UNIVERSIDADE FEDERAL DO RIO GRANDE DO NORTE

CENTRO DE CIÊNCIAS DA SAÚDE

DEPARTAMENTO DE ODONTOLOGIA

JOYCE FIGUEIREDO MACEDO DE LIMA

O EFEITO DO CONDICIONAMENTO ÁCIDO E DA CLOREXIDINA NA

RESISTÊNCIA ADESIVA DE UM SISTEMA ADESIVO UNIVERSAL ÀS DENTINAS

SADIA E AFETADA POR CÁRIE

NATAL/RN

2016

JOYCE FIGUEIREDO MACEDO DE LIMA

O EFEITO DO CONDICIONAMENTO ÁCIDO E DA CLOREXIDINA NA

RESISTÊNCIA ADESIVA DE UM SISTEMA ADESIVO UNIVERSAL ÀS

DENTINAS SADIA E AFETADA POR CÁRIE

Trabalho de Conclusão de Curso

apresentado ao Departamento de

Odontologia da Universidade

Federal do Rio Grande do Norte

como parte dos requisitos para

obtenção do título de Cirurgião-

dentista.

ORIENTADORA: PROFª DRª ISANA ÁLVARES FERREIRA

CO-ORIENTADORA: PROFª DRª ANA CAROLINA BOTTA

NATAL/RN

2016

JOYCE FIGUEIREDO MACEDO DE LIMA

O EFEITO DO CONDICIONAMENTO ÁCIDO E DA CLOREXIDINA NA

RESISTÊNCIA ADESIVA DE UM SISTEMA ADESIVO UNIVERSAL ÀS

DENTINAS SADIA E AFETADA POR CÁRIE

Trabalho de Conclusão de Curso

apresentado ao Departamento de

Odontologia da Universidade

Federal do Rio Grande do Norte

como parte dos requisitos para

obtenção do título de Cirurgião-

dentista.

Aprovado em ____/ ____/ ____

BANCA EXAMINADORA

_______________________________________

Profª Drª Isana Álvares Ferreira

Orientadora

_______________________________________

Profª Drª Marília Regalado Galvão Rabelo Caldas

Membro

_______________________________________

Prof. Dr. Boniek Castillo Dutra Borges

Membro

O EFEITO DO CONDICIONAMENTO ÁCIDO E DA CLOREXIDINA NA

RESISTÊNCIA ADESIVA DE UM SISTEMA ADESIVO UNIVERSAL ÀS

DENTINAS SADIA E AFETADA POR CÁRIE

Short title: RESISTÊNCIA ADESIVA DE SISTEMA ADESIVO UNIVERSAL ÀS

DENTINAS SADIA E CARIADA

Joyce Figueiredo Macedo de Limaa, Ana Carolina Bottab, Isana Alvares

Ferreirac

aGraduanda em Odontologia da Faculdade Federal do Rio Grande do Norte,

Natal, RN, Brasil, jcinhafml@hotmail.com

bProfessora e Diretora da Divisão de Dentística e Materiais Dentários do

Departamento de Odontologia Geral da Faculdade de Odontologia da

Universidade de Stony Brook, Stony Brook, NY, EUA,

anacarolina.deoliveira@stonybrookmedicine.edu

cProfessora Adjunto do Departamento de Odontologia da Universidade Federal

do Rio Grande do Norte, Natal, RN, Brasil, isanaalvares@hotmail.com

INFORMAÇÕES DA AUTORA:

Joyce Figueiredo Macedo de Lima

Rua do Espinheiro, 2005, San Valle

Natal, RN, Brasil

Fone: (84) 99966-8539

E-mail: jcinhafml@hotmail.com

Palavras-chave: Dentina, Clorexidina, Adesivos Dentinários, Resistência a

Tração, Ataque Ácido Dentário.

AGRADECIMENTOS

Primeiramente à Deus, meu amor maior, por cumprir em mim mais um de Seus

propósitos, para Sua glória.

À minha família e ao meu namorado Kayo, pelo amor incondicional que me

acompanha e fortalece todos os dias.

À Universidade Federal do Rio Grande do Norte, por tornar possível um sonho

ao oferecer um dos melhores cursos de Odontologia do país.

À minha orientadora, Profa. Dra. Ana Carolina Botta, por permitir que eu

apresentasse a pesquisa de estágio do programa Ciências sem Fronteiras

como TCC, por todos os aprendizados que tem me proporcionado e por sua

amizade sincera. Seu exemplo de vida e profissionalismo me inspiram, e sou

muito grata à Deus por ter cruzado os nossos caminhos.

À Prof. Dra. Isana Álvares, por ter sido sempre solícita antes, durante e depois

do meu intercâmbio. Sua ajuda, apoio e orientações foram de grande

importância para que eu alcançasse os meus objetivos, e serei sempre grata a

você por isso.

Aos demais professores do curso, que com muita dedicação e amor à docência

foram fundamentais para a minha formação acadêmica.

To Fariya and Johanna for all the help on the lab and kindness to me during my

internship in the Stony Brook Univeristy.

Às turmas 96 e 99 por terem feito dos meus dias de aprendizado na

universidade mais leve e significativos.

Aos demais amigos, que de um jeito ou de outro se fizeram presentes e

sempre torcem por minhas realizações.

Muito obrigado!

O EFEITO DO CONDICIONAMENTO ÁCIDO E DA CLOREXIDINA NA

RESISTÊNCIA ADESIVA DE UM SISTEMA ADESIVO UNIVERSAL ÀS

DENTINAS SADIA E AFETADA POR CÁRIE

RESUMO

Objetivo: Avaliar o efeito do condicionamento ácido e da clorexidina sobre a

força de microtração de um adesivo universal à dentina sadia e dentina afetada

por cárie. Metodologia: Seis terceiros molares intactos e seis cariados foram

seccionados, obtendo-se 2 espécimes de dentina média por dente. O sistema

adesivo (Prime & Bond Elect Universal, Dentsply) foi usado de duas diferentes

formas: condicionamento ácido total (ER, ácido fosfórico por 15s) e

autocondicionante (SE, sem ácido fosfórico). A clorexidina a 2% (CX, Cavity

Cleanser, Bisco) foi aplicada por 30s sobre ambas as dentinas. Os espécimes

foram distribuídos em 8 grupos (n=3) de acordo com os tratamentos para as

dentinas sadia e afetada por cárie: SE; ER; SE+CX e ER+CX. Todos os

espécimes foram restaurados com a resina composta TPH Spectra (Dentsply)

e seccionados para obtenção de espécimes de 0,8±0,1mm². O teste de

microtração foi realizado a 1mm/min. Os dados foram avaliados pela análise de

variância e teste de Dunn (α=0,05). Resultados: Não houve diferença

estatística significativa entre dentina sadia e dentina afetada por cárie

(p=0,513). A maior força de adesão foi obtida com a aplicação do ER

(35,16MPa). SE+CX apresentou a menor força de adesão sem diferença

estatística para ER+CX (p>0,05). Valores intermediários de força de adesão

foram observados para SE. Conclusões: O condicionamento ácido total

aumentou a força de adesão do sistema adesivo universal a dentina sadia e a

dentina afetada por cárie. A clorexidina reduziu a força de adesão a ambas as

dentinas independente do uso do ácido fosfórico. Significância clínica: O

sistema adesivo universal promoverá um aumento da força de adesão à

dentina sadia e a dentina afetada por cárie quando aplicado pela técnica do

condicionamento ácido.

Palavras-chave: Dentina, Clorexidina, Adesivos Dentinários, Resistência a

Tração, Ataque Ácido Dentário.

