Application of a tooth-surface coating material to teeth with
discolored crowns Takashi Hashimura, Aya Yamada*, Tsutomu Iwamoto, Makiko Arakaki, Kan Saito, Satoshi Fukumoto Division of Pediatric Dentistry, Department of Oral Health and Development Sciences, Tohoku University Graduate School of Dentistry, Sendai 980-8575, Japan a r t i c l e i n f o Article history: Received 10 December 2012 Received in revised form 4 March 2013 Accepted 6 March 2013 Available online 6 May 2013 Keywords: Discolored teeth Tooth coating material S-PRG ller Caries prevention a b s t r a c t Crown discoloration of permanent teeth is caused by trauma, periapical lesions of the deciduous teeth, pharmaceuticals, and systemic diseases. Crown discoloration has been treated with bleaching or crown restoration. However, these methods are not appropriate during the growth and development period of children. In this study, we used BeautiCoat (Shofu Inc., Kyoto, Japan), a tooth-surface coating material that contains high levels of controlled-release uoride, that temporarily im- proves crown color. We evaluated the effect of the primer on tooth-surface characteristics in addition to the coating agents shear bond strength, tooth-surface condition, and duration of attachment. Additionally, we surveyed patients satisfaction with the color improvement. The results showed no adverse effects of the primer on the enamel surface. The coating material itself showed a high degree of shear bond strength. Based on observations of shedding and fracturing in clinical applications, we found that the coating material maintained long-term attachment if applied under conditions of strict moisture prevention and it avoided areas of occlusion. Treated children and their parents were highly satised with the color improvement. These results suggest that this coating material is appropriate for improving the color of discolored teeth during childhood. 2013 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved. 1. Introduction Esthetic problems due to discolored crowns are common in pediatric clinical practice. Causes of crown discoloration during the formation of permanent teeth include periapical lesions due to severe cavities in deciduous teeth and enamel formationdisorders due to tooth trauma. Discoloration ranges from white spots in mild cases to substance loss with dark reddish-brown coloring. Crowns can also be discolored by the use of tetracycline antibiotics or systemic diseases during the tooth formative period [1,2]. Such crown discoloration can be treated in adults with crown restoration methods, such as resin, laminating ve- neers, facing crowns, and bleaching treatments. However, it is difcult to achieve esthetic improvement in young children during their period of growthand development using methods * Corresponding author. Tel.: 81 22 717 8382; fax: 81 22 717 8386. E-mail address: yamada-a@dent.tohoku.ac.jp (A. Yamada). Available online at www.sciencedirect.com Pediatric Dental Journal j ournal homepage: www. el sevi er. com/ l ocat e/ pdj p e d i a t r i c d e nt a l j o ur na l 2 3 ( 2 0 1 3 ) 4 4 e5 0 0917-2394/$ e see front matter 2013 The Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pdj.2013.03.011 intended for adults. For instance, almost all at-home and in- ofce bleaching procedures are not intended for young chil- dren. Further, the use of irreversible crown restoration treat- ments that require tooth preparation is not appropriate in young children, because the gingival margin height has not stabilized while the teeth are erupting or while the alveolar bone is still forming. Therefore, a temporary treatment for young children with crown discoloration is needed. One such method is the tooth manicure, which uses ma- terials that improve the color of teeth in a single day. However, the organic solvents used in nail manicures are difcult to use insidetheoral cavity; therefore, theeffectslast for only1e2days, and it is difcult to maintain long-term color improvement. In 2004, White Coat (Kuraray Medical Co., Osaka, Japan) was developed, which is a tooth-coating material for exclusive use in dental clinics. This material uses a self-etching primer, and its adhesion durability is about 1 month. This product has better durability compared to over-the-counter tooth mani- cures [3,4]. Progress has since been made in developing materials with better durability and good physical properties that cause little damage to the tooth. Surface reaction type pre-reacted glass ionomer (S-PRG) ller has been