMP-2 is required to induce the differentiation of SHED into odontoblasts.

Patient Risk Factors’ Influence on Survival of Posterior Composites

This practice-based retrospective study evaluated the survival of resin composite restorations in posterior teeth, focusing on the influence of potential patient risk factors. In total, 306 posterior composite restorations placed in 44 adult patients were investigated after 10 to 18 yrs. The history of each restoration was extracted from the dental records, and a clinical evaluation was performed with those still in situ. The patient risk status was assessed for caries and “occlusal-stress” (bruxism-related). Statistical analysis was performed by the Kaplan–Meier method and Cox-regression multivariate analysis. In total, 30% of the restorations failed, of which 82% were found in patients with 1 or 2 risk factors. Secondary caries was the main reason of failure within caries-risk patients, whereas fracture was the main reason in “occlusal-stress-risk” patients. The patient variables gender and age did not significantly affect survival, but risk did (p < .001). Tooth type (p < .001), arch (p = .013), and pulpal vitality (p = .003) significantly affected restoration survival. Within the limits of this retrospective evaluation, the survival of restorations is affected by patient risk factors, which should be included in survival analyses of restorations.

DENTAL PULP TISSUE ENGINEERING

Dental pulp is a highly specialized mesenchymal tissue that has a limited regeneration capacity due to anatomical arrangement and post-mitotic nature of odontoblastic cells. Entire pulp amputation followed by pulp space disinfection and filling with an artificial material cause loss of a significant amount of dentin leaving as life-lasting sequelae a non-vital and weakened tooth. However, regenerative endodontics is an emerging field of modern tissue engineering that has demonstrated promising results using stem cells associated with scaffolds and responsive molecules. Thereby, this article reviews the most recent endeavors to regenerate pulp tissue based on tissue engineering principles and provides insightful information to readers about the different aspects involved in tissue engineering. Here, we speculate that the search for the ideal combination of cells, scaffolds, and morphogenic factors for dental pulp tissue engineering may be extended over future years and result in significant advances in other areas of dental and craniofacial research. The findings collected in this literature review show that we are now at a stage in which engineering a complex tissue, such as the dental pulp, is no longer an unachievable goal and the next decade will certainly be an exciting time for dental and craniofacial research.

Effects of Morphogen and Scaffold Porogen on the Differentiation of Dental Pulp Stem Cells

INTRODUCTION Dental pulp tissue engineering is an emerging field that can potentially have a major impact on oral health. However, the source of morphogens required for stem cell differentiation into odontoblasts and the scaffold characteristics that are more conducive to odontoblastic differentiation are still unclear. This study investigated the effect of dentin and scaffold porogen on the differentiation of human dental pulp stem cells (DPSCs) into odontoblasts. METHODS Poly-L-lactic acid (PLLA) scaffolds were prepared in pulp chambers of extracted human third molars using salt crystals or gelatin spheres as porogen. DPSCs seeded in tooth slice/scaffolds or control scaffolds (without tooth slice) were either cultured in vitro or implanted subcutaneously in immunodefficient mice. RESULTS DPSCs seeded in tooth slice/scaffolds but not in control scaffolds expressed putative odontoblastic markers (DMP-1, DSPP, and MEPE) in vitro and in vivo. DPSCs seeded in tooth/slice scaffolds presented lower proliferation rates than in control scaffolds between 7 and 21 days (p < 0.05). DPSCs seeded in tooth slice/scaffolds and transplanted into mice generated a tissue with morphological characteristics similar to those of human dental pulps. Scaffolds generated with gelatin or salt porogen resulted in similar DPSC proliferation. The porogen type had a relatively modest impact on the expression of the markers of odontoblastic differentiation. CONCLUSIONS Collectively, this work shows that dentin-related morphogens are important for the differentiation of DPSC into odontoblasts and for the engineering of dental pulp-like tissues and suggest that environmental cues influence DPSC behavior and differentiation potential.

Flexural strength and modulus of elasticity of different types of resin-based composites

The aim of the study was to test whether the filler composition of resin composites influences their flexural strength and modulus of elasticity. Flexural strength and modulus of elasticity were obtained through a three-point bending test. Twelve bar shaped specimens of 5 commercially available composites--Supreme (3M/ESPE), a universal nanofilled composite; Esthet-X (Dentsply), Z-250 (3M/ESPE), Charisma (Heraeus Kulzer), universal hybrid composites; and Helio Fill (Vigodent), a microfine composite--were confectioned according to the ISO 4049/2000 specifications. The test was performed after a 7-days storage time using a universal test machine with a crosshead speed of 1 mm/min. The filler weight content was determined by the ashing technique. The data obtained on the mechanical properties were submitted to ANOVA and Tukey test (p < 0.05). Pearsons correlation test was used to determine the correlation between the filler content and the mechanical properties. A weak but significant correlation between the mechanical properties evaluated and the filler weight content was observed (p < 0.000). The microfine composite presented the lowest filler weight and the lowest mechanical properties. Statistically different flexural strength and modulus of elasticity results were observed among the universal hybrid composites. The nanofilled composite presented intermediary results. Within the limitations of this in vitro study, it could be concluded that the filler content significantly interfered in the flexural strength and modulus of elasticity of the composites tested.

