Chlorhexidine Application to Stabilize the Adhesive Interface: Why and How? Lorenzo Breschia IAAD WORKING INSTRUCTIONS Chlorhexidine Application to Stabilize the Adhesive Interface: Why and How ? The stability of the bonded interface relies on the creation of a compact hybrid layer through optimal impregnation of the dentin collagen by resin monomers.3,10,17,18 Unprotected collagen fibrils vulnerable to hydrolytic degradation may be present within the hybrid layer due to incomplete resin impregnation.15 Dentinal endogenous enzymes, named MMPs and cysteine cathepsins, can degrade the exposed collagen fibrils and contribute to aging of the adhesive interface over time.3,10-14,16-18 The application of chlorhexidine has been shown to effectively inhibit these enzymes (particularly MMP-2, -9, and -8, and cysteine cathepsins) and its protective role seems to continue over time.1,2,4-7,9-11 Chlorhexidine application should be performed on etched dentin, in association with etch-and-rinse adhesives, before primer and bonding application.1,2,4-7,9-11 Controversial findings were reported on self-etching adhesives and self-adhesive cements.8,19-21 Despite the fact that self-etching material activates MMPs,14 the role of chlorhexidine in stabilizing the bond in the absence of phosphoric-acid etching should be further investigated. CAUTION: After chlorhexidine application (in water solutions from 0.2% to 2% for at least 30 s), rinsing should be avoided, while dentin must be carefully air dried in accordance with the wet-bonding technique, followed by primer/bonding agent application.

REFERENCES 1. Breschi L, Cammelli F, Visintini E, Mazzoni A, Vita F, Carrilho M, Cadenaro M, Foulger S, Mazzoti G, Tay FR, Di Lenarda R, Pashley D. Influence of chlorhexidine concentration on the durability of etch-and-rinse dentin bonds: a 12month in vitro study. J Adhes Dent 2009;11:191-198. 2. Breschi L, Mazzoni A, Nato F, Carrilho M, Visintini E, Tjäderhane L, Ruggeri A Jr, Tay FR, Dorigo Ede S, Pashley DH. Chlorhexidine stabilizes the adhesive interface: a 2-year in vitro study. Dent Mater 2010;26:320-325. 3. Breschi L, Mazzoni A, Ruggeri A, Cadenaro M, Di Lenarda R, De Stefano Dorigo E. Dental adhesion review: aging and stability of the bonded interface. Dent Mater 2008;24:90-101. 4. Carrilho MR, Carvalho RM, de Goes MF, di Hipólito V, Geraldeli S, Tay FR, Pashley DH, Tjäderhane L. Chlorhexidine preserves dentin bond in vitro. J Dent Res. 2007;86:90-94. 5. Carrilho MR, Carvalho RM, Sousa EN, Nicolau J, Breschi L, Mazzoni A, Tjäderhane L, Tay FR, Agee K, Pashley DH. Substantivity of chlorhexidine to human dentin. Dent Mater 2010;26:779-785.

a

Professor, Department of Biomedical and Neuromotor Sciences, DIBINEM, University of Bologna, Bologna, Italy.

Correspondence: Prof. Lorenzo Breschi, Dental School, Department of Biomedical and Neuromotor Sciences, DIBINEM, University of Bologna, Alma Mater Studiorum, Via San Vitale, 59, 40125, Bologna, Italy. Tel: +39-051-20 88111, Fax: +39-051-22 5208. e-mail: [email protected]

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Materials

Do

Why

Etch-andrinse, two- or three-step adhesives

Apply 35% to 37% phosphoric acid on enamel for 15 to 30 s and dentin for 15s; rinse for 15 s with an air/water spray; air dry gently to remove excess moisture; apply 0.2% to 2% acqueous chlorhexidine solution; air dry gently to remove excess chlorhexidine solution according to the wet-bonding technique; apply primer/bonding agent in accordance with manufacturers’ instructions.

The application of chlorhexidine on etched dentin inhibits dentinal MMPs and cysteine cathepsins, protecting suboptimally exposed collagen.

