Cariology

CLINICAL AND TECHNOLOGICAL FACTORS IN DENTAL

POST-OPERATIVE SENSITIVITY

Cristina-Angela GHIORGHE1, Claudiu TOPOLICEANU2, Mihaela SALCEANU1,

Sorin ANDRIAN3, Andrei GEORGESCU2, Magdalena RUSU-NEGRAIA4
1
Assist. Prof., PhD, „Gr.T. Popa” University of Medicine and Pharmacy, Iaşi, Romania
2
Univ. Assist., PhD, „Gr.T. Popa” University of Medicine and Pharmacy, Iaşi, Romania
3
Prof., PhD, „Gr.T. Popa” University of Medicine and Pharmacy, Iaşi, Romania
4
Assist. Prof., PhD, „Dunărea de Jos” University, Galaţi, Romania
Corresponding author: Claudiu Topoliceanu; e-mail: claudiutopoliceanu@yahoo.com

Abstract stress caused by polymerization shrinkage are

The aim of this study was to evaluate the influence of
some clinical and technological factors on the onset and
intensity of post-operative sensitivity. A group of 57
patients suffering from post-operative sensitivity were
investigated using the Visual Analogue Scale (VAS). The
investigated factors were gender, age group (25-35 vs.
36-45), and type of composite resins and adhesive systems
used to restore the teeth (micro-hybrid composite Filtek
Z250- Adper Single Bond 2, 3M/ESPE, and nano-hybrid
composite Ceram X One Sphere Tec-Prime and Bond One,
Dentsply). The restorative treatments were performed by
the same practitioner on posterior and anterior teeth
diagnosed with mid-sized chronic cavitated carious
lesions. Total etch (etch and rinse) strategy of adhesion was
used for both composite resins. Mean scores for VAS
indices were significantly higher for Filtek Z250/Adper
Single Bond 2 and age group 36-45 (p<0.05).
Keywords: post-operative sensitivity, resin composite, total
etch strategy, Visual Analogue Scale.
1. INTRODUCTION
Nowadays, dentists use minimal invasive
operative procedures and adhesive materials to
respond to patients’ demand for a more
conservative and aesthetic dentistry [1]. Despite
the recent advances recorded in the quality of
adhesive restorations and of the proper
restorative techniques applied, composite
restorations may present marginal discoloration,
microleakage and post-operative sensitivity,
which can lead to patients' discomfort and
restoration failure [2,3]. Depending on experience
and skills, technique sensitivity and residual
reported as technological factors related to the
onset of post-operative sensitivity [4]. Patient’s
characteristics, the shape and extension of the
cavity and dentin-pulp complex protection are
reported as clinically-related factors to post-
operative sensitivity [5]. Post-operative
hypersensitivity is described as a moderate,
short-time pain, that appears spontaneously
when chewing, with hot and cold foods and, on
rare occasions, with sweet and acid foods, and it
disappears when the stimulus is removed [6].
The cold thermal stimulus generates the
movement of fluids within the gap formed by a
deficient seal of the tooth/restoration interface
and stimulates pulp nerve fibers [7]. Considering
the literature data, it seems that the rate of post-
operative sensitivity has significantly decreased
in the last 30 years, from over 30% [8] to 10% [9]
and 18% [10]. In a recent study, only 3% among
Class I restorations of microhybrid, packable, or
nanofilled composite restorations were replaced
after 6 months as a result of post-operative
sensitivity [11]. A research group reported post-
operative hypersensitivity in 15% of mesial-
occlusal/distal-occlusal (MO/DO) restorations,
and 5% of Class I restorations after 1 week [12].
Considering the potential risk for endodontic
treatments, practitioners must detect the factors
involved in the onset of post-operative sensitivity
and apply preventive measures when these
factors are present.

International Journal of Medical Dentistry 49

Cristina-Angela GHIORGHE, Claudiu TOPOLICEANU, Mihaela SALCEANU, Sorin ANDRIAN, Andrei GEORGESCU,
Magdalena RUSU-NEGRAIA

