Isabel C.C.M.

Porto IJRD ISSUE 1, 2012

REVIEW ARTICLE

Post-operative sensitivity in direct

resin composite restorations:
Clinical practice guidelines
Isabel C.C.M. Porto, PhD
Department of Operative Dentistry, Cesmac University Center and Federal University of Alagoas, Maceió,
AL, Brazil
Address for correspondence: Isabel Cristina Celerino de Moraes Porto, Centro Universitário Cesmac, Rua Cônego Machado, 918, Farol,
CEP: 57051-160, Farol, Maceió, Alagoas, Brazil. Tel.: +55 82 3215 5031; fax: +55 82 3215 5214.
e-mail: isabel.porto@cesmac.com.br / isabelcmporto@gmail.com

Abstract : Pain is one of the most frequent reasons for seeking dental treatment and clinical observations confirm that patients
complain of dentinal sensitivity under different conditions and degrees of intensity. This is a very frequent problem after dental
restorations with resin composite, even when there is no visible failure in the restoration. The aim of this bibliographic review was to
identify the causes of post-operative sensitivity in resin composite restorations and how it can be avoided so that professionals can use
this information to reduce the occurrence of this inconvenience in their daily practice. Complete texts of relevant articles on the subject
were analysed. There are various causes of post-operative sensitivity in direct resin composite restorations related to failures in
diagnosis and indications for treatment and/or cavity preparation, the stages of hybridization of hard dental tissues, insertion of the
material, and finishing and polishing the restoration. To avoid or minimize the occurrence of post-operative sensitivity, it is imperative to
make a good diagnosis and use the correct technique at all stages of the restorative procedure.
Keywords: composite resins, dental restoration, operative dentistry, toothache.

Introduction
Dentistry has possibly evolved more in the last
few years than in all of its previous history, and
this is due to a physicochemical phenomenon
called adhesion. The adhesive,which previously
required different treatments for different dental
substrates, can now be used on both enamel and
dentin, and it may be possible to dispense with
acid etching. The latest generation of adhesives
has attained a bond strength of 30 MPa,or more,
and they are formulated to interact simultane-
ously with enamel and dentin after total acid
etching of the tooth surface (total etch) (1) or, in
the so-called self-etching adhesives, to etch,
prepare and bond to the tooth surface simulta-
neously (2,3), forming an interdiffusion zone
called the hybrid layer (1). An understanding of
the principles of adhesion has allowed satisfactory
aesthetic procedures to be performed, with a
protective effect on the remaining tooth (4).
In the last few years, there has been a trend towards
replacement of amalgam restorations by more
aesthetic restorations, especially using resin
composite. This trend leads one to believe that for
most restorations, the dentist’s first choice is
restorations using adhesive characteristics, and
consequently, resin materials are used. Thus, to
understand the reasons for post-operative sensitivity,
it is natural to focus on the bonding procedures
(5,6).
Despite great progress, restorative techniques still
present a certain rate of failures (7,8). Discoloration,
marginal leakage, recurrent caries and loss of the
restoration are the main problems related to
restoration failures. Class I and II resin composite
restorations are the most predisposed to failure.
Perhaps the most intriguing and challenging
problem is post-operative dentin sensitivity, one of
the disadvantages of using direct resin composites in
posterior teeth (7).

Downloaded from www.jrdindia.org -1-

Isabel C.C.M. Porto IJRD ISSUE 1, 2012
After restorations with resin composite, especially in tubules after certain stimuli, which causes
posterior teeth, clinical observation has shown that intratubular pressure changes, thus leading to
patients complain of dentinal sensitivity at different excitation of the pulp nerve terminals, producing a
levels and in different situations. This is a common sensation of pain (4,14). Therefore, due to the
problem, even with no visible failures in the disposition, size and pattern of dentinal tubules, the
restoration (9). Pain is always a warning signal of type of dentin has a direct relationship with dentinal
possible aggression, and although it does not have a sensitivity.
direct relationship with the pathological processes, it Reduction in fluid movements and propagation of
is one of the most common reasons for seeking molecules through dentin occur due to reduction in
dental treatment, either in public service or private the tubular openings with the deposition of
clinics (4). peritubular dentin or the formation of other
Post-operative sensitivity in resin composite intratubular material. Reparative dentin, in contrast
restorations is a common occurrence that causes to secondary dentin, does not have continuous
discomfort in the patient and inconvenience to the tubules, thus leading to diminished permeability and
professional, because it has various causes. fluid movement, and this results in a reduction in
Although frequent, it has still not been fully sensitivity (14). Therefore, teeth with recently cut
explained. Therefore, it is important to study the secondary dentin have a greater propensity to
problem to establish a work routine to avoid it. develop sensitivity after direct restorations.
The aim of this bibliographic review was to identify Post-operative sensitivity in resin
the causes of post-operative sensitivity in resin
composite restorations and how it can be avoided, to composite restorations
enable professionals to reduce the occurrence of this Sensitivity is characterized as being a response
inconvenience in their daily practice. given by the body to say that something is wrong,
and this response may be originated by an
Dentinal sensitivity aggressive stimulus or in a spontaneous manner
The main morphological characteristic of dentin is (15). The sensory potential of the pulp makes it
that it is a tubular structure, filled with fluid, capable of reaction with an immediate painful
connecting the pulp to the enamel–dentine junction. response, even when the stimulus is applied at a
The lumen of dentinal tubules are surrounded by distance from the pulp tissue, such as in the
thin cuffs of mineralized tissue, called peritubular superficial layers of dentin (4).
