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Showing posts with label Scientific articles. Show all posts
Showing posts with label Scientific articles. Show all posts

Thursday, 28 July 2011

Clinical reproducibility of three electronic apex locators

Though it is not quite a dental materials subject, I have been involved in clinical testing of electronic apex locators with my colleagues at the University of Belgrade School of Dentistry. This paper has been published in the August issue of the International Endodontic Journal and can be found here. If you have trouble getting access, please email me.
Miletic V, Beljic-Ivanovic K, Ivanovic V. Clinical reproducibility of three electronic apex locators. International Endodontic Journal, 44, 769–776, 2011.


Aim  To compare the reproducibility of three electronic apex locators (EALs), Dentaport ZX, RomiApex A-15 and Raypex 5, under clinical conditions.
Methodology  Forty-eight root canals of incisors, canines and premolars with or without radiographically confirmed periapical lesions required root canal treatment in 42 patients. In each root canal, all three EALs were used to determine the working length (WL) that was defined as the zero reading and indicated by ‘Apex’, ‘0.0’ or ‘red square’ markings on the EAL display. A new K-file of the same size was used for each measurement. The file length was fixed with a rubber stop and measured to an accuracy of 0.01 mm. Measurements were undertaken by two calibrated operators. Differences in zero readings between the three EALs in the same root canal were statistically analysed using paired t-tests with the Bonferroni correction, Bland–Altman plot and Linn’s concordance correlation coefficients at α = 0.05.
Results  Mean and standard deviation values measured by the three EALs showed no statistically significant differences. Identical readings by all three EALs were found in 10.4% of root canals. Forty-three per cent of readings differed by less than ±0.5 mm and 31.3% exceeded a difference of ±1 mm.
Conclusions  The clinical reproducibility of Dentaport ZX, RomiApex A-15 and Raypex 5 was confirmed with the majority of readings within the ±1.0 mm range. However, the small number of identical zero readings suggests that EALs are not reliable as the sole means of WL determination under clinical conditions.

Tuesday, 15 February 2011

Water sorption and solubility of resin-based composites

Interaction of resin-based composites with water is a continuous process from the early stages of composite placement. Water plays an important role in the long-term stability of composite fillings and may induce hygroscopic expansion of the material, hydrolytic degradation of intra- and intermolecular bonds within the resin matrix and at the resin-filler interface, plasticization of polymer chains, elution of leachable substances and reduction in mechanical properties.

The importance of composite-water interaction has been acknowledged in the ISO standard 4049 which states the maximum values for water sorption and concurrent solubility for resin-based materials (composites and cements). In order to comply with this ISO standard, resin-based materials must have  water sorption and solubility values equal or lower than 40 micrograms per cubic milimetre (sorption) and 7.5 micrograms per cubic milimetre (solubility) for specimens 15 mm in diameter and 2 mm thick.

Water sorption and solubility values are based on mass changes of the samples before (m1) and after immersion (m2) in water and after dessication (m3) until constant mass is achieved.  Mass changes m2-m3 are divided by sample volume to calculate water sorption and m1-m3 divided by sample volume give solubility values. 

Recent papers* published in Dental Materials investigated water sorption and solubility and hygroscopic dimensional changes of several resin-based composites:

low-shrinkage Filtek Silorane
universal Gradia Kalore
micro-hybrid Gradia Direct Anterior and Posterior and
self-adhering flowable Vertise Flow.

After 150 days of storage in de-ionized water, the lowest sorption of about 13 μg/mm³ was found for Filtek Silorane and the greatest of about 72 μg/mm³ was found for Vertise Flow. Vertise Flow also showed the greatest solubility of about 16 μg/mm³ whereas other materials showed either negative values (Filtek Silorane and Gradia Kalore) or values below 4 μg/mm³. The authors suggested that the negative solubility values for Filtek Silorane and Gradia Kalore meant that the dessication was not sufficient or that some water was irreversibly bound to the resin matrix.

Hygroscopic dimensional expansion as the result of water sorption over the 150-day period was lowest for Filtek Silorane (about 0.7%) and highest for Vertise Flow (about 4.8%) whereas the values for Gradia composites were between 1.5 and 2%. Hygroscopic expansion may compensate to a certain extent polymerization shrinkage which was found to be 0.99% for  Filtek Silorane, 1.7-2.4% for Gradia composites and  4.4% for Vertise Flow. However, this expansion occurs over a much slower time scale than shrinkage and its effect on the clinical performance of resin-based composite is yet to be determined.

The greatest stability in the aqueous environment found for Filtek Silorane may be explained by the hydrophobic siloxane and low-shrinkage ring-opening oxirane units of the silorane monomer. Furthermore, cationic polymerization is relatively oxigen-insensitive with the potential of reaching higher degree of conversion than methacrylate-based composites.

On the other hand, aqueous instability of Vertise Flow was attributed to the hydrophilic monomer, GPDM, which is responsible for the self-adhesive property of Vertise Flow but also seems to attract more water uptake by the resin matrix compared to other resin-based composites.

* Wei YJ, Silikas N, Zhang ZT, Watts DC. Hygroscopic dimensional changes of self-adhering and new resin-matrix composites during water sorption/desorption cycles. Dent Mater. 2011 Mar;27(3):259-66.

[Reprints of the cited papers may be obtained from the corresponding authors]

Click here for more on Vertise Flow.

Wednesday, 2 February 2011

Monomer elution from nanohybrid and ormocer-based composites

Recently, a paper on monomer elution from resin-based composites by my research team has been accepted for publication in the leading peer-reviewed journal on dental materials. The paper is available online under "Articles in press" and awaits publication in the paper format of Dental Materials. For reprints, you may contact me at 


Dent Mater. 2010 Dec 17. [Epub ahead of print]

Monomer elution from nanohybrid and ormocer-based composites cured with different light sources

Manojlovic D, Radisic M, Vasiljevic T, Zivkovic S, Lausevic M, Miletic V.

University of Belgrade, School of Dentistry, Department of Restorative Dentistry
and Endodontics, Rankeova 4, 11000 Belgrade, Serbia.

