In Vitro Inhibition of Enamel Demineralisation by Fluoride-releasing Restorative Materials and Dental Adhesives

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1 ORIGINAL Dionsyopoulos ARTICLE In Vitro Inhibition of Enamel Demineralisation by Fluoride-releasing Restorative Materials and Dental Adhesives Dimitrios Dionysopoulos a / Eugenia Koliniotou-Koumpia b / Maria Helvatzoglou-Antoniades c / Nikolaos Kotsanos d Purpose: To determine the ability of 5 contemporary fluoride-releasing restoratives and 3 fluoride-releasing adhesives to inhibit enamel demineralisation surrounding restorations, and the associations between inhibition and the levels of fluoride released from these materials. Materials and Methods: Five fluoride-releasing restoratives (Fuji IX GP, Ketac N100, Dyract Extra, Beautifil II and Wave) and 3 fluoride-releasing adhesives (Stae, Prime & Bond NT and Fluoro Bond II) were investigated. Eight disks of each material were prepared. Fluoride release was measured daily using a fluoride-ion-selective electrode for 15 days. Twenty-four cavities for each group were restored with a restorative and an adhesive. Specimens were subjected to thermal stress and stored for 30 days in saline solution. After a 15-day ph-cycling regimen, two 150-μm-thick sections were derived from each specimen. Enamel lesion depth was measured at 0, 100, and 200 μm from each restoration s margin via polarised light microscopy. Results: Of the restoratives investigated, Fuji IX GP released the most fluoride. The fluoride-releasing restoratives tested exhibited shallower enamel lesions than did the control group at all distances tested (p < 0.05). Fuji IX GP yielded significantly lower enamel lesion depth than did the other experimental materials. The depths of enamel lesions did not differ significantly when comparing restoratives applied with a fluoride-releasing adhesive with those applied with a non-fluoride releasing adhesive. Conclusion: The fluoride-releasing materials tested reduced enamel demineralisation but to different extents, depending on their levels of fluoride release. Fluoride-releasing adhesives did not influence enamel lesion formation. Key words: fluoride-releasing adhesives, fluoride-releasing restoratives, inhibition of enamel demineralisation doi: /j.ohpd.a35747 Submitted for publication: ; accepted for publication: The most common cause of restoration failure in both permanent and primary dentition is secondary caries. The use of fluoride is one of the a Dentist, Department of Operative Dentistry, School of Dentistry, Aristotle University of Thessaloniki, Greece. Idea, hypothesis, experimental design, performed the experiment, wrote the manuscript. b Associate Professor, Department of Operative Dentistry, School of Dentistry, Aristotle University of Thessaloniki, Greece. Idea, experimental design, proofread the manuscript. c Professor Emeritus, Department of Operative Dentistry, School of Dentistry, Aristotle University of Thessaloniki, Greece. Proofread the manuscript, contributed substantially to discussion. d Professor, Department of Paediatric Dentistry, School of Dentistry, Aristotle University of Thessaloniki, Greece. Contributed substantially to discussion. Correspondence: Dr. Dimitrios Dionysopoulos, Department of Operative Dentistry, School of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece. Tel: ; ddiondent@gmail.com most effective methods of preventing caries. The rate and quantity of fluoride release from restorative materials, fluoride incorporation into hard dental tissues and subsequent reductions in their solubility may be associated with reduction in the frequency of secondary caries. Initial carious lesions in restoration margins reportedly require exposure to a crucial concentration of fluoride ions for a prolonged period of time in order to achieve cariostatic effects. 12 A variety of mechanisms are involved in the anticariogenic effect of fluoride, including reduction of demineralisation, enhancement of remineralisation, inhibition of pellicle and plaque formation, and inhibition of microbial growth and metabolism. 12 Fluoride released from restorative materials may possibly inhibit caries via all of these mechanisms; doi: /j.ohpd.a

