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Antibacterial activity in adhesive dentistry:

A literature review
Fereshteh Shafiei, DMD, MS   n  Mahtab Memarpour, DMD, MS

This literature review summarizes the published research when used in various bonding situations.
regarding the antibacterial agents used in adhesive dentistry. Received: September 15, 2011
This article provides information about the clinical applications, Accepted: January 31, 2012
beneficial effects, and possible disadvantages of antibacterials

A
dhesive systems are used
extensively in clinical practice
for bonding to tooth struc-
ture. Adhesive systems are used for
direct and indirect tooth-colored
esthetic restorations, amalgam
restorations, crowns and fixed
partial dentures, luting posts in
root dentin, fissure sealant therapy,
and enamel bonding when placing
orthodontic brackets.
Despite their qualities, adhesive
systems cannot prevent micro-gaps
from forming at the dentinal mar-
gins of composite restorations.1,2
Even when immediate complete
marginal sealing is established, the
resin-dentin interface can degrade
rapidly over time.1,3,4 In addition,
more plaque accumulates on the
surface of composites than on
enamel surfaces or other restorative
materials.5,6 The accumulation of
plaque means that microorganisms
are always in contact with the cured
adhesives via micro-gaps. The lack
of definitive and reliable assess-
ment criteria means that not all
microorganisms in carious dentin
can be detected and eliminated.7,8
The problem of bacteria remaining
in a cavity is more pronounced by
an increasing predilection toward
minimally invasive, tissue-saving
dentistry in which the intact tooth
structure is preserved to the greatest
extent possible.9 Residual bacteria
can survive for more than a year
and can proliferate even in the pres-
ence of a good seal.10 Adjunctive
treatment with antibacterial agents
during dentin bonding could pre-
vent the detrimental effects resulting
from residual bacteria or microleak-
age, such as pulp damage, hypersen-
sitivity, and recurrent caries (a major
cause of restoration replacement).11
A biologic seal can improve the
longevity of the restoration.
Antibacterial effect of
adhesive systems
Acid etchants used in etch-and-rinse
adhesives and the acidic monomers
found in self-etching adhesives with
low pH have both demonstrated
antibacterial activity.12-19 According
to Harper & Loesche, the pH values
that completely eliminated bacteria
over a three-hour period were 2.3 for
Lactobacillus casei and 3.0 for Strep-
tococcus mutans.20 However, certain
bacteria are acid-resistant; in addi-
tion, the buffering capacity of dentin
can limit the effects of the acid.16,20,21
Some monomers that promote
adhesion, such as N-methacryloyl
5-aminosalicylic acid (5-NMSA) and
Phenyl-P—particularly methylene
diphosphonate (MDP)— slightly
inhibit bacterial growth, due to the
specific antibacterial components
(such as glutaraldehyde) that are
found in some adhesives.17,18,22-25
However, photocuring self-etching
adhesives reduces their antibacterial
properties significantly. The litera-
ture has reported on the inability of
adhesives to inhibit bacterial growth
or secondary caries.18,19,25-31
Categorization of
antibacterial agents
Antibacterial activity is provided by
two types of materials: those that
release agents and those that do not
(the latter are known as contact anti-
bacterials).18,32,33 The agent-releasing
materials are used as a separate dis-
infecting material or as antibacterial-
incorporated materials when the
disinfecting step is eliminated.
Separate disinfecting materials
Originally, chemicals such as silver
nitrate precipitated with eugenol,
phenole, and thymol were recom-
mended for disinfecting cavity
preparations prior to placement of
restorations. These materials are no
longer used due to their irritating
effect on the pulp.32 Cavity dis-
infectants were initially proposed
by Brannstrom & Nyborg.34 They
recommended Tublicid (Global
Dental Products), a benzalkonium
chlorite-based disinfectant contain-
ing ethylenediaminetetraacetic

