Rowena quimson

LINERS RMGI liners are typically fluid materials that can adapt more readily to the internal aspects of a cavity preparation. Liners are materials that are placed as a thin coating (usually 0.5 mm) on the surface of a cavity preparation. Although they provide a barrier to chemical irritants, they are not used for thermal insulation or to add bulk to a cavity preparation.11 Furthermore, these materials do not have sufficient hardness or strength to be used alone in a deep cavity.12 Of the categories listed above, varnishes, calcium hydroxide, glass ionomers, and resins can be used as liners. Zinc eugenol, zinc phosphate, and zinc polycarboxylates are generally not used as liners. Varnish A varnish is defined as natural gum (copal or resin) dissolved in an organic solvent such as acetone, chloroform, or ether.13 After the dentin in the cavity preparation is covered with a varnish, the solvent evaporates, leaving the solute as a thin layer or film. The theory behind a varnish (example: Copalite/Cooley & Cooley) is that it seals the dentinal tubules, thus reducing the effects of micro-leakage. When amalgam is first placed, the tooth/amalgam interface is not microscopically sealed. Eventually the varnish dissolves and is replaced with the corrosion products of the amalgam.14 There are several fluoride-containing varnishes available (examples: Duraphat, Colgate Oral Pharmaceuticals; Duraflor, Pharmascience Inc; Fluor Protector, Ivoclar Vivadent). Although the FDA has approved these products both as cavity liners and for the treatment of sensitive teeth, they are not approved for caries prevention. 15 However, in Europe, fluoride varnishes have been used in caries prevention programs/studies since 1968. The results showed a reduction in caries ranging from 18% to 77%.16 In order for these varnishes to receive approval for use as a method of caries prevention, the manufacturer would need to submit clinical studies to the FDA, in which case the varnish would be classified as a drug. Calcium Hydroxide It is generally believed that calcium hydroxide (CH) is ideal for direct pulp capping since it accelerates the formation of reparative dentin. There are 2 reasons for this: first, since the material is basic (pH of 11), it serves as an irritant stimulating the formation of reparative dentin; and second, the therapeutic affect of CH may be due to its ability to extract growth factors from the dentin matrix.17 The result is the formation of a dentin bridge, which allows pulpal repair. However, these concepts are challenged by Schuurs et al,18 who concluded that although CH causes the formation of a dentin bridge, this seal does not last. Eventually the pulp will undergo necrosis as a result of microleakage. Due to the fact that CH has a basic pH, it is not generally supportive of bacterial growth. When the base and catalyst portions of CH were tested separately, only the catalyst component was shown to have any antibacterial effect. 19 In addition, since bacterial byproducts are acidic, CH will directly counteract this acidity and effectively neutralize these byproducts. It for this reason that CH is placed under zinc phosphate to help reduce the acidity of the zinc phosphate. CH is available in chemical- cured forms (example: Dycal, DENTSPLY Caulk) and light-cured forms (example: Prisma VLC Dycal, DENTSPLY Caulk) . Glass Ionomer

This material has been available for more than 30 years. A current version of glass ionomer (GI) is the resin-modified glass ionomer (example: Vitrebond, 3M ESPE). There are 2 clinical benefits attributed to GIs: first is their ability to ionically bond to tooth structure (between the carboxylate groups in the GI and the calcium ions in the enamel and dentin)20; and second, they release fluoride. The ability of fluoride to inhibit the formation of secondary caries is established. Prati et al21 demonstrated that when GI is used as a liner, a reduction in the consequences of microleakage is seen. They attributed this to its antimicrobial properties. This benefit, along with its ability to adhere to and seal the dentin,22 has made this material popular as a cavity liner. GIs should not be used as pulp-capping agents. Unlike calcium hydroxide, GI does not promote the formation of dentin bridges. In fact, in a clinical study, GI was found in the pulp chamber, which triggered a persistent inflammatory response and appeared to prevent the formation of dentin bridges. 23 One restorative procedure that is often used clinically is known as the sandwich technique. 24 In this technique, the lining materials are brought to the cavosurface margin. There are 2 advantages to this technique when using GI; first, released fluoride has a beneficial effect on the tooth structure at the margin of the restoration. Donly et al, 25 have shown that when this technique is used, there is less recurrent caries at the margin of restorations. Second, the fluoride that is released can be subsequently replaced with externally delivered fluoride. This can be via gel, mouthrinse, or toothpaste, with the gel being most effective.26 GIs, both conventional and resin modified, are available in both chemical- cured formulations (example: Ketacbond, 3M ESPE) and light-cured formulations (example: Vitrebond, 3M ESPE). The light-cured products have been shown to provide a better seal.27 Hand-mixed forms (examples: Vitrebond and Ketacbond) and encapsulated/cartridge-dispensed forms (example: Fuji Lining LC, GC America) are also available. GIs have certain disadvantages. They are extremely sensitive to moisture. A study by Cattani-Lorente et al,28 demonstrated that when GI comes in contact with water, there is a decrease in its physical properties. In addition, resin-modified GIs expand after coming in contact with water. Resin Of the materials discussed here, resins are the most recent additions to the clinicians armamentarium. They are very versatile (generally being of high compressive and tensile strength), possess low solubility, and are available in different viscosities and different shades. When resins are used as a cavity liner, it is important to remember that it is the dentin bonding agent (examples: Clearfil SE Bond, Kuraray America; Excite, Ivoclar Vivadent) that comes into contact with the dentin. There are different types of dentin bonding agents, and their performance differs.29 These resins are not recommended for direct pulp capping since, like glass ionomers, they do not promote the formation of dentin bridges. In fact, there is a persistent mild inflammatory pulpal response associated with resins when they are used as a direct pulp-capping agent.30 Studies do confirm, however, that adhesives placed below amalgam restorations reduce microleakage,31,32 thus supporting the current trend toward this practice of using resin as a liner. However, the clinician must consider the logistics of using adhesive resin liners. Lining cavities with copal varnish is faster and less technique-sensitive than using adhesive resin, and resins cost more and have a limited shelf life. In an attempt to overcome the polymerization shrinkage associated with traditional composite resin, a new material modified hybrid resinhas been developed. A resin with a reduced filler load, it is referred to as a flowable composite (examples: Unifil Flow, GC America; Tetric Flow, Ivoclar Vivadent). The better flow and reduced modulus of elasticity of these materials theoretically reduce microleakage by increasing adaptation and by forming a stress-absorbing layer.33 The result is a decrease in gap formation at the flowable-resin/tooth interface, which will ultimately lead to a decrease in secondary caries and pulpal inflammation and a longer lasting restoration. 34 Although there is increased

