DENTAL-2617; No.

of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.intl.elsevierhealth.com/journals/dema

Review

Is secondary caries with composites a

material-based problem?

Ivana Nedeljkovic a , Wim Teughels b , Jan De Munck a , Bart Van Meerbeek a ,

Kirsten L. Van Landuyt a,∗
a KU Leuven BIOMAT, Department of Oral Health Sciences, University of Leuven & Dentistry University Hospitals
Leuven, Kapucijnenvoer 7, 3000 Leuven, Belgium
b Oral Microbiology, Department of Oral Health Sciences, University of Leuven & Dentistry University Hospitals

Leuven, Kapucijnenvoer 7, 3000 Leuven, Belgium

a r t i c l e i n f o a b s t r a c t

Article history: Objective. Secondary caries (SC) is one of the most important reasons for the failure of com-
Received 5 December 2014 posite restorations, and thus has wide-reaching implications for the longevity of affected
Received in revised form teeth and the health expenditure. Yet, it is currently not known whether secondary caries
28 March 2015 with composites is a material-based problem. The objective was to review literature with
Accepted 1 September 2015 regard to SC around composite restorations to obtain better insights in the mechanisms
Available online xxx behind SC with composites.
Methods. Using Pubmed and Medline, international literature was searched for all articles
Keywords: about the clinical diagnosis, incidence and prevalence, histopathology and factors involved
Secondary caries in the onset and development of SC around composite restorations. Additional studies were
Recurrent caries included after checking the reference lists of included papers.
Composite Results. SC with composites is to some extent associated to the restorative material, as sig-
Resin-based restoration nificantly more caries occurred with composites than with amalgam. On the other hand, the
class of the composite restoration (class V versus others and class I versus class II) was also
determining for the development of SC, suggesting also other influencing factors than the
material itself. The mechanisms behind the development of SC are much less clear and are
most probably multifactorial. Even though the role of gaps an microleakage is questioned by
some researchers, there are also indications that interfacial failure may play a role. Interfa-
cial gaps larger than 60 ␮m seem to predispose interfacial demineralization, and may thus
lead to caries. The question is therefore whether such interfacial gaps occur clinically? Ini-
tially, a gap may originate through polymerization shrinkage and through failure to obtain a
good bond. Higher incidences of SC are observed in practice-based than in university-based
studies, which may be attributed to different caries risk profiles of the included patients, or
to the technique-sensitive placement procedure of composites. More research is necessary
to investigate whether large gaps may arise through degradation processes. Apart from

∗
Corresponding author. Tel.: +32 16 332790.
E-mail address: kirsten.vanlanduyt@med.kuleuven.be (K.L. Van Landuyt).
http://dx.doi.org/10.1016/j.dental.2015.09.001
0109-5641/© 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e2 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31

these factors, composites also seem to favor the growth of cariogenic bacteria on their sur-
face, which has been associated with specific surface properties, release of components and
lack of antibacterial properties.
Significance. Current literature suggests that the restorative material might influence the
development of secondary caries in different ways. However, it should be emphasized that
patient-related factors remain the most important determinant of secondary caries.
© 2015 Academy of Dental Materials. Published by Elsevier Ltd. All rights reserved.

Contents

1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .00
2. Search strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
3. Diagnosis of secondary caries next to composites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4. Incidence of secondary caries with composites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .00
5. Histopathology of secondary caries around composites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .00
6. Etiopathogenesis of secondary caries next to composites. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .00
7. Composite properties that influence the development of secondary caries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7.1. Sealing capacity of composites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7.1.1. Technique sensitivity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7.1.2. Polymerization shrinkage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7.1.3. Biodegradation of the interface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7.1.4. Mechanical degradation of the interface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7.2. Surface properties of composites and bacterial adhesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7.3. Interaction between bacteria and released composite components . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
7.4. Lack of antibacterial and buffering properties of composites . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
8. Strategies to decrease the susceptibility of composites to SC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
8.1. Incorporation of antibacterial and/or remineralizing agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
8.2. Preservation of good sealing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
8.3. Modification of composites’ surface properties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
9. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Acknowledgement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Appendix A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

teeth. All in all, the use of these versatile materials is still on

1. Introduction the rise.
However, a number of clinical studies have reported shorter
During the past decade, composites have become the most longevity and higher failure rates for composite restorations
commonly used restorative materials [1,2]. They have grad- compared to amalgams [2,7–13]. One of the main reasons for
ually replaced amalgams, which have been the standard failure was secondary or recurrent caries [8–10,12–17]. It is
restorative material for more than 100 years, not only because clear that these findings evoked scientific debate, as prema-
of their desirable esthetics, ease of handling and minimally ture renewal or replacement of restorations is a heavy burden
invasive preparation technique, but also because dental amal- on health care expenditure. In addition, secondary caries
gams have been associated with environmental pollution [3,4] (SC) always results in further tooth structure loss and may
and even with alleged negative health effects due to release weaken the remaining tooth. Especially in case of extensive
of mercury [5,6]. In addition, thanks to their bonding potential secondary-caries lesions and repetitive restorative interven-
to the tooth tissues, good mechanical properties and lower tions, this may eventually lead to premature loss of the
cost compared to other indirect restorations, the application tooth.
of composites has expanded to a wide variety of clinical situ- Various definitions of SC have been proposed in scientific
ations, some of which previously could only be treated with literature and medical dictionaries. First, the terms ‘sec-
indirect prosthetic restorations. Nowadays, composites are ondary’ and ‘recurrent’ caries are used interchangeably, with
not only used to restore decayed or traumatized teeth, but they the difference that ‘secondary caries’ is used more commonly
are also routinely used both as direct and indirect restoratives in European papers, while ‘recurrent caries’ is typically used
to improve esthetic properties of discolored or malpositioned in North America [18]. As for the meaning of these terms, it

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31
Fig. 1 – Clinicians often claim that secondary caries is a
much more frequent problem with composites than with
amalgam or other restorative materials. In this RX-bite
wing of a 59 years old patient, a recurrent caries was
diagnosed under a composite restoration in the first lower
molar. In contrast to the old amalgam restorations in all
other teeth, this restoration was placed only a couple of
years before. These typical clinical cases strengthen
clinician’s beliefs that composite restorations are more
sensitive to secondary caries.
seems that they can signify both ‘new caries around a restora-
tion’ (irrespective of the fact whether the restoration was
placed due to a primary caries) as well as ‘residual/remaining
caries’ depending on the context [19]. Nevertheless, Mjör
and Toffenetti [20] made a distinction between these terms
and defined SC as a ‘new lesion at the margin of existing
restorations’. Even though the clinical differentiation between
residual and newly developed caries is sometimes impossi-
ble, clear distinction is still preferable since residual caries
underneath a restoration is nowadays not always considered
anymore as failure due to a paradigm shift in caries treat-
ment. For example, carious dentin can be left on purpose
when applying conservative operative techniques, such as
stepwise excavation, partial caries removal or no-dentinal-
caries removal [21,22]. In the remainder of this review we
will reserve the term ‘secondary caries’ only for progressive
and active caries lesions at the margins or under compos-
ite restorations that were placed following complete caries
removal. Papers dealing with residual caries were excluded
from the review.
A recent Delphi survey on the future of restorative dentistry
for the next 20 years identified ‘prevention of secondary caries’
as of the highest importance [23]. Yet, it is currently not known
whether SC with composites is a material-based problem. It
is often stated by dentists and scientists that SC is a much
more frequent problem with composites than with amal-
gam or other restorative materials (Fig. 1) [10]. The purpose
of this narrative review was, therefore, to present the cur-
rent knowledge about the incidence and prevalence, clinical
Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
xxx.e3
diagnosis, histopathology and factors involved in the onset
and development of SC around composite restorations.
2. Search strategies
Using Pubmed and Medline, international literature was
searched for all papers about different aspects of secondary
caries such as clinical diagnosis, histopathology and all fac-
tors that were associated with the development of SC around
composite restorations, which were discussed in separate
paragraphs. Therefore, for each paragraph we performed a dif-
ferent search strategy with appropriate key words. Additional
studies were found after checking the reference lists of the
included papers. Since this review is narrative in nature, it
was practically not possible to strictly define inclusion and
exclusion criteria, and various types of papers were selected
(in vitro, in situ, clinical studies, different types of review
papers, as well as meta-analyses) based on a search with
the combination of the following keywords: secondary caries,
recurrent caries, dental composite, diagnosis, radiopacity,
histopathology, outer and wall lesion, microleakage, interfa-
cial gap, polymerization shrinkage, bacterial adhesion, surface
roughness, surface free energy, biodegradation of compos-
ites, antibacterial composites etc. Only for the evaluation of
the incidence of SC, a systematic search of literature was
performed and strict inclusion and exclusion criteria were
defined, which have been described in more detail below(§4,
Table 1 and Fig. 2)
3. Diagnosis of secondary caries next to
composites
Diagnosis of SC is always more difficult than that of primary
caries due to the sheer presence of the restoration, but some
researchers also suggested that there is a lack of standardized
diagnostic criteria. They even hinted that a great number of
composite restoration replacements due to this condition may
in fact be an overtreatment [18,24].
Traditionally, oral examination, based on visual and tac-
tile inspection combined with radiologic evaluation, is used
for diagnosis; however, all these techniques have certain lim-
itations in the detection of SC with composites. With visual
and tactile examination it is sometimes very difficult to dis-
tinguish SC from certain other conditions such as marginal
discoloration and so-called ‘amalgam tattoo’. Brown and
black marginal staining, as signs of marginal debonding and
consequent microleakage, are more easily detected around
tooth-colored restorations, compared to amalgams, and are
indeed very often interpreted as a first stage of SC [18,24].
Discolored dentin shining up through enamel often results
from uptake of corrosion products from a previous metal
restoration and is not necessarily a sign of caries underneath
the restoration. Furthermore, during tactile examination a
sharp probe can stick even into caries-free marginal gaps or
overhangs. Kidd and Beighton [25] indeed demonstrated the
inefficiency of these clinical parameters to reliably predict
the presence of the soft infected dentin under tooth-colored
restorations.
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e4 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31

Fig. 2 – Flow chart describes all phases of the systematic review of the incidences of secondary caries with composite
restorations reported in clinical studies. After the identification of the records in the database based on the specific
keywords, and their selection according to predetermined inclusion/exclusion criteria, 241 clinical studies were finally
included in the quantitative analysis of cumulative incidences (all studies are listed in Appendix A).

The most commonly used auxiliary method for the detec-
tion of SC around restorations is intraoral radiography.
Regarding sensitivity, specificity and accuracy, conventional
and digital intraoral radiographs are comparable, but lower
radiation doses give great advantage to digital over conven-
tional radiography. For SC diagnosis, however, both techniques
are limited by their two-dimensional nature and their diag-
nostic power depends on the angulation of the beam and
superimposition of details in the radiograph. This could be
overcome by using cone-beam computed tomography (CBCT)
[26,27], but the higher radiation doses compared to intraoral
techniques are not justifiable [28]. Also, the discriminative
ability of radiography to detect SC may be influenced by the
radiopacity of the restorative material. The radiopacity of most
of contemporary composites is slightly higher than that of
enamel, which allows more accurate detection of SC next to
composites than next to highly radiopaque amalgams [29];
On the other hand, there are unfortunately still commercial
composites with radiopacity lower than enamel, which may
hamper radiologic SC diagnosis [30]. Finally, if there is still
uncertainty regarding the diagnosis of SC after the use of tradi-
tional diagnostic methods, an exploratory preparation into the
restorative material adjacent to the suspicious site has been
recommended [18].
Promising alternative detection techniques based on flu-
orescence such as quantitative light-induced fluorescence
(QLF) (Inspector Research Systems, Holland) and DIAGNOdent
(Kavo, Biberach an der Riss, Germany) have also been tested to
detect SC around composites [31,32]. In vitro studies showed
a similar sensitivity, specificity and accuracy of these tech-
niques to bitewing radiographs in combination with visual
examination [33,34], and the results of a recent in vivo study
are also promising [35].
Apart from the detection of SC lesions, it has been sug-
gested that the diagnosis should also include the assessment
of the lesion activity. Differentiating between active and
arrested lesions is important for treatment planning, since the
latter could be treated following a more conservative approach
such as repair or refurbishment of the restoration, or by only
monitoring of the lesion [18,24].

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31
Table 1 – Inclusion and exclusion criteria used for the
selection of clinical studies.
Inclusion criteria
Clinical studies on the performance of composites (including
compomers)/adhesives
Studies using standardized criteria to assess clinical performance
of restorations, including presence/absence of secondary caries
Studies published between 2000 and August 2014
Studies written in English
Exclusion criteria
Composite restorations on primary teeth
Indirect composite restorations
Resin-modified glass-ionomer restorations
Unequal evaluation periods for evaluated restorations
Insufficient information available on the exact number of
evaluated restorations, recall rates, evaluation periods or the
number of secondary caries lesions
4. Incidence of secondary caries with
composites
Even though SC has been recognized as an important problem
related to composite materials, its incidence and prevalence
in the general population have not yet been fully investi-
gated. Surprisingly, there are currently no studies available
dealing exclusively with this issue. On the other hand, a lot of
information regarding the incidence of SC is available in clin-
ical studies on the performance and longevity of composite
restorations and/or dental adhesives.
Using different online databases (Pubmed, Medline), inter-
national literature available until August 2014 was searched
for articles in English published between 2000 and later that
reported on the performance of composites or adhesives.
Several papers were found by means of references in other
papers. The used keywords were: “adhesive”; “composite”,
“performance”, “clinical evaluation”, “longevity”, “survival”,
“failure rate”, “posterior/anterior/cervical composite”, and the
search filter was “clinical trial”. Inclusion and exclusion crite-
ria are presented in Table 1. The search and the inclusion
of articles was performed according to the PRISMA guide-
lines (Fig. 2) [36,37]. Ultimately, 241 studies could be included
(Appendix table). The cumulative incidence of SC, which is the
occurrence of SC within the follow-up periods of the study,
was calculated. Therefore, the obtained incidence values
should be interpreted only with the corresponding follow-
up periods, which varied from 1 up to 17 years. In studies
reporting data collected at several evaluation moments, we
calculated the incidence for each of them, and finally 252
cumulative incidences, could be included in the quantita-
tive analysis. Most of the included studies were prospective,
as retrospective studies often did not allow calculation
of the caries incidence (uneven evaluation periods for all
restorations).
In general, the caries incidence in included studies was
very variable, ranging between 0% and 44%, with most stud-
ies even without occurrence of SC (175 out of 252 incidences).
The overall incidences of SC are shown in Fig. 3, as retrieved
from studies included in the Appendix. The high variation in
caries incidences is most striking but not surprising consid-
ering the high variation in materials used, type, location and
Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
xxx.e5
size of restoration, number and type of patients and operators,
study setting (academic versus private practice) and follow-
up period. As it was previously speculated in the literature
[20], the study setting seemed to affect the incidence, as SC
occurred more often in practice-based studies (median = 0.83%
vs 0% in university-based studies) (Fig. 3a). This difference is
most probably due to the fact that majority of university stud-
ies included only low-caries risk patients. However, it may also
point to the high technique-sensitivity of the composite place-
ment technique, since in university-based studies operators
were usually calibrated and trained for the operative proce-
dure.
As expected, also the location of the restoration played a
major role in the occurrence of SC (Fig. 3b). Cervical com-
posite restorations (class V) were the least affected by SC,
which obviously may be related to the fact that many class
V studies were set up to evaluate the clinical effectiveness
of adhesives in non-carious cervical lesions in patients with
low caries risk and good oral hygiene. The highest overall
incidences were found in the posterior region. Also ante-
rior restorations (classes III and IV) seem to be vulnerable to
SC, but these results must be interpreted with care as only
few studies included anterior restorations (n = 12). Naturally,
the length of the observation period is also very important
while interpreting these data. Therefore, we subdivided the
included studies in short-term (evaluation period <3 years),
medium-term (evaluation period between 3 and 5 years) and
long-term (evaluation period >5 years) studies (Fig. 3c–e). Only
for class V restorations, the incidence of SC did not increase
over time (Fig. 3c), which again may be attributed to the
fact that the majority of studies involved non-carious lesions.
Nevertheless, there were some studies that did report the
presence of some SC next to cervical restorations. This find-
ing might point to a restoration-based cause (but not per se
material-based) for SC. In contrast, SC incidence significantly
increased over time in the other types of restorations, with
the highest median incidences recorded after 5 years, more
specifically 4% for anterior and 1.7% for posterior restora-
tions (Fig. 3d and e). When the incidence of the posterior
restorations was further evaluated in detail by subdividing
them in class I and II restorations (Fig. 3f), it was clear
that class II are more prone to SC than class I restorations.
In his practice-based survey, Mjör reported the highest per-
centage of SC lesions located gingivally, irrespective of the
restorative material used [38]. Unfortunately, in these studies
the exact location of the recurrent caries with regard to the
restoration (i.e. gingival, approximal or incisal/occlusal) was
often not described in detail and could thus not be retrieved.
Notably, even though caries incidence was generally very low
in the first years of the follow-up period, there were stud-
ies indicating that SC may already occur after 1 or 2 years
[39–41].
Even more interesting is comparing the incidence of SC
with composites to that with other types of restorations. In
Table 2, prospective clinical studies that compared the perfor-
mance and longevity of composites with amalgam are listed.
Most of these studies were practice-based. The incidence of
SC around amalgams varied between 0% and 4.9%. In contrast,
composites restorations tended to exhibit markedly more SC,
with incidences varying between 0% and 12.7%.
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e6 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31

Fig. 3 – The mean incidences of secondary caries (SC) next to composites as retrieved from the studies included in
Appendix Table. Due to the skewed distribution of the incidences, they are expressed as box plots with median (black line)
with 25% and 75% quartile. The outliers are shown as dots and the whiskers represent the lowest value still within 1.5
interquartile range (IQR) of the lower quartile, and the highest value still within 1.5 IQR of the upper quartile. The included
studies were subdivided in short-term (evaluation period <3 years), medium-term (evaluation period between 3 and 5 years)
and long-term (evaluation period >5 years) studies . (a) There was a marked difference in incidence depending on the study
setting. More secondary caries was observed in practice-based studies. A plausible explanation for this observation may be
the technique-sensitive adhesive procedure, but also differences in caries risk profile between university and practice
recruited patients. (b) The type or restoration was also very determining. Whereas class V restorations seldom exhibited
secondary caries (c), the median incidence after long-term periods was 4% for anterior restorations (d) and 1.7% for posterior
restorations (e). (f) Class II restorations were more prone to secondary caries than class I restorations.

