1108cei Dentsply Adhesives
Transcript of 1108cei Dentsply Adhesives
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Publication date: Sept. 2011Expiration date: Aug. 2014
AbstractDental adhesives used to bond composite resins to toothstructure have evolved over the last several decades. The earliestbonding systems required an acid-etch technique and were onlycompatible with enamel, and the challenge has always been topredictably bond to enamel and dentin simultaneously. Therecan be conusion as to what bonding agents are being described,because there are a number o dierent labeling categories.With a simplied, logical category description the clinician isbetter able to understand what each bonding agent is and howit is used. Bonding systems can in act be dierentiated into twodistinct classes: etch-and-rinse and sel-etch. Both classes obonding systems work well as long as one understands which touse or dierent treatment conditions. There is no one universal
bonding system that does it all, but recent advances in thechemistries o these adhesives allow many o them to be bondedto all intraoral substrates to enamel; to dentin; and to all typeso dental resins, ceramics and metals. The key to success is toprovide your patients with materials and techniques that you canreproduce to achieve the best, longest-lasting clinical results.
Learnng ObjectvesThe overall goal o this article is to provide the reader with
inormation on the classications, indications and current
techniques or restorative clinical success with adhesives. Ater
reading this article the reader should be able to:
1. Describe the dierences between etch-and-rinse and
sel-etch adhesives and relate these categories to other
naming systems
2. Discuss the current research evidence comparing etch-and-
rinse and sel-etch adhesives
3. List and describe the indications or etch-and-rinse and
sel-etch adhesives
4. Describe the clinical procedure or an etch-and-rinse and a
sel-etch single-step adhesive
Author ProflesDr. Howard Strassler is proessor in the department oendodontics, prosthodontics and operative dentistry at theUniversity o Maryland School o Dentistry. He is a ellow in theAcademy o Dental Materials and the Academy o General Den-tistry, a member o the the Academy o Operative Dentistry,and the International Association or Dental Research. Dr. Stras-sler has published more than 475 articles, coauthored sevenchapters in texts, and lectured nationally and internationally.Dr. Strassler is a consultant to over 15 dental manuacturers andis on editorial boards or several dental journals.
Dr. Mchael Mann is an assistant proessor in the AdvancedEducation in General Dentistry residency at the University oMaryland School o Dentistry. He is a member o the AmericanDental Association. He has lectured nationally and internation-
ally. Dr. Mann has a ull-time general practice with an emphasison comprehensive dental care and aesthetics.
Author DsclosureThe author(s) o this course have no commercial ties with thesponsors or the providers o the unrestricted educational grantor this course.
This course has been made p ossible through an unrestricted educational grant.
Supplement to PennWell PublicationsThis course was written for dentists, dental hygienists and assistants, from novice to skill ed.
Educational Methods: This course is a sel-instructional journal and web activity.
Provider Disclosure: Pennwell does not have a leadership position or a commercial interest in anyproducts or services discussed or shared in this educational activity nor with the commercial supporter.No manuacturer or third party has had any input into the development o course content.
Requirements for Successful Completion: To obtain 3 CE credits or this educational activity you must paythe required ee, review the material, complete the course evaluation and obtain a score o at least 70%.
CE Planner Disclosure: Michelle Fox, CE Coordinator does not have a leadership or commercial interest withDENTSPLY Caulk, the commercial supporter, or with products or services discussed in this educational ac tivity.
Educational Disclaimer: Completing a single continuing education course does not provide enough inormationto result in the participant being an expert in the feld related to the course topic. It is a combination o manyeducational courses and clinical experience that allows the participant to develop skills and expertise.
Registration: The cost o this CE course is $59.00 or 3 CE credits.Cancellation/Refund Policy: Any participant who is not 100% satisied with this course can request aull reund by contacting PennWell in writing.
Go Green, Go Online to take your coursePennWell designates this activit y for 3 Continuing Educational Credits
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Educational objectivesThe overall goal o this article is to provide the reader with
inormation on the classications, indications and current
techniques or restorative clinical success with adhesives.
Ater reading this article the reader should be able to:
1. Describe the dierences between etch-and-rinse and
sel-etch adhesives and relate these categories to other
naming systems2. Discuss the current research evidence comparing etch-
and-rinse and sel-etch adhesives
3. List and describe the indications or etch-and-rinse and
sel-etch adhesives
4. Describe the clinical procedure or an etch-and-rinse and
a sel-etch single-step adhesive
AbstractDental adhesives used to bond composite resins to tooth
structure have evolved over the last several decades. The
earliest bonding systems required an acid-etch techniqueand were only compatible with enamel, and the challenge has
always been to predictably bond to enamel and dentin simul-
taneously. There can be conusion as to what bonding agents
are being described, because there are a number o dierent
labeling categories. With a simplied, logical category de-
scription the clinician is better able to understand what each
bonding agent is and how it is used. Bonding systems can in
act be dierentiated into two distinct classes: etch-and-rinse
and sel-etch. Both classes o bonding systems work well as
long as one understands which to use or dierent treatment
conditions. There is no one universal bonding system thatdoes it all, but recent advances in the chemistries o these
adhesives allow many o them to be bonded to all intraoral
substrates to enamel; to dentin; and to all types o dental
resins, ceramics and metals. The key to success is to provide
your patients with materials and techniques that you can
reproduce to achieve the best, longest-lasting clinical results.
IntroductionImportant advances and innovations in restorative dental
treatment that have changed the way we treat patients or
the better would certainly include fuorides, local anes-
thesia, high-speed handpieces, dental radiography and
implants. Another innovation that would be near the top
o this elite list is dental resin adhesion. Little did Michael
Buonocore and colleagues at the Eastman Dental Center
in Rochester, New York, realize that the introduction o
adhesion, rst bonding to enamel, would change the way
we practice dentistry. G.V. Black described the retention o
restorations based upon cavity design and undercut dentin.1
Even with the caries removed, because o the limitations o
the restorative materials available at the time (gold oil anddental silver amalgam), additional tooth structure needed
to be removed to ulll the requirements or retention o
the restorative material. The goal o conservation o tooth
structure was limited by the materials that were available
up until the late 1960s, when clinical techniques with resin
adhesives bonded to etched enamel were introduced using
UV-light-cured resin restoratives, a resin sealant and a com-
posite resin that utilized the acid etch technique described
by Buonocore.2,3
Bonding to tooth substrates is now the standard o care
or single-tooth direct placement restorations and has beenthe driving orce in changing how we prepare and restore
teeth. With the use o adhesives, minimally invasive den-
tistry (MID) with a more conservative, tooth-structure
saving approach when treatment planning restorative dental
procedures is possible. While the majority o restorations
placed today are restoration replacements, minimally in-
vasive adhesive restorative dentistry not only relates to the
treatment o caries but also to these restoration replacements
and to elective esthetic dentistry. There has been a signi-
cant change in the principles o cavity preparation design,
rom the traditional principles o extension or preventiondescribed by G.V. Black to a more carious lesion-centered
approach.4-6 This lesion-centered approach is possible
through the advancements in adhesive restorative materials,
as well as through the introduction o computer-assisted
methods o caries detection, a better understanding o the
role o magnication, digital radiography and caries risk
assessment o the patient to allow or improved conserva-
tive caries management.7 One o the greatest benets o a
more conservative approach is that it allows the clinician to
maintain as much tooth structure as possible.
