Dental Materials
CDE
2 HOURS
CREDIT
Antibacterial activity in adhesive dentistry:
A literature review
Fereshteh Shafiei, DMD, MS
n Mahtab Memarpour, DMD, MS
This literature review summarizes the published research
regarding the antibacterial agents used in adhesive dentistry.
This article provides information about the clinical applications,
beneficial effects, and possible disadvantages of antibacterials
A
dhesive systems are used
extensively in clinical practice
for bonding to tooth structure. Adhesive systems are used for
direct and indirect tooth-colored
esthetic restorations, amalgam
restorations, crowns and fixed
partial dentures, luting posts in
root dentin, fissure sealant therapy,
and enamel bonding when placing
orthodontic brackets.
Despite their qualities, adhesive
systems cannot prevent micro-gaps
from forming at the dentinal margins of composite restorations.1,2
Even when immediate complete
marginal sealing is established, the
resin-dentin interface can degrade
rapidly over time.1,3,4 In addition,
more plaque accumulates on the
surface of composites than on
enamel surfaces or other restorative
materials.5,6 The accumulation of
plaque means that microorganisms
are always in contact with the cured
adhesives via micro-gaps. The lack
of definitive and reliable assessment criteria means that not all
microorganisms in carious dentin
can be detected and eliminated.7,8
The problem of bacteria remaining
in a cavity is more pronounced by
an increasing predilection toward
minimally invasive, tissue-saving
dentistry in which the intact tooth
structure is preserved to the greatest
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November/December 2012
when used in various bonding situations.
Received: September 15, 2011
Accepted: January 31, 2012
extent possible.9 Residual bacteria
can survive for more than a year
and can proliferate even in the presence of a good seal.10 Adjunctive
treatment with antibacterial agents
during dentin bonding could prevent the detrimental effects resulting
from residual bacteria or microleakage, such as pulp damage, hypersensitivity, and recurrent caries (a major
cause of restoration replacement).11
A biologic seal can improve the
longevity of the restoration.
Antibacterial effect of
adhesive systems
Acid etchants used in etch-and-rinse
adhesives and the acidic monomers
found in self-etching adhesives with
low pH have both demonstrated
antibacterial activity.12-19 According
to Harper & Loesche, the pH values
that completely eliminated bacteria
over a three-hour period were 2.3 for
Lactobacillus casei and 3.0 for Streptococcus mutans.20 However, certain
bacteria are acid-resistant; in addition, the buffering capacity of dentin
can limit the effects of the acid.16,20,21
Some monomers that promote
adhesion, such as N-methacryloyl
5-aminosalicylic acid (5-NMSA) and
Phenyl-P—particularly methylene
diphosphonate (MDP)— slightly
inhibit bacterial growth, due to the
specific antibacterial components
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(such as glutaraldehyde) that are
found in some adhesives.17,18,22-25
However, photocuring self-etching
adhesives reduces their antibacterial
properties significantly. The literature has reported on the inability of
adhesives to inhibit bacterial growth
or secondary caries.18,19,25-31
Categorization of
antibacterial agents
Antibacterial activity is provided by
two types of materials: those that
release agents and those that do not
(the latter are known as contact antibacterials).18,32,33 The agent-releasing
materials are used as a separate disinfecting material or as antibacterialincorporated materials when the
disinfecting step is eliminated.
Separate disinfecting materials
Originally, chemicals such as silver
nitrate precipitated with eugenol,
phenole, and thymol were recommended for disinfecting cavity
preparations prior to placement of
restorations. These materials are no
longer used due to their irritating
effect on the pulp.32 Cavity disinfectants were initially proposed
by Brannstrom & Nyborg.34 They
recommended Tublicid (Global
Dental Products), a benzalkonium
chlorite-based disinfectant containing ethylenediaminetetraacetic
acid (EDTA) and sodium fluoride
(NaF), for cavity disinfection.34
Tublicid is a quaternary ammonium compound with no pulpal
reactions.32,35,36 Other disinfectant
materials that have been used to
disinfect cavities include sodium
hypochlorite (NaOCl), hydrogen
peroxide (H2O2), and iodine-based
oral disinfectants. EDTA and
NaOCl were used primarily for
their other properties, including
the ability to serve as a calcium
chelator, remove the smear layer,
and help to remove collagen.