Finally, the incidence of SC naturally depended on the
caries risk of the patients included in the study. In the study
by van Dijken et al. [42], the calculated incidence of SC was
6.5%, but 63% of the SC lesions were found in patients with
high caries risk. Similarly, in the study by Opdam et al. [43],
the incidence of SC in the low caries risk group was much
lower than in the overall population (1.8% versus 6.6%, respec-
tively). Interestingly, this study found a comparable incidence
of SC between amalgams and composites in low and medium
caries-risk patients, while in high caries-risk patients SC inci-
dence was significantly higher around composites, suggesting
that the latter perform worse under cariogenic challenge
[43].
There is definitely need for more epidemiologic research
with regard to SC, as there is currently a lot of information
missing on the exact location of the caries, the size at diag-
nosis, the type of cavity (fresh cavity, or one that had been
restored for several times).

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31 xxx.e7

Table 2 – Incidence of secondary caries around composites versus amalgams in prospective clinical studies.
Author, year Type oType of study Evaluation No. of No. of No of CR No of AR Incidence Incidence
period evaluated evaluated with AC with SC around CR around AR
CR AR
Bernardo et al., RCT, university clinic 7 years 892 856 113 32 12.7 3.7
2007 [10]
Kopperud et al., PL, practice-based 4 years 3286 184 284 9 8.6 4.9
2012 [13]

Mannocci et al., RCT, practice-based 1 year 109 107 2 0 1.8 0

2005 [229]
3 years 105 105 3 1 2.9 1
5 years 97 100 10 3 10.3 3

Sachdeo et al., RCT, practice-based 2 years 70 35 0 0 0 0

2004 [230]
Soncini et al., RCT, practice-based 3.4 years 753 509 58 24 7.7 4.7
2007 [9]
Wilson et al., RCT, practice-based 1 year 49 49 0 0 0 0
2002 [231]

Abbreviations: AR: amalgam restorations; CR: composite restoration; RCT: randomized clinical trial; PL: prospective longitudinal.

This led to the conclusion that composites have much bet-

5. Histopathology of secondary caries
around composites
Histologically, SC has been found to be no different from pri-
mary caries, which has been described as a localized process
of both demineralization of enamel and dentin and enzymatic
and bacterial degradation of dentin [44,45].
Theoretically, secondary-caries lesions may consist of two
parts: (i) the outer lesion, developing from the tooth outer
surface next to the restoration margin, and (ii) the cavity
wall lesion, developing along the tooth-restoration interface
[46] (Fig. 4). In extensive lesions, an outer lesion usually also
involves the cavity wall, so that it is difficult to distinguish
between the two. It was described that the shape of an outer
lesion and its relation to the cavity-wall lesion depend on the
direction of the enamel prisms at the cavity margin (Fig. 4)
[46–51]. In contrast, a cavity-wall lesion, usually present as a
narrow zone of enamel or dentin demineralization at the cav-
ity wall, seems to progress independently of the angle between
prisms and the cavity wall [46–48]. Only wall lesions reach-
ing the dentin–enamel junction tends to spread laterally, thus
affecting dentin on a wider front [51]. In cavity-wall lesions,
demineralization develops perpendicularly to the cavity wall,
which implies that hydrogen ions first have to diffuse into the
microspace between tooth and restoration. Therefore, it has
been concluded that the wall lesion develops exclusively as a
consequence of microleakage, even in the absence of an outer
lesion [46–48,50–52], whereas outer lesions may be regarded as
primary caries lesions that happen to occur near an existing
restoration [53]. In other words, the histopathological appear-
ance of SC lesions may thus give some insights in the etiology
of SC.
In the past, several researchers tried to investigate the
histopathology of SC around composites restorations by
inducing artificial caries lesions in vitro and in vivo. They
concluded that, compared to lesions around amalgam, those
around composite exhibited significantly fewer wall lesions
[49,50,54], especially after etching of the cavity walls [55–57].
ter initial sealing capacity than amalgams, thereby preventing
microleakage and the formation of a cavity-wall lesion [50].
This conclusion is remarkable as some of these studies are
almost 40 years old, and the composites in these studies
were used without adhesive. Unfortunately, there are only
few recent clinical studies on this topic so that it is unclear
whether outer or cavity-wall lesions are more frequent with
contemporary composites in clinical situations. Thomas et al.
[58] found in an in situ study that SC next to composite
appeared merely as an outer lesion that seemed to progress
as primary caries. Some other researchers even suggested that
wall lesions next to composites do not really occur as a sepa-
rate entity, but that they are just an aspect of an outer lesion
developing toward and reaching the cavity wall, or a conse-
quence of extended etching of the cavity wall surface with
enamel prisms perpendicular to the cavity wall [20,59–61].
Nevertheless, there is some evidence from in vitro investiga-
tions suggesting that wall lesions can exist as own entity, but
only in the presence of gaps at the tooth-restoration inter-
face [58,62,63]. This would only be the case in composites that
could not properly seal the cavity walls. However, achieving a
good seal over a long time under clinical conditions, as will be
shown later, seems to be quite challenging.
6. Etiopathogenesis of secondary caries
next to composites
The etiology of SC is generally considered not to be different
from that of primary caries, which is in essence an infectious
disease with a bacterial origin. The initial demineralization
process is, however, just the final result of an interplay of
numerous factors. The presence of the restorative material
in the oral cavity no doubt makes this interplay even more
complex. First, the cariogenic attack in SC occurs not only
from the tooth surface as in primary caries, but also from
the tooth-restoration interface. Second, the restorative mate-
rial has the potential to interact with various factors involved

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e8 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31

Fig. 4 – Histopathology of secondary caries lesions next to composite. The location and shape of the lesion may give an
indication of the underlying cause. (a) Secondary caries may present as an outer lesion, a cavity-wall lesion or as a lesion
consisting of both an outer and cavity-wall lesion. (b) According to the theory by Hals et al. (1971) the shape of an outer
lesion and its relation to a wall lesion depend on the direction of the enamel prisms at the cavity wall: in case of
unsupported prisms at the cavity wall, an outer lesion develops from the surface toward the cavity, forming a
funnel-shaped connection with the wall lesion, while in case of the supported prisms, the outer lesion is triangular and
develops away from the cavity. According to this theory, the direction of the prisms adjacent to the restoration, will
determine the shape of the secondary caries . (c) A cavity-wall lesion is thought to be the result of microleakage. Some
researchers doubt whether secondary caries next to composite may present as wall lesions in clinic, but there is some
evidence from in vitro research that the presence of a gap may result in a wall lesion. (d) Most often in clinic, secondary
caries presents as an outer lesion which involves the interface with the composite restoration. In such case, it is unclear
whether microleakage played a role in the development of the caries.

in the caries-demineralization process, and thus could be
regarded as an additional determinant.
Microbial species associated with primary caries also seem
to be involved in SC [53,64]. However, the proportion of most
cariogenic bacteria, mutans streptococci and lactobacilli, was
significantly higher in the plaque from dentin and enamel
restored with composite than from unrestored specimens [53].
Another in situ study compared initial bacterial adhesion to
enamel and composite surface [65]. They found that signifi-
cantly more and morphologically different bacteria attached
to the composite surface in the early stages of plaque forma-
tion, possibly due to specific surface properties of composites,
which will be discussed later.
The composition of plaque around different restorative
materials has also been compared. Svanberg et al. [66] found
the highest number of total bacteria and significantly more
mutans streptococci around composites, compared to amal-
gams and glass-ionomers, while Splieth et al. [67] detected a
higher number of lactobacilli and greater microbial diversity
under composite restorations than under amalgams. These
results might suggest that composites lead to certain changes
in the dental biofilm favoring the outgrowth of more cariogenic
species. On the other hand, a study by Mo et al. [68] showed
that neither the type of restorative material nor the location
of the SC lesion have a significant effect on the microbiota
under the restoration. However, it should be emphasized that
in all reviewed studies, the composition of dental biofilms was
determined using traditional microbiological techniques con-
sisting of cultivation of microorganisms on different selective
and non-selective agar plates and subsequent identification by
physiological, biochemical and serological tests. Since it was
estimated that 40–50% of bacteria present in dental biofilms
is not cultivable [61], more sophisticated molecular methods
such as PCR, real-time PCR or DNA sequencing-based meth-
ods should in future be employed to obtain a better insight
into the effects of restorative materials on dental biofilm.
7. Composite properties that influence the
development of secondary caries
Although it is to date not possible to pinpoint the exact
reason for higher caries incidences around composite restora-
tions compared to other materials, literature suggests several
different factors that may contribute to the higher caries sus-
ceptibility of composites. Following properties of composite
restorations have been associated with their susceptibility to
recurrent caries.
7.1. Sealing capacity of composites
The presence of (micro-)gaps at the composite-tooth interface
and subsequent microleakage of bacteria, their metabolites
and other compounds from oral fluids, have long been

