1 OptiBond Fl 4.7 Kerr. 2 All-Bond Bisco. 3a Gluma Comfort Bond + Desensitizer 4.2 Heraeus. 3b OptiBond Solo plus 4.2 Kerr

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1 Reality s Choices Bonding Agents Total-Etch 1 OptiBond Fl 4.7 Kerr 2 All-Bond Bisco 3a Gluma Comfort Bond + Desensitizer 4.2 Heraeus 3b OptiBond Solo plus 4.2 Kerr 4a Adper Scotchbond Multi-Purpose Plus 4.1 3M ESPE 4b PQ1 4.1 Ultradent Self-Etch 1 Clearfil SE Bond 4.4 Kuraray 2 Peak 4.3 Ultradent 3a Bond Force 4.2 Tokuyama 3b Clearfil Protect Bond 4.2 Kuraray 4 Prelude 4.0 Danville Materials 5 Clearfil Liner Bond 2V 3.7 Kuraray 4c XP Bond 4.1 Dentsply/Caulk 5a All-Bond Bisco 5b One-Step Plus 4.0 Bisco 2009 Reality Publishing Co. Vol. 21 The Ratings 61

2 Total-Etch OptiBond FL Kerr All-Bond 3 Bisco Gluma Comfort Bond + Desensitizer Heraeus OptiBond Solo plus Kerr Adper Scotchbond Multi-Purpose Plus 3M ESPE Kit Bottle $14.33 N/A N/A $27.71 $20.55 Unit Dose N/A N/A N/A $27.71 N/A Price/ml Refills Bottle Primer or One- Component Adhesive $10.83 $11.25 $31.31 $27.71 $22.75 Bond Resin $10.83 $11.67/g N/A N/A $22.75 Catalyst N/A N/A N/A N/A $31.45 Unit Dose N/A $23.24 N/A Price/ Unit Dose Kit N/A N/A N/A $2.77 N/A Refills 4.87 N/A $2.80 $2.32 N/A Uses Direct restorations (all types) and indirect, metal-free restorations using light-cured and dual-cured cement All types of restorations Light-cured and dual-cured direct and indirect restorations plus self-cured direct restorations Light-cured and dual-cured direct and indirect, metal-free restorations All types of restorations ph Prime: 1.9 Part A/B: Activator : 8.1 Primer: 4.0 Immediate Bond Strength (MPa) to light-cured composite Enamel Dentin Bottle: 23.0 Unidose: 24.9 Bottle: 32.4 Unidose: 28.2 Moist: 23.6 Wet: 21.6 Moist: 24.2 Wet: Dentin Bond Strength (MPa) to self-cure composite 5 minutes N/A hours N/A 29.1 Can it Be Cured with LED? Probably Probably Probably Probably Probably Optimal Moisture Level After Etching Moist Moist or Wet Wet Moist Moist Primer or One- Component Adhesive Application Time (seconds) Method Gentle Agitation Gentle Agitation Scrubbing Gentle Agitation Gentle Agitation Air Pressure for Primer or One-Component Adhesive Solvent Evaporation Gentle Air Gentle Air Gentle Air Gentle Air Gentle Air Bond Resin Application Time (seconds) Method No Specific Time Required Brush-on/ Brush-off No Specific Time Required Brush-on/ Brush-off N/A N/A N/A N/A No Specific Time Required Brush-on/ Brush-off Light-Cure Time for Bond Resin or One-Component Adhesive (seconds) N/A The Ratings 2009 Reality Publishing Co. Vol. 21

3 Total-Etch PQ1 Ultradent XP Bond Dentsply/Caulk All-Bond 2 Bisco One-Step Plus Bisco Kit Bottle $32.08 $27.85-$28.88 $7.76 $17.83 Unit Dose N/A $25.38 N/A $18.25 Price/ml Refills Bottle Primer or One- Component Adhesive $14.37 $23.45 $9.67 $16.17 Bond Resin N/A N/A $4.50 N/A Catalyst N/A $30.06 $5.00 N/A Unit Dose N/A N/A N/A N/A Price/ Unit Dose Kit N/A $2.54 N/A $1.83 Refills N/A N/A N/A N/A Uses Light-cured and dual-cured direct and indirect restorations All types of restorations All types of restorations All types of restorations ph Primers A/B: Immediate Bond Strength (MPa) to light-cured composite Enamel 24.5 Dentin 20.1 Dry: 20.9 Moist: 22.6 Dry: 21.9 Moist: Dentin Bond Strength (MPa) to self-cure composite 5 minutes N/A hours N/A Can it Be Cured with LED? Probably Probably Probably Probably Optimal Moisture Level After Etching Moist Dry or moist Wet Wet Primer or One- Component Adhesive Application Time (seconds) Method Rubbing Gentle Agitation Gentle Agitation Gentle Agitation Air Pressure for Primer or One-Component Adhesive Solvent Evaporation Gentle Air Gentle Air Gentle Air Gentle Air Bond Resin Application Time (seconds) N/A N/A Method N/A N/A No Specific Time Required Brush-on/ Brush-off N/A N/A Light-Cure Time for Bond Resin or One-Component Adhesive (seconds) Reality Publishing Co. Vol. 21 The Ratings 63

4 Self-Etch Clearfil SE Bond Kuraray Peak SE Ultradent Bond Force Tokuyama Clearfil Protect Bond Kuraray Prelude Danville Materials Clearfil Liner Bond 2V Kuraray Kit Bottle $14.27 $36.25 $23.00 $18.64 $9.33 $10.25 Unit Dose N/A N/A $31.00 N/A N/A N/A Price/ml Refills Bottle Primer or One- Component Adhesive $7.71 $13.33 N/A $18.33 $10.79 $7.50 Bond Resin $21.00 $13.33 N/A $21.00 $10.79 $23.00 Catalyst N/A N/A N/A N/A $10.79 $21.00 Unit dose N/A $18.80 N/A N/A N/A N/A Price/Unit Dose Kit N/A N/A $3.10 N/A N/A N/A Refills N/A $3.76 N/A N/A N/A N/A Uses Light-cured and dual-cured direct restorations Light-cured and dual-cured direct restorations Light-cured and dual-cured direct restorations Light-cured and dual-cured direct restorations Light-cured, dual-cured, and self-cured direct restorations All types of restorations ph Primer: 2.0 Primer: Primer: 2.1 Primer: 2.1 Adhesive: 2.8 Link: 9.3 Primers A/B: 2.8 Immediate Bond Strength (MPa) to light-cured composite Enamel Dentin Self-Etch Etch w/pa Self-Etch Etch w/pa Dentin Bond Strength (MPa) to self-cure composite 5 minutes N/A N/A N/A N/A hours N/A N/A N/A N/A Can it Be Cured with LED? Probably Probably Probably Probably Probably, but dentin bond strengths were low Probably Optimal Moisture Level Before Applying Self-Etch Primer or One-Component Adhesive Dry Moist Dry Dry Moist Dry Primer or One-Component Adhesive Application Time (seconds) Method Gentle Agitation Rubbing Rubbing Gentle Agitation Scrubbing Gentle Agitation Air Pressure for Primer or One-Component Adhesive Solvent Evaporation Gentle Air Gentle Air Gentle Air, then forceful air Gentle Air Gentle Air Gentle Air Time (seconds) No Specific Time Required 10 N/A No Specific Time Required 15 No Specific Time Required Bond Resin Application Method Brush-on/ Brush-off Gentle Agitation N/A Brush-on/ Brush-off Scrubbing followed by gentle-medium air Brush-on/ Brush-off followed by gentle air Light-Cure Time for Bond Resin or One-Component Adhesive (seconds) The Ratings 2009 Reality Publishing Co. Vol. 21

5 Bonding agents or adhesives, as the name implies, are products that allow us to adhere various types of dental materials to enamel, dentin, and even other dental materials. Unlike the old hydrophobic materials used to bond to enamel, virtually all of the current bonding agents are typically hydrophilic to some extent to be compatible with dentin. However, it is this need to be hydrophilic that has caused most of the problems when it comes to bonding. Therefore, success or failure with these products depends as much on how they are applied as which product you choose to use. Types of Adhesives There are many ways to categorize bonding agents. One popular method uses the generations nomenclature. But, unless you are a dental historian, there is really no value in using the generations system. Who really cares if an adhesive is a fifth generation or sixth generation or seventh generation? Who is counting anyway? Apparently, manufacturers, since one of them is even featuring a tagline in its ads, stating its bonding agent may be the first eighth generation. Another way to separate these products is by the number of components. This system became popular (and has been used by us in the past) during the years that the single-component products were being introduced. We still use this nomenclature to describe the products, but not for categorization. We used to categorize these products as to whether they could be used for all procedures or just those for light-cured, direct procedures. These latter products were not effective when self-cured composites and/or indirect restorative procedures were used. However, even these products can usually be transformed into all-purpose by using various chemical activators. Therefore, we have dropped this separation. This brings us to the categorization we have chosen to use: total-etch vs. self-etch: Total-Etch Utilizes at least two steps, with the first one being the application of a phosphoric acid gel to the entire tooth surface that will be overlaid with the restorative material. This application is followed by a thorough lavage of the tooth. Then the actual bonding agent is applied. Still the most versatile and reliable, these bonding agents can be used for virtually any type of restoration and have the track record to prove it. The main reason many dentists stop using total-etch adhesives is due to their patients suffering from postoperative sensitivity. However, if you apply the adhesives carefully following our simplified instructions, we are confident that you can greatly minimize or eliminate the sensitivity problem in the vast majority of patients. Self-Etch Instead of using phosphoric acid to prepare the tooth surface for bonding, an acidic monomer is used. In two-component products, this is typically the job of the primer. In single-component adhesives, the bonding agent itself assumes this function. One advantage to this substitution is that the acidic monomer does not require rinsing. This is a big advantage, especially when the rubber dam is not being used. But, as mentioned previously, the primary reason for the growth of self-etchers is that they seem to cause less sensitivity. This is evidently due to the fact that since etching and priming are being done concurrently, it is not possible to etch deeper than the primer can penetrate. However, it doesn t mean a restoration was done properly just because a patient does not have any sensitivity. Self-etchers can work well in Class I, II, and V situations, but the application procedures of these materials can greatly influence their performance maybe even more so compared to total etch. And their ability to bond to self-cure composites and unprepared enamel is typically below that of the total-etchers. Indeed, some self-etchers recommend etching the enamel with phosphoric acid, especially if it s unprepared. One evaluator reported marginal staining as early as the 6-month recall, significantly worse than reported for total etchers. Components and Composition Most bonding agents still have two or more components, while a few have just one (other than the etchant) and the newest self-etchers incorporate everything into one bottle/unidose. Those with more than one component typically have the following: Primer Applied first, contains a solvent (making it hydrophilic), and usually (but not always) does not have any light-curing capabilities. This component is typically premixed and packaged in one bottle, syringe, or unidose, but some primers may have two components that require mixing. In self-etching systems, it is typically this component that etches and primes at the same time. Bonding Resin Applied after the primer. Can enhance adhesion by its wetting agent function or it can also have hydrophilic qualities and thus can actually contribute to enhancing the hybrid layer (see below). On the other hand, another theory is that the bonding resin should be hydrophobic to prevent formation of water trees (see below). If its companion primer is one component, the bonding resin may have two components that need to be mixed when it needs self-cure capability. Conversely, if the primer is in two components and needs to be mixed, the bonding resin may only need to be one component. And, in the products that only have a singlecomponent, the primer and bonding resin are mixed together in one bottle. Filled Adhesives Some adhesives add different types of fillers to the normally unfilled product for the following reasons: 1. Fluoride release if the filler glass has this capacity. While this is a noble goal, it is highly unlikely that there will be enough fluoride released by the adhesive to be of clinical value. 2. Lower modulus of elasticity to impart added flexibility to a restoration done with a stiff material such as a hybrid composite. Materials with more elasticity, such as microfills, may be better retained in Class V lesions due to their higher flexibility, compared to hybrids. The flexibility could also help to reduce the stress at the interface between the restoration and tooth caused by polymerization shrinkage. In other words, the elasticity of the adhesive could absorb within itself some of the curing stresses. By reducing this stress at the tooth-restoration interface, the restoration could be expected to have better retention. While this theory sounds feasible, it has yet to be proven. 3. Filler could actually reinforce and strengthen the hybrid layer. 4. Filler could help the adhesive cover the dentin surface in one application rather than multiple ones. Enamel vs. Dentin Enamel While dentin is the substrate that has garnered most of the interest, enamel is still the most reliable tooth tissue for bonding. Although some initial dentin bond strengths may even exceed those of enamel, the long-term bonding stability favors enamel. In addition, microleakage testing usually shows significantly lower scores on enamel compared to those on dentin/cementum. The main reason bonding to enamel is more reliable is that it is primarily inorganic. You etch it, you dry it, you bond to it. There is nothing complicated or very technique-sensitive about this procedure. Etching creates micromechanical retention by selectively demineralizing the surface. Once dried, low viscosity resin penetrates into the microscopic spaces in its surface that were created by the etching process. After curing the resin, it tenaciously adheres to the enamel. However, when a hydrophilic adhesive is used, drying the enamel is not necessary and may not even be beneficial. Our tests have shown moist or wet protocols, developed for dentin, are usually also effective on enamel. Nevertheless, if no dentin is exposed, a hydrophilic adhesive probably offers no benefits over a simple, unfilled resin applied to dry, etched enamel Reality Publishing Co. Vol. 21 The Ratings 65

