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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
I
Lee W. Boushell, DMD, MS | Gildo Coelho Santos, Jr., DDS, MSc, PhD
n 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-andrinse 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
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
Assistant Professor
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
Private Practice
London, Ontario, Canada
94
inside dentistry | February 2012 | www.dentalaegis.com/id
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 acidetched 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.
To read a CE article on Adhesives, visit:
dentalaegis.com/go/id79
Fourth-Generation
Adhesives
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 MultiPurpose 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, dualcure, 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
Fifth-generation adhesives (etch-andrinse 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 singlebottle, 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
“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.”
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 dualcure 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 predispensed 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
For product information about
Adhesives, visit:
dentalaegis.com/go/id80
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 seventhgeneration 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
Conclusion
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 longterm performance. Part II will also
examine the current status of the selfetch 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.
Disclosure
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.
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Biomater. 2004;15;69(1):25-32.
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38. Cardoso Pde C, Lopes GC, Vieira LC,
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