EFFECT OF ACID ETCHING AND CHLORHEXIDINE ON BOND

STRENGTHS OF UNIVERSAL DENTAL ADHESIVE TO SOUND AND

CARIES-AFFECTED DENTINS

ABSTRACT

Objective: To assess the effect of acid etching and chlorhexidine on the

microtensile strength of a universal adhesive agent to sound and caries-

affected dentins. Methods: Six intact third molars and six decayed third molars

were sectioned to obtain two middle dentin specimens per tooth. The universal

adhesive agent (Prime & Bond Elect Universal, Dentsply) was applied to

specimens in two different modes: etch-and-rinse (ER, phosphoric acid for 15s)

and self-etch (SE, no phosphoric acid). 2% chlorhexidine (CHX, Cavity

Cleanser, Bisco) was applied to both dentins for 30 seconds. Specimens were

randomly assigned into 8 groups (n = 3) according to the treatments applied to

sound and caries-affected dentins: SE; ER; SE+CHX; and ER+CHX. All

specimens were restored with the composite resin TPH Spectra (Dentsply) and

sectioned to obtain specimens of 0.8 ± 0.1mm². The microtensile bond strength

test was conducted at 1 mm/min. The data were statistically analyzed by

ANOVA and Dunn's test (α = 0.05). Results: There was no significant difference

between intact dentin and caries-affected dentin (p=0,513). The highest bond

strength was obtained with the application of the ER (35,16MPa). SE+CHX

promoted the lowest bond strength with no statistical difference to ER + CHX

(p> 0,05). Intermediate values of bond strength were observed for SE.

Conclusions: Etch-and-rinse mode for the universal adhesive agent yielded the

highest bond strength to sound and caries-affected dentin. Chlorhexidine

reduced the bond strength to both dentins regardless the application of

phosphoric acid. Clinical significance: The universal adhesive agent increased

the bond strength to sound and caries-affected dentins when applied by the

etch-and-rinse mode.

Keywords: Dentin, Chlorhexidine, Dentin Adhesives, Tensile Strength, Acid

Etching, Dental.

SUMÁRIO

INTRODUÇÃO ................................................................................................... 1

MATERIAIS E MÉTODOS ................................................................................. 3

RESULTADOS .................................................................................................. 6

DISCUSSÃO ..................................................................................................... 7

CONCLUSÃO .................................................................................................. 11

REFERÊNCIAS ............................................................................................... 12

LISTA DE TABELAS ........................................................................................20

LISTA DE FIGURAS ....................................................................................... 23

ANEXO (Regras da revista Journal of Dentistry) ........................................ 26

1

INTRODUÇÃO

Um dos maiores desafios dos sistemas adesivos atuais é ser um

material versátil e efetivo tanto para o esmalte quanto para a dentina [1], de

técnica simplificada [1, 2] e que promova uma alta longevidade [3, 4, 5]. Em

uma tentativa de alcançar esse objetivo, um novo grupo de adesivos dentais

tem sido recentemente introduzido no mercado como “Adesivo Universal” ou

“Multi-uso” [1]. Este sistema adesivo pode ser utilizado de diferentes formas: 1)

auto-condicionamento, quando o acido fosfórico não é aplicado; 2)

condicionamento acido total, quando associado ao uso do ácido fosfórico sobre

o esmalte e a dentina e 3) condicionamento ácido seletivo, quando o uso do

ácido fosfórico é feito apenas sobre um dos substratos, geralmente no esmalte

[1].

O ácido fosfórico promove a desmineralização do esmalte e da dentina e

remoção da smear layer, facilitando assim a penetração dos monômeros

resinosos do sistema adesivo sobre a área desmineralizada e embricamento

mecânico da estrutura a ser restaurada após da fotopolimerização [1]. Embora

já se saiba que o condicionamento ácido total deve ser a técnica de escolha

para o esmalte por aumentar efetivamente a sua força de adesão [1, 6, 7], há

ainda controvérsias sobre a adesão à dentina. Isso se deve a complexa

morfologia e características físico-químicas da dentina sadia e da dentina

afetada por cárie [8]. A força de adesão a dentina é afetada pela degradação

do colágeno que acontece na interface resina-dentina [9]. Isso se deve,

parcialmente, devido a atividade da matriz de metaloproteinases (MMPs) [10-

13], uma classe de enzimas endógenas de ação proteolítica do colágeno. Elas

são produzidas por odontoblastos como zimogênios inativos (pro-MMPs) [14],

que podem se tornar ativos pelo contato com ácidos fracos [12, 15-17]. Para

ambos os sistemas adesivos, auto-condicionante ou de condicionamento ácido

total, a degradação das fibrilas expostas do colágeno na camada híbrida ocorre

devido a presença de ácidos em suas composições [18-20]. A fim de prevenir a

perda da força de adesão por hidrólise e manter a integridade da restauração

2

por um tempo maior, se faz necessário a inibição dessas enzimas proteolíticas

[21].

3

Algumas estratégias têm sido estudadas para inibir as MMPs:

incorporação de agentes como o grupo de amónio quaternário (QAMs) e

Cloreto de Benzalcônio (BAC) em primers auto-condicionantes [22, 23], o uso

de cálcio e zinco com ácido etilenodiamino tetra-acético (EDTA) como um

condicionante [24-26], a produção de inibidoras sintéticas das MMPs, como as

tetraciclinas quimicamente modificadas (TQMs) [27] e o uso do agente

antimicrobiano clorexidina (CHX) [28]. É sabido que a CHX tem apresentado os

resultados mais proeminentes [28]. Dependendo de sua concentração [28, 29]

e sobre qual substrato ela está sendo utilizada (dentina sadia ou afetada por

cárie) [30], a CHX pode não apenas diminuir o risco de infecção residual [31],

como também aumentar a força de adesão de restaurações de resina

composta por inibição das enzimas MMPs ativadas. Várias pesquisas têm

demonstrado esses efeitos da CHX quando associado a técnica de

condicionamento ácido total [19, 20, 32], mas há poucos estudos in vitro e in

vivo que avaliam seus efeitos sob o uso da técnica auto-condicionante [14, 15,

21, 29] e em sistemas adesivos universais [33].

Dessa forma, o propósito desse estudo foi avaliar o efeito do

condicionamento ácido e da clorexidina na resistência adesiva de uma resina

composta e um sistema adesivo universal à dentina sadia e afetada por cárie,

simulando as técnicas adesivas de auto-condicionamento e condicionamento

ácido total. As hipóteses nulas testadas foram: 1) O fator tipo de dentina não

tem efeito significativo sobre a força de adesão; 2) O fator tipo de tratamento

empregado não tem efeito significativo sobre a força de adesão; 3) A interação

entre os fatores “dentina” x "tratamento” não tem efeito significativo sobre a

força de adesão

4

MATERIAIS E MÉTODOS

Os materiais empregados estão descritos na Tabela 1.

Preparo dos espécimes

Seis terceiros molares humanos sadios e seis terceiros molares cariados

foram limpos e armazenados em solução de cloramina a 0,5% (Fisher

Scientific, Pittsburg, PA, EUA) em uma temperatura de 4oC por 7 dias. Após o

processo de desinfecção, os dentes foram seccionados 2,5mm acima e 4,0mm

abaixo da junção amelocementária com um disco diamantado de alta precisão,

em baixa velocidade (IsoMet 1000, Buehler, Illinois, EUA). Uma terceira secção

perpendicular as demais foi realizada no sentido vestíbulo-lingual para

obtenção de 2 espécimes de dentina por dente (Figura 1). A polpa coronária e

radicular foi removida com instrumentos de mão pelo ápice da raiz. Os canais

radiculares foram condicionados com ácido fosfórico a 34% (Dentsply, Milford,

DE, EUA) por 15s e selados com sistema adesivo universal Prime & Bond Elect

(Dentsply, Milford, DE, EUA) e resina TPH Flow (Dentsply, Milford, DE, EUA)

seguindo as instruções dos fabricantes.

