Discussion

Numerous dental treatments necessitate attachment of prostheses and appliances to

the teeth by means of a luting agent. These include metal, metal ceramic, composite, and
ceramic restorations, provisional or interim acrylic restorations, laminate veneers for anterior
teeth, orthodontic appliances and pins and posts used for retention of restorations. The word
luting implies the use of a mouldable substance to seal a space or to cement two components
together; hence the term is descriptive of dental cementing agents. The various luting agents
used are zinc phosphate, zinc oxide eugenol, zinc carboxylate, glass ionomer, resin modified
glass ionomer, compomer and resin cements. The properties of these cements differ from one
another. Hence the choice of cement is mandated to a large degree by the functional and
biological demands of the specific clinical situation.
Before final cementation with resin cement, provisional restoration is usually given.
An interim covering after tooth preparation is necessary to preserve pulpal vitality and to
ensure gingival health, patient comfort and esthetics. Materials used for temporary
restorations are expected to last for a few days to a few weeks at the most. They can provide a
temporary restorative treatment while the pulp heals or until a more long-lasting restoration
can be fabricated and cemented.

Zinc oxide eugenol and zinc oxide non eugenol are

primarily used as temporary cementation materials.

A great number of studies have been conducted to evaluate the effect of temporary
cements or its residues on the adhesive procedures, [Mayer et al 20, Hansen et al7, Paul et al9]
resulting in highly contradictory statements. Therefore, this study aimed to elucidate the
influence of provisional cements, with or without eugenol, on the bond strength of resin
cement. In addition, the time period the provisional restoration is cemented is taken in to
consideration to provide a better idea on the effect of temporary cement on resin bond
strength.

32

Discussion
In this study zinc oxide eugenol temporary cement is selected. These cements are
routinely applied to dentin as temporary dressings, lining materials, bases and temporary
cements. They are usually dispensed in the form of zinc oxide powder and eugenol liquid or
sometimes as two pastes. Their pH is approximately 7 at the time of placement, which
potentially makes them least irritating of all dental materials. It is fairly well established that
the setting mechanism for ZOE materials consists of zinc oxide hydrolysis and a subsequent
reaction between zinc hydroxide and eugenol to form a chelate, resulting in grains of zinc
oxide embedded in a zinc eugenolate matrix. [Alan et al 2, 3]. Water is needed to initiate the
reaction, and is also a by-product of the reaction. Type III

zinc oxide eugenol is used for

temporary restorations.
Zinc oxide eugenol temporary cements are inexpensive, provide an excellent cavity
seal, and are easily removed after varying periods of time. Eugenol alone is accountable for
the beneficial, therapeutic effects or the damaging, irritating properties of these products.
Eugenol is the essential constituent of oil of cloves, a therapeutic agent that has been used for
the treatment of odontalgia since the 16th century3. Due to the water content in the dentinal
tubules, eugenol becomes able to penetrate dentin, achieving a concentration of about 10

-2

molar adjacent to a ZOE/dentin interface [Molnar et al 1]. It has been proved that eugenol has
the ability to progressively remove calcium from dentin resulting in softening of sound dentin
beneath clinically applied ZOE mixtures [Rotberg et al6].
There are observations indicating that Zinc oxide eugenol temporary cements may
have adverse effects on resin based restorative materials. Such effects have been attributed to
either change in the wetability and reactivity of the dentin [Hume et al16] or to remnants of the
material on the surface that may interact with the setting of resin composites [Watanabe et
al21]. It has been suggested that eugenol has the most detrimental effect on the setting of resin

33

Discussion
cements, because it is known to be a radical scavenger [Hume et al 16]. It may penetrate the
underlying dentin surface, and thus interfere with the polymerization reaction. [Hansen et
al7].
In the present study eugenol free temporary cement was selected. They were
introduced to eliminate the detrimental effects of eugenol on resin dentin bond by replacing
eugenol with essential oils. Recent researches represent that eugenol free cements do not
decline the strength of dentin binding. Eugenol free cements seem to have a comparable or
even higher retentive strength than those containing eugenol [Sabouhi et al43]. Hansen et al7 in
1987 stated that eugenol free cements did not influence the resin bond strength compared to
that of eugenol containing temporary cements which showed marked reduction in resin bond
strength. This is in accordance with the Al-Wazzan et al 8 study which showed that the
eugenol free temporary cement did not cause an adverse effect on the bond strength between
resin composite core materials tested on dentin.
In this study, self adhesive resin cement was used. Resin based adhesive luting
materials are widely used for the cementation of inlays and onlays, crowns, posts and
veneers. Currently all resin cements are based upon the use of etch and rinse or self etch
adhesive along with a low viscosity resin composite [Farokh et al 37].This multi step
application technique is complex and rather technique sensitive and consequently may
compromise bonding effectiveness [Braga et al22]. Therefore, in order to simplify the
cementation process, self adhesive resin cements have been developed, consisting of
monomers which are capable of etching and bonding to dental surface without the need for
separate application. The use of these materials not only simplifies the bonding procedure
between the tooth structure and indirect restoration, but also reduces cement film thickness
and clinical time spent [Andre et al41].