OBJECTIVES: To study monomer elution from four resin-based composites (RBCs)cured with different light sources.  
METHODS: Twenty-eight premolars were randomlyallocated to four groups. Standardized cavities were prepared and restored with ananohybrid (Filtek Supreme XT or Tetric EvoCeram), an ormocer (Admira) or a microhybrid RBC (Filtek Z250) which served as control. Buccal restorations were cured with a halogen and oral restorations with an LED light-curing unit. Elution of diurethane dimethacrylate (UDMA), Bisphenol A diglycidylether methacrylate (BisGMA), triethylene glycol dimethacrylate (TEGDMA) and 2-hydroxyethyl methacrylate (HEMA) was analyzed using high-performance liquid chromatography (HPLC) 1h to 28 days post-immersion in 75% ethanol. Data were analyzed using multivariate and repeated measures analysis of variance (α=0.05).  
RESULTS: The greatest elution of UDMA and BisGMA occurred from Tetric EvoCeram and the least from Filtek Z250 (p<0.05). LED and halogen light-curing units gave similar results for all RBCs (p>0.05) except Tetric EvoCeram which showed greater elution for the LED unit (p<0.05). TEGDMA was below the limit of quantification. HEMA eluted in similar concentrations from Filtek Supreme and Tetric EvoCeram (p>0.05).  
SIGNIFICANCE: The two nanohybrid RBCs eluted more cross-linking monomers than the ormocer and the control microhybrid RBC. Continuous elution over 28 days indicates that RBCs act as a chronic source of monomers in clinical  conditions. Light source may affect monomer elution since differences were found  for one out of four RBCs. Mathematical models for elution kinetics of UDMA and BisGMA indicated two elution mechanisms.

Sunday, 26 December 2010

Clinical evaluation of dental restorative materials - Part III: FDI criteria

In 2007, recommendations for conducting clinical trials approved by the FDI were published in several peer-reviewed journals. These recommendations not only addressed designing protocols for clinical trials but also challenged the Ryge criteria with an in-depth discussion of  clinical evaluation criteria and suggested a new approach in clinical evaluation of dental restorative materials and operative techniques.

In August 2010, an update of the "FDI clinical criteria for the evaluation of direct and indirect restorations" was published  by Hickel et al. in the Journal of Adhesive Dentistry and Clinical Oral Investigations. A lot of clinical examples were presented in the paper to illustrate various ratings.

The new FDI criteria set a different background for the evaluation of dental restorations by introducing 3 groups of criteria: esthetic, functional and biological. Each of these groups has subgroups with 16 evaluation criteria in total. These are:

Esthetic criteria
  1. Surface luster
  2. Staining: (a) surface and (b) margin
  3. Color match and translucency
  4. Esthetic anatomical form
Functional criteria
  1. Fracture of material and retention
  2. Marginal adaptation
  3. Occlusal contour and wear 
  4. Approximal anatomical form: (a) contact point and (b) contour
  5. Radiographic examination, where applicable
  6. Patient's view
Biological criteria
  1. Postoperative sensitivity and tooth vitality
  2. Recurrence of caries, erosion, abfraction
  3. Tooth integrity
  4. Periodontal response
  5. Adjacent mucosa
  6. Oral and general health
For all three groups, the following gradings are used for evaluation:
  1. Clinically excellent/very good
  2. Clinically good
  3. Clinically sufficient/satisfactory
  4. Clinically unsatisfactory
  5. Clinically poor
When judging a dental restoration using the FDI criteria, the score for each group is dictated by the most severe grading among the criteria for that particular group. Similarly, the overall score is determined by the worst grading among the groups. For example, if the functional criteria are unacceptable, the overall score is unacceptable. Detailed description of each grading is given in the previously mentioned paper: "FDI World Dental Federation - Clinical Criteria for the evaluation of direct and indirect restorations".

It is not mandatory to apply all of the FDI criteria in each study. In each particular study, the examiners should determine which criteria match their intended purposes best.

Gradings for the FDI criteria are substantially more detailed and sensitive than the Cvar and Ryge criteria and their modifications suggested by other authors. These detailed gradings challenge the training and calibration procedure of the examiners. To allow an easier and more efficient training, reduced variability in judgment and greater coherence in multi-centric studies, an online calibration system was established at It is emphasized by the authors of the FDI criteria that the e-calibration system does not replace the clinical setting but shortens clinical training significantly.

Beside their use in clinical trials, the FDI criteria are recommended for quality assessment of restorations by general dental practitioners in their everyday practice and as guidelines whether or not a restoration needs refurbishment, repair or replacement. Refurbishment is a minimal intervention such as polishing or contouring when no additional material is placed. Repair is a minimal intervention which requires additional material to be placed with or without a minimal preparation in the restoration or dental tissues.

Clinical investigators are strongly advised to use the new FDI criteria when designing and conducting clinical trials. However, the criteria are "not indefinitely fixed and defined" so investigators are asked for feedback and encouraged to contribute to the e-calib database with high quality images of clinical cases.


Hickel R, Peschke A, Tyas M, Mjör I, Bayne S, Peters M, Hiller KA, Randall R, Vanherle G, Heintze SD. FDI World Dental Federation - clinical criteria for the evaluation of direct and indirect restorations. Update and clinical examples. J Adhes Dent. 2010 Aug;12(4):259-72. doi: 10.3290/j.jad.a19262.

Hickel R, Roulet JF, Bayne S, Heintze SD, Mjör IA, Peters M, Rousson V, Randall R, Schmalz G, Tyas M, Vanherle G. Recommendations for conducting controlled clinical studies of dental restorative materials. Science Committee Project 2/98--FDI World Dental Federation study design (Part I) and criteria for evaluation (Part II) of direct and indirect restorations including onlays and partial crowns. J Adhes Dent. 2007;9 Suppl 1:121-47.

Sunday, 19 December 2010

Clinical evaluation of dental restorative materials - Part II: Modified Ryge criteria

Cvar and Ryge criteria[1] for clinical evaluation of dental restorative materials were first published in 1971 and re-evaluated in 1980 by Ryge.[2] Another post explains the original Cvar and Ryge criteria in greater detail. Also, read about the new FDI criteria in a separate post.

Modified criteria, often called modified Ryge criteria are mostly used in contemporary clinical evaluations of dental restorative materials. Modifications usually depend on the aim of the study i.e. the type(s) of restorations that are being compared. Here are some studies reporting on clinical performance of restorative materials based on modified Ryge criteria.

