The significant contribution of medicinal plants to the drug industry is due to the increasing number of phytochemical and biological studies. In developing countries the herbal medicines are important sources of products in order to treat different infectious diseases and also to overcome the problems related with the available antimicrobial agents. Herbal remedies are getting popularity as they provide safe alternatives for treating various types of cancers [82–85]. These remedies are gaining interest because of their multidimensional health benefits like they are even used in different alternative treatments like acupuncture and massage therapy and by various traditional practitioners. The medicinal uses of the plants range from administration of leaves, stem, barks, seeds, and roots to using of the decoction from different plants [86]. There has been an increase in the demand of different herbal products in the last few decades and even in countries like United States, herbal remedies are in use in the form of different dietary supplements [84, 87, 88].

**Figure 3.** Extraction and fractionation from the leaves of *Syzigium cumunii*.

**Figure 3** represents the general layout of extraction of useful secondary metabolites from plants taking *Syzygium cumini* as an example using different solvents.

#### **5. Why to go for natural resources**

others [46]. Drugs derived from plants are used to treat cancer, tuberculosis, different skin diseases, diabetes, hypertension, and many more [47]. The National Cancer Institute collected around 35,000 plants from 20 different countries and evaluated almost 114,000 extracts for potential anticancer activity [48]. Among the approved anticancer drugs worldwide, between 1983 and 1994, 60% are of natural origin [49]. Some medicinal plants that are used to treat dif-

Today, oral care products combined with medicinal plant extracts are gaining high interest due to their low toxicity [66, 67]. Cetylpyridinium chloride, amine fluorides, triclosan, and

Different secondary metabolites produced by plants like terpenoids, flavonoids, alkaloids, and tannins are new sources of antimicrobial substances which help in combating resistant pathogens. Plants synthesize different useful substances, majority of which are secondary metabolites and almost 12,000 of them have been isolated [68]. Owing to their diverse structures, synthesizable analogues [69] and frequent usage [70] natural products have become an important source of medicine. Plants have evolved multiple defense systems for their survival because of plethora of rivals in order to fight the environmental stresses [71]. Plants are in fact the complex storehouse of undiscovered bioactive compounds with great potential to be used in medicines [72]. Basically the chemicals produced by plants are divided into two categories, the primary and the secondary metabolites [73]. The *primary metabolites* are involved in the synthesis of the basic building blocks of the plant, while the *secondary metabolites* are involved in the defense mechanism of the plant against different microbial infections [74]. The important secondary metabolites in medicine include flavonoids, alkaloids, terpenes, tannins, and phenolic compounds [75–78]. Unlimited opportunities for drug discovery have been provided by plant extracts, whether pure compounds or standardized extracts, because of their chemical diversity [79]. All the plants that are used in traditional medicine contain diverse substances that

The significant contribution of medicinal plants to the drug industry is due to the increasing number of phytochemical and biological studies. In developing countries the herbal medicines are important sources of products in order to treat different infectious diseases and also to overcome the problems related with the available antimicrobial agents. Herbal remedies are getting popularity as they provide safe alternatives for treating various types of cancers [82–85]. These remedies are gaining interest because of their multidimensional health benefits like they are even used in different alternative treatments like acupuncture and massage therapy and by various traditional practitioners. The medicinal uses of the plants range from administration of leaves, stem, barks, seeds, and roots to using of the decoction from different plants [86]. There has been an increase in the demand of different herbal products in the last few decades and even in countries like United

States, herbal remedies are in use in the form of different dietary supplements [84, 87, 88].

chlorhexidine are not only toxic, but they cause staining of teeth.

can be used to treat different infectious and chronic diseases [80, 81].

ferent diseases are given in **Table 1**.

24 Dental Caries - Diagnosis, Prevention and Management

**4. Secondary metabolites of plants**

The commercially available chemicals, if not all, to most of the antibiotics commonly available to treat oral infections, can alter the oral microbiota along with certain undesirable side effects [41, 89] and bacterial resistance [90]. An alteration in the microenvironment like wounds, malnutrition, abrasions, and different pathological conditions enhances disease development [91]. Also, the presence of ethanol that is commonly found in mouth washes has been linked to oral cancer [66, 67, 92, 93]. As a result of this, the indiscreet use of allopathic drugs and improper diagnosis of microbial infections not only lead to untargeted therapy, but it also gives way to resistant pathogens [94, 95]. Therefore, the search for alternative methods and products continues, and for that the phytochemicals isolated from plants that are used in traditional medicines are proving to be the good alternative to synthetic chemicals [96].

In developing countries the herbal medicines are proving to be an important source of products in order to treat different infectious diseases and also to overcome the problems related with the available antimicrobial agents. Herbal remedies are also getting popularity for treating various types of cancers as they provide safe alternative [82–85].

#### **6. Conclusion**

Prevention of dental caries is challenging, as the incidence of the disease is very high in general population and it occurs in economically deprived people who cannot afford the commercially available oral hygiene products [97]. Even though caries is known to be an infectious disease for decades, very little effort has been done to use this information clinically [98]. Different from other commercially available chemicals, they not only alter the oral microbial environment but also play a role in developing the resistant strain. Hence, in order to prevent dental caries, it is time to focus our attention toward natural resources which have vast abilities to inhibit the growth of microbes that are responsible for caries. For this, we need to isolate the bioactive compounds from plants with little or no harmful effects.

[8] Marcenes W, Kassebaum N, Bernabé E, Flaxman A, Naghavi M, Lopez A, Murray C. Global burden of oral conditions in 1990-2010 a systematic analysis. Journal of Dental

Dental Caries, Etiology, and Remedy through Natural Resources

http://dx.doi.org/10.5772/intechopen.75937

27

[10] Chandki R, Banthia P, Banthia R. Biofilms: A microbial home. Journal of Indian Society

[11] Lang N, Mombelli A, Attström R. Oral biofilms and calculus. In: Clinical Periodontology and Implant Dentistry. Oxford, UK: Blackwell Munksgaard; 2008. pp. 197-205

[12] Processor J. Quorum sensing in biofilms. In: Dental Plaque revisited. Cardiff: Bioline;

[13] Benson PE, Douglas C, Martin MV. Fluoridated elastomers: Effect on the microbiology of plaque. American Journal of Orthodontics and Dentofacial Orthopedics. 2004;**126**(3):

[15] Hardie J. Oral microbiology: Current concepts in the microbiology of dental caries and

[16] Baelum V, Pongpaisal S, Pithpornchaiyakul W, Pisuithanakan S, Teanpaisan R, Papapanou PN, Dahlen G, Fejerskov O. Determinants of dental status and caries among

[17] Fejerskov O, Kidd EA, Fejerskov O, Kidd EA. Dental Caries. Munksgaard: Blackwell;

[18] Featherstone J. The continuum of dental caries—Evidence for a dynamic disease pro-

[19] Featherstone J. Dental caries: A dynamic disease process. Australian Dental Journal.

[20] Scheie AA, Petersen FC. The biofilm concept: Consequences for future prophylaxis of

[21] Dye BA, Tan S, Smith V, Lewis B, Barker L, Thornton-Evans G, Eke P, Beltrán-Aguilar E, Horowitz A, Li C. Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital and health statistics series 11. Data from the National Health Survey; **2007**(248):1-92

[22] Iwaki K, Koya-Miyata S, Kohno K, Ushio S, Fukuda S.Antimicrobial activity of Polygonum tinctorium Lour: Extract against oral pathogenic bacteria. Journal of Natural Medicines.

[23] Wright J, Hart T. The genome projects: Implications for dental practice and education.

[24] Taylor GW, Manz MC, Borgnakke WS. Diabetes, periodontal diseases, dental caries, and tooth loss: A review of the literature. Compendium of Continuing Education in

Dentistry (Jamesburg, NJ: 1995). 2004;**25**(3):179-184, 186-178, 190; quiz 192

oral diseases? Critical Reviews in Oral Biology & Medicine. 2004;**15**(1):4-12

[14] Roberts A. Bacteria in the mouth. Dental Update. 2005;**32**(3):134-136, 139-140, 142

periodontal disease. British Dental Journal. 1992;**172**(7):271-278

adults in southern Thailand. Acta Odontologica. 2002;**60**(2):80-86

cess. Journal of Dental Research. 2004;**83**(suppl 1):C39-C42

Journal of Dental Education. 2002;**66**(5):659-671

[9] Selwitz RH, Ismail AI, Pitts NB. Dental caries. The Lancet. 2007;**369**(9555):51-59

Research. 2013;**92**(7):592-597

1999. pp. 79-88

325-330

2003

2008;**53**(3):286-291

2006;**60**(2):121-125

of Periodontology. 2011;**15**(2):111

#### **Author details**

Lubna Tahir\* and Rabia Nazir

\*Address all correspondence to<EMAIL_ADDRESS>
Applied Chemistry Research Centre, Pakistan Council of Scientific and Industrial Research Laboratories Complex, Lahore, Pakistan

#### **References**

**6. Conclusion**

26 Dental Caries - Diagnosis, Prevention and Management

**Author details**

**References**

Lubna Tahir\* and Rabia Nazir

Laboratories Complex, Lahore, Pakistan

Journal. 1984;**34**(3):166-169

Paediatric Dentistry. 2011;**21**(6):432-440

\*Address all correspondence to<EMAIL_ADDRESS>
Prevention of dental caries is challenging, as the incidence of the disease is very high in general population and it occurs in economically deprived people who cannot afford the commercially available oral hygiene products [97]. Even though caries is known to be an infectious disease for decades, very little effort has been done to use this information clinically [98]. Different from other commercially available chemicals, they not only alter the oral microbial environment but also play a role in developing the resistant strain. Hence, in order to prevent dental caries, it is time to focus our attention toward natural resources which have vast abilities to inhibit the growth of microbes that are responsible for caries. For this, we need

Applied Chemistry Research Centre, Pakistan Council of Scientific and Industrial Research

[1] Petersen PE. The burden of oral disease: Challenges to improving oral health in the 21st

[2] Jamieson LM, Parker EJ, Armfield JM. Indigenous child oral health at a regional and

[3] Saparamadu K. Prevention of oral diseases in developing countries. International Dental

[4] Petersen PE. World Health Organization global policy for improvement of oral health-World Health Assembly 2007. International Dental Journal. 2008;**58**(3):115-121

[5] Guido JA, Martinez Mier EA, Soto A, Eggertsson H, Sanders BJ, Jones JE, Weddell JA, Villanueva Cruz I, de la Concha A, Luis J.Caries prevalence and its association with brushing habits, water availability, and the intake of sugared beverages. International Journal of

[6] Hicks J, Garcia-Godoy F, Flaitz C. Biological factors in dental caries: Role of remineralization and fluoride in the dynamic process of demineralization and remineralization

[7] Javed F, Ramalingam S, Ahmed HB, Gupta B, Sundar C, Qadri T, Al-Hezaimi K, Romanos GE. Oral manifestations in patients with neurofibromatosis type-1: A comprehensive lit-

(part 3). Journal of Clinical Pediatric Dentistry. 2004;**28**(3):203-214

erature review. Critical Reviews in Oncology/Hematology. 2014

century. Bulletin of the World Health Organization. 2005;**83**:3-3

state level. Journal of Paediatrics and Child Health. 2007;**43**(3):117-121

to isolate the bioactive compounds from plants with little or no harmful effects.

[25] Keyes P, Jordan H. Periodontal lesions in the Syrian hamster—III: Findings related to an infectious and transmissible component. Archives of Oral Biology. 1964;**9**(4):377-398

[42] Kubo I, Muroi H, Himejima M.Antimicrobial activity of green tea flavor components and their combination effects. Journal of Agricultural and Food Chemistry. 1992;**40**(2):245-248

Dental Caries, Etiology, and Remedy through Natural Resources

http://dx.doi.org/10.5772/intechopen.75937

29

[43] Tsai T-H, Tsai T-H, Chien Y-C, Lee C-W, Tsai P-J. In vitro antimicrobial activities against cariogenic *streptococci* and their antioxidant capacities: A comparative study of green tea

[44] Tellez N, Tellez M, Perdomo M, Alvarado A, Gamboa F. Anticariogenic activity of the active fraction from *Isertia laevis* against *S. mutans* and *S. sobrinus*: Comparison of two extraction methods. Acta Odontologica Latinoamericana: AOL. 2009;**23**(3):188-195 [45] Vaghasiya Y, Chanda S. Screening of some traditionally used Indian plants for antibacterial activity against *Klebsiella pneumonia*. Journal of Herbal Medicine Toxicology.

[46] Farnsworth N, Blowster R, Darmratoski D, Meer W, Cammarato L. Studies on Catharanthus alkaloids IV evaluation by means of TLC and ceric ammonium sulphate

[47] Chatterjee I, Chakravarty A, Gomes A. Daboia russellii and *Naja kaouthia* venom neutralization by lupeol acetate isolated from the root extract of Indian sarsaparilla *Hemidesmus*

[48] Shoeb M. Cytotoxic Compounds from the Genus Centaurea. 2005. openair.rgu.ac.uk

[49] Cragg GM, Newman DJ, Snader KM. Natural products in drug discovery and develop-

[50] Fernando M, Wickramasinghe SN, Thabrew M, Ariyananda P, Karunanayake E. Effect of *Artocarpus heterophyllus* and *Asteracanthus longifolia* on glucose tolerance in normal human subjects and in maturity-onset diabetic patients. Journal of Ethnopharmacology.

[51] Aderibigbe A, Emudianughe T, Lawal B. Antihyperglycaemic effect of *Mangifera indica*

[52] Dhanavade MJ, Jalkute CB, Ghosh JS, Sonawane KD. Study antimicrobial activity of lemon (*Citrus lemon* L.) peel extract. British Journal of Pharmacology and Toxicology.

