Incorporating Bioactivity and Antimicrobial Benefits into Your Restorative Cases

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Dental manufacturers and suppliers have been incorporating bioactive and antimicrobial agents in their materials. The proposed benefits sound great and may resolve some issues with recurrent decay with specific patient populations. We take a closer look at both types of materials and how they might benefit some of your restorative cases.

Peter Auster, DMD, a private-practice clinician in Pomona, New York, and frequent lecturer for the dental industry says bioactive and antimicrobial materials are trending. Dr Auster says that in 2 years, almost every company is going to have a bioactive product, “for better or worse.”

“Dental manufacturers tend to play follow the leader,” Dr Auster says.

What are Bioactive Materials?

The official definition of the word bioactive is that it is a material “having an effect on a living organism,” however there is not an “official” definition for bioactive dental restorative materials. The idea behind bioactive restorative dental materials is to switch dentists’ restorative mindset from reparative to a preventative one.

Bioactive dental restorative materials are different than other materials based on what they do after they are placed. Bioactive materials share the physical and mechanical properties of other dental composites, but they also release minerals—such as calcium, phosphate, and fluoride—into the tooth to strengthen and heal tooth structures and prevent future decay.

To read more about How Bioactive Materials Are Changing Restorative Dentistry, please click here.

However, not all bioactive restorative dental materials are the same or serve the same function. The American Dental Association’s ACE Panel Report from 2018, listed the “Most Commonly Used Bioactive Products,” which included:¹

Cements:

• Ceramir Crown and Bridge QuickCap (Doxa Dental)
• TheraCem (BISCO)
• ACTIVA BioACTIVE-CEMENT (Pulpdent)
• BioCem Universal BioActive Cement (NuSmile)

Liners:

• TheraCal LC (BISCO)
• Dycal Calcium Hydroxide Liner (Dentsply Sirona)/Life Pulp-Capping Material (Kerr)
• MTA-Angelus (Angelus)/ProRoot MTA Root Repair Material (Dentsply Sirona)
• Lime-Lite (Pulpdent)

Restoratives:

• ACTIVA BioACTIVE-RESTORATIVE (Pulpdent)
• Biodentine (Septodont)

In that 2018 ACE Panel Report, there is the beginning of a definition of what bioactive dental materials are. The ACE Panel defined dental biomaterials as those that can form surface apatite-containing material (ACM), which include hydroxyapatite in a simulated body fluid. The ACE panel also suggested that with these properties, they could be used at an open margin, at the interface of restorative materials and the tooth, or liners that contact with pulp. In these situations, the ACE Panel said that the bioactive materials will interact with pulpal tissue or preserve pulp vitality.¹

Dr Auster says that although some bioactive products have been available for upwards of 10 years, more research is warranted to determine their long-term results. Some of the proposed benefits about bioactive materials are more theory than practice, but the concept of continued nourishment and hydroxyapatite formation are proven and that is certainly a win-win for dentists and patients.

The concept that bioactive materials are products that “don’t die” is a great one, Dr Auster says. He explains that a conventional cement in a crown is passive, meaning it doesn’t do anything else once you place it.

However, Dr Auster continues, a bioactive material is active the entire life of the restoration. Bioactive products form a layer between the tooth and the material that is a hydroxyapatite layer, which is a natural, moisture-friendly bond that occurs in other parts of the body as well. The moisture friendly bond is key, he says, as the exchange of water going back and forth between the tooth and the material is also transporting minerals, calcium and phosphate into the tooth and recharging the tooth structure.

Bioactive materials are growing in popularity with many dental professionals. These restoratives support dental practice’s current environment that emphasizes infection control even more than usual and the patient populations’ growing awareness that a healthy oral cavity is an integral part of a patients’ overall health. Dr Auster says that the coronavirus disease 2019 (COVID-19) pandemic has brought these themes to the fore, making bioactive dental restorative materials an area to which many dental practices will pay attention.

“Good dental health and healthy internal organs go hand in hand,” Dr Auster says of today’s dental practice philosophy. “People with compromised organs are in more danger during a pandemic. It’s so important to everyone at this point in time. Anything that reduces microbial damage is a good thing.”

Dr Auster has been using bioactive products for quite some time, beginning with Pulpdent’s ACTIVA™ and Doxa Dental’s Ceramir Crown and Bridge QuickCap. Describing them as interesting products, he uses them a lot with immunocompromised patients, children, people with issues with bacteria or seniors who have problems with home care because of disabilities or other reasons. He recommends using bioactive products with a proven track record like the Pulpdent’s ACTIVA line over products that are brand new to the market.

