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Current Concepts and Techniques for Caries
and Adhesion to Residual Dentin
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Excavationlication
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Aline de Almeida Nevesa/Eduardo Coutinhob/Marcio Vivan Cardosoc/Paul Lambrechtsd/
Bart Van Meerbeeke
Abstract: The advent of “Adhesive Dentistry” has simplified the guidelines for cavity preparation enormously. The design and extent of the current preparations are basically defined by the extent and shape of the caries lesion, potentially slightly extended by bevelling the cavity margins in order to meet the modern concept of minimally invasive
dentistry. New caries excavation techniques have been introduced, such as the use of plastic and ceramic burs, improved caries-disclosing dyes, enzymatic caries-dissolving agents, caries-selective sono/air abrasion and laser ablation. They all aim to remove or help remove caries-infected tissue as selectively as possible, while being minimally
invasive through maximum preservation of caries-affected tissue. Each technique entails a specific caries-removal
endpoint and produces residual dentin substrates of different natures and thus different receptiveness for adhesive
procedures. This paper reviews the newest developments in caries excavation techniques and their effect on the remaining dentin tissue with regard to its bonding receptiveness.
Keywords: minimally invasive dentistry, dentin caries, caries excavation, bond strength of composite/dentin interfaces.
J Adhes Dent 2011; 13; 7-22.
doi: 10.3290/j.jad.a18443
T
he potential to bond restorative materials to tooth structure has altered the general principles of cavity preparation. While new steps were added to cavity preparation
procedures, especially for bonding, others – such as cutting
retentive cavity geometries – were omitted. In light of the minimally invasive dentistry concept,112 the macroretentive
“G.V.Black” cavities15 have been replaced by cavities limited
to removal of carious dentin that are at most extended with
some additional rounding off of sharp margin edges and/or
bevelling, the latter to the direct benefit of the subsequent
bonding process.
a
PhD student, Leuven BIOMAT Research Cluster, Department of Conservative
Dentistry, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery,
Catholic University of Leuven, Leuven, Belgium. Literatur review, wrote manuscript in partial fulfillment for PhD.
b
PhD student, Leuven BIOMAT Research Cluster, Department of Conservative
Dentistry, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery,
Catholic University of Leuven, Leuven, Belgium. Computer 3D-modeling of
carious teeth, proofread manuscript.
c
Postdoctoral Research Fellow, Leuven BIOMAT Research Cluster, Department
of Conservative Dentistry, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery, Catholic University of Leuven, Leuven, Belgium. Contributed to
content, proofread manuscript.
d
Full Professor, Leuven BIOMAT Research Cluster, Department of Conservative
Dentistry, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery,
Catholic University of Leuven, Leuven, Belgium. Neves’ PhD supervisor, contributed to content, proofread manuscript.
e
Full Professor, Leuven BIOMAT Research Cluster, Department of Conservative
Dentistry, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery,
Catholic University of Leuven, Leuven, Belgium. Neves’ PhD supervisor, defined manuscript outline, proofread manuscript.
Correspondence: B. Van Meerbeek, Leuven BIOMAT Research Cluster, Department
of Conservative Dentistry, School of Dentistry, Oral Pathology and Maxillo-Facial
Surgery, Catholic University of Leuven, Kapucijnenvoer 7, B-3000, Leuven, Belgium.
Tel: +32-16-337587, Fax: +32-16-332752. e-mail: bart.vanmeerbeek@med.kuleuven.be
Vol 13, No 1, 2011
Submitted for publication: 08.07.09; accepted for publication: 24.10.09.
However, the extent to which carious dentin should be removed in order to achieve a mechanically and biologically
successful restoration is still a matter of debate. In particular, no definite diagnostic tool is today available to clinically
define the caries-removal endpoint, enabling complete removal of infected tissue without overextending cavity preparation. In addition, the different techniques presently available for caries removal/cavity preparation produce residual
dentin substrates of different natures and thus different receptiveness for adhesion. The extent of carious dentin excavation, the type of dentin substrate generated by each
caries excavation technique, and the additional effect bonding agents exert on the residual dentin substrate are reviewed in this article, along with an in-depth discussion on
aspects of dental caries histopathology. The latter is of direct
importance for proper understanding of the rationale behind
the different caries removal techniques.
