|Year : 2020 | Volume
| Issue : 2 | Page : 138-144
Effect of three silver diamine fluoride application protocols on the microtensile bond strength of resin-modified glass ionomer cement to carious dentin in primary teeth
Savil Ramachandra Uchil1, Baranya Shrikrishna Suprabha1, Ethel Suman2, Ramya Shenoy3, Srikant Natarajan4, Arathi Rao1
1 Department of Pediatric and Preventive Dentistry, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Manipal, India
2 Department of Microbiology, Kasturba Medical College, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka, India
3 Department of Public Health Dentistry, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Manipal, India
4 Department of Oral Pathology and Microbiology, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education, Manipal, India
|Date of Submission||01-Apr-2020|
|Date of Acceptance||03-Jun-2020|
|Date of Web Publication||28-Jun-2020|
Dr. Baranya Shrikrishna Suprabha
Department of Pediatric and Preventive Dentistry, Manipal College of Dental Sciences, Light House Hill Road, Mangalore - 575 001, Karnataka
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Use of silver diamine fluoride (SDF) after selective caries excavation can arrest the further progress of the carious lesion. Application of potassium iodide (KI) can reduce the staining due to SDF.Aim:The aim of the study was to evaluate the effect of the application of SDF, with and without acid etching and KI on the bond strength of resin-modified glass ionomer cement (RMGIC) to the carious dentin of primary teeth. Materials and Methods:In thisin vitro study, caries was induced on the occlusal surface by inoculating Streptococcus mutans strain in 36 extracted primary molars. The teeth were divided into four groups (n = 9), and the following treatments were done to the carious dentin prior to final restoration with RMGIC: Group I: 10% polyacrylic acid conditioner, Group II: 38% SDF, Group III: 37% phosphoric acid etchant followed by 38% SDF, and Group IV: 37% phosphoric acid etchant followed by 38% SDF and 10% potassium iodide solution. The microtensile bond strength was measured using universal testing machine. Failure modes were recorded using a scanning electron microscope. Results: There was no significant difference in microtensile bond strengths between the groups (P = 0.665), with the highest value seen in Group III. Conclusions: Application of SDF with or without acid etching and KI does not affect the bond strength of RMGIC to carious dentin of primary teeth.
Keywords: Deciduous tooth, dental caries, glass ionomer cements, potassium iodide, silver diamine fluoride
|How to cite this article:|
Uchil SR, Suprabha BS, Suman E, Shenoy R, Natarajan S, Rao A. Effect of three silver diamine fluoride application protocols on the microtensile bond strength of resin-modified glass ionomer cement to carious dentin in primary teeth. J Indian Soc Pedod Prev Dent 2020;38:138-44
|How to cite this URL:|
Uchil SR, Suprabha BS, Suman E, Shenoy R, Natarajan S, Rao A. Effect of three silver diamine fluoride application protocols on the microtensile bond strength of resin-modified glass ionomer cement to carious dentin in primary teeth. J Indian Soc Pedod Prev Dent [serial online] 2020 [cited 2021 May 18];38:138-44. Available from: https://www.jisppd.com/text.asp?2020/38/2/138/288217
| Introduction|| |
The conventional protocol for the management of a carious lesion includes complete mechanical removal of the infected, demineralized tooth structure and placement of a restoration. Complete caries excavation can be a struggle for the clinician due to the limited cooperating ability of young child patients. With the current understanding of caries process as basically driven by the metabolic process in the dental plaque leading to demineralization, there is an increased emphasis on sealing the carious lesion rather than excavating all dentinal caries., This has resulted in the development of conservative caries excavation techniques such as selective caries excavation to soft or firm dentin.
Silver diamine fluoride (SDF) can be a useful tool in the management of dental caries by minimal intervention, by both preventing and arresting the carious lesion in primary and permanent teeth., The ability to arrest the existing caries is attributed to the formation of silver phosphate precipitate and calcium fluoride, from which the fluoride is available for remineralization. In addition, it possesses a broad spectrum of antibacterial action against various cariogenic microorganisms. SDF is commercially available as solutions with concentrations varying from 10 wt% to 38 wt%, of which, the 38 wt% concentration has been shown to be more effective. For improved bond strength, etching with 37% phosphoric acid prior to the application of SDF on carious dentin may be considered, as it facilitates permeation of SDF into the demineralized dentin. However, the use of SDF is limited by its staining property. Immediate application of potassium iodide solution (KI) after SDF application results in the formation of a yellowish precipitate of silver iodide, which decreases the availability of silver ions that stain the dentin black.
