Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2020; 65: 181–188

doi: 10.1111/adj.12744

Effect of the double application of universal adhesives on

the dentine bond strength after radiotherapy
M Ugurlu
Department of Restorative Dentistry, Faculty of Dentistry, S€
uleyman Demirel University, Isparta, Turkey.

ABSTRACT
Background: This study aimed to evaluate the effect of double application of universal adhesives on bond strength to
dentine after ionizing radiation.
Methods: One hundred and forty caries-free human third molars were used. Half of the teeth were irradiated (IR)
(70.2 Gy). The IR and non-IR teeth were assigned into seven groups (n = 10). Universal adhesives Single Bond Universal
(3M Oral Care), Gluma Bond Universal (Heraeus Kulzer) and Prime&Bond Elect (Dentsply) were employed (following
manufacturer’s instructions and double application). Two-step self-etch adhesive Clearfil SE Bond (Kuraray Noritake)
was used as control. After composite build-ups were bonded to mid-coronal occlusal dentine surfaces, the specimens
were stored in water (37°C/24 h) and sectioned into microspecimens. The specimens were subjected to lTBS testing
(1.0 mm/min). Failure analysis was performed using stereomicroscope and scanning electron microscopy. Data were
analysed with two-way ANOVA and Tukey’s test (P = 0.05).
Results: The radiotherapy caused reduction in the bond strength of universal adhesives when the adhesives were used
with single application after radiotherapy (P < 0.05). The double application resulted in increased bond strength of the
universal adhesives to IR dentine (P < 0.05).
Conclusions: The double application was beneficial in improving the dentine bond strength of universal adhesives
affected by radiotherapy after ionizing radiation.
Keywords: Dentine, double application, microtensile bond strength, radiotherapy, universal adhesive.
Abbreviations and acronyms: lTBS = microtensile bond strength; 10-MDP = 10-methacryloyloxydecyl dihydrogen phosphate; CT =
computed tomography; IR = irradiated.
(Accepted for publication 29 December 2019.)