Based on evidence from a study
by Anderson & Charbeneau on
residual bacteria in the cavities,
cavity disinfectants were recommended.12,36,37 However, adjunctive
use of disinfectants during bonding
procedures could have an adverse
effect on the bonding ability of different adhesive systems.32,36,38-41
Chlorhexide gluconate (CHX),
a bisphenol component containing
chlorine, has been used for many
years as a safe antiseptic with a
broad spectrum of action. Studies
have shown that CHX reduces the
number of microorganisms in plaque
and saliva and also reduces the level
of S. mutans in occlusal fissures and
root surfaces.42,43 CHX has been used
as an irrigant for the nonsurgical
treatment of periodontal diseases
and adjunctively used in endodontic
treatment.44,45 It is bacteriostatic in
low concentrations and bactericidal
in higher concentrations.46 These
effects have been reported primarily
on Gram-positive bacteria and less
on Gram-negative bacteria, such as S.
mutans and S. sobrinus, both of which
contribute to initial caries development and are more sensitive to the
antibacterial effect of CHX.42,43,47
CHX has strong cationic activity,
allowing it to be absorbed easily into
(and thus disrupt) the negatively
charged bacterial cell wall.36,46,47 This
chemical charge also allows CHX
to adhere to oral cavity surfaces and
tooth structure, which results in
longer antimicrobial activity (ranging
from 48 hours to 12 weeks) compared with other disinfectants.32,36,48,49
Fardal & Turnbull recommended
CHX as a cavity disinfectant in
1986.42 CHX, benzalkonium chloride, and cetylpyridinum chloride
have been used as additives to
phosphoric acid; the latter is capable
of cross-linking to collagen.50-52 A
considerable decrease in the number
of bacteria in the dentinal tubules
was reported following application of
0.2% CHX for five minutes.53
At least two solutions containing
2% CHX are available commercially: Cavity Cleanser (Bisco, Inc.)
and Consepsis (Ultradent Products,
Inc.). A 1% CHX gel (Drogsan
Pharmaceuticals) is also available.
These products have been used
to disinfect cavity preparations in
numerous studies and have produced interactions with the bonding
ability of adhesive systems used in
direct and indirect restorations that
appear to be material-specific. These
results—in addition to results from
other studies regarding the effects
of disinfectants on the bonding
efficacy of adhesive systems—are
summarized in Table 1.
The CHX binding to phosphate
groups might act as a co-surfactant
on the etched surface and increase
the surface free energy; however,
it can also have an adverse effect
on bond strength to primary
dentin.42,44,47,48,54 CHX has been
applied in different sequences,
including before etching, after
etching (with or without rinsing),
or CHX-containing phosphoric
acid.41,50,54-63 A number of authors
and a manufacturer of a commercial product, Consepsis (Ultradent
Products, Inc.), recommend
applying CHX for 60 seconds
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General Dentistry
after etching, then removing
excess moisture prior to applying a
hydrophilic adhesive or a rewetting
agent.55,58,64-68 CHX could conserve
and regulate the structural integrity
of the collagen matrix.65 Furthermore, removing the smear layer
during etching eliminates most of
the bacteria as well.12,37,58
CHX was applied on the smear
layer in association with self-etch
adhesives that have no separate
etching and washing steps; however,
it can affect the bonding ability
of the adhesives.41,56,60,69,70 The
adverse effect of CHX on some
self-etch adhesives is related to
residual moisture (a 2% CHX solution is composed of 98% water),
which contaminates the bonded
surface.71,72 The gel form of CHX
could have a limited penetration
depth and therefore would not
affect the bond.60 Self-etch adhesives
containing MDP might have been
adversely affected by CHX bonding
to loose, superficial apatites within
the smear layer.72 A 1996 study used
SEM analysis and reported that
CHX creates a acid-resistant layer,
inhibiting acidic monomers from
penetrating the dentin.41
Even at a very low concentration
(0.2%), CHX functions as a matrix
metalloproteinase (MMP) inhibitor
that can prevent both degradation
of collagen and disintegration of
the bonding interface.73-75 MMPs
are a class of metal-dependent
endopeptidases that remain latent
in the dentin matrix during tooth
development and can be activated
during dentin demineralization.74,76,77 CHX can bind to the
dentin matrix; in addition, it can be
retained in the dentin and covered
or sealed with adhesive.62,78,79
Long-term use of CHX solution can result in brown staining
of the teeth; however, studies that
used CHX for a short time during
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Dental Materials Antibacterial activity in adhesive dentistry
Table 1. In vitro studies regarding the interaction of cavity disinfectants and adhesive systems.
