Three-year evaluation of different adhesion strategies in non-carious cervical lesion restorations: a randomized clinical trial* * This clinical trial is a doctoral thesis follow-up and it can be found in the UNESP Institutional Repository since 12/19/2016. It is available in http://hdl.handle.net/11449/148789. In addition, the one-year follow-up article was published by Quintessence International and can be accessed via DOI number: 10.3290/j.qi.a44367.

Diego Felipe Mardegan Gonçalves Mirela Sanae Shinohara Paulo Roberto Marão de Andrade Carvalho Fernanda de Souza e Silva Ramos Laryssa de Castro Oliveira Érika Mayumi Omoto Ticiane Cestari Fagundes About the authors

Abstract:

Objective:

To evaluate non-carious cervical lesions (NCCLs) restored with different adhesion strategies.

Methodology:

This is a prospective, randomized, double-blind, split-mouth study. An adhesive restorative system (Single Bond Universal/Filtek Z350XT – SBU) was evaluated both without and with selective enamel conditioning (E-SBU), resin-modified glass-ionomer cements (Vitremer; RMGIC), and ethylenediaminetetraacetic acid pretreatment (EDTA; E-RMGIC). In total, 200 restorations, placed in 50 patients, were evaluated at baseline and at a 3-year follow-up using the modified United States Public Health Service (USPHS) criteria. Data were analyzed using the two-proportion equality test, multinomial logistic regression, Wilcoxon test, and Kaplan-Meier survival curves.

Results:

In total, 42 (84%) patients returned for the 3-year follow-up. SBU showed restoration losses statistically different from RMGIC. Retention was also statistically different in SBU between baseline and the 3-year follow-up. Marginal defects and surface texture were statistically significant for all groups in the period studied, except for the surface texture of SBU and the marginal integrity in E-RMGIC. We observed no statistically significant difference in wear, secondary caries, anatomical form, surface staining, and color over time. Recession degree was the only factor to influence retention rates. Cumulative survival (%) was 89, 98, 98, and 95.3, for SBU, SE-SBU, RMGIC, and E-RMGIC, respectively, without significant differences among them. There was a statistically significant difference between survival curves; however, multiple comparison procedures found no statistical differences.

Conclusion:

Selective enamel etching affected the retention of non-carious cervical restorations. Adhesion using EDTA and resin-modified glass-ionomer cements delayed marginal defects over time. The degree of gingival recession influenced retention rates. Resin composite restorations showed initial marginal defects, and ionomer restorations, reduced surface luster. EDTA pre-treatment followed by resin-modified glass-ionomer cements may be a promising adhesion strategy for NCCL restorations.

Keywords:
Acid etching; Adhesive systems; Non-carious cervical lesion; Glass-ionomer cements

Introduction

Non-carious cervical lesions (NCCL) are defined as the loss of tooth structure at the cemento-enamel junction area unrelated to dental caries, and their etiology has been described as multifactorial.11 Walter C, Kress E, Gotz H, Taylor K, Willershausen I, Zampelis A. The anatomy of non-carious cervical lesions. Clin Oral Investig. 2014;18(1):139-46. doi: 10.1007/s00784-013-0960-0
https://doi.org/10.1007/s00784-013-0960-...
Resin composites and glass-ionomer cements are currently the material of choice for NCCL restorations.22 Oz FD, Meral E, Ergín E, Gurgan S. One-year evaluation of a new restorative glass ionomer cement for the restoration of non-carious cervical lesions in patients with systemic diseases: a randomized, clinical trial. J Appl Oral Sci. 2020;28:e20200311. doi: 10.1590/1678-7757-2020-0311
https://doi.org/10.1590/1678-7757-2020-0...
1111 Perdigão J, Dutra-Corrêa M, Saraceni S, Ciaramicoli M, Kiyan V. Randomized clinical trial of two resin-modified glass ionomer materials: 1-year results. Oper Dent. 2012;37(6):591-01. doi: 10.2341/11-415-C
https://doi.org/10.2341/11-415-C...

Resin composites have some advantages, such as rapid polymerization, easy handling and reparability, and good mechanical and aesthetic properties;1212 Alzraikat H, Burrow MF, Maghaireh GA, Taha NA. Nanofilled Composite resin Properties and Clinical Performance: a review. Oper Dent. 2018;43(4):E173-190. doi: 10.2341/17-208-T
https://doi.org/10.2341/17-208-T...
however, they also entail biological effects due to monomers release.1313 Pagano S, Coniglio M, Valenti C, Negri P, Lombardo G, Costanzi E, et al. Biological effects of resin monomers on oral cell populations: descriptive analysis of literature. Eur J Paediatr Dent. 2019;20(3):224-32. doi: 10.23804/ejpd.2019.20.03.11
https://doi.org/10.23804/ejpd.2019.20.03...
This material peculiar features also pose challenges for its adhesion to the dentin substrate in NCCL.1414 Sabatini C, Campillo M, Hoelz S, Davis EL, Munoz CA. Cross-compatibility of methacrylate-based composite resins and etch-and-rinse one-bottle adhesives. Oper Dent. 2012;37(1):37-44. doi: 10.2341/11-095-L
https://doi.org/10.2341/11-095-L...
With the advent of universal adhesives, their composition enables the formation of chemical bonds, thus being less susceptible to hydrolytic degradation.1515 Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Torii Y, Ogawa T, et al. Self-assembled nano-layering at the adhesive interface. J Dent Res. 2012;91(4):376-381. doi: 10.1177/0022034512437375
https://doi.org/10.1177/0022034512437375...

