|Year : 2020 | Volume
| Issue : 2 | Page : 165-171
The effect of diode laser application on restoration of non carious cervical lesion: Clinical follow up
S Akarsu1, SA Karademir1, E Ertas2, S Atasoy1
1 Department of Restorative Dentistry, Faculty of Dentistry, Ordu University, Ordu, Turkey
2 Department of Restorative Dentistry, Faculty of Dentistry, OndokuzMayıs University, Samsun, Turkey
|Date of Submission||30-Jul-2019|
|Date of Acceptance||15-Sep-2019|
|Date of Web Publication||7-Feb-2020|
Ordu University, Faculty of Dentistry, Department of Restorative Dentistry Güzelyali 52100 Altinordu/ORDU
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aims: The aim of this study is to evaluate the effect of the diode laser used for dentin sensitivity on the clinical success of non-carious cervical lesion (NCCL) restorations restored with different adhesive systems. Methods: 20 NCCLs were restorated with Universal Single Bond (Self Etch) (3M, USA) and Grandio (Voco, Germany), 20 NCCLs were restorated with Universal Single Bond (Total Etch) and Grandio. After diode laser application, 20 NCCLs were restorated with Universal Single Bond and Grandio, 20 NCCLs were restorated with Universal Single Bond (Total Etch) and Grandio. The restorations were clinical evaluated by two examiners at baseline, for 6 and 18 months using modified United States Public Health Service (USPHS) Criteria. Chi-square test was used for statistical analyse. Results: The lowest rates of retention was found in the Group 1. There was no statistically significant difference among the groups in marginal discoloration, marginal integrity, sensitivity (P > 0.05). Conclusion: Diode laser application prior to the restoration of teeth with NCCL don't reduce the retention rate of restorations, may reduce hypersensitivity and may affect the success of restoration. However, further laboratory and clinical studies are required.
Keywords: Clinical evaluation, diode laser, non-carious cervical lesion
|How to cite this article:|
Akarsu S, Karademir S A, Ertas E, Atasoy S. The effect of diode laser application on restoration of non carious cervical lesion: Clinical follow up. Niger J Clin Pract 2020;23:165-71
|How to cite this URL:|
Akarsu S, Karademir S A, Ertas E, Atasoy S. The effect of diode laser application on restoration of non carious cervical lesion: Clinical follow up. Niger J Clin Pract [serial online] 2020 [cited 2020 Feb 25];23:165-71. Available from: http://www.njcponline.com/text.asp?2020/23/2/165/277869
| Introduction|| |
Non-carious cervical lesions (NCCLs) are defined as dental tissue loss that occurs without caries development at the cementoenamel junction. These lesions appear as wedges or discs according to their width and depth. Currently, the cause of NCCLs is believed to be a complex interaction of different mechanisms that include biocorrosion, stress, and friction.
Many materials, such as conventional glass ionomer cements, resin-modified glass ionomer cements (RMGICs), polyacid-modified glass ionomer cements and composite resins are used for the restoration of NCCLs, especially those due to poor aesthetics, nutrient intake, and cervical dentin sensitivity. However, when restorations performed in the cervical region were compared with occlusal and anterior restorations, a higher percentage of failures was observed, and the longevity of the restorations were unsatisfactory. Factors that lead to unsuccessful NCCL restorations include occluded dentinal tubules constituting the sclerotic formation, the presence of bacteria on the lesion surface and acid-resistant hyper-mineralized layers. A hyper-mineralized layer in the sclerotic dentin, and the bacterial and tubular mineral structure, serve as a barrier to the diffusion of primer and resin infiltration in a manner similar to the smear layer of intact dentin. As such, there is a need for new techniques and improvements in the adhesion of restorative materials to prolong the clinical longevity of restored cervical lesions.
The most recently developed “universal multi-mode” adhesives are single-stage adhesive systems that contain the acidic primers and bonding agents in the same bottle. These adhesives can be used in the etch-and-rinse and selective etch techniques with phosphoric acid or the self-etch technique. Most recently, developed universal adhesive formulations have a chemical bonding capacity conferred through functional hydroxyapatite monomers. Among the currently used functional monomers, methacryloyloxydecyl dihydrogen phosphate has been shown to form highly effective and resistant bonds with dentin.
Contemporary dental applications for lasers include caries diagnosis, removal of carious tooth structure(s), cavity preparation(s), etching before bonding, composite resin curing, removal of restorative materials, pain control, photo-biomodulation, dental bleaching, pulpotomy, contouring gingival margins, periodontal healing, and management of recurrent aphthous ulcers., In modern clinical applications, NCCLs and cervical dentin hypersensitivity are commonly observed together. In recent years, the use of lasers has become increasingly more common in the treatment of cervical dentin hypersensitivity; however, the mechanism of action remains unclear. The lasers interact with tooth tissue, causing different reactions depending on wavelength, power density, and optical characteristics of the target tissue. Low power output lasers (such as diode lasers) are assumed to mediate analgesic effects by depressing neural conduction. This effect is caused by blocking C-fiber afferent depolarization.
