july 2009tackling post operative sensitivity in composite restorations

8/13/2019 July 2009Tackling Post Operative Sensitivity in Composite Restorations

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TACKLING POST-OPERATIVE SENSITIVITY IN COMPOSITE RESTORATIONS

AbstractIn day to day clinical practice, post-operative sensitivity after composite restorations keeps onresurfacing. This article looks at the probable causes of post operative sensitivity. Relevant factors

like dentin, the adhesive systems and their interrelationship, optimization of bonding & Fusayamas

techni!ue of cavity preparation etc are considered. "linical recommendations are put for#ard tohelp minimize this problem.

Key words$ "omposite resin restorations, post operative sensitivity, dentin bonding, Fusayama

techni!ue.

Author:

Dr. Abhiit !a"hPostgraduate studentDept. of Conservative Dentistry & EndodonticsModern Dental College & Research Centre,Gandhinagar, Indore !"##$.

Contact % Eail'a(agh)#$*yahoo.co.in Mo+ile' -#%-!!!!//!.

%


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TACKLING POST-OPERATIVE SENSITIVITY IN COMPOSITE RESTORATIONS

In this age of aesthetic dentistry and the gro(ing trend to(ards inially invasive

dentistry, posterior coposite restorations have +ecoe the nor of conteporary dental

practice. It has +ecoe a routine for the 0(ell infored1 patient to deand posterior

22aesthetic1 restorations. 3ongst the availa+le options, directly placed coposite

restorations offer an e4cellent option as they are esthetic, afforda+le, can +e placed in a

single appointent and a+ove all, they conserve a lot of tooth structure 5eeping in line (ith

the philosophy of MID.

6o(ever, as (e all 5no(, placing direct posterior coposite restorations is a 0techni7ue

sensitive deanding art1 depending a lot on the clinical situation, the support of the allied

staff and ost iportantly the e4pertise of the dentist. In spite of the ost eticulous

procedure, post%operative sensitivity is one of the a8or pro+les associated (ith this type

of restoration. It is o+served that post%operative sensitivity is a+out #-9 copared (ith

aalga (hich is a+out "9#. :his has +een inii;ed no(adays (ith the evolution of

ne(er +onding agents. :here are various causes of post%operative sensitivity (ith

coposite restorations, +ut the oveent of fluid (ithin the dentinal tu+ules is argua+ly

the ost coon cause of post%operative coplaints$. :his occurs if the dentin surface

has not +een properly sealed (ith the +onding agent.

:his article (ill address the various factors that contri+ute or lead to post%operative

sensitivity and effective (ays to inii;e the. In the end, it is sued up +y soe

iportant clinical considerations (hile restoring posterior teeth (ith coposite resins.

%. D%&ti&a' ()*+%rs%&siti,it* u% to %&ti& +%r/%abi'it*

Dentine (ill only +e sensitive 2post%operatively< should the dentine +e left e4posed

after the restorative process and=or accopanying oral hygiene treatent. Dentin

perea+ility is pro+a+ly the ost iportant factor deterining pulp reactions to

caries, operative procedures & other locali;ed lesions. If the dentin is iperea+le,

either +ecause of intratu+ular inerali;ations or due to the lac5 of tu+ular

counications +et(een priary & secondary dentin, it ay +e a+le to prevent


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pulpal daage. In fact, this particular reaction pattern ay +e the +asis for

successful operative dentistry$.Every effort ust +e ade to restore the prepared

cavity fully. If any gaps are left +ehind, surely there are chances that the tooth (ill

+e sensitive post restoration. Careful inspection of the prepared cavity after

application of +onding agent has to +e done to rule out this factor. 3lso the

cavosurface of the restored cavity after polishing should +e siilarly inspected.

E00%cts o0 %&ti& thic1&%ss o& +%r/%abi'it*

:he hydraulic conductance of dentinal tu+ules is related inversely to their length &

directly related to the th po(er of their radius$. :hus, deeper the cavity ore

chances that the dentinal tu+ules have +ecoe shorter & hyperconductive. :his

increases the potential for dentin sensitivity & the need to seal the thin dentin.