Resin-modified glass-ionomer cements (RMGIC) can chemically bond to dental substrates. Since they can mechanically interlock with dentin, they are a good option for restoring NCCLs due to their excellent retention rates: between five and ten years.1616 Gurgan S, Kutuk ZB, Cakir FY, Ergin E. A randomized controlled 10 years follow up of a glass ionomer restorative material in class I and class II cavities. J Dent. 2020;94:103175. doi: 10.1016/j.jdent.2019.07.013
https://doi.org/10.1016/j.jdent.2019.07....
,1717 Franco EB, Benetti AR, Ishikiriama SK, Santiago SL, Lauris JR, Jorge MF, et al. 5-year clinical performance of composite resin versus resin modified glass ionomer restorative system in non-carious cervical lesions. Oper Dent. 2006;31(4):403-8. doi: 10.2341/05-87
https://doi.org/10.2341/05-87...
Given the excellent clinical retention of RMGIC - if applied under the manufacturers’ instructions, other pretreatment procedures may also be evaluated. The use of ethylenediaminetetraacetic acid (EDTA) before cement application is relevant, given that an in vitro study showed increased bond strength.1818 Fagundes TC, Toledano M, Navarro MFL, Osorio R. Resistance to degradation of resin-modified glass-ionomer cements dentine bonds. J Dent. 2009;37(5):342-47. doi: 10.1016/j.jdent.2009.01.002
https://doi.org/10.1016/j.jdent.2009.01....
Moreover, EDTA may be considered a metalloproteinases inhibitor (MMP).1919 Perdigão J, Reis A, Loguercio AD. Dentin adhesion and MMPs: a comprehensive review. J Esthet Restor Dent. 2013;25(4):219-41. doi: 10.1111/jerd.12016
https://doi.org/10.1111/jerd.12016...

Though some clinical trials in the literature evaluate universal adhesives and RMGIC in NCCL restorations separetely,22 Oz FD, Meral E, Ergín E, Gurgan S. One-year evaluation of a new restorative glass ionomer cement for the restoration of non-carious cervical lesions in patients with systemic diseases: a randomized, clinical trial. J Appl Oral Sci. 2020;28:e20200311. doi: 10.1590/1678-7757-2020-0311
https://doi.org/10.1590/1678-7757-2020-0...
,33 Shinohara MS, Carvalho PR, Neves Marcon L, Gonçalves DF, Ramos FS, Fagundes TC. Randomized clinical trial of different adhesion strategies in noncarious cervical lesion restorations: 1-year follow-up. Quintessence Int. 2020;51(5):352-63. doi: 10.3290/j.qi.a44367
https://doi.org/10.3290/j.qi.a44367...
studies investigating these adhesion strategies in a same clinical trial after 3 years are scarce. Thus, our research aims to compare these adhesive treatments over time, and the influence of initial characteristics on NCCL restoration retention. The null hypotheses tested were: (1) the four adhesive strategies would present no statistically significant differences after 3 years, for each clinical criterion and survival analysis; (2) the same adhesive strategy would show no statistically significant difference between baseline and the 3-year follow-up; and (3) the initial characteristics of NCCLs would not influence restoration retention rates after 3 years.

Methodology

Study Design

This prospective, randomized, double-blind, split-mouth study aimed to evaluate the clinical performance of NCCL restorations using two restorative materials applied with different adhesion strategies. This study was conducted following the Consolidated Standards of Reporting Trials (CONSORT). The informed consent form used was analyzed and approved by the local Ethics Committee for investigations involving human subjects (#668.963). This study was registered on the Brazilian Clinical Trials Registry (RBR-655c3z). All participants provided written consent before treatment.

Patient selection

Sample size was based on the retention rate of the Adper Single Bond (3M ESPE, St. Paul, USA), applied by simplified etch-and-rinse – the predecessor of the multi-mode adhesive. Its retention rate at 18 to 36-month follow-ups was reported to be 94%.2020 Loguercio AD, Bittencourt DD, Baratieri LN, Reis A. A 36-month evaluation of self-etch and etch-and rinse adhesives in noncarious cervical lesions. J Am Dent Assoc. 2007;138(4):507-14. doi: 10.14219/jada.archive.2007.0204
https://doi.org/10.14219/jada.archive.20...
2222 Perdigão J, Dutra-Corrêa M, Saraceni CH, Ciaramicoli MT, Kiyan VH, Queiroz CS. Randomized clinical trial of four adhesion strategies: 18-month results. Oper Dent. 2012;37(1):3-11. doi: 10.2341/11-222-C
https://doi.org/10.2341/11-222-C...
Using 80% power, two-sided testing, the minimum sample size would have to be 50 restorations per group to detect a 20% group difference.

Fifty patients from the local undergraduate clinic were selected for this study, with at least four NCCLs each, regardless of their location in the dental arch.

Patients showing good health, no history of allergies to dental products and medications, and adequate oral hygiene without active periodontal disease were included in the study. Pregnant or lactating women, individuals with active carious lesions, users of desensitizing agents, fluorine or orthodontic appliances, or with severe bruxism with more than 50% wear were excluded.

Teeth selection

Teeth with NCCL depth equal to or greater than 1 mm and a maximum depth of 4 mm, with at least 50% of their margins devoid of enamel were selected for the procedures. Careful clinical examination, including pulpal vitality tests (sensitivity to cold, hot, and percussion) verified the absence of periapical alterations in the selected teeth. No attempt was made to determine the etiology of the cervical lesions.

Initial characteristics of teeth

Dentin features were evaluated according to their degree of sclerosis,33 Shinohara MS, Carvalho PR, Neves Marcon L, Gonçalves DF, Ramos FS, Fagundes TC. Randomized clinical trial of different adhesion strategies in noncarious cervical lesion restorations: 1-year follow-up. Quintessence Int. 2020;51(5):352-63. doi: 10.3290/j.qi.a44367
https://doi.org/10.3290/j.qi.a44367...
as follows: 1 - no evident sclerosis, dentin is opaque, with yellow or whitish discoloration; 2- more than one but less than 50% sclerosis between categories 1 and 4; 3- less than 4, but more than 50% between categories 1 and 4; and 4- significant sclerosis present, dentin has a vitreous, dark yellow or even discolored (brown) appearance, with significant translucency or transparency.

Internal cavity angulation was measured and classified into 45-90°, 90-120°, or >120°. A millimeter probe measured the height, width, and depth of cavities in millimeters.

Gingival recession was categorized by the gingival margin in the mucogingival junction (MGJ) and the underlying alveolar bone as follows:2323 Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent. 1985;5(2):8-13. class I - recession not extending to the MGJ, with no interdental bone or soft tissue loss; class II - recession extending to or beyond the MGJ, with no interdental bone or soft tissue loss; class III - recession extending to or beyond the MGJ, with loss of interdental bone or soft tissue apical to the cementoenamel junction (CEJ), but coronal to the apical extent of the recession; and class IV - recession extending to or beyond the MGJ, with interdental bone loss extending to a level apical to the recession.

