RestorativeDentistry Enhanced CPD DO C

FJ Trevor Burke

Louis Mackenzie

Bonding to Dentine: An Update on

Universal Adhesives
Abstract: The ability to successfully bond restorations to dentine is central to minimally invasive restorative dentistry. While dentine
bonding agents have gone through a variety of ‘generations’, it is the purpose of this article to describe the latest clinical and laboratory
research on universal adhesives. Results from the latest laboratory and clinical research indicates that universal adhesives are a step forward
in the quest for the ultimate bond to tooth substance and ease of use of the adhesive. The wide variety of studies that indicates the
effectiveness of universal adhesives are discussed, along with research that indicates that selective enamel etching is a beneficial procedure
when using these materials.
CPD/Clinical Relevance: Universal adhesives appear to hold promise in the quest for a reliable bond to dentine.
Dent Update 2021; 48: 620–631

Dentine bonding agents play a central
role in the sealing and retention (where
necessary) of resin composite restorations,
which are increasingly placed by dentists
worldwide.1 Bonding to dentine is also
central to the practice of minimally invasive
dentistry, given that restorations, which
may be bonded to tooth substance, do not
require the macro-mechanical retentive
features such as locks and keys that are a
feature of (non-adhesive) dental amalgam
or gold cavity preparations.2
A dentine adhesive should perform the
following functions:3
 Provide an immediate, strong and
definitive bond to dentine;
FJ Trevor Burke, DDS, MSc, MDS, MGDS,
FDS (RCS Edin), FDS RCS (Eng), FFGDP
(UK), FADM, Emeritus Professor, University
of Birmingham School of Dentistry, UK.
Louis Mackenzie, BDS, FDS RCPS, Head
Dental Officer, Denplan UK, Winchester
and Clinical Lecturer, University of
Birmingham School of Dentistry, UK.
email: f.j.t.burke@bham.ac.uk
620 DentalUpdate
 Seal the cavity and minimize leakage;
 Resist microbial or
enzymatic degradation;
 Provide adhesion per se of the
restoration in cases where this
is necessary;
 Prevent post-operative sensitivity;
 Reduce the risk of recurrent caries;
 Prevent marginal staining;
 Be easy to use.
It is the intention of this article to trace the
history of dentine adhesives since that is
relevant to the performance of the latest
group of adhesives, the universal adhesives
(UAs), and thereby to update readers on
the progress of UAs since a previous Dental
Update paper in 2017,4 and to compliment
other Dental Update publications on the
subject, which readers may wish to read as
background, such as those by Green and
Banerjee,2 and, Green et al.5
A brief history of bonding
to dentine
In the past, dentine bonding agents were
classified into generations.6 However, this
means of identifying different groups of
bonding agents generally fell into disarray
because of confusion regarding which
‘generation’ each type of bonding agent
fitted into. Until recently, the classification
has therefore been to simply subdivide
resin-based dentine bonding agents into
etch and rinse materials (also known as total
etch materials) and self-etch materials, with
some workers classifying these according
to the number of steps involved in their
placement (one or two), or by their pH.3,7
The year 1955 heralded what we
now realize to be a game-changing
breakthrough in restorative dentistry,
namely the genesis of adhesive (and,
therefore, more minimally invasive)
dentistry by enabling clinicians to bond to
enamel, when this was first described by
Buonocore.8 This also has facilitated the
development of resin composite materials,
with these materials becoming increasingly
used worldwide,1 principally because of
patient concerns regarding mercury in
dental amalgam, the Minamata Agreement
of 2013 that recommended reduction in
the use of dental amalgam, and increasing
patient requests to receive tooth-coloured
restorations in their posterior teeth.9
September 2021

