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121]

Original Article

A novel method to reduce postoperative sensitivity

after composite restoration: A triple‑blinded in‑vivo
study
Chitra Janardhanan Vejai Vekaash, Kondas Vijay Venkatesh, Tripuravaram Vinay Kumar Reddy,
Karthika Devaraj
Department of Conservative Dentistry and Endodontics, SRM Kattankulathur Dental College and Hospital,
Tamil Nadu, India

ABSTRACT
Objective: To evaluate the efficacy of Zinc-carbonated hydroxyapatite  in the reduction of postoperative sensitivity during composite
placement.
Context: Postoperative sensitivity after composite restoration still remains a major clinical challenge.
Materials and Methods: Sixty class I cavities were prepared in 60 patients by the same operator with the following inclusion and
exclusion criteria: The patients selected for the study were between 20–45 years with vital pulp and having remaining dentin thickness
of 1mm. Previously restored, nonvital and tooth with periodical changes were excluded. Patients were randomly divided into two
groups of 30 each—Group I self‑etch and Group II selective‑etch with Subgroup A‑ zinc‑carbonated hydroxyapatite applied and
Subgroup B‑ zinc‑carbonated hydroxyapatite not applied. After the surface treatment, the teeth were restored with composite resin.
The patients were evaluated with visual analogue scale (VAS) at the end of one week and one month.
Statistical Analysis: Data were analyzed using Kruskal–Wallis one‑way analysis.
Results: Comparing within groups, Group I self‑etch mean values showed statistically significant lower values compared with Group II
selective‑etch (P < 0.01). Zinc‑carbonated hydroxyapatite Subgroup A showed statistically significant lower values compared with
Subgroup B where zinc‑carbonated hydroxyapatite was not applied (P < 0.01).
Conclusion: Application of zinc‑carbonated hydroxyapatite showed significant reduction in postoperative sensitivity after composite
placement.

Key words: Composite, postoperative sensitivity, selective etch, self‑etch, zinc‑carbonated hydroxyapatite

INTRODUCTION technical perspective and material science. Despite the

significant improvement in the material science and
Today’s dental practice revolves around the concept of adhesive techniques, this restoration may still present
minimal intervention and composite resin restoration a few clinical complications, such as microleakage
has made this possible.[1] Composite has gained a lot and postoperative sensitivity.[2]
of importance by means of greater changes in the
Many techniques have been introduced to overcome
Address for correspondence: most of these drawbacks and have been managed,
Dr. Chitra J. V. Vekaash, Department of Conservative Dentistry
and Endodontics, SRM Kattankulathur Dental College and This is an open access article distributed under the terms of the
Hospital, Tamil Nadu, India. Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0
E‑mail: vejaideepu@gmail.com
License, which allows others to remix, tweak, and build upon the
work non‑commercially, as long as the author is credited and the
Access this article online
new creations are licensed under the identical terms.
Quick Response Code:
Website:
For reprints contact: reprints@medknow.com
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How to cite this article: Vejai Vekaash CJ, Venkatesh KV,
DOI: Kumar Reddy TV, Devaraj K. A novel method to reduce postoperative
sensitivity after composite restoration: A triple-blinded in-vivo study. J
10.4103/JDRNTRUHS.JDRNTRUHS_37_17
NTR Univ Health Sci 2018;7:19-22.