Gallo et al.[3] conducted a three-year clinical evaluation of two flowable composites, Tetric Flow (Ivoclar Vivadent) and Esthet-X Flow (Dentsply/Caulk) which were used to restore Class I caries lesions. The authors used the original Cvar and Ryge criteria with two additional criteria: (1) retention and (2) polishability. Table 1 presents the codes and descriptions for each criterion. It should be noted that polishability is rated using more than the original 4 codes, introducing subtle differences in rating. This may, however, affect the variability of diagnostic judgement and intra- or inter-examiner reliability as it becomes more difficult to differentiate between e.g. Bravo B-a and B-b or C and D. Also, the term “unacceptable polish” comes as a rather unexpected vague description in contrast to detailed codes A-D and it is unclear what unacceptable means. For some dentists, “Rough and dull or satin, not reflective” may be completely “Unacceptable polish”. An obvious principle adopted by Cvar and Ryge in their original criteria should also be applied when modifying these criteria by introducing new ones – keep it simple.

Table 1. Codes and descriptions of two additional criteria, as used in Gallo et al.
(Click on the table)

Poon et al.[4] conducted a 3.5-year clinical evaluation of a packable (SureFil, Dentsply DeTrey) and a conventional (SpectrumTPH, Dentsply DeTrey) composite used with a self-etch adhesive system. Not only did the authors add more criteria, they also modified the descriptions of the original Cvar and Ryge criteria. Additional criteria were: (1) Retention, (2) Surface texture, (3) Surface staining, (4) Postoperative sensitivity and (5) Gingival bleeding in Class II restorations. All criteria in this study, with the exception of Postoperative sensitivity and Gingival bleeding, were rated as Alfa (A) or Bravo (B), where A was defined as “restorations meet all clinical standards with a range of excellence” and B was “though not ideal, restorations have a range of acceptability”. The rating for Postoperative sensitivity and Gingival Bleeding were “absent” or “present”.

Swift et al.[5] compared the 3-year clinical performance of two-step total-etch adhesives (OptiBond Solo, SDS Kerr and Prime & Bond 2.1, Dentsply Caulk). Their additional criteria were: (1) Retention, codes as in Table 1, (2) Postoperative sensitivity and (3) Other failure. The latter two were rated as “none” or “present”.

Moncada et al.[6] conducted a 3-year clinical trial to compare various treatment options for Class I and II restorations (sealed margins, repair, refurbishment, replacement or no treatment). Unlike previous cited papers, Moncada et al. did not use all of the original Cvar and Ryge criteria but selected only the following: (1) Marginal adaptation, (2) Anatomic form and (3) Caries. Also, they added two new criteria: (1) Surface roughness and (2) Luster, described in Table 2.

Table 2. Codes and descriptions of two additional criteria, as used in Moncada et al.
(Click on the table)

Kihn and Barnes[7] investigated clinical longevity of porcelain veneers after 4 years. They substituted Anatomic form from the original Cvar and Ryge criteria with Postoperative sensitivity which was rates “absent” or “present”.

Hamilton et al.[8] used modified Ryge criteria to evaluate pit and fissure restorations after 1 year of clinical service. Instead of the original Caries criterion, the authors added Surface smoothness which was rated as follows:

A - As smooth as natural adjacent tooth structure
B - Not as smooth as natural tooth structure but not pitted
C - Not as smooth as natural tooth structure and pitted

Hamilton et al.[8] also modified Margin discoloration and Margin adaptation to include subrating as described in Table 3. Quantification of discoloration along the margin was used and restorations rated as B1 for less than 50% of exposed margin or B2 for greater than 50% of exposed margin. A subtle one-way catch with an explorer during the assessment of margin adaptation was tolerated and rated as A2 instead of B. Also, code D for margin adaptation (Restoration mobile, fractured or missing in part of the tooth) was not taken into account, most likely because none was found.

Table 3. Modifications of the original Cvar and Ryge criteria by Hamilton et al.
(Click on the table)


Based on this short literature review, it is apparent that in contemporary clinical evaluation of restorative materials and treatment modalities, the original Cvar and Ryge criteria are modified in some way based on study objectives. These modifications include:

(1) Additional criteria are introduced: Retention, Polishability, Postoperative sensitivity, Surface roughness, Surface staining, Luster, Gingival bleeding; 

(2) Not all of the original Cvar and Ryge criteria are used; 

(3) Subrating are introduced to increase the precision of clinical judgment or the quality of the original criteria is reduced either through poorer description of rating or by excluding rating.

Despite the limitations, Cvar and Ryge rating scales, with or without modifications, remain the most frequently used method of clinical evaluation of dental restorative materials and operative techniques.

1. Cvar and Ryge criteria for the clinical evaluation of dental restorative materials. First published in U.S. Department of Health, Education, and Welfare, U.S. Public Health Service 790244, San Francisco Printing Office 1971:1–42. Reprinted in Clinical Oral Investigations 2005;9:215–232.
2. Ryge G. Clinical criteria. Int Dent J 1980;30:347-58
3. Gallo JR, Burgess JO, Ripps AH, Walker RS, Maltezos MB, Mercante DE, Davidson JM. Three-year clinical evaluation of two flowable composites. Quintessence Int. 2010 Jun;41(6):497-503.
4. Poon EC, Smales RJ, Yip KH. Clinical evaluation of packable and conventional hybrid posterior resin-based composites: results at 3.5 years. J Am Dent Assoc. 2005 Nov;136(11):1533-40.
5. Swift EJ Jr, Perdigão J, Wilder AD Jr, Heymann HO, Sturdevant JR, Bayne SC. Clinical evaluation of two one-bottle dentin adhesives at three years. J Am Dent Assoc. 2001 Aug;132(8):1117-23.
6. Moncada G, Martin J, Fernández E, Hempel MC, Mjör IA, Gordan VV. Sealing, refurbishment and repair of Class I and Class II defective restorations: a three-year clinical trial. J Am Dent Assoc. 2009 Apr;140(4):425-32.
7. Kihn PW, Barnes DM. The clinical longevity of porcelain veneers: a 48-month clinical evaluation. J Am Dent Assoc. 1998 Jun;129(6):747-52.
8. Hamilton JC, Dennison JB, Stoffers KW, Welch KB. A clinical evaluation of air-abrasion treatment of questionable carious lesions. A 12-month report. J Am Dent Assoc. 2001 Jun;132(6):762-9.

