THE EFFECT OF A 10% CARBAMIDE PEROXIDE BLEACHING AGENT ON MICROHARDNESS OF FOUR TYPES OF DIRECT RESIN BASED RESTORATIVE MATERIALS

Author- MQ AlQahtani Operative dentistry,2013,38-3, 316-323

No of slides- 53 No of illustrations- 9 Time taken for presentation-30min

References
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Attin et al Effect of bleaching on restorative materials and restorationsa systematic review Dental Materials (2004) 20, 852861 Yu, H., Li, Q., Cheng, H., & Wang, Y. (2011). The effects of temperature and bleaching gels on the properties of tooth-colored restorative materials. Journal of Prosthetic Dentistry, 105(2), 100-107. Gabriel Rodrigues Hatanaka . Effect of Carbamide Peroxide Bleaching Gel on Composite Resin Flexural Strength and Microhardness Brazilian Dental Journal (2013) 24(3): 263-266

AUJ Yap Wattanapayungkul .Effects of In-Office Tooth Whiteners on Hardness of Tooth-Colored Restoratives. Operative Dentistry, 2002, 27, 137-14 Effect of bleaching agents on the microhardness of toothcolored restorative materials. Journal of Prosthetic Dentistry Volume 95, Issue 4 , Pages 286-289, April 2006. Taher NM. The effect of bleaching agents on the surface hardness of tooth colored restorative materials. J Contemp Dent Pract. 2005;6(2):18-26. Effects of different concentrations of bleaching agent on the micro hardness and shear bond strength of restorative materials An in vitro study Journal of Dentistry and Oral Hygiene Vol. 2(1), pp. 7-14, June 2010

Effects of External Bleaching on Restorative Materials: A ReviewJ Can Dent Assoc 2011;71:b59 Jefferson KL, Zena RB, Giammara B. Effects of carbamideperoxide on dental luting agents. J Endod 1992;18:12832. Turker SB, Biskin T. Effect of three bleaching agents on the surface properties of three different esthetic restorative materials. J Prosthet Den2003;89:466 73.
Turker SB, Biskin T. The effect of bleaching agents on the microhardness of dental aesthetic restorative materials. J Oral Rehabil 2002;29:65761.

CONTENTS
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Introduction Reason for selection of the article Aim of the study Materials and methods Results Discussion Conclusion Critical analysis Clinical significance

Introduction
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Esthetics - (Arens, 1989).

Esthetics procedures to alter smile, alterations in form, texture, position and color of teeth. Bleaching- most conservative non invasive Most common 10% carbamide peroxide. Patients seeking bleaching agents may have metal or resin based restorations. Clinical durability of restorations might be affected by bleaching

Reason for selection of article ?

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The influence of bleaching agents on these restorative materials should be known to render proper treatment.

Aim of the study

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To evaluate the effect of a 10% carbamide peroxide bleaching agent on the microhardness of four types of direct resin based restorative materials.

Materials and methods

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Specimen fabrication Filtek Z250 microhybrid resin composite Matrix- Bis-GMA, UDMA, Bis EMA Filler- Zr/Si (0.01-3.5 m) Filler by volume- 60%

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Filtek Z 350 Nanofilled resin composite Matrix BIS GMA,UDMA, TEGDMA, and BIS EMA Filler- combination of aggregated zirconia/silica cluster filler(0.6-1.4m) and non aggregated 20 nm silica filler. Filler volume : 59.5%

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Filtek P90 lowshrink resin composite Matrix- new ring opening silorane Filler- epoxy functional silane treated silica and ytterbium fluoride (0.1 -2 m) Filler volume 55%

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Valux plus hybrid composite Matrix : Bis GMA ,TEGDMA Filler : single filler 100 % Zr/Si (0.001-3.5m) Filler volume: 66%

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OpalescencePF 10 % carbamide peroxide , potassium nitrate, carbopol, glycerine, 0.11% fluoride ion

Method
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30 DISK SHAPED specimens 10mm diameter 2 mm depth. A3 shade. Cylindrical rubber molds were positioned on a transparent plastic matrix strip lying on a glass plate. 2 mm increments Every specimen light polymerized -40 sec halogen light 480-520 mW/cm2

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Polished with medium, fine, super fine polishing discs This polished flattened surface was essential to prevent distorted indentation for hardness measurement on any material (Anusavice, 2003)

Final thickness measured with micrometer Ultrasonic cleaning with distilled water for 2 min

Groups
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3 groups . (10 / group) Control group : immersed for 14 days in artificial saliva, with no bleaching treatment . Group A : Treated with 10 % CP for 14 days Group B: Treated with 10 % CP for 14 days and then immersed in artificial saliva for 14 days.

CONTROL GROUP
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Stored in artificial saliva for 14 days at 37 C No bleaching Immersion in distilled water for 24 hrs. Saliva replaced daily. Composition NaCl 0.4 g KCl 0.4g CaCl2.H2O 0.795 g Sodium Dihydrogen phosphate 0.69 g Sodium sulphide 0.005 g Distilled water 1000 mL

Bleaching procedure
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On top of specimens in groups A, B At-home bleaching material (Opalescence PF 10% Carbamide Peroxide ) 1mm thickness. At the end of every bleaching application, treated specimens were first washed in distilled water and in ultrasonic cleaner. Placed in artificial saliva for 16hrs at 37 C Saliva replaced daily.