WHY SHOULD CARIOUS DENTIN BE REMOVED
BEFORE THE ACTUAL RESTORATION IS PLACED?
At the beginning of the past century, when the first operative dentistry guidelines were established, the term “caries
excavation” was defined as a synonym for “cavity preparation”, which in turn consisted of “mechanical treatment of
the injuries to the teeth produced by dental caries, as
would best fit the remaining part of the tooth to receive a
filling”.15 From this definition, it appears that caries excavation procedures were regarded as one of the many
mandatory steps to prepare a tooth to receive the filling
material. Furthermore, it has been described that the carious lesion should be excavated “until a hard pulpal floor
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was reached” and that “generally, when the cavity has
been cut to form, no carious dentin will remain”. 15 In
short, carious dentin should be removed until a sufficiently solid layer of dentin was reached to support condensation of the restorative material (“stability form”) and
to provide adequate retention for the filling material (“retention form”), promoting a successful and long-term survival of the restoration.
It is thus clear that when nonadhesive restorations were
the only available option to directly restore decayed teeth, no
distinct separation between caries removal and cavity preparation was made. In practical terms, it means that excavation of carious dentin was performed to remove necrotic,
soft material in order to best accommodate the filling material. Perhaps it explains the general confusion still seen
nowadays when dealing with the term “caries excavation” in
view of the minimally invasive dentistry concept.112 As already mentioned, the ability to bond restorations has downgraded the rules for cavity preparation to simply and solely
removing caries and, if needed, bevelling of the enamel cavity margins, while the main procedure of cavity preparation,
or the excavation of caries, still lacks a more objective definition.
This leads to the initial question: Does carious dentin
need to be removed prior to restoration placement? Clinical
follow-ups of bonded restorations placed over soft carious
dentin81 provided evidence that once the cavity margins are
laid in relatively sound tissue, adequate marginal sealing is
guaranteed and further progression of the carious lesion
can be arrested. Apparently, therefore, well-sealed margins
determine the long-term success of adhesive restorations, in
particular with respect to arresting the caries progress.81 After all, since bonding to carious dentin is generally not as
good as that to sound dentin, the somewhat unexpected answer to this question is that carious dentin is still removed
in order to provide adequate retention for the filling material (achieving better bonding), thus producing long-term successful restorations.
As caries excavation is still an important step towards
achieving good-quality bonded restorations, the next question arises: What is the current definition of the caries removal endpoint? Even now, there is still no better clinical criterion to define the caries excavation limit than the “normal”
hardness feeling of sound dentin when probed by hand instruments.94 Although this so-called “cris dentinaire” is very
subjective and dependent on the operator’s clinical background, it is still the gold-standard method to check residual
caries. It was strongly corroborated after research showed
that cariogenic bacteria were never found beyond the softening front of dentin.40 Further identification of a superficial
infected dentin layer and a subjacent affected dentin layer41
has laid the foundation for a more rational approach for
caries removal. Elimination of the heavily infected dentin
and preservation of the residual affected dentin were thus
defined as prerequisites for effectively arresting the carious
process without harming the long-term survival of the pulp
and the restoration.62 This has currently raised some discussion about moving toward more objective and hopefully
more conservative approaches to selectively remove carious
dentin.10,121
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HISTOPATHOLOGY OF DENTIN CARIES
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Dentin is a mineralized tissue permeated by cellular extentio
sions from odontoblasts, which are locatedtat
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eral zone of the pulp adjacent to the pre-dentin.110
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reason, dentin, as a vital tissue, is perfectly able to respond to any stimuli, even when invoked at the enamel
surface, such as an acid challenge produced by an organized, acid-producing biofilm.106
The first detectable change in dentin in response to a cariogenic biofilm at the outer enamel surface is an area of sclerotic dentin subjacent to the demineralized enamel site (Figs
1A and 1B). The predominant feature of this reactive dentin
is its increased translucency, which can be ascribed to intratubular mineral deposition.6 The translucent dentinal
tubules will be those localized precisely beneath the demineralized enamel surface, and appear even before the
enamel demineralization has reached the dentin-enamel
junction (DEJ). Only when the caries lesion has progressed
to a considerable length along the DEJ will the subjacent
dentin be demineralized14 and become recognizable by a
yellow to dark-brown discoloration (Figs 1C and 1D). At this
point, bearing in mind that the dentin response to dental
plaque is directly related to its metabolic activity77 and that
different maturation stages can coexist in a fully-formed
dental plaque depending on the self-cleaning ability of the
surface, different phases of caries progression will co-exist
within one lesion14 (Figs 2A and 2B).