Monday, 13 December 2010

Clinical evaluation of dental restorative materials - Part I: Cvar and Ryge criteria

Nearly 40 years ago John F. Cvar and Gunnar Ryge wrote that, although mechanical properties of the available dental restorative materials were well known, clinical scientific data were scarce. The lack of evidence-based studies was the result of the lack of well-defined measures to evaluate the clinical performance of dental materials. As a fast and relatively reliable solution, Cvar and Ryge developed the rating scales which assess five characteristics of dental restorative materials indicative of their aesthetics and functionality.(1) With some modifications, these criteria are still used in clinical evaluation of dental materials and operative techniques. Read about modified criteria and the new FDI criteria in separate posts.

The original Cvar and Ryge criteria or characteristics used for material clinical evaluation are color match, cavo-surface marginal discoloration, anatomic form, marginal adaptation and caries. Codes Alfa, Bravo, Charlie and Delta are used to rate the restorations according to the assigned descriptive values for each characteristic (Table 1). The rating is conducted in a clinical setting, usually by two examiners (dentists) and a recorder (e.g. dental assistant), by visual inspection of the restoration with the use of a mirror if necessary. In addition, an explorer is used to rate marginal adaptation and the presence of caries.

In 1980, Ryge published another paper on clinical criteria in which he systematically set out an approach in clinical assessment of restorative materials using the original Cvar and Ryge criteria.(2) In addition to the previously developed rating scales, Ryge introduced a classification of restorations. The four categories are:
  1. Restorations within a range of excellence,
  2. Restorations which are acceptable although showing minor deviations from the ideal,
  3. Restoration which should be replaced for preventive reasons to avoid the likelihood of future damage and
  4. Restorations which require immediate replacement.

Table 1. Original Cvar and Ryge criteria used to evaluate non-metallic restorations. (Click on the table)


1. Cvar and Ryge criteria for the clinical evaluation of dental restorative materials. First published in U.S. Department of Health, Education, and Welfare, U.S. Public Health Service 790244, San Francisco Printing Office 1971:1–42. Reprinted in Clinical Oral Investigations 2005;9:215–232.

2. Ryge G. Clinical criteria. Int Dent J 1980;30:347-58

Monday, 15 November 2010

Mineral Trioxide Aggregate (MTA): Free full text articles II

To see previously published list of free full text articles on MTA (part I), please click here.

Endodontics - Case reports

Unal GC, Maden M, Isidan T. Repair of Furcal Iatrogenic Perforation with Mineral Trioxide Aggregate: Two Years Follow-up of Two Cases. Eur J Dent. 2010 Oct;4(4):475-81.  

Yildirim T, Gencoglu N. Use of mineral trioxide aggregate in the treatment of large periapical lesions: reports of three cases. Eur J Dent. 2010 Oct;4(4):468-74.

Abarajithan M, Velmurugan N, Kandaswamy D. Management of recently traumatized maxillary central incisors by partial pulpotomy using MTA: Case reports with two-year follow-up. J Conserv Dent. 2010 Apr;13(2):110-3.

Chhabra N, Singbal KP, Kamat S. Successful apexification with resolution of the periapical lesion using mineral trioxide aggregate and demineralized freeze-dried bone allograft. J Conserv Dent. 2010 Apr;13(2):106-9.

Adiga S, Ataide I, Fernandes M, Adiga S. Nonsurgical approach for strip perforation repair using mineral trioxide aggregate. J Conserv Dent. 2010 Apr;13(2):97-101.

Ozbas H, Subay RK, Ordulu M. Surgical retreatment of an invaginated maxillary central incisor following overfilled endodontic treatment: a case report. Eur J Dent. 2010 Jul;4(3):324-8.

Araújo RA, Silveira CF, Cunha RS, De Martin AS, Fontana CE, Bueno CE. Single-session use of mineral trioxide aggregate as an apical barrier in a case of external root resorption. J Oral Sci. 2010;52(2):325-8.

Khatavkar RA, Hegde VS. Use of a matrix for apexification procedure with mineral trioxide aggregate. J Conserv Dent. 2010 Jan;13(1):54-7.

Mirikar P, Shenoy A, Mallikarjun GK. Nonsurgical management of endodontic mishaps in a case of radix entomolaris. J Conserv Dent. 2009 Oct;12(4):169-74.

Endodontics - scientific articles
Orosco FA, Bramante CM, Garcia RB, Bernardineli N, de Moraes IG. Sealing ability, marginal adaptation and their correlation using three root-end filling materials as apical plugs. J Appl Oral Sci. 2010 Mar-Apr;18(2):127-34.

Lessa FC, Aranha AM, Hebling J, Costa CA. Cytotoxic effects of White-MTA and MTA-Bio cements on odontoblast-like cells (MDPC-23). Braz Dent J. 2010 Jan;21(1):24-31.

Cintra LT, Bernabé PF, de Moraes IG, Gomes-Filho JE, Okamoto T, Consolaro A, Pinheiro TN. Evaluation of subcutaneous and alveolar implantation surgical sites in the study of the biological properties of root-end filling endodontic materials. J Appl Oral Sci. 2010 Feb;18(1):75-82.

Chemical analysis

Han L, Okiji T, Okawa S. Morphological and chemical analysis of different precipitates on mineral trioxide aggregate immersed in different fluids. Dent Mater J. 2010 Oct 14;29(5):512-7.

Thursday, 11 November 2010

Silorane technology in restorative dentistry - material properties and clinical application

I recently published a review article in the Serbian professional journal "Stomatolog" ["Dentist"] on Filtek Silorane material properties and clinical application steps. The article is in Serbian but I would be happy to translate it to English for interested colleagues. Contact me at


Polymerization shrinkage remains one of the main weaknesses of composite materials. Silorane technology significantly reduces material shrinkage compared to methacrylate composites. This review article compares chemical composition and polymerization process of methacrylate- and silorane-based composites. Systematically are reviewed studies on mechanical, aesthetic, antibacterial and chemical properties of Filtek Silorane, as well as its interaction with tooth tissues. Lower polymerization shrinkage and microbial adherence and comparable mechanical properties have been reported for Filtek Silorane compared to methacrylate-based composites. In the only clinical study that has been published so far, marginal adaptation of Filtek Silorane was found to be inferior than the nanocomposite Ceram.X  However, low inter-examiner reliability questions the results of this clinical study and scientific literature lacks more information on clinical performance of Filtek Silorane. 

