Adhesives: Newer Is Not Always Better—Part 1
Latest-generation adhesives often do not measure up to their predecessors in bonding strength and durability.
By Leendert (Len) Boksman, DDS, BSc, FADI, FICD | Gregg Tousignant, CDT | Lee W. Boushell, DMD, MS | Gildo Coelho Santos, Jr., DDS, MSc, PhD
In most fields of modern technology, the latest version of a product is usually an improvement over the previous ones. For example, smartphones, hybrid cars, the Blu-Ray disk, and high-definition television represented significant advancements over their predecessors. So why is this continual advancement apparently not the case when it comes to dental adhesives? Over the last 25 years, dentistry has seen significant generational changes, new materials categories, new chemistries, and new clinical protocols with dental adhesives—much of it driven by an effort to simplify or to shorten the bonding procedure. However, not all of the newer materials have necessarily offered improvements to the patient or for the long-term viability/prognosis of the restorations placed. How does the clinician make a rational choice from among more than 65 adhesives still on the market today? Among the so-called fourth-, fifth-, sixth-, and seventh-generation adhesives— alternatively known as the “etch-and-rinse” and “self-etch bonding agents”—which system gives the most consistent, long-term clinical results and has the longest viable bond strength over time? Which system resists oral degradation and allows for the integration of new methodology to treat the hybrid layer for long-term stability while addressing the inevitability of the presence of bacteria and composite polymerization and functional stress?
The current resin–dentin bonding mechanism, whether using etch-and-rinse or self-etch systems, relies on the formation of a hybridized layer that couples adhesives/resin-composites with the underlying mineralized dentin. With the exception of resin tags, which extend down into the dentinal tubules, only the collagen fibers offer physical continuity between the hybrid layer1 (as it is known after being infiltrated with resin) and the underlying mineralized dentin. The collagen fibers represent millions of fibril anchors, which emerge from the underlying mineralized dentin matrix into the demineralized layer.
In an excellent overview of factors that affect the bond strength of bonding agents, Powers et al2 point out that the type of substrate (ie, superficial dentin, deep dentin, permanent/primary dentition, carious dentin), phosphoric acid/acidic primers, preparation by air abrasion and laser, moisture, contaminants, desensitizing agents, and self-cured/light-cured restorative materials all affect the bond strength; bond strength is reduced by more than 50% when bonding conditions are not ideal. Further, when lasers are used to prepare hard tissues, studies show that bonding to these surfaces may be more problematic than bonding to conventionally bur-prepared preparations.3 Rushing to complete such procedures by reducing the priming time from 20 to 5 seconds can cause a 17% reduction in mean bond strength.4 In contrast, using a 20-second application time to agitate a self-etch adhesive significantly improves the shear bond strength to dentin.5 In addition to agitation, rather than applying a single coat of adhesive resin on dentin, up to four additional coatings increase the bond strength and decrease nanoleakage.6 Multiple research reports attest to the existence of material incompatibilities that depend on formulation, and that bond strengths can be reduced by 45% to 90% or more when incompatible combinations are applied clinically.7-9 Acetone-based adhesives show a high degree of technique sensitivity,10 and over- or under-drying the acid-etched dentin compromises the bond.11 Simplification of the bonding procedure does not necessarily lead to improved bonding performance, especially in the long term.12 Alex3 perhaps has stated it best: “The bottom line is, it is incumbent on every dentist to learn about their specific adhesive system, its idiosyncrasies, its strengths and weaknesses, and how to maximize its performance.”
Practitioners should be aware not only of the immediate bond strengths—whether shear or tensile (the immediate configuration factor [C-factor] polymerization shrinkage stress is about 24 MPa in a Class I cavity preparation)13 but also, the long-term performance or longevity (patency) of their bonding agent in actual clinical performance.14 Much of the bond testing has been done in a laboratory under ideal controlled conditions, which may not be possible to replicate in a clinical environment, and results may vary depending on the testing methods and devices used.15 Some studies test immediate or 24-hour bond strength only on dentin just below the enamel surface, where bonding is easiest and strongest; and most of these studies have been done in vitro on human or bovine teeth, without positive fluid flow or the positive pressure that exists clinically—both of which can drastically decrease long-term performance. A short, simplified overview of the systems and their clinical behavior follows.