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Group A Bleaching agent applied for 8 hrs daily 14 days at 37C

Stored in distilled water for 24 hrs at 37C Microhardness test

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Group B Bleaching agent applied for 8 hrs daily 14 days at 37C

Stored in artificial saliva for 14days at 37 C

Immersed in distilled water for 24 hrs at 37C Microhardness test

Vickers Hardness test

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After the specimens were dried,VHN

Statistical Analysis
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Data were subjected to one way analysis of variance and Tukeys HSD multiple comparisions test

Results
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Graph
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DISCUSSION
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HARDNESS Strength, ductility, elastic stiffnes , plasticity, strain, toughness, viscoelasticity, and viscosity. The ability of a material to abrade or to be abraded by opposing dental structures, materials,or any chemical softening has implications for the clinical durability of dental restorations. Temperature is fixed at 37 C for both bleached and unbleached samples in this study.

Effect of temperature
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Yu et al had evaluated the effect of bleaching agents with 2 different temperatures on 4 composites, compomer, GIC and ceramic. CP had greater effect on microhardness of resin based composite and GIC at 37 C than 25 C Reasons Due to release of more free radicals at higher temperature. Enhanced penetration ability of CP at a higher environmental temperature. Release of hydroxyl radicals from peroxide can be accelerated by heating
Yu, H., Li, Q., Cheng, H., & Wang, Y. (2011). The effects of temperature and bleaching gels on the properties of tooth-colored restorative materials. Journal of Prosthetic Dentistry, 105(2), 100-107.

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10 % Carbamide peroxide one third hydrogen peroxide two- thirds urea. Hydrogen peroxide

breaks down into free radicals oxidative cleavage of polymer chains chemical softening of dental materials.

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The free radicals eventually combine to form molecular oxygen and water. Some aspect of this chemical process might accelerate the hydrolytic degradation of composites described by Sderholm &others (1984)

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Artificial saliva accelerator in degradation of CP Mimic oral environment Minimize adverse effects of bleaching Salivary remineralization due to calcium and phosphates. In contrast, findings of this study showed no benefit using artificial saliva Reduction of microhardness , not inhibited

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Microhardness reduction percentages Filtek z250- 0.97% Filtek z 350 12.59% Filtek P-9018.39% Valux plus12.08%

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Order of Microhardness reduction

Silorane based low shrink Nanofilled Z350 Hybrid resin composites Microhybrid composite. - Minimal reduction

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Higher amount of TEGDMA in Z350 (nanofilled) and valux plus( hybrid) Absence of TEGDMA in Z250( microfilled) TEGDMA diluent monomers in resin matrix make it less resistant to bleaching agents and may increase softening of resin matrix. In contrast, reduction in microhardness of z 350 ( 12.59%) was higher than that of valux plus (12.08%) High molecular weight of resin matrix and low filler content in z 350 compared with valux plus.

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Siloranes (p 90) showed more reduction in microhardness compared with other tested materials. This is due to ring opening mechanism in resin matrix and lowfiller content . This resin matrix is softer than other resin matrices (Bis-GMA, UDMA, Bis-EMA) and easily soluble by bleaching agents.

Silorane composite
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Effect of bleaching on different restorative materials

STUDY 1:Gabriel et al. investigated the effect of 16% carbamide peroxide on microhardness of the hybrid, nanofill, and two micro-hybrid composites. Hybrid presented the highest microhardness value, followed by nanofill and finally by microhybrid. Reasons: Higher filler content (71%) of hybrid composite Better behaviour of nanofill is due to effect of composition and degree of conversion of the polymer matrix on hardness, as well as the resin matrix greater mechanical strength. Higher resistance of the aggregated zirconia/silica cluster filler to the Vickers indenter.

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Gabriel Rodrigues Hatanaka . Effect of Carbamide Peroxide Bleaching Gel on Composite Resin Flexural Strength and Microhardness

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Softening effect MICROHYBRID COMPOSITE Breakdown of CP Free radicals Oxidative cleavage of polymer chains .

This was not observed for hybrid and nanofilled because of different composition of monomer resins, which are not susceptible to the oxidative reaction.

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STUDY 2: Prabhakar et al (2010) 10 and 22% CP composites and compomers Result: composites similar reduction compomer- no significant reduction
REASON: Chemical softening of the restorative materials might occur if the bleaching products have solubility parameters similar to that of the resin matrix.
Effects of different concentrations of bleaching agent on the micro hardness and shear bond strength of restorative materials An in vitro study Journal of Dentistry and Oral Hygiene Vol. 2(1), pp. 7-14, June 2010

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The Bisphenol A-glycidyl methacrylate (BisGMA) and urethane dimethacrylate (UDMA) resin polymers used in composites can be softened by chemicals with solubility parameters in the range of 1.82 x 104 to 2.97 x 104 (J/m3) 1/2 (Wu & McKinney, 1982) This shows that the effect of carbamide peroxide gels may be material dependent.

