Effect of immune-boosting beverage, energy beverage, hydrogen peroxide superior, polishing methods and fine-grained dental prophylaxis paste on color of CAD-CAM restorative materials

doi:10.21203/rs.3.rs-4612586/v1

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Research Article

Effect of immune-boosting beverage, energy beverage, hydrogen peroxide superior, polishing methods and fine-grained dental prophylaxis paste on color of CAD-CAM restorative materials

https://doi.org/10.21203/rs.3.rs-4612586/v1

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Background The effect of an immune-boosting beverage (SAM) containing Sambucus Nigra, an energy beverage (ENE), an in-office bleaching (BLE) agent with 25% hydrogen peroxide superior, glazing (GLA) or polishing (POL) methods, and professional dental prophylaxis (PDP) on the color of CAD-CAM restorative materials is unknown.

Methods In total 210 specimens were prepared, consisting of CAD-CAM feldspathic (FC), zirconia-reinforced lithium disilicate ceramic (ZLS) and hybrid ceramic (HC). The ceramic specimens were divided according to the polishing methods of glazing (GLA) and mechanical polishing (POL). All materials were divided into two groups: with and without BLE. A 25% hydrogen peroxide superior (HPS) gel was used for BLE. After the baseline (BAS) measurement, the specimens were immersed in 3 different beverages (distilled water (DIS), SAM, ENE). After 28 days, a fine-grained (RDA 7) prophylaxis paste was applied. Statistical analysis of ∆E00 color difference values was performed by 3-way ANOVA and Bonferroni test (α=0.05).

Results The effect of all other actions except material-BLE-beverage on color for BAS-Day 28 was statistically different (p<0.05). The effect of material, material-BLE, beverage on color for Day 28-PDP was statistically different (p<0.05). After 28 days, the lowest color change was found in FC-GLA and HC immersed in DIS (p=0.0001) and the highest in FC-POL immersed in ENE (p=0.0002). PDP was efficient in color recovery in HC immersed to DIS, ENE and SAM (p=0.0010). For FC, HC and ZLS, BLE caused a higher color change (p<0.0001). Regardless of the material, the highest color change for BLE-beverage was found in BLE-treated specimens immersed in ENE (P=0.0496) and the lowest color change was found in non-BLE-treated specimens immersed in SAM (p=0.0074).

Conclusions In materials pre-exposed to 25% HPS, the effect of PDP on color recovery was lower than in unexposed materials. Mechanical polishing produced higher color change in FC compared to glazing, but the values were equal for ZLS. For material/polishing method, HC was the most effective. ENE caused higher color change than DIS and SAM. PDP was more effective than ENE in restoring color to DIS- and SAM-immersed specimens.

Covid-19 pandemic

CAD-CAM hybrid

Zirconia-reinforced lithium disilicate

Feldspathic ceramic

Office bleaching

Dental prophylaxis

Glazing

Hydrogen peroxide

Beverage

Sambucus Nigra

Dental restorations performed in regions where appearance is crucial should keep their physical properties long-term [1]. Restorative materials made by computer-aided design and computer-aided manufacturing (CAD-CAM) are frequently preferred for this purpose today. These types of materials may be glass ceramic, zirconium or resin based [2].

Feldspathic ceramics (FC) have a glassy structure containing a crystalline phase. In lithium disilicate ceramics, the metasilicate phase transforms into stronger disilicate phase by crystallization. Nowadays, zirconia-reinforced lithium disilicate ceramics (ZLS) have been developed [3,4]. One of the new developed materials is hybrid ceramics (HC), which contain dimethacrylate polymers and have a binary network structure [5].

While the smoothness of the surfaces of CAD-CAM ceramic materials can be performed by both glazing (GLA) and mechanical polishing (POL), GLA is not possible in resin-containing ceramics due to the loss of the organic matrix in firing [6,7]. On smoother surfaces, there would be less absorption of beverage-induced pigments to the material surface and consequently less discoloration would occur [8].

During the dental bleaching (BLE) process, when the BLE agent contacts the restoration surface, the existing physical features may change. BLE agents currently contain varying concentrations of carbamide peroxide (CP) or hydrogen peroxide (HP): 30–35% HP is usually used for in-office techniques, while 10–16% CP is commonly used at home [9]. In studies examining the effects of BLE with CP or HP on the restorative material, it was reported that BLE agents would degrade the surface integrity of the material by dissolving in the restorative material [10,11]. Nowadays, new BLE agents with different components have been developed and it is necessary to perform new studies to investigate the performance of these agents. The one of them is an office BLE agent containing 25% HP superior (HPS) [12,13].

Restorations discolored by beverages are polished regularly by clinicians to correct the color change of restorations and to remove dental plaque [14]. Current knowledge about professional dental prophylaxis (PDP), which is one of the methods applied for this purpose, is inadequate [15,16]. In recent years, various PDP pastes have been introduced to the market and there is a need for current research on these pastes with abrasives with low relative dentin abrasiveness (RDA) [17].

Studies examining the effect of beverages on the color of restorative materials have mostly focused on beverages such as tea, coffee, cola and wine [1,5,8,18]. After the Covid-19 pandemic, people's consumption habits have changed and as a result, the consumption of energy beverages has increased [19]. Therefore, it is necessary to investigate the effect of energy beverages on the color of CAD-CAM restorative materials. Another beverage with increasing consumption is black elderberry (Sambucus Nigra). This beverage, which is used as a treatment support in the Covid-19 pandemic, may change the color of dental materials because it contains anthocyanin [20]. There is no study on the effect of beverage with Sambucus Nigra on the color of CAD-CAM ceramic or hybrid ceramic materials. There are several studies [7,15,21–23] examining the effect of polishing methods, BLE or PDP on the color of CAD-CAM restorative materials, but no study has examined these variables together. For these reasons, the aim of this study was to evaluate the effect of energy beverage and immune-boosting beverage with Sambucus Nigra, in-office BLE with HPS and PDP on color of CAD-CAM FC, ZLS and HC. The null hypotheses were that (i) material/polishing method, BLE, beverages would have no effect on the color of tested materials and (ii) PDP would have no effect on the color recovery of discolored materials.

