Contemporary Dental Adhesives

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4 CE credits This course was written for dentists, dental hygienists, and assistants.

Contemporary Dental Adhesives for Direct Placement Composite Restorations A Peer-Reviewed Publication Written by Howard E. Strassler, DMD, FADM, FAGD and Luis Guilherme Sensi, DDS, MS, PhD

PennWell is an ADA CERP recognized provider ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual an ADAofCERP Recognized courses or instructors, nor PennWell does it imply is acceptance credit hours by boards ofProvider dentistry. Concerns of complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp.

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This course has been made possible through an unrestricted educational grant from Heraeus Inc. and Kerr Corporation. The cost of this CE course is $59.00 for 4 CE credits. Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.

Educational Objectives Upon completion of this course, the clinician will be able to do the following: 1. Discuss the differences between etch-and-rinse and self-etch adhesives, and relate these categories to other naming systems that have been previously presented. 2. Discuss current research evidence comparing etch-andrinse and self-etch adhesives. 3. Describe the indications for etch-and-rinse and selfetch adhesives. 4. Describe the clinical procedure for an etch-and-rinse and self-etch single-step adhesive.

Abstract Dental adhesives that bond composite resins to tooth structure have evolved over the last several decades. The earliest bonding systems required an acid-etch technique and were only compatible with enamel. The challenge has always been to predictably bond to enamel and dentin simultaneously. There can be confusion, however in what bonding agents are being described because there are a number of different labeling categories. With a simplified, logical category description the clinician is better able to understand what each bonding agent is and how it is used. No one universal bonding system does it all. The key to success is providing your patients with materials and techniques that you can reproduce to achieve the best, longest-lasting clinical results.

Introduction The Holy Grail for adhesion to enamel and dentin has been described as being an adhesive that can be placed routinely in a simple and reproducible technique. In the development of this adhesive, it has been generally accepted that if and when this universal adhesive becomes available, it will most likely be a single component, no-mix adhesive that can be applied directly to enamel and dentin for the purpose of bonding any restorative material to tooth structure. This adhesive would be equally effective in its physical properties to enamel and to dentin. It would be a bonus if it allowed us to bond to all intraoral materials — all types of dental metals, dental ceramics and dental resins. Manufacturers continue to work on the development of such a product, and while this product does not yet exist, monumental strides have been made. This towering challenge to develop a universal adhesive has been described in many articles. This author remembers reading an article in 1985 written by Dr. Wayne Barkmeier on the fundamental elements for an adhesive used for bonding to tooth structure. Recently these five key prerequisites for successful adhesion to tooth structure were reiterated, because they have not changed since 1985.1 These five prerequisites or criteria are: 1. The procedure must be safe and biologically acceptable. 2. The level of bond strength must be clinically significant to avoid discoloration at the margins and secondary caries. 2

3. The bond strength must be routinely achieved so that predictable results are obtained. 4. The bond must be established quickly in order to permit immediate finishing. 5. The bond must be stable in vivo for a clinically significant period of time. It has taken almost 20 years to reach these lofty goals. But there is no doubt that with the current adhesives available, reliable adhesion to tooth structure can be achieved.

Enamel Bonding The idea of adhesive bonding to dentin was theoretically postulated more than 50 years ago as being a potential chemical bond between the methacrylate group of resins to the collagen surface of dentin.2 While bonding to dentin was far from the profession’s reach 50 years ago, adhesion to enamel was successfully pursued. In 1955, Buonocore described a clinical technique that utilized a diluted phosphoric acid (actually the first trials were done with the phosphoric acid liquid in zinc phosphate cement) to etch the enamel surface and provide for retention of unfilled, self-cured acrylic resins.3 The resin mechanically locked to the microscopically roughened enamel surface, forming small “tags” as it flowed into enamel microporosities 10–40 micrometers deep and then polymerized (Figure 1). The first clinical use of this technique was the placement of sealants.4 The use of this acid-etch technique was extremely controversial, and led to a position paper requested by the American Dental Association criticizing the early sealant studies, with reports of caries prevention in pits and fissures after 18 months.5 Figure 1. SEM of etched enamel.

The first commercialization of bonding to enamel was in the late 1960s and early 1970s. The combination of acid etching enamel and adhesive composite resin restorations afforded the benefits of reduction or elimination of microleakage at the enamel margins, less discoloration at the margins, lower rates of recurrent caries, and improved retention of the restoration.6,7 Unfortunately, the composite resins used at that time had poor esthetic longevity. These composite resins shifted in color, were rough and difficult to polish, picked up surface stain, and wore in function. www.ineedce.com

The effectiveness and success of etched enamel/resin bond has been demonstrated in many reported clinical trials.8 In our everyday practice we do not think twice about using a dental adhesive when placing a restoration based upon the etched enamel/resin bond. The use of adhesives is well accepted for the placement of sealants.9 Clinically successful less invasive cavity preparations to restore carious pits and fissures using an enamel adhesive technique with preventive resin restorations (PRR) are well documented.10,11 All anterior preparations and restorations restored with composite resin with an enamel bonding technique have also been demonstrated to be highly successful.12 Predictable posterior composite resins that are clinically successful for more than 10–15 years with use of an etch-and-adhesive technique with composite resins have been demonstrated, and in fact it has been reported that posterior composite resins be considered amalgam alternatives in routine-sized preparations.13,14,15 The ultimate test of the enamel bond is the placement of a thin, inherently brittle veneer of porcelain to the facial surfaces of anterior and posterior teeth. In an up-to-20-year clinical evaluation of porcelain veneers fabricated from Cerinate Porcelain (Den-Mat) bonded to enamel, there was a 93% success rate with a mean of 15.2 years.16 In fact, over the course of the study there were no debonds of the veneers. This parallels Friedman’s retrospective study of porcelain veneers where he evaluated approximately 3,500 restorations and reported on 245 failures, once again a 93% success rate.17 Of those veneers that debonded completely, the margins were surrounded with dentin.

Dentin Bonding Unlike enamel bonding, dentin bonding has seen an evolution in its viability. Effective dentin-bonding materials should fulfill the following goals: • The material should adhere to dentin at a clinically acceptable level, and should be able to withstand intraoral forces of occlusion and mastication. • The bond should be instantaneous once the material has set. • The material and technique must be biocompatible. • The material should resist the forces of polymerization shrinkage of composite resins and the coefficient of thermal expansion and contraction to eliminate microleakage. • The material should create a long-lasting bond to dentin. • Postoperative sensitivity must be minimized or eliminated.

