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J Am Dent Assoc, Vol 138, No 7, 985-991.
© 2007 American Dental Association
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RESEARCH

JADA Continuing Education

The influence of dental unit waterline cleaners on composite-to-dentin bond strengths

André V. Ritter, DDS, MS, Eduardo Ghaname, DDS, MS and Ralph H. Leonard, DDS, MPH


   ABSTRACT
TOP
 ABSTRACT
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
Background. One approach to controlling dental unit waterline (DUWL) contamination by microorganisms is the addition of chemical cleaners to the treatment water. Yet, there is concern that these cleaners might affect the bonding of resin-based composites to enamel and dentin. The authors evaluated the influence of DUWL cleaners on composite-to-dentin bond strengths.

Methods. The authors tested the strength of resin-based composite bonded to dentin in specimens treated with distilled water (control) or one of four cleaners. They tested a total-etch adhesive, a self-etching primer/adhesive and an experimental self-etching primer/adhesive. The authors stored the specimens for 24 hours at 37 C and tested them to determine their bond strengths.

Results. The mean shear bond strengths (SBSs) varied according to the cleaner and adhesive used, ranging from 14.7 to 21.9 megapascals. However, the authors found no statistically significant differences and/or interactions between mean SBSs of specimens treated with the various DUWL cleaners and adhesives (P ≥ .05).

Conclusions. The tested DUWL cleaners did not significantly influence composite-to-dentin bond strengths for the total-etch adhesive and self-etching primer/adhesives used in this study.

Clinical Implications. The conclusions imply that bonding of resin-based composites to dentin is not affected by the cleaners tested when they are used to treat DUWL contamination.

Key Words: Dental unit waterline contamination; dental unit treatment water; dentin bonding

Abbreviations: DUWL: Dental unit waterline • NaClO: Sodium hypochlorite • SBS: Shear bond strength

The formation of biofilms on dental unit waterlines (DUWLs) is a problem in dentistry that has gained increased attention during the last several years.1–5 More than 40 species of microorganisms have been isolated from DUWLs.6,7 Gram-negative mesophilic heterotrophic water bacteria account for the majority of the microorganisms identified. However, opportunistic human pathogens such as Pseudomonas aeruginosa, Legionella species and nontuberculous Mycobacterium also have been documented.7–10

Bacterial counts in nontreated DUWLs can exceed 104 to 106 colony-forming units per milliliter.11 In 2003, the Centers for Disease Control and Prevention recommended that treatment water should contain less than 500 CFU/mL.4 Technologies exist that make this goal achievable. Options to improve dental unit treatment water include flushing the DUWL, filtration, antimicrobial tubing, independent reservoirs, filtration and intermittent chemical (shock) treatment.

Another approach to controlling DUWL contamination is the continuous addition of low-concentration antimicrobial solutions or cleaners to the treatment water. Some of the cleaners available for continuous use to control DUWL contamination are sodium hypochlorite, hypochlorous acid, chlorhexidine, chlorine dioxide, iodine, peroxides and silver nitrate. Research shows that chemical cleaners are effective in controlling microbial contamination of DUWLs.1,5,12–16 However, concern exists that the cleaners added to the treatment water might influence clinical procedures, such as bonding resin-based composites to enamel and dentin, because these substrates are exposed to the treatment water during clinical procedures.17–23

Within the past several years, self-etching primers and self-etching adhesives were introduced to the dental profession. These all-in-one adhesives do not require acid-etching of enamel or dentin before their use. The application protocol is substantially simplified, because no water is used and no concern exists regarding the moisture state of the dentin substrate before the adhesive is applied. Therefore, with self-etching primers and adhesives, there is no window of opportunity for contamination of the substrate with cleaners during application of the adhesive, which is the case when total-etch adhesives are used. However, DUWL cleaners still might affect simplified adhesives by being impregnated into or present on the tooth immediately after cavity preparation and rinsing.

To our knowledge, no information exists about the effect of DUWL cleaners on dentin bond strengths mediated by simplified self-etching primers and adhesives. Consequently, we evaluated the effect of DUWL cleaners on composite-to-dentin bond strengths mediated by both total-etch and self-etch dental adhesives. The null hypothesis we proposed was that dentin bond strengths are not affected by chemical DUWL cleaners when total-etch and self-etch dental adhesives are used.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 
We randomly divided 150 caries-free human pre-molars into five groups of 30 specimens. We exposed the dentin by polishing the labial surfaces with wet 240-, 400- and 600-grit silicon carbide abrasive paper. For each group of specimens, we used the cleaner tested as the solution used during the polishing procedures: distilled water (control), Sterilox (PuriCore, Malvern, Pa.), ICX solution (A-dec, Newberg, Ore.), 5.0 parts per million sodium hypochlorite and MicroCLEAR (Rowpar Pharmaceuticals, Scottsdale, Ariz.). Table 1Go lists the cleaners used, as well as their active ingredients. For each cleaner-treated group, we randomly assigned specimens to one of three subgroups (n = 10) according to the adhesive used.


