G uest Editorial

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SCLEROTIC DENTIN: CLINICAL IMPLICATIONS IN RESTORATIVE DENTISTRY

dhesive dentistry has advanced significantly

since the introduction of the adhesive resins almost four
decades ago. These resins aid in conserving tooth
structure, helping us to practice conservative dentistry in
its true sense. Resin adhesion to tooth structure is a
complex entity and can be achieved by one of the three
approaches; etch and rinse approach (total-etch), self-etch
technique or glass ionomer technique. The main mode of
adhesion in total-etch and self-etch technique is through
micromechanical retention while glass ionomer adheres
mainly through chemical adhesion and to some extent by
micromechanical retention.
The formation of bonds between two dissimilar materials
depends on two main variables. The first variable is the
substrate and the second is the composition of the material
that interacts with the substrate at the interface. The
interaction and the properties of the material are the major
determinants for the long term success of these bonds[1].
Bond strength to enamel is good due to its high inorganic
content. Dentin is more organic compared to enamel and
more humid due to the presence of water, making bonding
more difficult. It is a dynamic substrate where continuous
physiologic and pathological changes take place altering
the composition and microstructure of the substrate. One
such change is sclerotic dentin which has garnered little
attention in adhesive dentistry. This is mainly because
sclerotic dentin is multilayered and is difficult to replicate
for in-vitro studies. It is less receptive to bonding protocols
that are mainly designed for use in sound dentin.
Sclerotic dentin is formed either as a reactive process or
aging and is seen in the occlusal and non-carious cervical
lesions, latter being more common. The dentinal tubules
are partially or completely obliterated with rod like sclerotic
casts via peritubular apposition and minerals in the saliva.
These sclerotic plugs are protected by a layer of shiny
hypermineralized layer which is acid resistant and acts as a
diffusion barrier during adhesive procedures[2]. This layer
contains denatured collagen with large calcium and
phosphate crystals[3]. The non carious cervical lesions are
generally seen as wedge shaped defect covered by a
hypermineralized surface layer showing few discontinuities.
At the deepest part of the wedge it is 15m in thickness[4].
This part is inaccessible to brushing and contains bacteria.
At the occlusal wall of the wedge the hypermineralized layer
is 1-2m in thickness and at the gingival wall it is
approximately 200-300nm (thinnest). The density of the
minerals within the hypermineralized layer is higher and

e-Journal of Dentistry Jan 2011 Vol 1 Issue 1

they are larger and arranged longitudinally unlike that seen

in the underlying sclerotic dentin. The larger crystallites
are similar to that seen in cementum and remineralized
carious dentin[5]. The calcium to phosphate ratio in the
hypermineralized layer is 1.67 and that in the sclerotic casts
is 1.5.
Several adhesion strategies have been used. When the
hypermineralized dentin is thin, total etch and self-etch
(with intermediate pH) showed hybrid layer formation
resulting in good bond strength. When the hypermineralized
layer is continuous and thick, the etching effect of selfetch primer is limited, it cannot etch beyond this layer and
the hybrid layer formed within the hypermineralized layer
is 0.5 m in depth similar to that seen with aprismatic enamel.
When the hypermineralized dentin is discontinuous, selfetch primer diffused through these discontinuities to some
extent, but not completely. Bacteria are commonly present
in these discontinuities whose survival, depend on the
availability of carbohydrates in the oral environment and
may result in degradation of adhesion over a period of time.
When total-etch approach is used, the hybrid layer formed
is thicker. But in some areas of hypermineralized dentin the
hybrid layer formed is so thin that it is almost non-existent.
Any discontinuity in the bonding interface act as a weak
link and subsequently initiate adhesive failures in the
sclerotic dentin and reduces its durability even when best
restorative material is used. The eccentric hybrid layer
formed differs from that seen with sound freshly cut dentin
due to the absence of type I collagen.
So the main challenges of sclerotic dentin is the inability to
etch through the hypermineralized surface layer of the
lesion, particularly when such a layer is thicker than 0.5 mm
and when a mildly aggressive self-etching primer is used
alone. Inability to remove the sclerotic casts that obliterate
the dentinal tubules prevent the resin tag formation and
bacteria entrapment within the resin layer may introduce
defects that weaken the ultimate tensile strength of the
polymerized adhesive resin [6] . To improve the
micromechanical adhesion to sclerotic dentin, two strategies
can be followed. First strategy is by doubling the etching
time or by using stronger acids. However resin tag formation
does not occur in this approach. Other method of
overcoming the diffusion barrier is by removal of
hypermineralized layer using a rotary instrument to obtain
intertubular retention. However this may be detrimental
when the lesion is close to the pulp. Another disadvantage
of this approach is, the smear layer formed during this
5