e346 November/December 2012 General Dentistry www.agd.org

acid (EDTA) and sodium fluoride
(NaF), for cavity disinfection.34
Tublicid is a quaternary ammo-
nium compound with no pulpal
reactions.32,35,36 Other disinfectant
materials that have been used to
disinfect cavities include sodium
hypochlorite (NaOCl), hydrogen
peroxide (H2O2), and iodine-based
oral disinfectants. EDTA and
NaOCl were used primarily for
their other properties, including
the ability to serve as a calcium
chelator, remove the smear layer,
and help to remove collagen.
Based on evidence from a study
by Anderson & Charbeneau on
residual bacteria in the cavities,
cavity disinfectants were recom-
mended.12,36,37 However, adjunctive
use of disinfectants during bonding
procedures could have an adverse
effect on the bonding ability of dif-
ferent adhesive systems.32,36,38-41
Chlorhexide gluconate (CHX),
a bisphenol component containing
chlorine, has been used for many
years as a safe antiseptic with a
broad spectrum of action. Studies
have shown that CHX reduces the
number of microorganisms in plaque
and saliva and also reduces the level
of S. mutans in occlusal fissures and
root surfaces.42,43 CHX has been used
as an irrigant for the nonsurgical
treatment of periodontal diseases
and adjunctively used in endodontic
treatment.44,45 It is bacteriostatic in
low concentrations and bactericidal
in higher concentrations.46 These
effects have been reported primarily
on Gram-positive bacteria and less
on Gram-negative bacteria, such as S.
mutans and S. sobrinus, both of which
contribute to initial caries develop-
ment and are more sensitive to the
antibacterial effect of CHX.42,43,47
CHX has strong cationic activity,
allowing it to be absorbed easily into
(and thus disrupt) the negatively
charged bacterial cell wall.36,46,47 This
chemical charge also allows CHX
to adhere to oral cavity surfaces and
tooth structure, which results in
longer antimicrobial activity (ranging
from 48 hours to 12 weeks) com-
pared with other disinfectants.32,36,48,49
Fardal & Turnbull recommended
CHX as a cavity disinfectant in
1986.42 CHX, benzalkonium chlo-
ride, and cetylpyridinum chloride
have been used as additives to
phosphoric acid; the latter is capable
of cross-linking to collagen.50-52 A
considerable decrease in the number
of bacteria in the dentinal tubules
was reported following application of
0.2% CHX for five minutes.53
At least two solutions containing
2% CHX are available commer-
cially: Cavity Cleanser (Bisco, Inc.)
and Consepsis (Ultradent Products,
Inc.). A 1% CHX gel (Drogsan
Pharmaceuticals) is also available.
These products have been used
to disinfect cavity preparations in
numerous studies and have pro-
duced interactions with the bonding
ability of adhesive systems used in
direct and indirect restorations that
appear to be material-specific. These
results—in addition to results from
other studies regarding the effects
of disinfectants on the bonding
efficacy of adhesive systems—are
summarized in Table 1.
The CHX binding to phosphate
groups might act as a co-surfactant
on the etched surface and increase
the surface free energy; however,
it can also have an adverse effect
on bond strength to primary
dentin.42,44,47,48,54 CHX has been
applied in different sequences,
including before etching, after
etching (with or without rinsing),
or CHX-containing phosphoric
acid.41,50,54-63 A number of authors
and a manufacturer of a commer-
cial product, Consepsis (Ultradent
Products, Inc.), recommend
applying CHX for 60 seconds
www.agd.org General Dentistry
after etching, then removing
excess moisture prior to applying a
hydrophilic adhesive or a rewetting
agent.55,58,64-68 CHX could conserve
and regulate the structural integrity
of the collagen matrix.65 Further-
more, removing the smear layer
during etching eliminates most of
the bacteria as well.12,37,58
CHX was applied on the smear
layer in association with self-etch
adhesives that have no separate
etching and washing steps; however,
it can affect the bonding ability
of the adhesives.41,56,60,69,70 The
adverse effect of CHX on some
self-etch adhesives is related to
residual moisture (a 2% CHX solu-
tion is composed of 98% water),
which contaminates the bonded
surface.71,72 The gel form of CHX
could have a limited penetration
depth and therefore would not
affect the bond.60 Self-etch adhesives
containing MDP might have been
adversely affected by CHX bonding
to loose, superficial apatites within
the smear layer.72 A 1996 study used
SEM analysis and reported that
CHX creates a acid-resistant layer,
inhibiting acidic monomers from
penetrating the dentin.41
Even at a very low concentration
(0.2%), CHX functions as a matrix
metalloproteinase (MMP) inhibitor
that can prevent both degradation
of collagen and disintegration of
the bonding interface.73-75 MMPs
are a class of metal-dependent
endopeptidases that remain latent
in the dentin matrix during tooth
development and can be activated
during dentin demineraliza-
tion.74,76,77 CHX can bind to the
dentin matrix; in addition, it can be
retained in the dentin and covered
or sealed with adhesive.62,78,79
Long-term use of CHX solu-
tion can result in brown staining
of the teeth; however, studies that
used CHX for a short time during
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Dental Materials  Antibacterial activity in adhesive dentistry