Compared to current adhesives or bonding agents, those still considered to be the “gold standard” in long-term durability are fourth-generation adhesives (etch-rinse-prime-adhesive resin) or multi-bottle systems (eg, 3M™ ESPE™ Scotchbond™ MP Multi-Purpose Plus, 3M ESPE, www.3mespe.com; ALL-BOND 2© and ALL-BOND 3©, Bisco, Inc., www.bisco.com; Perma
Quick, Ultradent Products, Inc., www.ultradent.com; and OptiBond FL©, Kerr Corporation, www.kerrdental.com).16,17 These etch-and-rinse materials still provide the deepest, strongest, most predictable, and long-term bond to enamel.18 This strong layer resists microleakage and protects the dentin bond from water degradation, which may contribute to better long-term clinical performance.19-23 Arrais24 has reported that these three-step adhesives also form the thickest hybrid layer, followed by one-bottle adhesives, with the self-etching adhesives forming the thinnest hybrid layers. It must be noted that strict adherence to etching times is critical, as prolonged phosphoric acid-etching can form a deep demineralized dentin zone that may not be fully impregnated by the primer and adhesive, resulting in low bond strength.25 These products, which bond well to dentinal substrates, have lost some of their popularity due to the fact that they are multi-bottle, multi-step systems, which require etch, rinse, and application of hydrophilic primers followed by a hydrophobic adhesive layer. As such, these systems can be very technique-sensitive, if the sequencing and timing is not exactly adhered to, with some having complicated instructions on how to bond to tooth structure and other dental materials. The so-called fourth-generation bonding agents have the major benefit of being effectively used with self-cure, dual-cure, and light-cured composites as well as indirect restorations without concern. Representative bonding strengths for products in this category are: OptiBond FL, 39 MPa to dentin,26 and Scotchbond MP, 45.6 MPa to dentin.19
Fifth-generation adhesives (etch-and-rinse plus [primer and bond]) or the single-bottle systems, such as MPa™ (CLINICIAN’S CHOICE®, www.
clinicianschoice.com); Sealbond Ultima (RTD, Clinical Research Dental, www.clinicalresearchdental.com); OptiBond® Solo Plus (Kerr); Adper™ Single Bond Plus (3M ESPE); Prime & Bond® NT™ (DENTSPLY Caulk, www.caulk.com); PQ1 and Peak™ (Ultradent Products); ExciTE® (Ivoclar Vivadent, www.ivoclarvivadent.com); and One Step Plus and ACE® ALL-BOND TE™ (Bisco), contain primers and adhesive in a single bottle. This simplifies the bonding technique by eliminating some of the variables regarding the number of bottles and steps required. This single-bottle, etch-and-rinse adhesive type shows the same effectiveness as the fourth-generation systems in terms of microleakage,27 and shows good dentin bond strengths with excellent marginal seal in enamel.28-30 However, not all fifth-generation adhesives are compatible with dual- and self-cure composites or core materials. The lower pH of the oxygen-inhibited layer, or the acidic monomers in some simplified products, are too acidic and thereby de-activate the tertiary amine in chemical-cured composites. This results in no bonding, or weak bonding, with a material such as Prime & Bond NT in its light-cured version showing a bond strength of 0 MPa.31 Some adhesive systems such as OptiBond Solo Plus require a dual-cure activator, which is a resin-free benzene sulphinic-acid/sodium salt solution, which will raise the acidic pH of the oxygen-inhibited layer in order to bond to self-cured/dual-cured products. However, this additional step lowers bond strengths because of the dilution of the adhesive and the inherent permeability of the polymerized adhesive.32 Other products, such as MPa, Sealbond Ultima, and One Step Plus, do not require the use of a dual-cure activator. With a self-cure composite, One Step Plus shows bond strength of 21.4 MPa33 in one study and 19 MPa in another.34 In the later study, MPa showed a bond strength of 18.5 MPa to the self- cure composite; however, when the oxygen-inhibited layer was removed with alcohol, the bond strength more than doubled to 38.9 MPa to the level obtained using light-cured composite.34
