RESEACH ARTICLE

Effect of Toothbrushing on Color Changes of Esthetic

Restorative Materials
TUĞBA BEZGIN, DDS, PhD*, LEVENT ÖZER, DDS, PhD†, FIRDEVS TULGA ÖZ, DDS, PhD†,
PELIN ÖZKAN, DDS, PhD‡

ABSTRACT
Purpose: The aim of this study was to evaluate the effects of various drinks and toothbrushing on the color changes of
esthetic restorative materials used in pediatric dentistry.
Materials and Methods: Forty specimens were prepared from each of three restorative materials (compomer [Dyract
AP], glass ionomer cement [Ionofil Molar AC, Voco], composite resin [Filtek Z 250]). Specimens were divided into four
groups for immersion in three different staining solutions (cherry juice, cola, chocolate milk) and distilled water. Each
group was subdivided into brushing and non-brushing groups. The specimens in the brushing subgroups were brushed
with toothpaste once a day using an electric toothbrush. Color was measured using a colorimeter, and color changes
were calculated between baseline and 1, 7, 30, 60 days. Data was analyzed using Kruskal–Wallis, Mann–Whitney U,
Wilcoxon, and Wilcoxon Signed Rank tests.
Results: All the solutions evaluated yielded color changes, and these changes were significantly greater for composite
resin than for glass ionomer cement or compomer (p < 0.006). Brushing significantly decreased the color changes of
restorative materials (p < 0.004).
Conclusion: Brushing significantly influenced the color stability of esthetic restorative materials. The results of this study
also showed that glass ionomer cements and compomers had higher color stability than composite resins.

CLINICAL SIGNIFICANCE
The color stability values after brushing may better reflect the discoloration of the esthetic restorative materials. Any
color stability study model should consider the effects of toothbrushing that can remove the adsorbed colorants. The
results of this study also showed that glass ionomer cements and compomers can be used in anterior restorations of
children with their higher color stability than composite resins.
(J Esthet Restor Dent 27:S65–S73, 2015)

INTRODUCTION (compomers), and composite resins. Composite resins

were first introduced around 1970 and since then have
In today’s society, both adults and children are been used principally for direct esthetic restorations in
conscious of appearances, particularly smiles, and many both anterior and posterior regions.2 Glass ionomer
parents now choose for their children to undergo restorations have recently become very popular in
esthetic restoration of the anterior segment of the clinical pediatric dentistry due to favorable properties
dental arch.1 A variety of esthetic materials are available such as fluoride release and adhesion to tooth structure;
in pediatric dentistry, including glass ionomer cements however, GICs are technique sensitive in their
(GICs), polyacid-modified composite resins application and sensitive to degradation by organic

*Post-doctoral research fellow, Department of Pediatric Dentistry, Faculty of Dentistry, Ankara University, Ankara, Turkey
†
Professor, Department of Pediatric Dentistry, Faculty of Dentistry, Ankara University, Ankara, Turkey
‡
Professor, Department of Prosthodontics, Faculty of Dentistry, Ankara University, Ankara, Turkey

© 2015 Wiley Periodicals, Inc. DOI 10.1111/jerd.12136 Journal of Esthetic and Restorative Dentistry Vol 27 • No S1 • S65–S73 • 2015 S65
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COLOR CHANGES FROM TOOTHBRUSHING Bezgin et al.