2. MATERIALS AND METHODS protection with hydroxide calcium or glass

The study was performed on 57 male and
female patients (age 25-45) with 60 teeth
presenting post-operative sensitivity in
shallow/mid-sized class I micro-hybrid
composite resin restorations (Filtek Z250- Adper
Single Bond 2(3M/ESPE) and class III nano-
hybrid Ceramix One Sphere Tec- Prime&Bond
One (Etch & Rinse) (Dentsply) composite
restorations (Table 1). The patients reported
post-operative sensitivity 24 hours after coronal
filling (short-time sharp/dull pain that appears
with hot and cold foods or liquids and disappears
when the stimulus is removed). The restorative
treatments were performed by the same
practitioner on teeth with mid-sized chronic
carious lesions, to avoid the need for pulp
ionomer liners. The total etch (etch and rinse)
strategy of adhesion was used for both composite
resins, according to manufacturer’s instructions.
Inclusion criteria: age under 50; good health
status; shallow and mid-sized cavities; reported
sensitivity 24 hours after the placement of
restorations; no analgises medication.
The intensity of post-operative hypersensitivity
was assessed using the Visual Analogue Scale
(VAS), that divides pain feeling on a scale from 1
to 10, as mild (VAS 1-3), moderate (VAS 4-7), and
high (VAS 8-10). Recording of VAS indices was
performed using a questionnaire and by asking
the patients to indicate pain intensity according
to the VAS scale (Fig. 1). Data were analysed
using Mann-Whitney signed-rank tests. The
significance level of the tests was set at p<0.05.

Table 1. FiltekZ250 and CeramX Sphere Tec OneComposition and Manufacturer’s Instructions

MATERIALS CATEGORY COMPOSITIONS MANUFACTURER

INSTRUCTION
Filtek Z 250 Universal BIS-GMA and Low-viscosity Application of composite in less
3M ESPE microhybrid TEGMA Blend of UDMA and than 2 mm thick layers and cure
Dental composite Bis-EMA resin instead of with LED lamp Demetron for 40 s
Products, TEGDMA. Z250 is filled to of each layer of the composite resins
St.Paul, USA 60% by volume with
zirconia/silica particles with
a size range of 0.01-3.5
microns and average size of
0.6 microns
Scotch Bond Adhesive 35% phosphoric acid, Etching for 15 s, rinsing for 10 s,
Etchant (gel) system colloidal silica, water, blotting of excess water using a
(pH 0.6) total etch ethanol, HEMA, mini-sponge (the surface should
Adper Single dimethacrylates, functional appear glossy without pooling of
Bond2 (pH 4.7) methacrylate copolymers of water); immediately after blotting, 2
3M ESPE polyacrylic and polytaconic consecutive coats of adhesive were
Dental acids, (Bis-GMA), silica applied for 15 s with gentle agitation
Products, nanofillers and photo using a fully saturated applicator;
St.Paul, USA initiator gently apply air thin for 5 s to
evaporate solvents; light cure for 10 s
Ceram X Universal Poly-urethane methacrylate, Application of composite in less
Sphere Tec nano-hybrid Bis-GMA, TEGDMA, than 2 mm thick layers and curing
One ceramic prepolymerized fillers with LED lamp Demetron for 40 s
Dentsply De composite perfectly round spheres <1 of each layer of the composite resins
Trey Gmbh μm, non-agglomerated
Germany submicron barium glass and
ytterbium fluoride. (59-61%
by volume)

50 Volume 8 • Issue 2 April / June 2018 •

 CLINICAL AND TECHNOLOGICAL FACTORS IN DENTAL POST-OPERATIVE SENSITIVITY

Prime&Bond Adhesive Carboxylic acid modified
One Select system etch dimethacrylate (TCB resin),
Dentsply De and rinse phosphoric acid modified
Trey Gmbh acrylate resin (PENTA),
Germany UDMA, TEGDMA, HEMA,
butylated benzenediol
(stabilizer), ethyl
4(dimethylamino)benzoate,
camphor quinone,
functionalised amorphous
silica, tertiary butanol
The enamel and dentin were etched
with 36% phosphoric acid for 15 s
and rinsed for 10 s; blotting of
excess water using a mini sponge;
application of prime&bond® one
Etch&Rinse adhesive using the
applicator tip for 20 s; solvent
evaporation by thorough drying
with clean, dry air from a dental
syringe for 5 s (the surface should
have a uniform glossy appearance);
curing of prime&bond® one
Etch&Rinse adhesive for 10 s 2
using a curing light

Fig. 1. VAS scale [13]

3. RESULTS teeth restored with nano-hybrid composite

The mean values of VAS indices related to
post-operative sensitivity, in relation to the
type of composite resin and adhesive systems,
are presented in Table 2. For the teeth restored
with micro-hybrid composite resin Filtek Z250
(adhesive system AdperSingle Bond 2), the
mean value of VAS indices was 8.8; for the
resin CeramXSphere Tec One (adhesive
system Prime&BondOne Select), the mean
value of VAS indices was 7.3. Related to
gender, the mean value of VAS indices for
males was 8.4 and 7.7 for females, respectively.
As to age, the mean value of VAS indices was
7.7 for age group 25-35, and 8.7, respectively,
for age group 36-45.

