Is there any clinical evidence?

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1 Current treatment objectives Anticariogenic capacity of restorative materials in paediatric dentistry: in vitro evidence vs. clinical efficiency Prof. Lisa Papagianoulis Restoration with minimal intervention and caries prevention Longevity without secondary caries Evidence-based selection of materials and techniques Bergen November 2007 Is there any clinical evidence? Problems in interpreting the evidence There is very little real clinical research Marketing and sales thrive on laboratory results as evidence for product support. There is a need for understanding the complex intra-oral environment and the interactions of materials, interfaces and tissues over-time (Bayne, 2006) How accurately do clinicians interpret research evidence? How can research data be linked to clinical practice? How accurate and valid are research data? Marginal adaptation: setting shrinkage Consensus for replacement of restorations: criteria Quality of marginal adaptation /secondary caries Mechanical properties Color alteration Composite in Class I cavity Cavity view Composite bottom view Net pore volume Critical factors: Handling characteristics Setting shrinkage (3D micro-xct) 1

2 Marginal adaptation: marginal deterioration Secondary caries primary caries at defective restoration margins (Özer and Thylstrup A, 1995) liner dentin gap amalgam (Manakou et al 2005) Materials with anticariogenic capacity Assessment of F release from materials F Ca or OH (buffering effect) Sr, Al, Zn Antimicrobial agents (adhesives) Amount of F released Amount of F uptake by tooth tissues and plaque Resistance to caries development Expression of antimicrobial effect TYPE OF STUDIES In vitro In situ In vivo Clinical /retrieval 300 F release Cumulative amount F ( (ppm ppm) 150 Release rate time (days) Cumulative graphs have no meaning (assume close systems) All the materials demonstrate an initial short-term term high release period (elution) followed by a long-term low-release period (diffusion) The actual F amount required to obtain a cariostatic effect is unknown Increased F release should not be considered among the primary material selection criteria High F release rate indicates material dissolution 2

3 Assessment of F uptake F uptake from gels, liquids and varnishes SEM-WDS ELEMENTAL MAPPING Superficial CaF 2 rich layer (precipitation induced) F (Cruz et al, 1992) Ca (Are really CaF 2 particles available on enamel surface or are dehydration precipitates induced by HV-SEM imaging?) Depth of F penetration Artifacts F uptake from dental materials dentin dentin GI F map No counter ion or core material element as reference 60 μm Al, F Same distribution of Al and F for an AlF 3 system (fracture, not uptake) Ca map (Chu et al, 1988) Interfacial debonding in HV SEM/X-ray microanalysis: cohesive material fracture is frequently considered as an uptake phase. A common error in analysis of water-based cements. (Duschner et al, 1995) Surface contamination F uptake by hard tissues State of F uptake crystalline, amorphous, adsorbed F-material smears Smear-free zone Edge effect (smear entrapment) XPS C1s Curve Fitting C-H C-F Increased F uptake Reduced F uptake Adsorbed organic-f coating (not F uptake) XPS mapping 3

4 Interference of bonding agents F uptake by hard tissues Assessment of F uptake enamel F (%) 100 enamel 10 1 interface microns Pellicle and early plaque formed on restorative materials Functional groups of pellicle on restoratives COMPOSITE GLASS-IONOMER Glass-ionomer surfaces are very reactive up to maturation AMALGAM Assessment of F uptake protocols F uptake by interproximal contacts IN VITRO AND IN SITU STUDIES Glass-ionomers demonstrate a slight protective effect-less than a F toothpaste Topical fluoridation seems to overwhelm any effect of uptake from a tooth adjacent to a F releasing material CLINICAL STUDIES Few with contradictory findings 4

5 Assessment of F uptake F recharging of restorative materials To maintain the cariostatic activity since the F release reaches a low release plateau over time Glass-ionomers are better recharged due to the presence of Loosely bound water Structural porosity and solutes that enhance passive diffusion recharge processes APF gels are contraindicated as they may produce erosive damage Intraorally,, saliva and plaque strongly reduce F release from recharged surfaces Problems in the clinical evaluation of the anticariogenic properties of restorative materials In vitro Role of interfacial gaps in caries development Extremely difficult to differentiate the effect of adhesive marginal sealing from the therapeutic effect attributed to the release of species with anticariogenic capacity. Marginal defect Ketac-Fil/without gap Subsurface lesion Defect with no lesion Smaller lesions in the presence of interfacial gaps!! (increased area of F release) (Papagiannoulis et al 2002) Ketac-Fil/ with gap In vivo Role of interfacial gaps in caries development Raman Microprobe Κetac-Fil Retrieval analysis Optical microscopy Ca(OH) 2 VLC GI liner adhesive VHN Debonding of F releasing liners and bases Z-250 No lattice mode vibrations for CaF 2 FREQUENCY AND SIZE OF THE DEVELOPED LESIONS RESTORATIVE (n=8, 6 m) KETAC-FIL FREQUENCY (%) 75.0% LENGTH (μm) 754±43 DEPTH (μm) 277±22 Z % 384±36 214±22 5

6 RETRIEVAL ANALYSIS SEM/X-ray EDS microanalysis ANTICARIES EFFECT OF AMALGAM? BEI Mg Zn Si No F uptake from F-releasing GI In depth Zn diffusion Ca P CLINICAL STUDIES no evidence in favor of F releasing materials Conclusions Mjor IA. Quintessence Int 1996;27: Wilson NHF, Burke FJT, Mjor IA. Quintessence Int 1997;28: Randall R, Wilson NHF. J Dent Res 1999;78: Wiegand A, Buchalla W, Attin T. Dent Mater 2007;23: There is conflicting clinical evidence on whether the F releasing materials prevent or inhibit secondary caries compared to non-f restoratives More and well-designed clinical studies are required to evaluate the capacity of these materials in caries development and progression Until clear and critical information is available from clinical studies, no material should be designed focusing more on the F releasing capacity rather than adhesion, marginal durability mechanical strength 6

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