acids from dental plaque and food intake.3–6 of which focus on coffee, tea, and wine, which are
Polyacid-modified composite resins, or compomers, normally associated with adult tooth stains.6,16–20 Only a
were developed to overcome some of these limitations. few studies have evaluated the staining effects of
Compomers combine composite resin technology with common children’s beverages.1,10,21 Moreover, despite
that of glass ionomers, and therefore provides the the importance of toothbrushing, the effect of brushing
advantageous features of both materials in the on color stability of esthetic restorative materials has
formulation.7 not been previously reported. Studies performed on
enamel showed that some extrinsic stains can be
Staining is a problem common to all these materials removed partially or totally by means of toothbrushing
after long-term use.8–10 Both intrinsic and extrinsic with dentifrice.22 Therefore, this study aimed to assess
factors may be implicated in the discoloration of over a 60-day period the effects of several common
restorative materials.9,10 Intrinsic factors include children’s beverages and toothbrushing on the surface
discoloration of the resin material itself caused by staining of esthetic dental restorative materials used in
alterations in the resin matrix and the interface pediatric dentistry.
between matrix and filler.9,11 Extrinsic factors of
discoloration include staining by adsorption or The null hypothesis tested in this study was that there
absorption of colorants as a result of contamination are no differences among three different solutions on
from exogenous sources such as colored drinks.9,10,12 color stability of three different tooth-colored materials;
The oral environment is daily exposed to a variety of and that toothbrushing would not affect the stainability
media that have the potential to stain or otherwise alter of these restorative materials.
the surfaces of dental restorations, thereby causing
esthetic degradation. For this reason, it is important to
understand how long-term daily exposure to common MATERIALS AND METHODS
beverages can alter the color of restorative material and
whether or not this change is perceptible to the human This study was conducted using three restorative
eye.1–6 materials (Shade A2) (Dyract AP, a polyacid-modified
composite resin [compomer]; Ionofil Molar AC, Ionofil
To evaluate color changes of tooth-colored restorative Molar AC, a GIC; and Filtek Z250, a composite resin)
materials, both spectrophotometry and colorimetry can (Table 1) and four solutions (distilled water [W], cherry
be used.13,14 A spectrophotometer can measure color juice [CJ], cola [C], and chocolate milk [N]) (Table 2).
differences (ΔE) lower than 1.5; however, this rate Group W specimens served as the control group. The
cannot be detected by the human eye. Researchers pH values of the solutions were obtained by using a
considered that ΔE values below 3.3 is not perceptible digital pH electrode (Sentron, Drenthe, the Netherlands)
to the human eye and can be accepted clinically.15 that had been calibrated immediately prior to use.

The staining effects of beverages on esthetic dental A Teflon ring was used to prepare 40 disk-shaped
restorations have been examined in many studies, most specimens (10 mm diameter × 1.5 mm height) from

TABLE 1. Restorative materials used in the study

Product Material type Mixing Curing Manufacturer

Dyract AP Polyacid modified composite N/A Light-cure for 40 seconds DentsplyDeTrey GmbH,
resin Germany

Ionofil Molar AC Glass ionomer cement 10 seconds with a mixer No cure VOCO, Cuxhaven, Germany
Allowed to set 15 minutes

Filtek Z250 Composite resin N/A Light-cure for 40 seconds 3M/ESPE, St. Paul, MN, USA

S66 Vol 27 • No S1 • S65–S73 • 2015 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12136 © 2015 Wiley Periodicals, Inc.
 17088240, 2015, S1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.12136 by Universidad De Chile, Wiley Online Library on [13/03/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
COLOR CHANGES FROM TOOTHBRUSHING Bezgin et al.

