|Year : 2020 | Volume
| Issue : 1 | Page : 3-10
Bioactive glass in dentistry: A systematic review
Kashmira Sawant, Ajinkya M Pawar
Department of Conservative Dentistry and Endodontics, Nair Hospital Dental College, Mumbai, Maharashtra, India
|Date of Submission||22-Jul-2019|
|Date of Decision||20-Oct-2019|
|Date of Acceptance||05-Dec-2019|
|Date of Web Publication||05-Feb-2020|
Dr. Ajinkya M Pawar
301, Department of Conservative Dentistry and Endodontics, Nair Hospital Dental College, Mumbai - 400 008, Maharashtra
Source of Support: None, Conflict of Interest: None
Bioactive glass (BAG) is a benevolent biocompatible material used as an adjunct to various materials used in dentistry. BAG is proved to have a beneficent effect in promoting material–tissue bond. The objective is to analyze significant information available in the literature regarding application of BAG in dentistry. A literature search of electronic databases, including PubMed, Google Scholar, and ResearchGate using the keywords: (Dentifrice OR Dentifrices) OR (Toothpaste OR Toothpastes) AND (Treatment) AND (Dentin OR Dentine OR Tooth) AND (Hypersensitivity OR Sensitivity) AND (Dentifrício OR Dentifrícios) AND (Tratamento OR Tratamentos) AND (Dentinária OR Dentina OR Dente) AND (Hipersensibilidade OR Sensibilidade). The papers found were analyzed regarding title and abstract contents to eliminate the ones that were out of context and not relevant to the review. After this first filter, 31 papers were selected, in which the full-text available was considered of good quality and relevant to the context. The languages of the papers were predominantly English and articles published before 1999 were excluded. The material BAGs are currently used for implant coating, bone grafting, dentin desensitizer, and restorative materials. The current paper reviews the significant developments of BAGs in clinical application, especially dentistry.
Keywords: Bioactive glass, bone grafting, bone regeneration, dentine hypersensitivity, implant coating, osteoinduction
|How to cite this article:|
Sawant K, Pawar AM. Bioactive glass in dentistry: A systematic review. Saudi J Oral Sci 2020;7:3-10
| Introduction|| |
A material is reputed to be bioactive when the engineered substance produces a physiologically active response when it interacts with the biological system by forming a strong material tissue bond. The biocompatibility of a material is gauzed by its ability to exhibit harmony in vivo., The development of bioactive glasses (BAGs) is a milestone in the development of biocompatible material because of its properties, such as mechanical biocompatibility. The term “Bioglass” refers to original 45S5 composition by Hench. BAG has various applications in dentistry such as in coating implants,, bone grafting, and restorative material. The result of the interaction between the biological system and BAG is positive with no signs of inflammation, toxicity, and no foreign body response. This article aims to review the background, composition, and mechanism of bioactive bonding and its various applications in the field of clinical dentistry as the bioactive material. The aim of this study, therefore, was to review the published literature on application of BAG in dentistry, with a focus on the role of BAG-based implants coating, in the treatment of periodontal defect and in the remedy of dentinal hypersensitivity.
| Materials and Methods|| |
The current systematic review methodology is reported following the Preferred Reporting Items for Systematic Review and Meta-analyses statement.
The research question was designed based on PICOS framework: What is the application (O) of BAG (C) in dentistry (P) and its advantage (I) over other dental material
A thorough literature search of electronic databases was done including PubMed-MEDLINE, Google Scholar, and ResearchGate. Keywords such as bioactive glass, osteogenesis, dentinal hypersensitivity, implant coating, and periodontal defect were used to search relevant articles.
A literature search was performed on article with application of BAG in dentistry between January 1999 and September 2019.
Two reviewers examined the full texts of the remaining articles and established inclusion and exclusion criteria on the basis of the PICOS strategy.
- The articles published in PubMed-MEDLINE and ResearchGate index journals were selected
- The articles with application of BAG in field of dentistry were considered
- The articles that are complete were selected
- Articles were analyzed for properties such as osteoconduction and osteoinduction
- Studies published in English.
- Articles published in other index journals were not considered
- Articles with only abstracts and incomplete data were excluded
- Studies published in any other journals were excluded.