Spontaneous sensitivity to air and probing were assessed via the visual analogue scale (VAS) for perceived pain33 Shinohara MS, Carvalho PR, Neves Marcon L, Gonçalves DF, Ramos FS, Fagundes TC. Randomized clinical trial of different adhesion strategies in noncarious cervical lesion restorations: 1-year follow-up. Quintessence Int. 2020;51(5):352-63. doi: 10.3290/j.qi.a44367
https://doi.org/10.3290/j.qi.a44367...
, thus scored: 1 - no pain; 2 - mild; 3 - moderate; 4 - slightly worse; 5 - much worse; and 6 - severe pain.

Procedure details can be found in our previous paper.33 Shinohara MS, Carvalho PR, Neves Marcon L, Gonçalves DF, Ramos FS, Fagundes TC. Randomized clinical trial of different adhesion strategies in noncarious cervical lesion restorations: 1-year follow-up. Quintessence Int. 2020;51(5):352-63. doi: 10.3290/j.qi.a44367
https://doi.org/10.3290/j.qi.a44367...

Randomization and restorative procedures

Prophylaxis with a pumice stone and water was performed before the restorative procedures. After color selection, initial photographs were taken; and anesthesia was applied locally when necessary. Relative isolation was performed using cotton rolls and suction; non-carious cervical lesions underwent no cavity preparation.

Two graduate students identified in the procedure sheet conducted the restorative procedures. One person unrelated to this study prepared opaque sealed envelopes identifying each group by their initials (employed to conceal the randomization sequence). Treatment was allocated to the groups, a tooth was raffled for one treatment, while the remaining were assigned other treatments, following the split-mouth design. It is important to emphasize that each operator performed the same number of restorative treatments, both for control and test groups.

For the SBU group, the adhesive system (Universal Single Bond - USB, 3M ESPE, St. Paul, USA) was applied to the NCCL under agitation for 20 s on a slightly dry surface followed by a 5-second light air jet. Then, the adhesive system was photocured for 10 s (Radii-cal, 1200 mW/cm2, SDI, Victoria, Australia).

For the E-SBU group, the enamel margin was conditioned with 37% phosphoric acid (Total Etch – Ivoclar Vivadent, Liechtenstein) for 15 s, washed with a water jet for 20 s, and slight dried. Then, the USB adhesive system was applied as described above.

Both groups were restored with a nanoparticulate resin composite (Filtek Z350XT, 3M ESPE, St. Paul, USA) applied in oblique increments. Each increment was photocured for 20 s via an exponential light technique, and the last increment, for 40 s. Fine-grained and extra-fine diamond tips, and sequential polishing discs were used for restoration finishing during the same appointment (Soflex Pop On, 3M ESPE, St. Paul, USA).

For the RMGIC group, RMGIC use (Vitremer, 3M ESPE, St. Paul, USA) followed the manufacturers’ instructions. After dental prophylaxis, the tooth surface was rinsed, dried; the primer was applied with a brush on NCCL surface, and photocured for 20 s. RMGICs were manipulated in a 1:1 powder/liquid volume ratio (powder portion to 1 drop of liquid) on a glass plate using a plastic spatula for approximately 45 s. After manipulation, the material was inserted into the cavity using a disposable tip attached to a Centrix syringe (DFL, Rio de Janeiro, Brazil). The restorative material was condensed against the cavity surfaces without the use of a matrix, and photocured for 40 s. Finishing and polishing used the method applied for resin composite restorations. Then, a thin protective coating was applied onto the surface and photocured for 20 s (Finishing Gloss, 3M ESPE St. Paul, USA).

For the E-RMGIC group, 0.1 M EDTA was applied onto the NCCL surface for 60 s with a brush. Then, the surface was washed with water for 30 s, dried, and restored with RMGIC. In this group, the primer was not applied on the lesion surface to allow the RMGIC to chemically bond to the dentin. The RMGIC were manipulated and inserted as described for Group III.

Clinical evaluation

Restorations were evaluated by visual-tactile inspection using a flat mouth mirror, a periodontal probe, and a dental reflector; and classified according to the modified USPHS criteria. Restorations scored as Alpha or Bravo were considered clinically successful, those scored as Charlie, a failure. Two calibrated evaluators, blind to group assignment, examined and scored the restorations. In eventual disagreements, the evaluators reached a common agreement. Restorations were evaluated at baseline, and after 1, 2, and 3 years after the procedures.

Statistical analysis

The two-proportions equality test was used to compare the four groups at each time-point and each group over time according to USPHS criteria. Multiple logistic regression analyses verified the influence of initial characteristics in restoration survival based on retention as a dependent variable. Cumulative survival was assessed by the Wilcoxon test, Kaplan-Meier survival curves, and Holm-Šidák pairwise comparisons. Significance level was set at 5%. All statistical analyses were performed in the SPSS version 20, and SigmaPlot version 13.

Results

In total, 50 patients (34 male and 16 female) with a mean age of 61 years (ranging 38-92 years) participated in the study. We performed 200 restorations in total, homogenously distributed patients’ initial characteristics within four groups.33 Shinohara MS, Carvalho PR, Neves Marcon L, Gonçalves DF, Ramos FS, Fagundes TC. Randomized clinical trial of different adhesion strategies in noncarious cervical lesion restorations: 1-year follow-up. Quintessence Int. 2020;51(5):352-63. doi: 10.3290/j.qi.a44367
https://doi.org/10.3290/j.qi.a44367...
Three years after the procedures, 42 (84%) patients returned for follow-up. Figure 1 shows restoration and patients’ justified absence at each follow-up. We performed no intention-to-treat analysis.

Figure 1
Patient flowchart. Np: patient number, Nr: restoration number

Table 1 shows clinical data. SBU contained five lost restorations statistically different to the RMGIC group, with only one (p≤0.05). We found no statistically significant differences among other criteria (p≥0.05). As for intra-comparisons, retention was statistically different in SBU from baseline to the 3-year follow-up (p≤0.05). Marginal defects and surface texture were likewise statistically different within all groups between the 3-year follow-up and baseline (p≤ 0.05), except for the surface texture of SBU and the marginal integrity of E-RMGIC (p≥0.05). The E-RMGIC group also showed gingival healing 3 years after the restorative procedure (p≤0.05). We verified no statistically significant difference for wear, secondary caries, anatomical form, surface staining, and color over time (p≥0.05).