Table 1. In vitro studies regarding the interaction of cavity disinfectants and adhesive systems.

Author(s) Cavity disinfectant(s) Experimental design Procedure/adhesive Effect

Surmont et al (1989)151 Benzalkonium Root dentin bond strength Before self-etching/Gluma Bond No effect
chloride-based (Heraeus Dental North America)
Gwinnett (1992) 52 CHX Dentin bond strength Before etching/fourth generation bonding No effect
Benzalkonium Dentin bond strength Before etching/fourth generation bonding No effect
chloride-based
Filler et al (1994)155 CHX Enamel bond strength Before etching/Prisma APH (Dentsply Caulk) No effect
Perdigao et al (1994) 55 CHX Dentin bond strength After etching/All Bond 2 (Bisco, Inc.) No effect
Derhami et al (1995) 152
Benzalkonium Enamel and Super-Bond D Liner (Sun Medical Company, Ltd.), No effect
chloride-based dentin leakage Clearfil Liner Bond (Kuraray America, Inc.)
Meiers & Kresin (1996) 41 CHX Enamel and Before etching/Tenure (Den-Mat) No effect
dentin leakage Before self-etching/Syntac (Ivoclar Vivadent Inc.) No effect
Iodine-based Enamel and Before self-etching/Syntac Negative effect on
dentin leakage Syntac (dentin)
Meiers & Shook (1996) 56 CHX Dentin bond strength Before etching/Tenure No effect
Before self-etching/Syntac Negative effect
Cunningham & Meiers CHX Dentin bond strength Before conditioning/resin-modified glass ionomer No effect
(1997)38 (RMGI)
Damon et al (1997)153 CHX Enamel bond strength After etching/Transbond XT (3M Unitek) No effect
Tulunoglu et al (1998)154 CHX Primary dentin Before etching/Prime & Bond (Dentsply Caulk) Negative effect
Leakage Before self-etching/Syntac Negative effect
Gurgan et al (1999) 50 CHX Enamel and dentin bond Before etching Negative effect
strength After etching Negative effect
After etching and rinsing/Permagen (Ultradent No effect
Products, Inc.)
el-Housseiny & Jamjoum CHX Enamel and dentin bond Before etching/Scotch Bond Multi Purpose No effect
(2000)156 strength (3M ESPE)
Pilo et al (2001) 57 CHX Dentin bond strength After etching and rinsing/One-Step Plus Positive effect
(Bisco, Inc.)
Owens et al (2003) 51 CHX Enamel and dentin leakage After etching/PQ1 (Ultradent Products, Inc.) No effect
CHX + silicate glass Enamel and dentin leakage After etching/PQ1 Negative effect
Cetyl pyridinium Enamel and dentin leakage Incorporated into acid gel No effect
chloride
Vieira & da Silva CHX Dentin bond strength Before etching Adper/Single Bond (3M ESPE) Negative effect
(2003) 54 CHX incorporated into acid gel No effect

restorative procedures reported no Antibacterial–incorporated added to dental resins.81-85 These

such staining.59,62 CHX can reduce
postoperative sensitivity and increase
bonding durability as an additional
therapeutic primer, as long as it has
no adverse effect on the adhesive’s
immediate bond.80
materials
Antibacterial components such
as antibiotics, dodecylamine,
bipyridine, tannic acid derivatives,
polyhexanide, amphilic lipids,
silver, and fluorides have been
agents can extend the antibacterial
effect beyond the immediate area
of the adhesive restoration; how-
ever, they could also compromise
the mechanical and bonding prop-
erties of the carrier material.18,86

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 Table 1 cont’. In vitro studies regarding the interaction of cavity disinfectants and adhesive systems.