While enamel bonding and dentin bonding have beenpursued in parallel paths, the goal has been to develop a uni-
versal adhesive that bonds to all substrates used in dentistry:
enamel, dentin, metals, ceramics and composite resin. This
author remembers reading an article in 1985 written by
Dr. Wayne Barkmeier on the undamental elements or an
adhesive used or bonding restorative materials to tooth
structure. Recently these ve key prerequisites or success-
ul adhesion to tooth structure were reiterated because they
have not changed since then.8 (Table 1)
Table 1. Key prerequisites or successul adhesion
1. The procedure must be safe and biologically acceptable.
2. The level o bond strength must be clinically significanttoavoid discoloration at the margins and secondary caries.
3. The bond strength must be routinely achievedso thatpredictable results are obtained.
4. The bond must be established quicklyin order to permitimmediate inishing.
5. The bond must be stab le in vi vo or a clinically signiicantperiod o time.
Since then, signicant advances in the development odental adhesives have been accomplished. The adhesives
currently available oer reliable adhesion between restor-
ative materials and tooth structure.
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Enamel and dentin bonding: An historicalperspectiveIn 1955, Buonocore described a clinical technique that uti-
lized diluted phosphoric acid to etch the enamel surace and
provide or retention o unlled, sel-cured acrylic resins.9
The resin mechanically locked to the microscopically rough-
ened enamel surace, orming small tags as it fowed into
the 10-to-40-micrometer-deep enamel microporosities andthen polymerizing. (Figure 1) The rst clinical use o this
technique was or the placement o sealants.10 The combi-
nation o acid etching enamel and adhesive composite resin
restorations aorded the benets o reduction or elimination
o microleakage at the enamel margins with a decrease in
sensitivity, less discoloration at the margins, lower rates o
recurrent caries and improved retention o the restoration.11,12
The eectiveness and success o etched enamel/resin bond
has been demonstrated in many reported clinical trials.13
Figure 1. SEM o etched enamel
Unlike enamel bonding, dentin bonding has seen an
evolution in its viability. Eective dentin-bonding materials
should ulll several goals. (Table 2)
Table 2. Goals or eective dentin-bonding materials
The material should be retentive to dentin at a clinically acceptable level, and it should be able to withstand intraoralorces o occlusion and mastication.
The bond should be instantaneous once the material has set.
The material and technique must be biocompatible.
The material should resist the forces of pol ymerizationshrinkage o composite resins and the coeicient o thermalexpansion and contraction to eliminate microleakage.
The material should create a long-lasting bond to dentin.
Postoperative sensitivity must be minimized or eliminated.
The earliest research in 1956 with dentin bonding o-
cused on chemical adhesion o resins to the inorganic com-
ponents o dentin.14 This created a very weak bond, the basis
or which was the presence o the dentin smear layer.15 Other
attempts using similar technologies or dentin bonding were
not very successul.16, 17 These products had limited success
and the search or a better adhesive to dentin continued.
Another research path or dentin bonding investigated the
use o an etch-and-rinse (total-etch) approach by etching the
enamel and dentin simultaneously with phosphoric acid.18,19
At the time, there was concern that phosphoric acid placedon dentin would cause pulpal infammation and necrosis.20
Jennings and Ranly demonstrated that the pulpal eect o
phosphoric acid on dentin or one minute was minimal.21
Early results reported with dentin etching were disappoint-
ing because the adhesive resin used was the same unlled
hydrophobic Bis-GMA bonding resin used or etched
enamel.19 The hydrophobic resin would not wet the moist,
vital dentin and predictable adhesion could not be produced.
Contemporary adhesives
The breakthrough in the etch-and-rinse (total-etch) ap-proach was rst described in the late 1970s by Fusayama and
coworkers,22 Bertolotti23 and Kanca.24 They demonstrated
the success o the etch-and-rinse (total-etch) adhesive bond
based upon the addition o a hydrophilic monomer, usually
hydroxyethyl methylmethacrylate (HEMA), to the primer
and adhesive. This hydrophilic monomer allows the adhe-
sive resin to penetrate the peritubular dentin and dentinal
tubules.25-27 (Figure 2) Simultaneously, Bowen was investi-
gating the use o a dentin primer that in act was a sel-cure
adhesive that was painted on the enamel and dentin, and
that produced clinically acceptable bonds.28 In recent yearssel-etch adhesives or bonding to enamel and dentin have
been introduced,29 and some adhesives have added llers to
improve physical properties30. While the earlier generations
o adhesives to dentin were disappointing in their clinical
perormance, contemporary adhesives are demonstrating
excellent clinical success.31-37
Figure 2. SEM o multiple-bottle etch-and-rinse adhesive inil-trated dentin hybrid zone (3-E&R) (dentin has been dissolved todemonstrate resin iniltration)
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Classification of bonding systemsThe development o improved adhesion systems using
dierent chemistries with a variation in the numbers o re-
agents and steps or application led to several descriptions
o the categories and classication o adhesives. With no
standard on how adhesives were classied and described,
there was some conusion among clinicians and research-
ers alike. With the development o two dierent classes obonding systems that relied on the use o phosphoric acid
as a surace etchant came the classication and description
o bonding systems based upon generational time-line
changes. Fourth-generation bonding systems were re-
erred to as total-etch multi-bottle (multi-step) systems,
and th-generation systems were reerred to as total-etch
single-bottle bonding agents that contained both primer
and adhesive. Both ourth- and th-generation products
required a total-etch with phosphoric acid beore adhesive
placement.