The solvents in bonding agents can be either ethanol-based, a nonvolatile solvent, or acetone-based. Products such as Sealbond Ultima and One Step Plus contain acetone, a very volatile solvent that should never be pre-dispensed into a dappen dish before the actual clinical bonding procedure, because the evaporation of the solvent will drastically reduce the patency of the bonding agent. Products that use ethanol or acetone need the proper amount of moisture (a moist bonding protocol), to prevent the collapse of the exposed collagen network.35 The amount of impregnation of the hybrid layer can be reduced by 50% if the dentin is over dried.36 Ethanol-based adhesives contained in products such as MPa™, Peak™, and OptiBond Solo Plus generally are more forgiving in clinical application and show the highest microtensile bond strengths.35,37,38 It must be noted here that the 3 to 5 seconds recommended by some manufacturers for the evaporation of solvents is generally not enough to remove even half of the solvent, and therefore extension of this time is recommended.39
The clinician also needs to know whether they are using a filled or unfilled adhesive, as the inclusion of fillers changes the viscosity and thickness of the applied layer. As well, evidence in the literature supports the concept that filled resins provide stress relief at the tooth–restoration interface.40 Not all fifth-generation adhesives are the same in regards to the number of applications (unfilled need more applications), so it is critical to follow the manufacturer’s directions. Some products, such as One Step Plus and Adper Single Bond Plus, require two coats of the adhesive, while others like MPa™ and PQ1 require only one.41 Of course a single coat saves material and time, because less of each is required for bonding the restoration. Representative dentin bond strengths reported in this category are 42 MPa to dentin for Adper Single Bond Plus25 and 41 MPa for MPa™.34
Postoperative sensitivity can be induced with the etch-and-rinse technique when exacting protocols are not followed. This is more prevalent in deeper dentin preparations and in high C-factor cavity preparations.42 Simplification by combining the primer and adhesive into one bottle, which also applies to the so-called seventh-generation or self-etch all-in-one adhesives, increases the hydrophilicity and permeability of the bond, making them more likely to undergo hydrolysis. This is especially true for the unfilled bonding agents, as they create a thinner hybrid layer.43
Part II of this article discusses two techniques to minimize, if not totally eliminate, postoperative sensitivity with etch-and-rinse adhesives using glutaraldehyde/HEMA combinations, as well as a hydrophobic radiopaque liner to decrease the permeability of the bond and thereby increase long-term performance. Part II will also examine the current status of the self-etch adhesives, their categories, and the role of matrix metalloproteinases in the lack of longevity of bonding to dentin. In the future, research data on increasing the longevity of the bond by inhibiting the activity of these proteinases may alter current approaches to bonding and newer products may emerge as a result.
Dr. Boksman was previously a part-time paid consultant to Clinician’s Choice and Clinical Research Dental, holding the title of Director of Clinical Affairs. Dr. Santos is a consultant for R&D to Clinical Research Dental and Clinician’s Choice.
1. Nakabayashi N, Pashley DH. Hybridization of Dental Hard Tissues. Chicago, Illinois: Quintessence Publishing Co., Ltd; 1998.
2. Powers JM, O’Keefe KL, Pinzon LM. Factors affecting in vitro bond strength of bonding agents to human dentin. Odontology. 2003;91(1):1-6.
3. Alex G. Adhesive dentistry: the good, the bad, and the ugly. Compend Contin Educ Dent. 2009;30(8)553-568.
4. El-Badrawy W. Kozovski L, Nathan G, Roperto RC. 1490 Bond strength of dentin as a function of priming time Seq #180 Bond Strength of Composites to Enamel and Dentin—Application Technique [abstract]. IADR/AADR/CADR 85th General Session and Exhibition. March 21-24, 2007. Available at: http://iadr.confex.com/iadr/2007orleans/techprogram/abstract_89827.htm. Accessed October 11, 2011.
5. Velasquez LM, Sergent RS, Burgess JO, Mecante DE. Effect of placement agitation and placement time on the shear bond strength of 3 self-etching adhesives. Oper Dent. 2006;31(4):426-430.