Wednesday, 13 October 2010

Monomer elution from a dental composite

Recently, I started a series of studies on monomer elution from composites with colleagues from University of Belgrade School of Dentistry and Faculty of Technology and Metallurgy. One of these experiments was presented a month ago at an international material science and engineering conference YUCOMAT.

The nano-hybrid composite Filtek Z250 (3M ESPE) was used to study elution kinetics of monomers UDMA and HEMA over 28 days post-immersion in either distilled water or 75% ethanol. Kinetic models were proposed and it was shown that monomer elution followed the first order law for both UDMA and HEMA irrespective of the medium. However, there were some differences in that UDMA eluted more rapidly during the first 24 h and then much more slowly over the 28-day period. This indicates that during the first 24 h elution from the sample surface occurred whereas the slow phase corresponds to monomer elution from inside the polymer. On the other hand, HEMA did not start to elute immediately, but only after 24 h and the eluted concentrations increased over the 28 days. Though HEMA is not a genuine ingredient of the studied composite, its slow elution and small eluted amounts seem to support a previous statement by other authors that HEMA could elute as a product of degradation of UDMA. (We are currently investigating this hypothesis.)

Sunday, 12 September 2010

Journal of Esthetic and Restorative Dentistry gets its first impact factor

A Miletic et al. study among the top 5 cited papers

In the latest list of SCI Journal Impact Factors 2009 published by Thomson Reuters, Journal of Esthetic and Restorative Dentistry is listed with the impact factor of 0.797. The Journal thanks all authors, reviewers and readers and allows free access to the top cited articles. Easy online submissions through ScholarOne Manuscripts are encouraged as this speeds up the review process. Hopefully, the Journal will maintain a growing influence in the scientific literature and increase its impact factor in the future.

It was a pleasure to see that one of the papers I did with my colleagues at the University of Belgrade School of Dentistry was among the top 5 cited articles in the Journal of Esthetic and Restorative Dentistry.

Miletic V, Ivanovic V, Dzeletovic B, Lezaja M.
Temperature Changes in Silorane-, Ormocer-, and Dimethacrylate-Based Composites and Pulp Chamber Roof during Light-Curing.

I look forward to submitting the results of my current studies to the Journal of Esthetic and Restorative Dentistry.

Monday, 19 July 2010

88th IADR General Session (Barcelona, 2010)

Effect of Preparation and Storage on Adhesive Monomer Conversion

V. MILETIC,  University of Belgrade, Belgrade, Serbia,  
A. SANTINI, The University of Edinburgh, Edinburgh, United Kingdom
Objectives: To study the effect of sample preparation and storage conditions on the degree of conversion (DC) of two adhesive systems using micro-Raman spectroscopy.  
Methods: Sixty samples each of an etch-and-rinse (Excite) and a self-etch (Clearfil 3S) adhesive were prepared on glass slides and allocated to groups G1-G6 (n=10). Thirty samples of each adhesive were prepared on dentine discs according to manufacturer's instructions and allocated to groups D1-D6 (n=5). In groups G1 and D1, each sample was covered with a Mylar strip and cured for 10 s with a bluephase LED unit. In groups G2 and D2, samples were cured without the Mylar strip. Micro-Raman spectra were taken 5 min post-curing. Groups G3-G6 and D3-D6 were covered with Mylar strips, cured according to the same protocol and stored for 24 h: G3 and D3 at 22±2ºC and 45±3% humidity; G4 and D4 at 37±1ºC and 90±2% humidity; G5 and D5 in distilled water at 37±1ºC; G6 and D6 in buffered incubation medium at 37±1ºC. Micro-Raman spectra were taken 5 min post-curing and after storage. Data were analyzed using t-tests and repeated measures ANOVA and the level of significance was α=0.05.
Results: Higher DC values were found on dentine than glass for both adhesives (p<0.05). Higher DC values were found for both adhesives when cured on dentine with than without Mylar strips (p<0.05). Higher DC values were found for Excite cured on glass with than without Mylar strips (p<0.05), but there was no difference for Clearfil 3S (p>0.05). Both adhesives cured on dentine gave higher DC after 24 h storage irrespective of the medium (p<0.05). Excite G3 group and Clearfil 3S G3 and G4 groups showed higher DC values after storage (p<0.05).
Conclusions: Sample preparation methods and storage conditions significantly affected the DC of Excite and Clearfil 3S.

If you can't see this presentation, you should download Adobe Flash Player. It's free. Click here.

Wednesday, 7 July 2010

Current status of visible light activation units and the curing of light-activated resin-based composite materials - review by professor Ario Santini in Dental Update

Light activation units are standard items of equipment in dental practice. It is essential to understand the many factors which affect the polymerization of light-activated resin composite materials and the choice of a light curing unit. In this respect, the development of high-intensity halogen and light-emitting diode (LED) light curing units (LCUs), many with multiple curing modes, has revolutionized light curing techniques. This article reviews visible light activation unit design and development. Factors influencing the effective use of LCUs and polymerization of resin-based composite materials are discussed, as are the steps which should be taken to maintain the efficiency of units in clinical use.
CLINICAL RELEVANCE: Many LCUs produce lower output intensities than stated by the manufacturer. Newer high power LEDs may present as much of a heat problem as high power quartz tungsten halogen lamps (QTHs). The manufacturer's data should be followed to ensure that the emission spectra of the unit are compatible with the photo-initiator in the resin-based composite material.

Professor Ario Santini is the Director for Biomaterials Research at the Edinburgh Postgraduate Dental Institute, Chair Research at Faculty of General Dental Practice (UK), Professor at Faculty of Medicine and Surgery, University of Sassari (Italy), Visiting Professor at the University of Belgrade (Serbia) and Fellow of the Academy of Dental Materials. Professor Santini's research interests are dental material sciences, dental resin-based composites and adhesives, Raman spectroscopy, high performance liquid chromatography, pulp biology and research methodology. He has published numerous articles in international, peer-reviewed journals indexed in Thomson's Science Citation Index. Browse for more articles by professor Santini at

Dental Update is the leading dental journal of continuing professional development (CPD) in the United Kingdom. By reading the appropriate peer reviewed articles and then answering the questions in each issue of the journal, one can earn up to 40 hours of verifiable CPD per year.

