INTERMEDIARY LINERS AND BASES

Definition:
Cavity liners and insulating bases are materials placed between dentin
(sometimes pulp) and restorative material to provide pulpal protection or
pulpal response that is why called intermediary.

The reason behind using different intermediary liners and bases:

Prior to placement of the restoration, the pulp might have been irritated
by a variety of sources; including caries, heat generation and pressure
during cavity preparation. Cutting in dentin leads to opening of dentinal
tubules which will considered as direct pathways to the pulp. Cutting with
rotary instruments produces a layer of debris attached to tooth surface
called smear layer. The dentinal smear layer seals the opened dentinal
tubules and thus considered as an effective barrier against irritation.
However, smear layer is 20-30% porous and cannot therefore offer full
sealing of dentinal tubules. Furthermore, the physical and chemical
properties of the permanent restorative material can, in itself, produce an
irritation or aggravate the already existing one. Thus, it is essential to
prevent further irritation of tooth tissue as well as to improve the
defensive and reparative capabilities of the pulp dentin organ.
Sound dentin is the best barrier between the restorative material and the
pulp. The greater the thickness of the overlying dentin bridge, the lesser
the irritation reaching the underlying pulp organ. Further removal of
dentin will lead to increased cavity depth and subsequently decreased
amount of remaining dentin thickness or dentin bridge. In such case,
there is a need for a dentin substitute to provide pulpal protection and
hence we should use intermediary liners and bases.
Pulpal tissues require:
 Chemical protection against metallic ions, corrosion products,
residual monomer and acids from restorative materials or bacterial
toxins and salivary ions due to marginal leakage.
 Thermal protection against metallic restorations.
 Mechanical protection against condensation forces and masticatory
forces.
 Electrical protection against galvanism.

Ideal requirements for intermediary materials:

1. The material should provide a sedative action to the pulp.
2. Biocompatible to pulp tissue and stimulate reparative dentin formation.
3. Provide good sealing and adaptation to cavity walls; preferably
capable of bonding to tooth structure.
4. The material should provide thermal and electrical insulating capacity
at minimal film thickness.
5. The material should have sufficient strength to resist fracture or
distortion under the forces of condensation of the permanent restoration
as well as under masticatory forces during function.
6. It should be compatible with the overlying restorative material; it
should not interfere with their setting
7. The material should resist degradation in the oral fluids.
8. It should have sufficient workability and easily applied.

Types and classification of intermediary materials:

I-LINERS:
1-Solution Liners:
These are thin film forming materials that are used mainly for sealing of
dentinal tubules to provide chemical protection.
A) Varnish:
Form and Composition:
It is supplied in the form of a liquid composed of 10% natural gum (copal
or resin) or synthetic resin dissolved in 90% organic solvent such as
ether, acetone or chloroform.
Function of varnish:
1. It forms a barrier against chemical irritation from the restorative
material.
2. It seals dentinal tubules; thereby it reduces movement of dentinal fluid
and subsequently decreases hypersensitivity.
3. It can provide electrical insulation. However, it is too thin and cannot
provide thermal or mechanical insulation.
4. It is compatible with pulp-dentin organ, except if remaining dentin
thickness is less than1 mm.

Indications of varnish:
1- Under amalgam restoration:
It prevents penetration of metallic ions and corrosion products into
dentinal tubules, thus preventing pulpal irritation and tooth discoloration
(amalgam blues).
2- Under cast gold restoration:
Used to seal tubules but it should be compatible with the utilized luting
cement.
3- Under acidic base material such as Zinc phosphate cement.
Contraindications of varnish:
1- Under resin composite restorations:
It is not logical to use varnish under resin composite as it will prevent the
micro-mechanical interlocking of the resin into tooth structure. In
addition, the residual organic solvent in the varnish may react with or
soften the resin.
2- Under glass ionomer and polycarboxylate cement.
The varnish would negatively affects the adhesive potential of these
cements, as well as prevents the fluoride uptake from glass ionomer.
Manipulation of varnish:
It is applied to all prepared enamel and dentinal surfaces in a thin film
thickness of 2-5μm. Usually 2-3 coats are applied using a cotton pellet or
a microbrush. As each coat is dried, the solvent evaporates leaving a
semipermeable thin resinous film that seals and protects the underlying
structure.
b) Dentin sealers:
It is a resinous material that cures onto the smear layer to act as a
desensitizer. It has the same function and indications as the varnish
c) Bonding systems:
It is a resinous material that dissolves and penetrates the smear layer to
bond micromechanically to tooth substrate. It is polymerized by visible
light curing.
2- Cement Liners:
Types:
1. Calcium hydroxide (Ca (OH)2
2. Zinc oxide eugenol (ZnO/E)
3. Glass ionomer cement (GIC)
4. Resin modified glass ionomer cement (RMGICs)
Cement liners are materials placed in medium thickness (100-500μm) to
provide pulpal medication and/or chemical protection. There are two
important aspects of pulpal medication; relief of pulpal inflammation and
facilitating dentin bridge formation.
 Eugenol and calcium hydroxide are commonly used to provide pulpal
medication.
GIC and RMGIC provide chemical protection by sealing opened
dentinal tubules and mechanical protection.