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31
considered to be the cause of the SC wall lesion [46–48,50,51].
In literature, there is, however, no consensus on the role of
microleakage in the development of caries next to composites.
While operative dentists generally still consider microleak-
age as a main culprit for secondary caries, a group of
cariologists argue that the presence of microleakage at the
tooth-restoration interface might be completely irrelevant for
the development of secondary caries, and that the secondary
caries is a “primary caries at the filling margin” driven by the
activity of a biofilm on the tooth surface [18,20,61,69]. Never-
theless, there is some evidence from in vitro and in vivo studies
that the presence of a gap next to a composite restoration may
result in a cavity-wall lesion [58,70,71]. In addition, it seems
that the size and shape of the gap have an influence [62,63,72],
with a positive correlation between the gap size and the size
of the dentinal wall lesion [63,73]. The results of the most
recent study by Kuper et al. [74] did not confirm the existence
of this positive correlation, but they showed that the gap of
about 60 ␮m may lead to the development of the wall-lesion,
which is much less than previously thought [58,75]. In spite
of the opposing views, these data emphasize the importance
of achieving good cavity sealing by the restorative material to
prevent the development of SC and so to prolong the compos-
ite restoration’s lifespan.
Due to their bonding ability to hard tooth tissues via adhe-
sives, composite restoratives are considered to adequately seal
the tooth cavity. This quality of composites encouraged the
use of a minimally invasive operative technique and even
selective removal of carious tissue, i.e. when the carious tissue
is not completely removed but arrested by simply sealing the
cavity, under the tagline ‘the seal is the deal’ [61,76], and also
gave them a great advantage over amalgams.
However, while the sealing capacity of amalgams amelio-
rates over time with the deposition of corrosion products at the
tooth-amalgam interface [77], there are certain issues related
to composite resin restoratives that might jeopardize achiev-
ing and especially maintaining a good sealing of the cavity
over time. These factors, as listed below, could make them,
from that point of view, more prone to SC.
7.1.1. Technique sensitivity
The application of an adhesive prior to the placement of com-
posite is generally considered to be very technique-sensitive,
and its clinical success largely depends on the operating
conditions and the operator’s skills level [78]. Insufficient or
overextended etching, inadequate wetting or penetration, and
inadequate curing of the bonding agent may compromise good
adhesion, by which micro- and nanoleakage due to inadequate
bonding may occur [79–81]. In this regard, simplified adhesives
may allegedly have an advantage, because they require less
steps in their application, which means lower risk of making
application errors [82]. On the other hand, each step of a multi-
step adhesive system has its particular function. Separate and
successive application of the different steps is superior and
was clearly proven to result in a higher and more consistent
bonding effectiveness. A manipulation error in one of the steps
may even be compensated by the next steps [83]. It is also of
utmost importance for good adhesion to avoid contamination
of the cavity by saliva or blood, which is not always easy in
clinical circumstances.
Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
xxx.e9
Not only does the adhesion procedure seem to be critical
for the acquisition of a good seal, but also an adaptation of
the material into the cavity. Opdam et al. showed that it is
very challenging to restore the tooth with composite without
the formation of porosities and voids inside of material, some
of which very often exceed 1 mm in size [84]. It could easily
be perceived that this kind of voids at the outer margin may
compromise the cavity sealing and make the restoration more
prone to SC. Therefore, more attention should be given to com-
posite insertion and adaptation techniques in order to prevent
the formation of voids [85].
Finally, a proper polymerization of the composite restora-
tion is not only important for its good mechanical properties,
but it was also suggested that improperly cured composites
may lead to the higher bacterial accumulation on its surface
[86]. This is particularly important considering the fact that
the gingival parts of the class II restorations are very often
incompletely polymerized and these areas may be, according
to the literature, most susceptible to SC [38].
7.1.2. Polymerization shrinkage
One of the inherent shortcomings of composites, which has a
great impact on their sealing abilities, is that they undergo vol-
umetric contraction during polymerization. Polymerization
shrinkage was reported to be in the range of 1.5–5% [87]. This
phenomenon is a consequence of the reduction of intermolec-
ular distances by creation of single covalent bonds between
resin monomers during the formation of the polymer network.
It is clear that this kind of volumetric change might signif-
icantly affect the adaptation of the restoration to the tooth
cavity, leading to the formation of local interfacial gaps and
consequent micro-leakage. Adhesion to the cavity walls poses
a confinement to composite polymerization shrinkage and as
a result contraction stresses are generated [88,89]. These inter-
nal stresses generated in the composite can be transformed
into tensile forces at the tooth-restoration interface, and may
lead to a decreased bond strength [90] and, in cases when
they exceed it, to the formation of so-called stress-relieving
gaps that promote leakage [91,92]. It is still not clear, however,
whether these gaps could exceed the clinically relevant width
of around 60 ␮m at the outer margin of the restoration and
make the restoration more susceptible to SC.
Factors that influence the development of contraction
stresses in composite restorations are various and they are
described in details elsewhere [87–89,93]. By influencing some
of them, as will be shown later, polymerization shrinkage as
well as the resulting interfacial stress can be reduced.
7.1.3. Biodegradation of the interface
Even if a satisfactory initial sealing of the cavity with com-
posite is achieved, the composite-tooth interface may degrade
over time [94]. Biodegradation of composite materials includes
hydrolytic and enzymatic degradation. Hydrolytic degrada-
tion is related to the absorption of water by the polymeric
network, which may cause swelling, softening, plasticization,
and chain scission of the polymer network due to hydrol-
ysis of polar groups such as ethers, urethanes, hydroxyl
and, particularly prone to hydrolysis, ester groups [95,96].
Enzymatic degradation may involve the action of external
(salivary and bacterial) and intrinsic (dentinal) enzymes.
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e10 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31
Two salivary enzymes from the class of esterases are of
a particular importance in this regard, cholesterol esterase
(CE) – an inflammatory cell-derived enzyme, and pseudo-
cholinesterase (PCE) – a salivary-derived enzyme [97,98]. It has
been shown that these enzymes are able to degrade resin
monomers/polymers, and affect the surface topography of
composites [98]. In addition, it was demonstrated that their
activity is concentration-dependent and selective [99], with
CE having higher affinity for bisphenol A glycidyl methacry-
late (Bis-GMA), and PCE for triethylene glycol dimethacrylate
(TEGDMA) [97,99], although they act synergistically [99,100].
Kermanshahi et al. [101] also demonstrated that the syner-
gistic activity of salivary esterases, CE and PCE, may result
in degradation of Bis-GMA-based resins, extensive enough to
allow bacterial leakage at the interface. Recently, it was shown
that bacteria from dental plaque, for example Streptococcus
mutans, with a similar esterase activity as in saliva, may also
partake in the interfacial degradation [102,103].
Not only resin degradation, but also the degradation of the
exposed collagen fibrils and demineralization of dentin, con-
tribute to the disruption of the interfacial integrity [94]. In this
regard, special attention should be drawn to nanoleakage, a
phenomenon of leakage without the presence of microgaps
that occurs in the hybrid layer and that is much less exten-
sive and may occur independently from microleakage [79,104].
Such nanoleakage shows high regional variability [105] and
appears as a result of incomplete penetration of the low-
viscosity resin into dentin porosities formed by acid etching. In
this way, nanometer-sized porosities are left unsealed and col-
lagen fibrils exposed by etching are not fully impregnated with
resin. These pores are so small that they allow only the pas-
sage of water and some small molecules into the hybrid layer.
Nevertheless, this might be enough since exposed collagen
fibrils are also prone to hydrolytic degradation [106]. Fur-
thermore, this degradation may be catalyzed by host-derived
collagenases, matrix metalloproteinases (MMPs) and cathep-
sins, which could be present locally in dentin and activated
under acidic conditions created by bacterial acids and even by
the acidic properties of adhesives [44,107,108]. Beside dentinal
MMPs, salivary-derived MMPs might also take part in dentinal
collagen hydrolysis. These MMPs mainly originate from the
gingival cervical fluid, which might be associated with the
frequent onset of SC at the gingival wall.
Finally, it should be noted that biodegradation of composite
restorations depends largely on the material’s chemical com-
position [109,110], but also on certain patient-related factors,
such as the enzymatic profile of saliva, and the presence and
activity of plaque.
7.1.4. Mechanical degradation of the interface
Occlusal stresses generated during mastication and especially
during parafunctional activities, such as bruxism, were shown
to have a deleterious effect on the marginal adaptation of com-
posites [111]. Gingival margins are particularly prone to this
effect, since occlusal forces tend to concentrate in the cervi-
cal area of the tooth [112]. These mechanical stresses repeated
over time lead to the fatigue or weakening of the interface, and
once the concentrated stresses exceed the interfacial fracture
toughness, a crack could be formed that on its own turn may
further lead to the gap formation and micro-leakage [82]. In
Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
addition to occlusal stresses, thermal stresses generated by
intra-oral temperature changes exert a similar effect on the
composite-tooth interface because composites and adhesives
have a higher thermal contraction/expansion coefficient than
hard tooth tissues [113].
Not only through the formation of a gap at the interface
may occlusal load and thermal contraction or expansion con-
tribute to the development of SC next to composites, but also
through the percolation phenomenon. Both occlusal loading
and thermal cycling subject the restoration’s margins to open-
ing and closing forces, which could cause flowing of the oral
fluids in and out of the gap [113]. In this way, demineraliza-
tion products are actively removed from the gap, allowing SC
lesions to develop faster [114] (Fig. 4).
7.2. Surface properties of composites and bacterial
adhesion
A multitude of studies showed that composites accumulate
more plaque on their surface compared to other restorative
materials and intact enamel [66,115,116]. This finding has led
to the hypothesis that the susceptibility of composites for
SC should be attributed to their particular bacterial affinity.
Mechanisms involved in bacterial adherence are rather com-
plex and seem to be based on initially weak physico-chemical
interactions between the bacteria and the material, such as
van der Waal’s and electrostatic forces, followed by stronger
bonds through specific binding of bacterial adhesins to com-
plementary receptors in the acquired salivary pellicle [61,117].
Therefore, the adhesion process seems to be highly specific
for a bacterial strain and the material [118,119].
One of the composites’ surface characteristics with a great
influence on bacterial adhesion is its roughness [120]. This
has been confirmed in several studies with different compos-
ite materials, most of which used S. mutans strains [121–125].
Only Yamamoto et al. [126] found no influence of surface
roughness on adhesion of S. oralis. Interestingly, the average
surface roughness (Ra ) of all specimens tested in this study
was 0.2 ␮m and higher; it was shown that exactly this Ra value
is considered to be a threshold below which biofilm adhesion
is significantly lower, and the surface is regarded as smooth
[127]. Certain polishing techniques may also decrease bac-
terial adhesion by decreasing the roughness [123], but this
effect depends largely on the type of composite material [128].
Finally, it has been shown that bacteria from the dental biofilm
are able to change the surface topography of composites thus
rendering them even more adherent to bacteria [129–132].
Another surface characteristic associated with bacterial
adhesion is its free energy or hydrophobicity. It has been sug-
gested that increased surface-free energy facilitates biofilm
formation on the material’s surface [120]. In other words,
materials with hydrophobic properties should accumulate
less plaque. In this regard, special attention was drawn
to silorane-based composites, which were shown to have
the lowest susceptibility to oral streptococci adhesion after
in vitro evaluation [122,133]. This was assigned to their high
hydrophobicity imparted by the siloxane backbone. How-
ever, these results could not be confirmed by a more recent
in situ study, which showed that silorane-based compos-
ites are indeed more hydrophobic than methacrylate-based
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31
composites, yet equally susceptible to biofilm accumulation
[134]. Moreover, some studies showed no correlation between
surface-free energy and composite receptiveness to adhesion
of oral bacteria [135,136].
Another determining factor with great influence on bac-
terial adhesion is the composite’s surface composition.
Yamamoto et al. [126] showed by SEM that S. oralis adhered
to composite filler particles by fimbriae, suggesting that filler
particles might have an important role in bacterial adhesion
to composite surface. Apart from the fillers, the composite
resin chemistry is also an important determinant of biofilm
adhesion [133,135–137]. More research is definitely necessary
to unravel the mechanisms.
The acquired salivary pellicle apparently plays a very
important role. This acellular proteinaceous film forms on
the tooth and restoration surface within minutes to one hour
after their exposure to the oral environment. Among other
factors, the pellicle plays an important role in the initial bacte-
rial colonization of the tooth and restoration surface [61,138];
and it determines the amount and the composition of early
microbial colonizers [139–141]. Yet, the composition and ultra-
structure of the salivary pellicle also seems to be dependent
on the material’s chemistry [61,138,140]. Numerous studies
suggest that saliva coating generally decreases the bacte-
rial adhesion to teeth and restorative materials [125,142–145],
although one study found the opposite [146]. In addition, saliva
coating reduces the differences in bacterial adhesion to differ-
ent materials [145,147] and modifies certain properties of the
pure material such as surface-free energy and surface charge
[118,144]. Because of its putative impact on bacterial adhesion
and because it mimics the real situation in the mouth, pellicle
coating of specimens in in vitro bacterial studies on adhesion
is always preferable.
7.3. Interaction between bacteria and released
composite components
Polymerization of the composite resin is never complete
because the propagation of the radical-based cross-linking
reaction reduces the mobility of free monomers at the same
time. Depending on the material (adhesive or composite), the
maximum degree of conversion can vary between 50 and
90%, this measured 24 h after curing, and thus after the so-
called “dark” polymerization. Immediately after curing the
degree of conversion was even lower, being documented as
only 35–45% [148]. The unpolymerized monomers as well as
the biodegradation products can leach out of the restoration
into the oral cavity, where they might exhibit certain biologi-
cal effects. Apart from potential toxicological effects [149,150],
some researchers observed an effect on the oral microbiota,
which may be important from the aspect of cariogenicity.
Dental plaque is a microbial community, whose con-
stituent species develop metabolic interdependence through
the specific system of communication [151]. This mecha-
nism allows the coexistence of a great number of different
species and the maintenance of microbial homeostasis [61].
In addition, it enables the microbial community to respond
to environmental perturbations through so-called composi-
tional and physiological shifts. An example of these shifts
is the selection of more aciduric species as a result of a
Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
xxx.e11
sucrose-rich diet. It was therefore hypothesized that released
composite components may lead to similar shifts in dental
plaque by stimulating the growth of cariogenic bacteria or
by modulating the expression of their virulence factors, thus
making the biofilm more cariogenic. The results in literature
on this topic are, however, controversial. Kawai et al. [152] were
the first who found that eluates of two commercial compos-
ites and solutions of widely used methacrylate monomers,
such as diethylene glycol dimethacrylate (DEGDMA), urethane
dimethacrylate (UDMA) and TEGDMA, may stimulate the total
biomass production of S. mutans. This finding has triggered a
series of studies on this topic. Several years later Hansel et al.
[153] showed that EGDMA and TEGDMA and the extract of
another commercial composite stimulate the total growth of
another two cariogenic bacteria, S. sobrinus and L. acidophilus,
again by using spectrophotometry. However, spectophotome-
try measures the increase in turbidity of bacterial suspensions
and might thus be affected by some other factors than num-
ber of bacteria. Takahashi et al. [154] indeed found no influence
of TEGDMA and DEGDMA on the growth of S. sobrinus and S.
sanguinis using the plate-count method. They rather showed
that resin polymers formed during the incubation and accu-
mulated around the bacterial cells which resulted in increased
turbidity in the bacterial suspensions. Furthermore, another
research group showed a decrease in the viability of S. mutans,
S. sanguinis and S. gordonii exposed to TEGDMA [131]. Finally,
the effect of 2-hydroxyethyl methacrylate (HEMA), which is
the main constituent of the majority of contemporary adhe-
sives, was tested: it was demonstrated that it may decrease the
adhesion and viability of several strains of oral streptococci
[155].
Not only released monomers, but also biodegradation
products may modulate the growth and physiological func-
tions of caries-related bacteria. Several degradation products
have been tested to date, such as methacrylic acid (MA), tri-
ethylene glycol (TEG) and bishydroxypropoxyphenyl-propane
(Bis-HPPP). It has been shown that they could modify plank-
tonic and biofilm growth of S. mutans and S. salivarius in a
concentration and pH dependent manner [156,157]. Bis-GMA,
UDMA and TEGDMA were shown to stimulate the produc-
tion of water-insoluble glucans by S. sobrinus [158], while MA,
TEG and Bis-HPPP affected the expression of gtfB and yfiV,
genes involved in the biosynthesis of extracellular glucans and
membrane fatty acids, respectively [157,159]. It can be inferred
from the reviewed studies that TEGDMA and its degradation
products are of particular interest. This specific monomer has
been shown to have the greatest biological significance of all
resin monomers for a few reasons. First, because of its low
molecular weight and relatively high hydrophobicity, it may
penetrate intracellular and extracellular space of both eukary-
otic and prokaryotic cells, and secondly, it is one of the most
released resin monomers [160,161].
An important question that should be raised is how the
concentrations used in the presented studies correlate with
concentrations that these compounds could reach in the oral
cavity, or, more precisely in dental plaque, where they exert
the discussed biological effects. There is no in vivo study avail-
able to date, but there are a number of laboratory studies
performed to measure the amount of different composite
components released in various solvents by using different
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e12 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31
methods. Van Landuyt et al. [161] did a meta-analytical study,
in which they gathered and reviewed all relevant data in the
literature in order to obtain a better insight into the order of
magnitude of released compounds. According to the results
of this study, the total amounts of HEMA, Bis-GMA, TEGDMA,
and UDMA that could be released into organic solvents, from a
whole composite crown, after 24 h, are on average 0.127, 0.095,
0.059, and 0.024 mmol, respectively. These concentrations are
much lower than those used in the abovementioned stud-
ies. Furthermore, the amounts of released compounds found
under in vitro conditions are considered to be higher than what
is expected to be found clinically, due to a constant salivary
flow, food intake and the action of different salivary com-
ponents, including enzymes [162]. On the other hand, some
authors suggested that in vivo concentrations could be even
higher than those found in vitro, because plaque, behaving like
a diffusion barrier, might accumulate them [152,163].
Another remark on the currently available studies is the
extent to which experiments with monocultures could actu-
ally reflect the events in such a complex consortium of
different species as dental plaque. Although much more
challenging, experiments involving biofilm growth mode and
multiple species harvested from human dental plaque would
give more relevant information on the interaction between
composites and microbiota. Nevertheless, experiments with
single-species models are a good foundation and may facil-
itate the interpretation of the results obtained with more
complex multi-species models.
7.4. Lack of antibacterial and buffering properties of
composites
Typically, composites do not possess antibacterial proper-
ties [164–166], and this characteristic distinguishes them
from other commonly used restoratives such as amalgams,
which contain metal ions with an antibacterial effect like
Ag, Hg and Cu [164,167], and glass-ionomers with their
well-documented antibacterial effect due to fluoride release
[73]. As a result, unlike glass-ionomer-based materials and
amalgams, composites do not have the ability to prevent
or to reduce the formation of the biofilm and to retard
the progression of the SC. This has been demonstrated
in numerous studies [168–171]. However, a recent in situ
study by van de Sande et al. [172] disputes this, since they
found a similar mineral loss in dentin next to amalgam
and a mycrohybrid composite. In addition, they showed
that the same composite in combination with Clearfil SE
Protect adhesive, which contains an antibacterial monomer
12-methacryloyloxydodecylpyridinium bromide (MDPB), and
a nanohybrid composite significantly inhibited demineraliza-
tion of the adjacent dentin, compared to the previous two
groups.
The lack of buffering capacity of composites may also ren-
der them more prone to SC. Thomas et al. [53] found more
cariogenic, i.e. more aciduric species on enamel and dentin
restored with composite, compared to unrestored ones. They
suggested that this kind of self-selection occurs because com-
posites are unable to buffer the low pH of the plaque, which
Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
is then maintained for a longer time. However, further studies
are necessary to test this hypothesis.
8. Strategies to decrease the susceptibility
of composites to SC
Even though scientific evidence with regard to the exact
mechanisms behind the (alleged) high caries susceptibility of
composites is meager, and everything points in the direction of
multifactioral mechanisms, much research has already been
dedicated to strategies to improve SC resistance of composites.
In fact, the efforts to investigate improvements to compos-
ites to prevent caries by far exceed the efforts dedicated to
research investigating the extent and factors involved in the
problem. It should be, however, underlined that the patient-
related factors stay the dominant determinants of the caries
process, both primary and secondary, and all measures for the
prevention of caries in general (improvement of oral hygiene
and dietary habits, etc.) are paramount to decrease the inci-
dence of secondary caries next to composites and extend their
lifespan.
In general, three main strategies to control the material-
related factors can be distinguished: (1) incorporation of
antimicrobial or/and remineralizing agents, (2) strategies to
preserve a good sealing of the composite restoration and
(3) modifications of the surface properties of composites.
Most studies focused on incorporation of antibacterial agents
in composites and adhesives [173–176]. The rationale would
be that composites with antimicrobial characteristics would
accumulate less plaque on their surface, while antimicrobial
agents in adhesives might have a double effect. First, they
may disinfect the cavity before restoration placement, and
secondly, they may inhibit bacterial leakage at the interface.
8.1. Incorporation of antibacterial and/or
remineralizing agents
The role of fluorides in the prevention of primary caries, which
is based on their antibacterial effect and formation of fluoroa-
patite with lower solubility, is well documented. Therefore,
it is not surprising that there have been many attempts to
incorporate them into composite and adhesives. The most
common way is the use of fluoridated silicate glass filler par-
ticles, such as Ba–Al–F- and Ba–B–Al–F-silicate glass, or the
addition of inorganic F compounds, such as strontium fluo-
ride (SrF2 ) and ytterbium fluoride (YbF3 ), to the filler system
[177]. Another approach to obtain a fluoride-releasing com-
posite is the addition of pre-reacted glass-ionomer (S-PRG)
filler particles, which yielded a commercial composite Beau-
tifil II (Shofu Inc., Kyoto, Japan), with the potential to inhibit
bacterial adhesion in situ and in vitro, compared to conven-
tional composites [178]. A general problem with F-releasing
composites is to achieve an adequate fluoride release for a
long time, while maintaining good physical properties. Addi-
tion of CaF2 nanoparticles to reinforcing glass filler system
even in small fractions, resulted in high F-ions release without
compromising mechanical strength [179]. Also, the addition
of organic fluoride compounds, such as acrylic amine-HF salt
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31
and methacryloyl fluoride methyl methacrylate, to the resin
matrix, was suggested as a promising approach [180].
Zinc oxide and several silver-containing compounds have
also been used. Zinc oxide has been added to a commercial
composite in the form of nanoparticles, but it exhibited only a
short-term contact inhibition of bacterial growth, without the
release of zinc-ions [181]. Silver, well-known for its antimicro-
bial effects, was used both as a releasing and non-releasing
agent. Glass filler particles releasing silver ions have been
described [182,183], as well as filler particles based on silver
microparticles [184] and silver-supported zeolite (alumino-
silicate mineral) and silver-supported apatite [185]. Two other
silver carriers added to composites, silver-supported zirco-
nium phosphate and silver-supported silica gel, showed an
antibacterial effect even without the release of silver ions,
what is favorable for retaining the mechanical properties
[186,187].
The simplest way to develop composites and adhesives
with antimicrobial effect, seems to be the addition of a sol-
uble disinfectant, such as chlorhexidine [188–190], triclosan
[191], quaternary ammonium compounds such as benzalco-
nium chloride [192,195] and cetylpyridinium chloride [193],
the antibacterial biopolymer chitosan [194], the antibiotics
vancomycin and metronidazole [195] and epigallocatechin-3-
gallate (EGCG) (the major polyphenol present in green tea)
[196] to the resin matrix. However, all soluble compounds
added to composites tend to show so-called ‘burst effect’,
i.e. the largest amount leaches out in only few days, fol-
lowed by a substantial decrease in the concentration. In
addition, the release of these compounds resulted in a
material with a porous structure, which negatively affects
the material’s mechanical properties. An important step in
overcoming these drawbacks is the synthesis of monomers
with an antibacterial effect that can co-polymerize with
methacrylate resin monomers. The rationale would be that
resins containing such monomers exhibit a long-lasting
antibacterial effect upon contact with bacteria, without the
release of an active agent. The most extensively studied
antibacterial monomer, with the most promising results,
is certainly 12-methacryloyloxydodecylpyridinium bromide
(MDPB) [197,198], which was incorporated into an experimen-
tal composite in the form of pre-polymerized resin fillers
(PPRF) [199,200]. MDPB is also a component of the commercial
self-etching adhesive Clearfil Protect Bond (Kuraray Dental,
Japan) with a potential to prevent secondary caries in vitro
[201], and also in situ [172]. However, clinical evidence of its
better performance with regard to secondary caries prevention
is still missing. Other antibacterial monomers are quaternary
ammonium polyethyleneimine (QPEI), which has been added
to composites as nanoparticles to provide a large surface for a
strong antibacterial effect [176,202], methacryloxylethyl cetyl
dimethyl ammonium chloride (DMAE-CB) [203,204], and the
quaternary ammonium dimethacrylate (QADM) [205,206].
Last, different types of calcium-phosphates, such as tetra-
calcium phosphate microparticles (TTCP, Ca4 (PO4 )2 O) [207]
and nanoparticles of amorphous calcium phosphate (NACP)
[208–210] have been added to several experimental composites
and adhesives, to allow the release of calcium and phos-
phate ions at low pH. Recent studies show promising results
in vitro [211] and in situ [208], but more research is necessary
Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
xxx.e13
to evaluate whether the ion release can last over a longer
period.
8.2. Preservation of good sealing
Even though the role of the microleakage in the development
of the secondary caries has been questioned, a lot of research
has been focused on strategies to obtain and preserve a good
sealing of a composite restoration; two main approaches can
be distinguished: (1) procedures to reduce polymerization
shrinkage and (2) strategies to prevent hydrolytic degradation
of the interface. Several specific placement and light-curing
procedures have been proposed to control the development
of shrinkage stress. Also the use of a low-elastic modulus
liner, such as a layer of unfilled resin, multiple layers of
adhesive or a flowable composite has been described. It is
beyond the scope of this review to discuss these procedures in
detail, but some adaptions to the composite material formu-
lation are worth mentioning. Reduction in shrinkage stress
was achieved by adding non-bonded filler particles [212] or
high-density polyethylene spheres [213] to experimental com-
posites, or by increasing the concentration of polymerization
inhibitors [214], which reduced the polymerization rate and
allows more time for viscous flow. Apart from increasing
the filler load and reducing the number of functional groups
per molecular weight of the monomers, the development
of low-shrinkage monomers represents, however, the most
sophisticated approach. 3M ESPE (Seefeld, Germany) com-
mericialized ring-opening silorane monomers with verified
lower shrinkage [215].
Many investigations have focused on ways to prevent
or slow down interfacial degradation by endogenous col-
lagenases. It seems that the application of chlorhexidine
digluconate on acid-etched dentin prior to the applica-
tion of an adhesive has a great potential to preserve the
integrity of the hybrid layer both in vitro and in vivo [216–218].
Furthermore, attempts to incorporate chlorhexidine into
methacrylate co-monomers in order to achieve continuous
release gave promising results in in vitro studies [219,220].
Also EDTA, synthetic MMP inhibitors such as hydroxamate-
based bisphosphonates Batimastat and Galardin [221,222]
and thiol-based gelatinase inhibitor SB-3CT [223], quaternary
ammonium compounds such as polymerizable quaternary
ammonium methacrylates (QAMs) [224] and benzalconium
chloride[225] have been shown to inactivate endogenous
MMPs.
Finally, as already mentioned, more attention should be
paid to the technique-sensitive adhesive procedure, and espe-
cially to the improvement of the composite adaptation in the
cavity in order to avoid potentially harmful voids and porosi-
ties.
8.3. Modification of composites’ surface properties
Good polishability and smoothness of the composite sur-
face is important to reduce biofilm adhesion. During the past
two decades, composite materials have significantly been
improved in this regard by optimizing filler size. In a recent
in situ study it was demonstrated that secondary caries lesion
progresses significantly slower adjacent to a nanohybrid
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e14 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31