It is also well known that dentin caries will not spread laterally along the DEJ before dentin is cavitated and colonized
by cariogenic bacteria.34 From this moment, the demineralized and thus unprotected organic dentin matrix (collagen)
will be directly degraded through bacterial and host-mediated enzymes.65,107 Especially at peripheral parts of the cavity where the cariogenic biofilm is sheltered by the surrounding (undermined) enamel, the lesion may spread rapidly
along the DEJ (“hidden” caries lesion) (Figs 2B and 2C).
CARIES-EXCAVATION PROCEDURES
Conventional Excavation with Burs
Carbon-steel or tungsten-carbide burs
Tungsten-carbide burs replaced carbon-steel burs once
the process of hardening steel with tungsten carbide was
introduced to the dental bur industry. Microscopic tungsten-carbide particles are held together in a matrix of
cobalt or nickel at the head (working end) of the bur.120
The head has typical spiral-like cutting edges with or without additional cross cuts to improve cutting efficiency.
Carbon-steel burs possess the same caries-removing properties as tungsten-carbide burs and are less expensive,
but they are much more prone to corrosion and dulling.12
For caries removal, a round bur is recommended with diameters corresponding to the size of the carious lesion.
Water irrigation is optional because generally low-speed
(700 to 800 rpm) counter-angle handpieces are employed.
It is generally advised to start carious dentin excavation
from the periphery towards the center of the lesion in
order to minimize the risk of infection in case of accidental
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Fig 1A Proximal surface of a molar showing a
non-cavitated lesion (black arrow) beneath
the contact point (white arrow). The dotted
line indicates the location of the mesiodistal
section in Fig 1B.
Fig 1B Mesiodistal section reveals an area of
hypermineralized dentin (black arrow) beneath the area of enamel demineralization
(white arrow).
Fig 1C Occlusal surface of the same tooth
showing a non-cavitated lesion on the central
fossa (black arrow) and a cavitated lesion in
the occluso-palatal groove (white arrow). The
dotted line indicates the location of the
mesiodistal section in Fig 1D.
Fig 1D Mesiodistal section showing a yellowbrown discoloration under the demineralized
enamel (black arrow). The white arrow depicts
residual demineralized dentin originating
from the occluso-palatal lesion (C: white
arrow).
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Fig 2A Volume-rendered slices based on xray micro-CT data of a molar showing a cavitated lesion in the central fossa. The numbers
along the black lines in Fig 2B refer to each
corresponding volume rendering based on xray micro-CT data of the tooth. From 1 to 6, increasing progression stages can be observed
from the periphery to the center of the lesion.
Fig 2B Occlusal surface of the same tooth element. The dotted red line indicates the location of the mesiodistal section in Fig 2C. The
black lines indicate the location of the volume-rendered slices in Fig 2A.
Fig 2C Mesiodistal section showing the lateral spread of the dentin lesion (white arrows)
beyond the limit of the enamel cavitation (dotted lines).
pulp exposure. Larger burs are recommended for this reason as well.