Table 1
Numerical restoration results per group according to each criterion at baseline, and 1, 2 and 3 years after the procedure

The 3-year cumulative survival (%) was 89, 98, 98, and 95.3, for SBU, SE-SBU, RMGIC, and E-RMGIC, respectively, without significant differences among them. Figure 2 shows the statistically significant difference between survival curves (p=0.045); however, multiple comparisons found no statistical differences (p≥0.05). The degree of gingival recession was the only initial characteristic to influence restoration retention (Table 2).

Figure 2
Retention survival comparison among the four groups
Table 2
NCCL initial characteristics per group

Discussion

Several clinical studies in the literature address non-carious cervical lesions (NCCLs). In restoring these lesions, the chemical interaction with the dental structure is important for the quality and durability of adhesion.2424 Santos MJ, Ari N, Steele S, Costella J, Banting D. Retention of tooth-colored restorations in non-carious cervical lesions-a systematic review. Clin Oral Investig. 2014;18(5):1369-81. doi: 10.1007/s00784-014-1220-7
https://doi.org/10.1007/s00784-014-1220-...
Adhesion efficacy improved after the introduction of multi-mode adhesives containing 10-Methacryloyloxydecyl dihydrogen phosphate (10-MDP) which interacts chemically with dental substrates.2525 Carrilho E, Cardoso M, Ferreira MM, Marto CM, Paula A, Coelho AS. 10-MDP based dental adhesives: adhesive interface characterization and adhesive stability: a systematic review. Materials (Basel). 2019;12(5):790. doi: 10.3390/ma12050790
https://doi.org/10.3390/ma12050790...
Glass-ionomer materials promoted retentive stability due to their chemical interactions with the dentin substrate found in NCCL.2525 Carrilho E, Cardoso M, Ferreira MM, Marto CM, Paula A, Coelho AS. 10-MDP based dental adhesives: adhesive interface characterization and adhesive stability: a systematic review. Materials (Basel). 2019;12(5):790. doi: 10.3390/ma12050790
https://doi.org/10.3390/ma12050790...
Moreover, glass-ionomer cements delayed the acid-induced dissolution rate of root dentin.2626 Kantrong N, Mongkontunpimon W, Supameteeworakul S, Wongkhantee S. Differential induction of surface chemical compositional change on tooth structure by glass ionomer restorative materials. Odontology. 2021;109(1):124-38. doi: 10.1007/s10266-020-00528-6
https://doi.org/10.1007/s10266-020-00528...
A systematic review and meta-analysis found a superior retention rate in glass-ionomer restorations than resin composite ones; though, other parameters showed no significant difference.44 Bezerra IM, Brito AC, Sousa SA, Santiago BM, Cavalcanti YW, Almeida LF. Glass ionomer cements compared with composite resin in restoration of noncarious cervical lesions: a systematic review and meta-analysis. Heliyon. 2020;6(5):e03969. doi: 10.1016/j.heliyon.2020.e03969
https://doi.org/10.1016/j.heliyon.2020.e...

Retention is one of the most important evaluating criteria for restorative material performance, often used to assess its longevity. The American Dental Association (ADA) guidelines on adhesive materials requires the cumulative 18-month retention rate to be at least 90% for procedures in dentin and enamel to be fully acceptable.2727 American Dental Association. Council on Scientific Affairs. Revised American Dental Association acceptance program guidelines: dentin and enamel adhesives. Chicago: American Dental Association; 2001. However, the guidelines have no requirements for the long-term durability of adhesive systems. In our study, SBU lost approximately 11.9% retention three years after the procedure – the highest value recorded, – thus rejecting the first null hypothesis. Meta-analysis showed universal adhesives to have better adhesion after enamel etching.2828 Cuevas-Suárez CE, Rosa WL, Lund RG, Silva AF, Piva E. Bonding performance of universal adhesives: an updated systematic review and meta-analysis. J Adhes Dent. 2019;21(1):7-26. doi: 10.3290/j.jad.a41975
https://doi.org/10.3290/j.jad.a41975...
In that sense, universal adhesives applied through etch-and-rinse and selective-etch modes tend to achieve better clinical outcomes.22 Oz FD, Meral E, Ergín E, Gurgan S. One-year evaluation of a new restorative glass ionomer cement for the restoration of non-carious cervical lesions in patients with systemic diseases: a randomized, clinical trial. J Appl Oral Sci. 2020;28:e20200311. doi: 10.1590/1678-7757-2020-0311
https://doi.org/10.1590/1678-7757-2020-0...
,55 Ranjitha GR, Vikram R, Meena N, Vijayalakshmi L, Murthy CS. Clinical efficacy of universal adhesives for the restoration of noncarious cervical lesions: a randomized clinical trial. J Conserv Dent. 2020;23(3):227-32. doi: 10.4103/JCD.JCD_51_20
https://doi.org/10.4103/JCD.JCD_51_20...
,66 Zanatta RF, Silva TM, Esper M, Bresciani E, Gonçalves S, Caneppele T. Bonding Performance of simplified adhesive systems in noncarious cervical lesions at 2-year follow-up: a double-blind randomized clinical trial. Oper Dent. 2019;44(5):476-87. doi: 10.2341/18-049-C
https://doi.org/10.2341/18-049-C...
,88 Lawson NC, Robles A, Fu CC, Lin CP, Sawlani K, Burgess JO. Two-year clinical trial of a universal adhesive in total-etch and self-etch mode in non-carious cervical lesions. J Dent. 2015;43(10):1229-34. doi: 10.1016/j.jdent.2015.07.009
https://doi.org/10.1016/j.jdent.2015.07....
In our study, the group without selective enamel conditioning presented high initial debonding rates, and SBU, the lowest 3-year cumulative survival (89%). Some clinical studies evaluating universal adhesive restorations, based on USPHS or World Dental Federation (Fédération Dentaire Internationale - FDI) criteria, and 6 to 36-month follow-ups, also reported few clinical changes over time.22 Oz FD, Meral E, Ergín E, Gurgan S. One-year evaluation of a new restorative glass ionomer cement for the restoration of non-carious cervical lesions in patients with systemic diseases: a randomized, clinical trial. J Appl Oral Sci. 2020;28:e20200311. doi: 10.1590/1678-7757-2020-0311
https://doi.org/10.1590/1678-7757-2020-0...
1010 Perdigão J, Kose C, Mena-Serrano AP, Paula EA, Tay LY, Reis A, et al. A new universal simplified adhesive: 18-month clinical evaluation. Oper Dent. 2014;39(2):113-27. doi: 10.2341/13-045-C
https://doi.org/10.2341/13-045-C...