any more in enamel that contains 92–96 weight %

INTRODUCTION
Many head and neck cancer patients undergo
radiotherapy, either exclusively or together with
other therapeutic methods such as surgery and
chemotherapy.1,2 The ionizing radiation is used to
destroy tumor cells.3,4 Unfortunately, the ionizing
radiation can damage normal tissues located in the
fields of radiation and cause complications in the
oral cavity, including mucositis, xerostomia,
candidiasis, osteoradionecrosis and radiation car-
ies.1,4,5 Radiation caries is one of the most common
side-effects of radiotherapy in the head and neck
region.6,7 Radiotherapy can also influence the
properties of enamel, dentino-enamel junction and
dentine.8
The radiation effects on the dental hard tissues are
dependent on the mineral and organic content of
tooth structures.9 The effects of radiation might occur
© 2020 Australian Dental Association
of inorganic matter, compared to dentine that
has 70% of its weight as inorganic matter.
The radiation can also cause morphologic and
compositional alterations to the intratubular and
intertubular collagen.8 It has been reported that the
damage to the dentine collagen fibrils by radiotherapy
causes a significant reduction in microhardness10,11
and tensile strength.8 The changes to the organic
portion of the dentine can also interfere with the
bond strength of adhesive procedures.9,12–17 The
negative effects of radiotherapy on the bond strength
also be attributed to impairing the hybrid layer for-
mation by denaturation of the organic components of
dentine structures.8,9,12,17,18
It is well-known that the hybrid layer plays an
important role in the adhesion mechanism between
the dentine and adhesive resin.19–22 Regardless of the
adhesive used, the hybrid layer is created by the
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M Ugurlu
penetration of the hydrophilic functional monomers
into the exposed collagen network and subsequent
polymerization.20 It has been also stated that the
hybrid layer could provide a stress-breaking effect
when loading is applied during microtensile bond
strength testing.21 However, the hybrid layer has a
relatively low elastic modulus,20 and the actual hybrid
layer is thinner than it appears in the scanning elec-
tron micrographs.22 The insufficient stress-breaking
effect of the thin hybrid layer can be compensated
for with a thicker adhesive layer.23 The adhesive layer
helps to preserve the integrity of the hybridized den-
tine.23 The thick adhesive layer might absorb stress
imposed on the adhesive interface such as polymeriza-
tion shrinkage stress24 and improve stress distribution
during testing.25 The adhesive layer’s ability to absorb
stress imposed on the adhesive interface could reduce
because of a thinner adhesive layer.23,24 Previous studies
have shown that the double application of one-step self-
etch adhesives can improve the dentine bond strength
due to increasing the adhesive thickness.26–28 It has been
reported that if each coat is light-cured, the thickness of
the adhesive layer increases.28 The co-monomer concen-
tration which exists after each coating increases as the
solvent is evaporated between each coat, thereby
increasing the amount of resin impregnation within the
hybrid layer and the quality of hybrid layer.25
Universal adhesives were introduced as the latest
generation of adhesives.30,31 It has been stated that
the thin adhesive layer thickness and thin hybrid layer
may limit the bond strength of universal adhesives.32
Previous studies have shown improved bond strength
by the double application of universal adhesives32–34
and application of an extra adhesive layer.35 How-
ever, it is not clear how universal adhesives behave in
irradiated (IR) teeth. The effect of double application
of universal adhesives on bond strength to dentine
after ionizing radiation has not also been tested.
Therefore, the objective of this study was to evalu-
ate the effects of double application of universal adhe-
sives on the bond strength to dentine after ionizing
radiation. The null hypotheses to be tested were (i)
that the ionizing radiation would not affect the den-
tine bond strength of universal adhesives, and (ii) that
the double application of universal adhesives would
not improve the bond strength to dentine after ioniz-
ing radiation.
MATERIALS AND METHODS
Tooth selection and preparation
One hundred and forty caries-free human third molars
were used following ethical approval (ref no: 2019/
328). [Correction added on 30 July 2020, after first
online publication: in the preceding sentence, ref no. has
182
been corrected to “2019/328”.] The teeth were disin-
fected in 0.5% chloramine-T, stored in distilled water
and used within 3 months after extraction. The mid-
coronal dentine surface was prepared in all teeth after
sectioning the occlusal enamel using a water-cooled dia-
mond saw (Minitom, Struers, Denmark). The dentine
surfaces were controlled for the absence of enamel and/
or pulp tissue using a stereo-microscope (S4E; Leica
Microsystems, Germany). The exposed dentine surfaces
were further polished with wet #180 grit silicon carbide
paper for 60 s to standardize the smear layer (Fig. 1).
Radiotherapy process
Half of the teeth were randomly selected and IR simulat-
ing a radiotherapy procedure applied to head and neck
cancer patients. The teeth were placed into a glass con-
tainer containing distilled water. The X-ray computed
tomography (CT) images were obtained from the contain-
ers by using a CT scanner (Bright Speed Excel Select; Gen-
eral Electric Medical Systems, Fairfield, CT, USA). 3D
conformal planning technique was used as treatment
delivery. Before irradiation, the position of the containers
was verified by using a portal vision imaging system (Por-
tal Vision; Varian Medical System, Palo Alto, CA, USA).
Radiation was performed in a hospital environment using
a linear accelerator (Varian Clinac DBX 600 system; Var-
ian Medical System). The recommended protocol in previ-
ous studies was used:2,5 a total dose of 70.2 Gy divided
into 39 daily applications of 1.8 Gy. The treatment plan
was created by the radiotherapist using the Eclipse treat-
ment planning system (Varian Medical System). Anisotro-
pic Analytical Algorithm dose calculation algorithm was
used during planning process to ensure same radiation
dose to all teeth. The IR and non-IR teeth were stored in
distilled water and changed daily.
Experimental design and specimen preparation
The IR and non-IR teeth were randomly assigned into
seven groups (n = 10) according to the different bond-
ing strategies of the selected adhesive system (Table 1).
The three universal adhesive systems were tested in self-
etch mode: Single Bond Universal Adhesive (3M Oral
Care, St. Paul, MN, USA, also known as Scotchbond
Universal in some countries), Gluma Bond Universal
(Heraeus Kulzer GmbH, Hanau, Germany) and
Prime&Bond Elect (Dentsply DeTrey GmbH, Kon-
stanz, Germany). As control, the two-step self-etch
adhesive system Clearfil SE Bond (Kuraray Noritake,
Okayama, Japan) was used. All of the adhesives were
then applied according to manufacturer’s instructions
and light-cured using a LED light-curing unit (Smartlite
Focus; Dentsply, Milford, DE, USA, 1000 mW/cm2). In
the double application groups, the universal adhesives
were applied as one coat and light-cured according to
© 2020 Australian Dental Association
 Dentine bond strength after radiotherapy

Fig. 1 Schematic illustration of the experimental study design. lTBS = microtensile bond strength.