Para padronizar a smear layer, uma lixa de silicone carbonado de

granulação 600 foi utilizada sobre a dentina por 1 minuto.

Os espécimes foram distribuídos aleatoriamente em 8 grupos

experimentais (n=3) de acordo com o tipo de tratamento aplicado sobre a

dentina sadia (S) e dentina afetada por cárie (C). O sistema adesivo universal

Prime & Bond Elect foi aplicado sobre ambas as dentinas seguindo as

instruções do fabricante e de acordo com duas diferentes técnicas: 1) ER:

condicionamento ácido total com aplicação do ácido fosfórico a 34% por 15s;

and 2) SE: auto-condicionamento (sem aplicação do ácido fosfórico). A

clorexidina a 2% (CHX, Cavity Cleanser, Bisco Inc., Schaumburg, IL, EUA) foi

aplicada com um microbrush por 30s sobre as dentinas [34] após a o uso do

ácido fosfórico na técnica de condicionamento ácido total e anteriormente a

aplicação do sistema adesivo universal na técnica de auto-condicionamento.

5

Os tratamentos aplicados sobre ambas as dentinas estão descritos na Tabela

2.

Após o tratamento superficial do substrato, foi realizada uma

restauração de 5mm em cada espécime pela técnica incremental com auxílio

de uma matriz metálica, um porta matriz de Tofflemire e um compósito de

resina universal TPH Spectra (Alta viscosidade, cor A2, Dentsply, Milford, DE,

EUA). Cada incremento foi fotopolimerizado por 10s, com auxílio de um

aparelho fotopolimerizador (Smartlite Focus Shield Refill, 1000mw/cm²,

Dentsply, Milford, DE, EUA), seguindo as instruções do fabricante.

Os espécimes foram armazenados em água destilada em temperatura

de 37oC, por 24h, e posteriormente submetidos ao teste de resistência adesiva

por microtração.

Teste da Resistência Adesiva

Todos os espécimes foram seccionados por cortes nos eixos “x” e “y” a

interface adesiva para obtenção de palitos de espessura 0,8±0,1mm2 [35]. Os

palitos foram testados individualmente através da colagem deles ao jig de

microtração, usando uma cola de cianocrilato (Zapit Accelerator, Dental

Ventures of America Inc., Corona, CA, EUA). Os palitos foram então

submetidos a uma carga de microtração (100N) usando-se uma máquina de

teste universal (Instron Co, Canton, MA, EUA) a 1mm/minuto de velocidade.

Um paquímetro digital (Mitutoyo Corp, Kanogawa, Japan) foi utilizado para

medir os lados da interface adesiva e calcular a área de adesão em mm2. A

carga (em N) e área de adesão dos espécimes foram registrados e a força de

microtração calculada em MPa pelo software da máquina de ensaio universal.

Com auxílio de uma lupa estereoscópica (Zeiss: West Germany – tipo

475200/9901) de capacidade de 10x de magnificação, as falhas foram

classificadas em adesiva (quando aconteceram na interface adesiva), coesiva

(quando em dentina ou em resina), mista (quando envolvia dentina e resina) ou

prematura (quando os espécimes se romperam na interface adesiva antes do

teste de microtração e foram considerados com valores de 0MPa).

6

Análise Estatística

Foi realizado o teste de normalidade Kolmogorov-Smirnov, onde

verificou-se uma distribuição não paramétrica (p<0,005). Desta forma, os dados

foram avaliados estatisticamente pela análise de variância não paramétrica de

2 fatores (IBM SPSS Statistics 21.0 software, IBM Chicago, IL, EUA), seguido

pelo pós-teste de Dunn (α=0,05).

7

RESULTADOS

Não houve diferença estatisticamente significante entre dentina sadia e

dentina afetada por cárie, independente da aplicação do condicionamento

ácido e da clorexidina (p=0,513). A interação entre os fatores “dentina” x

"tratamento” não teve efeito significativo sobre a força de adesão (p=0,184). O

tipo de tratamento executado afetou a força de adesão às dentinas (p<0,001)

(Tabela 3 e Figura 3). A maior força de adesão foi obtida com a aplicação do

ER (35,16 MPa). SE+CHX apresentou a menor força de adesão sem diferença

estatística para ER+CHX (p>0,05). Valores intermediários de força de adesão

foram observados para SE.

A falha adesiva foi predominante para todos os tratamentos sobre a

dentina sadia e a dentina afeta por cárie, exceto para SE+CHX (Figuras 4 e 5).

8

DISCUSSÃO

A hipótese nula de que o fator tipo de dentina não tem efeito significativo

sobre a força de adesão foi aceita. A dentina sadia é um composto biológico

formado por hidroxiapatita (50%), colágeno (30%) e água (20%) [36] que está

sujeito a mudanças estruturais por processos fisiológicos [37] e patológicos

[38]. Lesões iniciais de cárie afetam a fase mineral da dentina ao expor as

fibras de colágeno, criando as condições necessárias para uma destruição

progressiva com consequente diminuição nas propriedades mecânicas desse

tecido [38]. Como uma resposta à atividade cariosa, a dentina afetada sofre

mudanças estruturais que resultam em uma maior mineralização e

consequente redução da permeabilidade dentinária [37, 8]. Embora as dentinas

sadia e afetada por cárie tenham morfologias diferentes [37, 8], não houve

diferença estatística significante na força de adesão à ambas dentinas neste

estudo.

A segunda hipótese nula de que o fator tipo de tratamento empregado

não tem efeito significativo sobre a força de adesão foi rejeitada, pois ambos os

tratamentos superficiais (condicionamento ácido e clorexidina) afetaram a força

de adesão. Existe uma controvérsia na literatura a respeito do benefício do uso

do ácido fosfórico associado a sistemas adesivos universais. Estudos

demonstraram que a força de adesão dos sistemas adesivos universais à

dentina não foi influenciada quando o ácido fosfórico foi usado antes da

aplicação desses adesivos [39, 40], ou produziram um resultado inferior [41,

42]. No presente estudo, entretanto, o condicionamento ácido total aumentou a

força de adesão do sistema adesivo universal à dentina sadia e à dentina

afetada por cárie. Rosa et al. sugeriram que as diferenças nas composições

dos sistemas adesivos universais pode ser a razão para as diferentes

performances do ácido fosfórico sobre a força de adesão [39].