6 Dentin Unlike enamel, dentin is primarily organic, mainly collagen and water, making it a much different substrate for bonding. It is also directly above the pulp, which tells us that whatever we do to dentin must be done in a way that it doesn t injure the pulp. Most efforts to bond to dentin have focused on both mechanical and theoretical chemical adhesion. The early adhesives tried to bond to the smear layer, which is basically the layer of preparation debris that is difficult to remove with conventional cleaning procedures, but, paradoxically, is not firmly attached to the dentin for bonding purposes. This means that trying to bond to the smear layer has been unreliable and not very successful. As mentioned previously, total-etch bonding agents use a phosphoric acid etchant to remove the smear layer and to demineralize the dentin surface. This leaves a lattice of unsupported collagen. The adhesive then infuses the collagen with resin, locking into it to form a micromechanical bond, similar to that of enamel. This complex of resin-reinforced dentin has been termed the hybrid layer. The self-etch products, however, presumably dissolve and penetrate through the smear layer but do not remove it. With self-etch products, the smear layer actually becomes part of the hybrid layer. Another issue of dentin bonding is the stability of the bond. This topic rarely arises with enamel, but the question is: Do dentin bonds get weaker or start to hydrolyze over time? To test this issue, we tested several adhesives after five months storage in the temperature/humidity chamber. The results clearly show bond strengths became higher, especially on dentin for the two, single-component products (Clearfil S 3 Bond and G-Bond). However, these specimens did not obviously have pulpal fluid with which to combat. Bond Strengths (MPa) Immediate 5 months Heliobond (control) Clearfil Protect Bond Clearfil SE Bond Clearfil S 3 Bond G-Bond Enamel Dentin N/A Enamel Dentin N/A In addition, a study by Editorial Team Member Dr. Franklin Tay showed that enzymes called matrix metalloproteinases (MMPs), which can break down the collagen scaffolding that is essential for stable bonds, can be inactivated by pretreatment of dentin with chlorhexidine that is not rinsed off. To inhibit MMP activity, the evidence suggests chlorhexidine in concentrations as low as 0.01% or even less is effective. Therefore, it seems applying aqueous chlorhexidine after etching but before the primer/adhesive is a prudent procedure. Bond Strength Tests These are the most common tests done on bonding agents. They can be done relatively quickly and are especially valuable when trying to distinguish between technique variations. Many manufacturers tout the superiority of their adhesives based on these scores. Indeed, there have even been conferences devoted to battle of the bonds, which are sort of like bond strength Olympiads! The most common yardstick to judge whether a specific bonding agent has an adequate bond strength is to compare it to an enamel control. Since bonding to frosty, dry, etched enamel using a conventional unfilled resin has been validated with over 30 years of clinical use, equivalent dentin values should be an indication that the product will perfor m satisfactorily. In the RRL, we periodically test bond strength to dry, frosty enamel using an unfilled, hydrophobic resin (Heliobond). While consistency is our goal, there have been variations in this bond strength test over the years based on the temperature and humidity in the lab, as well as differences in human extracted teeth. The range of these bond strengths have been from 20MPa to 27MPa. Therefore, bond strengths for adhesives that produce similar values should be clinically acceptable. However, the clinical significance of bond strength tests (and just about all in vitro tests) continues to be debated. No one really knows how much bond strength is enough. It is also unknown whether bonding agents with bond strengths, which exceed that of the enamel control, have any clinical advantages over those with equivalent values. Therefore, we continue to use bond strength tests as screening devices. For example, when we first discovered clinically that self-cured core materials were debonding when a single-component adhesive was used, we tested this combination in the lab and confirmed that there is a basic incompatibility between most one-component adhesives and self-cured composites. Spotting trends and discovering uses of these materials that just don t work are really the main purposes of these tests. Consequently, while bond strengths falling below that of the enamel control may cause some justifiable concern, we do not use these values as the sole determinant in ranking the products, unless the scores are significantly lower than the average in the group. Equipment Our usual testing apparatus (developed by Ultradent) employs a mold that produces a small cylinder of composite about 2.2mm in diameter and 2.0mm in height. While this is adequate for testing bonding agents in the light-cured mode using typical 2.0mm increments of composite, it does not permit testing when bulk filling a deep preparation for a core build-up. To solve this problem, we developed molds that are wider (3.8mm in diameter) to allow easier insertion of the restorative material and in various depths (2mm, 3mm, 4mm, and 5mm). These deeper and wider molds are manufactured by 3M ESPE. For example, using the 5mm deep molds, we can now test the bond strength of light-cured and dual-cured core materials, which would typically only be used in deep cavities. The other molds (2mm, 3mm, 4mm) are used to test the depth of cure of a product, in conjunction with hardness (see Hybrids and Packable Composites). And, using precured composite cylinders fabricated in the 5mm molds, we can test the best way to bond thick indirect restorations such as onlays. Tooth Specimens All bond strength testing in our lab is done on extracted teeth that have been embedded in acrylic and then flattened. While flattened teeth really do not simulate cavity preparations, this protocol is essential to conduct these tests. The only exception to this flat tooth rule is when unprepared enamel is tested. In this case, we select the extracted teeth that are as flat as nature would allow, but this variable is unavoidable. Consequently, we do not perform bond strength tests on unprepared enamel as a rule. Although dentin is the substrate that we are most often testing, all adhesives are also tested on enamel, especially self-etchers. Immediate vs. Delayed Testing Immediate Since we usually begin to stress a restoration with finishing procedures as soon as it is light cured, it is important to know this early bond strength. We literally test each adhesive as soon as light curing is completed. This is our most common test. 5 Minutes Typically used for all self-cured core materials and self-cured cements to simulate the usual waiting time for these materials to chemically polymerize in the mouth. Some testing of dual-cured materials is also done at this time, but not routinely since we have found only small differences in bond strength between immediate and five minutes. The time starts after the mold is filled and the specimen is placed in an incubator set at 37 C/95% humidity in an effort to simulate the oral environment if a patient is allowed to close during the polymerization period. (While the intraoral temperature and humidity may not perfectly match these parameters in all cases, it should be reasonably close.) Teeth used for these tests are typically warmed to body temperature prior to testing. 24 Hours Most common test reported by manufacturers. It may produce higher values compared to those recorded immediately. In addition, many research facilities do not have their equipment conveniently arranged for immediate testing, so the 66 The Ratings 2009 Reality Publishing Co. Vol. 21

7 24 hour test is done due to logistical considerations. We use this time delay typically only for dual-cured and self-cured core materials and cements, the latter of which is consistent with the typical advice given to patients to be careful with what they eat for the first 24 hours after luting a restoration. Specific Tests Moisture Status of Preparation After rinsing the phosphoric acid etchant when using a total-etch bonding agent or prior to applying a self-etch primer, you need to know the optimal moisture status of the preparation. Our tests show that this can be one of the most critical steps during the adhesive process. However, the directions from many manufacturers either omit this description entirely or it is covered inadequately. Therefore, we test all bonding agents using three protocols: Dry Air syringe is used to produce forceful air for 2-3 seconds for a small preparation or longer until the cavity is completely void of visible moisture, but not totally desiccated. Moist Blot with a lint-free, dry 2x2 gauze, mini-sponge, or virtually any absorbent product that will not leave a residue on the tooth surface. The result should be a tooth surface with no visible moisture, but appears to have either a matte or slightly shiny appearance (depending on the character of the dentin and type of instrument used to prepare it). This protocol will leave necessary moisture in the demineralized dentin (created by the etching process). Clinically, you would have to cut the 2x2 gauze (if used) into small sections or use other products such as an applicator tip or mini-sponge to siphon off the excess moisture in small areas. For large areas, such as a complete crown preparation, draping an intact 2x2 over the preparation may be more effective and expeditious. Wet Use the same type of blotting material described under Moist and dip it into distilled water. Then blot this wet material with a dry 2x2 to create a damp blotting material. Use this damp material to blot the cavity preparation, leaving tooth surface with a definite sheen of water on it, but be sure all puddles of water are removed. NOTE: To create the moist or wet status, many manufacturers will tell you to use your air syringe. Typical instructions will tell you to dry lightly for 2-3 seconds or some variation thereof. Our tests show that using air to create moist or wet options is not effective. From a clinical perspective, it is even more difficult. For example, if you are trying to dry lightly an MOD preparation, you may merely be blowing the excess water from one proximal box to another. Therefore, the blotting techniques we have developed have proven to be much more effective and easier to calibrate. In addition, when using the moist or wet option, you should apply the adhesive or primer immediately after blotting the tooth. If you wait even 15 seconds (especially if you are using the rubber dam), some of the moisture could evaporate, which could affect the performance of the adhesive. Method and Time for Applying the Primer/Adhesive The manner by which you apply a primer or adhesive can vary from the simple let sit of some manufacturers to literally scrubbing it into the surface of the preparation. Let sit may be effective in the laboratory on flat test teeth, but it rarely works with the complex surfaces found in many preparations, especially vertical ones. Scrubbing is a relative term and the force by which it is accomplished is limited by the application instrument. Gentle agitation, which refers to applying the primer/adhesive and then basically moving it around on the preparation surface to ensure that there is optimal contact in all areas, is inbetween scrubbing and let sit. Rubbing is basically the same as scrubbing, but it is accomplished in a less aggressive manner. Application time can also vary the effectiveness. Our tests found the best method and optimal time to apply the bonding agent. Be aware that the size of the preparation will affect the application time. While the stated times are application for small Class V preparations, you should extend the times for large Class IIs. In addition, don t start your timer until the preparation is thoroughly wet with primer or adhesive. Method of Evaporating the Solvent The monomers in the primers or in bonding agents themselves may be dissolved in solvents (usually ethanol, acetone, and water), which carry these monomers into the demineralized surface of the preparation. Etching with phosphoric acid or through the action of self-etching primers creates this demineralized surface. These solvents, besides being the vehicle in which the monomers are dissolved, need to be hydrophilic since the demineralized dentin surface contains moisture to prevent the collagen network from collapsing. The solvents also tend to be water-chasing. This property refers to the solvent being attracted to the moisture content of the dentin. As the solvent chases the water, it literally brings the active monomers with it. Once this job is done, however, the solvent needs to be evaporated, since it can actually interfere with adhesion if it remains in the adhesive. Part of the reason for the interference is the dilution factor. In other words, solvents literally water-down the adhesive. But even more important is that the hydrophilic nature of a solvent can prevent the bonding of the hydrophobic materials such as composites and cements subsequently being placed. After application of an adhesive or primer, the excess is usually first removed by suctioning, being careful to allow a continuous coating to remain on the tooth. If you don t suction the excess, there is a tendency to just blow the primer or adhesive from one part of the cavity to another section or onto the soft tissue, which can cause untoward reactions that are typically self-limiting but may provoke undesirable questions from the patient. After suctioning the excess, the solvent needs to be evaporated using air. The typical method is to place the tip of the air syringe about 1.0cm from the tooth and direct a gentle stream of air (like a breeze) at the preparation surface. Some adhesives, however, require a more forceful air flow, not only to evaporate the solvent, but also to keep the film thickness as minimal as possible so the layer of adhesive does not interfere with the complete seating of an indirect restoration. When using forceful air, be careful not to blow the primer or adhesive completely off the tooth. This can usually be done by starting the evaporation procedure with gentle air and proceed to forceful. We have determined the optimal technique for each adhesive. The result of this evaporation effort should be a layer of primer that appears dry (you can t move it around with the air syringe) and the preparation surface appears shiny. This air-evaporation effort may take five or more seconds, depending on the size of the cavity. If the dentin surface is not shiny, it may not be sealed. Therefore, it seems prudent to apply additional adhesive and repeat the evaporation process. Typically, the reapplication is merely applying the material and immediately beginning the evaporation process you don t need to wait as you may have when you applied it initially. If, after the second application, the dentin surface is still not shiny, we recommend applying the adhesive one final time. Light Curing the Primer/Adhesive If this is the final component of the bonding agent, you would typically cure it at this time. The conventional curing time has always been 20 seconds, using a halogen light. However, this may be overkill for some adhesives. We tested the optimal curing time for each adhesive. But be aware that even these times may need to be altered based on the distance from the tip of the light to the tooth surface. For some bonding agents used in the dual-cured or self-cured mode, in which an activator is mixed with the main component of the kit, you may need to wait until the restorative material or indirect restoration is placed to cure the adhesive or allow it to cure concurrently along with the dual-cured or self-cured composite or cement Reality Publishing Co. Vol. 21 The Ratings 67

