Jorge Perdigão

The clinical performance of adhesives

OBJECTIVES Traditional mechanical methods of retaining restorative materials have been replaced to a large extent by tooth conserving adhesive restorative techniques. Because adhesives have been evolving so rapidly for the last few years, the timing is right for evaluating the clinical status of present day adhesives. DATA SOURCES Current literature with regard to the clinical performance of adhesives has been reviewed. An overview of currently available adhesive systems is provided and a categorization of these adhesives according to their clinical application procedure and their intended mechanism of adhesion is proposed. Parameters of direct relevance to the clinical effectiveness of adhesives are discussed in relation to the clinical effectiveness of todays adhesives. CONCLUSIONS The clinical performance of present day adhesives has significantly improved, allowing adhesive restorations to be placed with a high predictable level of clinical success. Most modern adhesive systems are superior to their predecessors, especially in terms of retention that is no longer the main cause of premature clinical failure. Recent adhesives also appear less sensitive to substrate and other clinical co-variables. As the remaining major shortcoming of modern adhesives, none of these modern systems however appears yet to be able to guarantee hermetically sealed restorations with margins free of discoloration for a long time.

Dentin bonding-variables related to the clinical situation and the substrate treatment.

The wetness of dentin surfaces, the presence of pulpal pressure, and the thickness of dentin are extremely important variables during bonding procedures, especially when testing bond strength of adhesive materials in vitro with the intention of simulating in vivo conditions. The ultimate goal of a bonded restoration is to attain an intimate adaptation of the restorative material with the dental substrate. This task is difficult to achieve as the bonding process is different for enamel and for dentin-dentin is more humid and more organic than enamel. While enamel is predominantly mineral, dentin contains a significant amount of water and organic material, mainly type I collagen. This humid and organic nature of dentin makes this hard tissue very challenging to bond to. Several other substrate-related variables may affect the clinical outcome of bonded restorations. Bonding to caries-affected dentin is hampered by its lower hardness and presence of mineral deposits in the tubules. Non-carious cervical areas contain hypermineralized dentin and denatured collagen, which is not the ideal combination for a bonding substrate. Physiological transparent root dentin forms without trauma or caries lesion as a natural part of aging. Similar to the transparent dentin observed underneath caries lesions, the tubule lumina become filled with mineral from passive chemical precipitation, making resin hybridization difficult. An increase in number of tubules with depth and, consequently, increase in dentin wetness, make bonding to deeper dentin more difficult than to superficial dentin. While the application of acidic agents open the pathway for the diffusion of monomers into the collagen network, it also facilitates the outward seepage of tubular fluid from the pulp to the dentin surface, deteriorating the bonding for some of the current adhesives. Some dentin desensitizers have shown some promise as they can block dentinal tubules to treat and prevent sensitivity and simultaneously blocking the tubular fluid from flowing to the surface. A new approach to stop the degradation of dentin-resin interfaces is the use of MMP inhibitors. Although still in an early phase of in vitro and clinical research, this method is promising.

Morphological field emission-SEM study of the effect of six phosphoric acid etching agents on human dentin