TABLE 2. Media used in the study

Product Material type Manufacturer pH

Cherry juice Fruit juice Cappy, The Coca-Cola Co, USA 3.1

Cola Soft drink The Coca-Cola Co, İstanbul, Turkey 2.4

Chocolate milk Milk Nesquik, Nestle, Bursa, Türkiye 6.4

each material. A cellulose acetate matrix strip was recommendations using the white calibration standard
placed over the ring and held between two glass slides provided. Measurements were taken using the
(1 mm thick). According to the manufacturers’ Commission International de I’Eclairage (CIE) L*a*b*
instructions for all the tested materials; the GIC was system. ΔE was calculated using the following equation:
allowed to set for 15 minutes at room temperature, ΔE* = ([L1*-L0*]2 + [a1*-a0*]2 + [b1*-b0*])2.1,2
while the other restorative materials were polymerized
using a LED unit (Freelight 2 Elipar, 1,200 mw/cm2, 3M Data were analyzed using the statistical software SPSS
ESPE, Ireland) for 20 seconds to each surface, with the for Windows, Version 12.0.1 (SPSS Inc., Chicago, IL,
light tip placed over the glass slide (1 mm away from USA). Thus, data did not meet the preconditions for
the specimen) for a total of 40 seconds. Specimens were variance analysis, nonparametric tests were used to
polished with a series of polishing discs (Sof-Lex, 3M analyze the data. When there are two groups to
ESPE, St. Paul, MN, USA) with an electric handpiece at compare, Mann–Whitney U or Wilcoxon tests were
15,000 rpm for 10 seconds for each disc (coarse, used. The dependent two groups were analyzed using
medium, fine, and superfine). All specimens were Wilcoxon Signed Rank test. When groups were more
hydrated in 37°C distilled water for 24 hours. than two, Kruskal–Wallis test was used. To determine
which group differences accounted for significant
Baseline color data were obtained, and the specimens differences, multiple comparisons with Bonferroni’s
were distributed into four groups (N = 10) for correction were performed. A value of p < 0.008 was
immersion in one of the four solutions. Each group was considered statistically significant in identifying
also subdivided into brushing and non-brushing differences in staining capacity of the test solutions
subgroups (N = 5). Specimens were immersed in (according to the Bonferroni correction), whereas a
solutions for 3 hours per day at room temperature over value of p < 0.004 was considered significant in
a 60-day test period and replaced in distilled water identifying the effects of brushing on specimen color,
following immersion. The solutions were replaced daily. and a value of p < 0.006 was considered significant in
The specimens in the brushing subgroups were also identifying differences in the amount of color change
brushed with toothpaste (Oral-B Stages Fruit Blast, according to the restorative materials tested.
Gillette Group, London, UK) once a day using an
electric toothbrush (Braun Oral-B Plak Control Ultra)
for 5 seconds to each surface. Prior to color
measurement, specimens were drained of liquid, lightly RESULTS
rinsed with distilled water, and dried with paper tissue.
For all groups, the mean color differences (ΔE) and
Color was measured using a colorimeter (Minolta standard deviations are represented in Table 3. The data
CR-300, Minolta Co., Osaka, Japan). Color changes with the superscript letters in the table demonstrated
(ΔE) were calculated between baseline color statistically significant differences (a—for differences
measurements and measurements made after 1, 7, 30, between solutions, b—for differences between brushing
and 60 days. Prior to measurement, the colorimeter was or non-brushing groups, c—for differences between the
calibrated according to the manufacturer’s restorative materials).

© 2015 Wiley Periodicals, Inc. DOI 10.1111/jerd.12136 Journal of Esthetic and Restorative Dentistry Vol 27 • No S1 • S65–S73 • 2015 S67
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COLOR CHANGES FROM TOOTHBRUSHING Bezgin et al.

TABLE 3. The mean ΔE values and standard deviations for all groups
Materials Media

Water Cherry Cola Nesquik

Brushing Non- Brushing Non- Brushing Non- Brushing Non-

(ΔE ± SD) brushing (ΔE ± SD) brushing (ΔE ± SD) brushing (ΔE ± SD) brushing
(ΔE ± SD) (ΔE ± SD) (ΔE ± SD) (ΔE ± SD)

B-1 Comp 4.12 ± 0.24 3.92 ± 0.23c 3.83 ± 0.14 3.75 ± 0.36c 4.00 ± 0.04 3.94 ± 0.19c 4.19 ± 0.11 3.91 ± 0.16c

GIC 4.00 ± 0.64b 1.50 ± 0.27 3.89 ± 0.31b 1.18 ± 0.31 4.24 ± 0.23b 1.45 ± 0.27 4.10 ± 0.42 3.22 ± 0.71a

Comp resin 4.89 ± 0.37b 0.76 ± 0.32 4.92 ± 0.20b 0.74 ± 0.30 4.65 ± 0.52b 0.77 ± 0.31 4.66 ± 0.18b 1.00 ± 0.32

B-7 Comp 1.41 ± 0.27 1.87 ± 0.26 1.07 ± 0.15 1.36 ± 0.19 0.98 ± 0.23b 1.76 ± 0.14 1.43 ± 0.07b 2.20 ± 0.52a

