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4 CE credits
This course was
written for dentists,
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and assistants.

Contemporary Dental Adhesives

for Direct Placement
Composite Restorations
A Peer-Reviewed Publication
Written by Howard E. Strassler, DMD, FADM, FAGD
and Luis Guilherme Sensi, DDS, MS, PhD

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Educational Objectives
Upon completion of this course, the clinician will be able to
do the following:
1. Discuss the differences between etch-and-rinse and
self-etch adhesives, and relate these categories to other
naming systems that have been previously presented.
2. Discuss current research evidence comparing etch-and-
rinse and self-etch adhesives.
3. Describe the indications for etch-and-rinse and self-
etch adhesives.
4. Describe the clinical procedure for an etch-and-rinse
and self-etch single-step adhesive.
Abstract
Dental adhesives that bond composite resins to tooth struc-
ture have evolved over the last several decades. The earliest
bonding systems required an acid-etch technique and were
only compatible with enamel. The challenge has always been
to predictably bond to enamel and dentin simultaneously.
There can be confusion, however in what bonding agents
are being described because there are a number of differ-
ent labeling categories. With a simplified, logical category
description the clinician is better able to understand what
each bonding agent is and how it is used. No one universal
bonding system does it all. The key to success is providing
your patients with materials and techniques that you can re-
produce to achieve the best, longest-lasting clinical results.
Introduction
The Holy Grail for adhesion to enamel and dentin has been
described as being an adhesive that can be placed routinely in
a simple and reproducible technique. In the development of
this adhesive, it has been generally accepted that if and when
this universal adhesive becomes available, it will most likely
be a single component, no-mix adhesive that can be applied
directly to enamel and dentin for the purpose of bonding any
restorative material to tooth structure. This adhesive would
be equally effective in its physical properties to enamel and
to dentin. It would be a bonus if it allowed us to bond to all
intraoral materials — all types of dental metals, dental ce-
ramics and dental resins. Manufacturers continue to work on
the development of such a product, and while this product
does not yet exist, monumental strides have been made.
This towering challenge to develop a universal adhesive
has been described in many articles. This author remembers
reading an article in 1985 written by Dr. Wayne Barkmeier
on the fundamental elements for an adhesive used for bond-
ing to tooth structure. Recently these five key prerequisites
for successful adhesion to tooth structure were reiterated,
because they have not changed since 1985.1 These five pre-
requisites or criteria are:
1. The procedure must be safe and biologically acceptable.
2. The level of bond strength must be clinically significant to
avoid discoloration at the margins and secondary caries.
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3. The bond strength must be routinely achieved so that
predictable results are obtained.
4. The bond must be established quickly in order to permit
immediate finishing.
5. The bond must be stable in vivo for a clinically signifi-
cant period of time.
It has taken almost 20 years to reach these lofty goals. But
there is no doubt that with the current adhesives available,
reliable adhesion to tooth structure can be achieved.
Enamel Bonding
The idea of adhesive bonding to dentin was theoretically pos-
tulated more than 50 years ago as being a potential chemical
bond between the methacrylate group of resins to the colla-
gen surface of dentin.2 While bonding to dentin was far from
the profession’s reach 50 years ago, adhesion to enamel was
successfully pursued. In 1955, Buonocore described a clini-
cal technique that utilized a diluted phosphoric acid (actually
the first trials were done with the phosphoric acid liquid in
zinc phosphate cement) to etch the enamel surface and pro-
vide for retention of unfilled, self-cured acrylic resins.3 The
resin mechanically locked to the microscopically roughened
enamel surface, forming small “tags” as it flowed into enamel
microporosities 10–40 micrometers deep and then polymer-
ized (Figure 1). The first clinical use of this technique was the
placement of sealants.4 The use of this acid-etch technique
was extremely controversial, and led to a position paper re-
quested by the American Dental Association criticizing the
early sealant studies, with reports of caries prevention in pits
and fissures after 18 months.5
Figure 1. SEM of etched enamel.
The first commercialization of bonding to enamel was
in the late 1960s and early 1970s. The combination of acid
etching enamel and adhesive composite resin restorations af-
forded the benefits of reduction or elimination of microleak-
age at the enamel margins, less discoloration at the margins,
lower rates of recurrent caries, and improved retention of the
restoration.6,7 Unfortunately, the composite resins used at
that time had poor esthetic longevity. These composite resins
shifted in color, were rough and difficult to polish, picked up
surface stain, and wore in function.
 The effectiveness and success of etched enamel/resin bond
has been demonstrated in many reported clinical trials.8 In our
everyday practice we do not think twice about using a dental
adhesive when placing a restoration based upon the etched
enamel/resin bond. The use of adhesives is well accepted for
the placement of sealants.9 Clinically successful less invasive
cavity preparations to restore carious pits and fissures using
an enamel adhesive technique with preventive resin restora-
tions (PRR) are well documented.10,11 All anterior prepara-
tions and restorations restored with composite resin with an
enamel bonding technique have also been demonstrated to
be highly successful.12 Predictable posterior composite resins
that are clinically successful for more than 10–15 years with
use of an etch-and-adhesive technique with composite resins
have been demonstrated, and in fact it has been reported that
posterior composite resins be considered amalgam alterna-
tives in routine-sized preparations.13,14,15 The ultimate test
of the enamel bond is the placement of a thin, inherently
brittle veneer of porcelain to the facial surfaces of anterior and
posterior teeth. In an up-to-20-year clinical evaluation of por-
celain veneers fabricated from Cerinate Porcelain (Den-Mat)
bonded to enamel, there was a 93% success rate with a mean of
15.2 years.16 In fact, over the course of the study there were no
debonds of the veneers. This parallels Friedman’s retrospec-
tive study of porcelain veneers where he evaluated approxi-
mately 3,500 restorations and reported on 245 failures, once
again a 93% success rate.17 Of those veneers that debonded
completely, the margins were surrounded with dentin.
Dentin Bonding
Unlike enamel bonding, dentin bonding has seen an evo-
lution in its viability. Effective dentin-bonding materials
should fulfill the following goals:
• The material should adhere to dentin at a clinically ac-
ceptable level, and should be able to withstand intraoral
forces of occlusion and mastication.
• The bond should be instantaneous once the material
has set.
• The material and technique must be biocompatible.
• The material should resist the forces of polym-
erization shrinkage of composite resins and the
coefficient of thermal expansion and contraction to
eliminate microleakage.
• The material should create a long-lasting bond to dentin.
• Postoperative sensitivity must be minimized or eliminated.
Surmounting the smear layer impediment
The earliest research in 1956 with dentin bonding focused on
chemical adhesion of resins to the inorganic components of
dentin. Buonocore and coworkers developed a methacrylate-
based dentin adhesive that contained phosphate groups to
attach to the calcium ions on the dentin surface.18 The basis
of the bond was the presence of the dentin smear layer.19 The
dentin smear layer refers to the loosely bound debris consisting
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of fractured crystals of hydroxyapatite and denatured collagen.
This layer acts as a barrier to clog the dentin tubules and may
be responsible for desensitizing a cavity preparation after a
bur or hand instrument interacts with the dentin. This early
foray into dentin bonding attached to the smear layer, creating
a weak, clinically unacceptable bond to dentin. This basis of
a phosphate-calcium bond later became the third-generation
phosphate ester bonding systems. These bonding systems,
e.g., the original Scotchbond (3M) and BondLite (Kerr) among
others, adhered to the calcium-rich dentin smear layer and to
etched enamel. Bond strengths to dentin were limited by degree
of adherence of the smear layer to the dentin. Unfortunately
over a short time, 12–18 months or less, the durability of the
bond was impacted by hydrolysis that occurred at the phos-