The materials used and the study design are displayed in Table 1 and in Fig. 1, respectively. Using a diamond saw cutting machine (Micracut 201, Metkon, Turkey), 2 mm thick rectangular shaped specimens were obtained from FC, ZLS and HC blocks (N = 210). A total of 84 FC specimens were equally divided into two groups according to the polishing method (GLA or POL). A total of 84 ZLS specimens were also divided into two groups in the same way. These groups were further divided into two more groups of equal numbers, with and without prior BLE. A total of 42 HC specimens were prepared and divided into two groups of equal numbers, one with and without prior BLE.

Table 1

Materials tested in the study
Material	Code	Type	Composition	Manufacturer
Cerec C	FC	Feldspathic glass matrix ceramic	56–64% SiO₂, 20–23% Al₂O₃, 6–9% Na₂O, 6–8% K₂O	Sirona Dental, Beinsheim, Germany
Vita Suprinity	ZLS	Zirconia-reinforced lithium silicate ceramic	56%-64% SiO₂, 1%-4% Al₂O₃, 15%-22% Li₂O, 8%-12% ZrO₂, 1%-4% K₂O (∼0.5 µm)	VITA Zahnfabrik, Bad Sackingen,Germany
Vita Enamic	HC	Polymer-infiltrated ceramic network	86% inorganic (58–63% SiO₂, 20–23% Al₂O₃, 6–11% Na₂O, 4–6% K₂O, 0.5–2% B₂O₃), 11–14% organic (methacrylate polymer, UDMA, TEGDMA)	VITA Zahnfabrik, Bad Sackingen,Germany
Cavex Bite&White In-Office	BLE	Office bleaching gel	25% hydrogen peroxide superior, thickeners, pH regulators, reversible poloxamer, glycerine	Cavex Holland BV, Haarlem, Netherlands
Red Bull	ENE	Energizing beverage	Glucose, citric acid, carbodioxide, sodium bicarbonate, taurine, caffeine, plain caramel, riboflavin, vitamins B3, B5, B6, B12	Red Bull GmbH, Salzburg, Austria
Sambucol Plus Effervescent Tablet	SAM	Immune- boosting beverage with black elderberry	Black elderberry extract, citric acid, sodium hydrogen carbonate, L-ascorbic acid, zinc	Pharmacare Europe, UK
Proxyt Fine	PDP	Fine-grain professional prophylaxis paste	Silica (RDA 7 size particles), water, glycerine, sorbite, xylit, anorganic fillers, natriumfluoride, flavor and pigments	Ivoclar Vivadent, Schaan, Liechtenstein

FC-GLA and ZLS-GLA specimens were glazed using appropriate glaze powder and liquid (Vita Akzent Plus, VITA Zahnfabrik, Germany) in accordance with the manufacturer's recommendations. The HC specimens were only mechanically polished due to the microstructural limitation of containing resin content [24]. FC-POL, ZLS-POL and HC specimens were polished with a ceramic polishing set (Diasynt Plus HP, EVE Ernst Vetter, Germany). The specimens were controlled for thickness with a digital micrometer (Absolute Digimatic Caliper, Mitutoyo, Japan) and kept in an incubator (UM 400, Memmert, Germany) at 37°C for 24 hours.

Baseline color measurements (BAS) were taken in all specimens, and then a 25% HPS agent (Cavex Bite&White In-Office, Cavex Holland BV, Netherlands) was applied in the FC-GLA-BLE, FC-POL-BLE, ZLS-GLA-BLE, ZLS-POL-BLE and HC-BLE groups. For this purpose, a gel with a thickness of approximately 1 mm was applied to the specimen surface with an applicator and waited for 60 min. After BLE, the surfaces were washed, dried and color measurements were taken [12,13].

Each specimen was kept in its own 10 ml plastic container throughout the process. All specimens were immersed in the beverages. According to the manufacturers, the average consumption time for beverages such as tea or coffee are 15 minutes. In this case, 24 hours of storage in the beverage is roughly 1 month of consumption. To simulate a period of 2.5 years, a 28-day immersion period was applied, and color measurements were taken on the 1st, 14th and 28th days [25].

After immersion process, the specimens were washed, dried and then started to PDP. For this purpose, a dental angldruva (CrossPro, Anthogyr SA, France) operating at 16:1 speed was used and the rotational speed was set to 2500 rpm. A fine-particle prophylaxis paste (Proxyt Fine, Ivoclar Vivadent, Germany) was used as a paste. For each specimen, 0.05 mL of paste was applied to the specimen surface and POL was performed. PDP is performed 4 times a year and takes approximately 20 s to remove one side of a tooth. Therefore, PDP was performed for 1.5 min in each specimen to simulate a 1-year prophylaxis [14,15]. After PDP, color measurements were taken.

All color measurements were done in a custom made color booth to standardize the environmental conditions during measurements and to prevent the ambient light from causing errors in color measurements [26]. The inside of the booth prepared in dimensions of 30 cm × 130 cm × 70 cm was covered with neutral gray background cardboard, as suggested in previous studies [27, 28]. The booth had a daylight-imitating lamp (Philips Master TL-D 90 De Luxe 18W/965 1SL 65000K, Eindhoven, Netherlands) and was in a dark room. Color measurements were performed on the center of the specimens with a spectrophotometer (Vita Easyshade V, VITA Zahnfabrik, Germany). The spectrophotometer gives the three-dimensional color values of Commission Internationale de l'Eclairage (CIE) L* (lightness), a* (red-green) and b* (blue-yellow) [29, 30]. The magnitude of the color change was calculated using the following formula [31–33]:

ΔL', ΔC' and ΔH' are considered to be the differences in lightness, chroma and hue between color measurements. K_L, K_C and K_H are parametric factors for the effect of monitoring and illumination conditions, adjusted to 1 in this study. R_T is the function of the interaction of hue and chroma differences in the blue zone. S_L, S_C and S_H are weighting functions for color difference adjustment, considering the position change of L*, a* and b* coordinates [34].