2 however, it seems likely that enhancement of remineralisation is the most important mechanism in this context. 25 Fluoride in an aqueous phase surrounding dental tissues inhibits demineralisation much more effectively than does fluoride incorporated into crystals of apatite. Moreover, fluoride precipitated onto tooth surfaces in the form of CaF 2 serves as a reservoir of fluoride when the ph drops. 12 Only restorative materials that release high amounts of fluoride ions have been shown to effectively inhibit the demineralisation of tooth structures adjacent to restorative margins. 14 Currently, several types of fluoride-releasing restorative materials are commercially available. These include conventional glass-ionomer cements (GIC), resinmodified glass-ionomer cements (RMGIC), polyacid-modified composite resins (compomers), fluoridated composite resins and giomers. In marketing associated with all of these material types, the advantages associated with fluoride-release have been suggested to be of clinical significance. 32 Recently, fluoride-releasing adhesive systems have been developed that are designed to inhibit secondary caries both by promoting adhesion to dental tissues and releasing fluoride ions. Fluoridereleasing dental adhesives are an intuitively appealing concept, because such adhesives are not only in close contact with the dentinal margins of restorations but also partially diffuse into them. 13 Fluoride-releasing restoratives in combination with fluoride-releasing adhesives are currently assumed to be more effective with regard to secondary caries inhibition. The primary aim of this in vitro study was to compare the effects of 5 contemporary fluoride-releasing restorative materials and 3 fluoride-releasing dental adhesives with regard to inhibition of demineralisation adjacent to restorations in bovine enamel. Additionally, we investigated potential associations between such effects and the levels of fluoride released from these materials. Three null hypotheses were formulated prior to the study. The first was that all restorative materials and dental adhesives investigated would release a similar amount of fluoride ions during the experimental period. The second was that there would be no difference in inhibition of enamel demineralisation around restorations between the experimental groups. The third was that there would be no difference in inhibition of enamel demineralisation around restorations between different combinations of restorative materials with fluoride-releasing or non-fluoride-releasing dental adhesives. MATERIALS AND METHODS Five fluoride-releasing restorative materials (Fuji IX GP [GC; Tokyo, Japan], Ketac N100 [3M ESPE; St Paul, MN, USA], Dyract Extra [Dentsply DeTrey; Konstanz, Germany], Beautifil II [Shofu; Kyoto, Japan] and Wave [SDI; Bayswater, Victoria, Australia]) were investigated in the present study and a nonfluoride releasing composite resin (Filtek Z250 [3M ESPE]) was used as a control (Table 1). Additionally, three fluoride-releasing dental adhesives (Stae [SDI], Prime & Bond NT [Dentsply DeTrey] and Fluoro Bond II [Shofu]) were investigated and a nonfluoride-releasing dental adhesive (Adper Scotchbond 1 XT [3M ESPE]) was used as a control (Table 2). Fluoride release from the materials Preparation of specimens Eight disk-shaped specimens of each material were prepared according to manufacturer s instructions, by filling them into cylindrical Teflon molds (diameter, 7 mm; thickness, 2 mm). Polyester strips were placed on both sides of the mold, then glass plates were placed over the polyester strips and clamped tight to produce smooth surfaces. All specimens of resin-based materials were light cured for 20 s from both sides of the mold with a tungsten halogen light-curing unit (Elipar 2500, 3M ESPE; Seefeld, Germany) at 1300 mw/cm 2. The glass/powder mixture of the glass-ionomer specimens was prepared in accordance with the manufacturer s instructions. Immediately after mixing, cements were inserted into the mold and covered by a polyester strip. Fuji IX GP samples were left to set in the mold for 7 min, while Ketac N100 samples were light cured for 20 s from both sides of the mold. The dental adhesives were dropped into the mold in four increments (approximately 0.5 mm in thickness), covered with a polyester strip and a glass plate, and light cured for 30 s from both sides of the mold. Excess material extruding from the edge of the mold was carefully removed using a surgical blade. The disks were removed from the mold and stored in a humidor at 37 C for 1 h. The total surface area of each specimen was mm 2. The specimens were inspected via microscopy to ensure that the surface of the prepared specimens was free from air bubbles and cracks. 2 Oral Health & Preventive Dentistry