8 Method of Applying the Bonding Resin As this component does not typically contain any solvents and, indeed, is usually primarily hydrophobic, you do not have to apply air other than to thin out the layer. While this will work, overaggressive use of the air can lead to overthinning, which, in turn, can affect the performance of the bonding agent You can alternately remove the excess by using the same applicator, but blotting it with a 2x2 each time you remove more excess. This is known as the brush on, brush off technique and works well. Component(s) to use when bonding a dual-cured core or an indirect restoration such as an onlay It has been thought that, if you are using a dual-cured core material to build up a tooth or dual-cured cement to lute a thick, indirect restoration, you also need to use a dual-cured adhesive (two components) for compatibility and just in case the light doesn t penetrate to the tooth surface. However, if you can light cure all the way through the core or to the bottom of the indirect restoration (especially if you position the tip of the curing light on the facial, lingual, and occlusal surfaces and use a high-powered light), then a single-component, light-cured adhesive or the light-cured version of a multi-component product may be quite satisfactory. In addition, a light-cured cement may also work instead of a dual-cured version for the indirect restoration. The first test simulates a direct, dual-cured core build-up (5mm deep) immediately after light curing. If bond strengths are not substantial at this stage, you may be able to dislodge the core when you remove the core form or matrix band. The second test simulates bonding a 5mm thick onlay with both light-cured and dual-cured adhesives and/or cement. Component(s) to use when bonding a self-cured core or an indirect, metal-based restoration such as a ceramometal crown Similar to the dual-cured core test, this test is done by using the self-cured version of the adhesive (if it has one). The test simulates a direct, self-cured core build-up or indirect restoration cemented with a self-cured resin cement if you waited five minutes after placement to allow the material to chemically-cure. Miscellaneous Adhesive Issues Effect of Moisture on Restorative Materials If a restoration fractures, not only do we have to bond to the remaining section of the restoration, but also to any exposed tooth surface. If dentin is exposed, you would typically want to use an adhesive that will bond securely to it to ensure optimal adhesion and so the tooth will not be sensitive. If your typical bonding agent requires you to leave the tooth moist for optimal bond strength, then it may be difficult to leave the tooth moist but dry the fractured area of the restoration. We tested the effect of moisture on bond strength to several restorative materials. Using Prime & Bond NT, the level of moisture on the restorative materials was the same as if we were bonding to a tooth. This bond strength was then compared to the more typical dry bonding you would do when luting an indirect restoration. Our test results confirm that most indirect resins and ceramic materials should be repaired dry. Therefore, the use of an adhesive that bonds to dry enamel and dentin reasonably well would be the product of choice. Effect of Silane on Tooth Structure When a repair is done, silane is typically applied to the restorative material prior to applying the bonding agent on the tooth and restorative material. We wanted to know what effect silane could have on the bond of the repair material to dentin. Our test results show that silane can interfere with the bond of the composite to dentin. When doing a repair, make every attempt to confine the application of silane just to the fractured restorative material. Since silane is a liquid, this confinement will not be possible if you merely douse the tooth with it. But if you apply the silane with a fine brush, keeping it off the tooth is certainly a possibility. Water Additives With the increased concern about contaminated water lines, products are being added to dedicated water supplies. However, most of these products have not been tested properly as to their effects on adhesion. Our own testing of one product showed bond strengths decreased 22% compared to the untreated control. Therefore, we strongly suggest not adding any disinfectant to your water supply without having data on its effect on issues such as adhesion. Water Trees Even when the dentin is shiny and appears to be totally sealed, bonding agents that do not employ a final layer of a hydrophobic bonding resin may be subjected to a phenomenon called the semi-permeable membrane effect. Discovered by Editorial Team Member Dr. Franklin Tay, this effect is characterized by a porous hybrid layer, which allows pulpal fluid to diffuse onto the dentin surface and potentially interfere with the bond between the restorative material and adhesive. This diffusion effect simulates branches on a tree, thus the term water trees was created to describe it. However, while this effect has been shown to exist clinically, it remains to be seen what its long-term sequelae may be. Nevertheless, using a multi-component adhesive that includes a final layer of a hydrophobic bonding resin will presumably prevent this problem from occurring and is one reason that the multi-component adhesives are making somewhat of a comeback. Hybridizing the Dentin at the Preparation Appointment There is a trend to create a hybrid layer at the preparation appointment for an indirect restoration. The purposes of the hybrid layer in this instance are to protect the pulp by sealing the dentin surface, minimize or eliminate sensitivity between the preparation and seating appointments, and allow seating of the definitive restoration without having to anesthetize the tooth. While these are noble goals, there are also some downsides to this procedure. In the first place, the hybridizing procedure is done before taking the impression. Depending on the type of adhesive used to create the hybrid layer, the sharp margins of the preparation could be less distinct and more difficult for the lab to see. Second, applying an adhesive after preparing a tooth especially for full coverage may be difficult due to the challenges of adequately isolating the preparation. Third, the adhesive could bond with the provisional cement if a resin version is used. Fourth, bonding to this precured adhesive layer may not be as adhesive as starting with fresh tooth structure. And, finally, unless you are using a hydrophobic layer over your hydrophilic adhesive, this presumably sealed dentin surface may be susceptible to the formation of water trees. Therefore, this procedure may not produce all of its presumed benefits and may not be worth the effort it takes. Shaking the bottle/stirring the Unidose Many bonding agents suffer from phase separations of their components in bottles and unidose vessels. This means that most bottles should be shaken before dispensing and the contents of unidose vessels should be stirred before applying to the preparation. Some bottles even have a small ball inside to act as a shaker to help mix the components. When in doubt, shake or stir. Application Techniques In each product commentary, we have listed the application techniques that we have found to be most effective and practical for clinical use. In some instances, these procedures may vary from the manufacturer s directions. However, we feel strongly that our techniques will give you the best chance for success and will minimize failures. 68 The Ratings 2009 Reality Publishing Co. Vol. 21

9 Total-Etch Bonding Agents 1 (4.7) OptiBond FL Description The original filled adhesive and possibly the first with an alcohol solvent, which is now found in most adhesives. Uses Direct restorations (all types) and indirect, metal-free restorations using light-cured and dual-cure cement. Do not use with metal-based, indirect restorations. Composition Prime (1) HEMA, GPDM, mono (2-methacryloxy ethyl) phthalate (PAMM), ethyl alcohol, camphorquinone, and water. Adhesive (2) BIS-GMA, HEMA, barium aluminum borosilicate glass (0.6μ particle size), fumed silica, disodium hexafluorosilicate, glycerol dimethacrylate,and camphorquinone. Filled 48%. Raves & Rants + Dry, moist, wet all will work + Longest track record next to All-Bond 2 Only one small applicator included with unidose Cannot use with metal-based indirects Manufacturer Kerr Prices BOTTLE KIT $ ($14.33/ml) REFILLS Bottles 1 btl (8ml) of FL Prime or FL Adhesive $86.65 ($10.83/ml) Unidose $243.50/50/11.5ml ($21.17/ml or $4.87/unidose pair) SHELF LIFE 1 year for bottles 2 years for unidose ph Prime 1.9 Viscosity Prime Just right. Resin Just right. Odor Not really noticeable. Can You Cure It With an LED? Probably, since dentin bond strengths using an LED were close to that of the halogen control. What is the most effective application technique for DIRECT restorations? 2. Rinse and leave preparation MOIST. Directions only indicate that you air dry for a few seconds being careful not to dessicate dentin. We believe our moist blotting technique will provide more consistent results. 3. Apply Prime (1) for 15s with GENTLE AGITATION. Directions indicate that you use a light scrubbing motion. We believe gentle agitation is more than adequate and is easier to accomplish clinically compared to scrubbing. 5. Apply Adhesive (2) using brush-on/brush/off. Directions indicate that you use a light scrubbing motion for 15 seconds. We believe brush-on/brush-off is more than adequate and is easier to accomplish clinically compared to scrubbing. 6. Light-cure Adhesive (2) for 20s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate Bottles Unidose Enamel Dentin Using this technique, the bond strengths (MPa) with self-cured composite were: Substrate 5 min 24 hrs Dentin Reality Publishing Co. Vol. 21 The Ratings 69

10 What is the most effective application technique for INDIRECT restorations using light-cured, dual-cured, or self-cured cement? 2. Rinse and leave preparation MOIST. 3. Apply Prime (1) for 15s with GENTLE AGITATION. 5. Apply Adhesive (2) using brush-on/brush/off. 6. Seat restoration with light-cured or dual-cured cement and light-cure adhesive simultaneously with cement. Using this technique, the bond strengths (MPa) on dentin were: Cement Type Immediate 5 min 24 hrs Light-cured cement 13.9 N/A N/A Dual-cured cement 14.3 N/A 14.5 Self-cured cement N/A N/A N/A *All specimens fractured the dentin, indicating the bond strength exceeded the cohesive strength of dentin. For INDIRECT restorations, what do you apply on the inside surface of the restoration? Adhesive (2) or unfilled resin (apply and gently air-thin, do not cure). Post-Operative Sensitivity Minimal or none. Packaging Bottles Easy to stack box with convenient identification on three sides and top. Plastic shrink-wrapped for security. FL Adhesive even has a light bulb icon with the number of seconds (30) it should be cured imprinted directly on the bottle. (We found 20 seconds is more than sufficient to cure the Adhesive.) Cap and printing on FL Prime is yellow, offering instant differentiation with FL Adhesive, which has white printing and a black cap. Expiration dates have been heat-stamped into the side of the bottles and also on a label on the box. Unidose Large box with convenient identification on three sides, expiration date on one side, and plastic shrink-wrapped for security. The box is perforated on the bottom of the front side so that a drop-down door can be created to allow easy retrieval of these packets. There are also expiration dates on the foil packets. The pull-apart foil packs hold unidose rockets that are identical to those used for years with OptiBond Solo plus. Each foil packet holds one yellow unidose of Prime and one black unidose of Adhesive. In addition, one applicator tip is included you are supposed to use it with both components. However, we would prefer two applicators that have matching colors to the component for which they are indicated. The applicator tip provided also has a very small head, which is not appropriate for all but very small preparations. Directions Multi-language, plain paper in annoying foldout design plus plastic-laminated card for use in the treatment room, which includes color line drawings for each step in restoring a Class V lesion. Both versions omit indications on what type of restorations for which it can be used. 70 The Ratings 2009 Reality Publishing Co. Vol. 21

11 2 (4.3) All-Bond 3 Description Third generation of one of the legacy total-etch dental adhesives that was introduced in This version is designed to make the product less technique-sensitive and more resistant to the water-tree effect that was first described by Editorial Team Member Dr. Franklin Tay. It still has two primers that are mixed and applied after etching, followed by a bonding resin, but the chemistry has been tweaked. The acetone solvent in All-Bond 2 (as well as numerous other adhesives) has been eliminated. Rightly or wrongly, acetone-containing adhesives have been accused of being more technique-sensitive than those with ethanol solvents. Uses All types of restorations. Composition Part A Mg-NTG-GMA and ethanol. Raves & Rants + Much less technique sensitivity compared to precedessor + Can do everything with it Bonding resin is too thick Directions are strange and ambiguous Manufacturer Bisco Prices Bottle Kit $ REFILLS 1 btl of Part A and B (6ml ea) $ ($11.25/ml) 2 syringes of Resin (1.5g ea) $35.00 ($11.67/g) SHELF LIFE 2 years Part B BPDM (biphenyl dimethacrylate), BIS-GMA, and ethanol. Resin BIS-GMA, TEGMA, and YbF3. Filled 52% and is now radiopaque. ph Part A/B 5.1 Viscosity Part A/B 80% of the evaluators thought this mixture was just right, 15% felt they were too runny, and 5% thought they were too thick. Resin 60% of the evaluators thought it was just right, while the other 40% felt it was too thick. Odor 75% of the evaluators thought its smell was not really noticeable, while the remaining 25% felt it had a strong odor. One evaluator also thought it had a bad taste. Can You Cure It With an LED? Probably, since dentin bond strengths using an LED were roughly equal to those using a halogen light. What is the most effective application technique for DIRECT restorations? 2. Rinse and leave preparation MOIST or WET. We found moist was slightly better on enamel, while wet was better on dentin. 3. Mix Parts A & B and apply for 20s with GENTLE AGITATION, adding more of the mix after 10 seconds or so. 5. Light-cure primers for 10s. 6. Apply resin using brush-on/brush/off. 7. Light-cure resin for 10s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate Moist Wet Enamel Dentin Using the Wet technique, the bond strengths (MPa) with self-cured composite were: Substrate 5 min 24 hrs Dentin Reality Publishing Co. Vol. 21 The Ratings 71

12 What is the most effective application technique for INDIRECT restorations using light-cured, dual-cured, or self-cured cement? 2. Rinse and leave preparation MOIST or WET. 3. Mix Parts A & B and apply for 20s with GENTLE AGITATION, adding more of the mix after 10 seconds or so. 5. Light-cure primers for 10s. 6. Seat restoration with light-cured, dual-cured, or self-cured cement. Using the WET technique, the bond strengths (MPa) on dentin were: Cement Type Immediate 5 min 24 hrs Light-cured cement 19.3 N/A N/A Dual-cured cement 14.4 N/A 24.3 Self-cured cement N/A * *All specimens fractured the dentin, indicating the bond strength exceeded the cohesive strength of dentin. For INDIRECT restorations, what do you apply on the inside surface of the restoration? Apply the mixture of Parts A & B, air-thin, and light cure for 10 seconds. Our results were better when you light cure the A/B mix, but be sure there is no pooling on the inside of your restoration or you will have trouble fully seating it. Packaging Very basic, easy to stack, small footprint cardboard box with product identification on both ends and on top. Two evaluators missed the plastic tackle-like box of All-Bond 2. Expiration date is on a label on one end. Plastic shrink-wrapped for security. The color-coded labels on the bottles keep you from mixing them up and contain the expiration date, which resists removal during disinfection procedures reasonably well. Bonding resin is now packaged in a tuberculin-like syringe instead of the more typical bottle and has a moisture-resistant label. But the metal syringe tips have a fairly large, fuzzy material end that could encourage over-application. Light-protective reservoir is old-style with three wells, although it is only necessary to dispense and mix the primers. Directions Plain paper combined with MSDS. Plastic-laminated index cards that came with All-Bond 2 have been discontinued. Steps are reasonably easy to follow even if the monochromatic presentation without photos or illustrations could use a graphics boost. One evaluator was confused about what to apply to the internal surfaces of indirect restorations. Another evaluator was puzzled why there were no specific directions on how long to leave the primers on the tooth before evaporating the solvent. We found the term visibly moist to be ambiguous and not specific enough to describe how the tooth should appear after etching but before the primers are applied. There is also a strange directive to light cure the primers and resin at 500mW/cm 2. Most current lights emit significantly more energy, so advice like this is destined to be widely if not universally ignored. Post-Operative Sensitivity 75% of the evaluators had no patients complain of sensitivity. Of the other 25%, most stated the sensitivity resolved itself after several weeks. 72 The Ratings 2009 Reality Publishing Co. Vol. 21