Statistical analysis was performed with a statistical software package (Statistical Analysis Software SAS 9.4, SAS Institute, USA). For the analysis of discoloration values, 3-way ANOVA test were applied. Bonferroni corrected post-hoc test were used if a significant mean difference was found in any of these two independent variables. Cohen d test, one of the commonly used post-power tests [35], was applied to determine the effect size of the analyses (α = 0.05).

Results of 3-way ANOVA for color change values are shown in Table 2. The effect of material, material-beverage on color for BAS-Day 1 was statistically different (p < 0.05). The effect of material, BLE, material-BLE, BLE-beverage, material-BLE-beverage on color for BAS-Day 14 was statistically different (p < 0.05). The effect of all other actions except material-BLE-beverage on color for BAS-Day 28 was statistically different (p < 0.05). The effect of material, material-BLE, material-beverage, BLE-beverage, material-BLE-beverage on color for BAS-PDP was statistically different (p < 0.05). The effect of material, material-BLE on color for Day 1-Day 14 was statistically different (p < 0.05). The effect of all other actions except beverage on color for Day 14-Day 28 was statistically different (p < 0.05). The effect of material, material-BLE, beverage on color for Day 28-PDP was statistically different (p < 0.05).

Table 2

Results of 3-way ANOVA
	Source	SS	MS	FValue	ProbF	Cohend
BAS-Day 1	Material	38.205	9.551	6.932	0.000	0.785
	BLE	0.131	0.131	0.095	0.758	0.046
	Material-BLE	70.639	17.660	12.818	0.000	1.067
	Beverage	0.976	0.488	0.354	0.702	0.125
	Material-Beverage	21.374	2.672	1.939	0.057	0.587
	BLE-Beverage	0.964	0.482	0.350	0.705	0.125
	Material-BLE-Beverage	15.137	1.892	1.373	0.211	0.494
BAS-Day 14	Material	20.412	5.103	6.496	0.000	0.760
	BLE	10.654	10.654	13.564	0.000	0.549
	Material-BLE	22.412	5.603	7.133	0.000	0.796
	Beverage	0.690	0.345	0.439	0.645	0.140
	Material-Beverage	12.375	1.547	1.969	0.053	0.592
	BLE-Beverage	5.747	2.874	3.658	0.028	0.403
	Material-BLE-Beverage	27.825	3.478	4.428	0.000	0.887
BAS-Day 28	Material	148.497	37.124	17.151	0.000	1.235
	BLE	21.484	21.484	9.925	0.002	0.470
	Material-BLE	109.624	27.406	12.661	0.000	1.061
	Beverage	14.339	7.170	3.312	0.039	0.384
	Material-Beverage	87.951	10.994	5.079	0.000	0.950
	BLE-Beverage	19.202	9.601	4.436	0.013	0.444
	Material-BLE-Beverage	17.752	2.219	1.025	0.419	0.427
BAS-PDP	Material	153.277	38.319	17.979	0.000	1.264
	BLE	0.150	0.150	0.070	0.791	0.040
	Material-BLE	85.815	21.454	10.066	0.000	0.946
	Beverage	7.209	3.604	1.691	0.187	0.274
	Material-Beverage	39.091	4.886	2.293	0.023	0.638
	BLE-Beverage	14.206	7.103	3.333	0.038	0.385
	Material-BLE-Beverage	38.539	4.817	2.260	0.025	0.634
Day 1-Day 14	Material	74.935	18.734	11.954	0.000	1.031
	BLE	2.058	2.058	1.313	0.253	0.171
	Material-BLE	30.724	7.681	4.901	0.001	0.660
	Beverage	0.231	0.116	0.074	0.929	0.057
	Material-Beverage	10.206	1.276	0.814	0.591	0.380
	BLE-Beverage	1.016	0.508	0.324	0.724	0.120
	Material-BLE-Beverage	11.795	1.474	0.941	0.484	0.409
Day 14-Day 28	Material	187.317	46.829	19.849	0.000	1.328
	BLE	46.353	46.353	19.647	0.000	0.661
	Material-BLE	94.787	23.697	10.044	0.000	0.945
	Beverage	10.937	5.468	2.318	0.101	0.321
	Material-Beverage	44.933	5.617	2.381	0.018	0.651
	BLE-Beverage	44.410	22.205	9.412	0.000	0.647
	Material-BLE-Beverage	39.723	4.965	2.105	0.038	0.612
Day 28-PDP	Material	96.620	24.155	9.486	0.000	0.918
	BLE	0.184	0.184	0.072	0.789	0.040
	Material-BLE	51.598	12.899	5.066	0.001	0.671
	Beverage	20.991	10.496	4.122	0.018	0.428
	Material-Beverage	23.076	2.885	1.133	0.343	0.449
	BLE-Beverage	0.271	0.135	0.053	0.948	0.049
	Material-BLE-Beverage	10.073	1.259	0.494	0.859	0.296

The results of the Bonferroni test for beverage-material are in Table 3. For BAS-Day 1, the lowest color change was in the HC immersed in DIS and the highest color change was in ZLS-GLA immersed in DIS (∆E₀₀ = 2.6, p = 0.0001). For BAS-Day 14, the lowest color change was in HC immersed in SAM (∆E₀₀ = 0.9, p = 0.0015) and the highest color change was in ZLS-GLA immersed in SAM (∆E₀₀ = 2.3, p = 0.0015). For BAS-Day 28, the lowest color change was in HC immersed in DIS (∆E₀₀ = 1.3, p = 0.0001) and the highest color change was in FC-POL immersed in ENE (∆E₀₀ = 5.4, p = 0.0002). For BAS-PDP, the lowest color change was in ZLS-POL immersed in DIS (∆E₀₀ = 1.2, p = 0.0001) and the highest color change was in HC immersed in ENE (∆E₀₀ = 4.5, p = 0.0013). For Day 28-PDP, the lowest color change was in ZLS-POL immersed in DIS (∆E₀₀ = 1.3, p = 0.0001) and the highest color change was in FC-POL immersed in ENE (∆E₀₀ = 4.2, p = 0.0101).

