Article 235540 1 10 20210818.pt - en

Translated from Portuguese to English - www.onlinedoctranslator.
com
Research, Society and Development, v. 10, no. 10, e543101019206, 2021

(CC BY 4.0) | ISSN 2525-3409 | IT HURTS:http://dx.doi.org/10.33448/rsd-v10i10.19206
Current adhesive systems and main challenges in adhesion: narrative review
Received: 08/08/2021 | Revised: 15/08/2021 | Accepted: 08/16/2021 | Published: 08/18/2021
Lorena dos Santos Rodrigues

ORCID: https://orcid.org/0000-0001-6121-916X
Doctum Teaching Network, Brazil
E-mail: lorenasrodrigues.lr@gmail.com
Paula Sampaio de Mello Assis
ORCID: https://orcid.org/0000-0002-7972-6896
E-mail: paulasampaiomello@gmail.com
Adolfo Coutinho Martins
E-mail: adolfocmartins123@gmail.com
Nathalia Silveira Finck
E-mail: nathaliafinck@gmail.com
Summary
Adhesion is the force that allows substances or substrates of different compositions to hold together as long as
they are in close contact. Dental substrates have very different characteristics and are complex to understand
when subjected to adhesive systems, which is the main challenge that dentists have faced in restorative
dentistry. Considering that there is a great deficiency in the professional's knowledge regarding the techniques,
indications and properties of dental adhesives, the objective of this narrative literature review was to clarify the
classification and current aspects of adhesive systems, in addition to pointing out the main challenges that the
clinician can face. encountered during the process of adhesion to dental tissues. Currently, adhesive systems are
classified as conventional, self-conditioning and universal. Factors such as selective enamel etching when using
self-etching systems and the use of adhesive systems that contain functional monomers that favor chemical
adhesion to the dentin substrate are interesting for increasing bond strength. The literature points out factors
that negatively impact bond strength, such as the use of hemostatic solutions, patients who received
radiotherapy, carious dentin and sclerosed dentin.
Key words:Dental adhesives; Longevity; Physical and chemical properties.
Abstract
Adhesion is the force that allows substances or substrates of different compositions to remain united as they are in
close contact. Dental substrates have very different characteristics and are complex to understand when submitted to
adhesive systems, which is the main challenge that dentists have faced in restorative dentistry. Considering that there
is a great deficiency in the professional's knowledge regarding the techniques, indications and properties of dental
adhesives, the objective of this narrative literature review was to clarify the classification and current aspects of
adhesive systems, in addition to pointing out the main challenges that the clinician can face come across during the
process of adhesion to dental tissues. Currently, adhesive systems are classified as conventional, self-etching and
universal. Factors such as selective enamel conditioning when using self-etching systems and the use of adhesive
systems that contain functional monomers that favor chemical adhesion to dentin substrate are interesting for
increasing bond strength. The literature points to factors that negatively impact bond strength, such as the use of
hemostatic solutions, patients who received radiotherapy, carious dentin and sclerotic dentin.
Keywords:Dentin bonding agents; Longevity; Physical and chemical properties.
abstract
Adhesion is strength that allows substances or substrates of different compositions to remain united in close
contact. The dental substrates have very different characteristics and are complex to understand when they are
limited to adhesive systems, which is the main challenge faced by dentists in restorative dentistry. Considering
that there is a great deficiency in professional knowledge regarding the techniques, indications and properties
of dental adhesives, the objective of this narrative review of the literature was to clarify the classification and
current aspects of the adhesive systems, in addition to highlighting them. main challenges
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who face the clinic during the process of adhesión to the dental tissues. Currently, the adhesive systems are
classified as conventional, self-adhesive and universal. Factors such as the selective conditioning of enamel when
self-etched systems are used and the use of adhesive systems that contain functional monomers that favor
chemical adhesion to the dentinal substrate are interesting to increase the strength of union. The literature
points to factors that negatively impact the strength of union, such as the use of hemostatic solutions, patients
who received radiotherapy, carious dentin and sclerotic dentin.
Keywords:Dental veneers; longevity; Physical and chemical properties.
1. Introduction
Adherence in Dentistry has been described since 1951, when a group of researchers, in an attempt to unite
acrylic resin to the dental substrate, used the monomer GMDP (glycerophosphate dimethacrylate). In 1955, Michael Buonocore
revolutionized Restorative Dentistry through the introduction of the acid etching technique, whose technique is characterized by
the use of phosphoric acid in the tooth structure, promoting the demineralization of hydroxyapatite crystals, in order to create