developed, which possesses physical strength and high levels of controlled-release uo- ride [5]. The tooth-surface coating material BeautiCoat (Shofu Inc., Kyoto, Japan) contains this ller and is currently used to treat discolored crowns [6]. Dental materials using S- PRG ller include sealant materials [7], composite resin, or- thodontic resin bonding system [8], denture base resin [9,10], and root canal sealer [11]. Through the release and recharge of uoride and various other ions, cavities can be prevented in the area of repair and neighboring teeth, and the adhesion of plaque to the tooth surface can be suppressed [12,13]. This study investigated the shear-adhesion strength and durability of BeautiCoatin the oral cavity as well as the effect of its tooth-surface primer on enamel surface characteristics. Finally, a survey of patient satisfaction with color improve- ment was also conducted. 2. Materials and methods 2.1. Effect of the primer used in the tooth-surface coating material on enamel surface characteristics Bovine tooth enamel specimens were subjected to no treat- ment, the BeautiCoat Primer treatment (3 s), or 37% phos- phoric acid etching treatment (30 s). Enamel surface characteristics were then observed and analyzed with a scanning electron microscope (SEM; VE-7800, Keyence, Osaka, Japan) under gold-evaporated conditions. 2.2. Evaluation of shear bond strength of the tooth- surface coating material Enamel, dentin, metal, and porcelain were prepared under the following conditions before shear bonding strength (SBS) test. A bovine tooth surface was placed in an acrylic ring, and the ring was embedded in epoxy resin. The bovine tooth surface was polished using #600 SiC paper to expose enamel or dentin. Precious metal (a gold-silver-palladium alloy) was polished using #600 SiC paper, and the sandblast was applied to the surface of metal using alumina-sand of 50e100 mm. Porcelain was polished using #600 SiC paper to expose at surface. The surface of bonding specimen was treated according to the bonding method recommended by the manufacturer. A mold (4 mm diameter, 0.2 mm height) was tted onto the treated surface, lled with the coating material paste (BW2) and light-cured to obtain a test specimen for SBS testing. After being stored in water at 37
C and 2000 thermal cycling (4e60
C), the specimen was evaluated for its SBS before and after thermal cycling using a universal testing machine. 2.3. Clinical evaluation of the tooth-surface coating material BeautiCoat was applied to the teeth of 30 subjects (38 teeth; upper central incisors and upper lateral incisors) with crown discoloration believed to be caused by trauma or periapical lesions of the deciduous teeth under the informed consent from all parents. The patients were treated at the pediatric dentistry department of Tohoku University Hospital (Miyagi Japan) and Hashimura Dental Clinic (Saga, Japan). The surfaces of the affected teeth were cleaned with a low- speedconebrush. Primer Aandprimer Bwereplacedinadish1 drop at a time and mixed with a disposable chip brush. The mixed liquid was applied to the surface of the teeth. It was left in place for 3 s or more and was then dried with low-pressure air. Next, the previously selected color-tone paste (white base, BW1e4; white opaque, WO/paint color; yellowish, A0.5, A3) was applied uniformly to the surface of the tooth using a special BCapplicator. This was irradiatedfor 20s usingavisible light-curing unit (G-light, GC, Tokyo, Japan), and the non- polymerized layers were removed with dry gauze. Finally, Gloss Rene (Shofu Inc., Kyoto, Japan) was applied to the tooth surface, which was then polished with a bufng disk and washed. For the clinical evaluation of the tooth-surface coating material, shedding and partial fracturing of the tooth surface were observed at 1 week, 1 month, and 3 months after coating treatment. Photographs of the oral cavity were taken to eval- uate fractures. Fractured areas covering less than 5% of the surface area of the labial side of the tooth were classied as small fractures, and those covering 5% or more of the surface were classied as fractures. During observation, affected teeth in which fractures occurredwerere-coated; at thispoint, theseteethwereexcluded from the study. Moreover, if a tooths color made it difcult to determine the presence of fractures through photographs or surveys, a replica was made from a silicone impression, which was then observed with a stereomicroscope (SZX12, Olympus, Tokyo, Japan). 