Influence of Operator Experience on In Vitro Bond

Strength of Dentin Adhesives

Nimet Unlua / Solen Gunalb / Mustafa Ulkerc / Fusun Ozerd / Markus B. Blatze

Purpose: To examine the influence of operator experience level on shear bond strength (SBS) of a self-etching
adhesive (Clearfil SE Bond [CSE], Kuraray) and an etch-and-rinse adhesive (Single Bond [SB], 3M ESPE).
Materials and Methods: Flat dentin surfaces were created on 120 extracted human third molars. Bonding
agents and composite resin were applied and light cured according to manufacturers’ directions (n = 15). Four
operators with different levels of experience in operative dentistry performed the same specimen preparation
steps independently: group 1: specialist in operative dentistry; group 2: post-graduate student; group 3: under-
graduate dental student; group 4: private general practitioner. Specimens were stored in distilled water for 24 h
at 37°C before SBS testing. Statistical analyses were carried out with Mann-Whitney U- and Kruskall-Wallis tests.
Results: For CSE, mean SBS and standard deviations were: (1) 54.4 ± 15.6a, (2) 55.3 ± 7.6a, (3) 49.4 ±
10.5ab, (4) 41.6 ± 13.1b. For SB, they were: (1) 28.6 ± 10.3c, (2) 32.7 ± 11.2c, (3) 17.5 ± 5.6d, (4) 24.4
± 9.5cd. Groups with the same superscript letters are not significantly different. CSE showed higher bond
strengths than SB in all groups (p < 0.05). There was no significant difference in mean bond strengths between
groups 1 and 2 for each adhesive (p > 0.05). Depending on the adhesives, groups 3 and 4 were significantly dif-
ferent from groups 1 and 2, but not different from each other.
Conclusion: Operator experience influences dentin bond strength values of dentin adhesives. An increased level
of experience with a specific adhesive system and the associated application procedures correlates with higher
SBSs.

Keywords: dentin bond strength, operator experience, etch-and-rinse, self-etching.

J Adhes Dent 2012; 14: 223–227. Submitted for publication: 13.01.11; accepted for publication: 08.03.11
doi: 10.3290/j.jad.a22191

B onding of adhesive systems to dentin is mainly

achieved by allowing the resin to diffuse into a de-
mineralized and exposed collagen matrix, dentinal tu-
bules, and their lateral branches. Therefore, the bonding
a
Professor, Department of Operative Dentistry, Faculty of Dentistry, Selcuk
University, Konya, Turkey. Idea, hypothesis, performed statistical analysis.
b Associate Professor, Oral and Medical Health Department, International Hos-
pital, Istanbul, Turkey. Experimental design, performed experiments.
c Assistant Professor, Department of Operative Dentistry, Faculty of Dentistry,
Selcuk University, Konya, Turkey. Performed bond strength testing, wrote
manuscript.
d Professor, Department of Preventive and Restorative Sciences, School of
Dental Medicine, University of Pennsylvania, Philadelphia, PA, USA. Idea,
wrote manuscript, contributed substantially to discussion.
e Professor, Chairman of the Department of Preventive and Restorative Sci-
ences, School of Dental Medicine, University of Pennsylvania, Philadelphia,
PA, USA. Contributed to discussion, proofread manuscript.
Correspondence: Fusun Ozer, Department of Preventive and Restorative Sci-
ences, University of Pennsylvania School of Dental Medicine, 240 South 40th
Street, Room # 20F, Philadelphia, PA, USA. Tel: +1-215-573-7848, Fax: +1-
215-898-4558. e-mail: ozerf@dental.upenn.edu
mechanism of adhesive resins depends at least in part
on micromechanical interlocking of resin into a micropo-
rous surface.19 Compared to enamel bonding, several
factors contribute to the greater difficulties encountered
in dentin bonding, such as high organic content, tubu-
lar structure variations,8 the presence of outward fluid
movement, 12 dentin depth, 12 sclerosis, 6 caries, 7,15
and the presence of smear layer.12 The scatter in bond
strength data to dentin is quite obvious in the literature,
independent of testing method and adhesive material
selection.14
Several adhesive systems have been developed to
provide sufficient bonding to enamel and dentin. Many
of those require a multiple-step clinical approach and
specific application procedures, which introduce operator-
dependent and procedure-related variabilities.4,5,10
There are two main strategies for bonding resin-based
materials to dentin: etch-and-rinse and self-etching sys-
tems. Etch-and-rinse adhesive systems typically contain a
demineralizing agent, such as phosphoric acid, a primer,
and an adhesive resin. Depending on the number of bot-
tles, they can be further categorized into conventional