The RMGIC group showed a cumulative survival retention (98%) similar to other clinical trials assessing the same ionomer brand (Vitremer) after 5 years (93-96.4%).1717 Franco EB, Benetti AR, Ishikiriama SK, Santiago SL, Lauris JR, Jorge MF, et al. 5-year clinical performance of composite resin versus resin modified glass ionomer restorative system in non-carious cervical lesions. Oper Dent. 2006;31(4):403-8. doi: 10.2341/05-87
https://doi.org/10.2341/05-87...
,2929 Loguercio AD, Reis A, Barbosa NA, Roulet JF. Five-year double-blind randomized clinical evaluation of a resin modified glass ionomer and a polyacid-modified resin in noncarious cervical lesions. J Adhes Dent. 2003;5(4):323-32. According to Luque-Martinez, et al. (2015), EDTA conditioning improves self-etching adhesive restoration retention rates 18 months after the procedures.3030 Luque-Martinez I, Muñoz MA, Mena-Serrano A, Hass V, Reis A, Loguercio AD. Effect of EDTA conditioning on cervical restorations bonded with a self-etch adhesive: a randomized double-blind clinical trial. J Dent. 2015;43(9):1175-83. doi: 10.1016/j.jdent.2015.04.013
https://doi.org/10.1016/j.jdent.2015.04....
However, the literature lacks a clinical study evaluating the use of EDTA prior to the application of ionomeric cements in NCCLs, thus hindering a comparison with our results. Acting in zinc and calcium ions essential for metalloproteinase (MMPs) activity, EDTA may be an alternative pretreatment for NCCLs restorations,3131 Tezvergil-Mutluay A, Agee KA, Hoshika T, Carrilho M, Breschi L, Tjaderhane L, et al. The requirement of zinc and calcium ions for functional MMP activity in demineralized dentin matrices. Dent Mater. 2010;26(11):1059-67. doi: 10.1016/j.dental.2010.07.006
https://doi.org/10.1016/j.dental.2010.07...
possibly explaining the retention of all restorations in the E-RMGIC group at their 1-year follow-up.

When reliable adhesives are properly used, early restoration loss may not be the main clinical problem, given that marginal discoloration increases over time and may become a more prominent reason for repair or replacement.3232 Kubo S, Yokota H, Yokota H, Hayashi Y. Challenges to the clinical placement and evaluation of adhesively-bonded, cervical composite restorations. Dent Mater. 2013;29(1):10-27. doi: 10.1016/j.dental.2012.08.003
https://doi.org/10.1016/j.dental.2012.08...
At the 3-year follow-up, RMGIC restorations reached more acceptable ratings for marginal discoloration than resin composite restorations, thus rejecting our second hypothesis. Approximately 70% of NCCLs restored with RMGIC obtained Alpha scores for marginal discoloration, corroborating the literature results, which verified an Alpha score for this criterion ranging from 42.9% to 84.6% after 5 years of the procedure.2929 Loguercio AD, Reis A, Barbosa NA, Roulet JF. Five-year double-blind randomized clinical evaluation of a resin modified glass ionomer and a polyacid-modified resin in noncarious cervical lesions. J Adhes Dent. 2003;5(4):323-32.,3333 Folwaczny M, Mehl A, Kunzelmann KH, Hickel R. Clinical performance of a resin-modified glass-ionomer and a compomer in restoring non-carious cervical lesions. 5-year results. Am J Dent. 2001;14(3):153-6.

Studies found restorations that were minimum 2-3 years old in vivo to present an enamel-like layer adjacent to the ionomer due to a calcium and phosphorus increase in this surface layer. This suggests an additional “mineralization” of the restorative material,3434 Van Duinen RN, Davidson CL, De Gee AJ, Feilzer AJ. In situ transformation of glass-ionomer into an enamel-like material. Am J Dent. 2004;17(4):223-7.,3535 Zanata RL, Magalhães AC, Lauris JR, Atta MT, Wang L, Navarro MF. Microhardness and chemical analysis of high-viscous glass-ionomer cement after 10 years of clinical service as ART restorations. J Dent. 2011;39(12):834-40. doi: 10.1016/j.jdent.2011.09.003
https://doi.org/10.1016/j.jdent.2011.09....
possibly contributing to its best performance as to its marginal defects. The E-RMGIC group showed no statistical differences in marginal integrity between baseline and the 3-year follow-up, and marginal discoloration over time was delayed in this group. EDTA obtained less microleakage in primary teeth compared to other pretreatment alternatives for restorations with glass-ionomer cements, thus constituting an alternative to promote chemical and micromechanical adhesion of this material to the dental structure.3636 Mazaheri R, Pishevar L, Shichani AV, Geravandi S. Effect of different cavity conditioners on microleakage of glass ionomer cement with a high viscosity in primary teeth. Dent Res J (Isfahan). 2015;12(4):337-41. doi: 10.4103/1735-3327.161448
https://doi.org/10.4103/1735-3327.161448...

However, higher surface roughness was observed in ionomer restorations, corroborating the literature results.3737 Boing TF, Geus JL, Wambier LM, Loguercio AD, Reis A, Gomes OM. Are glass-ionomer cement restorations in cervical lesions more long-lasting than resin-based composite resins? A systematic review and meta-analysis. J Adhes Dent. 2018;20(5):435-52. doi: 10.3290/j.jad.a41310
https://doi.org/10.3290/j.jad.a41310...
In our study, approximately 80% of ionomer restorations reached an Alpha score for surface texture. The literature reports a progressive increase in surface roughness of ionomer restorations after 5 years, with Alpha scores ranging from 21.4% to 23%.2929 Loguercio AD, Reis A, Barbosa NA, Roulet JF. Five-year double-blind randomized clinical evaluation of a resin modified glass ionomer and a polyacid-modified resin in noncarious cervical lesions. J Adhes Dent. 2003;5(4):323-32.,3333 Folwaczny M, Mehl A, Kunzelmann KH, Hickel R. Clinical performance of a resin-modified glass-ionomer and a compomer in restoring non-carious cervical lesions. 5-year results. Am J Dent. 2001;14(3):153-6. Gingival tissue scores improved after three years of the procedure along with an improvement in patients’ dental hygiene, which may be owed to the referral for additional treatments in undergraduate clinics.