13 3a (4.2) Gluma Comfort Bond + Desensitizer Description Single-component with desensitizer built into adhesive. Uses Light-cured and dual-cured direct and indirect restorations plus self-cured direct restorations. Composition 4-META, UNMA, HEMA, glutaraldehyde, maleic acid, methacrylic polycarboxylic acid, and photoinitiator in ethanol and water. ph 2.4 Viscosity Acceptable. Raves & Rants + Tooth wetness status not critical + Bond and desensitize in one step Inconsistent bond strengths with LED Unidose applicator too large for small preps Manufacturer Heraeus0 Prices KITs None REFILLS Bottle $125.25/4ml ($31.31/ml) Single Dose $112.05/4ml/40 ($28.01/ml or $2.80/single dose) SHELF LIFE 3 years Odor Acceptable. Can You Cure It With an LED? Probably, since dentin bond strengths using an LED were only slightly lower than those using a halogen light. However, the bond strengths with the LED were not as consistent as they were with the halogen. What is the most effective application technique for DIRECT restorations? 2. Rinse and leave preparation WET. 3. Apply Adhesive for 20s with SCRUBBING MOTION adding more adhesive about every five seconds or so. 5. Light-cure Adhesive for 20s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate Bottles Unidose Enamel Dentin Using this technique, the bond strengths (MPa) with self-cured composite were: Substrate 5 min 24 hrs Dentin What is the most effective application technique for INDIRECT restorations using light-cured or dual-cured cement? 2. Rinse and leave preparation WET. 3. Apply Adhesive for 20s with SCRUBBING MOTION adding more adhesive about every five seconds or so. 5. Light-cure Adhesive for 20s. Using this technique, the bond strengths (MPa) on dentin were: Cement Type Immediate 5 min 24 hrs Light-cured cement 19.1 N/A N/A Dual-cured cement 13.1 N/A 15.8 Self-cured cement N/A N/A N/A 2009 Reality Publishing Co. Vol. 21 The Ratings 73

14 Bonding AGents For INDIRECT restorations, what do you apply on the inside surface of the restoration? GCB+D (apply and gently air-dry for five seconds to evaporate the ethanol and water, do not cure). Post-Operative Sensitivity Minimal to none. Packaging Both bottle and unidose are in easy to stack boxes with convenient identification on three sides and top. No plastic shrink-wrapped or even tape for security. Expiration dates on one side of bottle box and on top of unidose box. Bottle Cardboard box with rear-attached lid. The bottle of adhesive is secured in a white plastic tray. Dispensing into a mixing well is suggested, but this well is not included. The moisture-resistant label on the conventional black plastic bottle includes the expiration date. Single Dose Applicators come in foil pouches that are loose in the box. It is easy to open the foil pouch due to a notched area at one end. The pouches are well identified, have the expiration date embossed, and include three line drawings on how to actually use the single dose applicator. This applicator has a white plastic handle, which inserts into a two-stage black plastic cylinder. Using the handle, you push the smaller stage into the larger one. Then you pull out the applicator to find the head immersed in adhesive. You then apply the adhesive as you would with any applicator tip. For most restorations, the applicator was fine, but it may be somewhat large for smaller ones. Directions Multi-language, 99-page, plain paper booklet, but there is at least a table of contents on the front allowing you to find your preferred language quickly. There is also a small, double-sided, plastic-coated treatment room card (much large in the single dose box) with color illustrations displaying the application steps. While the illustrations are well-done, the lack of words hinders the card s usefulness. 3b (4.2) OptiBond Solo plus Description Single-component with heritage of OptiBond. Uses Light-cured and dual-cure direct and indirect, metal-free restorations. Composition BIS-GMA, HEMA, GDM, GPDM (glycero-phosphate dimethacrylate), ethanol, fumed silica, barium glass, sodium hexafluorosilicate, CQ (camphorquinone). Approximately 15% filled by weight with 0.4μ glass. ph 2.2 Viscosity Acceptable for directs, but needs to be carefully thinned out for indirects. Raves & Rants + Good bond strengths with indirects + Consistent, reliable performance Does not work with self-cured materials Need to thin out very carefully with indirects Manufacturer Kerr Prices KITs Bottle: $277.05/10ml ($27.71/ml) Unidose: $277.10/10ml/100 ($27.71/ml or $2.77/unidose) REFILLS Bottle: Unidose: SHELF LIFE 2 years $138.55/5ml ($27.71/ml) $232.35/10ml/100 ($23.24/ml or $2.32/unidose) Odor Not really noticeable. Can You Cure It With an LED? Probably, since dentin bond strengths using an LED exceeded those using a halogen light. What is the most effective application technique for DIRECT restorations? 2. Rinse and leave preparation MOIST. 3. Apply Adhesive for 15s with GENTLE AGITATION adding more adhesive about every five seconds or so. 5. Light-cure Adhesive for 10s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate Bottles Unidose Enamel 20.4 N/A Dentin The Ratings 2009 Reality Publishing Co. Vol. 21

15 What is the most effective application technique for INDIRECT restorations using light-cured or dualcured cement? 2. Rinse and leave preparation MOIST. 3. Apply Adhesive for 15s with GENTLE AGITATION adding more adhesive about every five seconds or so. 5. Light-cure Adhesive for 10s. Using this technique, the bond strengths (MPa) on dentin were: Cement Type Immediate 5 min 24 hrs Light-cured cement 24.2 N/A N/A Dual-cured cement 9.1 N/A 14.8 Self-cured cement N/A N/A N/A For INDIRECT restorations, what do you apply on the inside surface of the restoration? Unfilled resin or OptiBond Solo plus (apply and gently air-thin, do not cure). Post-Operative Sensitivity Minimal to none. Packaging The Unidose Kit comes in a large blue box with convenient identification on three sides and top, expiration date on one side, and plastic shrink-wrapped for security. There is another small blue one for the syringe of etchant and applicator tips. These cardboard boxes are shipped one on top of the other in a blue cardboard sleeve. The box containing the Unidose packets is perforated on the bottom of the front side so that a slot can be created to allow easy retrieval of these packets. There are also expiration dates on the foil packets. Each foil packet holds one Unidose and is torn open at the notch in its top side. The actual Unidose is black plastic and resembles a two-stage rocket, with the bottom looking like a real spaceship while the larger top section mimics a booster rocket. Grip the top section with one hand and the bottom with the other and twist the two sections apart. The adhesive can now be seen in the reservoir in the bottom section while the top section can be discarded. After using the adhesive, the bottom section is also discarded. If you prefer bottles, they are black and have moisture-resistant labels that include the expiration dates. Directions Multi-language, 96-page, coated paper booklet. Adequate, but there are still ambiguous areas. For example, you are told to dry lightly, do not desiccate after rinsing the etchant, but not whether the etched surface should be shiny or dull. There is also a plastic-coated, spiral-bound technique guide with color illustrations and brief instructions for direct, light-cured restorations, veneers, crowns, inlays, onlays, posts, and core materials. Some of the illustrations, however, are misleading and depict poor technique. For example, when curing a veneer, the light tip is shown as being about 1cm away from the surface of the veneer and the light tip itself is too small to cure the veneer. We continue to urge manufacturers to have clinically-accurate illustrations, since some users may think that the procedures as illustrated can be done in that manner. In addition, there is a statement to Light cure all surfaces a minimum of 40 seconds per surface, but then there is a sidebar telling you specific times for curing with the Optilux 501 and advising you to see manufacturer s recommendation for all other lights. Well, if you need to check with another manufacturer, then why even mention 40 seconds per surface? 2009 Reality Publishing Co. Vol. 21 The Ratings 75

16 Bonding AGents 4a (4.1) Adper Scotchbond Multi-Purpose Plus Description Venerable multi-component version of the Scotchbond line. Uses All types of restorations. Composition Activator, component 1.5 Ethanol-based solution of benzenesulfinic acid salt plus photoinitiator. Primer, component 2 Water, HEMA, and polycarboxylic acid copolymer. Adhesive, component 3 BIS-GMA and HEMA plus photoinitiator. Raves & Rants + Will bond to good old dry tooth structure + Light-cured, dual-cured, self-cured Keeping track of which components to use is confusing Low enamel bond strength Manufacturer 3M ESPE Prices KIT $493.30/24ml ($20.55/ml) REFILLS 1 btl (8ml) of primer or adhesive $ ($22.75/ml) 1 btl (4ml) of activator or catalyst $ ($31.45/ml) SHELF LIFE 3 years refrigerated Catalyst, component 3.5 BIS-GMA, HEMA, and benzoyl peroxide. ph Viscosity Acceptable. Component ph Activator 8.1 Primer 4.0 Activator/Primer (mixed) 4.7 Adhesive 8.2 Catalyst 5.7 Adhesive/Catalyst (mixed) 6.9 Odor Not really noticeable. Can You Cure It With an LED? Probably, although dentin bond strengths using an LED were somewhat lower than those using a halogen light. What is the most effective application technique for DIRECT Light-Cured/ Dual-Cured restorations? 2. Rinse and leave preparation MOIST. 3. Apply Primer (2) for 10s with GENTLE AGITATION. 5. Apply Adhesive (3) using brush-on/brush/off. 6. Light-cure Adhesive (3) for 10s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate Light-cured Enamel 17.7 Dentin 28.2 What is the most effective application technique for DIRECT Self-Cured restorations? 2. Rinse and leave preparation MOIST. 76 The Ratings 2009 Reality Publishing Co. Vol. 21

17 3. Apply Activator (1.5) and merely air-dry gently for five seconds. 4. Apply Primer (2) for 10s with GENTLE AGITATION. 5. Apply GENTLE AIR to evaporate the solvent. 6. Apply Adhesive (3) using brush-on/brush/off. 7. Light-cure Adhesive (3) for 10s. Using this technique, the bond strengths (MPa) with self-cured composite were: Substrate 5 min 24 hrs Dentin What is the most effective application technique for INDIRECT restorations using light-cured cement? 2. Rinse and leave preparation MOIST. 3. Apply Primer (2) for 10s with GENTLE AGITATION. 5. Apply Adhesive (3) using brush-on/brush/off. 6. Seat restoration with light-cured cement and light-cure adhesive simultaneously with cement. What is the most effective application technique for INDIRECT restorations using dual-cured cement? 2. Rinse and leave preparation MOIST. 3. Apply Activator (1.5) and merely air-dry gently for five seconds. 4. Apply Primer (2) for 10s with GENTLE AGITATION. 5. Apply GENTLE AIR to evaporate the solvent. 6. Mix Adhesive (3) and Catalyst (3.5) in 1:1 ratio using brush-on/brush/off. 7. Seat restoration with dual-cured cement and light-cure adhesive simultaneously with cement. What is the most effective application technique for INDIRECT restorations using self-cured cement? 2. Rinse and leave preparation MOIST. 3. Apply Activator (1.5) and merely air-dry gently for five seconds. 4. Apply Primer (2) for 10s with GENTLE AGITATION. 5. Apply GENTLE AIR to evaporate the solvent. 6. Apply Catalyst (3.5) using brush-on/brush/off. 7. Seat restoration with self-cured cement. Adhesive will self-cure along with cement. Using these techniques, the bond strengths (MPa) on dentin were: Cement Type Immediate 5 min 24 hrs Light-cured cement 25.2 N/A N/A Dual-cured cement 8.7 N/A 14.5 Self-cured cement N/A For INDIRECT restorations, what do you apply on the inside surface of the restoration? Light-cured Adhesive or unfilled resin (apply and gently air-thin, do not cure). Dual-cured Catalyst (apply and gently air-thin, do not cure). Self-cured Catalyst/Adhesive (apply and gently air-thin, do not cure). Post-Operative Sensitivity Minimal. Packaging Easy to stack box with convenient identification on three sides and top. No plastic shrink-wrapped or even tape for security. Expiration date on the bottom, but it would not be visible on a shelf. All of the bottles containing the various solutions are color-coded with different color tops or printing, which is moisture-resistant. Expiration dates are on the bottle labels and could not be rubbed off after vigorous disinfecting procedures. Directions Multi-language, plain paper in annoying foldout design using the smallest typeface possible. There are also plastic-laminated cards with illustrations summarizing the steps for chairside use. The paper instructions are detailed and cover all the different uses of this material except dual-cure core build-ups. In addition, there is advice to bevel all enamel margins when completing a direct composite. There are situations where beveling may not be indicated, such as the occlusal margins of Class I and II preparations. There is also no explanation why you dry the tooth after etching for five seconds for direct restorations, but only two seconds for indirect. Furthermore, you are supposed to leave the surface moist, but, at the same time, the etched enamel should have a frosty white appearance. How to accomplish this magic is not explained. And there is no description on how the dentin should look when it is moist. The technique cards are punched to fit into 3M s small custom binder for technique guides of all their products. This binder, measuring only 5 x 7, is extremely well done and provides quick and easy access to the directions for all of 3M ESPE products. The technique cards are easy to read, have nice color illustrations, and are easily disinfected. Unlike the paper instructions, the cards tell you to blot the excess water after etching, which is the better method compared to air drying Reality Publishing Co. Vol. 21 The Ratings 77