Two reviewers separately examined all titles and abstracts. In addition, full articles were reviewed if necessary when the abstracts did not provide enough information to make a decision. If there was disagreement, data were excluded unless further reasonable clarification was provided. Strict inclusion and exclusion criteria were applied for final selection [Figure 1].
|Figure 1: Preferred Reporting Items for Systematic Review and Meta-analyses flowchart followed in this systematic review|
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Two reviewers independently obtained data from eligible studies after reading their full text. From the studies included, important information was extracted, such as the first author and publication year, and 33 papers were selected after this first filter, in which the full-text available was considered of good quality and relevant to the context [Table 1].
|Table 1: The articles reviewed for application of bioactive glass in dentistry|
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Two reviewers independently completed the risk of bias assessment of the included studies using the Risk of Bias in Nonrandomized Studies-of Interventions assessment of bias risk tool. If there were any inconsistencies, discussion occurred.
The assessment tool includes five specific domains:
- Deviation from intended intervention
- Missing outcome data
- Measurement of outcome data
- Selection of the reported result
- In other bias, each domain was assessed as “low risk of bias,” “unclear risk of bias,” or “high risk of bias.” These assessments were reported for each selected study in the “risk of bias” table. The overall risk of bias associated with each study was evaluated as follows: (i) Low risk of bias: all domains were assessed as “low risk.” (ii) Moderate risk of bias: one or more domains were assessed as “unclear.” (iii) High risk of bias: one or more domains were assessed as “high risk” [Table 2].
|Table 2: Risk of bias assessment for studies included in this systematic review|
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| Results of Literature Review|| |
History of bioactive glass
In former days, it was a delusion that the introduction of foreign material in the body may lead to the development of foreign body reaction and formation of scar tissue at the interface of the material. The early material used mainly consisted of metals that were corrosion-resistant and insoluble as well as nontoxic polymers, which were designed to be biologically inert when exposed to the physiological environment., In 1969, a major breakthrough in the field of biomaterial was the development of BAG, which exhibited the ability to bond with host tissues. A chronological overview of the development of the BAG is summarized in [Table 3]. The first generation of biomaterial developed was a glass-ceramic which consisted of silica oxide–sodium oxide matrix with calcium and phosphate ions called 45S5 Bioglass. This Bioglass was implanted in femur bone of rats. A series ofin vivo andin vitro experiments further confirmed the hypothesis that BAG forms a hydroxyapatite layer at the bone–implant interface. The research in the application of BAG in various fields of clinical dentistry eventually led to the development of newer materials, such as BAG ceramics and synthetic hydroxyapatite. Research conducted by Hench in 1991 and Kokubo in 1991 revealed the formation of bone-like apatite by bioactive ceramics on implant and bone–defect interface.,
|Table 3: Chronological overview of development and application of bioactive glass|
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Composition and mechanism of bioactive bonding
The structure of the BAG greatly influences its mechanism of bonding. BAGs mainly consists of silicon oxide, calcium oxide, and phosphorus pentoxide. The original composition called as 45S5 Bioglass consisted of silicon oxide (46.2% mol), sodium oxide (24.3% mol), and phosphorus pentoxide (2.6% mol).,, Various compositions of BAG are developed depending on its application, and [Table 4] provides an overview of different components of BAG. The structure consists of Q2 silica chains with nonbridging oxygen atoms per silica tetrahedron. The base structure of the BAG consists of silica which is highly disrupted. The structure degrades in aqueous solution due to the presence of calcium and sodium ions as they introduce nonbridging oxygen bonds., The other fundamental component of BAG is phosphorus pentoxide which acts as a site for nucleation of crystals of amorphous calcium phosphate which further crystallizes to hydroxyl carbonate apatite (HCA). The bioactivity of BAG depends on the ratio of calcium oxide to phosphorus pentoxide. HCA layer further facilities the adsorption of growth factors, such as collagen, vitronectin, and fibronectin. Osteoblasts bind to these and lead to the formation of an intimate bond between BAGs and bone [Figure 2].
|Table 4: Composition of different bioactive glass used for medical dental and medical application|
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|Figure 2: Sequence of reaction between bioactive glass and bone interface|
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The bioactivity of BAG is further classified into two classes depending on its type and rate of response of host tissue toward bioactive implant; the BAG is classified further to Class A – Osteoproductive (fast rate of bonding to bone) and Class B – Osteoconductive (requiring more time to elicit host cellular response).
