L E T T E R S
with this hazard. The operative
words I used earlier—more of-
fices than I would have be-
lieved—for me meant just one.
Of the approximately 100 or so
offices I’ve dealt with on this
issue, maybe 6 to 8 percent
were over the permissible lim-
its. That’s approximately six to
eight offices. That’s a good
number of our personnel ex-
posed to this hazard, and most
of them are in their childbear-
ing years.
In some cases, we tested
twice to be sure before attempt-
ing to address the problem and
found the first test had been ac-
curate. The requirement then is
to investigate and correct the al-
leged problems, and test again.
Valves leak, solder joints in tub-
ing in the walls give occasional-
ly, lines are inadvertently juxta-
posed during installation (it has
happened), and, in one case, a
nail was driven into a nitrous
line in the wall.
So, are you feeling “unusual-
ly” happy at work lately? Sorry,
but these doses, mildly or exces-
sively over the permissible
limit, do not provide you with
clinical perception of the prob-
lem, and can have long-term
consequences.
Harold Edelman, D.D.S.
Principal
Professional Compliance
Group
Miller Place, N.Y.
Response from the ADA
Division of Science: The ADA
Council on Scientific Affairs has
published recommendations for
controlling nitrous oxide expo-
sure. The protocol includes
proper installation of nitrous
oxide delivery and scavenging
systems; daily testing for leaks;
daily inspection of all nitrous
oxide for worn parts, cracks,
40 8 JADA, Vol. 135, April 2004
Copyright ©2004 American Dental Association. All rights reserved.
holes or tears; and periodic per-
sonal sampling using dosime-
ters or infrared spectrophotome-
ter.1 Copies are available to
ADA members by contacting the
Division of Science using the
Association’s toll-free phone
line, Ext. 2878, or by e-mailing
the division at “science@
ada.org”.
P. L. Fan, Ph.D.
Senior Director, Research
Division of Science
American Dental
Association
1. ADA Council on Scientific Affairs, ADA
Council on Dental Practice. Nitrous oxide in
the dental office. JADA 1997;128(3):364-5.
TOTAL-ETCH VERSUS
SELF-ETCH
The December JADA study,
“Total-Etch Versus Self-Etch
Adhesive: Effect On
Postoperative Sensitivity,” by
Dr. Jorge Perdigão and col-
leagues, contains contradictory
information that may render
the study worthless.
For a peer-reviewed journal
as prestigious as JADA, it is
surprising that this article sur-
vived even a cursory reading by
reviewers without finding the
problems. It’s possible that the
problem is in the writing, rather
than the actual study, but it
should be clarified.
Compare the following state-
ments for contrast:
1. In the Abstract under
Methods on page 1621: “Prime
& Bond NT, … which uses 34
percent phosphoric acid to etch
enamel and dentin
simultaneously.”
2. Body of article, page 1623:
“Application of primer and ad-
hesive. The operators treated
the enamel and dentin walls of
the preparation by applying an
SE dentin/enamel primer … for
20 seconds or by etching with 34
percent phosphoric acid … for
15 seconds.”
The first statement does not
indicate that the operators actu-
ally used etching on dentin and
enamel, called total etch, but
states the manufacturer’s in-
struction for its use by the word
“uses.” The second statement
implies, but does not state
clearly, that etchant was used
on enamel and dentin.
Two other statements and a
photo suggest that dentin may
not have been etched by the
operators.
1. The “Instructions for Use”
column in Table 1 on page 1625
states, “Etch enamel with Caulk
34% Tooth Conditioner Gel for
15 seconds.”
2. The Figure F photo on
page 1624 shows only enamel
etched, not dentin. And the
Figure F legend states, “etching
with 34 percent phosphoric acid
… for 15 seconds, followed by
rinsing and application of TE
adhesive . . . on moist dentin.”
Nowhere in the study is there
a clear statement that total
etching was used on the dentin
before Prime & Bond NT. If this
is the case, the comparison be-
tween “total-etch” adhesives
and self-etching adhesives is
rendered useless.