© 2018 Journal of Dr. NTR University of Health Sciences | Published by Wolters Kluwer - Medknow 19
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Vekaash, et al.: Combating post-op sensitivity
except post‑op sensitivity, which still remains the biggest
challenge. Due to technique‑sensitive procedures, class I
and class II composite restoration showed more failure
rate than other restorations.[3] Previous clinical studies
have reported that 30% of patients present with post‑op
sensitivity after composite restoration.[4-7]
Enamel remineralization has gained a lot of popularity
in our practice since 1990s after the use of CCP-
ACP (Casein phosphopeptide-amorphous calcium
phosphate).[8-10] With the advent of nanotechnology,
this is the era of dentin remineralization. One
such dentin remineralizing agent is zinc‑carbonated
hydroxyapatite.[11-13] We developed a novel method to
remineralize the cavities before any surface treatment for
composite placement.
The aim of the study is to evaluate the role of dentin
remineralization in the reduction of post‑op sensitivity
in composite placement.
MATERIALS AND METHODS
The ethical approval was obtained to perform
this study from SRM Medical Ethical Committee.
Class I cavities from 60 patients were taken for the
study with the following inclusion and exclusion
criteria: The patients selected for the study were
between 20–45 years with vital pulp and having
remaining dentin thickness of 1mm. Previously
restored, nonvital and tooth with periodical changes
were excluded.The remineralizing agent selected
for the study was zinc‑carbonated hydroxyapatite
(Stomysens, Biorepair). The sample was randomly
divided into two groups based on self‑etch application
and selective‑etch application, which was further
divided into two subgroups on the basis of application
of zinc‑carbonated hydroxyapatite.
Group I = self‑etch (n = 30)
Group II = selective‑etch (n = 30)
Subgroup A = zinc‑carbonated hydroxyapatite
applied (n = 15)
Subgroup B = zinc‑ carbonated hydroxyapatite not
applied (n = 15)
Personnel blinded in the study were operator,
evaluator, and patients.
20 Journal of Dr. NTR University of Health Sciences | Volume 7 | Issue 1 | January-March 2018
Remaining dentin thickness was assessed using
direct digital radiography, and also it was made sure
that there was no pulp involvement or periapical
pathology.
Surface treatment protocols
Group I Subgroup A: After cavity
preparation, the pulpal floor was coated
with EDTA (Ethylenediaminetetraac etic
acid) solution (Septodont), and after 2 min, the
solution was washed away. This procedure helped
in removing the smear layer formed during the
cavity preparation and in enhancing the subsequent
remineralizing procedure. Later, the remineralizing
agent, zinc‑carbonated hydroxyapatite, was applied
to the pulpal floor with an applicator tip. After
5 min, the cavity was gently air‑dried using chip
blower to remove the excess agent. The entire cavity
was then coated with self‑etch (Tetric N self‑etch,
Ivoclar Vivadent) and scrubbed for 10 s and then
excess was removed and light cured. The cavity was
restored with bulk fill composite  (Tetric N bulk fill,
Ivoclar Vivadent).
Group I Subgroup B: After cavity preparation,
the entire cavity was then coated with self‑etch
(Tetric N self‑etch, Ivoclar Vivadent) and scrubbed
for 10 s and then excess was removed and light
cured. The cavity was restored with bulk fill
composite  (Tetric N bulk fill, Ivoclar Vivadent).
Group II Subgroup A: After cavity preparation,
the pulpal floor was coated with EDTA
solution (Septodont), and after 2 min, the solution
was washed away. This procedure helped in removing
the smear layer formed during the cavity preparation
and in enhancing the subsequent remineralizing
procedure. Later, the remineralizing agent,
zinc‑carbonated hydroxyapatite was applied to the
pulpal floor with an applicator tip. After 5  min, the
cavity was gently air‑dried using chip blower to
remove the excess agent. In this group, selective‑etch
technique was followed. Then 37% phosphoric
acid (Total‑etch, Ivoclar Vivadent) was applied on
to the cavosurface enamel first and after 10 s, the
etchant was applied to the remaining cavity. Within
2 s, the cavity was washed thoroughly for 1 min
with water. The entire cavity was gently air‑dried to
remove the surface moisture. Two coats of bonding
agent (Tetric N bond, Ivoclar Vivadent) were then
applied to the cavity. After 15 s, the excess was
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Vekaash, et al.: Combating post-op sensitivity
removed and light cured. The cavity was restored
with bulk fill composite  (Tetric N bulk fill, Ivoclar
Vivadent).
Group II Subgroup B: After cavity preparation,
37% phosphoric acid (Total‑etch, Ivoclar Vivadent)
was applied on to the cavosurface enamel first and
after 10 s, the etchant was applied to the remaining
cavity. Within 2 s, the cavity was washed thoroughly
