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Evaluation of Factors Affecting Fluoride Release from Compomer Restorative Materials: A Systematic Review.
| Materials | Oleniacz-Trawinska M, Kotela A, Kensy J, Kiryk S, Dobrzynski W, Kiryk J, Gerber H, Fast M, Matys J, Dobrzynski M. | 18(7):1627.
Dental materials - F release Systematic review Review
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Abstract

Objective: This systematic review evaluates the evidence on factors affecting fluoride release from compomer restorative materials to provide clinicians with insights for optimizing their use in caries prevention. Methods: In February 2025, an extensive digital search was conducted across reputable databases such as PubMed, Web of Science, and Scopus. The search utilized carefully chosen keywords: “fluoride release” AND “compomer” and followed the PRISMA guidelines. Initially, 287 articles were identified, but after applying the inclusion criteria, 34 studies were selected for review.

Results: This review found that fluoride release from compomers follows an initial burst phase before stabilizing at lower levels. Fifteen studies proved that compomers release less fluoride than glass ionomer cements but more than composite resins, as concluded from six studies. The release rate is significantly influenced by pH, with acidic conditions enhancing fluoride diffusion. Some studies also highlighted the potential for fluoride recharge through external applications such as toothpaste or varnish.

Conclusion: Compomer restorative materials offer a steady, moderate fluoride release that supports caries prevention. Their effectiveness is enhanced in acidic environments, supporting their use in high-risk patients.

Graphical Abstract

1. Introduction

Research into dental materials that meet the requirements for marginal sealing, fluoride ion release to prevent caries [1], and biocompatibility ensuring compatibility with oral cavity fluids such as saliva and gingival crevicular fluid has been ongoing for many years. Additionally, these materials should possess antibacterial properties [2], appropriate hardness, and aesthetic appeal. The development of compomers was an attempt to combine the beneficial properties of glass ionomers with composite technology [3]. These materials are polyacid-modified composite resins and are classified as composite materials because they consist of ion-leachable glass (usually calcium–aluminum–fluorosilicate glass) embedded in a polymer matrix [4,5]. However, as these materials do not bond without light activation, they are not classified as glass ionomer cements [6]. Compomers are a popular restorative material used in both primary and permanent anterior and posterior teeth [6,7,8]. They are commonly applied in direct restorations as aesthetic materials, in colored restorative materials [9,10] and as orthodontic cements [11,12].

For many years, clinical studies have demonstrated the importance of fluoride in preventing dental caries. Dental caries is the most prevalent infectious disease worldwide, affecting an estimated 60% to 90% of the global population, particularly children. Due to its extremely high prevalence and substantial adverse impact on overall health, well-being, and quality of life, it is recognized as a global public health problem [13,14]. Fluoride inhibits enamel demineralization in the presence of acids produced by cariogenic bacteria and supports the remineralization of teeth [15]. The use of fluoride-releasing materials for cavity restorations and build-ups has increased significantly in recent years [1,16]. Fluoride exerts its anti-caries effect through multiple mechanisms, including enhancing remineralization, interfering with pellicle and plaque formation, inhibiting the growth of microorganisms, and reducing demineralization [1,15,16,17]. Additionally, it slows the progression of caries in the dentin toward the pulp.

The effectiveness of fluoride ion release in different restorative materials is highly dependent on several variables, including temperature, pH, material preparation methodology, and the type of formulation used [18] (see Figure 1). The pH environment is particularly important clinically, as it varies significantly within the oral cavity [19,20,21]. Clinical studies have shown that pH can drop to a critical level of 4.0–4.5 after glucose metabolism. The threshold for caries development is set at pH 5.5, with values between 5.5 and 6.0 considered potentially cariogenic, while pH levels above 6.0 are regarded as clinically stable for preserving tooth structure [22,23,24]. Different fluoride formulations significantly impact remineralization potential and clinical efficacy [25]. Cement-based materials provide long-lasting fluoride release, creating a sustained protective environment [20,22,26], while varnishes serve as concentrated, temporary fluoride reservoirs with enhanced adhesion to tooth surfaces [27,28]. Gel formulations offer superior penetration into porous enamel structures but require precise application protocols [29,30]. In contrast, liquid formulations, characterized by their immediate ion availability, facilitate rapid remineralization but require more frequent applications due to their shorter duration of action [27,31].

