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J Am Dent Assoc, Vol 134, No 12, 1621-1629.
© 2003 American Dental Association
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COSMETIC & RESTORATIVE CARE

Total-etch versus self-etch adhesive

Effect on postoperative sensitivity



JORGE PERDIGÃO, D.M.D., M.S., Ph.D., SAULO GERALDELI, D.D.S., M.S., Ph.D. and JAMES S. HODGES, Ph.D.


   ABSTRACT
TOP
 ABSTRACT
CLINICAL PROTOCOL
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. Self-etching adhesives are believed to prevent postoperative sensitivity when used under posterior resin-based composite restorations. The authors tested a twofold hypothesis: a self-etch, or SE, adhesive would result in less postoperative sensitivity than a total-etch, or TE, adhesive; an SE adhesive would result in poorer enamel marginal integrity than a TE adhesive.

Methods. Patients were selected on the basis of requiring Class I and II restorations in molars and premolars. The authors placed 30 restorations with the SE material (Clearfil SE Bond, Kuraray America, New York) and 36 restorations with Prime & Bond NT (Dentsply Caulk, Milford, Del.), which uses 34 percent phosphoric acid to etch enamel and dentin simultaneously. Preparations were of standard design, with all margins in enamel without beveling. Upon rubber dam isolation, the authors conditioned the enamel and dentin walls with the self-etching primer (for Clearfil SE Bond) or etched with the proprietary 34 percent phosphoric acid (for Prime & Bond NT), followed by application of the corresponding dentin adhesive. Teeth were restored with the proprietary hybrid resin-based composite indicated for posterior restorations: Clearfil AP-X for Clearfil SE Bond or Esthet•X Micro Matrix Restorative for Prime & Bond NT. The restored teeth were evaluated preoperatively and at two weeks, eight weeks and six months postoperatively for sensitivity to cold (ice), air and masticatory forces, as well as for marginal discoloration.

Results. Analysis of variance revealed no statistically significant differences in postoperative sensitivity between the SE and TE materials at any recall time. Marginal discoloration was rated as "absent" for all restorations at six months. Only one tooth displayed sensitivity to occlusal forces at six months.

Conclusion. The SE adhesive did not differ from the TE adhesive in regard to sensitivity and marginal discoloration.

Clinical Implications. Postoperative sensitivity may depend on the restorative technique rather than on the type of dentin adhesive used.

Bonding to enamel has been successful since Buonocore introduced the acid-etch technique in 1955.1 Bonding to dentin has been less predictable because of the wet tubular ultrastructure and organic composition of the dentin substrate.2

The introduction of the total-etch, or TE, technique3 and recent developments in the chemistry of dentin adhesives have made resin-based composite restorative materials almost resistant to microleakage, with bond strengths that approach those of enamel bonding.4–6 The improvements seen in the laboratory have been confirmed in the clinical setting with the recent generation of adhesive systems.7,8 Bonding to etched enamel and dentin while relying on the entanglement of resin monomers with dental substrates, or hybridization, is now considered the fundamental mechanism for retention of resin-based composite restorations.9,10

The self-etch adhesive did not differ from the total-etch adhesive in regard to sensitivity and marginal discoloration.

Recent dentin adhesives use one of two strategies to interact with the dentin smear layer: the TE technique or the self-etch, or SE, technique.11 TE materials use 30 to 40 percent phosphoric acid to etch dentin and enamel before the clinician applies the adhesive to the preparation. Etching dentin removes the smear layer and opens up the dentinal tubules. SE adhesives, which are being used increasingly,12,13 do not require a separate acid-etch step, and do not remove the smear layer. They are composed of aqueous mixtures of acidic functional monomers, generally phosphoric acid esters, with a pH relatively higher than that of phosphoric acid-etching gels.14 While the pH for a 34 to 37 percent phosphoric acid gel is in the range of 0.5 to 1.0, the pH of Clearfil SE Bond (Kuraray America, New York) is 1.9 to 2.0.15,16 Miller13 reported that SE adhesives do not etch enamel to the level obtained with phosphoric acid.

