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Review Article
ISSN: 2471 657X
Immediate Post-Operative Sensitivity After Composite Resin Restoration – A Review of Treatment Protocol
Monu Survashe*1, Mitesh Parekh2
1BDS (India), MPH (UK), Ziecon Advanced Dental Clinic and Research Centre, Nashik, Maharashtra, India
2MDS, (Oral and Maxillofacial Pathology, Mumbai, India), Ziecon Advanced Dental Clinic and Research Centre, Nashik, Maharashtra, India
Corresponding author: Monu Survashe, BDS (India), MPH (UK), Ziecon Advanced Dental Clinic and Research Centre Nashik, Maharashtra, India. Tel: +919422226067, Email: monusurvashe@yahoo.com
Citation: Monu Survashe et al. (2016), Immediate Post-operative Sensitivity after Composite Resin Restoration – A Review of Treatment Protocol. Int J Dent and Oral Heal.2:2, 14-23. DOI: 10.25141/2471-657X-2016-2.0046
Copyright: ©2016 Monu Survashe et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Received Date: July 20, 2016; Accepted Date: July 25, 2016; Published Date: Aug 25, 2016

Abstract:

Immediate reports of Post-Operative Sensitivity (POS) reported after restoring teeth with direct composite resin restoration is a perplexing issue experienced by most dentists. This review hopes to look at some of the causes of post-operative sensitivity and the plausible solution and / or prevention to this arcane issue. In most studies on POS, the three most commonly cited reasons are: polymerization shrinkage of the resin, microleakage around the margins of the restoration and build-up of residual stress in the fabric of the tooth after placement of direct composite restoration. Knowledge gained by this review points towards soft start mode of polymerization using low light-cure intensities may help to reduce polymerization shrinkage and possibly postoperative sensitivity

Keywords: Post- Operative Sensitivity (POS), Polymerization Shrinkage, Microleakage, Composite Resin Restoration

Introduction:

Immediate reports of Postoperative sensitivity (POS) reported after restoring teeth with direct composite resin restoration [1] is a baffling issue experienced by most dentists. At-least five to twenty six percent patients report POS immediately after composite resin restoration1. In the authors’ observation, sensitivity typically lasts’ for a period of few days to months and finally settling down to normalcy and in very extreme cases there is pulp involvement leading to endodontic therapy. Sensitivity is mostly elicited at the margins of the restorations and sometimes at the center of the restoration inspite of dealing with the occlusal interferences. Composite resin based fillings are technique, instrument and material sensitive restorations as they mechanically and/ or chemically bond to the tooth structure[3]. Composite resins are irritant to the pulp and should be bonded carefully along with additional use of liner, desensitizing agents and resin modified glass ionomers[2,3] where necessary, especially in deep dentinal cavities so as to prevent postoperative sensitivity and subsequently pulp death; as total etch bonding systems may cause detrimental effects on the pulp[3].

Past studies have cited three most common reasons of postoperative sensitivity: polymerization shrinkage of the resin, microleakage around the margins of the restoration, and build-up of residual stress in the fabric of the tooth after placement of direct composite restoration[4,5,6,7,8].

At-least six percent of complaints of sensitivity after direct composite resin restorations on mastication and/ or sensation to cold and hot drinks can be attributed to increased cavity depth [9,10,11]. This study hopes to look at some of the causes of postoperative sensitivity and plausible solutions and / or prevention to this obscure issue in order to enhance patient comfort and function after restoration of teeth with composite resin.

Materials and Methods:

This study is a review of abstracts and /or full text of - clinical studies, systematic reviews, met-analysis and conference papers published on either postoperative sensitivity and/ or microleakage and / or polymerization shrinkage in composite resins. Cross-sectional studies, controlled clinical trials, RCT (Randomized or non- randomized control trial), since 1998 are included in this review. The studies were sourced from PubMed, Research gate, Elsevier Science direct (open access), and Google scholar using the key words- “Post-Operative Sensitivity”, “POS” and/or “Polymerization shrinkage” and/ or “Microleakage” in Composite Resin restoration. Studies done in- vivo (on patients) on any tooth type or any of the Black classification for restoration of teeth; studies which have either and/ or both elements i.e. in-vivo and in-vitro methods of investigation are considered for this review.

