Total-etch versus self-etch adhesive: Effect on

postoperative sensitivity
JORGE PERDIGÃO, SAULO GERALDELI and
JAMES S. HODGES
J Am Dent Assoc 2003;134;1621-1629

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 COSMETIC & R E S T O R AT I V E C A R E
Total-etch versus
self-etch adhesive
Effect on postoperative
sensitivity
JORGE PERDIGÃO, D.M.D., M.S., Ph.D.;
SAULO GERALDELI, D.D.S., M.S., Ph.D.;
JAMES S. HODGES, Ph.D.
onding to enamel has been successful since
B Buonocore introduced the acid-etch technique
in 1955.1 Bonding to dentin has been less pre-
dictable because of the wet tubular ultrastruc-
ture and organic composition of the dentin
substrate.2
The introduction of the total-etch, or TE, technique3
and recent developments in the chemistry of dentin
adhesives have made resin-based composite restorative
materials almost resistant to microleakage, with bond
strengths that approach those of enamel
bonding.4-6 The improvements seen in
The self-etch the laboratory have been confirmed in
adhesive did the clinical setting with the recent gen-
7,8
not differ from eration of adhesive systems. Bonding
the total-etch to etched enamel and dentin while
relying on the entanglement of resin
adhesive in
monomers with dental substrates, or
regard to hybridization, is now considered the
sensitivity and fundamental mechanism for retention of
marginal resin-based composite restorations.9,10
Recent dentin adhesives use one of
discoloration.
two strategies to interact with the
dentin smear layer: the TE technique or
the self-etch, or SE, technique.11 TE materials use 30 to
40 percent phosphoric acid to etch dentin and enamel
before the clinician applies the adhesive to the prepara-
tion. Etching dentin removes the smear layer and opens
up the dentinal tubules. SE adhesives, which are being
used increasingly,12,13 do not require a separate acid-etch
step, and do not remove the smear layer. They are
composed of aqueous mixtures of acidic functional
monomers, generally phosphoric acid esters, with a pH
Copyright ©2003 American Dental Association. All rights reserved.
ABSTRACT
Background. Self-etching adhesives are
believed to prevent postoperative sensitivity
when used under posterior resin-based com-
posite restorations. The authors tested a
twofold hypothesis: a self-etch, or SE, adhe-
sive would result in less postoperative sensi-
tivity than a total-etch, or TE, adhesive; an
SE adhesive would result in poorer enamel
marginal integrity than a TE adhesive.
Methods. Patients were selected on the
basis of requiring Class I and II restorations
in molars and premolars. The authors placed
30 restorations with the SE material
(Clearfil SE Bond, Kuraray America, New
York) and 36 restorations with Prime &
Bond NT (Dentsply Caulk, Milford, Del.),
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which uses 34 percent phosphoric acid to
etch enamel and dentin simultaneously.
Preparations were of standard design, with
all margins in enamel without beveling.
Upon rubber dam isolation, the authors con-
ditioned the enamel and dentin walls with
the self-etching primer (for Clearfil SE
Bond) or etched with the proprietary 34 per-
cent phosphoric acid (for Prime & Bond NT),
followed by application of the corresponding
dentin adhesive. Teeth were restored with
the proprietary hybrid resin-based composite
indicated for posterior restorations: Clearfil
AP-X for Clearfil SE Bond or Esthet·X Micro
Matrix Restorative for Prime & Bond NT.
The restored teeth were evaluated preopera-
tively and at two weeks, eight weeks and six
months postoperatively for sensitivity to cold
(ice), air and masticatory forces, as well as
for marginal discoloration.
Results. Analysis of variance revealed no
statistically significant differences in postop-
erative sensitivity between the SE and TE
materials at any recall time. Marginal dis-
coloration was rated as “absent” for all
restorations at six months. Only one tooth
displayed sensitivity to occlusal forces at six
months.
Conclusion. The SE adhesive did not
differ from the TE adhesive in regard to sen-
sitivity and marginal discoloration.
Clinical Implications. Postoperative
sensitivity may depend on the restorative
technique rather than on the type of dentin
adhesive used.
JADA, Vol. 134, December 2003 1621
COSMETIC & RESTORATIVE CARE
BOX
PATIENT EXCLUSION CRITERIA.
dFewer than 20 teeth
dNonvital tooth
dHistory of tooth sensitivity
dXerostomia or periodontal disease
dBruxism
dAllergy to resin materials
dInability to return for recall appointments
