Investigation of the Effect of Waterpik Use on the Surface Properties of Porcelain and Zirconium Materials

doi:10.21203/rs.3.rs-4814513/v1

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Investigation of the Effect of Waterpik Use on the Surface Properties of Porcelain and Zirconium Materials

https://doi.org/10.21203/rs.3.rs-4814513/v1

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Statement of Problem The surface properties of materials affect many parameters, including aesthetic, mechanical, and physical properties. Oral hygiene practices are among the factors that change surface properties over time.

Purpose. The purpose of this study is to investigate the effects of Waterpik usage at two different pressure levels on the surface roughness and surface hardness of two different materials frequently chosen in current prosthetic restorations.

Materials and Methods The study used two types of materials: monolithic zirconium and feldspathic porcelain with a metal cr-co substructure. The materials were shaped into rectangular prisms with dimensions of 10x10x2 mm. It was calculated using the G* power program that 10 samples from each material were needed for both 5 Psi and 10 Psi pressure values. The roughness (Ra) and hardness (Hv) values of the material surfaces were recorded after Waterpik applications. Kurtosis and skewness tests were conducted to examine the normal distribution of continuous variables. The ANOVA test was used to compare surface roughness and hardness values between groups when the normal distribution condition was met, and the Kruskal Wallis test was used when it was not. Post-hoc tests were performed using Levene's for independent groups and paired t-test for dependent groups after the ANOVA test. The level of statistical significance was set at P <0.05.

Results Both feldspathic porcelain and monolithic zirconium materials showed a significant increase in surface roughness values for both 5 Psi and 10 Psi pressure values (P<0.05). When surface hardness properties were examined, a significant decrease was observed in both feldspathic porcelain and monolithic zirconium samples at both 5 Psi and 10 Psi pressure values (P<0.05).

Conclusion Feldspathic porcelain and monolithic zirconium restorations produced under appropriate conditions do not have their clinical success affected by the change in surface properties observed when cleaned daily with a Waterpik under 5 Psi and 10 Psi pressure.

CLINICAL IMPLICATIONS The changes observed in the surface properties of feldspathic porcelain and monolithic zirconium restorations, which have been manufactured under appropriate conditions and cleaned daily with an oral irrigator at 5 Psi and 10 Psi pressure, do not affect the clinical success of the material.

Restorative materials that replace missing tooth tissues must mimic the mechanical and physical properties of the original tooth tissues.¹ Porcelain and zirconium restorations, which are commonly used today, have aesthetic qualities close to natural tooth tissue.^2,3 Feldspathic porcelain, used in fixed prosthesis applications and on top of implants, shows good biological compatibility with soft tissues.⁴ Due to its suitable surface properties and aesthetic features, it is often preferred as a veneering material either alone or on a suitable substructure.⁵ Periodontal tissues tolerate a crown prosthesis made of porcelain and zirconium much more positively compared to other materials.⁶ However, the materials' surfaces must be smooth and maintain the desired color and brightness.⁷ Especially in restorations close to the gum line, smoothness is very important for the continuation of gum health.⁸ High surface roughness in restorations can lead to dental plaque retention, and a restoration that has lost its polish can cause an inadequate aesthetic appearance.⁹ Secondary caries formation, surface staining, and inflammation in surrounding soft tissues can occur due to deteriorated surface properties.¹⁰ Consequently, wear in restorations over the long term should remain at a minimum level.¹¹ In addition to the natural properties of the material, many external factors affect the wear on the restoration surface, influencing color changes and surface deterioration.^12,13

Mechanical factors affecting surface roughness include oral hygiene procedures.¹⁴ Toothpaste, dental floss, interdental brushes, and recently, the increased use of oral irrigators are daily oral hygiene practices performed at home.¹⁵ In daily oral hygiene practices, not only existing teeth but also restorative material surfaces in the mouth are cleaned.^16,17 Toothpastes are frequently used twice a day in individuals' oral hygiene practices. There are numerous studies in the literature on the changes caused by toothpastes on the surface of restorative materials and enamel.^17,18 The prevalent view in the literature is that while long-term changes in surface hardness and roughness values are observed in composite restorations after tooth brushing procedures, the surface properties of amalgam and ceramic restorations are not affected.^19–21 A literature search showed that the number of studies on the effect of oral irrigators on the surface properties of dental restorative materials is not sufficient to express a general opinion on this topic.²²