The reviewed papers are tabulated as: Table 1- which compares studies on the basis of study design; Black Classification; method; possible causes and plausible solutions to POS.

Table 1: Review of studies on the possible causes and the plausible solutions of POS

Possible causes of post- operative sensitivity:

Polymerization shrinkage and Microleakage:

Post-operative sensitivity in teeth after doing a composite restoration is caused by residual stress buildup due to polymerization shrinkage resulting in de-bonding of the restoration ensuing in an enamel crack; microleakage at the margins of the restoration and secondary caries results in postoperative sensitivity[4]. This study used the amount of cuspal deformation as an indicator of polymerization shrinkage i.e. how many cusps show inward movement due to polymerization shrinkage[4].

C- Factor:

Another clarification on polymerization shrinkage is the theory of C- Factor or configuration factor that is the number of walls of a cavity the composite resin is bonded on to affects shrinkage[12, 49]. For example in a Class I restoration, the C- factor is 5; higher the C – Factor, more are the chances of de-bonding of the composite from the walls of the cavity due to shrinkage[1, 12, 13]. Therefore to counter the issue of C-Factor; step or pulse curing helps to reduce marginal voids, strain on the cusps and thus polymerization shrinkage 49. Incremental layering of composite as compared to horizontal placement especially in Class I restoration reduces C- Factor from 5 to 0.5[2].

Build-up of residual stress in the tooth:

Enamel tolerates greater bond stress and better shrinkage stress as compared to the dentin[14]. As dentin has more moisture than enamel thus bonding is less favourable as compared to the enamel. Furthermore bulk filling the composite resin results in more volumetric shrinkage and encounters more stress as compared to enamel[9]. With a view to measure residual stress this study[5] states that larger the tooth loss more is the polymerization shrinkage weighing down on the tooth itself and less on the restoration or tooth restorative interface. This study highlights an opinion that the issue of polymerization shrinkage is not due to the property of the composite but that of the tooth by itself i.e. its site, geometry, boundaries and the method of the restorative process[5].

Plausible solutions of post- operative sensitivity:

Soft start mode of curing:

A few studies[6,8,9,15,16,17,18,19] have expounded on the theory of “soft start mode” of start-up of polymerization to reduce shrinkage; that means initiate polymerization gradually using low light cure intensities to reach the gel point then increase to a higher intensity to complete polymerization[9] this helps to reduce overall polymerization shrinkage particularly at the margins of the finished restoration[49]. Their[16] view point is that use of LED (light emitting diode) curing light for 10 seconds by “step-curing method or soft curing” produced less postoperative sensitivity to cold. An in-vitro study stated that curing a composite resin restoration for 10 to 20 seconds from a distance of 1cm to 0 cm respectively helps in reduction of polymerization shrinkage without affecting the hardness of the resin[19]. Enamel and dentin are structurally different and need different material and techniques for restoration[6] . A study done in the past has identified that flowable composite or microhybrid resin composite should be cured progressively while restoring dentin; on the other hand, enamel restored with microhybrid resin should be cured with pulse delay curing technique[6]. This method can help to reduce polymerization shrinkage along with oblique and successive build-up of the cusp in multiple increments[1,6,20].

Oblique Layering of composite in incremental fashion to reduce POS:

In Class II cavities there is little or no enamel at the gingival cavosurface and polymerization shrinkage of two to five percent leaves a void at this region for bacterial penetration leading to POS. This can be resolved with a layering or incremental technique ,where each increment, when invidually cured, shrinks less as it involves lesser walls i.e. low C factor; thereby reducing the intercuspal tension in large restorations[49].