[53] Shaikh R, Pund M, Dawane A, Iliyas S. Evaluation of anticancer, antioxidant, and possible anti-inflammatory properties of selected medicinal plants used in Indian traditional medication. Journal of Traditional and Complementary Medicine. 2014;**4**(4):253-257 [54] Sharma A, Chandraker S, Patel VK, Ramteke P. Antibacterial activity of medicinal plants against pathogens causing complicated urinary tract infections. Indian Journal of

[55] Tahir L, Ahmed S, Hussain N, Perveen I, Rahman S. Effect of leaves extract of indigenous species of *Syzygium cumini* on dental caries causing pathogens. International Journal of

versus different herbs. Food Chemistry. 2008;**110**(4):859-864

*indicus* R. Br. Journal of Ethnopharmacology. 2006;**106**(1):38-43

ment. Journal of Natural Products. 1997;**60**(1):52-60

in rat. Phytotherapy Research. 1999;**13**(6):504-507

Pharmaceutical Sciences. 2009;**71**(2):136-139

Pharma and Bioscience. 2012;**3**(3):1032-1038

2009;**3**:161-164

1991;**31**(3):277-282

2011;**2**(3):119-122

spray reagent. Lloydia. 1967;**27**:302-314

[42] Kubo I, Muroi H, Himejima M.Antimicrobial activity of green tea flavor components and their combination effects. Journal of Agricultural and Food Chemistry. 1992;**40**(2):245-248

[25] Keyes P, Jordan H. Periodontal lesions in the Syrian hamster—III: Findings related to an infectious and transmissible component. Archives of Oral Biology. 1964;**9**(4):377-398

[26] König K. Caries and Caries Prevention. Munich, Germany: Goldmann; 1971. pp. 11-68

[27] Declerck D, Leroy R, Martens L, Lesaffre E, Garcia-Zattera MJ, Broucke SV, Debyser M, Hoppenbrouwers K. Factors associated with prevalence and severity of caries experience in preschool children. Community Dentistry and Oral Epidemiology. 2008;**36**(2):168-178

[28] Paster BJ, Boches SK, Galvin JL, Ericson RE, Lau CN, Levanos VA, Sahasrabudhe A, Dewhirst FE. Bacterial diversity in human subgingival plaque. Journal of Bacteriology.

[29] Aas JA, Paster BJ, Stokes LN, Olsen I, Dewhirst FE. Defining the normal bacterial flora of

[30] Paster BJ, Olsen I, Aas JA, Dewhirst FE. The breadth of bacterial diversity in the human periodontal pocket and other oral sites. Periodontology 2000. 2006;**42**(1):80-87

[31] Islam B, Khan SN, Khan AU. Dental caries: From infection to prevention. Medical Science

[32] Banas J, Vickerman M. Glucan-binding proteins of the oral *streptococci*. Critical Reviews

[33] Lemos JA, Burne RA. A model of efficiency: Stress tolerance by *Streptococcus mutans*.

[34] Loesche WJ. Role of *Streptococcus mutans* in human dental decay. Microbiological

[35] Watnick P, Kolter R. Biofilm, city of microbes. Journal of Bacteriology. 2000;**182**(10):

[36] Jeon J-G, Rosalen P, Falsetta M, Koo H. Natural products in caries research: Current (limited) knowledge, challenges and future perspective. Caries Research. 2011;**45**(3):243-263

[37] Sydney S, Lacy R, Bakhtiar M. The Betalactam Antibiotics Penicillin and Cephalosporin

[38] Mehrgan H, Mojab F, Pakdaman S, Poursaeed M. Antibacterial activity of Thymus pubescens methanolic extract. Iranian Journal of Pharmaceutical Research. 2010:291-295 [39] Nascimento GG, Locatelli J, Freitas PC, Silva GL. Antibacterial activity of plant extracts and phytochemicals on antibiotic-resistant bacteria. Brazilian Journal of Microbiology.

[40] Bisht R, Katiyar A, Singh R, Mittal P. Antibiotic resistance-A global issue of concern.

[41] Tenover FC. Mechanisms of antimicrobial resistance in bacteria. The American Journal

Asian Journal of Pharmaceutical and Clinical Research. 2009;**2**(2):34-39

the oral cavity. Journal of Clinical Microbiology. 2005;**43**(11):5721-5732

2001;**183**(12):3770-3783

28 Dental Caries - Diagnosis, Prevention and Management

Monitor. 2007;**13**(11):RA196

Reviews. 1986;**50**(4):353

2675-2679

2000;**31**(4):247-256

of Medicine. 2006;**119**(6):S3-S10

in Oral Biology & Medicine. 2003;**14**(2):89-99

in Perspective. Hodder and Stongton: London, UK; 1980

Microbiology. 2008;**154**(11):3247-3255

[56] Tahir L, Aslam A, Ahmed S.Antibacterial activities of *Diospyros blancoi*, *Phoenix dactylifera* and *Morus nigra* against dental caries causing pathogens: An in vitro study. Pakistan Journal of Pharmaceutical Sciences. 2017;**30**(1):163-169

[69] Paterson I, Anderson EA. The renaissance of natural products as drug candidates.

Dental Caries, Etiology, and Remedy through Natural Resources

http://dx.doi.org/10.5772/intechopen.75937

31

[70] Chin Y-W, Balunas MJ, Chai HB, Kinghorn AD. Drug discovery from natural sources.

[71] Ballhorn DJ, Kautz S, Heil M, Hegeman AD. Cyanogenesis of wild lima bean (*Phaseolus lunatus* L.) is an efficient direct defence in nature. PLoS One. 2009;**4**(5):e5450

[72] Plotkin MJ. Conservation, ethnobotany, and the search for new jungle medicines: Pharmacognosy comes of age… again. Pharmacotherapy: The Journal of Human

[73] Agosta WC. Bombardier Beetles and Fever Trees: A Close-up Look at Chemical Warfare

[74] Cowan MM. Plant products as antimicrobial agents. Clinical Microbiology Reviews.

[75] Kazmi MH, Malik A, Hameed S, Akhtar N, Noor Ali S. An anthraquinone derivative

[76] Omulokoli E, Khan B, Chhabra S. Antiplasmodial activity of four Kenyan medicinal

[77] Cosentino S, Tuberoso C, Pisano B, Satta M, Mascia V, Arzedi E, Palmas F. In-vitro antimicrobial activity and chemical composition of *Sardinian thymus* essential oils. Letters in

[78] Edeoga H, Okwu D, Mbaebie B. Phytochemical constituents of some Nigerian medicinal

[79] Cos P, Vlietinck AJ, Berghe DV, Maes L. Anti-infective potential of natural products: How to develop a stronger in vitro 'proof-of-concept'. Journal of Ethnopharmacology.

[80] Duraipandiyan V, Ayyanar M, Ignacimuthu S. Antimicrobial activity of some ethnomedicinal plants used by Paliyar tribe from Tamil Nadu, India. BMC Complementary and

[81] Aziz MM, Raza MA, Saleem H, Wajid M, Bashir K, ur Rehman MI. Medicinal values of herbs and plants, importance of phytochemical evaluation and ethnopharmacological screening: An illustrated review essay. Journal of Pharmaceutical and Cosmetic

[82] Lampronti I, Martello D, Bianchi N, Borgatti M, Lambertini E, Piva R, Jabbar S, Shahabuddin Kabir Choudhuri M, Tareq Hassan Khan M, Gambari R. In vitro antiproliferative effects on human tumor cell lines of extracts from the Bangladeshi medicinal

plant *Aegle marmelos* Correa. Phytomedicine. 2003;**10**(4):300-308

Science. 2005;**310**(5747):451-453

1999;**12**(4):564-582

2006;**106**(3):290-302

Sciences. 2014;**2**(1):6-10

The AAPS Journal. 2006;**8**(2):E239-E253

Pharmacology and Drug Therapy. 1988;**8**(5):257-262

and Signals in Animals and Plants. USA: Helix Books; 1996

from *Cassia italica*. Phytochemistry. 1994;**36**(3):761-763

Applied Mirobiology. 1999;**29**(2):130-135

Alternative Medicine. 2006;**6**(1):35

plants. Journal of Ethnopharmacology. 1997;**56**(2):133-137

plants. African Journal of Biotechnology. 2005;**4**(7):685-688

[69] Paterson I, Anderson EA. The renaissance of natural products as drug candidates. Science. 2005;**310**(5747):451-453

[56] Tahir L, Aslam A, Ahmed S.Antibacterial activities of *Diospyros blancoi*, *Phoenix dactylifera* and *Morus nigra* against dental caries causing pathogens: An in vitro study. Pakistan

[57] Koffi-Nevry R, Kouassi KC, Nanga ZY, Koussémon M, Loukou GY. Antibacterial activity of two bell pepper extracts: *Capsicum annuum* L. and *Capsicum frutescens*. International

[58] Bacon K, Boyer R, Denbow C, O'Keefe S, Neilson A, Williams R. Antibacterial activity of jalapeño pepper (*Capsicum annuum* var. *annuum*) extract fractions against select food-

[59] Biswas B, Rogers K, McLaughlin F, Daniels D, Yadav A. Antimicrobial activities of leaf extracts of Guava (*Psidium guajava* L.) on two gram-negative and gram-positive bacteria.

[60] Gonçalves FA, Andrade Neto M, Bezerra JN, Macrae A, Sousa OV, Fonteles-Filho AA, Vieira RH. Antibacterial activity of GUAVA, *Psidium guajava* Linnaeus, leaf extracts on diarrhea-causing enteric bacteria isolated from *Seabob shrimp*, *Xiphopenaeus kroyeri* (Heller). Revista do Instituto de Medicina Tropical de São Paulo. 2008;**50**(1):11-15 [61] Arunkumar S, Muthuselvam M. Analysis of phytochemical constituents and antimicrobial activities of *Aloe vera* L. against clinical pathogens. World Journal of Agricultural

[62] Alemdar S, Agaoglu S. Investigation of in vitro antimicrobial activity of *Aloe vera* juice.

[63] Mantle D, Gok MA, Lennard T.Adverse and beneficial effects of plant extracts on skin and skin disorders. Adverse Drug Reactions and Toxicological Reviews. 2001;**20**(2):89-103

[64] Heyman L, Houri-Haddad Y, Heyman SN, Ginsburg I, Gleitman Y, Feuerstein O. Combined antioxidant effects of Neem extract, bacteria, red blood cells and lysozyme: Possible relation to periodontal disease. BMC Complementary and Alternative Medicine.

[65] Gupta SC, Prasad S, Tyagi AK, Kunnumakkara AB, Aggarwal BB. Neem (*Azadirachta indica*): An indian traditional panacea with modern molecular basis. Phytomedicine.

[66] Knoll-Köhler E, Stiebel J. Amine fluoride gel affects the viability and the generation of superoxide anions in human polymorphonuclear leukocytes: An in vitro study.

[67] Neumegen RA, Fernández-Alba AR, Chisti Y. Toxicities of triclosan, phenol, and copper

[68] Lai P, Roy J. Antimicrobial and chemopreventive properties of herbs and spices. Current

sulfate in activated sludge. Environmental Toxicology. 2005;**20**(2):160-164

Journal of Pharmaceutical Sciences. 2017;**30**(1):163-169

borne pathogens. Food Science & Nutrition. 2017;**5**(3):730-738

Journal of Animal and Veterinary Advances. 2009;**8**(1):99-102

European Journal of Oral Sciences. 2002;**110**(4):296-301

Medicinal Chemistry. 2004;**11**(11):1451-1460

Journal of Food Properties. 2012;**15**(5):961-971

30 Dental Caries - Diagnosis, Prevention and Management

International Journal of Microbiology. 2013;**2013**:7

Sciences. 2009;**5**(5):572-576

2017;**17**(1):399

2017;**34**:14-20

[83] Yadav R, Agarwala M. Phytochemical analysis of some medicinal plants. Journal of Phytology. 2011;**3**(12):10-15

[96] Prabu G, Gnanamani A, Sadulla S.Guaijaverin—A plant flavonoid as potential antiplaque agent against *Streptococcus mutans*. Journal of Applied Microbiology. 2006;**101**(2):487-495

Dental Caries, Etiology, and Remedy through Natural Resources

http://dx.doi.org/10.5772/intechopen.75937

33

[97] Meyerowitz C, Watson GE. The efficacy of an intraoral fluoride-releasing system in irradiated head and neck cancer patients: A preliminary study. The Journal of the American

[98] Tanzer JM, Livingston J, Thompson AM. The microbiology of primary dental caries in

Dental Association. 1998;**129**(9):1252-1259

humans. Journal of Dental Education. 2001;**65**(10):1028-1037

[96] Prabu G, Gnanamani A, Sadulla S.Guaijaverin—A plant flavonoid as potential antiplaque agent against *Streptococcus mutans*. Journal of Applied Microbiology. 2006;**101**(2):487-495

[83] Yadav R, Agarwala M. Phytochemical analysis of some medicinal plants. Journal of

[84] Tiwari AA, Ayello J, van de Ven C, Barth MJ, Cairo MS. Obinutuzumab (GA101) significantly increases overall survival against CD20+ rituximab-sensitive and-resistant Burkitt (BL) and acute lymphoblastic leukemia (B-ALL): Potential targeted therapy in patients with high risk BL and pre-B-ALL. Cancer Research. 2014;**74**(19 Supplement):2902-2902

[85] Yarney J, Donkor A, Opoku SY, Yarney L, Agyeman-Duah I, Abakah AC, Asampong E. Characteristics of users and implications for the use of complementary and alternative medicine in Ghanaian cancer patients undergoing radiotherapy and chemotherapy: A cross-sectional study. BMC Complementary and Alternative Medicine. 2013;**13**(1):16

[86] Ogbulie J, Ogueke C, Nwanebu F. Antibacterial properties of *Uvaria chamae*, *Congronema latifolium*, *Garcinia kola*, *Vemonia amygdalina* and *Aframomium melegueta*. African Journal

[87] Briskin DP. Medicinal plants and phytomedicines. Linking plant biochemistry and

[88] Rahal A, Prakash A, Kumar Verma A, Kumar V, Roy D. Proximate and elemental analyses of *Tinospora cordifolia* stem. Pakistan Journal of Biological Sciences. 2014;**17**(5):744-747

[89] Park K, You J, Lee H, Baek N, Hwang J, Kuwanon G. An antibacterial agent from the root bark of *Morus alba* against oral pathogens. Journal of Ethnopharmacology. 2003;**84**(2):