OBJECTIVES This study evaluated the effects of six phosphoric acid-etching agents on dentin, the independent variables being two acid concentrations (10% and 32%-37%) and three thickener conditions (no thickener, silica, and polymer). The tested hypothesis was that the use of different etchants with similar concentrations of phosphoric acid would result in similar depths of dentin demineralization. METHODS Thirty dentin disks were obtained from extracted human teeth by microtome sectioning. The dentin surfaces were etched with one of the etching agents, fixed, dehydrated and dried. The specimens were observed using a FE-SEM. The mean deepest demineralization of intertubular dentin was measured from fracture surfaces of the disks. These values were analyzed by ANOVA and Duncans Test. The morphological appearance of the dentin surfaces was compared using the following observation criteria: 1) Presence of a cuff of peritubular dentin; 2) Relative thickness of the layer containing residual collagen or smear layer particles; and 3) Formation of a submicron hiatus at the bottom of the exposed collagen network. The pH of each of the etching agents was measured. A correlation analysis was made of the pH vs. the depth of dentin demineralization. RESULTS Silica-thickened etchants did not demineralize dentin as deeply as did polymer-thickened etchants and unthickened etchants. High magnifications revealed three distinct zones within the demineralized dentin layer; an upper porous zone of residual smear layer or denatured collagen and residual silica particles (in groups etched with silica-thickened etchants), an intermediate area with randomly oriented collagen fibers, and a lower zone with submicron hiatus, few collagen fibers, and scattered hydroxyapatite inclusions. This hiatus was observable in all the specimens etched with the polymer-thickened etchants, in 90% of the specimens etched with the unthickened phosphoric acid liquids, and in 60% of the specimens etched with the silica-thickened gels. SIGNIFICANCE The results obtained suggest that similar concentrations of phosphoric acid etchants containing distinct thickeners result in different demineralization depths as well as different morphology of etched dentin.

Effect of a sodium hypochlorite gel on dentin bonding

UNLABELLED It has been suggested that the hybrid layer (HL) does not play any important role in the mechanism of adhesion to dentin. To substantiate this hypothetical insignificance of the HL, sodium hypochlorite (NaOCl) has been used to remove collagen from etched dentin prior to bonding. OBJECTIVES The present study was conducted to determine the effect of a commercial 10% NaOCl gel on the dentin shear bond strengths and HL ultra-morphology of two simplified dentin adhesives. The null hypothesis tested was that treatment of etched dentin collagen with NaOCl would not compromise dentin bonding. METHODS The labial surface of eighty bovine incisors was polished to expose middle dentin. The specimens were randomly assigned to two total-etch adhesive systems (N = 40): Prime&Bond NT (Dentsply Caulk); and Single Bond (3M Dental Products Division). After rinsing off the etchant, one drop of 10% NaOCl (AD Gel, Kuraray Ltd.) was applied to the etched dentin surface and left for 0 (control), 15, 30, or 60 s. The gel was rinsed off with water and the dentin surface kept visibly moist prior to the application of the adhesive as per manufacturers instructions. The respective composite resin was subsequently applied and light-cured. After 24 h in water at 37 degrees C, the specimens were thermocycled for 500 cycles in baths kept at 5 and 55 degrees C and the shear bond strengths measured. The data were analyzed with two-way ANOVA. For TEM, sixteen dentin disks were taken from middle dentin of extracted human third molars, assigned to the eight treatment sequences, and observed. RESULTS The increase in the NaOCl application time resulted in a progressive decrease in shear bond strengths for both dentin adhesives. For Single Bond, the application of AD Gel for 60 s resulted in a reduction of bond strengths to 38% of that obtained for the control. For Prime&Bond NT, the mean bond strength obtained when AD Gel was applied for 60 s was 31% of that obtained for the control. The application of AD Gel resulted in distinct morphology for each one of the two adhesives tested. For Single Bond, the general morphology of the collagen network was maintained, regardless of the deproteinization time. The interfibrillar space within the collagen network increased with increasing deproteinization times. For Prime&Bond NT, the general appearance of the HL was maintained for deproteinization times of 15 and 30 s. When the NaOCl gel was applied for 60 s, the morphological appearance of the HL lost its fibrillar arrangement. While remnants of the collagen fibers were observed in one of the dentin disks, the other specimen showed an amorphous structure without any discernible HL morphological features. SIGNIFICANCE The integrity of the collagen fibrils left exposed upon acid-etching plays a major role in the mechanism of adhesion of the specific adhesive systems tested in this study. The intermingling of the adhesive monomers with the filigree of collagen fibers or HL should still be considered the paramount dentin bonding mechanism.

Clinical performance of vital bleaching techniques.