Use of Desensitizers, Liners, Glass ionomer and other elucidations to prevent POS:

Use of oxalate desensitizer[21] or 5% Glutaraldehyde [10] and 35% HEMA 10 as a desensitizer agent in deeper cavities helps to reduce post-operative sensitivity. Apply desensitizers twice for a minute each in deep cavities; this helps to decrease POS. The liners used beneath the resin should be about 0.5 to 1 mm in thickness[10]. In deep cavities it will be imperative to use self-etch cum bonding agent and the curing light should deliver at-least 1000 mW per cm[10]. While restoring deep Class II restorations with composite, the first layer should be 0.5mm thick; allow it to adjust to the body temperature before curing. Then gradually add 1mm each from the bottom of the cavity to the occlusal surface and cure[10]. It is advisable not to polish a restoration aggressively and use a good quality articulating paper in order to avoid POS[10].

Some other alternatives are - indirect laboratory processed composite resin restoration have better surface characteristics, less polymerization shrinkage, and decreased soft tissue irritation[22]. Postoperative sensitivity linked to microleakage and can be reduced by pre-conditioning the tooth with air abrasion of the cavity 8 or low level laser treatment of the tooth before restoration on the axial wall of Class V cavities[23].

Discussion:

In the authors’ experience the most common complaint of immediate post-operative sensitivity reported by the patient after a day was “pain on biting” which can be attributed to the fact that during polymerization the composite resin shrinks towards the curing light leaving a void. This void supposedly fills with fluid causing hydrostatic pressure in the dentinal tubules leading to pain on mastication[45]. Therefore sandwich technique[25] i.e. use of conventional glass ionomers or resin modified glass ionomers[24,25] and composite done with incremental layering technique[2] helps to reduce postoperative sensitivity in deep cavities in most cases but not all[26.27,45] and thereby knowledge gained by this review has highlighted some other causes and probable solution to this issue. The causes of POS after a composite filling range from patient characteristics i.e. location of the tooth, anatomy, margins of the prepared cavity, heavy occlusal contacts to operator issues such as the dentists’ skill[18,21,28,30], knowledge and their beliefs and perspective regarding the use of composite as a material of choice for restoration of teeth[31].

The most probable solution emerging from this review was that soft start mode of polymerization or low light-cure intensities i.e. soft start mode of curing which means initial slow polymerization[6,8,11,16,21,30,32] helps to reduce polymerization shrinkage but not microleakage[34,44,46]. Some studies did not find any results with benefits of low light cure intensities or C – factor to be responsible for polymerization shrinkage or POS [17,28,34,35]. This review has observed that plausible solutions to tackle immediate postoperative sensitivity after doing a composite filling are varied and conflicting due to differing methodologies of study design. For example as post- operative sensitivity is a subjective issue many studies conducted are in-vitro studies as opposed to in –vivo[47,48] which only imply the reduction of post-operative (POS) sensitivity[43]. Therefore results of this study have to be used with discretion and longitudinal studies and randomized control trials with quality of life outcomes may help to resolve this unsolved issue.

Conclusion:

A standardized protocol to be followed while doing a composite restoration can help to reduce postoperative sensitivity. This issue can be amended by incorporating Continuing Professional Development [31] on composite resin restoration in order to improve patient comfort and quality of life.

References:

  1. Naito T. Postoperative sensitivity in posterior composite restorations is relevant in class 2nd cavities. J Evid Based Dent Pract 2008; 8:225-6.
  2. Hassan K. Polymerization Shrinkage Stress Reduction in Direct Occlusal Composite Restoration Placed Using Split-increment Horizontal Technique - Case Report. Webmed CENTRAL DENTISTRY 2010; 1(9): WMCOO626.
  3. Christensen GJ. How to kill a tooth. JADA December 2005; Vol. 136: http://jada.ada.org.
  4. Tantbirojn D, Versluis A, Pintado MR, DeLong R, Douglas WH. Tooth deformation patters in molars after composite restorations. Dental materials 2003; 20(6): 535-42.
  5. Opdam NJ, Feilzer AJ, Roeters JJ, Smale I. Class 1 occlusal composite resin restorations: In vivo post-operative sensitivity, wall adaptation, and microleakage. Am J Dent. 1998; 11:229.
  6. Deliperi S, Bardwell DN. An alternative method to reduce polymerization shrinkage in direct posterior composite restorations. J Am Dent Assoc. 2002: Oct; 133(10):1387-98.
  7. Arora A, Acharya SR, Saraswathi M V, Sharma P. A comparative evaluation of dentinal hypersensitivity and microleakage associated with composite restorations in cavities preconditioned with air abrasion - An ex vivo study. Contemp Clin Dent 2012; 3:306-13.
  8. Zhao SL, Li F, Feng CZ. Influence of soft-start irradiation on polymerization shrinkage stress of universal hybrid composite resins. Zhonghua Kou Qiang Yi Xue Za Zhi. 2007. Oct; 42(10):633-6 [Article in Chinese].
  9. Kumar S, Chacko Y, Lakshminarayanan L. Microleakage in posterior resin composite restoration using different filling, curing and polishing techniques. J Conserv Dent. 2005; 8:52.
  10. Christensen GJ. Sensitivity in Class I and II composites is still present. Dental Economics.
  11. Auschill TM, Koch CA, Wolkewitz M, Hellwig E, Arweiler NB. Occurrence and Causing Stimuli of Postoperative Sensitivity in Composite Restorations. Operative Dentistry 01/2009; 34(1):3- 10. DOI: 10.2341/08-7.
  12. Singh SV. Polymerization Shrinkage a New Terminology. Volume 14 No: 1 “Impression” Jan –April 2015:849.
  13. Van Dijken JVW. Durability of resin composite restorations in high C-factor cavities: A 12-year follow-up. Journal of Dentistry 2010; 38(6); 469-474.
  14. Roulet JF: Benefits and disadvantages of tooth colored alternatives to amalgam. Journal of Dentistry, 25: 459 - 473.
  15. Choi JW, Lee SH, Lee NY. Effect of various liners on the polymerization shrinkage of composite resins. Research Gate 01/2006; 33(4).
  16. Alomari Q D, Omar R, Akpata E. Effect of LED Curing Modes on Postoperative Sensitivity After Class II Resin Composite Restorations. J Adhes Dent 2007; 9: Vol 9, No 5.
  17. Van Dijken Jan WV, Pallesen U. A 7-year randomized prospective study of a one-step self-etching adhesive in non-carious cervical lesions. The effect of curing modes and restorative material. Journal of dentistry 2012:40:1060 – 1067.
  18. Lim M-Y, Cho K-M, Hong C-U. Polymerization shrinkage of composite resins cured by variable light intensities. Research gate 01/2007; 32(1). DOI: 10.5395/JKACD.
  19. Subbiya A, Newbegin S G P M, Suresh M, Vivekanandhan P, Dhakshinamoorthy M, Sukumaran VG. Comparison of variation in the light curing cycle with a time gap and its effect on polymerization shrinkage, degree of conversion and microhardness of a nanohybrid composite. Journal of Conservative Dentistry. Mar-Apr 2015; Vol. 18. Issue 2. Pages 154 – 158.
  20. Romero MF, Haddock FJ, Brackett WW, Brackett MG. Class II Restoration Combining a Low-Shrinkage Composite and a Centripetal Technique A protocol for managing polymerization shrinkage and stress. Inside dentistry. October 2015. www.insidedentistry.net
