|Year : 2021 | Volume
| Issue : 2 | Page : 59-67
Is zinc oxide eugenol cement still impeding the use of resin-based restoration? A systematic review
Fawaz Pullishery1, Hajer Ayed Alhejoury2, Mohammed Turkistani2, Yasser Refay Souror3
1 Department of Community Dentistry and Research, Dentistry Program, Batterjee Medical College, Jeddah, Saudi Arabia
2 Department of Dental Intern, Dentistry Program, Batterjee Medical College, Jeddah, Saudi Arabia
3 Department of Pediatric Dentistry, Faculty of Dentistry, Al-Azhar University, Assuit, Egypt; Division of Pediatric and Community Dentistry, Faculty of Dentistry, Batterjee Medical College, Jeddah, Saudi Arabia
|Date of Submission||24-May-2021|
|Date of Decision||09-Jul-2021|
|Date of Acceptance||09-Jul-2021|
|Date of Web Publication||29-Nov-2021|
Department of Community Dentistry and Research, Dentistry Program, Batterjee Medical College, 21442 Jeddah
Source of Support: None, Conflict of Interest: None
Background: The use of zinc oxide eugenol (ZOE), along with resin restoration or cementation, is often a debatable topic in dentistry. This systematic review is aimed to explore the effect of ZOE on various properties of resin-based dental materials. Materials and Methods: An electronic research was carried out using the relevant keywords in different search engines such as MEDLINE/PubMed, Ebscohost, SCOPUS, Web of Science, and EMBASE SciFinder based on PRISMA guidelines. Only articles in the English language were included along with other specific inclusion criteria. Results: The entire articles were assessed for the eligibility and final review included 30 studies that were then classified according to the type of test conducted on the resin-based material. Conclusion: There is no consensus on the deleterious effect of ZOE on resin-based dental material. However, all the tests conducted were in vitro and most of them showed a significant reduction in the quality of resin restorative and cement materials when used with ZOE.
Keywords: Bond strength, eugenol, resin, restoration, zinc oxide
|How to cite this article:|
Pullishery F, Alhejoury HA, Turkistani M, Souror YR. Is zinc oxide eugenol cement still impeding the use of resin-based restoration? A systematic review. Dent Med Res 2021;9:59-67
|How to cite this URL:|
Pullishery F, Alhejoury HA, Turkistani M, Souror YR. Is zinc oxide eugenol cement still impeding the use of resin-based restoration? A systematic review. Dent Med Res [serial online] 2021 [cited 2022 Jan 27];9:59-67. Available from: https://www.dmrjournal.org/text.asp?2021/9/2/59/331390
| Introduction|| |
Since its introduction as dental material in the late 19th century (1890), until now zinc oxide eugenol (ZOE) is widely used by almost all dental specialties including restorative, endodontic, and prosthodontic purposes., The sedative and palliative effect of ZOE on inflamed pulp makes it the most favorable base under final restoration in deep cavities in both primary and permanent teeth with reversible pulpitis and after pulpotomy or pulpectomy in the primary dentition and also as an interim restoration after cavity preparation.,
ZOE is usually provided as a powder that mainly contains zinc oxide (ZO), rosin, and zinc acetate, and liquid that contains eugenol, which is responsible for the biological advantages that alleviate pain and reduce pulpal inflammation. Moreover, its antibacterial effect gives a better chance for pulp healing quickly and effectively.,, Despite its widespread use, ZOE has many drawbacks, and some of them were receded. The general weakness that ZOE had was improved by the incorporation of inert fillers and polymeric binders., Furthermore, these additives enhanced the physical and mechanical properties of ZOE and reduced the burning sensation that the ancient eugenol had. However, controversy still exists regarding the influence of ZOE on the mechanical properties of resin restorations.
Historically, the interaction between eugenol-based cement and resin-based restoration was first reported in 1981. Nonetheless, with the technological advancement and improvement of dental materials manufacturing in addition to the progress in testing technology of dental material properties, it was observed that the eugenol-containing materials have little or no effect on resin-containing restorative or cement materials.,, This review was conducted to explore the effect of ZOE on resin-based restorative and cement material by examining studies that attempted to explore this effect.
| Materials and Methods|| |
A systematic electronic search was conducted in search engines that included MEDLINE/PubMed, Ebscohost, SCOPUS, Web of Science, and EMBASE SciFinder focusing on evidence-based research articles published from January 1981 to January 2020. The following keywords or phrases were chosen “Eugenol” OR “ZOE” OR “Zinc oxide eugenol” AND “Composite resin” AND “bond strength” OR “shear strength” AND “Microtensile bond strength” AND “Microleakage” AND “Hardness.” Furthermore, the references of identified articles were manually searched for further data. We limited the search to articles that are published in the English language.