sites on the tooth surface for an adhesion. of resin monomers (Meerbeek, et al., 2020; Ahmed, et al., 2020; Perdigão, et al.,
2021).
The main challenge that Adhesive Dentistry has faced is to promote an efficient adhesion in dental substrates
with different nature. While enamel is composed of about 96% of mineral, dentin has 70% of mineral content and 20% of
organic material, in addition to the water present, due to this difference, adhesion to dentin must have greater care, as
the breakdown of existing collagen fibers can lead to adhesion failure. In this context, there are two types of adhesion,
micromechanical adhesion and chemical adhesion. Mechanical adhesion refers to the creation of micro retentions in the
mineral tissue, promoting microporosities, where thetagsof resin, which are adhered through mechanical interlocking,
these micro retentions can be achieved mechanically, by cavity preparation, and chemically, through acid etching.
Chemical adhesion is achieved from chemical bonds of specific functional monomers joining calcium ions from
hydroxyapatite to the synthetic material, and this type of adhesion is ideal for dentin (Matos, et al., 2017; Bedran-Russo,
et al., 2017; Nagarkar, et al., 2019; Meerbeek, et al., 2020; Perdigão, et al., 2021).
Achieving effective adhesion on enamel is simple, its composition is mostly mineral, due to this fact, acid
etching promotes the creation of microporosities on the enamel surface, thus increasing the surface energy,
whose micro retention is the ideal mechanism. for mechanical adhesion. However, acid etching on dentin not only
demineralizes, but also removes the smear layer and exposes the network of collagen fibers that make up the
dentin substrate. There is, then, the need to form the hybrid layer, described in 1982 by Nakabayashi, which refers
to the layer formed by demineralization and exposure of collagen fibers, followed by infiltration completely by the
binding and polymerization agent, in addition, the use of of functional monomers, such as 10-MDP (10-
methacryloyloxydecyl dihydrogen phosphate),
Several factors can compromise the success of Adhesive Dentistry, the physical-chemical properties of the material
to be used, the skill and knowledge of the operator and the patient's commitment to the treatment are the initial items to be
evaluated. Every year new adhesive systems are launched on the market and science, most of the time, takes time to prove their
efficiency in the long term, consequently professionals are at the mercy of the information provided by the material
manufacturer. In addition, in many cases, the lack of information on the part of clinical professionals in the search for
information in current scientific articles and the fact that most articles are published primarily in English contributes to the lack
of information (Matos, et al., 2017; Althaqafi, et al., 2017; Althaqafi, et al. al., 2020; Perdigão, 2020).
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Therefore, the objective of this review is, through a survey of the literature, to clarify classification and
of adhesive systems, in addition to pointing out the main challenges that the clinician may face during the process of adhesion
in dental tissues.
2. Methodology
A bibliographic survey was carried out in PubMed databases, looking specifically for systems
adhesives, properties, indications and challenges of adhesion using filters from the last 10 years and boolean
operators AND and OR, using the following descriptors in different combinations: Dentin adhesives, longevity,
Physical and chemical properties. A search was also carried out in the Scielo database using the same descriptors
and search terms as success in joining. Textbooks, journals and articles cited in selected relevant works were also
considered. Thirty-five articles in English and 01 textbook in Portuguese were identified and collected. For further
evaluation, the following inclusion criteria were defined: articles that described the adhesive technique of current
systems,
3. Theoretical Framework
3.1 Adhesive systems
Due to the increase in dental restorations with aesthetic and minimally invasive purposes, Adhesive Dentistry
had to develop quickly, and, from this rapid development, the various dental adhesives that are present in the dental
market emerged. The stickers were classified according to their generation, but because they cause confusion, they are
currently classified by the way they interact with the smear layer. Therefore, there are three types of adhesive systems,
they are the conventional system, which can be of three steps or two steps, the self-etching system, of two steps or one
step, and the universal system (Bedran-Russo, et al., 2017). ; Caldas, et al., 2019; Perdigão, et al., 2021).
The conventional system is the system that depends on the use of 37% phosphoric acid, separately, so that the
smear layer is removed, in addition, enamel and dentin demineralization occurs. In the subclassification of the
conventional adhesive system, there are two types, the conventional three-step and two-step adhesive. While the
conventional three-step system is composed of phosphoric acid, the primer and the adhesive in separate bottles, the
conventional two-step system is composed of phosphoric acid and the primer and adhesive in a single bottle (Bedran-