dentin. The matrix interposed between this Clinical studies on sensitivity arising after resin
cylindrical structure, the intertubular dentin, composite restorations have reported a frequent and
contains around 30% by volume of mineralized very variable prevalence of between 0 and 50% (16–
collagen type I fibrils (10,11) perpendicular to the 20), with predominance in posterior teeth and Class
long axis of the tubules (11). Much smaller II restorations. As the patient can have considerable
quantities of collagen (10% by volume) are present discomfort, professionals are sometimes obliged to
in peritubular dentin (10). Dentinal permeability is, change restorations because of the inability to
therefore, a direct consequence of this structural eliminate the problem (21). Patients have described
pattern. it as a moderate pain, of short duration, that appears
The closer one gets to the pulp, the greater is the spontaneously when chewing, with hot and cold
value of this porosity (45,000–65,000; 29,500– foods (4,8) and on rare occasions with sweet and
35,000; 15,000–20,000/mm2) and the diameter of acid foods, and it disappears when the stimulus is
the tubules (2.5 µm close to the pulp; 1.2 µm in the removed (4).
intermediate region; 0.5 µm at the enamel–dentine Innumerable restorative procedures are performed
junction). This explains the increase in dentin on a day-to-day basis in dental offices, and some
permeability in the area close to the pulp chamber stages of the procedure may generate stimuli that
(12). result in pain or potentiate already existing
The widely accepted hydrodynamic theory proposed sensitivity. Therefore, it is important to know what a
by Brännström and Ästron in 1964 (13) seeks to resin composite restoration is not: simply removing
explain the painful phenomenon that occurs in carious tissue and inserting restorative material in
dentin by the movement of fluid within the dentinal small increments. Instead, it comprises various steps
that must be carefully performed so that the
Downloaded from www.jrdindia.org -2-
Isabel C.C.M. Porto IJRD
restoration will be successful; that is, a perfectly record of painful symptoms or not, and avoid
sealed restoration that restores the shape and possible procedures that may trigger or exacerbate
function of the tooth, and is comfortable for the existing pain.
patient (15). Pulp condition
Post-operative sensitivity can be caused by multiple
factors and does not originate from one isolated
aspect. It results from the interaction between the
restorative technique, the clinical condition of the
tooth to be treated (health of the pulp and remaining
hard dental tissue) and the restorative material.
Therefore, there is a permanent and unpredictable
possibility of sensitivity occurring (4). In addition,
there are other factors related to the cause of post-
operative sensitivity, such as the individual profile
of each patient, the shape and extension of the cavity
preparation and protection of the dentin–pulp
complex (22).
Pre-operative causes
It is extremely important to establish a precise
diagnosis before any restorative procedure, in order
to be certain that the pain reported by the patient
does not originate from pre-existing causes, such as
cracks, tooth fractures, dentinal sensitivity resulting
from dentin exposure in the cervical region, or
reversible or irreversible inflammatory processes in
the pulp. A meticulous anamnesis associated with
careful clinical and radiographic examination will
allow other pathological processes that can affect the
pulp and the dental periapex to be excluded.
Cracks and fractures
Cracked tooth syndrome is an entity characterized
by the presence of incomplete cracks or fractures of
the enamel or enamel and dentin in a tooth, with
symptoms of pain when chewing and inexplicable
sensitivity to cold (23). The difficulty in visualizing
the crack and the patient’s report of symptoms,
which are not always well explained, sometimes
make it a complex diagnosis, and the symptoms may
be confused with post-operative sensitivity.
Cervical dentinal exposure
Areas of cervical dentinal exposure may present as
insensitive before the restoration, and may be
stimulated during the operative procedure due to
prolonged contact with the clip, or inadvertently, by
the prolonged presence of phosphoric acid during
cavity etching, which could lead to difficulties in
diagnosing the pain, and may lead to re-intervention
in the restoration (4). Thus, a meticulous
examination should be performed to identify the
presence of exposed dentin, whether there is a
Downloaded from www.jrdindia.org
ISSUE 1, 2012
A determinant factor before restoring the tooth is to
establish the condition of the pulp. Radiographic
examination should be done, previous procedures
should be observed, the presence or absence of
symptoms reported by the patient should be
recorded and pulp vitality tests should be performed.
All these procedures are essential to minimize the
risks of sensitivity. Frequently, inadequate
instrumentation during cavity preparation, without a
detailed analysis of the pulp condition, may cause
irreversible pulp damage due to the increase in
harmful stimulus on pulp that has been debilitated
by pre-existing conditions (15). In the presence of
pulp inflammation, it is necessary to make a
meticulous evaluation of the condition of the pulp to
consider whether endodontic treatment should be
done before the restoration.
Operative causes
Pain of dentinal origin is intimately related to
restorative procedures, and may occur by cutting and
exposing healthy dentin due to dentin dehydration
and the release of toxic substances from the
restorative material, among other causes.
Abusive dental structure wear
The use of burs and diamond tips with excessive
cutting or wearing pressure, without the use of
adequate cooling, may generate frictional heat and
dentin dehydration. Even if this happens for only a
short time, it causes displacement of the tubular
fluid and a painful pulp response. Zach and Cohen
(24) have shown that an increase in temperature of
5.6 ºC may trigger various degrees of inflammation
or even pulp necrosis. Blunt burs and diamond tips
demand greater pressure during cavity preparation,
inducing a rise in temperature. Diamond tips are
subject to increasing degrees of wear and diamond
particle loss, as they are submitted to a larger
number of cavity preparations, and must be
replaced. A previous study has attested that their use
after the fifth preparation is questionable, and they
must therefore be replaced after the fourth
preparation (the author’s unpublished data).
Excessive dentin dehydration may also occur
by repetitive cavity drying during preparation of the
tooth and/or while performing the restoration,
causing pain due to pulp fluid displacement, with
-3-
Isabel C.C.M. Porto IJRD ISSUE 1, 2012
pulp alterations that are generally reversible. pulp. In deep cavities, there is a smaller quantity of
Dehydration is limited by the resultant smear layer, odontoblasts remaining, which may be diminished
but prolonged exposure, especially after acid even further during the restorative procedure,
etching, may induce a more severe pulp trauma due drastically reducing the chances of pulp recovery
to dehydration (25). These types of damage can be (15).
avoided with the use of new burs and diamond tips, The increase in cavity depth is proportional to the
adequate cooling and cutting with intermittent dentinal permeability and significantly predisposes
movements. the dentin to post-operative sensitivity. Restorations
Incomplete carious tissue removal in deep cavities present four times greater risk of
failure, whereas cavities with pulp exposure have a
The environment found under restorations presents
14 times higher risk of failure, compared with
favourable conditions for microbial growth between
restorations in cavities with a greater dentin
the restorative material and the cavity wall (26).
thickness (8).
