Efecto Adverso.

De la CHX

Roberto Tello
1.
2. Etch & Rinse Self Etch Multi_Modo

3 pasos 2 pasos 2 pasos 1 paso 1 paso / 2 Pasos

3.
4.
5.
6.
7. Self Etch
2 pasos
Self Etch

1 paso
8.
Multi_Modo

1 paso / 2 Pasos
9.

Adherir
10.
11.. Durabilidad en el Tiempo .
 12.

Dentina
T

dentin tubule.

d e n t a l m a t e r i a l s 2 7 ( 2 0 1 1 ) 1–16 3

n micrograph of acid-etched de
*
DENTIN ADHESION AND MMPs Perdigão et al

of dentin etched with 34% phosphoric acid for 5 seconds.

of enamel etched with 34% phosphoric acid for 15 seconds.

FIGURE 2. Scanning electron microscopy (SEM) micrograph

FIGURE 1. Scanning electron microscopy (SEM) micrograph

T = dentin tubule; P = peritubular dentin; Thin arrow = collagen

bules containing remnants of Fig. 2 – Scanning electron micrograph of acid-etched dentin

fiber enveloped by hydroxyapatite; Block arrow = collagen fiber
with its characteristic striation; Asterisk = collagen fiber around

showing two dentinal tubules containing remnants of

peritubular dentin matrix. INSERT: High magnification of
branching collagen fibrils (ca. 75 nm in diameter) separated
by interfibrillar spaces that serve as channels for resin
infiltrations during bonding.
Et

ND

37 wt.% phosphoric acid completely demineralizes the surface
ix. INSERT: High magnification of 5–8 !m of the intertubular dentin matrix to create nanometer-
sized porosities (Fig. 2) within the underlying collagen fibrillar
matrix. This permits infiltration of solvated comonomers into
and around collagen fibrils to gain retention for tooth colored
resin-composite fillings [14]. Even more amazing is the con-
trast between the porosities of most bioengineered scaffolds
(5–20 !m) compared to the porosity of interfibrillar spaces
T
Fig. 3 – Transmission electron micrograph of an adhesive
layer containing a fluid-filled droplet of dentinal fluid that
exuded from a dentinal tubule before the adhesive
polymerized. H = hybrid layer; T = dentinal tubule;
D = underlying mineralized dentin that was demineralized
during laboratory processing, exposing cross-banded
collagen fibrils.

between resin-infiltrated collagen fibrils in hybrid layers that

are only 10–30 nm wide. Thus, the dental biocomposites that as the hybrid layer or interdiffusion zone (Table 1). However,
ls (ca. 75 nm in diameter) separat are made by dentists in situ are created at a nanometer scale
over a distance of 5–8 !m!
due to the presence of residual solvent, and due to fluid
movement out of dentinal tubules (Fig. 3) into the hypertonic
Composition of mineralized vs. demineralized dentin vs. hybrid comonomer mixtures [16,17] water replacement by resin is
T = dentin tubule; ND = normal dentin.

layers Mineralized dentin is composed of approximately
50 vol.% mineral phase, 30 vol.% collagen and 20 vol.% water
[15] (Table 1). During the acid-etching process in etch-and-
rinse adhesives, the entire 50 vol.% of surface and subsurface
24 hours as a result of water sorption after
Oc
never ideal [8]. This results in incomplete infiltration of resin
into water-filled collagen fibril matrices. Additional water
may enter the solvated comonomer-infiltrated demineralized
matrix from dentinal tubules during the solvate-evaporation

mineral is solubilized, extracted and is replaced by rinse- phase of bonding [18]. This creates small local regions within
water which, when combined with the intrinsic 20 vol.% of the polymerized hybrid layer that are water-rich and resin-
the collagen fibrils not fully enveloped by resin
polymerization and extraction of water-soluble

water yields a new water content of 70 vol.% surrounding the poor. These can be identified using water-soluble tracers [19].
hat serve as channels for resin
conversion of bisphenol A diglycidyl methacrylate
surface; Et = etched dentin with exposed collagen fibers;
The arrows point to tubular anastomoses. Oc = occlusal

degradation of adhesive polymers, decreasing their

30 vol.% collagen fibrils that remain anchored into the under- The distribution of these tracers in bonded interfaces has
(BisGMA)/HEMA mixtures as they undergo phase
physical properties.15,16 Absorption of water leads to

separation with the increase in water content.19 The

lying mineralized dentin. During the subsequent comonomer been called nanoleakage. It reveals the water distribution in
plasticization of the adhesive resulting in lower bond
of dentin etched with 34% phosphoric acid for 15 seconds.

elution of resin from hydrolytically unstable polymers

strengths.17 For example, 2-hydroxyethyl methacrylate
(HEMA) undergoes a decline in physical properties at

inside the hybrid layer may also cause exposure of the

water in the adhesive solution influences the degree of

infiltration phase of resin bonding, this 70 vol.% of water nanoscale porosities within bonded interfaces. Although the
collagen fibers. These newly exposed fibrils, along with
unreacted monomers.18 Additionally, the percentage of
FIGURE 3. Scanning electron microscopy (SEM) micrograph