Russo, et al., 2017; Caldas, et al., 2019; Perdigão, et al., 2021).
The self-etching system is the adhesive system that does not use the acid-etching step, thus,
there will be acidic monomers in the primer solution of this system, making it an acidic solution. The acidic primer will not
remove the smear layer, instead the primer will integrate the residue from the smear layer into the hybrid layer, while
promoting surface demineralization of the dentin. The differential of this system is the possibility of controlling the
demineralization of the dentin substrate through the acidity of the primer. In the dental market there are self-etching adhesive
systems whose pH varies between values lower than 1 or equal/greater than 2.5. In this system there will be two types of self-
etching adhesives, the two-step and one-step, the two-step is the one that has the acidic primer and the adhesive in separate
bottles and the one-step one is composed of the acidic primer and the adhesive in a bottle. single. If this system is used
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in enamel, the literature recommends selective etching with phosphoric acid in order to promote better adhesion and
marginal sealing of restorations (Caldas, et al., 2019; Perdigão, et al., 2021).
Universal adhesives were the last adhesives to be launched on the dental market in 2011, they are single-bottle, whose composition is
made up of acidic primer, adhesive and functional monomers, which is the main difference between universal and self-etching adhesives. Added
to this, in relation to the other adhesive systems, they are distinguished by providing the possibility for the operator to choose which type of
strategy will be used, which can be by the conventional way with phosphoric acid or by the self-etching way. The literature indicates that selective
enamel etching increases bond strength when these adhesives are used. The functional monomers present in this adhesive system, such as 10-
MDP, allow chemical adhesion, as they interact with the hydroxyapatite of the dental substrate, triggering chemical bonds, promoting a stable
and lasting adhesion, especially in dentin. In addition, another feature is that universal adhesives can be used in indirect restorations, such as
glass matrix ceramics, zirconia and metals. However, the literature points out that the silane present in universal adhesives was not enough to
cement these parts (Rosa, et al., 2015; Kalavacharla, et al., 2015; Carrilho, et al., 2019; Nagarkar, et al., 2019; Perdigão, 2020; Perdigão, et al.,
2021). et al., 2015; Kalavacharla, et al., 2015; Carrilho, et al., 2019; Nagarkar, et al., 2019; Perdigão, 2020; Perdigão, et al., 2021). et al., 2015;
Kalavacharla, et al., 2015; Carrilho, et al., 2019; Nagarkar, et al., 2019; Perdigão, 2020; Perdigão, et al., 2021).
3.2 Adhesion to enamel
Since the introduction of the etching technique, enamel has been considered the gold standard substrate for
dental bonding. Its inorganic phase represents about 94 to 96% of hydroxyapatite crystals, 4 to 5% of organic
composition and 1 to 4% of water. In addition, its mineral crystals are arranged in a regular and parallel manner, thus,
adhesion to enamel occurs simply and mechanically, through demineralization, caused by the use of 37% phosphoric
acid, increases energy and surface area. , as micro retentions will be created, allowing greater wettability by the adhesive
systems that will later form resin tags, which are adhered by mechanical interlocking (Sofan, et al., 2017; Bedran-Russo,
et al., 2017; Yao, et al., 2019; Perdigão, 2020; Perdigão, et al., 2021).
There are conditions that can negatively affect enamel adhesion, including molar-incisor
hypomineralization, hypoplasia due to imperfect amelogenesis and aprismatic enamel. The literature reports that
there is a decrease in adhesion strength promoted by conventional and self-etching adhesives compared to
normal enamel. The affected enamel presents a reduction in the quantity and quality of the mineral content,
consequently, it presents a reduction in the hardness of the dental substrate, an increase in porosity and
disorganization in the enamel hydroxyapatite prisms. These micromorphological changes will prevent an efficient
adhesion between the substrate and the restorative material from taking place, otherwise, the demineralization in
the affected enamel resulting from the acid etching is not uniform, thus resulting in
Adhesion in primary teeth must be taken into account differently. Primary teeth have a higher amount of
organic matter and a layer of aprismatic enamel when compared to the enamel of the permanent dentition. Due to this
difference, studies show that the adhesion of the teeth of the first dentition is lower than that of the permanent
dentition, resulting in secondary carious lesions and fractured restorations. A good adhesion will depend on a good
pattern of demineralization of the mineral content of the dental substrate, which will allow, then, to reach a good
retentive capacity, as the deciduous dentition presents a difference in the mineral amount, in the structure and in the
morphology, techniques have been proposed in the literature. in order to modify the organic content of deciduous
enamel, One of these techniques is enamel deproteinization, which consists of the use of 5% sodium hypochlorite before