Table 1. Adhesive systems used, chemical composition and application procedure

Adhesive Composition Application procedure
system/manufacturer

Single Bond Universal (3M
Oral Care, St. Paul, MN,
USA) Lot no: 602724
Gluma Bond Universal
(Heraeus Kulzer GmbH,
Hanau, Germany) Lot no:
K010033
Prime&Bond Elect
(Dentsply DeTrey GmbH,
Konstanz, Germany) Lot
no: 1802000551
Clearfil SE Bond (Kuraray
Noritake, Osaka, Japan)
Lot no: 000273
10-MDP phosphate monomer, dimethacrylate resins,
HEMA, methacrylate-modified polyalkenoic acid
copolymer, filler, ethanol, water, initiators, silane
MDP phosphate monomer, 4-META, dimethacrylate
resins, acetone, fillers, initiators, silane
HEMA, 2-hydroxy-3 acryloyloxypropyl methacrylate,
UDMA, trimethylolpropane trimethacrylate, PENTA,
diketone, organic phosphine oxide, stabilizers,
cetylamine hydrofluoride, acetone, water
Primer: Water, 10-MDP, HEMA, camphorquinone,
hydrophilic dimethacrylateBond: 10-MDP, Bis-GMA,
HEMA, camphorquinone, hydrophobic
dimethacrylate, N,N-diethanol p-toluidine bond,
colloidal silica
(1) Apply the adhesive to the entire preparation with a
microbrush and rub it in for 20 s
(2) Direct a gentle stream of air over the liquid for about 5 s
until it no longer moves and the solvent is evaporated
completely
(3) Light-cure for 10 s
(1) Apply the adhesive to the entire cavity wall with the
applicator brush and rubbed for 20 s
(2) Dry sufficiently by blowing mild air for more than 5 s
until the adhesive resin does not move
(3) Light-cure for 10 s
(1) Apply the adhesive to air-dried enamel/dentin surface
with rubbing for 20 s
(2) Gentle stream of air applied over the liquid for at least
5s
(3) Light-cure for 10 s
(1) Apply primer to tooth surface and leave in place for 20 s
(2) Dry with air stream to evaporate the volatile ingredients
(3) Apply bond to the tooth surface and then create a
uniform film using a gentle air stream
(4) Light-cure for 10 s

Composition as provided by the manufacturers: 10-MDP = 10-methacryloyloxydecyl dihydrogen phosphate; HEMA = hydroxyethylmethacry-
late; 4 META = 4-methacryloxyethyl trimellitate anhydride; UDMA = urethane dimethacrylate; PENTA = dipentaerythritol penta acrylate
monophosphate; Bis-GMA = bisphenol-glycidyl methacrylate.