Unlike enamel, dentine is a vital
substrate with circa 20% organic
material and 10% water by weight.
These factors make bonding to dentine
more challenging than to enamel. Also
involved in this challenge is the smear
layer on the dentine surface, this having
been defined as a ‘layer which appears on
the surface of teeth that have undergone
dental instrumentation procedures,
such as cutting with a dental bur: it
cannot be rinsed away, but it can be
dissolved by dilute organic acids, such
as phosphoric acid’.10 This crystalline,
uniform layer comprises debris consisting
of hydroxyapatite particles, altered
collagen and bacteria. Early resin-based
dentine bonding agents were little more
than wetting agents that penetrated the
smear layer. When it was realized that
the smear layer was not well adherent
to the underlying dentine, it became
obvious that it was necessary to treat it in
some way. Until recently, therefore, there
were two distinct types of resin-based
dentine adhesive.
Etch and rinse (or total etch) materials
The etch and rinse (or total etch)
materials are for which the smear layer
was dissolved by the application of
30–35% phosphoric acid, followed by
washing, drying and the application
of a primer and the bonding agent.
These materials, with a four-stage
clinical application protocol, could be
considered technique sensitive because
of the risk of a failure if any stage was not
carried out optimally.3 However, some
materials of this type, such as Optibond
FL (Kerr, Orange, CA, USA) remain in
use, given that they are considered by
some clinicians to be the gold standard
to which other bonding agents must
be compared.11 This material has been
shown to provide excellent retention at
13 years in non-carious cervical lesions
(NCCL).12 It may also be relevant to note
that, according to two reviews, Optibond
FL and Clearfil SE (Kuraray, Tokyo, Japan)
have been considered to be the gold
standard of etch and rinse and self-etch
adhesives, respectively.13,14
What happens to the smear layer with
etch and rinse adhesives? The smear layer
is dissolved and then washed away, with
September 2021
the acid also dissolving the most superficial
1–5 microns of dentine, removing
hydroxyapatite, leaving only collagen fibres.
When the resin bonding agent is applied
to the decalcified dentine surface, a layer is
formed on the decalcified dentine surface,
with the resin polymerizing around the
collagen fibres: this was termed the hybrid
layer by Nakabayashi (Figure 1).15
Self-etch adhesives
Because of the clinical technique sensitivity
associated with etch and rinse materials, and
the belief by manufacturers that clinicians
seek materials that are easy and fast to use,
the group of bonding agents known as self-
etch adhesives were presented to clinicians
in the early 1990s. (In this regard, it has been
considered that a material that is easy to use
will produce optimal results.16) In these self-
etch bonding systems, the bonding resin is
combined with an acid (generally phosphoric
acid) in order to reduce the pH to a level that
is said to be sufficiently low to carry out the
etching step at the same time as producing
bonding. These materials were, therefore,
significantly simpler to use than the etch
and rinse materials and could be presented
in only one bottle, thereby facilitating
their use. The so-called self-etch adhesives
may be considered to have advantages
when compared to etch and rinse types,
for example:3
 No post-conditioning rinsing, hence less
operator sensitivity;
 Less sensitive to the degree of wetness/
dryness of the dentine surface;
 Single unit dose packaging possible,
hence reduced risk of cross infection,
and simple to use;
 Simultaneous demineralization and
resin-infiltration meant that it was
not possible to over-etch the dentine,
leading to reduced levels of post-
operative sensitivity.
What happens to the smear layer with
self-etch adhesives? The acidic resin does
not remove the smear layer: the slightly
decalcified surface leads to the formation of
a hybrid layer, with the smear layer becoming
incorporated into the hybrid layer (Figure 2).
Among the disadvantages of self-etch
adhesives listed in 2004 was: ‘adhesion to
enamel requires further long-term evaluation
in some systems’.3 Hence, the development
of the concept of selective enamel etching.
RestorativeDentistry
Figure 1. The hybrid layer.
The advent of selective
enamel etching
While laboratory testing allows variables
to be investigated, it may be considered
that the ultimate test of adhesives is their
clinical performance in a non-retentive
class V cavity. Results of a 5-year landmark
study from Peumans and colleagues17
involving the clinical use of the (so-called)
self-etch adhesive, Clearfil SE (Kuraray), in
100 non-retentive class V cavities, restored
with resin composite, has indicated that,
when the enamel margins were ‘selectively
etched’ with phosphoric acid, the enamel
cavity margins had advantages in terms of
integrity and lack of staining. Accordingly,
the concept of selective enamel etching was
born.17 When these workers extended their
study to 13 years,18 the results, with a 62%
recall rate and 96% retention rate, continued
to indicate fewer small marginal defects on
enamel in the selective enamel etch group
(16% cf 4% in the self/non-etch group).
The authors commented that ‘the limited
micromechanical retention of the enamel
surface conditioned by the self-etching
primer (pH = 2) and the stable chemical
bond between 10-methacryloyloxydecyl
dihydrogen phosphate (10-MDP) and
hydroxyapatite (HA), seems to be strong
and durable enough to have a clinically
acceptable enamel bond in 95% of
restorations after 13 years of clinical
functioning. The authors added that ‘the only
remarkable (not significant) difference in the
present clinical trial was that small marginal
defects and/or superficial discoloration
at the enamel side were observed more
frequently in the solely self-etch group.
This difference between both groups, also
noticed at previous recalls, has remained
DentalUpdate 621
 RestorativeDentistry

a quite stable during the last 5 years’. In this

regard, the so-called self-etch adhesives
were introduced because of dentists’
requests for ease of use and speed, with this
not involving the use of phosphoric acid.
However, with the benefit of hindsight, it
could be considered that clinicians were
naïve to expect materials with a pH of circa
2.5 to provide similar marginal integrity
or low incidence/absence of marginal
discolouration on enamel margins as could
be obtained when these were etched using
phosphoric acid (pH circa 0.5), remembering
that pH operates on a logarithmic scale.

Universal adhesives
It should be added that the two groups
of bonding agents discussed above were
b type specific, in other words, for the etch
and rinse materials to be clinically effective,
the dentine surface must be etched, while
for the self-etch materials, the dentine
surface must not be etched, but merely be
physically clean. In this regard, the present
authors suggest cleaning with pumice
and water. A new group of adhesives, the
universal adhesives (UAs), has therefore
been introduced to overcome the type
specificity associated with previous
adhesives in regard to mode of etching.
A UA has been defined as one that:19
 Is capable of being used in whichever
etching mode that the operator
considers appropriate (total etch,
c self-etch or selective enamel etch):
the authors of this paper consider
that selective enamel etching is
appropriate, as will be demonstrated
when the results of recent research are
discussed later;
 May be used for direct and indirect
dentistry, the latter generally in
conjunction with a resin-based luting
system from the same manufacturer
as the bonding agent, with the luting
system incorporating a material-specific
initiator. However, at the time of writing,
this only applies to the materials from
two manufacturers, 3M and GC.
In addition:
 According to Matos and co-workers,20
the term ‘universal’ is appropriate due to
Figure 2. (a) Dentine prior to application of adhesive. The smear layer is on the dentine surface. (b) the addition of the resinous monomer
Application of the self-etch adhesive modifies the smear layer. (c) When the adhesive is polymerized, a 10-MDP to provide chemical bonding to
hybrid layer is formed, with the smear layer particles within it.
hard tissue and metals;
622 DentalUpdate September 2021