All cement liners could be used as cement bases, by changing the

powder/liquid ratio. Decreasing the powder/liquid ratio will lead to a
decrease in the strength properties, and an increase in the flow and
solubility so they could be used only as a liner.
On the other hand, increasing the powder/liquid ratio increases the final
compressive strength, and decreases the flow and solubility so they could
be used only as a base material.
Calcium hydroxide
Form and composition:
It is a liner material composed of calcium hydroxide dispersed in aqueous
or resinous solution. It can be supplied as:
-cured, conventional) e.g.: Dycal
-cured, Resin), e.g.: Calcimol LC.

The setting reaction is an acid-base reaction to produce an alkaline paste

of pH =11. The final set cement is hydrolytically unstable; calcium,
hydroxyl and salicylate ions are continuously released from the mass.
N.B.: After certain period of time, the entire mass will disappear from
under the restoration.

Properties and indications:

1. Ca (OH)2 is applied for pulpal medication in cases of direct contact
with the exposed pulp tissue (direct pulp capping). It will stimulate
odontoblasts to form reparative dentin and form calcific bridging at the
exposure site. It also relieves pulpal inflammation. This is owed to
calcium ion concentration, alkalinity and antibacterial potential of this
cement. That’s why it is used in direct pulp capping.
2. It is porous and soluble; therefore it is neither an electric insulator nor
a chemical insulator. However, its alkalinity has a neutralizing effect on
acids of subsequently placed bases or restorative materials.
3. Conventional formulations used as liners are too thin to provide
thermal insulation. On the other hand, resin hard-setting formulations
have excellent handling characteristics and can be built up to the
thickness required for thermal insulation. These formulations are strong
enough to withstand condensation forces, but since they degrade over
time, they can no longer provide mechanical support for the restoration.
4. The release of Ca and OH ions from resin formulations is much more
difficult than conventional formulations.
5. It is compatible with pulp-dentin organ, base materials and all
restorative materials. It has no effect on the setting reaction or properties
of any base or restorative material.

Manipulation:
It is applied only onto the required area, in cases of direct pulp exposure.
II. Cement Bases:
These are materials with thick consistency applied in thick sections (500-
2000μm) to substitute lost dentin and provide thermal and mechanical
protection (applied on pulpal and axial walls only).
Types of bases:
1. Resinous Hard-setting Calcium hydroxide (Ca(OH)2)
2. Reinforced Zinc oxide and eugenol (RZO/E)
3. Zinc phosphate cement (ZPC)
4. Zinc polycarboxylate (PCC)
5. Glass ionomer (GIC)
6. Resin modified glass ionomer cement (RMGIC)

Zinc oxide and eugenol (ZO/E and RZO/E)

Form and Composition:
It is supplied in the form of a powder of zinc oxide and a liquid of 85%
eugenol or clove oil. Polymers, fillers are added to increase the strength
and homogeneity of the mix, and to decrease the flow and solubility. In
the modified formulations (Reinforced Zinc oxide and eugenol RZO/E),
substitution of a portion of eugenol with ethoxy benzoic acid results in an
increase in strength, and a decrease in the solubility.
Function:
1. It has multiple pharmacological actions. Eugenol has a palliative,
sedative, obtundant, and anti-inflammatory action on the pulp. It is thus
used to alleviate discomfort resulting from mild to moderate pulpal
inflammation.
2. ZO/E can be placed in moderately deep cavities, when remaining
dentin thickness is as low as 1mm. However, RZO/E can have irritating
action on pulp tissues at this depth.
3. It is an excellent thermal insulator in a film thickness as low as
0.25mm.
4. It is an excellent electrical insulator and has a good sealing ability.
5. ZOE has low strength properties, not rigid enough to be used as a base.
Despite improved strength properties of RZO/E, it is still inferior to
that of other cements.
Indications:
1- ZO/E can be used as a liner in moderately deep cavities to enhance
pulpal healing. It can also be used as a temporary filling material and for
temporary cementation.
2- RZO/E can be used as a base material, when biological
consideration is more important than mechanical one.