Vol 14, No 3, 2012 223

Unlu et al
three-step etch-and-rinse, and two-step etch-and-rinse ad-
hesive systems.
For acetone/ethanol-based two-step etch-and-rinse
adhesive systems, the presence of a moist dentin sur-
face is particularly important. A certain amount of water
is necessary to prevent the collapse of the exposed
dentin collagen scaffold. Therefore, the clinician has
to control a certain amount of moisture and decide on
the proper timing for adhesive application. In addition,
the combined primer/adhesive resin solutions of two-
step etch-and-rinse adhesives have a higher solvent-to-
monomer ratio, bearing the risk that such adhesives are
applied in layers that are too thin. To achieve adequate
bonding, two-step etch-and-rinse adhesives must be ap-
plied liberally.19
Separate etching and water-rinsing phases can be
omitted with acidic-monomer containing self-etching ad-
hesive systems, making the adhesive applications less
technique-sensitive for clinicians. Most self-etching ad-
hesive systems are water based and therefore simplify
dentin moisture control. A variable related to their ap-
plication which possibly influences their bond strength
is the air-drying step. The duration of air blowing and the
pressure of the air stream are different for each product,
and deviations from the suggested protocols may affect
the bond strength values.17 Another influencing factor
when using a self-etching adhesive is the required rub-
bing action during application. Yu et al20 reported that
some self-etching adhesives applied with rubbing show
increased bond strength to dentin. Dentin bonding proce-
dures require multiple application steps that are prone to
different errors. Therefore, the final outcome is not only
dependent on material-related factors, but also on the
performance of the individual operator.18
In the light of the above facts, it must be assumed
that dentin bonding success is strongly influenced by a
clinician’s experience and working routines. The efficacy
of dentin bonding agents is frequently evaluated by ten-
sile or shear bond strength measurements under in vitro
conditions to indicate possible clinical performance. All of
these variables are likely to cause variations in the results
of laboratory bond strength studies.
The primary objective of this study was to investigate
the effect of operator experience on in vitro shear bond
strength (SBS) of a two-step self-etching adhesive and a
two-step etch-and-rinse adhesive. The null hypothesis was
that operators’ clinical experience influences in vitro bond
strengths of dentin adhesives.
MATERIALS AND METHODS
One hundred twenty freshly extracted noncarious human
molars were stored at 4°C in a distilled water/0.2%
chloramin T solution. Soft tissue remnants and calculus
were removed from the teeth before they were cleaned
with fluoride-free pumice and rubber cups.
The roots of the teeth were cut off with a water-cooled
diamond disk. The occlusal surfaces of the teeth were
removed with a low-speed diamond saw (Isomet, Buehler;
224
Lake Bluff, IL, USA) under constant water cooling to obtain
flat, sound dentin surfaces at a level 1 mm below the
dentin-enamel junction. The cut dentin surfaces were then
hand-polished with 600-grit silicon carbide abrasive paper
for 60 s under running water to create a uniform surface
and smear layer. The surfaces were then rinsed for 30 s
with distilled water and gently air dried before adhesive ap-
plications. The teeth were embedded in cylindrical molds
(2 cm in diameter and height) with fast-setting acrylic resin
so that the flattened dentin surface was exposed and
parallel to the base of the mold.
Two adhesive systems were tested in this study: a two-
step etch-and-rinse adhesive system (Single Bond [SB],
3M ESPE; Seefeld, Germany) and a two-step self-etching
adhesive system (Clearfil SE Bond [CSE], Kuraray; Osaka,
Japan; Table 1). Restorations were simulated with a hy-
brid composite resin (Clearfil AP-X, Kuraray).
The groups of operators tested in this study were:
y Group 1: Operative dentistry specialist.
y Group 2: Post-graduate student, experienced in the
use of adhesives and composite resins in operative
dentistry.
y Group 3: Undergraduate student, some clinical expe-
rience with adhesive materials.
y Group 4: General practitioner, graduated 10 years
ago and familiar with adhesives.
All operators received the same instruction on specimen
preparation prior to testing. They were asked to apply
the adhesive systems to dentin surfaces according to
manufacturer’s directions. Each operator prepared 15
specimens for each adhesive (n = 15) in the same loca-
tion, with the same instruments, and under standard-
ized conditions. The adhesives were cured for 10 s with
a curing light (Heliolux II, Vivadent; Schaan, Liechten-
stein) with a power density of 676 mW/cm2. The same
operators then added the composite resin to the bond-
ing dentin surfaces by packing the material into cylindri-
cal plastic matrices with an internal diameter of 2.34
mm and a height of 3 mm (Ultradent; South Jordan, UT,
USA). Excess composite resin was carefully removed
from the periphery of the matrix with an explorer. The
composite resin was cured with the same curing light for
40 s. The specimens were then stored in distilled water
at 37°C for 24 h before bond strength testing.
For SBS testing, the specimens were mounted in a
universal testing machine (Model 500, Testometric; Ro-
chdale, Lancashire, UK). A notch-shaped apparatus (Ul-
tradent) attached to a compression load cell at a cross-
head speed of 0.5mm/min was applied to each specimen
at the interface between the tooth and composite until
failure occurred. The maximum load (N) was divided by the
cross-sectional area of the bonded composite cylinders to
calculate SBS in MPa.
The failure mode of each fractured specimen was de-
termined by means of an optical stereomicroscope at 20X
magnification (Olympus SZ4045 TRPT; Tokyo, Japan) by
one calibrated evaluator. Failure modes were designated
as adhesive (90% to 100% of the bonded interface failed
between the dentin and composite resin), cohesive frac-
The Journal of Adhesive Dentistry
 Unlu et al