phate/calcium interface.20,21 These products had very limited
success when dentin was the primary bonding substrate.
At the same time a parallel research path investigated the
use of a total-etch approach, etching the enamel and dentin
simultaneously.22,23 At the time there was concern that phos-
phoric acid placed on dentin would cause pulpal inflammation
and necrosis.24 Jennings and Ranly demonstrated that the
pulpal effect of phosphoric acid on dentin for one minute was
minimal.25 Early results reported with dentin etching were dis-
appointing because the adhesive resin used was the same un-
filled hydrophobic Bis-GMA bonding resin used for bonding
to etched enamel.26 The hydrophobic resin would not wet the
moist, vital dentin and predictable adhesion could not be pro-
duced. The breakthrough in simultaneous adhesion to enamel
and dentin was first described in the late 1970s by Fusayama
and coworkers27 Bertolotti28 and Kanca.29 They referred to
their technique as “total etch.” They demonstrated the suc-
cess of the total-etch adhesive bond based upon the removal
of the smear layer through dissolving with the phosphoric acid
and by adding a hydrophilic monomer, usually hydroxyethyl
methylmethacrylate (HEMA) to the primer and adhesive.
This hydrophilic monomer allows the adhesive resin to pen-
etrate the moist intertubular dentin, peritubular dentin, and
dentinal tubules, creating an infiltrated hybrid zone allowing
for intimate union of the dentin and adhesive.30 (Figure 2).
Figure 2. SEM of multiple-bottle etch-and-rinse adhesive infil-
trated dentin hybrid zone (3-E&R) (OptiBOND FL) (dentin has been
dissolved to demonstrate resin infiltration).
 These concepts led to the development in the late 1980s
and early 1990s of multi-step adhesive bonding systems
(3-E&R), which required the application of a primer and
then an adhesive resin that used a total-etch technique
with phosphoric acid. In the mid 1990s, clinicians sought
a simplified approach that used fewer steps for adhesive
placement. Manufacturers responded with the introduc-
tion of single-bottle primer/adhesive bonding systems
that required etching of the enamel and dentin. These
single-bottle primer/adhesive bonding systems (2-E&R)
combined with etching of the dentin and enamel provided
the same hybridization of the dentin that was seen with the
multiple-bottle systems (Figure 3).
Figure 3. SEM of single-bottle etch-and-rinse adhesive (2-E&R)
infiltrated dentin hybrid zone (OptiBOND Solo Plus) (dentin has
been dissolved to demonstrate resin infiltration).
SEM courtesy of Kerr-Sybron
The search for even greater simplification lead to
continued research with adhesives that would incorporate
the etching-priming-adhesive steps simultaneously. The
challenge was to create a stable chemistry that would have
an adequate shelf life. The earliest self-etching adhesives
required two separate application steps — a self-etching
primer and then the adhesive (2-SEA) (Clearfil SE Bond,
Kurary). Other products followed this same chemistry
(e.g., Tyrian SPE, Bisco; Adper ScotchBond SE, 3M-
ESPE). Later, single-step products providing separate
bottles that needed to be mixed were introduced (1-SEA).
The introduction of iBOND® Self Etch (Heraeus) was the
first single-bottle (or unit dose), one-step self-adhesive
(1-SEA) that created a gap-free dentin-infiltrated hybrid
zone . Other 1-SEA systems also provide for a resin-
infiltrated hybrid zone (e.g., OptiBOND All-In-One,
Kerr; Xeno IV, Dentsply-Caulk; Adper Easy Bond SE,
3M-ESPE) (Figure 4).
Classification of bonding systems
The development of improved adhesion systems using
different chemistries with a variation in the numbers of
reagents and steps for application led to a number of dif-
ferent descriptions of the categories and classification
of adhesives. With no standard for classification and de-
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Figure 4A. SEM of composite resin/dentin interface that is gap-free
with a single-step self-etching adhesive (1-SEA) (iBOND ® Self
Etch).
SEM courtesy of Heraeus
Figure 4B. SEM of infiltrated dentin hybrid zone with a single-step
self-etching adhesive (1-SEA) (OptiBOND All-In-One).
SEM courtesy of Kerr-Sybron
scription, there was some confusion among clinicians and
researchers alike.
With the development of two different classes of bond-
ing systems that relied on the use of phosphoric acid as a
surface etchant came the classification and description of
bonding systems based upon generational timeline changes.
Fourth-generation bonding systems were referred to as total-
etch multi-bottle (multi-step) systems, and fifth-generation
systems were referred to as total-etch single-bottle bond-
ing agents that contained both primer and adhesive. Both
fourth- and fifth-generation products required a total-etch
with phosphoric acid before adhesive placement.
In reaching for the goal of adhesive simplification of both
techniques and reduction in the number of steps, the earli-
est self-etching bonding systems were introduced. These
adhesives did not require the additional step of applying
phosphoric acid, rinsing and drying before application.
The classification system became even more complex when
bonding systems that had the additional step of phosphoric
acid etching were referred to as total etch, and those adhe-
sives that did not require the additional step of phosphoric
acid were referred to as self-etch. Others continued with
generational descriptions building on the fourth- and fifth-
generation model. The self-etching systems were referred
to as sixth and seventh generation. These terminologies do
not adequately describe the current adhesives being used
for composite resin bonding. (Indications for each adhesive
system are listed in Table 1.)
Table 1. Clinical applications for adhesive systems Table 2. Classification of adhesives according to Van Meerbeek et al. 31
Etch-and-Rinse Adhesive Systems: Etch-and-Rinse Adhesives
Multiple-bottle all uses, including self-cure composite Three-step multiple-bottle etch-and-rinse adhesives (3-E&R)
(3-E&R): resin cores and dual-cure composite resin
cementation Two-step single-bottle etch-and-rinse adhesives (2-E&R)
Single-bottle direct composite resin placement, and
(2-E&R): with systems that have an activator use Self-Etch Adhesives
with self-cure and dual-cure composites Two-step multiple-bottle self-etch adhesives (2-SEA)
One-step multiple-bottle mix self-etch adhesives (1-SEA)
Self-etching systems:
(not indicated with self-cure or dual-cure composites unless the One-step no-mix self-etch adhesives (1-SEA)
manufacturer makes the recommendation)
Table 3. Etch-and-rinse adhesives
Multi-step systems direct placement Class I, II, III, and V with (check with manufacturer for those products that can be used with self- and dual-cure
composite resins)
(2-SEA): prepared enamel
Single-step mix direct placement Class I, II, III, and V with Multiple-Bottle Three-Step Etch-and-Rinse (3-E&R)
systems (1-SEA): prepared enamel OptiBOND FL Kerr
Single-step no-mix (1-SEA): Gluma Solid Bond Heraeus
Syntac Ivoclar/Vivadent
Use of any adhesive is manufacturer-specific for use with self-
cure and dual-cure composite resin systems. Tenure MP Den-Mat
At the current time self-etching systems can be used for Class IV incisal edge repair, facial Scotchbond MP 3M-ESPE
veneering and porcelain veneers with a light cure cement (or flowable composite as a luting
agent) with the use of a total etch of the enamel surface with phosphoric acid etchant. As ProBond Dentsply/Caulk
more evidence becomes available in clinical trials this recommendation may change. Also, if
phosphoric acid is used with an SE adhesive, only the enamel needs to be etched. Dentastic Pulpdent
All Bond 3 Bisco
Rational approach to nomenclature
for dental adhesives Single-Bottle Two-Step Etch-and-Rinse (2-E&R)
All adhesives used today exhibit the same phenomenon for
OptiBOND Solo Plus Kerr
adhesion to enamel of micromechanical locking to the etched
enamel prisms and to dentin through hybridization.31 The Gluma Comfort Bond + Heraeus
use of the classification “total etch” is in fact a misnomer. Desensitizer
All adhesives, including the self-etching systems, etch tooth Prime and Bond NT Dentsply/Caulk
structure “totally” and are applied to the enamel and dentin XP Bond Dentsply/Caulk
simultaneously. Also, the number of steps for adhesion has Single Bond Plus 3M-ESPE
been misstated as being a single step for so-called fifth-
generation adhesives, when in fact there is the additional Excite Ivoclar/Vivadent
step of application and rinsing and drying of the phosphoric IntegraBond Premier Dental
acid. In 2003 Van Meerbeek et al. proposed a rational, logi- Syntac Single Component Ivocalar/Vivadent
cal categorization and classification of the current adhesives Dentastic Uno Pulpdent
based upon what is required to achieve the adhesive interface
One Coat Bond Coltene/Whaledent
to enamel and dentin32 (Table 2). Based upon the current ad-
hesives that are being used in our practices, the classification Tenure Quick Den-Mat
of adhesives falls into two distinct categories: etch-and-rinse Clearfil Photobond Kuraray Medical
(Table 3) and self-etch (SE) (Table 4). One Step Plus Bisco