Author(s) Cavity disinfectant(s) Experimental design Procedure/adhesive Effect

de Castro et al (2003)71 CHX Dentin bond strength After etching No effect
Before etching/Prime & Bond, Single Bond No effect
Before self-etching/Clearfil SE Bond No effect
(Kuraray America, Inc.)
Say et al (2004) 58 CHX Dentin bond strength After etching/One-Step Optibond Solo No effect
(Kerr Corporation)
Benzalkonium Dentin bond strength After etching/One-Step Optibond Solo No effect
chloride-based
Turkun et al (2004) 69 CHX Enamel and dentin leakage Before self-etching/Clearfil SE Bond, No effect
Prompt L-Pop (3M ESPE)
Benzalkonium Enamel and dentin leakage Before self-etching/Clearfil SE Bond, No effect
chloride-based Prompt L-Pop
Iodine-based Enamel and dentin leakage Before self-etching/Clearfil SE Bond, Negative effect
Prompt L-Pop
Sung et al (2004) 64 CHX Dentin leakage After etching/Optibond Solo No effect
NaCl Dentin leakage After etching/Optibond Solo No effect
NaOCl Dentin leakage After etching/Optibond Solo No effect
Erdemir et al (2004) 161
CHX Root dentin Before etching/C&B Metabond (Parkell, Inc.) No effect
NaOCl Bond strength Before etching/C&B Metabond Negative effect
H2 O 2 Bond strength Before etching/C&B Metabond Negative effect
Turkun et al (2005)157 CHX; Dentin bond strength After etching/Syntac, Variolink (Ivoclar No effect
Benzalkonium Vivadent Inc.), DenTASTIC (Pulpdent No effect
chloride-based Corporation), ResiLute (Pulpdent Corporation)
Pappas et al (2005)39 CHX, then Dentin bond strength Before etching/All Bond 2 No effect
benzalkonium
chloride-based, then
NaOCl
Cacciafesta et al CHX Enamel bond strength Before conditioning/glass ionomer Negative effect
(2006)158 (Fuji Ortho LC, GC America, Inc.)
Geraldo-Martins et al CHX Enamel and dentin leakage Before self-etching/Clearfil SE Bond No effect
(2007)159
Soares et al (2008) 59 CHX Dentin bond strength Before etching No effect
After etching No effect
Incorporated into acid gel/Adper Single Bond, No effect
Rely X ARC (3M ESPE)

Also, a strict control of release
kinetics is difficult, and long-term
antibacterial effects are not to be
expected.18,86-88
CHX has been added to restor-
ative materials, provisional and
permanent conventional cements,
and polymethyl methacrylate-based
resin cements.18,87,89-92 The literature
has reported that adding CHX
to self-etching primers did not
compromise bonding ability and
might even preserve bond strength
to dentin.93-95 Conversely, a 2009
study by Cadenaro et al demon-
strated that CHX had an adverse
effect on the physical property of
a primer.96 Furthermore, CHX
release can be affected by water
sorption and hydrophilic character-
istics of resin composites.97

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Dental Materials  Antibacterial activity in adhesive dentistry

Table 1 cont’. In vitro studies regarding the interaction of cavity disinfectants and adhesive systems.