Table 3

Bonferroni test results of beverage-material
		ENE (n = 70)	DIS (n = 70)	SAM (n = 70)	P¹-value
BAS-Day 1	FC-GLA	1.8 (1.54)	2.4 (2.13)a	1.3 (0.61)	0.1943
	FC-POL	1.6 (1.21)	1.1 (0.44)^b	1.9 (0.88)	0.0634
	ZLS-GLA	2.3 (1.31)	2.6 (1.40)^a	2.2 (1.84)	0.7868
	ZLS-POL	1.1 (0.42)	0.9 (0.70)^b	1.5 (2.24)	0.5283
	HC	1.3 (1.06)	0.7 (0.82)^b	1.6 (1.22)	0.0887
p-value		0.1123	0.0001	0.5378
BAS-Day 14	FC-GLA	1.9 (1.39)^a	1.2 (1.16)	1.1 (0.48)^c	0.1093
	FC-POL	1.1 (0.63)^b	1.5 (1.54)	1.6 (1.12)^b	0.5137
	ZLS-GLA	1.9 (0.80)^a	1.9 (1.54)	2.3 (1.22)^a	0.5789
	ZLS-POL	1.0 (0.64)^b	1.3 (0.78)	0.9 (0.46)^c	0.1654
	HC	1.4 (1.06)^b	1.0 (0.79)	1.5 (0.98)^b	0.2579
p-value		0.0316	0.3935	0.0015
BAS-Day 28	FC-GLA	2.6 (1.35)^b,A	1.5 (1.01)^c,B	2.6 (1.23)^A	0.0271
	FC-POL	5.4 (4.27)^A,a	4.8 (1.20)^a,A	2.4 (1.95)^B	0.0177
	ZLS-GLA	1.7 (1.07)^c	2.2 (1.55)^b	2.7 (1.09)	0.1299
	ZLS-POL	2.1 (1.12)^b	2.0 (1.35)^b	2.1 (2.06)	0.9810
	HC	2.7 (1.08)^b,A	1.3 (0.81)^c,B	1.9 (1.07)^B	0.0028
p-value		0.0002	0.0001	0.6659
BAS-PDP	FC-GLA	1.9 (0.97)^b	1.8 (1.50)^c	2.0 (0.33)^c	0.8502
	FC-POL	4.4 (5.03)^a	3.5 (0.41)^a	2.7 (1.35)^b	0.3205
	ZLS-GLA	2.2 (0.65)^b	2.9 (1.77)^b	2.7 (0.98)^b	0.2888
	ZLS-POL	1.5 (0.72)^C,b	1.2 (0.74)^c,B	2.0 (0.92)^c,A	0.0716
	HC	4.5 (1.24)^a,A	2.9 (0.95)^b,C	3.7 (0.82)^a,B	0.0010
p-value		0.0013	0.0001	< 0.0001
Day 1-Day 14	FC-GLA	1.5 (2.10)^b	1.5 (1.92)^b	0.5 (0.46)^c	0.2184
	FC-POL	1.1 (0.39)^b	1.0 (1.30)^b	1.2 (0.44)^b	0.9199
	ZLS-GLA	2.2 (1.34)^a	2.1 (2.15)^a	2.4 (1.77)^a	0.9292
	ZLS-POL	0.9 (0.48)^c	0.9 (0.53)^b	1.3 (2.15)^b	0.7320
	HC	0.4 (0.24)^c	0.4 (0.16)^c	0.3 (0.28)^c	0.9302
p-value		0.0017	0.0287	0.0008
Day 14-Day 28	FC-GLA	2.8 (1.85)^b,A	1.6 (0.42)^c,B	1.9 (0.89)^b,B	0.0266
	FC-POL	4.9 (4.63)^a	4.1 (1.84)^a	2.9 (2.33)^a	0.2487
	ZLS-GLA	2.2 (1.26)^c	2.2 (2.16)^b	3.2 (1.19)^a	0.1272
	ZLS-POL	2.1 (1.20)^c	2.4 (1.51)^b	2.0 (1.75)^b	0.7405
	HC	1.4 (0.38)^d,A	0.8 (0.75)^c,B	0.9 (0.44)^c,B	0.0192
p-value		0.0027	0.0001	0.0006
Day 28-PDP	FC-GLA	1.7 (0.84)^b,B	1.5 (0.99)^c,B	2.6 (0.66)^A	0.0065
	FC-POL	4.2 (4.53)^a	2.4 (1.01)^b	3.0 (1.61)	0.2431
	ZLS-GLA	1.8 (0.81)^b	1.6 (0.60)^c	2.0 (1.10)	0.4761
	ZLS-POL	1.9 (1.53)^b	1.3 (1.25)^c	2.5 (1.94)	0.1670
	HC	3.6 (1.29)^a	3.1 (1.17)^a	3.3 (0.95)	0.5254
p-value		0.0101	0.0001	0.1085
¹ ANOVA F-test p-value: Same superscript lowercase letters represent no significant difference in columns and same superscript capital letters indicate no significant difference in rows.

Bonferroni test results of BLE-material are shown in Table 4. For BAS-Day 1, the lowest color change was in non-BLE HC (∆E₀₀ = 0.5, p < 0.0001) and the highest color change was in non-BLE ZLS-GLA (∆E₀₀ = 2.8, p < 0.0001). For BAS-Day 14, the lowest color change was in HC without BLE (∆E₀₀ = 0.7, p < 0.0001) and the highest color change was in ZLS-GLA with BLE (∆E₀₀ = 2.3, p = 0.0011). For BAS-Day 28, the lowest color change was in BLE-treated ZLS-GLA (∆E₀₀ = 1.2, p < 0.0001) and the highest color change was in BLE-treated FC-POL (∆E₀₀ = 5.4, p < 0.0001). For BAS-PDP, the lowest color change was in non-BLE ZLS-POL (∆E₀₀ = 1.5, p < 0.0001) and the highest color change was in BLE FC-POL (∆E₀₀ = 4.6, p < 0.0001). For Day 28-PDP, the lowest color change was in BLE-treated ZLS-POL (∆E₀₀ = 1.5, p = 0.0006) and the highest color change was in non-BLE-treated HC (∆E₀₀ = 4.6, p < 0.0001).

