Staining of dental composite resins with chlorhexidine mouthwashes

original article
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Staining of dental composite resins
with chlorhexidine mouthwashes
ated composite resins in the same way as conventional 0.2% chlorhexidine mouthwash.
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Claudio Poggio
Alberto Dagna
Marco Lombardini
Marco Chiesa
Stefano Bianchi
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Key words: composite resins, chlorhexidine mouthwash,
staining.
Department of Operative Dentistry
University of Pavia, Italy
Sommario
Pigmentazione di resine composite esposte all’azione
di collutori alla clorexidina.
Obiettivo. Lo scopo di questo studio è valutare la pigmentazione di quattro resine composite, due microriempite e due nanoriempite, esposte all’azione di differenti collutori alla clorexidina.
Materiali e metodi. Le resine composite (Esthet-X, Gradia Direct, Ceram-X Mono e Filtek Supreme XT) sono
state polimerizzate all’interno di 120 anelli di plastica
(altezza 2 mm; diametro interno 4 mm; diametro esterno 6 mm) al fine di ottenere campioni identici. I campioni sono stati esposti all’azione di due collutori alla
clorexidina (Corsodyl 0.2% e Curasept ADS 0.2%), uno
dei quali dotato di sistema ADS (Anti Discoloration System). I campioni sono stati immersi per 1 minuto, due
volte al giorno (ogni 12 ore) per 15 giorni, nei collutori
e in acqua distillata (controllo). Il colore dei campioni è
stato misurato con uno spettrofotometro (CIE L*a*b*
system) dopo la polimerizzazione dei compositi, dopo
7 giorni e dopo 14 giorni di trattamento con i collutori
alla clorexidina. Sono state calcolate le differenze di
colore (ΔEab*) tra ogni misurazione. I dati ottenuti sono
stati analizzati statisticamente (ANOVA test).
Risultati. Tutti i campioni hanno presentato un significativo aumento del grado di pigmentazione con entrambi i collutori.
Conclusioni. I compositi microriempiti e quelli nanoriempiti hanno presentato un comportamento sovrapponibile. Il colluttorio dotato di sistema ADS ha presentato un comportamento simile a quello del collutorio convenzionale.
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Correspondence to:
Prof. Claudio Poggio
Department of Operative Dentistry
Piazzale Golgi 3, 27100 Pavia, Italy
Ph: +39 0382 516257
Fax: +39 0382 516224
E-mail: [email protected]
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Submitted for publication: 24/02/2009
Accepted for publication: 16/03/2009
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Summary
Staining of dental composite resins with chlorhexidine
mouthwashes
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Objective. The purpose of this in vitro study was to evaluate staining of 4 dental composite resins, two microfilled and two nanofilled, exposed to different chlorhexidine mouthwashes.
Materials and methods. The composite resins (Esthet-X,
Gradia Direct, Ceram-X Mono, and Filtek Supreme XT)
were polymerized into 120 plastic rings (height 2 mm;
internal diameter 4 mm; external diameter 6 mm) to obtain identical specimens. The specimens were subjected to 2 chlorhexidine mouthwashes (Corsodyl 0.2% and
Curasept ADS 0.2%), one of those containing an antidiscoloration system. The specimens were dipped for 1
minute, twice at day (every 12 hours), for 15 days into
the mouthwash and into distilled water (as control). Color of specimens was measured with a spectrophotometer according to the CIE L*a*b* system after light-polymerization of composite resin specimens, after 7 days
and after 14 days of treatment with chlorhexidine. The
color differences (ΔEab*) between each measurement
were calculated. Analysis of variance (ANOVA) was
used to analyze the data.
Results. All specimens showed a significant progressive increase in staining with increasing number of
rinsing in all chlorhexidine mouthwashes, with a similar trend and no significant differences between microfilled and nanofilled composite resins.
Significance. Microfilled and nanofilled composite
resins had similar in vitro discoloration in both 0.2%
chlorhexidine mouthwashes. Chlorhexidine mouthwash with anti discoloration system stained the evalu-
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Parole chiave: resine composite, collutori alla clorexidina,
pigmentazione.