Author(s) Cavity disinfectant(s) Experimental design Procedure/adhesive Effect

Bansal & Tewarsi CHX Dentin leakage Before etching/Prime & Bond; before self-etching/ Positive effect on
(2008)160 Xeno III (Dentsply Ltd.) Xeno III
Iodine-based Dentin leakage Before etching/Prime & Bond; before self-etching/ Positive effect on
Xeno III (Dentsply Ltd.) Xeno III
NaOCl Dentin leakage Before etching/Prime & Bond; before self-etching/ No effect
Xeno III (Dentsply Ltd.)
Erhardt et al (2008) 65 CHX Dentin bond strength After etching/Adper Scotch Bond 1 (3M ESPE) No effect
Catalbas et al (2009)162 CHX Enamel bond strength Before etching/Transbond XT Negative effect
CHX gel Enamel bond strength Before etching/Transbond XT Negative effect
Ersin et al (2009) 163
CHX Primary dentin bond strength After etching/Prime & Bond No effect
After conditioning/glass ionomer No effect
(Vitremer, Ketac Molar, 3M ESPE)
Hiraishi et al (2009)72 CHX Dentin bond strength After etching/Adper Single Bond-RelyX ARC No effect
Before self-etching/ED Primer II, Panavia F 2.0 Negative effect
(Kuraray America, Inc.)
Before self-adhesive/RelyX Unicem (3M ESPE) Negative effect
Siso et al (2009)70 CHX Enamel leakage Before self-etching/Clearfil SE Bond Negative effect
on enamel
Dentin leakage Before self-etching/Clearfil SE Bond No effect on
dentin
Ercan et al (2009) 60 CHX Dentin bond strength After etching/Prime & Bond NT (Dentsply Caulk); Negative effect
before self-etching/Clearfil SE Bond on self-etch
NaOCl Dentin bond strength After etching/Prime & Bond NT; before Negative effect
self-etching/Clearfil SE Bond on self-etch
H2 O 2 Dentin bond strength After etching/Prime & Bond NT; before Negative effect
self-etching/Clearfil SE Bond on self-etch
CHX gel Dentin bond strength After etching/Prime & Bond NT; before No effect
self-etching/Clearfil SE Bond
Saber & El-Askary CHX Dentin bond strength Before self-etching/Clearfil S3 Bond Negative effect
(2009)164 NaOCl Dentin bond strength Before self-etching/Clearfil S3 Bond Negative effect

To provide cariostatic and
antibacterial effects, fluoride has
been incorporated into restorative
materials, sealants, and adhesive sys-
tems; however, the beneficial effect
of fluoride has more to do with
inhibiting demineralization and
enhancing remineralization than
any antibacterial activity.21,85,98,99
According to Francci et al, released
fluoride has little or no effect on the
inhibition of S. mutans.100
Non-agent releasing (contact)
antibacterial materials
Methacryloyloxydodecyl pyridinium
bromide (MDPB) is a unique
monomer that was developed to
provide resin-based materials with
long-lasting antibacterial activity
without releasing the antibacte-
rial agent. After curing, MDPB is
covalently bonded to the polymer
network and acts as a contact
inhibitor against the bacteria that
comes in direct contact with the
polymer.87,101,102 In 2008, Xiao et
al developed a similar monomer,
methacryloxylethyl cetyl dimethyl
ammonium chloride (DMAE-CB), a
compound of the antibacterial agent
quaternary ammonium with a meth-
acryloyl group.103 The adsorption of
the positively charged agent onto a
negatively charged bacterial surface
can disrupt cell membranes.36,38
Both of these monomers have been

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 Table 1 cont’. In vitro studies regarding the interaction of cavity disinfectants and adhesive systems.