Table 4

Bonferroni test results of BLE-material
		No (n = 105)	Yes (n = 105)	p-value
BAS-Day 1	FC-GLA	1.2 (1.19)^b	2.4 (1.73)^a	0.0122
	FC-POL	2.2 (0.66)^a	0.8 (0.62)^c	< 0.0001
	ZLS-GLA	2.8 (1.99)^a	1.8 (0.35)^b	0.0246
	ZLS-POL	1.4 (1.84)^b	0.9 (0.54)^c	0.2412
	HC	0.5 (0.51)^c	2.0 (1.03)^a	< 0.0001
p-value		< 0.0001	< 0.0001
BAS-Day 14	FC-GLA	0.9 (0.40)^b	1.9 (1.38)^a	0.0040
	FC-POL	1.5 (0.35)^a	1.4 (1.61)^b	0.7361
	ZLS-GLA	1.8 (1.25)^a	2.3 (1.14)^a	0.1634
	ZLS-POL	1.3 (0.77)^a	0.9 (0.44)^b	0.0306
	HC	0.7 (0.44)^b	2.0 (0.88)^a	< 0.0001
p-value		< 0.0001	0.0011
BAS-Day 28	FC-GLA	1.8 (0.75)^b	2.7 (1.56)^b	0.0239
	FC-POL	3.0 (1.35)^a	5.4 (3.74)^a	0.0094
	ZLS-GLA	3.2 (0.77)^a	1.2 (0.83)^c	< 0.0001
	ZLS-POL	1.5 (1.29)^b	2.7 (1.53)^b	0.0091
	HC	1.6 (0.89)^b	2.3 (1.23)^b	0.0273
p-value		< 0.0001	< 0.0001
BAS-PDP	FC-GLA	1.8 (0.77)^d	2.0 (1.24)^c	0.4350
	FC-POL	2.5 (0.96)^c	4.6 (3.96)^a	0.0263
	ZLS-GLA	3.4 (1.18)^b	1.7 (0.55)^c	< .0001
	ZLS-POL	1.5 (0.99)^d	1.7 (0.66)^c	0.5469
	HC	4.2 (1.15)^a	3.2 (0.98)^b	0.0021
p-value		< 0.0001	< 0.0001
Day 1-Day 14	FC-GLA	0.7 (1.30)^c	1.7 (1.90)^a	0.0503
	FC-POL	1.1 (0.43)^b	1.1 (1.07)^b	0.9027
	ZLS-GLA	2.9 (2.17)^a	1.6 (0.83)^a	0.0159
	ZLS-POL	1.4 (1.75)^b	0.7 (0.29)^b	0.0875
	HC	0.4 (0.24)^c	0.3 (0.22)^c	0.2482
p-value		< 0.0001	< 0.0001
Day 14-Day 28	FC-GLA	1.7 (0.64)^b	2.5 (1.65)^b	0.0519
	FC-POL	2.2 (0.95)^a	5.7 (3.69)^a	0.0001
	ZLS-GLA	2.4 (1.82)^a	2.7 (1.48)^b	0.5397
	ZLS-POL	2.0 (1.66)^a	2.3 (1.29)^b	0.5344
	HC	1.1 (0.65)^c	0.9 (0.52)^c	0.2117
p-value		0.0196	< 0.0001
Day 28-PDP	FC-GLA	1.8 (0.84)^b	2.1 (1.02)^b	0.4112
	FC-POL	2.4 (1.21)^b	4.0 (3.74)^a	0.0676
	ZLS-GLA	1.9 (1.00)^b	1.7 (0.71)^c	0.5324
	ZLS-POL	2.2 (1.67)^b	1.6 (1.57)^c	0.2270
	HC	4.0 (0.90)^a	2.7 (0.93)^b	< 0.0001
p-value		< 0.0001	0.0006

The results of the Bonferroni test of BLE- beverage are in Table 5. The values between specimens with and without BLE immersed in ENE for BAS-Day 14 (p = 0.0149), in ENE or SAM for BAS-Day 28 (p = 0.0496, p = 0074, respectively), and in ENE or SAM for Day 14-Day 28 (p = 0.0039, p = 0.0002, respectively) were statistically different.

Table 5

Bonferroni test results of BLE-beverage
		No (n = 105)	Yes (n = 105)	p-value
BAS-Day 1	ENE	1.6 (1.24)	1.6 (1.18)	0.9579
	DIS	1.5 (1.54)	1.6 (1.37)	0.8333
	SAM	1.8 (1.91)	1.6 (0.87)	0.5032
p-value		0.7041	0.9380
BAS-Day 14	ENE	1.2 (0.57)	1.8 (1.24)	0.0149
	DIS	1.4 (1.18)	1.4 (1.27)	0.9934
	SAM	1.1 (0.52)	1.9 (1.22)	0.0009
p-value		0.3879	0.1915
BAS-Day 28	ENE	2.3 (0.96)	3.5 (3.31)	0.0496
	DIS	2.4 (1.53)	2.2 (1.92)	0.6186
	SAM	1.9 (1.20)	2.8 (1.67)	0.0074
p-value		0.1299	0.1033
BAS-PDP	ENE	2.6 (1.56)	3.2 (3.43)	0.2995
	DIS	2.7 (1.55)	2.2 (1.23)	0.1061
	SAM	2.7 (1.18)	2.5 (1.05)	0.3030
p-value		0.8541	0.1193
Day 1-Day 14	ENE	1.2 (1.09)	1.2 (1.45)	0.9864
	DIS	1.3 (1.80)	1.1 (1.18)	0.4764
	SAM	1.3 (1.88)	1.0 (0.77)	0.3426
p-value		0.9628	0.6816
Day 14-Day 28	ENE	1.8 (1.05)	3.6 (3.32)	0.0039
	DIS	2.4 (1.69)	2.0 (1.92)	0.4277
	SAM	1.5 (0.86)	2.9 (1.96)	0.0002
p-value		0.0101	0.0427
Day 28-PDP	ENE	2.6 (1.60)	2.7 (3.09)	0.9696
	DIS	2.1 (1.33)	1.9 (1.06)	0.5992
	SAM	2.7 (1.17)	2.7 (1.56)	0.8857
p-value		0.1131	0.2363