Tungsten-carbide or carbon-steel burs in low-speed
counter-angle handpieces are the most efficient method to excavate carious lesions in terms of time,24 and are therefore
still the most widely used caries-excavation method. However, in terms of minimal invasiveness, bur-prepared cavities,
combined with the use of a dental explorer to check for the
caries removal endpoint, tend to overexcavate. This was
Vol 13, No 1, 2011
found, for instance, when auto-fluorescence induced by bacterial metabolites was used to detect carious tissue.8 When
studied by scanning electron microscopy (SEM), this method
leaves a homogeneous smear layer with more or less uniform
roughness, and dentinal tubules visibly obstructed with smear
plugs.116 With regard to bonding receptiveness, the smearcovered surface does not interfere with etch-and-rinse adhesives, but has been shown to potentially reduce the bonding
effectiveness of self-etching adhesives.91.
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cavities prepared with conventional tungsten-carbide
r P burs.
ubto cariIn addition, not only the microtensile bond strength
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ous dentin excavated with SmartPrep burs was lowerca
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both etch-and-rinse and self-etching adhesives,
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mission electron microscopy (TEM) of the bonded
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Fig 3 CeraBurs with different diameters. From left to right: 10-,
14-, 18-, and 23-mm diameter.
Polymeric burs
In an attempt to develop a selective caries-removal rotating instrument, a “plastic” bur was made of a polyamide/
imide (PAI) polymer, possessing slightly lower mechanical
properties than sound dentin. However, soon it became
clear that if the bur touches sound or caries-affected
dentin, it quickly becomes dull and produces undesirable
vibration, making further cutting impossible. The blade design was developed to remove dentin by locally depressing
the carious tissue and pushing it forward along the surface until it ruptures and is carried out of the cavity. With a
prototype, single-use instrument, complete removal of carious tissue could be accomplished from extracted teeth
when a 1% acid-red-propylene glycol solution was used as
caries detector.17
The commercial version of these burs (SmartPrep, SSWhite Burs; Lakewood, NJ, USA) consisted of a polymer
(PEKK – polyether-ketone-ketone) with a particular hardness
of 50 KHN, which was higher than the hardness attributed
to carious dentin (0 to 30 KHN), but lower than that of sound
dentin (70 to 90 KHN).103 As opposed to conventional carbide burs, their cutting edges were not spiralled but straight.
One disadvantage was that by keeping to the recommendation to excavate caries from the center to the periphery in order to avoid contact with sound tooth tissue, the bur would
be prematurely and irreversibly damaged.28 Local anaesthesia was said not to be needed, based on the claim that
these plastic burs would remove only the insensitive, soft,
and necrotic carious dentin (caries-infected dentin), leaving
the demineralized, noninfected sensitive layer (caries-affected dentin). Nevertheless, while the need for local anaesthesia during cavity preparation was in fact reduced, some
patients still reported one or more episodes of pain sensation during treatment.3
The efficacy of the SmartPrep burs for caries removal was
questioned in a histological study when excavated tooth sections were stained with Mallory-Azan.28 More residual caries
was found in cavities excavated with SmartPrep burs than in
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disclosed remnants of carious tissue at the excavated
dentin/composite interface. It was then suggested that the
efficiency of the polymer burs could be enhanced if the hardness of the polymeric material could be increased.
An improved version of the polymeric burs was more recently marketed (SmartBurs, SSWhite Burs; Lakewood, NJ,
USA) and resulted, in primary teeth, in the highest coincidence between the caries removal endpoint obtained by auto-fluorescence of carious dentin and the actual degree of
caries removal. A great amount of residual caries was nevertheless still found, especially in inactive caries-arrested lesions. This can probably be explained by the still rather low
surface hardness of the SmartBurs (26.6 KHN) as compared to the hardness of arrested carious dentin (39.2
KHN).24
Ceramic burs
A new line of slow-speed rotary cutting instruments made
of ceramic materials is now commercially available for removal of carious dentin. The CeraBurs (Komet-Brasseler;
Lemgo, Germany) are all-ceramic round burs made of alumina-yttria stabilized zirconia and are available in different
diameter sizes (Fig 3). The manufacturer claims that besides its high cutting efficiency in infected, soft dentin, the
use of this instrument for caries removal replaces both the
explorer and the excavation spoon (commonly needed to
evaluate the degree of decay removal) by simultaneously
providing tactile sensation, self-evidently reducing preparation time.