Figure 3. Chemical formula of 10-MDP.
 According to Nagarkar and
colleagues,21 there is no official
definition for what qualifies as a
UA, the literature describes it as
a single-bottle, no-mix adhesive
system that performs equally well
with any adhesion strategy and
bonds adequately to tooth structure,
as well as to different direct and
indirect restorative materials;
 According to Perdigão et al,22 UAs
were recommended for a number
of clinical applications, including
direct and indirect restorations,
core build-ups, zirconia primers and
dentine densensitizing.
So, while the etch and rinse and self-
etch bonding agents were type specific,
the UAs are indeed universal, insofar that
they can be used in whichever etching
mode a clinician feels is appropriate
and for other clinical applications.
Factors involved in the decision process
regarding etch mode may include:
 Not wishing to etch dentine for fear
of producing post-op sensitivity
(particularly in posterior teeth) while
etching enamel margins to optimize
the marginal characteristics (ie no
long-term defects or staining) of
the restoration (ie using selective
enamel etching);
 Using self-etch mode in a patient
lacking co-operation, or for speed
of use;
 Using etch and rinse mode because
of a belief that this is superior.
September 2021
The rise and rise of 10-MDP
Another difference between UAs and
self-etch adhesives are the functional
phosphate and/or carboxylate monomers
incorporated into their constituents that
facilitate chemical bonding to the calcium
in HA. A factor that the majority of this new
group of bonding agents has in common
is the resin 10-MDP,23 with this monomer
first appearing in the adhesive, Clearfil New
Bond (Kuraray), in the early 1980s (Figure
3). Van Meerbeck and colleagues24 have
considered that 10-MDP is one of the most
effective monomers to strongly ionically
bond to HA, forming stable 10-MDP-Ca
salts, with these authors adding that this
chemically stable bond has been shown
to contribute to bond durability. This has
been demonstrated clinically in the 13-year
study by Peumans et al18 when using Clearfil
SE Bond (Kuraray), which includes 10-MDP,
as adhesive for restoration of class V resin
composite restorations, with very positive
results,18 this having been attributed by
the authors to the presence of 10-MDP in
the formulation, given that the restorations
without selective enamel etching were still
retained despite marginal discrepancies.
It has been considered by Perdigão25
that, without calcium, it is unclear how
10-MDP adhesives are able to bond ionically
to etched dentine. They therefore stated
that 10-MDP-containing adhesives may
need to be applied only on unetched
dentine, additionally using a selective
enamel-etching technique.
The length of the long hydrophobic
10-carbon chain has also been reported to
contribute to its bonding ability.26 However,
in this regard, longer chains in monomers
such as 10-MDP are more hydrophobic,
which could enhance the chemical
interaction with calcium and reduce
their degradation.27
In summary, therefore, it may be
considered that the incorporation of
10-MDP into an adhesive’s formulation
provides a ‘belt and braces’ approach,
this uniquely providing an ionic bond
to calcium, ie to HA in dentine, via the
hydrophilic group incorporated in the
molecule, along with a micromechanical
bond via the hybrid layer. However,
although Van Meerbeck and colleagues,24
in their comprehensive review of dental
adhesives, termed 10-MDP as ‘today’s
RestorativeDentistry
most effective functional monomer’,
they stated that it was not the perfect
functional monomer because it was
sensitive to hydrolytic degradation at the
two ester groups linking both functional
groups to the central spacer group. The
10-MDP patent expired in 2003, with the
result that manufacturers other than the
patent holders, Kuraray, were able to start
adding this phosphate monomer to their
new adhesives.
The components of some universal
bonding agents are presented in Table
1.21,22 From this, it is apparent that all UAs
contain 10-MDP and some have an added
resin to facilitate bonding, such as G
Premio Bond with 4-META (developed by
Nakaybashi), Optibond Universal (GPDM,
Kerr) Prime&Bond Active (PENTA, Dentsply
Sirona, Weybridge, UK) and others have
a polyalkenoate derivative such as PAC
(Scotchbond Universal and Scotchbond
Universal Plus, both 3M, MN, USA), and
MCAP (Adhese Universal, Ivoclar-Vivadent,
Schaan, Liechtenstein).
So, just how good are
universal adhesives?
As with any recently introduced material,
there is a relative paucity of evidence
relating to these new materials, although
this is building. The most researched UA is
Scotchbond Universal Adhesive (SBU, 3M),
given that this was the first of this group of
materials to be released commercially, but
other UAs have recently been examined.
UAs may be classified, similarly to
self-etch adhesives, according to their pH,
according to the classification by Miyazaki
et al28 and van Meerbeck and colleagues24 in
which the material was classified as shown
in Table 2.
Laboratory studies
A number of laboratory studies were
presented previously,4 namely those by
Loguerico and co-workers,29 da Rosa and
co-workers,30 Munoz and co-workers,31
Chen and co-workers32 and others,33–36
with generally positive results concerning
the in vitro performance of UAs. Three
substantial review articles will be used to
update readers on the current laboratory
performance of UAs.
A recent systematic review, by Cuevas-
Suarez and colleagues,37 of shear bond
DentalUpdate 623
 RestorativeDentistry

Universal adhesive Manufacturer Classification Functional Classification pH

by pH monomer(s)
Strong <1
All-Bond Universal BISCO Ultra-mild 3.2 10-MDP
Intermediately 1–2
(ABU)
strong
AdheSE Universal Ivoclar Vivadent Ultra-mild 2.5–3.0 10-MDP, MCAP
Mild ≈2
Optibond Universal Kerr Ultra-mild 2.5–3.0 GPDM, 10-MDP Ultra-mild ≥2.5