the use of 37% phosphoric acid, thus increasing the surface area for acid etching and, subsequently, adhesion. . THE
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The literature reports that this technique has been successful, there has been an increase in the adhesion strength of restorative
materials to the primary tooth (Christopher, et al., 2018; López-Luján, et al., 2019).
3.3 Adhesion to dentin
Dentin is considered a complex substrate for dental adhesion due to differences in its composition when
compared to dental enamel. Therefore, there is a greater need for the care and attention of the clinician during
the clinical routine. The dentin substrate is moist and more organic, its mineral content varies from 50 to 70%,
while its organic phase varies from 20 to 30% (90% type I collagen and 10% non-collagenous proteins), 10 to 20%
would be composed of Water. Furthermore, as the depth in the dentin increases, there will be an increase in the
number of dentinal tubules present in the dentin that surrounds the dental pulp. The dentinal tubules are
extremely permeable, the moisture present in the internal structure of the dentin is due to the existing fluid, in
addition to containing odontoblastic extensions and intratubular collagen fibers.
In view of the composition of the dentin, the adhesion procedure to it must occur with a moist substrate, in order to
prevent the exposed collagen fibers from drying out and collapsing, which prevents an adequate wetting of the surface. With
the wet substrate, it is possible that the collagen fibers are totally infiltrated by the resinous monomers, and, later,
polymerization occurs, forming, then, the hybrid layer, described by Nakabayashi in 1982. However, the adhesion to the dentin
can fail, there are several factors that may be related, among them is the enzymatic degradation of the collagen mesh of dentin
through metalloproteinases. Metalloproteinases are endogenous enzymes activated by contact with acids or by proteinases.
From the moment they are activated, the enzymatic degradation of the matrix occurs and, consequently, the dentin-resin bonds
of the hybrid layer formed are broken. This phenomenon occurs when the infiltration of monomers from the adhesive system
was insufficient, not covering the exposed collagen fibers and interfering with the longevity of adhesive restorations (Bedran-
Russo, et al., 2017; Matos, et al., 2017; De Lima, et al., 2017; De Lima, et al. al., 2018; Meerbeek, et al., 2020; Perdigão, et al.,
2021).
In addition, conditions such as sclerosed dentin or dentin affected by the carious lesion make the adhesion
process even more complicated. A sclerosed dentin has obliterated dentin tubules, due to the presence of the
hypermineralized layer composed of mineral crystals that cause obliteration, dentin becomes less susceptible to
acid demineralization compared to normal dentin, in view of this, adhesion in sclerosed dentin forms tags of
unfavorable resins and the hybrid layer is formed only on the intertubular dentin, interfering with the durability of
the restorations. Techniques used to improve adhesion in sclerotic dentin consist of using stronger acids, doubling
the etching time on dentin, or removing the hypermineralized layer during cavity preparation. Meraji, et al., 2018;
Hass, et al., 2019; Kwansirikul, et al., 2020). Meraji, et al., 2018; Hass, et al., 2019; Kwansirikul, et al., 2020).
3.4 Challenges in joining
Adhesion is a force that holds two substances or substrates with different compositions together as long as their
molecules are in close contact. The challenge in Adhesive Dentistry is to unite synthetic materials in biological substrates.
For a correct adhesion, there is a need for a correct wetting of the surface by the adhesive systems, so that this
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occurs satisfactorily, it is necessary to increase the surface free energy reaching perfect wetting by the materials. That is,
considering the need for close contact between the molecules and perfect wetting on the surface, it is noteworthy that
the presence of contaminants has a negative impact on the success of the adhesive process (Reis & Loguercio, 2021).
During the adhesion process, especially in class II and class V restorations, which are cavities located close to the gingival tissue, it is difficult to control contaminants in these cavities, such as blood and gingival fluid, due to the difficult accommodation of
the rubber sheet. in these regions. As a result, hemostatic agents are widely used in order to keep the operative field as free of contaminants as possible, in addition, these agents will act as astringents and vasoconstrictors, acting on blood clotting and vasoconstriction. In
most hemostatic agents, aluminum chloride and ferric sulfate are the main components of the solutions, however, the literature reports that these substances can act as contaminants and, thus, obstruct the dentinal tubules, which, consequently, it affects the formation of
the hybrid layer. Although scientific findings report the negative impact, the use of hemostatic agents is still necessary in the presence of blood, the adhesion performed when only the hemostatic agent contaminates the site, is still greater than when the contamination is