3 Table 1 Details of the restorative materials investigated Restorative material Type Manufacturer Composition Lot number Fuji IX GP Capsule Highly viscous conventional GIC GC; Tokyo, Japan Powder: Fluoro-alumino-silicate glass 70% 80% Liquid: Polyacrylic acid 10 15% Distilled water 10-15% Paste A: Fluoro-alumino-silicate glass 40% 50%, silane-treated ZrO 2 silica 20% 30%, silanetreated silica 5% 15%, PEGDMA 5% 15%, HEMA 1% 10%, bis-gma <5%, TEG-DMA <5% Ketac N100 Resin-modified GIC containing nanofillers (nano-ionomer) 3Μ ESPE; St Paul, MN, USA Paste B: Silane-treated ceramic 20% 30%, silane-treated silica 20% 30%, water 10% 20%, HEMA 1% 10%, acrylic/itaconic acid copolymer 20% 30% Fillers: 69% w/w (2/3 nanofillers) Dyract Extra Polyacid-modified composite resin (Compomer) Dentsply DeTrey; Konstanz, Germany Strontium-alumino-sodium-fluoro-phosphorsilicate glass UDMA, TEG-DMA, TCB, SrF 2, SiO 2 fillers , Beautifil II Composite resin containing S-PRG fillers (Giomer) Shofu; Kyoto, Japan S-PRG fillers 68.6% w/v, 83.3% w/w Bis-GMA, TEG-DMA Wave Flowable fluoridecontaining composite resin SDI; Bayswater, Victoria, Australia N, Strontium, silica fillers 40% w/v, 65% w/w N, Multifunctional methacrylic ester, UDMA, SrF N Filtek Ζ250 Non-fluoridated microhybrid composite resin (control) 3Μ ESPE Zirconia/silica fillers 60% w/v, 82% w/w Bis-GMA, bis-ema, UDMA 7TM, 7MA Table 2 Details of the dental adhesives investigated Dental adhesive Type Manufacturer Composition Lot number Stae Fluoride-releasing etch-and-rinse (2 step) adhesive system SDI; Bayswater, Victoria, Australia Proprietary hydrophilic/hydrophobic monomer HEMA, acetone/water solvents Prime & Bond NT Fluoride-releasing etch-and-rinse (2-step) adhesive system Dentsply DeTrey; Konstanz, Germany SiO 2 nanofillers, di-, tri-methacrylate resins, bis-gma, PENTA, TEG-DMA, acetone solvent, cetylamine hydrofluoride FL-Bond II Giomer self-etching (2-step) adhesive system Shofu; Kyoto, Japan Primer: Carboxylic acid monomer, phosphoric acid monomer, water/ethanol solvents Bonding agent: S-PRG fillers,udma, 2-HEMA, TEG-DMA 0808 Adper Scotchbond 1 ΧΤ Non-fluoridated etch-and-rinse (2-step) adhesive system (control) 3Μ ESPE; St Paul, MN, USA Silica nanofillers 10%, bis-gma, HEMA, dimethacrylates, water/ethanol solvents, methacrylate copolymer of polyacrylic and polyitaconic acids Ν Fluoride-ion selective electrode method Each prepared specimen was suspended with nonfluoride dental floss in 4 ml deionized water in a plastic container, and incubated at 37 C ± 0.5 C throughout the experimental period. The first measurement of the fluoride concentration of each solution was performed 24 h after preparation of the specimens. Each sample was rinsed with 1 ml of doi: /j.ohpd.a

4 Table 3 Combinations of restorative materials and adhesive systems by group Group Restorative material Dental adhesive 1 Fuji IX GP - 2 Ketac N100-3 Dyract Extra Prime & Bond NT 4 Dyract Extra Scotchbond 1 XT 5 Beautifil II Fluoro Bond II 6 Beautifil II Scotchbond 1 XT 7 Wave Stae 8 Wave Scotchbond 1 XT 9 Filtek Ζ250 Stae 10 (control) Filtek Ζ250 Scotchbond 1 XT deionized water in a plastic container and the specimen was transferred to a new plastic container containing 4 ml of deionized water. 0.5 ml of total ionic strength adjustment buffer (TISAB III, Thermo Fisher Scientific; Beverly, MA, USA) was added, creating a constant background ionic strength for fluoride measurement. Fluoride concentrations were measured using a microanalytical technique with an inverted fluorideion-selective electrode (Orion 9609BNWP, Ionplus Sure-Flow Fluoride, Thermo Scientific) coupled to a bench-top analyzer (Orion Star Series ISE Meter, Thermo Scientific) with a detection limit of ± ppm, and all data were recorded in ppm. This regimen of specimen transfer and fluoride analysis of storage media was continued daily for 15 days. All measurements were