This study compared the clinical outcome of bleaching techniques in vital teeth. After IRB approval and informed consent, 90 subjects were selected based on the shade of their anterior teeth (A2 or darker, Vita Classic shade guide). Subjects were assigned to three treatment groups in a split-mouth study design: Group I: HB (at-home bleaching with 10% carbamide peroxide for two weeks) vs OBL (in-office bleaching with 35% hydrogen peroxide, two sessions, two-week intervals, with light irradiation); Group II: OB (in-office bleaching without light irradiation) vs OBL; Group III: HB vs combination (one session plus HB). Color change and color rebound (deltaE) were measured for a 16-week period. Color measurements were carried out with both a spectrophotometer and a shade guide at baseline, 1, 2, 4, 8 and 16 weeks. Tooth sensitivity was evaluated using a VAS scale for 15 days. Both the Students t-test and Tukey-Kramer test were used to analyze the results (p < 0.05). After one week, one session of OBL followed by HB resulted in lower color values, compared with the other bleaching methods. Group III resulted in the least shade values at one-week evaluation, when compared with the other bleaching methods. After two weeks, HE alone resulted in similar color changes as OB, OBL and OBL+HB. The use of light irradiation did not improve bleaching efficacy (OB = OBL). OBL and OB resulted in higher sensitivity rates than HB.

In vitro Bond Strengths and SEM Evaluation of Dentin Bonding Systems to Different Dentin Substrates

In comparison to enamel, bonding to normal dentin is a greater challenge because of its organic constituents, fluid-filled tubules, and variations in intrinsic composition. Bonding to sclerotic dentin is even more difficult. To evaluate the shear bond strengths of four adhesive systems to dentin substrates with different levels of mineralization, 120 extracted human teeth were randomly assigned to three groups (n = 40). After mid-coronal dentin was exposed, groups of specimens were artificially hypermineralized by immersion in a remineralizing solution, demineralized by means of an acetic acid demineralizing solution, or stored in distilled water to model sclerotic, carious, and normal dentin, respectively. Resin composite was bonded to dentin by use of commercial adhesive systems. After the specimens were thermocycled, shear bond strengths were determined in an Instron universal testing machine. Dentin substrates and resin/dentin interfaces were examined by SEM. For each adhesive system, the mean shear bond strength to normal dentin was significantly higher than that to either of the other substrates. Shear bond strengths to hypermineralized dentin were significantly higher than those to demineralized dentin with all adhesives except Prisma Universal Bond 3.

The effect of a re-wetting agent on dentin bonding

OBJECTIVES Recently, a new generation of simplified one-bottle dentin bonding systems, sensitive to variations in the degree of substrate moisture, was introduced. This in vitro project compared the dentin bond strengths and interfacial ultra-morphology formed by three one-bottle bonding systems [OptiBond SOLO (ethanol-based), Prime&Bond 2.1 (acetone-based), and Single Bond (ethanol- and water-based)]. The null hypothesis tested was that re-wetting a dried dentin surface with a HEMA aqueous solution would not result in bond strengths, and resin impregnation into demineralized dentin, comparable to those obtained for moist dentin. METHODS Dentin specimens were assigned to the following three etched surface conditions: moist dentin-control group; dentin dried for 5 s; and dentin dried for 5 s and re-moistened with a commercial 35% HEMA aqueous solution. Mean shear bond strengths were calculated and analyzed with one- and two-way ANOVA. Dentin discs treated with the same combination of surface condition/adhesive were processed and observed under both transmission and scanning electron microscopes. RESULTS For moist dentin, the morphology of the resin-dentin interfaces showed penetration of the dentin adhesives to the depth of the transition between demineralized and unaffected dentin. Drying dentin for 5 s resulted in a significant decrease in mean bond strengths and an incompletely infiltrated collagen structure with areas of unveiled collagen fibers, regardless of the solvent. Re-wetting dentin with the aqueous HEMA solution re-established the level of bond strengths obtained to moist dentin and resulted in a raise of the fiber network with simultaneous increase in interfibrillar space dimensions. SIGNIFICANCE The results suggest that the use of an aqueous HEMA solution might compensate for the dryness induced on dentin surfaces by using air blasts from an air syringe, after rinsing off the etchant. As the behavior of the material that contained water was also affected by surface dryness, the percentage of water included in the composition of current ethanol- and water-based adhesives, such as Single Bond, may not be enough to compensate for the collapse of the collagen filigree upon drying.