Table 2. Classification of adhesives according

One Coat 7 Coltene Ultra-mild 2.8 10-MDP, to pH.
Universal methacrylated
polyacid
Scotchbond 3M Ultra-mild 2.7 10-MDP, PAC
Universal results of their review, Cuevas-Suarez and
colleagues37 provided the following helpful
Scotchbond 3M Ultra-mild 2.7 10-MDP, PAC recommendations to clinicians:
Universal Plus
 ‘when applied to dentine, prior acid
Prime&Bond Elect Dentsply Sirona Ultra-mild 2.5 10-MDP, PENTA etching before the use of intermediately
strong and ultra-mild universal
Clearfil Universal Kuraray Dental Mild 2.3 10-MDP adhesives it is not recommended’; and,
Bond  ‘selective etching of enamel followed
Futurabond U VOCO Mild 2.3 10-MDP by the application of a mild universal
adhesive currently appears to be the
iBOND Universal Kulzer Intermediate strong 10-MDP, 4-META best choice to effectively achieve a
1.6–1.8 durable bond to tooth tissues since
bonding performance of mild universal
G-Premio Bond GC Intermediate strong 10-MDP, 4-META, adhesives could be improved by using
1.5 MDTP the selective enamel-etch strategy.
Table 1. Constituents of some universal adhesives, after Nagarkar et al21 and Perdigão et al.22 When applied to dentine, mild universal
10-MDP: 10-methacryloyloxydecyl dihydrogen phosphate; MCAP: methacrylated carboxylic acid adhesives seem to provide better
polymer; GPDM: glycero-phosphate dimethacrylate; PAC: polyalkenoic acid copolymer; PENTA: stability in both etch-and-rinse and self-
dipentaerythritol penta acrylate monophosphate; 4META: 4-methacryloxyethyl trimellitic acid; MDTP: etch strategies’.
methacryloyloxdecyl dihydrogen thiophosphate.
Nagarkar and co-workers21 reviewed the
laboratory testing and clinical performance
of UAs. They identified 1250 articles,
strength testing to dentine, has updated  After this, in situ polymerization leads to including 285 for final data analysis, of
a 2015 review by the same group. They the formation of a hybrid layer, which, which, 12 were clinical studies (vide infra).
identified 9284 publications, 81 of which in combination with the presence They pointed out that chemical bonding
promoted by 10-MDP was more effective
were read in full and 57 finally accepted for of resin tags within the dentinal
and stable in water than that provided by
the review. Their results indicated that: tubules, provides the resin composite
other functional monomers, but concluded
 The bond strength to dentine was restoration adhesion.
that, overall, for durable bonding with UAs,
affected by the bonding strategy and the Cuevas-Suarez and colleagues37 finally laboratory studies recommend the use of
pH of the adhesive used, with the etch- stated that ‘the new meta-analyses a selective enamel-etching strategy for
and-rinse approach improving the bond performed in this update demonstrated permanent teeth, and an etch and rinse
strength to dentine of intermediately that the stability of multimode adhesives’ strategy for primary teeth. They concluded
strong universal adhesives; bond strength to dentine depends largely that ‘available laboratory and clinical
 When an etch-and-rinse approach is on their pH’. On enamel, irrespective of evidence does not support the claim that
used, the acid etching step solubilizes the pH of the adhesive, bond strength UAs can be used with any adhesive strategy’.
the mineral content of dentine was improved by prior phosphoric acid Van Meerbeck and colleagues24
(including the smear layer), with etching. On the other hand, dentine bond reviewed the pros and cons of UAs. They
subsequent application of the adhesive strength of mild UAs was not dependent considered that, while the etch and rinse
allowing monomer infiltration into the on the adhesive strategy used, and these strategy was ‘undoubtedly’ the best
collagen network, replacing the water adhesives seemed to be the materials bonding strategy to enamel, the resultant
between the collagen fibrils;38 with better stability. Summarizing the thick and hydroxyapatite-free hybrid layer
624 DentalUpdate September 2021

formed on dentine was highly sensitive to
degradation with time.
Finally, recent laboratory studies
include the work by Lago and co-workers39
who compared the shear bond strength
of six UAs to dentine, using Clearfil SE
Bond (Kuraray) as control. The results
indicated highest bond strength values for
Scotchbond Universal (3M) (33.9MPa), but
this was not significantly different to Clearfil
Universal (Kuraray) and Tetric N-Bond
(Ivoclar-Vivadent). All six UAs provided
superior bond strength values to the Clearfil
SE control.
In summary, therefore, laboratory
studies appear to confirm that the bond
strengths obtained by UAs are generally
an improvement over those previously
attained, with a selective enamel etch
strategy being preferred.
Clinical studies
While laboratory data may provide an
indicator regarding the performance of
a given material, there is no substitute
for clinical evaluation, given the tenuous
association between in vitro and in vivo
studies.40 The previous paper4 cited
Loguerico and colleagues,41 Perdigão
and colleagues42 and Lawson et al,43 in
demonstrating the short-term clinical
success of Scotchbond Universal (SBU).
Recently published clinical research on UAs,
with evaluation periods of greater than
2 years, includes the following:
 The laboratory work of Loguerico
and co-workers,29 and Munoz and
co-workers,31 could be considered to
be in agreement with results, published
in 2017, of a randomized controlled
trial by Burke and colleagues from a
practice-based research group19 who
used a split mouth design study to assess
restorations (mainly in loadbearing
cavities in posterior teeth) bonded
with SBU (3M) in self-etch mode (ie no
etching with phosphoric acid) or total
etch mode (all surfaces in the cavity
etched with phosphoric acid). The results
indicated that, when 45 restorations
were evaluated at 3 years, there was no
difference in the quality of the margins;19
 However, the numbers were relatively
small in comparison with a recent
publication by Matos and colleagues,20
who placed a total of 200 class V
September 2021
restorations in 39 patients and
evaluated these at 5 years. There were
four different treatment groups, namely:
– SBU etch and rinse + moist dentine;
– SBU etch and rinse + dry dentine;
– SBU selective enamel etch; and
– SBU self-etch.
The recall rate was 86%, with 19 restorations
(of 153 assessed) lost, and the results
indicated that the SBU adhesive performed
worse in self-etch mode. Significant
differences were also observed for both
marginal staining and adaptation, with the
clinical behaviour of this UA being better in
etch and rinse mode when compared with
the self-etch category. The authors therefore
recommended that, if a self-etch strategy was
used, selective enamel etching be employed.
 Ruschel et al44 carried out a 3-year
evaluation of UAs in NCCLs, involving 63
patients who had 203 NCCLs restored
using resin composite and one of two
UAs, Scotchbond Universal (SBU, 3M)
and Prime&Bond Elect (PBE, Dentsply
Sirona) used in either self-etch or
etch and rinse modes. At the 3-year
review, 150 restorations were assessed.
Three restorations in the PBE self-etch
group failed due to loss of retention,
and restorations with etched margins
were more likely to score optimally for
marginal discolouration than in the
self‑etch groups;
 Atalay and co-workers45 compared the
3-year performance of a UA used with
different adhesive strategies in NCCL.
They placed 165 restorations in 35
patients, using three etch protocols,
namely: selective enamel etch; etch
and rinse; and self-etch, placed using
Single Bond Universal (3M), known in
the UK as Scotchbond Universal. A recall
rate of 98% was achieved, with three
restorations (one from each group)
having failed due to loss of retention.
For all groups, only one criterion was
significantly different. Restorations
in the self-etch mode showed ‘less
satisfying’ performance for marginal
staining and marginal adaptation;
 Zanatta et al46 evaluated the bonding
performance of three adhesives, SBU
(3M) (a UA system), Adper Single Bond
(3M) (an etch and rinse) and Clearfil
SE Bond (Kuraray) (self-etch) in a total
of 152 restorations in 34 patients.
RestorativeDentistry
The results indicated that the UA
system performed similarly to the
‘conventional’ etch and rinse or self-
etch systems;
 Oz and colleagues47 examined 20
patients in a randomized controlled
prospective trial, where each had
a minimum of seven NCCLs, giving
a total of 155 restorations. Seven
different adhesives and application
modes were employed. The recall
rate was 82%. The results indicated
that the cumulative retention
rate for the self-etch groups was
significantly lower than for the
other experimental groups. The
authors concluded that GLUMA
Universal (Hereaus Kulzer, Germany)
and All-Bond Universal (Bisco, IL,
USA) showed better results in etch
and rinse and selective enamel
etch modes, compared with the
restorations placed in the self-etch
mode, concluding that the strategies
in which the enamel was etched
provided better clinical outcomes,
including retention, marginal
adaptation and marginal staining;
 Perdigão et al,48 in a randomized
controlled trial, assessed restorations
of NCCLs in 39 subjects using
four different etch protocols and
evaluated whether an additional
layer of hydrophobic bonding resin
improved clinical behaviour. The
cumulative failure rate was 8.6%, with
retention rate being worst for the self-
etch category. The authors concluded
that ‘phosphoric acid etching is still
recommended to provide retention
for composite restorations in NCCLs;’
 Van Dijken and Pallesen49 examined
the clinical performance of a UA
(All Bond Universal, Bisco) with
the control, the two-step self-etch
adhesive Optibond XTR (Kerr).
A total of 114 ‘extended’ class
II resin composite restorations
were assessed at 3 years. Eight
restorations failed, principally
due to composite fractures. The
success rate of the restorations
placed with the UA adhesive was
94.7% and the control 91.2%.
The authors concluded that the
class II restorations placed using a
one-step UA showed good short-
DentalUpdate 625
 RestorativeDentistry