18 Bonding AGents 4b (4.1) PQ1 Raves & Rants Description Single-component in the famous Ultradent syringe. Uses Light-cured and dual-cured direct and indirect restorations. Composition HEMA, proprietary monomers, camphorquinone, 40% filled with barium borosilicates (0.7μ), proprietary natural resins, and fluoride in 8% ethanol. ph 1.7 Viscosity Acceptable for directs, but needs to be carefully thinned out for indirects. Odor Acceptable. + Convenient syringe delivery + High filler leads to consistent bonding Milky look only for mustaches Mediocre results with indirects Manufacturer Ultradent Prices KIT Introductory $76.99/2.4ml ($32.08/ml) REFILLS 4 pack $68.99/4.8ml ($14.37/ml) SHELF LIFE 1.5 years refrigerated Can You Cure It With an LED? Probably, since dentin bond strengths using an LED were only slightly less than those using a halogen light. What is the most effective application technique for DIRECT restorations? 2. Rinse and leave preparation MOIST. 3. Apply Adhesive for 15s with RUBBING MOTION adding more primer about every five seconds or so. 4. Apply GENTLE AIR to evaporate the solvent and to eliminate the milky appearance. You are finished when the coat of PQ1 is translucent. 5. Light-cure Adhesive for 20s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate MPa Enamel 24.5 Dentin 20.1 What is the most effective application technique for INDIRECT restorations using light-cured or dual-cured cement? 2. Rinse and leave preparation MOIST. 3. Apply Adhesive for 15s with RUBBING MOTION adding more primer about every five seconds or so. 4. Apply GENTLE AIR to evaporate the solvent and to eliminate the milky appearance. You are finished when the coat of PQ1 is translucent. 5. Seat restoration with light-cured or dual-cured cement and light-cure PQ1 simultaneously with cement. Using this technique, the bond strengths (MPa) on dentin were: Cement Type Immediate 5 min 24 hrs Light-cured cement 9.4 N/A N/A Dual-cured cement 5.9 N/A 16.3 Self-cured cement N/A N/A N/A For INDIRECT restorations, what do you apply on the inside surface of the restoration? PQ1 (apply and gently air-thin and evaporate the ethanol, do not cure). 78 The Ratings 2009 Reality Publishing Co. Vol. 21

19 Post-Operative Sensitivity Minimal to none. Packaging Easy to stack box with product identification on every side and top and bottom. Expiration date is on a label on the bottom. Kit is only secured by tape. Syringe application is quick and easy, yet it takes a little time to get used to controlling the flow rate of the material. The expiration date is embossed on the syringe. Directions Multi-language, plain paper in annoying foldout design. Includes illustrations and photos. Straightforward, although require some knowledge of other Ultradent products to be completely understood. 4c (4.1) XP Bond Raves & Rants + Easy to apply + Virtually no post-op sensitivity Nasty odor and taste Still can fail semi-permeable membrane test Manufacturer Dentsply/Caulk Prices KIT Introductory Bottle $139.25/5ml ($27.85/ml) Dual Cure Introductory $274.40/9.5ml ($28.88/ml) Unit Dose (100) $253.75/10ml ($25.38/ml or $2.54/dose) REFILLS Bottle $117.25/5ml ($23.45/ml) Self Cure Activator $135.25/4.5ml ($30.06/ml) SHELF LIFE 2 years Description Total-etch dental adhesive that follows in the footsteps of the iconic product that defined the singe-component movement, Prime & Bond (P&B). Since its introduction in 1995, P&B has gone through several reincarnations to reach its current version, NT. Although it has the potential to perform quite well, it is also known to be somewhat technique-sensitive. Thus, when Dentsply decided to tweak its formulation once again, it decided to rename the product to try to convince everyone that XP Bond was more than a rebadged P&B. So how different is XP Bond compared to P&B? Well, it still contains PENTA, which is Dentsply s main adhesive monomer and that which has formed the backbone of P&B from the beginning. It also contains standardized P&B resins such as UDMA and TEGDMA, plus the nanofillers that made their debut with NT. However, XP Bond adds HEMA and TCB, plus it substitutes an alcohol (t-butanol) as a solvent instead of P&B s acetone, which has been a suspected culprit causing the aforementioned technique sensitivity. According to Dentsply, t-butanol is an even more effective solvent compared to ethanol, which is the alcohol solvent used in most adhesives. T-butanol is stated to be less reactive with resins, helps the resin wet a moist tooth surface, and is more stable. In addition, it is less than 25% of the adhesive s volume, which is another presumed advantage over other adhesives that are reportedly 35%-45% solvent. All evaluators considered its viscosity about right, although most also commented about the strong odor. Uses All types of restorations. Composition XP Adhesive PENTA (dipentaerythritol penta acrylate monophosphate), UDMA, HEMA, TCB, camphorquinone, and nanofillers (amorphous silicon dioxide) in t-butanol. Self-Cure Activator UDMA, di- and trimethacrylate resins, and arylborate salt in acetone and water. ph Viscosity All of the evaluators thought it was just right. Odor About 60% of the evaluators thought its smell was strong, with one evaluator also commenting on the bad taste, while the remaining 40% felt it was not really noticeable. Can You Cure It With an LED? Probably, since dentin bond strengths using an LED were virtually the same when halogen light was used. What is the most effective application technique for DIRECT, LIGHT-CURED restorations? 2. Rinse and leave preparation DRY or MOIST. Both will work, but most evaluators used moist. Wet even works on enamel, but not as well on dentin Reality Publishing Co. Vol. 21 The Ratings 79

20 3. Apply XP Adhesive for 20s with GENTLE AGITATION. The directions tell you to apply and allow it to dwell undisturbed for 20 seconds. However, without some agitation, it will run off the tooth. The evaluators were split between gentle and medium air. However, our tests showed bond strengths will decrease as the air pressure you use to evaporate the solvent increases. 5. Light-cure XP Adhesive for 10s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate dry moist Wet Enamel Dentin What is the most effective application technique for DIRECT, DUAL-CURED OR SELF-CURED restorations? 2. Rinse and leave prepar ation DRY or MOIST. (Both will work.) 3. Mix XP Adhesive and Self-Cure Activator in 1:1 ratio and apply for 20s with GENTLE AGITATION adding more adhesive about every five seconds or so. 5. Do NOT light-cure. Place restorative material and allow adhesive to selfcure along with the restorative material. Using the MOIST technique, the dentin bond strengths (MPa) with self-cured composite were: Substrate 5 min 24 hrs Dentin What is the most effective application technique for INDIRECT restorations using light-cured cement? 2. Rinse and leave preparation DRY or MOIST. (Both will work.) 3. Apply XP Adhesive for 20s with GENTLE AGITATION. 5. Seat restoration and cure adhesive with light-cured cement. What is the most effective application technique for INDIRECT restorations using dual-cured cement? 2. Rinse and leave preparation DRY or MOIST. (Both will work.) 3. Mix XP Adhesive and Self-Cure Activator in 1:1 ratio and apply for 20s with GENTLE AGITATION. 5. Do NOT light-cure. 6. Seat restoration with dual-cured cement. What is the most effective application technique for INDIRECT, METAL-BASED restorations using self-cured cement? 2. Rinse and leave preparation DRY or MOIST. (Both will work.) 3. Mix XP Adhesive and Self-Cure Activator in 1:1 ratio and apply for 20s with GENTLE AGITATION. 5. Do NOT light-cure. 6. Seat restoration with self-cure cement and allow adhesive to self-cure along with the cement. Using the MOIST technique, the bond strengths (MPa) on dentin were: Cement Type Immediate 5 min 24 hrs Light-cured cement 18.2 N/A N/A Dual-cured cement 13.4 N/A Self-cured cement N/A All specimens fractured the dentin, indicating the bond strength exceeded the cohesive strength of dentin. 2 83% of specimens fractured the dentin, indicating the bond strength in most specimens exceeded the cohesive strength of dentin. For INDIRECT restorations, what do you apply on the inside surface of the restoration? 1. If you are using a LIGHT-CURED cement, you can use unfilled resin such as Heliobond (do not cure) or you can use XP Adhesive, gently air-thin and do not cure. 2. With dual-cured or self-cured cement, mix XP Adhesive and Self-Cure Activator (apply and gently air-thin, do not cure). Post-Operative Sensitivity All evaluators except one reported no incidents. Packaging Introductory and Dual Cure Introductory Kits Easy to stack boxes with product identification on two sides and top. Expiration date is on a label on one side. Dual Cure is plastic shrink-wrapped for security, but single-component kit is not secured in any manner. The labels on the bottles contain the expiration date, which resists removal during disinfection procedures reasonably well. Adhesive is in a semi-translucent, photobloc-type orange bottle with silver label and cap, while the self cure activator is in a more conventional, black bottle with blue label and pink cap for instant differentiation. The adhesive bottle has a ringlike seal for its cap, the type that you break when opening the bottle. However, one evaluator had a problem breaking the seal. The new item is light-protective container called CliXdish. This is essentially a white plastic well with front and rear legs raising the center section off the countertop about 1.0cm. In addition, there is a light-protective orange lid that is rear-hinged to the base. According to Dentsply, you can dispense XP Bond into container and, as long as the lid is closed, the adhesive can be used up to 15 minutes after dispensing. We tested the bond strength of the material right after dispensing and then again after it had dwelled in the container for 15 minutes. We found no differences, indicating that the CliXdish actually works for the 15 minutes stated by the manufacturer. Unit Dose Kit Rectangular cardboard box with product identification on every side and top, plastic shrink-wrapped for security, with a drawer in the bottom section that rotates out and down to reveal a recess containing the unit doses in a Ziploc bag. We assume you are supposed to empty the bag into the recess, since there are no instructions concerning the packaging. This makes a fairly good dispenser for the unit doses, but you still may choose to transfer these unit doses to a receptacle of your choosing. 80 The Ratings 2009 Reality Publishing Co. Vol. 21

21 Inside the top lid of the box are the holders for the unit doses, two boxes of applicator tips, and the instructions. The holder is blue plastic and shaped like a pedestal for a table, with a wide, circular base, thin circular stem, and round top. There is a hole through the holder, in which the unit dose sits and another smaller hole in the circular base, ostensibly for an applicator, since there is no description for the purpose of this hole anywhere in the instructions. The unit dose itself is a two-stage, black plastic cylinder with an orange cap, clearly marked with the product name and expiration date. The bottom part of the cylinder containing the adhesive is placed in the hole of the holder. Then, with your thumb, you apply lateral pressure on the top part to snap the cylinder open. At this point, the top of the remaining section of the cylinder is flush with the top of the holder. Directions Plain paper in the annoying, foldout style, but thankfully only in one language (although international versions may include a multi-language booklet). It is wellorganized and covers most of the important steps, including how the dentin should be dried, but not how it should look prior to applying the adhesive. There are also two plastic-laminated, treatment room cards: one for direct, light-cured procedures and included in the Introductory and Unit Dose kits and another for indirect restorations included in the Dual Cure kit. Both feature color illustrations and easy-to-follow, step-by-step application procedures. 5a (4.0) All-Bond 2 Description Second generation of the classic adhesive that practically defined this category. Uses All types of restorations. Raves & Rants + Has longest track record + Can do everything with it Too many bottles Very susceptible to overdrying Manufacturer Bisco Prices COMPLETE KIT $163.00/21ml ($7.76/ml) REFILLS 1 btl (6ml) of Primer A or B $58.00 ($9.67/ml) 1 btl of Dentin/Enamel Bonding Resin (6ml) $27.00 ($4.50/ml) 1 btl of Pre-Bond (3ml) $15.00 ($5.00/ml) SHELF LIFE 2 years Composition Primer A NTG-GMA, acetone, and ethanol. Primer B BPDM (biphenyl dimethacrylate), acetone, and ethanol. Dentin/Enamel Bonding Resin BIS-GMA, UDMA, and HEMA. Pre-Bond BIS-GMA, triethyleneglycol dimethacrylate, HEMA, and benzoyl peroxide. This acts as a wetting agent and slows down the reaction between Primers A & B and a dual-cured or self-cured resin cement used for indirect restorations. Slowing down the setting time between the adhesive and resin cement helps tremendously when cleaning the excess cement off the restoration. The benzoyl peroxide will chemically polymerize when it is sandwiched between the tertiary amine in Primer A and the dual-cured or self-cured resin cement. For a true dual-cured/self-cured bonding resin, mix Pre-Bond with the Dentin/Enamel Bonding Resin. ph Primers A/B 5.7 Viscosity Acceptable. Odor Not really noticeable. Can You Cure It With an LED? Probably, since dentin bond strengths using an LED were roughly equal to those using a halogen light. What is the most effective application technique for DIRECT restorations? 2. Rinse and leave preparation WET. 3. Mix Primers A & B and apply for 20s with GENTLE AGITATION adding more of the primer mix about every five seconds or so Reality Publishing Co. Vol. 21 The Ratings 81

22 5. Apply D/E Resin using brush-on/brush/off. 6. Light-cure D/E Resin for 20s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate MPa Enamel 21.3 Dentin 25.3 Using this technique, the bond strengths (MPa) with self-cured composite were: Substrate 5 min 24 hrs Dentin What is the most effective application technique for INDIRECT restorations using light-cured or dualcured cement? 2. Rinse and leave preparation WET. 3. Mix Primers A & B and apply for 20s with GENTLE AGITATION adding more of the primer mix about every five seconds or so. 5. Apply D/E Resin using brush-on/brush/off. 6. Seat restoration with light-cured or dual-cured cement and light-cure D/E Resin simultaneously with cement. What is the most effective application technique for INDIRECT restorations using self-cured cement? 2. Rinse and leave preparation WET. 3. Mix Primers A & B and apply for 20s with GENTLE AGITATION adding more of the primer mix about every five seconds or so. 5. Mix D/E Resin and Pre-Bond in 1:1 ratio using brush-on/brush/off. 6. Quickly seat restoration with self-cured cement. Adhesive will self-cure along with cement. For INDIRECT restorations, what do you apply on the inside surface of the restoration? Using light-cured or dual-cured cement D/E Resin (apply and gently air-thin, do not cure) Using self-cured cement Primer B (apply and gently air-thin and evaporate the acetone, do not cure). Post-Operative Sensitivity When the application technique is followed precisely, sensitivity is minimal, but incidence increases when shortcuts are attempted or the instructions are misunderstood. Packaging Clear plastic fishing tackle-like box sealed in plastic shrink-wrap for security. The only identification is on the top, although there is a sticker with the expiration date on one side. There are clear plastic dividers, which are removable if you want to reconfigure the box and rearrange the components. There is a plastic insert summarizing the directions, but we strongly suggest becoming thoroughly familiar with the technique cards described under Directions instead of relying on these brief instructions. The labels on the bottles include the expiration date and are moisture-resistant. Directions Multi-language, plain paper in annoying foldout design that gives brief instructions, but the main instructions are printed on plastic-laminated index cards that are joined with a spiral binding. Each technique has its own color card for quick reference. Overall, the information is helpful, but there are a few confusing areas. For example, the introduction to all the techniques describe Bisco s two etchants, All-Etch, which is 10% phosphoric acid, and Uni-Etch, which is 32% phosphoric acid. However, All-Etch has been discontinued. After etching, the excess water is supposed to be removed with a brief burst of air. However, we feel that using air can lead to overdrying and prefer a blotting technique. You are also supposed to end up with a moist surface, but exactly what that means is not explained. For self-cure composites, you are supposed to light-cure the primers but allow the mixture of D/E Resin and Pre-Bond, which follows the primers, to self-cure along with the self-cure composite. We found this technique was appropriate for self-cure indirect restorations, but unnecessary for direct restorations. Using this technique, the bond strengths (MPa) on dentin were: Cement Type Immediate 5 min 24 hrs Light-cured cement 20.6 N/A N/A Dual-cured cement 13.6 N/A 15.6 Self-cured cement N/A The Ratings 2009 Reality Publishing Co. Vol. 21