In silver modified atraumatic restorative technique (SMART), carried out to prevent further progression of the carious lesion, SDF is placed on the carious dentin after selective caries excavation to soft dentin and restored or sealed immediately with glass ionomer cement (GIC)., Based on the scientific evidence, resin-modified glass ionomer cement (RMGIC) has been recommended as a restorative material for primary molars. It has advantages over the conventional GIC due to better bond strength, high early strength, and less moisture sensitivity, thus resulting in low solubility and disintegration. While the bond strength of autocure GIC after application of SDF + KI has been studied earlier,,, the effect of the application of SDF + KI on the bonding of RMGIC to dentin has not been studied.
Hence, the aim of the study was to compare the microtensile bond strength of RMGIC to carious dentin surfaces in primary teeth, with and without treatment of SDF and KI. In addition, the effect of application of SDF with and without acid etching on bond strength was studied. In addition, the failure modes (cohesive, adhesive, and mixed) on the debonded surfaces of the specimen were determined. The null hypothesis was that microtensile bond strengths of RMGIC to carious dentin of primary teeth are not affected by the application of SDF, with or without acid etching and with or without the application of KI.
| Materials and Methods|| |
For thisin vitro experimental study, primary molars extracted for orthodontic reasons with no dental caries or with carious lesions limited to the outer enamel were selected. The sample size was nine in each group, with a total of 36 primary molars. The sample size was calculated at 5% level of significance and 90% power, assuming that the difference to be tested relative to standard deviation of the mean tensile bond strength is 4 MPa with a standardized difference of one, when the samples are equally allocated to each group (r = 1). The study was initiated after obtaining clearance from the institutional ethics committee (ref no. 18041).
The collected teeth were stored in 10% formalin for at least 14 days and no longer than a month. Formalin was used as a storage media for specimens, as it does not affect the bond strength of materials when stored up to 1 month., The collected teeth were examined under a light microscope (OLYMPUS CH20i, Olympus Corporation, Japan), and those with cracks and structural defects were discarded. The tooth roots were severed using a high-speed handpiece with a water coolant and diamond bur, 2 mm below the cemento-enamel junction. The pulp chambers were cleaned using a large round bur in a slow-speed handpiece, excavating the pulp with a spoon excavator from the root end. To increase the resistance form of the tooth, the cleaned pulp chambers were filled and sealed with resin composite. The occlusal enamel was ground flat using a slow-speed diamond disc with the water coolant. The surfaces were then abraded and smoothened with silicon carbide paper (600 grit) on a water-cooled lathe to expose a flat dentin surface and reducing the dentin thickness by 1 mm. The exposed tooth surfaces were examined under a light microscope to ensure that no enamel remains. The specimens were covered with nail varnish to leave only the area of flat dentin exposed.
Caries was induced on the exposed dentin microbiologically, by inoculating Streptococcus mutans MTCC 497 (108 colony-forming unit/ml). As a first step, the specimens were autoclaved and then aseptically transferred to cariogenic solution in a Mac Cartney bottle. The cariogenic solution consisted of 3.7 g of brain–heart infusion (BHI) broth, 2.0 g of sucrose, 1.0 g of glucose, and 0.5 g of yeast extract for every 100 ml of distilled water with a pH of around 4.0. Prior to the inoculation of 2% of S. mutans, the solution was autoclaved at 121°C for 20 min. The teeth were immersed in the acidic cariogenic solution and incubated at 37°C in a CO2 incubator for 6 weeks. To provide additional fresh substrate to the microorganisms, the specimens were transferred to a Mac Cartney bottle which contained a fresh cariogenic solution, every 48 h. The viability of the organism was maintained by repeated subculture into a fresh BHI broth every 24 h. The S. mutans strain was preserved in 20% glycerol broth at −20°C. Caries induction was confirmed by examining the dentin. Change in the color of the dentin to yellowish brown and softness felt by a blunt probe was considered the end point of caries induction. The biofilm covering the teeth was cleaned with a gauze, and the specimens were autoclaved.