term performance;
 Finally, Szesz and colleagues50
carried out a systematic review
and meta-analysis, identifying
2689 articles but retaining only
10, in order to identify if selective
etching of enamel margins
improves the retention rates of
cervical composite restorations in
NCCLs. While their findings related
to self-etch adhesives, it may be
considered that their results are
pertinent to UAs used in self-
etch mode. They concluded that
selective enamel etching prior to
application of self-etch adhesive Figure 4. Comparison of radiopacity between Scotchbond Universal (original) and Scotchbond
systems in NCCLs can produce Universal Plus.
composite restorations with
better aesthetics (lower marginal
discoloration rates and better
marginal integrity) and higher class V: 182; other: 20) and rating the Universal, except that a radiopaque
longevity (higher retention rates). material on visual analogue scales. resin has been incorporated,
The results indicated that the bonding substituting the BisGMA in the original
In summary therefore, there is a
agent used prior to the evaluation version, and the silane has been
strong body of evidence that indicates
scored 4.0 out of 5.0 (where 5 indicated improved, along with the adhesive’s
that recently developed UAs provide
optimal ease of use), with SBU scoring ability to bond to carious dentine,
clinical effectiveness as good as, or
4.9. More recently, G-Premio Bond according to manufacturer’s data. The
better, than previous ‘gold standard’
(GC, Leuven, Belgium), Prime&Bond addition of the radiopaque resin helps
adhesives, and that selective etching
Active (Dentsply Sirona) and Zipbond clinicians avoid any doubt regarding
of the enamel is desirable, given that
(SDI, Melbourne, Australia) have been whether a radiolucent layer at the base
the results presented above indicate
evaluated,52–54 with ease of use scores of a posterior composite restoration
improved retention rates of class
being 4.9, 4.8 and 4.9, respectively. is a pool of (non-radiopaque) resin or
V restorations when the margins
It may therefore be concluded that residual/secondary caries (Figure 4).
are etched, and reduced levels of
the UAs tested, and possibly UAs in
discolouration around the margins of
general, score highly for ease of use. Back to the future?
all restorations. The present authors
Finally, it has been considered GC have followed the ‘wish list’ for an
therefore strongly recommend this
that patient- and operator-related ideal dentine adhesive published by Van
procedure. Does that statement apply
factors may have a higher impact on Meerbeck and colleagues24 in which they
to all UAs? It is the authors’ view that,
restoration longevity than the actual stated the following:
in view of the similarities between
adhesive employed,55 therefore, with
many of the UAs (Table 121,22), and The ideal adhesive system should contain:
the fact that their pH values tend to regard to the clinical use of UAs, it
is worth adding that, while isolation  A separate primer, which has the
lie between 1.5 and 3, it is prudent following features:
to suggest that this is carried out if with rubber dam is optimal (although
not universally used56) and moisture – It acts as the adhesion promoter
the clinician wishes to limit marginal and allows use of selective enamel
staining over time. control (by whatever means) is
essential, it may be considered that etching;
a further advantage is the reduced – chemical bonding based on
Handling evaluations number of steps, and concomitant 10-MDP;
There have been four ‘handling’ reduced technique sensitivity of these – photo-initiators, to ensure all areas,
evaluations of UAs51–54 by a UK-based new adhesive systems. even in the deeper parts of the
practice-based research group, hybrid layer, will be covered.
the PREP (Product Research and  A separate bonding agent that can
Recent innovations be light cured immediately with the
Evaluation by Practitioners) Panel.
The first51 involved SBU soon after its A radiopaque dentine adhesive following features:
release, with 12 evaluators placing a 3M have recently introduced – Solvent-poor/free adhesive
total of 875 restorations (class 1:172; Scotchbond Universal Plus, which resin, hydrophobic to reduce the
class II:189; class III: 134; class IV: 178; bears similarities to Scotchbond water uptake;
626 DentalUpdate September 2021