Incomplete carious tissue removal leads to the
possibility of bacteria remaining between the The quality of remaining dentin found between the
restoration and the cavity wall, increasing the cavity floor and the pulp is of important in
susceptibility of the pulp to leakage of the bacteria preventing pulp complications caused by operative
themselves and their toxins (4). Bacterial activity procedures. The patient’s age must also be
results in pulp infection or inflammatory reactions considered. A young tooth has a larger pulp cavity
resulting from bacterial products (26). than an adult tooth, which has received more
Consequently, post-operative sensitivity results from physiological stimuli or injuries during the course of
pulp aggression caused by the presence of carious life, and in which more reparative dentin has
dentin and the low quality of the adhesive bond to formed, and consequently, the pulp chamber is
dentin. The deficient bond causes marginal gaps and reduced in size (15).
consequently, microleakage, recurrent caries and The use of resin composite materials during
pulp inflammation (4). restorations is a controversial but important topic. It
The presence of bacteria and their products may be has been questioned whether it is really necessary to
detected at any stage of the restorative procedure. use a lining material under a composite restoration,
Contamination of the cavity may occur during cavity when a good seal can be obtained with the
preparation with the presence of carious dentin, by application of an adhesive system. Furthermore,
saliva penetration during cavity preparation, while why cover the dentin, which is an excellent bond
performing the restoration, with the use of surface, with a lining of questionable value? (27–
contaminated instruments, or in the post-operative 29).
stage due to the presence of marginal leakage (4). To some authors, an almost perfect seal is very
Negligence in protecting the dentin–pulp complex difficult to achieve clinically, therefore, under the
condition of a not so perfect seal, a cavity floor
Undoubtedly, dentin is the best pulp protection
lining may still be of great value. Liners, when used,
material. At the time of deciding about protecting
must support (and continue to support) the
the dentin–pulp complex during a resin composite
restorations superimposed upon them, since any
restoration, dentinal permeability and the type and
decomposition will result in a defective base,
quality of remaining dentin should be assessed.
causing a pumping action and marginal percolation
Whether dentin is removed by pathological or
during chewing, resulting in sensitivity (14,15). The
professional means, if its thickness is reduced the
indiscriminate use of calcium hydroxide linings to
dentinal tubule openings are increased, making it
stimulate secondary dentin formation continues to
more permeable and consequently, more susceptible
be controversial. On the one hand, it is argued that
to irritation by chemical or bacterial agents.
secondary dentin will form in any case, as a
Another very important factor is cavity depth, which response to the repair process. On the other hand,
varies from shallow to medium and deep, and it is the need to form secondary dentin is questioned
fundamental to know how to act in each case. when there is good cavity sealing (22,30–34).
Shallow and medium cavities present a larger Irrespective of this, the use of calcium hydroxide is
quantity of dentin, which favours the maintenance of recommended in very deep cavities in which the
the number of odontoblasts. The larger the number remaining dentin thickness (<500 µm) is not capable
of odontoblasts, the greater the repair capacity of the of protecting the pulp against the possible
Downloaded from www.jrdindia.org -4-
Isabel C.C.M. Porto IJRD
undesirable effects of toxicity of adhesives and of resin monomers and collagen fibrils, altering the
composite resin (35,36). physical and chemical properties of this tissue (39).
Post-operative sensitivity may be minimized with
the use of protective materials that will act on the
dentin–pulp complex, such as glass ionomer cement,
calcium hydroxide and resin-based adhesive
systems. These materials must present bacteriostatic
and bactericidal characteristics, protect the pump
against thermal or electrical stimuli, and have good
compatibility with the pulp and restorative material.
It is desirable for these characteristics to be present
simultaneously, however, there is still no material
that presents all these features. The professional
must have full knowledge of the type of action that
is required for each cavity in order to select the best
protective material possible (37). Consideration of
the need for mechanical protection (tubular
obliteration) or biologic protection (need for a
material with greater biologic compatibility and
capacity to induce reparative dentin formation) may
be the key to improved protection of the dentin–pulp
complex.
The thickness of the adhesive layer applied to the
tooth may also help to reduce sensitivity, and
multiple layers of adhesive may have a better effect
than one thinner layer. The use of resin-reinforced
glass ionomer cement as a lining on the pulp and
axial walls before the use of acid has produced the
same effect (16). All these procedures lead to
obliteration of the dentinal tubules, and
consequently, to eliminating or lowering the
incidence of cases of post-operative sensitivity.
Inadequate isolation of the operative field
Absolute isolation is indicated to reduce two issues
that cause post-operative sensitivity generated by
penetration of saliva into the operative field:
contamination of the cavity by microorganisms that
cause pulp inflammation and contamination by
humidity, which harms the bond and facilitates
marginal leakage (4). The study of Auschill et al. (8)
showed that the type of isolation, with a rubber dyke
or cotton wool rolls, has no influence on the
occurrence of post-operative pain, provided that
cavity contamination is avoided.
Failure in dental tissue hybridization
Hybridized dentin is prepared at the interface of the
surface demineralized by previous acid etching to
expose the collagen fibers in the dentin matrix and
allow infiltration of adhesive monomer into the
exposed fiber network (38). Therefore, dentin
hybridization is a process that creates a mixed layer
Downloaded from www.jrdindia.org
ISSUE 1, 2012
The formation of a bond interface that is as perfect
as possible and minimizes or prevents the entry of
bacterial fluids is fundamental to guarantee greater
longevity of resin composite restorations. Inadequate
formation results in marginal leakage, resin
discoloration and post-operative sensitivity
(3,33,40,41). Therefore, dentin hybridization, acid
etching, application and light activation of the
adhesive system must be meticulously performed.