[90] Palombo EA. Traditional medicinal plant extracts and natural products with activity against oral bacteria: Potential application in the prevention and treatment of oral diseases. Evidence-based Complementary and Alternative Medicine. 2011;**2011**(90):1-15 [91] Madenspacher JH, Azzam KM, Gowdy KM, Malcolm KC, Nick JA, Dixon D, Aloor JJ, Draper DW, Guardiola JJ, Shatz M. p53 integrates host defense and cell fate during bac-

terial pneumonia. The Journal of Experimental Medicine. 2013;**210**(5):891-904

[92] Lachenmeier DW, Sohnius E-M. The role of acetaldehyde outside ethanol metabolism in the carcinogenicity of alcoholic beverages: Evidence from a large chemical survey. Food

[93] McCullough M, Farah C. The role of alcohol in oral carcinogenesis with particular reference to alcohol-containing mouthwashes. Australian Dental Journal. 2008;**53**(4):302-305

[94] Kumarasamy KK, Toleman MA, Walsh TR, Bagaria J, Butt F, Balakrishnan R, Chaudhary U, Doumith M, Giske CG, Irfan S. Emergence of a new antibiotic resistance mechanism in India, Pakistan, and the UK: A molecular, biological, and epidemiological study. The

[95] Ewam UPCVV. Evidence based antibacterial potentials of medicinal plants and herbs countering bacterial pathogens especially in the era of emerging drug resistance: An

integrated update. International Journal of Pharmacology. 2014;**10**(1):1-43

physiology to human health. Plant Physiology. 2000;**124**(2):507-514

Phytology. 2011;**3**(12):10-15

32 Dental Caries - Diagnosis, Prevention and Management

of Biotechnology. 2007;**6**(13):1549-1553

and Chemical Toxicology. 2008;**46**(8):2903-2911

Lancet Infectious Diseases. 2010;**10**(9):597-602

181-185

**Chapter 4**

**Provisional chapter**

**Etiology of Secondary Caries in Prosthodontic**

**Etiology of Secondary Caries in Prosthodontic**

DOI: 10.5772/intechopen.76097

When preparing prosthetic restorations, dentists always try to create restorations functionally ideal while not compromising on esthetics. The factors that make a restoration successful include how well they fit both internally and marginally, their ability to withstand punishment without breaking, and their visual appeal. Imperfect marginal adaptation can lead to unpleasant and unwanted side effects such as plaque accumulation, marginal discoloration, microleakage, carious and endodontic lesions, and periodontal disease. If there is a gap between the crown and the prepared tooth, this can result in the dissolution of the luting material. If the fit of the restoration and the thickness of the cement are designed to be favorable, the cement is not dissolved and the abutment tooth is prevented from secondary caries. The marginal fit of the restorations is considerably affected by the materials and techniques used when making dental crowns. This chapter

Throughout the history of dentistry, dental clinicians, prosthodontists, and manufacturers have strived to create dental restorations that are both esthetically pleasing and function perfectly. Multiple factors determine how therapeutic the restorations are and how long they last. Just how successful a dental restoration depends on three principal factors: how esthetically pleasing it is, how resistant it is to fracturing, and marginal adaptation, meaning how well they fit [1, 2]. More recently developed materials have a high esthetic value and are

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

Arzu Zeynep Yildirim Bicer and Senem Unver

Arzu Zeynep Yildirim Bicer and Senem Unver

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

contains reviews on marginal fitting and caries. **Keywords:** caries, marginal fitting, restoration

http://dx.doi.org/10.5772/intechopen.76097

**Treatments**

**Abstract**

**1. Introduction**

**Treatments**

#### **Etiology of Secondary Caries in Prosthodontic Treatments Etiology of Secondary Caries in Prosthodontic Treatments**

DOI: 10.5772/intechopen.76097

Arzu Zeynep Yildirim Bicer and Senem Unver Arzu Zeynep Yildirim Bicer and Senem Unver

Additional information is available at the end of the chapter Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76097

#### **Abstract**

When preparing prosthetic restorations, dentists always try to create restorations functionally ideal while not compromising on esthetics. The factors that make a restoration successful include how well they fit both internally and marginally, their ability to withstand punishment without breaking, and their visual appeal. Imperfect marginal adaptation can lead to unpleasant and unwanted side effects such as plaque accumulation, marginal discoloration, microleakage, carious and endodontic lesions, and periodontal disease. If there is a gap between the crown and the prepared tooth, this can result in the dissolution of the luting material. If the fit of the restoration and the thickness of the cement are designed to be favorable, the cement is not dissolved and the abutment tooth is prevented from secondary caries. The marginal fit of the restorations is considerably affected by the materials and techniques used when making dental crowns. This chapter contains reviews on marginal fitting and caries.

**Keywords:** caries, marginal fitting, restoration

#### **1. Introduction**

Throughout the history of dentistry, dental clinicians, prosthodontists, and manufacturers have strived to create dental restorations that are both esthetically pleasing and function perfectly. Multiple factors determine how therapeutic the restorations are and how long they last. Just how successful a dental restoration depends on three principal factors: how esthetically pleasing it is, how resistant it is to fracturing, and marginal adaptation, meaning how well they fit [1, 2]. More recently developed materials have a high esthetic value and are

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

mechanically very resilient. The factors that affect marginal adaption include how well the restoration bonds to the prepared surface, how effective the seal is, and the characteristics of the adhesive used to bond the restoration to the tooth. When a prosthetic restoration does not fit properly, this can cause plaque accumulation [2, 3]. This in turn can lead to microleakage and endodontic inflammation [4], and it increases the probability of carious lesions [5, 6]. The periodontal and endodontic lesions that form as a result may require the prosthetic restoration to be replaced or necessitate endodontic treatment, or even tooth extraction.

#### **2. Caries**

"Dental caries is determined by the dynamic balance between the pathological factors that lead to demineralization and the protective factors that lead to remineralization." [7] Caries is a tissue consisting of densely packed crystallites formed in a single axis having both inter- and intra-prismatic micropores measuring between 1 and 30 nm in width. Caries appears in the enamel first and this is accompanied by hypermineralization of the dentine below the cavity [8]. One common characteristic of this is sclerotic dentinal tubules [9]. The dentine starts to demineralize at the outer edge of the lesion matching the outer edge of the enamel lesion [10]. Dentinal caries develops and spreads quickly from the dentine-enamel border moving under the enamel, and this results in caries [8].

#### **2.1. Secondary caries**

Secondary caries develops at the site where the tooth and the prosthetic restoration interface. They are considered the main reason why prosthetics fail no matter what restorative material is used [11, 12].

If the conditions around the seal become acidic, the site will start to demineralize in a manner similar to primary caries because of the process of demineralization and remineralization [11]. All the factors that accelerate the accumulation of biofilm mass or impede its removal can be regarded as potential causes of secondary caries, and this is likely why secondary caries mainly occur on the adjacent surfaces [13] (**Figure 1**).

coronal, or sagittal planes. This method is called Cone Beam Computed Tomography (CBCT). It is better than a medical CT because it gives 3D tomographic images while subjecting the patient to less radiation. While it is useful in cases where 2D imaging techniques are inadequate, it nevertheless uses more radiation than 2D radiographic imaging techniques, so the

Etiology of Secondary Caries in Prosthodontic Treatments

http://dx.doi.org/10.5772/intechopen.76097

37

The condition can only be diagnosed as secondary caries if the mineralized tissues around the strain have become soft or if cavitation occurs at the edge of the restoration. The gap will probably contain bacteria, but that does not always mean that secondary caries is going to occur. It is useful to remember that many types of bacteria exist in the mouth and that only some of them can produce caries and only then under certain conditions. In fact, there is no documented proof of any relationship between the onset of secondary caries lesions and gaps where the prosthetic restoration joins the tooth, other than when the gaps are large, for

technician has to exercise care when using this method [18].

**Figure 2.** Radiographic image of secondary caries around a prosthetic restoration.

example, 250 [19] or 400 μm [20].

**Figure 1.** Image of a crown.

#### **2.2. Diagnosis of secondary caries**

Secondary caries has to be caught early on in order to increase the treatment's chances of success and to stop the hard tissue from being destructed [14–16]. To diagnose secondary caries adjacent to restorations, several different radiographic techniques can be used and these include periapical, bitewing, occlusal, and panoramic imaging (**Figure 2**). In order to prevent wrong diagnoses, radiographic examination must be made together with a clinical examination [17]. It is hard to diagnose secondary carries at the buccal or lingual area on the tooth because these methods only give 2D images. There is a 3D imagine method used by clinicians to assess the area being examined without the need to place other objects in the axial,

**Figure 1.** Image of a crown.

mechanically very resilient. The factors that affect marginal adaption include how well the restoration bonds to the prepared surface, how effective the seal is, and the characteristics of the adhesive used to bond the restoration to the tooth. When a prosthetic restoration does not fit properly, this can cause plaque accumulation [2, 3]. This in turn can lead to microleakage and endodontic inflammation [4], and it increases the probability of carious lesions [5, 6]. The periodontal and endodontic lesions that form as a result may require the prosthetic restora-

"Dental caries is determined by the dynamic balance between the pathological factors that lead to demineralization and the protective factors that lead to remineralization." [7] Caries is a tissue consisting of densely packed crystallites formed in a single axis having both inter- and intra-prismatic micropores measuring between 1 and 30 nm in width. Caries appears in the enamel first and this is accompanied by hypermineralization of the dentine below the cavity [8]. One common characteristic of this is sclerotic dentinal tubules [9]. The dentine starts to demineralize at the outer edge of the lesion matching the outer edge of the enamel lesion [10]. Dentinal caries develops and spreads quickly from the dentine-enamel border moving under

Secondary caries develops at the site where the tooth and the prosthetic restoration interface. They are considered the main reason why prosthetics fail no matter what restorative material

If the conditions around the seal become acidic, the site will start to demineralize in a manner similar to primary caries because of the process of demineralization and remineralization [11]. All the factors that accelerate the accumulation of biofilm mass or impede its removal can be regarded as potential causes of secondary caries, and this is likely why secondary caries

Secondary caries has to be caught early on in order to increase the treatment's chances of success and to stop the hard tissue from being destructed [14–16]. To diagnose secondary caries adjacent to restorations, several different radiographic techniques can be used and these include periapical, bitewing, occlusal, and panoramic imaging (**Figure 2**). In order to prevent wrong diagnoses, radiographic examination must be made together with a clinical examination [17]. It is hard to diagnose secondary carries at the buccal or lingual area on the tooth because these methods only give 2D images. There is a 3D imagine method used by clinicians to assess the area being examined without the need to place other objects in the axial,

tion to be replaced or necessitate endodontic treatment, or even tooth extraction.

**2. Caries**

the enamel, and this results in caries [8].

36 Dental Caries - Diagnosis, Prevention and Management

mainly occur on the adjacent surfaces [13] (**Figure 1**).

**2.2. Diagnosis of secondary caries**

**2.1. Secondary caries**

is used [11, 12].

**Figure 2.** Radiographic image of secondary caries around a prosthetic restoration.

coronal, or sagittal planes. This method is called Cone Beam Computed Tomography (CBCT). It is better than a medical CT because it gives 3D tomographic images while subjecting the patient to less radiation. While it is useful in cases where 2D imaging techniques are inadequate, it nevertheless uses more radiation than 2D radiographic imaging techniques, so the technician has to exercise care when using this method [18].

The condition can only be diagnosed as secondary caries if the mineralized tissues around the strain have become soft or if cavitation occurs at the edge of the restoration. The gap will probably contain bacteria, but that does not always mean that secondary caries is going to occur. It is useful to remember that many types of bacteria exist in the mouth and that only some of them can produce caries and only then under certain conditions. In fact, there is no documented proof of any relationship between the onset of secondary caries lesions and gaps where the prosthetic restoration joins the tooth, other than when the gaps are large, for example, 250 [19] or 400 μm [20].

#### **3. Etiology of secondary caries**

#### **3.1. Microleakage**

The classic definition of microleakage is the movement of matter, such as bacteria, oral fluids, even ions, into a fluid-filled gap or a naturally occurring structural defect, or between restorations and the tooth [21]. Microleakage is regarded as one of the principal causes of failure in crowns, so it is one of the main factors that determine the clinical lifespan of dental restorations [22]. Not only does microleakage adversely affect a restoration's clinical use, it can also lead to hypersensitivity, discoloration along the margin [23] (**Figure 3**), secondary caries, inflammation, or necrosis of the vital pulp and often requires endodontic treatment [24, 25].

Maintaining the gap along the edge as small as possible is very important because the potential for microleakage increases as the size of the gap increases [40]. No matter what type of cement is used, gaps between 100 and 120 μm are considered clinically acceptable [41] in terms of minimizing the problems that might result in cement loss [42]; 90 μm or less is the acceptable size for gaps in computer-aided design/computer-aided manufacturing (CAD/ CAM)-generated restorations [27, 43–45]. Variations in the internal fit can cause fatigue, possibly weakening the restoration. The thickness of the layer of dental cement along the axial walls of the preparation affects how well the restoration sits in place. Among the factors that influence film thickness are preparation, how the margin is designed and configured, how rough the surface is, how much pressure is applied during cementation and for how long, the cement's powder/liquid ratio, the type of cement, the spacers used, and the method used for

Etiology of Secondary Caries in Prosthodontic Treatments

http://dx.doi.org/10.5772/intechopen.76097

39

The fitting of the restoration and proximal surfaces may be checked before cementation to prevent any overhangs that can cause plaque accumulation and secondary caries. Even tiny overhangs, which are often hard to detect clinically, can lead to plaque accumulation, periodontal disease, and the onset of secondary caries. The edges of crown's margins are susceptible to microleakage, and clinical tests have shown that large gaps can result in secondary caries [47, 48]. Caries is the second most common biological complaint in crowned teeth next

Laser videography [50], profile projection [51], micro-CT, and CAD/CAM scans [52] are some of the ways in which the adaptation of prosthetic restorations can be assessed. One commonly used technique is the cement analog or Replica Technique (RT). This method allows the dimensions of the internal and marginal gaps in prosthetic restorations to be estimated with a fair degree of accuracy [53]. This nondestructive technique involves sitting the restoration on top of a prepared die using an impression material instead of cement. Once set, the impression material and the restoration are carefully removed from the die and the thickness of the cement analog layer is measured [54–58]. Another nondestructive method that can be used to check the size and shape of gaps in prosthetic restorations is the "Weight Technique" (WT). It costs less than RT and is easier to do. In WT, the material used to simulate the cement layer is weighed at certain points rather than having its thickness measured like in RT. The weight corresponds to the thickness of the gap between the restoration and

The gap between the tooth and the edge of the restoration, known as the marginal gap, is measured to determine how well the restoration fits the tooth and is called absolute margin discrepancy [60, 61]. Marginal gap has been given several definitions: vertical marginal discrepancy, horizontal marginal discrepancy, over-extended margin, under-extended margin, seating discrepancy, and absolute marginal discrepancy. Of them all, absolute marginal discrepancy is regarded as the best method for measuring the marginal gap because it yields the largest error [62]. Currently, there is no standard method for measuring how well the margin fits but the most popular method is to use a microscope to measure the distance once the embedded specimens have been sectioned. This method cannot be used

cementation [46].

the die [59].