Application of bioactive glass in dentistry
BAG has osteoconduction properties by the formation of a hydroxyapatite-like surface layer when in contact with biological fluids and osteoinduction properties by leading bone cells toward the path of regeneration and self-repairs. These properties are used for developing various dental and medical materials to enhance patient care. BAG is most commonly used in the field of dentistry for treating dentinal hypersensitivity and implant coating, whereas in the field of medicine, it is most frequently used for bone grafting. Other application of BAG includes the development of Ceravital® glass-ceramic, endosseous ridge maintenance implant development, PerioGlas for correction of bony defect, and antimicrobial property used in dental cement.,,, Few common applications of BAG have been listed and explained in due course of the current review paper. [Table 4] lists of the article reviewed for application of BAG in dentistry.
BAG's osteoconductive property aids in using it as a bone graft to compensate for bone loss in cases of trauma and infection., It is used in dentistry as a bone substitute for bone loss in periodontal diseases., The ideal properties for a material to be used as graft material are biocompatibility, bioresorbability, and osteogenicity. BAG has a porous structure, which supports the growing bone and improves implant stability by biological fixation. Froum et al. reported significantly better healing of sites, with the less gingival recession when BAG synthetic bone graft particles in the treatment of human periodontal osseous defects compared to open debridement sites.
To compare the properties of BAG and hydroxyapatite, a study was conducted by Oonishi et al., where they used BAG for bone grafting in an animal model, and the results concluded that BAG is easier to manipulate and they restore the bone within 12 weeks as compared to hydroxyapatite.
Regeneration of bone
Evidence has proved that the BAG has the potential to regenerate bone. In 1993, PerioGlas was developed as the first bioactive product with a particle size of 90–710 μm, which is used for repair of bony defects of jaws and periodontal defects. It was also used for guided tissue regeneration membrane which helped regeneration of bone on its scaffold structure. A histological study was conducted of different composition of BAG (PerioGlas and BioGran) to evaluate the bone formation in defects of the tibia of rats, and the results indicated an excellent osteoconductive property of BAG and comparable bone formation with both compositions of BAG.
Treatment of dentinal hypersensitivity
A common problem related to the teeth faced by the general population is dentinal hypersensitivity. The reason for dentinal hypersensitivity is the exposed dentinal tubules due to wear of enamel layer due to trauma, periodontal disease, and abrasive tooth brushing., According to the hydrodynamic theory of dentinal hypersensitivity mechanism, external stimuli such as hot, cold, and osmotic pressure cause fluid movement within dentinal tubules; this change further results in pressure change which causes excitation of nerve ending in the pulp. A fine Bioglass matrix called NovaMin (GlaxoSmithKline, UK) is used as an active repair agent in toothpaste. With a particle size of 18 μm, it mineralizes the exposed dentinal tubules and decreases dentinal hypersensitivity. A clinical study was conducted in 100 volunteers with NovaMin (GlaxoSmithKline) containing toothpaste, and the results showed a reduction in gingival bleeding and plaque growth reduction by 58.8% and 16.4%, respectively, compared to control group using normal toothpaste. Anotherin vitro scanning electron microscope (SEM) was conducted on human dentin demonstrated superior occlusion of dentinal tubules by BAG-containing dentifrice as compared to the regular dentifrice.
Antimicrobial property of bioactive glass
BAG can be used as antibacterial due to its potential to raise the pH in aqueous solution due to the release of cation, and most microbes do not sustain in this condition. Allan et al. conducted a study to analyze the effect of BAG as an antimicrobial agent in the treatment of periodontal defects and the results proved that BAG inhibits bacterial colonization by providing calcium ions to the defective area and raises pH. Anotherin vitro study by Zhang et al. conducted on S53P4 types of BAG reported that it can kill microbes such as Streptococcus mutans, Actinomyces naeslundii, and Aggregatibacter actinomycetemcomitans, which are related to enamel caries, root caries, and periodontitis, respectively. One of the most common reasons for the failure of endodontic and periodontal treatment is the failure to control the bacterial count which causes infection. Antibacterial and disinfectants play a key role in clinical dentistry.,
Coating of dental implants
The metallic implants consist of inert metal, which prevents bond formation between implant surface and tissue. The implant surfaces coated by BAG exhibit enhanced osteointegration of the implant to the alveolar bone. However, the major concern with such implants is the degradation of the bioactive coating over time, which may lead to instability of the placed implant. The thermal coefficient of expansion of implant and BAG coating should match to prevent pulling away of glass during processing.