than next to a microhybrid composite [172], probably due though the traditional (micro)leakage theory has been chal-
to the smoother surface which accumulates less plaque. lenged by many researches, especially cariologists, there are
Some research has also focused on changing other surface indications that interfacial failure and the presence of an
characteristics of composites. Rutterman et al. tested experi- interfacial gap may indeed play a role. A gap larger than
mental composites modified with low-surface tension agents 60 ␮m seems to predispose interfacial demineralization, and
and observed decreased bacterial adhesion and cell viability may thus lead to caries. The question is thus whether such
[136,226]. interfacial gaps do occur in clinic? Initially, a gap may origi-
nate through polymerization shrinkage and through failure to
obtain a good adaptation and sufficient bond of the restora-
9. Conclusions
tion. The fact that higher incidences of SC are observed in
practice-based studies than in university-based studies may
Even though SC is one of the most important reasons for
also point to the technique-sensitive placement procedure for
failure of composite restorations, and thus has a significant
composites. More research is necessary to investigate whether
impact on the longevity of affected teeth and on health expen-
large gaps may arise through degradation processes at the
diture, it was not clear whether the composite’s material
interface. Apart from these factors, composites also seem to
properties favor the development of new caries lesions. The
favor the growth of cariogenic bacteria on their surface, which
results of this review suggest that SC with composites is to
has been associated with specific surface properties, release
some extent associated with the restorative material, as sev-
of components and lack of antibacterial properties.
eral studies observed significantly more caries with composite
In order to design a new generation of composites less
than with amalgam. On the other hand, the type and the loca-
prone to SC, more fundamental research will be necessary to
tion of the composite restoration was also determining for
unravel all underlying causes promoting SC.
development of recurrent caries, suggesting other influencing
factors than the material itself. It should be, however, pointed
out that the patient-related factors (individual caries risk) Acknowledgement
remain the dominant determinant of the secondary caries
This research was supported by FWO (Research Foundation –
process, since the incidence in low-caries-risk patients is con-
Flanders) grant G.0884.13.
siderably lower.
The mechanisms behind the development of SC are not Appendix A.
entirely clear and are most probably multifactorial. Even

Author, journal, year, Study University/ Location Evaluation No. of No. of Incidence
volume, pages type practice- period evaluated restorations of SC (%)
based (years) restorations with SC

Abdalla and El Sayed, RCT University Cervical 2 107 0 0

Am J Dent,
2008;21:327–30
Abdalla and RCT University Cervical 2 175 0 0
Garcia-Godoy, Am J
Dent, 2006;19:289–92
Abdalla and RCT University Cervical 2 152 0 0
Garcia-Godoy, J Dent,
2007;35:558–63
Abdalla et al., J Oral RCT University Cervical 2 140 0 0
Rehabil, 2002;29:714–9
Akimoto et al., Oper PCS University Anterior 10 19 0 0.0
Dent, 2007;32:3–10
Cervical 10 19 0 0.0
Posterior 10 6 0 0.0
Andersson-Wenckert RCT Practice- Posterior 7 169 12 7.1
et al., Am J Dent, based
2004;17:43–50
Posterior 6 220 9 4.1
Andrade et al., Gen RCT University Posterior 1 123 0 0.0
Dent, 2012;60:e255–62
Arhun et al., Oper Dent, RCT University Posterior 2 82 2 2.4
2010;35:397–404
Aw et al., J Am Dent RCT University Cervical 3 146 0 0
Assoc,
2005;136:311–22

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31 xxx.e15

Appendix A (Continued )

Author, journal, year, Study University/ Location Evaluation No. of No. of Incidence
volume, pages type practice- period evaluated restorations of SC (%)
based (years) restorations with SC

Aw et al., Am J Dent, RCT University Cervical 1 171 0 0

2004;17:451–6
Barabanti et al., J Dent, RCT University Posterior 5 100 0 0.0
2013;41:436–42
Baracco et al., Oper RCT University Posterior 1 75 1 1.3
Dent, 2012;37:117–29
Baratieri et al., Oper RCT University Cervical 3 61 0 0
Dent, 2003;28:482–7
Barcellos et al., Oper RCT University Anterior 2 162 1 0.6
Dent, 2013;38:258–66
Bartlett and Sundaram, RCT University Posterior 2 29 1 3.4
Int J Prosthodont,
2006;19:613–7
Beck et al., Dent Mater, RCT University Posterior 1 1108 8 0.7
2014;30:824–38
Bekes et al., J Oral RCT University Posterior 2 67 0 0.0
Rehabil,
2007;34:855–61
Bernardo et al., J Am RCT University Posterior 7 892 113 12.7
Dent Assoc,
2007;138:775–83
Boeckler et al., J Adhes RCT University Posterior 4 60 0 0.0
Dent, 2012;14:585–92
Boeckler et al., RCT University Posterior 2 88 0 0.0
Quintessence Int,
2012;43:279–86
Bottenberg et al., J Dent, RCT University Posterior 5 77 4 5.2
2009;37:198–203
Bottenberg et al., J Dent, RCT University Posterior 3 79 2 2.5
2007;35:163–71
Brackett et al., Oper RCT University Cervical 2 74 2 2.7
Dent, 2010;35:273–8
Brackett et al., Oper RCT University Cervical 1 31 0 0.0
Dent, 2002;27:112–6
Brackett et al., Oper RCT University Cervical 2 27 0 0.0
Dent, 2003;28:477–81
Brackett et al., Oper RCT University Cervical 2 32 3 9.4
Dent, 2001;26:12–6
Brackett et al., Oper RCT University Cervical 1.5 72 0 0.0
Dent, 2005;30:424–9
Brackett et al., Oper RCT University Cervical 1 52 0 0.0
Dent, 2002;27:218–22
Brackett et al., Oper RCT University Posterior 1.5 50 1 2.0
Dent, 2007;32:212–6
Braun et al., Clin Oral RCT University Posterior 1 99 0 0.0
Investig, 2001;5:139–47
Browning et al., Oper RCT University Cervical 2 58 1 1.7
Dent, 2000;25:46–50
Browning et al., RCT University Posterior 1 44 0 0.0
Quintessence Int,
2006;37:361–8
Burgess et al., Am J RCT University Cervical 3 81 1 1.2
Dent, 2004;17:147–50

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e16 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31

Appendix A (Continued )

Author, journal, year, Study University/ Location Evaluation No. of No. of Incidence
volume, pages type practice- period evaluated restorations of SC (%)
based (years) restorations with SC

Burke et al., Dent Mater, PCS Practice- Posterior 2 100 0 0.0

2011;27:622–30 based
Burke et al., Quintessence PCS Practice- Posterior 1 88 0 0.0
Int, 2003;34:594–9 based
Burke et al., Br Dent J, PCS Practice- Posterior 2 88 0 0.0
2005;199:293–6 based
Burrow and Tyas, Clin RCT University Cervical 3 54 0 0.0
Oral Investig,
2012;16:1089–94
Burrow, Aust Dent J, PCS University Cervical 3 23 0 0.0
2011;56:401–5
Burrow and Tyas, Oper RCT University Cervical 3 34 0 0.0
Dent, 2007;32:11–5
Burrow and Tyas, Am J PCS University Cervical 5 24 0 0.0
Dent, 2007;20:361–4
Burrow and Tyas, Aust PCS University Cervical 1 42 0 0.0
Dent J, 2003;48:180–2
Burrow and Tyas, J Adhes PCS University Cervical 2 37 0 0.0
Dent, 2005;7:65–8
Burrow and Tyas, Aust RCT University Cervical 5 27 0 0.0
Dent J, 2012;57:458–63
Burrow and Tyas, Aust RCT University Cervical 1 60 0 0.0
Dent J, 2008;53:235–8
Busato et al., Am J Dent, PCS University Posterior 6 90 0 0.0
2001;14:304–8
Can Say et al., Clin Oral RCT University Cervical 3 92 0 0.0
Investig,
2014;18:1427–33
Candan et al., J Clin RCT University Posterior 2.5 69 0 0.0
Pediatr Dent,
2013;38:1–6
Cehreli and Altay, J Dent, PCS University Posterior 3 116 3 2.6
2000;28:117–22
Celik et al., Oper Dent, RCT University Cervical 2 172 0 0.0
2007;32:313–21
Cetin et al., Oper Dent, RCT University Posterior 5 67 1 1.5
2013;38:E1–11.
Coelho-De-Souza et al., J RCT University Posterior 1 29 0 0.0
Appl Oral Sci,
2012;20:174–9
da Rosa Rodolpho et al., J RS Practice- Posterior 17 282 22 7.8
Dent, 2006;34:427–35 based
Dalton Bittencourt et al., RCT University Cervical 1.5 60 0 0.0
Acta Odontol Scand,
2005;63:173–8
Daudt et al., J Adhes Dent, RCT University Cervical 1 140 0 0.0
2013;15:27–32
de Andrade et al., J Dent, RCT University Posterior 2.5 111 1 0.9
2011;39:8–15
de Moura et al., J Adhes RCT University Posterior 1 56 0 0.0
Dent, 2004;6:157–62
de Souza et al., RCT University Posterior 1 36 0 0.0
Quintessence Int,
2005;36:41–8

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31 xxx.e17

Appendix A (Continued )

Author, journal, year, Study University/ Location Evaluation No. of No. of Incidence
volume, pages type practice- period evaluated restorations of SC (%)
based (years) restorations with SC

Deliperi and Bardwell, J PCS University Posterior 2.5 25 0 0.0

Esthet Restor Dent,
2006;18:256–65
Demirci et al., Oper RCT University Anterior 2 87 0 0.0
Dent, 2008;33:7–14
Demirci and Sancakli, PCS University Posterior 5 66 1 1.5
Am J Dent,
2006;19:41–6
Demirci and Ucok, Am J PCS University Posterior 2 86 1 1.2
Dent, 2002;15:312–6
Demirci et al., Am J PCS University Anterior 5 62 5 8.1
Dent, 2006;19:293–6
Demirci et al., Oper PCS University Anterior 3 62 1 1.6
Dent, 2002;27:223–30
Demirci et al., Clin Oral PCS University Cervical 5 62 1 1.6
Investig,
2008;12:157–63
Demirci et al., Dent PCS University Cervical 3 81 0 0.0
Mater J, 2005;24:321–7
Demircia, J Adhes Dent, PCS University Posterior 5 104 12 11.5
2007;9:547–53
Di Lenarda et al., Oper RCT University Cervical 4 45 2 4.4
Dent, 2000;25:382–7
Dresch et al., Oper Dent, RCT University Posterior 1 148 0 0.0
2006;31:409–17
Dutra-Correa et al., J RCT University Cervical 1.5 92 0 0.0
Adhes Dent,
2013;15:287–92
Efes et al., Am J Dent, RCT University Posterior 2 88 0 0.0
2006;19:236–40
Efes et al., J Adhes Dent, RCT University Posterior 2 92 0 0.0
2006;8:119–26
Efes et al., Am J Dent, RCT University Posterior 2 100 0 0.0
2013;26:33–8
Eliguzeloglu Dalkilic RCT University Cervical 2 158 0 0.0
and Omurlu, J Appl
Oral Sci, 2012;20:192–9
Ergücü and Turkun, J RCT University Posterior 1.5 90 0 0.0
Adhes Dent,
2007;9:209–16
Ermis et al., Oper Dent, RCT University Anterior 3 40 0 0.0
2010;35:147–55
Ermis et al., Clin Oral RCT University Cervical 2 150 0 0.0
Investig,
2012;16:889–97
Ermis, Quintessence Int, RCT University Cervical 2 68 0 0.0
2002;33:542–8
Ernst et al., Clin Oral RCT University Posterior 2 111 1 0.9
Investig, 2003;7:129–34
Ernst et al., Compend RCT University Posterior 2 70 1 1.4
Contin Educ Dent,
2002;23:711–4
Ernst et al., Clin Oral RCT University Posterior 2 112 0 0.0
Investig,
2006;10:119–25