Nosso resultado está de acordo com Munõz et al. [43] e Tekce et al. [33]

que encontraram valores inferiores de força de adesão à dentina no modo SE

para diferentes sistemas adesivos universais usados, quando comparado ao

modo ER. Isso pode ser explicado pelas características dos monômeros de pH

9

acídicos contidos nos sistemas adesivos auto-condicionantes, os quais podem

ser classificados de acordo com seu pH e profundidade de penetração na

dentina como: ultra-fracos (pH>2.5, 0.2-0.5μm profundidade de penetração),

fracos (pH = 1-2; 1-2 μm profundidade de penetração) e fortes (pH <= 1, >=

5μm profundidade de penetração, similar ao condicionamento com ácido

fosfórico) [1]. Chen et al. classificaram o sistema adesivo universal Prime &

Bond Elect como fraco baseado em observações da espessura da camada

híbrida através de microscopia eletrônica de varredura e de seu pH [44]. O

ácido fosfórico (30-40%) expõe as fibras de colágeno que irão formar a camada

hibrida com os monômeros resinosos através da desmineralização superficial

da dentina, com remoção simultânea da smear layer e dos fosfatos de cálcio

dissolvidos [43, 2]. Já os monômeros de pH acídicos fracos presentes nos

sistemas auto-condicionantes foram desenvolvidos para condicionar ao mesmo

tempo em que os monômeros resinosos infiltram as fibras de colágeno

expostas [1]. Entretanto, eles não são capazes de remover a smear layer

completamente [1, 40] e os fosfatos de cálcio dissolvidos adequadamente [1],

servindo como uma barreira física para a formação da camada híbrida [45, 46].

Isto justifica a menor força de adesão observada com o modo SE comparado

ao ER. Para confirmar essa hipótese, sistemas adesivos SE que possuem

monômeros acídicos fortes em sua constituição têm apresentado melhores

resultados na capacidade de remoção da smear layer e na formação da

camada híbrida [47, 48]. Além disso, outros estudos têm demonstrado que o

uso do ácido fosfórico antes do sistema adesivo SE [49, 50] e do sistema

adesivo universal (modo ER) [40], tem assegurado uma penetração mais

profunda dos monômeros resinosos, gerando prolongamentos mais longos e

camadas híbridas mais espessas.

Entretanto, embora a aplicação do ácido fosfórico antes do sistema SE

tenha melhorado a morfologia da interface dentina-resina, muitas dessas

interfaces mostraram uma diminuição significativa na força de adesão, com um

grande número de falhas adesivas [42, 51, 52]. Um possível diferencial do

Prime & Bond Elect para os demais sistemas adesivos universais e SE que

pode ter influenciado nos valores da força de adesão de nosso estudo é que,

segundo Chen et al., embora o aprisionamento de água residual comprometa a

10

performance dos sistemas adesivos universais, o fato do Prime & Bond Elect

possuir acetona ao invés de etanol como solvente [44], facilita a remoção

desse acúmulo porque seu isótropo contém mais água em sua constituição e

um maior valor de pressão de vapor [53]. Em consequência, isso pode resultar

em menor degradação enzimática das fibrilas de colágeno e das falhas

adesivas [54, 55].

Um outro fator que pode explicar os resultados obtidos nesse estudo é a

forma como o sistema adesivo foi aplicado [56]. Taschner et al. verificaram

maiores valores de μTBS quando uma segunda camada de sistema adesivo foi

aplicada; o que foi associado com interfaces adesivas mais espessas e

resistentes [56].

Sabe-se que as metaloproteinases estão presentes no colágeno exposto

e não infiltrado abaixo da camada híbrida, e que podem ser ativadas mediante

presença de ácidos fracos, seja no sistema ER ou SE [18-20]. Assim,

independente do tipo de sistema adesivo utilizado, o objetivo das técnicas

adesivas tem sido infiltrar completamente o colágeno exposto por ácido ou

inibir as MMPs localizadas na área desmineralizada [55]. O uso da CHX como

um primer terapêutico tem se mostrado promissor pois ele age como um

inibidor inespecífico alterando a estrutura tridimensional das MMPs e

competindo com os íons metálicos (Ca2+, Zn2-) necessários para suas funções

[15, 57]. Embora haja evidência de que a CHX seja capaz de inibir a ação das

MMPs, não é claro o seu efeito na força de adesão de sistemas adesivos

universais [33] pois os resultados têm se mostrado contraditórios.

Tekce et al. observaram que a curto prazo, a CHX aumentou a força de

adesão de sistemas adesivos universais a dentina, porém esta resistência

adesiva foi significantemente reduzida a longo prazo dependendo da

composição do sistema adesivo universal utilizado e devido a degradação da

camada híbrida pelo processo de hidrólise [33].

Neste estudo a aplicação da CHX apresentou uma redução significativa

na força de adesão para ambos os modos (ER e SE) 24h após a realização do

procedimento restaurador. A formação de precipitados sobre a dentina após a

aplicação de CHX a 2%, como observado por Hipólito et al. [58] através de

11

microscopia eletrônica de varredura, pode justificar estes resultados. As duas

cargas positivas da molécula simétrica da CHX [59] podem ter atraído

eletrostaticamente os ânions do fosfato presente na hidroxiapatita [60],

formando cristais na forma de “agulhas birrifigentes” [58]. De acordo com os

autores, a CHX a 2% pode ter afetado a força de adesão ao diminuir a

quantidade de íons Ca+ disponíveis na dentina para a união química com o

sistema adesivo, e ao formar cristais que atuariam como uma barreira

mecânica à formação adequada da camada híbrida [58]. Embora a aplicação

de CHX tenha afetado a força de adesão tanto no modo ER quanto no SE,

falhas adesivas foram predominantes para o modo ER e prematuras para o

modo SE. O ácido fosfórico usado antes do sistema adesivo universal no modo

ER ao promover uma maior desmineralização da dentina e remoção da smear

layer pode ter também facilitado a penetração do sistema adesivo universal,

mesmo com a formação de precipitados pela aplicação da CHX. Já para o

modo SE, a penetração superficial do sistema adesivo universal associado com

os efeitos da CHX sobre a superfície dentinária pode ter resultado na formação

de uma camada híbrida inadequada; o que explicaria a maior quantidade de

falhas na interface adesiva quando comparado as falhas do ER antes mesmo

do teste de microtração (prematuras).

A interação entre os fatores “dentina” x "tratamento” não teve efeito

significativo sobre a força de adesão (p=0,184) e, portanto, a terceira hipótese

nula foi aceita.

Como nesse estudo a força de adesão do Prime and Bond Elect no

modo ER e SE foi observada apenas nas primeiras 24h, outros estudos

precisam ser realizados a fim de esclarecer os efeitos do uso da CHX 2% e do

ácido fosfórico 34% sobre a força de adesão a longo prazo; bem como as

diferentes composições dos sistemas adesivos universais podem influenciar

nessas performances. A avaliação da camada híbrida por meio de imagens de

microscopia também se faz necessária para o melhor entendimento da

penetração do sistema adesivo universal sobre a superfície dentinária.

12

CONCLUSÃO

Concluiu-se que o condicionamento ácido total aumentou a força de

adesão do sistema adesivo universal Prime and Bond Elect à dentina sadia e à

dentina afetada por cárie. A clorexidina reduziu a força de adesão a ambas as

dentinas independente do uso do ácido fosfórico.

13

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21

LISTA DE TABELAS

Tabela 1. Características dos materiais utilizados no desenvolvimento

desta pesquisa.

Materiais Composição

Fabricante

Lote Local de

fabricação

Cloramina 0,5%

20g de Cloramina T

trihidratada a 97% e 4L

de agua destilada

Fisher

Scientific A0336095

Pittsburg,

PA, EUA

Resina Composta

TPH Flow

Vidro de silicato de bario-

aluminio fluorado, dioxido

de silicone amorfo,

resinas dimetacrilatas

polimerizaveis, Bis-GMA,

Uretano modificado de

dimetacrilato Bis-GMA

Dentsply 150811 Milford, DE,

EUA

Sistema Adesivo

Universal (Prime &

Bond Elect)

Resinas de metacrilato

mono-, di- e tri; PENTA

(monofosfato

dipentaeritritol penta

acrilato); dicetona; óxido

de fosfina orgânica;

estabilizadores; fluoridrato

cetilamino; Acetona; água.