performed at a constant room temperature of 23 C and were converted to μg/cm 2 for statistical analysis. Inhibition of enamel demineralisation surrounding restorations Preparation of specimens One hundred twenty sound bovine incisors from animals of the same age were collected for this study and stored in 0.5% chloramines solution for 15 days prior to use. The teeth were mechanically cleaned, the roots cut off and the pulp tissues removed. Two Class V cavities were prepared (3 mm long, 1.5 mm wide [gingivally-incisally], 1.5 mm deep) in the enamel on the buccal surface of each tooth using a carbide bur (ISO #245) mounted in a high-speed handpiece with air-water coolant. The distance between the two cavities prepared was approximately 4 mm and the cavity margins were not beveled. After preparation of the cavities, the teeth were randomly divided into 10 groups. Twenty-four cavities (12 teeth) in each group were restored with a restorative material and an adhesive system according to the manufacturer s instructions (Table 3). In group 1, before restoration of the cavity with Fuji IX GP, GC Cavity Conditioner was applied. Similarly, in group 2 before restoration of the cavity with Ketac N100, Primer Ionomer N100 was applied to the cavity walls. In groups 3, 5, 7 and 9, the restorative materials were used in combination with a fluoride-releasing dental adhesive; in groups 4, 6, 8 and 10, a non-fluoride-releasing adhesive was used. This facilitated estimation of the comparative effectiveness of fluoride-releasing dental adhesives with regard to inhibition of enamel demineralisation. Group 10 (Filtek Z250 + Scotchbond 1XT) was the control group of the study. The specimens were stored at 37 C and 100% relative humidity for 24 h before being finished with polishing disks of 2 grades (fine and extra-fine) (Sof-Lex, 3M ESPE; St Paul, MN, USA) for 15 s at low speed with water cooling. After finishing of the restorations, the specimens were subjected to thermal stress in a thermocycling machine (3000 cycles of 5 C 37 C 50 C), with a dwell time of 15 s, and were then stored for 30 days at 37 C in saline solution (0.9% NaCl). Artificial secondary caries challenge Two coats of acid-resistant varnish were applied to the specimen surface, leaving a 1 mm window around the cavity margins. Artificial caries challenge was applied to the specimens via a 15-day ph-cycling regimen to simulate caries development. 4 Oral Health & Preventive Dentistry

5 μg/cm 2 F Days Fuji IX GB Ketac N100 Wave Dyract Extra Beautifil II Filtek Z250 Fig 1 Fluoride release from the restorative materials investigated (μg/ cm 2 ) during 15-day period μg/cm 2 F Stae Prime & Bond NT FL-Bond II Scotchbond 1 XT Days Fig 2 Fluoride release from the dental adhesives investigated (μg/cm 2 ) during 15-day period. Specimens were stored in individual bottles containing 10 ml of a demineralisation solution at ph 4.5 (2.2 mm Ca, 2.2 mm P, 50 mm acetate buffer) for 8 h at 37 C and then in 10 ml of a remineralisation solution at ph 7.0 (1.5 mm Ca, 0.9 mm P, 130 mm KCl, 20 mm buffer TCP) for 16 h at 37 C (15 cycles), similar to the methods reported in ten Cate and Duijsters 30 and Featherstone et al. 11 After ph cycling, the specimens were embedded in epoxy resin and two 150-μm-thick longitudinal sections were made in the middle of both restorations utilising a low-speed diamond saw microtome (Isomet, Buehler; Lake Bluff, IL, USA). A drop of distilled water was placed on all sections, which were then examined using polarised light microscopy (Nikon eclipse 50i, ; Tokyo, Japan) at 400X magnification. The enamel lesion depth, perpendicular to the enamel surface, was measured at 0, 100 and 200 μm from the restoration s margins. Photomicrographs of the lesions from each section were projected onto a digitised, computer-interfaced tablet and the mean depths were determined via a self-contained micrometer (accuracy ± 10 μm). Depth measurements were carried out by two independent researchers who were unaware of the group of the tested specimens and each other s measurements. Statistical analysis Results were analysed statistically using one-way ANOVA (SPSS 17.0). Differences between experimental groups were evaluated using the Bonferroni test, paired t-test and non-parametric Wilcoxon test; p < 0.05 was deemed to indicate