"in vivo" [63].

to the loss of pulp vitality [49].

The degree of microleakage depends on several factors including the tooth's own structure, the luting or bonding agents used to cement the restoration, and the interaction of other factors involved with dental restoration [26].

#### **3.2. Marginal and internal fitting**

One of the main factors affecting the longevity of dental restoration is marginal adaptation or how well it fits the tooth [27]. Any gap in the seal exposes the cement to the oral environment. With large gaps, the luting agent is more exposed to oral fluids, and this accelerates both the breakdown of the cement and microleakage [28]. These imperfections along the edge make it easier for oral bacteria to stick and for food and other refuse to build up ultimately leading to plaque retention. This alters the way the subgingival flora is distributed, which in turn leads to the onset of periodontal disease [29] and secondary caries [30].

Fit is determined by many factors such as fabrication [31], the type of CAM system used [32, 33], the number of units in the substructure [34], the tooth's location and preparation [35], the rigidity of the material [36], the type and thickness of the luting agent [37], and the presence of a luting agent [38]. Both the size of the gap at the edge and the amount of resin used have to be kept to a minimum in order to provide a better fit and to increase the cement's longevity [39].

**Figure 3.** Discoloration along the edge of an endocrown restoration.

Maintaining the gap along the edge as small as possible is very important because the potential for microleakage increases as the size of the gap increases [40]. No matter what type of cement is used, gaps between 100 and 120 μm are considered clinically acceptable [41] in terms of minimizing the problems that might result in cement loss [42]; 90 μm or less is the acceptable size for gaps in computer-aided design/computer-aided manufacturing (CAD/ CAM)-generated restorations [27, 43–45]. Variations in the internal fit can cause fatigue, possibly weakening the restoration. The thickness of the layer of dental cement along the axial walls of the preparation affects how well the restoration sits in place. Among the factors that influence film thickness are preparation, how the margin is designed and configured, how rough the surface is, how much pressure is applied during cementation and for how long, the cement's powder/liquid ratio, the type of cement, the spacers used, and the method used for cementation [46].

**3. Etiology of secondary caries**

38 Dental Caries - Diagnosis, Prevention and Management

tors involved with dental restoration [26].

to the onset of periodontal disease [29] and secondary caries [30].

**Figure 3.** Discoloration along the edge of an endocrown restoration.

**3.2. Marginal and internal fitting**

The classic definition of microleakage is the movement of matter, such as bacteria, oral fluids, even ions, into a fluid-filled gap or a naturally occurring structural defect, or between restorations and the tooth [21]. Microleakage is regarded as one of the principal causes of failure in crowns, so it is one of the main factors that determine the clinical lifespan of dental restorations [22]. Not only does microleakage adversely affect a restoration's clinical use, it can also lead to hypersensitivity, discoloration along the margin [23] (**Figure 3**), secondary caries, inflammation, or necrosis of the vital pulp and often requires endodontic treatment [24, 25]. The degree of microleakage depends on several factors including the tooth's own structure, the luting or bonding agents used to cement the restoration, and the interaction of other fac-

One of the main factors affecting the longevity of dental restoration is marginal adaptation or how well it fits the tooth [27]. Any gap in the seal exposes the cement to the oral environment. With large gaps, the luting agent is more exposed to oral fluids, and this accelerates both the breakdown of the cement and microleakage [28]. These imperfections along the edge make it easier for oral bacteria to stick and for food and other refuse to build up ultimately leading to plaque retention. This alters the way the subgingival flora is distributed, which in turn leads

Fit is determined by many factors such as fabrication [31], the type of CAM system used [32, 33], the number of units in the substructure [34], the tooth's location and preparation [35], the rigidity of the material [36], the type and thickness of the luting agent [37], and the presence of a luting agent [38]. Both the size of the gap at the edge and the amount of resin used have to be kept to a minimum in order to provide a better fit and to increase the cement's longevity [39].

**3.1. Microleakage**

The fitting of the restoration and proximal surfaces may be checked before cementation to prevent any overhangs that can cause plaque accumulation and secondary caries. Even tiny overhangs, which are often hard to detect clinically, can lead to plaque accumulation, periodontal disease, and the onset of secondary caries. The edges of crown's margins are susceptible to microleakage, and clinical tests have shown that large gaps can result in secondary caries [47, 48]. Caries is the second most common biological complaint in crowned teeth next to the loss of pulp vitality [49].

Laser videography [50], profile projection [51], micro-CT, and CAD/CAM scans [52] are some of the ways in which the adaptation of prosthetic restorations can be assessed. One commonly used technique is the cement analog or Replica Technique (RT). This method allows the dimensions of the internal and marginal gaps in prosthetic restorations to be estimated with a fair degree of accuracy [53]. This nondestructive technique involves sitting the restoration on top of a prepared die using an impression material instead of cement. Once set, the impression material and the restoration are carefully removed from the die and the thickness of the cement analog layer is measured [54–58]. Another nondestructive method that can be used to check the size and shape of gaps in prosthetic restorations is the "Weight Technique" (WT). It costs less than RT and is easier to do. In WT, the material used to simulate the cement layer is weighed at certain points rather than having its thickness measured like in RT. The weight corresponds to the thickness of the gap between the restoration and the die [59].

The gap between the tooth and the edge of the restoration, known as the marginal gap, is measured to determine how well the restoration fits the tooth and is called absolute margin discrepancy [60, 61]. Marginal gap has been given several definitions: vertical marginal discrepancy, horizontal marginal discrepancy, over-extended margin, under-extended margin, seating discrepancy, and absolute marginal discrepancy. Of them all, absolute marginal discrepancy is regarded as the best method for measuring the marginal gap because it yields the largest error [62]. Currently, there is no standard method for measuring how well the margin fits but the most popular method is to use a microscope to measure the distance once the embedded specimens have been sectioned. This method cannot be used "in vivo" [63].

The gap between the inside surface of the crown and the outside surface of the tooth can be checked using a silicone paste in order to evaluate discrepancies. This technique is not without its faults, and readings can be adversely affected by defects in the silicone material in the area being measured and by inaccuracies when reading the measurement of the thickness of the paste under a microscope [64].

**3.4. Fabrication method**

their cores [77].

coping will fit.

developed [77].

tion of copings.

strength in the laboratory can be fabricated [94, 95].

Prosthetic restorations can be made in a number of ways depending on the material used for

Etiology of Secondary Caries in Prosthodontic Treatments

http://dx.doi.org/10.5772/intechopen.76097

41

Metal-ceramic crowns are still the most common way to make full coverage crowns and fixed partial dentures [78]. Many studies have been done into the fit and distortion of metal-ceramic crowns, including how the manufacturing process affects fit. Since the ceramic veneer and the alloy coping expand at different rates under heat, firing the ceramic might affect how the crown fits. The casting process is a complex one. This plus the different rates at which the various materials expand and contract make it very difficult indeed to ensure that a casted

The classic method for making the metal core is the "lost-wax technique." However, this technique has several disadvantages such as possible distortion of the wax patterns, imperfections in the cast metal, complicated procedures, and it takes up much time. These disadvantages have been countered now by CAD/CAM and processes such as milling and Direct Metal Laser Sintering (DMLS), which are used now in fabricating the metal frameworks for metalceramic crowns. In the CAD/CAM milling system, CAD is used to design a pre-production digital frame, which is then manufactured (CAM) using this CAD data [79, 80]. A solid Co-Cr blank is milled into shape using the digitally created frame as a template. DMLS is a fabrication technology that uses metal powder as an additive. By means of a high-temperature laser beam, metal powder is smelted and forged into the shape of the digital CAD template to make the framework. A thin layer of the beamed area becomes fused, and the metal framework is manufactured by building up layer upon layer of metal in order to achieve the final shape

[81]. CAD/CAM and DMLS make laboratory procedures easier and save time [82].

In contrast to metal-ceramic crowns, a high-strength ceramic framework is used that is resistant to loads when constructing ceramic crowns. In addition to being fracture resistant, ceramic crowns owe their success and quality to their esthetic value and near perfect marginal and internal fit [83, 84]. The use of the ceramic systems has increased as new technologies are

Various different high-strength materials and manufacturing methods are used in making the framework for ceramic crowns [85–88]. Techniques such as slip casting [89], heat pressing [90], copy milling [85], CAM [86], and CAD-CAM [87, 88, 91] are widely used in the produc-

The use of full-ceramic materials in dentistry has developed in parallel with the introduction and use of CAD/CAM systems. Crowns, inlays, onlays, laminate veneers, and abutment are among the many dental restorative methods that make use of CAD/CAM systems [92, 93]. Resin composites or porcelain shaped using CAD/CAM technology give patients esthetically pleasing restorations that are of similar appearance to teeth and that can be cemented into the patient's mouth during the same appointment. This decreases the treatment time and makes interim prostheses unnecessary (**Figures 4** and **5**). With the CAD/CAM milling of porcelain blocks and optimum manufacturing conditions, the restorations that have a higher intrinsic

#### **3.3. Material type**

Different materials such as metal or ceramic are used to make the framework for the prosthetic restorations. The "gold-standard" metal-supported restorations have superior mechanical properties and proven longevity in clinical trials and are the restoration of choice today [65]. While metal-ceramic hybrid crowns are very strong, the increase in the popularity of esthetically attractive restorations in recent years has promoted the development of crowns that are entirely ceramic [37]. Zirconia has started to become popular as a framework material in all ceramic restorations because of such characteristics as high biocompatibility, superior mechanical properties, corrosion resistance, low affinity for plaque accumulation, no allergic reaction to metal in the gingiva, as well as its poor ability to conduct heat and electricity [66]. Zirconia also has some downsides such as phase transformation in reaction to surface treatments, being opaque, and degrading at low temperatures [67]. The most common complication observed in zirconia substructure restorations is reportedly the superstructure ceramic layer coming away from the substructure in layers or by fracturing [68, 69].

All ceramic crowns are esthetically very pleasing and work just as well with anterior teeth as with posterior ones. They interact well with the gingival tissues and offer a great biocompatibility [70]. On the downside, however, they can be brittle (particularly those made from glass or feldspathic ceramics). They fracture easily and can cause excessive wear on the opposite teeth. They also necessitate a greater tooth reduction and tend to favor certain techniques over others [71].

Contrary to direct composite restorations, CEREC composite blocks are produced under the best conditions possible, thus improving the degree of monomer polymerization and preventing voids from being formed, thereby giving them optimal mechanical properties [72].

Semi-sintered zirconia requires shorter milling times and produces less wear on the cutting burs. However, this technique requires a final sintering stage after milling [73]. This sintering procedure entails a certain amount of shrinkage. This technique does have its downsides such as uncertainty with respect to the correct enlarging factor and a marginal fit that does not meet the most exacting demands. On the contrary, milled, fully sintered zirconia is subjected to hot isostatic pressing and offers a much better marginal fit [63].

The strength and fit of the final restoration are affected by such factors as the different materials and techniques used when manufacturing it [74]. Clinicians are advised to adhere closely to the technical guidelines in order to overcome the problems inherent with marginal gaps. It is recommended that they use only the highest-quality materials when constructing prostheses so as to achieve the best marginal compatibility [75, 76].

#### **3.4. Fabrication method**

The gap between the inside surface of the crown and the outside surface of the tooth can be checked using a silicone paste in order to evaluate discrepancies. This technique is not without its faults, and readings can be adversely affected by defects in the silicone material in the area being measured and by inaccuracies when reading the measurement of the thickness of

Different materials such as metal or ceramic are used to make the framework for the prosthetic restorations. The "gold-standard" metal-supported restorations have superior mechanical properties and proven longevity in clinical trials and are the restoration of choice today [65]. While metal-ceramic hybrid crowns are very strong, the increase in the popularity of esthetically attractive restorations in recent years has promoted the development of crowns that are entirely ceramic [37]. Zirconia has started to become popular as a framework material in all ceramic restorations because of such characteristics as high biocompatibility, superior mechanical properties, corrosion resistance, low affinity for plaque accumulation, no allergic reaction to metal in the gingiva, as well as its poor ability to conduct heat and electricity [66]. Zirconia also has some downsides such as phase transformation in reaction to surface treatments, being opaque, and degrading at low temperatures [67]. The most common complication observed in zirconia substructure restorations is reportedly the superstructure ceramic layer coming away from the substructure in layers

All ceramic crowns are esthetically very pleasing and work just as well with anterior teeth as with posterior ones. They interact well with the gingival tissues and offer a great biocompatibility [70]. On the downside, however, they can be brittle (particularly those made from glass or feldspathic ceramics). They fracture easily and can cause excessive wear on the opposite teeth. They also necessitate a greater tooth reduction and tend to favor certain techniques over

Contrary to direct composite restorations, CEREC composite blocks are produced under the best conditions possible, thus improving the degree of monomer polymerization and preventing voids from being formed, thereby giving them optimal mechanical properties [72].

Semi-sintered zirconia requires shorter milling times and produces less wear on the cutting burs. However, this technique requires a final sintering stage after milling [73]. This sintering procedure entails a certain amount of shrinkage. This technique does have its downsides such as uncertainty with respect to the correct enlarging factor and a marginal fit that does not meet the most exacting demands. On the contrary, milled, fully sintered zirconia is subjected

The strength and fit of the final restoration are affected by such factors as the different materials and techniques used when manufacturing it [74]. Clinicians are advised to adhere closely to the technical guidelines in order to overcome the problems inherent with marginal gaps. It is recommended that they use only the highest-quality materials when constructing prosthe-

to hot isostatic pressing and offers a much better marginal fit [63].

ses so as to achieve the best marginal compatibility [75, 76].

the paste under a microscope [64].