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  		TABLE 1 DUWL* cleaners tested in study.

 
PQ1 total-etch adhesive (Ultradent Products, South Jordan, Utah). We etched the dentin with 35 percent phosphoric acid gel (Ultra-Etch, Ultradent Products) for 15 seconds, rinsed with 50 mL of the respective cleaner and blot-dried the specimens with wipes (Kimwipes EX-L absorbent wipers, Kimberly-Clark, Dallas) to avoid desiccation. We then used a disposable applicator to rub the adhesive on the moist etched dentin surface for 10 seconds and gently air-thinned the adhesive. We light-cured the adhesive for 20 seconds.

Clearfil SE Bond self-etching primer/ adhesive (Kuraray America, New York City). We gently dried the dentin, applied the primer with a disposable applicator and left the specimens undisturbed for 20 seconds. We then gently air-dried them, applied the adhesive with a disposable applicator and gently air-thinned it. We then light-cured the adhesive for 10 seconds.

UPI-EXP experimental self-etching primer/adhesive (now marketed as Peak SE adhesive system) (Ultradent Products). We gently dried the dentin, applied the experimental self-etching primer with a disposable applicator and left the specimens undisturbed for 20 seconds. We then gently air-dried them, applied the PQ1 adhesive with a disposable applicator and gently air-thinned it. We then light-cured the adhesive for 20 seconds.

Resin-based composite. Using a specimen-forming matrix (Ultradent Products), we applied the resin-based composite (Z100, 3M ESPE, St. Paul, Minn.) to each of the treated surfaces and light-cured them for 40 seconds. We completed all light-curing procedures with a Ultra-Lume LED 5 curing light (Ultradent Products), following the manufacturer’s instructions. We stored the bonded specimens in distilled water for 24 hours at 37 C. We then tested them by using a universal materials testing machine (model 4411, Instron, Norwood, Mass.) to determine the composite-to-dentin shear bond strengths (SBSs).

We determined the SBS (in megapascals) by dividing the maximum failure load (in newtons) by the bonded area (2.35 square millimeters). We analyzed the data using two-way analysis of variance (P = .05) in a statistical software package (Statistica 5.5, StatSoft, Tulsa, Okla.). As an additional outcome, we studied the specimens’ fracture modes after the SBS test by using an optical microscope at x25 magnification.

</b>We matched each specimen to one of four fracture modes: adhesive, cohesive in dentin, cohesive in resin-based composite or mixed (adhesive and cohesive). We then calculated the fracture mode for each experimental group as a percentage of the total number of specimens in that group. For the purposes of this study, we considered an adhesive fracture to be a fracture anywhere within the dentin-composite adhesive interface.


   RESULTS
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSION
 REFERENCES
 
The SBS results are presented in Table 2Go. The mean SBS varied according to the cleaner-adhesive combination used (ranging from 14.7 to 21.9 MPa). We observed no statistically significant differences and/or interactions between the mean SBS of specimens treated with the various adhesives and cleaners (P ≥ .05). The figureGo shows the distribution of the specimens’ fracture modes.


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  		TABLE 2 Mean (SD*) composite-to-dentin shear bond strengths (in MPa{dagger}), as a function of adhesive and dental unit waterline cleaner (n = 10).{ddagger}

 

Figure 1
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  		Figure. Percentage distribution of specimens’ fracture modes according to the adhesive-cleaner combination. No resin cohesive fractures were found. PQ1-Water: PQ1 adhesive, water (control); PQ1-Sterilox: PQ1 adhesive, Sterilox cleaner; PQ1-ICX: PQ1 adhesive, ICX cleaner; PQ1-NaClO: PQ1 adhesive, sodium hypochlorite cleaner; PQ1-MicroCLEAR: PQ1 adhesive, MicroCLEAR cleaner; Clearfil-Water: Clearfil SE Bond adhesive, water (control); Clearfil-Sterilox: Clearfil SE Bond adhesive, Sterilox cleaner; Clearfil-ICX: Clearfil SE Bond adhesive, ICX cleaner; Clearfil-NaClO: Clearfil SE Bond adhesive, sodium hypochlorite cleaner; Clearfil-MicroCLEAR: Clearfil SE Bond adhesive, MicroClear cleaner; EXP-Water: UPI-EXP adhesive, water (control); EXP-Sterilox: UPI-EXP adhesive, Sterilox cleaner; EXP-ICX: UPI-EXP adhesive, ICX cleaner; EXP-NaClO: UPI-EXP adhesive, sodium hypochlorite cleaner; EXP-MicroCLEAR: UPI-EXP adhesive, MicroCLEAR cleaner. PQ1 is manufactured by Ultradent Products, South Jordan, Utah; Clearfil SE Bond, Kuraray America, New York City; UPI-EXP (now marketed as Peak SE adhesive system), Ultradent Products. Sterilox is manufactured by PuriCore, Malvern, Pa.; ICX, A-dec, Newberg, Ore.; MicroCLEAR, Rowpar Pharmaceuticals, Scottsdale, Ariz.

