Professional Documents
Culture Documents
Townsend 2004
Townsend 2004
N
CON
self-etching adhesive.
IO
Methods. The authors
contamination on
T
T
A
N
I
C
divided 120 extracted U
IN U
A G ED
3
molars into enamel and RT
I CLE
enamel and dentin dentin groups of 60 specimens
each, and then further divided each group
A how phosphoric acid improved adhesion of Results. Mean shear bond strength was
paint to metal surfaces in industry and 16.7 megapascals (± 3.0 standard deviation,
applied this concept to the dental profession. or SD) for the dentin control group, 14.8
That discovery and the development of MPa (± 2.3 SD) for dentin contaminated
bisphenol glycidyldemethacrylate resin by Bowen3 in the with saliva before adhesive application,
early 1960s led to the evolution of the first dentin adhe- 15.9 MPa (± 3.8 SD) for dentin contami-
sive systems. Failure rates for the early dentin adhesive nated with saliva after adhesive applica-
systems were high.4-6 It was not until the early 1990s tion, 19.1 MPa (± 4.8 SD) for the enamel
that significant advances in dentin bonding were made control group, 12.3 MPa (± 4.4 SD) for
with the development of multistep enamel contaminated with saliva before
dentin adhesive systems. These fourth- adhesive application, and 13.1 MPa (± 5.5
SD) for enamel contaminated with saliva
Self-etching generation adhesive systems typically
after adhesive application. One-way
adhesives are used conditioners, primers or both to
ANOVA detected no difference in the dentin
not as pretreat dentin to make the hydrophilic groups, but the authors found a significant
dentin substrate more receptive to
tolerant of difference among enamel groups. Uncon-
bonding. The final step in this compli-
contamination cated bonding scheme was the applica- taminated enamel had higher bond
of enamel tion of a low-viscosity adhesive resin strengths than either of the contaminated
enamel groups.
surfaces as that copolymerized with the primed
Conclusions. Saliva contamination did
they are of dentin surface, creating a hybrid layer
not affect the dentin shear bond strength of
contamination that was amenable to bonding with the
the self-etching adhesive. Saliva did have a
restorative composite material.7
of dentin detrimental effect on enamel bond strength.
To reduce the number of steps
surfaces. involved in fourth-generation bonding, Clinical Implications. Newer genera-
researchers and manufacturers devel- tions of adhesives appear to be more tol-
oped more simplified systems by combining the etchant erant of saliva contamination, but proper
and primer, or the primer and adhesive. These fifth- isolation still should be accomplished until
generation adhesive systems demonstrated similar bond further research proves otherwise.
strengths to dentin in vitro8,9 and in vivo,10,11 but their
claims of significantly reduced application times may
have been premature. Self-etching primer sys- and Garcia-Godoy,20 Vargas and colleagues21 and
tems generally were regarded as the “sixth” gen- Hitmi and colleagues22 were unable to demon-
eration, but these systems still required the sepa- strate statistically significant decreases in shear
rate application of an adhesive. bond strength to tooth surfaces contaminated
To simplify things further, researchers devel- with saliva when testing modern adhesive sys-
oped all-inclusive adhesive systems. These dentin- tems that incorporated a primer in the adhesive.
bonding agents incorporate etchant, primer and el-Kalla23 also reported that salivary contamina-
adhesive into one bottle. There is some disagree- tion did not affect the formation of the hybrid
ment on the classification of these adhesive sys- layer. These in vitro results suggest that modern
tems, and it should be noted that the nomencla- adhesive systems may be more forgiving of con-
ture is dictated by the manufacturer who releases tamination on dentin and enamel than were ear-
the products to the dental market and not by sci- lier separate-bottle systems.
entific categorization. A better classification The dental profession uses all of the adhesive
system would separate adhesives into total-etch system categories. Depending on the adhesive
and self-etch categories. Total-etch systems then system used, bonding resin-based composite to
would be subdivided into separate-bottle systems, tooth structure can involve multiple steps, and the
in which the primer and adhesive are separate, operative field could become contaminated during
and one-bottle systems that combine the primer any of these steps. Some studies have reported
and adhesive. These total-etch systems require that salivary contamination could adversely affect
that both the enamel and dentin be the bond strength to dentin, but
etched with acid before placement only when contamination occurred
of the adhesive. Self-etching adhe- Depending on the after adhesive application23 or light
20
sives would be subdivided into self- adhesive system used, curing. Because self-etching adhe-
etching primers that require a sepa- sives incorporate etchant, primer
bonding resin-based
rate application of adhesive and and adhesive into one application,
all-in-one self-etching adhesives composite to tooth the time points at which salivary
that combine etchant, primer and structure can involve contamination could occur are
adhesive. multiple steps, and reduced. There are few studies eval-
With the addition of a glu- the operative field uating whether saliva contamina-
taraldehyde disinfectant, a “sev- could become tion affects the enamel and dentin
enth” generation surfaced in 2003. bond strength of self-etching adhe-
contaminated during
However, Settembrini and col- sive systems.