40 Dental Caries - Diagnosis, Prevention and Management

**3.3. Material type**

or by fracturing [68, 69].

others [71].

Prosthetic restorations can be made in a number of ways depending on the material used for their cores [77].

Metal-ceramic crowns are still the most common way to make full coverage crowns and fixed partial dentures [78]. Many studies have been done into the fit and distortion of metal-ceramic crowns, including how the manufacturing process affects fit. Since the ceramic veneer and the alloy coping expand at different rates under heat, firing the ceramic might affect how the crown fits. The casting process is a complex one. This plus the different rates at which the various materials expand and contract make it very difficult indeed to ensure that a casted coping will fit.

The classic method for making the metal core is the "lost-wax technique." However, this technique has several disadvantages such as possible distortion of the wax patterns, imperfections in the cast metal, complicated procedures, and it takes up much time. These disadvantages have been countered now by CAD/CAM and processes such as milling and Direct Metal Laser Sintering (DMLS), which are used now in fabricating the metal frameworks for metalceramic crowns. In the CAD/CAM milling system, CAD is used to design a pre-production digital frame, which is then manufactured (CAM) using this CAD data [79, 80]. A solid Co-Cr blank is milled into shape using the digitally created frame as a template. DMLS is a fabrication technology that uses metal powder as an additive. By means of a high-temperature laser beam, metal powder is smelted and forged into the shape of the digital CAD template to make the framework. A thin layer of the beamed area becomes fused, and the metal framework is manufactured by building up layer upon layer of metal in order to achieve the final shape [81]. CAD/CAM and DMLS make laboratory procedures easier and save time [82].

In contrast to metal-ceramic crowns, a high-strength ceramic framework is used that is resistant to loads when constructing ceramic crowns. In addition to being fracture resistant, ceramic crowns owe their success and quality to their esthetic value and near perfect marginal and internal fit [83, 84]. The use of the ceramic systems has increased as new technologies are developed [77].

Various different high-strength materials and manufacturing methods are used in making the framework for ceramic crowns [85–88]. Techniques such as slip casting [89], heat pressing [90], copy milling [85], CAM [86], and CAD-CAM [87, 88, 91] are widely used in the production of copings.

The use of full-ceramic materials in dentistry has developed in parallel with the introduction and use of CAD/CAM systems. Crowns, inlays, onlays, laminate veneers, and abutment are among the many dental restorative methods that make use of CAD/CAM systems [92, 93]. Resin composites or porcelain shaped using CAD/CAM technology give patients esthetically pleasing restorations that are of similar appearance to teeth and that can be cemented into the patient's mouth during the same appointment. This decreases the treatment time and makes interim prostheses unnecessary (**Figures 4** and **5**). With the CAD/CAM milling of porcelain blocks and optimum manufacturing conditions, the restorations that have a higher intrinsic strength in the laboratory can be fabricated [94, 95].

There have been many studies evaluating marginal and internal fitting of fixed prosthetic restorations prepared with different production techniques from different materials [82, 97, 98]. No significant difference between the various manufacturing techniques was reported. While the thickness of occlusal cement was highest with the laser-sintering method, used for making

Etiology of Secondary Caries in Prosthodontic Treatments

http://dx.doi.org/10.5772/intechopen.76097

43

Even with all the advances in manufacturing technology, it is still a major challenge to create a long-lasting and well-sealed marginal fit where the tooth meets the crown [99]. As a result, CAD/CAM systems may be more advantageous because ceramic materials with a high

Marginal gaps that are an important component in fixed prosthetic restorations need to be sealed effectively with luting cements, and cements preserve the tooth from microbial invasion [100]. Microleakage and marginal openings are important causes of fixed restoration failures. The increase of the marginal gap in the fixed restorations results in greater microleakage and cement disintegration with cement exposed to oral fluids [37]. Because of the cement decomposition or dissolution in oral fluids, shrinkage on setting, the cement losses the bonding effect between the cement and the dentine or cement and restoration [101]. When the cement does not seal the gap properly, this can lead to inflammation in the pulp and subsequent pulpal necrosis, which in turn adversely affects longevity of the restorations [100, 102]. Other factors contributing to microleakage include the mechanical properties of the cement and the degree to which the cement adheres to the tooth. One final factor contributing to the

Another cause of failure of nonmetallic esthetic restorations is clinical fractures [104]. It has been shown that resin-luting agents have the strength necessary for all-ceramic esthetic restorations when used together with established bonding procedures, resulting in a very strong luting unit with good retention properties and that is almost insoluble. Generally, resin cements are capable of dual polymerization and are known for being mechanically strong and

The past 20 years have seen ceramics and composites being used more and more in posterior teeth as well, thanks to the important improvements made in their mechanical properties in addition to advances in cements and their properties [21]. With the development of dentine-bonding agents and the improvements seen in the properties of resin composites for direct filling, resinbased cements have become popular with clinicians working with all-ceramic restorations [37, 106, 107]. The mechanical- and/or chemical-bonding properties of resin-luting agents between the tooth and the restoration are what contribute to the success of indirect, fixed restorations with resin bonding [108]. Resin-based cements possess many ideal properties such as insolubility, very good strength, better adhesion, and the ability to form a solid bond with the tooth [109]. Other factors affect how effectively the adhesive bonds are related to the actual material and they include filler content, monomer composition, and curing mode. The nature of the substrate surface, for example, enamel, alloys, ceramics, dentin, or composites, can also affect

the metal framework, this thickness is approved as acceptable values [82].

mechanical resistance can produce more esthetic restorations in a shorter time.

severity of microleakage is the adhesive having weak-bonding properties [103].

having excellent esthetic properties [105, 106].

**3.5. Cementation**

**Figure 4.** CAD imaging.

**Figure 5.** All-ceramic restoration.

In CAD/CAM systems, extra space for the cement can be programmed, potentially making for a better fit both marginally and internally [63]. When casting a prosthetic restoration die, spacers have to be added to form the space for the cement but this space can be created and minutely adjusted digitally using CAD/CAM. The accuracy of fit was found to depend much on the spacing of dies [96].

There are some factors that can influence the marginal fit when using CAD/CAM system such as the scanning, the design software, sintering, and milling processes themselves, any and all of which can lead to errors when manufacturing the ceramic framework. One reason for the difference in marginal gaps seen between copings made using CAD/CAM technology and those made using only CAM technology might be the long fabrication chain involved in the CAM process, which is as follows: (1) preparing the master cast and spacers, (2) adding the wax, and then (3) removing the wax pattern from the master cast. Manually adding the wax can result in nonuniform layers, and this in turn can create a distorted product during the sintering process. Taking the cast off can also adversely affect accuracy. Furthermore, it is harder for a scanner to scan the concave inner surface of the wax pattern than the convex master cast [63].

There have been many studies evaluating marginal and internal fitting of fixed prosthetic restorations prepared with different production techniques from different materials [82, 97, 98]. No significant difference between the various manufacturing techniques was reported. While the thickness of occlusal cement was highest with the laser-sintering method, used for making the metal framework, this thickness is approved as acceptable values [82].

Even with all the advances in manufacturing technology, it is still a major challenge to create a long-lasting and well-sealed marginal fit where the tooth meets the crown [99]. As a result, CAD/CAM systems may be more advantageous because ceramic materials with a high mechanical resistance can produce more esthetic restorations in a shorter time.

#### **3.5. Cementation**

In CAD/CAM systems, extra space for the cement can be programmed, potentially making for a better fit both marginally and internally [63]. When casting a prosthetic restoration die, spacers have to be added to form the space for the cement but this space can be created and minutely adjusted digitally using CAD/CAM. The accuracy of fit was found to depend much

There are some factors that can influence the marginal fit when using CAD/CAM system such as the scanning, the design software, sintering, and milling processes themselves, any and all of which can lead to errors when manufacturing the ceramic framework. One reason for the difference in marginal gaps seen between copings made using CAD/CAM technology and those made using only CAM technology might be the long fabrication chain involved in the CAM process, which is as follows: (1) preparing the master cast and spacers, (2) adding the wax, and then (3) removing the wax pattern from the master cast. Manually adding the wax can result in nonuniform layers, and this in turn can create a distorted product during the sintering process. Taking the cast off can also adversely affect accuracy. Furthermore, it is harder for a scanner to scan the concave inner surface of the wax pattern

on the spacing of dies [96].

**Figure 5.** All-ceramic restoration.

**Figure 4.** CAD imaging.

42 Dental Caries - Diagnosis, Prevention and Management

than the convex master cast [63].

Marginal gaps that are an important component in fixed prosthetic restorations need to be sealed effectively with luting cements, and cements preserve the tooth from microbial invasion [100]. Microleakage and marginal openings are important causes of fixed restoration failures. The increase of the marginal gap in the fixed restorations results in greater microleakage and cement disintegration with cement exposed to oral fluids [37]. Because of the cement decomposition or dissolution in oral fluids, shrinkage on setting, the cement losses the bonding effect between the cement and the dentine or cement and restoration [101]. When the cement does not seal the gap properly, this can lead to inflammation in the pulp and subsequent pulpal necrosis, which in turn adversely affects longevity of the restorations [100, 102]. Other factors contributing to microleakage include the mechanical properties of the cement and the degree to which the cement adheres to the tooth. One final factor contributing to the severity of microleakage is the adhesive having weak-bonding properties [103].

Another cause of failure of nonmetallic esthetic restorations is clinical fractures [104]. It has been shown that resin-luting agents have the strength necessary for all-ceramic esthetic restorations when used together with established bonding procedures, resulting in a very strong luting unit with good retention properties and that is almost insoluble. Generally, resin cements are capable of dual polymerization and are known for being mechanically strong and having excellent esthetic properties [105, 106].

The past 20 years have seen ceramics and composites being used more and more in posterior teeth as well, thanks to the important improvements made in their mechanical properties in addition to advances in cements and their properties [21]. With the development of dentine-bonding agents and the improvements seen in the properties of resin composites for direct filling, resinbased cements have become popular with clinicians working with all-ceramic restorations [37, 106, 107]. The mechanical- and/or chemical-bonding properties of resin-luting agents between the tooth and the restoration are what contribute to the success of indirect, fixed restorations with resin bonding [108]. Resin-based cements possess many ideal properties such as insolubility, very good strength, better adhesion, and the ability to form a solid bond with the tooth [109].

Other factors affect how effectively the adhesive bonds are related to the actual material and they include filler content, monomer composition, and curing mode. The nature of the substrate surface, for example, enamel, alloys, ceramics, dentin, or composites, can also affect the strength of the bond [110]. Significant differences have been noted between adhesiveluting agents in studies investigating at their ability to prevent leakage between the surfaces in cemented restorations [21, 111, 112].

Different cements have different degrees of microleakage [104]. A study of the microleakage results obtained using resin, zinc phosphate, and glass-ionomer cements showed that zinc-phosphate cement is not as successful as glass-ionomer and resin cements in reducing microleakage. One reason for this may be the high solubility of zinc-phosphate cement when compared to glass-ionomer and resin cements in addition to the properties of its bond with dentine, which is entirely mechanical. Clinical studies have shown that despite these negative characteristics, restorations fixed with zinc-phosphate cement are stable for long periods of time. Resin and glass-ionomer cements are less soluble than zinc-phosphate cement and their chemical composition allows them to bond strongly both chemically and mechanically with dentine. In experimental conditions, resin and glass-ionomer cements performed better in terms of microleakage when compared to zinc-phosphate cement. However, only though long-term clinical trials will the advantages and disadvantages of the various cements in

Etiology of Secondary Caries in Prosthodontic Treatments

http://dx.doi.org/10.5772/intechopen.76097

45

Furthermore, maintaining microleakage to a minimum requires the use of cements with good sealing properties. Of all the different types of cements that are used in dentistry, resin-based and glass-ionomer cements have shown the best results due to their leaching of fluoride ions,

Nowadays, with the developing technology, there are many restorative materials and different fabrication methods for prosthetic restorations. Marginal adaptation is the most important factor for clinical use and success of the restorations. Failure to provide marginal adaptation increases microleakage and causes microorganisms to colonize between tooth and restoration, thus causing secondary caries. In fixed prosthetic restorations, CAD/CAM technologies can be used to prepare infrastructures to have optimal marginal and internal fitting, mechanically resistant, biocompatible, and low cement spacing. More bonding efficiency and less water solubility of the adhesive resin cements result in less microleakage than other cements; for this reason, adhesive resin cements can be preferred for a suitable option. In glass-ionomer cement, secondary caries risk is decreased because of the presence of fluoride. Before the planning of prosthetic restorations, abutment teeth, periodontal tissues, prosthetic material,

terms of durability become clear [127, 128].

**4. Conclusion**

**Author details**

creating an additional mechanical bond with the tooth [75, 76].

cement, and fabrication method must be chosen carefully.

Arzu Zeynep Yildirim Bicer\* and Senem Unver

\*Address all correspondence to<EMAIL_ADDRESS>
Faculty of Dentistry, Depertment of Prosthodontic, Gazi University, Ankara, Turkey

Typically, there are three steps in the process of adhesive cementation: etching, priming, and applying the cement. Every step of this process is technique-sensitive and requires attention to detail [100, 113, 114]. The latest generation of proprietary self-adhesive resin cements is self-etching and bonds to dentine without the need for additional primers or etching agents. Resin cements are self-adhesive and dual-polymerizing. By design, they are easy to use and have good mechanical properties, high esthetic values, and adhere well to both the restoration and the tooth [115]. Even so, the durability of the bond, the resin cement to the tooth and the resin cement to the ceramic surface, is still a crucial point [116–118].

Crowns that are cemented using self-etching resin cements demonstrated much lower average microleakage scores than using self-adhesive resin cement. This might be due to differences in the different cements' adhesion mechanisms. Self-etching resin cement comes with an etch-prime agent with a 2.4 pH and monomers possessing low-molecular weight. They diffuse selectively into the dentine [119] and create a hybrid complex [120, 121]. As a result, these monomers create a small amount of dentine demineralization that allows the cement and the dentine to bond. However, this is not the case with self-adhesive resin cements. They contain multifunctional phosphonic acid methacrylates, and these react with hydroxylapatite [122]. One recent study showed that self-adhesive resin cement presented no evidence of decalcification/infiltration into dentine even though the initial pH value was acidic [123].