Etch-and-rinse approach
The etch-and-rinse adhesives can be recognized by the initial
step of the application of phosphoric acid to the enamel/den-
tin followed by the mandatory rinsing step. The enamel etch-
ing leaves a microscopically roughened surface to bond to.
The etch-and-rinse technique uses a 10–40% phosphoric acid
that removes the dentin smear layer and is then rinsed with
water and dried from the dentin. The dentin is then rewetted
with water, leaving a damp, glossy surface. An adhesive resin
is then applied. The adhesive resin is provided as either two
bottles, a dentin primer and a separate adhesive (also referred
to as three-step etch-and-rinse (3-E&R) (e.g., OptiBOND
FL, Kerr, ScotchBond MP, 3M-ESPE)), or as a single bottle
that contains both primer and adhesive (also referred to as
two-step etch-and-rinse (2-E&R) (e.g., OptiBOND Solo
Plus, Kerr and Gluma Comfort Bond + Desensitizer, Her-
aeus)). For the single-bottle etch-and-rinse systems, many of
these products are provided in single-unit doses. In the case
of multiple-bottle 3-E&R, OptiBOND FL is supplied as unit
dose packaging for primer and adhesive.

www.ineedce.com 5
Table 4. Self-etching adhesives self-etching adhesive systems. Self-etch adhesives (SE) use a
Two-Step Self-Etch (2-SEA) more acidic monomer in a HEMA/water-based adhesive. As
Adper ScotchBond SE 3M-ESPE such they do not require a separate etch-and-rinse step. The
SE approach does not require a separate etching step because
Clearfil Liner Bond 2V Kuraray
the etchant is incorporated in the adhesive (either in a sepa-
Clearfil SE Bond Kuraray rate self-etching primer or in the adhesive). Also, a separate
Apex Dental Kuraray rewetting with water step is eliminated because SE adhesives
Tyrian SPE Bisco contain water and are never completely dried from the tooth.
Simplicity Apex Dental SE adhesives do not remove the smear layer but incorporate
it in the adhesive. Their compositions are aqueous mixtures
Single-Step Self-Etch Mix systems (1-SEA) of acidic functional monomers, usually phosphoric acid esters
Den-Mat Ivoclar/Vivadent with a pH value higher than phosphoric acid gels.37 It has been
reported that the pH of Clearfil SE Bond (Kuraray America)
Prompt-L-Pop 3M-ESPE
is approximately 2.0, when compared to a pH of 0.5–1.0 for
Touch and Bond Parkell typical phosphoric acid gels.38 Unlike the etch-and-rinse
One-Up Bond F Plus J. Morita adhesives that dissolve the dentin smear layer and remove it
during the rinsing of the etchant, the self-etching adhesives
Single-Step Self-Etch No-Mix system (1-SEA) incorporate the smear layer into the adhesive. Investiga-
iBOND ® Self Etch Heraeus tions have demonstrated that SE systems provide for similar
OptiBOND All-in-One Kerr hybridization and infiltration of dentin as is seen with etch-
G-Bond GC America and-rinse adhesives. There has also been concern about the
Xeno IV Dentsply quality of bonding of SE adhesives to enamel. If enamel is left
unprepared, it is resistant to etching and adhesion with most
Clearfil S3 Kuraray
SE adhesives.39,40,41 Also at the current time the use of a SE
Adper Easy Bond SE 3M-ESPE adhesive for restoring Class IV incisal edge fractures, esthetic
facial veneering and diastema closures with direct composite
Based upon the evidence to date, bonding to enamel is best resin and bonding porcelain veneers is contraindicated.42
accomplished with this technique. Etching as a separate step A chief complaint among practitioners with composite
increases the surface area of the enamel by microscopically resin restorations has been the rate of postoperative sensitiv-
roughening the surface, and increases the surface energy to al- ity, especially using etch-and-rinse adhesives following the
low the resin to synergistically flow into the enamel micropo- placement of Class I, II and V restorations. Several clinical
rosities for improved retention and sealing. Also, both in vitro studies have investigated postoperative sensitivity using
and in vivo research have demonstrated that etch-and-rinse both etch-and-rinse and SE adhesives.43,44,45,46,47 The results
adhesives can reliably bond to both enamel and dentin.33,34,35 of these studies demonstrated no difference in postoperative
Clinical success with etch-and-rinse adhesives is depen- sensitivity between the adhesive types. In fact, the conclusion
dent on this basic clinical technique: of one study stated that postoperative sensitivity may depend
1. Tooth preparation (all classes of preparation; can be in on the restorative technique and variability among operators
enamel-only Class IV, facial veneers, porcelain veneers) rather than on the type of enamel-dentin adhesive used.48
2. Etch with a phosphoric acid (range of concentration One area of inconsistency with etch-and-rinse bonding has
10%–37%) for 15–30 seconds (15 seconds for dentin only) been the bonding potential to desiccated dentin.49,50 The in-
3. Rinse with air-water spray for 10 seconds herent chemical nature of SE adhesives is that they are water
4. Dry the tooth, leaving the enamel frosty, dentin containing; because they are no-rinse, the dentin surface is
glossy (moist)35,36 left moist. This may account for the case reports of minimized
5. Apply adhesive system of choice; light curing postoperative sensitivity.51 Also with SE bonding the variabil-
6. Apply restorative material; light curing ity between operators can be minimized by simplifying the
technique of adhesive placement.52,53 There has been concern
Self-etch adhesives that the chemical reagents in SE adhesives, especially single-
It was obvious that the more steps required to bond a restora- component adhesives, require attention to detail due to the
tion, the greater the potential for inconsistency of timing of solvent and water in the mixture. It is important that during
application, rinsing, drying, rewetting dentin and maintaining the drying process, the water and solvent be evaporated with
a controlled operative field during treatment.36 This inconsis- a gentle air spray following the timing as noted in the manu-
tency can lead to an impact on the success of the bond and facturer’s instructions, and that the adhesive be thinned; too
the durability of the restoration. Manufacturers responded to thick a layer will compromise the bonding. Adequate air-
this desire by placing research efforts in the development of drying (also called “air-thinning”) is needed to remove most