Multiple logistic regression showed how gingival recession influenced restoration retention after 3 years, also rejecting our third null hypothesis. Considering the multifactorial etiology of NCCLs, oral health, teeth positioning in the dental arch, and occlusal interferences and overloads may influence the apical migration of the gingival margin over the years.3838 Litonjua LA, Andreana S, Bush PJ, Tobias TS, Cohen RE. Wedged cervical lesions produced by toothbrushing. Am J Dent. 2004;17(4):237-40. Nine restorations were lost between follow-ups, whereby five were classified as degree 1, three as degree 2, and one as degree 3. Other factors that may have contributed for retention failures are the exposure of restoration margins (mainly in the SBU group, lacking enamel conditioning), the effect of occlusal forces, or excessive pressure during brushing.3939 Sawlani K, Lawson NC, Burgess JO, Lemons JE, Kinderknecht KE, Givan DA, et al. Factors influencing the progression of noncarious cervical lesions: A 5-year prospective clinical evaluation. J Prosthet Dent. 2016;115(5):571-7. doi: 10.1016/j.prosdent.2015.10.021
https://doi.org/10.1016/j.prosdent.2015....

NCCLs have a multifactorial etiology, including erosion (chemical degradation), mechanical stress (tension), and friction.4040 Medeiros TL, Mutran SC, Espinosa DG, Faial KC, Pinheiro HH, Couto RS. Prevalence and risk indicators of non-carious cervical lesions in male footballers. BMC Oral Health. 2020;20(1):215. doi: 10.1186/s12903-020-01200-9
https://doi.org/10.1186/s12903-020-01200...
It is known that risk factors such as occlusal forces, overbrushing, and acidic beverages may influence the evolution in NCLL intensity, duration, and frequency.4040 Medeiros TL, Mutran SC, Espinosa DG, Faial KC, Pinheiro HH, Couto RS. Prevalence and risk indicators of non-carious cervical lesions in male footballers. BMC Oral Health. 2020;20(1):215. doi: 10.1186/s12903-020-01200-9
https://doi.org/10.1186/s12903-020-01200...
Our clinical trial faced different challenges in controlling all influencing factors, and providing enough evidence to conclusively support the causes of the lesions,4141 Bhundia S, Bartlett D, O'Toole S. Non-carious cervical lesions - can terminology influence our clinical assessment? Br Dent J. 2019;227(11):985-8. doi: 10.1038/s41415-019-1004-1
https://doi.org/10.1038/s41415-019-1004-...
we, thus, did not classify the type of NCCL – which may be deemed a limitation of this study.4141 Bhundia S, Bartlett D, O'Toole S. Non-carious cervical lesions - can terminology influence our clinical assessment? Br Dent J. 2019;227(11):985-8. doi: 10.1038/s41415-019-1004-1
https://doi.org/10.1038/s41415-019-1004-...
Furthermore, attrition may have introduced biases because the characteristics of individuals absent for follow-ups can differ between the randomized groups.4242 Dumville JC, Torgerson DJ, Hewitt CE. Reporting attrition in randomised controlled trials. BMJ. 2006;332(7547):969-71. doi: 10.1136/bmj.332.7547.969
https://doi.org/10.1136/bmj.332.7547.969...
Longer follow-up periods would most likely detect more differences among adhesion strategies for NCCL restorations.

Conclusions

Based on the 3-year results of this randomized clinical trial, we conclude that selective enamel etching affected NCCL restoration retention. Furthermore, the adhesive strategy using EDTA followed by RMGIC delayed marginal defects over time. Finally, the degree of gingival recession may affect NCCL restoration retention.

  • *
    This clinical trial is a doctoral thesis follow-up and it can be found in the UNESP Institutional Repository since 12/19/2016. It is available in http://hdl.handle.net/11449/148789. In addition, the one-year follow-up article was published by Quintessence International and can be accessed via DOI number: 10.3290/j.qi.a44367.