for 1 min with water. The entire cavity was gently
air‑dried to remove the surface moisture. Two coats
of bonding agent (Tetric N bond, Ivoclar Vivadent)
were then applied to the cavity. After 15s, the excess
was removed and light cured. The cavity was restored
with bulk fill composite  (Tetric N bulk fill, Ivoclar
Vivadent).
To maintain standardization of procedures mentioned,
the entire process starting from cavity preparation to
restoration was performed by a single operator.
Then, the patients were analyzed using visual analogue
scale (VAS). VAS had a score of 0 to 10, 0 and 1 ‑ no
sensitivity; 2 and 3 ‑ mild, annoying sensitivity; 4
and 5 ‑ nagging, uncomfortable and troublesome
sensitivity; 6 and 7 ‑ distressing and miserable
sensitivity; 8 and 9 ‑ intense, dreadful and horrible
sensitivity; 10 ‑ worst possible, unbearable sensitivity.
The patients were recalled at one week and one
month for evaluation and VAS score was taken. Data
were analysed using Kruskal–Wallis one‑way analysis.
RESULTS
The results of this in vivo study are given in
Table 1. In all the groups evaluated, the mean
value obtained with the use of zinc‑carbonated
hydroxyapatite Subgroup A showed statistically
significant lower values compared to Subgroup B
where zinc‑carbonated hydroxyapatite was not
applied (P < 0.01). Comparing within groups,
Group I self‑etch mean values showed statistically
significant lower values compared to Group II
TABLE 1: 1 WEEK AND 1 MONTH POST-OP RESULTS
OBTAINED
Duration Group 1 Group 2
A B A B
1 week 0.31±0.2 1.82±0.5 0.53±0.7 1.97±0.7
1 month 0.22±0.4 1.64±0.8 0.49±0.4 1.74±0.7
Journal of Dr. NTR University of Health Sciences | Volume 7 | Issue 1 | January-March 2018
selective‑etch (P < 0.01). The mean value of one
month Group  IA showed statistically significant lower
values compared to one week Group IA (P < 0.01).
DISCUSSION
The advent of newer techniques and concepts
in adhesive dentistry has increased the number
of composite restorations done. The associated
complications of composite restorations are yet to be
solved, such as marginal discoloration and post‑op
sensitivity, which directly attributes to polymerization
shrinkage and related stress at the bonded interface.[2]
Etching dentin and formation of hybrid layer
introduced by Nakabyashi in 1992 were promising
theoretically, but the related complications of etching
created quite a few complications practically, one
of which being the post‑op sensitivity. Hence, the
self‑etch concept came into practice but still never
gave a complete solution.
Another issue with bonded interface during
polymerization is excessive stress that leads to
dentin crack formation on the pulpal floor and
sensitivity while chewing. Despite modifications of
surface treating the tooth, incremental placement of
composite and changes in polymerization techniques,
the problem of post‑op sensitivity still remains.[7]
Dentin remineralization happens when zinc‑carbonated
hydroxyapatite reacts with inorganic component of
dentin and forms hydroxyapatite crystals covering
dentinal tubules, making the patient less susceptible
to post‑op sensitivity. So, after etching either with self
or selective method, less damage to dentin happens.
Studies show that remineralization happens within
2 min on application and progresses gradually.[13‑15]
Therefore, we thought about a novel idea of
remineralizing the dentin before surface treating it for
adhesive protocols. Age group of 25–45 was selected;
thus dentin is not too young or old and has a good
remineralizing potential. EDTA was used to disturb
the smear layer and make the surface active for dentin
remineralization.[16,17]
In this study, it was found that there was significant
reduction in post‑op sensitivity in the patients where
dentin remineralizing agent was applied before adhesive
protocols. The remineralized pulpal floor would
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Vekaash, et al.: Combating post-op sensitivity
definitely be resistant to the surface treatment employed
(self‑etch, selective‑etch) for adhesive restorations. Hence,
the hybridization of remineralized area will not be as
effective as the non‑remineralized area. But clinically
what is more important is the cavosurface seal. This has
been perfectly obtained in this study. Further studies in
this regard would give a perfect insight about the issues
of hybridization in the remineralized areas.
The reason for the reduction of post‑op sensitivity is
probably due to the effect of dentin remineralization,
as explained above.
CONCLUSION
Under the limitations of the study, it was found that
there was significant reduction in post‑op sensitivity
in patients who underwent surface treatment before
adhesive protocols. Further, long‑term studies and
evaluation of bond strength will make this procedure
possible in class II restoration.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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