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water (solvent) from the adhesive before light-curing the
adhesive otherwise the residual water may negatively affect
the curing of the adhesive and therefore bond strength.
Santini and coworkers investigated microleakage around
Class V restorations bonded with etch-and-rinse and SE
adhesives.54 They concluded that SE systems were as reli-
able as TE systems. Some clinicians are concerned about
bacterial contamination of cavity preparations and use cavity
disinfectants before application of dental adhesives. The use
of benzalkonium chloride and chlorhexidine gluconate had
no detrimental effects on the sealing ability of non-rinse
self-etching adhesives.55 In some cases the self-etching ad-
hesive acts as its own disinfectant. Both iBOND® Self Etch
(Heraeus) and Protect Bond (Kuraray) have data to support
this claim.
Clinical success with self-etch adhesives is dependent on
the basic clinical technique:
1. Tooth preparation (preparations that are self-
retentive; Class V; not Class IV, not facial veneers, not
porcelain veneers).
2. Apply the SE adhesive following the manufacturer’s
instructions for dwell time — this is very product specific.
3. Air dry the tooth following the timing and type of air spray
from the product intructions; do not take any shortcuts.
4. Light cure the adhesive.
5. Apply restorative material; light cure.
Adhesion to tooth structure: clinical challenges
Not all dentin and enamel is equally bondable. In the course
of tooth preparation we encounter teeth that have existing
amalgam restorations that are defective and teeth that have
been invaded by the carious process. Also, there are tooth
conditions that can affect the quality of etching and the qual-
ity of adhesion to enamel and dentin.
A significant part of a restorative practice is the replace-
ment of existing restorations. There has been a trend to replace
defective amalgam restorations with composite resins. When
removing an amalgam restoration it is not unusual to find
discolored enamel and dentin present due to the leaching of
metallic ions and corrosion products into the dentin tubules.
Harnirattisai et al. found no differences in adhesion to normal
dentin and discolored amalgam-affected dentin with both an
etch-and-rinse adhesive and a self-etch adhesive.56 Also, when
removing caries, there is controversy as to when to stop in the
cavity preparation — are we truly removing all caries or is there
some caries remaining. Bonding to caries-affected dentin has
been shown to have decreased bonding strength.57,58,59 With
the increase in the use of fluorides both through fluoride in our
drinking water and other beverages and in oral care products,
there has been an increase in fluorosis seen in the general pop-
ulation. We see it as mottled enamel, especially when teeth are
isolated with cotton rolls for routine restorations. Fluorosed
enamel and dentin is more difficult to bond to. For enamel
fluorosis the recommendation is to prepare the enamel with a
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bur or diamond to improve bonding.60 For dentin, self-etching
adhesives provide for better bonding to fluoride-rich dentin.61
Of note, with the increased interest in tooth whitening and the
availability of over-the-counter peroxide-based products, the
clinician may not know if patients are bleaching their teeth.
Research supports waiting at least one week after bleaching
before any restorative procedure with either an etch-and-
rinse or an SE adhesive to prevent interference with bonding
adhesion and material setting.62,63,64,65,66 It is important to know
whether or not your patients are using peroxide products be-
fore any bonding procedure.
Clinical technique with etch-and-rinse adhesives
Case report 1
A 27-year-old female patient presented with a history of a
non-carious cervical lesion (NCCL) on the maxillary right
canine that was sensitive to air and cold (Figure 5). After a
thorough examination the diagnosis of dentin hypersensitiv-
ity was made. The treatment plan was to place an adhesive
composite resin restoration. The area was anesthetized with
local anesthesia. Isolation for the placement of the restoration
was accomplished with lip retractors and placement of gingi-
val retraction cord to control any seepage of gingival fluids or
bleeding. The tooth was cleaned with a water-pumice paste
with a prophylaxis cup.
Figure 5. Class V NCCL on the maxillary canine that exhibits dentin
hypersensitivity.
A minimal enamel bevel of 1.0 mm was placed using a
fine finishing diamond with a slow-speed handpiece. The
dentin on the root surface was minimally prepared using a
#2 round bur to leave a consistent dentin smear layer. A two-
stage enamel-dentin etch was used. The enamel was etched
for a total of 30 seconds, the dentin for 15 seconds using a
dye-free 40% phosphoric acid etchant (Onyx, Centrix Den-
tal) (Figure 6). The black silicon carbide particles provide for
coloring for visibility and when agitated can impart a gentle
abrasive action on the dentin and enamel. The surfaces were
rinsed for 10 seconds with an air-water spray. The enamel
was gently dried, leaving a frosty, etched appearance. The
dentin was hydrated using a damp cotton pellet, leaving the
dentin slightly glossy (Figure 7).
Figure 6. Two-stage etching of the preparation: 15-second dentin Figure 8. Application of the OptiBOND primer with 15 seconds of
etch and 30-second enamel etch. agitation. It was then air-dried.

Figure 7. Evidence of etching enamel (frosty appearance) and

lightly wetted dentin (glossy appearance). Figure 9. Application of the OptiBOND adhesive, air thinned and
light cured.

For this case a multiple-bottle, etch-and-rinse adhesive

(3-E&R) (OptiBOND FL, Kerr-Sybron, Orange, CA) was Figure 10. Placement of the hybrid composite resin
(Herculite XRV).
used. OptiBOND FL has been demonstrated to be effective
at bonding to both enamel and dentin surfaces.67,68,69,70 In a
number of studies, OptiBOND FL was used as the standard
for a multiple-bottle etch-and-rinse adhesive when compar-
ing to self-etch adhesives because of its clinically successful
long-term clinical data.71 OptiBOND FL primer was applied
to the etched dentin and was agitated with a microapplica-
tor brush for 15 seconds (Figure 8). The primer was gently
air dried to evaporate the organic solvent from the primer
for 5 seconds. The surface then had a glossy appearance. If
primer gets on the etched enamel, this is not a problem. The
OptiBOND FL adhesive is a lightly filled adhesive with
nanofillers, which allows it to be applied thickly or thinly.
OptiBOND FL adhesive was applied in a uniform thin layer Figure 11. Shaping the composite resin with a sculpting plastic
to the etched enamel and dentin surfaces. If the adhesive filling instrument (PFI-AB1, HuFriedy) wetted with the OptiBOND
adhesive to minimize composite resin stickiness to instrument.
pools and is too thick it can be gently air thinned. The adhe-
sive was light cured for 20 seconds.
A hybrid composite resin (Herculite XRV, Kerr) was
applied to the tooth (Figure 10) and was sculpted to full con-
tour using a thin metal plastic filling-sculpting instrument
(PFI-AB1, HuFriedy, Chicago, IL) that was slightly wetted
with the OptiBOND FL adhesive so the composite resin
would not pull away from any preparation margins (Figure
11). Since the preparation was less than 2.0 mm in depth, a
single increment was used for application of the composite.
The restoration was light cured with a quartz-halogen curing