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Figure 1. Factors affecting fluoride release.
Understanding the complex factors influencing fluoride release from compomer restorative materials remains a critical challenge in restorative dentistry. While numerous individual studies have examined specific aspects of fluoride release, previous systematic reviews have primarily focused on glass ionomer cement or fluoride-releasing composites, with limited emphasis on compomers. To our knowledge, no prior systematic review has comprehensively assessed the factors influencing fluoride release from compomer materials. This systematic review aims to bridge this gap by evaluating the available evidence on fluoride release from compomers, considering key variables such as storage conditions, pH environment, and material composition. This review provides a more detailed and structured assessment compared to previous studies by systematically analyzing the trends and influencing factors. The findings offer clinicians evidence-based insights to optimize the selection and use of compomer restorations for caries prevention in clinical practice.

2. Materials and Methods

2.1. Focused Question

The systematic review followed the PICO framework as presented in [32], posing the following focused question: In case of compomer restorative materials (population) what are the factors (investigated condition) increasing the fluoride release (outcome) from these materials compared to other restorative materials (comparison condition)?
2.2. Protocol

The article selection process for the systematic review was systematically detailed using the PRISMA flow diagram [33] (Figure 2). The systematic review was registered on the Open Science Framework under the following link: https://osf.io/9q4am (accessed on 20 March 2025).

Materials 18 01627 g002
Figure 2. PRISMA 2020 flow diagram.

2.3. Eligibility Criteria

The researchers decided to only include articles that fulfilled the following criteria [33]:
  • Compomer restorative materials;
  • Fluoride release evaluation;
  • In vitro studies;
  • Studies in English;
  • Full-text articles.
The reviewers established the following exclusion criteria [33]:
  • Not a compomer restorative material;
  • Evaluation of other physical or chemical properties than fluoride release;
  • Studies without a control group;
  • Non-English papers;
  • Systematic review articles;
  • Review articles;
  • Full text not accessible;
  • Duplicated publications.

2.4. Information Sources, Search Strategy, and Study Selection

In February 2025, a systematic search was performed in the PubMed, Scopus, and Web of Science (WoS) databases to identify articles that met the specified inclusion criteria. To focus on factors affecting fluoride release from compomer restorative materials, the search was limited to titles and abstracts using the keywords: fluoride release AND compomer. All searches followed the predefined eligibility criteria, and only full-text articles available for access were included.

2.5. Data Collection Process and Data Items

Five independent reviewers (M.O., A.K., W.D., J.K. and S.K.) carefully selected articles that met the inclusion criteria. The extracted data included the first author, publication year, study design, article title, compomer dental restorative materials, and the materials’ fluoride release properties. All relevant information was recorded in a standardized Excel version 15.0.4.569.1504 file.

2.6. Risk of Bias and Quality Assessment

In the initial stage of study selection, each reviewer independently assessed the titles and abstracts to minimize potential bias. Cohen’s k test was used to evaluate the level of agreement among reviewers. Any disagreements about including or excluding an article were resolved through discussion among the authors [34].

2.7. Quality Assessment

Two reviewers (J.M. and M.D.) independently evaluated the quality of the selected studies. The evaluation criteria focused on aspects such as study design, execution, and analysis, including the following details: randomization, sample size calculation, control group, detailed description of material composition, exposure time characteristics, ion release measurement method (utilization of TISAB—Total Ionic Strength Adjustment Buffer, Sigma-Aldrich, St. Louis, MO, USA), and sample storage method (environment pH/temperature—1 point; two methods—2 points). The studies were scored on a scale of 0 to 10 points, with a higher score indicating better study quality. The risk of bias was assessed as follows: 0–4 points indicated a high risk, 5–7 points indicated a moderate risk, and 8–10 points indicated a low risk. Any discrepancies in scoring were resolved through discussion until a consensus was reached.