23 5b (4.0) One-Step Plus Description Filled version of one of the original single-component adhesives and one that actually can be used across-theboard. Uses All types of restorations. Composition BPDM (biphenyl dimethacrylate), BIS-GMA, HEMA, acetone, 8.5% fluoroaluminosilicate glass fillers. ph 4.4 Viscosity Acceptable for directs, but needs to be carefully thinned out for indirects. Raves & Rants + Best bond to self-cured materials for single components + Filler makes it less technique-sensitive Dry prep causes much lower bond strength Must be shaken before using don t forget! Manufacturer Bisco Prices KITS Bottle w/ Syringe Etchant $107.00/6ml ($17.83/ml) Unit-Dose $146.00/8ml/80 ($18.25/ml or $1.83/unidose) REFILLS Bottle $97.00 ($16.17/ml) SHELF LIFE 2 years Odor Not really noticeable. Can You Cure It With an LED? Probably, since dentin bond strengths using an LED were equal to those using a halogen light. What is the most effective application technique for DIRECT restorations? 2. Rinse and leave preparation WET. 3. Apply Adhesive for 15s with GENTLE AGITATION adding more adhesive about every five seconds or so. 5. Light-cure Adhesive for 10s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate MPa Enamel 23.4 Dentin 22.7 Using this technique, the bond strengths (MPa) with self-cured composite were: Substrate 5 min 24 hrs Dentin What is the most effective application technique for INDIRECT restorations using light-cured, dual-cured, or self-cured cement? 2. Rinse and leave preparation WET. 3. Apply Adhesive for 15s with GENTLE AGITATION adding more adhesive about every five seconds or so. 5. Light-cure Adhesive for 10s. 6. Seat restoration with light-cured, dual-cured, or self-cured cement. Using this technique, the bond strengths (MPa) on dentin were: Cement Type Immediate 5 min 24 hrs Light-cured cement Immediate N/A min 24 N/A hrs Light-cured Dual-cured cement N/A 17.5 N/A Dual-cured Self-cured cement 14.4 N/A 12.1 N/A Reality Publishing Co. Vol. 21 The Ratings 83

24 For INDIRECT restorations, what do you apply on the inside surface of the restoration? One-Step Plus (apply and gently air-dry for five seconds to evaporate the acetone, do not cure). For self-cured indirects, use Primer B from the All-Bond 2 kit. Post-Operative Sensitivity When the application technique is followed precisely, sensitivity is minimal, but incidence increases when shortcuts are attempted or if the prep is not left wet after rinsing the etchant. Packaging Bottle Kit Clear plastic fishing tackle-like box sealed in plastic shrink-wrap for security. The only identification is on the top, although there is a sticker with the expiration date on one side. There are clear plastic dividers, which are removable if you want to reconfigure the box and rearrange the components. The moisture-resistant labels on the conventional black squeeze bottles include the expiration date. Due to One-Step Plus being filled, there is a small metal ball in the bottle that acts as a shaker to help disperse the filler particles. Unit-Dose Kit Plastic shrink-wrapped large white cardboard box with foldout doors on the bottom of the front side to allow easy retrieval of the foil packets. The full product name is only on the front and top, while the expiration date is on the back of the box. In the unidose box, there are individual foil packets of adhesive plus a plastic tube containing the ampules of etchant. This tube, however, is buried under all the foil packets and it would be easy to miss it. The foil packet is torn open at either of the perforated ends. The actual unit-dose of adhesive is a two-part, black cylinder-shaped plastic container that already houses a white plastic applicator. To use, push the top section into the slightly larger bottom one and merely withdraw the applicator, whose head should be infused with adhesive. The ampule of etchant is clear plastic with a squeezable bowl and a long cannula for dispensing. To use, the end of the cannula must be cut with scissors. Directions Multi-language, plain paper in annoying foldout design plus coated paper treatment room card with the color illustrations. Both types of instructions are welldone and explain the basic application procedure well. 84 The Ratings 2009 Reality Publishing Co. Vol. 21

25 Self-Etch Bonding Agents 1 (4.4) Clearfil SE Bond Description Two-component, sequential application. Uses Light-cured and dual-cured direct restorations. Composition Primer 10-Methacryloyloxydecyl dihydrogen phosphate (MDP), HEMA, hydrophilic dimethacrylate, dl-camphorquinone, N,N-diethanol p-toluidine, water. Bond 10-Methacryloyloxydecyl dihydrogen phosphate (MDP), BIS-GMA, HEMA, hydrophobic aliphatic dimethacrylate, dl-camphorquinone, N,N-diethanol ptoluidine, silanated colloidal silica. Filled 10% by weight. Raves & Rants + Gold standard for self-etchers + Clinical performance exemplary Two bottles are very nearly the same color Weak effectiveness with indirects Manufacturer Kuraray Prices KIT $157.00/11ml ($14.27/ml) REFILLS 1 btl of self-etching Primer (6ml) $46.25 ($7.71/ml) 1 btl of Bond liquid (5ml) $ ($21.00/ml) SHELF LIFE 2 years refrigerated ph Primer 2.0 Viscosity Primer Just right. Bond Just right. Odor Not really noticeable. Can You Cure It With an LED? Probably, although dentin bond strengths using an LED were lower than those using a halogen light. What is the most effective application technique for DIRECT restorations? 1. Leave preparation DRY, but don t desiccate the tooth. 2. Apply Primer for 20s with GENTLE AGITATION adding additional Primer during the 20-second application period. 5. Apply Bond resin using brush on/brush off method, then use GENTLE AIR to thin this layer to create an even, medium-thin, shiny coating. 6. Light-cure Bond resin for 10s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate Self-Etch Etch w/pa Enamel Dentin This shows etching the enamel with PA is beneficial, although it s not mandatory except when the enamel is unprepared. It also shows there is no benefit to etching the dentin. Packaging Easy to stack box with product identification on two sides and top. Plastic shrink-wrapped for security. Expiration date is on a label on one side. The standard squeeze-type bottles of Primer and Bond have caps that are supposed to be color-coded to the colors of the actual liquids, but the difference is barely noticeable. Fortunately, the caps and bottles are shaped and sized differently, with the caps not being interchangeable. The Primer bottle is smaller and round in cross-section, while the Bond bottle is larger and oval. The moisture-resistant printing on the bottles clearly indicates the expiration date, which resists removal during disinfection procedures Reality Publishing Co. Vol. 21 The Ratings 85

26 Bonding AGents The bottles can be used conventionally or can be inserted into the translucent plastic squeeze dispenser that allows dispensing from both bottles with one hand. It has two dedicated squeeze areas on one side to correspond with the position of the bottles. These squeeze areas have elevated flaps that facilitate expressing the drops. Around these flaps is a space to allow easier movement. However, this space is a definite compromise when asepsis procedures are performed. To use, you remove the yellow cap from the dispenser and open it by releasing the lock on one side. There are two chambers in the dispenser, one for each bottle. Remove the caps from the bottles, insert the bottles into the appropriate chambers, and close the dispenser. The yellow dispenser cap replaces the caps for each bottle. When it is time to use the product, remove the yellow cap from the dispenser, press the elevated flaps on the squeeze areas adjacent to the Primer and Bond bottles, and dispense a drop of each. There are color-coded, moisture-resistant labels on these flaps for distinguishing the Primer from the Bond. Directions Plain paper foldout design in three languages and plastic-laminated treatment room cards attached with a plastic ring. The paper instructions are ambiguous on how to leave the preparation prior to applying the primer it only states that a rubber dam is recommended to keep the tooth dry. There is also a statement that you should use caution not to allow saliva or exudate to contact the treated surfaces. How did exudate get into this scene anyway? The laminated, treatment room cards feature color illustrations and easy-to-follow, step-by-step application procedures. They are held together with a plastic ring, which is inserted through a hole punched in the corner of the cards. Overall, the cards are well done, but still omit how to treat the tooth prior to applying the primer and suggest that porcelain can be etched with K-Etchant Gel, a 40% phosphoric acid, in five seconds. Even though this gel may help acidify the restoration and make it more amenable to repair, it is highly doubtful it will be able to etch porcelain in such a short period of time. 2 (4.3) Peak Description Two-component, sequential application in syringes. Even though this product is primarily being promoted as a self-etcher, you have the option of using a conventional phosphoric acid etch as the first step followed by the bonding resin. Uses Light-cured and dual-cured direct restorations. Raves & Rants + Unique syringe mixing system for primers + Works moist or wet Doesn t work with self-cured materials Dispensing from syringes sometimes hard to control Manufacturer Ultradent Prices Introductory: $86.99/2.4ml ($36.25/ml) REFILLS 4 pack Primer: $63.99/4.8ml ($13.33/ml) Bond Resin: $63.99/4.8ml ($13.33/ml) Unit Dose 50 pack/bond Resin: $187.99/10ml ($18.80/ml or $3.76/unit dose) SHELF LIFE 1.5 years refrigerated (30 days from activation) 86 Composition Primer Methacrylic acid, HEMA, and ethanol. Bond Resin Methacrylic acid, HEMA, and ethanol, but in different ratios compared to the primer. Filled 7.5% by weight. ph Primer 1.2 Viscosity Primer Just right. Bond Resin Just right. Odor Most evaluators considered it not really noticeable, although one thought it was strong but tolerable. Can You Cure It With an LED? Probably, since dentin bond strengths using an LED were equal to those using a halogen light. What is the most effective application technique for DIRECT restorations? 1. Leave preparation MOIST. 2. Apply Primer for 20s with RUBBING. 4. Apply GENTLE AIR for a few seconds to evaporate the solvent. It will not be shiny. 5. Apply Bond Resin for 10 seconds using GENTLE AGITATION and then use GENTLE AIR for 10 seconds to thin this layer to create an even, medium-thin, shiny coating and to evaporate the solvent. It will look shinier on dentin compared to enamel. 6. Light-cure Bond Resin for 10s. The Ratings 2009 Reality Publishing Co. Vol. 21

27 Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate Self-Etch Etch w/pa Enamel Dentin This shows etching the enamel with PA is not beneficial, although it s still prudent when the enamel is unprepared. It also shows there is virtually no benefit to etching the dentin. Packaging Clear plastic box in a slide-off cardboard sleeve shrink-wrapped for security. Stacks well on shelf with product identification on the sleeve on two sides and top and bottom. Expiration date is on a label on the bottom. While the syringe with the bond resin is conventional, the primers are mixed in a unique syringe called the JetMix. This is actually a syringe within a syringe. The front barrel is a dark grayish blue opaque and looks like virtually all the other syringes from Ultradent. This section contains one part of the primer. Immediately behind this barrel is the second section, which is a translucent blue chamber and holds the other part of the primer. The back end of the syringe is a thin, translucent plunger with a flattened area. On one of our initial evaluation kits, this flattened area was painted flat white, while the other was missing the white background. Before activating the primer, you are supposed to write either the activation or expiration date (30 days after activation). While this was not a problem on the plunger with the white surface, it was not possible on the syringe missing this background. To activate the primer, you merely push the clear plunger quickly and forcibly into the blue chamber. This ruptures the membrane between the two chambers and pushes the component in the blue chamber into the main opaque barrel. Once both components are in the main barrel, mixing is automatic; you are not told to shake the syringe to help mix the two components. A conventional Ziploc bag holds the unit dose syringes of the bond resin (the primers are not available in unidose), which are individually sealed in small clear plastic bags. The syringes themselves are identical to those in the kit, but they are only partially filled. Syringe application is quick and easy, yet it takes a little time to get used to controlling the flow rate of the material. Directions Multi-language, plain paper booklet. Very basic, but straightforward. Tell you to leave prep moist, but doesn t define moist. Our tests showed it worked as well on wet dentin as it did on moist, so there is some leeway with this product, but moist should still be defined. Mentions Peak Indirect Primer for indirect procedures, but we did not receive this component for testing. There is also a chairside card with color illustrations of the application steps, but the lack of words leaves you guessing on some steps. The card is also not laminated Reality Publishing Co. Vol. 21 The Ratings 87