The teeth were then randomly divided into four groups, which consisted of nine teeth each, and the following treatments were done to the carious dentin prior to final restoration with RMGIC:
- Group I (conventional): Caries-induced flat dentin surface was conditioned with 10% polyacrylic acid (GC Dentin Conditioner, GC Dental Corporation, Tokyo, Japan) applied using a micro brush for 20 s. The specimen was rinsed with water to remove remnants of polyacrylic acid and blot dried with a cotton pellet.
- Group II: Caries-induced flat dentin was treated with 38% SDF (Fagamin®, Tedequim Company, Córdoba, Argentina) (44,800 ppm fluoride) using a micro brush for 2 min, rinsed for 30 s with distilled water.
- Group III: Caries-induced flat dentin surface was treated with 37% phosphoric acid etchant (3M™ ESPE™ Scotchbond Etchant, 3M ESPE, St. Paul, Minnesota, USA) for 5 s. The tooth specimen was then rinsed with water for 15 s and blot dried. 38% SDF was applied as in Group II.
- Group IV: Caries-induced flat dentin surface was treated with an etchant as in Group III. 38% SDF was applied as in Group II. Immediately after SDF application, KI (Lugol's solution 10 wt%, Nice Chemicals, Kochi, India) was applied using a separate micro brush. The KI liquid was reapplied until no white precipitation was observed to form and then washed with distilled water.
After different surface treatments of the carious dentin, all the specimens were blot dried with a sponge to leave moist dentin. A T-band metal matrix was placed to enclose the entire border of the tooth sample. RMGIC (GC Gold Label Light Cured Universal Restorative Material, GC Corporation, Tokyo, Japan) was mixed as per manufacturer's instructions. 4-mm-thick buildups of RMGIC were placed using a cement carrier on the treated surface dentin, condensed with a cement condenser to avoid voids, and cured using a visible light-curing device (Elipar 2500, 3M ESPE, Dental Products, St Paul, MN, USA) for 20 s. The light intensity of the halogen light-curing device was tested using a radiometer (Demetron 100, Demetron Research Corporation, Danbury, Connecticut, USA) for each specimen (minimum threshold = 600 mW/cm2).
The completed specimens were stored in distilled water for 7 days. Each tooth specimen was sectioned serially in the occluso-gingival direction, producing 1–mm-thick slabs with a water-cooled diamond saw at slow speed (Bainmet, Chennai Metco Company, Chennai, India, with Buehler Isomet Wafering Blade, LakeBluff, IL, USA). The resulting specimens, termed as beams, had cross-sectional areas of 1.0 mm × 8.0 mm, with RMGIC at the upper half and dentin at the lower half. At least two beams were derived from each tooth specimen. Each specimen was placed in the testing jig of a universal testing machine (Zwick Roell Testing Machines, Chennai, India) and stressed in tension at a crosshead speed of 1 mm/min until bond failure was seen. The maximum stress at failure was documented and converted to megapascal units (MPa).
The specimens were air dried and mounted on brass stubs using carbon tape, with the area to be studied facing upward. A thin layer of pure gold (30-μm thickness) was coated on each specimen using an ion sputtering unit of 10 mA (JFC-1600 Auto Fine Coater, JEOL, Tokyo, Japan) for a period of 100 s. The stubs were loaded in a special tray and placed in a vacuum chamber of scanning electron microscope (JSM-6380 LA, JEOL, Akishima, Japan). To determine the failure mode, the dentin side of the fractured specimens was scanned and the most characteristic areas were photographed at ×35, ×200, and ×500 magnifications.
The failure modes were described as follows:
- Adhesive failure: If 100% of the bonded interface failed between the dentine and the restorative material (no restorative material remaining on the dentin surface)
- Cohesive failure: If 100% of the failure was in the material with no dentin surface exposed
- Mixed failure: Partially adhesive and partially cohesive failures with some material remaining on the dentin surface.