GIC 1.06 ± 0.64b 2.55 ± 0.45 1.25 ± 0.38b 2.02 ± 0.13 1.02 ± 0.54b 1.78 ± 0.82 1.32 ± 0.38b 2.62 ± 0.29

Comp resin 2.09 ± 0.15 2.62 ± 0.29 2.66 ± 0.46 2.70 ± 0.22c 2.09 ± 0.44 2.74 ± 0.20 2.17 ± 0.31 2.34 ± 0.69

B-30 Comp 1.85 ± 0.16 1.67 ± 0.29 2.29 ± 0.44a,b 1.11 ± 0.13 0.79 ± 0.11 1.34 ± 0.11 1.49 ± 0.17 1.47 ± 0.08

GIC 1.96 ± 0.63 2.00 ± 0.19 2.52 ± 0.41 1.87 ± 0.48 1.42 ± 0.71 1.77 ± 0.18 1.50 ± 0.41 1.60 ± 0.65

Comp resin 0.89 ± 0.20b,c 1.81 ± 0.14 0.93 ± 0.25b,c 2.10 ± 0.13 0.82 ± 0.34b,c 1.86 ± 0.24 0.88 ± 0.20b,c 1.84 ± 0.62

B-60 Comp 1.05 ± 0.35b 3.89 ± 0.10 1.49 ± 0.47b 3.28 ± 0.39 2.66 ± 0.12a,b 2.51 ± 0.67c 1.52 ± 0.33b 3.20 ± 0.33

GIC 0.65 ± 0.39b 4.39 ± 0.43 1.13 ± 0.98b 4.76 ± 0.44 1.20 ± 0.64b 3.64 ± 0.27 1.26 ± 0.53b 3.64 ± 0.45

Comp resin 0.26 ± 0.05b 4.20 ± 0.34 0.22 ± 0.44b 4.52 ± 0.13 0.31 ± 0.30b 4.26 ± 0.55 0.43 ± 0.14b 4.20 ± 0.48

a
differences between solutions.
b
differences between brushing or non-brushing groups.
c
differences between the restorative materials.

FIGURE 1. ΔE values between

baseline and 1 day.

Figure 1 shows the mean ΔE values and standard (p < 0.008). Brushing significantly increased the ΔE in
deviations of the three restorative materials exposed to the GIC and composite resin specimens except Nesquik
staining solutions after 1 day. No significant differences group in the GIC specimens (p < 0.004). Among the
in ΔE values among the groups were observed for any non-brushed specimens, discoloration in the compomer
of the solutions tested except Nesquik (Nestle Co., group was significantly greater than in the GIC and
Bursa, Turkey) in the non-brushed GIC specimens that composite resin groups for all staining media tested
exhibited greater ΔE values than other solutions (p < 0.006).

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COLOR CHANGES FROM TOOTHBRUSHING Bezgin et al.

FIGURE 2. ΔE values between

baseline and 7 days.

FIGURE 3. ΔE values between

baseline and 30 days.

Figure 2 shows the mean ΔE values after 7 days. ΔE (p < 0.008). When the effects of brushing were
values of non-brushed compomer specimens were examined, ΔE values in the brushed specimens
significantly higher following exposure to Nesquik when compared to the non-brushed specimens were found to
compared to the cherry juice (p < 0.008). No significant be significantly higher in the compomer groups exposed
difference in ΔE was observed between the brushed and to cherry; however, ΔE values of non-brushed
non-brushed composite resin specimens specimens were significantly higher in the composite
(p > 0.004); however, brushing significantly lowered resin groups exposed to all solutions tested (p < 0.004).
the ΔE caused by cola and Nesquik in the compomer When ΔE values of the restorative materials were
specimens and by all solutions in the GIC specimens compared, brushed composite resin specimens showed
(p < 0.004). When ΔE values of the restorative lower ΔE values than other brushed restorative
materials were compared, no significant differences materials except compomer specimens in cola
were found in any of the brushed or non-brushed (p < 0.006).
groups with the exception of the non-brushed
composite resin specimens, which showed significantly Figure 4 shows the mean ΔE values after 60 days. No
higher ΔE following exposure to cherry juice when significant differences were observed in ΔE values of the
compared to the other restorative materials tested GIC and composite resin specimens for the different
(p < 0.006). solutions tested (p > 0.008). However, cola caused
significantly higher ΔE values than cherry juice and
Figure 3 shows the mean ΔE values after 30 days. Nesquik in the brushed compomer specimens
Cherry juice caused significantly higher ΔE values than (p < 0.008). Brushing significantly lowered the ΔE in all
cola and Nesquik in the brushed compomer specimens the restorative materials tested except cola in the