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e18 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31

Appendix A (Continued )

Author, journal, year, Study University/ Location Evaluation No. of No. of Incidence
volume, pages type practice- period evaluated restorations of SC (%)
based (years) restorations with SC

Ernst et al., Clin Oral RCT University Posterior 3 165 Not 3.5
Investig, 2001;5:148–55 reported
2.5 166 Not 1.3
reported
1.5 167 Not 0.6
reported
Fagundes et al., J Am RCT University Posterior 5 60 1 1.7
Dent Assoc,
2009;140:447–54
Fagundes et al., Clin RCT University Posterior 2 60 0 0.0
Oral Investig,
2006;10:197–203
Fennis et al., J Dent Res, RCT University Posterior 5 80 0 0.0
2014;93:36–41
Folwaczny et al., Am J RCT University Cervical 5 20 0 0.0
Dent, 2001;14:153–6
Folwaczny et al., Clin RCT University Cervical 3 71 0 0.0
Oral Investig,
2001;5:31–9
Folwaczny et al., Oper RCT University Cervical 2 89 0 0.0
Dent, 2000;25:251–8
Franco et al., Oper Dent, RCT University Cervical 5 33 2 6.1
2006;31:403–8
Frankenberger et al., RCT University Posterior 8 68 0 0.0
Clin Oral Investig,
2014;18:125–37
Fron et al., Dent Mater, RCT Practice- Cervical 2 40 0 0.0
2011;27:304–12 based
Gallo et al., Oper Dent, RCT University Cervical 3 90 0 0.0
2005;30:275–81
Gallo et al., RCT University Posterior 3 58 2 3.4
Quintessence Int,
2010;41:497–503
Geitel et al., J Adhes RCT Practice- Anterior 2 200 8 4.0
Dent, 2004;6:247–53 based
Gianordoli Neto et al., J RCT University Posterior 1 70 0 0.0
Contemp Dent Pract,
2008;9:26–33
Gonçalves et al., Am J RCT University Posterior 1.5 88 2 2.3
Dent, 2013;26:93–8
Gordan et al., J Am Dent PCS University Posterior 8 41 0 0.0
Assoc, 2007;138:621–7
Gordan et al., Am J Dent, PCS University Posterior 4 39 0 0.0
2005;18:45–9
Gordan et al., J Esthet PCS University Posterior 2 60 1 1.7
Restor Dent,
2002;14:296–302
Guanabara Araújo et al., RCT University Cervical 2 102 0 0.0
J Dent, 2014
Huth et al., Am J Dent, PCS University Posterior 4 39 2 5.1
2004;17:51–5
Huth et al., Am J Dent, PCS University Posterior 3 39 1 2.6
2003;16:255–9
Karaman et al., J Adhes RCT University Cervical 2 72 0 0.0
Dent, 2012;14:485–92

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31 xxx.e19

Appendix A (Continued )

Author, journal, year, Study University/ Location Evaluation No. of No. of Incidence
volume, pages type practice- period evaluated restorations of SC (%)
based (years) restorations with SC

Kim et al., Oper Dent, RCT University Cervical 2 122 0 0.0

2009;34:507–15.
Kinomoto et al., Am J RCT University Posterior 2 51 0 0.0
Dent, 2004;17:253–6.
Kiremitci et al., Oper PCS University Posterior 6 44 0 0.0
Dent, 2009;34:11–7
Kohler et al., J Dent, RCT Practice- Posterior 5 51 7 13.7
2000;28:111–6 based
Kopperud et al., Eur J PCS Practice- Posterior 4 3286 284 8.6
Oral Sci, based
2012;120:539–48
Koubi et al., J Contemp PCS University Cervical 1 42 0 0.0
Dent Pract,
2006;7:42–53
Krämer et al., Am J RCT University Posterior 4 54 0 0.0
Dent, 2006;19:61–6
Krämer et al., Am J RCT University Posterior 2 93 0 0.0
Dent, 2005;18:75–81
Krämer et al., Dent RCT Practice- Posterior 6 68 0 0.0
Mater, 2011;27:455–64 based
Krämer et al., Dent RCT Practice- Posterior 4 68 0 0.0
Mater, 2009;25:750–9 based
Krämer et al., Am J RCT Practice- Posterior 2 68 0 0.0
Dent, 2009;22:228–34 based
Kubo et al., J Dent, RCT University Cervical 5 71 0 0.0
2006;34:97–105
Kubo et al., J Dent, RCT University Cervical 3 98 0 0.0
2010;38:191–200
Kubo et al., J Dent, RCT University Cervical 2 106 0 0.0
2009;37:149–55
Kurokawa et al., Dent RCT University Cervical 1 98 0 0.0
Mater J, 2007;26:14–20
Lindberg et al., J Dent, RCT Practice- Posterior 9 135 8 5.9
2007;35:124–9 based
Loguercio et al., J Adhes RCT University Anterior 1 114 0 0.0
Dent, 2007;9:57–64
Loguercio et al., J Adhes RCT University Cervical 5 14 0 0.0
Dent, 2003;5:323–32
Loguercio et al., J Am RCT University Cervical 3 78 0 0.0
Dent Assoc,
2007;138:507–14
Loguercio and Reis, J Am RCT University Cervical 1.5 108 0 0.0
Dent Assoc,
2008;139:53–61
Loguercio et al., Clin RCT University Cervical 2 120 0 0.0
Oral Investig,
2011;15:589–96
Loguercio et al., Oper RCT University Cervical 2 66 0 0.0
Dent, 2010;35:265–72
Loguercio et al., J Oral RCT University Posterior 3 75 0 0.0
Rehabil,
2006;33:144–51
Loguercio et al., Oper RCT University Posterior 1 84 0 0.0
Dent, 2001;26:427–34

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e20 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31

Appendix A (Continued )

Author, journal, year, Study University/ Location Evaluation No. of No. of Incidence
volume, pages type practice- period evaluated restorations of SC (%)
based (years) restorations with SC

Lopes et al., Clin Oral RCT University Posterior 1 76 0 0.0

Investig, 2002;6:79–83
Lopes et al., Clin Oral RCT University Posterior 2 74 0 0.0
Investig, 2003;7:123–8
Lund et al., Oper Dent, RCT University Posterior 6 27 0 0.0
2007;32:118–23
Lundin and Rasmusson, PCS Practice- Posterior 2 140 1 0.7
Quintessence Int, based
2004;35:758–62
Luo et al., Quintessence PCS University Posterior 1 82 3 3.7
Int, 2000;31:630–6
Lygidakis et al., Eur J PCS University Posterior 4 49 0 0.0
Paediatr Dent,
2003;4:143–8
Mahmoud et al., J Adhes RCT University Posterior 3 156 0 0.0
Dent, 2014;16:285–92
Mahmoud et al., J Adhes RCT University Posterior 2 140 2 1.4
Dent, 2008;10:315–22
Manhart et al., J Prosthet RCT University Posterior 3 30 4 13.3
Dent, 2000;84:289–96
Manhart et al., J Adhes RCT University Posterior 4 83 0 0.0
Dent, 2010;12:237–43
Manhart et al., RCT University Posterior 1.5 94 0 0.0
Quintessence Int,
2008;39:757–65
Mannocci et al., J RCT University Posterior 3 50 0 0.0
Prosthet Dent,
2002;88:297–301
Mannocci et al., Oper RCT Practice- Posterior 5 97 10 10.3
Dent, 2005;30:9–15 based
3 105 3 2.9
1 109 2 1.8
Matis et al., J Am Dent RCT University Cervical 3 78 1 1.3
Assoc, 2004;135:451–7
McComb et al., Oper RCT University Cervical 2 18 8 44.4
Dent, 2002;27:430–7
Memarpour et al., J Dent PCS University Posterior 3.5 25 0 0.0
Child, 2010;77:92–8
Mena-Serrano et al., J RCT University Cervical 0.5 200 0 0.0
Esthet Restor Dent,
2013;25:55–69
Perdigão et al., Oper RCT University Cervical 1.5 191 0 0.0
Dent, 2014;39:113–27
Merte et al., J Biomed RCT University Cervical 2 82 0 0.0
Mater Res,
2000;53:93–9
Monteiro et al., J Am RCT University Posterior 2 92 2 2.2
Dent Assoc,
2010;141:319–29
1 96 1 1.0
Moosavi et al., Oper RCT University Cervical 1.5 87 0 0.0
Dent, 2013;38:134–41
Moretto et al., J Dent, RCT University Cervical 3 157 0 0.0
2013;41:675–82

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31 xxx.e21

Appendix A (Continued )

Author, journal, year, Study University/ Location Evaluation No. of No. of Incidence
volume, pages type practice- period evaluated restorations of SC (%)
based (years) restorations with SC

Moura et al., Braz Dent J, PCS University Anterior 3 151 0 0.0

2011;22:111–6
Posterior 3 68 0 0.0
Närhi et al., Clin Oral RCT Practice- Anterior 1 141 0 0.0
Investig, 2003;7:241–3 based
Oberländer et al., Clin RCT Practice- Posterior 1 104 2 1.9
Oral Investig, based
2001;5:102–7
Onal and Pamir, J Am RCT University Cervical 2 106 0 0.0
Dent Assoc,
2005;136:1547–55

Opdam et al., J Endod, RCT Practice- Posterior 7 41 0 0.0

2008;34:808–11 based
Ozel et al., Aust Dent J, RCT University Cervical 1 104 0 0.0
2010;55:156–61
Ozgünaltay and Onen, J RCT University Cervical 3 40 0 0.0
Oral Rehabil,
2002;29:1037–41
Palaniappan et al., Dent RCT University Posterior 3 37 0 0.0
Mater,
2009;25:1302–14
Palaniappan et al., Clin RCT University Posterior 3 49 0 0.0
Oral Investig,
2010;14:441–58
Pallesen et al., Clin Oral PCS Practice- Posterior 8 3654 305 8.3
Investig, based
2014;18:819–27
Pallesen and Qvist, Clin RCT University Posterior 11 128 6 4.7
Oral Investig,
2003;7:71–9
Pazinatto et al., J Appl RCT University Posterior 4.7 67 1 1.5
Oral Sci, 2012;20:323–8
Perdigão et al., J Adhes RCT University Cervical 1.5 110 1 0.9
Dent, 2005;7:253–8
Perdigão et al., Am J RCT University Cervical 1.5 87 1 1.1
Dent, 2005;18:135–40
Perdigão et al., RCT University Cervical 0.5 120 0 0.0
Compend Contin Educ
Dent, 2004;25:33–4
Perdigão et al., J Adhes RCT University Posterior 2 91 2 2.2
Dent, 2009;11:149–59
1 111 1 0.9
Perdigão et al.I, Oper RCT University Cervical 1.5 94 6 6.4
Dent, 2012;37:3–11
0.5 107 1 0.9
Perry et al., Compend PCS University Posterior 1 20 0 0.0
Contin Educ Dent,
1999;20:544–50
Perry and Kugel, PCS University Posterior 2 22 0 0.0
Compend Contin Educ
Dent, 2000;21:1067–72
Peumans et al., Dent RCT University Cervical 7 114 0 0.0
Mater, 2007;23:749–54

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e22 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31

Appendix A (Continued )

Author, journal, year, Study University/ Location Evaluation No. of No. of Incidence
volume, pages type practice- period evaluated restorations of SC (%)
based (years) restorations with SC

Peumans et al., Clin Oral RCT University Cervical 13 109 0 0.0

Investig,
2012;16:129–37
Peumans et al., J Adhes RCT University Cervical 5 84 0 0.0
Dent, 2007;9:7–10
Peumans et al., Dent RCT University Cervical 8 76 0 0.0
Mater,
2010;26:1176–84
Peumans et al., Eur J RCT University Cervical 3 90 0 0.0
Oral Sci,
2005;113:512–8
Pollington and van RCT Practice- Cervical 3 60 0 0.0
Noort, Am J Dent, based
2008;21:49–52
Poyser et al., J Oral PCS University Anterior 2.5 133 0 0.0
Rehabil,
2007;34:361–76
Preussker et al., Am J PCS University Cervical 3 120 0 0.0
Dent, 2014;27:73–8
Qin et al., Clin Oral RCT University Cervical 2 112 0 0.0
Investig,
2013;17:799–804
Reis and Loguercio, Oper RCT University Cervical 3 78 0 0.0
Dent, 2009;34:384–91
Reis et al., J Am Dent RCT University Cervical 1.5 120 0 0.0
Assoc,
2009;140:877–85
Reis et al., Am J Dent, RCT University Cervical 2 66 0 0.0
2010;23:231–6
Reis and Loguercio, Oper RCT University Cervical 2 74 0 0.0
Dent, 2006;31:523–9
Ritter et al., J Am Dent RCT University Cervical 8 56 0 0.0
Assoc, 2009;140:28–37
Ritter et al., Oper Dent, RCT University Cervical 3 94 0 0.0
2008;33:370–8
Rocha Gomes Torres RCT University Posterior 2 78 0 0.0
et al., J Dent,
2014;42:793–9
Sachdeo et al., Eur J RCT Practice- Posterior 2 60 0 0.0
Prosthodont Restor based
Dent, 2004;12:15–20
Sadeghi et al., J Oral RCT University Posterior 1.5 102 1 1.0
Rehabil, 2010;37:532–7
Santiago et al., Braz RCT University Cervical 2 33 0 0.0
Dent J, 2010;21:229–34
Sartori et al., Oper Dent, RCT University Cervical 1.5 64 1 1.6
2013;38:249–57
Sartori et al., J Adhes RCT University Cervical 1.5 109 0 0.0
Dent, 2012;14:183–9
Schattenberg et al., Clin RCT University Cervical 2 104 0 0.0
Oral Investig,
2008;12:225–32
Schirrmeister et al., J RCT University Posterior 4 54 0 0.0
Adhes Dent,
2009;11:399–404

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31 xxx.e23

Appendix A (Continued )

Author, journal, year, Study University/ Location Evaluation No. of No. of Incidence
volume, pages type practice- period evaluated restorations of SC (%)
based (years) restorations with SC

Schirrmeister et al., Clin RCT University Posterior 2 61 0 0.0

Oral Investig,
2006;10:181–6
Shi et al., Oper Dent, RCT University Posterior 3 80 0 0.0
2010;35:11–9
Söderholm et al., Am J RCT University Cervical 4 66 0 0.0
Dent, 2013;26:28–32
Soncini et al., J Am Dent RCT Practice- Posterior 3.4 753 58 7.7
Assoc, based
2007;138:763–72
Spreafico et al., J Dent, RCT University Posterior 3.5 22 0 0.0
2005;33:499–507
Stefanski and van RCT Practice- Posterior 2 92 0 0.0
Dijken, Clin Oral based
Investig,
2012;16:147–53
Stojanac et al., Oper RCT University Cervical 2 74 0 0.0
Dent, 2013;38:12–20
Sundfeld et al., Oper RCT University Posterior 1 97 0 0.0
Dent, 2012;37:E1–8
Swift et al., Am J Dent, RCT University Posterior 3 51 1 2.0
2008;21:148–52
Swift et al., J Am Dent RCT University Cervical 3 91 0 0.0
Assoc,
2001;132:1117–23
Swift et al., J Dent, RCT University Cervical 1.5 97 0 0.0
2001;29:1–6
Torres et al., Gen Dent, RCT University Posterior 3 39 0 0.0
2010;58:338–43
Tuncer et al., Aust Dent RCT University Cervical 2 123 0 0.0
J, 2013;58:94–100
Türkün and Celik, J RCT University Cervical 2 100 0 0.0
Adhes Dent,
2008;10:399–405
Türkün, J Am Dent RCT University Cervical 1 163 0 0.0
Assoc,
2005;136:656–64
Türkün et al., PCS University Posterior 3 47 0 0.0
Quintessence Int,
2005;36:365–72
Türkün et al., J Am Dent PCS University Posterior 2 50 0 0.0
Assoc,
2003;134:1205–12
Türkün et al., RCT University Posterior 7 70 4 5.7
Quintessence Int,
2003;34:418–26
Türkün and Aktener, J RCT University Posterior 2 107 0 0.0
Am Dent Assoc,
2001;132:196–203
Türkün, J Dent, RCT University Cervical 2 88 0 0.0
2003;31:527–34
Tyas, Oper Dent, PCS University Cervical 3 36 0 0.0
2000;25:152–4
van Dijken JW, Dent RCT University Cervical 8 112 0 0.0
Mater, 2010;26:940–6