Author(s)
Cavity disinfectant(s) Experimental design
Procedure/adhesive
Effect
Surmont et al (1989)151
Benzalkonium
chloride-based
Root dentin bond strength
Before self-etching/Gluma Bond
(Heraeus Dental North America)
No effect
Gwinnett (1992) 52
CHX
Dentin bond strength
Before etching/fourth generation bonding
No effect
Benzalkonium
chloride-based
Dentin bond strength
Before etching/fourth generation bonding
No effect
Filler et al (1994)155
CHX
Enamel bond strength
Before etching/Prisma APH (Dentsply Caulk)
No effect
Perdigao et al (1994) 55
CHX
Dentin bond strength
After etching/All Bond 2 (Bisco, Inc.)
No effect
Derhami et al (1995)
Benzalkonium
chloride-based
Enamel and
dentin leakage
Super-Bond D Liner (Sun Medical Company, Ltd.),
Clearfil Liner Bond (Kuraray America, Inc.)
No effect
Enamel and
dentin leakage
Before etching/Tenure (Den-Mat)
No effect
Enamel and
dentin leakage
Before self-etching/Syntac
Negative effect on
Syntac (dentin)
Dentin bond strength
Before etching/Tenure
No effect
Before self-etching/Syntac
Negative effect
152
Meiers & Kresin (1996) 41 CHX
Iodine-based
Meiers & Shook (1996) 56 CHX
Before self-etching/Syntac (Ivoclar Vivadent Inc.) No effect
Cunningham & Meiers
(1997)38
CHX
Dentin bond strength
Before conditioning/resin-modified glass ionomer No effect
(RMGI)
Damon et al (1997)153
CHX
Enamel bond strength
After etching/Transbond XT (3M Unitek)
No effect
Tulunoglu et al (1998)154 CHX
Primary dentin
Before etching/Prime & Bond (Dentsply Caulk)
Negative effect
Leakage
Before self-etching/Syntac
Negative effect
Gurgan et al (1999) 50
Enamel and dentin bond
strength
Before etching
Negative effect
After etching
Negative effect
After etching and rinsing/Permagen (Ultradent
Products, Inc.)
No effect
CHX
el-Housseiny & Jamjoum CHX
(2000)156
Enamel and dentin bond
strength
Before etching/Scotch Bond Multi Purpose
(3M ESPE)
No effect
Pilo et al (2001) 57
CHX
Dentin bond strength
After etching and rinsing/One-Step Plus
(Bisco, Inc.)
Positive effect
Owens et al (2003) 51
CHX
Enamel and dentin leakage
After etching/PQ1 (Ultradent Products, Inc.)
No effect
CHX + silicate glass Enamel and dentin leakage
After etching/PQ1
Negative effect
Cetyl pyridinium
chloride
Enamel and dentin leakage
Incorporated into acid gel
No effect
CHX
Dentin bond strength
Before etching Adper/Single Bond (3M ESPE)
Negative effect
CHX incorporated into acid gel
No effect
Vieira & da Silva
(2003) 54
restorative procedures reported no
such staining.59,62 CHX can reduce
postoperative sensitivity and increase
bonding durability as an additional
therapeutic primer, as long as it has
no adverse effect on the adhesive’s
immediate bond.80
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Antibacterial–incorporated
materials
Antibacterial components such
as antibiotics, dodecylamine,
bipyridine, tannic acid derivatives,
polyhexanide, amphilic lipids,
silver, and fluorides have been
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added to dental resins.81-85 These
agents can extend the antibacterial
effect beyond the immediate area
of the adhesive restoration; however, they could also compromise
the mechanical and bonding properties of the carrier material.18,86
Table 1 cont’. In vitro studies regarding the interaction of cavity disinfectants and adhesive systems.