  21. Ivanović V, Savić-Stanković T , Karadzić B , Ilić J, Santini A , Beljić-lvanović K. Srpski arhiv za celokupno lekarstvo. Postoperative sensitivity associated with low shrinkage versus conventional composites. Srpski arhiv za celokupno lekarstvo 09/2013; 141(7- 8):447-53.
  22. Karaarslan ES, Ertas E, Bulucu B. Clinical evaluation of direct composite restorations and inlays: Results at 12 months. J Res Dent 2014; 2:70-7.
  23. Moosavi H, Maleknejad F, Sharifi M F. A randomized clinical trial of the effect of low-level laser therapy before composite placement on postoperative sensitivity in class V restorations. Lasers in Medical Science 05/2014; 30(4). DOI: 10.1007/s10103-014-1565-9.
  24. Naoum SJ, Ellakwa A, Martin E, Mutzelburg PR, Shumack TG , Thode DJG. Conference Paper:Reducing Composite Restoration Polymerization Shrinkage Stress Through Glass Ionomer Adhesives. Australian Dental Journal 2013; 60(4).
  25. Kasraei S, Azarsina M, Majidi S. . In vitro comparison of microleakage of posterior resin composites with and without liner using two-step etch-and-rinse and self-etch dentin adhesive systems. Oper Dent. 2011 Mar-Apr; 36(2):213-21. doi: 10.2341/10-215-L.
  26. Strober B, Veitz-Keenan A, Barna JA, Matthews AG, Vena D, Craig RG, Curro FA, Thompson VP.Effectiveness of a resin-modified glass ionomer liner in reducing hypersensitivity in posterior restorations: A study from the Practitioners Engaged in Applied Research and Learning Network. JADA 2013; 144(8), 886-897.
  27. Banomyong D and Messer H. Two-year clinical study on postoperative pulpal complications arising from the absence of a glass-ionomer lining in deep occlusal resin-composite restorations. Journal of Investigative and Clinical Dentistry 2013; 4, 265–270.
  28. Sancakli HS, Yildiz E, Isil Bayrak I , Sevda Ozel S. Effect of different adhesive strategies on the post-operative sensitivity of class I composite restorations. European journal of dentistry 03/2014; 8(1):15- 22. DOI:10.4103/1305-7456.126234.
  29. Briso ALF, Mestrener SR, Delicio G, Sundfeld RH, Russo AKB, Sversut de Alexandre R, Ambrosano. Clinical Postoperative Sensitivity in Posterior Composite Restorations. Oper Dent 2007; 32(5):421-6.
  30. Suh BI, Controlling and understanding the polymerization shrinkage-induced stresses in light-cured composites. Compendium of Continuing Education in Dentistry. 1999; (25):S34-41.
  31. Iftikhar Akbar. Knowledge and Attitudes of General Dental Practitioners towards Posterior Composite Restorations in Northern Saudi Arabia. Researchgate 02/2015; 9(2):ZC61-4. DOI:10.7860/ JCDR/2015/11843.561.
  32. Ernst CP, Brand N, Frommator U, Rippin G, Willershausen B. Reduction of polymerization shrinkage stress and marginal microleakage using soft-start polymerization. J Esthet Restor Dent.2003; 15(2):93-103.
  33. Ries A, Dourado Loquercio, Schroeder M, Luque – Martinez I, Masterson D, Cople Maia L. Does the adhesive strategy influence the post-operative sensitivity in adult patients with posterior resin composite restorations? A systematic review and meta-analysis. Dent Mater. 2015 Sep; 31(9):1052-67. doi: 10.1016/j.dental.2015.06.001.
  34. Hardan LS, Amm EW, Ghayad A. Effect of different modes of light curing and resin composites on microleakage of Class II restorations. See comment in PubMed Commons belowOdontostomatol Trop.2008 Dec; 31(124):27-34.
  35. Yazici AR, Celik C, Dayangac B, and Ozgunaltay G. Effects of Different Light Curing Units/Modes on the Microleakage of Flowable Composite Resins. Eur J Dent. 2008 Oct; 2: 240–246.
  36. Davidović L, Radović I, Krunić J. Prevention of Postoperative Sensitivity in Composite Restorations. Serbian Dental J 2014; 61(2):84-92; DOI: 10.2298/SGS1402084D.
  37. Tay FR, Pashley DH, Mak YF, Carvalho RM, Lai SCN, and Suh BI. Integrating Oxalate Desensitizers with Total-etch Twostep Adhesive. J Dent Res 2003; 82(9):703-707.