It is obvious that the more steps required to bond arestoration, the greater the potential or inconsistency o
timing o application, rinsing, drying, rewetting dentin
and maintaining a controlled operative eld during
treatment.38 Manuacturers responded to this by put-
ting research eorts into the development o simpli-
ed adhesive systems and reduction in the number o
steps required. Thus the earliest sel-etching bonding
systems were introduced. These did not require the ad-
ditional steps o applying phosphoric acid, rinsing and
drying beore adhesive application. The classication
system became more conusing in that bonding systemsthat had the additional step o phosphoric acid etching
were reerred to as total-etch, and those adhesives that
did not require the additional step o phosphoric acid
were reerred to as sel-etch. Other bonding systems
continued with generational descriptions building on the
ourth- and th-generation model, and the sel-etching
systems were reerred to as sixth and seventh genera-
tion. These terminologies do not adequately describe the
current adhesives that are being used or composite resin
bonding.
All adhesives used today exhibit the same phenomena
or adhesion, i.e., micromechanical locking to the etched
enamel prisms and to dentin through hybridization.38
There have been several attempts to better describe the
dierent bonding systems based upon the steps required
and the chemistry o the adhesives. In 2003, Van Meer-
beek et al. proposed a rational, logical categorization and
classication o the current adhesives based upon what is
required to achieve the adhesive interace to enamel and
dentin.39 (Table 3) Based upon the current adhesives being
used in our practices, the classication o adhesives can bebroken down into two distinct categories: etch-and-rinse
(E&R), which is also reerred to as total-etch (TE ), and
sel-etch (SE).
Table 3. Classiication o adhesives according to Van Meerbeek et al.23
Etch-and-Rinse Adhesives (also referred to asTotal-Etch)
Three-step multiple-bottle etch-and-rinse adhesives (3-E&R)
Two-step single-bottle etch-and-rinse adhesives (2-E&R)
Self-Etch Adhesives
Two-step multiple-bottle sel-etch adhesives (2-SEA)
One-step multiple-bottle mix sel-etch adhesives (1-SEA)One-step no-mix sel-etch adhesives (1-SEA)
Etch-and-Rinse approachThe etch-and-rinse (E&R) or total-etch (TE) adhesives can
be recognized by the initial application o a 10%-40% phos-
phoric acid to the enamel/dentin ollowed by the mandato-
ry rinsing step. The enamel etching leaves a microscopically
roughened surace to bond to and removes the dentin smear
layer. The enamel surace can be completely dried with air,
but the dentin should remain damp and glossy. To leave the
dentin slightly damp, the wet dentin can be blotted dry orater air drying can be rewetted with a slightly damp cotton
pellet.40-45 This will leave the dentin as a damp, glossy sur-
ace. An adhesive resin is then applied. The adhesive resin
is provided as either two bottles, a separate dentin primer
and separate adhesive (also reerred to as three-step etch-
and-rinse) (3-E&R) (e.g., ProBond, Dentsply-Caulk; Op-
tibond FL, Kerr; ScotchBond MP, 3M-ESPE), or a single
bottle that contains both primer and adhesive (also reerred
to as two-step etch-and-rinse) (2-E&R) (e.g., Prime and
Bond NT, Dentsply-Caulk; XP Bond, Dentsply-Caulk;
Optibond Solo Plus, Kerr; One Step Plus, Bisco). Manyo the single-bottle etch-and-rinse systems are provided as
a unit dose. Based upon the evidence to date, bonding to
enamel is best accomplished with this technique. In vitro
and in vivo research has demonstrated that etch-and-rinse
adhesives can reliably bond to both enamel and dentin.46-48
The duration o enamel etching has been suggested as
15-30 seconds, while research has demonstrated that or
most clinical situations dentin should be etched or only 15
seconds. Dentin age can also have an eect on adhesion, and
it has been recommended to increase etching time to 30 sec-
onds or sclerotic dentin (ound in patients in the age range
o 55-60 years and older), the rationale being that compared
to normal dentin, sclerotic dentin exhibits hypermineraliza-
tion and is resistant to phosphoric acid etching.49-51
Clncal success wth etch-and-rnse adhesves s depen-dent on the basc clncal technque:1. Prepare the tooth (all classes o cavity preparations; can be in
enamel-only Class IV, acial veneers, porcelain veneers).2. Etch with a phosphoric acid (range o concentration 10%-40%)
or 15-30 seconds (15 seconds or normal dentin and 30 secondsor sclerotic dentin).
3. Rinse with air-water spray or 10 seconds.4. Dry the tooth, leaving the enamel rosty, dentin glossy (moist).52, 53
5. Apply adhesive system o choice using a rubbing action54; light cure.6. Apply restorative material; light cure.
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Self-etch adhesivesSel-etch adhesive systems are aqueous mixtures o acidic
unctional monomers, usually phosphoric acid esters with a
pH value higher than that o phosphoric acid gels.55 The SE
approach does not require a separate etching step because
the etchant is incorporated into the adhesive (either in a
separate sel-etching primer or in the adhesive). Addition-
ally, the step o rewetting with water is eliminated becauseSE adhesives contain water and are never completely dried
rom the tooth. SE adhesives do not remove the smear layer,
instead incorporating it into the adhesive. Investigations
have demonstrated that SE systems provide hybridization
and inltration o dentin similar to that seen with etch-and-
rinse adhesives.56-58 There has been concern about the qual-
ity o bonding o SE adhesives to enamel. I enamel is let
unprepared, it is resistant to etching and adhesion with most
SE adhesives.59-61 For preparations that include both dentin
and enamel, it is recommended that the enamel be prepared
with a bur or diamond to optimize the bond to the enamel.Currently, the use o an SE adhesive or restoring Class IV
incisal edge ractures, esthetic acial veneering and diastema
closures with direct composite resin and bonding porcelain
veneers is contraindicated. 62
A chie complaint among practitioners has been the rate
o postoperative sensitivity observed ollowing placement
o Class I, II and V composite resin restorations, especially
using etch-and-rinse adhesives. However, several clinical
studies have ound no dierences in postoperative sensi-
tivity with etch-and-rinse or SE adhesives.63-67 In act, the
conclusion o one study stated that postoperative sensitivitymay depend on the restorative technique and variability
among operators rather than on the type o enamel-dentin
adhesive used.63 Postoperative sensitivity may, however,
be linked to using a TE adhesive bonding to desiccated
dentin.44,45 Since SE adhesives contain water and require no
rinsing or drying, the dentin remains moist, which may ac-
count or reports o minimized postoperative sensitivity.68,69
Santini and coworkers investigated microleakage around
Class V restorations bonded with etch-and-rinse and SE
adhesives, concluding that SE systems were as reliable as
TE systems.70
Clncal success wth self-etch adhesves s dependenton the followng basc clncal technque:1. Prepare the tooth (preparations that are self-retentive,
e.g., box-like Class I, II, III and V, and Class V NCCL with anenamel bevel; not Class IV, not facial veneers, not porcelainveneers).