Comparative chemical study of MTA and portland cements

Portland cement has been analyzed and compared to mineral trioxide aggregate (MTA) because of their chemical similarity. The possibility of using this material as a less expensive alternative to MTA in dental practice should be considered. In view of this, the present study compared the components of a Portland cement (Votoran) to two commercial brands of MTA (Pro-Root and MTA-Angelus). Twelve specimens of each material were fabricated and examined by scanning electron microscopy (SEM) with energy dispersive spectroscopy (EDS) to obtain their percentage of chemical elements. The means of the chemical elements found in each material was compared by descriptive statistics. Bismuth was present only in MTA cements to provide radiopacity. In conclusion, the tested cements have similar components, which supports, as far as composition is concerned, the possible clinical use of Portland as an option to MTA.

Effect of polishing techniques and time on surface roughness, hardness and microleakage of resin composite restorations.

This study evaluated the effects of immediate and delayed polishing on the surface roughness, microhardness and microleakage of a microfilled (Filtek A110) and a hybrid (Filtek Z250) resin composite. Standardized preparations were made on the buccal surfaces of 256 bovine teeth; half were restored with each composite (128 teeth per composite). Immediately after curing, gross finishing was carried out with #280 sandpaper. The specimens restored with each composite were divided into two subgroups. The first group (IM) was polished immediately after gross finishing, using three different systems (n=16): Sequence A, Sof-Lex; Sequence B, Flexicups and Sequence C, Flexicups + Jiffy Polishing Brush + Flexibuffs. The specimens were then stored for three weeks in saline 37 degrees C. The second group (DE) was stored for two weeks, then polished with the same systems and stored for one additional week. The controls (n=16) were analyzed without polishing. Five readings per specimen were taken for surface roughness and hardness. After immersion in basic fuchsin, microleakage was evaluated (40x) using standardized scores. The data were analyzed at a significance level of 0.05, with analysis of variance and an SNK test (surface roughness and microhardness) or with Kruskal-Wallis (microleakage). In both composites, only for the sequential technique was there an influence of delay in polishing on roughness (Ra). Flexicups exhibited the highest Ra of the three systems. The IM and Filtek Z-250 groups showed higher hardness than the DE and Filtek A-110 groups, respectively. Dentin margins showed more leakage than enamel margins; the sequential technique produced more leakage than the other techniques in dentin (p<0.05) and delay of polishing was not significant in the majority of situations. In conclusion, several conditions--composite, time and polishing technique--had a significant influence on surface roughness, hardness and microleakage. Generally, immediate polishing produced no detrimental effect compared to delayed polishing.

Efficacy and Safety of 10% and 16% Carbamide Peroxide Tooth-whitening Gels: A Randomized Clinical Trial

This double-blind randomized clinical trial evaluated the efficacy and safety of two carbamide peroxide concentrations used in at-home vital bleaching. Ninety-two volunteers with a shade mean of C1 or darker for the six maxillary anterior teeth were randomized into two balanced groups (n=46) according to bleaching agent concentration: 10% (CP10) or 16% (CP16) carbamide peroxide. The patients were instructed to use the whitening agent in a tray for two hours once a day for three weeks. Shade evaluations were done with a value-oriented shade guide and a spectrophotometer at baseline and one week post-bleaching (four-week evaluation). Tooth sensitivity was measured daily using a scale ranging from 0 (no sensitivity) to 4 (severe sensitivity). At the end of the study, the volunteers filled out a questionnaire with seven questions aimed to give their opinion about the adopted treatment regimen. Both carbamide peroxide concentrations resulted in significantly lighter teeth at the four-week evaluation compared to the baseline for all color parameters (p < 0.0001) and shade median (p < 0.001). There was no significant difference between the two groups in terms of shade change difference with either the spectrophotometer (p = 0.1) or the shade guide (p = 0.7). Also, no statistically significant difference was found in relation to deltaL* (p = 0.7), delta a* and deltaE* (p = 0.5). A significant reduction in yellowness (delta b*) was observed for CP16 compared to CP10 (p = 0.05) in crude analysis, which disappeared after controlling for b* parameter at baseline. The group treated with CP16 experienced more tooth sensitivity during the first (p = 0.02) and third (p = 0.01) weeks of treatment compared to the CP10 group. However, no major difference was observed (p = 0.09) when the degree of tooth sensitivity between groups was compared. Both 10% and 16% carbamide peroxide concentrations were equally effective and safe for a three-week at-home tooth-bleaching treatment.