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Journal of Oral Rehabilitation 2008 35; 291–299

Review Article
Accuracy and stability of impression materials subjected to
chemical disinfection – a literature review
E. KOTSIOMITI, A. TZIALLA & K. HATJIVASILIOU Department of Removable Prosthodontics, The Dental
School, Aristotle University of Thessaloniki, Thessaloniki, Greece

SUMMARY Disinfection of impressions by immersion tions broadly agree that the disinfection process does
or spraying with disinfecting solutions is considered not generally affect the dimensional integrity of the
nowadays mandatory for effective infection control. impressions, in spite of the statistically significant
The purpose of this review was to examine existing differences occasionally found. However, the immer-
evidence on the effects that chemical disinfection sion in the disinfecting solution encourages water
may have on critical qualities of impressions, namely absorption phenomena in the case of the so-called
dimensional accuracy and stability over time. hydrophilic impression materials, especially after the
A PubMed search was conducted to include original long-term immersion. Chemical interactions
laboratory research articles written in English, pub- between impressions and disinfectants may occur,
lished between 1980 and 2005 in peer-reviewed jour- but they do not appear to influence the dimensional
nals and investigating the effect of chemical behaviour of the former. The overall effect of the
disinfection, by immersion or spraying, on the dimen- disinfection is influenced not only by the changes
sional changes that the impression materials experi- experienced by the impression per se, but also by the
ence after setting. Studies were also sought manually, alterations of the acrylic tray containing the impres-
by tracing the references cited in the retrieved arti- sion and of the gypsum product poured in it.
cles. The reports on dimensional changes of disinfec- KEYWORDS: impression materials, disinfecting solu-
ted impression materials, although rather numerous, tions, dimensional changes, accuracy, stability
are difficult to compare and analyze because of
variations of the experimental design. The investiga- Accepted for publication 28 April 2007

major authoritative bodies (6, 7), manufacturers (8),


Introduction
academics (1, 9) and textbooks on dental materials (10–
Disinfection of dental impressions was not a routine 15). However, the recommendations are often not
procedure until the late 20th century, when the detailed enough and in many cases they contradict each
outbreak of AIDS brought up the need for infection other, concerning what particular solution, method, or
control in dental practice. It was then realized that all application time is suitable for the disinfection of each
items exiting the dental office should be free from impression material (3). This inconsistency is not
pathogenic micro-organisms; for dental impressions surprising, as it reflects the confusing and conflicting
that reasonably meant that they should be disinfected input from the research which has been published on
before their transfer to the laboratory (1). Nowadays the subject and upon which the specific instructions are
most dental schools (2) and hospitals (3) as well as an based. Indeed, to extract a clear outcome of the
increasing, though still low, number of practitioners (4) available information is a complicated task, firstly
and laboratories (5) disinfect their impressions before because there are numerous combinations of impres-
using them for the construction of casts. Guidelines sion materials and disinfectants – implying equally
about the proper procedures are continuously issued by numerous, potentially harmful interactions – and

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292 E . K O T S I O M I T I et al.