Previous acid etching transforms the tooth surface,
making it more receptive to bonding with the
adhesive system and resin composite, and
facilitating the formation of resin tags within the
dentinal tubules, which gives the restoration greater
resistance and durability (34,42).
Acid etching for a longer time than that
recommended by the manufacturer leads to many
conditions that result in sensitivity. Most acids are
hypertonic and cause pulp fluid displacement,
leading to movement of the odontoblasts as a pulp
response. Acid solutions used in excess of the
recommended time (15 s) denature the collagen
fibers, increase dentin permeability and humidity,
facilitate chemical aggression by the adhesive
system and bacterial infiltration, and for all these
reasons, harm the bond and may cause pain (4).
Dentin demineralization of over 5 µm is not of much
value to the clinical procedure, and may result from
longer exposure of dentin to the acid. An increase in
the demineralized dentin layer will not guarantee the
formation of a thicker hybrid layer and a better
bond, as the primer/adhesive may not have the
capacity to infiltrate throughout its entire thickness,
causing exposure of the collagen within and at the
base of the hybrid layer, which could lead to
degradation and leakage. The greater the flow of
adhesive between the collagen fibrils and through
the complex of demineralized channels, the better
will be the quality of the hybrid layer, giving it a
higher degree of resistance to hydrolysis and
offering greater protection against microleakage
(4,43). An increased dentin etching time is another
clinical error responsible for the occurrence of post-
operative sensitivity (4).
With the advancements in adhesive dentistry,
simplified techniques and improved clinical
developments are increasingly being sought.
Adhesive systems began to present two forms of
application according to whether or not previous
-5-
Isabel C.C.M. Porto IJRD ISSUE 1, 2012
acid etching was necessary. Self-etching adhesives possibility of developing dentinal sensitivity after
have an advantage over adhesives that require acid restorative treatment and demands greater attention
etching. As the primer is acidified, acid etching is from the professional with regard to the application
performed without the need for washing. Although technique.
the hybrid layer formed is thinner, the entire etched Handling restorative material
area is occupied by adhesive, thus diminishing the
chances of hydrolysis occurring in the area. Resin composites are have a broad range of
Research has indicated that one of the disadvantages indications in clinical dentistry. They consist of an
is lower resin bonding to enamel as a result of the organic matrix permeated with inorganic particles
acidic primer buffering. Due to this limitation, surrounded by a bonding agent that makes them
attempts have been made to combine the two adhesive to the resin matrix. The organic base of
techniques and tests have suggested the use of contemporary resin composites is composed of the
phosphoric acid on enamel before the self-etching monomer bisphenol A-glycidyl dimethacrylate (bis-
adhesive is applied throughout the cavity, with the GMA) in combination with other di-methacrylates
intention of enhancing the bond to enamel, such as triethylene glycol dimethacrylate
providing good marginal sealing and greater (TEGDMA), urethane dimethacrylate (UDMA) and
longevity of the restoration (44). The use of total- bisphenol A-glycidyl dimethacrylate ethoxylate
etch or self-etch adhesives presented no statistically (BisEMA) (57). Despite the differences in their
significant difference with regard to the occurrence formulations, all the methacrylate-based composite
of post-operative sensitivity (45,46). are polymerized by the generation of free radicals
(58). In this process, the approximation of the
For the step-by-step performance of hybridization, methacrylate monomers to establish covalent bonds
the tooth must be kept moist. Without adequate with one another during the polymerization reaction
humidity, the exposed collagen fibrils collapse and causes a significant reduction in the volume of resin
make it difficult for the adhesive system to penetrate after polymerization (59), thereby leading to the
into the demineralized tissue. The exposed fibrils at greatest inconvenience of resin composites:
the margins and within the restoration allow the polymerization shrinkage (60).
passage of fluids and bacterial enzymes that may
attack the collagen (47–50). The cumulative effect To reduce the polymerization shrinkage stress of
of these actions may be debilitation of the integrity dental composites, a new compound, called Silorane
of the restoration margin (43). was developed using a monomer system with low
shrinkage, derived from the combination of siloxane
The definition of humidity may vary from one and oxirane radicals. It has a different
operator to another, and a larger or smaller quantity polymerization mechanism based on the opening of
of water on the dentin, available for interacting with cationic rings of the oxirane radicals (61), which is
the adhesive system, may interfere in the adequate responsible for the low shrinkage and low stress
formation of the hybrid layer, favouring the presence generation, while siloxane give the material its
of gaps and fluid accumulation at the tooth– hydrophobic properties. Thus, the main
restoration interface. characteristic of the new composite is less than 1%
Although good bond efficiency can be obtained with polymerization shrinkage, in comparison with more
acetone-based adhesives in vitro, the high sensitivity than 2% in methacrylate-based resins (59,61).
of these types of adhesives, particularly the two-step Although reduced in the more recent resins,
type, may lead to poorer results in the long term polymerization shrinkage of resin composites during
(3,51–53). Acetone in contact with moist dentin the polymerization process persists, and is the
induces an increase in the remaining water vapor consequence of the reaction of monomer
pressure (54), which, if it is not in a sufficiently high transformation into polymers, with the change from
quantity, rapidly reduces dentin permeability, the viscous to the solid state. During this
making it difficult for the resin monomers to transformation, the resin develops forces that may
penetrate (55) and form the hybrid layer. The cause rupture of the bond between the adhesive
difficulty of standardizing dentinal humidity may be system and cavity walls, reducing the useful life of
more prejudicial to the bond strength of acetone- restorations because of the existence of microscopic
based adhesive system than that of water and gaps at the tooth/restoration interface. These gaps
alcohol-based systems (56). Thus, the use of allow entry of bacteria, and may lead to the
adhesives with acetone as solvent may increase the
Downloaded from www.jrdindia.org -6-
Isabel C.C.M. Porto IJRD
formation of caries, staining and post-operative polymerized (up to 2 mm) and the number of walls
sensitivity. with which the resin comes into contact (4). The
smaller the number of bonded faces, the greater will
Various recommendations have been made to reduce
the effects caused by polymerization shrinkage of be the resin’s capacity to flow and release stress,
resin composites. The use of gradual and careful favouring the resin bond to the tooth (4,65).
light activation techniques and care with maintaining
the wavelength emitted by the light source, inserting
the resin in small increments and the use of a base of
materials with a low modulus of elasticity are some
of the suggestions (62–65).