Resin-based materials have a tendency to accumulate more plaque, and this plaque is more cariogenic than that found on enamel and other materials used for restoration. Even so, one study has shown that cariogenic bacteria on enamel, glass ionomers, and resin-based materials are the same [124].

Glass-ionomer cement has properties that make it ideal for cementation such as a reduced film thickness and a very low coefficient of thermal expansion coupled to its strong physicochemical bond to both dentin and enamel, as well as its hydrophilic qualities and low solubility. Moreover, glass-ionomer cements leach calcium fluoride giving it the advantage of inhibiting caries [125]. The molecular interactions, ionic and polar, between the cement and the tooth affect the adhesive quality of glass-ionomer cement. These mechanisms are only effective if a close intermolecular contact is achieved between the cement and the tooth. One reason why glass-ionomer cements fail may be the porosities that can appear when the cement is mixing, and these porosities reduce the intermolecular contact between the tooth and the cement [74].

Rosentritt et al. [126] concluded that the resin cements and self-adhesive materials demonstrate good marginal integrity with minimal microleakage. They noted that the easily applied self-adhesive resin cements have the potential to be an alternative to resin cements.

Traditionally, water-based cements have been used to fill the space between the tooth and the restoration. However, the water-based cements are highly soluble in oral fluids, so their ability to seal depends largely on how well the restoration fits [75].

Different cements have different degrees of microleakage [104]. A study of the microleakage results obtained using resin, zinc phosphate, and glass-ionomer cements showed that zinc-phosphate cement is not as successful as glass-ionomer and resin cements in reducing microleakage. One reason for this may be the high solubility of zinc-phosphate cement when compared to glass-ionomer and resin cements in addition to the properties of its bond with dentine, which is entirely mechanical. Clinical studies have shown that despite these negative characteristics, restorations fixed with zinc-phosphate cement are stable for long periods of time. Resin and glass-ionomer cements are less soluble than zinc-phosphate cement and their chemical composition allows them to bond strongly both chemically and mechanically with dentine. In experimental conditions, resin and glass-ionomer cements performed better in terms of microleakage when compared to zinc-phosphate cement. However, only though long-term clinical trials will the advantages and disadvantages of the various cements in terms of durability become clear [127, 128].

Furthermore, maintaining microleakage to a minimum requires the use of cements with good sealing properties. Of all the different types of cements that are used in dentistry, resin-based and glass-ionomer cements have shown the best results due to their leaching of fluoride ions, creating an additional mechanical bond with the tooth [75, 76].

#### **4. Conclusion**

the strength of the bond [110]. Significant differences have been noted between adhesiveluting agents in studies investigating at their ability to prevent leakage between the surfaces

Typically, there are three steps in the process of adhesive cementation: etching, priming, and applying the cement. Every step of this process is technique-sensitive and requires attention to detail [100, 113, 114]. The latest generation of proprietary self-adhesive resin cements is self-etching and bonds to dentine without the need for additional primers or etching agents. Resin cements are self-adhesive and dual-polymerizing. By design, they are easy to use and have good mechanical properties, high esthetic values, and adhere well to both the restoration and the tooth [115]. Even so, the durability of the bond, the resin cement to the tooth and the

Crowns that are cemented using self-etching resin cements demonstrated much lower average microleakage scores than using self-adhesive resin cement. This might be due to differences in the different cements' adhesion mechanisms. Self-etching resin cement comes with an etch-prime agent with a 2.4 pH and monomers possessing low-molecular weight. They diffuse selectively into the dentine [119] and create a hybrid complex [120, 121]. As a result, these monomers create a small amount of dentine demineralization that allows the cement and the dentine to bond. However, this is not the case with self-adhesive resin cements. They contain multifunctional phosphonic acid methacrylates, and these react with hydroxylapatite [122]. One recent study showed that self-adhesive resin cement presented no evidence of decalcifi-

Resin-based materials have a tendency to accumulate more plaque, and this plaque is more cariogenic than that found on enamel and other materials used for restoration. Even so, one study has shown that cariogenic bacteria on enamel, glass ionomers, and resin-based materi-

Glass-ionomer cement has properties that make it ideal for cementation such as a reduced film thickness and a very low coefficient of thermal expansion coupled to its strong physicochemical bond to both dentin and enamel, as well as its hydrophilic qualities and low solubility. Moreover, glass-ionomer cements leach calcium fluoride giving it the advantage of inhibiting caries [125]. The molecular interactions, ionic and polar, between the cement and the tooth affect the adhesive quality of glass-ionomer cement. These mechanisms are only effective if a close intermolecular contact is achieved between the cement and the tooth. One reason why glass-ionomer cements fail may be the porosities that can appear when the cement is mixing, and these porosities reduce the intermolecular contact between the tooth and the cement [74]. Rosentritt et al. [126] concluded that the resin cements and self-adhesive materials demonstrate good marginal integrity with minimal microleakage. They noted that the easily applied

cation/infiltration into dentine even though the initial pH value was acidic [123].

self-adhesive resin cements have the potential to be an alternative to resin cements.

ity to seal depends largely on how well the restoration fits [75].

Traditionally, water-based cements have been used to fill the space between the tooth and the restoration. However, the water-based cements are highly soluble in oral fluids, so their abil-

resin cement to the ceramic surface, is still a crucial point [116–118].

in cemented restorations [21, 111, 112].

44 Dental Caries - Diagnosis, Prevention and Management

als are the same [124].

Nowadays, with the developing technology, there are many restorative materials and different fabrication methods for prosthetic restorations. Marginal adaptation is the most important factor for clinical use and success of the restorations. Failure to provide marginal adaptation increases microleakage and causes microorganisms to colonize between tooth and restoration, thus causing secondary caries. In fixed prosthetic restorations, CAD/CAM technologies can be used to prepare infrastructures to have optimal marginal and internal fitting, mechanically resistant, biocompatible, and low cement spacing. More bonding efficiency and less water solubility of the adhesive resin cements result in less microleakage than other cements; for this reason, adhesive resin cements can be preferred for a suitable option. In glass-ionomer cement, secondary caries risk is decreased because of the presence of fluoride. Before the planning of prosthetic restorations, abutment teeth, periodontal tissues, prosthetic material, cement, and fabrication method must be chosen carefully.

#### **Author details**

Arzu Zeynep Yildirim Bicer\* and Senem Unver \*Address all correspondence to<EMAIL_ADDRESS>Faculty of Dentistry, Depertment of Prosthodontic, Gazi University, Ankara, Turkey

#### **References**

[1] Felton DA, Kanoy BE, Bayne SC, Wirthman GP. Effect of in vivo crown margin discrepancies on periodontal health. Journal of Prosthetic Dentistry. 1991;**65**:357-364

[16] Okida RC, Mandarino F, Sundfeld RH, de Alexandre RS, Sundefeld ML. In vitro evaluation of secondary caries formation around restoration. The Bulletin of Tokyo Dental

Etiology of Secondary Caries in Prosthodontic Treatments

http://dx.doi.org/10.5772/intechopen.76097

47

[17] Murat S, Kamburoglu K, Isayev A, Kursun S, Yuksel S. Visibility of artificial buccal recurrent caries under restorations using different radiographic techniques. Operative

[18] Vedpathak PR, Gondivkar SM, Bhoosreddy AR, Shah KR, Verma GR, Mehrotha GP, Nerkar AC. Cone beam computed tomography- an effective tool in detecting caries under fixed dental prostheses. Journal of Clinical and Diagnostic Research. 2016;**10**(8):10-13 [19] Kidd EA, Joysten-Bechal S, Beighton D. Marginal ditching and staining as a predictor of secondary caries around amalgam restorations: A clinical and microbiological study.

[20] Özer L. The relationship between gap size microbial accumulation and the structural features of natural caries in extracted teeth with class II amalgam restorations [thesis].

[21] Trajtenberg CP, Caram SJ, Kiat-amnuay S. Microleakage of all-ceramic crowns using

[22] Tay FR, Pashley DH, Suh BI, Carvalho R, Itthagarun A. Single-step adhesives are perme-

[23] Larson TD. The clinical significance of marginal fit. Northwest Dentistry. 2012;**91**(1):22-29 [24] Alani AH, Toll CG. Detection of microleakage around dental restorations: A review.

[26] Rossetti PHO, Valle AL, Carvalho RM, Goes MF, Pegoraro LF. Correlation between margin fit and microleakage in complete crowns cemented with three luting agents. Journal

[27] Syrek A, Reich G, Ranftl D, Klein C, Cerny B, Brodesser J. Clinical evaluation of all-ceramic crowns fabricated from intraoral digital impressions based on the principle of active

[28] Beschnidt SM, Strub JR. Evaluation of the marginal accuracy of different all-ceramic crown systems after simulation in the artificial mouth. Journal of Oral Rehabilitation.

[29] Bader JD, Rozier RG, McFall WT Jr, Ramsey DL. Effect of crown margins on periodontal conditions in regularly attending patients. Journal of Prosthetic Dentistry. 1991;**65**:75-79

[30] Kokubo Y, Ohkubo C, Tsumita M, Miyashita A, Vult von Steyern P, Fukushima S. Clinical marginal and internal gaps of Procera AllCeram crowns. Journal of Oral Rehabilitation.

self-etching resin luting agents. Operative Dentistry. 2008;**33**(4):392-399

[25] Taylor MJ, Lynch E. Microleakage. Journal of Dentistry. 1992;**20**(1):3-10

wavefront sampling. Journal of Dentistry. 2010;**38**:553-559

College. 2008;**49**(3):121-128

Dentistry. 2013;**38**:197-207

Journal of Dental Research. 1995;**74**:1206-1211

Denmark: University of Copenhagen; 1997

Operative Dentistry. 1997;**22**:173-185

of Applied Oral Science. 2008;**16**(1):64-69

1999;**26**:582-593

2005;**32**:526-530

able membranes. Journal of Dentistry. 2002;**30**:371-382

[16] Okida RC, Mandarino F, Sundfeld RH, de Alexandre RS, Sundefeld ML. In vitro evaluation of secondary caries formation around restoration. The Bulletin of Tokyo Dental College. 2008;**49**(3):121-128

**References**

Dentistry. 1982;**48**:396-400

46 Dental Caries - Diagnosis, Prevention and Management

Association. 1970;**81**:1395-1401

Publishing Inc.; 2002

Dentistry. 1985;**10**:88-92

Research. 2004;**38**(4):350-356

**16**(6):445-451

Oral Rehabilitation. 1986;**13**:423-432

cess. Journal of Dental Research. 2004;**83**:39-42

Illinois: Quintessence Publishing Inc.; 2012

Collage of Dental Surgeons. 1984;**8**:138-145

[1] Felton DA, Kanoy BE, Bayne SC, Wirthman GP. Effect of in vivo crown margin discrepancies on periodontal health. Journal of Prosthetic Dentistry. 1991;**65**:357-364

[2] Gardner FM. Margins of complete crowns-literature review. Journal of Prosthetic

[3] Behrend DA. Crown margins and gingival health. Annals of the Royal Australasian

[4] Bergenholtz G, Cox CF, Loesche WJ, Syed SA. Bacterial leakage around dental restorations: Its effect on the dental pulp. Journal of Oral Pathology & Medicine. 1982;**11**:439-450

[5] Schwartz NL, Whitsett LD, Berry TG, Stewart JL. Unserviceable crowns and fixed partial dentures: Life-span and causes for loss of serviceability. Journal of the American Dental

[6] Karlsson S. A clinical evaluation of fixed bridges, 10 years following insertion. Journal of

[7] Featherstone JDB. The continuum of dental caries- evidence for a dynamic disease pro-

[8] Mjör IA. Chapter 4: Dental caries: Characteristics of lesionsand pulpal reactions. In: Mjör IA, editor. Pulp-Dentinbiology in Restorative Dentistry. Illinois: Quintessence

[9] Tay FR, Messer H, Schwartz R. Chapter 14: Caries, restorative dentistry, and the pulp. In: Hargreaves KM, Goodis HE, Tay F, editors. Seltzer and Bender's Dental Pulp. 2nd ed.

[10] Bjørndal L, Thylstrup A. A structural analysis of approximalenamel caries lesions and subjacent dentin reactions. European Journal of Oral Sciences. 1995;**103**:25-31

[12] Mjör IA, Davis ME, Abu-Hanna A. CAD/CAM restorations and secondary caries: A lit-

[13] Mjör IA. Frequency of secondary caries at various anatomical locations. Operative

[14] Arnold WH, Sonkol T, Zoellner A, Gaengler P. Comparative study of in vitro caries-like lesions and natural caries lesions at crown margins. Journal of Prosthodontics. 2007;

[15] Ando M, Gonzalez-Cabezas C, Isaacs RL, Eckert GJ, Stookey GK. Evaluation of several techniques for the detection of secondary caries adjacent to amalgam restorations. Caries

[11] Jokstad A. Secondary caries and microleakage. Dental Materials. 2016;**32**(1):11-25

erature reviewwith illustrations. Dental Update. 2008;**35**(2):118-120

[31] Att W, Komine F, Gerds T, Strub JR. Marginal adaptation of three different zirconium dioxide three-unit fixed dental prostheses. Journal of Prosthetic Dentistry. 2009; **101**:239-247

[46] Chu-Jung W, Philip LM, Dan N. Effects of cement, cement space, marginal design, seating aid materials, and seating force on crown cementation. Journal of Prosthetic

Etiology of Secondary Caries in Prosthodontic Treatments

http://dx.doi.org/10.5772/intechopen.76097

49

[47] Sailer I, Feher A, Filser F, Gauckler LJ, Luthy H, Hammerle CH. Five-year clinical results of zirconia frameworks for posterior fixed partial dentures. The International Journal of

[48] Sailer I, Feher A, Filser F, Luthy H, Gauckler LJ, Scharer P, et al. Prospective clinical study of zirconia posterior fixed partial dentures: 3-year follow-up. Quintessence Inter-

[49] Pjetursson BE, Sailer I, Zwahlen M, Hammerle CH. A systematic review of the survival and complication rates of allceramic and metal-ceramic reconstructions after an observation period of at least 3 years. Part I: Single crowns. Clinical Oral Implants Research.

[50] Quintas AF, Oliveira F, Bottino MA. Vertical marginal discrepancy of ceramic copings with different ceramic materials, finish lines, and luting agents: An in vitro evaluation.