secondly because of the great variability of experimen- haps to a practically harmless level (60)], it has been
tal designs, methods and presentation of results (2). shown that measurable bacterial load remains on
Publications examining the interactions between impressions and can be transferred to casts (61).
impression materials and chemical disinfectants began Therefore, the effort to eliminate as many potential
to appear in the dental literature on about 1980 and risks as possible seems logical and the application of a
were quite frequently found for 1 or 2 decades there- disinfection treatment on impressions is considered
after. The research was readily oriented towards two mandatory. Although alternative methods are being
main areas, which comprise the main requirements for proposed, such as ethylene oxide (46, 62), autoclave
a disinfectant: the efficiency of the disinfecting solu- (46, 62), microwave (55), ultraviolet radiation (63, 64),
tions in eliminating the pathogens and the influence of or even immediate pour and disinfection of the casts
the disinfection treatment on the properties of the (65, 66), chemical disinfection, preferably by immers-
impression material (16). ion, seems to be the most reliable and practical method,
Critical qualities, which could be affected by the provided that it does not adversely affect the dimen-
disinfection procedure, are surface properties such as sional integrity of the impressions.
detail reproduction, surface roughness and wettability, Dimensional stability of disinfected impressions is
and dimensional alterations, commonly termed accu- therefore critical and a considerable number of articles
racy and stability (10). This article reviews the infor- were found reporting on it. As can be seen in Table 1,
mation available regarding the effect of chemical the investigations showed a remarkable variation of
disinfection on the dimensional changes that the important experimental attributes; the differences can
impression materials experience after setting. The aim be briefly summarized as follows:
was to assess the scientific knowledge on the subject Various combinations of impression materials ⁄ disin-
and to point out the interactions which should be fecting solutions were encountered. Addition silicone
expected during the execution of the disinfection was the most frequently used impression material,
procedure. followed by polyether, irreversible hydrocolloid,
A PubMed search was conducted for laboratory polysulphide, condensation silicone, and reversible
research articles, published in English peer-reviewed hydrocolloid; the so-called ‘rigid’ materials – zinc
journals between 1980 and 2005, on impression mate- oxide–eugenol paste, modelling plastic impression com-
rials subjected to chemical disinfection and tested for pound, and impression plaster – were considerably less
their dimensional properties, termed as either stability investigated. Glutaraldehyde seemed to be the pre-
or accuracy. The search results were combined and 28 ferred disinfectant, but chlorine compounds, iodophors,
articles were selected and retrieved in full text. An phenolic and alcohol compounds were also tested.
additional search was subsequently performed to trace The specimens were usually immersed in the disin-
relevant studies cited in the retrieved material, as well fectant or control solution, but spraying as an applica-
as in dental materials’ textbooks; 13 more titles were tion technique was also investigated. The time of
found and obtained in full-text. Thus, 41 original contact between the impression material and disinfect-
research studies, reporting on dimensional changes of ing solution was, in most cases, limited to <60 min and
chemically disinfected impression materials, were selected according providers’ instructions and relevant
finally collected (17–57). These articles, represented guidelines. However, 12 investigations studied the
by the first author’s name, arranged by year of effect of long-time contact, several hours or even days.
publication and briefly described by the tested materials Control specimens were left either in water – usually
and main attributes of experimental design, are distilled or deionized – or in air; in nine studies the
presented in Table 1. control sample consisted of impression specimens
poured immediately. Nine studies used both water
and air as control environments. The experimental
Literature review
specimens consisted of either impressions or the casts
Micro-organisms can survive on, or even inside, the poured on them. Two articles (34, 51) measured
impressions (58, 59). Even though their number dimensions of both impressions and their casts.
decreases rapidly after impression making (58) and The usual method to estimate dimensional changes
rinsing with water further eliminates them (59) [per- involves measurement of distances between selected

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DIMENSIONAL CHANGES OF DISINFECTED IMPRESSIONS 293

Table 1. References, materials used and gross experimental design of studies on dimensional accuracy and stability of disinfected
impression materials