of fractured crystals of hydroxyapatite and denatured collagen. This layer acts as a barrier to clog the dentin tubules and may be responsible for desensitizing a cavity preparation after a bur or hand instrument interacts with the dentin. This early foray into dentin bonding attached to the smear layer, creating a weak, clinically unacceptable bond to dentin. This basis of a phosphate-calcium bond later became the third-generation phosphate ester bonding systems. These bonding systems, e.g., the original Scotchbond (3M) and BondLite (Kerr) among others, adhered to the calcium-rich dentin smear layer and to etched enamel. Bond strengths to dentin were limited by degree of adherence of the smear layer to the dentin. Unfortunately over a short time, 12–18 months or less, the durability of the bond was impacted by hydrolysis that occurred at the phosphate/calcium interface.20,21 These products had very limited success when dentin was the primary bonding substrate. At the same time a parallel research path investigated the use of a total-etch approach, etching the enamel and dentin simultaneously.22,23 At the time there was concern that phosphoric acid placed on dentin would cause pulpal inflammation and necrosis.24 Jennings and Ranly demonstrated that the pulpal effect of phosphoric acid on dentin for one minute was minimal.25 Early results reported with dentin etching were disappointing because the adhesive resin used was the same unfilled hydrophobic Bis-GMA bonding resin used for bonding to etched enamel.26 The hydrophobic resin would not wet the moist, vital dentin and predictable adhesion could not be produced. The breakthrough in simultaneous adhesion to enamel and dentin was first described in the late 1970s by Fusayama and coworkers27 Bertolotti28 and Kanca.29 They referred to their technique as “total etch.” They demonstrated the success of the total-etch adhesive bond based upon the removal of the smear layer through dissolving with the phosphoric acid and by adding a hydrophilic monomer, usually hydroxyethyl methylmethacrylate (HEMA) to the primer and adhesive. This hydrophilic monomer allows the adhesive resin to penetrate the moist intertubular dentin, peritubular dentin, and dentinal tubules, creating an infiltrated hybrid zone allowing for intimate union of the dentin and adhesive.30 (Figure 2). Figure 2. SEM of multiple-bottle etch-and-rinse adhesive infiltrated dentin hybrid zone (3-E&R) (OptiBOND FL) (dentin has been dissolved to demonstrate resin infiltration).

Surmounting the smear layer impediment The earliest research in 1956 with dentin bonding focused on chemical adhesion of resins to the inorganic components of dentin. Buonocore and coworkers developed a methacrylatebased dentin adhesive that contained phosphate groups to attach to the calcium ions on the dentin surface.18 The basis of the bond was the presence of the dentin smear layer.19 The dentin smear layer refers to the loosely bound debris consisting www.ineedce.com

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These concepts led to the development in the late 1980s and early 1990s of multi-step adhesive bonding systems (3-E&R), which required the application of a primer and then an adhesive resin that used a total-etch technique with phosphoric acid. In the mid 1990s, clinicians sought a simplified approach that used fewer steps for adhesive placement. Manufacturers responded with the introduction of single-bottle primer/adhesive bonding systems that required etching of the enamel and dentin. These single-bottle primer/adhesive bonding systems (2-E&R) combined with etching of the dentin and enamel provided the same hybridization of the dentin that was seen with the multiple-bottle systems (Figure 3). Figure 3. SEM of single-bottle etch-and-rinse adhesive (2-E&R) infiltrated dentin hybrid zone (OptiBOND Solo Plus) (dentin has been dissolved to demonstrate resin infiltration).

Figure 4A. SEM of composite resin/dentin interface that is gap-free with a single-step self-etching adhesive (1-SEA) (iBOND ® Self Etch).

SEM courtesy of Heraeus

Figure 4B. SEM of infiltrated dentin hybrid zone with a single-step self-etching adhesive (1-SEA) (OptiBOND All-In-One).

SEM courtesy of Kerr-Sybron

SEM courtesy of Kerr-Sybron

The search for even greater simplification lead to continued research with adhesives that would incorporate the etching-priming-adhesive steps simultaneously. The challenge was to create a stable chemistry that would have an adequate shelf life. The earliest self-etching adhesives required two separate application steps — a self-etching primer and then the adhesive (2-SEA) (Clearfil SE Bond, Kurary). Other products followed this same chemistry (e.g., Tyrian SPE, Bisco; Adper ScotchBond SE, 3MESPE). Later, single-step products providing separate bottles that needed to be mixed were introduced (1-SEA). The introduction of iBOND® Self Etch (Heraeus) was the first single-bottle (or unit dose), one-step self-adhesive (1-SEA) that created a gap-free dentin-infiltrated hybrid zone . Other 1-SEA systems also provide for a resininfiltrated hybrid zone (e.g., OptiBOND All-In-One, Kerr; Xeno IV, Dentsply-Caulk; Adper Easy Bond SE, 3M-ESPE) (Figure 4). Classification of bonding systems The development of improved adhesion systems using different chemistries with a variation in the numbers of reagents and steps for application led to a number of different descriptions of the categories and classification of adhesives. With no standard for classification and de4

scription, there was some confusion among clinicians and researchers alike. With the development of two different classes of bonding systems that relied on the use of phosphoric acid as a surface etchant came the classification and description of bonding systems based upon generational timeline changes. Fourth-generation bonding systems were referred to as totaletch multi-bottle (multi-step) systems, and fifth-generation systems were referred to as total-etch single-bottle bonding agents that contained both primer and adhesive. Both fourth- and fifth-generation products required a total-etch with phosphoric acid before adhesive placement. In reaching for the goal of adhesive simplification of both techniques and reduction in the number of steps, the earliest self-etching bonding systems were introduced. These adhesives did not require the additional step of applying phosphoric acid, rinsing and drying before application. The classification system became even more complex when bonding systems that had the additional step of phosphoric acid etching were referred to as total etch, and those adhesives that did not require the additional step of phosphoric acid were referred to as self-etch. Others continued with generational descriptions building on the fourth- and fifthgeneration model. The self-etching systems were referred to as sixth and seventh generation. These terminologies do not adequately describe the current adhesives being used for composite resin bonding. (Indications for each adhesive system are listed in Table 1.) www.ineedce.com

Table 1. Clinical applications for adhesive systems

Table 2. Classification of adhesives according to Van Meerbeek et al. 31

Etch-and-Rinse Adhesive Systems:

Etch-and-Rinse Adhesives

Multiple-bottle (3-E&R):

all uses, including self-cure composite resin cores and dual-cure composite resin cementation

Three-step multiple-bottle etch-and-rinse adhesives (3-E&R)

Single-bottle (2-E&R):

direct composite resin placement, and with systems that have an activator use with self-cure and dual-cure composites

Self-etching systems: (not indicated with self-cure or dual-cure composites unless the manufacturer makes the recommendation)

Two-step single-bottle etch-and-rinse adhesives (2-E&R) Self-Etch Adhesives Two-step multiple-bottle self-etch adhesives (2-SEA) One-step multiple-bottle mix self-etch adhesives (1-SEA) One-step no-mix self-etch adhesives (1-SEA) Table 3. Etch-and-rinse adhesives

Multi-step systems (2-SEA):

direct placement Class I, II, III, and V with prepared enamel

Single-step mix systems (1-SEA):

direct placement Class I, II, III, and V with prepared enamel

Multiple-Bottle Three-Step Etch-and-Rinse (3-E&R) OptiBOND FL

Kerr

Single-step no-mix

(1-SEA):

Gluma Solid Bond

Heraeus

Syntac

Ivoclar/Vivadent

Tenure MP

Den-Mat

Scotchbond MP

3M-ESPE

ProBond

Dentsply/Caulk

Dentastic

Pulpdent

All Bond 3

Bisco

Use of any adhesive is manufacturer-specific for use with selfcure and dual-cure composite resin systems. At the current time self-etching systems can be used for Class IV incisal edge repair, facial veneering and porcelain veneers with a light cure cement (or flowable composite as a luting agent) with the use of a total etch of the enamel surface with phosphoric acid etchant. As more evidence becomes available in clinical trials this recommendation may change. Also, if phosphoric acid is used with an SE adhesive, only the enamel needs to be etched.