leagues12 demonstrated that acid any of these steps. We conducted this study to inves-
etching alone appears to suffice as tigate whether saliva contamination
a disinfectant. at various time points has an effect
Before the introduction of hydrophilic primers, on the shear bond strength of an all-in-one self-
the bonding of resin-based composite to etched etching adhesive system used on enamel and
enamel involved the application of a hydrophobic dentin.
resin, which required meticulous attention to the
operative field. Proper isolation was necessary to MATERIALS AND METHODS
prevent unwanted contamination of the tooth sur- We collected 120 recently extracted human
face that could significantly decrease the bonding molars that were free from restorations or caries,
efficacy of resin to enamel.13,14 As early as 1963, and we stored them in a solution of 0.5 percent
Buonocore2 concluded that a dry tooth surface chloramine-T and refrigerated them until we used
was essential for achieving good adhesion because them in the study. No more than six months
etched tooth surfaces readily absorb salivary con- elapsed between the extraction of the molars and
stituents, thus reducing their surface energy and their use in the study.
rendering them less favorable to bonding. This We randomly divided the teeth into two groups
finding has been supported by other for enamel and dentin specimen preparation. For
researchers.14-18 the dentin group, we ground the occlusal surfaces
The concept of salivary contamination’s of the teeth serially with 180-, 320- and 600-grit
decreasing bond strength is not universally silicon carbide paper on a polishing lathe under
accepted, however. Fritz and colleagues,19 el-Kalla running water until all islands of enamel were
just removed. We then embedded the specimens Mass.) with a crosshead speed of 0.5 mm per
in dental mounting stone inside acrylic molds to minute until we noted failure. We calculated
expose a flat dentin surface for bonding. mean shear bond strength for all groups and sub-
For the enamel group, we ground the teeth jected the data to a one-way analysis of variance,
serially with 180-, 320- and 600-grit silicon car- or ANOVA, to determine if a difference existed
bide paper until a flat enamel surface of at least among the groups. We used Tukey’s Honestly Sig-
10 square millimeters was prepared. We nificant Difference post hoc test to identify the
embedded the specimens in dental mounting differences. We considered all statistical analyses
stone inside acrylic molds to expose a flat enamel to be significant at the P < .05 level.
surface for bonding. We kept all specimens moist
before bonding. RESULTS
We further separated the dentin and enamel Results of the one-way ANOVA comparing the
groups into three additional subgroups each. The shear bond strength of resin-based composite to
experimental groups were as follows: dentin and enamel are presented in Tables 1 and
ddentin group 1: no saliva contamination 2. We found no evidence to suggest a difference
(control); among any of the three dentin groups (P = .16).
ddentin group 2: saliva contamination before Among the enamel groups, we found that the non-
application of self-etching adhesive system; contaminated enamel control group demonstrated
ddentin group 3: saliva contamination after higher bond strengths than either of the groups
application of self-etching adhesive that were contaminated with
system, but before light curing; saliva. This difference was signifi-
denamel group 1: no saliva The noncontaminated cant (P < .05).
contamination (control); enamel control group
denamel group 2: saliva contami- DISCUSSION
demonstrated higher
nation before application of self- The advantage of self-etching adhe-
etching adhesive system; bond strengths than sive systems is that all three basic
denamel group 3: saliva contami- either of the groups steps (etching, priming and
nation after application of self- that were applying adhesive) occur simulta-
etching adhesive system, but before contaminated neously. The benefits of simplicity
light curing. with saliva. and time savings are intuitive, but
The principal investigator (R.T.) an added advantage is that there
collected his fresh whole saliva. are fewer time points during place-
After contaminating each tooth specimen, he ment when contamination can occur. Self-etching
gently air-thinned the saliva with an air-water adhesive systems simultaneously demineralize
syringe, leaving the specimens visibly moist with dentin while infiltrating it with monomers to the
saliva. He did not rinse or blot dry the specimens. same depth, and they then are polymerized in
We placed the self-etching adhesive system on situ.24 Simultaneous demineralization-infiltration
the tooth specimens according to the manufac- might improve the marginal seal and adhesion to
turer’s recommendations. To bond a cylinder of dentin; when etching and priming are accom-
resin-based composite to each specimen, we plished in separate steps, some regions of de-
secured a circular, split polyethylene mold (inner mineralized dentin may not be penetrated by the
diameter: 3.0 mm; height: 3.0 mm) to the flat resin primer. Self-etching primer systems do not
tooth surface. We filled the mold with a light- require the primer to be rinsed off after applica-
curable resin-based composite in two equal tion. What happens to the acid still is not under-
increments. We polymerized each increment stood completely, but it is thought to be neutral-
separately for 40 seconds with a curing light. To ized at some point by hydroxyl ions that are
ensure a minimum intensity of at least 500 milli- released from the hydroxyapatite during deminer-
watts per square centimeter, we used a hand-held alization.24 The high buffering ability of the
curing radiometer to test the light output after dentin should limit further demineralization of
each specimen was handled. After storing the hydroxyapatite.