The aim of this study was to evaluate the effect of a diode laser used to treat dentin hypersensitivity on the clinical success of NCCL restorations performed using different adhesive systems.
| Methods|| |
The protocol for this clinical study was reviewed and approved by the Ethics Committee of Ordu University (Ordu, Turkey; 2018-58). Patients included in the study were selected from among those who applied to the Restorative Dentistry Clinic of the Faculty of Dentistry of Ordu University due to NCCL. Informed consent was obtained from all participants.
Power analysis was conducted based on the results of a previous study comparing the 1-year clinical performance of resin composite restorations, which indicated a minimum sample size of 15 for a 90% power confidence interval. The current study therefore was conducted using 20 samples per group.
Inclusion criteria were as follows: (patients with) at least four NCCL-containing teeth; adequate oral hygiene; low caries index; and vital teeth. Individuals with advanced periodontitis, periapical lesion(s), bruxism, traumatic occlusion, removable or fixed partial dentures antagonist to NCCL teeth, teeth with anamnesis of pulpal pathology, and teeth with cervical caries together with NCCL, were excluded from this study. According to these criteria, the final sample consisted of 20 patients (38-62 years of age) with 80 NCCLs with a depth of 1 to 2 mm. Restorative materials and restoration planning were performed according to American Dental Association recommendations for testing adhesive restorative materials in clinical trials.
80 teeth with NCCLs were randomly assigned to four groups, with each patient having at least one from each group. The NCCL surfaces were mechanically cleaned using a rubber cup and a non-fluoridated prophylactic paste. No preparation procedure was performed on the enamel or dentin. Isolation was achieved using a retractor, cotton roll, saliva ejector and retraction cord. No local anesthesia was performed before restoration. Consistent with manufacturer's recommendations, all NCCLs were restored by the same restorative dentistry researcher. The power of the polymerization device was controlled by a radiometer. The materials used in the present study are summarized in [Table 1].
The teeth were divided into four groups as follows:
Group 1 (Self-etch): 3M Universal Single Bond (3M ESPE, Maplewood, MN, USA) was applied for 20 s, gently dried for 5 s, and polymerized for 10 s using a polymerization device (Elipar S10, 3M ESPE, USA).
Group 2 (Etch-and-rinse): Scotchbond™ Universal Etchant (3M, USA) was applied to the tooth surface for 15 s, and dissolved mineral and acid wastes from residual acid and enamel were removed by rinsing with water for 15 s. 3M Universal Single Bond was applied for 20 s, gently dried for 5 s, and polymerized for 10 s using the Elipar S10 polymerization device.
Group 3 (Diode laser + self-etch): A Doctorsmile diode laser (AMD, Vicenza, Italy) 0.2 Watts (W), 20 s; 0.5 W, 20 s; 1 W, 20 s was applied to tooth surfaces using a 400 μm wide fiber. One day later, 3M Universal Single Bond was applied to the tooth surface for 20 s, gently dried for 5 s, and polymerized for 10 s using the Elipar S10 polymerization device.
Group 4 (Diode laser + etch-and-rinse): A Doctorsmile diode laser (0.2 W, 20 s; 0.5 W, 20 s; 1 W, 20 s) was applied to tooth surfaces using a 400 μm wide fiber. After 15 s of Scotchbond™ Universal Etchant application to the tooth surface, dissolved mineral and acid wastes from residual acid and enamel were removed by rinsing with water for 15 s. 3M Universal Single Bond was applied for 20 s, gently dried for 5 s, and polymerized for 10 s using the Elipar S10 polymerization device.
All restorations were completed with Grandio (VOCO GmbH, GERMANY), which is a universal nanohybrid composite. They were polymerized for 20 s using the Elipar S10 polymerization device and finalized using yellow band diamond finishing burs and soflex pop-on finishing discs (Soflex Pop-on, 3M ESPE, Maplewood, MN, USA).
A visual analog scale was used to assess dentin hypersensitivity. When determining the degree of sensitivity, the cervical region was isolated by finger to keep it excluded. Air was sprayed from the air-water spray of the dental unit at a distance of 1 cm for a maximum of 5 s. Patients were asked if they experienced any sensitivity during this maneuver.
6 and 18 months after restoration, clinical evaluation of the restorations was performed by 2 experienced dentists using 5 × magnification loupes according to modified United States Public Health Service (USPHS) criteria [Table 2]. Any inconsistencies between the evaluating dentists were re-evaluated. Following which, a joint decision was reached.