Author(s) Cavity disinfectant(s) Experimental design Procedure/adhesive Effect

Campos et al (2009) 66
Mobarak et al (2010) 61
Celik et al (2010)145
Sharifian et al (2010)165 CHX
Lindblad et al (2010)166
Pelegrine et al (2010)146 CHX gel
Kustarci & Sokucu
(2010)167
Shafiei & Memarpour
(2010)168
Shafiei et al (2011) 169
Shafiei et al (2010)170
CHX Dentin bond strength After etching/Adper Single Bond No effect
Before self-etching/Clearfil S3 Negative effect
CHX Dentin bond strength Before self etching/Clearfil SE Bond No effect
CHX Dentin bond strength After etching Adper/Single Bond Positive effect
Before self-etching/Clearfil SE Bond No effect
Root dentin bond strength Before self-etching/Resilon-Epiphany No effect
(Dentsply Caulk)
CHX Root dentin bond strength After etching/All Bond 2, Duolink (Bisco, Inc.), No effect
Perma Flow DC (Ultradent Products, Inc.)
Before self-adhesive/RelyX Unicem No effect
Root dentin bond strength Before self-etching/Clearfil SE Bond, RelyX ARC No effect
NaOCl Root dentin bond strength Before self-etching/Clearfil SE Bond, RelyX ARC No effect
CHX Enamel leakage After etching/Transbond XT No effect
CHX Dentin bond strength After etching/Variolink 2 (Ivoclar Vivadent Inc.) No effect
Before self etching /Panavia F2.0 (Kuraray Inc.) No effect
Before self adhesive-Relay X Unicem No effect
CHX Enamel and dentin leakage After etching/Nexus 2 (Kerr Corporation) No effect
Before self-etching/ Panavia F 2.0 No effect
CHX Enamel and dentin leakage After etching/Scotchbond Multi-Purpose (3M No effect
ESPE), Excite (Ivoclar Vivadent Inc.)
Before self-etching/Clearfil SE Bond, iBond No effect
(Heraeus Kulzer Dental Products)

CHX = Chlorhexidine solution

Note: Four other studies (Stanislawczuk et al, Ricci et al, Breschi et al, and Carrilho et al ) demonstrated the preservative effect of CHX (after etching) on dentin bonding
and showed no adverse effect on immediate bond strength; these studies are not included in Table 1.63, 68, 73, 75

incorporated into resin composite
and adhesive systems.86,87,101-105
Although studies have demon-
strated the antibacterial effect of
the incorporated composite even
after a year of water storage, other
reports have described the loss of
this effect.18,87,106,107 The adsorption
of proteins on the surface could
account for the reduced antibacte-
rial effect.18 While the antibacterial
effects of composite restorations
primarily involve inhibiting
surface plaque accumulation, the
antibacterial effect of adhesives
involves disinfecting the cavity and
rendering inactive any bacteria
that might enter through marginal
microleakage.18 A self-etch primer
containing 5% MDPB killed S.
mutans within 30 seconds of contact
before curing.8,104 Following copo-
lymerization with other monomers,
this self-etch primer had an inhibi-
tory effect on the growth and adher-
ence of bacteria on its surface.21,22,102
MDPB has demonstrated antibac-
terial activity against various bacteria
isolated from both root and dentin
caries.8,9,16,29,31,32,102,108-111 Studies
have reported that incorporating
antibacterial monomers does not
compromise bonding efficacy and
stability, curing ability, cytotoxicity,
or marginal adaptation.18,104,112-116
MDPB is a more hydrophobic
monomer than hydroxyethyl meth-
acrylate (HEMA). Incorporation
of MDPB increases viscosity of the
adhesive. These properties could
slightly decrease the infiltration
of MDPB-containing adhesive
into demineralized smear layer
and dentin.112 It has been reported
that resins containing MDPB are