Materials tested Experimental design

First author name Application Measurements Immersion


(reference no.) Impression materials* Disinfectants† method Control on time

Bergman (17) AS, CS, PE, PS G, Cl Immersion Water Impressions 60 min


Storer (18) MC, ZOE, IH, CS, PE, PS G, Cl Immersion Water, air Casts 16 h
Olsson (19) ZOE G, Cl Immersion Water Impressions 60 min
Bergman (20) IH G, Al, Cl, Ph Immersion, Water Impressions 60 min ⁄ 24 h
spraying
Herrera (21) IH, AS, PE, PS G, I, Cl, Ph Immersion Air Casts 30 min
Durr (22) IH G, Cl Immersion Poured immediately Casts 10 min
Johansen (23) AS, CS, PE, PS G Immersion Air Impressions 16 h
Merchant (24) PS G, Cl, I Immersion Water, air Cast gold inlays 30 min
Olsson (25) RH G, Cl, Ph Immersion, Water Impressions 60 min ⁄ 24 h
spraying
Johnson (26) AS. PE G, Ph Immersion Air Casts 10 min
Jones (27) IH G Immersion Poured immediately Casts 10–60 min
Tullner (28) IH, AS, PE, PS G, I, Cl Immersion Poured immediately Casts 15 min
Drennon (29) AS, PE, PS Ph, G, I Spraying Air Casts 10 min
McCormick (30) AS, CS, PE G Immersion Water, air Casts 10 min–72 h
Merchant (31) RH G, Cl, I Immersion Water, air Cast gold inlays 30 min
Peutzfeldt (32) IH, AS, PE G, Cl, Al Immersion Water ⁄ air (humidor) Casts 10 ⁄ 60 min
Chia (33) AS, PE G Immersion Air Casts 15 h
Fong (34) MC, IP, ZOE G Immersion Water, air Impressions, casts 20 min
Giblin (35) IH, RH, AS I Immersion Poured immediately Casts 10, 30 min
Jones (36) IH G Immersion Poured immediately Casts 10, 30 min
Langenwalter (37) AS, PE, PS G, I, Cl Immersion Water, air Impressions 10 min
Matyas (38) IH, AS, CS G, Ph, Cl Immersion Air Casts 10 min
Minagi (39) AS G Immersion Poured immediately Casts 10–120 min
Salem (40) AS, PE, PS, CS G, Cl Immersion Water, air Impressions 6h
Rueggeberg (41) IH Cl Immersion, Water ⁄ poured Casts 10 min
spraying immediately
Kern (42) IH, RH, AS, PE G Immersion Air (humidor) Impressions 10 min
Tan (43) IH Cl, I, Ph Spraying Water Casts 10–60 min
Davis (44) AS, PE G Immersion Air Casts 30 min–24 h
Hilton (45) IH Cl, I, Ph Immersion Poured immediately Casts 3 ⁄ 10 min
Olin (46) AS G Immersion Poured immediately Casts 12 h
Vandewalle (47) IH Cl Immersion Water Casts 1–10 min
Rios (48) AS, PE G Immersion Water, air Impressions 30, 60 min
Thouati (49) AS, CS, PE G, Cl Immersion Air Casts 30 ⁄ 60 min
Lepe (50) AS, PE G Immersion Air Casts 18 h
Al-Omari (51) IH, AS Cl, Al Immersion, Water Impressions, casts 2 ⁄ 5 ⁄ 30 min
spraying
Johnson (52) IH, AS, PE G, I, Ph Immersion Air Casts 10 min
Adabo (53) AS, CS, PE, PS G, Cl Immersion Air Casts 10 ⁄ 30 min
Taylor (54) IH Cl Immersion Air Casts 10 min
Abdelaziz (55) AS, PE G Immersion Air Impressions 8h
Jagger (56) IH, AS, PE G, Cl, Al Immersion, Air Casts 5–30 min
spraying
Wadhwani (57) AS, PE G Immersion Air Casts 20 min

*Impression materials are encoded as follows: RH, reversible hydrocolloid; IH, irreversible hydrocolloid; PE, polyether; PS, polysulfide; AS,
addition silicone; CS, condensation silicone; ZOE, zinc oxide–eugenol; MC, modelling plastic impression compound; IP, impression plaster.

Disinfectants (generic names) are encoded as follows: G, glutaraldehyde; I, iodophors; Cl, chlorine compound; Al, alcohol; Ph, phenol.