Rational approach to nomenclature for dental adhesives All adhesives used today exhibit the same phenomenon for adhesion to enamel of micromechanical locking to the etched enamel prisms and to dentin through hybridization.31 The use of the classification “total etch” is in fact a misnomer. All adhesives, including the self-etching systems, etch tooth structure “totally” and are applied to the enamel and dentin simultaneously. Also, the number of steps for adhesion has been misstated as being a single step for so-called fifthgeneration adhesives, when in fact there is the additional step of application and rinsing and drying of the phosphoric acid. In 2003 Van Meerbeek et al. proposed a rational, logical categorization and classification of the current adhesives based upon what is required to achieve the adhesive interface to enamel and dentin32 (Table 2). Based upon the current adhesives that are being used in our practices, the classification of adhesives falls into two distinct categories: etch-and-rinse (Table 3) and self-etch (SE) (Table 4). Etch-and-rinse approach The etch-and-rinse adhesives can be recognized by the initial step of the application of phosphoric acid to the enamel/dentin followed by the mandatory rinsing step. The enamel etching leaves a microscopically roughened surface to bond to. The etch-and-rinse technique uses a 10–40% phosphoric acid that removes the dentin smear layer and is then rinsed with water and dried from the dentin. The dentin is then rewetted with water, leaving a damp, glossy surface. An adhesive resin is then applied. The adhesive resin is provided as either two www.ineedce.com

(check with manufacturer for those products that can be used with self- and dual-cure composite resins)

Single-Bottle Two-Step Etch-and-Rinse (2-E&R) OptiBOND Solo Plus

Kerr

Gluma Comfort Bond + Desensitizer

Heraeus

Prime and Bond NT

Dentsply/Caulk

XP Bond

Dentsply/Caulk

Single Bond Plus

3M-ESPE

Excite

Ivoclar/Vivadent

IntegraBond

Premier Dental

Syntac Single Component

Ivocalar/Vivadent

Dentastic Uno

Pulpdent

One Coat Bond

Coltene/Whaledent

Tenure Quick

Den-Mat

Clearfil Photobond

Kuraray Medical

One Step Plus

Bisco

bottles, a dentin primer and a separate adhesive (also referred to as three-step etch-and-rinse (3-E&R) (e.g., OptiBOND FL, Kerr, ScotchBond MP, 3M-ESPE)), or as a single bottle that contains both primer and adhesive (also referred to as two-step etch-and-rinse (2-E&R) (e.g., OptiBOND Solo Plus, Kerr and Gluma Comfort Bond + Desensitizer, Heraeus)). For the single-bottle etch-and-rinse systems, many of these products are provided in single-unit doses. In the case of multiple-bottle 3-E&R, OptiBOND FL is supplied as unit dose packaging for primer and adhesive. 5

Table 4. Self-etching adhesives Two-Step Self-Etch (2-SEA) Adper ScotchBond SE Clearfil Liner Bond 2V Clearfil SE Bond Apex Dental Tyrian SPE Simplicity

3M-ESPE Kuraray Kuraray Kuraray Bisco Apex Dental

Single-Step Self-Etch Mix systems (1-SEA) Den-Mat Ivoclar/Vivadent Prompt-L-Pop 3M-ESPE Touch and Bond Parkell One-Up Bond F Plus J. Morita Single-Step Self-Etch No-Mix system (1-SEA) iBOND ® Self Etch Heraeus OptiBOND All-in-One Kerr G-Bond GC America Xeno IV Dentsply Clearfil S3 Kuraray Adper Easy Bond SE 3M-ESPE Based upon the evidence to date, bonding to enamel is best accomplished with this technique. Etching as a separate step increases the surface area of the enamel by microscopically roughening the surface, and increases the surface energy to allow the resin to synergistically flow into the enamel microporosities for improved retention and sealing. Also, both in vitro and in vivo research have demonstrated that etch-and-rinse adhesives can reliably bond to both enamel and dentin.33,34,35 Clinical success with etch-and-rinse adhesives is dependent on this basic clinical technique: 1. Tooth preparation (all classes of preparation; can be in enamel-only Class IV, facial veneers, porcelain veneers) 2. Etch with a phosphoric acid (range of concentration 10%–37%) for 15–30 seconds (15 seconds for dentin only) 3. Rinse with air-water spray for 10 seconds 4. Dry the tooth, leaving the enamel frosty, dentin glossy (moist)35,36 5. Apply adhesive system of choice; light curing 6. Apply restorative material; light curing Self-etch adhesives It was obvious that the more steps required to bond a restoration, the greater the potential for inconsistency of timing of application, rinsing, drying, rewetting dentin and maintaining a controlled operative field during treatment.36 This inconsistency can lead to an impact on the success of the bond and the durability of the restoration. Manufacturers responded to this desire by placing research efforts in the development of 6

self-etching adhesive systems. Self-etch adhesives (SE) use a more acidic monomer in a HEMA/water-based adhesive. As such they do not require a separate etch-and-rinse step. The SE approach does not require a separate etching step because the etchant is incorporated in the adhesive (either in a separate self-etching primer or in the adhesive). Also, a separate rewetting with water step is eliminated because SE adhesives contain water and are never completely dried from the tooth. SE adhesives do not remove the smear layer but incorporate it in the adhesive. Their compositions are aqueous mixtures of acidic functional monomers, usually phosphoric acid esters with a pH value higher than phosphoric acid gels.37 It has been reported that the pH of Clearfil SE Bond (Kuraray America) is approximately 2.0, when compared to a pH of 0.5–1.0 for typical phosphoric acid gels.38 Unlike the etch-and-rinse adhesives that dissolve the dentin smear layer and remove it during the rinsing of the etchant, the self-etching adhesives incorporate the smear layer into the adhesive. Investigations have demonstrated that SE systems provide for similar hybridization and infiltration of dentin as is seen with etchand-rinse adhesives. There has also been concern about the quality of bonding of SE adhesives to enamel. If enamel is left unprepared, it is resistant to etching and adhesion with most SE adhesives.39,40,41 Also at the current time the use of a SE adhesive for restoring Class IV incisal edge fractures, esthetic facial veneering and diastema closures with direct composite resin and bonding porcelain veneers is contraindicated.42 A chief complaint among practitioners with composite resin restorations has been the rate of postoperative sensitivity, especially using etch-and-rinse adhesives following the placement of Class I, II and V restorations. Several clinical studies have investigated postoperative sensitivity using both etch-and-rinse and SE adhesives.43,44,45,46,47 The results of these studies demonstrated no difference in postoperative sensitivity between the adhesive types. In fact, the conclusion of one study stated that postoperative sensitivity may depend on the restorative technique and variability among operators rather than on the type of enamel-dentin adhesive used.48 One area of inconsistency with etch-and-rinse bonding has been the bonding potential to desiccated dentin.49,50 The inherent chemical nature of SE adhesives is that they are water containing; because they are no-rinse, the dentin surface is left moist. This may account for the case reports of minimized postoperative sensitivity.51 Also with SE bonding the variability between operators can be minimized by simplifying the technique of adhesive placement.52,53 There has been concern that the chemical reagents in SE adhesives, especially singlecomponent adhesives, require attention to detail due to the solvent and water in the mixture. It is important that during the drying process, the water and solvent be evaporated with a gentle air spray following the timing as noted in the manufacturer’s instructions, and that the adhesive be thinned; too thick a layer will compromise the bonding. Adequate airdrying (also called “air-thinning”) is needed to remove most www.ineedce.com