8 www.ineedce.com
light (Optilux 501, Kerr Sybron) for 30 seconds. The restora-
tion was finished using a 15-bladed finishing bur (SS White
Burs) and a composite resin polishing paste (Luster Paste,
Kerr) with a soft cupped prophylaxis angle (Figure 12). The
completed restoration sealed the tooth, esthetically eliminat-
ing all postoperative sensitivity (Figure 13). At 13 years, the
restoration is still performing satisfactorily (Figure 14). In a
long-term clinical trial of 13 years with OptiBOND restored
with Herculite XRV, retention of Class V restorations was
98%, and teeth with dentin hypersensitivity at the start of the
study demonstrated elimination of that sensitivity one week
after restoration placement.72
Figure 12. Polishing the composite resin with a composite
polishing paste.
Figure 13. The completed Class V restoration
(dentistry by Dr. A.A. Boghosian).
Figure 14. 13-year recall of the OptiBond/Herculite
XRV restoration.
www.ineedce.com 9
Case report 2
A 23-year-old female patient presented to the dental school’s
clinic for treatment. She had a past history of not having
had dental treatment for five years. After a comprehensive
examination, caries was diagnosed in the pits and fissures of
the maxillary second premolar, first and second molars (Fig-
ure 15). The second molar and first molar had conventional
preparations using a 245 bur (SS White Burs). The mesio-
occlusal pit of the first molar and occlusal pit in the second
premolar had minimal caries and were prepared for preven-
tive resin restorations using a NTF Micro Narrow Tapered
Fissurotomy bur (SS White Burs) (Figure 16). The outline
of the final preparations was dictated by the extension of the
caries (Figure 17).
Figure 15. Pit and fissure caries on the second premolar and first
and second maxillary molars.
Figure 16. A minimally invasive preventive resin preparation done
with a Fissurotomy bur (SS White Burs).
Figure 17. Final preparations of #13, 14 and 15.
 The preparations were etched with a 35% phosphoric acid,
Gluma Etch 35 Gel, (Heraeus) for 15 seconds (Figure 18).
The teeth were thoroughly rinsed with an air-water spray for
10 seconds and dried, leaving the teeth slightly moist. The
adhesive, Gluma Comfort Bond + Desensitizer (Heraeus)
was applied to the tooth preparations using a BendaBrush
Micro (Centrix) (Figure 19) and allowed to sit for 15 seconds.
A gentle air stream was blown over the surface of the adhesive
to evaporate organic solvent and thin the adhesive before
light curing. The adhesive was light-cured for 20 seconds.
The smaller preventive resin preparations were restored with
flowable composite resin (Flowline, Heraeus), and the larger
preparations were restored using Solitaire 2 (Heraeus) (Figure
20). The completed restorations were well sealed and esthetic
(Figure 21).
Figure 18. Etching preparations with 35% phosphoric acid.
Figure 19. The 1-E&R adhesive (Gluma Comfort Bond + Desensi-
tizer) was applied with a BendaBrush Micro.
Figure 20A. A packable composite resin (Solitaire 2) was placed
into the conventional cavity preparations.
10 www.ineedce.com
Figure 20B. A flowable composite resin (Flowline) was placed into
the preventive resin minimally invasive preparations.
Figure 21. The completed restorations.
Self-etch single-bottle adhesive case reports
Self-etch adhesives afford the clinician the benefit of ease of
use with the elimination of multiple steps that can lead to an
inconsistency during adhesive and restoration placement. The
first single-component, non-mix dental bonding agent intro-
duced was iBOND® (Heraeus). More recently, iBOND® Self
Etch has replaced the former iBOND® and requires no mix-
ing or the application of multiple layers. It offers a simplified
and more convenient application, less technique sensitivity
with high bond strengths to both dentin and enamel, and im-
proved marginal integrity due to easy evaporation.73,74 Other
companies have introduced their own single-component
non-mix self-etch adhesive, e.g., All-in-One (Kerr), Xeno IV
(Dentsply-Caulk), Clearfil S3 (Kuraray). Unlike two-bottle
1-SEA systems that must be dispensed and mixed, single-
component SE systems can be dispensed in single-patient
unit-dose capsules.
According to manufacturers’ instructions and current evi-
dence, when using an SE adhesive system wherever there is an
enamel interface, the enamel should be prepared with a bur or
diamond. Based on the best available evidence, self-etching
adhesives are indicated for composite resin restorations that
are being bonded to defined cavity preparations, Class I, II,
III, and V.75
Case report 3
A 35-year-old male patient had a chief complaint of pain upon
biting on his mandibular first molar (Figure 22). An examina-
tion revealed an existing occlusal composite restoration. Using a
Tooth Slooth (Professional Results Inc.) and transillumination,
the diagnosis of a cracked tooth with a fracture of the distolin-
Figure 22. Mandibular first molar with occlusal composite
resin restoration and tooth exhibiting signs and symptoms of a
cracked tooth.
Figure 23. Diagnosis of cracked cusp with Tooth Slooth.
gual cusp was made (Figure 23). The existing composite resin
was removed using a 245 enhanced-blade, geometry-dentated
bur (Great White 245 GW, SS White Burs). The completed
preparation included removal of the distolingual cusp (Figure
24). A single-component, unit-dose-dispensed self-etch ad-
hesive (1-SEA) (iBOND® Self Etch, Heraeus) was applied to
the cavity preparation by painting the cavity preparation with
iBOND® Self Etch; it was agitated in the tooth preparation
for 20 seconds. A gentle air stream was then used to thin and
evaporate organic solvent from the adhesive. The tooth sur-
faces had a glossy appearance and the adhesive was then light
cured for 20 seconds with a conventional quartz-halogen light-
curing unit (Optilux 501). A wear-resistant, nanofilled hybrid
color-adaptive composite resin, Venus, was placed into the cav-
ity preparation and light cured. The restoration anatomy was
defined and finished with composite resin finishing burs (Axis)
(Figure 25). The surface was then polished with a diamond-
infused universal composite resin polishing cup (Jazz, SS
White Burs) (Figure 26). The completed esthetic restoration
was well sealed (Figure 27). The patient reported no sensitivity
to mastication after the restoration was placed.
www.ineedce.com 11
Figure 24. Completed cavity preparation with the removal of the
distolingual cusp.
Figure 25. After placement of a 1-SEA (iBOND ® Self Etch) light
curing and a color adaptive nanohybrid composite (Venus), the
restoration was shaped with a finishing bur (Axis).
Figure 26. Final finish and polish with a diamond-infused univer-
sal composite polisher (Jazz).
Case report 4
A proximal carious lesion was seen clinically on the distal
surface of the maxillary first premolar. While not evident radio-
graphically, the caries manifested itself as a slight cavitation on
the distal surface and the marginal ridge had a slightly opaque
appearance (Figure 28). Since the occlusal surface was not cari-
ous, a minimally invasive preparation of the distal surface using
a slot preparation to provide for access to restore and finish the
final restoration was done (Figure 29). The patient had a past
history of sensitivity when an etch-and-rinse adhesive had been
used for previous posterior composite restorations. The deci-
sion was made to use a self-etch adhesive (1-SEA) (OptiBOND
All-In-One) to minimize any potential for postoperative sensi-
tivity. The tooth was restored using a sectional matrix system
Figure 27. Completed restoration, eliminating patient’s symptoms
of cracked tooth.
Figure 28. Distal caries on the maxillary first premolar.
Figure 29. Minimally invasive distal slot preparation.
Figure 30. Final restoration using a 1-SEA (OptiBOND All-In-One)
and nanohybrid composite resin (Point Four).
12 www.ineedce.com
(ComposiTight Matrix with a G-Ring, Garrison Dental)
system with an optimized particle nanohybrid composite resin
(Point 4, Kerr) (Figure 30). The patient had no postoperative
sensitivity after placement of the restorations.
Conclusion
Long-term clinical trials with posterior composite resin res-
torations, porcelain veneers, crowns, and resin and ceramic
inlays and onlays provide strong evidence of clinical success
and durability when using an etch-and-rinse adhesive tech-
nique. While the multiple-bottle etch-and-rinse adhesives are
still the gold standard for all-purpose bonding, based upon
the current clinical evidence and the recommendations of
manufacturers, SE adhesive systems can be used successfully
for the restoration of Class I, II, III, and V preparations. Also
when the enamel interface is prepared to include non-carious
cervical lesions, SE adhesives provide adequate enamel etch-
ing to resist microleakage and marginal staining, and adequate
retention of both prepared teeth and NCCL Class V restora-
tions. Whichever system the clinician selects to use, he or she
should follow the manufacturer’s recommendations for clini-
cal applications to ensure clinical success.
References
1 Barkmeier WW. Current status of adhesives in dentistry. Functional esthetics and restorative dentistry.
2008. 2(1):6.
2 Leinfelder KF, Kurdziolek SM. Self-etching bonding agents. Compend Contin Educ Dent. 2003;
24:447–456.
3 Buonocore MG, Wileman W, Brudevold F. Simple method of increasing the adhesion of acrylic filling
materials to enamel surfaces. J Dent Res. 1955; 34:849.
4 Cueto EI, Buonocore MG. Sealing of pits and fissures with an adhesive resin: its use in caries prevention.
J Am Dent Assoc. 1967; 75:121–128.
5 Gwinnett AJ, Buonocore MG. Adhesives and caries prevention: a preliminary report. Br Dent J. 1965; Jul
20; 119:77–80.
6 Torney DL, Denehy GE, Teixeira LD. The acid etch Class III composite resin restoration. J Prosthet Dent.
1977; 38:623–6.
7 Jordan RE, Suzuki M, Gwinnett AJ, Hunter JK. Restoration of fractured and hypoplastic incisors by the
acid etch resin technique: a three-year report. J Am Dent Assoc. 1977; 95:795–803.
8 Strassler HE. Applications of total-etch adhesive bonding. Compend Contin Educ Dent. 2003;
24:427–36.
9 Mertz-Fairhurst EJ, Fairhurst CW, Williams JE, et al. A comparative clinical study of two pit and fissure
sealants: 7-year results in Augusta, GA. J Am Dent Assoc. 1984; 109:252–255.
10 Simonsen RJ. Preventive resin restorations(I). Quintessence Int. 1978; 9:69–76.
11 Strassler HE, Goodman HS. A durable flowable composite resin for preventive resin restorations. Dent
Today 2002; (21)(10):116–121.
12 Bargheri J, Denehy GE. Effect of enamel bevel and restoration length on Class 4 acid-etch retained
composite resin restorations. J Am Dent Assoc 1983; 107:951–953.