Statistical data were analyzed using IBM SPSS Statistics for Windows, Version 20 (IBM Corporation, Armonk, NY, USA). Descriptive data were obtained, and the Shapiro–Wilk test was used for testing the normality of the data. Nonparametric Kruskal–Wallis test was used for comparison of microtensile bond strength values between the groups. The frequency of failure modes between the groups was analyzed using Chi-square test.
| Results|| |
Microtensile bond strength comparison
The control group samples had the least mean microtensile bond strength, whereas the maximum mean bond strength was seen in Group III, where SDF was applied after acid etching. Shapiro–Wilk test for testing normality of the data was statistically significant (P < 0.001). Because the data revealed a nonnormal distribution, the Kruskal–Wallis test was used for comparison of the microtensile bond strengths between the groups, which indicated that the difference between the groups was not statistically significant (P = 0.665) [Table 1].
|Table 1: Microtensile bond strengths of the groups compared using Kruskal-Wallis test|
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Failure mode observation
Overall, the frequency of adhesive failures was the highest, followed by mixed failures. Chi-square test indicated that there was a statistically significant difference in failure modes between the control group and test group (χ2 = 17.52; df = 6; P = 0.008). In the control group, all specimens showed adhesive failure. Cohesive failure was the predominant failure mode in Group II. In Group III and Group IV, both mixed and adhesive failures occurred with equal frequencies [Table 2].
|Table 2: The frequency distribution of different failure modes for each group|
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[Figure 1] and [Figure 2] illustrate the representative images of adhesive, cohesive, and mixed failures. In adhesive failure specimens of silver diamine groups, a uniform layer was seen covering the dentinal tubules, representing the impregnation of silver into the dentinal tubules. However, in Group I, areas of smear layer were still visible, indicating that polyacrylic acid did not completely remove the smear layer. On the other hand, specimens with cohesive failure were covered with a thin layer of RMGIC. In specimens with mixed failures, areas with agglomerates of glass ionomer were visible along with areas of open dentinal tubules.
|Figure 1: Scanning electron microscopy images of representative fracture surfaces of Group 1 and Group 2. (1a-1c) Group 1 (control group): Debonded surface of the specimen at ×35, ×200, and ×500 magnification, respectively. (2a-2c) Group 2 (SDF and RMGIC group): Debonded surface of the specimen at ×35, ×200, and ×500 magnification, respectively. (1b) Adhesive failure, where most of the dentin surface is exposed with smear layer remaining on the dentin surface (white arrow). (1c) Some material was adherent to the dentin surface (yellow arrow) and the dentin was partly denuded. (2b) Cohesive failure where dentin surface is fully covered with the material. (2c) Image at higher magnification shows dense spherical granular structures in the intertubular area|
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|Figure 2: Scanning electron microscopy images of representative fracture surfaces of Group 3 and Group 4. (3a-3c) Group 3: (Etchant, SDF and RMGIC group): Debonded surface of the specimen at ×35, ×200, and ×500 magnification, respectively. (4a-4c) Group 4: (Etchant, SDF, KI, and RMGIC): Debonded surface of the specimen at ×35, ×200, and ×500 magnification, respectively. (3b) Both partial adhesive failure and partial cohesive failure, shows areas of dentinal fragmentation, denudation, and partial material coverage; open dentinal tubules in many areas (yellow arrow). (3c) At higher magnification shows open dentinal tubules (yellow arrow) and blocked dentinal tubules due to the penetration of silver phosphate; penetration of material into the dentinal tubules (white arrow). (4b) Both partial adhesive failure and partial cohesive failure, show areas of dentinal fragmentation, denudation, and partial material coverage; open dentinal tubules in many areas (yellow arrow); penetration of material into the dentinal tubules (white arrow). (4c) Partially blocked tubule (white arrow). SDF on carious dentin leads to precipitation of silver phosphate that block the dentinal tubules|
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| Discussion|| |
The principal objective of this study was to examine if pretreating carious primary dentin with SDF using three protocols, would adversely affect the bond strength between RMGIC and carious dentin. The present study used the microtensile bond test method as it is scientifically most widely accepted and most reliable test method for measuring bond strength to dentin. This test method utilizes multiple specimens from a single tooth; allows testing of small areas, thus overcoming the variation seen in bond strength at larger cross-sectional areas; and better reflects the adhesive failure.
SDF releases fluoride ions and helps in the deposition of silver phosphate to restore the mineral content, resulting in increase in microhardness of the carious dentin surfaces, thus increasing bond strength. The silver granule precipitate formed on the denatured collagen fibrils after application of SDF could, however, result in lower bond strength of restorative material to SDF-modified dentin.