References

  • 1
    Walter C, Kress E, Gotz H, Taylor K, Willershausen I, Zampelis A. The anatomy of non-carious cervical lesions. Clin Oral Investig. 2014;18(1):139-46. doi: 10.1007/s00784-013-0960-0
    » https://doi.org/10.1007/s00784-013-0960-0
  • 2
    Oz FD, Meral E, Ergín E, Gurgan S. One-year evaluation of a new restorative glass ionomer cement for the restoration of non-carious cervical lesions in patients with systemic diseases: a randomized, clinical trial. J Appl Oral Sci. 2020;28:e20200311. doi: 10.1590/1678-7757-2020-0311
    » https://doi.org/10.1590/1678-7757-2020-0311
  • 3
    Shinohara MS, Carvalho PR, Neves Marcon L, Gonçalves DF, Ramos FS, Fagundes TC. Randomized clinical trial of different adhesion strategies in noncarious cervical lesion restorations: 1-year follow-up. Quintessence Int. 2020;51(5):352-63. doi: 10.3290/j.qi.a44367
    » https://doi.org/10.3290/j.qi.a44367
  • 4
    Bezerra IM, Brito AC, Sousa SA, Santiago BM, Cavalcanti YW, Almeida LF. Glass ionomer cements compared with composite resin in restoration of noncarious cervical lesions: a systematic review and meta-analysis. Heliyon. 2020;6(5):e03969. doi: 10.1016/j.heliyon.2020.e03969
    » https://doi.org/10.1016/j.heliyon.2020.e03969
  • 5
    Ranjitha GR, Vikram R, Meena N, Vijayalakshmi L, Murthy CS. Clinical efficacy of universal adhesives for the restoration of noncarious cervical lesions: a randomized clinical trial. J Conserv Dent. 2020;23(3):227-32. doi: 10.4103/JCD.JCD_51_20
    » https://doi.org/10.4103/JCD.JCD_51_20
  • 6
    Zanatta RF, Silva TM, Esper M, Bresciani E, Gonçalves S, Caneppele T. Bonding Performance of simplified adhesive systems in noncarious cervical lesions at 2-year follow-up: a double-blind randomized clinical trial. Oper Dent. 2019;44(5):476-87. doi: 10.2341/18-049-C
    » https://doi.org/10.2341/18-049-C
  • 7
    Ruschel VC, Shibata S, Stolf SC, Chung Y, Baratieri LN, Heymann HO, et al. Eighteen-month clinical study of universal adhesives in noncarious cervical lesions. Oper Dent. 2018;43(3):241-49. doi: 10.2341/16-320-C
    » https://doi.org/10.2341/16-320-C
  • 8
    Lawson NC, Robles A, Fu CC, Lin CP, Sawlani K, Burgess JO. Two-year clinical trial of a universal adhesive in total-etch and self-etch mode in non-carious cervical lesions. J Dent. 2015;43(10):1229-34. doi: 10.1016/j.jdent.2015.07.009
    » https://doi.org/10.1016/j.jdent.2015.07.009
  • 9
    Loguercio AD, Paula EA, Hass V, Luque-Martinez I, Reis A, Perdigão J. A new universal simplified adhesive: 36-Month randomized double-blind clinical trial. J Dent. 2015;43(9):1083-92. doi: 10.1016/j.jdent.2015.07.005
    » https://doi.org/10.1016/j.jdent.2015.07.005
  • 10
    Perdigão J, Kose C, Mena-Serrano AP, Paula EA, Tay LY, Reis A, et al. A new universal simplified adhesive: 18-month clinical evaluation. Oper Dent. 2014;39(2):113-27. doi: 10.2341/13-045-C
    » https://doi.org/10.2341/13-045-C
  • 11
    Perdigão J, Dutra-Corrêa M, Saraceni S, Ciaramicoli M, Kiyan V. Randomized clinical trial of two resin-modified glass ionomer materials: 1-year results. Oper Dent. 2012;37(6):591-01. doi: 10.2341/11-415-C
    » https://doi.org/10.2341/11-415-C
  • 12
    Alzraikat H, Burrow MF, Maghaireh GA, Taha NA. Nanofilled Composite resin Properties and Clinical Performance: a review. Oper Dent. 2018;43(4):E173-190. doi: 10.2341/17-208-T
    » https://doi.org/10.2341/17-208-T
  • 13
    Pagano S, Coniglio M, Valenti C, Negri P, Lombardo G, Costanzi E, et al. Biological effects of resin monomers on oral cell populations: descriptive analysis of literature. Eur J Paediatr Dent. 2019;20(3):224-32. doi: 10.23804/ejpd.2019.20.03.11
    » https://doi.org/10.23804/ejpd.2019.20.03.11
  • 14
    Sabatini C, Campillo M, Hoelz S, Davis EL, Munoz CA. Cross-compatibility of methacrylate-based composite resins and etch-and-rinse one-bottle adhesives. Oper Dent. 2012;37(1):37-44. doi: 10.2341/11-095-L
    » https://doi.org/10.2341/11-095-L
  • 15
    Yoshida Y, Yoshihara K, Nagaoka N, Hayakawa S, Torii Y, Ogawa T, et al. Self-assembled nano-layering at the adhesive interface. J Dent Res. 2012;91(4):376-381. doi: 10.1177/0022034512437375
    » https://doi.org/10.1177/0022034512437375
  • 16
    Gurgan S, Kutuk ZB, Cakir FY, Ergin E. A randomized controlled 10 years follow up of a glass ionomer restorative material in class I and class II cavities. J Dent. 2020;94:103175. doi: 10.1016/j.jdent.2019.07.013
    » https://doi.org/10.1016/j.jdent.2019.07.013
  • 17
    Franco EB, Benetti AR, Ishikiriama SK, Santiago SL, Lauris JR, Jorge MF, et al. 5-year clinical performance of composite resin versus resin modified glass ionomer restorative system in non-carious cervical lesions. Oper Dent. 2006;31(4):403-8. doi: 10.2341/05-87
    » https://doi.org/10.2341/05-87
  • 18
    Fagundes TC, Toledano M, Navarro MFL, Osorio R. Resistance to degradation of resin-modified glass-ionomer cements dentine bonds. J Dent. 2009;37(5):342-47. doi: 10.1016/j.jdent.2009.01.002
    » https://doi.org/10.1016/j.jdent.2009.01.002
  • 19
    Perdigão J, Reis A, Loguercio AD. Dentin adhesion and MMPs: a comprehensive review. J Esthet Restor Dent. 2013;25(4):219-41. doi: 10.1111/jerd.12016
    » https://doi.org/10.1111/jerd.12016
  • 20
    Loguercio AD, Bittencourt DD, Baratieri LN, Reis A. A 36-month evaluation of self-etch and etch-and rinse adhesives in noncarious cervical lesions. J Am Dent Assoc. 2007;138(4):507-14. doi: 10.14219/jada.archive.2007.0204
    » https://doi.org/10.14219/jada.archive.2007.0204
  • 21
    Reis A, Loguercio AD. A 36-month clinical evaluation of ethanol/water and acetone-based etch-and rinse adhesives in non-carious cervical lesions. Oper Dent. 2009;34(4);384-91. doi: 10.2341/08-117
    » https://doi.org/10.2341/08-117
  • 22