Oral irrigators are devices that work based on the principle of sending pressurized water to the desired surface at certain intervals for cleaning dental plaque and materia alba from the surface of enamel and restorative materials.^23–25 The pressure of the water used can be up to 0.6 MPa. Previous studies have reported that the levels of water pressure used in oral irrigators do not cause any destructive effect on the junctional epithelium.²⁶ Although the use frequency of oral irrigators has increased nowadays, the product was introduced in the 1960s.²⁷ Many authors have reported that oral irrigators are much more successful in removing dental plaque compared to dental floss.²⁸⁻²⁰ Moreover, the use of oral irrigators is recommended for effective cleaning in patients with complex and hard-to-clean prosthetic restorations such as fixed prostheses on implants, as well as in cases with orthodontic brackets and wires, where the patient's manual dexterity is low or in patients at risk for infective endocarditis.^31–33 A previous study reported that a 3-second vibration with an oral irrigator after proper tooth brushing procedures reduced dental plaque by 99%.³⁴

The aim of this study is to investigate the effect of using oral irrigators at two different pressure levels on the surface roughness and hardness of two commonly preferred materials in current prosthetic restorations. One of the materials used is feldspathic ceramic veneer material on a metal substructure; the other is monolithic zirconium material. Our study has two hypotheses. The first hypothesis is that changes in surface properties will be observed in materials under high pressure, and the second hypothesis is that the surface hardness values of feldspathic porcelain and monolithic zirconium will not change under high pressure.

In this study, two types of materials were used: feldspathic porcelain (VITA VMK 95) for veneering on a metal substructure and monolithic zirconium. Oral irrigator applications at two different pressure values were performed for each material type. The dimensions of the samples used in the study were prepared to be 10 mm in width, 10 mm in height, and 2 mm in thickness (10x10x2). The sample size for the study was calculated with a confidence interval of 80% using the G*Power software program (v3.0.10). According to the calculated sample size, there are a total of 40 samples, with 10 samples for each group (n = 10).

The samples were prepared by a commercial dental laboratory. Monolithic zircon samples were obtained by milling from monolithic zirconium blocks (Aidite Biomic 3D Pro Multi-layer Zirconia) using a CAD-CAM device (VHF K5, Leipzig). For the preparation of feldspathic porcelain samples, firstly, metal substructures of 10x10x1 mm dimensions were produced by laser cutting (Concept Laser) from cr-co (Sint-Tec2724G, PM100 Dental). Then, feldspathic porcelain was added onto the metal substructure by layering method. Surface finishing processes were carried out in the same manner as required in routine applications to simulate the form applied in the clinic. A glaze layer was applied to the surface of feldspathic porcelain samples. (Order No: 13003, Swiss Dental Instruments) The surface of the monolithic zircons was polished according to the manufacturer's instructions with a three-stage polishing kit (EVE Diacera, EVA Ernst Vetter GmbH).

After the samples were randomly numbered, the surface roughness measurements of the samples were made with a profilometer (Taylor Hobson,). Three surface roughness measurements were made for each sample, and the average surface roughness (Ra) values were recorded. Ra is defined as the arithmetic average of the absolute values of vertical deviations from the line over the mean line along the profile. Microhardness measurement was performed using a Vickers microhardness tester (Future Tech FM-800e, Future Tech Corp) with a force of 500 g for 15 seconds. Three measurements were made from each sample, and HV values were calculated. Monolithic and feldspathic samples were randomly divided into two groups within themselves. For the first group, pressured water application was performed with the #5 pressure level found on the device; for the second group, with the #10 pressure level. Feldspathic porcelain samples were named F5 for the #5 pressure value, and F10 for the #10 pressure value; zirconium samples were named Z5 for the #5 pressure value, and Z10 for the #10 pressure value. The naming method used for the samples in the study is given in Table 1.

Table 1

Groups of the study
Materyal içeriği	Pressure	Group code
Zirkonyum	#5	Z5
Zirkonyum	#10	Z10
Feldspatik	#5	F5
Feldspatik	#10	F10

To better simulate the clinical situation, the application was carried out four times a week for 16 weeks. The Waterpik device was used for 5 minutes in each use (a total of 320 minutes in 16 weeks). The estimated usage time of the Waterpik, assuming it is used twice a day for 3 seconds each time on the surface, is equivalent to one year of use. A classic jet tip suitable for supragingival use of the Waterpik WP100 (Waterpik, Inc) was used. The tip of the device was applied to the porcelain surfaces at a right angle from approximately 2 mm away, according to the manufacturer's instructions. The samples and the handle of the device were mounted and secured to form a uniform situation. The liquid chamber of the device was continuously filled to be used continuously until the end of the treatment. Then each sample was rinsed with water spray for 10 seconds. After the Waterpik application, final surface roughness and hardness measurements were made.