Wednesday, 19 May 2010

Mineral Trioxide Aggregate (MTA) and direct pulp capping

Two papers have been published recently on the use of mineral trioxide aggregate (MTA) for direct pulp capping.

A large clinical trial was conducted between 2001 and 2006 at Ruprecht-Karls-University of Heidelberg, Germany (1). Direct pulp capping with either MTA or Calcium hydroxide was done in 167 teeth of 149 patients. Treatment outcome was evaluated clinically and radiographically by calibrated examiners 12-80 months post-treatment. The authors reported a high recall rate of more than 70% and based the statistical analysis on 108 patients and 122 treated teeth. A significantly greater success rate was found for MTA (78% of teeth) than Calcium hydroxide (60% of teeth). It seems critical to restore such teeth permanently as soon as possible after pulp capping. This study showed that teeth permanently restored ≥2 days after capping had a significantly worse prognosis irrespective of the capping material. The authors concluded that "MTA appears to be more effective than calcium hydroxide for maintaining long-term pulp vitality after direct pulp capping".

Another study is an immunohistological study on Wistar rats (2). It compared the proliferation of pulp cells 1, 3, and 7 days after direct pulp capping with either MTA or Calcium hydroxide. After 3 days, the number of proliferating cells (fibroblasts, endothelial cells and Hoell's cells) was significantly greater when capping was performed irrespective of the material compared to the control group with no capping. After 7 days, however, there were no differences between MTA and Calcium hydroxide groups and the control group. The authors concluded that "Immunohistologic analysis demonstrated that MTA showed similar results when compared with Calcium hydroxide within the first week after direct pulp capping".

(1) Mente J, Geletneky B, Ohle M, Koch MJ, Friedrich Ding PG, Wolff D, Dreyhaupt J, Martin N, Staehle HJ and Pfefferle T. Mineral trioxide aggregate or calcium hydroxide direct pulp capping: an analysis of the clinical treatment outcome. J Endod 2010;36:806-13.

(2) Dammaschke T, Stratmann U, Wolff P, Sagheri D and Schafer E. Direct pulp capping with mineral trioxide aggregate: an immunohistologic comparison with calcium hydroxide in rodents. J Endod 2010;36:814-9.

Reprints of both studies should be available from the authors: (1)
and (2)


Sunday, 21 March 2010

Filtek Silorane composite: temperature changes during light-curing

Some time ago, my colleagues and I published a paper on temperature changes during curing of Filtek Silorane, Admira (ormocer) and Herculite XRV (microhybrid, control) composites. It was interesting to notice substantially higher temperature rise in Filtek Silorane compared to the other two materials. However, there was no difference in the temperature rise inside the pulp chamber, probably due to the insulating effect of the remaining dentine.

The abstract of this paper may be found on MEDLINE and I will be happy to email the full text to anyone interested in this subject. Feel free to contact me at

J Esthet Restor Dent 2009;21(2):122-31.
Temperature changes in silorane-, ormocer-, and dimethacrylate-based composites and pulp chamber roof during light-curing.
Miletic V, Ivanovic V, Dzeletovic B, Lezaja M.

STATEMENT OF THE PROBLEM: Light-curing of resin-based composites (RBCs) is associated with temperature increase in the pulp chamber, which may have a detrimental effect on the vital pulp.
PURPOSE: The purpose of the study was to evaluate temperature changes of silorane-, ormocer-, and dimethacrylate-based RBCs at the bottom surface of the RBC and in the pulp chamber roof dentin (PCRD) during curing.  
MATERIALS AND METHODS: In part A, temperatures were measured for Filtek LS (3M ESPE, St. Paul, MN, USA), Admira (Voco GmbH, Cuxhaven, Germany), and Herculite XRV (Kerr Corp., Orange, CA, USA) with a high-power light-emitting diode (LED) unit by placing thermocouples in contact with the bottom surface of the material in standardized acrylic molds. In part B, temperature changes in PCRD were measured in extracted molars during light-curing of adhesives and RBCs in 2-mm-deep cavities with a remaining dentin thickness (RDT) of 1 mm.
RESULTS: Filtek LS showed a different temperature curve compared with Admira and Herculite XRV. Significantly higher temperatures were recorded for Filtek LS (p < 0.001) than for Admira and Herculite XRV in acrylic molds. Temperature rises recorded in PCRD for adhesives and RBCs were between 4.1 and 6.4 degrees C. No significant differences in PCRD temperatures were found between the three groups during adhesive curing and RBC curing (p > 0.05).  
CONCLUSIONS: Filtek LS showed a different heat-generation pattern from and significantly higher temperatures than Admira and Herculite XRV when the materials were tested in acrylic molds. Similar temperatures were recorded in the PCRD during curing of adhesives and RBCs.
CLINICAL SIGNIFICANCE: Although a substantial temperature rise in the bulk material occurred during light-curing of the three resin-based composites, a remaining dentin thickness of 1 mm caused a significant reduction in pulp chamber roof dentin temperatures. Temperatures measured in the pulp chamber roof dentin corresponding to the zone occupied by the postmitotic odontoblast layer were not statistically different for the three types of resin-based composites.


Saturday, 27 February 2010

The effect of light source on monomer conversion of dental adhesives

The most recent paper by Santini Miletic research group will be published in Journal of Adhesive Dentistry, hopefully in the next issue. The abstract is available on PubMed/MEDLINE.

J Adhes Dent. 2009 Nov 27. doi: 10.3290/j.jad.a17855. [Epub ahead of print]

Micro-Raman Assessment of the Ratio of Carbon-Carbon Double Bonds of Two Adhesive Systems Cured with LED or Halogen Light-curing Units.

Miletic V, Santini A.