The results of this study, which showed that application of SDF does not significantly affect the bond strength of RMGIC, follow a similar pattern to the results of earlier studies., They measured the microtensile bond strength of conventional or reinforced autocure GIC, used as a restorative material in atraumatic restorative treatment, after application of SDF, and found no significant difference in bond strength. However, lower bond strength was reported when the SDF was allowed to dry after application. It should be noted that the currentin vitro studies on bond strengths of GIC to dentin after SDF application vary in the type of bond strength test, SDF treatment protocol to dentin, and the type of GIC used. While in earlier studies, SDF was applied over demineralized dentin or carious dentin;, in the current study, microbiological caries induction method was used to simulate the color and texture of natural carious lesion and the microtensile bond strength of RMGIC was tested after SDF application. Because SDF is to be applied on carious dentin, it is appropriate to study its effect on bond strength of materials after microbiological caries induction.
The results also showed that prior acid etching and application of KI did not affect bond strength. Traditionally, 10% polyacrylic acid solution is applied to condition the dentin surfaces, prior to the placement of GIC. In contrast to the conditioning, the smear layer and smear plug are additionally removed by the application of 37% phosphoric acid, which decreases the surface bioload. Although acid etching is known to cause the collapse of the collagen fibers in dentin, it does not significantly affect the tensile bond strength of GIC to dentin. The bond strength further increased when SDF was applied after acid etching, similar to the results of an earlier study. This is due to the property of SDF to increase the mineral content of dentin by penetrating into the dentinal tubules and collagen fibril network,, thus leading to an increase in bond strength. Application of SDF after acid etching, enhances fluoride uptake in the demineralized dentin, with no interference in the uptake of strontium ions, indicating no interference in bonding. RMGIC bonds to the dentin by chemical and also micromechanical bonding, similar to resin adhesives. The silver uptake by the dentinal tubules after application of SDF can occlude the flow of dentinal fluid, thus facilitating the micromechanical bonding of the resin component of the RMGIC. Further studies are required to clearly understand the ultrastructural bonding mechanism of RMGIC to dentin after application of SDF. Knight et al. inferred that the shear bond strength of auto-cure GIC to dentin is significantly reduced when SDF-KI precipitate is left on the surface, and hence should be washed off. Hence, in this study, the same protocol was used. In concurrence with the findings of this study, Zhao et al. also concluded that the immediate application of KI solution after SDF treatment does not negatively affect adhesion of GICs to artificial caries-affected dentine.
This study also sought to observe the surface morphology of the fractured specimens. In the control group which had lower bond strengths, all specimens showed adhesive failure, confirming that the values observed in this study are representative of adhesive bond strength. The maximum number of cohesive failures observed in Group II may indicate higher tensile bond strengths when compared to the tensile strength of the material itself. The separation between two materials is dependent on the differences in the elastic moduli and energy dissipation per unit crack extension, in addition to the strength of the interfacial bonds. In case of glass ionomer-dentin bonds, because both elastic moduli and the energy dissipation per unit crack extension are in the same direction, in the presence of high tensile bond strength, fracture of one of the phases may occur. Both adhesive and mixed failures were seen in Group III and Group IV, both of which had slightly higher tensile bond strengths. This implies that the bond strength at the interface surpasses the tensile strength of the dentin and RMGIC.
Considering that acid etching followed by application of SDF with KI does not unfavorably affect the bond strength of RMGIC, this protocol of pretreatment can be applied to carry out SMART RMGIC restorations in children. However, being anin vitro study, the study has its limitations that should be considered before extrapolating the results for clinical application. The degree of demineralization of the dentin was not assessed, which could have influenced the bond strengths. The results should be further validated through clinical trials before it can be recommended for routine clinical use.
| Conclusion|| |
Within the limitations of the study, it can be concluded that, application of SDF with or without acid etching and KI does not affect the bond strength of resin-modified GIC to carious dentin of primary teeth. Pretreatment with SDF and KI may be considered after selective caries excavation to arrest caries, as it does not interfere with the bonding of RMGIC to carious dentin in primary teeth.
The authors would like to acknowledge Mr. Anandhan Srinivasan and Mr. Ravishankar K.S., Department of Metallurgical Materials and Engineering, and Mr. M. N. Satyanarayan, Department of Physics, at National Institute of Technology, Surathkal, Karnataka, for their technical expertise during the conduct of the study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]