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e24 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31

Appendix A (Continued )

Author, journal, year, Study University/ Location Evaluation No. of No. of Incidence
volume, pages type practice- period evaluated restorations of SC (%)
based (years) restorations with SC

van Dijken, Dent Mater, RCT University Cervical 13 170 0 0.0

2008;24:915–22
van Dijken et al., Dent RCT University Cervical 13 275 0 0.0
Mater, 2007;23:1101–7
van Dijken and Pallesen, RCT University Cervical 7 135 0 0.0
J Dent, 2012;40:1060–7
van Dijken, Dent Mater, RCT University Cervical 3 98 0 0.0
2000;16:285–91
van Dijken, Am J Dent, RCT University Cervical 2 141 1 0.7
2004;17:27–32
van Dijken and Pallesen, RCT University Posterior 6 118 8 6.8
Dent Mater,
2013;29:191–8
van Dijken and RCT University Posterior 6 75 5 6.7
Sunnegardh-
Gronberg, J Dent,
2006;34:763–9
van Dijken and Pallesen, RCT University Posterior 7 114 4 3.5
Dent Mater,
2011;27:150–6
van Dijken and Pallesen, RCT University Posterior 4 162 2 1.2
J Dent, 2011;39:16–25
van Dijken and RCT University Posterior 4 67 0 0.0
Sunnegardh-
Gronberg, J Adhes
Dent, 2005;7:343–9
van Dijken, Dent Mater, RCT University Posterior 6 92 0 0.0
2003;19:423–8
van Dijken, J Dent, RCT University Posterior 12 76 0 0.0
2010;38:469–74
Van Landuyt et al., Eur J RCT University Cervical 3 256 0 0.0
Oral Sci,
2011;119:511–6
Van Landuyt et al., J RCT University Cervical 1 265 0 0.0
Dent, 2008;36:847–55
Van Meerbeek et al., RCT University Cervical 3 146 0 0.0
Oper Dent,
2004;29:376–85
Van Meerbeek et al., RCT University Cervical 2 86 0 0.0
Dent Mater,
2005;21:375–83
Wassell et al., J Dent, RCT University Posterior 5 65 0 0.0
2000;28:375–82
Wilder et al., J Am Dent RCT University Cervical 12 46 0 0.0
Assoc,
2009;140:526–35
Wilson et al., Oper Dent, RCT Practice- Posterior 1 49 0 0.0
2002;27:423–9 based
Wilson et al., J Adhes PCS University Posterior 3 108 1 0.9
Dent, 2006;8:47–51
Wucher et al., Am J RCT University Posterior 3 60 1 1.7
Dent, 2002;15:274–8
Yaman et al., Clin Oral RCT University Cervical 3 120 0 0.0
Investig,
2014;18:1071–9

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31 xxx.e25

Appendix A (Continued )

Author, journal, year, Study University/ Location Evaluation No. of No. of Incidence
volume, pages type practice- period evaluated restorations of SC (%)
based (years) restorations with SC

Yazici et al., J Adhes RCT University Cervical 3 114 0 0.0

Dent, 2010;12:231–6
Poon et al., J Am Dent RCT University Posterior 3.5 49 2 4.1
Assoc,
2005;136:1533–40
Yip KH et al., J Am Dent RCT University Posterior 1 78 0 0.0
Assoc,
2003;134:1581–9
Zanata et al., J Public RCT Practice- Anterior 2 106 1 0.9
Health Dent, based
2003;63:221–6
Zander-Grande et al., RCT University Cervical 2 124 8 6.5
Oper Dent,
2014;39:228–38
Zander-Grande et al., J RCT University Cervical 2 160 0 0.0
Am Dent Assoc.
2011;142:828–35
Zhou et al., Am J Dent. RCT University Cervical 1 328 0 0.0
2009;22:235–40

Abbreviations: PCS: prospective clinical study; RCT: randomized controlled clinical trial; RS: retrospective study.

references [11] Roumanas ED. The frequency of replacement of dental

restorations may vary based on a number of variables,
including type of material, size of the restoration, and
caries risk of the patient. J Evid Based Dent Pract
[1] Mjor IA, Shen C, Eliasson ST, Richter S. Placement and
2010;10:23–4.
replacement of restorations in general dental practice in
[12] Rho YJ, Namgung C, Jin BH, Lim BS, Cho BH. Longevity of
Iceland. Oper Dent 2002;27:117–23.
direct restorations in stress-bearing posterior cavities: a
[2] Sunnegardh-Gronberg K, van Dijken JW, Funegard U,
retrospective study. Oper Dent 2013;38:572–82.
Lindberg A, Nilsson M. Selection of dental materials and
[13] Kopperud SE, Tveit AB, Gaarden T, Sandvik L, Espelid I.
longevity of replaced restorations in Public Dental Health
Longevity of posterior dental restorations and reasons for
clinics in northern Sweden. J Dent 2009;37:673–8.
failure. Eur J Oral Sci 2012;120:539–48.
[3] Chin G, Chong J, Kluczewska A, Lau A, Gorjy S, Tennant M.
[14] Opdam NJ, Bronkhorst EM, Roeters JM, Loomans BA. A
The environmental effects of dental amalgam. Aust Dent J
retrospective clinical study on longevity of posterior
2000;45:246–9.
composite and amalgam restorations. Dent Mater
[4] Horsted-Bindslev P. Amalgam toxicity – environmental and
2007;23:2–8.
occupational hazards. J Dent 2004;32:359–65.
[15] Palotie U, Vehkalahti MM. Reasons for replacement of
[5] Schuurs AH. Reproductive toxicity of occupational
restorations: dentists’ perceptions. Acta Odontol Scand
mercury. A review of the literature. J Dent 1999;27:249–56.
2012;70:485–90.
[6] Ritchie KA, Burke FJ, Gilmour WH, Macdonald EB, Dale IM,
[16] Gordan VV, Riley III JL, Geraldeli S, Rindal DB, Qvist V,
Hamilton RM, et al. Mercury vapour levels in dental
Fellows JL, et al. Repair or replacement of defective
practices and body mercury levels of dentists and controls.
restorations by dentists in The Dental Practice-Based
Br Dent J 2004;197:625–32, discussion 1.
Research Network. J Am Dent Assoc 2012;143:593–601.
[7] Van Nieuwenhuysen JP, D’Hoore W, Carvalho J, Qvist V.
[17] Chrysanthakopoulos NA. Reasons for placement and
Long-term evaluation of extensive restorations in
replacement of resin-based composite restorations in
permanent teeth. J Dent 2003;31:395–405.
Greece. J Dent Res Dent Clin Dent Prosp 2011;5:87–93.
[8] Collins CJ, Bryant RW, Hodge KL. A clinical evaluation of
[18] Mjor IA. Clinical diagnosis of recurrent caries. J Am Dent
posterior composite resin restorations: 8-year findings. J
Assoc 2005;136:1426–33.
Dent 1998;26:311–7.
[19] Ozer L, Thylstrup A. What is known about caries in relation
[9] Soncini JA, Maserejian NN, Trachtenberg F, Tavares M,
to restorations as a reason for replacement? A review. Adv
Hayes C. The longevity of amalgam versus
Dent Res 1995;9:394–402.
compomer/composite restorations in posterior primary
[20] Mjor IA, Toffenetti F. Secondary caries: a literature review
and permanent teeth: findings From the New England
with case reports. Quintessence Int 2000;31:165–79.
Children’s Amalgam Trial. J Am Dent Assoc
[21] Ricketts D, Lamont T, Innes NP, Kidd E, Clarkson JE.
2007;138:763–72.
Operative caries management in adults and children.
[10] Bernardo M, Luis H, Martin MD, Leroux BG, Rue T, Leitao J,
Cochrane Database Syst Rev 2013;3:CD003808.
et al. Survival and reasons for failure of amalgam versus
[22] Schwendicke F, Dorfer CE, Paris S. Incomplete caries
composite posterior restorations placed in a randomized
removal: a systematic review and meta-analysis. J Dent Res
clinical trial. J Am Dent Assoc 2007;138:775–83.
2013;92:306–14.