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Dental Materials  Antibacterial activity in adhesive dentistry
capable of reducing extracellular
polysaccharides in the plaque matrix
(restricted to plaque over the mar-
gins); however, these resins have no
effect on biofilm formation or ini-
tial adherence of S. mutans.30,117,118
Clearfil Protect Bond (Kuraray
America, Inc.) adds 5% MDPB to
its self-etching primer adhesive,
Clearfil SE Bond.
A 2007 study reported that
Clearfil Protect Bond demonstrated
satisfactory clinical performance
when used in posterior composite
restorations.119 Tziafas et al reported
that Clearfil Protect Bond main-
tained pulp vitality but interfered
with reparative dentin formation
in exposed, infected pulp.120 Other
studies have reported that Clearfil
Protect Bond offers good bonding
durability stability and has a a rela-
tively high bond strength associated
to resin cements.33,121,122
Cetylpyridinium chloride is
another antibacterial agent that has
been immobilized in an adhesive
and showed an inhibitory effect
on bacteria which were in contact
with its surface.123 Recently, the
combination of bioactivity and
bacterial effect has been proposed to
create a dental adhesive containing
crystalline titania nanoparticles that
reduces the incidence of secondary
caries and promotes closure of the
gaps formed at the interface via
remineralization.124
Antibacterial activity in
enamel bonding
Enamel bonding in fissure
sealants
Little information is available regard-
ing antibacterial activity in sealants.
An antibacterial adhesive under a
sealant might exhibit antibacterial
action on the original bacteria in
pits and fissures and inhibit caries
formation following microleakage or
a partial loss of the sealant. A 2005
e352 November/December 2012
study placed an adhesive associated
with sealant and composite resin on
uncut enamel and reported that the
bond was comparable to that of a
total-etch adhesive.125
Enamel bonding in orthodontic
brackets
Demineralization is a major side
effect of fixed appliance orthodontic
treatments, with prevalence reports
of 50–70%.126,127 Demineralization
around fixed orthodontic appli-
ances results from gap formation
due to polymerization shrinkage,
more retention sites, and increased
plaque accumulation.127,128 Fluoride
and CHX are the most common
preventive approaches; however,
their effects are limited in duration
and are not completely effective. The
antibacterial-incorporated type could
compromise the bonding ability of
the adhesives.86,129,130 Furthermore,
the ability of fluoride-releasing
adhesives to inhibit demineralization
is still in doubt, since the low pH
environment created by bacteria
prevents remineralization; for this
reason, the combination of fluoride
and antibacterial agents has been
suggested.131,132 Studies that used
Clearfil Protect Bond have reported
promising results in terms of bond
strength and sealing ability.133-136
The low bond strength reported
in some studies could be attributed
to an insufficient etching pattern on
unground enamel because Clearfil
Protect Bond is a mild self-etch
adhesive with a pH of 2.137 Some
studies performed enamel etching for
10 seconds, while others suggested
that etching might not be necessary
and did not recommend it.137-140
Other antibacterial agents that
have been added to the adhesives
used in bracket bonding include
benzalkonium chloride (as a releasing
agent) and silver nanoparticles (as a
non-releasing agent). The latter has
General Dentistry www.agd.org
the disadvantage of a discoloration
problem related to silver ions.141-143
Randomized controlled clinical long-
term trials should be conducted to
confirm the positive effect of these
agents on enamel decalcification
during orthodontic treatment.
Antibacterial effect of lasers
A 1997 article by Klinke et al pro-
posed using lasers to decontaminate
cavities or root dentin.144 Although
laser pretreatment might not
affect the bonding ability of some
adhesives, it does represent a more
expensive and complex treatment
modality in respect to getting a
homogenous laser application with
suitable irradiation parameters to all
parts of the cavity.70,145-147
Antibacterial effect of ozone
Acording to the literature, applying
ozone for 20 seconds can kill 99.9%
of microorganisms found in primary
caries lesions.148 Studies have sug-
gested that ozone gas can disinfect the
cavity prior to performing restorative
procedures, without affecting the
enamel or dentin bond strength.149,150
Summary
According to the in vitro and
limited in vivo data found in the
literature, CHX can be used with
etch-and-rinse adhesives as a cavity
disinfectant while improving bond-
ing durability; however, long-term
clinical studies are necessary to
confirm these advantages.
Clearfil Protect Bond appears
to offer long-lasting antibacterial
activity in adhesive dentistry; how-
ever, additional testing is needed
to determine its effect on bacteria
invading the adhesive interface
in vivo. In addition, long-term in
vivo evaluations using standardized
protocols should be conducted to
determine the practical application
of mechanical and biologic sealing.
Disclaimer
The authors certify that they do not
have any commercial interest that
represents a conflict of interest in
connection with the manufacturers
listed in this article.
Author information
Dr. Shafiei is an associate profes-
sor, Department of Operative
Dentistry, Shiraz University of
Medical Sciences, Shiraz, Iran,
where Dr. Memarpour is an associ-
ate professor, Pediatric Dentistry
Department, School of Dentistry.
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