3. Results

3.1. Study Selection

An initial database search of PubMed, Scopus, and WoS identified 287 potentially relevant articles for this review. After removing duplicates, 166 articles remained for screening. Following the initial screening of titles and abstracts, 129 articles that did not focus on fluoride release from dental compomers were excluded. Additionally, the full text of three articles was unavailable. Ultimately, 34 articles were included in the qualitative synthesis of this review. Due to the considerable heterogeneity among the included studies, conducting a meta-analysis was not feasible.

3.2. General Characteristics of the Included Studies

The included studies investigated fluoride release from compomer restorative materials under different experimental conditions [1,18,19,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65]. To facilitate systematic comparison, the studies were grouped according to two primary methodological variables: storage conditions and pH of the storage medium.

The studies demonstrated that the storage medium plays a significant role in fluoride release. Among the analyzed research, distilled water was the most frequently used storage medium, appearing in 21 studies. Fluoride release in distilled water varied significantly, with values ranging from 0.2 ppm to 3.4 ppm, depending on the study [35,38,42]. Artificial saliva was used in nine studies [18,38,42,44,48,59,60,61,63], and comparisons showed that fluoride release was generally lower in artificial saliva than in distilled water. For instance, Sirinoglu-Capan et al. [38] reported that Dyract released 2.0 ppm of fluoride in artificial saliva (pH 7) compared to 3.4 ppm in distilled water (pH 5). The ionic composition of artificial saliva may influence fluoride retention and release. Other studies found that fluoride release was highest when stored in acidic environments, indicating the importance of pH in fluoride dynamics [19,37,59].

Another key factor affecting fluoride release was the pH of the storage solution. Several studies confirmed that fluoride release increased significantly in acidic environments (pH 4.0–5.5) [19,37,60,61]. Moreau et al. [19] demonstrated that Dyract Flow exhibited the highest cumulative fluoride release at pH 4.0, with values reaching 516 ± 6 µg/cm2 over 84 days. Similar findings were reported for Freedom, which released more fluoride at pH 4.3 (2.7 µg/cm2) than at pH 6.2 (1.2 µg/cm2) [60,61]. Conversely, fluoride release decreased in neutral or alkaline environments, with studies showing lower values at pH 7.0 compared to acidic conditions [18,38]. This suggests that fluoride ion diffusion from compomers is more effective in cariogenic environments where the pH is lower.

Comparisons among different compomers also revealed variability in fluoride release performance. Among commercially available materials, F-2000 exhibited the highest fluoride release, maintaining 1.62 ppm on day one and 0.11 ppm after four weeks, outperforming Dyract in long-term fluoride emission [47]. Other compomers, such as Compoglass and Glasiosite, showed varying levels of fluoride release, with Glasiosite releasing three times more fluoride than Compoglass on day one [55]. Experimental compomers tested by Adusei et al. [51] exhibited even higher fluoride release, with values exceeding 500 ppm after six weeks, though the absence of detailed storage conditions limited direct comparisons.

In addition to fluoride release, some studies examined fluoride recharge potential. Fluoride uptake from external sources, such as fluoride gels, varnishes, and toothpaste, played a role in enhancing fluoride release. Studies showed that NaF gels increased fluoride emission significantly, though this effect was temporary [55]. Senthilkumar et al. [62] found that daily brushing with fluoride toothpaste resulted in sustained fluoride release, comparable to the effect of a single fluoride varnish application. These findings highlight the potential for enhancing fluoride release through external fluoride exposure, which may be beneficial in clinical applications (Table 1).