Incomplete resin composite polymerization is also
responsible for post-operative sensitivity (4).
Problems associated with inadequate polymerization
include inferior physical properties, diminished
retention, greater degradation in the oral
environment and adverse pulp responses. In clinical
practice, only one appliance is bought and used to
polymerize all the materials available in the dental
office, as it is not possible for dentists to suit their
appliances to the different materials. Inadequate
power due to degradation of the components (bulbs,
reflectors, filters and light conducting tips), which
occurs with use over time, contributes to difficulties
in polymerizing these materials (65).
It is impossible for the naked eye to identify
differences between the types of light sources,
variations in wavelength and changes in pulse and
intensity. The light intensity is directly proportional
to the number of photons that stimulate the
photoinitiator, which is responsible for initiating the
resin polymerization reaction (66,67). Therefore,
frequent evaluation of the light intensity and care in
the maintenance of light sources used for
polymerization are among the ways of preventing
post-operative sensitivity (65).
Many light polymerizing appliances used in dental
offices are operating at a light intensity below the
recommended level, and this means that insufficient
resin composite polymerization is occurring and a
larger quantity of substances harmful to the pulp,
such as unreacted resin monomers and
camphorquinone, may be released (16,65).
Moreover, the bond and sealing present failures that
may trigger pain and reduce the useful life of
restorations (16).
The contraction stress that occurs during
polymerization has received considerable attention.
A recommendation for reducing the stress caused by
polymerization shrinkage is to activate the resin
composite in small increments within the cavity
(65), observing the size of the increment to be
Downloaded from www.jrdindia.org
ISSUE 1, 2012
In addition to resin composite insertion in small
increments and gradual light activation, the use of
materials with a low modulus of elasticity, such as
resin flow or ionomer materials has been proposed
in an attempt to minimize the effects of shrinkage
and increase the longevity of the restoration,
especially of the Class II type (68–71).
In cavities that present margins limited to coronal
enamel, the beveled and etched enamel helps to
contain the contraction forces. In Class II cavities
that present the cervical margin located apically to
the cement/enamel line, in an area with no enamel
where the material bond to dentin is weaker, rupture
of the bond between the material and cavity wall
may occur due to the polymerization shrinkage
forces of the resin composite. This rupture of the
bond causes the formation of spaces, which serve as
a port of entry to bacteria and their products, leading
to secondary caries, marginal stains, pulp
inflammation and hypersensitivity to cold (72,73).
Due to the deficient seal at the tooth/restoration
interface, the free extremities of the tubules are
exposed, generating a flow of fluids due to
differences in gradient when they come into contact
with the external medium (16). The sensitivity to
cold that is present in this situation may be
explained by a small change in the fluid volume
present at the gap. When it receives the cold thermal
stimulus, contraction of the fluid within the gap
occurs, which causes rapid movement within the
dentinal tubules, leading to stimulation of the pulp
nerve fibers, causing the painful sensation (26). This
occurs mainly in the presence of infection, as in
cases in which there is communication with the oral
cavity. With elimination of the gap and any existing
infection, the sensitivity rarely persists unless the
pulp has been irreversibly compromised (74). Very
severe pulp inflammation may present even in the
presence of small gaps, therefore the size of the gap
may be of less importance than the other factors,
such as bacterial invasion and their toxic products,
and the effects these could have on the pulp.
Recent studies have shown that patients with resin
composite restorations with low polymerization
shrinkage have not presented post-operative
sensitivity (75). It is possible to eliminate post-
operative sensitivity, even in restorations with
-7-
Isabel C.C.M. Porto IJRD
cavities that have a high C factor value, when they lead to pain and can be avoided by paying attention
are restored using small increments and gradual light to all stages of the restorative procedure.
activation (76).
Therefore, to perform a resin composite restoration,
all the clinical stages must be strictly followed.
Among these, knowledge, skill and professional
organization must be included. It is essential for
professionals to have full understanding of how
complex the adhesive restorative technique is, so
that they obtain adequate aesthetics and seal the
cavity, thereby guaranteeing the success of the
restorative treatment, without complaints of pain
from their patients.
Post-operative causes
Restoration finishing and polishing
Finishing and polishing are commonly performed by
dentists. Restorations must be done in such a way
that the finishing and polishing stages are restricted
to small adjustments in the shape and superficial
smoothness of the restoration. Purposely inserting a
large excess of material and then performing
finishing is extremely unfavourable to the tooth and
the restoration (4). Immediate and excessive
superficial wear of a recently placed resin composite
generates alterations in the resin matrix by the heat
produced, disturbs the post-irradiation phase of
polymerization, and removes the superficial layer,
which theoretically obtains the highest degree of
conversion. The possibility of pulp injury due to the
exaggerated frictional heat generated by the high
speed bur is increased. The careful use of burs and
abrasive instruments at this stage avoids possible
damage to the restoration margins and adjacent
dental tissue, avoiding failures at the
tooth/restoration interface.
Occlusal interference
During mastication of solid foods, or when the
restoration is in occlusion with the antagonist tooth,
deformation of the margins and interfaces occurs,
and this may lead to a dimensional change that could
cause fluid movement within the dentinal tubules
and cause pain (4,16).