dFractured or cracked teeth
dSubject in another, ongoing clinical dentistry
evaluation
dSubject receiving desensitizing therapy,
including desensitizing dentifrices or other
over-the-counter products
dMedical, psychiatric or pharmacotherapeutic
history that might compromise the protocol,
including the long-term use of anti-
inflammatory, analgesic and psychotropic drugs
dPregnancy or breast-feeding
dAllergies and idiosyncratic responses to product
ingredients
dOrthodontic appliance treatment within the
previous three months
dTeeth restored in the preceding three months
dAbutment teeth used for fixed or removable
prostheses
dTeeth or supporting structures with any painful
pathology
dPeriodontal surgery within the previous three
months
relatively higher than that of phosphoric acid-
etching gels.14 While the pH for a 34 to 37 percent
phosphoric acid gel is in the range of 0.5 to 1.0,
the pH of Clearfil SE Bond (Kuraray America,
New York) is 1.9 to 2.0.15,16 Miller13 reported that
SE adhesives do not etch enamel to the level
obtained with phosphoric acid.
Postoperative sensitivity after placing posterior
composite restorations has been a problem experi-
enced by clinicians for almost 20 years,17-20 even
when a dentin liner is used.21 For some clinicians,
however, postoperative sensitivity does not seem
to occur frequently after placing composite
restorations in their patients. For other dentists,
postoperative sensitivity remains a problem for
Class I, II and V resin-based composite
restorations.19
Few clinical studies have focused on postopera-
tive sensitivity caused by dentin adhesives.
Opdam and colleagues20 conducted a study in
which they used a TE dentin adhesive and resin-
based composite to restore teeth. They found that
up to 56 percent of the restorations in posterior
teeth resulted in sensitivity on loading, while an
additional 14 percent of the teeth experienced
spontaneous postoperative sensitivity at five to
1622 JADA, Vol. 134, December 2003
Copyright ©2003 American Dental Association. All rights reserved.
seven weeks. However, the TE dentin adhesive
used in their study was a multibottle, water-
based dentin adhesive with a composition and
application mode different from that of currently
used simplified one-bottle materials. Although
another study reported sensitivity to be virtually
zero for an SE adhesive, the researchers did not
use a TE adhesive as a positive control.22
The hypothesis tested in our clinical study was
twofold: an SE adhesive would result in less post-
operative sensitivity than a TE adhesive; an SE
adhesive would result in greater enamel marginal
discoloration than a TE adhesive.
CLINICAL PROTOCOL
Before participating in the study, patients signed
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a consent form. Both the form and this research
protocol were reviewed and approved by the Insti-
tutional Review Board at the University of Min-
nesota School of Dentistry, Minneapolis. All 25
patients required Class I and Class II restora-
tions in molars and premolars, either for replace-
ment of an existing restoration or for treatment of
primary carious lesions. The dental health status
of patients was normal in all other respects,
except for ongoing restorative procedures in unre-
lated and unopposed quadrants. The box enumer-
ates specific exclusion criteria.
We obtained preoperative bitewing radiographs
of the teeth to be restored, unless the patient had
had radiographs taken within the previous year.
The teeth to be restored had a normal occlusal
relationship with natural dentition and an
opposing and adjacent tooth contact. The average
faciolingual width of each preparation was
greater than or equal to one-third of the distance
between the cusp tips. All preparations were of
conventional amalgam design and cavosurface
angles were entirely within enamel, without any
intentional bevel (Figures 1 and 2).
Two of us (J.P., S.G.) placed at least two
restorations in simulated Class II preparations to
practice this technique before we placed the first
actual restoration. The director of the study (J.P.)
stated that if a pink color was observed on the
pulpal or axial wall of the preparation after cari-
ous dentin excavation, a microexposure of the
pulp was to be suspected, and the operators
should place a thin layer of calcium hydroxide
liner (Dycal, Dentsply Caulk, Milford, Del.) in
those deep areas, followed by a thin layer of resin-
modified glass ionomer cement (Vitrebond, 3M
ESPE, St. Paul, Minn.).
 COSMETIC & RESTORATIVE CARE