6. Hashimoto M, Sano H, Yoshida E, et al. Effects of multiple adhesive coatings on dentin bonding. Oper Dent. 2004;29(4):416-423.
7. Hagge MS, Lindemuth JS. Shear bond strength of an auto-polymerizing core build-up composite bonded to dentin with 9 adhesive systems. J Prosthet Dent. 2001;86(6):620-623.
8. Jung H, Friedl KH, Hiller KA, Schmalz G. 0341 Bond strength of composite resins using a new one-step adhesive system [abstract]. Seq #49 Self-etching Adhesive Systems 3, Adhesion Composite Bond Strength Program. 81st General Session of the International Association for Dental Research. June 25-28, 2003. Available at: http://iadr.confex.com/iadr/2003Goteborg/techprogram/abstract_31644.htm. Accessed October 11, 2011.
9. Carvalho RM, Garcia FC, E Silva SM, et al. Critical appraisal: adhesive-composite incompatibility, part 1. J Esthet Restor Dent. 2005;17(2):131.
10. Van Meerbeek B, Vargas S, Inoue S, et al. Adhesives and cements to promote preservation dentistry. Oper Dent. 26;S119-S144.
11. Kanca J. Effect of resin primer solvents and surface wetness on resin composite bond strength to dentin. Am J Dent. 1992;5:213-215.
12. Shirai K, De Munck JD, Yoshida Y, et al. Effect of cavity configuration and aging on the bonding effectiveness of six adhesives to dentin. Dent Mat. 2005;21(2):110-124.
13. Asmussen E, Munksgaard EC. Adhesion of restorative resins to dentinal tissues. In: Vanherle G, Smith DC, eds. Posterior Composite Restorative Materials. Amsterdam: Peter Szule Publishing Co.; 1985:228.
14. Hashimoto M, Ohno H, Kaga M, et al. In vivo degradation of resin-dentin bonds in humans over 1-3 years. J Dent Res. 2000:79(6):1385-1391.
15. Pecora N, Yaman P, Dennison J, Herrero A. Comparison of shear bond strength relative to two testing devices. J Prosthet Dent. 2002;88(5):511-515.
16. De Munck J, Van Landuyt K, Peumans M, et al. A critical review of the durability of adhesion to tooth tissue: Methods and results. J Dent Res. 2005;84(2):118-132.
17. Thunpithayakul C, Cobb DS, Denehy G, et al. 0346 In vitro microtensile dentin bond strength of adhesives by classification. Seq #70 Bond strength of composites to enamel and dentin with self-etching adhesives [abstract]. IADR/AADR/CADR 85th General session and exhibition. March 21-24, 2007. Available at: http://iadr.confex.com/iadr/2007orleans/techprogram/abstract_90534.htm. Accessed October 13, 2011.
18. Hashimoto M, Ohno H, Yoshida E, et al. Resin-enamel bonds made with self-etching primers on ground enamel. Eur J Oral Sci. 2003;111(5):447-453.
19. De Munck J, Van Meerbeek B, Yoshida Y, et al. Four year water degradation of total-etch adhesives bonded to dentin. J Dent Res. 2003;82(2):136-140.
20. May KN, Swift EJ, Wilder AD, Futrell SC. Effect of surface sealant on microleakage of Class V restorations. Am J Dent. 1996;9:133-136.
21. Abdalla AI, Feilzer AJ. Four year water storage of a total-etch and two self-etching adhesives bonded to dentin. J Dent. 2008;26:611-617.
22. Gamborgi GP, Loguercio A, Reis A. Influence of enamel border and regional variability on durability of resin-dentin bonds. J Dent. 2007;35(5):371-376.
23. Frankenberger R, Strobel WO, Lohbauer U, et al. The effect of six years of water storage on resin composite bonding to human dentin. J Biomed Mater Res B Appl Biomater. 2004;15;69(1):25-32.
24. Arrais CA, Giannini M. Morphology and thickness of the diffusion of resin through demineralized or unconditioned dentinal matrix. Pesqui. Odontol Bras. 2002;16(2):115-120.