2. Apply the SE adhesive ollowing the manuacturer s timingand application instructions. This is very product speciic.
3. DO NOT RINSE. Air-dry the tooth ollowing the timing andintensity o air spray rom the product instructions; do not
take any shortcuts.4. Light cure the adhesive.5. Apply restorative material.6. Light cure.
Adhesion to tooth structure: ClinicalchallengesNot all dentin and enamel is equally bondable. Factors
infuencing the bond include the presence o amalgam resto-
rations, caries and other tooth conditions that can aect the
quality o etching and the quality o adhesion to enamel and
dentin. There has been a trend to replace deective amalgam
restorations with composite resins. When removing an amal-gam restoration it is not unusual to nd discolored enamel
and dentin present due to the leaching o metallic ions and
corrosion products into the dentin tubules. Harnirattisai et al.
ound no dierences in adhesion between normal dentin and
discolored amalgam-aected dentin with either an etch-and-
rinse adhesive or a sel-etch adhesive.71 However, bonding
to caries-aected dentin has been shown to be reduced.72-74
Fluorosed enamel and dentin can also be more dicult to
bond to. For enamel fuorosis, the recommendation is to
prepare the enamel with a bur or diamond to improve bond-
ing.75 For fuoride-rich dentin, sel-etching adhesives providebetter bonding.76 O note, with the increased interest in tooth
whitening and the availability o over-the-counter peroxide-
based products, the clinician may not know i their patients
are bleaching their teeth. Research supports waiting at least
one week ater bleaching beore any restorative procedure
with either an etch-and-rinse or SE adhesive to prevent inter-
erence with bonding adhesion and material setting.77-81
An area o recent investigation has been the compatibility
o TE and SE systems with sel-cure and dual-cure composite
resins. There is contradictory evidence on whether or not SE
and TE single-bottle adhesive systems bond well to sel-cureand dual-cure composite resins due to the acidity o the sin-
gle-bottle primer-adhesive. Some studies have demonstrated
a decreased bond and other studies have demonstrated no
eect.82-84 Some recent studies evaluating TE and SE systems
and their compatibility with dual-cure and sel-cure compos-
ite resins have demonstrated some changes in chemistry that
have resulted in composite resin-adhesive compatibility.85-89
This variability requires that the clinician review the manu-
acturers recommendations or use with sel-cure and dual-
cure composite resins.
There has been concern over the durability and longevity o
the bond to dentin, and the in vitro bond strength to dentin has
been shown to decrease over time or some adhesives.90-94 The
mechanism o bond degradation has been attributed to the loss
o hybrid layer integrity, which then compromises resin-dentin
bond stability. A number o researchers have ocused on the
matrix metalloproteinases (MMPs) within the collagen that
may be partially responsible or hybrid layer degradation.95 To
prevent or decrease the degradation o bonding using either TE
or SE adhesives, a number o chemical reagents that are known
to inhibit MMPs have been evaluated. Chlorhexidine (CHX)has been shown to have an inhibitory eect on MMPs,96 and a
number o studies have evaluated the successul use o CHX to
inhibit the degradation o adhesion to dentin.97-100 Other MMP
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inhibitors that produce results similar to those o CHX have
also been investigated, including polyvinylphosphonic acid101
and quaternary ammonium methacrylates102. Another ap-
proach to inhibiting bond degradation has been to use ethanol
instead o water when wetting the dentin.103,104 With a better
understanding o improving bond durability by using prote-
ase inhibitors, there will be changes in adhesive chemistries
to refect the need to inhibit MMPs with recommendationswith TE adhesives to apply CHX or one minute ater etching
and/or to use CHX as a primer beore use o an SE.105-107 Some
manuacturers are reviewing the addition o CHX or other
MMP inhibitors into SE adhesives.
Clinical applicationsThe recommendations or the use o adhesive systems are
product specic. A summary o the indications and clinical
applications or each adhesive system is provided in Table 4,
based upon the clinical evidence and clinical reports.
Table 4. Clinical applications or adhesive systems.
Etch-and-Rinse (Total-Etch) Adhesive Systems
Multiple-bottle (3-E&R): All uses includingsel-cure composite resin coresand dual-cure composite resincementation
Single-bottle (2-E&R): Direct compositeresin placement and withsystems that have an activatoruse with sel-cure and dual-
cure composites is acceptableSelf-Etching Adhesive Systems (not indicated withsel-cure or dual-cure composites unless the manuacturermakes the recommendation and has a sel-cure activator)
Multiple-step systems (2-SEA): Direct placement Class I, II, IIIand V with prepared enamel
Single-step mix systems (1-SEA): Direct placement Class I, II, IIIand V with prepared enamel
Single-step no mix (1-SEA): Direct placement Class I, II, III and Vwith prepared enamel
Use o any adhesive is manuacturer specic or use withsel-cure and dual-cure composite resin systems. Currently,sel-etching systems can be used or Class IV incisal edgerepair, acial veneering and porcelain veneers with a lightcure cement (or fowable composite as a luting agent) with theuse o a total-etch o the enamel surace with phosphoric acidetchant. As more evidence becomes available in clinical trialsthis recommendation may change. Also, i phosphoric acid isused with an SE adhesive, only the enamel needs to be etched.
Anterior direct composite resin restorations:
Class III, IV, V and facial veneersWhen preparing Class III, IV and V restorations, as wellas acial veneer preparations, the type o preparation will
determine whether an etch-and-rinse or sel-etch adhesive
technique will be used. When shade matching is important
due to the margin o the preparation being in an esthetic
area, an esthetic blend o composite resin rom restoration
to tooth is better accomplished using a cavosurace margin
bevel in esthetic areas. At gingival margins, i the enamel
is very thin or i the margin is on the root surace, no bevel
should be placed.