water (solvent) from the adhesive before light-curing the adhesive otherwise the residual water may negatively affect the curing of the adhesive and therefore bond strength. Santini and coworkers investigated microleakage around Class V restorations bonded with etch-and-rinse and SE adhesives.54 They concluded that SE systems were as reliable as TE systems. Some clinicians are concerned about bacterial contamination of cavity preparations and use cavity disinfectants before application of dental adhesives. The use of benzalkonium chloride and chlorhexidine gluconate had no detrimental effects on the sealing ability of non-rinse self-etching adhesives.55 In some cases the self-etching adhesive acts as its own disinfectant. Both iBOND® Self Etch (Heraeus) and Protect Bond (Kuraray) have data to support this claim. Clinical success with self-etch adhesives is dependent on the basic clinical technique: 1. Tooth preparation (preparations that are selfretentive; Class V; not Class IV, not facial veneers, not porcelain veneers). 2. Apply the SE adhesive following the manufacturer’s instructions for dwell time — this is very product specific. 3. Air dry the tooth following the timing and type of air spray from the product intructions; do not take any shortcuts. 4. Light cure the adhesive. 5. Apply restorative material; light cure.

bur or diamond to improve bonding.60 For dentin, self-etching adhesives provide for better bonding to fluoride-rich dentin.61 Of note, with the increased interest in tooth whitening and the availability of over-the-counter peroxide-based products, the clinician may not know if patients are bleaching their teeth. Research supports waiting at least one week after bleaching before any restorative procedure with either an etch-andrinse or an SE adhesive to prevent interference with bonding adhesion and material setting.62,63,64,65,66 It is important to know whether or not your patients are using peroxide products before any bonding procedure.

Adhesion to tooth structure: clinical challenges Not all dentin and enamel is equally bondable. In the course of tooth preparation we encounter teeth that have existing amalgam restorations that are defective and teeth that have been invaded by the carious process. Also, there are tooth conditions that can affect the quality of etching and the quality of adhesion to enamel and dentin. A significant part of a restorative practice is the replacement of existing restorations. There has been a trend to replace defective amalgam restorations with composite resins. When removing an amalgam restoration it is not unusual to find discolored enamel and dentin present due to the leaching of metallic ions and corrosion products into the dentin tubules. Harnirattisai et al. found no differences in adhesion to normal dentin and discolored amalgam-affected dentin with both an etch-and-rinse adhesive and a self-etch adhesive.56 Also, when removing caries, there is controversy as to when to stop in the cavity preparation — are we truly removing all caries or is there some caries remaining. Bonding to caries-affected dentin has been shown to have decreased bonding strength.57,58,59 With the increase in the use of fluorides both through fluoride in our drinking water and other beverages and in oral care products, there has been an increase in fluorosis seen in the general population. We see it as mottled enamel, especially when teeth are isolated with cotton rolls for routine restorations. Fluorosed enamel and dentin is more difficult to bond to. For enamel fluorosis the recommendation is to prepare the enamel with a

Figure 5. Class V NCCL on the maxillary canine that exhibits dentin hypersensitivity.

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Clinical technique with etch-and-rinse adhesives Case report 1 A 27-year-old female patient presented with a history of a non-carious cervical lesion (NCCL) on the maxillary right canine that was sensitive to air and cold (Figure 5). After a thorough examination the diagnosis of dentin hypersensitivity was made. The treatment plan was to place an adhesive composite resin restoration. The area was anesthetized with local anesthesia. Isolation for the placement of the restoration was accomplished with lip retractors and placement of gingival retraction cord to control any seepage of gingival fluids or bleeding. The tooth was cleaned with a water-pumice paste with a prophylaxis cup.

A minimal enamel bevel of 1.0 mm was placed using a fine finishing diamond with a slow-speed handpiece. The dentin on the root surface was minimally prepared using a #2 round bur to leave a consistent dentin smear layer. A twostage enamel-dentin etch was used. The enamel was etched for a total of 30 seconds, the dentin for 15 seconds using a dye-free 40% phosphoric acid etchant (Onyx, Centrix Dental) (Figure 6). The black silicon carbide particles provide for coloring for visibility and when agitated can impart a gentle abrasive action on the dentin and enamel. The surfaces were rinsed for 10 seconds with an air-water spray. The enamel was gently dried, leaving a frosty, etched appearance. The dentin was hydrated using a damp cotton pellet, leaving the dentin slightly glossy (Figure 7). 7

Figure 6. Two-stage etching of the preparation: 15-second dentin etch and 30-second enamel etch.

Figure 7. Evidence of etching enamel (frosty appearance) and lightly wetted dentin (glossy appearance).

For this case a multiple-bottle, etch-and-rinse adhesive (3-E&R) (OptiBOND FL, Kerr-Sybron, Orange, CA) was used. OptiBOND FL has been demonstrated to be effective at bonding to both enamel and dentin surfaces.67,68,69,70 In a number of studies, OptiBOND FL was used as the standard for a multiple-bottle etch-and-rinse adhesive when comparing to self-etch adhesives because of its clinically successful long-term clinical data.71 OptiBOND FL primer was applied to the etched dentin and was agitated with a microapplicator brush for 15 seconds (Figure 8). The primer was gently air dried to evaporate the organic solvent from the primer for 5 seconds. The surface then had a glossy appearance. If primer gets on the etched enamel, this is not a problem. The OptiBOND FL adhesive is a lightly filled adhesive with nanofillers, which allows it to be applied thickly or thinly. OptiBOND FL adhesive was applied in a uniform thin layer to the etched enamel and dentin surfaces. If the adhesive pools and is too thick it can be gently air thinned. The adhesive was light cured for 20 seconds. A hybrid composite resin (Herculite XRV, Kerr) was applied to the tooth (Figure 10) and was sculpted to full contour using a thin metal plastic filling-sculpting instrument (PFI-AB1, HuFriedy, Chicago, IL) that was slightly wetted with the OptiBOND FL adhesive so the composite resin would not pull away from any preparation margins (Figure 11). Since the preparation was less than 2.0 mm in depth, a single increment was used for application of the composite. The restoration was light cured with a quartz-halogen curing 8

Figure 8. Application of the OptiBOND primer with 15 seconds of agitation. It was then air-dried.

Figure 9. Application of the OptiBOND adhesive, air thinned and light cured.

Figure 10. Placement of the hybrid composite resin (Herculite XRV).

Figure 11. Shaping the composite resin with a sculpting plastic filling instrument (PFI-AB1, HuFriedy) wetted with the OptiBOND adhesive to minimize composite resin stickiness to instrument.

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light (Optilux 501, Kerr Sybron) for 30 seconds. The restoration was finished using a 15-bladed finishing bur (SS White Burs) and a composite resin polishing paste (Luster Paste, Kerr) with a soft cupped prophylaxis angle (Figure 12). The completed restoration sealed the tooth, esthetically eliminating all postoperative sensitivity (Figure 13). At 13 years, the restoration is still performing satisfactorily (Figure 14). In a long-term clinical trial of 13 years with OptiBOND restored with Herculite XRV, retention of Class V restorations was 98%, and teeth with dentin hypersensitivity at the start of the study demonstrated elimination of that sensitivity one week after restoration placement.72 Figure 12. Polishing the composite resin with a composite polishing paste.