28 Bonding AGents 3a (4.2) Bond Force Description Single component, self-etching adhesive. Presumably uses new technology in the form of a proprietary 3D Self- Reinforcing adhesive monomer, which is reported to be the key material that allows it to go beyond conventional lateral point to point linkage. Uses Light-cured and dual-cured, direct restorations. Composition Phosphoric acid monomer (Methacryloyloxyalkyl acid phosphate), BIS-GMA, TEGDMA, HEMA, fluoride releasing glass filler, and CQ (camphorquinone) in water and alcohol (C2-4 alkyl). Approximately 5% filled by weight. ph 2.3 Raves & Rants + Consistently good bond strengths + Excellent adaptation to cavity walls Need to rub during application a nuisance Two-stage drying not intuitive Manufacturer Tokuyama Prices Bottle Kit $115.00/5ml ($23.00/ml) Unidose Kit $155.00/50/5ml ($31.00/ml or $3.10/dose) SHELF LIFE 3 years refrigerated Viscosity All but one of the evaluators thought it was just right, with the lone exception feeling it was too runny. Odor About 80% of the evaluators thought its smell was not really noticeable, while the remaining 20% felt it had a strong odor, with one evaluator commenting on the bad taste. Can You Cure It With an LED? Probably, since dentin bond strengths using an LED were similar than when halogen light was used. Most evaluators also used an LED to cure it. What is the most effective application technique for DIRECT, LIGHT-CURED restorations? 1. Leave preparation DRY, but don t desiccate the tooth. Almost 60% of our evaluators used it dry, while the other 40% used it on moist teeth. However, the dry protocol produced higher bond strength results than moist. 2. Apply Adhesive RUBBING it into the tooth for 20s. However, most evaluators (70%) used gentle agitation, while the other 30% used rubbing/scrubbing. Our bond strength results showed, however, that rubbing/ scrubbing was more effective. 3. Apply GENTLE AIR until there is no movement and then FORCEFUL AIR for another 5s. Most evaluators followed this regimen. 4. Light-cure Adhesive for 10s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate Self-Etch Etch w/pa Enamel Dentin NOTE: This product is being promoted for uncut as well as cut enamel. Our tests, which show no advantage to etching with phosphoric acid, were performed on cut enamel and dentin. While it may perform acceptably on uncut enamel, we were not able to validate that claim. For enamel margins that are esthetically prominent, where you will be feathering the composite onto the adjacent uncut enamel, it would still be prudent to etch them to be on the safe side. Half of our evaluators etched unprepared enamel with phosphoric acid in either some or all of their preps. Post-Operative Sensitivity All evaluators except one reported no incidents. 88 The Ratings 2009 Reality Publishing Co. Vol. 21

29 Packaging The boxes are shrink-wrapped and even tapped for security, while the product is identified on two sides and the top. Expiration dates can be found on labels on the back of the boxes and imprinted directly on the bottle, the latter of which is not removed with disinfection. The bottle is a conventional, black squeeze plastic type with a silver reflective cap. The unidoses are black cylinders with lateral arms on both the top and bottom. The top is identified by a red insert. To open, the top section is twisted until it breaks free from the cylinder holding the adhesive. Then the top section can be mounted on the bottom to give the unidose a wider base, allowing it to stand upright on its own. Very clever design. Or the top can be used to protect the exposed adhesive from ambient light, but then the cylinder will not stand on its own. Each unidose is identified as Bond Force, but the expiration date is missing. Directions Multi-language, plain paper in the annoying, foldout style and a plastic-laminated card. Paper version is well-organized and covers most of the important steps. The plastic-laminated treatment room card features color illustrations and easyto-follow, step-by-step application procedures. 3b (4.2) Clearfil Protect Bond Description Two-component, sequential application clone of stablemate, Clearfil SE Bond, with the addition of an antimicrobial agent in the primer and fluoride in the bond. Uses Light-cured and dual-cured direct restorations. Composition Primer 10-Methacryloyloxydecyl dihydrogen phosphate (MDP), HEMA, hydrophilic dimethacrylate, 12-methacryloyloxydodecylpyridinium, water. Bond 10-Methacryloyloxydecyl dihydrogen phosphate (MDP), BIS-GMA, HEMA, hydrophobic aliphatic dimethacrylate, dl-camphorquinone, N, N-diethanol p-toluidine, silanated colloidal silica, sodium fluoride. Filled 10% by weight. Raves & Rants + Great bonding and kill bugs at the same time + Follows success of SE Bond More expensive than stablemate Difficult to disinfect dispenser Manufacturer Kuraray Prices KIT $205.00/11ml ($18.64/ml) REFILLS 1 btl of self-etching Primer (6ml) $ ($18.33/ml) 1 btl of Bond liquid (5ml) $ ($21.00/ml) SHELF LIFE 2 years refrigerated ph Primer 2.1 Viscosity Primer Just right. Bond Just right. Odor Not really noticeable. Can You Cure It With an LED? Probably, since dentin bond strengths using an LED were equal to those using a halogen light. What is the most effective application technique for DIRECT restorations? 1. Leave preparation DRY, but don t desiccate the tooth. 2. Apply Primer for 20s with GENTLE AGITATION adding additional Primer during the 20-second application period. 3. Apply GENTLE AIR to evaporate the solvent. 4. Apply Bond resin using brush on/brush off method, then use GENTLE AIR to thin this layer to create an even, medium-thin, shiny coating. 5. Light-cure Bond resin for 10s Reality Publishing Co. Vol. 21 The Ratings 89

30 Using this technique, the bond strengths (MPa) with light-cured composite were: substrate Self-Etch Etch w/pa Enamel Dentin This shows etching the enamel with PA is not beneficial, although it s still probably prudent when the enamel is unprepared. It also shows there is no benefit to etching the dentin. Packaging Easy to stack box with product identification on two sides and top. Plastic shrinkwrapped for security. Expiration date is on a label on one side. The standard squeeze-type bottles of Primer and Bond are shaped and sized differently, with the caps not being interchangeable. The Primer bottle is smaller and round in cross-section, while the Bond bottle is larger and oval. The moisture-resistant printing on the bottles clearly indicates the expiration date, which resists removal during disinfection procedures. The bottles can be used conventionally or can be inserted into the translucent plastic squeeze dispenser that allows dispensing from both bottles with one hand. It has two dedicated squeeze areas on one side to correspond with the position of the bottles. These squeeze areas have elevated flaps that facilitate expressing the drops. Around these flaps is a space to allow easier movement. However, this space is a definite compromise when asepsis procedures are performed. To use, you remove the blue cap from the dispenser and open it by releasing the lock on one side. There are two chambers in the dispenser, one for each bottle. Remove the caps from the bottles, insert the bottles into the appropriate chambers, and close the dispenser. The blue dispenser cap replaces the caps for each bottle. When it is time to use the product, remove the blue cap from the dispenser, press the elevated flaps on the squeeze areas adjacent to the Primer and Bond bottles, and dispense a drop of each. There are color-coded, moisture-resistant labels on these flaps for distinguishing the Primer from the Bond. Directions Plain paper foldout design in three languages and plastic-laminated treatment room cards attached with a plastic ring. The paper instructions are ambiguous on how to leave the preparation prior to applying the primer it only states that a rubber dam is recommended to keep the tooth dry. There is also a statement that you should use caution not to allow saliva or exudate to contact the treated surfaces. How did exudate get into this scene anyway? The laminated, treatment room cards feature color illustrations and easy-to-follow, step-by-step application procedures. They are held together with a plastic ring, which is inserted through a hole punched in the corner of the cards. Overall, the cards are well done, but still omit how to treat the tooth prior to applying the primer. 90 The Ratings 2009 Reality Publishing Co. Vol. 21

31 4 (4.0) Prelude Description Multi-component self-etcher that works with self-cured composite. Uses Primer + Adhesive Light-cured and dual-cured direct restorations. Primer + Adhesive + Link Self-cured direct restorations. Composition Primer HEMA and GPDM in ethanol and water. Adhesive BIS-GMA, HEMA, GPDM, barium aluminoborosilicate glass, fumed silica, and sodium hexaflorosilicate in ethanol. Filled 25% by weight; average particle size is 0.4μ. Raves & Rants + No mixing for self-cured mode + Highest bond strength of self-etchers to selfcured cores 2-compartment well is not consistent with 3 components Enamel bond strength was on the low end Manufacturer Danville Materials Prices KIT Self-Etch $139.95/15ml ($9.33/ml) REFILLS 1 btl (5ml) of Primer, Adhesive, or Link $53.95 ($10.79/ml) SHELF LIFE 2 years Link BIS-GMA, TEGDMA, and accelerators in ethanol. ph Primer 2.1 Adhesive 2.8 Link 9.3 Viscosity Acceptable. Odor Not really noticeable. Can You Cure It With an LED? Probably, since enamel bond strengths using an LED were equal to those using a halogen light. However, dentin bond strengths were much lower using the LED. What is the most effective application technique for DIRECT restorations? Using light-cured and dual-cured materials 1. Leave preparation MOIST. Dry was slightly less effective on dentin and slightly more effective on enamel. 2. Apply Primer for 10-15s with SCRUBBING. 3. Apply GENTLE AIR to evaporate the solvent. 4. Apply Adhesive IMMEDIATELY using SCRUBBING for 10 15s, then use GENTLE TO MEDIUM AIR to evaporate the solvent and thin this layer. 5. Light-cure Adhesive for 10s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate Self-Etch Etch w/pa Enamel Dentin This shows etching the enamel with PA is only minimally beneficial, although it s still probably prudent when the enamel is unprepared. It also shows there is no benefit to etching the dentin. Using self-cured materials 1. Leave preparation MOIST. Dry was slightly less effective on dentin and slightly more effective on enamel. 2. Apply Primer for 10 15s with SCRUBBING. 3. Apply GENTLE AIR to evaporate the solvent Reality Publishing Co. Vol. 21 The Ratings 91

32 Bonding AGents 4. Apply Adhesive IMMEDIATELY using SCRUBBING for 10 15s, then use GENTLE TO MEDIUM AIR to evaporate the solvent and thin this layer. 5. Light-cure Adhesive for 10s. 6. Apply Link using brush on/brush off method, then use GENTLE AIR to evaporate solvent, which produces a dull surface. Allow to cure with self-cure composite. Using this technique, the bond strengths (MPa) with self-cured composite were: Substrate 5 min 24 hrs Dentin Packaging Plastic tackle-like box sealed in plastic shrink-wrap for security. The only identification is on the top, along with a sticker with the expiration date. The moistureresistant labels on the conventional black squeeze bottles include the expiration date. Color-coded labels and caps distinguish the three components. There are disposable wells that have two sections marked A and B, but there are 3 bottles marked 1, 2, and 3 the wells should match the bottles. There are also applicators supplied, but they are all the same color, which could cause some cross-contamination. The CE mark is blacked out, but this mark is quickly removed during disinfection. Directions Glossy card with good color illustrations. Easy to understand, but omits how to treat the tooth prior to applying the primer. Good advice that phosphoric acid will eliminate any residual eugenol, which means total etch has an advantage over self-etch in these instances. 5 (3.7) Clearfil Liner Bond 2V Description Original multi-component self-etcher. Uses Primers + Bond A Light-cured direct restorations. Primers + Bond A/Bond B Self-cured direct and indirect restorations. Raves & Rants + Surprisingly good bond to prepared enamel + Highest bond strength to dentin Not very effective with indirects Tepid results with self-cured materials Manufacturer Kuraray Prices KIT $205.00/20ml ($10.25/ml) REFILLS 1 btl (6ml) of Primer A or B (6ml): $45.00 ($7.50/ml) 1 btl of Bond A (5ml): $ ($23.00/ml) 1 btl of Bond B (3ml): $63.00 ($21.00/ml) SHELF LIFE 2 years refrigerated Composition Primer A 2-hydroxyethyl methacrylate, hydrophilic dimethacrylate, 10-methacryloyloxydecyl, dihydrogen phosphate, N, N-diethanol-p-toluidine, d,1-camphorquinone, water. Primer B 2-hydroxyethyl methacrylate, hydrophilic dimethacrylate, water. Bond A Silanated colloidal silica, bisphenol A diglycidylmethacrylate, 2-hydroxyethyl methacrylate, hydrophobic dimethacrylate, 10-methacryloyloxydecyl, dihydrogen phosphate, N, N-diethanol-p-toluidine,d,l-camphorquinone. Bond B Silanated colloidal silica, bisphenol A diglycidylmethacrylate, 2-hydroxyethyl methacrylate, hydrophobic dimethacrylate, benzoyl peroxide. ph Primers A/B (mixed) 2.8 Viscosity Acceptable. Odor Not really noticeable. Can You Cure It With an LED? Probably, since dentin bond strengths using an LED were equal to those using a halogen light. What is the most effective application technique for DIRECT restorations? Using light-cured and dual-cured materials 1. Leave preparation DRY, but don t desiccate the tooth. 92 The Ratings 2009 Reality Publishing Co. Vol. 21