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e26 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31
[23] Seemann R, Flury S, Pfefferkorn F, Lussi A, Noack MJ.
Restorative dentistry and restorative materials over the
next 20 years: a Delphi survey. Dent Mater 2014;30:
442–8.
[24] Dennison JB, Sarrett DC. Prediction and diagnosis of clinical
outcomes affecting restoration margins. J Oral Rehabil
2012;39:301–18.
[25] Kidd EA, Beighton D. Prediction of secondary caries around
tooth-colored restorations: a clinical and microbiological
study. J Dent Res 1996;75:1942–6.
[26] Murat S, Kamburoglu K, Isayev A, Kursun S, Yuksel S.
Visibility of artificial buccal recurrent caries under
restorations using different radiographic techniques. Oper
Dent 2013;38:197–207.
[27] Charuakkra A, Prapayasatok S, Janhom A, Pongsiriwet S,
Verochana K, Mahasantipiya P. Diagnostic performance of
cone-beam computed tomography on detection of
mechanically-created artificial secondary caries. Imaging
Sci Dent 2011;41:143–50.
[28] European Commission, editor. European Guidelines on
Radiation Protection in Dental Radiology, RP 136. 2004.
Luxembourg.
[29] Espelid I, Tveit AB, Erickson RL, Keck SC, Glasspoole EA.
Radiopacity of restorations and detection of secondary
caries. Dent Mater 1991;7:114–7.
[30] Hitij T, Fidler A. Radiopacity of dental restorative materials.
Clin Oral Investig 2013;17:1167–77.
[31] Kositbowornchai S, Sukanya C, Tidarat T, Chanoggarn T.
Caries detection under composite restorations by laser
fluorescence and digital radiography. Clin Oral Investig
2013;17:2079–84.
[32] Gonzalez-Cabezas C, Fontana M, Gomes-Moosbauer D,
Stookey GK. Early detection of secondary caries using
quantitative, light-induced fluorescence. Oper Dent
2003;28:415–22.
[33] Rodrigues JA, Neuhaus KW, Hug I, Stich H, Seemann R,
Lussi A. In vitro detection of secondary caries associated
with composite restorations on approximal surfaces using
laser fluorescence. Oper Dent 2010;35:564–71.
[34] Bamzahim M, Shi XQ, Angmar-Mansson B. Secondary
caries detection by DIAGNOdent and radiography: a
comparative in vitro study. Acta Odontol Scand
2004;62:61–4.
[35] Hamishaki KS, Chiniforush N, Monzavi A, Khazarazifard
MJ. An in vivo comparison of two diagnostic methods in
secondary caries detection. J Dent (Tehran) 2014;11:17–21.
[36] http://www.prisma-statement.org/.
[37] Moher D, Liberati A, Tetzlaff J, Altman DG, Group P.
Preferred reporting items for systematic reviews and
meta-analyses: the PRISMA statement. PLoS Med
2009;6:e1000097.
[38] Mjor IA. The location of clinically diagnosed secondary
caries. Quintessence Int 1998;29:313–7.
[39] Geitel B, Kwiatkowski R, Zimmer S, Barthel CR, Roulet JF,
Jahn KR. Clinically controlled study on the quality of class
III, IV and V composite restorations after two years. J Adhes
Dent 2004;6:247–53.
[40] Luo Y, Lo EC, Fang DT, Wei SH. Clinical evaluation of
polyacid-modified resin composite posterior restorations:
one-year results. Quintessence Int 2000;31:630–6.
[41] Perdigao J, Dutra-Correa M, Saraceni CH, Ciaramicoli MT,
Kiyan VH, Queiroz CS. Randomized clinical trial of four
adhesion strategies: 18-month results. Oper Dent
2012;37:3–11.
[42] van Dijken JW, Pallesen U. A six-year prospective
randomized study of a nano-hybrid and a conventional
hybrid resin composite in Class II restorations. Dent Mater
2013;29:191–8.
Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
[43] Opdam NJ, Bronkhorst EM, Loomans BA, Huysmans MC.
12-year survival of composite vs amalgam restorations. J
Dent Res 2010;89:1063–7.
[44] Chaussain-Miller C, Fioretti F, Goldberg M, Menashi S. The
role of matrix metalloproteinases (MMPs) in human caries.
J Dent Res 2006;85:22–32.
[45] Nascimento FD, Minciotti CL, Geraldeli S, Carrilho MR,
Pashley DH, Tay FR, et al. Cysteine cathepsins in human
carious dentin. J Dent Res 2011;90:506–11.
[46] Hals E, Nernaes A. Histopathology of in vitro caries
developing around silver amalgam fillings. Caries Res
1971;5:58–77.
[47] Hals E, Simonsen LT. Histopathology of experimental
in vivo caries around silver amalgam fillings. Caries Res
1972;6:16–33.
[48] Hals E, Andreassen BH, Bie T. Histopathology of natural
caries around silver amalgam fillings. Caries Res
1974;8:343–58.
[49] Hals E, Kvinnsland I. Structure of experimental in vitro and
in vivo lesions around composite (Addent XV) fillings.
Scand J Dent Res 1974;82:517–26.
[50] Kidd EA. Microleakage in relation to amalgam and
composite restorations. A laboratory study. Br Dent J
1976;141:305–10.
[51] Kidd EA. The histopathology of artificial lesions created
in vitro in relation to unfilled and filled cavities. Caries Res
1977;11:173–7.
[52] Grossman ES, Matejka JM. Reliability of outer lesion
secondary caries as a predictor of wall lesions. Am J Dent
1999;12:31–6.
[53] Thomas RZ, van der Mei HC, van der Veen MH, de Soet JJ,
Huysmans MC. Bacterial composition and red fluorescence
of plaque in relation to primary and secondary caries next
to composite: an in situ study. Oral Microbiol Immunol
2008;23:7–13.
[54] Hals E, Laegreid O. Experimental in vitro lesions adjacent to
composite restorations in etched cavities. Oral Surg Oral
Med Oral Pathol 1976;41:225–34.
[55] Eriksen HM, Pears G. In vitro caries related to marginal
leakage around composite resin restorations. J Oral Rehabil
1978;5:15–20.
[56] Gilmour SM, Edmunds DH, Dummer PM. The production of
secondary caries-like lesions on cavity walls and the
assessment of microleakage using an in vitro microbial
caries system. J Oral Rehabil 1990;17:573–8.
[57] Gilmour AS, Edmunds DH, Newcombe RG, Clark MF. An
in vitro study into the effect of a bacterial artificial caries
system on the enamel adjacent to composite and amalgam
restorations. Caries Res 1993;27:169–75.
[58] Thomas RZ, Ruben JL, ten Bosch JJ, Fidler V, Huysmans MC.
Approximal secondary caries lesion progression, a 20-week
in situ study. Caries Res 2007;41:399–405.
[59] Gilmour AS, Edmunds DH. The polarized light microscopic
appearance of caries-like lesions adjacent to restored
cavities in the crowns and roots of extracted human teeth.
J Oral Rehabil 1998;25:929–39.
[60] Barata JS, Casagrande L, Pitoni CM, De Araujo FB,
Garcia-Godoy F, Groismann S. Influence of gaps in adhesive
restorations in the development of secondary caries
lesions: an in situ evaluation. Am J Dent 2012;25:
244–8.
[61] Fejerskov O, Kidd EAM. Dental caries: the disease and its
clinical management. 2nd ed. Oxford/Ames, IA: Blackwell
Munksgaard; 2008.
[62] Diercke K, Lussi A, Kersten T, Seemann R. Isolated
development of inner (wall) caries like lesions in a
bacterial-based in vitro model. Clin Oral Investig
2009;13:439–44.
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31
[63] Nassar HM, Gonzalez-Cabezas C. Effect of gap geometry on
secondary caries wall lesion development. Caries Res
2011;45:346–52.
[64] Gonzalez-Cabezas C, Li Y, Gregory RL, Stookey GK.
Distribution of cariogenic bacteria in carious lesions
around tooth-colored restorations. Am J Dent
2002;15:248–51.
[65] Konishi N, Torii Y, Kurosaki A, Takatsuka T, Itota T,
Yoshiyama M. Confocal laser scanning microscopic
analysis of early plaque formed on resin composite and
human enamel. J Oral Rehabil 2003;30:790–5.
[66] Svanberg M, Mjor IA, Orstavik D. Mutans streptococci in
plaque from margins of amalgam, composite, and
glass-ionomer restorations. J Dent Res 1990;69:861–4.
[67] Splieth C, Bernhardt O, Heinrich A, Bernhardt H, Meyer G.
Anaerobic microflora under Class I and Class II composite
and amalgam restorations. Quintessence Int
2003;34:497–503.
[68] Mo SS, Bao W, Lai GY, Wang J, Li MY. The microfloral
analysis of secondary caries biofilm around Class I and
Class II composite and amalgam fillings. BMC Infect Dis
2010;10:241.
[69] Kidd EA. Diagnosis of secondary caries. J Dent Educ
2001;65:997–1000.
[70] Papagiannoulis L, Kakaboura A, Eliades G. In vivo vs in vitro
anticariogenic behavior of glass-ionomer and resin
composite restorative materials. Dent Mater 2002;18:
561–9.
[71] Espejo LC, Simionato MR, Barroso LP, Netto NG, Luz MA.
Evaluation of three different adhesive systems using a
bacterial method to develop secondary caries in vitro. Am J
Dent 2010;23:93–7.
[72] Totiam P, Gonzalez-Cabezas C, Fontana MR, Zero DT. A new
in vitro model to study the relationship of gap size and
secondary caries. Caries Res 2007;41:467–73.
[73] Cenci MS, Pereira-Cenci T, Cury JA, Ten Cate JM.
Relationship between gap size and dentine secondary
caries formation assessed in a microcosm biofilm model.
Caries Res 2009;43:97–102.
[74] Kuper NK, Opdam NJ, Ruben JL, de Soet JJ, Cenci MS,
Bronkhorst EM, et al. Gap size and wall lesion development
next to composite. J Dent Res 2014;93, 108S–13S.
[75] Kidd EA, Joyston-Bechal S, Beighton D. Marginal ditching
and staining as a predictor of secondary caries around
amalgam restorations: a clinical and microbiological study.
J Dent Res 1995;74:1206–11.
[76] Kidd EA. How ‘clean’ must a cavity be before restoration?
Caries Res 2004;38:305–13.
[77] Ben-Amar A, Cardash HS, Judes H. The sealing of the
tooth/amalgam interface by corrosion products. J Oral
Rehabil 1995;22:101–4.
[78] Demarco FF, Correa MB, Cenci MS, Moraes RR, Opdam NJ.
Longevity of posterior composite restorations: not only a
matter of materials. Dent Mater 2012;28:87–101.
[79] Pioch T, Staehle HJ, Duschner H, Garcia-Godoy F.
Nanoleakage at the composite–dentin interface: a review.
Am J Dent 2001;14:252–8.
[80] Tay FR, Gwinnett AJ, Pang KM, Wei SH. Variability in
microleakage observed in a total-etch wet-bonding
technique under different handling conditions. J Dent Res
1995;74:1168–78.
[81] Hilton TJ. Can modern restorative procedures and
materials reliably seal cavities? In vitro investigations. Part
1. Am J Dent 2002;15:198–210.
[82] De Munck J, Van Landuyt K, Peumans M, Poitevin A,
Lambrechts P, Braem M, et al. A critical review of the
durability of adhesion to tooth tissue: methods and results.
J Dent Res 2005;84:118–32.
Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
xxx.e27
[83] Van Landuyt KL, Mine A, De Munck J, Jaecques S, Peumans
M, Lambrechts P, et al. Are one-step adhesives easier to use
and better performing? Multifactorial assessment of
contemporary one-step self-etching adhesives. J Adhes
Dent 2009;11:175–90.
[84] Opdam NJ, Roeters JJ, Joosten M, Veeke O. Porosities and
voids in Class I restorations placed by six operators using a
packable or syringable composite. Dent Mater
2002;18:58–63.
[85] Opdam NJ, Roeters JJ, de Boer T, Pesschier D, Bronkhorst E.
Voids and porosities in class I micropreparations filled with
various resin composites. Oper Dent 2003;28:9–14.
[86] Brambilla E, Gagliani M, Ionescu A, Fadini L, Garcia-Godoy
F. The influence of light-curing time on the bacterial
colonization of resin composite surfaces. Dent Mater
2009;25:1067–72.
[87] Ferracane JL. Developing a more complete understanding
of stresses produced in dental composites during
polymerization. Dent Mater 2005;21:36–42.
[88] Davidson CL, Feilzer AJ. Polymerization shrinkage and
polymerization shrinkage stress in polymer-based
restoratives. J Dent 1997;25:435–40.
[89] Braga RR, Ballester RY, Ferracane JL. Factors involved in the
development of polymerization shrinkage stress in
resin-composites: a systematic review. Dent Mater
2005;21:962–70.
[90] Van Ende A, Mine A, De Munck J, Poitevin A, Van Meerbeek
B. Bonding of low-shrinking composites in high C-factor
cavities. J Dent 2012;40:295–303.
[91] Ferracane JL, Mitchem JC. Relationship between composite
contraction stress and leakage in Class V cavities. Am J
Dent 2003;16:239–43.
[92] Yoshikawa T, Sano H, Burrow MF, Tagami J, Pashley DH.
Effects of dentin depth and cavity configuration on bond
strength. J Dent Res 1999;78:898–905.
[93] Carvalho RM, Pereira JC, Yoshiyama M, Pashley DH. A
review of polymerization contraction: the influence of
stress development versus stress relief. Oper Dent
1996;21:17–24.
[94] Hashimoto M, Ohno H, Kaga M, Endo K, Sano H, Oguchi H.
In vivo degradation of resin–dentin bonds in humans over
1 to 3 years. J Dent Res 2000;79:1385–91.
[95] Ferracane JL. Hygroscopic and hydrolytic effects in dental
polymer networks. Dent Mater 2006;22:211–22.
[96] Koin PJ, Kilislioglu A, Zhou M, Drummond JL, Hanley L.
Analysis of the degradation of a model dental composite. J
Dent Res 2008;87:661–5.
[97] Lin BA, Jaffer F, Duff MD, Tang YW, Santerre JP. Identifying
enzyme activities within human saliva which are relevant
to dental resin composite biodegradation. Biomaterials
2005;26:4259–64.
[98] Jaffer F, Finer Y, Santerre JP. Interactions between resin
monomers and commercial composite resins with human
saliva derived esterases. Biomaterials 2002;23:
1707–19.
[99] Finer Y, Santerre JP. Biodegradation of a dental composite
by esterases: dependence on enzyme concentration and
specificity. J Biomater Sci Polym Ed 2003;14:837–49.
[100] Finer Y, Jaffer F, Santerre JP. Mutual influence of cholesterol
esterase and pseudocholinesterase on the biodegradation
of dental composites. Biomaterials 2004;25:1787–93.
[101] Kermanshahi S, Santerre JP, Cvitkovitch DG, Finer Y.
Biodegradation of resin–dentin interfaces increases
bacterial microleakage. J Dent Res 2010;89:996–1001.
[102] Li Y, Carrera C, Chen R, Li J, Lenton P, Rudney JD, et al.
Degradation in the dentin–composite interface subjected to
multi-species biofilm challenges. Acta Biomater
2014;10:375–83.
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e28 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31
[103] Bourbia M, Ma D, Cvitkovitch DG, Santerre JP, Finer Y.
Cariogenic bacteria degrade dental resin composites and
adhesives. J Dent Res 2013;92:989–94.
[104] Sano H, Takatsu T, Ciucchi B, Horner JA, Matthews WG,
Pashley DH. Nanoleakage: leakage within the hybrid layer.
Oper Dent 1995;20:18–25.
[105] Coutinho E, Cardoso MV, Fernandes CP, Neves AA, Gouvea
CV, Van Landuyt KL, et al. Nanoleakage distribution at
adhesive–dentin interfaces in 3D. J Dent Res
2011;90:1019–25.
[106] Hashimoto M, Tay FR, Ohno H, Sano H, Kaga M, Yiu C, et al.
SEM and TEM analysis of water degradation of human
dentinal collagen. J Biomed Mater Res B: Appl Biomater
2003;66:287–98.
[107] Pashley DH, Tay FR, Yiu C, Hashimoto M, Breschi L,
Carvalho RM, et al. Collagen degradation by host-derived
enzymes during aging. J Dent Res 2004;83:216–21.
[108] Zhang SC, Kern M. The role of host-derived dentinal matrix
metalloproteinases in reducing dentin bonding of resin
adhesives. Int J Oral Sci 2009;1:163–76.
[109] Delaviz Y, Finer Y, Santerre JP. Biodegradation of resin
composites and adhesives by oral bacteria and saliva: a
rationale for new material designs that consider the
clinical environment and treatment challenges. Dent Mater
2014;30:16–32.
[110] Santerre JP, Shajii L, Leung BW. Relation of dental
composite formulations to their degradation and the
release of hydrolyzed polymeric-resin-derived products.
Crit Rev Oral Biol Med 2001;12:136–51.
[111] Qvist V. The effect of mastication on marginal adaptation
of composite restorations in vivo. J Dent Res 1983;62:904–6.
[112] Francisconi LF, Graeff MS, Martins Lde M, Franco EB,
Mondelli RF, Francisconi PA, et al. The effects of occlusal
loading on the margins of cervical restorations. J Am Dent
Assoc 2009;140:1275–82.
[113] Gale MS, Darvell BW. Thermal cycling procedures for
laboratory testing of dental restorations. J Dent
1999;27:89–99.
[114] Kuper NK, Opdam NJ, Bronkhorst EM, Ruben JL, Huysmans
MC. Hydrodynamic flow through loading and in vitro
secondary caries development. J Dent Res 2013;92:
383–7.
[115] Skjorland KK, Sonju T. Effect of sucrose rinses on bacterial
colonization on amalgam and composite. Acta Odontol
Scand 1982;40:193–6.
[116] Skjorland KK. Plaque accumulation on different dental
filling materials. Scand J Dent Res 1973;81:538–42.
[117] Katsikogianni M, Missirlis YF. Concise review of
mechanisms of bacterial adhesion to biomaterials and of
techniques used in estimating bacteria-material
interactions. Eur Cell Mater 2004;8:37–57.
[118] Weerkamp AH, Uyen HM, Busscher HJ. Effect of zeta
potential and surface energy on bacterial adhesion to
uncoated and saliva-coated human enamel and dentin. J
Dent Res 1988;67:1483–7.
[119] Gong K, Ouyang T, Herzberg MC. A streptococcal adhesion
system for salivary pellicle and platelets. Infect Immun
1998;66:5388–92.
[120] Teughels W, Van Assche N, Sliepen I, Quirynen M. Effect of
material characteristics and/or surface topography on
biofilm development. Clin Oral Implants Res 2006;17(Suppl.
2):68–81.
[121] Montanaro L, Campoccia D, Rizzi S, Donati ME, Breschi L,
Prati C, et al. Evaluation of bacterial adhesion of
Streptococcus mutans on dental restorative materials.
Biomaterials 2004;25:4457–63.
[122] Hahnel S, Henrich A, Rosentritt M, Handel G, Burgers R.
Influence of artificial ageing on surface properties and
Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
Streptococcus mutans adhesion to dental composite
materials. J Mater Sci Mater Med 2010;21:823–33.
[123] Aykent F, Yondem I, Ozyesil AG, Gunal SK, Avunduk MC,
Ozkan S. Effect of different finishing techniques for
restorative materials on surface roughness and bacterial
adhesion. J Prosthet Dent 2010;103:221–7.
[124] Eick S, Glockmann E, Brandl B, Pfister W. Adherence of
Streptococcus mutans to various restorative materials in a
continuous flow system. J Oral Rehabil 2004;31:278–85.
[125] Mei L, Busscher HJ, van der Mei HC, Ren Y. Influence of
surface roughness on streptococcal adhesion forces to
composite resins. Dent Mater 2011;27:770–8.
[126] Yamamoto K, Ohashi S, Taki E, Hirata K. Adherence of oral
streptococci to composite resin of varying surface
roughness. Dent Mater J 1996;15:201–4.
[127] Bollen CM, Lambrechts P, Quirynen M. Comparison of
surface roughness of oral hard materials to the threshold
surface roughness for bacterial plaque retention: a review
of the literature. Dent Mater 1997;13:258–69.
[128] Ono M, Nikaido T, Ikeda M, Imai S, Hanada N, Tagami J,
et al. Surface properties of resin composite materials
relative to biofilm formation. Dent Mater J 2007;26:613–22.
[129] Beyth N, Bahir R, Matalon S, Domb AJ, Weiss EI.
Streptococcus mutans biofilm changes surface-topography of
resin composites. Dent Mater 2008;24:732–6.
[130] Fucio SB, Carvalho FG, Sobrinho LC, Sinhoreti MA,
Puppin-Rontani RM. The influence of 30-day-old
Streptococcus mutans biofilm on the surface of esthetic
restorative materials – an in vitro study. J Dent
2008;36:833–9.
[131] Gregson KS, Shih H, Gregory RL. The impact of three strains
of oral bacteria on the surface and mechanical properties of
a dental resin material. Clin Oral Investig 2012;16:1095–103.
[132] Willershausen B, Callaway A, Ernst CP, Stender E. The
influence of oral bacteria on the surfaces of resin-based
dental restorative materials – an in vitro study. Int Dent J
1999;49:231–9.
[133] Buergers R, Schneider-Brachert W, Hahnel S, Rosentritt M,
Handel G. Streptococcal adhesion to novel low-shrink
silorane-based restorative. Dent Mater 2009;25:269–75.
[134] Claro-Pereira D, Sampaio-Maia B, Ferreira C, Rodrigues A,
Melo LF, Vasconcelos MR. In situ evaluation of a new
silorane-based composite resin’s bioadhesion properties.
Dent Mater 2011;27:1238–45.
[135] Hahnel S, Rosentritt M, Burgers R, Handel G. Surface
properties and in vitro Streptococcus mutans adhesion to
dental resin polymers. J Mater Sci Mater Med
2008;19:2619–27.
[136] Ruttermann S, Bergmann N, Beikler T, Raab WH, Janda R.
Bacterial viability on surface-modified resin-based dental
restorative materials. Arch Oral Biol 2012;57:1512–21.
[137] Ikeda M, Matin K, Nikaido T, Foxton RM, Tagami J. Effect of
surface characteristics on adherence of S. mutans biofilms
to indirect resin composites. Dent Mater J 2007;26:915–23.
[138] Hannig C, Hannig M. The oral cavity – a key system to
understand substratum-dependent bioadhesion on solid
surfaces in man. Clin Oral Investig 2009;13:123–39.
[139] Siqueira WL, Custodio W, McDonald EE. New insights into
the composition and functions of the acquired enamel
pellicle. J Dent Res 2012;91:1110–8.
[140] Schweikl H, Hiller KA, Carl U, Schweiger R, Eidt A, Ruhl S,
et al. Salivary protein adsorption and Streptococccus gordonii
adhesion to dental material surfaces. Dent Mater
2013;29:1080–9.
[141] Carlen A, Olsson J, Ramberg P. Saliva mediated adherence,
aggregation and prevalence in dental plaque of Streptococcus
mutans, Streptococcus sanguis and Actinomyces spp., in young
and elderly humans. Arch Oral Biol 1996;41:1133–40.
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31
[142] Lassila LV, Garoushi S, Tanner J, Vallittu PK, Soderling E.
Adherence of Streptococcus mutans to fiber-reinforced filling
composite and conventional restorative materials. Open
Dent J 2009;3:227–32.
[143] Suljak JP, Reid G, Wood SM, McConnell RJ, van der Mei HC,
Busscher HJ. Bacterial adhesion to dental amalgam and
three resin composites. J Dent 1995;23:171–6.
[144] Satou J, Fukunaga A, Morikawa A, Matsumae I, Satou N,
Shintani H. Streptococcal adherence to uncoated and
saliva-coated restoratives. J Oral Rehabil 1991;18:421–9.
[145] Pratt-Terpstra IH, Weerkamp AH, Busscher HJ. The effects
of pellicle formation on streptococcal adhesion to human
enamel and artificial substrata with various surface
free-energies. J Dent Res 1989;68:463–7.
[146] Tanner J, Carlen A, Soderling E, Vallittu PK. Adsorption of
parotid saliva proteins and adhesion of Streptococcus mutans
ATCC 21752 to dental fiber-reinforced composites. J Biomed
Mater Res B: Appl Biomater 2003;66:391–8.
[147] Shahal Y, Steinberg D, Hirschfeld Z, Bronshteyn M,
Kopolovic K. In vitro bacterial adherence onto
pellicle-coated aesthetic restorative materials. J Oral
Rehabil 1998;25:52–8.
[148] Alshali RZ, Silikas N, Satterthwaite JD. Degree of conversion
of bulk-fill compared to conventional resin-composites at
two time intervals. Dent Mater 2013;29:e213–7.
[149] Reichl FX, Seiss M, Kleinsasser N, Kehe K, Kunzelmann KH,
Thomas P, et al. Distribution and excretion of BisGMA in
guinea pigs. J Dent Res 2008;87:378–80.
[150] Gerzina TM, Hume WR. Diffusion of monomers from
bonding resin–resin composite combinations through
dentine in vitro. J Dent 1996;24:125–8.
[151] Biradar B, Devi P. Quorum sensing in plaque biofilms:
challenges and future prospects. J Contemp Dent Pract
2011;12:479–85.
[152] Kawai K, Torii M, Tuschitani Y. Effect of resin components
on the growth of Streptococcus mutans. J Osaka Univ Dent
Sch 1988;28:161–70.
[153] Hansel C, Leyhausen G, Mai UE, Geurtsen W. Effects of
various resin composite (co)monomers and extracts on two
caries-associated micro-organisms in vitro. J Dent Res
1998;77:60–7.
[154] Takahashi Y, Imazato S, Russell RR, Noiri Y, Ebisu S.
Influence of resin monomers on growth of oral
streptococci. J Dent Res 2004;83:302–6.
[155] D’Ercole S, Di Giulio M, Grande R, Di Campli E, Di
Bartolomeo S, Piccolomini R, et al. Effect of 2-hydroxyethyl
methacrylate on Streptococcus spp. biofilms. Lett Appl
Microbiol 2011;52:193–200.
[156] Khalichi P, Cvitkovitch DG, Santerre JP. Effect of composite
resin biodegradation products on oral streptococcal
growth. Biomaterials 2004;25:5467–72.
[157] Singh J, Khalichi P, Cvitkovitch DG, Santerre JP. Composite
resin degradation products from BisGMA monomer
modulate the expression of genes associated with biofilm
formation and other virulence factors in Streptococcus
mutans. J Biomed Mater Res A 2009;88:551–60.
[158] Kawai K, Tsuchitani Y. Effects of resin composite
components on glucosyltransferase of cariogenic
bacterium. J Biomed Mater Res 2000;51:123–7.
[159] Khalichi P, Singh J, Cvitkovitch DG, Santerre JP. The
influence of triethylene glycol derived from dental
composite resins on the regulation of Streptococcus mutans
gene expression. Biomaterials 2009;30:452–9.
[160] Geurtsen W, Leyhausen G. Chemical–biological interactions
of the resin monomer triethyleneglycol-dimethacrylate
(TEGDMA). J Dent Res 2001;80:2046–50.
[161] Van Landuyt KL, Nawrot T, Geebelen B, De Munck J,
Snauwaert J, Yoshihara K, et al. How much do resin-based
Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
xxx.e29
dental materials release? A meta-analytical approach. Dent
Mater 2011;27:723–47.
[162] Santerre JP, Shajii L, Tsang H. Biodegradation of
commercial dental composites by cholesterol esterase. J
Dent Res 1999;78:1459–68.
[163] Kraigsley AM, Tang K, Lippa KA, Howarter JA, Lin-Gibson S,
Lin NJ. Effect of polymer degree of conversion on
Streptococcus mutans biofilms. Macromol Biosci
2012;12:1706–13.
[164] Beyth N, Domb AJ, Weiss EI. An in vitro quantitative
antibacterial analysis of amalgam and composite resins. J
Dent 2007;35:201–6.
[165] Karanika-Kouma A, Dionysopoulos P, Koliniotou-Koubia E,
Kolokotronis A. Antibacterial properties of dentin bonding
systems, polyacid-modified composite resins and
composite resins. J Oral Rehabil 2001;28:157–60.
[166] Boeckh C, Schumacher E, Podbielski A, Haller B.
Antibacterial activity of restorative dental biomaterials in
vitro. Caries Res 2002;36:101–7.
[167] Morrier JJ, Suchett-Kaye G, Nguyen D, Rocca JP, Blanc-Benon
J, Barsotti O. Antimicrobial activity of amalgams, alloys and
their elements and phases. Dent Mater 1998;14:150–7.
[168] Sousa RP, Zanin IC, Lima JP, Vasconcelos SM, Melo MA,
Beltrao HC, et al. In situ effects of restorative materials on
dental biofilm and enamel demineralisation. J Dent
2009;37:44–51.
[169] Paradella TC, Koga-Ito CY, Jorge AO. Ability of different
restorative materials to prevent in situ secondary caries:
analysis by polarized light-microscopy and
energy-dispersive X-ray. Eur J Oral Sci 2008;116:375–80.
[170] Gama-Teixeira A, Simionato MR, Elian SN, Sobral MA, Luz
MA. Streptococcus mutans-induced secondary caries adjacent
to glass ionomer cement, composite resin and amalgam
restorations in vitro. Braz Oral Res 2007;21:368–74.
[171] Lobo MM, Goncalves RB, Ambrosano GM, Pimenta LA.
Chemical or microbiological models of secondary caries
development around different dental restorative materials.
J Biomed Mater Res B: Appl Biomater 2005;74:
3725–31.
[172] van de Sande FH, Opdam NJ, Truin GJ, Bronkhorst EM, de
Soet JJ, Cenci MS, et al. The influence of different
restorative materials on secondary caries development in
situ. J Dent 2014;42:1171–7.
[173] Imazato S. Antibacterial properties of resin composites and
dentin bonding systems. Dent Mater 2003;19:449–57.
[174] Chen L, Shen H, Suh BI. Antibacterial dental restorative
materials: a state-of-the-art review. Am J Dent
2012;25:337–46.
[175] Wang Z, Shen Y, Haapasalo M. Dental materials with
antibiofilm properties. Dent Mater 2014;30:e1–16.
[176] Beyth N, Farah S, Domb AJ, Weiss EI. Antibacterial dental
resin composites. React Funct Polym 2014;75:81–8.
[177] Xu X, Burgess JO. Compressive strength, fluoride release
and recharge of fluoride-releasing materials. Biomaterials
2003;24:2451–61.
[178] Saku S, Kotake H, Scougall-Vilchis RJ, Ohashi S, Hotta M,
Horiuchi S, et al. Antibacterial activity of composite resin
with glass-ionomer filler particles. Dent Mater J
2010;29:193–8.
[179] Xu HH, Moreau JL, Sun L, Chow LC. Novel CaF(2)
nanocomposite with high strength and fluoride ion release.
J Dent Res 2010;89:739–45.
[180] Hicks J, Garcia-Godoy F, Donly K, Flaitz C. Fluoride-releasing
restorative materials and secondary caries. J Calif Dent
Assoc 2003;31:229–45.
[181] Aydin Sevinc B, Hanley L. Antibacterial activity of dental
composites containing zinc oxide nanoparticles. J Biomed
Mater Res B: Appl Biomater 2010;94:22–31.
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
xxx.e30 d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31
[182] Yamamoto K, Ohashi S, Aono M, Kokubo T, Yamada I,
Yamauchi J. Antibacterial activity of silver ions implanted
in SiO2 filler on oral streptococci. Dent Mater 1996;12:227–9.
[183] Kawashita M, Tsuneyama S, Miyaji F, Kokubo T, Kozuka H,
Yamamoto K. Antibacterial silver-containing silica glass
prepared by sol-gel method. Biomaterials 2000;21:393–8.
[184] Burgers R, Eidt A, Frankenberger R, Rosentritt M, Schweikl
H, Handel G, et al. The anti-adherence activity and
bactericidal effect of microparticulate silver additives in
composite resin materials. Arch Oral Biol 2009;54:595–601.
[185] Syafiuddin T, Hisamitsu H, Toko T, Igarashi T, Goto N,
Fujishima A, et al. In vitro inhibition of caries around a
resin composite restoration containing antibacterial filler.
Biomaterials 1997;18:1051–7.
[186] Yoshida K, Tanagawa M, Atsuta M. Characterization and
inhibitory effect of antibacterial dental resin composites
incorporating silver-supported materials. J Biomed Mater
Res 1999;47:516–22.
[187] Tanagawa M, Yoshida K, Matsumoto S, Yamada T, Atsuta
M. Inhibitory effect of antibacterial resin composite against
Streptococcus mutans. Caries Res 1999;33:366–71.
[188] Anusavice KJ, Zhang NZ, Shen C. Controlled release of
chlorhexidine from UDMA-TEGDMA resin. J Dent Res
2006;85:950–4.
[189] Hiraishi N, Yiu CK, King NM, Tay FR. Antibacterial effect of
experimental chlorhexidine-releasing polymethyl
methacrylate-based root canal sealers. J Endod
2009;35:1255–8.
[190] Hiraishi N, Yiu CK, King NM, Tay FR. Effect of chlorhexidine
incorporation into a self-etching primer on dentine bond
strength of a luting cement. J Dent 2010;38:496–502.
[191] Rathke A, Staude R, Muche R, Haller B. Antibacterial
activity of a triclosan-containing resin composite matrix
against three common oral bacteria. J Mater Sci Mater Med
2010;21:2971–7.
[192] Othman HF, Wu CD, Evans CA, Drummond JL, Matasa CG.
Evaluation of antimicrobial properties of orthodontic
composite resins combined with benzalkonium chloride.
Am J Orthod Dentofacial Orthop 2002;122:288–94.
[193] Ehara A, Torii M, Imazato S, Ebisu S. Antibacterial activities
and release kinetics of a newly developed recoverable
controlled agent-release system. J Dent Res 2000;79:824–8.
[194] Elsaka SE. Antibacterial activity and adhesive properties of
a chitosan-containing dental adhesive. Quintessence Int
2012;43:603–13.
[195] Kudou Y, Obara K, Kawashima T, Kubota M, Abe S, Endo T,
et al. Addition of antibacterial agents to MMA-TBB dentin
bonding systems – influence on tensile bond strength and
antibacterial effect. Dent Mater J 2000;19:65–74.
[196] Du X, Huang X, Huang C, Wang Y, Zhang Y.
Epigallocatechin-3-gallate (EGCG) enhances the therapeutic
activity of a dental adhesive. J Dent 2012;40:485–92.
[197] Imazato S, Imai T, Russell RR, Torii M, Ebisu S. Antibacterial
activity of cured dental resin incorporating the
antibacterial monomer MDPB and an adhesion-promoting
monomer. J Biomed Mater Res 1998;39:511–5.
[198] Thome T, Mayer MP, Imazato S, Geraldo-Martins VR,
Marques MM. In vitro analysis of inhibitory effects of the
antibacterial monomer MDPB-containing restorations on
the progression of secondary root caries. J Dent
2009;37:705–11.
[199] Imazato S, Ebi N, Takahashi Y, Kaneko T, Ebisu S, Russell
RR. Antibacterial activity of bactericide-immobilized filler
for resin-based restoratives. Biomaterials 2003;24:
3605–9.
[200] Ebi N, Imazato S, Noiri Y, Ebisu S. Inhibitory effects of resin
composite containing bactericide-immobilized filler on
plaque accumulation. Dent Mater 2001;17:485–91.
Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001
[201] Pinto CF, Paes-Leme AF, Ambrosano GM, Giannini M.
In vitro secondary caries inhibition by adhesive systems in
enamel around composite restorations. Oper Dent
2010;35:345–52.
[202] Beyth N, Yudovin-Farber I, Bahir R, Domb AJ, Weiss EI.
Antibacterial activity of dental composites containing
quaternary ammonium polyethylenimine nanoparticles
against Streptococcus mutans. Biomaterials
2006;27:3995–4002.
[203] Xiao YH, Ma S, Chen JH, Chai ZG, Li F, Wang YJ.
Antibacterial activity and bonding ability of an adhesive
incorporating an antibacterial monomer DMAE-CB. J
Biomed Mater Res B: Appl Biomater 2009;90:813–7.
[204] Li F, Chen J, Chai Z, Zhang L, Xiao Y, Fang M, et al. Effects of
a dental adhesive incorporating antibacterial monomer on
the growth, adherence and membrane integrity of
Streptococcus mutans. J Dent 2009;37:289–96.
[205] Cheng L, Zhang K, Melo MA, Weir MD, Zhou X, Xu HH.
Anti-biofilm dentin primer with quaternary ammonium
and silver nanoparticles. J Dent Res 2012;91:598–604.
[206] Zhang K, Melo MA, Cheng L, Weir MD, Bai Y, Xu HH. Effect of
quaternary ammonium and silver nanoparticle-containing
adhesives on dentin bond strength and dental plaque
microcosm biofilms. Dent Mater 2012;28:842–52.
[207] Cheng L, Weir MD, Limkangwalmongkol P, Hack GD, Xu HH,
Chen Q, et al. Tetracalcium phosphate composite
containing quaternary ammonium dimethacrylate with
antibacterial properties. J Biomed Mater Res B: Appl
Biomater 2012;100:726–34.
[208] Melo MA, Weir MD, Rodrigues LK, Xu HH. Novel calcium
phosphate nanocomposite with caries-inhibition in a
human in situ model. Dent Mater 2013;29:231–40.
[209] Melo MA, Cheng L, Weir MD, Hsia RC, Rodrigues LK, Xu HH.
Novel dental adhesive containing antibacterial agents and
calcium phosphate nanoparticles. J Biomed Mater Res B:
Appl Biomater 2013;101:620–9.
[210] Moreau JL, Sun L, Chow LC, Xu HH. Mechanical and acid
neutralizing properties and bacteria inhibition of
amorphous calcium phosphate dental nanocomposite. J
Biomed Mater Res B: Appl Biomater 2011;98:80–8.
[211] Xu HH, Moreau JL, Sun L, Chow LC. Nanocomposite
containing amorphous calcium phosphate nanoparticles
for caries inhibition. Dent Mater 2011;27:762–9.
[212] Condon JR, Ferracane JL. Reduced polymerization stress
through non-bonded nanofiller particles. Biomaterials
2002;23:3807–15.
[213] Ferracane JL, Ferracane LL, Braga RR. Effect of admixed
high-density polyethylene (HDPE) spheres on contraction
stress and properties of experimental composites. J Biomed
Mater Res B: Appl Biomater 2003;66:318–23.
[214] Braga RR, Ferracane JL. Contraction stress related to degree
of conversion and reaction kinetics. J Dent Res
2002;81:114–8.
[215] Weinmann W, Thalacker C, Guggenberger R. Siloranes in
dental composites. Dent Mater 2005;21:68–74.
[216] Hebling J, Pashley DH, Tjaderhane L, Tay FR. Chlorhexidine
arrests subclinical degradation of dentin hybrid layers in
vivo. J Dent Res 2005;84:741–6.
[217] Carrilho MR, Geraldeli S, Tay F, de Goes MF, Carvalho RM,
Tjaderhane L, et al. In vivo preservation of the hybrid layer
by chlorhexidine. J Dent Res 2007;86:529–33.
[218] Carrilho MR, Carvalho RM, de Goes MF, di Hipolito V,
Geraldeli S, Tay FR, et al. Chlorhexidine preserves dentin
bond in vitro. J Dent Res 2007;86:90–4.
[219] Pallan S, Furtado Araujo MV, Cilli R, Prakki A. Mechanical
properties and characteristics of developmental
copolymers incorporating catechin or chlorhexidine. Dent
Mater 2012;28:687–94.
DENTAL-2617; No. of Pages 31
ARTICLE IN PRESS
d e n t a l m a t e r i a l s x x x ( 2 0 1 5 ) xxx.e1–xxx.e31 xxx.e31