Introduction
Long term stability in the oral environment is a crucial
property of esthetic restorative materials and unacceptable color match is a primary reason for replacement of
composite resin restoration (Villalta et al., 2006). Although improvements in composite resins composition
have been achieved during recent years, color stability
remains a problem. Dental composite resins are susceptible to various degrees of discoloration after prolonged exposure to the oral environment (Uchida et al.,
1998; Hosoya, 1999; Vargas et al., 2001; Janda et al.,
Annali di Stomatologia 2009; LVIII (3): 62-67
Staining of dental composite resins
2005). Three types of discolorations are generally described (Dietschi et al., 1994): (1) external discoloration
due to the accumulation of plaque and surface stains
(extrinsic stain), (2) surface or sub-surface color alteration implying superficial degradation or slight penetration and reaction of staining agents within the superficial layer of composite resins (absorption), and (3) body
or intrinsic discoloration due to physico-chemical reactions in the deeper portion of the restoration. The structure of the composite resin and the characteristics of its
particles have a direct impact on its susceptibility to extrinsic staining (Tjan and Chan, 1989). In addition, the
finishing and polishing procedures may also influence
composite resins surface quality and can therefore be
related to early discoloration (Shintani et al., 1985). The
external and surface types of discolorations are also
closely related to hygiene, dietary and smoking habits
(Asmussen and Hansen, 1986). Every component of
composite resins may be involved in sub-surface or intrinsic discolorations (Setz et al., 1990). The affinity of
composite resin for stains is modulated by its conversion rate and its chemical characteristics, water sorption rate being particularly important (De Gee et al.,
1984). An insufficient resin conversion rate will favour
the absorption of some colorants and the color stability
of composite resins depends on various factors like curing time, curing mode, aging conditions and composition of the materials (Janda et al., 2007). The intrinsic
color of composite resins can also be altered with the
passage of time as a result of various influences such
as visible and ultra-violet irradiation, thermal changes
and humidity (Burrow et al., 1991). The lighter shades
of composite resins are likely to be subject to higher
color degradation through the effects of environmental
exposure to ultraviolet light (Uchida et al., 1998; Kolbeck et al., 2006). The staining susceptibility of a composite resin may be also attributed to its filler type:
nanofilled absorbs staining substances more easily
than microfilled Villalta et al., 2006).
Chlorhexidine is used in chemical control of dental
plaque (Loe and Schiott, 1970). It inhibits formation of
plaque and development of gingivitis (Schiott et al.,
1970; Loe et al., 1976). Chlorhexidine is a bisbiguanide
antiseptic molecule, for many uses in dental practice
and preventive dentistry (Greenstein et al., 1985). It is
used as a solution (in water) with various concentrations
(0.12%, 0.2%, 0.3%) or as a gel or as a spray form or
included in toothpaste (Schiott et al., 1970; Greenstein
et al., 1985). One of its most frequent local side effects
is the appearance of stains on teeth, restorative materials, tongue and mucous membranes (Loe and Schiott,
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1970; Schiott et al., 1970; Loe et al., 1976; Greenstein
et al., 1985; Addy et al., 2001; Sanz et al., 1994; Stober
et al., 2001; Bernardi et al., 2004; Lee and Powers,
2005; Lee et al., 2005). This is a limiting factor in longterm use of this anti-plaque agent, even if these effects
are local and reversible. The mechanism of staining is
debated, but several studies demonstrate that it’s principally caused by interaction of chlorhexidine with dietary
chromogens on teeth, restorations and mucous surfaces
(Flotra et al., 1971; Davies, 1973; Addy et al., 1979; Addy et al., 1991; Watts and Addy, 2001; Kim et al., 2006).
Besides staining effect is dose dependent and staining
increases with increasing number of rinsing passages
(Smith et al., 1995). To avoid staining side-effects,
mouthwashes containing chlorhexidine with anti-discoloration systems (ADS) have recently become available.
These products are purported maintain their antiseptic
properties and qualities without the side effect of staining (Addy et al., 1991; Smith et al., 1995; Stober et al.,
2001; Addy et al., 2005; Cortellini et al., 2008), even
though some authors report that mouthwashes with
ADS could have less efficacy than traditional ones (Arweiler et al., 2006).
The purpose of this study was to evaluate staining of 4
dental composite resins, 2 microfilled and 2 nanofilled,
exposed to 2 chlorhexidine mouthwashes. The first hypothesis was that chlorhexidine staining of nanofilled
dental composite resins would be higher than microfilled dental composite resins. The second hypothesis
was to test an ADS chlorhexidine mouthwash as a possible agent to reduce chlorhexidine staining.
Materials and methods
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Two microfilled (Esthet-X; Dentsply De Trey, Konstanz,
GmbH, Germany; and Gradia Direct; GC Dental Products Corp, Tokyo, Japan) and 2 nanofilled (Ceram-X
Mono; Dentsply De Trey, Konstanz, GmbH, Germany;
and Filtek Supreme XT; 3M ESPE, St. Paul, Minn)
composite resins were evaluated in this study (Table I).