 

   DISCUSSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSION
 REFERENCES
 
As chemical cleaners are introduced and used to treat DUWL contamination, their influence in clinical procedures needs to be investigated. Bonding to enamel and dentin may be influenced by contaminated DUWLs, as well as by the cleaners used to treat them.17–23 Treatment water from the DUWL may alter the dental substrates during tooth preparation procedures whenever a water-cooled cutting instrument is used. In addition, for total-etch adhesives, water is used during the application sequence to rinse off the acid used to etch enamel and dentin. Better bond strengths are achieved when dentin is kept moist after acid-etching.24–27 Therefore, the treatment water’s composition may be critical, as not all of the water used to rinse off the acid is removed from the etched tooth. Cleaners present in the residual treatment water after acid-etching may interact with the adhesive and/or act as a contaminant and affect enamel and dentin bonding.

Cleaner effects. This potential clinical problem has been investigated only recently. Roberts and colleagues17 tested the effect of sodium hypochlorite (3 ppm), 0.12 percent chlorhexidine gluconate, 1:10 Listerine (Pfizer, New York City; now manufactured by McNeil-PPC, Morris Plains, N.J.) and 0.224 percent citric acid on dentin bond strengths with the use of an ethanol-based total-etch adhesive. When compared with the distilled water controls, the diluted mouthrinse and chlorhexidine gluconate resulted in significantly lower bond strengths to dentin. Using the same total-etch adhesive as Roberts and colleagues17 used, Taylor-Hardy and colleagues19 also reported that 0.12 percent chlorhexidine gluconate reduced enamel bond strengths compared with the distilled water control, but this negative effect was reversed when the substrate was rinsed off with tap water just before the researchers applied the adhesive. Other studies found that chlorhexidine had no effect on dentin bond strengths.28,29

Taylor-Hardy and colleagues19 also found that sodium hypochlorite and hydrogen peroxide had a negative influence on enamel bond strengths when used as DUWL cleaners, and that another mouthrinse (diluted Scope, Procter & Gamble, Cincinnati) had no statistically significant effect on enamel bond strengths.

Knight and colleagues18 compared the influence of diluted Scope on enamel and dentin bond strengths with that of distilled water and municipal water in a study that used a total-etch adhesive. These authors found no statistically significant differences between the mean SBS of specimens treated with either the diluted mouthrinse or the water. More recently, von Fraunhofer and colleagues21,22 tested the effect of DUWL treatments on composite-to-dentin bond strengths. They concluded that exposing an etched dentin surface to either diluted Listerine or ICX solution had no adverse effect on subsequent dentin bond strengths.

Adhesives. Interestingly, Betke and colleagues23 reported that the influence of chemical water disinfectants on dentin bond strengths might be adhesive-specific. These authors compared the influence of two disinfectants (Alpron, QWS, Innsbruck, Austria, and Dentosept, Metasys, St. Georgen, Germany) on dentin bond strengths mediated by four different total-etch adhesives and their respective composites. They found that although the disinfectants tested did not affect bond strengths for most of the adhesive-composite combinations, one adhesive-composite combination was affected by the disinfectants when compared with the distilled water controls.

Most of the specimens experienced adhesive fracture, which indicates that the failures occurred at the composite-dentin interface.

The adhesive’s composition, particularly its solvent content, may play a role in the neutralization of any potential effects of DUWL cleaners. PQ1, the total-etch adhesive used in our study, contains 8 percent ethyl alcohol as a solvent, while UPI-EXP, the experimental self-etching primer/ adhesive tested, contains 30 percent ethyl alcohol. Clearfil SE Bond, the other self-etching primer/adhesive, contains no organic solvent. Research shows that solvent-containing adhesives have the potential to offset substrate contamination by saliva, blood and even oil.30–32 Although our study results suggest that the presence and amount of solvent did not play a significant role in the dentin bond strengths, the potential interaction between solvent and cleaner deserves further investigation.