Contraindications:
1. Cannot be placed in very deep cavities (dentin bridge ≤ 0.5mm) or as a
direct pulp capping material.
2. With resin tooth coloured restoratives, eugenol interferes with the
setting reaction of any polymer and can even depolymerize already set
polymeric materials.
3. With glass ionomer cements as well as polycarboxylate cement, where
it would deprive the bonding capabilities of these materials.

Manipulation:
After proper proportioning of Powder/Liquid ratio, incorporation of all
powder into liquid is done. The zinc oxide is slowly wetted by the
eugenol; therefore, prolonged and vigorous spatulation is required to
produce a homogenous mix, especially for a base or temporary filling
consistency. Water is an important component for the setting reaction of
ZO/E as the setting reaction can be accelerated with moisture.
Zinc phosphate cement (ZPC)
Form and Composition:
ZPC is supplied in the form of a powder and a liquid. The powder is
mainly Zinc oxide, with up to 10% magnesium oxide. The liquid is a
buffered 45-55% aqueous solution of orthophosphoric acid. The setting
reaction is an acid-base reaction producing amorphous zinc phosphate.
Properties:
1. It has high compressive strength. It is the most rigid, tough and
durable intermediary base material and thus provides best mechanical
protection.
2. It is an excellent thermal insulator in thickness of 1mm or more. It also
provides good electrical protection.
3. It is the most irritating base material, owing to its acidic pH. Two
minutes after the start of mixing, the pH is approximately 2, and then it
will increase to reach neutrality after 48 hours.
4. It has an exothermic setting reaction and can thus cause thermal
irritation if not properly manipulated.
5. It has no effect on the setting reaction or properties of any permanent
restorative material or base.
Indications:
It is used as a base under metallic restorations and as a luting cement.
Contraindications:
1. Cannot be used as a liner as its acidity can be detrimental to pulp-
dentin organ.

2. It is not recommended to place ZPC when remaining dentin bridge is

less than 1.5 mm without an underlying protective liner (sub-base).

Manipulation:
During manipulation, it should be taken into consideration that the
reaction is exothermic and hence, heat of the reaction should be
neutralized and dissipated. Also, the reactivity of the powder and liquid is
very fast and so we need to extend the working time of the cement during
manipulation. This is achieved via usage of a dry cool glass slab and add
powder in small increments to liquid and mix over a wide area.
Zinc polycarboxylate cement (PCC)
Form and Composition:
PCC is supplied in the form of a powder and a liquid. The powder is
mainly zinc oxide with small amounts of magnesium oxide and silica. The
liquid is an aqueous solution of 40-50% polyacrylic acid. The setting
reaction involves the release of zinc and magnesium ions which blend
with the carboxylic groups forming a cross-linked polyacrylate matrix.
The carboxylic groups that did not enter the reaction will chelate
calcium of the hydroxyapatite of the tooth structure and chemically bond
to tooth structure.
Properties and functions:
1. It bonds chemically to tooth structure, which leads to proper chemical
protection as well as decreased microleakage.
2. The pH of the cement liquid is 1.7. In spite of its initial acidic property,
it produces minimal irritation to pulp-dentin organ. This is probably due
to:
rises rapidly to 3.4 after two
minutes from the start of mixing.
weaker than phosphoric acid.
low diffusion mobility into the underlying dentin
due to its high molecular weight.
3. PCC has somewhat lower compressive strength than ZPC, but
significantly higher tensile strength. It provides proper mechanical
protection.
4. It is a good thermal insulator in thickness not less than 1.5 mm. It is
also an electrical insulator.
5. It is compatible with all permanent restorative materials. It is
compatible with other intermediary materials with the exception of ZOE
and varnish.
Indications:
It is used as a base under any restorative material and as luting cement.
Manipulation:
The setting reaction is fast with short working time. A dry cool glass slab
is recommended to extend working time. The powder may be cooled but
not the liquid to avoid increasing its viscosity. The mix should be applied
while it is in a glossy appearance which indicates the availability of
unreacted carboxylic groups for chemical adhesion.