Use in drug delivery
The properties for a material to be used for drug delivery are that it should be biologically compatible and inert, has good mechanical strength, is easy to administer and fabrication, and can carry high doses of the drug, with no risk of accidental release. Studies have proved the use of BAG as successful drug delivery carrier. A study conducted with BAG as a solid carrier to treat osteomyelitis with teicoplanin exhibited favorable results. The results concluded hydroxyapatite formation through stimulation from BAG after drug delivery. Another study was conducted in which vancomycin on Bioglass carrier was tested with successful treatment of osteomyelitis.
| Discussion|| |
BAG is an altruistic biocompatible material used as an adjunct to various materials used in dentistry. BAG is proved to have a beneficent effect in promoting material–tissue bond. This property is attributed to its chemical composition that closely mimics the mineral makeup of human bone and dentin. With the exceptional properties such as biocompatibility, regenerativity and antimicrobial nature, Bioactive glass has wide application in the field of dentistry and medicine. BAG has application in bone regeneration, bone grafting, coating of implant, antimicrobial activity, treatment of dentinal hypersensitivity, and drug delivery.
On research in application of BAG in the treatment of dentinal hypersensitivity, it has become evident that BAG can occlude the dentinal tubules, so it can be beneficial for individuals suffering from dentinal sensitivity to use toothpaste incorporated with BAG particles. A study published by Neuhaus et al. in 2013 on subjects with dentinal sensitivity to compare the effectiveness of toothpaste-containing 15% calcium sodium phosphosilicate with and without fluoride in a clinical study. The results showed a significant reduction in dentinal sensitivity after 28 days of treatment for both toothpaste groups with or without fluoride, which suggests that any improvement in dentinal hypersensitivity was due to BAG particles and independent of the presence of fluoride particles.
BAGs have osteoinductive properties by the formation of hydrated silica gel which further crystallizes to form HCA which in turn induces bone formation and growth. This property of BAGs is used in a study conducted by Froum et al. in 2002 which histologically compared the healing of extraction socket implanted with BAG and demineralized freeze-dried bone allograft. The results of the study portrayed no significant difference in bone formation between both the groups, but BAG material was observed to act as an osteoconductive material, which had a positive effect on socket healing at 6–8 months postextraction. Another study conducted by Turunen et al. in 2004 used BAG granules as an adjunctive to autonomous bone material in maxillary sinus floor augmentation. Trephine biopsies for histological, SEM and energy-dispersive X-ray were taken at an interval of 21–34 weeks and 49–62 weeks, respectively. The results portrayed that the percentage of bone formation in BAG–autonomous bone mixture was significantly more compared to only autonomous bone graft. This evidence proved the osteoinductive property of BAG.
In recent year, research is conducted to explore the antibacterial potential of BAG. Following this, various modes of action have been proposed which such as changes in the environmental pH and osmotic pressure, which could facilitate the penetration of antimicrobial agents in cell cytoplasm. A recent study by Bortolin et al. in 2018 investigated the antimicrobial activity of BAG S53P4 combined with an autologous bone graft. It was observed that BAG maintains a goodin vitro antimicrobial activity in the presence of human body fluids and tissues.
The host response to titanium alloy implants is not always favorable as a layer of fibrous tissue is formed between skeletal tissue and implant interface. BAG is used as a coating on implant surface to induce osseointegration between implant surface and bone. Ramaswamy et al. in 2009 conducted a study to evaluate thein vitro response of human osteoblast cells with titanium implants coated with bioceramics. The results show that titanium ceramic-coated implants showed new bone formation comparable to that of the hydroxyapatite coatings used as control. Ideally, the thermal coefficient of expansion of BAG should be similar to the metal on which it is coated to prevent the glass from pulling away from the implant on thermal processing. However, the thermal coefficient of expansion is significantly higher than the titanium implant. A further study is required in this field to develop a different composition of BAG with a thermal coefficient of expansion, similar to the implant metal.
The common application of BAG is coating implant surface to form a stable bond between the metallic implant and host bone. A major limitation of BAG is its biodegradable nature that depends on glass composition and environmental pH. A highly reactive Bioglass composition will degrade at a faster rate and will cause instability to the underneath metallic implant. This further limits the use of BAG for implant coating compared to other bioceramics.
| Conclusion|| |
BAG with various compositions and unique mechanisms of action has found various applications in the field of clinical dentistry and medicine. With its properties such as osteoinduction and osteoconduction, it leads to regeneration and remineralization of bone; it has led to the development of the various products to achieve better treatment objective. To enhance its clinical application, morein vivo research and clinical trials are required to be to explore its potential as an ideal biomaterial in the future.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]