Table 1. General characteristics of studies.

3.3. Main Study Outcomes

The reviewed studies consistently indicate that fluoride release from compomer restorative materials follows a characteristic pattern. Most studies report an initial burst release, where fluoride concentrations are highest within the first 24 h, followed by a rapid decline over the next few days, and subsequent stabilization at a lower level over time [18,35,37,38,41,42]. This trend is consistent across different storage conditions, with variations observed depending on the material composition, storage medium, and pH environment.

A systematic comparison of the included studies revealed that compomers generally release less fluoride than glass ionomer cements (GICs) but more than composite resins [18,35,37,38,41,42,43,44,45,46,47,49,53,63,64]. For example, Dyract XP, Dentsply Sirona, Konstanz, Germany, one of the most extensively studied compomers, exhibited an initial fluoride release of 0.2–3.4 ppm in distilled water, with fluoride levels declining by 50–70% after 48 h [35,38,42]. By day 7, fluoride release from Dyract stabilized at approximately 0.15–0.6 ppm, which was three to five times lower than GICs but approximately twice the release rate of composite resins [18,35,37,38,41,42,44]. Similar findings were observed for other compomers, such as F-2000, which demonstrated superior fluoride release compared to Dyract XP, with 1.62 ppm recorded on day one and maintaining higher long-term fluoride release (0.11 ppm at week four compared to Dyract’s 0.06 ppm) [47].

The analysis of fluoride release trends across various compomers highlights differences in their performance. Compoglass F, Ivoclar Vivadent, Schaan, Liechtenstein, studied in five papers, showed an initial fluoride release of 10–15 µg/cm2/day, which declined to 1–2 µg/cm2/day after one week [55,56,57,58]. When exposed to sodium fluoride (NaF) gel, its fluoride release increased temporarily from 0.27 ppm to 2.4 ppm, but this effect lasted only two days [55]. On the other hand, Twinky Star, VOCO GmbH, Cuxhaven, Germany, exhibited an initial release of 0.95 ppm, which declined to 0.24 ppm by day 30 [63]. After fluoride varnish application, fluoride release increased to 1.83 ppm, significantly lower than glass ionomer sealants, which released up to 35.95 ppm [62]. Similarly, Glasiosite showed low fluoride release (0.2 ppm on day seven, which was one-fourth of Compoglass F), but after NaF treatment, its release increased to 0.37 ppm. Compared to GICs, Glasiosite released 10–15 times less fluoride, positioning it closer to composite resins than to GICs in terms of fluoride release properties [55].

The pH environment significantly influences fluoride release rates, with most compomers demonstrating increased fluoride release in acidic conditions. Freedom, for instance, released 2.7 µg/cm2 at pH 4.3, compared to 1.2 µg/cm2 at pH 6.2 [61]. This pH-dependent behavior was also observed in studies by Silva et al. [60], Sen et al. [37], and Moreau et al. [19], confirming that lower pH enhances fluoride release. Dyract Flow, tested by Moreau et al., exhibited cumulative fluoride release of 516 ± 6 µg/cm2 at pH 4 over 84 days, whereas fluoride levels at neutral pH were significantly lower. Conversely, studies such as those by Kosior et al. [59] and Hammouda et al. [58] confirmed that the highest fluoride release occurs within the first 24 h, after which fluoride levels stabilize for at least six months.

Beyond passive fluoride release, some studies examined the fluoride recharge potential of compomers. Daily brushing with fluoride-containing toothpaste or exposure to fluoride varnish enhanced fluoride release, albeit temporarily. Senthilkumar et al. [62] found that daily fluoride brushing resulted in sustained fluoride release comparable to a single fluoride varnish application. Similarly, Makkai et al. [63] reported that fluoride release after brushing lasted longer than after fluoride gel application. This suggests that compomers can act as fluoride reservoirs, but their recharge capacity is lower than that of GICs. Experimental compomers have also shown promise in improving fluoride release capabilities. Adusei et al. [51] tested novel compomer formulations, with one experimental compomer maintaining 527.5 ppm fluoride release after six weeks—significantly higher than conventional compomers like Dyract AP (459.2 ppm). These results suggest that modifications in compomer composition could enhance their long-term fluoride release properties, potentially bridging the gap between traditional compomers and GICs (see Table 2).