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294 E . K O T S I O M I T I et al.

points on the experimental ⁄ control specimens and This experimental design can be extended in time to
comparison with analogous distances on the recorded include stability, however, stability as defined above
object – a master arch model or a standardized metal may be better assessed by using the dimensions of the
block. The results were then presented either as raw just-made impression as baseline and calculating the
differences or as percentages. In two studies (24, 31) the differences thereafter.
distortions were evaluated by estimating the fit of Measurements can be taken either on the impres-
completed inlay castings. sions or on the casts produced by them (34, 35).
Because of the above differences, an overall combi- Measuring impressions is perhaps advantageous, in
nation and direct comparison of the collected material that it permits a more thorough, scientifically correct,
was not feasible. The considerable amount of informa- view of the phenomena under study, by restricting
tion provided by the retrieved publications can, how- the materials involved and illuminating the inter-
ever, be used to stress the need for a standardized actions. On the other hand, measurements on casts
experimental design, to provide an insight on the are more correlated to the actual clinical and labor-
interactions, and to identify additional factors related to atory practice and, though they complicate the
the clinical practice, whose effect may have not yet experimental procedure, they are often practically
been adequately appreciated. advantageous.
According to the above, in estimating dimensional
changes of impressions, a researcher has to decide on
Parameters related to the experimental estimation of
the baseline measurements (evaluating accuracy, sta-
dimensional changes
bility, or both), and on the experimental materials
The impression is a crucial part of the process of involved (impression materials alone or in combination
constructing a well fitting prosthesis; it is imperative with their stone casts). A further step would be to
that it copies the exact topography of the recorded site incorporate the disinfecting procedure into the experi-
and translates it accurately to its cast. To achieve this, mental protocol. One key point in such a design would
the impression material must be both accurate and be the assignment of the control group. Many of the
stable (14). investigations included in this review examined the
Accuracy is the quality related to the copying of the effect of disinfectants in comparison with control
recorded topography. Part of it refers to the reproduc- specimens left in air, which generally replicates clinical
tion of the fine details of the imprinted area, and practice, where the impression will either be left on a
depends on parameters of the fluid, unset material, bench or immersed in (or sprayed by) the disinfecting
such as viscosity, pseudoplasticity and wettability. solution. Such an approach, however, estimates the
Another part relates to the transfer of the dimensions effect of the disinfectant as both an aqueous solution
of the original shape, and is influenced by events and a chemical. Using water as a control storage
occurring during setting and removal, such as poly- medium may help in isolating the effect of water,
merization contraction, thermal contraction, and elastic imbibition or dissolution, from the chemical interac-
recovery (10, 15). tions possibly occurring.
The stability of an impression is also related to its
shape, but it involves the concept of time, as it
Assessment of published evidence on dimensional
represents the ability of the record to remain unaffected
accuracy ⁄ stability of disinfected impressions
by its storage. Factors such as continuing polymeriza-
tion, release of stresses and interactions with the In general, dimensional accuracy and stability were
storage environment may, if allowed to act long found to remain practically unaffected by the disinfec-
enough, alter the impression dimensions and produce tion procedure. Although most of the reviewed authors
a distorted reproduction (10). report occasional statistically significant dimensional
The accuracy, in terms of dimensional differentiation changes related to the disinfection procedure, almost all
of an impression in comparison with the original, can agree that these are not likely to have a clinical
be experimentally tested by calculating the difference significance. Tullner et al. (28) reported that the dis-
between marked points of the recorded object (master crepancies observed after disinfection were well within
model) and its replica, shortly after impression making. the acceptable limits for the production of adequately