However, an in vitro investigation of the caries-removal efficiency (time consumption for excavation) and efficacy (ability to remove all carious material from the cavity) did not
show any significant difference between the ceramic and
conventional tungsten-carbide burs.27 Nevertheless, one important aspect to be emphasized – and which applies to all
kinds of bur instruments – is its nonspecificity. Especially if
no tactile instrument is used to check the cavity for its hardness, areas of underprepared dentin are likely to be left,59
as can be observed in the 3D volumetric reconstruction of a
carious tooth when caries was excavated using ceramic burs
(Fig 4). Further in vivo studies testing the effectiveness of
these new burs are unfortunately still lacking.
Caries-disclosing Dyes
Early TEM and biochemical characterization of carious
dentin revealed that the most superficial carious layer is
necrotic, highly decalcified, and contains irregularly scattered granular crystals and irreversibly denatured collagen
fibrils. Underneath this “caries-infected” dentin, the
deeper “caries-affected” dentin layer exhibits decreased
collagen crosslinks, but comprises needle-like apatite crystals, regularly attached to collagen fibrils with no signs of
bacterial invasion.68,90 Based on this knowledge, the ideal
caries-disclosing dye should stain solely the caries-infected, but not the caries-affected dentin.
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Fig 4A Occlusal surface of a tooth presenting
dentin caries.
Fig 4B Occlusal view after minimally invasive
preparation and carious dentin excavation
with Ceraburs. The dotted line depicts the location of the volume-rendered slice in Fig 4C.
Fig 4C Volume-rendered slice based on x-ray
micro-CT data of the section depicted by dotted line in Fig 4B. The arrow denotes an area
of residual caries according to the mineraldensity calibration shown at the left side. The
caries-removal endpoint was determined by
the self-limiting property of the bur.
0.5% Basic fuchsin in a propylene glycol base
One of the first caries-disclosing dyes was based on a solution of 0.5% basic fuchsin in propylene glycol and was
claimed to stain exclusively the top, irreversibly destroyed
carious layer, enabling differentiation from what could be
left in the cavity.42 The mechanism of this differential
staining was initially ascribed to the irreversible collagen
denaturation of caries-infected dentin, caused by breakdown of the intermolecular crosslinks through bacterial
lactic acid.69 Later, the differential stainability was attributed rather to differences in the degree of mineralization
in the carious lesion than being specific for denatured collagen fibrils.119 The exact mechanism for the differential
staining is however still unknown.
The first combined clinical/laboratory study on the reliability of this caries-disclosing dye has pointed out that the extent of dentin excavated by the fuchsin-guided method was
larger than the extent of demineralized dentin, as shown by
conventional dental radiographs taken before histological
sections were made.100 Later, others also showed that when
caries was removed using conventional tactile probing to determine the caries removal endpoint, both in primary and
permanent teeth, the cavity walls and floors were still
fuchsin-stainable.119 Some concerns were also raised regarding possible carcinogenic effects of fuchsin for intra-oral
Vol 13, No 1, 2011
use,119 and for this reason, alternative caries-disclosing
dyes are sought.