through blood, the systems of self-etching adhesives have a greater impact compared to the conventional adhesive system. Several methods are described to promote the cleaning of the hemostatic agent from the cavity, as well as the use of EDTA (ethylenediamine
tetraacetic acid), particles that promote abrasion such as aluminum oxide, application of 37% phosphoric acid and jet and air spray. , however, studies in the area are still needed to validate such techniques (De Oliveira, et al., 2014; Groddeck, et al., 2017). affects the
formation of the hybrid layer. Although scientific findings report the negative impact, the use of hemostatic agents is still necessary in the presence of blood, the adhesion performed when only the hemostatic agent contaminates the site, is still greater than when the
contamination is through blood, the systems of self-etching adhesives have a greater impact compared to the conventional adhesive system. Several methods are described to promote the cleaning of the hemostatic agent from the cavity, as well as the use of EDTA
(ethylenediamine tetraacetic acid), particles that promote abrasion such as aluminum oxide, application of 37% phosphoric acid and jet and air spray. , however, studies in the area are still needed to validate such techniques (De Oliveira, et al., 2014; Groddeck, et al., 2017).
affects the formation of the hybrid layer. Although scientific findings report the negative impact, the use of hemostatic agents is still necessary in the presence of blood, the adhesion performed when only the hemostatic agent contaminates the site, is still greater than
when the contamination is through blood, the systems of self-etching adhesives have a greater impact compared to the conventional adhesive system. Several methods are described to promote the cleaning of the hemostatic agent from the cavity, as well as the use of
EDTA (ethylenediamine tetraacetic acid), particles that promote abrasion such as aluminum oxide, application of 37% phosphoric acid and jet and air spray. , however, studies in the area are still needed to validate such techniques (De Oliveira, et al., 2014; Groddeck, et al.,
2017). Although scientific findings report the negative impact, the use of hemostatic agents is still necessary in the presence of blood, the adhesion performed when only the hemostatic agent contaminates the site, is still greater than when the contamination is through
blood, the systems of self-etching adhesives have a greater impact compared to the conventional adhesive system. Several methods are described to promote the cleaning of the hemostatic agent from the cavity, as well as the use of EDTA (ethylenediamine tetraacetic
acid), particles that promote abrasion such as aluminum oxide, application of 37% phosphoric acid and jet and air spray. , however, studies in the area are still needed to validate such techniques (De Oliveira, et al., 2014; Groddeck, et al., 2017). Although scientific findings report the negative impa
As already described, adhesion may occur mechanically (embrication) and chemically (presence of
functional monomers). Therefore, giving preference to adhesive systems that present such monomers can be an
interesting alternative for successful adhesion. In dentin, another factor that makes the bonding process difficult is
the depth of the cavity that will be restored. This is because the deeper the cavity, the greater the number of
dentinal tubules per square millimeter, reducing the area of intertubular dentin and collagen fibers. Therefore, in
deep cavities, lining with materials suitable for the function is indicated. Another option is to indicate self-etching
adhesive systems, which have a greater control of tissue demineralization. The presence of the Smear Layer is not
a problem,
When the adhesive process is performed using a conventional three- or two-step technique, there is a
need for prior acid etching on enamel (30 seconds) and dentin (15 seconds). The choice of acid is also important,
since it must have homogeneity and low flow. This material should be washed twice as long (60 seconds) using air
and water spray. Ideally, this process should be carried out in association with absolute isolation, since
contamination by saliva forms a film of water and salivary glycoproteins on the conditioned surface, preventing
adhesion. An overconditioning with phosphoric acid in the dentin would be a problem, since the demineralization
by the acid would be greater than the infiltration by the monomers, leaving the deeper portion of the collagen
exposed.
Primer application on dentin is critical, as it stabilizes the collagen network and removes excess water,
which also increases surface free energy, preparing it for adhesive application. For this, it is important for the
clinician to apply the primer actively, rubbing it with a micro brush for 30 seconds and then wait for the solvent to
evaporate. There is no need to apply the primer on enamel, as this tissue already has high surface free energy and
no collagen. Among the solvents that may be present in the primer are: acetone,
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alcohol and water. Acetone is quite volatile and shortens working time. Ethanol provides hydrogen bonds with water
favoring evaporation and ideally should have a concentration of 25% or less when there is a correct proportion of