tooth specimens in water at 37 C for 48 hours, we The components of the adhesive system we
subjected them to shear force in a universal used in our study are listed in Table 3. Bonding
testing machine (model 1541s, Instron, Canton, agent A contains phosphoric acid and methacry-
reduced greatly if the saliva was rinsed off or and uncontami- Force Upwood, Ramsey,
England.
Lackland Air Force
Base, Texas. Address
blotted dry. They also determined that any con- nated dentin reprint requests to
Dr. Dunn at 9406
tamination of the already cured adhesive layer specimens. However, enamel Tranquil Park Dr.,
seriously compromised the bond—regardless of specimens contaminated with San Antonio, Texas,
e-mail “William.dunn@
how the contaminant was removed or altered— saliva displayed a significant lackland.af.mil”.
and that the entire bonding procedure should be decrease in mean shear bond
repeated to ensure adequate adhesion. strength compared with uncon-
The long-term effects of saliva contamination taminated enamel specimens. Although the shear
are not known. It is conceivable that contamina- bond strength to dentin was not significantly
tion could result in nanoleakage in the hybrid affected, the long-term effects of saliva contami-
layer itself. Nanoleakage is thought to be the nation on the integrity of the hybrid layer are not
result of incomplete resin infiltration of deminer- known. Incomplete hybridization between the
alized dentin, which leaves exposed collagen fibers resin adhesive and dentin likely will lead to
and results in nanopores in the hybrid layer.28 future failure of the restoration. Therefore, rou-
These nanopores are large enough to allow fluid tine use of isolation techniques still is highly
entry into the hybrid layer, but small enough to encouraged. ■
prevent invasion by microorganisms. Nanoleakage The views expressed in this article are those of the authors and do
is a laboratory discovery, and its long-term effects not reflect the official policy of the Department of Defense or other
departments of the United States government.
on the longevity of the bond are unknown.29 There
is, however, concern that the exposed collagen 1. Buonocore MG. A simple method of increasing the adhesion of
acrylic filling materials to enamel surfaces. J Dent Res 1955;34:849-53.
fibrils will hydrolyze over time, leading to micro- 2. Buonocore MG. Principles of adhesive retention and adhesive
leakage and failure of the restoration in the long restorative materials. JADA 1963;67:383-91.
3. Bowen RL, inventor. Dental filling material comprising vinyl
term.Traditionally, tooth structure has been re- silane treated fused silica and a binder consisting of the reaction
etched to compensate for contamination of tooth product of bispenol and glycidyl acrylate. U.S. patent 3 066 112.
Nov. 27, 1962.
structure. Research by Perdigão and Lopes30 4. Buonocore M, Wileman W, Brudevold F. A report on a resin compo-
demonstrated that reapplication of acid etchant on sition capable of bonding to human dentin surfaces. J Dent Res 1956;
35:846-51.
tooth structure demineralizes deeper into dentin 5. Bowen RL. Adhesive bonding of various materials to hard tooth tis-
than a single application for the same amount of sues, II: bonding to dentin promoted by a surface-active comonomer. J
Dent Res 1965;44:895-905.
time. This suggests that re-etching dentin could 6. Asmussen E, Hansen EK. Dentine bonding agents. In: Vanherle G,
result in increased risks of nanoleakage in the Degrange M, Willems G, ed. State of the art on direct posterior filling
materials and dentine bonding: Proceedings of the International Sym-
hybrid layer or poor hybridization due to the col- posium Euro Disney. 2nd ed. Leuven, Belgium: Van der Poorten;
lapse of the collagen fibers. 1994:33.