Figure 3a. Maxillary lateral incisor with distal caries and mesial
temporary restoration
Figure 3b. Completed ML and DL preparations maxillary lateral incisor
Figure 3c. Restoration o both preparations using an SE adhesive
(Xeno IV) and micromatrix hybrid composite resin (TPH3)
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Class III restorations can be required to replace a deec-
tive restoration or due to initial caries. Class III prepara-
tions with box-like eatures and retentive walls can be
restored with TE or SE adhesives. (Figure 3) When using
a sel-etch adhesive with a Class III preparation, it is im-
portant to ollow the manuacturers directions, especially
the length o time the adhesive is on the tooth as well as
whether or not the sel-etch adhesive needs to be agitatedduring placement since this is product dependent.
Class IV preparations can be required due to initial car-
ies, a deective restoration or when there has been a traumatic
racture. Typically, the Class IV restoration is placed or teeth
that have been ractured. Class IV preparations generally rely
upon enamel adhesion or retention; the same is true when
placing direct composite resin acial veneers. In both circum-
stances, the current evidence recommends that a TE adhesive
be used with etching o the enamel surace, typically or 15-30
seconds. (Figure 4)
Figure 4a. 14-year-old patient with amelogenesis imperecta
Figure 4b. Direct esthetic bonding ater minimal tooth preparation
using a TE adhesive (Prime and Bond NT) and highly polishable,
esthetic micromatrix hybrid (Esthet-X HD)
Class V lesions are classied as non-carious cervical
lesions (NCCL), caries or a combination. Preparing the
enamel suraces with a 1-2 mm long bevel using a diamond
bur and roughening and cleaning the dentin surace with
a round bur or diamond beore the adhesive procedure
are important or success with either TE or SE adhesives.
Margins on root suraces should not be beveled. For Class V
carious lesions, there is a denitive outline orm and depth,
usually with a box-like design. For these preparations, since
they are retentive, either a TE or an SE adhesive technique
can be used.
Posterior direct composite resin restorations:Class I and IIWith the use o an etch-and-rinse adhesive technique
with composite resin, clinical studies have demonstrated
that composite resins can be considered amalgam alter-
natives in routine-sized preparations.108-112 In contrast
to amalgam, composite resins today are highly esthetic,
reinorce tooth structure and can conserve more tooth
structure in their preparation design.113 Occlusal caries
can be very minimal or more extensive. For preventiveresin restorations, it is generally recommended that a TE
adhesive be used with a fowable composite resin. (Figure
5) For more extensive Class I where the extent o the car-
ies or the removal o a deective restoration provides or
a more box-like preparation design which improves the
sel-retentive characteristics o the restoration either a
TE or an SE can be used. For Class II preparations that
are box-like and retentive, either a TE or an SE adhesive
system can be used successully.13,62 To avoid marginal
staining, with both etch-and-rinse and sel-etch adhesives
it is critical to lightly prepare the enamel by rougheningbeyond the cavosurace margins and etching beyond the
margins, using either a phosphoric acid etchant or an
etch-and-rinse adhesive or using a sel-etch adhesive.
The reason or roughening the enamel is that composite
is dicult to nish and polish to the cavosurace margins
because the composite translucency matches the tooth
shade.
Figure 5a. Pit and issure caries on the irst maxillary molar and
irst premolar
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Figure 5b. A minimally invasive preventive resin preparation done
with a issurotomy bur on the maxillary molar; preparation o
occlusal surace o maxillary irst premolar
Figure 5c. Etching or 15 seconds
Figure 5d. Application o TE adhesive
Figure 5e. Restoration o PRR preparation irst molar with lowable
composite resin (Esthet-X Flow Liquid Micro Hybrid); irst premolar
with micromatrix hybrid composite
Some general guidelines to improve clinical success with
posterior composite resins include:
1. Excellent isolation with a dental dam or other isolating
devices
2. Right-angled enamel margins in stress-bearing areas
3. To minimize postoperative sensitivity, use an SE
adhesive and a low-shrink composite (Figure 6)
4. Adequate light curing in the proximal box o a ClassII (at least 10-20 seconds with a high-intensity light
[greater than 1100 mW/cm2] (Figure 7), 20-30 seconds
with a conventional quartz halogen curing light) or the
adhesive and rst increment o composite resin placed
in the proximal box to ensure polymerization o the
adhesive and composite resin over the distance to the end
o the gingival margin114
Following these guidelines, successul posterior compos-
ites can be placed. (Figure 8)
Figure 6a. Cavity preparation
Figure 6b. SE adhesive (Xeno IV) applied to preparation
Figure 6c. Bulk ill with low-shrink lowable composite base (SureFil
SDR Flow) or proximal box and deep occlusal portion o preparation
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Figure 7. 10 seconds light curing with high-intensity LED
curing light
Figure 8. Completed restoration with micromatrix hybrid
composite (TPH3)
Foundations/cores for fixed prosthodonticsBeore preparation and restoration with a crown, i there
are substantial deects or the tooth has been endodonti-
cally treated, a oundation/core must be placed rst.
While dental amalgam has been a highly successul
restorative material or oundation/cores or crown
and bridge, the use o dual-cured composite resins has
become more prevalent. The use o dual-cure compos-
ite resins or oundations/cores rather than light-cured
composites is recommended due to the depth o these
more extensive preparations and, in the case o endodon-
tically treated teeth, the lack o reliable light curing o a
composite resin within the pulp chamber o a posterior
tooth. Colored composite resin core materials (blue col-
ored) or composites that are more opaque in appearance
can also be used to allow or dierentiation between tooth
structure and composite or crown margin placement.
The clinician must ollow the manuacturers instruc-
tions to ensure adhesion between the TE or SE adhesive
and the composite. As stated earlier, many light-cure-
only adhesives are not recommended with sel-cure anddual-cure composites. The authors use a dual-cure TE or
an SE adhesive with an activator when placing composite
resin cores. (Figure 9)
Figure 9a. Deective amalgam restoration, patient has symptoms
o cracked tooth syndrome maxillary irst molar
Figure 9b. Preparation
Figure 9c. Matrix placed, etched 15 seconds with phosphoric acidetchant
Figure 9d. Ater etchant rinsed rom preparation, dentin is blotted
dry with cotton pellet
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Figure 9e. Application o TE adhesive (XP Bond)
Figure 9f. Placement of dual-cure composite resin core
(FluoroCore 2+)
Figure 9g. Completed composite core restoration
Expanded clinical applications with TEadhesivesTeeth that are periodontally compromised with loss o at-
tachment and bone height have increasing levels o mobility.