Analyses were performed with IBM SPSS 20 statistical analysis software. Data were presented as mean, standard deviation, median, minimum, maximum, percentage, and count. The normal distribution of continuous variables was checked with Kurtosis and skewness test.

For comparing surface roughness and hardness values between groups, ANOVA test was used if the normal distribution condition was met; otherwise, Kruskal Wallis test was used. Post-hoc tests after the ANOVA test were performed using Levene’s test for independent groups and paired t-test for dependent groups. The level of statistical significance was set at p < 0.05.

When examining the statistical analysis results, significant differences were found between the surface roughness values of the zirconium and feldspathic groups after 5 Psi and 10 Psi pressures. (P < 0.05) The difference between the surface roughness values of zirconium and feldspathic samples after 5 Psi and 10 Psi pressures is not statistically significant. (P > 0.05) The statistical analysis results of the Skewness test among independent groups are shown in Table 2. When examining the surface hardness values of the zirconium and feldspathic groups after 5 Psi and 10 Psi pressures, a statistically significant decrease was observed for both groups after the application. (P < 0.05) The statistical analysis results of the Kurtosis test among independent groups are shown in Table 3.

Table 2

Statistical analysis of surface roughness tests between independent groups
	Levene's Test for Equality of Variances		t-test for Equality of Means
	F	Sig.	t	df	p	Mean Difference	Std. Error Difference	95% Confidence Interval of the Difference
	F	Sig.	t	df	p	Mean Difference	Std. Error Difference	Upper	Lower
Z5	,001	,971	-,131	18	,897	-,00900	,06879	-,15352	,13552
Z10	,015	,903	1,412	18	,175	,08200	,05807	-,04000	,20400
F5	,001	,971	-,131	17,981	,897	-,00900	,06879	-,15353	,13553
F10	,015	,903	1,412	17,956	,175	,08200	,05807	-,04002	,20402

Table 3

Statistical analysis of surface hardness tests between independent groups
	Levene's Test for Equality of Variances		t-test for Equality of Means
	F	Sig.	t	df	p	Mean Difference	Std. Error Difference	95% Confidence Interval of the Difference
	F	Sig.	t	df	p	Mean Difference	Std. Error Difference	Upper	Lower
Z5	1,487	,238	30,562	18	,000	687,0300	22,4797	639,8018	734,2582
Z10	18,967	,000	28,814	18	,000	690,6100	23,9683	640,2546	740,9654
F5	1,487	,238	30,562	14,274	,000	687,0300	22,4797	638,9025	735,1575
F10	18,967	,000	28,814	11,516	,000	690,6100	23,9683	638,1433	743,0767

The surface roughness value of feldspathic porcelains showed a significant increase for both 5 Psi and 10 Psi pressure levels. (P < 0.05) For zirconium samples, the surface roughness value significantly increased for both 5 Psi and 10 Psi pressure levels. (P < 0.05) The t-test results of the surface roughness values for Z5, Z10, F5, and F10 are shown in Table 4.

Table 4

Paired Samples t-test results for Ra
	Mean Std.Deviation Std. Error Mean			95% Confidence Interval of the Difference		t df p
	Mean Std.Deviation Std. Error Mean			Lower	Upper	t df p
Z5	-,03000	,01414	,00447	-,04012	-,01988	-6,708	9	,000
F5	-,05300	,01252	,00396	-,06195	-,04405	-13,390	9	,000
Z10	-,06000	,00816	,00258	-,06584	-,05416	-23,238	9	,000
F10	-,08600	,01075	,00340	-,09369	-,07831	-25,299	9	,000

When examining surface hardness properties, a significant decrease was observed in feldspathic porcelains for both 5 Psi and 10 Psi pressure levels. (P < 0.05) For zirconium samples, a significant decrease in surface hardness was shown for both 5 Psi and 10 Psi pressure levels. (P < 0.05). The t-test results of the surface hardness values for Z5, Z10, F5, and F10 are shown in Table 5.