Postoperative sensitivity after placing posterior composite restorations has been a problem experienced by clinicians for almost 20 years,17–20 even when a dentin liner is used.21 For some clinicians, however, postoperative sensitivity does not seem to occur frequently after placing composite restorations in their patients. For other dentists, postoperative sensitivity remains a problem for Class I, II and V resin-based composite restorations.19

Few clinical studies have focused on postoperative sensitivity caused by dentin adhesives. Opdam and colleagues20 conducted a study in which they used a TE dentin adhesive and resin-based composite to restore teeth. They found that up to 56 percent of the restorations in posterior teeth resulted in sensitivity on loading, while an additional 14 percent of the teeth experienced spontaneous postoperative sensitivity at five to seven weeks. However, the TE dentin adhesive used in their study was a multibottle, water-based dentin adhesive with a composition and application mode different from that of currently used simplified one-bottle materials. Although another study reported sensitivity to be virtually zero for an SE adhesive, the researchers did not use a TE adhesive as a positive control.22

The hypothesis tested in our clinical study was twofold: an SE adhesive would result in less postoperative sensitivity than a TE adhesive; an SE adhesive would result in greater enamel marginal discoloration than a TE adhesive.


   CLINICAL PROTOCOL
TOP
 ABSTRACT
 CLINICAL PROTOCOL
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Before participating in the study, patients signed a consent form. Both the form and this research protocol were reviewed and approved by the Institutional Review Board at the University of Minnesota School of Dentistry, Minneapolis. All 25 patients required Class I and Class II restorations in molars and premolars, either for replacement of an existing restoration or for treatment of primary carious lesions. The dental health status of patients was normal in all other respects, except for ongoing restorative procedures in unrelated and unopposed quadrants. The boxGo enumerates specific exclusion criteria.


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  		BOX PATIENT EXCLUSION CRITERIA.

 
We obtained preoperative bitewing radiographs of the teeth to be restored, unless the patient had had radiographs taken within the previous year. The teeth to be restored had a normal occlusal relationship with natural dentition and an opposing and adjacent tooth contact. The average faciolingual width of each preparation was greater than or equal to one-third of the distance between the cusp tips. All preparations were of conventional amalgam design and cavosurface angles were entirely within enamel, without any intentional bevel (Figures 1Go and 2Go).



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  		Figure 1. Clinical case in which self-etch, or SE, adhesive (Clearfil SE Bond, Kuraray America, New York) and resin-based composite material (Clearfil AP-X, Kuraray America) were used to restore tooth no. 18. A. Carious lesion on tooth no. 18. B. Removal of soft carious dentin with excavator. C. Removal of carious dentin with slow-speed carbide bur. D. Application of primer (Clearfil SE Bond Primer, Kuraray America). E. Application of SE adhesive (Clearfil SE Bond). F. Insertion of first increment of resin-based composite material (Clearfil AP-X). G. After light-curing the first increment, the operator inserted the second increment of composite material and light-cured it. H. Immediate postoperative view. I. Tooth at the six-month recall appointment.

 


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  		Figure 2. Clinical case in which total-etch, or TE, adhesive (Prime & Bond NT, Dentsply Caulk, Milford, Del.) and resin-based composite material (Esthet•X Micro Matrix Restorative, Dentsply Caulk) were used to restore tooth no. 12. A. Existing faulty restoration on tooth no. 12. B. Removal of soft carious dentin with excavator. C. Removal of carious dentin with slow-speed carbide bur. D. Use of an explorer to check for the hardness of remaining dentin. E. Preparation after removal of infected dentin. F. Etching with 34 percent phosphoric acid (Caulk 34% Tooth Conditioner Gel) for 15 seconds, followed by rinsing and application of TE adhesive (Prime & Bond NT) on moist dentin. G. After light-curing the first increment, the operator inserted the second increment of composite material and light-cured it. H. Immediate postoperative view. I. Tooth at the six-month recall appointment.

 
Two of us (J.P., S.G.) placed at least two restorations in simulated Class II preparations to practice this technique before we placed the first actual restoration. The director of the study (J.P.) stated that if a pink color was observed on the pulpal or axial wall of the preparation after carious dentin excavation, a microexposure of the pulp was to be suspected, and the operators should place a thin layer of calcium hydroxide liner (Dycal, Dentsply Caulk, Milford, Del.) in those deep areas, followed by a thin layer of resin-modified glass ionomer cement (Vitrebond, 3M ESPE, St. Paul, Minn.).

All operative procedures were performed under local anesthesia, and all operating sites were isolated with a rubber dam. The operators applied an appropriate matrix (Palodent, Dentsply Caulk, or HO Bands no. 1, Young Dental, Earth City, Mo.) and Sycamore wood wedges (Premier Dental Products, Plymouth Meeting, Pa.) to the cervical margins of Class II preparations.

Application of primer and adhesive. The operators treated the enamel and dentin walls of the preparation by applying an SE dentin/enamel primer (Clearfil SE Bond Primer, Kuraray America) for 20 seconds or by etching with 34 percent phosphoric acid (Caulk 34% Tooth Conditioner Gel, Dentsply Caulk) for 15 seconds. Although the SE primer was not rinsed, the phosphoric acid was washed for 10 seconds and the dentin was left visibly moist (glistening), or the dentin was remoistened to an acceptable moisture level. The operators then applied the adhesives to the walls of the preparations according to the manufacturers’ instructions (Table 1Go, page 1625).