manufacturer instructions (Table 1). Then, the second
layer was applied and light-cured similarly.
After the adhesive procedures were completed, the
resin composite crowns were built with a nano filled
resin composite (Filtek Ultimate; 3M Oral Care) in
© 2020 Australian Dental Association
increments of 2 mm each to a height of 5-6 mm. Each
increment was light-cured for 20 s using the LED light-
curing unit. After storage in distilled water for 24 h at
37°C, the specimens were sectioned longitudinally in
mesiodistal and buccal-lingual directions across the
183
M Ugurlu
bonded interface with a slow-speed diamond saw to
obtain resin-dentine beams with a cross sectional area
of approximately 1 mm2 measured using a digital cali-
per (Digimatic Caliper; Mitutoyo, Tokyo, Japan). The
five longest central beams were selected from each
tooth to minimize regional dentine variability and
tested for microtensile bond strength test (lTBS). Fifty
specimens were tested per each group (n = 50).
Microtensile bond strength test
The beams were attached to a custom-made microten-
sile testing jig with cyanoacrylate glue (Loctite Super
Glue, Henkel, Germany) and stressed at a crosshead
speed of 1 mm/min until failure in a universal testing
machine (Autograph AGS-X; Shimadzu, Kyoto, Japan).
After measuring the exact dimension of each fractured
beam with the digital caliper, the lTBS was calculated
in MPa, as derived from dividing the imposed force (in
N) at the time of fracture by the bond area (in mm2).
Statistical analyses
For each experimental group, the mean of lTBS of
the sticks originating from the same tooth was calcu-
lated and the mean bond strength was used as one
unit for statistical analysis, as in a previous study.35
Statistical analyses were performed with the SPSS Pro-
gram, version 20.0 (Statistical Package for the Social
Sciences; SPSS, Chicago, IL, USA). The Kolmogorov–
Smirnov test was applied to verify if the data were
normally distributed. Data were submitted to two-
way ANOVA. The adhesive strategy (universal adhe-
sive, universal adhesive with double application, two-
step self-etch adhesive) and irradiation were the two
main factors. Tukey’s post-hoc multiple comparison
test was used for pairwise comparisons. A significance
level of 0.05 was used for all tests.
Failure analyses
The failure mode analysis was performed under a
stereomicroscope at 9 80 magnification. The failure
mode was classified as adhesive failure, cohesive fail-
ure in dentine, cohesive failure in resin composite or
mixed failure when more than one of these occurred
in one fracture surface. Some representative samples
were selected. The samples were placed in an alu-
minium sample holder with a carbon glue and
observed with a scanning electron microscope (SEM,
Quanta Feg 250; FEI, Eindhoven, The Netherlands).
RESULTS
The two-way ANOVA disclosed statistically signifi-
cant differences for the main factors irradiation
184
Table 2. Two-way ANOVA results for microtensile
bond strength test
Source Sum of df Mean square F P
squares
Irradiation 475.986 1 475.986 19.206 0.000*
Adhesive strategy 5735.776 6 955.963 38.574 0.000*
Interaction 102.380 6 17.063 0.689 0.659
*Statistically significant differences (P < 0.05).
(P = 0.000) and adhesive strategy (P = 0.000); how-
ever, no significant interaction was found between the
two factors (Table 2). The overall mean lTBS of all
experimental groups, including the standard devia-
tions, are detailed in Table 3. The results of multiple
comparisons statistical analysis are also given in
Table 3. There were no pre-test failures in this study.
Radiotherapy caused a statistically significant reduc-
tion in the bond strength of universal adhesives only
when the adhesives were applied as asingle coat after
radiotherapy (P < 0.05). The double application
increased the bond strength of the three universal
adhesives to non-IR dentine, but it was not statisti-
cally significant (P> 0.05). The double application
resulted in statistically significant increases in the
bond strength of universal adhesives to IR dentine
(P < 0.05). The bond strength of the two-step self-
etch adhesive was not affected by the radiotherapy
(P> 0.05). The two-step self-etch adhesive showed
higher bond strength to both non-IR and IR teeth
than the three universal adhesives when the universal
adhesives were applied as a single coat (P < 0.05).
The results of the failure modes are shown in
Fig. 2. The predominance of the adhesive failures was
detected in all experimental groups. In IR specimens,
the number of cohesive failures in dentine increased.
DISCUSSION
This study was carried out to evaluate the effects of
double application of universal adhesives on the bond
strength to dentine after ionizing radiation. The results
showed that the radiotherapy procedure used in the
treatment of head and neck cancer decreased the den-
tine bond strength of the universal adhesives. The dou-
ble application improved the dentine bond strength of
universal adhesives after the ionizing radiation. There-
fore, the null hypotheses (i) that the ionizing radiation
would not affect the dentine bond strength of universal
adhesives, and (ii) that the double application of univer-
sal adhesives would not improve the dentine bond
strength after ionizing radiation were rejected.
In the present study, radiotherapy negatively influ-
enced the dentine bond strength of the universal adhe-
sives. The findings are in agreement with previous
studies,9,12–16 and these results could be attributed to
© 2020 Australian Dental Association
 Dentine bond strength after radiotherapy

Table 3. The mean microtensile bond strengths (lTBS in MPa  SD) of the different experimental groups
Non-IR dentin IR dentin

Single Bond Universal 33.73  4.29abA

28.15  3.81abB
Single Bond Universal – double application 39.28  5.42abcA 36.68  5.44cA
Gluma Bond Universal 32.32  4.08aA 27.35  3.55aB
Gluma Bond Universal – double application 38.08  5.04abA 36.08  4.08cA
Prime&Bond Elect 40.32  5.03bcA 34.13  4.63bcB
Prime&Bond Elect – double application 46.18  5.28cdA 43.35  5.21dA
Clearfil SE Bond 49.91  6.48dA 48.28  6.33dA

IR = irradiated; lTBS = microtensile bond strength.

n = 50, total number of specimens for each experimental group. Same superscript small or capital letter indicates no statistically significant dif-
ference in the columns and rows respectively.