statistical significance. RESULTS Fluoride release Fluoride release patterns of the tested restorative materials and dental adhesives during the 15-day experimental period are shown in Figs 1 and 2, respectively. Cumulative fluoride release (means and standard deviations) from restorative materials and dental adhesives over a 15-day period is shown in Table 4. According to statistical analysis of the results of this study, fluoride-containing materials release different amounts of fluoride ions, depending on the type and composition of the material. Fuji IX GP, which is a conventional GIC, released the highest amount of fluoride ions during the 15-day peri- doi: /j.ohpd.a

6 Table 4 Mean values and standard deviations (μg/cm 2 ) of cumulative fluoride release during the 15-day period for all dental materials tested Restoratives Cumulative fluoride release (μg/cm 2 ) Fuji IX GP Ketac N100 Dyract Extra Beautifil II Wave Filtek Z ± a ± b ± 2.11 c ± 2.63 d ± 2.36 d 0.46 ± 0.00 e Adhesives Prime & Bond NT Stae Fluorobond II Scotchbond 1XT ± 2.83 a ± 2.15 b ± 1.80 b 0.19 ± 0.00 c *Same superscript letters indicate no significant differences (p > 0.05) among the restorative materials or dental adhesives. a b c Fig 3a Representative photomicrograph illustrating lesion development adjacent to Fuji IX GP restoration (400X). RE: restoration; EN: enamel; DE: dentin; SL: surface lesion; IZ: inhibition zone. Fig 3b Representative photomicrograph illustrating lesion development adjacent to Ketac N100 restoration (400X). RE: restoration; EN: enamel; DE: dentin; SL: surface lesion; IZ: inhibition zone. Fig 3c Representative photomicrograph illustrating lesion development adjacent to Filtek Z250 + Scotchbond 1 XT (control group) restoration (400X). RE: restoration; EN: enamel; DE: dentin; SL: surface lesion. od among the restorative materials (p < 0.05), followed by Ketac N100 (RMGIC). The resin-based materials released lower amounts of fluoride ions. Dyract Extra exhibited greater fluoride release than Beautifil II and Wave (p < 0.05), which did not differ significantly from each other. Among the dental adhesives, the highest amount of fluoride ions during the 15-day period was released from Prime & Bond NT (p < 0.05), followed by Stae and Fluoro Bond II, which did not differ significantly from each other. Inhibition of enamel demineralisation surrounding restorations Enamel lesions were evident adjacent to all restorations tested at incisal and cervical margins. The enamel lesion depths (means and standard deviations) surrounding the restorations as determined by polarised light microscopy are presented in Table 5. Statistically significant differences between experimental groups and distances are also shown in Table 5. Representative photomicrographs of typical lesions associated with the various materials are presented in Fig 3a to 3c. 6 Oral Health & Preventive Dentistry

7 Table 5 Means and standard deviations in μm of depth of enamel lesions at the three distances 0, 100 and 200 μm from the restoration margins for each group tested (percent reduction of surface lesion depth for each group in comparison with the group 10 [control]) 0 μm 100 μm 200 μm 1 Fuji IX GP 56.0 ± ,a (84.5%) 85.2 ± ,b (75.8%) ± ,c (69.3%) 2 Ketac N ± ,a (71.4%) ± ,b (60.3%) ± ,c (55.3%) 3 Dyract Extra + Prime &Bond NT ± ,4,5,a (53.6%) ± ,4,5,6,b (40.4%) ± ,4,5,6,c (38.1%) 4 Dyract Extra + Scotchbond 1 XT ± ,4,5,6,a (47.9%) ± ,4,5,6,b (34.5%) ± ,4,5,6,7,c (31.5%) 5 Beautifil II + Fluoro Bond II ± ,4,5,6,a (45.2%) ± ,4,5,6,7,b (33.8%) ± ,4,5,6,7,c (31.7%) 6 Beautifil II + Scotchbond 1 XT ± ,5,6,7,a (39.3%) ± ,4,5,6,7,b (32.2%) ± ,4,5,6,7,c (28.5%) 7 Wave + Stae ± ,7,8,a (30.8%) ± ,6,7,8,b (23.1%) ± ,5,6,7,8,c (20.2%) 8 Wave + Scotchbond 1 XT ± ,8,9,a (20.7%) ± ,8,9,b (15.4%) ± ,8,9,10,c (10.0%) 9 Filtek Z250 + Stae ± ,9,10,a (10.6%) ± ,9,10,a (6.1%) ± ,9,10,a (6.0%) 10 Filtek Z250 + Scotchbond 1 XT ± ,10,a Control ± ,10,a Control ± ,9,10,a Control Superscript group numbers in the same column indicate no statistically significant difference between these groups. Same superscript letters (in rows) indicate no statistically significant difference between distances. The fluoride-releasing restorative materials tested in this study yielded significantly shallower enamel lesions than those