13 Wilder AD Jr, May KN Jr, Bayne SC, Taylor DF, Leinfelder KF. Seventeen-year clinical study of ultraviolet-
cured posterior composite Class I and II restorations. J Esthet Dent. 1999; 11:135–142.
14 Lundin SA, Koch G. Class I and II posterior composite restorations after 5 and 10 years. Swed Dent J.
1999; 23(5–6):165–171.
15 Gaengler P, Hoyer I, Montag R. Clinical evaluation of posterior restorations: the 10-year report. J Adhes
Dent. 2001; 3:185–194.
16 Strassler HE. Long-term clinical evaluation of Cerinate etched porcelain veneers. J Dent Res. 2005; 84
(Special Issue A) abstract no. 432.
17 Friedman MJ. A 15-year review of porcelain failure — a clinician’s observations. Compend Contin Educ
Dent. 1996;19:625–638.
18 Buonocore MG, Wileman W, Brudevold F. A report on a resin capable of bonding to human dentin
surfaces. J Dent Res. 1956; 35:846–50.
19 Diamond A, Carrel R. The smear layer: a review of restorative progress. J Pedod. 1984; 8:219–26.
20 Retief DH, et al. Tensile bond strengths of four dentin bonding agents to dentin. Dent Mater. 1986;
2:72–7.
21 Eliades GC, Caputo AA, Vougionklakis A. Composition, wetting properties and bond strength with
dentin of six new dentin adhesives. Dent Mater. 1985; 1:170–6.
22 Lee HL, et al. Effects of acid etchants on dentin. J Dent Res. 1973; 52:1228–33.
23 Torney DL. The retentive ability of acid-etched dentin. J Prosthet Dent. 1978; 39:169–72.
24 Skinner EW, Phillips RW. The Science of Dental Materials. 5th ed. Philadelphia, PA: WB Saunders; 1960;
277.
25 Jennings RF, Ranly DM. Autoradiographic studies of P32 penetration into enamel and dentin during
acid etching. J Child Dent. 1972; 39:69–71.
26 Torney DL. The retentive ability of acid-etched dentin. J Prosthet Dent. 1978; 39:169–72.
27 Fusayama T, et al. Non-pressure adhesion of a new adhesive restorative system. J Dent Res. 1979;
58:1364–1370.
28 Bertolotti RL. Acid etching of dentin. Quintessence Int. 1990; 21:77–78.
29 Kanca J III. One-year evaluation of a dentin-enamel bonding system. J Esthet Dent. 1990; 2:100–103.
30 Van Meerbeek B, et al. Enamel and dentin adhesion. In Fundamentals of Operative Dentistry a
Contemporary Approach. 3rd edition. Ed. Summitt JB, Robbins JW, Hilton TJ, Schwartz RS. Quintessence
Books, 2006, p. 183–260.
31 Van Meerbeek B. Mechanism of resin adhesion: dentin and enamel bonding. Functional Esthet Restor
Dent. 2008; 2(1):18–25.
32 Van Meerbeek B, De Munck J, Yoshida Y, et al. Buonocore memorial lecture. Adhesion to enamel and
dentin: current status and future challenges. Oper Dent. 2003; 28:215–35.
33 Peumans M, Kannumill PV, De Munck J, et al. Clinical effectiveness of contemporary adhesives: a
systematic review of current clinical trials. Dent Mater. 2005; 21:864–881.
34 Inoue S, Vargas MA, Abe Y, et al. Microtensile bond strength of eleven contemporary adhesives to
enamel. Am J Dent. 2003; 16:329–334.
35 Shirai K, De Munck J, Yoshida Y, et al. Effect of cavity configuration and aging on the bonding
effectiveness of six adhesives to dentin. Dent Mater. 2005; 21:110–124.
36 Van Meerbeek B. Mechanism of resin adhesion: dentin and enamel bonding. Functional Esthet Restor
Dent. 2008; 2(1):18–25.
37 Tay FR, et al. An ultrastructural study of the influence of acidity on self-etching primers and smear layer
thickness on bonding to intact dentin. J Adhes Dent. 2000; 2:83–98.
38 Perdigao J, et al. Morphological field emissions: SEM study of the effect of six phosphoric acid etching
agents on human dentin. Dent Mater. 1996; 12:262–71.
39 Perdigao J, Geraldeli S. Bonding characteristics of self-etching adhesives to intact versus prepared
enamel. J Esthet Restor Dent. 2003:5:32–42.
40 Brackett WW, Ito S, Nishitani Y, Haisch LD, Pashley DH. The microtensile bond strength of self-etching
adhesives to ground enamel. Oper Dent. 2006; 31:332–37.
41 Di Hipolita V, de Goes MF, Carrilho MR, Chan DC, Daronch M, Sinhoreti MA. SEM evaluation of
contemporary self-etching primers applied to ground and unground enamel. J Adhes Dent. 2005;
7:203–11.
42 Strassler HE. Self-etching resin adhesives. Inside Dentistry 2007; 3(2):50–4.
43 Perdigao J, Geraldeli S, Hodges JS. Total-etch versus self-etch adhesive effect on postoperative
sensitivity. J Am Dent Assoc. 2003; 134:1621–1629.
44 Akpata ES, Behbehani J. Effect of bonding systems on postoperative sensitivity from posterior
composites. Am J Dent. 2006; 19:151–4.
45 Perdigao J, Anauate-Netto C, Carmo AR, Hodges JS, et al. The effect of adhesive and flowable composite
on postoperative sensitivity: 2-week results. Quintessence Int. 2004; 35:777–84.
46 Unemori M, Matsuya Y, Akashi A, Goto Y, Akamine A. Self-etching adhesives and postoperative
sensitivity. Am J Dent. 2004; 17:191–5.
47 Browning WD, Myers M, Downey M, Schull GF, Davenport MB. Reduction in postoperative sensitivity: a
community-based study. J Dent Res (Special Issue B) 2006, 85: Abstract no. 1151.
48 Perdigao J, Geraldeli S, Hodges JS. Total-etch versus self-etch adhesive effect on postoperative
sensitivity. J Am Dent Assoc. 2003; 134:1621–1629.
49 Kanca J. Improved bond strength through acid etching of dentin and bonding to wet dentin surfaces. J
Am Dent Assoc. 1996; 123:35–43.
50 Gwinnett AJ. Moist versus dry dentin: its effect on shear bond strength. Am J Dent. 1992; 5:127–129.
51 Lee R, Blank JT. Simplify bonding with a single step: one component, no mixing. Contemp Esthet Rest
Practice. 2003; 7(5):45–46.
52 Lee R, Blank JT. Simplify bonding with a single step: one component, no mixing. Contemp Esthet Rest
Practice. 2003; 7(5):45–46.
53 Miller MB. Self-etching adhesives: solving the sensitivity conundrum. Pract Proced Aesthet Dent. 2002;
14:406.
54 Santini A, Ivanovic V, Ibbetson R, Milia E. Influence of cavity configuration on microleakage around Class
V restorations bonded with seven self-etching adhesives. J Esthet Restor Dent. 2004; 16:128–136.
55 Turkun M, et al. Effect of cavity disinfectants on the sealing ability of nonrinsing dentin-bonding resins.
Quintessence Int. 2004; 35:469–476.
56 Harnirattisai C, Senawongse P, Tagami J. Microtensile bond strengths of two adhesive resins to
discolored dentin after amalgam removal. J Dent Res. 2007; 86:232–6.
57 Ceballos L, Camego DG, Victoria Fuentes M, et al. Microtensile bond strength of total-etch and self-
etching adhesives to caries-affected dentine. J Dent. 2003; 31:469–77.
58 Say EC, Nakajima M, Senawongse P, et al. Bonding to sound vs. caries-affected dentin using photo- and
dual-cure adhesives. Oper Dent. 2005; 30:90–8.
59 Omar H, El-Badrawy W, El-Mowafy O, et al. Microtensile bond strength of resin composite bonded to
caries-affected dentin with three adhesives. Oper Dent. 2007; 32:24–30.
60 Waidyasekera PG, Nikaido T, Weerasinghe DD, et al. Bonding of acid-etch and self-etch adhesives to
human fluorosed dentin. J Dent. 2007; 35:915–22.
61 Ermis RB, De Munck J, Cardoso MV, et al. Bonding to ground versus unground enamel in fluorosed
www.ineedce.com 13
teeth. Dent Mater. 2007; 23:1250–5.
62 Godwin JM, Barghi N, Berry TG, et al. Time duration for dissipation of bleaching effects before enamel
bonding. J Dent Res; 71:179 (Abstr 590), 1992.
63 Cvitko E, Denehy GE, Swift EJ Jr, et al. Bond strength of composite resin to enamel bleached with
carbamide peroxide. J Esthet Dent. 1991; 3:100–2.
64 Basting RT, Rodrigues JA, Serra MC, Pimenta LAF. Shear bond strength of enamel treated with seven
carbamide peroxide bleaching agents. J Esthet Restor Dent. 2004 16:250–60.
65 Cadenaro M, Breshi L, Antoniolli F, et al. Influence of whitening on the degree of conversion of dental
adhesives on dentin. Eur J Oral Sci. 2006; 114:257–62.
66 Swift EJ Jr. Critical appraisal: effects of bleaching on tooth structure and restorations, Part II: enamel
bonding. J Esthet Restor Dent. 2008; 20:68–73.
67 Moll K, Schuster B, Haller B. Dentin bonding of light and self-curing resin composites using simplified
total- and self-etch adhesives. Quintessence Int. 2007; 38:27–35.
68 Ernst CP, Galler P, Willershausen B, et al. Marginal integrity of class V restorations: SEM versus dye
penetration. Dent Mater. 2008; 24:319–27.
69 Magne P, So WS, Casecione D. Immediate dentin sealing supports delayed restoration placement. J
Prosthet Dent. 2007; 98:166–74.
70 Boghosian AA, Drummond JL, Lautenschlager E. Clinical evaluation of a dentin adhesive system: 13
year results. J Dent Res (Special Issue) 2007; 86: abstract no. 228.
71 Boghosian AA, Drummond JL, Lautenschlager E. Clinical evaluation of a dentin adhesive system: 13
year results. J Dent Res (Special Issue) 2007; 86: abstract no. 228.
72 Boghosian AA, Drummond JL, Lautenschlager E. Clinical evaluation of a dentin adhesive system: 13
year results. J Dent Res (Special Issue) 2007; 86: abstract no. 228.
73 Hannig M. In vitro investigation on the marginal gap and internal adaptation of different bonding
agents and composites in class II cavities. Data on file.
74 Haller B. Marginal integrity of class II composite fillings with iBOND Self Etch. Data on file.
75 Strassler HE. Self-etching resin adhesives. Inside Dentistry 2007; 3(2):50–4.
Author Profile
Howard E. Strassler, DMD, FADM, FAGD
Dr. Howard Strassler is professor and director of operative
dentistry at the University of Maryland Dental School in the
Departments of Endodontics, Prosthodontics, and Operative
Dentistry. He has lectured nationally and internationally on
techniques and a selection of dental materials in clinical use and
aesthetic restorative dentistry. He is a fellow in the Academy
of Dental Materials and the Academy of General Dentistry, a
member of the American Dental Association, the Academy of
Operative Dentistry, and the International Association of Dental
Research. He is on the editorial board of numerous publications.
He is a consultant and clinical evaluator to more than 15 dental
manufacturers. Dr. Strassler has a general practice in Baltimore,
Maryland, that is limited to restorative dentistry and aesthetics.
Luis Guilherme Sensi, DDS, MS, PhD
Dr. Sensi is an Assistant Professor and Coordinator of Es-
thetic at the University of Maryland Dental School in the
Department of Endodontics, Prosthodontics, and Opera-
tive Dentistry. Dr. Sensi has over 20 publications and three
Chapters in dental texts. He is a member of the International
Association of Dental Research. He has been involved in
research on adhesives, light curing and composite resins. He
has lectured in the United States and Brazil.
Disclaimer
The authors of this course have no commercial ties with the sponsors or the providers of the unrestricted
educational grant for this course.
Reader Feedback
We encourage your comments on this or any PennWell course. For your convenience, an online feedback
form is available at www.ineedce.com.