Tarnow and Fletcher described three primary rationales or
controlling tooth mobility with periodontal splinting115: 1)
primary occlusal trauma 2) secondary occlusal trauma and 3)
progressive mobility, migration and pain on unction.
Periodontal splinting has been ound to improve periodon-
tal prognosis.116, 117
In recent years, conservative splinting operiodontally compromised teeth using a total-etch adhesive
technique with a continuous woven-ber reinorcement has been
described and become a well-accepted technique.118,119 (Figure 10)
Figure 10a. Periodontally compromised and mobile mandibular
anterior teeth
Figure 10b. Radiograph showing 40% bone loss
Figure 10c. Ater phosphoric acid etching, gingival embrasuresblocked out with ast-setting PVS impression material
Figure 10d. Placement o iber-reinorced splint (Ribbond) with TEadhesive (Prime and Bond NT), micromatrix hybrid composite (TPH3)
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As our patients retain their teeth longer, destructive loss
o tooth structure on the biting suraces o posterior teeth
and the incisal edges o anterior teeth is caused by attrition
due to normal unction and paraunction. This loss o tooth
structure is requently observed in the anterior region as the
cupping o exposed dentin in the incisal edges with enamel
chipping. (Figure 11) I an intervention occurs beore anterior
teeth demonstrate moderate to severe wear, the wear can bereduced.120 For these cases a conservative approach is a deni-
tive preparation using either a small pear-shaped bur (#329
or #330) or a small round bur (#1/2 or #1) into the dentin
to a depth o 1.0 mm, leaving a shell o enamel that will be
bonded to. (Figure 12) This depth into the dentin allows or
adequate composite resin longevity as the restoration unc-
tions. A periodontal probe should be used to veriy the pulpal
depth o 1.0 mm o the tooth preparation o all enamel walls.
Using a TE adhesive technique with an etching time o not
more than 15 seconds, the teeth can then be restored. (Figure
13) These restorations have demonstrated good durability.
Figure 11. Attrition and wear o mandibular anterior teeth
Figure 12. Preparation o mandibular teeth
Figure 13. Restoration with TE adhesive (Prime and Bond NT) withmicromatrix hybrid composite (TPH3)
ConclusionMultiple generations o adhesive systems have been devel-
oped in the last 40 years. Many o these have required mul-
tiple steps that include etching with phosphoric acid, rinsing
with an air-water spray, drying, rewetting the preparation,
applying the primer, drying, applying the adhesive resin and
light curing. More recently, simplied systems have been in-
troduced where the adhesive provides or the etching, primerand adhesive all in one. The clinician needs to evaluate the
clinical requirements o any adhesive restorative system he
or she selects or restoring the natural dentition. Long-term
clinical trials with posterior composite resin restorations, por-
celain veneers, crowns, and resin and ceramic inlays and on-
lays provide strong evidence o clinical success and durability
when using a total-etch adhesive technique. Additionally, it
has been ound that the restorative technique and variabil-
ity among operators may relate to the presence or absence
o post-operative sensitivity rather than the type o enamel-
dentin adhesive used. O note, when using an etch-and-rinsetechnique the dentin should remain damp and glossy and not
be desiccated prior to application o the adhesive, to reduce
the risk o sensitivity. While the multiple-bottle etch-and-
rinse adhesives are still the gold standard or all-purpose
bonding, based upon the current clinical evidence and the
recommendations o manuacturers, SE adhesive systems can
be used successully or the restoration o Class I, II, III and
V preparations. Whichever system the clinician selects to use,
he or she should ollow the manuacturers recommendations
or clinical applications to ensure clinical success.
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105. Ricci HA, Sanabe ME, de Souza Costa CA, Pashley DH, Hebling J.Chlorhexidine increases the longevity o in vivo resin-dentin bonds. EurJ Oral Sci. 2010;118:411-6.
106. Breschi L, Mazzoni A, Nato F, Carriho M, et al. Chlorhexidine stabilizesthe adhesive interace: a 2-year in vitro study. Dent Mater. 2010;26:320-5.
107. Campos EA, Correr GM, Leonardi DP, Barato-Filho F, et al.Chlorhexidine diminishes the loss o bond strength over time undersimulated pulpal pressure and thermo-mechanical stressing. J Dent.2009;37:108-14.
108. Wilder AD Jr, May KN Jr, Bayne SC, Taylor DF, Leinelder KF.Seventeen-year clinical study o ultraviolet-cured posterior compositeClass I and II restorations. J Esthet Dent. 1999;11:135-42.
109. Lundin SA, Koch G. Class I and II posterior composite restorationsater 5 and 10 years. Swed Dent J. 1999;23(5-6):165-71.
110. Gaengler P, Hoyer I, Montag R. Clinical evaluation o posteriorrestorations: the 10-year report. J Adhes Dent. 2001;3:185-94.
111. Statement on posterior resin-based composites. J Am Dent Assoc.1998;129:1627-8.
112. Smales RJ, Webster DA, Leppard PI. Survival predictions o amalgamrestorations. J Dent. 1991;19:272-7.
113. Strassler HE. Predictable and successul posterior packable Class II
composite resins. Amer Dent Instit or CE. 2001;75:15-23.114. Felix CA, Price RB. Eect o distance on power density rom curing
lights. J Dent Res. (Special Issue B). 2006; 85: abstract no. 2468.115. Tarnow DP, Fletcher P. Splinting o periodontally involved teeth:
indications and contradictions. New York State Dent J. 1986;52(5):24-7.116. McGuire MK, Nunn ME. Prognosis versus actual outcome. II. The
eectiveness o clinical parameters in developing an accurate prognosis.J Periodontol. 1996;67:666-74.
117. Strassler HE. Tooth stabilization improves periodontal prognosis: a casereport. Dent Today. 2009;28(9):88-93.
118. Strassler HE. New generation bonding reinorcing materials or anteriorperiodontal tooth stabilization and splinting. Dent Clin North Am.1999;43(1):105-26.
119. Strassler HE, Brown C. Periodontal splinting with a thin high-moduluspolyethylene ribbon. Compend Contin Educ Dent. 2001;22:696-708.