Author(s)
Cavity disinfectant(s) Experimental design
de Castro et al (2003)71 CHX
Say et al (2004) 58
Turkun et al (2004) 69
Sung et al (2004) 64
Erdemir et al (2004)
161
Dentin bond strength
Procedure/adhesive
Effect
After etching
No effect
Before etching/Prime & Bond, Single Bond
No effect
Before self-etching/Clearfil SE Bond
(Kuraray America, Inc.)
No effect
CHX
Dentin bond strength
After etching/One-Step Optibond Solo
(Kerr Corporation)
No effect
Benzalkonium
chloride-based
Dentin bond strength
After etching/One-Step Optibond Solo
No effect
CHX
Enamel and dentin leakage
Before self-etching/Clearfil SE Bond,
Prompt L-Pop (3M ESPE)
No effect
Benzalkonium
chloride-based
Enamel and dentin leakage
Before self-etching/Clearfil SE Bond,
Prompt L-Pop
No effect
Iodine-based
Enamel and dentin leakage
Before self-etching/Clearfil SE Bond,
Prompt L-Pop
Negative effect
CHX
Dentin leakage
After etching/Optibond Solo
No effect
NaCl
Dentin leakage
After etching/Optibond Solo
No effect
NaOCl
Dentin leakage
After etching/Optibond Solo
No effect
CHX
Root dentin
Before etching/C&B Metabond (Parkell, Inc.)
No effect
NaOCl
Bond strength
Before etching/C&B Metabond
Negative effect
H2 O 2
Bond strength
Before etching/C&B Metabond
Negative effect
Turkun et al (2005)157
CHX;
Benzalkonium
chloride-based
Dentin bond strength
After etching/Syntac, Variolink (Ivoclar
Vivadent Inc.), DenTASTIC (Pulpdent
Corporation), ResiLute (Pulpdent Corporation)
No effect
No effect
Pappas et al (2005)39
CHX, then
Dentin bond strength
benzalkonium
chloride-based, then
NaOCl
Before etching/All Bond 2
No effect
Cacciafesta et al
(2006)158
CHX
Enamel bond strength
Before conditioning/glass ionomer
(Fuji Ortho LC, GC America, Inc.)
Negative effect
Geraldo-Martins et al
(2007)159
CHX
Enamel and dentin leakage
Before self-etching/Clearfil SE Bond
No effect
Soares et al (2008) 59
CHX
Dentin bond strength
Before etching
No effect
After etching
No effect
Incorporated into acid gel/Adper Single Bond,
Rely X ARC (3M ESPE)
No effect
Also, a strict control of release
kinetics is difficult, and long-term
antibacterial effects are not to be
expected.18,86-88
CHX has been added to restorative materials, provisional and
permanent conventional cements,
and polymethyl methacrylate-based
resin cements.18,87,89-92 The literature
has reported that adding CHX
to self-etching primers did not
compromise bonding ability and
might even preserve bond strength
to dentin.93-95 Conversely, a 2009
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study by Cadenaro et al demonstrated that CHX had an adverse
effect on the physical property of
a primer.96 Furthermore, CHX
release can be affected by water
sorption and hydrophilic characteristics of resin composites.97
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Dental Materials Antibacterial activity in adhesive dentistry
Table 1 cont’. In vitro studies regarding the interaction of cavity disinfectants and adhesive systems.
Author(s)
Cavity disinfectant(s) Experimental design
Procedure/adhesive
Bansal & Tewarsi
(2008)160
CHX
Dentin leakage
Before etching/Prime & Bond; before self-etching/ Positive effect on
Xeno III (Dentsply Ltd.)
Xeno III
Iodine-based
Dentin leakage
Before etching/Prime & Bond; before self-etching/ Positive effect on
Xeno III (Dentsply Ltd.)