For each brand, the universal A2 Vita shade was selected. All composite resins were polymerized according to manufacturers’ instructions into plastic rings
(height 2 mm; internal diameter 4 mm; external diameter 6 mm) to obtain specimens identical in size. Cavities
of these rings were slightly overfilled with material, covered by a Mylar strip (Henry Schein; Melville, NY),
placed between 2 glass slides and polymerized for 40
seconds on each side using a polymerization unit (Elipar Trilight; 3M ESPE, St. Paul, Minn.) with light intensi-
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Table I - Composite resins evaluated.
Code
Brand Name
Classification
Shade
Batch Number
Manufacturer
EX
Esthet-X
Microfilled
A2
0410998
Dentsply De Trey, GmbH,
Konstanz, Germany
GD
Gradia Direct
Microfilled
A2
0609251
GC Dental Products Corp,
Tokyo, Japan
CX
Ceram-X Mono
Nanofilled
A2
0510175
Dentsply De Trey GmbH
FS
Filtek Supreme XT
Nanofilled
A2B
5AG
3M ESPE, St. Paul, Minn
Annali di Stomatologia 2009; LVIII (3): 62-67
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ΔEab* = [(ΔL*)2 + (Δa*)2 + (Δb*)2]1/2
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where L* is lightness, a* is green-red component (-a* =
green; +a* = red) and b* is blue-yellow component (-b*
= blue; +b* = yellow).
A value of ΔEab* < 3.3 was considered clinically acceptable in the present study (Craig and Powers, 2002;
Lee and Powers, 2005; Villalta et al., 2006). The color
measurements of the experimental groups were compared with those of the control group. Differences in
color change by the immersion protocols were calculated and a statistical analysis was performed using statistical software (Stata 7; College Station, Tex, USA). Descriptive statistics that included mean, standard deviation, median, and minimum and maximum values were
calculated. A 2-way analysis of variance test (ANOVA)
was applied to determine whether significant differences existed among the groups. For the post-hoc test,
the Scheffé test was used. A preset alpha level of .05
was used for all statistical analyses. The distributions
were assessed and found to be normal (Kolmogorov
Smirnov Test).
Results
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ty of 800 mW/cm2. The intensity of the light was verified
with a radiometer (SDS Kerr, Orange, Calif). The light
was placed perpendicular to the specimen surface, at
distance of 1.5 mm. The upper surface of each specimen was then polished with fine and superfine polishing disks (Sof-Lex Pop On; 3M ESPE, St. Paul, Minn.)
to simulate clinical conditions. Thirty cylindrical specimens of each material were prepared in this manner,
for a total of 120 specimens. After polymerization and
during the experimentation, the specimens were stored
in artificial saliva (Idrum; F.I.R.M.A. SpA, Florence,
Italy). All specimens were subjected to 500 thermal cycles between 5°C (± 5°C) and 50°C (± 5°C) with a dwell
time of 30 seconds in each water bath in order to simulate aging conditions (Lee et al., 2005).
The specimens were assigned to 3 groups of 10 for
each type of composite resin and subjected to the action of Corsodyl 0.2% (GSK GlaxoSmithKline, Brentford, Middlesex, UK), Curasept ADS 0.2% (Curaden
Healthcare S.r.l., Saronno, Italy) and distilled water as
control. The specimens were dipped for 1 minute, twice
at day (every 12 hours), for 15 days into the mouthwash or distilled water to simulate a period of clinical
exposure. After each dip, the specimens were rinsed
for 1 minute in disitilled water and replaced in artificial
saliva at 37°C.
A colorimetric evaluation according to the CIE L*a*b*
system was performed at 3 experimental periods, immediately after light-polymerization, at 7 days, and at
14 days. Color of the specimens was measured with a
spectrophotometer (SP820λ; Techkon Gmbh, KonigStein, Germany) against a black background in order
to simulate the absence of light in the mouth. All specimens were chromatically measured 4 times and the
average values were calculated; then each color parameter for each specimens of the same shade was averaged. The CIE 1976 L* a* b* color system is used
for the determination of color differences (Wyszecki et
al., 1982; Burrow and Makinson, 1991; Hosoya, 1999;
Vargas et al., 2001; Villalata et al., 2006; Kim et al.,
2006; Lee et al., 2007). The L* value refers to “lightness”; the higher is the L value, the higher is the lightness (a value of 100 corresponds to perfect white and
that of zero to black). The a* b* values are called the
“chromaticity coordinates”; “a*” shows red color on
positive values and green color on negative values;
“b*” shows yellow color on positive values and blue
color on negative values (Kolbeck et al., 2001). The
total color differences (ΔEab*) were calculated as follows (Wyszecki et al., 1982):
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Table II shows mean values of color change (ΔE*) for
each group of composite resin according to the CIE
L*a*b* system after immersion in both chlorhexidine
mouthwashes for each experimental period (after 7
days and after 14 days). ΔEab* of microfilled composite resins after 7 days of treatment with chlorhexidine
was in the range 0.31-0.46, which increased to 0.881.02 after 14 days. ΔEab* of nanofilled composite
resins after 7 days of treatment with chlorhexidine was
in the range 0.31-0.37, which increased to 0.82-1.12
after 14 days. It means that all specimens showed a
significant progressive increase (P<.05) in color
change with increasing number of rinsing in all
chlorhexidine mouthwashes. Staining was observed in
each specimen of composite resin, with no significant
differences between microfilled and nanofilled composite resins (P>.05). Control group (specimens
dipped in distilled water) showed negligible differences in color change after 7 days and after 14 days.