adaptation of the resin to the cavity preparation, the material has a reduced filler content. This leads to an increase in polymerization shrinkage. The net result, however, is a reduction in gingival microleakage when flowable resin is used, compared to a conventional composite resin.35 It has been observed that some adhesives do not bond well to dentin in deep cavity preparations. This makes them more susceptible to polymerization shrinkage stress that develops in deep cavities. 36 Since the bond strength to dentin near the pulp chamber is low, the polymerization shrinkage that the resin undergoes can cause a gap to form. This was the conclusion reached by Gordan et al, who also showed that the weakest bond was at the flowableresin/tooth interface and dentin near the pulp chamber. 37 One study comparing a resin-modified GI, a flowable composite, and a dentin bonding agent concluded that the resin-modified GI was associated with less microleakage than the other materials. 38

CAVITY LINERS AND BASES.Mostdentists use some type of cavity liner or base in almostall cavity preparations. They are used primarily toprotect the pulp and to aid the pulp in recoveringfrom irritation resulting from cavity preparation.Liners and bases are placed when the cavitypreparation is completed, just before insertion of therestorative material.Glass ionomer cements and dentin bonding agentsare used primarily to seal the dentin and protect thepulp from bacterial invasion. Calcium hydroxide can be used in extremely deep areas as an antibacterial agent and/or as a pulp capping material . Cavity varnish is a liner used to seal the dentinal tubules to help prevent microleakage and is placed in acavity to receive amalgam alloy after any bases have been placed. Cavity varnish is being used less and lesswith amalgam restorations, and dentin bonding agentsare replacing cavity varnish as the liner of choice. Cavity varnish has an organic solvent of ether or chloroform that quickly evaporates, leaving the resin as a thin film over the preparation. This varnish shouldbe slightly thicker than water. If it becomes very thick,discard it. Cavity varnish is not used with compositessince the varnish retards the set of composites andinterferes with the bonding of composites.A small cotton pellet held by cotton forceps isdipped into the varnish just enough to wet the pellet. The cavity varnish is applied to the pulpal area, wallsof the cavity preparation, and onto the edge of themargins of the preparation. Any excess varnish can beremoved from the enamel with a fresh cotton pellet. Asecond application of cavity varnish is placed over thefirst to thoroughly coat the surfaces of the dentin andfill any voids from bubbles created when the firstapplication dries. After liners and bases are placed intothe cavity preparation, the tooth may be restored withmaterials, such as amalgam, composite resin, or glassionomer
Currently, there are a number of methods for preparing a cavity, including use of a bur, air abrasives, lasers, and hand instruments. The method by which tooth structure is removed does not affect microleakage. 9

Table. Materials used for liners, bases, and cements

Varnish

Liner Base Cement X

Calcium Hydroxide

Zinc Oxide Eugenol

Zinc Oxyphosphate Zinc Polycarboxylate

Advantages Limitations low cost, washes out long history at margins of use X low cost, most (temporary) long history effective of use when in contact with pulp X X antibacterial, unable to long history, withstand sealing condensation ability forces X X long history low pH X X long history thickness may inhibit seating of casting moisture sensitive moisture, technique sensitive

Glass Ionomer Resin

X X

X X

fluoride release adhesive strength

Reprinted with permission of the Academy of General Dentistry from: Weiner R. Liners, Bases, and Cements: A Solid Foundation. Gen Dent. 2002; 50: 442-445.

Reference: http://www.dentistrytoday.com/materials/1482 http://medical.tpub.com/14275/css/14275_124.htm