Cervical dentin exposure
The restorative procedure may trigger or increase
pain coming from areas of exposed dentin in the
cervical region of the tooth. Inadequate use of clips
may result in traumatic gingival displacement and
consequent cervical dentinal exposure. Similarly, the
inadvertent permanence of acid in this region can
Downloaded from www.jrdindia.org
ISSUE 1, 2012
Final considerations
The clinical performance of resin composite
restorations in posterior teeth can be maintained at
satisfactory levels, and post-operative sensitivity can
be avoided or maintained at minimal levels when
restorations are inserted strictly in accordance with
the technical recommendations (18). Several causes
of sensitivity result from errors in technique before,
during and after placement of the restoration. The
dynamics of a poorly conducted restoration may also
trigger post-operative dentinal sensitivity.
Dentistry demands complicity between professionals
and the material they use. The material must offer
properties that justify their choice and it is the
responsibility of professionals to be familiar with
these properties, understand their indications, and
know how to apply them with the necessary skill
(4). Many procedures performed using the same
restorative materials, applied with the same
technique and under similar clinical conditions
generate sensitivity in some cases and not in others.
Only by allying knowledge and command of the
technique and the material applied is it possible to
ensure the placement of adequate restorations, and
the patient’s physical and psychological well-being
in return.
Briefly, the causes of post-operative sensitivity in
direct resin composite restorations are diverse, and
comprise failures in the diagnosis and indication for
the procedure, cavity preparation and/or stages of
insertion of the material, finishing and polishing the
restoration, through to occlusal adjustment of the
restoration.
The recommendations for avoiding or minimizing
post-operative sensitivity involve all the principles
for attaining excellence in restorative dentistry; that
is, making a good diagnosis before performing the
restoration; analysing the initial health of the pulp
and periapical region; the use of new burs with
abundant cooling; use of adequate isolation to
prevent contamination; not dehydrating dentin with
excessive drying; strictly following all the criteria
indicated in the stages of hybridization, insertion,
finishing, polishing and occlusal adjustment of the
restoration.
References
1. Pereira JC, Segala AD (2002)
Hipersensibilidade pós-tratamento
-8-
Isabel C.C.M. Porto IJRD
restaurador. In: Cardoso RJA, Gonçalves 12.
EAN eds. Odontologia: dentística laser,
Artes Médicas, São Paulo, 337–388. (in
Portuguese).
2. Manchorova NA, Vladimirov SB,
Donencheva ZK, Drashkovich IS,
Kozhuharov PZH, Manolov SK, et al. (2006)
A study of post-operative sensitivity in class
I and class II restorations with self-etching
adhesive and nanofilled composite. Folia
Med (Plovdiv) 48, 63–69.
3. Nakabayashi N, Pashley DH. (1998).
Hybridization of dental hard tissues.
Quintessence Publishing, Tokyo, 129.
4. Akpata ES, Sadiq W (2001) Post-operative
sensitivity in glass-ionomer versus adhesive
resin-lined posterior composites Am J Dent
14, 34–38.
5. Unemori M, Matsuya Y, Hyakutake H,
Matsuya S, Goto Y, Akamine A (2007 Long-
term follow-up of composite resin
restorations with self-etching adhesives J
Dent 35, 535–540.
6. Montenegro G, Coelho CG, Pereira CA,
Berno G (2002) Restaurações semidiretas
com resina de alta densidade. Rev ABO Nac
10, 174–178 (in Portuguese).
7. Holland GR (1944) Morphological features
of dentin pulp related to dentin sensitivity.
Archs Oral Biol 39, 3S–11S.
8. Sab TBB (2008) Sensibilidade pós-
operatória em dentística restauradora. SBTD
(Brazilian Association of Dental
Traumatology). Available at:
http://www.sbtd.org.br/artigos_sbtd_detalhes
.asp?IdArtigo=6 (in Portuguese).
9. Jung LA, Barbosa NA, Reston EG, Wolwacz
VF(2003) Sensibilidade pós-operatória em
restaurações de resina composta. Rev ABO
Nac (in Portuguese).
10. Addy, M. Pearce, N (1944) Aetiological,
predisposing and environmental factors in
hypersensitive dentine. Archs Oral Biol 39,
33S–38S.
11. Pereira JC, Segala AD (2003) Sensibilidad
pos restaución adhesiva: causa y tratamiento.
In: Henostroza G ed. Adhedión in
odontologia restauradora (in Spanish).
Downloaded from www.jrdindia.org
ISSUE 1, 2012
Alves EMA (2006) Avaliação clínica de
sensibilidade pós-operatoria em restaurações
de resina composta em dentes posterores:
efeito da interposição do oxalato de potássio
ou do ionômero de vidro. Belém (in
Portuguese).
13. Christensen, GJ (1995) Acceptability of
alternatives for conservative restoration of
posterior teeth. J Esthet Dent 7, 228–232.
14. Baratieri LN. Ritter AV, Perdigão J, Felipe
LA (1998) Direct posterior composite resin
restorations: current concepts for the
technique. Pract Periodont Aesthet Dent 10,
875–886.
15. Dietschi D, Spreafico R (1997) Adhesive
metal free restorations: current concepts for
the esthetic treatment of posterior teeth.
ChicagoQuintessence Books, Chicago, IL.
16. Lienfelder KF, Bayne SC, Swift EJ Jr (1999)
Packable composites: overview and technical
considerations. J Esthet Dent 11, 234–249.
17. Casertani RSA, Pfeifer CSC, Braga RR
(2007) Influência da técnica de inserção e do
modo de fotoativação na microinfiltração de
restauração de CIV em compósito. Scientifc-
A 1, 54–59 (in Portuguese).
18. Dijken JWVD, Grönberg KS (2206) Fiber-
reinforced packable resin composites in class
II cavities. J Dent 34, 763–769.
19. Yamazaki PCV, Bedran-Russo AVB, Pereira
PNR, Swift-Junior ED (2006) Microleakage
evaluation on a new low-shrinkage
composite restorative material. Oper Dent
31, 670–676.
20. Buonocore MG (1955) A simple method of
increasing the adhesion of acrylic filling
materials to enamel surfaces. J Dent Res 34,
849–853.
21. Perdigão J, Lopes M (1999) Dentin bonding
– state of the art 1999. Compend Contin
Educ Dent 20, 1151–1158, 1160–1162.