Purpose: The purpose of the study was to compare the ratio of carbon-carbon double bonds (RDB) of two adhesive systems cured by five different light-curing units (LCUs) using micro-Raman spectroscopy.
Materials and Methods: Ten samples of an etch-and-rinse (Excite), a two-step self-etching adhesive system (AdheSE) - ie, primer and bond mixed - and AdheSE Bond only were prepared and cured with one of the following LEDs: Elipar Freelight2; Bluephase; SmartLite; Coltolux, each for 10 s; or a conventional halogen Prismetics Lite for 10 s or 20 s. Micro-Raman spectra were obtained from uncured and cured samples of all three groups to calculate the RDB. Data were statistically analyzed using ANOVA.  
Results: The mean RDB values were 62% to 76% (Excite), 36% to 50% (AdheSE Primer+Bond) and 58% to 63% (AdheSE Bond). At 20 s, Prismetics Lite produced significantly higher RDB in Excite than the other LCUs and Prismetics Lite at 10 s (p < 0.05). Prismetics Lite at 20 s and Elipar produced comparable RDB values of AdheSE Bond and AdheSE Primer+Bond (p > 0.05). Excite showed significantly higher RDB values than AdheSE (p < 0.05) whilst AdheSE Bond showed significantly higher RDB than AdheSE Primer+Bond (p < 0.05).  
Conclusion: The etch-and-rinse adhesive cured with the halogen LCU for 20 s gave higher conversion than LED LCUs or halogen for 10 s curing time. The highest intensity LED [Elipar] produced higher or comparable conversion compared to the lower intensity LED LCUs for the same curing time. The etch-and-rinse adhesive showed higher RDB than the self-etching adhesive system. The presence of the primer in the self-etching adhesive compromised polymerisation.


Tuesday, 12 January 2010

Mineral Trioxide Aggregate (MTA): Free Full Text Articles I

This is the list of scientific articles on mineral trioxide aggregate (MTA) available in full text. All articles can be downloaded following the links on MEDLINE. You may also be interested in other posts on MTA. Click here for part II of the list of free full text articles on MTA.

Pulp capping

1. Bogen G, Kim JS, Bakland LK. Direct pulp capping with mineral trioxide aggregate: an observational study. J Am Dent Assoc. 2008 Mar;139(3):305-15; quiz 305-15.

2. Ford TR, Torabinejad M, Abedi HR, Bakland LK, Kariyawasam SP. Using mineral trioxide aggregate as a pulp-capping material. J Am Dent Assoc. 1996 Oct;127(10):1491-4.


3. Ghaziani P, Aghasizadeh N, Sheikh-Nezami M. Endodontic treatment with MTA apical plugs: a case report. J Oral Sci. 2007 Dec;49(4):325-9.

4. Winik R, Araki AT, Negrão JA, Bello-Silva MS, Lage-Marques JL. Sealer penetration and marginal permeability after apicoectomy varying retrocavity preparation and retrofilling material. Braz Dent J. 2006;17(4):323-7.

5. Witherspoon DE, Small JC, Harris GZ. Mineral trioxide aggregate pulpotomies: a case series outcomes assessment. J Am Dent Assoc. 2006 May;137(5):610-8.

6. Silberman A, Cohenca N, Simon JH. Anatomical redesign for the treatment of dens invaginatus type III with open apexes: a literature review and case presentation. J Am Dent Assoc. 2006 Feb;137(2):180-5. Review.

7. Schwartz RS, Mauger M, Clement DJ, Walker WA 3rd. Mineral trioxide aggregate: a new material for endodontics. J Am Dent Assoc. 1999 Jul;130(7):967-75. Review.

Chemical analysis

8. Oliveira MG, Xavier CB, Demarco FF, Pinheiro AL, Costa AT, Pozza DH. Comparative chemical study of MTA and Portland cements. Braz Dent J. 2007;18(1):3-7.

(The link to each article is in the top right corner as shown in this image. Click to enlarge.)

The following articles are available from PubMed Central.


9. Taia Maria Berto Rezende, Leda Quercia Vieira, Antônio Paulino Ribeiro Sobrinho, Ricardo Reis Oliveira, Martin A. Taubman, and Toshihisa Kawai. The influence of Mineral Trioxide Aggregate (MTA) on adaptive immune responses to endodontic pathogens in mice. J Endod. 2008 September; 34(9): 1066–1071.

Tissue engineering (Genetics)

10. Paul C Edwards and James M Mason. Gene-enhanced tissue engineering for dental hard tissue regeneration: (2) dentin-pulp and periodontal regeneration. Head Face Med. 2006; 2: 16.

11. Rebecca S. Prescott, Rajaa Alsanea, Mohamed I. Fayad, Bradford R. Johnson, Christopher S. Wenckus, Jianjun Hao, Asha S. John, and Anne George. In-vivo Generation of Dental Pulp-Like Tissue Using Human Pulpal Stem Cells, a Collagen Scaffold and Dentin Matrix Protein 1 Following Subcutaneous Transplantation in Mice. J Endod. 2008 April; 34(4): 421–426.

(The link is shown in the image below. Click to enlarge.)


Monday, 28 September 2009

Recommendations for conducting controlled clinical studies of dental restorative materials

Inspired by the recent debate, I did a literature search on clinical trials in various dental disciplines. As expected, there are loads of such studies on dental materials and clinical procedures, so the argument that something can't be tested is invalid. Everything can and must be tested using scientifically structured protocols before certain claims are made.

Two years ago, a group of scientists associated with the FDI Science Committee published recommendations for conducting clinical trials on dental materials. These recommendations are related to study design and evaluation criteria.

The following is the abstract of this paper and the full text can be obtained from J Adhes Dent or the first author, Dr Reinhardt Hickel of the University of Munich, Germany

Recommendations for conducting controlled clinical studies of dental restorative materials. Science Committee Project 2/98--FDI World Dental Federation study design (Part I) and criteria for evaluation (Part II) of direct and indirect restorations including onlays and partial crowns.

Hickel R, Roulet JF, Bayne S, Heintze SD, Mjör IA, Peters M, Rousson V, Randall R, Schmalz G, Tyas M, Vanherle G.

J Adhes Dent 2007; 9 Suppl 1:121-147. Erratum in J Adhes Dent. 2007 Dec;9(6):546.