Water plays an important role in the partial hydrolytical

should ideally be completely replaced by 70 vol.% of resin water-rich zones are generally sparse in freshly created bonds,
comonomers that polymerize in situ to produce a hybridized they increase in size with aging [19]. Some nanoleakage occurs
biocomposite of resin, reinforced with collagen fibrils known in adhesive layers. When nanoleakage occurs in freshly made

ing. Table 1 – Theoretical composition of demineralized dentin before and after bonding procedures.
Mineralized dentin Etched/rinsed dentin Primed/infiltrated dentin Aged/degradation
Mineral 50 0 0 0
Collagen 30 30 30 0–30b
Water 20 70 0a 0–30b
Resin 0 0 70a 20–50c
a
Perfect hybrid layer.
b
Water replaces destroyed collagen fibrils.
c
Loss of collagen fibrils often leads to loss of interfibrillar resin.

completely demineralizes the surf

r dentin matrix to create nanome
ithin the underlying collagen fibri
ltration of solvated comonomers i
ils to gain retention for tooth colo
[14]. Even more amazing is the c
ities of most bioengineered scaffo
the porosity of interfibrillar spa
collagen fibrils in hybrid layers t
Thus, the dental biocomposites t
situ are created at a nanometer sc
!
Esmalte

ized vs. demineralized dentin vs. hy

 Oc
13. Et Acid etching of human enamel in clinical
applications: A systematic review
Jia Jun Zhu, BDS, MDS,a Alexander T. H. Tang, BDS, OdontDr,b
Jukka P. Matinlinna, BSc, MSc, PhD,c and
Urban Hägg, DDS, OdontDrd
Faculty of Dentistry, the University of Hong Kong, Hong Kong SAR;
Faculty of Health Sciences, University of Copenhagen, Copenhagen,
Denmark
Statement of problem. The laboratory-based enamel acid-etching doctrine with 30% to 50% phosphoric acid for 60 seconds
to generate the maximum amount of Type 1 and/or Type 2 etch pattern has been established for more than 30 years.
However, this recommendation may not be clinically relevant.

Purpose. The purpose of this systematic review was to compare clinically accepted protocols of enamel acid etching with the
laboratory protocol.

Material and methods. Studies were identified by searching 4 electronic databases: Medline, CINAHL Plus, Embase, and
Cochrane Library. The final search was run on November 8, 2012. All clinical studies published in English that investigated
enamel acid pretreatment methods on human permanent teeth were included. Additional publications were obtained from
the reference lists of the included studies. The clinical evidence of all included studies was tabulated.

Results. Initially, 4543 publications were retrieved from the databases. A total of 4508 articles were excluded, including 2285
duplicates, 1805 publications according to exclusion criteria by their titles and abstracts, 368 laboratory articles, 49 reviews,
and 1 pilot study. Only 1 study was added from reference lists of the included studies. Finally, 36 clinical publications were
included. The included clinical studies provided different levels of clinical evidence on the efficacy of acid-etching protocols to
enable successful enamel adhesion.

Conclusions. Clinical protocols of enamel acid etching differ from the laboratory-generated doctrine, which may imply

T
that maximization of the Type 1 and/or Type 2 etch pattern is not important in the clinical acid etching of human enamel.
(J Prosthet Dent 2014;112:122-135)

Clinical Implications
Clinical protocols of enamel acid etching varied from the ideal
laboratory protocol to maximize Type 1 or 2 enamel etch patterns.
However, all protocols demonstrated clinically successful enamel
adhesion. The laboratory-based acid-etching doctrine may not be
clinically relevant.

The lack of long-term adhesion with the placement of acrylic resin. This enamel surfaces after acid etching
human teeth was the main shortcoming method significantly increased the under scanning electron microscopy
of dental restorative materials before duration of resin adhesion to enamel. showed 3 types of etch patterns.2
1955, when Buonocore1 reported the This study is considered to be the Type 1 (preferential dissolution of

Esmalte
etching of enamel surfaces intraorally foundation of lasting enamel adhesion. enamel prism cores) and Type 2 (pref-
with 85% phosphoric acid followed by In the 1970s, the examination of erential dissolution of enamel prism

ND
a
Research postgraduate student, Paediatric Dentistry and Orthodontics, Faculty of Dentistry, the University of Hong Kong.
b
Clinical Assistant Professor, Paediatric Dentistry and Orthodontics, Faculty of Dentistry, the University of Hong Kong.
c
Associate Professor, Dental Materials Science, Faculty of Dentistry, the University of Hong Kong.
d
Professor Emeritus and Honorary Professor, Paediatric Dentistry and Orthodontics, Faculty of Dentistry, the University of Hong Kong.

The Journal of Prosthetic Dentistry Zhu et al

 14.