Table 1 Adhesive systems used in this study

Product Manufacturer Type Conditioner Composition

Single Bond (SB) 3M ESPE; St Paul, Two-step etch-and-rinse 35% phosphoric HEMA, bis-GMA, dimethacrylate, copolymer
MN, USA acid with methacrylic, function, polyacrylic and
polyitaconic acids, water, ethanol

Clearfil SE Bond Kuraray; Osaka, Two-step self-etching none Primer: HEMA, MDP, dimethacrylate, water,
(CSE) Japan catalyst Adhesive: MDP, HEMA, dimethacry-
late monomer, microparticles, catalyst

Table 2 Mean (± SD) shear bond strength values Table 3 Modes of failure after shear bond strength
in MPa testing (n = 15)

Group N CSE SB Group Material Adhesive Mixed Cohe-

failure failure sive
failure
1 15 54.4 ± 15.6a 28.6 ± 10.3c 1 Single Bond 13 (86.6%) 2 (13.4%) 0

Clearfil SE Bond 11 (73.3%) 4 (26.7%) 0

2 15 55.3 ± 7.6a 32.7 ± 11.2c
2 Single Bond 13 (86.6%) 2 (13.4%) 0
3 15 49.4 ± 10.5ab 17.5 ± 5.6d
Clearfil SE Bond 10 (66.6%) 5 (33.3%) 0
4 15 41.6 ± 13.1b 24.4 ± 9.5cd
3 Single Bond 15 (100%) 0 0
Means with the same superscript letter are not statistically significantly
Clearfil SE Bond 12 (80%) 3 (20%) 0
different from each other (p > 0.05). Group 1: specialist in operative
dentistry; group 2: postgraduate student; group 3: undergraduate dental
4 Single Bond 15 (100%) 0 0
student; group 4: general dental practitioner.
Clearfil SE Bond 14 (93.3%) 1 (6.7%) 0

ture (90% to 100% of the failure was in the composite DISCUSSION

resin or dentin), or mixed (failure was partially adhesive
and partially cohesive).
SBS data were statistically analyzed with Kruskal-Wal-
lis and Mann-Whitney U-tests at a significance level of
p ≤ 0.05.
RESULTS
Mean SBS values, standard deviations, and significant
differences between groups are presented in Table 2.
CSE showed higher SBS values than SB in all operator
groups (p < 0.05). For CSE, no significant differences
were observed among the SBS results obtained in
groups 1 to 3 (p > 0.05). Group 4 revealed lower SBS
than groups 1 and 2 (p < 0.05). For SB, no significant
differences were observed among the SBS values of
groups 1, 2, and 4 (p > 0.05). Group 3 showed lower
SBS than groups 1 and 2 (p < 0.05). The lowest SBS
values were observed with group 4 for CSE (41.6 ± 13.1
MPa) and with group 3 for SB (17.5 ± 5.6 MPa).
Failure modes observed in the specimens are shown in
Table 3. For both adhesives, the most frequent pattern of
failure was adhesive in all operator groups.
The results of this in vitro study confirmed our hy-
pothesis that SBS of adhesive resins to dentin was
associated with the experience of the operator. The
self-etching and etch-and-rinse adhesives used in this
study showed the best SBS results with the specialist in
operative dentistry and the postgraduate student. This
finding is not surprising because these two participants,
both staff members in an operative dentistry depart-
ment for several years, have used, investigated, and
taught the two tested adhesives and their application
procedures on a routine basis. The other operators had
only limited experience with the specific materials and
associated application protocols.
Several new dentin adhesives have been introduced
onto the dental market in recent years. The application
procedures of these newly developed bonding systems
have been made simpler than the traditional multiple-
step systems. However, effective application is still a
determining factor for high bond strengths.10,17,18,20 It
is generally accepted that self-etching adhesives are
less sensitive to differences in etching and rinsing pro-
cedures and to variations in dentin moisture.4,5,19 The
results of this study, however, indicate that there are