[220] Yiu CK, Hiraishi N, Tay FR, King NM. Effect of chlorhexidine
incorporation into dental adhesive resin on durability of
resin–dentin bond. J Adhes Dent 2012;14:
355–62.
[221] Osorio R, Erhardt MC, Pimenta LA, Osorio E, Toledano M.
EDTA treatment improves resin–dentin bonds’ resistance
to degradation. J Dent Res 2005;84:736–40.
[222] Thompson JM, Agee K, Sidow SJ, McNally K, Lindsey K,
Borke J, et al. Inhibition of endogenous dentin matrix
metalloproteinases by ethylenediaminetetraacetic acid. J
Endod 2012;38:62–5.
[223] De Munck J, Van den Steen PE, Mine A, Van Landuyt KL,
Poitevin A, Opdenakker G, et al. Inhibition of enzymatic
degradation of adhesive–dentin interfaces. J Dent Res
2009;88:1101–6.
[224] Liu N, Li F, Chen YJ, Zhang L, Lu S, Kang JJ, et al. The
inhibitory effect of a polymerisable cationic monomer on
functional matrix metalloproteinases. J Dent
2013;41:1101–8.
[225] Tezvergil-Mutluay A, Mutluay MM, Gu LS, Zhang K, Agee
KA, Carvalho RM, et al. The anti-MMP activity of
benzalkonium chloride. J Dent 2011;39:57–64.
[226] Ruttermann S, Trellenkamp T, Bergmann N, Raab WH,
Ritter H, Janda R. A new approach to influence contact
angle and surface free energy of resin-based dental
restorative materials. Acta Biomater 2011;7:1160–5.

Please cite this article in press as: Nedeljkovic I, et al. Is secondary caries with composites a material-based problem? Dent Mater (2015),
http://dx.doi.org/10.1016/j.dental.2015.09.001