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  		TABLE 1 ADHESIVE SYSTEM, COMPOSITION AND INSTRUCTIONS FOR USE.

 
Each subject received two or three restorations, with each etching method applied to one or two teeth. We assigned etching methods randomly to teeth for each subject.

Placement of resin-based composite restoration. The operators inserted resin-based composite restorative material (Esthet•X Micro Matrix Restorative, Dentsply Caulk, for Prime & Bond NT adhesive or Clearfil AP-X, Kuraray America, for Clearfil SE Bond adhesive) in two or three increments, and used a curing light to polymerize for 40 seconds per increment and 40 seconds for both facial and lingual gingival corners. They checked the intensity of the light with a radiometer after every 20 restorations were placed to ensure that it exceeded 400 milliwatts/square centimeter.

After polymerization, the clinicians performed coarse finishing with appropriate finishing carbide burs (Brasseler USA, Savannah, Ga.), aluminum oxide disks (Sof-Lex XT, 3M ESPE), cups and points (Enhance, Dentsply Caulk) and pastes (Prisma Gloss, Dentsply Caulk). They performed proximal finishing using a no. 12 blade and abrasive strips (Brasseler USA). All restoration insertions for each patient were done in one or two appointments (if they had three restorations in different quadrants).

Evaluation of hypersensitivity. In addition to the assessments made immediately before treatment, the operators evaluated hypersensitivity at two weeks, eight weeks and six months after treatment. At each evaluation, the operator recorded the sensitivity of each tooth to applications of compressed air, a cold stimulus and masticatory forces as the patient’s spoken response to a visual analogue scale from 0 to 10 (continuous measurements). They applied cold in the form of an ice stick and compressed air from the three-way dental unit syringe at a distance of approximately 2 cm. The clinicians timed the applications of each stimulus until the subject responded by raising his or her left hand, with a maximum application lasting 15 seconds. Immediate responses were recorded as zero seconds. Two of us (J.P., S.G.) were present at each evaluation to help ensure standardization.

The clinicians examined patients at recall appointments that were scheduled as close as possible to the actual day prescribed by the study design (that is, two weeks, eight weeks, six months). For the purpose of data collection, we considered any recall visit that occurred within plus or minus 10 percent of the scheduled time for recall as occurring at that time.

Evaluation of marginal discoloration. To evaluate marginal discoloration, we collected intraoral color photographs at baseline and at each recall appointment. Clinical photographs consisted of digital images taken at an original magnification of x1.0 or x1.5. The two operators evaluated marginal discoloration at six months according to this scale: Alfa = no marginal discoloration; Bravo = slight staining that disappears on polishing; Charlie = discoloration that penetrates the interface and cannot be polished; Delta = evidence of caries.

Statistical methods. We analyzed four dependent variables: cold sensitivity and response time, and air sensitivity and response time. Each analysis was a repeated-measures analysis of variance in which each subject provided measures for both treatments at three follow-up times (two weeks, eight weeks, six months). (Preliminary analyses showed that this analysis gave the same results as analyses in which the dependent variable was the change from baseline to each follow-up time, so we omitted the latter analyses.)

For subjects with more than one tooth receiving a given treatment, we averaged the dependent variables at each visit across the teeth that received a given treatment. Thus, the analysis used one measure per subject per treatment at each visit.


   RESULTS
TOP
 ABSTRACT
 CLINICAL PROTOCOL
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
We restored 66 teeth (42 molars, 24 premolars) in 25 subjects (seven men, 18 women; age range, 21 to 54 years). Nine subjects had two teeth restored and 16 subjects had three teeth restored. Of the 30 teeth restored with Clearfil SE Bond, 20 (67 percent) were molars. Of the 36 teeth restored with Prime & Bond NT, 22 (61 percent) were molars (the difference was not significant).

Table 2Go shows means and standard errors for "severity of response" and "time to response" for both air and cold stimuli. For all four dependent variables (that is, air sensitivity, air response time, cold sensitivity, cold response time), neither main effect (treatment or time) was significant, nor was the interaction between treatment and time. (The treatment main effect answers the question, "Averaging over visits, do the two treatments differ?"; the visit main effect answers the analogous question for visits. The interaction answers the question, "Is the difference between treatments the same for all three visits?")


