Why better adhesion means happier patients

Adhesive dentistry has many benefits to the patient, from preserving more tooth structure to less cutting for a dental filling and even in some cases to reinforcing the tooth structure. Dentists have more options to restore or repair teeth thanks to advances in adhesive dentistry. However, these options all rely on bond strength. Without it, your restoration will fail, and your patient could come unglued.

“Adhesive dentistry is a significant improvement in dentistry, both cosmetically and restoratively,” says Dr. Richmond Chung, DMD, a private practice general dentist in Orange County, Calif. “But when the adhesive fails, the restoration will become displaced. Another big challenge with adhesive dentistry is post-op sensitivity, where the restoration is satisfactory, but maybe it wasn't isolated as nicely as you would like and there was some contamination, and now there’s some sensitivity.”

Related reading: How self-etch adhesives can help prevent sensititvity

Dr. Leah Capozzi, DDS, who practices in Buffalo, N.Y., explains that if a filling partially de-bonds, it can allow leakage, recurrent decay and exposed dentin. Unfortunately, the dentist and patient may not realize there is a problem with the bond in these cases until they replace the filling. On the other hand, a fully de-bonded filling can lodge in an uncomfortable position against the gum tissue and expose the tooth to the oral environment.

“Either situation will cause patients to return to the office to have the treatment redone," she said, which can infringe on the patient's time and erode their confidence in the dentist. 

For all of these reasons, excellent adhesion leads to happier patients.

“Better adhesion can prevent de-bonding and leakage, saving both the patient and dentist from spending time on replacing fillings. Better adhesion can also reduce post-op sensitivity for patients,” Dr. Capozzi says.

What makes a patient happy?

Dr. Ford Gatgens, DDS, who practices just outside Nashville in Dickson, Tenn., said patients want everything to function like it is supposed to and look natural as well. Most of all, they want to avoid postoperative problems after their dental visit.

“Obviously, if the patient had work done and he or she says, ‘Man! When I left, I couldn’t even tell I had been at the office. Everything feels just like it belongs,’ I would say that’s a happy patient,” he said.

Dr. Kalmanovich agrees that happy patients are those who feel comfortable in your chair and confident they are in good hands. He ensures he is doing the right steps, so his patients don’t have post-operative sensitivity.

“They can see that you are doing things in a step-by-step strategic manner and not fumbling around not knowing what you are doing,” he says.

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Dr. Kalmanovich, who usually etches and then applies Gluma to prevent sensitivity before using the adhesive, compared his bonding procedure with his dental assistant to watching an orchestra perform -- precise and systematic while working together to achieve a result.

“We do the same thing every time. I get the etch. I get the Gluma. I get the primer. I get the bonding. She light cures it for the same time every time. I put in my liner and I put in my composite. Everything flows well. The patients appreciate that,” Dr. Kalmanovich explains.

“Whenever they don’t have to come back after dental work has been done, they feel comfortable and confident, everything functions the way it is supposed to and they look good as well -- that’s a happy patient,” Dr. Gatgens says.

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Which adhesives do our experts prefer?

Adhesive dentistry is a sticky subject. Most dentists compare adhesives based on bond strength. However, ease of use is another important criterion. Some dentists swear by total-etch adhesives while others prefer self-etching. Some use different adhesives for different cases while still others prefer universal adhesives. Many dentists have a drawer full of products that they use in various circumstances.

Since 1955, there have been seven generations of adhesives with varying degrees of success in both areas. When Dr. Chad Duplantis, DDS, looks back over the history of adhesives, he notes the most successful were those with both a priming agent and a bonding agent in a total etch procedure. The downside with these adhesives was that when used inappropriately, they caused considerable postoperative sensitivity. The dental industry tried to improve these bond strengths while reducing sensitivity over time.

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Dr. Duplantis admits he has switched adhesives 10 times in the 18 years he has been in private practice in Fort Worth, Texas. For a while he was using two adhesives: a total-etch and a self-etch. However, the self-etching adhesives weren't robust enough for his anterior composite restorations. He compensated for this by using a total-etch adhesive on his anterior restorations and a self-etch on his posterior restorations. But he was still challenged by de-bonds, chips or abrade on his anterior restorations.

“I don’t feel that the self-etching adhesives are as strong as they say they are. I have never had good luck with a self-etching adhesive,” he says.

Now, Dr. Duplantis uses a universal adhesive. One of the biggest reasons is that it works with everything he uses in his practice.

“I chose the Scotchbond Universal [from 3M] for a number of reasons, but mostly because it fits all of my needs. It’s been a very good product for me,” he says. “Knock on wood, I have not had any sensitivity or de-bond issues since I have been using it.”

Dr. Gatgens has been practicing for more than 10 years. He also chose a universal adhesive for his practice, Dentsply Sirona’s Prime and Bond Elect. When he switched to the universal, he said he didn’t have a lot of the problems he had experienced in the past.

“Not only do I find the product works well in my hands, but I also know it’s gone through the rigors of all the testing against all the other possibilities. I feel comfortable using products like that to make sure I am getting my patients the best results possible,” Dr. Gatgens explains.

Dr. Gatgens uses lasers with all of his procedures, a step he feels sterilizes the bonding surface for optimal strength.

“When I use the lasers to open up the tubules to clean out any debris, I feel comfortable and confident with that process and use the universal,” he says.

Dr. Capozzi wanted an adhesive that is straight-forward and easy to apply. “I use Ivoclar Adhese universal, which is a universal adhesive.  I have had great results with bond strength and decreased postoperative sensitivity for patients,” she said. 

Dr. Kalmanovich prefers to use dual systems, not all-in-ones. Dr. Chung says he is happiest with his fourth-generation, multi-step bond adhesive because it is time-tested and proven.

“I don't believe the hype just because it's the latest product and they claim all these great things,” Dr. Chung says. “You've got to feel comfortable with the one you use, as long as you are not having any problems with it in your practice and you're having real success with it, which, for the most part, we have been.”

But no matter which adhesive you choose, the most important aspect for your patient is the efficacy of your bond. Otherwise, Dr. Duplantis says, the patient couldn’t care less which one you use.  

“A patient is not going to care what generation you are using or what type of adhesive you are using. They care about two things: that the restoration is going to stay in their mouth and that they don’t have sensitivity afterward,” Dr. Duplantis says. “The patient trusts that the dentist has done their research so that those two things occur.”