Fig. 2 Graphical presentation of the incidence of failure modes. IR = irradiated.

the negative effects of radiotherapy on the collagen
network,9,13,15,17 impairing the hybridization pro-
cess,8–10,17,18,36 as demonstrated by the morphological
alterations observed in previous studies.10,12 Radio-
therapy induces the formation of free radicals of
hydrogen and hydrogen peroxide. These free radicals,
in the presence of water, can act as a strong oxidant
that might cause denaturation of molecular struc-
tures.4,12 The radiation could influence the properties
of the dentine as it is a tissue with a considerable
amount of water.12 The radiation might lead to
denaturation of the organic components of dentine
structures which are mostly formed by collagen.36
The biological breakdown of collagen fibrils by
© 2020 Australian Dental Association
irradiation might damage the integrity of the
hybrid layer.8–10,18,36 The irradiation could also
affect the apatite crystals of dental hard tissues, thus
potentially interfering with adhesion.16 It has been
reported that irradiation causes a destruction of the
interaction between intertubular and peritubular
dentine, an increase in microhardness, and a decrease
in elastic modulus.12 These alterations in dentine
biomechanical properties induce low bond strength
due to the formation of a standard permeable adhe-
sive interface.12
In previous studies related to the effects of radio-
therapy on bond strength, total-etch or self-etch adhe-
sives were used.9,12–17 Only one study tested a
185
M Ugurlu
universal adhesive, Single Bond Universal, and the
study concluded that the dentine bond strength of
Single Bond Universal was not affected by irradia-
tion.37 Based on the results of the present study, the
irradiation caused lower dentine bond strength of the
universal adhesives. However, the double application
of universal adhesives improved the impaired bond
strengths. The bond strength could be improved by
increasing the quality of hybridization or the adhesive
layer thickness with double application. Furthermore,
the increased adhesive thickness could compensate for
the integrity of the hybrid layer that might be dam-
aged by irradiation.
Previous studies have reported that the double appli-
cation positively affected the bond strength of universal
adhesives.33,34 The increased dentine bond strength by
double application is the result of several mechanisms
operating simultaneously.25 When light-curing is per-
formed after solvent evaporation between each coat,
the co-monomers concentration that exists after each
coating increases, thereby the infiltration of the func-
tional monomer, the degree of conversion, and the
quality of the hybrid layer improve.25,26,28,29,33 The
double application might increase the adhesive layer
thickness, and increasing the adhesive layer thickness
might also enhance the mechanical properties of the
adhesive layer,24,27,33,38 thus the adhesive layer might
reduce polymerization stresses24 and improve stress dis-
tribution during testing.25–28 However, it is not clear
what an optimum thickness for the adhesive layer of
each adhesive.34 It has been demonstrated that the dou-
ble application increased the hardness of the adhesive
layer and the resin-dentine interface.33,39 The increase
in hardness could improve the dentine bond strength of
universal adhesives.33 The double application might
also produce a more uniform adhesive layer and com-
pensate for possible application defects.34 The alter-
ations that could occur in the hybrid and adhesive layer
with the double application might improve the
impaired bond strengths caused by irradiation.
On the other hand, double application of the uni-
versal adhesives did not influence the bond strengths
to non-IR dentine. The double application could be
effective on the dentine influenced by irradiation. The
double application might affect the long-term stability
of the dentine bond strengths to non-IR dentine by
sealing the adhesive interface better against water
uptake, as stated in previous studies.25,34,38 Unfortu-
nately, the ultra-morphological characteristic and
interfacial structure of the resin-dentine interfaces
could not be assessed in the present study. Further
studies should focus on the ultra-morphological char-
acteristic and interfacial structure of the resin-dentine
interfaces obtained from IR dentine.
As reported in previous studies,32,35 the two-step
self-etch adhesive, Clearfil SE Bond, presented better
186
results than the universal adhesives when the universal
adhesives were applied as a single coat. The bonding
effectiveness of Clearfil SE Bond is believed to be asso-
ciated with the 10-methacryloyloxydecyl dihydrogen
phosphate (10-MDP) monomer, and to the separation
of the application of its functional primer and its bond-
ing agent that does not contain solvent but contains
10-MDP and hydroxyethylmethacrylate.19,40 Although
Scotchbond Universal and Gluma Bond Universal
include MDP phosphate monomer, the difference in
the bond strengths of these universal adhesives and
Clearfil SE Bond might result from the separate appli-
cation of the functional primer and bonding agent of
Clearfil SE Bond.19 The universal adhesives are single-
component and one-step adhesives.31 The bond
strength of Clearfil SE Bond was not influenced by irra-
diation. As reported in previous studies, it could result
from the formation of a more homogeneous hybrid
layer with Clearfil SE Bond.13,17 The primer used with
Clearfil SE Bond has a pH of 2.0, this causes partial
demineralization of dentine and forms a uniform
hybrid layer with hydroxyapatite of 0.5–1 lm, which
could protect the collagen network.19,41 Moreover, the
adhesive layer of two-step self-etch adhesives is more
hydrophobic than those of the universal adhesives since
separating the priming and bonding steps.34 A
hydrophobic adhesive layer has higher mechanical
properties to a hydrophilic one, and it is thought to
tolerate degradation factors well.42,43 The superior
mechanical properties of the hydrophobic adhesive
layer might also compensate for the effects of irradia-
tion on the bond strength.
This study has demonstrated that the prevalence of
cohesive dentine failures increased with irradiation. As
attributed in previous studies, this result could be
related to the changes in dentine by irradiation, such as
the weakening of the dentine structure.9,12,37 It has
been reported that dentine microhardness is decreased
by radiation, suggesting that radiotherapy could be
responsible for the denaturation of the organic compo-
nents of the dentine and that the destruction of these
organic components could reduce the inner stability of
the dentine.44 However, the adhesive strength cannot
be evaluated truly with the cohesive failures in dentin.
The cohesive failures have been stated as non-adhesive
failures.45 It has been reported that the cohesive fail-
ures were associated with higher microtensile bond
strengths.38 But, the cohesive failure in dentin might
also be related to the lower bond strengths due to the
negative effects of irradiation on dentin.
With the increasing number of patients with head
and neck cancer, and associated radiotherapy treat-
ments, it becomes more important to understand the
effects of radiotherapy on teeth, and how it can influ-
ence the performance of restorations. A previous
study has reported that rinsing with chlorhexidine
© 2020 Australian Dental Association