Xeno III
NaOCl
Dentin leakage
Before etching/Prime & Bond; before self-etching/ No effect
Xeno III (Dentsply Ltd.)
CHX
Dentin bond strength
After etching/Adper Scotch Bond 1 (3M ESPE)
No effect
Catalbas et al (2009)162 CHX
Enamel bond strength
Before etching/Transbond XT
Negative effect
CHX gel
Enamel bond strength
Before etching/Transbond XT
Negative effect
CHX
Primary dentin bond strength After etching/Prime & Bond
Erhardt et al (2008) 65
Ersin et al (2009)
163
Hiraishi et al (2009)72
Siso et al (2009)70
Ercan et al (2009) 60
Saber & El-Askary
(2009)164
CHX
No effect
After conditioning/glass ionomer
(Vitremer, Ketac Molar, 3M ESPE)
No effect
After etching/Adper Single Bond-RelyX ARC
No effect
Before self-etching/ED Primer II, Panavia F 2.0
(Kuraray America, Inc.)
Negative effect
Before self-adhesive/RelyX Unicem (3M ESPE)
Negative effect
Enamel leakage
Before self-etching/Clearfil SE Bond
Negative effect
on enamel
Dentin leakage
Before self-etching/Clearfil SE Bond
No effect on
dentin
CHX
Dentin bond strength
After etching/Prime & Bond NT (Dentsply Caulk); Negative effect
before self-etching/Clearfil SE Bond
on self-etch
NaOCl
Dentin bond strength
After etching/Prime & Bond NT; before
self-etching/Clearfil SE Bond
Negative effect
on self-etch
H2 O 2
Dentin bond strength
After etching/Prime & Bond NT; before
self-etching/Clearfil SE Bond
Negative effect
on self-etch
CHX gel
Dentin bond strength
After etching/Prime & Bond NT; before
self-etching/Clearfil SE Bond
No effect
CHX
Dentin bond strength
Before self-etching/Clearfil S3 Bond
Negative effect
NaOCl
Dentin bond strength
Before self-etching/Clearfil S3 Bond
Negative effect
CHX
To provide cariostatic and
antibacterial effects, fluoride has
been incorporated into restorative
materials, sealants, and adhesive systems; however, the beneficial effect
of fluoride has more to do with
inhibiting demineralization and
enhancing remineralization than
any antibacterial activity.21,85,98,99
According to Francci et al, released
fluoride has little or no effect on the
inhibition of S. mutans.100
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Dentin bond strength
Effect
November/December 2012
Non-agent releasing (contact)
antibacterial materials
Methacryloyloxydodecyl pyridinium
bromide (MDPB) is a unique
monomer that was developed to
provide resin-based materials with
long-lasting antibacterial activity
without releasing the antibacterial agent. After curing, MDPB is
covalently bonded to the polymer
network and acts as a contact
inhibitor against the bacteria that
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comes in direct contact with the
polymer.87,101,102 In 2008, Xiao et
al developed a similar monomer,
methacryloxylethyl cetyl dimethyl
ammonium chloride (DMAE-CB), a
compound of the antibacterial agent
quaternary ammonium with a methacryloyl group.103 The adsorption of
the positively charged agent onto a
negatively charged bacterial surface
can disrupt cell membranes.36,38
Both of these monomers have been
Table 1 cont’. In vitro studies regarding the interaction of cavity disinfectants and adhesive systems.
Author(s)
Cavity disinfectant(s) Experimental design
Procedure/adhesive
Effect
Campos et al (2009) 66
CHX
After etching/Adper Single Bond
No effect
Before self-etching/Clearfil S3
Negative effect
Mobarak et al (2010)
Dentin bond strength
CHX
Dentin bond strength
Before self etching/Clearfil SE Bond
No effect
CHX
Dentin bond strength
After etching Adper/Single Bond
Positive effect
Before self-etching/Clearfil SE Bond
No effect
Sharifian et al (2010)165 CHX
Root dentin bond strength
Before self-etching/Resilon-Epiphany
(Dentsply Caulk)
No effect
Lindblad et al (2010)166
Root dentin bond strength
After etching/All Bond 2, Duolink (Bisco, Inc.),
Perma Flow DC (Ultradent Products, Inc.)