1. The earliest bonding systems required
an acid-etch technique and were only
compatible with dentin.
a. True
b. False
2. The differentiation of bonding systems is
in fact two distinct classes: ____ and ____.
a. step-etch; etch-and-rinse
b. rinse-and-seal; self-etch
c. etch-and-rinse; self-etch
d. none of the above
3. For successful adhesion of a bonding
agent to tooth structure, prerequisites
include that _________.
a. the procedure must be safe and
biologically acceptable
b. the bond strength must be routinely achieved,
established quickly and clinically significant
c. the bond must be stable in vivo for a clinically
significant period of time
d. all of the above
4. The idea of adhesive bonding to dentin
was theoretically postulated more than 50
years ago.
a. True
b. False
5. The first clinical application in dentistry
of acid-etching and resin adhesion was
for _________.
a. indirect restorations
b. sealants
c. direct resin composites
d. none of the above
6. Friedman’s retrospective study of
porcelain veneers, where he evaluated
approximately 3,500 restorations and re-
ported on 245 failures, found a _________
success rate.
a. 753%
b. 88%
c. 93%
d. 96%
7. Effective dentin-bonding materials
should _________.
a. be retentive to dentin at a clinically acceptable level
b. be able to withstand intraoral forces of occlusion
and mastication
c. be biocompatible and minimize or eliminate
postoperative sensitivity
d. all of the above
8. Dental bonding materials should resist
the forces of polymerization shrinkage
of composite resins and the coefficient
of thermal expansion and contraction to
eliminate microleakage.
a. True
b. False
9. The earliest research on dentin bonding
focused on chemical adhesion of resins to
the inorganic components of dentin, with
the development of _________.
a. an ethacrylate-based dentin adhesive that
contained phosphate groups to attach to the
calcium ions on the dentin surface
b. a methacrylate-based dentin adhesive that
contained carbonate groups to attach to the
calcium ions on the dentin surface
c. a methacrylate-based dentin adhesive that
contained phosphate groups to attach to the
calcium ions on the dentin surface
d. none of the above
10. The dentin smear layer _________.
a. consists of loosely bound debris including
fractured crystals of hydroxyapatite and
denatured collagen
b. acts as a conduit for the dentin tubules
c. acts as a barrier to clog the dentin tubules
d. a and c
14 www.ineedce.com
Questions
11. Dentin bonding attached to the smear
layer creates a strong, clinically accept-
able bond to dentin.
a. True
b. False
12. The total-etch approach
involves _________.
a. etching the enamel totally, but not the dentin
b. etching the enamel first and then the dentin
c. etching the enamel and dentin simultaneously
d. none of the above
13. All adhesives used today exhibit the
same phenomenon for adhesion to
enamel of _________.
a. micromechanical locking to both the etched
enamel prisms and dentinal tubules
b. micromechanical locking to the etched enamel
prisms and to dentin through hybridization
c. macromechanical locking to the etched
enamel interprismatically and to dentin through
hybridization
d. all of the above
14. In the mid 1990s clinicians sought a
simplified approach that used fewer steps
for adhesive placement.
a. True
b. False
15. The etch-and-rinse adhesives
involve _________.
a. an initial step of the application of up to 10%
phosphoric acid to the enamel/dentin, followed by
rinsing and drying of the dentin
b. an initial step of the application of 10%–40% maleic
acid to the enamel/dentin, followed by rinsing and
drying of the dentin
c. an initial step of the application of 10%–40%
phosphoric acid to the enamel/dentin, followed by
rinsing and drying of the dentin
d. any of the above
16. _________ demonstrated that the pulpal
effect of phosphoric acid on dentin for
one minute was minimal.
a. Hemmings and Ranly
b. Jennings and Manly
c. Jennings and Ranly
d. none of the above
17. In vitro and in vivo research have
demonstrated that _________.
a. etch-and-rinse adhesives can reliably bond to both
enamel and dentin
b. etch-and-rinse adhesives can reliably bond
only to enamel
c. etch-and-rinse adhesives can reliably bond
only to dentin
d. none of the above
18. Based upon the evidence to date, bond-
ing to enamel is best accomplished with
the self-etch technique.
a. True
b. False
19. The basic clinical technique influences
clinical success and includes _________.
a. etching with a phosphoric acid of the appropriate
concentration for 15–30 seconds
b. rinsing with air–water spray for 10 seconds and
leaving the tooth wet
c. rinsing with air–water spray for 10 seconds and
drying the tooth, leaving the enamel frosty, the
dentin glossy
d. a and c
20. A separate rewetting with water step
is eliminated with self-etch adhesives
because they contain water and are never
completely dried from the tooth.
a. True
b. False
21. Self-etch adhesives _________.
a. use a more acidic monomer in a GLUMA/
water-based adhesive
b. use a more acidic monomer in a HEMA/water-
based adhesive
c. do not require a separate etch-and-rinse step
d. b and c
22. Self-etching adhesives incorporate the
smear layer into the adhesive.
a. True
b. False
23. A number of studies have demon-
strated no difference in postoperative
sensitivity between etch-and-rinse and
self-etch adhesives.
a. True
b. False
24. Self-etch adhesives _________.
a. are water containing
b. can minimize operator variability by simplifying
the technique used
c. require that the adhesive be thinned with a gentle
spray of air following application
d. all of the above
25. A very thick layer of self-etch
adhesive _________.
a. will have no impact on bonding
b. will compromise bonding
c. results in a stronger composite restoration
d. none of the above
26. Harnirattisai et al. found no differ-
ences in adhesion to normal dentin and
discolored amalgam-affected dentin with
both an etch-and-rinse adhesive and a
self-etch adhesive.
a. True
b. False
27. _________ adhesives provide for better
bonding to fluoride-rich dentin.
a. Self-etch
b. Etch-and-rinse
c. The combined use of self-etch and etch-and-rinse
d. none of the above
28. Clinical success with self-etch adhesives
is dependent on the basic clinical
technique, including _________.
a. tooth preparation (not Class IV, not facial veneers,
not porcelain veneers)
b. applying the adhesive following the manufacturer’s
instructions for dwell time
c. air drying the tooth following the timing and type
of air spray given in the product instructions
d. all of the above
29. Bonding to caries-affected dentin has
been shown to _________.
a. have increased bonding strength
b. result in a reduced level of hypersensitivity,
compared to bonding to virgin dentin
c. have decreased bonding strength
d. none of the above
30. Research supports waiting at least
one week after bleaching before any
restorative procedure with either an etch-
and-rinse or a self-etch adhesive is carried
out, to prevent interference with bonding
adhesion and material setting.
a. True
b. False
 ANSWER SHEET