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Unlu et al
other variables that influence the bond strength of these
adhesives, such as the air blowing17 and rubbing ac-
tion.20 The lowest SBS values were observed in group
4 (general practitioner) with CSE, which may be due to
insufficient experience of the operator with self-etching
adhesives. In fact, the operator indicated his prefer-
ence for etch-and-rinse adhesives in his everyday clinical
practice. Sano et al13 confirmed that to obtain optimal
bonding performance with a dentin adhesive system, the
operator should be aware of technique sensitivity of the
system and importance of clinical experience, especially
when using the new system in clinical practice. Another
study confirms that optimal outcomes with dental ad-
hesives can only be achieved with an advanced level
of familiarity with the application procedures and the
components of the specific systems.1
Bouillaguet et al2 tested the performance of general
practitioners and demonstrated that if a dentist has suf-
ficient experience and receives appropriate education with
the adhesives she/he uses, any of the adhesives can give
reasonable results in clinical applications. However, very
few reports on the importance of operator’s experience
on the clinical performance of other dental materials are
available in the literature.16,18 Most of the materials used
in clinical practice may not be considered as technique
sensitive as dentin adhesive systems. In two recent in
vitro studies, the operator’s experience did not affect the
outcome of fiber post and stainless steel rod cementation
with resin composite cement.16,18
Group 3 demonstrated higher bond strength values
with CSE than with SB. The operator was an undergradu-
ate dental student in his last year. Dental students were
exposed to both of the adhesive systems employed here
during their clinical training. It can be speculated that the
omission of the etch-and-rinse step with the self-etching
adhesive CSE reduced the risk of errors during application
and manipulation of the material and, therefore, caused
the higher SBS values. The etch-and-rinse technique re-
quires etching, rinsing, and drying, which may be more
difficult for inexperienced clinicians to master. In particu-
lar, the dentin must be dried after rinsing the phosphoric
acid etching gel, according to the demands of the sol-
vent contained in the adhesive. Previous studies showed
that keeping the dentin surface in an appropriately moist
condition is critical for the two-step etch-and-rinse adhe-
sives with ethanol/water or acetone solvents to achieve
the highest bond strength to dentin.9,21 Miyazaki et al10
studied the operator influence on dentin bond strength
using SB and stated that mean bond strengths for under-
graduate students were statistically significantly lower
than mean bond strengths for dentists at the university.
Giachetti et al4 evaluated the influence of operator skill on
microleakage in Class V restorations using two-step bond-
ing systems. Operator skill had no influence on leakage at
the dentin margin. At the enamel margin, the microleak-
age of the self-etching adhesive within the student group
was lower than that within the expert group. On the other
hand, the microleakage with the etch-and-rinse adhesive
within the expert group was lower than that within the
student group.4
226
The operators filled composite resins into standard
cylindrical plastic matrixes on the dentin surfaces. Thus,
the area of bonding, thickness of the composite resin,
and distance of the curing light were standardized. SBS
testing was performed with a notch-shaped apparatus (Ul-
tradent Testing Device). The testing device wraps around
the composite material, contacting a larger area of the
composite sample. Stresses are distributed over a larger
surface area and, therefore, may yield more valid results
than traditional SBS test configurations.3,11
In vitro conditions simplify standardization protocols
and calibration parameters. One of the limitations of this
study is, however, that it was not carried out in a clinical
setting. Randomized clinical trials are preferred tools to
evaluate dental materials and draw clinically relevant
conclusions. However, due to the rapid development
of bonding agents and the fact that material screen-
ing methods such as shear, tensile, and microtensile
bond strength tests are inexpensive testing routines in
research laboratories, bond strength tests are frequently
used to predict the clinical performance of dental ad-
hesives.14 However, the level of clinical experience of
the operator/researcher with an adhesive material is of
great importance to obtain valid and reliable results in
laboratory bond strength trials.
CONCLUSION
Operator experience influences dentin bond strength
values of etch-and-rinse and self-etching adhesive sys-
tems. An increased level of experience with a specific
adhesive system and the associated application proce-
dures correlates with higher shear bond strengths.
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