monomers. Water as a solvent has the ability to re-expand collagen fibers by breaking the hydrogen bonds between
them (Van Landuyt, et al., 2007).
An important factor that the clinician needs attention is related to the storage and handling of the material. You
simplified adhesives may have the primer evaporated, so it is important that the packaging is closed immediately after
use. In addition, the increase in temperature will also influence facilitating the evaporation of the solvent while still in the
flask. Therefore, vials must be stored in a refrigerated environment. By this logic, it is recommended that in simplified
systems the adhesive is only dispensed at the time of application, so that the solvent evaporation process does not start.
The appearance of the adhesives must be evaluated, since when the solvents evaporate from the flasks of simplified
systems, only the adhesive remains, which looks like "honey", in this situation, the material will not present satisfactory
adhesion, mainly in dentin, where the primer is essential for successful adhesion (Sofan et al., 2017; Carrilho, et al., 2019;
Perdigão, 2020; Reis & Loguercio, 2021).
Adhesives are fluid resins responsible for adhesion, are hydrophobic and can be filled. In dentin, the
Adhesives penetrate the surface prepared by the primer and form the hybrid layer, resulting in a nanointeraction
between the tissues. After application, there is a need for 20 to 30 seconds for it to go through the entire collagen web
and removal of the excess, which can be done with a dry micro brush, aiming at a more uniform layer before light-curing
the material. It is important to point out that the light curing is performed using properly calibrated devices capable of
presenting the irradiance required by the manufacturer. The light curing time must also be respected considering the
manufacturer's instructions (De Lima, et al., 2018; Cadenaro, et al., 2019; Perdigão, 2020).
Saliva contamination after the adhesive polymerization causes the adsorption of glycoproteins on the poorly
polymerized and air-inhibited adhesive surface, impairing the process. When comparing self-etching and conventional
adhesives, self-etching adhesives are less sensitive to contamination by saliva, because their hydrophilic characteristics
and acidity mean that, in addition to penetrating the smear layer, they also cross the mucopolysaccharides of saliva
(Kermanshah , et al., 2010; Gupta, et al., 2015).
An internal degradation factor is the aqueous ramifications that weaken the hybrid layer, the presence of
hydrophilic monomers attract fluids and the water breaks the bond between the monomers resulting in the loss of resin
mass. In simplified adhesive systems (primer and adhesive in a single bottle), there is a higher concentration of solvent,
therefore, the application of more than one layer is indicated, since these adhesives allow the passage of dentinal fluid
more easily and also, due to their thin layer, there is inhibition of polymerization by oxygen. Considering these factors,
the application of a low viscosity resin (immediate dentin sealing technique) is indicated (Hashimoto, et al., 2009).
Patients who have undergone radiotherapy treatment may have poor adhesion to dental tissues.
Radiation therapy is used as a first option or in combination to treat malignant head and neck tumors. Adverse
effects can occur as a result of radiotherapy, especially in the oral region, due to the production of toxicities in
healthy tissues that are around the tumor, which can cause hyposalivation, osteoradionecrosis, xerostomia and
carious lesions, which are commonly seen after radiotherapy. In this context, adhesive restorations may be
susceptible to the direct or indirect effects of radiotherapy. Regarding restorations that were performed prior to
radiotherapy, the negative impact is observed when high doses of ionizing radiation are applied, the
microstructure and mechanical properties of the restoration can be affected, and the hybrid layer resin-dentin
bonds can be broken. In enamel, morphological changes of hydroxyapatite crystals can occur, making the
7
surface of the more porous substrate after radiotherapy. Dentin can undergo changes in its organic composition
through free radicals formed in the presence of water, acting as oxidants, causing denaturation of molecular structures,
consequently interfering with bond strength (Troconis, et al., 2017; Rodrigues, et al., 2018; Arid, et al., 2020; Cunha, et al.,
2020; Muñoz, et al., 2020).
4. Discussion
According to Nagarkar et al. (2019), success in Adhesive Dentistry is related to a stable and lasting adhesion
between the different substrates. Several dental adhesive systems are developed in order to achieve this goal and can be
classified as conventional, self-etching and universal. Self-etching adhesives are interesting for dentin due to greater
control over demineralization and infiltration by monomers and can be classified according to pH (Strong, Medium, Weak
and Very Weak). This classification is important since acidity results in profound demineralization of enamel and dentin.
Therefore, the literature highlights that the ideal pH for these adhesives would be weak and very weak, as they
demineralize the dentin in a micrometer, keeping the hydroxyapatite bound to the collagen allowing sufficient mating