    Perdigão J, Dutra-Corrêa M, Saraceni CH, Ciaramicoli MT, Kiyan VH, Queiroz CS. Randomized clinical trial of four adhesion strategies: 18-month results. Oper Dent. 2012;37(1):3-11. doi: 10.2341/11-222-C
    » https://doi.org/10.2341/11-222-C
  • 23
    Miller PD Jr. A classification of marginal tissue recession. Int J Periodontics Restorative Dent. 1985;5(2):8-13.
  • 24
    Santos MJ, Ari N, Steele S, Costella J, Banting D. Retention of tooth-colored restorations in non-carious cervical lesions-a systematic review. Clin Oral Investig. 2014;18(5):1369-81. doi: 10.1007/s00784-014-1220-7
    » https://doi.org/10.1007/s00784-014-1220-7
  • 25
    Carrilho E, Cardoso M, Ferreira MM, Marto CM, Paula A, Coelho AS. 10-MDP based dental adhesives: adhesive interface characterization and adhesive stability: a systematic review. Materials (Basel). 2019;12(5):790. doi: 10.3390/ma12050790
    » https://doi.org/10.3390/ma12050790
  • 26
    Kantrong N, Mongkontunpimon W, Supameteeworakul S, Wongkhantee S. Differential induction of surface chemical compositional change on tooth structure by glass ionomer restorative materials. Odontology. 2021;109(1):124-38. doi: 10.1007/s10266-020-00528-6
    » https://doi.org/10.1007/s10266-020-00528-6
  • 27
    American Dental Association. Council on Scientific Affairs. Revised American Dental Association acceptance program guidelines: dentin and enamel adhesives. Chicago: American Dental Association; 2001.
  • 28
    Cuevas-Suárez CE, Rosa WL, Lund RG, Silva AF, Piva E. Bonding performance of universal adhesives: an updated systematic review and meta-analysis. J Adhes Dent. 2019;21(1):7-26. doi: 10.3290/j.jad.a41975
    » https://doi.org/10.3290/j.jad.a41975
  • 29
    Loguercio AD, Reis A, Barbosa NA, Roulet JF. Five-year double-blind randomized clinical evaluation of a resin modified glass ionomer and a polyacid-modified resin in noncarious cervical lesions. J Adhes Dent. 2003;5(4):323-32.
  • 30
    Luque-Martinez I, Muñoz MA, Mena-Serrano A, Hass V, Reis A, Loguercio AD. Effect of EDTA conditioning on cervical restorations bonded with a self-etch adhesive: a randomized double-blind clinical trial. J Dent. 2015;43(9):1175-83. doi: 10.1016/j.jdent.2015.04.013
    » https://doi.org/10.1016/j.jdent.2015.04.013
  • 31
    Tezvergil-Mutluay A, Agee KA, Hoshika T, Carrilho M, Breschi L, Tjaderhane L, et al. The requirement of zinc and calcium ions for functional MMP activity in demineralized dentin matrices. Dent Mater. 2010;26(11):1059-67. doi: 10.1016/j.dental.2010.07.006
    » https://doi.org/10.1016/j.dental.2010.07.006
  • 32
    Kubo S, Yokota H, Yokota H, Hayashi Y. Challenges to the clinical placement and evaluation of adhesively-bonded, cervical composite restorations. Dent Mater. 2013;29(1):10-27. doi: 10.1016/j.dental.2012.08.003
    » https://doi.org/10.1016/j.dental.2012.08.003
  • 33
    Folwaczny M, Mehl A, Kunzelmann KH, Hickel R. Clinical performance of a resin-modified glass-ionomer and a compomer in restoring non-carious cervical lesions. 5-year results. Am J Dent. 2001;14(3):153-6.
  • 34
    Van Duinen RN, Davidson CL, De Gee AJ, Feilzer AJ. In situ transformation of glass-ionomer into an enamel-like material. Am J Dent. 2004;17(4):223-7.
  • 35
    Zanata RL, Magalhães AC, Lauris JR, Atta MT, Wang L, Navarro MF. Microhardness and chemical analysis of high-viscous glass-ionomer cement after 10 years of clinical service as ART restorations. J Dent. 2011;39(12):834-40. doi: 10.1016/j.jdent.2011.09.003
    » https://doi.org/10.1016/j.jdent.2011.09.003
  • 36
    Mazaheri R, Pishevar L, Shichani AV, Geravandi S. Effect of different cavity conditioners on microleakage of glass ionomer cement with a high viscosity in primary teeth. Dent Res J (Isfahan). 2015;12(4):337-41. doi: 10.4103/1735-3327.161448
    » https://doi.org/10.4103/1735-3327.161448
  • 37
    Boing TF, Geus JL, Wambier LM, Loguercio AD, Reis A, Gomes OM. Are glass-ionomer cement restorations in cervical lesions more long-lasting than resin-based composite resins? A systematic review and meta-analysis. J Adhes Dent. 2018;20(5):435-52. doi: 10.3290/j.jad.a41310
    » https://doi.org/10.3290/j.jad.a41310
  • 38
    Litonjua LA, Andreana S, Bush PJ, Tobias TS, Cohen RE. Wedged cervical lesions produced by toothbrushing. Am J Dent. 2004;17(4):237-40.
  • 39
    Sawlani K, Lawson NC, Burgess JO, Lemons JE, Kinderknecht KE, Givan DA, et al. Factors influencing the progression of noncarious cervical lesions: A 5-year prospective clinical evaluation. J Prosthet Dent. 2016;115(5):571-7. doi: 10.1016/j.prosdent.2015.10.021
    » https://doi.org/10.1016/j.prosdent.2015.10.021
  • 40
    Medeiros TL, Mutran SC, Espinosa DG, Faial KC, Pinheiro HH, Couto RS. Prevalence and risk indicators of non-carious cervical lesions in male footballers. BMC Oral Health. 2020;20(1):215. doi: 10.1186/s12903-020-01200-9
    » https://doi.org/10.1186/s12903-020-01200-9
  • 41
    Bhundia S, Bartlett D, O'Toole S. Non-carious cervical lesions - can terminology influence our clinical assessment? Br Dent J. 2019;227(11):985-8. doi: 10.1038/s41415-019-1004-1
    » https://doi.org/10.1038/s41415-019-1004-1
  • 42
    Dumville JC, Torgerson DJ, Hewitt CE. Reporting attrition in randomised controlled trials. BMJ. 2006;332(7547):969-71. doi: 10.1136/bmj.332.7547.969
    » https://doi.org/10.1136/bmj.332.7547.969

Publication Dates

  • Publication in this collection
    22 Oct 2021
  • Date of issue
    2021

History

  • Received
    31 Mar 2021
  • Reviewed
    22 July 2021
  • Accepted
    11 Aug 2021
Faculdade De Odontologia De Bauru - USP Serviço de Biblioteca e Documentação FOB-USP, Al. Dr. Octávio Pinheiro Brisolla 9-75, 17012-901 Bauru SP Brasil, Tel.: +55 14 32358373 - Bauru - SP - Brazil
E-mail: jaos@usp.br