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DIMENSIONAL CHANGES OF DISINFECTED IMPRESSIONS 295

fitting metal castings. Merchant et al. (24) evaluated the materials, however, seem to have overcome imbib-
fit of metal inlays constructed on disinfected impres- ition problems, and were found as stable as silicones
sions and found no distortion resulting in unacceptable (40, 48–50, 52, 57).
castings. According to Johnson et al. (52) the distortion The recent introduction of hydrophilic addition
of casts made on disinfected impressions, is smaller than silicones added one more water-friendly material to
physiologic tooth movement and distortion of the the above. These newly developed materials, incorpor-
mandible during mouth opening, therefore, disinfected ating surface active ingredients, tend to absorb water
elastomeric impressions can be safely used for the and expand if left long enough in the solutions (39).
preparation of fixed prostheses and hydrocolloid mate- Information on their behaviour following the long-
rials can be used for the construction of diagnostic casts. term disinfection is, however, still lacking. On the other
Kern et al. (42) stated that the impression process, along hand, the traditional hydrophobic addition silicones
with various factors associated with the fabrication of were the most stable materials (28, 29, 32, 35, 37, 38,
the prosthesis, might represent a greater source of 42, 48, 49, 51, 52), even after long-term immersion in
random error than the effects of disinfection. The the disinfecting solutions (23, 30, 33, 50). Fast setting
dimensional changes of disinfected impressions were polyvinyl siloxanes were found to be as advantageous
found to even be advantageous, compared to non- as traditional materials (57).
disinfected ones (49). Therefore, most authors conclude that, excluding the
Limited as it may be, the influence of disinfection on possibility of water uptake, interactions between
the dimensions of impressions was often clear and in impression material and disinfectant do not produce
many instances was found to stem from imbibition of significant differences (28, 37, 40, 42, 48, 53) concern-
water. Such an effect is evident in the behaviour of the ing the accuracy, either short- or long-term, of the
materials most susceptible to a wet environment, record. However, investigations using both dry and wet
namely hydrocolloids and polyethers. (water-immersed) controls (18, 24, 30, 31, 34, 37, 48)
The imbibition characterizing the hydrocolloids im- indicate that chemical interactions may take place
posed restrictions concerning time of immersion, with during disinfection. For example irreversible hydrocol-
the majority of researchers applying disinfection times loids tend to be superficially dissolved or deteriorated
of no more than 30 min (22, 28, 35, 36, 38, 40, 42, 45, by sodium hypochlorite (28, 38, 41, 54) and dehydrated
51, 52, 54). According to Taylor et al. (54), a 10-min by ethanol (32). Condensation silicones and polysul-
imbibition can be beneficial, as it counteracts the phides could benefit from disinfection, as their poly-
syneresis-associated shrinkage. Spraying instead of merization shrinkage is counterbalanced by the
immersion was suggested in many, but not all (38, reduced vaporization of by-products.
51) of the reports, as it limits the exposure in the wet Rigid impression materials, such as zinc oxide–euge-
environment and produces remarkably stable impres- nol pastes, modelling plastic impression compound, and
sions (20, 25, 42) and accurate casts (29, 41, 43). impression plaster, present differences between dry
However, spraying combined with reduced contact controls, wet controls and disinfected specimens, which
time may restrict the efficiency of disinfection, especi- are statistically significant, but not clinically important
ally for the porous, hydrophilic hydrocolloids, where (34). Zinc oxide–eugenol pastes can be disinfected in a
micro-organisms can penetrate and survive in the body wide range of solutions (18, 19); modelling plastic
of the impression (58, 59, 61). Incorporation of disin- impression compound seems less resistant, as it deteri-
fectants in the hydrocolloid powder (14, 58) or mixing orates in glutaraldehyde, formaldehyde and chlorine
water (67, 68) was found to provide an effective means solutions (18).
of additional decontamination, with no adverse effects Finally, interactions have been reported that cannot
in stability (36) and accuracy (69, 70). be attributed to major ingredients; these probably
For polyethers, the water absorption potential originate from reactions of specific components of
contributes to relatively big changes compared to individual products and are expressed as incompatibil-
dry controls (18, 23, 26, 30, 33, 37, 40), therefore ities between specific brands (32, 34, 42, 51, 52). It
spraying, which proved efficacious in eliminating must be pointed out that the interactions, beyond water
micro-organisms (29), as well as drying for 24 h after absorption, mostly affect colour stability and surface
disinfection (32), have been advocated. Modern properties, such as detail reproduction and wettability,