2.4. Satisfaction survey regarding the tooth-surface coating material A questionnaire was administered to the 30 affected children and their parents. The questionnaire contained questions concerning the level of satisfaction with the tooth-surface coating material treatment of discolored teeth. The subjects p e d i a t r i c d e nt a l j our na l 2 3 ( 2 0 1 3 ) 4 4 e5 0 45 were surveyed immediately after the coating treatment, 1 month after treatment, and 3 months after treatment. The possible responses were: a) very satised, b) satised, c) neutral, and d) not satised. 3. Results 3.1. Effect of the primer used in the tooth-surface coating material on enamel surface characteristics We evaluated the effect of the primer that is used before applying the tooth-surface coating material on enamel sur- face characteristics. To examine the effect of primer on tooth, the primer was applied to the enamel surface of bovine teeth. After performing gold-evaporation treatment, the enamel was observed under a SEM. The enamel surfaces treated with a 37% phosphoric acid solution displayed decalcication, and the enamel rods were exposed as in previous reports (Fig. 1C). However, in the group treated with the primer, there was no marked decalcication of the enamel surface, and the surface characteristics were similar to the control (untreated) group (Fig. 1A and B). These results suggest that this primer has few adverse effects on the enamel. 3.2. Evaluation of shear bond strength of the tooth- surface coating material In order to evaluate the SBS of the tooth-surface coating ma- terial, the material was bonded to enamel, dentin, precious metal, and porcelain using a brass ring, after which the SBS was measured. SBS of 10 MPa or more was observed in enamel and dentin 24 h after adhesion. Maintenance of high bond strength was conrmed in the group that received thermal cycle treatment as well. SBS in precious metal and porcelain was inferior to that of enamel and dentin (Fig. 2), but the tooth-surface coating material displayed sufcient SBS more than 10 MPa after a thermal cycle. 3.3. Clinical evaluation of the tooth-surface coating material After applying the tooth-surface coating material, shedding and fracturing of the tooth surface were investigated. The coating material was applied to the teeth of 32 subjects (38 teeth). Of these, investigations were conducted in 30 subjects (36 teeth) 1 week after application, in 26 subjects (31 teeth) 1 month after application, and in 21 subjects (25 teeth) 3 months after application. Shedding and fracturing were observed in 5 of 36 teeth (13.9%) 1 week after applying the tooth-surface Fig. 1 e Scanning electron microscope micrographs of the enamel surface. (A) is the non-treated enamel surface. (B) and (C) are the enamel surfaces after treatment by BeautiCoat Primer (Shofu Inc., Kyoto, Japan) for 3 s and 37% phosphoric acid for 30 s respectively. Fig. 2 e The shear bond strength of the tooth-surface coating material to enamel, dentin, precious metal, porcelain, and resin were evaluated. p e d i a t r i c d e nt a l j o ur na l 2 3 ( 2 0 1 3 ) 4 4 e5 0 46 coating material, 10 of 31 teeth (32.2%) 1 month after, and 8 of 25 teeth (32.0%) 3 months after (Table 1). Most of the fracturing was observed on the incisal margin and cervix of the incisors (Fig. 3). In 1 case, there was complete shedding of the coating material from the tooth surface, which occurred at 1 month after application. In this case, the child was not satised with the color of the application. The child attempted to remove the coating material, which resulted in complete shedding of the material. Thus, there were no cases of complete shedding under normal conditions. 3.4. Satisfaction with the tooth-surface coating material The affected teeth mainly involved white turbidness of the labial surface of the upper incisors, tooth substantial defect in the crown, or generalized crown discoloration caused by pulp necrosis due to trauma. The subjects reported being very satised and satised in 23 of 24 cases (95.8%) immediately after the procedure, in 19 of 20 cases (95.0%) 1 month after, and in 17 of 17 cases (100%) 3 months after (Fig. 4). Although this is a preliminary study, color improvements after treatment with the tooth-surface coating material were examined in different cases. In one case involving white turbidness of the labial surface of the tooth, there was a marked difference in color on the borders of the turbid and normal areas. Applying a highly transparent paint did not sufciently improve the tooth color, and