A B C D E F GA HB I C D E F GA HB I C D E F G H I

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B C D E F GA H B I C D E F GA HB I C D E F G H I

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

All operative procedures were performed under
local anesthesia, and all operating sites were iso-
lated with a rubber dam. The operators applied
an appropriate matrix (Palodent, Dentsply Caulk,
or HO Bands no. 1, Young Dental, Earth City,
Mo.) and Sycamore wood wedges (Premier Dental
Products, Plymouth Meeting, Pa.) to the cervical
margins of Class II preparations.
Application of primer and adhesive. The
operators treated the enamel and dentin walls of
the preparation by applying an SE dentin/enamel
primer (Clearfil SE Bond Primer, Kuraray
America) for 20 seconds or by etching with 34
percent phosphoric acid (Caulk 34% Tooth
Conditioner Gel, Dentsply Caulk) for 15 seconds.
Although the SE primer was not rinsed, the phos-
phoric acid was washed for 10 seconds and the
dentin was left visibly moist (glistening), or the
dentin was remoistened to an acceptable moisture
level. The operators then applied the adhesives to
the walls of the preparations according to the
manufacturers’ instructions (Table 1, page 1625).
Each subject received two or three restorations,
with each etching method applied to one or two
teeth. We assigned etching methods randomly to
teeth for each subject.
Placement of resin-based composite
restoration. The operators inserted resin-based
composite restorative material (Esthet•X Micro
Matrix Restorative, Dentsply Caulk, for Prime &

JADA, Vol. 134, December 2003 1623

Copyright ©2003 American Dental Association. All rights reserved.
 COSMETIC & RESTORATIVE CARE

A B C D E F GA HB I C D E F GA H B I C D E F G H I

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A B C D E F GA HB I C D E F GA HB I C D E F G H I

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

Bond NT adhesive or Clearfil AP-X, Kuraray
America, for Clearfil SE Bond adhesive) in two or
three increments, and used a curing light to poly-
merize for 40 seconds per increment and 40 sec-
onds for both facial and lingual gingival corners.
They checked the intensity of the light with a
radiometer after every 20 restorations were
placed to ensure that it exceeded 400
milliwatts/square centimeter.
After polymerization, the clinicians performed
coarse finishing with appropriate finishing car-
bide burs (Brasseler USA, Savannah, Ga.), alu-
minum oxide disks (Sof-Lex XT, 3M ESPE), cups
and points (Enhance, Dentsply Caulk) and pastes
(Prisma Gloss, Dentsply Caulk). They performed
proximal finishing using a no. 12 blade and abra-
sive strips (Brasseler USA). All restoration inser-
tions for each patient were done in one or two
appointments (if they had three restorations in
different quadrants).
Evaluation of hypersensitivity. In addition
to the assessments made immediately before
treatment, the operators evaluated hypersensi-
tivity at two weeks, eight weeks and six months
after treatment. At each evaluation, the operator
recorded the sensitivity of each tooth to applica-

1624 JADA, Vol. 134, December 2003

Copyright ©2003 American Dental Association. All rights reserved.
 COSMETIC & RESTORATIVE CARE

TABLE 1

ADHESIVE SYSTEM, COMPOSITION AND INSTRUCTIONS FOR USE.