– applied in a sufficiently thick
layer, this provides stress-
absorbing potential;
– a good seal of the interface.
GC’s recently introduced G2-Bond
Universal appears to have been
modelled on these features. In this, a
hydrophilic primer containing 4META,
MDP, MDTP, dimethacrylates, water,
acetone, photoinitiator and filler has
been designed to wet and self-etch
the tooth surface. A second bottle
containing dimethacrylates, BisGMA,
fillers and photoinitiator is then
applied. Interestingly, this contains
no solvent. In common with other
UAs, clinicians may use whichever
mode of etching that they wish.
Universal adhesives as
zirconia/ceramic primers?
It is beyond the scope of this article
to address these topics in detail.
a b c d
e f g
h i j
Figure 5. (a–j) Stages in a bonding restorative procedure.
September 2021
However, in short, given that the resin
10-MDP has a demonstrable adhesion
to zirconia by ionic and hydrogen
bonding,57 UAs containing this resin
may act as zirconia primers. On the
other hand, the bond strength has
been shown to reduce following
6 months’ storage in water58 and a
further study questioned whether
UAs containing 10-MDP produced a
significant effect regarding bonding
to zirconia.59 It would therefore appear
that more work is required to solve one
of dental materials' most problematical
problems, namely, how to achieve a
reliable bond of resin to zirconia.
Two UAs contain a silane in their
list of components, namely Clearfil
Universal (Kuraray) and Scotchbond
Universal/Universal Plus (3M). These
UAs could therefore be used as primers
for materials such as glass ceramics,
alumina ceramics and lithium disilicate,
especially when used in conjunction
RestorativeDentistry
with the resin luting material from the
same manufacturer.
MMPs: friend or foe
Matrix metalloproteinases (MMPs) are
proteolytic enzymes, found in dentine, that
can lead to the destruction of collagen
(ie the organic matrix) in dentine when
the pH is low. Destruction of the collagen
in the hybrid layer can result, potentially
leading to a reduction in bond strength,
and which could be extrapolated to
failure of adhesive restorations. As a result,
MMP inhibitors have been proposed by
some workers, adding an extra step in a
dentine bonding protocol, such as the
application of chlorhexidine. Most of the
work on this subject has been carried out
in vitro; however, a meta-analysis has failed
to endorse the use of MMP inhibitors.60
Clinicians may therefore breathe a sigh of
relief that their dentine bonding has not
been made more difficult!
DentalUpdate 627
 RestorativeDentistry
a a
b
Figure 6. (a, b) This 35-year-old patient presented b
with palatal erosion (with large areas of dentine
exposed) affecting his upper anterior teeth, and
chipped incisal edges. Using a dentine adhesive,
the worn palatal surfaces were restored with resin
composite and the incisal edges of UL3 to UR3
restored with resin composite at an increased
occlusal vertical dimension. The patient received
oral hygiene instruction. This improved as his tooth
sensitivity decreased following treatment.
a electrosurgery carried out to expose fracture
b
Figure 7. Dentine adhesives facilitate the use
of non-retentive cavities with no resistance to
distal displacement. (a) Non-retentive minimally
invasive cavity design. (b) Cavity restored with
resin composite.
628 DentalUpdate
Figure 8. (a) UR1 fractured in cycling accident.
Fragment retained by patient. (b) UR1 root filled,
margin and fragment replaced using dentine and
enamel bonding. Illustration taken after 2 weeks.
The repair was successful for 2 years, following
which further trauma led to loss of the tooth.
However, it is thought to be psychologically good
for the patient to have their own ‘tooth’ replaced.
If bonding is as good
as this, what are the
clinical applications?
Figures 5–8 present a variety of the
clinical applications that could be
appropriate to today’s universal
adhesives.
Conclusions
In summary, universal adhesives
hold promise and:
 Can be used in total etch, self-
etch, selective enamel etch
modes, depending on the
clinician’s choice. The need to
selectively etch the enamel
has been demonstrated to be
beneficial in many of the studies
quoted in this review, both from
the point of view of retaining
class V restorations, but also
because marginal staining and
defects will be reduced;
 In addition, in view of the
potential to cause post-
operative sensitivity as a result of
(over) etching dentine, particularly in
posterior teeth, it is the authors’ view
that this is not necessary or desirable
and that selective enamel etching is
the method of choice;
 Some are compatible with direct and
indirect procedures, when used with
a designated resin luting material
from the same manufacturer as the
bonding agent because this will
contain a separate activator;
 May be suitable primers for silica
and zirconia;
 Can bond to different substrates,
such as metal.
However, as with any new material
or technique, more long-term clinical
evaluations (alongside those referenced
above) are needed to adequately
demonstrate the value of these
universal adhesives.
Acknowledgements
Thanks are due to Ms Georgia Critoph-
Evans for drawing Figures 2a, 2b and 2c.
Compliance with Ethical Standards
Conflict of Interest: The authors declare
that they have no conflict of interest.
Informed Consent: Informed consent was
obtained from all individual participants
included in the article.
References
1. Burke FJT. Amalgam to tooth-
coloured materials – implications
for clinical practice and dental
education: governmental restrictions
and amalgam-usage survey results. J
Dent 2004; 32: 343–350. https://doi.
org/10.1016/j.jdent.2004.02.003.
2. Green DJ, Banerjee A. Contemporary
adhesive bonding: bridging the
gap between research and clinical
practice. Dent Update 2011; 38:
439–450. https://doi.org/10.12968/
denu.2011.38.7.439.