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COLOR CHANGES FROM TOOTHBRUSHING Bezgin et al.

FIGURE 4. ΔE values between

baseline and 60 days.

FIGURE 5. Color changes of restorative materials in various media with toothbrushing.

compomer group (p < 0.004). When ΔE values of the solutions, all of the non-brushed groups except
restorative materials were compared, brushed compomer in cola showed high color changes
compomer specimens exposed to cola showed the (Figure 4). However, there was no statistically
highest ΔE values than other brushed specimens of significant difference between solutions tested and
restorative materials (p < 0.006). However, non-brushed distilled water used as control (p > 0.008). Distilled
compomer specimens in cola showed lower ΔE values water produced high color changes after 1 day for the
than GIC and composite resin (p < 0.006). brushed and non-brushed compomer specimens and
for all brushed groups of GIC and composite resin.
Figure 5 shows the color changes of brushed specimens Also, after 60 days, distilled water showed unacceptable
exposed to cherry juice, cola, and Nesquik over time. color changes in all non-brushed specimens.
Statistically significant differences were observed
between baseline color measurements and color
measurements after 60 days for all solutions and DISCUSSION
restorative materials tested (p < 0.05).
The results of this study showed the null hypothesis
When the rate of color changes was investigated for all that different solutions and toothbrushing would not
solutions and restorative materials for all examination affect the stain susceptibility of tooth-colored
periods, ΔE values were lower than 3.3 (not perceptible restorative materials was rejected.
to the human eye) except 1 day and 60 days for some
groups. Color changes of brushing groups of GIC and Both spectrophotometry and colorimetry have been
composite resin and both the brushed and non-brushed used to measure color change in dental materials.13,14
groups of compomer were higher than 3.3 after 1 day For this study, the CIE L*a*b* system was chosen
(Figure 1). Although, after 60-day exposure to the because of its ability to detect small differences in

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COLOR CHANGES FROM TOOTHBRUSHING Bezgin et al.