ADHESIVE SYSTEM CLASSIFICATION COMPOSITION OF ADHESIVE INSTRUCTIONS FOR USE
(BATCH NUMBER)* SYSTEM

Clearfil SE Bond Self-etch adhesive Primer: water; 10-methacryloy-
(Primer: 00199A loxy decyl dihydrogenphosphate;
Bond: 00198B) 2-hydroxyethyl methacrylate, or
Kuraray America, New HEMA; hydrophilic dimethacry-
York late; N,N-diethanol-p-toluidine;
Bond: methylene diphosphonate,
bisphenol A diglycidylmethacry-
late, HEMA, hydrophilic
dimethacrylate silanated
colloidal silica, N,N-diethanol-
p-toluidine, camphoroquinone
Dispense and apply Clearfil
SE Bond Primer, leave
undisturbed for 20 seconds,
dry with mild airflow; apply
Clearfil SE Bond, apply
gentle airflow, light-cure for
10 seconds

Prime & Bond NT Total-etch Etchant (gel): 34% phosphoric Etch enamel with Caulk 34%
(34% Phosphoric Acid adhesive acid with silica; Tooth Conditioner Gel for 15

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Gel: 0102161; Adhesive: PENTA†, urethane
Adhesive: 010519) dimethacrylate and T-resin
Dentsply Caulk, (cross-linking agent) and D-resin
Milford, Del. (small hydrophilic molecule),
butylated hydroxitoluene, 4-
ethyl dimethyl aminobenzoate,
cetylamine hydrofluoride,
acetone, silica nanofiller
seconds. Rinse thoroughly for
10 seconds. Blot dry; dentin
should be moist. Immedi-
ately brush on generous
amounts of Prime & Bond
NT adhesive to thoroughly
wet the cavity surface.
Surface should remain wet
for 20 seconds, which may
necessitate additional
application of adhesive.

* Batch numbers of resin-based composites used in the study are as follows (composite shade in parentheses): Clearfil AP-X (Kuraray America):
00643A (A2), 00396A (A4), 00787A (A3), 00319A (C2), 00338A (B3), 00350B (B2); Esthet•X Micro Matrix Restorative (Dentsply Caulk):
0012113 (A40), 010514 (U), 0105213 (C40), 010511 (A20), 010525 (A2), 0105092 (A3.5), 010411 (B20), 0105182 (C10), 0105183 (D30),
0105011 (YE), 0101112 (AE), 010504 (GE).
† PENTA: Dipentaerythritol penta acrylate monophosphate.

tions of compressed air, a cold stimulus and mas-
ticatory forces as the patient’s spoken response to
a visual analogue scale from 0 to 10 (continuous
measurements). They applied cold in the form of
an ice stick and compressed air from the three-
way dental unit syringe at a distance of approxi-
mately 2 cm. The clinicians timed the applica-
tions of each stimulus until the subject responded
by raising his or her left hand, with a maximum
application lasting 15 seconds. Immediate
responses were recorded as zero seconds. Two of
us (J.P., S.G.) were present at each evaluation to
help ensure standardization.
The clinicians examined patients at recall
appointments that were scheduled as close as
possible to the actual day prescribed by the study
design (that is, two weeks, eight weeks, six
months). For the purpose of data collection, we
considered any recall visit that occurred within
plus or minus 10 percent of the scheduled time for
recall as occurring at that time.
Evaluation of marginal discoloration. To
evaluate marginal discoloration, we collected
intraoral color photographs at baseline and at
each recall appointment. Clinical photographs
consisted of digital images taken at an original
magnification of ×1.0 or ×1.5. The two operators
evaluated marginal discoloration at six months
according to this scale: Alfa = no marginal discol-
oration; Bravo = slight staining that disappears
on polishing; Charlie = discoloration that pene-
trates the interface and cannot be polished;
Delta = evidence of caries.
Statistical methods. We analyzed four
dependent variables: cold sensitivity and
response time, and air sensitivity and response
time. Each analysis was a repeated-measures
analysis of variance in which each subject pro-
vided measures for both treatments at three
follow-up times (two weeks, eight weeks, six
months). (Preliminary analyses showed that this
analysis gave the same results as analyses in
which the dependent variable was the change
from baseline to each follow-up time, so we
omitted the latter analyses.)
For subjects with more than one tooth