Glass ionomer cements (GIC and RMGIC)

Form and Composition:
Glass ionomer cements are composed of an acid-soluble fluoro-alumino-
silicate glass powder and a liquid of polyacrylic acid (PAA). The setting
is through acid-base reaction. RMGIC is a hybrid ionomer modified by
resin monomers, usually Hydroxy Ethyl Methacrylate (HEMA) is added
to the liquid, while photo-activated accelerator is added to the powder.
The setting of RMGIC is basically by acid-base reaction, in addition to
immediate command setting light polymerization.
Properties and functions:
1. It has an excellent sealing ability due to chemical adhesion to tooth
structure through carboxylate ions released from PAA liquid.
2. It has an anticariogenic property due to fluoride release from the
powder glass component.
3. It is biocompatible with pulp tissue and all permanent restorative
materials.
4. It provides adequate thermal, chemical and mechanical protection as
well as proper sealing of dentinal tubules. It is the best material to be
used as a dentin substitute.

Advantages of RMGIC over GIC:

RMGIC has a flexible working time due to command setting by light
curing. It also has improved strength and wear properties in addition to
ease of handling. However, GIC has higher fluoride release especially
during the first 24 hours (initial fluoride burst).
Indications:
It can be used as a liner, base, luting cement and even a restoration.
Sandwich Technique: where GI is used as a base under resin composite
to combine the benefit of adhesion and fluoride release of GI with better
aesthetic and higher mechanical properties of resin composite. In
addition, the use of glass ionomer base under resin composite reduces the
total volume of the cavity preparation, thereby reducing the total
volumetric polymerization shrinkage of resin composite. Moreover, it
does not interfere with the aesthetics and optical properties of resin
composite. It is also more economical and reduces the cost of the final
restoration. RMGIC is more popular as a liner/base under resin composite
owing to its ease of handling and its ability to bond to resin composite
due to its resin content (HEMA).
Manipulation:
The cavity should be conditioned with polyacrylic acid before GIC and
RMGIC application to promote adhesion. They are available as powder
and liquid to be hand mixed or in pre-dosed capsules that are
mechanically mixed and then injected into the cavity. Manipulation of
GIC is carried out in the same way as PCC. Packing of the cement should
be done before it loses its glossy appearance, in order to gain its full
adhesive potential. GIC will undergo chemical acid base reaction during
setting, while RMGIC is dual-cured; first through light activated
polymerization, then the conventional acid-base reaction proceeds in the
usual manner.
All cement liners and bases have some degree of solubility in the oral
fluids. Thus, they should be placed only on dentin and should be
completely removed from cavity walls and margins.
Clinical considerations for use of intermediary materials
Clinical judgment for the need of a specific liner or base depends
mainly on:
Remaining dentin thickness (RDT):
As the depth of the cavity increases, the RDT decreases and the greater
the need for intermediary materials before inserting a permanent
restoration.
Adhesive properties of liner or base:
Intermediary adhesive materials should be applied directly on the tooth
structure to benefit from its adhesive potential, except where pulpal
medication is essential.
Type of restorative material:
Whether it is a metallic or aesthetic restoration, direct or indirect
restoration.

After shallow tooth excavation (RDT ≥ 2mm), there is no need for pulpal
protection other than chemical protection (i.e. sealing). In case of an
amalgam restoration, only a solution liner (varnish, dentin sealer or
bonding system in case of bonded amalgam) is utilized. In case of resin
composite, only its bonding system is needed. GIC restoration does not
need any pulpal protection in this case. While in case of indirect
restoration, a solution liner is needed for sealing in addition to the use of
luting cement. In cast gold restoration, a varnish or dentin sealer may be
used while with composite/ceramic inlays a dentin bonding agent is used
with luting cement.

In moderately-deep caries excavation (RDT=0.5-2mm), amalgam

restoration would require the use of a cement liner/base that is capable of
pulpal sedation, e.g. ZOE or Ca(OH)2 in addition to a solution liner for
sealing. With resin composite, dentin bonding agent will provide
sufficient sealing, while a liner/base of GIC or RMGI might sometimes
be needed to reduce the volume of the cavity preparation not for pulpal
protection. GIC restoration does not need placement of any intermediary
material. Indirect restorations will also need sealing in addition to
liner/base and luting cement.

If extensive dentin is lost (RDT ≤ 0.5mm), there is strong need for pulpal
protection. In this case, pulpal medication with Ca(OH)2 is essential with
all restorative materials to induce secondary dentin formation and relief
pulpal inflammation. Sealing is also essential in addition to a strong base
to substitute dentin loss. Thus, the same recommended procedures for
sealing and placement of base cement previously mentioned for moderate
depth (RDT = 0.5- 2mm) becomes mandatory at this depth (RDT ≤
0.5mm).