2YrRandomizedClinicalTrialof3BondingTechniquesinNCCL

Clinically acceptable after 2 yrs
After 2 years,
one-step self-etch =total etch, = selective enamel etch and self-etch adhesive
(retention rate or marginal adaptation)
> 2ys
marginal adaptation and staining were worse
None presented a caries occurrence.

1. 1 PRESENTED BY Dr. SNEHANGSHU DUTTA PG STUDENT UTTARANCHAL DENTAL AND MEDICAL RESEARCH INSTITUTE DEPARTMENT OF CONSERVATIVE DENTISTRY AND ENDODONTICS JOURNAL CLUB PRESENTATION TOPIC A 2-Year Randomized Clinical Trial of Three Bonding Techniques in Non-Carious Cervical Lesions Eftychia Pappa , Grigoria Gkavela and Afrodite Kakaboura , Ioanna Sampri , Konstantinos Masouras , Christos Rahiotis DEPARTMENT OF OPERATIVE DENTISTRY, DENTAL SCHOOL, NATIONAL AND KAPODISTRIAN UNIVERSITY OF ATHENS, GREECE MEDICINA Volume-60 Issue-6

2. INTRODUCTION AIM AND OBJECTIVE MATERIALS AND METHODS STATISTICAL ANALYSIS RESULTS CONCLUSION 2

3. 3 INTRODUCTION One-step self-etch adhesives are the latest evolution in adhesive systems for resin composite restorations. The rationale for introducing self-etch adhesives was to simplify and accelerate the application technique. By integrating the etching step into the bonding procedure, it was presumed that all the potential over-etching disadvantages and humidity-related limitations observed with the etch-and-rinse (total-etch) adhesives could be surpassed. Moreover, the retention of the smear layer could prevent tooth sensitivity. Unfortunately, not all self-etch adhesives effectively etch enamel. Thus, selective enamel etching with phosphoric acid was proposed in conjunction with the use of self-etch adhesives. In addition, many studies showed inferior bonding performance and durability of one-step self-etch agents compared with etch-and-rinse and two-step self-etch adhesives

4. NCCLs and Their Use in Bonding Research What Are NCCLs? Non-carious cervical lesions (NCCLs) are defects near the gum line (cement-enamel junction) were tooth structure wears away. They often look like a wedge or a shallow cup and are usually caused by acids, brushing too hard, or stress on the tooth. Why Are NCCLs Used in Bonding Research? NCCLs are commonly used in dental studies because many teeth in the same mouth may have them. This allows researchers to test different restoration methods under similar conditions. Why Are They Challenging for Bonding? These lesions don’t have natural grooves or undercuts to hold the filling, and there’s very little enamel. This means the bonding mostly depends on dentin – which is harder to bond with than enamel – making NCCLs a good way to test how well adhesives really work. 4

5. To compare the 2-year clinical performance of resin composite restorations placed at NCCLs with one-step self-etch, total-etch, selective enamel etch and self-etch adhesive techniques. 5 AIM

6. MATERIAL AND METHODS . 6 The clinical trial was a split-mouth, single-center, randomized, controlled study with blinding patients and clinical evaluators. Before patient enrollment, the Committee for Research and Ethics of the School of Dentistry, National and Kapodistrian University of Athens, Athens, Greece, approved the research protocol (Register No. 118). The clinical trial conforms to the guidance set by ClinicalTrials.gov (NCT04565938).

7. 2 OPERATIVE DENTISTRY RESIDENTS 32 PARTICIPANTS, 92 LESIONS Mechanical removal of sclerotic dentin with a round diamond bur Enamel beveling (0.05mm wide) WRITTEN INFORMED CONSENT Atleast 3 NCCLs on the incisors and/or canines and/or premolar of the upper or lower jaw. Located on cervical third of the buccal surface of the tooth Cervical wall placed on dentin 5mm X 3mm X 1.5mm 7

8. INCLUSION CRITERIA > 19 years of age good general health being available for follow-up visits having at least 20 teeth.  8 EXCLUSION CRITERIA Rampant uncontrolled caries/high caries activity Advanced untreated periodontal disease or receiving periodontal treatment >2 cigarette packs/day or equivalent chewing tobacco Systemic or local disorders that contraindicate dental procedure Xerostomia Severe bruxism, clenching, or TMD Patients undergoing orthodontic treatment.