About 35 years ago, Ryge provided a practical approach to the evaluation of the clinical performance of restorative materials. This systematic approach was soon universally accepted. While that methodology has served us well, a large number of scientific methodologies and more detailed questions have arisen that require more rigor. Current restorative materials have vastly improved clinical performance, and any changes over time are not easily detected by the limited sensitivity of the Ryge criteria in short-term clinical investigations. However, the clinical evaluation of restorations not only involves the restorative material per se but also different operative techniques. For instance, a composite resin may show good longevity data when applied in conventional cavities but not in modified operative approaches. Insensitivity, combined with the continually evolving and nonstandard investigator modifications of the categories, scales, and reporting methods, has created a body of literature that is extremely difficult to interpret meaningfully. In many cases, the insensitivity of the original Ryge methods leads to misinterpretation as good clinical performance. While there are many good features of the original system, it is now time to move on to a more contemporary one. The current review approaches this challenge in two ways: (1) a proposal for a modern clinical testing protocol for controlled clinical trials, and (2) an in-depth discussion of relevant clinical evaluation parameters, providing 84 references that are primarily related to issues or problems for clinical research trials. Together, these two parts offer a standard for the clinical testing of restorative materials/procedures and provide significant guidance for research teams in the design and conduct of contemporary clinical trials. Part 1 of the review considers the recruitment of subjects, restorations per subject, clinical events, validity versus bias, legal and regulatory aspects, rationales for clinical trial designs, guidelines for design, randomization, number of subjects, characteristics of participants, clinical assessment, standards and calibration, categories for assessment, criteria for evaluation, and supplemental documentation. Part 2 of the review considers categories of assessment for esthetic evaluation, functional assessment, biological responses to restorative materials, and statistical analysis of results. The overall review represents a considerable effort to include a range of clinical research interests over the past years. As part of the recognition of the importance of these suggestions, the review is being published simultaneously in identical form in both the Journal of Adhesive Dentistry and Clinical Oral Investigations. Additionally, an extended abstract will be published in the International Dental Journal, giving a link to the web full version. This should help to introduce these considerations more quickly to the scientific community.

Friday, 18 September 2009

Journal of Dental Research: Top 50 most-frequently read and cited articles

Some time ago, I wrote a post about the Top 10 'hottest' articles published in Journal of Dentistry (J Dent). Similarly to J Dent, lists of most-frequently read and cited articles are generated every month for Journal of Dental Research (J Dent Res), one of the leading dental journals with the 2008 impact factor of 3.142. These lists are based on full-text and pdf views and the latest can be found here: most-frequently read and cited.

Though both J Dent Res and J Dent cover a wide area of research in dentistry, their lists of 'hottest' articles differ significantly as to the nature of research subjects. Whilst 8 out 10 'hottest' articles in J Dent are related to dental materials, there is not a single article among the top 10 most-frequently read and cited articles in J Dent Res related to dental materials. J Dent Res does have a Biomaterials section in every issue and publishes a certain amount of articles related to dental materials. However, the majority of articles gravitate to more basic sciences, such as (patho)physiology, (patho)histology, immunology, genetics, pharmacology... This is also reflected in the lists of most-frequently read and cited articles.

Tuesday, 8 September 2009

Research on tooth-bleaching agents by Dr Tatjana Savic-Stankovic BDS, MSc

Dr Tatjana Savic-Stankovic BDS, MSc, my colleague and friend from the University of Belgrade School of Dentistry, completed an extensive study for her MSc thesis on tooth-bleaching agents.

Dr Savic-Stankovic defended her MSc thesis in a viva but also presented the highlights of her research at the School of Dentistry Anniversary in June 2009. Click on the image to enlarge the poster. Since the poster is in Serbian, the abstract in English is given below. Copyright belongs to Dr Savic-Stankovic. For further contact, please use the email address

The effect of different concentrations of bleaching agents on enamel properties in vitro and clinical efficiency of the „walking bleach“ technique

Dr Tatjana Savic-Stankovic BDS, MSc

Introduction. Bleaching results in slow transformation of organic substances into chemical intermediary products which are lighter than the original. Bleaching efficiency is related to the cause of tooth discoloration.

Aims. To evaluate changes in enamel microhardness and morphological aspects of enamel after treatment with different concentrations of bleaching agents. The aim of the clinical study was to evaluate the bleaching efficiency with regard to the cause of discoloration: trauma, necrosis, endo-sealer or unknown.

Materials and Methods. Twenty freshly extracted sound human molars were treated with 10%, 20% and 35% carbamide peroxide and 38% hydrogen peroxide (Opalescence gel, Ultradent. Pro.) in clinically recommended intervals. Knoop microhardness measurements were performed at baseline and 8 hours, 21 days and 3 weeks post-treatment. SEM was used to evaluate morphological changes in enamel post-treatment.

Forty non-vital central incisors were bleached using sodium perborate and hydrogen peroxide mixture which was changed weekly. Based on patients' dental history and clinical examination, discolored teeth were allocated to four groups depending on the cause of discoloration: trauma, necrosis, endo-sealer and unknown. Aesthetic results of the applied “walking bleach” technique were evaluated before and after treatment using the standardized colour-coded key for colour comparison.

Results. No statistically significant differences and no changes in enamel surface morphology were observed between 10% and 20 % carbamide peroxide groups. A significant decrease in enamel microhardness was found in 35% carbamide peroxide and 38% hydrogen peroxide groups. Mild and moderate changes in enamel surface morphology were observed in the group treated with 35% carbamide peroxide whilst substantial changes were found in the group treated with 38% hydrogen peroxide.

The shortest treatment (15.7 days) and greatest number of shades before and after bleaching were found in patients whose aetiological factor for discoloration was „trauma”. Bleaching efficiency decreased with age. No correlation was found between bleaching efficiency and the initial shade.

Conclusions. Increasing concentrations of tooth-bleaching agents resulted in lower enamel microhardness values and more profound changes in enamel surface morphology. The cause of tooth discoloration had a significant effect on the clinical efficiency of the "walking bleach" technique.

Keywords: dental materials, tooth bleaching, tooth whitening, carbamide peroxide, hydrogen peroxide, enamel, clinical trial, walking bleach

Sunday, 6 September 2009

Journal of Dentistry: Top 10 Hottest articles

The list of Top 10 Hottest articles, most frequently downloaded from Journal of Dentistry is regularly published on this journal's website. The latest list can be found HERE.

Eight out of ten most downloaded articles are related to dental materials. The single most popular article is the review of the effect of polyphenols on oral health and disease. The most popular field represented by the greatest number of articles (4) in the Top 10 seems to be the bleaching of teeth. The most popular research article is a study on the effect of different adhesive systems and laser treatment on the shear bond strength of bleached enamel.

Journal of Dentistry is a SCI journal, published monthly, with the current impact factor of 2.033.