Case report 2 A 23-year-old female patient presented to the dental school’s clinic for treatment. She had a past history of not having had dental treatment for five years. After a comprehensive examination, caries was diagnosed in the pits and fissures of the maxillary second premolar, first and second molars (Figure 15). The second molar and first molar had conventional preparations using a 245 bur (SS White Burs). The mesioocclusal pit of the first molar and occlusal pit in the second premolar had minimal caries and were prepared for preventive resin restorations using a NTF Micro Narrow Tapered Fissurotomy bur (SS White Burs) (Figure 16). The outline of the final preparations was dictated by the extension of the caries (Figure 17). Figure 15. Pit and fissure caries on the second premolar and first and second maxillary molars.

Figure 13. The completed Class V restoration (dentistry by Dr. A.A. Boghosian). Figure 16. A minimally invasive preventive resin preparation done with a Fissurotomy bur (SS White Burs).

Figure 14. 13-year recall of the OptiBond/Herculite XRV restoration.

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Figure 17. Final preparations of #13, 14 and 15.

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The preparations were etched with a 35% phosphoric acid, Gluma Etch 35 Gel, (Heraeus) for 15 seconds (Figure 18). The teeth were thoroughly rinsed with an air-water spray for 10 seconds and dried, leaving the teeth slightly moist. The adhesive, Gluma Comfort Bond + Desensitizer (Heraeus) was applied to the tooth preparations using a BendaBrush Micro (Centrix) (Figure 19) and allowed to sit for 15 seconds. A gentle air stream was blown over the surface of the adhesive to evaporate organic solvent and thin the adhesive before light curing. The adhesive was light-cured for 20 seconds. The smaller preventive resin preparations were restored with flowable composite resin (Flowline, Heraeus), and the larger preparations were restored using Solitaire 2 (Heraeus) (Figure 20). The completed restorations were well sealed and esthetic (Figure 21).

Figure 20B. A flowable composite resin (Flowline) was placed into the preventive resin minimally invasive preparations.

Figure 21. The completed restorations.

Figure 18. Etching preparations with 35% phosphoric acid.

Self-etch single-bottle adhesive case reports

Figure 19. The 1-E&R adhesive (Gluma Comfort Bond + Desensitizer) was applied with a BendaBrush Micro.

Figure 20A. A packable composite resin (Solitaire 2) was placed into the conventional cavity preparations.

Self-etch adhesives afford the clinician the benefit of ease of use with the elimination of multiple steps that can lead to an inconsistency during adhesive and restoration placement. The first single-component, non-mix dental bonding agent introduced was iBOND® (Heraeus). More recently, iBOND® Self Etch has replaced the former iBOND® and requires no mixing or the application of multiple layers. It offers a simplified and more convenient application, less technique sensitivity with high bond strengths to both dentin and enamel, and improved marginal integrity due to easy evaporation.73,74 Other companies have introduced their own single-component non-mix self-etch adhesive, e.g., All-in-One (Kerr), Xeno IV (Dentsply-Caulk), Clearfil S3 (Kuraray). Unlike two-bottle 1-SEA systems that must be dispensed and mixed, singlecomponent SE systems can be dispensed in single-patient unit-dose capsules. According to manufacturers’ instructions and current evidence, when using an SE adhesive system wherever there is an enamel interface, the enamel should be prepared with a bur or diamond. Based on the best available evidence, self-etching adhesives are indicated for composite resin restorations that are being bonded to defined cavity preparations, Class I, II, III, and V.75 Case report 3 A 35-year-old male patient had a chief complaint of pain upon biting on his mandibular first molar (Figure 22). An examination revealed an existing occlusal composite restoration. Using a Tooth Slooth (Professional Results Inc.) and transillumination, the diagnosis of a cracked tooth with a fracture of the distolin-

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Figure 22. Mandibular first molar with occlusal composite resin restoration and tooth exhibiting signs and symptoms of a cracked tooth.

Figure 24. Completed cavity preparation with the removal of the distolingual cusp.

Figure 23. Diagnosis of cracked cusp with Tooth Slooth. Figure 25. After placement of a 1-SEA (iBOND ® Self Etch) light curing and a color adaptive nanohybrid composite (Venus), the restoration was shaped with a finishing bur (Axis).

Figure 26. Final finish and polish with a diamond-infused universal composite polisher (Jazz).

gual cusp was made (Figure 23). The existing composite resin was removed using a 245 enhanced-blade, geometry-dentated bur (Great White 245 GW, SS White Burs). The completed preparation included removal of the distolingual cusp (Figure 24). A single-component, unit-dose-dispensed self-etch adhesive (1-SEA) (iBOND® Self Etch, Heraeus) was applied to the cavity preparation by painting the cavity preparation with iBOND® Self Etch; it was agitated in the tooth preparation for 20 seconds. A gentle air stream was then used to thin and evaporate organic solvent from the adhesive. The tooth surfaces had a glossy appearance and the adhesive was then light cured for 20 seconds with a conventional quartz-halogen lightcuring unit (Optilux 501). A wear-resistant, nanofilled hybrid color-adaptive composite resin, Venus, was placed into the cavity preparation and light cured. The restoration anatomy was defined and finished with composite resin finishing burs (Axis) (Figure 25). The surface was then polished with a diamondinfused universal composite resin polishing cup (Jazz, SS White Burs) (Figure 26). The completed esthetic restoration was well sealed (Figure 27). The patient reported no sensitivity to mastication after the restoration was placed. www.ineedce.com

Case report 4 A proximal carious lesion was seen clinically on the distal surface of the maxillary first premolar. While not evident radiographically, the caries manifested itself as a slight cavitation on the distal surface and the marginal ridge had a slightly opaque appearance (Figure 28). Since the occlusal surface was not carious, a minimally invasive preparation of the distal surface using a slot preparation to provide for access to restore and finish the final restoration was done (Figure 29). The patient had a past history of sensitivity when an etch-and-rinse adhesive had been used for previous posterior composite restorations. The decision was made to use a self-etch adhesive (1-SEA) (OptiBOND All-In-One) to minimize any potential for postoperative sensitivity. The tooth was restored using a sectional matrix system 11

Figure 27. Completed restoration, eliminating patient’s symptoms of cracked tooth.

(ComposiTight Matrix with a G-Ring, Garrison Dental) system with an optimized particle nanohybrid composite resin (Point 4, Kerr) (Figure 30). The patient had no postoperative sensitivity after placement of the restorations.

Conclusion

Figure 28. Distal caries on the maxillary first premolar.

Long-term clinical trials with posterior composite resin restorations, porcelain veneers, crowns, and resin and ceramic inlays and onlays provide strong evidence of clinical success and durability when using an etch-and-rinse adhesive technique. While the multiple-bottle etch-and-rinse adhesives are still the gold standard for all-purpose bonding, based upon the current clinical evidence and the recommendations of manufacturers, SE adhesive systems can be used successfully for the restoration of Class I, II, III, and V preparations. Also when the enamel interface is prepared to include non-carious cervical lesions, SE adhesives provide adequate enamel etching to resist microleakage and marginal staining, and adequate retention of both prepared teeth and NCCL Class V restorations. Whichever system the clinician selects to use, he or she should follow the manufacturer’s recommendations for clinical applications to ensure clinical success.