A New Universal Simplified Adhesive: 18-Month Clinical Evaluation

PURPOSE To evaluate the 18-month clinical performance of a multimode adhesive (Scotchbond Universal Adhesive, SU, 3M ESPE, St Paul, MN, USA) in noncarious cervical lesions (NCCLs) using two evaluation criteria. MATERIALS AND METHODS Thirty-nine patients participated in this study. Two-hundred restorations were assigned to four groups: ERm, etch-and-rinse + moist dentin; ERd, etch-and-rinse + dry dentin; Set, selective enamel etching; and SE, self-etch. The composite resin, Filtek Supreme Ultra (3M ESPE), was placed incrementally. The restorations were evaluated at baseline, and at 18 months, using both the World Dental Federation (FDI) and the United States Public Health Service (USPHS) criteria. Statistical analyses were performed using Friedman repeated-measures analysis of variance by rank and McNemar test for significance in each pair (α=0.05). RESULTS Five restorations (SE: 3; Set: 1; and ERm: 1) were lost after 18 months (p>0.05 for either criteria). Marginal staining occurred in four and 10% of the restorations evaluated (p>0.05), respectively, for USPHS and FDI criteria. Nine restorations were scored as bravo for marginal adaptation using the USPHS criteria and 38%, 40%, 36%, and 44% for groups ERm, ERd, Set, and SE, respectively, when the FDI criteria were applied (p>0.05). However, when semiquantitative scores (or SQUACE) for marginal adaptation were used, SE resulted in a significantly greater number of restorations, with more than 30% of the total length of the interface showing marginal discrepancy (28%) in comparison with the other groups (8%, 6%, and 8%, respectively, for ERm, ERd, and Set). CONCLUSIONS The clinical retention of the multimode adhesive at 18 months does not depend on the bonding strategy. The only differences between strategies were found for the parameter marginal adaptation, for which the FDI criteria were more sensitive than the USPHS criteria.

Effect of acid etching and collagen removal on dentin wettability and roughness

It was recently reported that removal of the collagen network from etched dentin does not affect dentin bond strengths. The aim of this study was to determine if the removal of the collagen fibers results in changes in dentin roughness and wettability. Twenty cary-free extracted human third molars were sectioned parallel to the occlusal surface to expose either superficial or deep dentin. Dentin was ground flat through 600-grit SiC abrasive paper under water to provide uniform surfaces. Observed contact angle measurements were performed to assess wettability by using the axisymmetric drop shape analysis technique using water and a water-based primer. Average roughness was determined with a profilometer. The specimens were analyzed just after being ground, after etching with 35% H(3)PO(4) gel for 15 s, and after etching and deproteinization with 5% NaOCl for 2 min. Data were analyzed with two-way ANOVA and Newman-Keuls multiple comparison t test procedure. Etching resulted in an increase in surface roughness and dentin wettability. For deep dentin, collagen removal did not influence the average roughness, but it resulted in a significantly greater degree of wettability. The degree of wettability for deep dentin was greater than for superficial dentin.

Dentin bonding as a function of dentin structure.

The traditional principles of operative dentistry have been challenged since Dr. Buonocore introduced the aid-etch technique in 1955. In spite of the numerous changes in clinical protocols and adhesive techniques, adhesion to dentin remains difficult. The importance of micromechanical bonding to dentin has been recognized over the last decade. Researchers now believe that dentin adhesion relies primarily on the penetration of adhesive monomers into the filigree of collagen fibers left exposed by acid etching. Two main strategies are currently in use for bonding to enamel and dentin: the self-etch technique and the total-etch technique. The efficiency of either bonding strategy depends very much on the dentin substrate used for bonding. Laboratory tests use ideal dentin from extracted teeth, which does not reflect the clinical reality. Clinical studies are the ultimate test for any dental adhesive material.