[51] Nakamura T, Nonaka M, Maruyama T. In vitro fitting accuracy of copy-milled alumina cores and all-ceramic crowns. The International Journal of Prosthodontics. 2000;

[52] Borba M, Cesar PF, Griggs JA, Della Bona A. Adaptation of all-ceramic fixed partial den-

[53] Molin M, Karlsson S. The fit of gold inlays and three ceramic inlay systems. A clinical

[54] Rahme HY, Tehini GE, Adib SM, Ardo AS, Rifai KT. In vitro evaluation of the "replica technique" in the measurement of the fit of Procera crowns. Journal of Contemporary

[55] Coli P, Karlsson S. Fit of a new pressure-sintered zirconium dioxide coping. The Inter-

[56] Goldin EB, NW3rd B, Goldstein GR, Hittelman EL, Thompson VP. Marginal fit of leucite-glass pressable ceramic restorations and ceramic-pressed-to-metal restorations.

[57] Reich S, Wichmann M, Nkenke E, Proeschel P. Clinical fit of all-ceramic three-unit fixed partial dentures, generated with three different CAD/CAM systems. European Journal

[58] Gemalmaz D, Kukrer D. In vivo and in vitro evaluation of marginal fit of class II ceromer

and in vitro study. Acta Odontologica Scandinavica. 1993;**51**(4):201-206

Dentistry. 1992;**67**:786-790

national. 2006;**37**:685-693

2007;**18**(3):73-85

**13**(3):189-193

Prosthodontics. 2007;**20**:383-388

Journal of Prosthetic Dentistry. 2004;**92**(3):250-257

tures. Dental Materials. 2011;**27**(11):1119-1126

national Journal of Prosthodontics. 2004;**17**(1):59-64

Journal of Prosthetic Dentistry. 2005;**93**(2):143-147

inlays. Journal of Oral Rehabilitation. 2006;**33**(6):436-442

Dental Practice. 2008;**9**(2):25-32

of Oral Science. 2005;**113**:174-179

[46] Chu-Jung W, Philip LM, Dan N. Effects of cement, cement space, marginal design, seating aid materials, and seating force on crown cementation. Journal of Prosthetic Dentistry. 1992;**67**:786-790

[31] Att W, Komine F, Gerds T, Strub JR. Marginal adaptation of three different zirconium dioxide three-unit fixed dental prostheses. Journal of Prosthetic Dentistry. 2009;

[32] Beuer F, Aggstaller H, Edelhoff D, Gernet W, Sorensen J. Marginal and internal fits of

[33] Gonzalo E, Suarez MJ, Serrano B, Lozano JF. Comparative analysis of two measurement methods for marginal fit in metal-ceramic and zirconia posterior FPDs. The International

[34] Beuer F, Neumeier P, Naumann M. Marginal fit of 14-unit zirconia fixed dental prosthe-

[35] Beuer F, Aggstaller H, Richter J, Edelhoff D, Gernet W. Influence of preparation angle on marginal and internal fit of CAD/CAM-fabricated zirconia crown copings. Quintessence

[36] Monaco C, Krejci I, Bortolotto T, Perakis N, Ferrari M, Scotti R. Marginal adaptation of 1 fiber-reinforced composite and 2 all-ceramic inlay fixed partial denture systems. The

[37] Albert FE, El-Mowafy OM. Marginal adaptation and microleakage of Procera AllCeram crowns with four cements. The International Journal of Prosthodontics. 2004;**17**:529-535

[38] Bindl A, Mörmann WH. Fit of all-ceramic posterior fixed partial denture frameworks in vitro. The International Journal of Periodontics Restorative Dentistry. 2007;**27**:567-575

[39] Cho SH, Chang WG, Lim BS, Lee YK. Effect of die spacer thickness on shear bond strength of porcelain laminate veneers. Journal of Prosthetic Dentistry. 2006;**95**:201-208

[40] Shiratsuchi H, Komine F, Kakehashi Y, Matsumura H. Influence of finish line desing on marginal adaptation of electroformed metal-ceramic crowns. Journal of Prosthetic

[41] Holmes JR, Sulik WD, Holland GA, Bayne SC. Marginal fit of castable ceramic crowns.

[42] Schwickerath H. Marginal cleft and solubility. Deutsche Zahnarztliche Zeitschrift. 1979;

[43] Baig MR, Tan KBC, Nicholls JI. Evaluation of the marginal fit of a zirconia ceramic computer-aided machined (CAM) crown system. Journal of Prosthetic Dentistry. 2010;

[44] Abduo J, Lyons K, Swain M. Fit of zirconia fixed partial denture: A systematic review.

[45] Ural C, Burgaz Y, Sarac¸ D. In vitro evaluation of marginal adaptation in five ceramic restoration fabricating techniques. Quintessence International. 2010;**41**:585-590

fixed dental prostheses zirconia retainers. Dental Materials. 2009;**25**:94-102

Journal of Prosthodontics. 2009;**22**:374-377

International. 2009;**40**:243-250

48 Dental Caries - Diagnosis, Prevention and Management

Dentistry. 2006;**95**(3):237-242

**34**:664-669

**104**:216-227

Journal of Prosthetic Dentistry. 1992;**67**:594-599

Journal of Oral Rehabilitation. 2010;**37**:866-876

sis retainers. Journal of Oral Rehabilitation. 2009;**36**:142-149

International Journal of Prosthodontics. 2006;**19**:373-382

**101**:239-247

[59] Lee KB, Park CW, Kim KH, Kwon TY. Marginal and internal fit of all-ceramic crowns fabricated with two different CAD/CAM systems. Dental Materials Journal. 2008; **27**(3):422-426

[75] Hill EE, Lott J. A clinically focused discussion of luting materials. Australian Dental

Etiology of Secondary Caries in Prosthodontic Treatments

http://dx.doi.org/10.5772/intechopen.76097

51

[76] Burke FJ. Trends in indirect dentistry: 3. Luting materials. Dental Update. 2005;**32**(5):

[77] Qualtrough AJ, Piddock V.Dental ceramics: What's new? Dental Update. 2002;**29**(1):25-33 [78] Petteno D, Schierano G, Bassi F, Bresciano ME, Carossa S. Comparison of marginal fit of 3 different metal-ceramic systems: An in vitro study. The International Journal of

[79] Hamza TA, Ezzat HA, El-Hossary MM, Katamish HA, Shokry TE, Rosenstiel SF.Accuracy of ceramic restorations made with two CAD/CAM systems. Journal of Prosthetic

[80] AndreiotelliM, Kamposiora P, Papavasiliou G. Digital data management for CAD/CAM technology. An update of current systems. European Journal of Prosthodontics and

[81] Persson A, Andersson M, Oden A, Sandborgh- Englund G. A three-dimensional evaluation of a laser scanner and a touch-probe scanner. Journal of Prosthetic Dentistry. 2006;

[82] Tamac E, Toksavul S, Toman M. Clinical marginal and internal adaptation of CAD/CAM milling, laser sintering, and cast metal ceramic crowns. Journal of Prosthetic Dentistry.

[83] Rinke S, Hüls A, Jahn L. Marginal accuracy and fracture strength of conventional and copy-milled all-ceramic crowns. The International Journal of Prosthodontics. 1995;**8**(4):

[84] Sulaiman F, Chai J, Jameson LM, Wozniak WT. A comparison of themarginal fit of in-Ceram, IPS empress and Procera crowns. The International Journal of Prosthodontics.

[85] Raigrodski AJ. Contemporary all-ceramic fixed partial dentures: A review. Dental Clinics

[86] Komine F, Gerds T, Witkowski S, Strub JR. Influence of framework configuration on themarginal adaptation of zirconium dioxide ceramic anterior four-unit frameworks. Acta

[87] Apholt W, Bindl A, Lüthy H, Mörmann W. Flexural strength of Cerec 2 machined and jointed together in Ceram-alumina and InCeram-zirconia bars. Dental Materials. 2001;

[88] Raigrodski AJ. Clinical and laboratory considerations for the use of CAD/CAM Y-TZPbased restorations. Practical Procedures & Aesthetic Dentistry. 2003;**15**(6):469-476 [89] Pröbster L. Diehl J. Slip casting alumina ceramics for crown and bridge restorations

Journal. 2011;**56 Suppl 1**:67-76

Prosthodontics. 2000;**5**:405-408

Restorative Dentistry. 2013;**21**:9-15

Dentistry. 2013;**109**:83-87

**95**:194-200

303-310

2014;**112**(4):909-913

1997;**10**(5):478-484

**17**(3):260-267

of North America. 2004;**48**(2):531-544

Odontologica Scandinavica. 2005;**63**(6):361-366

Quintessence International. 1992;**23**(1):25-29

251-4,257-8,260

[75] Hill EE, Lott J. A clinically focused discussion of luting materials. Australian Dental Journal. 2011;**56 Suppl 1**:67-76

[59] Lee KB, Park CW, Kim KH, Kwon TY. Marginal and internal fit of all-ceramic crowns fabricated with two different CAD/CAM systems. Dental Materials Journal. 2008;

[60] Suarez MJ, Gonzalez de Villaumbrosia P, Pradies G, Lozano JF. Comparison of the marginal fit of Procera AllCeram crowns with two finish lines. The International Journal of

[61] Pelekanos S, Koumanou M, Koutayas SO, Zinelis S, Eliades G. Micro-CT evaluation of the marginal fit of different In-Ceram alumina copings. European Journal of Esthetic

[62] Holmes JR, Bayne SC, Holland GA, Sulik WD. Considerations in measurement of mar-

[63] Alghazzawi TF, Liu PR, Essig ME. The effect of different fabrication steps on the marginal adaptation of two types of glass-infiltrated ceramic crown copings fabricated by

[64] Böning K, Wolf B, Schmidt A. K¨ astner K, Walter M. Klinische Randspaltmessungen an Procera AllCeram-Kronen. Deutsche Zahnarztliche Zeitschrift. 2000;**55**:97-100

[65] Zarone F, Russo S, Sorrentino R. From porcelain-fused-to-metal to zirconia: Clinical and

[66] Çömlekoğlu ME, Dündar M, Özcan M, Güngör MA, Gökçe B, Artunç C. Evaluation of bond strength of various margin ceramics to a zirconia ceramic. Journal of Dentistry.

[67] Kelly JR, Denry I. Stabilized zirconia as a structural ceramic: An overview. Dental

[68] Schmitter M, Mueller D, Rues S. Chipping behaviour of all-ceramic crowns with zirconia framework and CAD/CAM manufactured veneer. Journal of Dentistry. 2012;**40**:154-162

[69] Uludamar A, Aygün Ş, Kulak ÖY. Zirkonya esaslı tam seramik restorasyonlar. Atatürk

[70] Toksavul S. Ulusoy, Toman M. Clinical application of all-ceramic fixed partial dentures

[71] Blatz MB. Long-term clinical success of all-ceramic posterior restorations. Quintessence

[72] Kassem AS, Atta O, El-Mowafy O. Fatigue resistance and microleakage of CAD/CAM ceramic and composite molar crowns. Journal of Prosthodontics. 2012;**21**(1):28-32 [73] Beuer F, Schweiger J, Edelhoff D. Digital dentistry: An overview of recent developments for CAD/CAM generated restorations. British Dental Journal. 2008;**204**:505-511

[74] Yüksel E, Zaimoğlu A. Influence of marginal fit and cement types on microleakage of all-

ceramic crown systems. Brazilian Oral Research. 2011;**25**(3):261-266

CAD/CAM Technology. Journal of Prosthodontics. 2012;**21**(3):167-172

ginal fit. Journal of Prosthetic Dentistry. 1989;**62**:405-408

experimental considerations. Dental Materials. 2011;**27**:83-96

Üniversitesi Diş Hekimliği Fakültesi Dergisi. 2012;**5**:132-141

and crowns Quintessence International. 2004;**35**(3):185-188

**27**(3):422-426

Prosthodontics. 2003;**16**:229-232

50 Dental Caries - Diagnosis, Prevention and Management

Dentistry. 2009;**4**:278-292

2008;**36**:822-827

Materials. 2008;**24**:289-298

International. 2002;**33**:415-426

[90] Oh SC, Dong JK, Lüthy H, Schaörer P. Strength and microstructure of IPS empress 2 glass-ceramic after different treatments. The International Journal of Prosthodontics. 2000;**13**(6):468-472

[106] Chang JC, Hart DA, Esty AW, Chan JT. Tensile bond strength of five luting agents to two CAD/CAM restorative materials and enamel. Journal of Prosthetic Dentistry. 2003;

Etiology of Secondary Caries in Prosthodontic Treatments

http://dx.doi.org/10.5772/intechopen.76097

53

[107] Blatz M, Sadan A, Kern M. Resin-ceramic bonding: A review of the literature. Journal of

[108] Hooshmand T, Mohaherfar M, Keshvad A, Motahhary P. Microleakage and marginal gap of adhesive cements for noble alloy full cast crowns. Operative Dentistry.

[109] Heintze SD. Crown pull-off test (crown retention test) to evaluate the bonding effective-

[110] Piwowarcyzk A, Lauer HC, Sorensen JA. In vitro shear bond strength of cementing agents to fixed prosthodontic restorative materials. Journal of Prosthetic Dentistry.

[111] Jacques LB, Ferrari M, Cardoso PE. Microleakage and resin cement film thickness of luted all-ceramic and gold electroformed porcelain-fused-to-metal crowns. Journal of

[112] Lindquist TJ, Connolly J. In vitro microleakage of cementing agents and crown founda-

[113] El-Mowafy OM. The use of resin cements in restorative dentistry to overcome retention

[114] Bindl A, Mormann WH. Clinical and SEM evaluation of all ceramic chair side CAD/ CAM generated partial crowns. European Journal of Oral Sciences. 2003;**3**:163-169 [115] Gerth H, Dammaschke T, Zuchner H, Schafer E. Chemical analysis and bonding reaction of Unicem and Bifix composite. A comparative study. Dental Materials. 2006;**22**:934-941

[116] Friederich R, Kern M. Resin bond strength to densely sintered alumina ceramic. The

[117] Kern M, Thompson VP. Bonding to glass infiltrated alümina ceramic: Adhesive meth-

[118] Aoki K, Kitasako Y, Ichinose S. BurrowMF, AriyoshiM, Nikaido T, Tagami J. Ten-year observation of dentin bonding durability of 4-META/MMA-TBB resin cement-a SEM

[119] Al-Assaf K, Chakmakchi M, Palaghias G, Karanika-Kouma A, Eliades G. Interfacial characteristics of adhesive luting resins and composites with dentine. Dental Materials.