found in the control group (group 10) at all distances (p < 0.05). Statistical analysis of the results indicated that Fuji IX GP, the material that exhibited the greatest fluoride-release ability, exhibited significantly lower enamel lesion depths surrounding the restorations than did the other materials, followed by Ketac N100. Groups 4 and 6 did not differ significantly from each other in lesion depth, while group 8 was only superior to the control group with regard to reduced lesion depth (p < 0.05). In comparison with the control group, the reduction in mean lesion depth was 84.5% for Fuji IX GP and 71.4% for Ketac N100, while for the other groups it ranged between 20.7% and 53.6% at a 0-μm distance. For all fluoride-releasing materials, the degree of protection was greater near the material and there was an increase in lesion area associated with distance (p < 0.05, Table 4). Moreover, the results yielded no statistically significant difference in the depth of enamel lesions based on whether the restorative materials were applied with a fluoride-releasing or a non-fluoride-releasing dental adhesive (p < 0.05, Table 4). DISCUSSION Fluoride release The fluoride-containing materials evaluated in this study released measureable quantities of fluoride during the 15-day experimental period. However, there was a substantial variation in the amount of fluoride released. Consequently, the first null hypothesis is rejected. This observation is in agreement with the findings of many other authors. 2,9,24 The elution of fluoride ions is a complex process. It can be affected by several intrinsic factors, such as formulation of organic matrix and fillers, amount of inherent or added fluoride, as well as solubility and porosity of the materials. 35 It is also influenced by external variables such as ph and temperature of the environment, frequency of changing the stor- doi: /j.ohpd.a

8 age solution, plaque and pellicle formation, as well as the type of storage media utilised. 17 Additionally, the powder:liquid ratio used in preparing the material, as well as the method of mixing, curing time and exposed surface area of the material may all affect fluoride release. 3,31 The greatest amount of fluoride ions was released by Fuji IX GP (conventional GIC), followed by Ketac N100 (RMGIC). GICs have different fluoride release mechanisms and contain higher amounts of fluoride than do resin-based materials. Two mechanisms have been proposed by which fluoride may be released from GICs into an aqueous environment. The first is a short-term reaction which involves rapid dissolution of fluoride from the outer surface into the solution and the second is more gradual, resulting in a sustained diffusion of fluoride through the bulk cement. 6 RMGICs have generally been found to release fluoride in amounts equivalent to those of conventional GICs. 9 This potential may be affected not only by the formation of complex fluoride compounds and their interaction with polyalkenoate acid, but also by the type and amount of resin used for the photochemical polymerisation reaction. 34 Resin-based materials released much lower amounts of fluoride ions than did GICs. This is in agreement with many other studies. 28 Dyract Extra is a compomer, which contains a mixture of monomers and reactive glass fillers containing SrF 2. The initial setting happens by photopolymerisation, which is followed by an acid/base reaction that arises from water sorption. 10 Beautifil II (giomer) also contains fluoridated glass fillers with a glassionomer matrix layer. Unlike compomers, fluoroalumino-silicate glass particles have reacted with polyacrylic acid prior to inclusion into the resin matrix. 18 Fluoride levels leached from fluoride-releasing composites such as Wave are much lower than levels released from GICs, and also somewhat lower than that released from compomers. 21 This may be because they do not undergo an acid/base reaction. It may also be a result of their low initial fluoride content. Fluoride-releasing dental adhesives released low amounts of fluoride ions during the experimental period. The quantitative differences between the materials may be attributed to differences in inherent fluoride, or fluoride added by the manufacturer. The fluoride release of dental adhesives may also be influenced by the solubility and type of the active component, as well as by the phase (organic or inorganic) to which it is added. 