Table 2. VAS indices changes related to the type of composite resin/adhesive

Ceram X Sphere Group 25- Group 36-

Filtek Z 250 Male Female
Tec One 35 45
No 30 30 27 33 39 21
Minimum 7 7 7 7 7 7
Maximum 10 8 10 10 10 10
Mean 8.80 7.30 8.44 7.73 7.69 8.71
S.D. ±1.095 ±0.466 ±1.281 ±0.876 ±0.832 ±1.309

International Journal of Medical Dentistry 51

Cristina-Angela GHIORGHE, Claudiu TOPOLICEANU, Mihaela SALCEANU, Sorin ANDRIAN, Andrei GEORGESCU,
Magdalena RUSU-NEGRAIA
Table 3. Mann-Whitney Test Comparisons of Post-Operative Sensitivity
VAS Values for Materials, Sex and Age
Ceram X
Filtek Z 250 Sphere Tec
One
No 30 30
Mean Rank 41.75 19.25
Asymp. Sig.
0.0001*
(2-tailed)p
Table 3 lists comparatively the Mann-Whitney
test of VAS indices mean values between
materials/adhesives (Filtek Z250/AdperSingle
Bond 2 vs. Ceram XSphere Tec One/
Prime&BondOne Select), gender (males vs.
females) and age groups (25-35 vs. 36-45). The
rank mean of VAS indices was higher for post-
operative sensitivity recorded to Filtek Z250
(MFZ250=41.75) than for Ceram X (MCeramX=19.25).
The rank mean of VAS indices was higher for
post-operative sensitivity recorded for males
(Mmale=35.33) than for females (Mfemale=26.55). The
rank mean of VAS indices was higher for post-
operative sensitivity recorded for age group ”36-
45” (M 36-45=38.64) than age group ”25-35”
(M25-35=26.12). Significant statistical differences of
VAS indices were observed between Filtek Z250
and Ceram X coronal restorations, as well as
between age groups (p<0.005).
4. DISCUSSION
Along the study, the influence of cavity shape
and extension, the working conditions and the
restorative and adhesive techniques were
reduced during the treatment performed by the
same practitioner. Also, the use of a checked
power light source and of a gradual light
activation technique, as well as the insertion of
composite resin in small increments, decreased
composite resins polymerisation shrinkage [14].
The intensity of post-operative sensitivity was
recorded using the visual analogue scale,
considering the high test-retest reliability and
repeatability, the consistent internal measures
taken against clinical and experimental pain, the
sensitivity to pain changes and the ability to
measure the multiple dimensions of pain [15,16].
52
Age group Age group
Male/ Female
25-35 36-45
27 33 39 21
35.33 26.55 26.12 38.64
0.039 0.005
Lower mean values of the VAS indices were
recorded for Ceram X (7.3) compariatnvely with
Filtek Z250 (8.8). These differences can be
explained both by the different composition and
interaction with the dentin of the adhesive
systems and by the different polymerisation
shrinkage of the two composites, due to their
structure (Filtek Z250 is a microhybride
composite, CeramX is a nanohybrid composite).
Inclusion of standard shallow and medium
cavity depth and the avoidance of liners
eliminated the influence of cavity depth or liners
in the onset of post-operative sensitivity [17].
The practitioner observed the strict standards
related to the total-etch technique (etch-and-
raise) applied, trying to standardise acid etching,
as well as the application and light activation of
the adhesive system. The quality of the adhesive
systems influences the possibility of avoiding the
onset of post-operative sensitivity, as the bond
interface can prevent entrance of bacterial fluids
and ensure both a proper formation of hybrid
layer hybridization and prevention of marginal
leakage, resin discoloration and post-operative
sensitivity [18,19].
The influence of the type of composite resins
and the adhesive strategy used in the prevention
of microleakage (potential ethiological factor for
post-operative sensitivity) is proved by many
studies. One of them demonstrated that the
thicker hybrid layer is associated to the total-etch
technique, comparatively with the self-etch
technique [20]. The role of the different
polymerisation shrinkage of various composite
resins is proved by the higher microleakage
recorded for micro-hybrid composite restorations
compared to the coronal restorations performed
with a nano-hybrid composite. [21,22]. Also,
post-operative sensitivity is more frequently
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 CLINICAL AND TECHNOLOGICAL FACTORS IN DENTAL POST-OPERATIVE SENSITIVITY