color,5,23 although color changes of less than 3.3 are despite its low pH, have less staining capacity than
considered clinically insignificant.4,5 other agents. However, a study by Tunç and colleagues21
examining the staining potential of Nesquik, grape juice
In contrast to previous studies,10,11,24 the specimens in and cola found cola to cause greater staining of esthetic
the present study did not remain in continuous contact restorative materials than Nesquik and grape juice. The
with the staining solutions tested, but similar to Nasim lack of a yellow colorant in cola may be a factor in its
and colleagues25 the specimens were immersed in either limited staining potential found in the present study.
of the beverages for 3 hours per day, and then An interesting finding was that distilled water chosen
immersed in distilled water for the rest of the day in for negative control group produced color differences
order to more closely replicate the actual clinical perceptible to the human eye on the first and 60-day
situations. examinations which did not differ from other solutions
used. Several studies have been performed to assess the
Even though a smooth surface was obtained with effect of water on color change of esthetic restorative
matrix strips, it contains a resin-rich layer on the materials.14,15,33–35 Similar to this study, these studies
surface which needs to be eliminated.26,27 Therefore, have demonstrated statistically significant differences
regardless of the cavity class and location, polishing of between baseline and post-immersion color values.
tooth-colored restorations, which enhance both Color changes at 24 hours could be attributed to the
esthetics and longevity of restorations, is an essential post-irradiation polymerization reaction that lasts for
step in restorative dentistry.28 In this study, to mimic up to 24 hours;34,35 whereas changes after long-term
clinical situations, polishing with aluminum oxide-based immersion could be attributed to hygroscopic
abrasive devices (Sof-Lex discs) whose efficacy was absorption of water in the material.14,15,34 Buchalla and
proven in previous studies was used.28–31 The surface colleagues34 stated that changes in optical properties of
texture of a tooth-colored restoration influences the the material due to water absorption could have been
stain resistance of the restoration which can be affected responsible for the different values of ΔE. According to
by polishing.27,32 In a recent study, Erdemir and the results of this study; a long-term in vitro study is
colleagues31 showed that compomer produced the required for further investigations regarding the color
smoothest surface after being polished with Sof-Lex changes after storage in water as the color changes are
discs which did not significantly differ from thought to continue even after 60 days of storage.
microhybrid composite; whereas GIC produced the
roughest surface. This study did not investigate surface Previous studies have shown that fluoride-releasing
roughness, however, after standard polishing procedure materials have a greater ion release when submitted to
for all materials tested; GIC, which may have a rough pH variations that could lead to lower color stability
surface, showed lower staining than composite resin. when compared to composite resins.36,37 However in the
This result can be attributed to a low staining present study, the acidic media used (cola and cherry
susceptibility relating to a low water absorption rate or juice) did not cause greater staining of GIC and
low resin content rather than surface texture.6 compomer than composite resin. A study by Imparato
and colleagues38 also found that pH variations do not
The staining potential of liquids varies according to increase the color changes of fluoride-releasing dental
their composition, pH, and other characteristics.6,18,19 In materials.
the present study, all materials were discolored by all
staining agents tested. The most significant color Differences in color stability among restorative
change occurred following immersion in Nesquik, materials can be ascribed to the constituents (water and
followed by cherry juice and cola, although the amount of fillers) and water sorption.4,5,23 Restorative
difference in the degree of color change following juice materials capable of absorbing water may also be
and cola immersion was not statistically significant. capable of absorbing other fluids that can result in
A study by Bagheri and colleagues6 also found cola, discoloration.6,11 It has previously been suggested that

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COLOR CHANGES FROM TOOTHBRUSHING Bezgin et al.

conventional GICs are less susceptible to staining even prevent coffee and tea from staining resin-based
because their high water content allows them to absorb veneering materials. Similarly, the present study found
less water.6 Conversely, it has also been suggested that that good oral hygiene, i.e., brushing at regular
hydrophilic materials such as GIC are more susceptible intervals, decreases the amount of color change in
to staining than hydrophobic materials such as esthetic restorative materials over time. It can be argued
composite resin.1,12,24 In the present study, composite that, any color stability study model should consider the
resin showed the greatest susceptibility to staining, effects of toothbrushing that can remove the adsorbed
whereas the difference in the susceptibility of colorants.
compomer and GIC was not statistically significant.
Higher color change of composite resin may be
correlated to the higher resin content.6,15 The extent of CONCLUSION
discoloration was not very high for GIC and
compomer, possible reason may be the glass filler All materials tested were susceptible to staining by all
particles will not absorb staining agents into the bulk of solutions tested, with composite resin showing
the material.6 It can be argued that although compomer significantly higher susceptibility than both compomer
has resin content, the glass filler particles inside did not and GIC, which showed no difference. Brushing
allow higher absorption of the colorants. significantly influenced the color stability of esthetic
restorative materials.
Surface conditions of the restorative materials are
another determining factor in color stability. Fine
colorant particles may be deposited into the pits of
DISCLOSURE AND ACKNOWLEDGEMENTS
restorative materials. This discoloration caused by
surface adsorption may be prevented by
None of the authors have any financial interest in the
toothbrushing.4,5,23 In this study, it was assumed that
products/companies used in this study.
brushing the specimens inhibited the adsorption of
colorants onto the surface of the restorative materials
and decreased the amount of color change over time.
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