No effect
Before self-adhesive/RelyX Unicem
No effect
Before self-etching/Clearfil SE Bond, RelyX ARC
No effect
61
Celik et al (2010)145
CHX
Pelegrine et al (2010)146 CHX gel
Root dentin bond strength
NaOCl
Root dentin bond strength
Before self-etching/Clearfil SE Bond, RelyX ARC
No effect
Kustarci & Sokucu
(2010)167
CHX
Enamel leakage
After etching/Transbond XT
No effect
Shafiei & Memarpour
(2010)168
CHX
Dentin bond strength
After etching/Variolink 2 (Ivoclar Vivadent Inc.)
No effect
Before self etching /Panavia F2.0 (Kuraray Inc.)
No effect
Before self adhesive-Relay X Unicem
No effect
169
Shafiei et al (2011)
CHX
Enamel and dentin leakage
After etching/Nexus 2 (Kerr Corporation)
Before self-etching/ Panavia F 2.0
No effect
No effect
Shafiei et al (2010)170
CHX
Enamel and dentin leakage
After etching/Scotchbond Multi-Purpose (3M
ESPE), Excite (Ivoclar Vivadent Inc.)
No effect
Before self-etching/Clearfil SE Bond, iBond
(Heraeus Kulzer Dental Products)
No effect
CHX = Chlorhexidine solution
Note: Four other studies (Stanislawczuk et al, Ricci et al, Breschi et al, and Carrilho et al ) demonstrated the preservative effect of CHX (after etching) on dentin bonding
and showed no adverse effect on immediate bond strength; these studies are not included in Table 1.63, 68, 73, 75
incorporated into resin composite
and adhesive systems.86,87,101-105
Although studies have demonstrated the antibacterial effect of
the incorporated composite even
after a year of water storage, other
reports have described the loss of
this effect.18,87,106,107 The adsorption
of proteins on the surface could
account for the reduced antibacterial effect.18 While the antibacterial
effects of composite restorations
primarily involve inhibiting
surface plaque accumulation, the
antibacterial effect of adhesives
involves disinfecting the cavity and
rendering inactive any bacteria
that might enter through marginal
microleakage.18 A self-etch primer
containing 5% MDPB killed S.
mutans within 30 seconds of contact
before curing.8,104 Following copolymerization with other monomers,
this self-etch primer had an inhibitory effect on the growth and adherence of bacteria on its surface.21,22,102
MDPB has demonstrated antibacterial activity against various bacteria
isolated from both root and dentin
caries.8,9,16,29,31,32,102,108-111 Studies
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General Dentistry
have reported that incorporating
antibacterial monomers does not
compromise bonding efficacy and
stability, curing ability, cytotoxicity,
or marginal adaptation.18,104,112-116
MDPB is a more hydrophobic
monomer than hydroxyethyl methacrylate (HEMA). Incorporation
of MDPB increases viscosity of the
adhesive. These properties could
slightly decrease the infiltration
of MDPB-containing adhesive
into demineralized smear layer
and dentin.112 It has been reported
that resins containing MDPB are
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Dental Materials Antibacterial activity in adhesive dentistry
capable of reducing extracellular
polysaccharides in the plaque matrix
(restricted to plaque over the margins); however, these resins have no
effect on biofilm formation or initial adherence of S. mutans.30,117,118
Clearfil Protect Bond (Kuraray
America, Inc.) adds 5% MDPB to
its self-etching primer adhesive,
Clearfil SE Bond.