E00%ct o0 r%"io&a' i00%r%&c% i& %&ti& o& +%r/%abi'it*

:he perea+ility of dentin is not unifor throughout the teeth. Dentin located near

the pulp is ore perea+le than that at DE>. :he (ater content of dentin near the

pulp is also ore than at DE>. ?$$9 to #9@. Dentin near pulp horns is ore

perea+le than dentin farther a(ay +ecause of high density & diaeters of tu+ules.

34ial dentin is ore perea+le than pulpal floors. Root dentin is less perea+le

than coronal dentin and the sclerotic dentin +eneath the carious lesions is also lessperea+le +ecause of hyperinerali;ation of that ;one. Aith so uch variation in

dentin, the clinician ust ta5e every precaution to seal the dentin giving careful

consideration to area that is +eing sealed$.

$. D%&ta' Cari%s

3n inflaatory response is the natural defense echanis of the pulp of any

tooth (ith caries that is reaching into the dentine. Early caries does not cause any

pain, +ut any trauatic procedure, such as cavity preparation and=or the placeent

of a restoration, ay trigger an enhanced inflaatory response (ith associated

pain. Bpontaneous pain then occurs once the anaesthetic has (orn off, or soon

after. :he possi+ility of such pain occurring (ill depend on the severity of the caries,

as (ell as possi+le traua caused during the restorative process. 3ny additional

'


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+acterial activity due to post%operative icro%lea5age (ill also e4aggerate the

e4isting inflaation, there+y causing pain.

2. Li&%rs

:his is a controversial, +ut iportant. Do (e really need any for of liner under acoposite restoration (hen a good seal can +e achieved using a +onding syste

Ahy cover the dentine, (hich is an e4cellent +onding surface for conteporary

+onding agents, (ith a liner (ith 7uestiona+le value Current thin5ing is steering

a(ay fro the use of liners +ut still ore research needs to +e done. It has to +e

5ept in ind that a near 2perfect< seal in the clinical situation is very difficult to

achieve, (hile in the situation of a 0not so perfect seal1, the liner ight still have a

real value2. iners, (hen used, need to support ?and 5eep on supporting@ the

overlaying coposite restoration3. 3ny decoposition (ill result in a defective +ase,

causing a possi+le puping=percolating action during astication % resulting in

sensitivity. :he use of calciu hydro4ide liners to stiulate secondary dentine

foration for pulp protection is +eing re%considered. Boe researchers say

secondary dentine (ill for in any case % as a response to the restorative process,

(hile others 7uestion the need for secondary dentine (hen a good seal can +e

provided4. Regardless, any still advocate the use of Calciu 6ydro4ide in near

e4posures. f late use of M:3 has also gained support fro any clinicians.

3pplying a suita+le +onding agent norally eliinates the need for additional cavity

lining5. ne of the ost popular and siplest (ays of reducing or eliinating

postoperative hypersensitivity is +y applying a desensiti;ing +onding agent.

Desensiti;er is applied to the entire cavity surface after it has +een etched, rinsed

and dried. 3fter application, the desensiti;er is dried +riefly (ith a slo( air 8et +efore

the adhesive is applied and polyeri;ed according to the anufacturer


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penetrates directly into the dentinal tu+uli, produces protein coagulation in the

depths of the tu+uli and stops oveent of the tu+ular fluid +y foring a septu.

Many advocate the use of Resin odified Glass ionoer liners or plain Glass

ionoer liners for effective sealing of the dentin follo(ed +y a layer of flo(a+le

coposite263. :his definitely helps in reducing sensitivity and +etter control of

polyeri;ation stress contraction. 6o(ever, handling of GIC is little difficult and

often leads to voids, iproper sealing. It can detach fro the dentin under the filling,

after the filling has +een placed. :his can result in icrocrac5s, (hich lead to

pro+les (hile che(ing and su+se7uent post operative sensitivity.