3. Burke FJT. What's new in dentine
bonding? Self-etch adhesives.
Dent Update 2004; 31: 580–589.
https://doi.org/10.12968/
denu.2004.31.10.580.
4. Burke FJT, Lawson A, Green
DJB, Mackenzie L. What’s new
September 2021
 RestorativeDentistry
in dentine bonding? Universal
adhesives. Dent Update 2017; 44:
328–340. https://doi.org/10.12968/
denu.2017.44.4.328.
5. Green D, Mackenzie L, Banerjee
A. Minimally invasive long-term
management of direct restorations:
the '5 Rs'. Dent Update 2015; 42:
413–426. https://doi.org/10.12968/
denu.2015.42.5.413.
6. Burke FJT, McCaughey AD. The four
generations of dentin bonding. Am
J Dent 1995; 8: 88–92.
7. Van Meerbeek B, Yoshihara K,
Yoshida Y et al. State of the art of
self-etch adhesives. Dent Mater
2011; 27: 17–28. https://doi.
org/10.1016/j.dental.2010.10.023.
8. Buonocore MG. A simple method of
increasing the adhesion of acrylic
filling materials to enamel surfaces.
J Dent Res 1955; 34: 849–853.
https://doi.org/10.1177/0022034555
0340060801.
9. Burke FJT. Attitudes to posterior
composite filling materials: a survey
of 80 patients. Dent Update 1989:
16: 114–120.
10. Mosby’s Dental Dictionary. 3rd edn.
2014. St Louis, MO, USA: Elsevier
Mosby.
11. Helvey GA. Adhesive dentistry: the
development of immediate dentin
sealing/selective etching bonding
technique. Compend Contin Educ
Dent 2011; 32: 22–35.
12. Peumans M, De Munck J, Van
Landuyt KL et al. A 13-year clinical
evaluation of two three-step etch-
and-rinse adhesives in non-carious
class-V lesions. Clin Oral Investig
2012; 16: 129–1
13. Van Meerbeek B, Peumans M,
Poitevin A et al. Relationship
between bond-strength tests and
clinical outcomes. Dent Mater
2010; 26: e100–121. https://doi.
org/10.1016/j.dental.2009.11.148.
14. De Munck J, Van Landuyt K,
Peumans M et al. A critical review of
the durability of adhesion to tooth
tissue: methods and results. J Dent
Res 2005; 84: 118–32. https://doi.org
/10.1177/154405910508400204.
15. Nakabayashi N, Kojima K, Masuhara
E. The promotion of adhesion by
the infiltration of monomers into
630 DentalUpdate
tooth substrates. J Biomed Mater
Res 1982; 16: 265–273. https://doi.
org/10.1002/jbm.820160307. .
16. Burke FJT, Liebler M, Eliades
G, Randall RC. Ease of use vs
clinical effectivenss of restorative
materials. Quintessence Int 2010;
32: 239–242.
17. Peumans M, Munck J, Van
Landuyt K et al. Three-year clinical
effectiveness of a two-step self-
etch adhesive in cervical lesions.
Eur J Oral Sci 2005; 113: 512–518.
https://doi.org/10.1111/j.1600-
0722.2005.00256.x.
18. Peumans M, De Munck J, Van
Landuyt K, Van Meerbeek B.
Thirteen-year randomized
controlled clinical trial of a two-
step self-etch adhesive in non-
carious cervical lesions. Dent Mater
2015; 31: 308–314. https://doi.
org/10.1016/j.dental.2015.01.005.
19. Burke FJT, Crisp RJ, Cowan AJ et al.
A randomised controlled trial of a
universal bonding agent at three
years: self etch vs total etch. Eur J
Prosthodont Restor Dent 2017; 25:
220–227. https://doi.org/10.1922/
EJPRD_01692Burke08.
20. de Paris Matos T, Perdigão J, de
Paula E et al. Five-year clinical
evaluation of a universal adhesive:
a randomized double-blind trial.
Dent Mater 2020; 36: 1474–1485.
https://doi.org/10.1016/j.
dental.2020.08.007.
21. Nagarkar S, Theis-Mahon N,
Perdigão J. Universal dental
adhesives: current status,
laboratory testing, and clinical
performance. J Biomed Mater Res
B Appl Biomater 2019; 107: 2121–
2131. https://doi.org/10.1002/
jbm.b.34305.
22. Perdigão J, Araujo E, Ramos
RQ et al. Adhesive dentistry:
current concepts and clinical
considerations. J Esthet Restor
Dent 2021; 33: 51–68. https://doi.
org/10.1111/jerd.12692.
23. Perdigão J, Swift EJ Jr. Universal
adhesives. J Esthet Restor Dent
2015; 27: 331–334. https://doi.
org/10.1111/jerd.12185.
24. Van Meerbeek B, Yoshihara K, Van
Landuyt K et al. From Buonocore's
pioneering acid-etch technique to
self-adhering restoratives. A status
perspective of rapidly advancing dental
adhesive technology. J Adhes Dent 2020;
22: 7–34. https://doi.org/10.3290/j.jad.
a43994.
25. Perdigão J. Current perspectives on
dental adhesion: (1) Dentin adhesion
– not there yet. Jpn Dent Sci Rev 2020;
56: 190–207. https://doi.org/10.1016/j.
jdsr.2020.08.004.
26. Yoshihara K, Yoshida Y, Nagaoka N et al.
Adhesive interfacial interaction affected
by different carbon-chain monomers.
Dent Mater 2013; 29: 888–897. https://
doi.org/10.1016/j.dental.2013.05.006.
27. Feitosa VP, Sauro S, Ogliari FA et al.
Impact of hydrophilicity and length
of spacer chains on the bonding of
functional monomers. Dent Mater 2014;
30: e317–323. https://doi.org/10.1016/j.
dental.2014.06.006.
28. Miyazaki M, Tsubota K, Takamizawa
T et al. Factors affecting the in vitro
performance of dentin-bonding
systems. Jpn Dent Sci Rev 2012; 48:
53–60.
29. Loguercio AD, Muñoz MA, Luque-
Martinez I et al. Does active application
of universal adhesives to enamel in self-
etch mode improve their performance?
J Dent 2015; 43: 1060–1070. https://doi.
org/10.1016/j.jdent.2015.04.005.
30. Rosa WL, Piva E, Silva AF. Bond strength
of universal adhesives: a systematic
review and meta-analysis. J Dent 2015;
43: 765–776. https://doi.org/10.1016/j.
jdent.2015.04.003.
31. Muñoz MA, Luque-Martinez I, Malaquias
P et al. In vitro longevity of bonding
properties of universal adhesives to
dentin. Oper Dent 2015; 40: 282–292.
https://doi.org/10.2341/14-055-L.
32. Chen C, Niu LN, Xie H et al. Bonding of
universal adhesives to dentine – old
wine in new bottles? J Dent 2015; 43:
525–536. https://doi.org/10.1016/j.
jdent.2015.03.004.
33. Cardenas AM, Siqueira F, Rocha J et
al. Influence of conditioning time
of universal adhesives on adhesive
properties and enamel-etching pattern.
Oper Dent 2016; 41: 481–490. https://
doi.org/10.2341/15-213-L.
34. Takamizawa T, Barkmeier WW, Tsujimoto
A et al. Influence of different etching
modes on bond strength and fatigue
September 2021