Dentsply 150924 Milford, DE,

EUA

Ácido fosfórico

34%

Acido Fosforico,

Surfactante, Aerosil 200,

Agua deionizada e

Pigmento.

Dentsply 151008 Milford, DE,

EUA

Clorexidina a 2%

Solução aquosa de

digluconato de clorexidina

a 2%.

Bisco Inc. 15000030

42

Schaumburg,

IL, EUA

22

Tabela 2. Distribuição dos 8 grupos experimentais de acordo com o tipo

de tratamento: técnica de aplicação do ácido fosfórico (ER: condicionamento

ácido total e SE: auto-condicionante) e da clorexidina (CHX) sobre a dentina

sadia (S) e dentina afetada por cárie (A).

Grupos Tratamento Dentina

1 SE

S 2 ER

3 SE+CHX

4 ER+CHX

5 SE

A

6 ER

7 SE+CHX

8 ER+CHX

Tabela 3. Formação de grupos homogêneos (de mesmo desempenho)

quanto a mediana e quartis (Quartil 1; Quartil 3) em MPa de acordo com o tipo

Resina universal

TPH Spectra Alta

viscosidade

BisGMA Uretano

modificado, Vidro de Bário

Silanizado, Boro Silicato

de Alumínio. Sílica

Pirolítica Silanizada,

Canforoquinona, EDAB,

Hidroxitolueno Butilado,

corantes mineirais e

fluorescência natural.

Dentsply 160111 Milford, DE,

EUA

Cola de

Cianocrilato

(Zapit)

Heptano, Acetona N, N-

dimetil-P-toluidina.

Dental

Ventures of

America,

Inc.

H13B Corona, CA,

EUA

23

de tratamento aplicado para ambas as dentinas (sadia e afetada por cárie).

Teste de Dunn (5%)

Tratamentos Mediana (Quartis) Grupos homogêneos*

SE 17,86 (0,12;30,44) B

ER 35,16 (20,00;50,00) A

SE+CHX 0,00 (0,00;23,14) C

ER+CHX 13,80 (0,00;31,76) BC

*medianas seguidas de letras diferentes indicam diferença estatisticamente

significante.

24

LISTA DE FIGURAS

Figura 1 – Preparo dos espécimes: Todos os dentes foram seccionados

2,5mm acima e 4,0mm abaixo da junção amelocementária com um disco

diamantado de alta precisão, em baixa velocidade (IsoMet 1000, Buehler,

Illinois, EUA). Uma terceira secção perpendicular as demais foi realizada no

sentido vestíbulo-lingual para obtenção de 2 espécimes de dentina por dente.

Figura 2 – Um paquímetro digital foi utilizado para medir os lados da

interface adesiva e calcular a área de adesão em mm2. Os palitos foram então

submetidos a uma carga de microtração usando-se uma máquina de teste

universal (Instron Co, Canton, MA, EUA) a 1mm/minuto de velocidade.

25

Figura 3 – Grafico boxplot da força de adesão (MPa) de acordo com o

tipo de tratamento aplicado para ambas as dentinas.

Figura 4 – Falhas dos espécimes (%) de acordo com o tipo de

tratamento aplicado para a dentina sadia.

26

Figura 5 – Falhas dos espécimes (%) de acordo com o tipo de

tratamento aplicado para a dentina afetada por cárie.

27

ANEXO

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same form, in English or in any other language, including electronically

without the written consent of the copyright-holder. To verify originality,

30

your article may be checked by the originality detection service CrossCheck

https://www.elsevier.com/editors/plagdetect.

Changes to authorship

Authors are expected to consider carefully the list and order of authors

before submitting their manuscript and provide the definitive list of authors

at the time of the original submission. Any addition, deletion or

rearrangement of author names in the authorship list should be made only

before the manuscript has been accepted and only if approved by the

journal Editor. To request such a change, the Editor must receive the

following from the corresponding author: (a) the reason for the change in

author list and (b) written confirmation (e-mail, letter) from all authors that

they agree with the addition, removal or rearrangement. In the case of

addition or removal of authors, this includes confirmation from the author

being added or removed.

Only in exceptional circumstances will the Editor consider the addition,

deletion or rearrangement of authors after the manuscript has been

accepted. While the Editor considers the request, publication of the

manuscript will be suspended. If the manuscript has already been published

in an online issue, any requests approved by the Editor will result in a

corrigendum.

Clinical trial results

In line with the position of the International Committee of Medical Journal

Editors, the journal will not consider results posted in the same clinical trials

registry in which primary registration resides to be prior publication if the

results posted are presented in the form of a brief structured (less than 500

words) abstract or table. However, divulging results in other circumstances

(e.g., investors' meetings) is discouraged and may jeopardise consideration

of the manuscript. Authors should fully disclose all posting in registries of

results of the same or closely related work.

Reporting clinical trials

Randomized controlled trials should be presented according to the

CONSORT guidelines. At manuscript submission, authors must provide the

CONSORT checklist accompanied by a flow diagram that illustrates the

progress of patients through the trial, including recruitment, enrollment,

randomization, withdrawal and completion, and a detailed description of the

randomization procedure. The CONSORT checklist and template flow

diagram can be found on http://www.consort-statement.org.

31

Registration of clinical trials

Registration in a public trials registry is a condition for publication of clinical

trials in this journal in accordance with International Committee of Medical

Journal Editors (ICMJE, http://www.icmje.org) recommendations. Trials

must register at or before the onset of patient enrolment. The clinical trial

registration number should be included at the end of the abstract of the

article. A clinical trial is defined as any research study that prospectively

assigns human participants or groups of humans to one or more health-

related interventions to evaluate the effects of health outcomes. Health-

related interventions include any intervention used to modify a biomedical

or health-related outcome (for example drugs, surgical procedures, devices,

behavioural treatments, dietary interventions, and process-of-care

changes). Health outcomes include any biomedical or health-related

measures obtained in patients or participants, including pharmacokinetic

measures and adverse events. Purely observational studies (those in which

the assignment of the medical intervention is not at the discretion of the

investigator) will not require registration.

Article transfer service

This journal is part of our Article Transfer Service. This means that if the

Editor feels your article is more suitable in one of our other participating

journals, then you may be asked to consider transferring the article to one

of those. If you agree, your article will be transferred automatically on your

behalf with no need to reformat. Please note that your article will be

reviewed again by the new journal. More information about this can be

found here: https://www.elsevier.com/authors/article-transfer-service.

Copyright

Upon acceptance of an article, authors will be asked to complete a 'Journal

Publishing Agreement' (for more information on this and copyright, see

https://www.elsevier.com/copyright). An e-mail will be sent to the

corresponding author confirming receipt of the manuscript together with a

'Journal Publishing Agreement' form or a link to the online version of this

agreement.

Subscribers may reproduce tables of contents or prepare lists of articles

including abstracts for internal circulation within their institutions.

Permission of the Publisher is required for resale or distribution outside the

institution and for all other derivative works, including compilations and

translations (please consult https://www.elsevier.com/permissions). If

excerpts from other copyrighted works are included, the author(s) must

32

obtain written permission from the copyright owners and credit the

source(s) in the article. Elsevier has preprinted forms for use by authors in

these cases: please consult https://www.elsevier.com/permissions.

For open access articles: Upon acceptance of an article, authors will be

asked to complete an 'Exclusive License Agreement' (for more information

see https://www.elsevier.com/OAauthoragreement). Permitted third party

reuse of open access articles is determined by the author's choice of user

license (see https://www.elsevier.com/openaccesslicenses).