Bonferroni test results for material, beverage and BLE are in Table 6. For BAS-Day 1, the ranking of material color change was ZLS-GLA > FC-GLA > FC-POL > ZLS-POL > HC (p = 0.0003). The ranking of material color change for BAS-Day 14 was ZLS-GLA > FC-POL > FC-GLA > FC-GLA > HC > ZLS-POL (p = 0.0011). For BAS-Day 28, the ranking of material color change was FC-POL > FC-GLA = ZLS-GLA > ZLS-POL > HC (p < 0.0001). The ranking of material color change for BAS-PDP was HC > FC-POL > ZLS-GLA > FC-GLA > ZLS-POL (p < 0.0001). The ranking of color change for Day 28-PDP material was HC > FC-POL > ZLS-POL > FC-GLA > ZLS-GLA (p < 0.0001). The ranking of color change for Day 28-PDP beverage was ENE > SAM > DIS (p = 0.0355). For BAS-Day 14, BAS-Day 28 and Day 14-Day 28, the values in BLE-treated specimens were higher than those in non-BLE-treated specimens (p = 0.0022, p = 0.0181, p = 0.0009, respectively).

Table 6

Bonferroni test results for material, beverage and BLE
	FC-GLA (n = 42)	FC-POL (n = 42)	ZLS-GLA (n = 42)	ZLS-POL (n = 42)	HC (n = 42)	p-Value
BAS-Day 1	1.8 (1.59)^B	1.5 (0.94)^B	2.3 (1.51)^A	1.2 (1.36)^C	1.2 (1.09)^C	0.0003
BAS-Day 14	1.4 (1.12)^B	1.4 (1.15)^B	2.0 (1.21)^A	1.1 (0.66)^C	1.3 (0.96)^B	0.0011
BAS-Day 28	2.2 (1.29)^B	4.2 (3.03)^A	2.2 (1.29)^B	2.1 (1.52)^B	2.0 (1.13)^B	< 0.0001
BAS-PDP	1.9 (1.03)^C	3.5 (3.03)^A	2.6 (1.23)^B	1.6 (0.83)^C	3.7 (1.19)^A	< 0.0001
Day 1-Day 14	1.2 (1.69)^B	1.1 (0.81)^B	2.2 (1.74)^A	1.0 (1.29)^B	0.4 (0.23)^C	< 0.0001
Day 14-Day 28	2.1 (1.29)^B	4.0 (3.21)^A	2.5 (1.64)^B	2.2 (1.48)^B	1.0 (0.59)^C	< 0.0001
Day 28-PDP	1.9 (0.93)^B	3.2 (2.87)^A	1.8 (0.86)^B	1.9 (1.63)^B	3.3 (1.14)^A	< 0.0001
			ENE (n = 70)	DIS (n = 70)	SAM (n = 70)	p-value
BAS-Day 1			1.6 (1.20)	1.5 (1.45)	1.7 (1.48)	0.7742
BAS-Day 14			1.5 (1.00)	1.4 (1.21)	1.5 (1.01)	0.7438
BAS-Day 28			2.9 (2.49)	2.3 (1.72)	2.3 (1.52)	0.1569
BAS-PDP			2.9 (2.66)	2.5 (1.42)	2.6 (1.12)	0.3539
Day 1-Day 14			1.2 (1.27)	1.2 (1.51)	1.1 (1.44)	0.9437
Day 14-Day 28			2.7 (2.60)	2.2 (1.81)	2.2 (1.66)	0.2794
Day 28-PDP			2.7 (2.44)^A	2.0 (1.20)^B	2.7 (1.37)^A	0.0355
				No (n = 105)	Yes (n = 105)	p-value
BAS-Day 1				1.6 (1.57)	1.6 (1.15)	0.7934
BAS-Day 14				1.2 (0.81)	1.7 (1.25)	0.0022
BAS-Day 28				2.2 (1.27)	2.9 (2.44)	0.0181
BAS-PDP				2.7 (1.43)	2.6 (2.21)	0.8354
Day 1-Day 14				1.3 (1.62)	1.1 (1.16)	0.3087
Day 14-Day 28				1.9 (1.30)	2.8 (2.54)	0.0009
Day 28-PDP				2.5 (1.40)	2.4 (2.10)	0.8103

On BAS-Day 1, ZLS-GLA (∆E₀₀ = 2.3) had the highest color change and HC (∆E₀₀ = 1.2) had the lowest (P = 0.0003). At BAS-Day 14, ZLS-GLA (∆E₀₀ = 2.3) had the highest color change and ZLS-POL (∆E00 = 1.2) had the lowest (P = 0.0011). At BAS-Day 28, FC-POL (∆E₀₀ = 4.2) had the highest color change and HC (∆E₀₀ = 2.0) had the lowest (P < 0.0001). At Day 1-Day 14, ZLS-GLA (∆E₀₀ = 2.2) had the highest color change and HC (∆E₀₀ = 0.4) had the lowest (P = 0.0001). At Day 14-Day 28, FC-POL had the highest color change (∆E₀₀ = 4.0) and HC had the lowest (∆E₀₀ = 1.0) (P < 0.0001). At Day 28-PDP, HC (∆E₀₀ = 3.3) had the highest color change and ZLS-GLA (∆E₀₀ = 1.8) had the lowest (P < 0.0001). At BAS-Day 28, beverage color change tended to be highest in ENE (∆E₀₀ = 2.9) and lowest in DIS (∆E₀₀ = 2.3) (P < 0.05). At Day 28-PDP, the highest color change for the beverage was in ENE (∆E₀₀ = 2.7) and the lowest in DIS (∆E₀₀ = 2.0) (P = 0.0355). At BAS-Day 14, regardless of material and beverage, when BLE was analyzed, the color change in BLE-treated (∆E₀₀ = 1.7) specimens was higher than in untreated (∆E₀₀ = 1.2) specimens (P = 0.0022). At BAS-Day 28, regardless of material and beverage, when BLE was analyzed, the color change in BLE-treated (∆E₀₀ = 2.9) specimens was higher than in untreated (∆E₀₀ = 2.2) specimens (P = 0.0181). At Day 14-Day 28, regardless of material and beverage, when BLE was analyzed, the color change in the BLE treated (∆E₀₀ = 2.8) was higher than that in untreated (∆E₀₀ = 1.9) specimens (P = 0.0009).