22. Sarrett DC (2005) Clinical challenges and
the relevance of materials testing for
posterior composite restorations. Dental
Mater 21, 9–20.
23. Johnson G, Brannström M (1971)
Dehydration of dentin by some restorative
materials. J Prosthet Dent 26, 307–313.
-9-
Isabel C.C.M. Porto IJRD
24. Carrilho MR, Tay FR, Pashley DH,
Tjäderhane L, Carvalho RM (2005)
Mechanical stability of resin-dentin bond
components. Dent Mater 21, 232–241.
25. Van Meerbeek B, De Munck J, Yoshida Y,
Inoue S, Vargas M, Vijay P, et al. (2003)
Buonocore memorial lecture. Adhesion to
enamel and dentin: current status and future
challenges. Oper Dent 28, 215–235.
26. Kidd EA (1976) Microleakage: a review. J
Dent 4, 199–206.
27. Brännström M (1986) The cause of post-
restorative sensitivity and it prevention. J
Endod 12, 475–481.
28. Christensen GJ (2002) Avoiding pulpal death
during fixed prosthodontic procedures. J Am
Dent Assoc 133, 1563–1564.
29. Tay FR, Frankenberger R, Krejci I,
Bouillaguet S, Pashley DH, Carvalho RM,
Lai CN (2004) Single-bottle adhesives
behave as permeable membranes after
polymerization. J Dent 32, 611–621.
30. Christensen GJ (2002) Preventing
postoperative tooth sensitivity in Class I, II
and V restorations. J Am Dent Assoc 133,
229–231.
31. Perdigão J, Geraldeli S, Hodges JS (2003)
Total-etch versus self-etch adhesives: effect
on postoperative sensitivity. J Am Dent
Assoc 134, 1621–1629.
32. Clavijo VGR, Sousa NC, Kabbach W,
Rigolizzo DS, Andrade MF (2006)
Utilização do sistema adesivo
autocondicionante em restauração direta de
resina composta. Dental Press Estét 3, 34–42
(in Portuguese).
33. Mehl A, Hickel R, Kunzelmann KH (1997)
Physical properties and gap formation of
light-cured composites with and without
“softstart-polymerization”. J Dent 25, 321–
330.
34. Suh BI, Feng L, Wang Y, Cripe C, Cincione
F, de Rjik W (1999) The effect of the pulse-
delay cure technique on residual strain in
composites. Compend Cont Educ Dent 20,
4–12.
35. Yamauti M (1999) Avaliação da infiltração
marginal em restaurações de resina composta
empregando-se diferentes técnicas de
Downloaded from www.jrdindia.org
ISSUE 1, 2012
inserção e de ativação da polimerização do
material. Bauru, 141 p. Dissertação
(Mestrado) – Faculdade de Odontologia de
Bauru, Universidade de São Paulo (in
Portuguese).
36. Nagel R (1999) Operation and diagnostic
features of the VIP light. Compend Cont
Educ Dent 20, 34–41.
37. Rueggeberg F. (1999) Contemporary issues
in photo-curing. Compend Cont Educ Dent
20, 4–15.
38. Leinfelder KF (1995) Posterior composite
resins: the materials and their clinical
performance. J Am Dent Assoc 126, 663–
676.
39. Lyons K (1997) Alternatives to amalgam. N
Z Dent J 93, 47–50.
40. Opdam NJ, Roeters FJ, Feilzer AJ,
Verdonschot EH. (1998) Marginal integrity
and postoperative sensitivity in class 2 resin
composite restorations in vivo. J Dent 26,
555–562.
41. Rueggeberg F, Jordan DM (1993) Effect of
light-tip distance on polymerization of resin
composite. Int J Prosthodont 6, 364–370.
42. Blankenau R, Erickson RL, Rueggeberg F
(1999) New light curing options for
composite resin restorations. Compend Cont
Educ Dent 20, 122–131.
43. Sakaguchi RL, Berge HX (1998) Reduced
light energy density decreases post-gel
contraction while maintaining degree of
conversion in composites. J Dent 26, 695–
700.
44. Asmussen E, Peutzfeld A (1998) Influence
of UEDMA, BisGMA and TEGDMA on
selected mechanical properties of
experimental resin composites. Dent Mater
14, 51–56.
45. Maghaireh G, Bouschlicher MR, Qian F,
Armstrong SR (2007) The effect of energy
application sequence on the microtensile
bond strength of different C-factor cavity
preparations. Oper Dent 2007 32, 124–132.
46. Fares NH, Coutinho KQ, Couto MG, Couto-
Junior M, Nagem-Filho H (2004) Tensões de
contração das resinas compostas geradas
durante a polimerização. Rev Port de
- 10 -
Isabel C.C.M. Porto IJRD
Estômato Med Dent e Cir maxil 45, 177–182
(in Portuguese).
47. Jacobsen PH (1975) Clinical aspects of
composite restorative materials. Br Dent J
139, 276–280.
48. Opdam NJ, Feilzer AJ, Roeters JJ, Smale I.
(1998) Class I occlusal composite resin
restoration: in vivo postoperative sensitivity,
wall adaptation and microleakage. Am J
Dent 11, 229–234.
49. Weinmann W, Thalacker C, Guggenberger R
(2005) Siloranes in dental composites. Dent
Mater 21, 68–74.
50. Leprince J, Palin WM, Mullier T, Devaux J,
Vreven J, Leloup G (2010) Investigating
filler morphology and mechanical properties
of new low-shrinkage resin composite types.
J Oral Rehabil 37, 364–376.
51. Mine A, De Munck J, Van Ende A, Cardoso
MV, Kuboki T, Yoshida Y, Van Meerbeek B
(2010) Characterization of a silorane
composite bonded to enamel/dentin. Dent
Mater 26, 524–532.
52. Carvalho RM, Pereira JC, Yoshiyama M,
Pashley DH (1996) A review of
polymerization contraction: the influence of
stress development versus stress relief. Oper
Dent 21, 17–24.