Data were analyzed using the Shapiro-Wilk test to verify the assumption of normality. The Chi-squared test was performed using the Number Cruncher Statistical System 2007 software (NCSS, Utah, USA) package. The level of statistical significance was set at P < 0.05, with a confidence interval of 95%.
| Results|| |
All patients included in the present study attended appointments during the evaluation process. In the evaluation performed according to USPHS criteria after completion of the restoration, all teeth were assigned an alpha score for marginal discoloration, marginal integrity, secondary caries, and postoperative sensitivity. Evaluation results at 6 and 18 months are presented in [Table 3].
When the 80 NCCL restorations were evaluated at 6 months, 6 restorations in Group 1, 3 in Group 2, 3 in Group 3, and 2 in Group 4 were totally lost. Retention rates after 6 months varied among the groups as follows: Group 1, 70%; Groups 2 and 3, 85%; and Group 4, 90%.
Evaluation at 18 months revealed that 2 restorations in Group 1, 1 in Group 2, and 1 in Group 3 were totally lost. Retention rates after 18 months varied among the groups as follows: Group 1, 60%; and Groups 2, 3, and 4, 80%.
Restoration losses were higher during the first 6 months. Evaluations at 6 and 18 months revealed that Group 4 exhibited the highest retention rate. The lowest retention rate was observed in Group 1, in which a universal single-bond was used as a self-etch. However, there were no statistically significant differences among the groups (P > 0.05).
When the NCCL restorations were evaluated in terms of marginal discoloration at both 6 and 18 months, there was no staining down to the dentin in the pulpal direction at the restoration margins. There were no statistically significant differences among the groups in terms of marginal discoloration (P > 0.05).
When the NCCL restorations were evaluated in terms of marginal integrity at 6 months in the remainder of the groups, there was “No detectable crevice with explorer or visible on the restoration margins”. At 18 months, “detectable crevice with explorer and visible on the restoration margins” was observed in 2 teeth in each of Groups 1, 2, and 3, and in 1 tooth in Group 4. None of the groups exhibited “crevice in which dentin is exposed”. There were no statistically significant differences among the groups in terms of marginal integrity (P > 0.05).
All teeth included in the present study exhibited tolerable sensitivity before restoration. Evaluations after restoration completion did not exhibit any postoperative sensitivity. Evaluations at 6 months revealed uncomfortable hypersensitivity in 2 teeth in Group 2 and in 1 tooth in Group 4. However, at 18 months, uncomfortable hypersensitivity was observed in 2 teeth in Group 1, 3 in Group 2, and 2 in Group 4. Although less hypersensitivity was observed in the groups in which diode laser was applied before the restoration, there were no statistically significant differences among the groups at 18 months (P > 0.05). Furthermore, none of the restorations exhibited any secondary caries.
| Discussion|| |
The unclear etiology, pathogenesis, diagnosis, and optimal restorative procedure for NCCLs are significant problem in dentistry. Due to difficulties in restoration. Therefore NCCLs remain a challenge for every clinician.
The retention of restorations in restorative dentistry is the primary criterion in clinically evaluating the success of adhesive systems and restorative materials. Retention is the most reliable diagnostic criterion and the most obvious indication of a failed restoration because it is independent of the personal assessment of the observer. NCCLs are suitable models for testing the bonding of restorative materials to dental tissue as they do not have a retentive shape and do not require preparation before restoration.
Although laboratory tests provide information regarding the longevity of the restoration, the long-term performance of adhesive systems remains dependent on clinical considerations. Difficulties with patient compliance, objectively evaluating the success of restorations and routinely obtaining a heterogeneous group in the clinic are variables that affect the outcome of studies. As such, clinical studies require more effective approaches and more precision in experimental design.
It is difficult to compare the durability of NCCL restorations with other clinical studies because many factors affect restoration retention. Differences in results may be due to cavity morphology, operator skill, occlusion type, bonding capacity of the restorative system, and polymerization of the restorative material.,
In the literature, different retention rates have been reported in studies in which the lesion depth was standardized, and clinical follow-up of NCCL restorations was conducted. In the study by Tuncer et al., in which two different adhesive systems were used for the restoration of NCCLs, retention rates at 6 months were 82% and 75%, while those at 12 months were 77%. Stojanac et al. reported a retention rate of 93.3% in a 2-year clinical follow-up of NCCL restorations in which two different composites and a compomer were used. In a study by Santiago et al., who conducted a 1-year clinical follow-up of the composite and RMGICs in the restoration of NCCLs, reported a composite retention rate of 86%.
On the other hand, in the present study, in which NCCLs of 1 to 2 mm depth were included, the retention rates at 6 months for each group were 70% (Group 1), 85% (Group 2), 85% (Group 3), and 90% (Group 4), while the rates at 18 months for each group were 60% (Group 1), 80% (Group 2), 80% (Group 3), and 90% (Group 4).