34

Discussion
The specimen preparation for the shear bond strength followed the method of fonseca
et al. The teeth were fixed on an acrylic support, parallel to the support. Bandgar et al 28 in
1997 also mounted the teeth in acrylic block using cold cure resin for easy handling and to
insert in universal testing machine for shear bond strength testing. Paul et al 9 tested the
specimens with the dentin being kept under intra-pulpal pressure and the samples
simultaneously exposed to thermal cycling.
In the present study dimensions of 442mm was selected for provisional restoration
and also for permanent restoration. Fonseca et al 26 fabricated provisional restorations of
335 mm dimensions with acrylic resin. In Andre et al41 study provisional and permanent
restorations were fabricated in form of discs of 10mm diameter and 2mm thickness. Nasreen
et al45 also fabricated the specimens in the form of discs with 2mm diameter and 3mm height.
According to Bandger et al28 study the provisional and permanent crowns were fabricated for
the teeth. In Sarac et al study32, to simulate provisional restoration, 441mm acrylic resin
plates were fabricated using a provisional restorative material. Watannabe et al 19 also
fabricated temporary and permanent restorations measuring 1052mm. Following the
previous studies [Fonseca et al26, Watannabe et al19] specimen dimensions of 442mm were
selected to simulate overlying laboratory processed temporary and permanent restorations.
Two different time intervals [7th day and 14th day] were evaluated in this study as the
residual eugenol left behind may vary at given point of time thus influencing the bond
strength values of resin [Ribeiro et al 38]. This is in accordance with the Peutzfeldt et al 27 study
in which the specimens were stored for 7 days before the shear bond strength testing. This is
in contrast to the study of Leirsker et al11 in which the specimens were stored for 6 days and
also according to wattanbe et al19 study the storage of specimens was for 48 hrs only.

35

Discussion
In this study 14 days time period is also selected for evaluation of temporary cement
effect on resin bond strength. According to Nasreen et al 45 study the time intervals selected
were 1week and 2 weeks. As stated by Jung et al in his study, the diffusion of eugenol
through dentin diminished to 0.08nmol/min after 14 days which had negligible effect on bond
strength. Hansen et al study has done provisional cementation for 3 hours. This may seem
inappropriate to clinical practice; because a temporary filling will hardly ever be inserted for
such a short time before final restoration is made. It is logical to use provisional restorations
for a week or longer. Clinically 7 days or more is a reasonable period for provisional
restorations in most situations. Nonetheless, additional studies are necessary to evaluate
other periods of exposure between 24hrs and one week.
To simulate the clinical environment the prepared specimens in this study were stored
in artificial saliva. This is in accordance with Dillenberg et al 33 study in which they had stored
the specimens in a culture oven in artificial saliva. But this is in contrast to several other
studies in which the storage medium was distilled water. [watanabe et al 19, Leirskar et al11,
Fonseca et al26]. Andre et al41 had stored the specimens in distilled, deionized water at 37
degrees for 24 hours. In Hansen et al 7 study the specimens were stored in tap water. Artificial
saliva is selected as storage medium in this study for better evaluation of bond strength, as it
closely mimics the oral environment.
In the present study shear bond strength testing was done using universal testing
machine. Shear bond strength is the common laboratory parameter most often used to
evaluate bond strength of restorative materials to dental structures. Most in vitro studies used
shear bond strength test for this purpose [Peutzfeldt et al 27, Fiori et al34]. Many studies have
suggested that conventional tests, such as shear bond strength test, have limitaions when bond
strengths exceed 25 Mpa, common in newer adhesive systems [Powers et al24]. Powers et al24