  38. Yiu CKY, King NM, Suh BI, Sharp LJ, Carvalho RM, Pashley DH, and Tay FR. Incompatibility of Oxalate Desensitizers with Acidic, Fluoride-containing Total-etch Adhesives. J Dent Res 2005; 84(8).
  39. Van Dijken Jan WV, Pallesen U. A 7-year randomized prospective study of a one-step self-etching adhesive in non-carious cervical lesions. The effect of curing modes and restorative material. Journal of dentistry 2012:40:1060 – 1067.
  40. Al-Nahlawi T, Altaki Z, Abbood D. Post-operative sensitivity of Class I, II amalgam and composite resin restorations: Clinical evaluation in an undergraduate program. International Dental & Medical Journal of Advanced Research. 2015; 1: 1–4.
  41. Unemori M, Matsuya Y, Akashi A, Goto Y, Akamine A. Composite resin restoration and postoperative sensitivity: clinical follow-up in an undergraduate program. Journal of Dentistry. 2001; 29; 7-13.
  42. Lygidakis NA, Chaliasou A, Siounas G. Evaluation of composite restorations in hypomineralised permanent molars: a four year clinical study. European Journal of Paediatric Dentistry. 2003; 3; 143-148.
  43. Umer F and Khan FR. Postoperative sensitivity in Class V composite restorations: Comparing soft start vs. constant curing modes of LED. J Conserv Dent. 2011 Jan-Mar; 14(1): 76–79.Doi: 10.4103/0972-0707.80738.
  44. Alomari QD, Barrieshi-Nusair K and Ali M. Effect of C-factor and LED Curing Mode on Microleakage of Class V Resin Composite Restorations. Eur J Dent. 2011 Oct; 5(4): 400–408.
  45. Azevedo LM, Casas-Apayco LC, Villavicencio Espinosa CA , Wang L, Navarro MF, and Atta MT. Effect of resin-modified glassionomer cement lining and composite layering technique on the adhesive interface of lateral wall. J Appl Oral Sci. 2015 May-Jun; 23(3): 315–320. Doi: 10.1590/1678-775720140463.
  46. Yazici AR, Celik C, Dayangac B and Ozgunaltay G. Effects of Different Light Curing Units/Modes on the Microleakage of Flowable Composite Resins. Eur J Dent. 2008 Oct; 2: 240–246.
  47. Heintze S. Systematic reviews: I. The correlation between laboratory tests on marginal quality and bond strength. 2nd. The correlation between marginal quality and clinical outcome. J Adhes Dent 2007; 9:77.
  48. 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.
  49. Tooth- Coloured Restoratives. Principles and Techniques. Ninth edition. Albers HF. BC Deckers Inc. 2002.Hamilton, London.
  50. Khoroushi M, Karvandi TM, Kamali B, Mazaheri H. Marginal microleakage of resin-modified glass-ionomer and composite resin restorations: effect of using etch-and-rinse and self-etch adhesives. Indian J Dent Res. 2012 May-Jun; 23(3):378-83. doi: 10.4103/0970- 9290.102234.
  51. Glazer HS. Limiting Postoperative Sensitivity in Composite Restorations - PART II. Dental Newsletter 2010.
  52. Kramer N, Lohbauer U, Gracia Godoy F, Frankenberger R. Light curing of resin-based composites in the LED era. Am J Dent. 2008 Jun; 21(3):135-42.
  53. Hayashi M, Wilson NH. Failure risk of posterior composites with post-operative sensitivity. Oper Dent 2003, 28(6):681-688.
  54. Alomari QD, Barrieshi –Nusair Kefah, Ali M. Effect of C-factor and LED Curing Mode on Microleakage of Class V Resin Composite Restorations. Eur J Dent. 2011 Oct; 5(4): 400–408.
  55. Chandurkar AM, Metgud SS, Yakub SS, Kalburge VJ, Biradar BC. Comparative Evaluation of the Effects of Light Intensities and Curing Cycles of QTH, and LED Lights on Microleakage of Class V Composite Restorations. J Clin Diagn Res. 2014 Mar; 8(3):221-4. doi: 10.7860/JCDR/2014/7463.4167.
  56. Pallesen U, Van Dijken JW. A randomized controlled 27 years follow up of three resin composites in Class II restorations. J Dent. 2015 Dec; 43(12):1547-58. doi: 10.1016/j. jdent.2015.09.003.

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