In this study, two hypotheses were rejected, because material/polishing method, BLE, beverages and PDP led to discoloration of the tested materials. The ∆E₀₀ color difference formula is reported to be superior to the previously used formula (∆E_ab) in terms of perceptibility and acceptability of color difference [36]. This formula, developed by the CIE in 2013, is considered the standard for color difference detection [37]. The ∆E_ab formula basically measures the distance between two points in color space, whereas the ∆E₀₀ formula includes the luminance effect by adding S_L. Therefore, the ∆E₀₀ color difference formula was chosen for this study. In previous studies testing CAD-CAM FC [31], ZLS [32] and HC [33], 0.8/1.8 was found to be appropriate for PT/AT values; therefore, 0.8/1.8 was chosen for PT/AT in this study.

A limitation of this study is the possibility that spectrophotometers may introduce edge loss error [38]. Despite this possibility, contact spectrophotometers are widely used to detect color differences in translucent materials [39]. Previous studies had shown that the Vita Easyhade spectrophotometer could be used for teeth [40], polymethylmethacrylates [41], resin composites [42] and ceramics [15]. Klotz et al. [43] reported that the Vita Easyshade device gave reliable results, even to the extent that it was not affected by environmental light. Dozic et al. [44] stated that Vita Easyshade can make reliable measurements compared with some colorimeters and digital cameras and explained that these three different types of devices can be tested in in vitro studies. Igiel et al. [45] stated that given their accuracy (from 66.8–92.6%) and precision (from 87.4–99.0%), it is an excellent example among color determination methods. Therefore, the Vita Easyshade V device was used in this study. A custom made color booth was prepared to ensure standardization and to prevent the ambient light from causing errors [26].

According to the results, the color change exceeded the AT after 28 days in all specimens, regardless of the beverage in which they were immersed, except for FC-GLA and HC specimens immersed in DIS. Between day 1 and day 14, AT was exceeded in all other specimens, except for ZLS-GLA immersed in DIS, ENE or SAM. From day 14 to day 28, AT was exceeded only in FC-GLA immersed in DIS and not in HC immersed in DIS, ENE or SAM. When the color change values obtained from BAS to day 1, BAS to day 14 or BAS to day 28 were examined, no specimens, regardless of the beverage in which they were immersed, had a color change lower than PT.

In this study, a new HP formula (25% HPS) was used for in-office BLE. In this study, BLE was found to be influenced in color change of restorative materials, which was consistent with previous studies [12, 46–49]. In this study, CAD-CAM HC was more influenced by BLE than ceramics. Yılmaz and Gul [10] reported that materials containing resin composites can be influenced by external factors due to the monomer and particle structure of the organic matrix. Conventional in-office BLE gels mostly contain 30–35% HP [10, 11]. It has been reported by the manufacturer that 25% HPS has a different content than conventional in-office BLE gels and therefore is more effective [13]. It was necessary to investigate this claim. In previous studies [12, 46] the 6% formulation of HPS used for at-home BLE was tested and the magnitude of the effect was found increased with time. In this study, 25% HPS produced a similarly noticeable effect on the materials tested. According to the results, at the end of 28 days, the color change did not exceed AT in FC-GLA, ZLS-POL and HC specimens without BLE, but exceeded it in specimens with BLE (p = 0.0239, p = 0.0091, p = 0.0273, respectively). These results were possibly due to the amount of content and concentration. In contrast to conventional BLE gels, HPS contains CP and vinyl pyrrolidone peroxide in combination, as well as heat-reversible poloxamer to adjust the viscosity. When the gel comes into contact with the tooth surface, an exothermic reaction cycle occurs, resulting in an increase in the magnitude of the effect.

When the BLE agent contacts the surface of a ceramic material for a long time, it may cause surface deterioration as in resin composites [10, 11, 22]. Free radicals such as H⁺ and H₃O⁺ produced by alkali ions infiltrate into the material matrix and cause dissolution of ceramic glass networks, disintegration of SiO₂ and K₂O₂ components, abrasion of the surface, destruction of chromogens and formation of a less light-reflecting surface [22, 50]. The quality of surface polishability reduces the magnitude of exposure to external factors [49]. Alshali et al. [48] reported that the polishability quality may change depending on the material structure. In this study, when the results of BLE treated ceramic specimens after 28 days were analysed, it was found that mechanically polished FC was more influenced than glazed FC, mechanically polished ZLS was more influenced than glazed FC and ceramics were more influenced than hybrid ceramics (p < 0.0001).

Previous studies [49, 51] had reported that the application time is significant in the effect of BLE on ceramics. Similar to this study, the number of studies in which glazed and mechanically polished ceramics were examined together is insufficient, and studies [21, 23, 47, 52] found that glazed surfaces were less affected than mechanically polished surfaces in parallel with this study. The researchers reported that the magnitude of the effect of BLE is related to the application time.

The different structural properties of the materials may influence the magnitude of BLE damage. In previous studies [53–55], researchers have reported that the crystal phase structure, shape, size, and material content of the materials are influential in the external exposure of ceramic surfaces, but it is difficult to determine which is the primary factor. Further studies on this subject are necessary. In this study, at the end of 28 days, the magnitude of the effect of BLE was FC-POL > FC-GLA = ZLS-POL > ZLS-GLA > HC, respectively (p < 0.0001).