33 2. Mix Primers A & B and apply for 30s with GENTLE AGITATION adding additional Primer during the 30-second application period. 3. Apply GENTLE AIR to evaporate the solvent. Surface of preparation will look nonshiny. 4. Apply Bond resin A using brush on/brush off method, then use GENTLE AIR to thin this layer to create an even, medium-thin, shiny coating. 5. Light-cure Bond resin A for 10s. Using this technique, the bond strengths (MPa) with light-cured composite were: Substrate Self-Etch Etch w/pa Enamel Dentin This shows etching the enamel with PA is not beneficial, although it s still probably prudent when the enamel is unprepared. It also shows there is no benefit to etching the dentin. Using self-cured materials 1. Leave preparation DRY, but don t desiccate the tooth. 2. Mix Primers A & B and apply for 30s with GENTLE AGITATION adding additional Primer during the 30-second application period. 3. Apply GENTLE AIR to evaporate the solvent. Surface of preparation will look nonshiny. 4. Mix and apply Bond resins A & B using brush on/brush off method, then use GENTLE AIR to thin this layer to create an even, medium-thin, shiny coating. 5. Light-cure the mixture of Bond resin A & B for 10s. Using this technique, the bond strengths (MPa) with self-cured composite were: Substrate 5 min 24 hrs Dentin What is the most effective application technique for INDIRECT restorations using light-cured or dualcured cement? Using light-cured cement 1. Leave preparation DRY, but don t desiccate the tooth. 2. Mix Primers A & B and apply for 30s with GENTLE AGITATION adding additional Primer during the 30-second application period. 3. Apply GENTLE AIR to evaporate the solvent. Surface of preparation will look nonshiny. 4. Apply Bond resin A using brush on/brush off method, then use GENTLE AIR to thin this layer to create an even, medium-thin, shiny coating. 5. Seat restoration and light-cure Bond resin A simultaneously with cement. Using dual-cured cement 1. Leave preparation DRY, but don t desiccate the tooth. 2. Mix Primers A & B and apply for 30s with GENTLE AGITATION adding additional Primer during the 30-second application period. 3. Apply GENTLE AIR to evaporate the solvent. Surface of preparation will look nonshiny. 4. Mix and apply Bond resins A & B using brush on/brush off method, then use GENTLE AIR to thin this layer to create an even, medium-thin, shiny coating. 5. Seat restoration and light-cure the mixture of Bond resins A & B simultaneously with cement. Using self-cured cement 1. Leave preparation DRY, but don t desiccate the tooth. 2. Mix Primers A & B and apply for 30s with GENTLE AGITATION adding additional Primer during the 30-second application period. 3. Apply GENTLE AIR to evaporate the solvent. Surface of preparation will look nonshiny. 4. Mix Bond resins A & B and apply using brush on/brush off method, then use GENTLE AIR to thin this layer to create an even, medium-thin, shiny coating. 5. Seat restoration with self-cured cement and allow Bond resin mix to polymerize simultaneously with cement. Using these techniques, the bond strengths (MPa) on dentin were: Cement Type Immediate 5 min 24 hrs Light-cured cement Immediate N/A min 24 N/A hrs Light-cured Dual-cured cement N/A N/A 5.2 Dual-cured Self-cured cement 14.4 N/A N/A For INDIRECT restorations, what do you apply on the inside surface of the restoration? Light-cured indirect restorations Bond Liquid A, but do not cure. Dual-cure/self-cure indirect restorations Bond Liquid A/B (mix), but do not cure. Packaging Easy to stack box with product identification on all four sides and top. Plastic shrink-wrapped for security. Expiration date is printed directly on the box on one side. There is a unique gray plastic tray which opens like a fan to display seven holes for organizing the various bottles of Primers A & B, Bond Liquids A & B, Porcelain Bond Activator, and K-Etchant Gel. However, Porcelain Bond Activator and K-Etchant are not included in the kit and must be purchased separately. The labels for this tray are not attached, just in case you don t want to use them. You probably will, however, since they are not only nicely color-coordinated, but descriptive functionally by reminding you that the primers must be applied for 30 seconds while the Bond Liquid A must be cured for 20 seconds. The primer and adhesive bottles are the standard squeeze-type with moistureresistant printing and color-coded caps, although the primer bottles are round in cross-section while the Bond liquid bottles are oval for further differentiation. When dispensing Primer B, use caution since it tends to come out fast. The bottles are clearly labeled with the expiration date, which resists removal during disinfection procedures. Directions Plain paper foldout design in three languages and plastic-laminated treatment room cards attached with a plastic ring. The paper instructions are ambiguous on how to leave the preparation prior to applying the primer mixture it only states that a rubber dam is recommended to keep the tooth dry. There is also a statement that you should use caution not to allow saliva or exudate to contact the treated surfaces. How did exudate get into this scene anyway? The laminated, treatment room cards feature color illustrations and easy-to-follow, step-by-step application procedures. They are held together with a plastic ring, which is inserted through a hole punched in the corner of the cards. Overall, the cards are well done, but still omit how to treat the tooth prior to applying the primers Reality Publishing Co. Vol. 21 The Ratings 93

34 Reality Total-Etch OptiBond FL Strengths Winner of our 20th Anniversary Legacy Award, least technique-sensitive of any bonding agent, amazing track record, available in bottles or unidose, works in almost all situations. Weaknesses Not effective when luting a metal-based indirect restoration. BOTTOM LINE With a clinical heritage second to none, it is the safe choice for all but metal-based indirects. All-Bond 3 Strengths Can handle virtually all adhesive tasks. Ethanol solvent reduces technique sensitivity can be used moist or wet. Most evaluators reported no sensitivity. Hydrophobic bonding resin should overcome the water tree problem. Almost always achieved a shiny surface after evaporating the solvent. Primers have an acceptable viscosity not too runny or too thick. Weaknesses Bonding resin is overly thick almost half of the evaluators felt it was too thick and application is not facilitated by fuzzy ends on syringe tips. No unidose. Still need to mix primers. Direction to use a curing light at 500mW/cm 2 is strange and application protocol is ambiguous. BOTTOM LINE Improved version of the most universal and complete system available today, but bonding resin needs tweaking along with the directions. Gluma Comfort Bond + Desensitizer Strengths Adhesive and desensitizer in one simple bottle. By using the proven chemistry of Gluma Desensitizer (glutaraldehyde and HEMA) and 4-META in an ethanol/water solvent, this is a product that not only performs well, but is also less techniquesensitive than some of its competitors due to its ability to bond under dry, moist, or wet conditions. Even the application method and curing time do not seem to affect its performance very much. In addition, it registered a surprisingly high bond strength with the self-cure composite. Weaknesses Basic bond strengths were on the low end of the continuum and its cost is on the high end. The rather large head of the applicator in the single-dose may not fit into a small preparation very well. Name is descriptive but cumbersome. BOTTOM LINE If you are still plagued with patients complaining of sensitivity and still prefer to use a total etch bonding agent, this product could solve your problems. OptiBond Solo Plus Strengths It has been a stellar performer (along with the original version) for over 11 years, being the gold standard for most of our direct, light-cured bond strength tests. It was also the first with unidose packaging. From a clinical perspective, there has been very little post-operative sensitivity reported by the evaluators. Its increased viscosity makes applying it very easy, with only two evaluators reporting any problems seating an indirect restoration after light curing it. Weaknesses Need to be sure to thin it out before curing when using it with indirect restorations. Doesn t work with self-cure materials. BOTTOM LINE Performs with consistency and reliability, but only with light-cured materials. Adper Scotchbond Multi-Purpose Plus Strengths Seems to work almost as well when the tooth is dry, compared to moist. This is a great convenience over having to worry whether you overdried or left it too wet and makes it a good choice for repairs, when the restorative material that is fractured needs to be dry. And, you don t even have to mix anything, even with self-cure procedures, where its bond strength with directs was the highest. Due to its hydrophobic bonding resin, it should overcome any water tree issues. Weaknesses Decimal point components can get confusing and enamel bond strength results were disappointing. No unidose option. BOTTOM LINE Versatile bonding agent with a proven track record, but using the right combination of components can be a challenge. 94 The Ratings 2009 Reality Publishing Co. Vol. 21

35 Reality PQ1 Strengths Stable chemistry and application technique that no longer requires white-knuckled scrubbing it into the surface of the preparation. Weaknesses No option for self-cure and syringe application may limit access in some areas. BOTTOM LINE Satisfactory performance with the convenience of syringe delivery. XP Bond Strengths Less technique-sensitivity than with its still-available stable mate, Prime & Bond NT. This means you can expect little or no post-op sensitivity. Applies easily and dentin is usually shiny after evaporating the t-butanol solvent, which seems to evaporate faster than ethanol. CliXdish has a clever design and can keep the adhesive active for 15 minutes. Available in bottle and unidose. You don t need to precure before seating indirect restorations. Weaknesses Nasty odor and taste. Bond strength in direct, lightcured mode is somewhat lower than other, top-rated adhesives. Over-thinning adhesive when evaporating the solvent can cause lower performance. One evaluator reported soft tissue ulcers if material seeped onto the gingival. Still could suffer from water tree effect. BOTTOM LINE The pedigree of Prime & Bond without its application snafus, but no quantum leap in adhesive technology. All-Bond 2 Strengths Proven two-primer system and hydrophobic bonding resin that should overcome the water tree problem. Our tests show that taking advantage of all the components will give you results that exceeded or came very close to all of our controls. This certainly provides peace of mind that any procedure you need to accomplish can be handled using it. Weaknesses Definitely requires a moist or even wet dentinal surface. Reports of postoperative sensitivity are probably related to the application technique. One study club had numerous failures when the directions were not followed precisely. All the various components can also be confusing and the instructions are not always as clear as they could be. No unidose option. BOTTOM LINE Still among the most universal and complete systems available, but All-Bond 3 offers the same benefits with less technique-sensitivity. One-Step Plus Strengths Second generation, filled version of the original single-component product in this category that bonds to self-cure materials. This property is probably due to the fact that its ph is relatively high compared to most other single component adhesives. Least expensive unidose. Weaknesses Even though the addition of the filler makes it easier to coat the dentin, you definitely need to use it on a tooth that is wet, making its application protocol critical. BOTTOM LINE Only having to deal with one bottle definitely simplifies all the uses, but keep it wet for success. Self-Etch Clearfil SE Bond Strengths Most dependable self-etching product in this category. While its older sibling, Liner Bond 2V, has more impressive bond strength test results, SE Bond is simpler and easier to use. Its excellent clinical performance to date combined with its exceptional lab results makes it the gold standard for self-etchers. The unique dispenser allows you to handle both bottles with one hand. Weaknesses Squeezing the dispenser requires more pressure than is normally needed to express primers from the bottles. It can also be somewhat messy and asepsis is compromised. Its effectiveness with indirect restorations is mediocre and it does not bond to self-cured materials (without the help of an adhesion promoter). No unidose option. BOTTOM LINE For conventional light-cured restorations, it s the one to choose if you want to use a self-etcher. Peak SE Strengths Innovative, easy method of activating and mixing primer, convenient syringe delivery, works well moist or wet, does not require white-knuckled scrubbing it into the surface of the preparation, bond strengths in upper echelon. Weaknesses Syringe application may limit access in some areas and can interfere with consistent dispensing. BOTTOM LINE The convenience of syringe delivery along with impressive performance without technique sensitivity Reality Publishing Co. Vol. 21 The Ratings 95

36 Reality Bond Force Strengths Applies evenly, consistent and very good bond strength results (especially on dentin), Virtually no post-operative sensitivity. Innovative unidose design allows it to stand on its own or allows it to be recapped. In a laser scanning microscopy study by ET Member Dr. Inokoshi, cavity preparations were prepared in bovine teeth with both convex and concave internal line angles. After restoring the teeth using several adhesives and composite, they were sectioned and viewed. The results showed that in the cavities restored with Bond Force, there was an intimate and uniform thickness of adhesive, regardless of the internal morphology. Other adhesives did not perform as well. Weaknesses Two evaluators experienced several debonded Class V restorations ranging from 1-4 weeks after placement, but they used the gentle agitation application technique instead of the more effective rubbing/scrubbing. However, the rubbing/ scrubbing technique can be cumbersome. One evaluator had soft tissue untoward effects. Two-stage solvent evaporation (gentle followed by forceful air) is not intuitive. BOTTOM LINE Could be the best of the one-component self-etchers, although its performance needs longevity to match the more established, multi-component products. Clearfil Protect Bond Strengths SE Bond with an antibacterial agent and sodium fluoride. These additional ingredients presumably add an extra level of protection against the inevitable microbial invasion via microleakage and may eliminate even trying to disinfect the preparation prior to placing restorations. While this approach is sound and there is at least one study giving credence to its efficacy, it would be better if it performed up to the level of SE Bond AND had the aforementioned benefits. Fortunately, our tests show that its performance is quite good and even exceeds the lofty status of its brethren on enamel. Weaknesses Don t follow the manufacturer s advice of just letting it sit undisturbed you should agitate the primer on the tooth surface. Same problems as SE Bond when it comes to indirect and/or self-cure usage. And it is much more expensive than its sibling. No unidose option. BOTTOM LINE Almost as good as SE Bond, but with the added antimicrobial and fluoride action. Prelude Strengths Has both total etch and self-etch versions, but the latter variant is the prime mover and shaker. It utilizes a different approach than most multi-component adhesives in that both its primer and adhesive contain a solvent. Therefore, you must apply air to the adhesive not just to thin it out, but to evaporate the solvent. In addition, its self-cured mode is mediated by the application of a third component (Link) that is placed sequentially instead of mixed. While several total etch products use this approach, this product is the only self-etcher with this protocol. Self-cured bond strengths using the Link component were adequate at 5 minutes and increased substantially after 24 hours to offer the best retention for self-etchers. Its dentin bond strength exceeded that of the control. Etching enamel with phosphoric acid before applying it had virtually no effect on bond strength. Our clinical evaluation found no lost restorations and no sensitivity. Least expensive of the self-etchers. New study from Editorial Team Member Dr. Shigehisa Inokoshi found excellent results when Prelude was used as the bonding agent when restoring Class V restorations in bovine teeth. Weaknesses Enamel bond strength was lower than the control. No unidose option. BOTTOM LINE Versatile product that is challenging the Clearfil dominance in this subcategory. Clearfil Liner Bond 2V Strengths Highest dentin bond strength with light-cured composite of any product in this category, conventional or self-etch Weaknesses Only reasonably adequate with dual-cured and self-cured directs and rather poor test results with indirects. No unidose option. BOTTOM LINE Longest track record and second generation of the original self-etch adhesive, but using it with indirects is not its strong suit. 96 The Ratings 2009 Reality Publishing Co. Vol. 21