strength to dentin using universal
adhesive systems. Dent Mater 2016;
32: e9–21. https://doi.org/10.1016/j.
dental.2015.11.005.
35. Thanaratikul B, Santiwong B,
Harnirattisai C. Self-etch or etch-and-
rinse mode did not affect the microshear
bond strength of a universal adhesive
to primary dentin. Dent Mater J 2016;
35: 174–179. https://doi.org/10.4012/
dmj.2015-109.
36. Saikaew P, Chowdhury AF, Fukuyama
M et al. The effect of dentine surface
preparation and reduced application
time of adhesive on bonding strength.
J Dent 2016; 47: 63–70. https://doi.
org/10.1016/j.jdent.2016.02.001.
37. Cuevas-Suárez CE, da Rosa WLO,
Lund RG et al. Bonding performance
of universal adhesives: an updated
systematic review and meta-analysis. J
Adhes Dent 2019; 21: 7–26. https://doi.
org/10.3290/j.jad.a41975.
38. Perdigão J, Lambrechts P, Van Meerbeek
B et al. The interaction of adhesive
systems with human dentin. Am J Dent
1996; 9: 167–173.
39. Lago MCA, Mendes CL, Annibal H et al.
Evaluation of bond strength to dentin of
universal adhesive systems. Dent Mater
2019; 35(S1): 41.
40. Bayne SC. Correlation of clinical
performance with 'in vitro tests' of
restorative dental materials that
use polymer-based matrices. Dent
Mater 2012; 28: 52–71. https://doi.
org/10.1016/j.dental.2011.08.594.
41. Loguercio AD, de Paula EA, Hass V et
al. A new universal simplified adhesive:
36-Month randomized double-
blind clinical trial. J Dent 2015; 43:
1083–1092. https://doi.org/10.1016/j.
jdent.2015.07.005.
42. Perdigão J, Kose C, Mena-Serrano AP et
al. A new universal simplified adhesive:
18-month clinical evaluation. Oper
Dent 2014; 39: 113–127. https://doi.
org/10.2341/13-045-C.
43. Lawson NC, Robles A, Fu CC et al. Two-
year clinical trial of a universal adhesive
in total-etch and self-etch mode in non-
carious cervical lesions. J Dent 2015; 43:
1229–1234. https://doi.org/10.1016/j.
jdent.2015.07.009.
44. Ruschel VC, Stolf SC, Shibata S et
al. Three-year clinical evaluation of
universal adhesives in non-carious
September 2021
cervical lesions. Am J Dent 2019; 32:
223–228.
45. Atalay C, Ozgunaltay G, Yazici AR.
Thirty-six-month clinical evaluation
of different adhesive strategies of a
universal adhesive. Clin Oral Investig
2020; 24: 1569–1578. https://doi.
org/10.1007/s00784-019-03052-2.
46. Zanatta RF, Silva TM, Esper M et al.
Bonding performance of simplified
adhesive systems in noncarious cervical
lesions at 2-year follow-up: a double-
blind randomized clinical trial. Oper
Dent 2019; 44: 476–487. https://doi.
org/10.2341/18-049-C.
47. Oz FD, Ergin E, Canatan S. Twenty-
four-month clinical performance of
different universal adhesives in etch-
and-rinse, selective etching and self-
etch application modes in NCCL – a
randomized controlled clinical trial.
J Appl Oral Sci 2019; 27: e20180358.
https://doi.org/10.1590/1678-7757-
2018-0358.
48. Perdigão J, Ceballos L, Giráldez I et al.
Effect of a hydrophobic bonding resin
on the 36-month performance of a
universal adhesive – a randomized
clinical trial. Clin Oral Investig 2020;
24: 765–776. https://doi.org/10.1007/
s00784-019-02940-x.
49. van Dijken JW, Pallesen U. Three-year
randomized clinical study of a one-
step universal adhesive and a two-step
self-etch adhesive in class ii composite
restorations. J Adhes Dent 2017; 19:
287–294. https://doi.org/10.3290/j.jad.
a38867.
50. Szesz A, Parreiras S, Reis A, Loguercio
A. Selective enamel etching in cervical
lesions for self-etch adhesives: A
systematic review and meta-analysis.
J Dent 2016; 53: 1–11. https://doi.
org/10.1016/j.jdent.2016.05.009.
51. Burke FJT, Crisp RJ. A practice-based
assessment of the handling properties
of 3M ESPE Scotchbond universal
adhesive. The Dentist 2014; February:
50–54.
52. Burke FJT, Crisp RJ. Handling evaluation
of GC G-Premio Bond. The Dentist 2021;
January: 54–57.
53. Burke FJT, Crisp RJ, Sands P. A ‘handling’
evaluation of the Dentsply Sirona Class
II solutions system by the PREP Panel.
Dent Update 2018; 45: 1032–1040.
54. Burke FJT, Crisp RJ. Clinical evaluation
RestorativeDentistry
of SDI Zipbond by the PREP Panel. The
Dentist 2020; October: 52–55.
55. Demarco FF, Corrêa MB, Cenci MS et
al. Longevity of posterior composite
restorations: not only a matter of
materials. Dent Mater 2012; 28:
87–101. https://doi.org/10.1016/j.
dental.2011.09.003.
56. Brunton PA, Burke FJT, Sharif MO et al.
Contemporary dental practice in the
UK: demographic details and practising
arrangements in 2008. Br Dent J 2012;
212: 11–15. https://doi.org/10.1038/
sj.bdj.2011.1098.
57. Nagaoka N, Yoshihara K, Feitosa VP et
al. Chemical interaction mechanism
of 10-MDP with zirconia. Sci Rep 2017;
7: 45563. https://doi.org/10.1038/
srep45563. .
58. de Souza G, Hennig D, Aggarwal A, Tam
LE. The use of MDP-based materials
for bonding to zirconia. J Prosthet
Dent 2014; 112: 895–902. https://doi.
org/10.1016/j.prosdent.2014.01.016.
59. Passia N, Mitsias M, Lehmann F, Kern
M. Bond strength of a new generation
of universal bonding systems to
zirconia ceramic. J Mech Behav Biomed
Mater 2016; 62: 268–274. https://doi.
org/10.1016/j.jmbbm.2016.04.045.
60. Göstemeyer G, Schwendicke F.
Inhibition of hybrid layer degradation
by cavity pretreatment: meta- and
trial sequential analysis. J Dent 2016;
49: 14–21. https://doi.org/10.1016/j.
jdent.2016.04.007.
CPD ANSWERS
June 2021
1. A 6. C
2. A 7. D
3. D 8. D
4. A 9. B
5. C 10. B
DentalUpdate 631