FCs have a silicate-based microstructure with 4 µm grains, while ZLSs have a glassy, lithium disilicate-containing microstructure in which needle-shaped particles coexist with zirconia particles (56–58). Ramos et al. [58] reported that the pores of FCs are well coated by glazing, so they are resistant to external factors. Similarly, glazing can provide a better shield against external factors in ZLSs. In this study, mechanical polishing exhibited higher resistance to external factors compared to glazing, which may be due to the lack of a glaze layer that protects the porous structure of FC and the long-irregular rod structure of ZLS with zirconia particles. The microstructural character of HC, which contains oxygen, silicon, aluminium, sodium and potassium in a similar ratio to ceramics, may have been effective in the color change of HC that exceeds AT similar to ceramics [58, 59].

Dental materials can be discolored over time by saliva or acidic beverages [60–62]. In this study, RedBull energy beverage with a pH of 3.18 was used [19]. Silva et al. [19] reported that the surface degrading effect of RedBull varied with consumption frequency and time. Mosallam et al. [23] found that even when carbon dioxide evaporated from energy beverages, the pH level remained low. Dos Santos et al. [63] reported that citric acid in carbonated beverages is the main factor for material surface degradation. Acidic beverages for dental ceramics cause selective extraction of alkali metal ions with low stabilisation in the glass matrix. Insufficient polymerisation of the material, water absorption and the pigment type of the beverage for resin-containing ceramics are important factors [64]. ENE and SAM used in this study, contain citric acid and staining pigments. The staining pigments contained in these beverages possibly caused the discoloration and over time the acid caused the surface of the material to deteriorate, facilitating the retention of the pigment.

In this study, FC-POL immersed in ENE had the highest color change after 28 days (∆E₀₀ = 5.4, p = 0.0002) and HC immersed in DIS had the lowest color change (∆E₀₀ = 1.3, p = 0.0001). Hybrid ceramics may be more resistant to color change because they contain different types and amounts of resins than conventional resin composites [17]. According to the BLE-beverage interaction, at the end of 28 days, the highest color change was found in the specimens with BLE and immersed in ENE (∆E₀₀ = 3.5, p = 0.0496), and the lowest in the specimens without BLE and immersed in SAM (∆E₀₀ = 1.9, p = 0.0074). When the literature was reviewed, no study on the effect of energy beverages on HC was found, but a few studies [18,20 on the effect of energy beverages on ZLS were found and in these studies, it was reported that low pH and dietary habits affected on the effect of energy beverages on discoloration. Since energy beverage consumption increased especially in young people after the Covid-19 pandemic, this type of study was needed [20]. The other beverage whose consumption increased after Covid-19 was an immune-boosting beverage with Sambucus Nigra, and there was no evidence in the literature on the effect of this beverage on the color of dental materials.

There are many studies investigating the effect of beverages on the color of restorative materials. These studies mostly include beverages such as tea, coffee, cola, and wine [1, 5, 8, 18]. There is no study in the literature on the effect of black elderberry immune-boosting beverage, whose consumption has increased since the Covid-19 pandemic due to its antiviral properties, on the color of ceramic [65, 66]. Tokuc and Sukur (65) evaluated resin composites for white spot lesions in their study on children's teeth. Consistent with this study, Sambucus Nigra caused clinically unacceptable color change. In this study, after 28 days, SAM tended to produce a color change similar to DIS. The fact that the specimens had been subjected to BLE increased the magnitude of color change due to SAM.

PDP is a polishing procedure that the majority of clinicians perform after prosthetic treatment to remove discoloration and plaque deposits [67]. Nowadays, a new generation of PDP pastes with lower dentin abrasiveness has been developed and their effects on dental materials should be investigated. This study is in agreement with the study of Elhamid and Mosallam [23] who investigated the effect of PDP on resin composites. Depending on the type of paste, the effect of PDP on the surface may differ [68]. In this study, a paste containing fine silica particles with a RDA of 7 was used. According to the findings of this study, PDP is effective for restoring the color of materials discolored by beverages. This restoring effect was most successful in ZLS-GLA and HC for ENE, FC-GLA, ZLS-GLA and HC for DIS, and FC-POL and HC for SAM. Regardless of the beverage, when BLE and non-BLE specimens were compared, color recovery was more successful in non-BLE specimens; HC and ZLS-GA were superior to other materials in this respect. Regardless of the material, when evaluated in terms of BLE-beverage, color recovery was better in all specimens without BLE and immersed in DIS, ENE or SAM compared to those with BLE.

A limitation of this study is that intraoral conditions cannot be fully simulated. Exposing both sides of the specimens to beverages does not fully represent clinical scenarios where only one side is mostly exposed to colorants. This study adds to the literature in many ways, but future in vivo and in vitro studies are needed to investigate the effects of immune-boosting beverages, energy beverages, bleaching and new PDP paste on the surface properties of newly developed CAD-CAM materials.

The results within the limitations of this study are as follows:

1. After 28 days, the highest color change was in FC-POL immersed to ENE and the lowest in HC immersed to DIS. Color recovery by PDP was most effective in HC specimens immersed ENE, DIS or SAM.

2. The BLE treatment of the materials resulted in a higher magnitude of color change due to beverages. In both BLE and non-BLE HC specimens, PDP provided effective correction of color. At the end of 28 days, the highest color change was found in specimens immersed in ENE and BLE, and the lowest in specimens immersed in SAM and no BLE. Color recovery was lower in BLE treated specimens compared to non-BLE treated specimens, regardless of the beverage in which they were immersed.

3. In terms of material, FC-POL had the highest color change and HC the lowest, while in terms of beverage, ENE had the highest color change and SAM and DIS the lowest.

Competing interests

The authors have no conflicts of interest relevant to this article.

Funding Declaration

The authors do not have any financial interest in the companies whose materials are included in this article.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article and its supplementary materials.

Author contributions

K.Y. Creation of the methodology, preparation of specimens, performing the tests, writing the manuscript. E.Ö. Writing the tables and figures, visualisation, writing the manuscript. F. G. Project administration, validation, writing the manuscript.

Acknowledgements

I would like to thank, Pharmacist Gülşah Akbülbül Yılmaz for her efforts.

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No competing interests reported.

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Effect of immune-boosting beverage, energy beverage, hydrogen peroxide superior, polishing methods and fine-grained dental prophylaxis paste on color of CAD-CAM restorative materials

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