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  		TABLE 2 SEVERITY AND TIME OF RESPONSE TO COMPRESSED AIR, COLD AND MASTICATORY FORCES.

 
No tooth exhibited sensitivity to masticatory forces, except for one tooth that had a macroscopic pulp exposure that we capped with calcium hydroxide and resin-modified glass ionomer. This tooth, which was restored with Prime & Bond NT and Esthet•X Micro Matrix Restorative, resulted in a sensitivity score of 1 (0 to 10 scale) in response to occlusal forces at six months.


   DISCUSSION
TOP
 ABSTRACT
 CLINICAL PROTOCOL
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
Postoperative sensitivity has been attributed to several factors, including dentin etching and bacterial penetration of the pulp,23 occlusal discrepancies, deformation of the cusps by shrinkage stress16 and deformation of composite by occlusal forces.24 The problem recently resurfaced, as many dentists report that postoperative sensitivity is still prevalent.19 Only a few clinical studies have measured postoperative sensitivity of SE adhesives, TE adhesives or both in posterior restorations, and the results have been mixed.20,22 One study20 compared an SE adhesive with a TE adhesive, but these were multistep materials that are no longer popular among clinicians.

Self-etch adhesives are less technique-sensitive than are total-etch adhesives.

SE adhesives. SE adhesives condition and prime enamel and dentin simultaneously without rinsing; they rely on their ability to partially dissolve hydroxyapatite to yield a resin-infiltrated zone with minerals incorporated.25 However, not all SE materials are similar in their ability to interact with the smear layer. Accordingly, they have been classified in three categories: mild, moderate and aggressive, with Clearfil SE Bond being a mild SE adhesive.16

One of the shortfalls of SE adhesives is that they do not etch enamel to the level achieved with phosphoric acid.13 Several studies have evaluated SE adhesives for their enamel-etching ability.26–30 Some of these studies indicated that enamel bonding with SE adhesives is as effective as enamel bonding after conventional phosphoric acid etching.29 Other studies demonstrated that SE adhesives are effective only on ground enamel, but are less effective on intact enamel,16,28 because SE materials do not result in an enamel-etching pattern as well-defined as the one produced by phosphoric acid etching.28

Miyazaki and colleagues30 conducted a study in which they found a significant decrease in enamel bond strengths for the three SE adhesives tested when specimens were thermocycled up to 30,000 cycles, while for three of the four TE adhesives tested, they found no significant differences from baseline to 30,000 cycles. This decrease in bond strength with thermal fatigue might be a sign that enamel marginal adaptation under clinical conditions might not be optimized, and microleakage might occur around enamel margins. However, in our study, we found no clinical signs of marginal degradation at six months for restorations bonded with the SE adhesive.

SE adhesives are less technique-sensitive than are TE adhesives. SE adhesives do not remove the smear layer from dentin completely, so clinicians13 believe they cause less postoperative sensitivity than do TE adhesives. Furthermore, SE adhesives are not likely to result in a discrepancy between the depth of demineralization and the depth of resin infiltration,13,14 because both processes occur simultaneously. Another advantage of SE adhesives is that moist bonding is not required.

TE adhesives. For Prime & Bond NT, the operators followed the manufacturer’s instructions, which call for application of additional adhesive if the tooth surface does not remain totally wetted by the material after the first application of the TE adhesive. The operators placed at least two coats of adhesive in all restorations that were bonded with Prime & Bond NT, because the pulpal floor never looked consistently covered by the adhesive after application of the first coat. They used magnification loupes for every procedure in this clinical study.

After applying the last coat of the dentin adhesive, the operators inspected the pulpal floor of each preparation to check for any area that was not covered with the adhesive material. If they found a dry spot, which happened only with Prime & Bond NT, the operators applied an extra coat of adhesive according to the manufacturer’s instructions. This might have prevented the dentin tubules from being in direct contact with the resin-based composite in the dry spot areas, thereby preventing postoperative sensitivity probably due to hydraulic pressure from occlusal forces.31 In fact, Platt and colleagues32 have shown that when Prime & Bond NT is applied in one layer, bond strengths are substantially reduced.

Clinical conditions. This study was carried out in ideal clinical conditions, under rubber dam isolation, and each appointment was scheduled for two hours per patient during the insertion phase (a patient needed to return for a second appointment only if he or she required more than two restorations). The environment in which the clinical study is carried out raises a somewhat debatable issue.

Academic environment versus clinical practice setting. Should the study be conducted in an academic environment (in which students and faculty typically have more time to perform procedures, a wider selection of dental materials may be available for use, and research data regarding the correct use of materials are more readily available), or should it be carried out in a clinical practice setting in which the material is used most often? We definitely need to know the behavior of materials used under ideal conditions, so all materials should be tested first in the ideal academic setting (for example, one of the conditions for inserting posterior resin-based composites always has been rubber dam isolation).