7. Nakabayashi N, Pashley DH. Hybridization of dental hard tissues.
Although a simple-to-use, all-in-one adhesive Tokyo: Quintessence; 1998.
system is appealing, no long-term data exist on 8. Fortin D, Swift EJ Jr., Denehy GE, Reinhardt JW. Bond strength
and microleakage of current dentin adhesives. Dent Mater 1994;
the clinical performance of self-etching adhesive 10:253-8.
systems or the effects of salivary contamination. 9. Swift EJ Jr, Triolo PT Jr, Barkmeier WW, Bird JL, Bounds SJ.
Effect of low-viscosity resins on the performance of dental adhesives.
Therefore, we recommend caution in interpreting Am J Dent 1996;9:100-4.
these in vitro results, as they cannot necessarily 10. Van Meerbeek B, Peumans M, Verschueren M, et al. Clinical
status of ten dentin adhesive systems. J Dent Res 1994;73:1690-702.
be extrapolated to the clinical situation. Further 11. Van Meerbeek B, Peumans M, Gladys S, Braem M, Lambrechts
clinical studies are required, and use of proper P, Vanherle G. Three-year clinical effectiveness of four total-etch
dentinal adhesive systems in cervical lesions. Quintessence Int
isolation techniques still is highly encouraged. 1996;27:775-84.
12. Settembrini L, Boylan R, Strassler H, Scherer W. A comparison of
CONCLUSIONS antimicrobial activity of etchants used for a total-etch technique. Oper
Dent 1997;22:84-8.
In this in vitro investigation, we did not find any 13. Tagami J, Hosoda H, Fusayama T. Optimal technique of etching
enamel. Oper Dent 1988;13:181-4.
evidence to suggest a difference in mean shear 14. Barghi N, Knight GT, Berry TG. Comparing two methods of mois-
ture control in bonding to enamel: a clinical study. Oper Dent 1991; systems. J Adhes Dent 1999;1:219-32.
16:130-5. 23. el-Kalla IH. Saliva contamination and resin micromorphological
15. Silverstone LM. State of the art on sealant research and priorities adaptation to cavity walls using single-bottle adhesives. Am J Dent
for further research. J Dent Edu 1984;48:107-18. 1999;12:172-6.
16. Thomson JL, Main C, Gillespie FC, Stephen KW. The effect of 24. Watanabe I, Nakabayashi N, Pashley DH. Bonding to ground
salivary contamination on fissure sealant: enamel bond strength. J dentin by a phenyl-P self-etching primer. J Dent Res 1994;73:1212-20.
Oral Rehabil 1981;8:11-8. 25. Powers JM, Finger WJ, Xie J. Bonding of composite resin to con-
17. Hormati AA, Fuller JL, Denehy GE. Effects of contamination and taminated human enamel and dentin. J Prosthodont 1995;4:28-32.
mechanical disturbance on the quality of acid-etched enamel. JADA 26. Gordan VV, Vargas MA, Cobb DS, Denehy GE. Evaluation of
1980;100:34-8. adhesive systems using acidic primers. Am J Dent 1997;10:219-23.
18. Xie J, Powers JM, McGuckin RS. In vitro bond strength of two 27. Van Meerbeek B, Inoue S, Perdigao J, Lambrechts P, Vanherle G.
adhesives to enamel and dentin under normal and contaminated condi- Enamel and dentin adhesion. In: Summitt JB, Robbins JW, Schwartz
tions. Dent Mater 1993;9:295-9. RS, eds. Fundamentals of operative dentistry: A contemporary
19. Fritz UB, Finger WJ, Stean H. Salivary contamination during approach. 2nd ed. Carol Stream, Ill.: Quintessence; 2001:181.
bonding procedures with a one-bottle adhesive system. Quintessence 28. Sano H, Takatsu T, Ciucchi B, Horner JA, Pashley DH.
Int 1998;29:567-72. Nanoleakage: leakage within the hybrid layer. Oper Dent 1995;20:
20. el-Kalla IH, Garcia-Godoy F. Effect of saliva contamination on 18-25.
micromorphological adaptation of single-bottle adhesives to etched 29. Sano H, Uno S, Inoue S, eds. Modern trends in adhesive den-
enamel. J Clin Pediatr Dent 1999;24:69-74. tistry: Proceedings of the adhesive dentistry forum, Sapporo, Japan,
21. Vargas MA, Denehy GE, Silberman JJ. Bond strength to etched Feb. 21, 1998. Tokyo: Dental Materials Department, Medical Products
enamel and dentin contaminated with saliva. Am J Dent 1994;7:325-7. Division, Kuraray; 1998:6-10.
22. Hitmi L, Attal JP, Degrange M. Influence of the time-point of sali- 30. Perdigão J, Lopes M. The effect of etching time on dentin dem-
vary contamination on dentin shear bond strength of 3 dentin adhesive ineralization. Quintessence Int 2001;32:19-26.