for hybridization. However, there is a consensus in the literature that the different compositions of dental tissue make it
difficult to use only one adhesive for all cases (Sofan, et al., 2017; Nagarkar, et al., 2019).
The authors Bedran-Russo et al. (2017) and Perdigão et al. (2021) corroborate that enamel adhesion has a greater
stability due to the nature of the substrate, predominantly mineral, making it more reliable and simple when compared
to dentin. Etching enamel with phosphoric acid and using adhesives consisting only of monomers is considered the gold
standard. However, the maintenance of acid etching in enamel must be carried out even if the adhesive used is self-
etching (selective enamel etching). According to Strauch et al. (2018) and Sundfeld et al. (2020), pathological conditions
such as molar-incisor hypomineralization, amelogenesis imperfecta and aprismatic enamel negatively affect enamel
adhesion, interfering with the longevity of adhesive restorations. Sundfeld et al. (2020) reports that the complete removal
of hypomineralized enamel is necessary, in order not to compromise the quality of adhesion between the adhesive
system and the enamel. Strauch et al. (2018) state that indirect restorations have greater predictability and longevity in
affected enamels when compared to direct restorations.
In primary teeth, Christopher et al. (2018) and López-Luján et al. (2019) attest that adhesion is less efficient
when compared to permanent teeth. In order to improve adhesion in teeth of the first dentition, Christopher et al.
(2018), López-Luján et al. (2019) agree that the use of 5% sodium hypochlorite prior to acid etching is an efficient
and non-invasive method for deproteinization of teeth, allowing improvement in the pattern and area to be
conditioned of the tooth (Bedran-Russo, et al. ., 2017; Christopher, et al., 2018; Strauch, et al., 2018; López-Luján, et
al., 2019; Sundfeld, et al., 2020; Perdigão, et al., 2021).
Bonding in dentin, according to Nagarkar et al. (2019) and Perdigão. (2020), is less predictable and more challenging,
its composition is dynamic and complex because in addition to having a higher organic content, there is a significant
amount of water in the dentinal tubules. According to Bedran-Russo et al. (2017) and Perdigão. (2020), chemical adhesion
is facilitated due to the orientation of the hydroxyapatite crystals and their reduced size, thus promoting additional
retention. In this context, there is a consensus in the literature about the 10-MDP monomer, its molecular structure
allows the monomer to interact with the hydroxyapatite of the dentin substrate, forming MDP-calcium salts, these
chemical bonds will then allow to achieve a stable adhesion in the dentin. Sofan et al. (2017), report that the solvents
present in the adhesives contribute to promoting a moist dentin surface, preparing the collagen web for, subsequently,
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In agreement with Sofan et al. (2017), Perdigão et al. (2021) add that after application of the adhesive, the evaporation
of solvents helps to prevent the hydrolytic degradation of the hybrid layer, preserving the physical properties of the resin
monomers after polymerization. The active application of the adhesive on the dentin surface, according to Nagarkar et al. (2019)
and Carrilho et al. (2019), it helps not only the evaporation of solvents but also the infiltration of monomers and, thus, an
increase in the effectiveness and quality of the hybrid layer in dentin and, in addition, Perdigão. (2020) reports that the agitation
of the adhesive bottle, especially the simplified ones, promotes an improvement in the infiltration of monomers on the
conditioned dentin.
Adhesion in dentin can still undergo enzymatic degradation by metalloproteinases, according to Bedran-Russo et al.
(2017), this phenomenon occurs due to incomplete infiltration of the adhesive monomers and, as a result,
metalloproteinase inhibitors have been explored in scientific research. According to Matos et al. (2017), 2% chlorhexidine
solution is an efficient enzyme inhibitor, being used after acid etching. Perdigão et al. (2021) state that the use of
chlorhexidine promotes the durability of restorations, however there are few studies that recommend the use of
chlorhexidine, and further studies in this area are needed.
According to Bedran-Russo et al. (2017), dentin affected by carious lesion and/or with features of sclerosis are
substrates that clinicians commonly treat daily. For carious dentin, Bedran-Russo et al. (2017) and Meraji et al. (2018)
state that despite its composition being altered, the marginal seal must be in a healthy dental substrate for better
adhesion. Isolan et al. (2018) claim that the literaturein vitroindicates that conventional adhesive systems promote
greater bond strength when compared to self-etching, however, studiesin vivo are necessary. Bedran-Russo et al. (2017)
and Kwansirikul et al. (2020) corroborate that, for sclerosed dentin, mechanical preparation with multilaminated drills,
removing the hypermineralized layer, and the use of 37% phosphoric acid for up to 30 seconds increases adhesion in
sclerosed dentin (Bedran-Russo, et al., 2017). ; Matos, et al., 2017; Sofan et al., 2017; Meraji, et al., 2018; Isolan, et al.,