Inclusion and exclusion criteria
Only in vitro studies that measured the effect of ZOE on resin restoration or cement and that tested the properties of resin restoration or cement with ZOE were only included for our review. The studies with insufficient data, a poor methodology that did not evaluate the properties of ZOE with composite resin restoration or cement and articles in other languages other than English were excluded. Furthermore, in vivo studies, editorials, questionnaire surveys, case reports, letters to the editor, and commentaries were not included.
Two reviewers, HA and FP independently assessed the titles and abstracts of the selected articles by full-text reading. The articles selected after eligibility check underwent a full-text assessment and a collection of study to be evaluated was created. Both authors separately assessed the quality of the methodology of the studies included in our review using the 15-point checklist given by Downs and Black.
Two independent reviewers, YS and MT, did the data extraction and discrepancies in data were rectified by consensus. The information from the selected articles after extraction was then tabulated, and the articles were divided into categories according to the type tests conducted on resin materials. The literature search strategy for the review is summarized in [Figure 1].
|Figure 1: Flow diagram for literature search according to PRISMA guidelines|
Click here to view
| Results|| |
The electronic search identified 371 titles and abstracts, of which 189 were chosen for evaluation. Hence, thirty studies were included in the review. Of the 30 included studies; 1410 extracted teeth (579, 240 primary molars, 591 not specified primary or permanent) were examined in vitro, one study used 160 acrylic resin block and 1 used 60 composite core form, one study examined 15 bovine incisors, two studies used plastic molds, and one study used plastic teeth. Fifteen studies tested ZOE as temporary filling, four studies as base materials, two studies as a sealer, three studies as a root canal filling material in primary teeth, and six studies as a temporary cement before final resin cementation.
Shear bond strength
In our review, we had 15 studies that evaluated the shear bond strength (SBS) of ZOE.,,,,,,,,,,,,,, Out of this, 7 studies showed a significant influence of ZOE on SBS of composite restorations;,,,,,, 6 studies showed no significant differences with the control groups,,,,,, and 2 studies showed a significant reduction after 24 h exposure time and no significant reduction after 1 and 2 weeks [Table 1].,
|Table 1: Overview of all included studies that tested shear bond strength|
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Tensile bond strength
We included ten studies,,,,,,,,, that evaluated the microtensile bond strength (TBS) of ZOE. Four of them,,, showed a significant reduction in the TBS of composite restorations; four studies,,, showed no significant differences and the other two studies', results varied according to the exposure time of ZOE and adhesive type [Table 2].
|Table 2: Overview of all included studies that tested tensile bond strength|
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The review included three studies,, that evaluated microleakage, out of which two studies, showed a significant increase in composite restoration microleakage when used over ZOE and one study showed no statistically significant difference compared to the control group [Table 3].
To evaluate the microhardness of composite, we had included four studies,,, in this review. Out of these, two of them, demonstrated a significant reduction in microhardness when using conventional composite, while one study showed no significant reduction in microhardness when using hybrid composite. Only one study showed no statistically significant reduction of the hardness of composite [Table 4].
| Discussion|| |
This review included 30 articles that evaluated the multiple properties of ZOE cement, which included SBS, TBS, microleakage, and hardness.
Shear bond strength
Fifteen studies investigated the influence of ZOE on SBS with resin-based restoration compared to a control group without ZOE application or other experimental groups with different materials. Regarding the use of ZOE as a sealer, one study with a sample size of 144 extracted molars showed significantly lower resin-dentine SBS in ZOE sealers to eugenol-free sealers as control groups. A recent study conducted by Pires et al. in 32 extracted primary molars, lesser resin-dentine micro-SBS values were reported with ZOE that found premature failure compared to two other root canal filling materials. The conflicting results of SBS in these studies might be due to the differences in adhesive technique, powder-liquid ratio (P:L) of ZOE, and temporization period.
Eight studies,,,,,,, mentioned the role of the total-etch system in eliminating eugenol and other temporary filling remnants to obtain proper substrate, which can form a good resin-dentine interface. When using self-etch systems, there is only a shallow degree of demineralization that may not be sufficient to remove eugenol remnants, which might cause a significant reduction in SBS of the composite. This is also supported by findings given by Leirskar and Nordbø, which demonstrated the total removal of eugenol from dentin with 96% ethanol following mechanical removal of ZOE leads to an insignificant reduction of SBS. When P:L ratio decreased (increased eugenol concentration), the total-etch system could not eliminate the adverse effects of eugenol in bond strength. Yap et al. stated that the effect of ZOE is highly dependent on eugenol concentration.
Regarding exposure time effect, two studies that tested ZOE with different exposure time (24 h, 7, or 14 days) showed a statistically significant reduction of SBS only after 24 h exposure time and no adverse effect was reported after a week or 2., These findings show that SBS is influenced both by the period of ZOE exposure and the postremoval delay time.