References

Figure 29. Minimally invasive distal slot preparation.

Figure 30. Final restoration using a 1-SEA (OptiBOND All-In-One) and nanohybrid composite resin (Point Four).

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1 Barkmeier WW. Current status of adhesives in dentistry. Functional esthetics and restorative dentistry. 2008. 2(1):6. 2 Leinfelder KF, Kurdziolek SM. Self-etching bonding agents. Compend Contin Educ Dent. 2003; 24:447–456. 3 Buonocore MG, Wileman W, Brudevold F. Simple method of increasing the adhesion of acrylic filling materials to enamel surfaces. J Dent Res. 1955; 34:849. 4 Cueto EI, Buonocore MG. Sealing of pits and fissures with an adhesive resin: its use in caries prevention. J Am Dent Assoc. 1967; 75:121–128. 5 Gwinnett AJ, Buonocore MG. Adhesives and caries prevention: a preliminary report. Br Dent J. 1965; Jul 20; 119:77–80. 6 Torney DL, Denehy GE, Teixeira LD. The acid etch Class III composite resin restoration. J Prosthet Dent. 1977; 38:623–6. 7 Jordan RE, Suzuki M, Gwinnett AJ, Hunter JK. Restoration of fractured and hypoplastic incisors by the acid etch resin technique: a three-year report. J Am Dent Assoc. 1977; 95:795–803. 8 Strassler HE. Applications of total-etch adhesive bonding. Compend Contin Educ Dent. 2003; 24:427–36. 9 Mertz-Fairhurst EJ, Fairhurst CW, Williams JE, et al. A comparative clinical study of two pit and fissure sealants: 7-year results in Augusta, GA. J Am Dent Assoc. 1984; 109:252–255. 10 Simonsen RJ. Preventive resin restorations(I). Quintessence Int. 1978; 9:69–76. 11 Strassler HE, Goodman HS. A durable flowable composite resin for preventive resin restorations. Dent Today 2002; (21)(10):116–121. 12 Bargheri J, Denehy GE. Effect of enamel bevel and restoration length on Class 4 acid-etch retained composite resin restorations. J Am Dent Assoc 1983; 107:951–953. 13 Wilder AD Jr, May KN Jr, Bayne SC, Taylor DF, Leinfelder KF. Seventeen-year clinical study of ultravioletcured posterior composite Class I and II restorations. J Esthet Dent. 1999; 11:135–142. 14 Lundin SA, Koch G. Class I and II posterior composite restorations after 5 and 10 years. Swed Dent J. 1999; 23(5–6):165–171. 15 Gaengler P, Hoyer I, Montag R. Clinical evaluation of posterior restorations: the 10-year report. J Adhes Dent. 2001; 3:185–194. 16 Strassler HE. Long-term clinical evaluation of Cerinate etched porcelain veneers. J Dent Res. 2005; 84 (Special Issue A) abstract no. 432. 17 Friedman MJ. A 15-year review of porcelain failure — a clinician’s observations. Compend Contin Educ Dent. 1996;19:625–638. 18 Buonocore MG, Wileman W, Brudevold F. A report on a resin capable of bonding to human dentin surfaces. J Dent Res. 1956; 35:846–50. 19 Diamond A, Carrel R. The smear layer: a review of restorative progress. J Pedod. 1984; 8:219–26. 20 Retief DH, et al. Tensile bond strengths of four dentin bonding agents to dentin. Dent Mater. 1986; 2:72–7. 21 Eliades GC, Caputo AA, Vougionklakis A. Composition, wetting properties and bond strength with dentin of six new dentin adhesives. Dent Mater. 1985; 1:170–6. 22 Lee HL, et al. Effects of acid etchants on dentin. J Dent Res. 1973; 52:1228–33. www.ineedce.com

23 Torney DL. The retentive ability of acid-etched dentin. J Prosthet Dent. 1978; 39:169–72. 24 Skinner EW, Phillips RW. The Science of Dental Materials. 5th ed. Philadelphia, PA: WB Saunders; 1960; 277. 25 Jennings RF, Ranly DM. Autoradiographic studies of P32 penetration into enamel and dentin during acid etching. J Child Dent. 1972; 39:69–71. 26 Torney DL. The retentive ability of acid-etched dentin. J Prosthet Dent. 1978; 39:169–72. 27 Fusayama T, et al. Non-pressure adhesion of a new adhesive restorative system. J Dent Res. 1979; 58:1364–1370. 28 Bertolotti RL. Acid etching of dentin. Quintessence Int. 1990; 21:77–78. 29 Kanca J III. One-year evaluation of a dentin-enamel bonding system. J Esthet Dent. 1990; 2:100–103. 30 Van Meerbeek B, et al. Enamel and dentin adhesion. In Fundamentals of Operative Dentistry a Contemporary Approach. 3rd edition. Ed. Summitt JB, Robbins JW, Hilton TJ, Schwartz RS. Quintessence Books, 2006, p. 183–260. 31 Van Meerbeek B. Mechanism of resin adhesion: dentin and enamel bonding. Functional Esthet Restor Dent. 2008; 2(1):18–25. 32 Van Meerbeek B, De Munck J, Yoshida Y, et al. Buonocore memorial lecture. Adhesion to enamel and dentin: current status and future challenges. Oper Dent. 2003; 28:215–35. 33 Peumans M, Kannumill PV, De Munck J, et al. Clinical effectiveness of contemporary adhesives: a systematic review of current clinical trials. Dent Mater. 2005; 21:864–881. 34 Inoue S, Vargas MA, Abe Y, et al. Microtensile bond strength of eleven contemporary adhesives to enamel. Am J Dent. 2003; 16:329–334. 35 Shirai K, De Munck J, Yoshida Y, et al. Effect of cavity configuration and aging on the bonding effectiveness of six adhesives to dentin. Dent Mater. 2005; 21:110–124. 36 Van Meerbeek B. Mechanism of resin adhesion: dentin and enamel bonding. Functional Esthet Restor Dent. 2008; 2(1):18–25. 37 Tay FR, et al. An ultrastructural study of the influence of acidity on self-etching primers and smear layer thickness on bonding to intact dentin. J Adhes Dent. 2000; 2:83–98. 38 Perdigao J, et al. Morphological field emissions: SEM study of the effect of six phosphoric acid etching agents on human dentin. Dent Mater. 1996; 12:262–71. 39 Perdigao J, Geraldeli S. Bonding characteristics of self-etching adhesives to intact versus prepared enamel. J Esthet Restor Dent. 2003:5:32–42. 40 Brackett WW, Ito S, Nishitani Y, Haisch LD, Pashley DH. The microtensile bond strength of self-etching adhesives to ground enamel. Oper Dent. 2006; 31:332–37. 41 Di Hipolita V, de Goes MF, Carrilho MR, Chan DC, Daronch M, Sinhoreti MA. SEM evaluation of contemporary self-etching primers applied to ground and unground enamel. J Adhes Dent. 2005; 7:203–11. 42 Strassler HE. Self-etching resin adhesives. Inside Dentistry 2007; 3(2):50–4. 43 Perdigao J, Geraldeli S, Hodges JS. Total-etch versus self-etch adhesive effect on postoperative sensitivity. J Am Dent Assoc. 2003; 134:1621–1629. 44 Akpata ES, Behbehani J. Effect of bonding systems on postoperative sensitivity from posterior composites. Am J Dent. 2006; 19:151–4. 45 Perdigao J, Anauate-Netto C, Carmo AR, Hodges JS, et al. The effect of adhesive and flowable composite on postoperative sensitivity: 2-week results. Quintessence Int. 2004; 35:777–84. 46 Unemori M, Matsuya Y, Akashi A, Goto Y, Akamine A. Self-etching adhesives and postoperative sensitivity. Am J Dent. 2004; 17:191–5. 47 Browning WD, Myers M, Downey M, Schull GF, Davenport MB. Reduction in postoperative sensitivity: a community-based study. J Dent Res (Special Issue B) 2006, 85: Abstract no. 1151. 48 Perdigao J, Geraldeli S, Hodges JS. Total-etch versus self-etch adhesive effect on postoperative sensitivity. J Am Dent Assoc. 2003; 134:1621–1629. 49 Kanca J. Improved bond strength through acid etching of dentin and bonding to wet dentin surfaces. J Am Dent Assoc. 1996; 123:35–43. 50 Gwinnett AJ. Moist versus dry dentin: its effect on shear bond strength. Am J Dent. 1992; 5:127–129. 51 Lee R, Blank JT. Simplify bonding with a single step: one component, no mixing. Contemp Esthet Rest Practice. 2003; 7(5):45–46. 52 Lee R, Blank JT. Simplify bonding with a single step: one component, no mixing. Contemp Esthet Rest Practice. 2003; 7(5):45–46. 53 Miller MB. Self-etching adhesives: solving the sensitivity conundrum. Pract Proced Aesthet Dent. 2002; 14:406. 54 Santini A, Ivanovic V, Ibbetson R, Milia E. Influence of cavity configuration on microleakage around Class V restorations bonded with seven self-etching adhesives. J Esthet Restor Dent. 2004; 16:128–136. 55 Turkun M, et al. Effect of cavity disinfectants on the sealing ability of nonrinsing dentin-bonding resins. Quintessence Int. 2004; 35:469–476. 56 Harnirattisai C, Senawongse P, Tagami J. Microtensile bond strengths of two adhesive resins to discolored dentin after amalgam removal. J Dent Res. 2007; 86:232–6. 57 Ceballos L, Camego DG, Victoria Fuentes M, et al. Microtensile bond strength of total-etch and selfetching adhesives to caries-affected dentine. J Dent. 2003; 31:469–77. 58 Say EC, Nakajima M, Senawongse P, et al. Bonding to sound vs. caries-affected dentin using photo- and dual-cure adhesives. Oper Dent. 2005; 30:90–8. 59 Omar H, El-Badrawy W, El-Mowafy O, et al. Microtensile bond strength of resin composite bonded to caries-affected dentin with three adhesives. Oper Dent. 2007; 32:24–30. 60 Waidyasekera PG, Nikaido T, Weerasinghe DD, et al. Bonding of acid-etch and self-etch adhesives to human fluorosed dentin. J Dent. 2007; 35:915–22. 61 Ermis RB, De Munck J, Cardoso MV, et al. Bonding to ground versus unground enamel in fluorosed