Author rights

As an author you (or your employer or institution) have certain rights to

reuse your work. For more information see

https://www.elsevier.com/copyright.

Role of the funding source

You are requested to identify who provided financial support for the conduct

of the research and/or preparation of the article and to briefly describe the

role of the sponsor(s), if any, in study design; in the collection, analysis and

interpretation of data; in the writing of the report; and in the decision to

submit the article for publication. If the funding source(s) had no such

involvement then this should be stated.

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Elsevier has established a number of agreements with funding bodies which

allow authors to comply with their funder's open access policies. Some

authors may also be reimbursed for associated publication fees. To learn

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https://www.elsevier.com/fundingbodies.

After acceptance, open access papers will be published under a

noncommercial license. For authors requiring a commercial CC BY license,

you can apply after your manuscript is accepted for publication.

Open access

This journal offers authors a choice in publishing their research:

Open access

• Articles are freely available to both subscribers and the wider public with

permitted reuse.• An open access publication fee is payable by authors or

on their behalf (e.g. by their research funder or

33

institution).Subscription• Articles are made available to subscribers as

well as developing countries and patient groups through our universal

access programs (https://www.elsevier.com/access).• No open access

publication fee payable by authors.

Regardless of how you choose to publish your article, the journal will apply

the same peer review criteria and acceptance standards.

For open access articles, permitted third party (re)use is defined by the

following Creative Commons user licenses:

Creative Commons Attribution-NonCommercial-NoDerivs (CC BY-NC-ND)

For non-commercial purposes, lets others distribute and copy the article,

and to include in a collective work (such as an anthology), as long as they

credit the author(s) and provided they do not alter or modify the article.

The open access publication fee for this journal is USD 2000, excluding

taxes. Learn more about Elsevier's pricing policy:

https://www.elsevier.com/openaccesspricing.

Green open access

Authors can share their research in a variety of different ways and Elsevier

has a number of green open access options available. We recommend

authors see our green open access page for further information

(http://elsevier.com/greenopenaccess). Authors can also self-archive their

manuscripts immediately and enable public access from their institution's

repository after an embargo period. This is the version that has been

accepted for publication and which typically includes author-incorporated

changes suggested during submission, peer review and in editor-author

communications. Embargo period: For subscription articles, an appropriate

amount of time is needed for journals to deliver value to subscribing

customers before an article becomes freely available to the public. This is

the embargo period and it begins from the date the article is formally

published online in its final and fully citable form.

This journal has an embargo period of 12 months.

Language (usage and editing services)

Please write your text in good English (American or British usage is

accepted, but not a mixture of these). Authors who feel their English

language manuscript may require editing to eliminate possible grammatical

or spelling errors and to conform to correct scientific English may wish to

use the English Language Editing service available from Elsevier's WebShop

34

(http://webshop.elsevier.com/languageediting/) or visit our customer

support site (http://support.elsevier.com) for more information.

Submission

Our online submission system guides you stepwise through the process of

entering your article details and uploading your files. The system converts

your article files to a single PDF file used in the peer-review process.

Editable files (e.g., Word, LaTeX) are required to typeset your article for

final publication. All correspondence, including notification of the Editor's

decision and requests for revision, is sent by e-mail.

Submit your article

Referees

Please submit the names and institutional e-mail addresses of several

potential referees. For more details, visit our Support site. Note that the

editor retains the sole right to decide whether or not the suggested

reviewers are used.

PREPARATION

Double-blind review

This journal uses double-blind review, which means that both the reviewer

and author name(s) are not allowed to be revealed to one another for a

manuscript under review. The identities of the authors are concealed from

the reviewers, and vice versa. For more information please refer to

https://www.elsevier.com/reviewers/peer-review. To facilitate this, please

include the following separately:

Title page (with author details): This should include the title, authors'

names and affiliations, and a complete address for the corresponding author

including an e-mail address.Blinded manuscript (no author details): The

main body of the paper (including the references, figures, tables and any

Acknowledgements) should not include any identifying information, such as

the authors' names or affiliations.

Use of word processing software

It is important that the file be saved in the native format of the word

processor used. The text should be in single-column format. Keep the

layout of the text as simple as possible. Most formatting codes will be

removed and replaced on processing the article. In particular, do not use

35

the word processor's options to justify text or to hyphenate words.

However, do use bold face, italics, subscripts, superscripts etc. When

preparing tables, if you are using a table grid, use only one grid for each

individual table and not a grid for each row. If no grid is used, use tabs, not

spaces, to align columns. The electronic text should be prepared in a way

very similar to that of conventional manuscripts (see also the Guide to

Publishing with Elsevier: https://www.elsevier.com/guidepublication). Note

that source files of figures, tables and text graphics will be required whether

or not you embed your figures in the text. See also the section on Electronic

artwork.

To avoid unnecessary errors you are strongly advised to use the 'spell-

check' and 'grammar-check' functions of your word processor.

Introduction

The introduction must be presented in a structured format, covering the

following subjects, although not under subheadings: succinct statements of

the issue in question, and the essence of existing knowledge and

understanding pertinent to the issue. In keeping with the house style of

Journal of Dentistry, the final paragraph of the introduction should clearly

state the aims and/or objective of the work being reported. Prospective

authors may find the following form of words to be helpful: "The aim of this

paper is to ..." Where appropriate, a hypothesis (e.g. null or a priori) should

then be stated.

Essential title page information

• Title. Concise and informative. Titles are often used in information-

retrieval systems. Avoid abbreviations and formulae where possible.•

Author names and affiliations. Please clearly indicate the given name(s)

and family name(s) of each author and check that all names are accurately

spelled. Present the authors' affiliation addresses (where the actual work

was done) below the names. Indicate all affiliations with a lower- case

superscript letter immediately after the author's name and in front of the

appropriate address. Provide the full postal address of each affiliation,

including the country name and, if available, the e-mail address of each

author.

• Corresponding author. Clearly indicate who will handle correspondence

at all stages of refereeing and publication, also post-publication. Ensure

that the e-mail address is given and that contact details are kept up

to date by the corresponding author.

• Present/permanent address. If an author has moved since the work

36

described in the article was done, or was visiting at the time, a 'Present

address' (or 'Permanent address') may be indicated as a footnote to that

author's name. The address at which the author actually did the work must

be retained as the main, affiliation address. Superscript Arabic numerals are

used for such footnotes.

The title page should contain the following information:- Title of paper-

Short title- Name(s), job titles and address(es) of author(s) (no academic

degrees necessary) - Name, address, telephone, fax and e-mail of the

corresponding author

- Up to 6 keywordsSpelling: International English.Authors are urged to

write as concisely as possible.

The house style of Journal of Dentistry requires that articles should be

arranged in the following order: Title, Abstract, Introduction, Materials and

Methods, Results, Discussion, Conclusions, Acknowledgements, References,

Tables, Figures. A cover letter should accompany the new manuscript

submission, within which the authors should indicate the significance of the

work being submitted in a statement no more than 100 words. A signed

permission note (details below) must also be included.

Abstract: should not exceed 250 words and should be presented under the

following subheadings: Objectives, Methods; Results; Conclusions (For

Reviews: Objectives; Data; Sources; Study selection; Conclusions). A 50

word 'Clinical Significance' statement should appear at the end of the

abstract advising readers of the clinical importance and relevance of their

work. These subheadings should appear in the text of the abstract. Please

repeat the title of the article at the top of the abstract page.