G uest Editorial
procedure contains acid resistant hypermineralized dentin
chips and whitlockite crystals derived from sclerotic casts
that creates additional diffusion barrier when total-etch or
self-etch technique is used.
Sclerotic dentin being a part of bodys natural defence
mechanism, should be preserved whenever possible[7]. The
best way to restore these lesions is by removing a thin
surface layer of hypermineralized dentin to obtain a
consistent hybrid layer. It also helps in eliminating the
adherent surface layer of bacteria. When occlusal lesions
in moderate stress bearing areas are restored, adjacent
enamel and sound dentin should be cut and etched to
provide additional micromechanical retention. The
substrate is then disinfected using 2% chlorhexidine. The
sclerotic dentin is pre-etched using 37% phosphoric acid
for 10 seconds along with 20secs etching of enamel. Selfetch primer is used which demineralize only to a depth of
1m retaining the hydroxyapatite covering of the collagen
intact [8]. This hydroxyapatite serves as a receptor for
additional chemical bonding along with micromechanical
interlocking through hybridization. So adhesive resins
containing 10-MDP(10-methacryloxydecyl dihydrogen
phosphate) which shows chemical bonding with calcium
of residual apatite crystals should be used. The preparation
is finally restored with hybrid composite. The cervical
lesions are restored with microfilled composite instead of
hybrid composite as their modulus of elasticity (6GPa)is
lesser than hybrid composites(10-14GPa). When occlusal
load is applied, microfilled composites compress rather than
dislodge during tooth flexure[9]. Studies have shown that
when hybrid composites were used to restore cervical
lesions, there was bond failure during tooth flexure due to
their stiffness. This created more cervical gaps[10]. When
esthetics is not of concern, conventional glass ionomers,
resin modified glass ionomers(elastic modulus is 3-9Gpa)
and giomers should be used as they adhere well to the
hypermineralized sclerotic dentin. Their retention rate is
very high but they are available in limited shades[11,12].

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References
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Ellis TH, Sacher E. Adhesion to Tooth Structure Mediated by Contemporary

Bonding Systems. Dent Clin N America 2007;51:677-694.

2.

Mixson JM, Spencer P, Moore DL, Chappell RP, Adams S. Surface

morphology and chemical characterization of abrasion/erosion lesions.
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3.

Duke ES, Lindemuth J. Variability of clinical dentin substrates. American

Journal of Dentistry 1991;4:241-246.

4.

Tay FR, Pashley DH. Resin bonding to cervical sclerotic dentin: A review.
Journal of Dentistry 2004;32:173-196.

5.

Takuma S, Ogiwara H, Suzuki H. Electron probe and electron microscope

studies of carious dentinal lesions with remineralized surface layer. Caries
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SM Kwong, GSP Cheung, LH Kei, A Itthagarun, RJ Smales, FR Tay, DH.

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Kusunoki M, Itoh K, Hisamitsu H, Wakumoto S. The efficacy of dentin

adhesive to sclerotic dentine. Journal of Dentistry 2002;30:91-97.

8.

Van Meerbeek B, De Munck J, Yoshida Y, Inoue S, Vargas M, Vijay P, Van

Landuyt K, LambrechtsP, Vanherle G. Adhesion to enamel and dentin:
Current status and future challenges. Oper Dent 2003; 28: 215-235.

9.

Bayne SC, Heymann HO, Sturdevant JR, Wilder AD, Sluder TB.
Contributing co-variables on clinical trials. Am J Dent 1991;4:247-250.

10.

Kemp-Scholte CM, Davidson CL. Marginal sealing of curing contraction

gaps in Class V composite resin restorations. J Dent Res 1988;67:841845.

11.

Burrow MF, Tyas MJ. Clinical evaluation of three adhesive systems for the
restoration of non-cariouscervical lesions. Oper Dent 2007; 32: 11-15.

12.

Neo J, Chew CL. Direct tooth-colored materials for noncarious lesions: A

3-year clinical report. Quintessence International 1996;27:1838.

Jayshree Hegde
Professor and Head
Department of Conservative Dentistry and Endodontics
The Oxford Dental College, Hospital and Research Center
Bengaluru, Karnataka
India.
E-mail : drjhegde@hotmail.com

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