Yap & Wattanapayungkul: Effects of In-Office Tooth Whiteners on Hardness of Tooth-Colored RestorativesOperative Dentistry, 2002, 27, 137-141

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STUDY 3: Yap et al (2002) investigated the effects of35% CP and 35% HP on the hardness of hybrid , polyacid-modified ,PRG composites and a resin-modified glass ionomer cement ..

No significant difference in hardness was observed between treatment groups for polyacid and PRG composites . For and Hybrid and glass ionomer , specimens treated with 35 % CP were significantly harder than those treated with 35% HP. Reason: Active ingredient for both bleaching gels is the same Presence of carotene in opalesent xtra ( 35% HP)

AUJ Yap Wattanapayungkul .Effects of In-Office Tooth Whiteners on Hardness of Tooth-Colored Restoratives. Operative Dentistry, 2002,

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Study 4: Mujdeci et al (2006) evaluated the effect of a 10 % CP and 14% HP on the microhardness of nanohybrid composite resin ,a polyacid-modified composite resin , glass-ionomer cement . The bleaching products used in this study did not adversely affect the microhardness of the restorative materials. REASONS: changes in structure or composition of restorative materials have provied more resistant surfaces against bleaching treatments.

The frequency with which the bleaching agents were changed may also contribute to the disparity between the results of the studies.
The application times of the bleaching agents might have affected this result

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The influence of different bleaching gels depends on the oxidation process that occurs in the organic matrix, which can facilitate water absorption and lead to loss of particles, reducing superficial integrity and microhardness.

Attin et al Effect of bleaching on restorative materialsand restorationsa systematic reviewDental Materials (2004) 20, 852861

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Bleaching can also alter the optical properties of composite resins, which depend on the composition of materials as well as on the bleaching agent. The inorganic content of resin composites however, offers resistance to bleaching. Form, amount and distribution of fillers are all aspects that determine the clinical performance of these restorative materials.

Attin et al Effect of bleaching on restorative materialsand restorationsa systematic reviewDental Materials (2004) 20, 852

To summarize
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The effects of in-office tooth whiteners on hardness were material dependent. Filler matrix interactions have great effect on increasing the resistance of composite resin. The discrepancies between these studies may be explained by the differences in experimental methodologies, bleaching agents applied, and restorative materials used. Some tooth colored restorative materials may be more susceptible to alterations Some bleaching agents are more likely to cause such alterations( Swift &Peridagao 1983) Also attributed to different ph of bleaching agents .

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High concentration carbamide peroxide bleaching gel, used as intended by the manufacturers, poses minimal risk to composite restorations.

Glass ionomer cement

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Jefferson et al. examined alterations of atomic weight percentages in glass ionomer cement after contact with 10% carbamide peroxidewith pH 4.5. He reported that the matrix of the specimens showed surface wash-off and corrosion with the cores of the silica more exposed and a decrease of surface aluminum content.

Jefferson KL, Zena RB, Giammara B. Effects of carbamideperoxide on dental luting agents. J Endod 1992;18:12832.

GIC
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Turker and biskin found increased microhadrness of GIC after bleaching REASON: The increase is due to silica core localized at surface after erosion of glass ionomer cement.

Turker SB, Biskin T. The effect of bleaching agents on themicrohardness of dental aesthetic restorative materials.J Oral Rehabil 2002;29:65761

CERAMICS
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Turker and Biskin found 1016% carbamide peroxide gels (applied for 8 h per day for 30 days) were able to significantly decrease surface hardness of the porcelain material tested.

REASON: Degradation in ceramics due to the interaction between free radicals released from the bleaching gels and the ceramic glass network, which leads to the loss of alkali metal ions from the glass surface

Turker SB, Biskin T. Effect of three bleaching agents on the surface properties of three different esthetic restorative materials. J Prosthet Den2003;89:46673.
Turker SB, Biskin T. The effect of bleaching agents on themicrohardness of dental aesthetic restorative materials.J Oral Rehabil 2002;29:65761.

Conclusions
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10 % CP bleaching agent had an adverse effect on microhardness of nano filled, silorane based low shrink, hybrid types of resin-based composite materials compared with micro hybrid type. The microhardness reduction in different resin based composite materials after bleaching was not inhibited by the use of artificial saliva storage media during and after bleaching procedure.

Critical appraisal
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Merits:

Used different types of composites

Demerits Did not evaluate different concentrations. Did not compare different temperatures. Did not evaluate the other associated effects of bleaching on restorations such as the surface roughness, microleakage and color changes in tooth colored restorative materials .

Clinical relevance
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Bleaching agents should not be used indiscriminately in the patients mouth. Teeth that have extensive tooth-colored restorations should not be exposed to bleaching agents or at least protected. Patients should be informed that the physical properties of tooth colored restorations might be affected by bleaching procedure and the restorations might be softened.

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This could potentially predispose to increased adherence of cariogenic bacteria ,surface wear rate, stain absorption and potential marginal strengths of these restorations and that they may need to be replaced.

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Thank you

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