Introduction: must be presented in a structured format, covering the

following subjects, although not under subheadings: succinct statements of

the issue in question, and the essence of existing knowledge and

understanding pertinent to the issue. In keeping with the house style of

Journal of Dentistry, the final paragraph of the introduction should clearly

state the aims and/or objective of the work being reported. Prospective

authors may find the following form of words to be helpful: "The aim of this

paper is to ..." Where appropriate, a hypothesis (e.g. null or a priori) should

then be stated.

Keywords: up to 6 keywords should be supplied.Abbreviations and

acronyms: terms and names to be referred to in the form of abbreviations

or acronyms must be given in full when first mentioned.

Units: SI units should be used throughout. If non-SI units must be quoted,

37

the SI equivalent must immediately follow in parentheses.

The complete names of individual teeth must be given in the test. In tables

and legends for illustrations individual teeth should be identified using the

FDI two-digit system.

Statistics

Statistical methods should be described with enough detail to enable a

knowledgeable reader with access to the original data to verify the reported

results. When possible, findings should be quantified and appropriate

measures of error or uncertainty (such as confidence intervals) given.

Details about eligibility criteria for subjects, randomization and the number

of observations should be included. The computer software and the

statistical method(s) used should be specified with references to standard

works when possible (with pages specified). See

http://www.icmje.org/manuscript_1prepare.html for more detailed

guidelines.

References: These should appear in the text in numerical order and should

follow a modified form of the Vancouver Reference system (details may be

found at http://www.icmje.org/ index.html#reference. Please note that the

house style of the Journal of Dentistry is different from the standard

Vancouver reference style in that it includes a requirement:

- to refer to the name of the Journal in full - to put the name of the Journal

in Italics - to put the volume number in bold

Examples as follows:

Journal articles

Lynch CD, Frazier KB, McConnell RJ, Blum IR, Wilson NHF. State-of-the-art

techniques in Operative Dentistry: contemporary teaching of posterior

composites in UK and Irish dental schools. British Dental Journal 2010;

209: 129 - 36.

Wilson NHF, Mjör I. The teaching of class I and class II direct composite

restorations in European dental schools. Journal of Dentistry 2000; 28: 15-

21.

Please note that in-press/ accepted articles that are awaiting assignment of

page numbers should be cited including their DOI number (Digital Object

Identifier), for example:

Books

38

Lynch CD. Successful posterior composites. London: Quintessence

Publishing Co., 2008.

Book chapters

Phillips SJ, Whisnant JP. The role of dentine under restorations. In: Laragh

JH, Brenner BM, editors. The science of restorative dentistry. 2nd ed.

Oxford: Elsevier; 2003. p.266-78.

If there are seven or more authors please list the first six and et al.,

otherwise list all authors. Journal titles should be given in full. If websites

are used as references, the full URL should be cited, along with the date on

which it was accessed.

Illustrations: should be submitted electronically using appropriate

commercial software. Prospective authors should follow the relevant

guidelines (available from: http://www.elsevier.com/ artworkinstructions).

In addition, it is noted that while authors sometimes need to manipulate

images for clarity, manipulation for purposes of deception or fraud will be

seen as scientific ethical abuse and will be dealt with accordingly. For

graphical images, journals published by Elsevier apply the following policy:

no specific feature within an image may be enhanced, obscured, moved,

removed, or introduced. Adjustments of brightness, contrast, or color

balance are acceptable if and as long as they do not obscure or eliminate

any information present in the original. Nonlinear adjustments (e.g.

changes to gamma settings) must be disclosed in the figure legend.

Abstract

The Abstract should not exceed 250 words and should be presented under

the following subheadings: Objectives, Methods; Results; Conclusions (For

Reviews: Objectives; Data; Sources; Study selection; Conclusions). A 50

word 'Clinical Significance' statement should appear at the end of the

abstract advising readers of the clinical importance and relevance of their

work. These subheadings should appear in the text of the abstract. Please

repeat the title of the article at the top of the abstract page.

Graphical abstract

Although a graphical abstract is optional, its use is encouraged as it draws

more attention to the online article. The graphical abstract should

summarize the contents of the article in a concise, pictorial form designed

to capture the attention of a wide readership. Graphical abstracts should be

submitted as a separate file in the online submission system. Image size:

Please provide an image with a minimum of 531 × 1328 pixels (h × w) or

39

proportionally more. The image should be readable at a size of 5 × 13 cm

using a regular screen resolution of 96 dpi. Preferred file types: TIFF, EPS,

PDF or MS Office files. See https://www.elsevier.com/graphicalabstracts for

examples.

Authors can make use of Elsevier's Illustration and Enhancement service to

ensure the best presentation of their images and in accordance with all

technical requirements: Illustration Service.

Keywords

Provide a maximum of 6 keywords, using British spelling and avoiding

general and plural terms and multiple concepts (avoid, for example, 'and',

'of'). Be sparing with abbreviations: only abbreviations firmly established in

the field may be eligible. These keywords will be used for indexing

purposes.

Artwork

Image manipulation

Whilst it is accepted that authors sometimes need to manipulate images for

clarity, manipulation for purposes of deception or fraud will be seen as

scientific ethical abuse and will be dealt with accordingly. For graphical

images, this journal is applying the following policy: no specific feature

within an image may be enhanced, obscured, moved, removed, or

introduced. Adjustments of brightness, contrast, or color balance are

acceptable if and as long as they do not obscure or eliminate any

information present in the original. Nonlinear adjustments (e.g. changes to

gamma settings) must be disclosed in the figure legend.

Electronic artworkGeneral points• Make sure you use uniform lettering

and sizing of your original artwork.• Embed the used fonts if the

application provides that option.• Aim to use the following fonts in your

illustrations: Arial, Courier, Times New Roman, Symbol, or use fonts that

look similar.• Number the illustrations according to their sequence in the

text.• Use a logical naming convention for your artwork files.• Provide

captions to illustrations separately.• Size the illustrations close to the

desired dimensions of the published version.• Submit each illustration as a

separate file.A detailed guide on electronic artwork is available on our

website: https://www.elsevier.com/artworkinstructions.You are urged to

visit this site; some excerpts from the detailed information are

given here. FormatsIf your electronic artwork is created in a Microsoft

Office application (Word, PowerPoint, Excel) then please supply 'as is' in the

native document format.Regardless of the application used other than

40

Microsoft Office, when your electronic artwork is finalized, please 'Save as'

or convert the images to one of the following formats (note the resolution

requirements for line drawings, halftones, and line/halftone combinations

given below):EPS (or PDF): Vector drawings, embed all used fonts.TIFF

(or JPEG): Color or grayscale photographs (halftones), keep to a minimum

of 300 dpi.TIFF (or JPEG): Bitmapped (pure black & white pixels) line

drawings, keep to a minimum of 1000 dpi. TIFF (or JPEG): Combinations

bitmapped line/half-tone (color or grayscale), keep to a minimum of 500

dpi.Please do not:• Supply files that are optimized for screen use (e.g.,

GIF, BMP, PICT, WPG); these typically have a low number of pixels and

limited set of colors;• Supply files that are too low in resolution;• Submit

graphics that are disproportionately large for the content.

Color artwork

Please make sure that artwork files are in an acceptable format (TIFF (or

JPEG), EPS (or PDF), or MS Office files) and with the correct resolution. If,

together with your accepted article, you submit usable color figures then

Elsevier will ensure, at no additional charge, that these figures will appear

in color online (e.g., ScienceDirect and other sites) regardless of whether or

not these illustrations are reproduced in color in the printed version. For

color reproduction in print, you will receive information regarding

the costs from Elsevier after receipt of your accepted article. Please

indicate your preference for color: in print or online only. For further

information on the preparation of electronic artwork, please see

https://www.elsevier.com/artworkinstructions.