The 2-way ANOVA analysis of variance showed no
significant chromatic variations (ΔE*) between the 2
mouthwashes. The result demonstrated similar discoloration for each mouthwash.
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Table II - Mean (SD) values of ΔE* for composite resins evaluated.
After 7 days
After 14 days
CRD
ADS
DW
CRD
ADS
DW
Esthet-X
0.46 (0.18)
0.33 (0.10)
0.06 (0.11)
0.94 (0.21)
0.94 (0.21)
0.09 (0.09)
Gradia Direct
0.31 (0.12)
0.32 (0.09)
0.07 (0.12)
1.02 (0.18)
1.02 (0.18)
0.08 (0.11)
Ceram-X Mono
0.37 (0.10)
0.31 (0.12)
0.09 (0.09)
0.98 (0.10)
0.98 (0.10)
0.08 (0.10)
Filtek Supreme XT
0.41 (0.13)
0.36 (0.12)
0.05 (0.11)
1.12 (0.19)
1.12 (0.19)
0.06 (0.13)
CRD, Corsodyl 0.2%; ADS, Curasept ADS 0.2%; DW, distilled water.
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The primary hypothesis that chlorhexidine staining of
nanofilled dental composite resins would be higher than
microfilled dental composite resins was not accepted.
There were no significant differences in staining of
specimens of 4 groups as both microfilled and
nanofilled composite resins showed similar values of
color change. However the color differences after 7
days and after 14 days of chlorhexidine treatment was
lower than the clinical acceptable limit of ΔEab* < 3.3
for all the specimens. The color differences after 7 days
and after 14 days in control group were negligible for
both nanofilled and microfilled dental composite resins.
Villalta et al. (2006), Lee et al. (2005) and Stober et al.
(2001) obtained varying results when comparing in vitro
staining of microfilled and nanofilled composite resins
submitted to various solutions. It is interesting to note
that Villalta et al. (2006) and Stober et al. (2001) submitted specimens to the action of different staining solutions but did not use chlorhexidine. Villalta et al. (2006)
assesed that staining susceptibility of a material may be
attribuited to its resin or filler type. The authors demonstrated that nanofilled composite resins absorb stains
such as coffee or red wine more easily than microfilled
composite resins. Lee et al. (2005) obtained analogous
results using chlorhexidine and other substances, concluding that the smoothest surfaces were not necessarily the most stain-resistant, and staining ability was influenced by each composite monomer and filler composition.
In contrast with the results of these authors, nanofilled
and microfilled composite resins reacted in the similar
way to the action of chlorhexidine mouthwashes, with
no significant differences after 7 days or 14 days of
treatment in the present study. Color change was observed in each specimen after 7 days and was higher
after 14 days. The control groups of all composite
resins (distilled water) showed negligible staining after
7 days (ΔEab* = 0.05-0.09) and after 14 days (ΔEab* =
0.06-0.09). Addy et al. (2005) assessed that the use of
water as control serves to confirm the conduct of the
study indicating that the stain is because of the
chlorhexidine and not the aqueous vehicle. In these in
vitro conditions both nanofilled and microfilled composite resins showed similar values of color change after
chlorhexidine exposure. This study evaluated only A2
Vita shades of all materials; thus, the results may not
be applicable to other shades.
The second hypothesis that an ADS containing
chlorhexidine mouthwash can reduce chlorhexidine
staining was not accepted because there were no significant differences in staining of specimens subjected
to the action of chlorhexidine mouthwash containing the
anti discoloration system. Both mouthwashes showed
similar values of color change.