Table 5

Paired Samples t-test results for Hv
	Mean Std.Deviation Std. Error Mean			95% Confidence Interval of the Difference		t df p
	Mean Std.Deviation Std. Error Mean			Lower	Upper	t df p
Z5	9,5100	,7475	,2364	8,9753	10,0447	40,231	9	,000
F5	6,5900	,7838	,2479	6,0293	7,1507	26,588	9	,000
Z10	10,9300	1,3720	,4339	9,9485	11,9115	25,193	9	,000
F10	9,0800	,5827	,1843	8,6632	9,4968	49,275	9	,000

This study investigated the effects of oral irrigator use on current prosthetic restorative materials in terms of changes in surface roughness and hardness. The oral irrigator application was standardized using a sliding mechanism by a single applicator, equivalent to a period of 10 years. Many studies have reported that for changes in surface properties of feldspathic porcelains and Monolithic zirconium to be observed, a usage period of at least 8–12 years is required.^36,37

For surface roughness, we used the arithmetic mean height of the surface (Ra), equivalent to the line's arithmetic average height used in most previous surface roughness studies.³⁵ To measure surface hardness values, Vickers test measurements were conducted to observe the microhardness value, frequently used in literature to measure the surface hardness of porcelain and zirconium materials.^38,39

The initial surface roughness values obtained in this study are consistent with other studies where roughness values for feldspathic porcelain range from 0.4–1.0 µm; for monolithic zirconium, it ranges from 0.09–0.2 µm.^40,41 Our measured initial Vickers microhardness values, ranging from 331.5–472.0 for feldspathic porcelain and 1014.2-1185.3 kg/mm2 for monolithic zirconium, are consistent with previously reported surface hardness values of these materials in the literature.^39–42

The study's first hypothesis was accepted. The Ra values of feldspathic porcelain and monolithic zirconium samples showed statistically significant changes at both #5 and #10 pressure levels. (P < 0.05) The study's second hypothesis was rejected since the Hv values of materials changed at all pressure levels. (P < 0.05)

Under 5 Psi pressure, changes in surface roughness and hardness were much higher for feldspathic porcelains, and similarly, the highest increase in surface roughness values under 10 Psi pressure was observed in the feldspathic porcelain group. The increases observed for both material groups are below 0.2 µm, the minimum roughness level required for bacterial colonization to commence on the surface.⁴³ The material group least affected by the use of high-pressure oral irrigators was monolithic zirconium, which exhibited an average increase in surface roughness of 0.01 µm. This characteristic aligns with literature information, indicating monolithic zirconium surfaces are resistant to surface treatments and have high hardness values.⁴⁴

The changes in Hv values under 5Psi and 10 Psi pressure for feldspathic porcelain and zirconium samples ranged between 8–10 kg/m2, with similar values for both materials. After 10 Psi pressure, the Hv values for monolithic zirconium samples were 1101.640, and for feldspathic porcelain samples, 411.030, which are sufficient levels according to the surface hardness grades reported in the literature.^3,45 Due to the insufficient number of articles investigating the impact of oral irrigator use on the surface properties of ceramic and zircon materials, it has not been possible to make a comparison with previous studies on this topic. In our literature research, unlike our study, a previous study reported that the surface roughness values of composite samples with lower surface hardness did not show a significant difference after the application of oral irrigators at 5Psi pressure, and the differences after the application of 10 Psi pressure were significant.²²

Within the capabilities of this in vitro study, the following results have been obtained:

1. The application of oral irrigators at 5Psi and 10 Psi significantly affected the surface roughness and hardness levels of feldspathic porcelain and monolithic zirconium surfaces. (P<0.05)

2. The surface roughness values of feldspathic porcelain and monolithic zirconium surfaces cleaned with the oral irrigator procedure under 5 Psi and 10 Psi pressure are at levels that will not affect the clinical success of the restoration.

3. The surface hardness values of feldspathic porcelain and monolithic zirconium surfaces cleaned with the oral irrigator procedure under 5 Psi and 10 Psi pressure are at levels that will not affect the clinical success of the restoration.

Author Contribution

N.Y. prepared the draft of the study, M.K. provided the material and equipment needs of the study, N.K. completed the experimental phase of the study and analyzed the results, B.T. wrote and edited all parts of the work. created the final version of the work.

Funding Declaration

No financial support was received

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No competing interests reported.

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Investigation of the Effect of Waterpik Use on the Surface Properties of Porcelain and Zirconium Materials

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