Tensile bond strength
Nine studies evaluated TBS, and results varied. In 2014, Pinto et al. examined different exposure times of ZOE temporary cement with various adhesives on 40 extracted molars. The results showed that, regardless of adhesive type, with an exposure time of 45 days, results were similar to the control group, and a significant reduction of TBS with 24 h exposure time. Another study with a larger sample size (199 extracted molars) showed different results; the significant reduction was found after 7 and 28 days with a self-etch bonding system. Concerning ZOE and ZO without eugenol, four studies were conducted to test micro-TBS with a total sample size of 72 permanent molars and 15 bovine incisors and the results showed no significant differences between eugenol-containing and eugenol-free temporization and the control groups.,,, One study was conducted in the year 2003 to test the use of ZOE and ZO without eugenol temporary cement on a composite core. The results showed a statistically significant reduction in TBS with eugenol-containing temporary cement. On the use of ZOE as a root canal filling material, a sample size of 90 primary molars was tested with different root canal fillings and different final coronal restoration and a significant reduction in restoration bond strength to pulp chamber dentin was observed in groups where ZOE was used as a root canal filling and composite as final restoration. Another study tested the influence of ZOE sealers on adhesive luting cement (self-polymerized), and the results were a significant bond strength reduction, especially in cervical segments. TBS variations were observed, and this variation was caused by the same factors mentioned in the SBS section (adhesive type, the time factor, and ZOE form).
The rule of using of total-etch can eliminate the negative effect of eugenol and self-etch is insufficient to eliminate eugenol remnants' influence. Of the nine studies, only three studies showed discrepant findings., Double the failure rates of total-etch were reported with self-etch systems. Reduced bond strength can be expected with self-etch adhesives irrespective of the type of temporary filling (eugenol-containing or eugenol-free)., It was reported that ZOE's negative effect with a self-etch system could be neutralized after 45 days, while a total-etch system eliminates the adverse effect after 7 days of exposure of ZOE., Three studies showed contradictory findings regarding self-etch and total-etch to that reported in other studies. However, one was done with nonhuman teeth and small sample size (15 bovine incisors), and the results showed no adverse effect with the self-adhesive system. The second study showed a negative effect of ZOE with both self-etch and total-etch, and no effect on the duration of exposure to ZOE was found. This might have contributed to the composition of premeasured IRM capsules used in this study. The third study tested the effect of self-polymerized adhesives, and the total etches in which negative results were reported, in which there was no attempt made to remove eugenol-contaminated dentin. However, this reduction in TBS may be due to the time factor and also due to application of an adhesive after 1 h of ZOE placement.
Bargrizan et al. assessed microleakage of composite restorations in pulpotomized primary molars with different bases covering the ZOE layer. The results showed that the highest microleakage resulted in a group where ZOE was not covered with a base before composite restoration was applied. Another study that tested different root filling materials and their influence on composite restorations showed that the ZOE group showed a significant increase in microleakage compared to other experimental groups on primary canines. The findings were contrasting in another study done on 36 extracted premolar teeth that showed no statistically significant difference. Again, the etching procedures during resin composite restoration might contribute to eliminating the eugenol that may affect resin polymerization.
A study done on a plastic mold with 60 base-composite samples to evaluate the effect of different base materials on the composite hardness that used different composite types (micro-filled systems, visible light-activated and chemically activated, and conventional composite) showed that ZOE softens all types of composites. However, Itskovich et al. in 2014 evaluated the influence of ZOE on microhardness of different types of composite (micro-fill hybrid, micro-hybrid, micro-hybrid nonmethacrylate, and hybrid) using ZOE as a base material and then placing different modern composite and found that only hybrid composite groups showed no significant reduction in microhardness compared to the control group.
Bayindir et al. tested the difference of ZOE and noneugenol cement on a microhybrid composite that showed a significant reduction in microhardness of composite resin with ZOE but no difference seen between noneugenol and control group. Another study done in plastic teeth loaded with both ZOE and composite showed no statistical reduction on microhardness and elastic modulus of a composite at a distance of 100 μm ZOE-composite interface with a bonding system application. However, with the employment bonding system, the hardness of composite was not reduced significantly. It is clear that the eugenol affects the polymerization of the composite, which subsequently reduces its hardness; however, the type of composite and use of the bonding system and the depth of polymerization affection are essential factors to consider before any clinical use of ZOE with a composite restoration.
| Conclusion|| |
The result of this systematic review finds that there is no clinical study to confirm the success of using ZOE with resin-based restoration or cementation. However, some recent types of composite restoration showed an insignificant effect when used with ZOE. Besides, employing the total-etch technique before the application of resin restoration seems to eliminate the deleterious effect of ZOE on resins.
This review depended only on the studies that were published in English and we did not sort the study according to the quality standard like sample size. Furthermore, we did not use Cochrane central for the literature search due to some technical inconvenience.
All the authors would like to thank the institution library in helping out to carry out the required literature search.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4]