In their 2-year clinical study, in which NCCLs were restored using the etch-and-rinse adhesive system and two micro-hybrid composites, Tuncer et al. reported that the rate of retention after 6 months was 100%, while the rate of retention after 12 months was 89.6-91.8%. However, there was no limitation reported on the depth of the cervical lesions in their study (NCCLs with depth of 1-2 mm were included in our study). Kubo et al. reported a retention rate of 100% at 5 years in the restoration of NCCLs, in which enamel was beveled using a dental bur on the enamel before the restorative procedure. Although there are studies in the literature reporting that the beveling process positively affects bonding, in our study, no pre-treatment procedure was applied to the enamel or dentin before the restorative procedure.
In many studies, in which clinical follow-up of NCCL was performed, both anterior and posterior teeth were included.,, However, localization of the NCCLs in the dental arch, in which restoration losses in the posterior region are more prevalent than those in the anterior, may affect the longevity of the restoration due to stress intensity and moisture contamination in the cervical region., Accordingly, premolar teeth were included in our study.
As dentin is exposed to the oral environment for a long time in NCCLs, the dentin is hyper-mineralized and transformed into an acid-resistant structure. Consequently, in some studies, it was reported that bond strength to the cervical sclerotic dentin was less successful than that to sound dentin. The teeth with NCCLs included in our study were in categories 2 and 3 according to the Sclerotic Dentin Scale. In in-vitro studies using universal multi-mode adhesive systems, the etch-rinse and self-etch techniques did not exhibit significantly different bond strengths for dentin., In clinical studies investigating NCCL, no differences were found between universal adhesive applications for either etch-and-rinse or self-etch., There was a similar result in our study. In evaluations at both 6 and 18 months, the retention rate of the teeth in Group 1 was lower than that in Group 2. However, the difference was not statistically significant.
Considering that failures in composite restorations are largely related to bonding integrity or are the result of poor initial adhesion, interface bond strength appears to be the main performance metric. Good adhesion is important for the life of the restoration. Dentin has been characterized as a biological composite of collagen matrix, filled with apatite crystallites, dispersed between parallel micrometer-size, hyper-mineralized, collagen-poor dentinal tubules containing peritubular dentin. The strength of the adhesive bonds formed between restorative materials and dentin is affected by the number and concentration of dentinal tubules per square millimeter and their diameter as well as the amount of intra- and inter-tubular dentin. Middle-output lasers melt the superficial layer of dentin when recrystallization occurs, it seals the dentin tubules in a depth of 3 to 4 μm. A previous in vitro study demonstrated a durable 90% occlusion of the exposed dentin tubules under scanning electron microscope (SEM) examination. Akça et al. demonstrated that pretreatment of the dentin surface with neodymium-doped yttrium aluminum garnet (i.e. Nd:YAG) laser significantly reduced the bond strength of composite to dentin. It is reported that diode lasers are characterized by a high absorption in chromophores found in soft tissue. However, for diode lasers in the near infrared portion of the electromagnetic spectrum, part of the energy is absorbed by the mineral structures of dentin, such as phosphate and carbonate, disrupting the crystalline arrangement because of thermochemical ablation and inducing melting of the dentin tissue. Ultrastructural changes in irradiated dentin was found in SEM analysis. Although the mechanism of action of diode lasers in the treatment of dentin hypersensitivity is not exactly certain, in this study, we found that diode laser did not reduce the retention rate in NCCL restorations.
Cervical dentin sensitivity and NCCLs are frequently observed together in clinical settings. In cases of NCCL with open dentin tubules close to the pulp, or dentin tubules in contact with the oral environment for a long time, dentin sensitivity may not continue even if restorative treatment is performed. Treatment in such cases will involve not only occlusion of the dentinal tubules for decreased permeability but will also aim to control intra-pulpal sensory nerve effects to reduce the impact of external stimulators., Femiano et al. investigated the effects of an 808 nm diode laser on oral pain before composite restoration of symptomatic NCCLs that did not respond to desensitization agents. The authors found that sensitivity was lower in teeth treated with diode laser before restoration. There was a similar result in our study. Sensitivity was lower in the groups in which the diode laser was applied before restoration than in those in which the laser was not applied before the restoration; however, there were no statistically significant differences between the groups.
One particular limitation of our study was that the etiology of NCCLs were not taken into consideration. However, patients were informed about the etiological factors to control such factors whenever possible.
| Conclusion|| |
Results of this in vivo study demonstrated lower sensitivity in groups in which diode laser was applied before restoration than in those in which the laser was not applied before the restoration. Furthermore, diode laser application before restoration of teeth with NCCLs did not reduce the retention rate of restorations but may have affected the success of restoration. Nevertheless, further laboratory and clinical studies are required.
None of the authors has financial interest related to this study to disclosure.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]