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teeth. Dent Mater. 2007; 23:1250–5. 62 Godwin JM, Barghi N, Berry TG, et al. Time duration for dissipation of bleaching effects before enamel bonding. J Dent Res; 71:179 (Abstr 590), 1992. 63 Cvitko E, Denehy GE, Swift EJ Jr, et al. Bond strength of composite resin to enamel bleached with carbamide peroxide. J Esthet Dent. 1991; 3:100–2. 64 Basting RT, Rodrigues JA, Serra MC, Pimenta LAF. Shear bond strength of enamel treated with seven carbamide peroxide bleaching agents. J Esthet Restor Dent. 2004 16:250–60. 65 Cadenaro M, Breshi L, Antoniolli F, et al. Influence of whitening on the degree of conversion of dental adhesives on dentin. Eur J Oral Sci. 2006; 114:257–62. 66 Swift EJ Jr. Critical appraisal: effects of bleaching on tooth structure and restorations, Part II: enamel bonding. J Esthet Restor Dent. 2008; 20:68–73. 67 Moll K, Schuster B, Haller B. Dentin bonding of light and self-curing resin composites using simplified total- and self-etch adhesives. Quintessence Int. 2007; 38:27–35. 68 Ernst CP, Galler P, Willershausen B, et al. Marginal integrity of class V restorations: SEM versus dye penetration. Dent Mater. 2008; 24:319–27. 69 Magne P, So WS, Casecione D. Immediate dentin sealing supports delayed restoration placement. J Prosthet Dent. 2007; 98:166–74. 70 Boghosian AA, Drummond JL, Lautenschlager E. Clinical evaluation of a dentin adhesive system: 13 year results. J Dent Res (Special Issue) 2007; 86: abstract no. 228. 71 Boghosian AA, Drummond JL, Lautenschlager E. Clinical evaluation of a dentin adhesive system: 13 year results. J Dent Res (Special Issue) 2007; 86: abstract no. 228. 72 Boghosian AA, Drummond JL, Lautenschlager E. Clinical evaluation of a dentin adhesive system: 13 year results. J Dent Res (Special Issue) 2007; 86: abstract no. 228. 73 Hannig M. In vitro investigation on the marginal gap and internal adaptation of different bonding agents and composites in class II cavities. Data on file. 74 Haller B. Marginal integrity of class II composite fillings with iBOND Self Etch. Data on file. 75 Strassler HE. Self-etching resin adhesives. Inside Dentistry 2007; 3(2):50–4.

Author Profile Howard E. Strassler, DMD, FADM, FAGD Dr. Howard Strassler is professor and director of operative dentistry at the University of Maryland Dental School in the Departments of Endodontics, Prosthodontics, and Operative Dentistry. He has lectured nationally and internationally on techniques and a selection of dental materials in clinical use and aesthetic restorative dentistry. He is a fellow in the Academy of Dental Materials and the Academy of General Dentistry, a member of the American Dental Association, the Academy of Operative Dentistry, and the International Association of Dental Research. He is on the editorial board of numerous publications. He is a consultant and clinical evaluator to more than 15 dental manufacturers. Dr. Strassler has a general practice in Baltimore, Maryland, that is limited to restorative dentistry and aesthetics. Luis Guilherme Sensi, DDS, MS, PhD Dr. Sensi is an Assistant Professor and Coordinator of Esthetic at the University of Maryland Dental School in the Department of Endodontics, Prosthodontics, and Operative Dentistry. Dr. Sensi has over 20 publications and three Chapters in dental texts. He is a member of the International Association of Dental Research. He has been involved in research on adhesives, light curing and composite resins. He has lectured in the United States and Brazil.

Disclaimer

The authors of this course have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

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Questions 1. The earliest bonding systems required an acid-etch technique and were only compatible with dentin.