25. Hashimoto M, Ohno H, Endo K, et al. The effect of hybrid layer thickness on bond strength: demineralized dentin zone of the hybrid layer. Dent Mater. 2000;16(6):406-411.
26. Christensen GJ. Bonding agents: Is convenience overriding strength? Clinician’s Report reprint from June 2010. Dental Economics. 2010;3(6):1-3.
27. Schmitt DC, Lee J. Microleakage of adhesive resin systems in the primary and permanent dentitions. Pediatr Dent. 2002;24(6):587-593.
28. Gallo JR, Comeaux R, Haines B, et al. Shear bond strength of four filled bonding systems. Oper Dent. 2001;26:44-47.
29. El-Kalla IH, Garcia-Godoy F. Saliva contamination and bond strength of single bottle adhesives to enamel and dentin. Am J Dent. 1997;10:83-87.
30. Castelnuovo J, Tjan AH, Liu P. Microleakage of multi-step and simplified-step bonding systems. Am J Dent. 1996;9:245-248.
31. O’Keefe KL, Powers JM. Adhesion of resin composite core materials to dentin. Int J Prosthodont. 2001;14(5):451-456.
32. Tay FR, Suh BI, Pashley DH, et al. Factors contributing to the incompatibility between simplified-step adhesives and self-cured or dual-cured composite. Part II. Single bottle total etch adhesive. J Adhes Dent. 2003;5(2):91-105.
33. Swift EJ Jr, Perdigão J, Combe EC, et al. Effects of restorative and adhesive curing methods on dentin bond strengths. Am J Dent. 2001;14(3):137-140.
34. Walter R, Swift EJ Jr., Ritter AV, et al. Dentin bonding of an etch-and-rinse adhesive using self-and light-cured composites. Am J Dent. 2009;22(4):215-218.
35. Lopes GC, Cardoso PC, Vieira LC, et al. Shear bond strength of acetone-based one-bottle adhesive systems. Br Dent J. 2006;17(1):39-43.
36. Hashimoto M, Ohno H, Kaga M, et al. The extent to which resin can infiltrate dentin by acetone-based adhesives. J Dent Res. 2002;81(1):74-78.
37. Nunes MF, Swift EJ, Perdigão J. Effects of adhesive composition on microtensile bond strength to human dentin. Am J Dent. 2001;14(6):340-343.
38. Cardoso Pde C, Lopes GC, Vieira LC, Baratieri LN. Effect of solvent type on microtensile bond strength of a total-etch one-bottle adhesive system to moist or dry dentin. Oper Dent. 2005;30(3):376-781.
39. Pashley DH, Tay FR, Breshi L, et al. State of the art etch-and-rinse adhesives. Dent Mater. 2011;27(1):1-16.
40. Swift EJ Jr, Vargas MA. Dentin/enamel adhesives: Their current status. Oral Health. 2009;12-22.
41. Montes MA, de Goes MF, da Cunha MR, Soares AB. A morphological and tensile bond strength evaluation of an unfilled adhesive with low-viscosity composited and a filled adhesive in one and two coats. J Dent. 2001;29(6):435-441.
42. Opdam NJ, Feilzer AJ, Roeters JJ, Smale I. Class I occlusal composite restorations: In vivo post-operative sensitivity, wall adaptation, and microleakage. Am J Dent. 1998;11(5):229-234.
43. Tay FR, Pashley DH. Have dentin adhesives become too hydrophilic? J Can Dent Assoc. 2003;69(11):726-731.
About the Authors
Leendert (Len) Boksman, DDS, BSc, FADI, FICD
Retired from Private Practice
London, Ontario, Canada
Gregg Tousignant, CDT
Technical Support Manager
Clinical Research Dental
London, Ontario, Canada
Lee W. Boushell, DMD, MS
Department of Operative Dentistry
University of North Carolina School of Dentistry
Chapel Hill, North Carolina
Gildo Coelho Santos, Jr., DDS, MSc, PhD
Assistant Professor and Chair Division of Restorative Dentistry
Schulich School of Medicine and Dentistry
University of Western Ontario
London, Ontario, Canada
London, Ontario, Canada