the parent was not satised with the result. Therefore, a white base with a lower level of transparency was applied to the border areas to obscure their edges, and the paint color was then applied. This improved the parents level of satisfaction. In a case involving brown-colored enamel hypoplastic defect accompanied by substance loss of the labial surface of the tooth, the white base with the lowest transparency, BW3, was applied. After this, paint color A3 was used, which resulted in color improvement (Fig. 5). Fig. 6 shows a case inwhichtrauma to the upper-left lateral and central deciduous incisors at age 1 year 6 months led to early loss of the tooth from pulp necrosis, which caused early eruption of the permanent tooth (upper central incisor) at age 4 years 3 months. The prior trauma caused spots on areas of low enamel formation. As there was a difference in color Table 1 e Frequency of shedding and fracturing of the tooth-surface coating material. Patient no. Tooth no. None Fracture (5%<) Fracture (5%>) Fallout 1 week 30 36 31 (86.1%) 3 (8.3%) 2 (5.6%) 0 (0%) 1 month 26 31 21 (67.7%) 8 (25.8%) 1 (3.2%) 1 (3.2%) 3 months 21 25 17 (68.0%) 5 (20.0%) 3 (12.0%) 0 (0%) Fig. 3 e Shedding and fracturing of the tooth-surface coating material from the tooth were observed using replica model. (A) is frontal view of fractured materials, and (B) is another case. (B-a): frontal view and (B-b) is incisal view. Fig. 4 e Satisfaction with the tooth-surface coating material was investigated immediately after the procedure, and 1 month after, and 3 months after. p e d i a t r i c d e nt a l j our na l 2 3 ( 2 0 1 3 ) 4 4 e5 0 47 between the crown of the permanent tooth and the deciduous teeth, the subject desired color improvement of the anterior teeth. Paint color A0.5, which was close to the crown color of the deciduous teeth, was applied to the surface of the per- manent tooth. Coating of the permanent tooth crown with A3 led to an even higher level of satisfaction. In this case, because the tooth-surface coating was performed during eruption of the tooth, a difference in level between the tooth-gingival margin and the coating material was observed on the labial side of the tooth cervix 10 months after application. Further, a microscopic fracture was observed on the mesial periphery of the coating material. This fractured area was re-coated, and no fracturing was observed 4 months later. However, a new fracture was observed in the incisal margin (Fig. 7). Fig. 5 e Clinical cases before and after treatment by the tooth-surface coating material to the case with white-colored enamel hypoplastic defect. Fig. 6 e Clinical cases before and after treatment by the tooth-surface coating material to the case with discolored permanent tooth caused by the trauma of deciduous tooth. p e d i a t r i c d e nt a l j o ur na l 2 3 ( 2 0 1 3 ) 4 4 e5 0 48 4. Discussion S-PRG ller was developed as an advanced material that can recharge and release uoride and other ions. This PRG ller possesses the excellent characteristics of bothresins and glass ionomer cements through its incorporation of resin-type materials [14]. These materials are generally termed giomer products, which are currently sold as composite resin, bonding material, resin cement, sealant material, tooth- surface coating material, and bonding material for use in teeth straightening [15]. Furthermore, recent developments in tooth-surface treatment agents have ledto the development of tooth-surface coating materials that use self-etching primers. These have allowed for relatively long-term retention of the coating materials onthe toothsurface. This study investigated a tooth-surface coating material that uses a self-etching primer containing this S-PRG ller to treat teeth with dis- colored crowns, which are frequently observed in pediatric clinical practice. The primer for the tooth-surface coating material used in this study uses a methacrylate monomer 6-methacryloxyhex- ylphosphonoacetate with an acidic base and an adhesive monomer that is resistant to moisture. Observation under a SEM demonstrated that this primer did not cause marked sur- face decalcication of the enamel, and there was little damage to the enamel. Thus, this gentle tooth-surface treatment ma- terial is appropriate for use inthe immature permanent teeth of childhood. Further, the tooth-surface coating material had sufciently high bonding strength in shear bond tests and even possessed high bonding strength with metal and porcelain surfaces. This material is applicable