2018; Carrilho, et al., 2019; Nagarkar, et al., 2019; Kwansirikul, 2019; et al., 2020; Perdigão. 2020; Perdigão, et al., 2021).
In addition to factors associated with dental substrates, contamination through saliva, hemostatic solutions,
lubricants, and blood, inadequate light curing and radiotherapy can be challenges for dental adhesion. Moisture control is a daily challenge in adhesive
procedures and, therefore, among the current adhesive systems, self-etching systems were pointed out by the authors as being less affected by
contamination by saliva, because it allows the diffusion of the adhesive to be carried out without much damage, even through contamination by saliva. The
use of hemostatic solutions helps to control blood contamination during restorative dentistry procedures, however, according to De Oliveira et al. (2014)
and Groddeck et al. (2017), the solution particles promote the obliteration of dentinal tubules and, consequently, affect the formation of the hybrid layer.
Given this, De Oliveira et al. (2014) report that self-etching adhesives are the most affected system due to the integration of the smear layer into the hybrid
layer and also because there is no acid attack prior to the application of the adhesive, which would remove this debris. Methods for cleaning hemostatic
solutions from the adhesive surface, such as the use of EDTA, aluminum oxide, application of 37% phosphoric acid, and jet and air spray are techniques
described by De Oliveira et al. (2014) that still need to be investigated. application of 37% phosphoric acid and jet and air spray are techniques described by
De Oliveira et al. (2014) that still need to be investigated. application of 37% phosphoric acid and jet and air spray are techniques described by De Oliveira et
al. (2014) that still need to be investigated.
According to Cadenaro, et al., 2019, the stability of the adhesive interface is strongly related to the degree of
conversion of the monomers of the adhesive system. The light curing protocol must be carefully carried out, conditions
such as the irradiance that the light curing device emits, the distance between the light curing tip and the tooth and the
use of radiometers to measure the irradiance of the devices must be taken into account in order to promote the
adequate polymerization of resin monomers present in adhesive systems.
9
It is a consensus in the literature that radiotherapy affects dental substrates through ionizing radiation. As a
result, dental restorations, according to Troconis et al. (2017), may be affected by the effects of radiotherapy. While in
enamel surface changes can be seen, in dentin structures can be denatured, thus ionizing therapy can affect the bond
strength of both enamel and dentin (Kermanshah, et al., 2010; De Oliveira, et al., 2010; De Oliveira, et al. al., 2014; Gupta,
et al., 2015; Groddeck, et al., 2017; Cadenaro, et al., 2019).
Currently, we already find bioactive adhesive systems on the market and, for the near future, the literature indicates
that the evolution of these materials will lead to therapeutic actions and tissue remineralization stimuli (Bedran-Russo, et al.,
2017; Meerbeek, et al., 2020).
5. Final Considerations
Current adhesive systems can be classified as conventional, self-etching and universal systems. The works
demonstrate that the selective enamel etching together with the self-etching technique and adhesive with weak
pH (approximately 2.5) work safer.
The challenges inherent to adherence deserve the attention of professionals, among them, it can be highlighted as points that
impact the success of the adhesive technique:
● In order to obtain satisfactory adhesion, regardless of the system used, it is necessary for the clinician to know the material and
its indications and limitations and to respect each recommended step to obtain a satisfactory bond strength.
● In dentin, it is interesting to use self-etching adhesives that contain functional monomers, such as MDP, in
order to promote chemical adhesion. In addition, sclerosed dentin, carious dentin remains or patients who
have undergone radiotherapy, lead to reduced bond strength results.
● When using universal adhesive systems, selective enamel conditioning is recommended.
● The presence of hemostatic, saliva, phosphoric acid thickener or fluids in general on the tooth surface can interfere,
presenting itself as a contaminant and preventing the intimate contact of the molecules of the different substrates.
● Literature points to the evolution of adhesive systems as bioactive materials that have therapeutic actions and
that stimulate tissue remineralization.
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Research, Society and Development, v. 10, no. 10, e543101019206, 2021

Current adhesive systems and main challenges in adhesion: narrative review

Current adhesive systems and main challenges in adhesion: narrative review

Current adhesive systems and main challenges in adhesion: narrative review

Received: 08/08/2021 | Revised: 15/08/2021 | Accepted: 08/16/2021 | Published: 08/18/2021

Lorena dos Santos Rodrigues

3.1 Adhesive systems

3.2 Adhesion to enamel

3.3 Adhesion to dentin

3.4 Challenges in joining

al. (2014) that still need to be investigated.

2017; Meerbeek, et al., 2020).

impact the success of the adhesive technique:

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