Postoperative sensitivity, fracture of the enamel and opening of restoration margins may result in microleakage, staining of marginal gaps and recurrent caries, and are the most common clinical problems caused by polymerization shrinkage.33 The amount of curing contraction stress generated by light-curing resin-based composites in the preparation is deemed to be an important factor in determining the longevity of the restoration. The magnitude of the curing stress is a function of the ratio of the bonded surface area to the unbonded surface area of the restoration,34,35 as well as of the properties of the composite.36,37

The polymerization shrinking stresses are critical for the microscopic integrity of the adhesive bond to dentin.38 To minimize the deleterious effects of shrinkage stresses on the marginal integrity of the composite restorations, we used an incremental filling technique in this study. Researchers39,40 have shown that increments should be no larger than 2 millimeters to provide uniform and maximum polymerization.

Our study showed that the choice of dentin adhesive (that is, SE or TE) did not result in any significant difference in postoperative sensitivity. The clinical technique, therefore, may be more relevant for the development of postoperative sensitivity than is the type of adhesive itself. Future studies should focus on the long-term performance of TE versus SE adhesives, and include other variables such as the use of flowable composites as the cervical increment in Class II composite restorations.


   CONCLUSION
TOP
 ABSTRACT
 CLINICAL PROTOCOL
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
The SE adhesive Clearfil SE Bond did not result in less postoperative sensitivity at any recall period than that of the TE adhesive Prime & Bond NT. Both of the adhesives resulted in excellent enamel marginal integrity at six months.



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  		Dr. Perdigão is an associate professor, Division of Operative Dentistry, Department of Restorative Sciences, University of Minnesota, 8-450 Moos Tower, 515 S.E. Delaware St., Minneapolis, Minn. 55455, e-mail "perdi001{at}umn.edu". Address reprint requests to Dr. Perdigão.

 


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  		At the time this study was conducted, Dr. Geraldeli was a visiting professor, Division of Operative Dentistry, Department of Restorative Sciences, University of Minnesota, Minneapolis. He currently is a research professor, University of Santo Amaro, SP, Brazil.

 


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  		Dr. Hodges is a senior research associate, Division of Biostatistics, University of Minnesota, Minneapolis, and director, Biostatistical Core, School of Dentistry, University of Minnesota.

 


   FOOTNOTES
 

This project received the financial support of Kuraray America, New York.


Materials were donated by Kuraray America; Dentsply Caulk, Milford, Del.; 3M ESPE, St. Paul, Minn.;. and Premier Dental Products, Plymouth Meeting, Pa.


   REFERENCES
TOP
 ABSTRACT
 CLINICAL PROTOCOL
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

  1. Buonocore MG. A simple method of increasing the adhesion of acrylic filling materials to enamel surfaces. J Dent Res 1955;34:849–53.[Abstract/Free Full Text]

  2. Swift EJ, Perdigão J, Heymann HO. Bonding to enamel and dentin: a brief history and state of the art, 1995. Quintessence Int 1995;26:95–110.[Medline]

  3. Fusayama T, Nakamura M, Kurosaki N, Iwaku M. Non-pressure adhesion of a new adhesive restorative resin. J Dent Res 1979;58: 1364–70.[Abstract/Free Full Text]

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  7. Van Meerbeek B, Peumans M, Verschueren M, et al. Clinical status of ten adhesive systems. J Dent Res 1994;73:1690–702.[Abstract/Free Full Text]

  8. Swift EJ, Perdigão J, Wilder AD, Heymann HO, Sturdevant JR, Bayne SC. Clinical evaluation of two one-bottle dentin adhesives at three years. JADA 2001;132:1117–23.

  9. Nakabayashi N, Kojima K, Masuhara E. The promotion of adhesion by the infiltration of monomers into tooth substrates. J Biomed Mater Res 1982;16:265–73.[Medline]

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  27. Ferrari M, Mannocci F, Vichi A, Davidson CL. Effect of two etching times on the sealing ability of Clearfil Liner Bond 2 in Class V restorations. Am J Dent 1997;10:66–70.[Medline]

  28. Perdigão J, Geraldeli S. Bonding characteristics of self-etching adhesives to intact versus prepared enamel. J Esthet Restor Dent 2003;15:32–41.[Medline]

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  30. Miyazaki M, Sato M, Onose H. Durability of enamel bond strength of simplified bonding systems. Oper Dent 2000;25:75–80.[Medline]

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