0.12% partially limited the alterations in IR coronal
dentine by inhibition of radiotherapy-activated prote-
olytic enzymes.18 The rinsing of dentine with
chlorhexidine before adhesive application might
improve bond strength to IR dentine. It has been sug-
gested that restorative dental treatments should be
done before radiotherapy.9 However, it has been
reported that the irradiation negatively influenced the
dentine bond strength though the restorations were
done before radiotherapy.13,17 It is difficult to predict
the clinical performance of universal adhesives after
radiotherapy by the results of the present study. Fur-
ther in vitro studies must be carried out, and the clini-
cal studies are necessary to confirm the results.
Because in vitro studies cannot take into account the
effects of alteration in salivary flow or oral flora after
irradiation.
Under the limitations of this in vitro study, it can
be concluded that radiotherapy could affect the den-
tine bond strength of universal adhesives. The double
application of universal adhesives might be beneficial
in improving the decreased dentine bond strength.
The two-step self-etch adhesive, Clearfil SE Bond,
presented with better results than the universal
adhesives, and the bond strength of Clearfil SE Bond
was not influenced by the irradiation. A careful
follow-up will be beneficial for the restorations done
after radiotherapy.
ACKNOWLEDGEMENTS
The author thanks to 3M Oral Care, Heraeus Kulzer
and Dentsply, for the material support of this study,
and Salih Aky€
urekli for SEM analyses.
ETHICS APPROVAL
The ethical approval was received by Commission for
Medical Ethics of the Suleyman Demirel University.
CONFLICT OF INTEREST
The author declares no conflict of interest.
FUNDING
This research did not receive any specific grant from
funding agencies in the public, commercial or not-for-
profit sectors.
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Address for correspondence:
Muhittin Ugurlu
Faculty of Dentistry
S€
uleyman Demirel University
East Campus
32100 Isparta
Turkey
Email: dtmuhittinugurlu@gmail.com
© 2020 Australian Dental Association