16 Furthermore, fluoride release from dental adhesives increased with the hydrophilicity and acidity of the polymer matrix. 1 Inhibition of enamel demineralisation surrounding restorations Many in vitro studies have shown that fluoride-releasing restoratives can inhibit the enamel demineralisation induced by acidic gels or demineralising buffer solutions. This ability depends on the amount of fluoride released from the materials. 33 In the present study, all fluoride-releasing materials tested had an inhibitory effect on the development of experimental lesions around the fluoride-releasing materials when compared with a non-fluoridated composite. This inhibitory effect may be due to the presence of fluoride ions around restorations and was dependent on the concentration of fluoride ions released. As a consequence, the second null hypothesis is rejected. Inhibition of enamel demineralisation has been shown to occur in vitro at distances of up to 7 mm from RMGIC restorations. 29 Other studies reported that the degree of protection was highest in close vicinity to the restorations, and that the depth of lesions increased with the distance and was inversely associated with the level of fluoride released. 13 In this study, the degree of protection offered by the fluoride releasing materials tested was greater near the material, and there was an increase in the lesion depth associated with distance. Fuji IX GP yielded significantly shallower enamel lesions around the restorations than all of the other materials tested. This is in agreement with other studies. 26,33 Enamel lesion depth was reduced by 84.5% as compared to the lesion depth adjacent to non-fluoridated filling materials. Reported reductions in lesion depth yielded by conventional GICs as compared to non-fluoridated materials range from 58% to 80%; 32 the results of the present study exceeded this range. Four specimens of group 1 (Fuji IX GP) exhibited complete inhibition of demineralisation around the restorations (Fig 3a). Similar findings have been reported previously, 23 and they were attributed to the high levels of fluoride released from GICs. Dijkman et al 7 reported that a monthly cumulative fluoride release of 200 to 300 μg/cm 2 is sufficient to completely inhibit enamel demineralisation. In the present study Fuji IX GP released μg/cm 2 F - after 15 days. Ketac N100 yielded shallower enamel lesion depth than did resin-based restoratives. These re- 8 Oral Health & Preventive Dentistry

9 sults are in agreement with those of other authors. 15 Reduction in lesion depth was 71.4% compared to control material; this lies within the reduction range reported for RMGICs compared to non-fluoridated materials, which ranges from 35% to 75%. 32 Group 4 (compomer) exhibited less enamel lesion depth than group 8 (fluoridated composite) and control group 10, but did not differ significantly from group 6 (giomer). Reduction in lesion depth for Dyract Extra restorations was 47.9% compared to the lesion depth adjacent to control material. This is in agreement with previous studies investigating compomers. 32 Similarly, reduction in lesion depth for Beautifil II restorations was 39.3% compared to the control group. It has been found that giomers inhibit enamel demineralisation around restorations. 15 Wave reduced lesion depth by 20.7% compared to the control group. This is in agreement with previous reports that fluoride-releasing composite resins can reduce lesion depth by 9% to 40% as compared to non-fluoridated control material. 32 In our study, there was no significant difference in enamel lesion depth when the same restoratives were compared with a fluoride-releasing or a nonfluoride-releasing adhesive. Consequently, the third null hypothesis cannot be rejected. The explanation for this finding may be that the amount of fluoride ions released from fluoride-releasing adhesives is low, and/or that adhesives are applied to cavities in very small quantities. Jacobson et al 20 showed that a concentration of fluoride ions of approximately 3 ppm initiates the remineralisation of enamel, while at lower concentrations, there is no inhibition of demineralisation of enamel. In the present study, fluoride release from the dental adhesives tested ranged from 0.89 ppm to 1.59 ppm on the first day of the experiment. It has been reported that fluoride concentrations between 5 and 80 ppm at the interface between restoration and tooth tissues may be the optimal range to prevent caries formation. 