11. Dentin bonding attached to the smear layer creates a strong, clinically acceptable bond to dentin.

2. The differentiation of bonding systems is in fact two distinct classes: ____ and ____.

12. The total-etch approach involves _________.

a. True b. False a. b. c. d.

step-etch; etch-and-rinse rinse-and-seal; self-etch etch-and-rinse; self-etch none of the above

3. For successful adhesion of a bonding agent to tooth structure, prerequisites include that _________. a. the procedure must be safe and biologically acceptable b. the bond strength must be routinely achieved, established quickly and clinically significant c. the bond must be stable in vivo for a clinically significant period of time d. all of the above

4. The idea of adhesive bonding to dentin was theoretically postulated more than 50 years ago. a. True b. False

5. The first clinical application in dentistry of acid-etching and resin adhesion was for _________. a. b. c. d.

indirect restorations sealants direct resin composites none of the above

6. Friedman’s retrospective study of porcelain veneers, where he evaluated approximately 3,500 restorations and reported on 245 failures, found a _________ success rate. a. b. c. d.

753% 88% 93% 96%

7. Effective dentin-bonding materials should _________.

a. be retentive to dentin at a clinically acceptable level b. be able to withstand intraoral forces of occlusion and mastication c. be biocompatible and minimize or eliminate postoperative sensitivity d. all of the above

8. Dental bonding materials should resist the forces of polymerization shrinkage of composite resins and the coefficient of thermal expansion and contraction to eliminate microleakage. a. True b. False

9. The earliest research on dentin bonding focused on chemical adhesion of resins to the inorganic components of dentin, with the development of _________. a. an ethacrylate-based dentin adhesive that contained phosphate groups to attach to the calcium ions on the dentin surface b. a methacrylate-based dentin adhesive that contained carbonate groups to attach to the calcium ions on the dentin surface c. a methacrylate-based dentin adhesive that contained phosphate groups to attach to the calcium ions on the dentin surface d. none of the above

10. The dentin smear layer _________. a. consists of loosely bound debris including fractured crystals of hydroxyapatite and denatured collagen b. acts as a conduit for the dentin tubules c. acts as a barrier to clog the dentin tubules d. a and c

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a. True b. False a. b. c. d.

etching the enamel totally, but not the dentin etching the enamel first and then the dentin etching the enamel and dentin simultaneously none of the above

13. All adhesives used today exhibit the same phenomenon for adhesion to enamel of _________.

a. micromechanical locking to both the etched enamel prisms and dentinal tubules b. micromechanical locking to the etched enamel prisms and to dentin through hybridization c. macromechanical locking to the etched enamel interprismatically and to dentin through hybridization d. all of the above

14. In the mid 1990s clinicians sought a simplified approach that used fewer steps for adhesive placement. a. True b. False

15. The etch-and-rinse adhesives involve _________.

a. an initial step of the application of up to 10% phosphoric acid to the enamel/dentin, followed by rinsing and drying of the dentin b. an initial step of the application of 10%–40% maleic acid to the enamel/dentin, followed by rinsing and drying of the dentin c. an initial step of the application of 10%–40% phosphoric acid to the enamel/dentin, followed by rinsing and drying of the dentin d. any of the above

16. _________ demonstrated that the pulpal effect of phosphoric acid on dentin for one minute was minimal. a. b. c. d.

Hemmings and Ranly Jennings and Manly Jennings and Ranly none of the above

17. In vitro and in vivo research have demonstrated that _________.

a. etch-and-rinse adhesives can reliably bond to both enamel and dentin b. etch-and-rinse adhesives can reliably bond only to enamel c. etch-and-rinse adhesives can reliably bond only to dentin d. none of the above

18. Based upon the evidence to date, bonding to enamel is best accomplished with the self-etch technique. a. True b. False

19. The basic clinical technique influences clinical success and includes _________.

a. etching with a phosphoric acid of the appropriate concentration for 15–30 seconds b. rinsing with air–water spray for 10 seconds and leaving the tooth wet c. rinsing with air–water spray for 10 seconds and drying the tooth, leaving the enamel frosty, the dentin glossy d. a and c

20. A separate rewetting with water step is eliminated with self-etch adhesives because they contain water and are never completely dried from the tooth. a. True b. False

21. Self-etch adhesives _________.

a. use a more acidic monomer in a GLUMA/ water-based adhesive b. use a more acidic monomer in a HEMA/waterbased adhesive c. do not require a separate etch-and-rinse step d. b and c

22. Self-etching adhesives incorporate the smear layer into the adhesive. a. True b. False

23. A number of studies have demonstrated no difference in postoperative sensitivity between etch-and-rinse and self-etch adhesives. a. True b. False

24. Self-etch adhesives _________.

a. are water containing b. can minimize operator variability by simplifying the technique used c. require that the adhesive be thinned with a gentle spray of air following application d. all of the above

25. A very thick layer of self-etch adhesive _________. a. b. c. d.

will have no impact on bonding will compromise bonding results in a stronger composite restoration none of the above

26. Harnirattisai et al. found no differences in adhesion to normal dentin and discolored amalgam-affected dentin with both an etch-and-rinse adhesive and a self-etch adhesive. a. True b. False

27. _________ adhesives provide for better bonding to fluoride-rich dentin. a. b. c. d.

Self-etch Etch-and-rinse The combined use of self-etch and etch-and-rinse none of the above

28. Clinical success with self-etch adhesives is dependent on the basic clinical technique, including _________.

a. tooth preparation (not Class IV, not facial veneers, not porcelain veneers) b. applying the adhesive following the manufacturer’s instructions for dwell time c. air drying the tooth following the timing and type of air spray given in the product instructions d. all of the above

29. Bonding to caries-affected dentin has been shown to _________. a. have increased bonding strength b. result in a reduced level of hypersensitivity, compared to bonding to virgin dentin c. have decreased bonding strength d. none of the above

30. Research supports waiting at least one week after bleaching before any restorative procedure with either an etchand-rinse or a self-etch adhesive is carried out, to prevent interference with bonding adhesion and material setting. a. True b. False

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ANSWER SHEET

Contemporary Dental Adhesives for Direct Placement Composite Restorations Name:

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Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. Mail completed answer sheet to

Educational Objectives 1. Discuss the differences between etch-and-rinse and self-etch adhesives, and relate these categories to other naming

Academy of Dental Therapeutics and Stomatology, A Division of PennWell Corp.

P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447

systems that have been previously presented. 2. Discuss current research evidence comparing etch-and-rinse and self-etch adhesives. 3. Describe the indications for etch-and-rinse and self-etch adhesives.

For immediate results, go to www.ineedce.com and click on the button “Take Tests Online.” Answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619.

4. Describe the clinical procedure for an etch-and-rinse and self-etch single-step adhesive.

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Objective #3: Yes No

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10. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________________________ 11. Was there any subject matter you found confusing? Please describe. ___________________________________________________________________ ___________________________________________________________________ 12. What additional continuing dental education topics would you like to see? ___________________________________________________________________ ___________________________________________________________________

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PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. AUTHOR DISCLAIMER The author(s) of this course has/have no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant from Heraeus Inc. and Kerr Corporation. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or [email protected]. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: [email protected].

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INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination. EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise.

COURSE CREDITS/COST All participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verification form verifying 4 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 3274. The cost for courses ranges from $49.00 to $110.00. Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANB’s annual continuing education requirements. To find out if this course or any other PennWell course has been approved by DANB, please contact DANB’s Recertification Department at 1-800-FOR-DANB, ext. 445.

RECORD KEEPING PennWell maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. © 2008 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

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