Illustration services

Elsevier's WebShop (http://webshop.elsevier.com/illustrationservices) offers

Illustration Services to authors preparing to submit a manuscript but

concerned about the quality of the images accompanying their article.

Elsevier's expert illustrators can produce scientific, technical and medical

style images, as well as a full range of charts, tables and graphs. Image

'polishing' is also available, where our illustrators take your image(s) and

improve them to a professional standard. Please visit the website to find out

more.

Figure captions

Ensure that each illustration has a caption. Supply captions separately, not

attached to the figure. A caption should comprise a brief title (not on the

figure itself) and a description of the illustration. Keep text in the

illustrations themselves to a minimum but explain all symbols and

abbreviations used.

41

Tables

Please submit tables as editable text and not as images. Tables can be

placed either next to the relevant text in the article, or on separate page(s)

at the end. Number tables consecutively in accordance with their

appearance in the text and place any table notes below the table body. Be

sparing in the use of tables and ensure that the data presented in them do

not duplicate results described elsewhere in the article. Please avoid using

vertical rules.

References

Citation in text

Please ensure that every reference cited in the text is also present in the

reference list (and vice versa). Any references cited in the abstract must be

given in full. Unpublished results and personal communications are not

recommended in the reference list, but may be mentioned in the text. If

these references are included in the reference list they should follow the

standard reference style of the journal and should include a substitution of

the publication date with either 'Unpublished results' or 'Personal

communication'. Citation of a reference as 'in press' implies that the item

has been accepted for publication.

Reference links

Increased discoverability of research and high quality peer review are

ensured by online links to the sources cited. In order to allow us to create

links to abstracting and indexing services, such as Scopus, CrossRef and

PubMed, please ensure that data provided in the references are correct.

Please note that incorrect surnames, journal/book titles, publication year

and pagination may prevent link creation. When copying references, please

be careful as they may already contain errors. Use of the DOI is

encouraged.

Web references

As a minimum, the full URL should be given and the date when the

reference was last accessed. Any further information, if known (DOI, author

names, dates, reference to a source publication, etc.), should also be given.

Web references can be listed separately (e.g., after the reference list) under

a different heading if desired, or can be included in the reference list.

References in a special issue

Please ensure that the words 'this issue' are added to any references in the

42

list (and any citations in the text) to other articles in the same Special

Issue.

Reference management software

Most Elsevier journals have their reference template available in many of

the most popular reference management software products. These include

all products that support Citation Style Language styles

(http://citationstyles.org), such as Mendeley

(http://www.mendeley.com/features/reference-manager) and Zotero

(https://www.zotero.org/), as well as EndNote

(http://endnote.com/downloads/styles). Using the word processor plug-ins

from these products, authors only need to select the appropriate journal

template when preparing their article, after which citations and

bibliographies will be automatically formatted in the journal's style. If no

template is yet available for this journal, please follow the format of the

sample references and citations as shown in this Guide.

Users of Mendeley Desktop can easily install the reference style for this

journal by clicking the following link:http://open.mendeley.com/use-

citation-style/journal-of-dentistryWhen preparing your manuscript, you will

then be able to select this style using the Mendeley plug- ins for Microsoft

Word or LibreOffice.

Reference styleText: Indicate references by number(s) in square brackets

in line with the text. The actual authors can be referred to, but the

reference number(s) must always be given.Example: '..... as demonstrated

[3,6]. Barnaby and Jones [8] obtained a different result ....'

List: Number the references (numbers in square brackets) in the list in the

order in which they appear in the text.Examples:Reference to a journal

publication:

[1] J. van der Geer, J.A.J. Hanraads, R.A. Lupton, The art of writing a

scientific article, J. Sci. Commun. 163 (2010) 51–59.Reference to a

book:[2] W. Strunk Jr., E.B. White, The Elements of Style, fourth ed.,

Longman, New York, 2000. Reference to a chapter in an edited book:

[3] G.R. Mettam, L.B. Adams, How to prepare an electronic version of your

article, in: B.S. Jones, R.Z. Smith (Eds.), Introduction to the Electronic Age,

E-Publishing Inc., New York, 2009, pp. 281–304. Reference to a

website:[4] Cancer Research UK, Cancer statistics reports for the UK.

http://www.cancerresearchuk.org/

aboutcancer/statistics/cancerstatsreport/, 2003 (accessed 13.03.03).

43

Journal abbreviations source

Journal names should be abbreviated according to the List of Title Word

Abbreviations:

http://www.issn.org/services/online-services/access-to-the-ltwa/.

Video data

Elsevier accepts video material and animation sequences to support and

enhance your scientific research. Authors who have video or animation files

that they wish to submit with their article are strongly encouraged to

include links to these within the body of the article. This can be done in the

same way as a figure or table by referring to the video or animation content

and noting in the body text where it should be placed. All submitted files

should be properly labeled so that they directly relate to the video file's

content. In order to ensure that your video or animation material is directly

usable, please provide the files in one of our recommended file formats with

a preferred maximum size of 150 MB. Video and animation files supplied

will be published online in the electronic version of your article in Elsevier

Web products, including ScienceDirect: http://www.sciencedirect.com.

Please supply 'stills' with your files: you can choose any frame from the

video or animation or make a separate image. These will be used instead of

standard icons and will personalize the link to your video data. For more

detailed instructions please visit our video instruction pages at

https://www.elsevier.com/artworkinstructions. Note: since video and

animation cannot be embedded in the print version of the journal, please

provide text for both the electronic and the print version for the portions of

the article that refer to this content.

Supplementary material

Supplementary material can support and enhance your scientific research.

Supplementary files offer the author additional possibilities to publish

supporting applications, high-resolution images, background datasets,

sound clips and more. Please note that such items are published online

exactly as they are submitted; there is no typesetting involved

(supplementary data supplied as an Excel file or as a PowerPoint slide will

appear as such online). Please submit the material together with the article

and supply a concise and descriptive caption for each file. If you wish to

make any changes to supplementary data during any stage of the process,

then please make sure to provide an updated file, and do not annotate any

corrections on a previous version. Please also make sure to switch off the

'Track Changes' option in any Microsoft Office files as these will appear in

the published supplementary file(s). For more detailed instructions please

44

visit our artwork instruction pages at

https://www.elsevier.com/artworkinstructions.

AudioSlides

The journal encourages authors to create an AudioSlides presentation with

their published article. AudioSlides are brief, webinar-style presentations

that are shown next to the online article on ScienceDirect. This gives

authors the opportunity to summarize their research in their own words and

to help readers understand what the paper is about. More information and

examples are available at https://www.elsevier.com/audioslides. Authors of

this journal will automatically receive an invitation e-mail to create an

AudioSlides presentation after acceptance of their paper.

Submission checklist

The following list will be useful during the final checking of an article prior to

sending it to the journal for review. Please consult this Guide for Authors for

further details of any item.Ensure that the following items are

present:One author has been designated as the corresponding author with

contact details:

• E-mail address

• Full postal address

All necessary files have been uploaded, and contain:

• Keywords

• All figure captions

• All tables (including title, description, footnotes)Further considerations

• Manuscript has been 'spell-checked' and 'grammar-checked'

• References are in the correct format for this journal

• All references mentioned in the Reference list are cited in the text, and

vice versa

• Permission has been obtained for use of copyrighted material from other

sources (including the Internet)Printed version of figures (if applicable) in

color or black-and-white

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