36

Discussion
stated that in this type of test, there is a concentration of stress on the bonding interface that
induces the early rupture of the bond, which may cause interpretation errors.
Smaller bonding areas, as seen in newer tests such as microshear bond strength, could
minimize the stress generated on the interface [Ribeiro et al38]. Therefore, these tests would
be more appropriate for assessing the bond strength of newer bonding systems to dentin.
Only a few studies that assessed the effect of temporary cements on the bond strength of
resinous materials used this methodology [Nakabayashi et al 5, Carvalho et al29]. Hence it is
possible to assume that different methodologies are partially responsible for the divergence
among studies. A major disadvantage of shear bond strength is that it does not consider the
three dimensional geometry of tooth preparation and consequent variations in polymerization
shrinkage vectors. Therefore, data deriving from shear bond strength tests should be
evaluated along with clinical assessment results. However, this test is an excellent tool for
screening new materials and comparing different adhesive systems.
The bond strengths of control group specimens in which permanent restoration
with resin cement was done without any provisional cementation, varied between 20 and 28
Mpa which is in agreement with the shear bond strength values measured by Paul et al 9.
However, there should not be too much emphasis on comparisons with the data from the
literature, because of the variation in both materials and testing methods in laboratory.
The bond strengths of specimens in which provisional restoration was done with
eugenol free zinc oxide cement, were shown to be inferior to that of control group. The
average shear bond strength obtained was 22Mpa. The values were similar to that obtained by
Bagis et al36 in their study. This is in contrast to that of Schwartzer et al 30 study which showed
higher values of 26 Mpa. There was no difference between the time periods with respect to
the strength of the bond promoted to dentin. The reduced bond strength of resin after the
37

Discussion
usage of provisional cement is believed to be related to the presence of provisional cement
residues not completely removed before cementation as stated by the previous study of Paul
et al9.
The bond strengths of specimens in which provisional restoration was done with
eugenol temporary cement, was less compared to that of control group. The average bond
strength obtained is 19Mpa. Same values were obtained by Leirskar et al 11 for specimens,
following the influence of ZOE for 6 days. Higher shear bond strength values were obtained
by Peutzfeldt et al10 ranging from 24 to 28Mpa, which stated that eugenol containing cement
did not influence the bond strength of resin cement. Hasen et al 7,Paul et al9.Hume et al14 in
1984 reported that eugenol released from ZOE mixtures can penetrate dentin and interact
with resin based restorative materials thus resulting in reduction of bond strength. As
discussed before the reduction in bond strength is either due to temporary cement remnants or
the effect of eugenol on dentin.
The reduced bond strengths in this group substantiate the findings of Carvalho et al 29
which stated that the hydroxyl group of the eugenol molecule tends to protonize the free
radicals formed during polymerization of resin based materials, thereby blocking their
reactivity and reducing the degree of conversion of these materials. In this group of
specimens there was no significant difference between the time periods with respect to the
bond strength. This is in accordance with the Nasreen et al45 study which proved that previous
use of provisional restorations containing eugenol for one week or two weeks did not
interfere with bond strength. This is explained by the fact that the diffusion rate of eugenol
released from ZOE cement increased to a peak up to 24h (about 0.3nmol/min) and then
decreased slowly thereafter. After 14 days the diffusion through dentin diminished to
0.08nmol/min [Hume et al14]. Therefore, it is expected that eugenol concentration in dentin

38

Discussion
after 1 week or 2 weeks will not significantly affect bond strength as eugenol concentration is
decreased to non-inhibitory levels [Ribeiro et al38].
So the probable reason for the decreased bond strengths in this group of specimens is
due to the presence of temporary cement remnants. According to Carvalho et al 29 and woody
et al mechanical removal of temporary cements is not totally effective and cement remnants
were observed microscopically on surfaces that appeared macroscopically clean. This may be
the reason why eugenol cements affect bond strength. This fact also supports the hypothesis
that effective cement residue removal is more important than the effect of residual eugenol, as
previously reported by Paul et al9.
The present study findings show no significant difference of bond strengths between
provisional restorations with zinc oxide eugenol and provisional restorations with non zinc
oxide eugenol cement. This is in accordance with the findings of Peutzfeldt et al 10, Peters et
al12, and Sabouhi et al43 which showed that zinc oxide non eugenol temporary cement and
zinc oxide eugenol cement do not influence the resin dentin bond strength.
All the temporary cement groups showed a decrease in shear bond strengths compared
to the control. The cement type does not seem to affect the bond strength. This is in
accordance with studies by Linegard et al4 and Hansen et al7. As discussed earlier the
probable reason for reduced bond strength is temporary cement remnants. The results of the
study by Mojon et al18 in 1992 indicate that the bond strength of adhesive resin cement to
dentin contaminated with ZOE and cleaned with flour of pumice is lower than that of an
uncontaminated control. Watanabe et al19 in 1997 proved that temporary cement remnants
could not be mechanically removed by an excavator and remained on the dentin surface.
Even when pre-conditioners of the adhesive resin cement systems were applied, the
temporary cements could not be completely eliminated. The present findings lend no support
39

Discussion
to the common opinion that eugenol containing cements should be avoided as temporary
cement on tooth surfaces later to be bonded by resin cement.
Employing the proper cleaning method seems to be enough to ensure that the
adhesive procedures will not be compromised. Further research is needed to evaluate the
influence of eugenol or the cement residue on the bond strength during shorter period.
Nevertheless, the clinician must pay careful attention to dentin cleaning method before
adhesively inserting the restoration.

40