A 2007 study reported that
Clearfil Protect Bond demonstrated
satisfactory clinical performance
when used in posterior composite
restorations.119 Tziafas et al reported
that Clearfil Protect Bond maintained pulp vitality but interfered
with reparative dentin formation
in exposed, infected pulp.120 Other
studies have reported that Clearfil
Protect Bond offers good bonding
durability stability and has a a relatively high bond strength associated
to resin cements.33,121,122
Cetylpyridinium chloride is
another antibacterial agent that has
been immobilized in an adhesive
and showed an inhibitory effect
on bacteria which were in contact
with its surface.123 Recently, the
combination of bioactivity and
bacterial effect has been proposed to
create a dental adhesive containing
crystalline titania nanoparticles that
reduces the incidence of secondary
caries and promotes closure of the
gaps formed at the interface via
remineralization.124
Antibacterial activity in
enamel bonding
Enamel bonding in fissure
sealants
Little information is available regarding antibacterial activity in sealants.
An antibacterial adhesive under a
sealant might exhibit antibacterial
action on the original bacteria in
pits and fissures and inhibit caries
formation following microleakage or
a partial loss of the sealant. A 2005
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study placed an adhesive associated
with sealant and composite resin on
uncut enamel and reported that the
bond was comparable to that of a
total-etch adhesive.125
Enamel bonding in orthodontic
brackets
Demineralization is a major side
effect of fixed appliance orthodontic
treatments, with prevalence reports
of 50–70%.126,127 Demineralization
around fixed orthodontic appliances results from gap formation
due to polymerization shrinkage,
more retention sites, and increased
plaque accumulation.127,128 Fluoride
and CHX are the most common
preventive approaches; however,
their effects are limited in duration
and are not completely effective. The
antibacterial-incorporated type could
compromise the bonding ability of
the adhesives.86,129,130 Furthermore,
the ability of fluoride-releasing
adhesives to inhibit demineralization
is still in doubt, since the low pH
environment created by bacteria
prevents remineralization; for this
reason, the combination of fluoride
and antibacterial agents has been
suggested.131,132 Studies that used
Clearfil Protect Bond have reported
promising results in terms of bond
strength and sealing ability.133-136
The low bond strength reported
in some studies could be attributed
to an insufficient etching pattern on
unground enamel because Clearfil
Protect Bond is a mild self-etch
adhesive with a pH of 2.137 Some
studies performed enamel etching for
10 seconds, while others suggested
that etching might not be necessary
and did not recommend it.137-140
Other antibacterial agents that
have been added to the adhesives
used in bracket bonding include
benzalkonium chloride (as a releasing
agent) and silver nanoparticles (as a
non-releasing agent). The latter has
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the disadvantage of a discoloration
problem related to silver ions.141-143
Randomized controlled clinical longterm trials should be conducted to
confirm the positive effect of these
agents on enamel decalcification
during orthodontic treatment.
Antibacterial effect of lasers
A 1997 article by Klinke et al proposed using lasers to decontaminate
cavities or root dentin.144 Although
laser pretreatment might not
affect the bonding ability of some
adhesives, it does represent a more
expensive and complex treatment
modality in respect to getting a
homogenous laser application with
suitable irradiation parameters to all
parts of the cavity.70,145-147
Antibacterial effect of ozone
Acording to the literature, applying
ozone for 20 seconds can kill 99.9%
of microorganisms found in primary
caries lesions.148 Studies have suggested that ozone gas can disinfect the
cavity prior to performing restorative
procedures, without affecting the
enamel or dentin bond strength.149,150
Summary
According to the in vitro and
limited in vivo data found in the
literature, CHX can be used with
etch-and-rinse adhesives as a cavity
disinfectant while improving bonding durability; however, long-term
clinical studies are necessary to
confirm these advantages.
Clearfil Protect Bond appears
to offer long-lasting antibacterial
activity in adhesive dentistry; however, additional testing is needed
to determine its effect on bacteria
invading the adhesive interface
in vivo. In addition, long-term in
vivo evaluations using standardized
protocols should be conducted to
determine the practical application
of mechanical and biologic sealing.
Disclaimer
The authors certify that they do not
have any commercial interest that
represents a conflict of interest in
connection with the manufacturers
listed in this article.
Author information
Dr. Shafiei is an associate professor, Department of Operative
Dentistry, Shiraz University of
Medical Sciences, Shiraz, Iran,
where Dr. Memarpour is an associate professor, Pediatric Dentistry
Department, School of Dentistry.
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