120. Strassler HE, Kihn PW, Yoon R. Conservative treatment o the worndentition with adhesive composite resin. Contemp Esthet Rest Pract.
1999;3(4):42-52.
Author ProfileDr. Howard Strassler is proessor in the
department o endodontics, prosthodon-
tics and operative dentistry at the Uni-
versity o Maryland School o Dentistry.
He is a ellow in the Academy o Dental
Materials and the Academy o General
Dentistry, a member o the the Academy
o Operative Dentistry, and the International Association
or Dental Research. Dr. Strassler has published more than475 articles, coauthored seven chapters in texts, and lectured
nationally and internationally. Dr. Strassler is a consultant to
over 15 dental manuacturers and is on editorial boards or
several dental journals.
Dr. Michael Mann is an assistant proes-
sor in the Advanced Education in General
Dentistry residency at the University o
Maryland School o Dentistry. He is a
member o the American Dental As-
sociation. He has lectured nationally and
internationally. Dr. Mann has a ull-time
general practice with an emphasis on comprehensive dental
care and aesthetics.
DisclaimerThe author(s) o this course has/have no commercial ties with
the sponsors or the providers o the unrestricted educational
grant or this course.
Reader FeedbackWe encourage your comments on this or any PennWell course.For your convenience, an online eedback orm is available at
www.ineedce.com.
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1. _________ have improved the way we treat
patients.a. Fluorides
b. Local anestheticsc. Dental resin adhesion innovations
d. all o the above
2. _________ described the retention o
restorations based upon cavity design and
undercut dentin.a. Buonocore
b. Black
c. Ferrante
d. all o the above
3. _________ has been the driving orce in
changing how we prepare and restore
teeth.a. Fluoride-releasing cementb. The electric handpiece
c. Bonding to tooth substrates
d. all o the above
4. _________ has/have contributed to the
ability to have a lesion-centered approach
to restorative treatment.a. Advancements in adhesive restorative materials
b. Caries risk assessment
c. The introduction o computer-assisted methods o
caries detection
d. all o the above
5. _________ is a key prerequisite or suc-cessul adhesion to tooth structure.a. A sae and biologically acceptable procedure
b. Bond strength that is clinically signicant
c. A bond that is stable in vivo or a clinically
signicant period o time
d. all o the above
6. _________ wrote an article in 1985 on the
undamental elements or an adhesive
used or bonding restorative materials to
tooth structure.a. Dr. Wayne Swit
b. Dr. Wayne Barkmeier
c. Dr. Dwayne Smithd. none o the above
7. Establishing a bond slowly _________.a. is essential or bond strength
b. is essential or adequate nishing
c. a and b
d. none o the above
8. _________ is a phenomenon or all
adhesives used today.a. Micromechanical locking to the etched enamel
prisms
b. Bonding to dentin through hybridization
c. Micromechanical locking to etched dentin
crystalsd. a and b
9. For successul dentin bonding, the bond
should _________.
a. mature gradually
b. snap-set and then mature gradually
c. be instantaneous
d. none o the above
10. _________ is a goal or an eective dentin
bonding material.a. Retention at a clinically acceptable level
b. Biocompatibility
c. A long-lasting bond to dentin
d. all o the above
11. The success o the etch-and-rinse adhe-
sive bond was demonstrated by several
researchers, based upon the addition o a
_________.a. hydrophilic monomer
b. hydrophobic monomer
c. hydrophilic polymer
d. hydrophobic polymer
12. Some adhesives have added _________ to
improve physical properties.a. fuoride
b. llers
c. carbonite
d. none o the above
13. The etch-and-rinse adhesives can be
recognized by the initial application o a
_________ to the enamel/dentin.a. 10%-20% phosphoric acid
b. 10%-40% phosphoric acidc. 10%-20% acetic acid
d. 10%-40% hydrochloric acid
14. The etch-and-rinse technique is also
known as the _________ technique.a. sel-etch
b. total-etch
c. no-etch
d. none o the above
15. With the etch-and-rinse technique, prior
to bonding the enamel surace can be
_________ with air, and the dentin should
remain _________.
a. completely dried; dryb. partially dried; dry
c. completely dried; damp and glossy
d. none o the above
16. Based upon the evidence to date, bond-
ing to enamel is best accomplished with
the _________ technique.a. sel-etch
b. no-etch
c. etch-and-rinse
d. none o the above
17. The etch-and-rinse technique involves
the use o a ___________ adhesive resin.a. one-bottle
b. one- or two-bottle
c. three-bottle
d. none o the above
18. ___________ is a requirement or clinical
success with etch-and-rinse adhesives.a. Rinsing with air-water spray or 10 seconds ater
etchingb. Drying the tooth ater rinsing
c. Leaving the enamel rosty and dentin glossy
(moist) ater drying
d. all o the above
19. The sel-etch technique involves the use
o _________.a. a separate etchant
b. a our-bottle technique
c. a one-step or two-step technique
d. a and c
20. Sel-etch adhesive systems are aqueous
mixtures o _________.a. acidic unctional polymers
b. acidic unctional monomers
c. alkaline unctional polymers
d. alkaline unctional monomers
21. The sel-etch approach _________.a. requires a separate etching step
b. does not require a separate etching step or rewetting
c. requires an additional rewetting step
d. a and c
22. Currently, the use o an sel-etch
adhesive or direct composite restoration
_________ is contraindicated.
a. o Class IV incisal edge racturesb. o esthetic acial veneering
c. or diastema closures
d. all o the above
23. Sclerotic dentin _________.a. exhibits hypermineralization
b. is resistant to phosphoric acid etching
c. is ound in patients age 55 and above
d. all o the above
24. It has been recommended to increase
etching time to _________ or sclerotic
dentin.a. 20 seconds
b. 30 secondsc. 40 seconds
d. 50 seconds
25. Several clinical studies have ound
_________ dierences in postoperative
sensitivity with etch-and-rinse or sel-etch
adhesives.a. major
b. minimal
c. no
d. none o the above
26. When using a sel-etch adhesive, the area
_________ ater adhesive application.a. must be rinsed
b. must not be rinsed
c. must be light-cured
d. b and c
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15 www.ineedce.com
27. _________ is more dicult to bond to.
a. Caries-aected dentin
b. Fluorosed enamel
c. Fluorosed dentin
d. all o the above
28. _________ is a matrix metalloproteinase
inhibitor that has been used to decrease
or prevent bond degradation.