Dentina

n micrograph of acid-etched de
bules containing remnants of
ix. INSERT: High magnification of
ls (ca. 75 nm in diameter) separat
hat serve as channels for resin
ing.

completely demineralizes the surf

r dentin matrix to create nanome
ithin the underlying collagen fibri
ltration of solvated comonomers i
ils to gain retention for tooth colo
[14]. Even more amazing is the c
ities of most bioengineered scaffo
the porosity of interfibrillar spa
collagen fibrils in hybrid layers t
Thus, the dental biocomposites t
situ are created at a nanometer sc
!
ized vs. demineralized dentin vs. hy
 La Inestabilidad de la capa híbrida es causada por :

- Degradación Hidrolítica de la CH .
- Degradación Protéica de la CH .
- Fatiga Mecánica e Hidráulica CH .

15.
 La Inestabilidad de la capa híbrida es causada por :

- Degradación Hidrolítica de la CH .
- Degradación Protéica de la CH .
- Fatiga Mecánica e Hidráulica CH .

16.
17.
 18.
Es bien sabido que la activación y mecanismos de acción de las famosas Metaloproteinasas ( MMPs ) no son
exclusivas de la Dentina , si no de todo el cuerpo humano y uno de los artículos que menciona la actividad estas
MMPS en el Tejido Periodontal son Gendron R., Grenier D., Mayrand D. que sugieren que una familia de enzimas
protelíticas derivadas del huésped llamadas MMPS y juegan un rol importante en la enfermedad Periodontal , por lo
tanto la inhibición de las MMPs sería un buen complemento para cualquier Tratamiento Periodontal y concluyen que
la Clohexidina ( CHX ) es un agente valioso para el tratamiento de Enfermedades Periodontales y puede usarse en
enjuagues bucales u otros métodos de administración local . La inhibición de las MMPa por CHX demuestra nuevas
propiedades conocidas de esta sustancia y son muy útiles en el tratamiento de la Periodontitis .

19.
La matriz de dentina contiene MMPs, una clase de Endopeptidasas dependientes
de calcio activadas por zinc, que juegan un papel estratégico en el desarrollo de
los dientes y la caries dentinaria. Las MMP son un grupo de 23 enzimas de
mamíferos capaces de degradar todos los componentes de la matriz extracelular.
La dentina humana contiene al menos colagenasa (MMP-8), gelatinasas (MMP-2 y
MMP-9) y enamelisina (MMP-20) .
20
21.
22.
Donde inicia entonces el problema de las MMPs es que como dijimos que el ambiente ácido
en el tejido dentinario las activa , es por ello que en todo proceso carioso ese conglomerado
de bacterias cariogénicos toleran altas concentraciones de sacarosa produciendo altos niveles
de ácido láctico esto es llamado, por muchos autores como “portón del lactato”. El portón de
lactato parece ser una de las características clave de las bacterias relacionadas con la caries,
ya que “abriendo” el portón, los ácidos son rápidamente formados, y en una cantidad tan
grande que el fosfato de calcio es solubilizado, iniciándose la pérdida de minerales del diente.
23.
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30
PROTOCOLO
Etch & Rinse
Ac. Fosfórico
+ Clorhexidina 2%
+ + +
Primer Adhesivo Buen Fotopolimerizado

31
Self Etc

32
33
34 Funcionales
Acrilato Cadena Espaciadora
Metacrilato

Interconexión
35.
 !  Humectación

Monómero Interconexión
36
!  Desmineralización Phenyl-P
onómero Funciona
!  Propiedades antibacterianas.
10-MDP
!  Mejora resistencia de la unión
de los adhesivos.

!
Bart!Van!Meerbeek!Systema0c!review!of!the!chemical!composi0on!of!contemporary!dental!adhesives!Biomaterials!28!(2007)!3757–3785!

Monómeros Interconexión
cionales
Bis-GMA

TEGDMA ***

HEMA UDMA
GPDM bisphenol*A*diglycidyl*methacrylate*
triethylene*glycol*dimethacrylate*
Bart*Van*Meerbeek*Systema9c*review*of*the*chemical*composi9on*of*contemporary*dental*adhesives*Biomaterials*28*(2007)*3757–3785* *
*

Phenyl-P
37.
Clasificación
pH
Strong (pH < 1.0),
Intermediate (pH = 1.5)
Mild (pH > 2)
Ultra-mild (pH > 2.5)
38
39.
40
41
 Los
mostr
increm
MMP-
aplica

Control Grupo adhesivos

42
 Smear Layer • Detritus
43
• Sangre
• Saliva
1-5 µm
• Bacterias
• Fragmentos de las
fresas
Pashley DH. Smear Layer: Physcological Considerations. Oper Dent 1984,3:13-29
44
 45.

¿?
46.
47
48
49
50
PROTOCOLO
Self Etch
Primer Acídico
+ Adhesivo
+ Buen Fotopolimerizado

51.
PROTOCOLO
Universal
Adhesivo Universal
+ Buen Fotopolimerizado

52.