JADA, Vol. 134, December 2003 1625

Copyright ©2003 American Dental Association. All rights reserved.
COSMETIC & RESTORATIVE CARE

TABLE 2

SEVERITY AND TIME OF RESPONSE TO COMPRESSED AIR, COLD AND

MASTICATORY FORCES.
STIMULUS BEFORE TWO WEEKS EIGHT WEEKS SIX MONTHS BEFORE TWO WEEKS EIGHT WEEKS SIX MONTHS
TREAT- AFTER AFTER AFTER TREAT- AFTER AFTER AFTER
MENT TREATMENT TREATMENT TREATMENT MENT TREATMENT TREATMENT TREATMENT

Clearfil SE Bond* Prime & Bond NT †

Air

Mean 1.63 1.72 2.17 1.27 1.83 1.12 1.76 1.06

(SE‡§) (0.29) (0.18) (0.18) (0.18) (0.29) (0.18) (0.18) (0.18)
Severity
(1 to 10
Scale)

Mean 9.71 10.08 9.68 11.30 9.81 10.32 9.70 11.36

(SE) (0.79) (0.50) (0.50) (0.50) (0.79) (0.50) (0.50) (0.50)
Response

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Time (0
to 15
Seconds)

Cold

Mean 2.49 2.79 2.80 2.00 2.71 2.06 2.74 2.44

(SE) (0.42) (0.25) (0.25) (0.25) (0.42) (0.25) (0.25) (0.25)
Severity
(1 to 10
Scale)

Mean 8.94 7.34 7.84 9.42 8.29 8.44 7.08 8.94

(SE) (0.86) (0.62) (0.62) (0.62) (0.86) (0.62) (0.62) (0.62)
Response
Time (0
to 15
Seconds)

Masti-
catory
force

Mean 0 0 0 0 0 0 0 0.03
(SE)
Severity
(1 to 10
Scale)

* Clearfil SE Bond adhesive is manufactured by Kuraray America, New York.

† Prime & Bond NT adhesive is manufactured by Dentsply Caulk, Milford, Del.
‡ SE: Standard error.
§ For each dependent variable, the SEs are derived from two analyses of variance, or ANOVAs, one for baseline and one for the posttreatment times.
Thus, for a given dependent variable, the SEs are the same for both treatments at baseline and the same for all six treatment/time combinations after
baseline. Deriving the SEs from the ANOVA instead of from each group individually provides more statistical power.

receiving a given treatment, we averaged the
dependent variables at each visit across the teeth
that received a given treatment. Thus, the analy-
sis used one measure per subject per treatment at
each visit.
RESULTS
We restored 66 teeth (42 molars, 24 premolars) in
25 subjects (seven men, 18 women; age range, 21
to 54 years). Nine subjects had two teeth restored
and 16 subjects had three teeth restored. Of the
30 teeth restored with Clearfil SE Bond, 20 (67
percent) were molars. Of the 36 teeth restored
with Prime & Bond NT, 22 (61 percent) were
molars (the difference was not significant).
Table 2 shows means and standard errors for
“severity of response” and “time to response” for
both air and cold stimuli. For all four dependent
variables (that is, air sensitivity, air response
time, cold sensitivity, cold response time), neither
main effect (treatment or time) was significant,
nor was the interaction between treatment and
time. (The treatment main effect answers the
question, “Averaging over visits, do the two

1626 JADA, Vol. 134, December 2003

Copyright ©2003 American Dental Association. All rights reserved.