Compare this study of 30
restorations with Clinical
Research Associates’ survey1
that arrived the same day as
the December JADA. The sur-
vey was of 4,446 respondent
dentists and the results indicat-
ed that “no post-op sensitivity is
2 times higher for SEP adhe-
sives (24%) compared to total-
etch adhesives (12%).” This is a
huge contradiction in results
from the study in JADA.
Reliance on one study or
survey to determine which cat-
egory of materials is best is

foolish, of course. However,
considering the flaws in the
JADA article, be they procedu-
ral or written, if I was betting,
I’d put my money on 4,446 col-
leagues and the personal peace
I have from so few complaints
of sensitivity from composite
restorations bonded with a
self-etching primer.
Richard W. Featherstone,
D.D.S.
Henderson, Nev.
1. CRA Newsletter. Self-etch primer (SEP)
adhesives update. November/December
2003;27(1112):1.
Authors’ response: First,
we would like to thank Dr.
Featherstone for his candid
comments. It has been common
knowledge since the early 1990s
among updated dental re-
searchers and clinicians that
the terms “total-etch” or “all-
etch” mean simultaneous etch-
ing1,2 of enamel and dentin with
phosphoric acid (in the past,
other acids have been used as
well). It is also common knowl-
edge that ”self-etching” means
the application of an acidic
primer to enamel and dentin
without rinsing. To explain the
meanings of these terms, and
how the etching gel is applied,
in an article published in 2003
would be redundant, to say the
least.
Regarding Dr. Featherstone’s
Copyright ©2004 American Dental Association. All rights reserved.
comment, “The Figure F photo
on page 1624 shows only enam-
el etched, not dentin.” Unfortu-
nately, a photograph is not a dy-
namic image—we cannot
publish video files to show how
the acid is applied first to enam-
el, and then to dentin.
Dr. Featherstone states, “the
second statement implies, but
does not state clearly, that
etchant was used on enamel
and dentin.” Again, it is com-
mon knowledge that “total-etch”
means application of the
etchant to enamel and dentin.
Regarding Dr. Featherstone’s
comment, “Nowhere in the
study is there a clear statement
that total etching was used on
the dentin before Prime & Bond
NT. If this is the case, the com-
parison between ‘total-etch’ ad-
hesives and self-etching adhe-
sives is rendered useless”: a
total-etch adhesive, as its name
indicates, uses a total-etch
technique.
We are avid readers of the
CRA Newsletter, and praise the
work of Dr. Gordon Christensen
and co-workers. However, one
cannot compare a survey with a
controlled clinical study. While
there is merit for both, it is like
comparing apples and oranges.
In that survey,3 dentists re-
ported patients who complained
of sensitivity versus patients
L E T T E R S
who did not complain of sensi-
tivity (it might have included
patients who did not come back
to the same practice for further
treatment). Our clinical study
evaluated sensitivity with con-
tinuous measurements on a
scale from 0 to 10. Not better,
not worse, simply different.
Jorge Perdigão, D.M.D.,
M.S., Ph.D.
Associate Professor
Division of Operative
Dentistry,
Department of
Restorative Sciences,
University of Minnesota
Minneapolis
Saulo Geraldeli,
D.D.S., M.S., Ph.D.
Research Professor
University of Santo Amaro,
São Paulo, Brazil
James Hodges, Ph.D.
Senior Research Associate
Division of Biostatistics,
University of Minnesota
Minneapolis
1. Kanca J 3rd. One-year evaluation of a
dentin-enamel bonding system. J Esthet Dent
1990;2(4):100-3.
2. Kanca J 3rd. A method for bonding to
tooth structure using phosphoric acid as a
dentin-enamel conditioner. Quintessence Int
1991; 22(4):285-90.
3. CRA Newsletter. Self-etch primer (SEP)
adhesives update. November/December
2003;27(1112):1.
JADA, Vol. 135, April 2004 40 9