53. Nagem Filho H (2000) Materiais dentários –
resinas compostas. 2nd ed. Produções Artes
Gráficas Ltda, Bauru (in Portuguese).
54. Feilzer AJ, Gee AG, Davidson CL (1987)
Setting stress in composite resin in relation
to configuration of the restoration. J Dent
Res 66, 1636–1639.
55. Andersson-Wenckert IE, Sunnegårdh-
Grönberg K (2006) Flowable resin
composite as a Class II restorative in primary
molars: a two-year clinical evaluation. Acta
Odontol Scand 64, 334–340.
56. Andersson-Wenckert IE, van Dijken JWV,
Hörstedt P (2002) Modified Class II open
sandwich restorations: evaluation of
interfacial and influence of different
restorative techniques. Eur J Oral Sci 110,
270–275.
57. Dietrich T, Lösche AC, Lösche GM, Roulet
JF (1999) Marginal adaptation of direct
composite and sandwich restorations in Class
Downloaded from www.jrdindia.org
ISSUE 1, 2012
II cavities with cervical margins in dentine. J
Dent 27, 119–128.
58. Davison CL, De Gee AJL, Feilzer A (1984)
The competition between the composite
dentin bond strength and the polymerization
contraction stress. J Dent Res 63, 1396–
1399.
59. Van Meerbeek B, Perdigão J, Lambrechts P,
Vanherle G (1998) The clinical performance
of adhesives. J Dent 26, 1–20.
60. Bayne SC, Heyman H, Swift Jr EJ (1994)
Update of dental composite restorations. J
Am Dent Assoc 125, 687–701.
61. Brännström M (1987) Infection beneath
composite resin restorations: can it be
avoided? Oper Dent 12, 158–163.
62. Brännström M, Äström A (1964) A study on
the mechanism of pain elicited from the
dentin. J Dent Res 43, 619–625.
63. Agbaje LO, Shaba OP, Adegbulugbe IC
(2010) Evaluation of post-operative
sensitivity and secondary caries in posterior
composite restorations: a 12 month study.
Niger J Clin Pract 13, 441–444.
64. Christensen GJ (1998) Preventing sensitivity
in Class II composite resin restorations. J
Am Dent Assoc 129, 1469–1470.
65. Brandt PD, de Wet FA (2006) Posterior
composite restorations and post-operative
sensitivity. SADJ 61, 064, 066-8.
66. Nakabayashi N, Kojima K, Masuhara E
(1982) The promotion of adhesion by the
infiltration of monomers into tooth
substrates. J Biomed Mater Res 16, 265–273.
67. De Munck J, Van Landuyt K, Peumans M,
Poitevin A, Lambrechts P, Braem M, Van
Meerbeek B (2005) A critical review of the
durability of adhesion to tooth tissue:
methods and results. J Dent Res 84, 118–
132.
68. Bouillaguet S (2004) Biological risks of
resin-based materials to the dentin-pulp
complex. Crit Rev Oral Biol Med 15, 47–60.
69. Kinney JH, Pople JA, Marshall GW,
Marshall SJ (2001) Collagen orientation and
crystallite size in human dentin: a small
angle x-ray scattering study. Calcified Tissue
Int 69, 31–37.
- 11 -
Isabel C.C.M. Porto IJRD ISSUE 1, 2012
70. Qin Q-H, Swain MV (2004) A micro- 81. van Dijken JW (2010) Durability of resin
mechanics model of dentin mechanical composite restorations in high C-factor
properties. Biomaterials 25, 5081–5090. cavities: a 12-year follow-up. J Dent 38,
469–474.
71. Van Meerbeek B, Vargas S, Inoue S,
Yoshida Y, Peumans M, Lambrechts P, 82. Perdigão J, Dutra-Corrêa M, Saraceni CH,
Vanherle G (2001) Adhesives and cements Ciaramicoli MT, Kiyan VH, Queiroz CS
to promote preservation dentistry. Oper Dent (2012) Randomized clinical trial of four
6, S119–S144. adhesion strategies: 18-month results. Oper
Dent 37, 3–11.
72. Okuda M, Pereira PN, Nakajima M, Tagami
J (2001) Relationship between nano-leakage
and long-term durability of dentin bonds.
Oper Dent 26, 482–490.
73. Nunes M, Swift EJ, Perdigão J (2001)
Effects of adhesive composition on
microtensile bond strength to human dentin.
Am J Dent 14, 340–343.
74. Porto, ICCM (2004) Effect of light intensity,
configuration factor and light sources on
composite resin polymerization. J Bras Clin
Odontol Integr 8, 335–339 (in Portuguese).
75. Ferracane JL (2005) Developing a more
complete understanding of stresses produced
in dental composites during polymerization.
Dent Mater 21, 36–42.
76. Reis A (2007) Materiais dentários
restauradores diretos: dos fundamentos à
aplicação clínica. Santos, São Paulo 423 p.
(in Portuguese).
77. Anusavice KJ (2005) Phillips’ science of
dental materials 11th ed. Elsevier, Rio de
Janeiro. 764 p.
78. Sideridou I, Tserki V, Papanastasiou G
(2002) Effect of chemical structure of degree
of conversion in light-cured dimethacrylate-
based dental resins. Biomaterials 23, 1819–
1829.
79. Navarra CO, Cadenaro M, Armstrong SR,
Jessop J, Antoniolli F, Sergo V, Di Lenarda
R, Breschi L (2010) Degree of conversion of
Filtek Silorane adhesive system and Clearfil
SE Bond within the hybrid and adhesive
layer: an in situ Raman analysis. Dent Mater
25, 1178–1185.
80. Burke FJ, Crisp RJ, James A, Mackenzie L,
Pal A, Sands P, Thompson O, Palin WM
(2011) Two year clinical evaluation of a low-
shrink resin composite material in UK
general dental practices. Dent Mater 27,
622–630.
Downloaded from www.jrdindia.org - 12 -