treatments differ?”; the visit main effect answers
the analogous question for visits. The interaction
answers the question, “Is the difference between
treatments the same for all three visits?”)
No tooth exhibited sensitivity to masticatory
forces, except for one tooth that had a macro-
scopic pulp exposure that we capped with calcium
hydroxide and resin-modified glass ionomer. This
tooth, which was restored with Prime & Bond NT
and Esthet·X Micro Matrix Restorative, resulted
in a sensitivity score of 1 (0 to 10 scale) in
response to occlusal forces at six months.
DISCUSSION
Postoperative sensitivity has been attributed to
several factors, including dentin etching and bac-
terial penetration of the pulp,23
occlusal discrepancies, deformation
of the cusps by shrinkage stress16 Self-etch adhesives
and deformation of composite by are less technique-
occlusal forces.24 The problem
sensitive than are
recently resurfaced, as many den-
tists report that postoperative sen- total-etch adhesives.
sitivity is still prevalent.19 Only a
few clinical studies have measured
postoperative sensitivity of SE adhesives, TE
adhesives or both in posterior restorations, and
the results have been mixed.20,22 One study20 com-
pared an SE adhesive with a TE adhesive, but
these were multistep materials that are no longer
popular among clinicians.
SE adhesives. SE adhesives condition and
prime enamel and dentin simultaneously without
rinsing; they rely on their ability to partially dis-
solve hydroxyapatite to yield a resin-infiltrated
zone with minerals incorporated.25 However, not
all SE materials are similar in their ability to
interact with the smear layer. Accordingly, they
have been classified in three categories: mild,
moderate and aggressive, with Clearfil SE Bond
being a mild SE adhesive.16
One of the shortfalls of SE adhesives is that
they do not etch enamel to the level achieved
with phosphoric acid.13 Several studies have
evaluated SE adhesives for their enamel-etching
ability.26-30 Some of these studies indicated that
enamel bonding with SE adhesives is as effective
as enamel bonding after conventional phosphoric
acid etching.29 Other studies demonstrated that
SE adhesives are effective only on ground
enamel, but are less effective on intact
enamel,16,28 because SE materials do not result in
an enamel-etching pattern as well-defined as the
Copyright ©2003 American Dental Association. All rights reserved.
COSMETIC & RESTORATIVE CARE
one produced by phosphoric acid etching.28
Miyazaki and colleagues30 conducted a study in
which they found a significant decrease in enamel
bond strengths for the three SE adhesives tested
when specimens were thermocycled up to 30,000
cycles, while for three of the four TE adhesives
tested, they found no significant differences from
baseline to 30,000 cycles. This decrease in bond
strength with thermal fatigue might be a sign
that enamel marginal adaptation under clinical
conditions might not be optimized, and
microleakage might occur around enamel mar-
gins. However, in our study, we found no clinical
signs of marginal degradation at six months for
restorations bonded with the SE adhesive.
SE adhesives are less technique-sensitive than
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are TE adhesives. SE adhesives do
not remove the smear layer from
dentin completely, so clinicians13
believe they cause less postopera-
tive sensitivity than do TE adhe-
sives. Furthermore, SE adhesives
are not likely to result in a discrep-
ancy between the depth of deminer-
alization and the depth of resin
infiltration,13,14 because both processes occur
simultaneously. Another advantage of SE adhe-
sives is that moist bonding is not required.
TE adhesives. For Prime & Bond NT, the
operators followed the manufacturer’s instruc-
tions, which call for application of additional
adhesive if the tooth surface does not remain
totally wetted by the material after the first
application of the TE adhesive. The operators
placed at least two coats of adhesive in all
restorations that were bonded with Prime & Bond
NT, because the pulpal floor never looked consis-
tently covered by the adhesive after application of
the first coat. They used magnification loupes for
every procedure in this clinical study.
After applying the last coat of the dentin adhe-
sive, the operators inspected the pulpal floor of
each preparation to check for any area that was
not covered with the adhesive material. If they
found a dry spot, which happened only with
Prime & Bond NT, the operators applied an extra