As confirmed in the literature chlorhexidine causes the
appearance of stains on teeth, restorative materials,
tongue and mucous membranes (Loe and Schiott
,1970; Flotra et al., 1971; Davies, 1973; Addy et al.,
1979; Addy et al., 1991; Watts and Addy, 2001; Kim et
al., 2006). This is a limiting factor in long-term usage of
this anti-plaque agent. Even though these effects are
local and reversible, patients object to this side effect.
This problem has been approached by attempting to re-
duce the staining effect adding substances or anti discoloration systems (ADS) to chlorhexidine mouthwashes. Curasept ADS 0.2% contains an anti discoloration
system based on ascorbic acid and sodium metabisulphite, in order to avoid staining side-effects (Bernardi et
al., 2004). Recent clinical studies (Bernardi et al, 2004;
Cortellini et al., 2008) which compare Curasept ADS
0.2% to a traditional 0.2% chlorhexidine mouthwash
demonstrate that it maintains its antiseptic properties
and efficacy against plaque without staining.
In the present study both chlorhexidine mouthwashes
caused acceptable color changes (ΔEab* < 3.3).
Curasept ADS 0.20% caused an acceptable color change
after 7 days (ΔEab* = 0.31-0.36) and after 14 days, even
if increased (ΔEab* = 0.82-0.99). Similar results were obtained for Corsodyl 0.20% after 7 days (ΔEab* = 0.310.46) and after 14 days (ΔEab* = 0.94-1.12).
A clinical trial performed by Cortellini et al. (2008) evaluated the side effects and efficacy of Curasept ADS
0.2% comparing to a non-defined conventional mouthwash containing 0.2% chlorhexidine. This study was
performed with 48 patients after periodontal flap
surgery. After periodontal flap surgery, the patients
were prescribed to rinse twice daily for two weeks with
randomly assigned mouthwashes. No brushing and interdental cleaning was allowed for the experimental
time. Presence of pigmentation, gingival parameters
and patient acceptance were recorded at week 1 and at
week 2. Results showed that ADS caused less pigmentation and was as effective as control chlorhexidine
mouthwash in reducing gingival signs of inflammations,
so it was more acceptable by patients. The same results were obtained in another clinical trial by Bernardi
et al. (2004). These authors reported that there were no
significant differences in the ability of ADS and nonADS chlorhexidine mouthwashes to prevent bacterial
plaque accumulation and gingival inflammation, but
staining was significantly reduced in ADS mouthwash.
Contradictory results were obtained in a clinical
crossover study by Arweiller et al. (2006). The authors
examined the antibacterial and plaque-inhibiting properties of Curasept ADS 0.2% comparing to Corsodyl
0.2%. Two groups of volunteers refrained from all oral
hygiene measures and only rinsed twice daily with
mouthwashes, one group with Curasept ADS 0.2%, the
other with Corsodyl 0.2%. Plaque index, plaque area
and bacterial vitality were assessed after 24 hours and
after 96 hours. On comparing the 2 mouthwashes, Corsodyl 0.2% showed significantly higher reductions of all
parameters (plaque index, plaque area and bacterial vitality). The authors concluded that Curasept ADS 0.2%
has less efficacy in reducing bacterial vitality and
plaque re-growth.
The outcomes reported by Addy et al. (2005) established
no efficacy of Curasept ADS 0.12% and Curasept ADS
0.2% in reducing chlorhexidine pigmentation. Mouthwashes with the ADS would cause staining in vitro and
would have the same anti-plaque efficacy in vivo as conventional chlorhexidine products. So this work is in disagreement with the results of the in vivo study by Bernardi et al. (2004) and the in vivo study by Cortellini et al.
(2008). A possible explanation for those differences
could be the presence and interaction of the dietary chromogens in both the clinical studies. Probably anti discoloration system has efficacy only on dietary chromogens
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Discussion
Annali di Stomatologia 2009; LVIII (3): 62-67
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The authors thank Dr Andrea Scribante, University of
Pavia, Italy, Department of Orthodontics, for his help
with the statistical analysis.
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Acknowledgements
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Different composite resins (microfilled and nanofilled)
reacted in the same way when exposed in vitro twice a
day to chlorhexidine mouthwashes for 7 days and 14
days. Microfilled and nanofilled composite resins had
similar in vitro discoloration in both 0.2% chlorhexidine
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and reduces their interferences with chlorhexidine, but
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(2005) did not confirm the anti-staining properties reported by the previous clinical studies.
This study evaluated only A2 shades and only 2 brands
for each type of composite resins. The results may not
be applicable to other shades and moreover to all commercial microfilled and nanofilled composite resins. Further in vivo and in vitro investigations are required to
estimate the action of ADS products, because results in
literature are still different and sometimes contradictory.
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Annali di Stomatologia 2009; LVIII (3): 62-67
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