9. RANDOMIZATION The restorations were performed by a single experienced dentist One of the three adhesive procedures for each tooth was selected in a statistically random order using randomization tables. The first randomly selected method was used to restore the tooth with the lowest tooth number (according to the FDI system), and the second method was used for the tooth with the second lowest number, and the third one with the highest. The randomization was performed by a person not involved in the study. 9

10. 10

11. 11

12. 12 Method A : Enamel was etched with 37% phosphoric acid for 30 s and dentin for 15 s, ExciTE F adhesive agent was applied and photocured with 800 mW /cm2 light intensity (Cure TC-01, Spring Health Products, Inc., Norristown, PA, USA), Resin composite Tetric EvoCeram was placed, a transparent cervical matrix (Kerr-Hawe, Orange, CA, USA) covered its surface, the resin composite was photopolymerized for 40s, Finishing/polishing was followed with diamond finishing burs, polishing disks, and silicone polishers. Method B : enamel etching was not performed; AdheSE One F adhesive agent was applied, and the next clinical steps were the same as in Method A. Method C : enamel was etched with N-etch for 30 s, then AdheSE One F adhesive agent was applied, and the next clinical steps were the same as in Method A.

13. BLINDING & FOLLOW UP Two experienced and calibrated examiners performed the evaluation These examiners were not involved with the restoration placement, and therefore, they were blinded relative to the group assignment Before starting the evaluation, an intra-examiner and inter-examiner agreement of at least 85% was necessary The patients did not know which teeth had which restoration. 13

14. Restorations were evaluated at baseline,6, 12, 18, 24 months post-operation. (FDI clinical guideline) 14 Retention and occurrence of caries along the restoration margins were scored as yes or no. The criteria for marginal adaptation and staining were graded from 1 to 5

15. STATISTICAL ANALYSIS 15 Sample size# G*Power 3.1 software Time bonding technique Age gender frequency of brushing Visit to the dentist Number of teeth with abraded surfaces A = 0.05 B= 0.8 Effect size F2 0.35 Sample size = 26 pts MULTIPLE REGRESSION ANALYSIS 32 patients to balance a possible drop-out Logistic regression analysis Cohen’s kappa statistic – Inter examiner agreement

16. RESULT Teeth Group Method A Method B Method C Upper premolars 10 9 10 Lower premolars 9 10 9 Upper canines 7 7 6 Lower canines 4 4 5 Upper incisors 2 2 2 16 DISTRIBUTION OF LESION PER METHOD

17. Women -59.4% Av age-59.5yrs Recall rate: 6 Mo- 100% 24 Mo-87.5% 17 32 32 30 2 Patients Dropped due to health 29 1 Patient dropped out due to immigration 28 1 Patient dropped Due to a personal problem BASELINE 6 MONTHS 12 MONTHS 18 MONTHS 24 MONTHS

18. RETENTION RATE 18 MARGINAL ADAPTATION

19. MARGINAL DISCOLORATION 19 CO RELATION OF MARGINAL ADAPTATION

20. METHOD- A (Total etch) METHOD-B (Self etch) METHOD-C (Selective enamel etch+ Self etch) CARIES (A most common finding in most studies) KAPPA=1 NO NO NO MARGINAL ADAPTATION (clinically perfect restoration after 24 months) 26.9% 16% 25.9% MARGINAL STAINING 3.12% 26.11% 21.64% RETENTION 92.26% 86.8% 93.63% 20

21. CONCLUSION Clinically acceptable after 2 yrs After 2 years, one-step self-etch =total etch, = selective enamel etch and self-etch adhesive ( retention rate or marginal adaptation ) > 2ys marginal adaptation and staining were worse None presented a caries occurrence. 21

22. 22 Results : After 18 months, significantly higher retention rates (95% CI) were observed for the EDTA group (95.5 [84.9–98.7]) than the control group (79.6% [65.5–88.9]) ( p = 0.02). Significant deterioration of the marginal adaptation and marginal discoloration were observed for both groups over the 18-month evaluation. Conclusions : The preliminary conditioning with EDTA before application of a one-step self-etch adhesive significantly improved the retention rates of composite restorations in cervical lesions. Clinical significance: Conditioning with EDTA is an alternative that improves the 18-month retention rate of cervical restorations bonded with a self-etch adhesive.