Table 2. Detailed characteristics of studies.

3.4. Quality Assessment

Of the total number of articles included in the present review, six [18,37,39,49,59,61] were classified as high quality, ranging from 8 to 9 out of 10. In contrast, twenty-three studies [1,19,35,37,38,40,41,42,43,44,45,46,48,50,51,52,54,56,57,60,63,64,65] demonstrated a moderate risk of bias, with scores falling between 5 and 7. Additionally, five studies [36,47,53,55,58] were deemed to have low quality, receiving scores ranging from 2 to 4 (refer to the Table 3).

Table 3. Quality assessment of included studies.

4. Discussion

Fluoride release from compomers is influenced by various factors, including material composition, storage conditions, and fluoride recharge. Most studies confirm that compomers release less fluoride than glass ionomer cements (GICs) but more than composite resins [18,35,37,38,41,42,43,44,45,46,47,49,53,63,64]. However, some findings contradict this trend. Zhao et al. [57] reported no significant difference in fluoride release between compomers and composites, while Dhull et al. [65] found that giomers released more fluoride than compomers. The storage medium also affects fluoride diffusion, with some studies indicating greater release in deionized water than in artificial saliva [18,42], whereas others found the opposite [37], likely due to differences in ionic composition. A common release pattern was observed across studies, with the highest fluoride levels detected within the first 24 h, followed by a gradual decline and stabilization over several months [58,59]. Additionally, external fluoride applications—such as toothpaste, varnish, or gels—can enhance and prolong fluoride release [55,62,63]. Research on extracted teeth suggests that fluoride uptake is most effective in immature permanent teeth, particularly when pre-conditioning agents are used [48]. These findings highlight the role of compomers as materials capable of sustained fluoride release, particularly for patients at high risk of caries, where additional fluoride exposure can maximize their protective effects.

One of the most significant external factors influencing fluoride release from compomers is the pH of the surrounding environment. Studies included in this review demonstrate that fluoride release increases under acidic conditions, particularly at pH levels below 5.5, which mimic cariogenic environments [18,19,38,42,59,60,61]. Kosior et al. [59] found that compomers released the highest fluoride levels in artificial saliva at pH 4.5, whereas significantly lower levels were observed in neutral or alkaline solutions. Similarly, ?irino?lu-Çapan et al. [38] reported enhanced fluoride release in acidic conditions, likely due to increased material degradation and ion diffusion. This trend aligns with the broader literature indicating that resin-based materials release more fluoride in acidic environments due to ion exchange and filler hydrolysis [54]. Additionally, glass ionomer-based materials, including compomers, function as pH-dependent fluoride reservoirs, releasing more fluoride during cariogenic acid attacks [66]. A study by Al-Jadwaa et al. further supported this, demonstrating that fluoride release from composite resins was significantly higher at pH 4 compared to neutral or alkaline conditions [67]. Moreover, Nigam et al. [18] observed that pH-cycling—simulating alternating periods of demineralization and remineralization—further influences fluoride release patterns, with the highest release occurring during acidic phases. While the ability of compomers to release fluoride in response to pH fluctuations enhances their cariostatic potential, maintaining a balance between fluoride release and long-term material stability remains crucial. Further research is needed to optimize formulations that ensure both durability and sustained therapeutic benefits.