3. Ca,it* Pr%+aratio& T%ch&i7u%s

a8 Trau/a

:his is an iportant factor often overloo5ed as a possi+le cause of post%operative

pain. Aith dentine +eing a living tissue (e should e4pect soe response, no atter

ho( 0atrauatically1 the caries is reoved and cavity prepared. Bharp +urs,

inial pressure and ade7uate (ater coolant can inii;e the traua during

cavity preparation.

b8 )%at

:his can +e generated during cavity preparation due to e4cessive pressure, and is

often caused +y +lunt +urs. Cavity preparation (ithout using proper (ater spray

could also result in e4cessive heat +uild%up or dehydration of the pulp. Even a sall

! to./FC pulpal teperature rise could cause severe pulpal necrosis. Bharp +urs

(ith ade7uate (ater spray should al(ays +e used during preparation, as (ell as an

interittent drilling action. perators should +e especially careful (hen using slo(

handpieces for caries reoval +urs ust +e sharp, (hile the pressure applied and

duration of contact ust +e 5ept to a iniu.

c8 Pu'+a' %h*ratio&

)


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:his can occur due to the displaceent of pulpal fluid. Dehydration is liited +y the

resulting sear layer, +ut prolonged e4posure, especially after etching, could lead

to pulpal traua through dehydration.

8 Pu'+a' %9+osur%If coplicated (ith +acterial containation, it can definitely cause sensitivity. Caries

on the pulpal floor area should +e reoved last to prevent=liit +acterial

containation in case of an accidental pulpal e4posure ?first reove caries along

the cavity (alls@.

%8 Ca,it* Mar"i&s

3n iportant factor in preventing possi+le icro%lea5age ?and thus sensitivity@ is the

part of the tooth in (hich the cavity argins are located. :he +onding procedure is

only relia+le in dentine and enael +ut 7uestiona+le in ceentu. 3lthough, a

hy+rid layer can +e esta+lished in ceentu, +ut it is not clear if long ter sta+ility

can +e aintained. Root ceentu is often poorly inerali;ed due to :oesD, $))# #'#, "%"N.

!. Christensen G Preventing sensitivity in Class II coposite resin restorations.

>3D3, #--N #$-, #/-%#).

/. Christensen G Preventing postoperative tooth sensitivity in Cl I, II & L

restorations. >3D3, $))$ #""' $$-%$"#.

. Perdigao > et al Dentin +onding as a function of dentin su+strate. DC3, $))$

/'$, $%")$.

. Ho5san 3n overvie( of the current status of posterior coposite resin

aterials and insertion techni7ues. :he Dental 3nnual, #-NNN!%#)).

-. :agai > :ips for successful posterior resin coposite restorations. Ouraray Bp

Report, $))! #%!.

#).Kusayaa : 3 ne( dental caries treatent syste developed in >apan. Proc.

>apan 3cad., #--) //'H, #$#%#$/.

##. Pashley D :he evolution of dentin +onding fro no etch to total etch to self etch.

Ouraray Bp Report, $))$ #%!.#$.6e(lett E Resin adhesion to enael & dentin' 3 revie(. > Cal Dent 3sso, $))"

/)", #%#.

#".Perdigao > et al :otal etch versus self etch adhesive' Effect on post operative

sensitivity. >3D3, $))" #"' #/$#%#/$-.

#.:ay K et al Aater oveent across +onded dentin :oo uch of a good thing. >

3ppl ral Bci, $)) #$?Bp Issue@' #$%$!.

#!.Eic5 > et al Current concepts of adhesion to dentin. Crit Rev ral Hiol Med, #--

N'", ")/%""!.

#/.Aeinann A et al 6istorical evolution of voluetric polyeri;ation shrin5age of

restorative coposites. I3DR, $)))"%)/.

#.Gianchetti et al 3 revie( of polyeri;ation shrin5age stress' Current techni7ues

for posterior direct resin restorations. >CDP, $))/ ', #%#".


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%. >ac5son R, Morgan M :he ne( posterior resins & a siplified placeent

techni7ue. >3D3, $))) #"#' "!%"N"

%. Hichacho :he centripetal +uild%up for coposite resin restorations. PP&3%

Cosetic dentistry ed.,#-- /'",#%$".

$).Goldstein :he final finishing & polishing of coposites. Cont. Esth. Dent., #--/

$'$, #%!.

$#.:ay K et al 6ave dentin adhesives +ecoe too hydrophilic >CD3, $))" /-'##,

$/%"#.

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july 2009tackling post operative sensitivity in composite restorations

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