“You are trying to stop biofilms from forming and causing recurrent decay,” Dr Auster says.

However, there are situations where he would reach for a conventional dental restorative over a bioactive one. Dr Auster’s personal preference is to avoid using bioactive products in highly esthetic areas because some bioactive cements are more opaque and he gets better results with conventional composites. He also avoids using them in heavy occlusion areas because the mechanical properties are not quite as strong as conventional composites. Also, there can be more staining around the edges when using bioactive materials. Dr Auster warns patients who are smokers or heavy red wine drinkers that he will have to polish the restoration occasionally if he chooses to use a bioactive restorative material for their treatment.

Despite these drawbacks to the materials, Dr Auster says as the bioactive materials improve in their physical and mechanical properties, he would consider using them in more cases. For example, he likes TheraCem® from BISCO, which he describes as a conventional self-adhesive cement with bioactive properties and TheraCal PT® and LC®

Pulpotomies and pulp caps respectively.

“It does have a fair amount more strength, so that's a very interesting product that I've been using,” he says.

Bioactive materials feel different in your hands than composite, per Dr Auster. He recommends getting more comfortable with bioactive restorative materials through a test run on your countertop or in a Dentiform tooth before you try it in the mouth.

“Once you figure out the feel, it’s very simple,” Dr Auster says. “But it just takes a little while to get used to it.”

What Are Antimicrobial Materials?

Antimicrobial materials are designed to prevent bacteria adhering to the tooth and biofilm formation. Per the International Journal of Oral Science, antimicrobial dental materials usually work by releasing an agent, killing upon contact, and “multifunctional strategies” to prevent initial bacterial attachment and biofilm formation after completing the restoration.²

There are a few different antimicrobial restorative materials. The first antimicrobials that were release-based were made of silver compounds in the 20th century and have evolved to include the nanotechnology of the 21st century. The nanotechnology behind antimicrobials either improves the antimicrobial qualities of existing materials or make new antimicrobial dental restorative materials.³

If you want to know more about the details of antimicrobial restorative materials described in the International Journal of Oral Science, please click here.

When it comes to antimicrobials, Dr Auster says there are very few patients he wouldn’t use them on. For many years, he says, dental professionals have used glutaraldehyde and there are a lot of excellent glutaraldehyde products available from the different manufacturers, like GLUMA® from Kulzer, and Telio CS Desensitizer from Ivoclar Vivadent, to name a couple. GLUMA is antibacterial and blocks the dentin tubules so the fluid can’t leak out, which stops the decay and desensitizes the tooth.

Another popular antimicrobial agent is chlorhexidine. Chlorhexidine is a bactericidal agent that also prevents the formation of bacteria where it is used. Chlorhexidine destroys bacteria by binding to its cell wall and interfering with the membrane transport systems, which causes the protein to deposit out of the cytoplasm.3 While it is used in all kinds of products outside of dental practices, for the oral cavity it comes in many forms, including mouth rinses, gels, root canal irrigants, varnishes and more. Dr Auster uses the chlorhexidine antimicrobial solution Concepsis™ from Ultradent Products to clean off the tooth.

The question with both glutaraldehyde and chlorhexidine antimicrobial agents, he says, is how long do they continue to function? The research isn’t conclusive.

“Once you put the crown on, the effect of the anti-microbial agent is over…probably. But we really don't know the longevity,” Dr Auster says. “And if you go with your gut on this, anything that’s anti-viral at this point in time sounds good to me.”

There are new antimicrobial products coming on the market, too. Dr Auster thinks the new product FiteBac® Antimicrobial Cavity Cleanser by FiteBac Dental is interesting. The technology and chemistry behind the product created a new class of antimicrobial compounds. Unlike some of the other cleansers on the market, FiteBac is FDA-approved as both a cleanser and a bactericidal product. Dr Auster says likes the idea of it doing both.

“A new frontier in dentistry will be antimicrobial agents included as part of mainstream composites, cements, and other restoratives,” Dr Auster says. “Stay tuned…they are coming.”

References

1. Ace Panel Report Bioactive Materials. Ada.org. https://www.ada.org/~/media/ADA/Science%20and%20Research/Files/ACE_Panel_Report_Bioactive_Materials_Q2 _2018.pdf?la=en. Published 2018. Accessed February 4, 2021.

2. Jiao, Y., Tay, F.R., Niu, Ln. et al. Advancing antimicrobial strategies for managing oral biofilm infections. Int J Oral Sci 11, 28 (2019). https://doi.org/10.1038/s41368-019-0062-1

3. Enna S, Bylund D, Mariotti A. Xpharm. Amsterdam: Elsevier; 2008:1-4.