As discussed above, DUWL cleaners may contaminate the enamel and dentin substrates by becoming impregnated in the substrate during cavity preparation, by remaining on the substrate after cavity preparation or by remaining on the substrate after the clinician rinses off the acid-etch solution used in the bonding protocol. The latter scenario can be avoided by using all-in-one, simplified self-etching primers and adhesives, which do not require a separate acid-etching step. Although the potential for contamination still exists, the risk is reduced by using self-etching primers and adhesives. However, as the results of our study indicate, the self-etching approach did not result in any significant beneficial effect when compared with the total-etch technique for the cleaners tested. This finding might be related to the composition of the adhesives tested, to the innocuous effect of the cleaners tested, to the methods used to evaluate bond strength or to a combination of these factors.

The results of our study indicate that the chemical cleaners evaluated had no statistically significant influence on the composite-to-dentin SBS of specimens treated with the three adhesives (P ≥ .05). Although bond strengths were affected—either positively or negatively—the results of our study are similar to those of comparable studies for the cleaners evaluated.15,21,22,33

Fracture mode. Although we investigated the type of composite-dentin failure—or specimen fracture mode—in our study, we did not conduct any statistical analysis of these data. Most of the specimens experienced adhesive fracture, which indicates that the failures occurred at the composite-dentin interface. The noted exceptions to this trend were the specimens treated with distilled water and bonded with PQ1 or Clearfil SE Bond. These specimens experienced dentin cohesive fractures in addition to adhesive fractures and, in the case of Clearfil SE Bond, one mixed fracture (FigureGo). Interestingly, these two groups also had the two highest numerical mean SBS values (20.8 and 21.9 MPa, respectively), which might indicate a positive correlation between bond strength values and fracture modes.

A positive correlation between SBS values and fracture mode, as well as the fact that the majority of fractures were adhesive, suggest that our test did not induce undue tensions in the specimens, as might have been the case if a large number of resin cohesive and/or dentin cohesive fractures were noted. The bond strength test is expected to test the strength of the bond between the composite and substrate, and our data suggest that the test was conducted properly. Adhesive fractures might implicate the DUWL cleaner and/or any interactions between the cleaner and the adhesives used. However, cohesive failures, either in the composite or dentin, would not be related directly to the cleaner used; rather, they would indicate that upon testing, the bond between the composite and dentin was stronger than the cohesive strength of the composite or dentin. Cohesive fractures also might be a result of the mechanics of the SBS test. Despite our observation that dentin cohesive fractures occurred mainly in the specimens treated with distilled water, the statistical analysis of the SBS data did not indicate a significantly different performance for these specimens.

The exact mechanism by which DUWL cleaners affect bond strengths is not known. Speculation ranges from oxidation reaction at the interface between the composite and enamel/ dentin to the deposition of some type of impermeable or hydrophobic layer on the substrate’s surface. Further studies in this area are warranted. As advances in adhesive dentistry occur and as new cleaners and technologies to control DUWL contamination reach the marketplace, clinicians should be cognizant of the possible interactions between dental adhesives and DUWL cleaners and be judicious in their use.

In vitro SBS tests commonly are used to analyze quantitatively and rank the performance of adhesive resins on enamel and dentin surfaces.17,19,21,22,34,35 However, although SBS tests are used in many in vitro bonding studies,36 they have been criticized for their lack of standardization and consistency.37,38 However, the SBS test has been shown to be appropriate and as effective as tensile and microtensile bond tests for evaluating and contrasting different bonding systems in vitro.39,40 Whether the results of these in vitro mechanical tests can be extrapolated to indicate the clinical performance of the materials tested is unclear.41


   CONCLUSION
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
REFERENCES
 
On the basis of the study results, we confirmed the null hypothesis. The four tested DUWL cleaners did not significantly influence composite-to-dentin bond strengths for the total-etch and self-etching dental adhesives.


   FOOTNOTES
 

Dr. Ritter is an associate professor, Department of Operative Dentistry, University of North Carolina School of Dentistry, 441 Brauer Hall, CB#7450, Chapel Hill, N.C. 27599-7450, e-mail "rittera{at}dentistry.unc.edu". Address reprint requests to Dr. Ritter.


Dr. Ghaname is a graduate student, Department of Operative Dentistry, University of North Carolina School of Dentistry, Chapel Hill.


Dr. Leonard is a clinical associate professor, Department of Diagnostic Sciences and General Dentistry, University of North Carolina School of Dentistry, Chapel Hill.


This report was presented in part at the 2005 Organization for Safety and Asepsis Procedures Symposium, June 2–5, Denver.


DISCLOSURE: This study was supported in part by Ultradent Products, South Jordan, Utah.


   REFERENCES
TOP
 ABSTRACT
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSION
 REFERENCES
 

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