coat of adhesive according to the manufacturer’s
instructions. This might have prevented the
dentin tubules from being in direct contact with
the resin-based composite in the dry spot areas,
thereby preventing postoperative sensitivity prob-
ably due to hydraulic pressure from occlusal
forces.31 In fact, Platt and colleagues32 have shown
JADA, Vol. 134, December 2003 1627
COSMETIC & RESTORATIVE CARE
Dr. Perdigão is an At the time this study
associate professor, was conducted, Dr.
Division of Operative Geraldeli was a visiting
Dentistry, Department professor, Division of
of Restorative Sciences, Operative Dentistry,
University of Minnesota, Department of Restora-
8-450 Moos Tower, tive Sciences, Univer-
515 S.E. Delaware St., sity of Minnesota,
Minneapolis, Minn. Minneapolis. He
55455, e-mail currently is a research
“perdi001@umn.edu”. professor, University of
Address reprint requests Santo Amaro, SP, Brazil.
to Dr. Perdigão.
that when Prime & Bond NT is applied in one
layer, bond strengths are substantially reduced.
Clinical conditions. This study was carried
out in ideal clinical conditions, under rubber dam
isolation, and each appointment was scheduled for
two hours per patient during the insertion phase (a
patient needed to return for a second appointment
only if he or she required more than two restora-
tions). The environment in which the clinical study
is carried out raises a somewhat debatable issue.
Academic environment versus clinical
practice setting. Should the study be conducted
in an academic environment (in which students
and faculty typically have more time to perform
procedures, a wider selection of dental materials
may be available for use, and research data
regarding the correct use of materials are more
readily available), or should it be carried out in a
clinical practice setting in which the material is
used most often? We definitely need to know the
behavior of materials used under ideal conditions,
so all materials should be tested first in the ideal
academic setting (for example, one of the condi-
tions for inserting posterior resin-based compos-
ites always has been rubber dam isolation).
Postoperative sensitivity, fracture of the
enamel and opening of restoration margins may
result in microleakage, staining of marginal gaps
and recurrent caries, and are the most common
clinical problems caused by polymerization
shrinkage.33 The amount of curing contraction
stress generated by light-curing resin-based com-
posites in the preparation is deemed to be an
important factor in determining the longevity of
the restoration. The magnitude of the curing
stress is a function of the ratio of the bonded sur-
face area to the unbonded surface area of the
1628 JADA, Vol. 134, December 2003
Copyright ©2003 American Dental Association. All rights reserved.
restoration,34,35 as well as of the properties of the
composite.36,37
The polymerization shrinking stresses are crit-
ical for the microscopic integrity of the adhesive
bond to dentin.38 To minimize the deleterious
effects of shrinkage stresses on the marginal
Dr. Hodges is a senior integrity of the composite restorations, we used
research associate,
Division of Biostatistics, an incremental filling technique in this study.
University of Minnesota, Researchers39,40 have shown that increments
Minneapolis, and
director, Biostatistical should be no larger than 2 millimeters to provide
Core, School of uniform and maximum polymerization.
Dentistry, University of
Minnesota. Our study showed that the choice of dentin
adhesive (that is, SE or TE) did not result in any
significant difference in postoperative sensitivity.
The clinical technique, therefore, may be more
relevant for the development of postoperative sen-
Downloaded from jada.ada.org on March 30, 2011
sitivity than is the type of adhesive itself. Future
studies should focus on the long-term perfor-
mance of TE versus SE adhesives, and include
other variables such as the use of flowable com-
posites as the cervical increment in Class II com-
posite restorations.
CONCLUSION
The SE adhesive Clearfil SE Bond did not result
in less postoperative sensitivity at any recall
period than that of the TE adhesive Prime &
Bond NT. Both of the adhesives resulted in excel-
lent enamel marginal integrity at six months. ■
This project received the financial support of Kuraray America,
New York.
Materials were donated by Kuraray America; Dentsply Caulk,
Milford, Del.; 3M ESPE, St. Paul, Minn.;. and Premier Dental Prod-
ucts, Plymouth Meeting, Pa.
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