6. Carrilho MR, Geraldeli S, Tay F, de Goes MF, Carvalho RM, Tjäderhane L, Reis AF, Hebling J, Mazzoni A, Breschi L, Pashley D. In vivo preservation of the hybrid layer by chlorhexidine. J Dent Res. 2007;86:529-433. 7. Collares FM, Rodrigues SB, Leitune VC, Celeste RK, Borba de Araújo F, Samuel SM. Chlorhexidine application in adhesive procedures: a meta-regression analysis. J Adhes Dent 2013;15:11-18. 8. Di Hipólito V, Rodrigues FP, Piveta FB, Azevedo Lda C, Bruschi Alonso RC, Silikas N, Carvalho RM, De Goes MF, Perlatti D‘Alpino PH. Effectiveness of self-adhesive luting cements in bonding to chlorhexidine-treated dentin. Dent Mater 2012;28:495-501. 9. Kim J, Uchiyama T, Carrilho M, Agee KA, Mazzoni A, Breschi L, Carvalho RM, Tjäderhane L, Looney S, Wimmer C, Tezvergil-Mutluay A, Tay FR, Pashley DH. Chlorhexidine binding to mineralized versus demineralized dentin powder. Dent Mater 2010;26:771-778. 10. Liu Y, Tjäderhane L, Breschi L, Mazzoni A, Li N, Mao J, Pashley DH, Tay FR. Limitations in bonding to dentin and experimental strategies to prevent bond degradation. J Dent Res 2011;90:953-968. 11. Mazzoni A, Carrilho M, Papa V, Tjäderhane L, Gobbi P, Nucci C, Di Lenarda R, Mazzotti G, Tay FR, Pashley DH, Breschi L. MMP-2 assay within the hybrid layer created by a two-step etch-and-rinse adhesive: biochemical and immunohistochemical analysis. J Dent 2011;39:470-477. 12. Mazzoni A, Nascimento FD, Carrilho M, Tersariol I, Papa V, Tjäderhane L, Di Lenarda R, Tay FR, Pashley DH, Breschi L. MMP activity in the hybrid layer detected with in situ zymography. J Dent Res 2012;91:467-472. 13. Mazzoni A, Pashley DH, Tay FR, Gobbi P, Orsini G, Ruggeri A Jr, Carrilho M, Tjäderhane L, Di Lenarda R, Breschi L. Immunohistochemical identification of MMP-2 and MMP-9 in human dentin: correlative FEI-SEM/TEM analysis. J Biomed Mater Res A 2009;88:697-703. 14. Mazzoni A, Scaffa P, Carrilho M, Tjäderhane L, Di Lenarda R, Polimeni A, Tezvergil-Mutluay A, Tay FR, Pashley DH, Breschi L. Effects of etch-and-rinse and self-etch adhesives on dentin MMP-2 and MMP-9. J Dent Res 2012;92:82-86. 15. Pashley DH, Tay FR, Breschi L, Tjäderhane L, Carvalho RM, Carrilho M, TezvergilMutluay A. State of the art etch-and-rinse adhesives. Dent Mater 2011;27:1-16. 16. Pashley DH, Tay FR, Yiu C, Hashimoto M, Breschi L, Carvalho RM, Ito S. Collagen degradation by host-derived enzymes during aging. J Dent Res 2004;83:216-221. 17. Tjäderhane L, Nascimento FD, Breschi L, Mazzoni A, Tersariol IL, Geraldeli S, Tezvergil-Mutluay A, Carrilho MR, Carvalho RM, Tay FR, Pashley DH. Optimizing dentin bond durability: control of collagen degradation by matrix metalloproteinases and cysteine cathepsins. Dent Mater 2013:116-135. 18. Tjäderhane L, Nascimento FD, Breschi L, Mazzoni A, Tersariol IL, Geraldeli S, Tezvergil-Mutluay A, Carrilho M, Carvalho RM, Tay FR, Pashley DH. Strategies to prevent hydrolytic degradation of the hybrid layer-A review. Dent Mater 2013;29:999-1011. 19. Yiu CKC, Hiraishi NN, Tay FRF, King NMN. Effect of chlorhexidine incorporation into dental adhesive resin on durability of resin-dentin bond. J Adhes Dent 2012;14:355-362. 20. Zhou J, Tan J, Yang X, Cheng C, Wang X, Chen L. Effect of chlorhexidine application in a self-etching adhesive on the immediate resin-dentin bond strength. J Adhes Dent 2010;12:27-31. 21. Zhou J, Tan J, Yang X, Xu X, Li D, Chen L. MMP-inhibitory effect of chlorhexidine applied in a self-etching adhesive. J Adhes Dent 2011;13:111-115.

The Journal of Adhesive Dentistry

Chlorhexidine application to stabilize the adhesive interface: why and how?

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