Contemporary Dental Adhesives for Direct Placement Composite Restorations

Name: Title: Specialty:

Address: E-mail:

City: State: ZIP:

Telephone: Home ( ) Office ( )

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.

Mail completed answer sheet to

Educational Objectives Academy of Dental Therapeutics and Stomatology,
1. Discuss the differences between etch-and-rinse and self-etch adhesives, and relate these categories to other naming A Division of PennWell Corp.

systems that have been previously presented. P.O. Box 116, Chesterland, OH 44026
or fax to: (440) 845-3447
2. Discuss current research evidence comparing etch-and-rinse and self-etch adhesives.
3. Describe the indications for etch-and-rinse and self-etch adhesives. For immediate results, go to www.ineedce.com
and click on the button “Take Tests Online.” Answer
4. Describe the clinical procedure for an etch-and-rinse and self-etch single-step adhesive. sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
P ayment of $59.00 is enclosed.
Course Evaluation (Checks and credit cards are accepted.)
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. If paying by credit card, please complete the
following: MC Visa AmEx Discover
1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No
Acct. Number: _______________________________
Objective #2: Yes No Objective #4: Yes No
Exp. Date: _____________________
2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0
Charges on your statement will show up as PennWell
3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0

4. How would you rate the objectives and educational methods? 5 4 3 2 1 0

5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0

6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0

7. Was the overall administration of the course effective? 5 4 3 2 1 0

8. Do you feel that the references were adequate? Yes No

9. Would you participate in a similar program on a different topic? Yes No

10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________

11. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
___________________________________________________________________

12. What additional continuing dental education topics would you like to see?
___________________________________________________________________
___________________________________________________________________ AGD Code 253

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AUTHOR DISCLAIMER INSTRUCTIONS COURSE CREDITS/COST RECORD KEEPING

The author(s) of this course has/have no commercial ties with the sponsors or the providers of
the unrestricted educational grant for this course.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational grant from Heraeus
Inc. and Kerr Corporation. No manufacturer or third party has had any input into the
development of course content. All content has been derived from references listed,
and or the opinions of clinicians. Please direct all questions pertaining to PennWell or
the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK
74112 or macheleg@pennwell.com.
COURSE EVALUATION and PARTICIPANT FEEDBACK
We encourage participant feedback pertaining to all courses. Please be sure to complete the
survey included with the course. Please e-mail all questions to: macheleg@pennwell.com.
All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confirmation of passing by receipt of a verification
form. Verification forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily reflect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the field related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.
All participants scoring at least 70% (answering 21 or more questions correctly) on the
examination will receive a verification form verifying 4 CE credits. The formal continuing
education program of this sponsor is accepted by the AGD for Fellowship/Mastership
credit. Please contact PennWell for current term of acceptance. Participants are urged to
contact their state dental boards for continuing education requirements. PennWell is a
California Provider. The California Provider number is 3274. The cost for courses ranges
from $49.00 to $110.00.
Many PennWell self-study courses have been approved by the Dental Assisting National
Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet
DANB’s annual continuing education requirements. To find out if this course or any other
PennWell course has been approved by DANB, please contact DANB’s Recertification
Department at 1-800-FOR-DANB, ext. 445.
PennWell maintains records of your successful completion of any exam. Please contact our
offices for a copy of your continuing education credits report. This report, which will list
all credits earned to date, will be generated and mailed to you within five business days
of receipt.
CANCELLATION/REFUND POLICY
Any participant who is not 100% satisfied with this course can request a full refund by
contacting PennWell in writing.
© 2008 by the Academy of Dental Therapeutics and Stomatology, a division
of PennWell
ADHE0805PAT

www.ineedce.com 15