7 Furthermore, the adhesive layer may absorb some of the fluoride ions released from fluoridereleasing restoratives, and thus the diffusion of fluoride ions into cavity enamel may be reduced. 5 There are several in vitro studies investigating the effectiveness of fluoride-releasing dental adhesives on the inhibition of secondary caries, but the results of these studies are not consistent. Some report an influence on inhibition of demineralisation 19 but others did not detect any relationship. 27 Most in vitro studies have found evidence for inhibition of enamel demineralisation around restorations by fluoride-releasing restoratives, although they were not able to eliminate the enamel lesions. Currently, relatively few in vivo and in situ studies have investigated the demineralisation behaviour of enamel adjacent to fluoride-releasing restoratives. Because the results of these studies are not consistent, the clinical relevance of fluoride-releasing restoratives is still debatable. 32 In the oral environment, the protective effect of fluoride-releasing materials against caries may be related to the capacity of the material to release adequate amounts of fluoride ions for sustained periods of time and during acidic attack. The fluoride recharging ability of these materials and the utilisation of fluoridated agents such as fluoride solutions, gels, or dentifrices, may be of great importance for this purpose. Despite the high release of fluoride ions from restoratives in some studies, particularly from GICs, secondary caries has been found to be the main reason for the clinical failure of restorations. 4 Moreover, GICs are not considered to have adequate physical and mechanical properties for general use, 22 while compomers and composite resins exhibit good clinical performance over time. On the other hand, GICs are mostly found to have a significantly better capacity as fluoride reservoirs than do resin-based materials. 8 Consequently, fluoride-releasing materials may be useful as a part of a caries preventive programme, especially for patients with high caries risk. In order to provide a constant release of high amounts of fluoride, the development of restorative materials with excellent physicomechanical properties and fluoride release and recharge abilities is of great importance with regard to the longevity of restorations. CONCLUSIONS Within the limitations of this study, it can be concluded that fluoride-releasing restorative materials reduce enamel demineralisation around restorations, albeit to different extents depending on the levels of fluoride they release. Glass-ionomer materials inhibit enamel demineralisation more effectively than do resin-based materials. Fluoride-releasing dental adhesives do not influence artificial enamel lesion formation. Further clinical studies, preferably using the split-mouth design, are needed to evaluate the impact of fluoride-releasing restoratives and adhesives on secondary caries formation. doi: /j.ohpd.a

10 REFERENCES 1. Asmussen E, Peutzfeldt A. Long-term fluoride release from a glass ionomer cement, a compomer, and from experimental resin composites. Acta Odontol Scand 2002;60: Attar N, Onen A. Fluoride release and uptake characteristics of aesthetic restorative materials. J Oral Rehabil 2002;29: Brooks ES, Miller BH, Nakajima H, Guo I. Manipulation effects on fluoride release from chemically-cured and resinmodified glass ionomers. Am J Dent 1997;10: Burke FJT, Cheung SW, Mjor IA, Wilson NHF. Restoration longevity and analysis of reasons for the placement and replacement of restorations provided by vocational dental practitioners and their trainees in the United Kingdom. Quintessence Int 1999;30: Castro GW, Gray SE, Buikema DJ, Reagan SE. The effect of various surface coatings on fluoride release from glassionomer cement. Oper Dent 1994;19: Dhondt CL, De Maeyer EA, Verbeeck RM. Fluoride release from glass ionomer activated with fluoride solutions. 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