[120] Reis A, Grandi V, Carlotto L, Bartoli G, Patzlaff R, Rodrigues Accorinte Mde L, Dourado Loguercio A. Effect of smear layer thickness and acidity of self-etching solutions on early and long-term bond strength to dentin. Journal of Dentistry. 2005;**33**:549-559

ods and their durability. Journal of Prosthetic Dentistry. 1995;**73**:240-249

tion material. Journal of Prosthetic Dentistry. 2001;**85**(3):292-298

problems. Journal of Canadian Dental Association. 2001;**67**:97-102

International Journal of Prosthodontics. 2002;**15**:333-338

and TEM study. Dental Materials. 2011;**30**:438-447

ness of luting agents. Dental Materials. 2010;**26**(3):193-206

**90**:18-23

2011;**36**(3):258-265

2004;**92**(3):265-273

2007;**23**:829-839

Prosthetic Dentistry. 2003;**89**:268-274

Adhesive Dentistry. 2003;**5**(2):145-152

[106] Chang JC, Hart DA, Esty AW, Chan JT. Tensile bond strength of five luting agents to two CAD/CAM restorative materials and enamel. Journal of Prosthetic Dentistry. 2003; **90**:18-23

[90] Oh SC, Dong JK, Lüthy H, Schaörer P. Strength and microstructure of IPS empress 2 glass-ceramic after different treatments. The International Journal of Prosthodontics.

[91] Anderson M, Razzoog ME, Oden A, Hegenbarth EA, Lang BR. Procera a new way to achieve an all-ceramic crown. Quintessence International. 1998;**29**(5):285-296

[92] Beuer F, Schweiger J, Eichberger M, Kappert HF, Gernet W, Edelhoff D. High-strength CAD/CAM-fabricated veneering material sintered to zirconia copings-a new fabrica-

[93] Kanat B, Çömlekoğlu ME, Çömlekoğlu Dündar M, Şen BH, Özcan M, Güngör MA. Effect of various veneering techniques on mechanical strength of computer-controlled zirco-

[94] Mormann WH, Bindl A. The Cerec 3-a quantum leap for computer-aided restorations:

[95] Liu PR. A panorama of dental CAD/CAM restorative systems. Compendium of Con-

[96] Gonzalo E, Suarez MJ, Serrano B, Lozano JFL. A comparison of the marginal vertical discrepancies of zirconium and metal ceramic posterior fixed dental prostheses before

[97] Quante K, Ludwig K, Kern M. Marginal and internal fit of metal-ceramic crowns fabricated with a new laser melting technology. Dental Materials. 2008;**24**(10):1311-1315 [98] Colpani JT, Borba M, Della Bona A. Evaluation of marginal and internal fit of ceramic

[99] Van Meerbeek B, Perdigão J, Lambrechts P, Vanherle G. The clinical performance of

[100] Rosenstiel SF, Land MF, Crispin BJ. Dental luting agents: A review of the current litera-

[101] Irie M, Suzuki K. Current luting cements: Marginal gap formation of composite inlay

[102] Mjor IA, Moorhead JE, Dahl JE. Reasons for replacement of restorations in permanent teeth in general dental practice. International Dental Journal. 2000;**50**(6):361-366 [103] Lyons KM, Rodda JC, Hood JAA. Use of a pressure chamber to compare microleakage of three luting agents. The International Journal of Prosthodontics. 1997;**10**(5):426-433

[104] Gu X, Kern M. Marginal discrepancies and leakage of all-ceramic crowns: Influence of luting agent and aging conditions. The International Journal of Prosthodontics. 2003;

[105] Gernhardt CR, Bekes K, Schaller C. Short term retentive values of zirconium oxide post cemented with glass ionomer and resin cement: An in vitro study and a case report.

and after cementation. Journal of Prosthetic Dentistry. 2009;**102**(6):378-384

tion mode for all-ceramic restorations. Dental Materials. 2009;**25**:121-128

nia framework designs. Journal of Prosthodontics. 2014;**23**:445-455

Initial clinical results. Quintessence International. 2000;**31**:699-712

tinuing Education in Dentistry. 2005;**25**:507-516

crown copings. Dental Materials. 2013;**29**(2):174-180

ture. Journal of Prosthetic Dentistry. 1998;**80**(3):280-301

and their mechanical properties. Dental Materials. 2001;**17**:347-353

adhesives. Journal of Dentistry. 1998;**26**(1):1-20

Quintessence International. 2005;**36**:593-601

**16**:109-116

2000;**13**(6):468-472

52 Dental Caries - Diagnosis, Prevention and Management

[121] Walker MP, Wang Y, Spencer P. Morphological and chemical characterization of the dentin/resin cement interface produced with a self-etching primer. The Journal of Adhesive Dentistry. 2002;**4**:181-189

**Chapter 5**

**Provisional chapter**

**The Relationship between Orthodontic Treatment and**

**The Relationship between Orthodontic Treatment and**

Orthodontic treatment is the main treatment procedure to achieve a well-aligned dental arch and an esthetic smile. For this purpose, various types of removable or fixed orthodontic appliances are designed. However, each has their specific disadvantages. The most important one is that orthodontic appliances especially the brackets and the ligation mode create new retention areas in addition to blocking plaque-removing shear forces arising from fluid flow and masticatory loads with a resultant undesired effect of accumulation of dental plaque. Increased amount of dental plaque containing cariogenic bacteria is the main etiologic factor in decalcification of enamel during orthodontic treatment. This demineralization of the tooth surfaces results in appearance of white spots or even caries. However, in the literature, there are conflicting results in the relationship between orthodontic treatment and development of dental caries. Many preventive methods such as topical fluoride application, using bonding materials releasing fluoride, using mouth rinse with sodium fluoride, applying chlorhexidine, and so on were defined. The general comment of the authors is that supplying an adequate oral hygiene has the main role in prevention of demineralization-caries during orthodontic treatment. In the light of the previous studies' results, it can be concluded that professional application like a varnish

**Keywords:** orthodontic treatment, conventional brackets, self-ligating brackets, enamel

Malocclusions are not life-threatening conditions; however, they can affect the health of oral tissues and may cause psychological and social problems [1]. Nonalignment of the teeth on

> © 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use,

distribution, and reproduction in any medium, provided the original work is properly cited.

DOI: 10.5772/intechopen.76470

**Dental Caries**

**Abstract**

**1. Introduction**

**Dental Caries**

Gamze Metin-Gürsoy and Fatma Deniz Uzuner

can be provided for patients who have high caries incidence.

demineralization, white spot lesion, dental caries, microbial colonization

Gamze Metin-Gürsoy and Fatma Deniz Uzuner

Additional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76470

#### **The Relationship between Orthodontic Treatment and Dental Caries The Relationship between Orthodontic Treatment and Dental Caries**

DOI: 10.5772/intechopen.76470

Gamze Metin-Gürsoy and Fatma Deniz Uzuner Gamze Metin-Gürsoy and Fatma Deniz UzunerAdditional information is available at the end of the chapter

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/intechopen.76470

#### **Abstract**

[121] Walker MP, Wang Y, Spencer P. Morphological and chemical characterization of the dentin/resin cement interface produced with a self-etching primer. The Journal of

[122] Moszner N, Salz U, Zimmermann J. Chemical aspects of self-etching enamel-dentin

[123] Yang B, Ludwig K, Adelung R, Kern M. Micro-tensile bond strength of three luting

[124] Van Dijken JW, Persson S, Sjostrom S. Presence of Streptococcus mutans and lactobacilli in saliva and on enamel, glass ionomer cement, and composite resin surfaces.

[125] Tjan AHL, Peach KD, VanDenburgh SL, Zbaraschuk ER. Microleakage of crowns cemented with glass ionomer cemment: Effects of preparation finish and conditioning

[126] Rosentritt M, Behr M, Lang R, Handel G. Influence of cement type on the marginal adaptation of all-ceramic MOD inlays. Dental Materials. 2004;**20**(5):463-469

[127] Gerdolle AD, Mortier E, Loos-Ayav C, Jacpot B, Panighi MM. In vitro evaluation of microleakage of indirect composite inlays cemented with four luting agents. Journal of

[128] Goodcare CJ, Bernal G, Rungcharassaeng K, Kan JYK. Clinical complications in fixed

with polyacrylic acid. Journal of Prosthetic Dentistry. 1991;**66**(5):602-606

adhesives: A systematic review. Dental Materials. 2005;**21**:895-910

resins to human regional dentin. Dental Materials. 2006;**22**:45-56

Scandinavian Journal of Dental Research. 1991;**99**:13−19

prosthodontics. Journal of Prosthetic Dentistry. 2003;**90**:31-41

Adhesive Dentistry. 2002;**4**:181-189

54 Dental Caries - Diagnosis, Prevention and Management

Prosthetic Dentistry. 2005;**93**:563-570

Orthodontic treatment is the main treatment procedure to achieve a well-aligned dental arch and an esthetic smile. For this purpose, various types of removable or fixed orthodontic appliances are designed. However, each has their specific disadvantages. The most important one is that orthodontic appliances especially the brackets and the ligation mode create new retention areas in addition to blocking plaque-removing shear forces arising from fluid flow and masticatory loads with a resultant undesired effect of accumulation of dental plaque. Increased amount of dental plaque containing cariogenic bacteria is the main etiologic factor in decalcification of enamel during orthodontic treatment. This demineralization of the tooth surfaces results in appearance of white spots or even caries. However, in the literature, there are conflicting results in the relationship between orthodontic treatment and development of dental caries. Many preventive methods such as topical fluoride application, using bonding materials releasing fluoride, using mouth rinse with sodium fluoride, applying chlorhexidine, and so on were defined. The general comment of the authors is that supplying an adequate oral hygiene has the main role in prevention of demineralization-caries during orthodontic treatment. In the light of the previous studies' results, it can be concluded that professional application like a varnish can be provided for patients who have high caries incidence.

**Keywords:** orthodontic treatment, conventional brackets, self-ligating brackets, enamel demineralization, white spot lesion, dental caries, microbial colonization

#### **1. Introduction**

Malocclusions are not life-threatening conditions; however, they can affect the health of oral tissues and may cause psychological and social problems [1]. Nonalignment of the teeth on

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

the oral cavity limits the mechanical self-cleaning process providing by saliva and musculature movement. With the resultant effect of all these factors, pH value of dental biofilm drops in the presence of fermentable carbohydrates and accelerates the accumulation and maturation of cariogenic biofilm. The biofilm especially contains *Streptococcus mutans* (*S. mutans*) which are aciduric and acidogenic microorganisms and considered to be the primary etiologic factors of

The Relationship between Orthodontic Treatment and Dental Caries

http://dx.doi.org/10.5772/intechopen.76470

57

When the use of removable orthodontic appliances was assessed in terms of active dental caries or tooth loss due to caries, no difference was reported between children with and without removable orthodontic appliances. Oral hygiene in children with removable orthodontic appliances was found to be as good as the oral hygiene of children without removable orthodontic appliances. In another words, in terms of oral hygiene assessment, no difference was observed between individuals using removable orthodontic appliances and those using no orthodontic appliances [10]. In support, Karkhanechi et al. [11] reported that in patients treated with removable orthodontic appliances (**Figure 2**), as indicated by the lower BANA test results, the amount of anaerobic bacteria in supragingival plaque samples was lower due to the better oral hygiene. No such risk was observed in removable orthodontic appliances. Instead, it was

On the contrary, other authors [12, 13] reported the undesired effects of removable appliances on tooth enamel. Batoni et al. [14] reported a higher amount of *S. mutans* in children using removable appliances. Considering the acrylic removable appliances; there may be plaque accumulation and even calculus on the unpolished acrylic surfaces, especially in noncompliant patients. Acrylic structure of them may influence the proliferation of microorganisms when it acts as a food deposit. Depending on its smoothness and size, it may provide plaque accumulation that leads to enamel decalcification [9, 12, 14]. Addy et al. [15] showed that palatal plaque scores were significantly higher in wearers of removable appliances compared with a control group without orthodontic treatment. As these appliances mainly cover the lingual/palatal surfaces of the teeth, plaque occurrence in that region tend to be higher than other sides.

found to be safer, especially in patients with poor oral hygiene control [8].

dental caries [9].

**2.1. Removable appliances**

**Figure 2.** Acrylic removable appliances.

**Figure 1.** Extreme enamel demineralization and cavitation.

the jaws may cause dental caries due to the accumulation of dental plaques resulting from difficult-to-reach areas in the mouth. For this reason, dental caries is seen as an important side effect of malocclusions. However, the fact that caries formation is directly related to individual oral hygiene leads to many differences in results. There are studies reporting that there is no significant association between malocclusion and caries formation [2, 3]. On the other hand, other authors are reporting a negative correlation which notes that dental caries is less common in individuals with malocclusions [4].

There are many orthodontic treatment methods based on the existing malocclusion type. However, the common goal of all orthodontic treatment methods is to ensure that the teeth are aligned properly on the jaws, as well as in harmony with each other. A balanced soft tissue appearance and an esthetic smile are virtually the greatest passion of patients and orthodontists. Fixed or removable orthodontic treatment appliances used for this purpose may cause some undesirable side effects, as it may be seen in every treatment process. The most common side effect of orthodontic treatments is that they cause changes in mouth flora due to the formation of non-cleanable surfaces, and therefore they cause areas of decalcification on the enamel and eventually periodontal diseases (**Figure 1**) [5–7].

In this chapter, effects of orthodontic treatments on the development of enamel decalcification/caries were discussed in detail. The effects of bracket materials, designs, and different ligations on the levels of cariogenic bacteria were evaluated, the associated microbiota were discussed in conjunction to previous studies' result. Additionally, the prevention methods such as topical fluoride application, using bonding materials releasing fluoride, using mouth rinse with sodium fluoride, applying chlorhexidine, and so on were evaluated.

#### **2. Relationship between orthodontic appliances and dental caries**