Another factor influencing fluoride release from the tested compomers was the medium in which the material samples were stored. The deionized water used in many studies [1,18,35,37,38,39,40,41,42,45,46,47,52,53,54,55,56,57,58,60,61] does not accurately reflect the complex chemistry of the oral environment. Therefore, several authors also tested the materials in artificial saliva [18,37,38,42,43,44,48,59,62,63,64] that contained NaCl, KCl, urea, Na2S × 9H2O, NaH2PO4 × 2H2O, and calcium ions in the form of CaCl2 × 2H2O. Additionally, one study used natural saliva [49], while another utilized a 0.9% saline solution [19,59]. According to Silva et al., fluoride release from the tested restorative materials varied depending on the storage medium due to differences in ion flow mechanisms and pH levels. In most studies, the storage medium was changed daily. Kosior et al. [59] found that compomers released the highest fluoride levels in artificial saliva, while much lower levels were observed in other solutions, which was largely influenced by the pH of the medium. In contrast, Nigam et al. [18] observed that fluoride ion release was highest in the pH-cycling model across all tested restorative materials, followed by deionized water, with artificial saliva yielding the lowest release.

Temperature fluctuations in the oral cavity, caused by the consumption of hot or cold foods and beverages, make it essential to analyze fluoride release from compomer materials at different temperatures. In most studies, the tested materials were stored at 37 °C, which best represents the oral environment. However, exceptions include studies [47,53] where the temperature was 25 °C, and one study [48] where the medium was kept at room temperature. In a study by Sen et al. [18], the authors tested fluoride release at three different temperatures, 4 °C, 37 °C, and 55 °C, finding that the highest fluoride release occurred at 55 °C. In general, fluoride release increased with rising temperature, with one exception: after 14 days, fluoride release from glass ionomer cement (GIC) at 37 °C was higher than at 55 °C. Yan Z. et al. [68], in a study on glass ionomer materials, confirmed that all tested glass ionomers exhibited higher fluoride loading capacity at elevated temperatures. Additionally, increasing the ambient temperature enhanced both fluoride release and material loading capacity. These findings are crucial for developing optimized fluoride delivery strategies in restorative materials.

These findings open promising avenues for further research in this field. However, it is important to acknowledge the limitations of the current systematic review. To enhance the evaluation of this topic, further studies are warranted—preferably with larger sample sizes and including both clinical and in vivo investigations. Future research should also incorporate a broader range of commercial materials, tested over extended periods, under varying temperatures, media, and pH conditions. Additionally, it would be valuable to explore the impact of fluoride release on the antibacterial properties of these materials, as well as their physicochemical characteristics.

5. Conclusions

This review highlights that compomer restorative materials predictably release fluoride—starting with an initial burst, followed by a steady, lower release phase. They release more fluoride than composite resins but less than glass ionomer cement, making them a viable choice for moderate fluoride release in clinical applications. Most studies supporting these findings present a moderate risk of bias, with relatively few high-quality studies available. This gap in evidence underscores the need for more rigorous research. Their specific formulations influence fluoride release and stability in compomers. Some compomers release more fluoride in acidic conditions, while others demonstrate better recharge potential after fluoride exposure. Future studies should further explore these differences, particularly in a clinical setting, to better understand their role in cavity prevention and long-term durability.

Despite these insights, the limitations of this systematic review must be acknowledged. Additional studies are needed to provide a more comprehensive evaluation of this topic, preferably with larger sample sizes and including both clinical and in vivo investigations. Future research should also explore a broader range of commercial materials, including metal-based nanomaterials, which have emerged as promising agents for treating and preventing dental caries [69]. Evaluating these materials under varying temperatures, media, and pH conditions would enhance understanding of their clinical performance. Additionally, further studies should investigate the impact of fluoride release on these materials’ antibacterial properties and physicochemical characteristics to assess their full potential in restorative dentistry.

Funding

This work was financed by a subsidy from Wroclaw Medical University.
Institutional Review Board Statement

Not applicable.
Informed Consent Statement

Not applicable.
Data Availability Statement

Not applicable.
Conflicts of Interest

The authors state that there are not any conflicts of interest related to this study.
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