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296 E . K O T S I O M I T I et al.

and not dimensional accuracy and stability. It is [perforated or not (48)] on the behaviour of the
interesting to note that through such reactions, and disinfected materials.
for certain impression material ⁄ disinfectant combina-
tions, detail reproduction and wettability often benefit
Conclusions
from immersion in disinfectants (71–75).
The outcome of the research on dimensional stability of
disinfected impressions cannot be systematically asses-
Factors influencing the dimensional stability in the course of
sed, because the available laboratory studies vary in
clinical and laboratory practice
terms of specimen dimensions, baseline measurements,
In practice, the dimensional changes of impressions method of measurement and reporting. A commonly
are transferred to the cast and are combined with the accepted experimental method must be established and
alterations occurring during the setting of the gypsum modern technology could be helpful in achieving more
product. Al-Omari et al. (51) reported that changes of precise evaluation and direct data comparison.
impressions produced by certain disinfectants were The reviewed studies agree that chemical disinfection
compensated by the setting expansion of the stone produces dimensional changes that are not likely to affect
used to make the casts. This means that, provided the clinical performance; chemical disinfection should
they occur in the right direction, the changes of therefore be considered virtually harmless. It is, how-
impressions and casts can balance each other, produ- ever, implied that, for certain materials, restrictions
cing stone casts that are dimensionally closer to the concerning duration and method of disinfection should
original object than the impressions. For this to be applied, to preserve the dimensions and surface of the
happen, the impression material should expand dur- impression, providing at the same time effective micro-
ing disinfection to a degree analogous to the expan- bial elimination. These restrictions relate to the chemical
sion that the stone mix would have on setting (35). nature of the materials and can be summarized as
Such an effect is possible, but difficult to pursue in follows:
the clinical and laboratory setting, as it involves two 1 Hydrocolloids should be disinfected for a limited time
additional, very important parameters: the setting period. Immersion is more secure than spraying and
characteristics of the gypsum product and the stability self-disinfecting materials are efficacious, but better
of the tray containing the impression. accompanied by immersion.
The experimental studies, where stone casts are 2 Polyethers, on the other hand, can be effectively
produced and measured, commonly use only one brand disinfected by spraying. Although this seems to be
of stone in order to always have the same setting the preferred method for disinfection of these water-
expansion and reduce the possibility of statistical bias. friendly materials, modern polyethers seem to with-
In only a few studies (47, 54, 56) there were more than stand immersion, even long-term.
one gypsum product, which means that the stone 3 Little information could be traced considering the
product was an additional experimental variable; how- stability of hydrophilic silicones upon prolonged
ever, its effect was not sufficiently commented or immersion disinfection. Until more sound evidence
interpreted. The performance of varying combinations is available, long-term exposure of them in the
of disinfectants ⁄ impression materials ⁄ stone products disinfectants should be applied cautiously, as they
may need to be studied in greater detail, if the accuracy may have an enhanced absorption potential.
of the cast and consequently the fit of the final casting 4 Hydrophobic elastomeric materials can be safely
are to be evaluated. immersed in disinfectants and left for a long period.
Acrylic trays, used frequently to support the impres- The laboratory testing of the disinfection procedure
sion material, tend to absorb and expand in a wet in the future should also:
environment and their alterations should be added to 1 Further focus on dimensional alterations after long-
the dimensional changes of the impressions (56). term (overnight) disinfection, which is more con-
Measurable distortion of acrylic trays during disinfec- veniently incorporated in the clinical practice.
tion has been reported, but only after long-term 2 Explore the effect of the disinfection procedure on
immersion (33, 46, 55); others do not detect any the dimensions of the tray, especially in relation with
influence of tray adhesion (23) nor of tray design the long-term contact.

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DIMENSIONAL CHANGES OF DISINFECTED IMPRESSIONS 297

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