a. Chlorhexidine
b. Quaternary ammonium methacrylate
c. Polyvinylphosphonic acid
d. all o the above
29. When preparing Class III, IV and V
restorations, the type o _________ will
determine whether an etch-and-rinse or
sel-etch adhesive technique will be used.
a. etchantb. lesion
c. preparation
d. a and b
30. Research supports waiting at least
_________ ater bleaching beore any
restorative procedure with an etch-and-
rinse or sel-etch adhesive.
a. one week
b. two weeks
c. three weeks
d. one month
31. Class III preparations with box-likeeatures and retentive walls can be
restored with _________.
a. sel-etch adhesives only
b. total etch adhesives only
c. sel-etch or total-etch adhesives
d. none o the above
32. A minimally invasive preventive resin
preparation can be perormed with a
_________ bur.
a. large carbide
b. large pear-shaped diamond
c. end-cutting
d. ssurotomy
33. The mechanism o dentin bond
degradation has been attributed to the
loss o _________.
a. hybrid layer integrity
b. prisms
c. the sealed surace
d. all o the above
34. For preventive resin restorations, it is
generally recommended that a ________
adhesive be used with a fowable
composite resin.
a. sel-etch
b. total-etch
c. sel-etch or total-etch
d. none o the above
35. To avoid _________, with both etch-
and-rinse and sel-etch adhesives it is
critical to lightly prepare the enamel.
a. dentin discoloration
b. marginal stainingc. racture
d. none o the above
36. One approach to inhibiting bond
degradation has been to use _________
instead o water when wetting the dentin.
a. acetylamide
b. ethanol
c. essential oils
d. fuoride rinse
37. Postoperative sensitivity _________.
a. may be linked to using total-etch adhesive bonding
to desiccated dentinb. may depend on the restorative technique rather
than the type o adhesive system used
c. is a chie complaint among practitioners ollowing
placement o Class I, II and V restorations
d. all o the above
38. With the use o an etch-and-rinse
adhesive technique, clinical studies have
demonstrated that composite resins can
be considered _________.
a. inerior alternatives to amalgam
b. amalgam alternatives in routine-sized preparations
c. equivalent to cast gold crowns
d. a or b
39. An esthetic blend o composite resin
rom restoration to tooth is better ac-
complished using a _________ in esthetic
areas.
a. line angle bevel
b. cavosurace level
c. cavosurace margin bevel
d. none o the above
40. The use o _________ composite resin is
recommended or oundations/cores.
a. light-cured
b. dual curec. light-cured or dual cure
d. none o the above
41. _________ described three primary
rationales or controlling tooth mobility
with periodontal splinting.
a. Fletcher and Lang
b. Tarnow and Fletcher
c. Tarnow and Lang
d. Tarnow and Buser
42. I phosphoric acid is used with a
sel-etch adhesive, _________ need(s) to
be etched.
a. only the enamel
b. only the dentin
c. both the dentin and the enamel
d. none o the above
43. I phosphoric acid is used with an etch-
and-rinse adhesive, _________ be etched.a. only the enamel may
b. only the dentin may
c. both the dentin and the enamel cand. none o the above
44. Colored (blue) composite resin is used
or _________.a. Class I restorations
b. sealants
c. oundations/cores
d. all o the above
45. Conservative splinting o periodontally
compromised teeth using a _________
adhesive technique with a(n) _________
woven-ber reinorcement has been
described.
a. sel-etch; intermittentb. sel-etch; continuous
c. total-etch; continuous
d. none o the above
46. Destructive loss o tooth structure on
the biting suraces o posterior teeth
and the incisal edges o anterior teeth is
caused by _________.a. attrition due to normal unction
b. attrition due to paraunction
c. periodontal disease
d. a and b
47. Anterior teeth with incisal edge tissue
loss can be restored using a _________adhesive technique with an etching time
o not more than _________.a. sel-etch; 10 seconds
b. total-etch; 10 seconds
c. sel-etch; 15 seconds
d. total-etch; 15 seconds
48. _________ clinical trials with posterior
composite resin restorations provide
strong evidence o clinical success and
durability when using a total-etch
adhesive technique.a. Short-term
b. Long-termc. No
d. none o the above
49. _________ adhesives are still the gold
standard or all-purpose bonding.a. Single-bottle sel-etch
b. Single-bottle etch-and-rinse
c. Multiple-bottle sel-etch
d. Multiple-bottle etch-and-rinse
50. Based upon the current clinical
evidence, sel-etch adhesive systems can
be used successully or the restoration o
_________ preparations.a. Class I and II
b. Class III
c. Class V
d. all o the above
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Educational Objectives1. Describe the diferences between etch-and-rinse and sel-etch adhesives and relate these categories to other naming systems
2. Discuss the current research evidence comparing etch-and-rinse and sel-etch adhesives
3. List and describe the indications or etch-and-rinse and sel-etch adhesives
4. Describe the clinical procedure or an etch-and-rinse and a sel-etch single-step adhesive
Course Evaluation
1. Were the individual course objectives met? Objective #1:YesNo Objective #3:YesNoObjective #2:YesNo Objective #4:YesNoPlease evaluate this course by responding to the ollowing statements, using a scale o Excellent = 5 to Poor = 0.2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 03. Please rate your personal mastery o the course objectives. 5 4 3 2 1 0
4. How would you rate the objectives and educational methods? 5 4 3 2 1 0
5. How do you rate the authors grasp o the topic? 5 4 3 2 1 0
6. Please rate the instructors efectiveness. 5 4 3 2 1 0
7. Was the overall administration o the course efective? 5 4 3 2 1 0
8. Please rate the useulness and clinical applicability o this course. 5 4 3 2 1 0
9. Please rate the useulness o the supplemental webliography. 5 4 3 2 1 0
10. Do you eel that the reerences were adequate? Yes No
11. Would you participate in a similar program on a diferent topic? Yes No
12. I any o the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
13. Was there any subject matter you ound conusing? Please d escribe.
___________________________________________________________________
___________________________________________________________________
14. How long did it take you to complete this course?
___________________________________________________________________
___________________________________________________________________15. What additional continuing dental education topics would you like to see?
___________________________________________________________________
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ANSWER SHEET
Dental Adhesives for Direct Placement Composite Restorations: An Update
Name: Title: Specialty:
Address: E-mail:
City: State: ZIP: Country:
Telephone: Home () Ofce () Lic. Renewal Date:Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
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you 3 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822
AGD Code 253