for the repair of porcelain fractures or discoloration as well as the esthetic improvement of metal repairs. However, as this material has less bonding than resin-type materials, it is a temporary method. In actual clinical applications, apart from a single case where the child intentionally removed the coating, no cases of natural shedding were observedduring 3 months of observation. Incases where fracturing occurred, the fractures appeared mostly in the incisal margins involved in occlusion. However, there were no malocculusions, suchastheedge-to-edgeocclusionandcrossbite in these subjects. This suggests that fracture of coating materials could be prevented by avoiding the incisal margin during the coating procedure. In fractures near the gingival margin, perme- ation of liquid from the gingival sulcus likely inuenced bonding strength; however, fractureswerepreventedinthisareawhenthe procedure was conducted under complete moisture prevention. Therefore, more stable, long-term tooth-surface coating can be achieved by completely preventing moisture using a rubber dam and adjusting the extent of coating in the incisal margin area. Furthermore, this tooth-surface coating material contains S-PRGller, whichcansuppress bacterial plaque adhesionand canrecharge and control the release of uoride and other ions. The cavity-preventing effect of uoride ions is well known, but of other ions released by this ller, strontium ions are partic- ular in their ability to resist acid release from dental plaque, inhibit bone resorption, promote bone formation, induce calcication in dentin, and seal dentinal tubules [7,16e19]. Based on these functions, coating tooth surfaces with this material not only achieves esthetic improvement, but also can increase acid resistance, remineralization, and suppress adhe- sion of plaque and bacteria to the tooth surface [6]. Further, this material showed higher uoride release compared with con- ventional sealant, but not glass ionomer cement (data not shown). Thus, this coating material not only covers the surface, but can also contribute to cavity prevention in the surrounding area, which makes it appropriate for use in childhood. Indeed, discolored portions of teeth have low calcication, and the cavity rate tends to be high. Nevertheless, there were nocavities observed in the affected teeth treated with this tooth-surface coating or in the neighboring teeth. Moreover, tooth discoloration caused by tetracycline anti- biotics darkens over time due to the effect of ultra-violet rays [20]. Although no such cases were included in this study, Fig. 7 e Clinical progress of the case treated by the tooth-surface coating material for the erupting tooth. This is the same case as that shown in Fig. 6. p e d i a t r i c d e nt a l j our na l 2 3 ( 2 0 1 3 ) 4 4 e5 0 49 application of this tooth-surface coating material could limit the progression of discoloration by blocking ultra-violet rays [21]. The degree of satisfaction with the tooth-surface coating material among affected children and their parents was extremely high in this study. Even in cases that involved frac- tures, the fractures themselves did not inuence the degree of satisfaction, since the subjects were informed beforehand that the procedure is a temporary method. Rather, because the coating could be removed from the tooth to return it to its normal state with almost no damage, the coating could be used without worry, and color improvement could be tested easily. Further, in a case of partial fracture of coating material, since it is easily removable, it may be re-coated after removal. In addition to the subjective evaluation of patient satis- faction, further research on chronological changes for prog- nosis prediction, such as quantication of color changes, abrasion by tooth brush, and effect of the thickness of coating material and occlusion is important in the future. 5. Conclusion The results from the present study suggest that this tooth- surface coating material is extremely useful for improving color in teeth with discolored crowns in pediatric dental practice. It is a valuable dental material that can improve es- thetics as well as prevent cavities and strengthen teeth. Disclosure None of the authors has any conicts of interest that should be declared. r e f e r e n c e s [1] Conchie JM, Munroe JD, Anderson DO. The incidence of staining of permanent teeth by the tetracyclines. Can Med Assoc J 1970;103:251e5. [2] Antonini LG, Luder HU. 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