23. 23 Conclusion As a conclusion, the mild 2-step self-etch adhesive Clearfil SE Bond showed good clinical performance in NCCLs after 13 years. The minor positive influence of selective enamel phosphoric acid etching on marginal integrity and absence of marginal discoloration has remained stable during the last 5 years.

24. 24

25. REFERENCES Sturdevant’s Art & Science of Operative Dentistry, 2nd South Asia Edition Thirteen-year randomized controlled clinical trial of a two-step self-etch adhesive in non-carious cervical lesions M. Peumansa,∗, J. De Munckb , K. Van Landuyta , B. Van Meerbeeka Thirteen-year randomized controlled clinical trial of a two-step self-etch adhesive in non-carious cervical lesions M. Peumansa,∗, J. De Munckb , K. Van Landuyta , B. Van Meerbeeka Effect of adhesive strategy of universal adhesives in noncarious cervical lesions– an updated systematic review and meta-analysis 1✉ Krisha Doshi1, M. S. Nivedhitha1, Pradeep Solete1, Delphine Pricilla Antony S1, Arthi Balasubramaniam2, Benoy Jacob1 and Riluwan Siddique Adhesive dentistry: Current concepts and clinical considerations Jorge Perdig ~ ao DMD, MS, PhD, Professor1 | Edson Araujo DDS, MS, PhD, Associate Professor2 | Renato Q. Ramos DDS, MS, Graduate Student3 George Gomes DDS, MSD, Private Practice4 | Lucas Pizzolotto DDS, MS, Graduate Studen Recommendations for conducting controlled clinical studies of dental restorative materials R. Hickel & J.-F. Roulet & S. Bayne & S. D. Heintze & I. A. Mjör & M. Peters & V. Rousson & R. Randall & G. Schmalz & M. Tyas & G. Vanherle Received: 14 December 2006 /Accepted: 14 December 2006 / Published online: 30 January 2007 Classification review of dental adhesive systems: from the IV generation to the universal type 25

26. CASE PRESENTATION A 30-year-old female patient presented to the Department of Conservative Dentistry and Endodontics with a chief complaint of discoloration in her lower right back tooth region. On intraoral examination, a Glass Ionomer Cement restoration was observed for teeth numbers 46 and 47. Carious lesions were seen around the restored tooth. The patient had no pain and tenderness on percussion was also negative. Based on the intraoral and radiographic findings, a diagnosis of Secondary caries was made wrt 46 & 47. Patient wanted to get her 46 treated first, so a treatment plan was finalized based on the findings. 26

27. 27 Isolation of the tooth (multiple tooth isolation) was done using a rubber dam and clamps ( molar and premolar clamps). Fig 1 The area was cleaned and air dried to prepare a clean surface area for work. The caries and old restoration were removed using a round bur. (no.245) { Fig 2} After careful examination of caries removal, the tooth was etched with 37% phosphoric acid gel.{Fig 3}

28. After etching for 15 seconds, the etchant was rinsed off and the tooth was air dried. 28 After the bonding agent was applied to the tooth and rubbed vigorously with a soft applicator tip, followed by air drying , curing with an LED curing light for 10 – 15 seconds was done.{Fig 3}

29. After application of bonding agent, a layer of flowable composite was applied, followed by packable composite till the occlusal level. Occlusal carving was done, and then the composite was cured using the same light unit for 20 – 30 seconds. 29 Finishing and polishing were done using composite polishing discs.{Fig 4}

30. THANK YOU 30