present when coronal restorations are performed
using total-etch adhesive systems [23].
The quality of adhesion can be significantly
reduced with the total-etch technique, due to
dentin’s surface wetness and to the longer acid-
etching process [24]. Also, the use of self-etching
systems is characterised by the absence of a
separate etching step and by a uniform
penetration of resin into the etched dentin [25,26].
The onset of post-operative sensitivity is
prevented by the adhesive systems that include
the hydrophilic component HEMA, with a
significant role in increasing adhesion to dentin
collagen [27,28]. Prevention of post-operative
sensitivity is also insured by the inclusion of
glutaraldehyde/HEMA in the composition of the
investigated adhesive systems, which assures the
increase of surface energy and facilitates the
diffusion of the hydrophilic resin monomer into
dentin [29]. Inclusion of glutaraldehyde stimulates
the formation of a coagulation plug inside the
dentinal tubules, which may contribute to the
prevention of post-operative sensitivity [30,31].
Coronal restorations were performed using
two adhesive systems that incorporate colloidal
silicate fillers which form an uniform and stable
hybrid layer. The solvents influence the quality of
adhesion, as the adhesive containing tertiary
butanol shows a stronger bond strenght than the
adhesive systems that include ethanol. Adper
Single Bond 2 contains in its composition ethanol,
and Prime & Bond - tertiary butanol. Some
differences regarding the technique are considered
as Adper Single Bond 2 (adhesive system for
Filtek Z250), requiring 2-3 successive adhesive
coats, while Prime & Bond (adhesive system for
Ceram X) - only 1 coat. All these data can explain
the lower post-operative hypersensitivity
observed for Ceram X restoration.
Further studies with greater sample size are
requested to compare the characteristics of post-
operative sensitivity for various materials and
adhesives, depth cavity, and liners.
5. CONCLUSIONS
The intensity of post-operative sensitivity is
significantly higher in microhybrid composite
restorations, compared to nano-hybrid composite
International Journal of Medical Dentistry
restorations. Significant differences regarding
the intensity of post-operative intensity were
found between males and females (significantly
higher for males), as well as between the age
groups (significantly higher for patients with
ages of 36-45).
The results obtained evidence no statistically
significant differences between sexes.
References
1. Andrian S, Georgescu A, Stoleriu S, Dimbu E. New
data on the clinical and therapeutic management of
occlusal caries (III). 2017; 7(2): 110-116
2. Christensen GJ. Preventing postoperative tooth
sensitivity in class I, II and V restorations. J Am Dent
Assoc. 2002;133(2):229-31.
3. Beck F, Lettner S, Graf A, Bitriol B, Dumitrescu N,
Bauer P, Moritz A, Schedle A. Survival of direct resin
restorations in posterior teeth within a 19-year period
(1996-2015): A meta-analysis of prospective studies.
Dent Mater.2015;31(8):958-85.
4. Tantbirojn D, Versluis A, Pintado MR, DeLong R,
Douglas WH. Tooth deformation patterns in molars
after composite restoration. Dent. Mater.
2004;20(6):535-42.
5. Sarrett DC.Clinical challenges and the relevance of
materials testing for posterior composite restorations.
Dent. Mater. 2005;21(1):9-20.
6. Akpata ES, Sadiq W. Post-operative sensitivity in
glass-ionomer versus adhesive resin-lined posterior
composites. Am J Dent. 2001;14(1):34-8.
7. Brännstrom M. Etiology of dentin hypersensitivity.
Proc Finn Dent Soc.1992; 88(suppl 1):7-13.
8. Letzel H. Survival rates and reasons for failure of
posterior composite restorations in multicentre
clinical trial. J Dent. 1989;17 Suppl 1:S10-7.
9. Pallesen U, Van Dijken JW, Halken J, Hallonsten Al,
Höigaard R.A prospective 8-year follow-up of
posterior resin composite restorations in permanent
teeth of children and adolescents in Public Dental
Health Service: reasons for replacement. Clin Oral
Investig. 2014;18(3):819-27.
10. Berkowitz G, Spielman H, Matthews A, Vena D,
Craig R, Curro F, Thompson V.Postoperative
hypersensitivity and its relationship to preparation
variables in Class I resin-based composite restorations:
findings from the practitioners engaged in applied
research and learning (PEARL) Network. Part
1.Compend Contin Educ Dent. 2013;34(3):44-52.
11. Sadeghi M, Lynch CD, Shahamat N.Eighteen-month
clinical evaluation of microhybrid, packable and
nanofilled resin composites in Class I restorations. J
Oral Rehabil. 2010; 37(7):532-7.
12. Briso AL, Mestrener SR, Delício G, Sundfeld RH,
Bedran-Russo AK, de Alexandre RS, Ambrosano
53
Cristina-Angela GHIORGHE, Claudiu TOPOLICEANU, Mihaela SALCEANU, Sorin ANDRIAN, Andrei GEORGESCU,
Magdalena RUSU-NEGRAIA
GM. Clinical assessment of postoperative sensitivity
in posterior composite restorations. Oper Dent.
2007;32(5):421-6.
13. Breivik H, Borchgrevink PC, Allen SM, Rosseland LA,
Romundstad L, Hals EK, Kvrstein G, Stubhaug
A.Assessment of pain. Br J Anaesth. 2008;101(1):17-24.
14. Coghill RC, McHaffie JG, Yen YF. Neural correlates
of interindividual differences in the subjective
experience of pain. Proc. Natl. Acad. Sci. USA.
2003;100(14): 8538-42.
15. Rosier EM, Iadarola MJ, Coghill RC.Reproducibility
of pain measurement and pain perception. Pain.
2002;98(1-2):205-16.
16. Price DD, Staud R, Robinson ME. How should we
use the visual analogue scale (VAS) in rehabilitation
outcomes? II: Visual analogue scales as ratio scales:
an alternative to the view of Kersten et al. J Rehabil
Med. 2012;44(9): 800-1.
17. Xu J, Stangel I, Butler IS, Gilson DFR, An FT-Raman
spectroscopic investigation of dentin and collagen
surfaces modified by 2-hydroxyethylmethacrylate. J
Dent Res. 1997; 76(1):596-601.
18. Caughman WF, Rueggeberg FA, Curtis JW Jr. Clinical
guidelines for photocuring restorative resins.  J Am
Dent Assoc.1995;126(9):1280-2.
19. Opdam NJ, Roeters FJ, Feilzer AJ, Verdonschot EH.
Marginal integrity and postoperative sensitivity in
Class 2 resin composite restorations in vivo. J Dent.
1998; 26(7): 555-62.
20. Iovan G, Stoleriu S, Ghiorghe CA, Cimpoesu N,
Georgescu A, Andrian. S. Evaluation of the interfacial
morphology between a single component adhesive
and dentin with or without preliminary acid etching.
Mat Plast. 2014;51(4):421-3.
21. Ghiorghe CA, Iovan G, Andrian S, Nica I, Topoliceanu
C, Pancu G. Studies on adhesion of composite resins
and glass-ionomer cements in open-sandwich
technique. Rev. Chim. (Bucharest). 2017; 68(8):1890-4.
22. Ghiorghe CA, Iovan G, Sălceanu M, Moldovan A,
Iordache C. Electronic microscopy studies on the
54
adhesion of total etch adhesive systems in glass-
ionomers and compomers. Rom J Oral Rehab.
2017;9(3):11-6.
23. Yousaf A, Aman N, Manzoor MA, Shah JA,
Dilrasheed. J. Postoperative sensitivity of self etch
versus total etch adhesive. J Coll Physicians Surg Pak.
2014;24(6):383-6.
24. Sancakli HS, Yildiz E, Bayrak I, Ozel S. Effect of
different adhesive strategies on the post-operative
sensitivity of class I composite restorations. Eur J
Dent. 2014;8(1):15-22.
25. Wegehaupt F, Betke H, Solloch N, Musch U, Wiegand
A, Attin T. Influence of cavity lining and remaining
dentin thickness on the occurrence of postoperative
hypersensitivity of composite restorations. J Adhes
Dent. 2009;11(2):137-41.
26. Iovan G, Stoleriu S, Andrian S. Self-etch bonding
systems: more reliable or more challenging for the
practitioner? International Journal of Medical
Dentistry 2017; 7(3): 189-195
27. Bansal A, Shivanna V. Effect of rewetting agents on
the shear bond strength of different bonding agents
when applied on dry dentin. J Cons Dent. 2007;10:26-
32.
28. Podariu AC, Jumanca D, Galuscan A, Popovici RA,
Podariu AS, Nitipir C, Chiscop I, Barlean LM.
Evaluation of impact of technological factors on
dental composites. Mat Plast. 2015; 52(4):604-7.
29. Christensen GJ. Is now the time to purchase an
in-office CAD/CAM device? J Am Dent Assoc.
2006;137(2):235-6, 238.
30. De Paiva Gonçalves SE, Burim RA, Pleffken PR,
Barcellos DC, Gomes APM, Huhtala MFR. A
comparative study of the physical proprieties of
conventional and Grander-modified adhesive
systems. Rev Odonto Cienc 2011;26(4):315-320.
31. Ladalardo TC, Pinheiro A, Campos RA, Brugnera
Júnior A, Zanin F, Albernaz PL, Weckx LL. Laser
therapy in the treatment of dentine hypersensitivity.
Braz Dent J. 2004;15(2):144-50.
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