1% Acid-red in propylene glycol base
Although a 1% acid-red solution (Caries Detector, Kuraray;
Tokyo, Japan) was launched as an alternative to fuchsin
for intra-oral use,69 clinical inconsistencies have been reported when assessing the presence of stained tissue at
the DEJ by means of the usual tactile probing method. Two
studies have shown that more than half of the teeth
judged clinically as having no caries at the DEJ could be
stained with acid red.60,61 Microbiological assessment of
the caries-stained and stain-free dentin at the DEJ failed to
disclose differences in level of infection.61
Moreover, it has been demonstrated that a 1% acid-red
solution can lead to staining of dentin clinically judged as
“sound”, with a 30% false positive diagnosis of residual
caries.18 At the pulpal floor, also more than half of the teeth
diagnosed as having “hard” and “sound” pulpal floors still
took up some stain.60 In fact, it has been reported that
sound circumpulpal dentin takes up stain more easily, because of its lower degree of mineralization18,119 (Fig 5). For
all these reasons, the use of caries-staining agents is still
much criticized.
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dentin.
Fig 5B Higher magnification of the dotted
area in Fig 5A after staining with a 1% acidred-in-propylene-glycol solution. Note staining
of circumpulpal dentin (black arrow) and
areas of hypermineralized dentin (white
arrow).
Fig 6A Volume rendering based on x-ray
micro-CT data (occlusal view) from a tooth presenting dentin caries (insert: stereomicroscopic view).
Fig 6B Volume rendering based on x-ray
micro-CT data of the same tooth after excavation with the aid of a pepsin-based gel and a
specially designed plastic instrument (SFCVIII, 3M ESPE) (insert: stereomicroscopic
view).
Fig 6C Volume rendering based on x-ray micro-CT data of one slice (corresponding to the
dotted line in Fig 6A before excavation, showing the extent of the lesion into dentin (blue =
carious lesion; green = sound dentin).
Fig 6D Volume rendering based on x-ray
micro-CT data of one slice (corresponding to
the dotted line in Fig 6B after excavation,
showing the extent of the excavated dentin
(blue = carious lesion; green = sound dentin).
Comparing acid red to basic fuchsin, both in propylene
glycol bases, acid-red produces a less intense and less
bound stain with a more intense staining of the outer than
the inner layer of carious dentin.119 Further in vitro studies
have shown that the light pink staining from acid red, typically seen at the inner layer of carious dentin, was related to
a low degree or absence of bacterial infection55 as well as
to a low level of peritubular dentin dissolution and increased
hardness.96,125 For these reasons, the lightly stained tissue
should not be removed.
Another concern is that the propylene glycol base of both
staining agents can easily penetrate into normal dentin due
its low molecular weight (76 MW), which could thus also explain the overstaining frequently reported for commercial
products, such as Caries Detector.48 This finding has recently led to the introduction of a 1% acid-red dye in a
polypropylene glycol base (Caries Check, Nippon Shika
Yahuhin; Japan). The higher molecular weight of polypropylene glycol (300 MW) makes it more caries specific than a
propylene-glycol-based dye. The fluorescence readings of
residual dentin using DIAGNOdent (Kavo Dental; Jena, Germany) after caries removal guided by acid red in polypropylene-glycol-based dye were higher than those when caries
was removed using a propylene-glycol-based dye, indicating
that less dentin was removed with the former caries-disclosing dye.48,64
12
Clinically, both formulations of Caries Check (1% acid red
or a 1% brilliant blue FCF in a polypropylene glycol base) also produced significantly lower DIAGNOdent readings after
caries removal than an 1% acid red in propylene glycol.49
The blue version of the dye was introduced to facilitate identification of caries in heavily stained cavities, where the red
color is more difficult to differentiate.
Chemo-mechanical Excavation
Sodium hypochlorite-based agents
The first attempt to develop of a chemical solubilizer that
would selectively act on carious dentin resulted in a
sodium hypochlorite solution buffered with an amino-acidcontaining mixture of amino butyric acid, sodium chloride
and sodium hydroxide.43 Even though sodium hypochlorite
is a nonspecific deproteinizing agent, the capability to
selectively remove carious dentin was attributed to the
buffering effect of the amino acid mixture, originally intended to reduce the aggressiveness of sodium hypochlorite on sound dentin and to enhance the disrupting effect
on degenerated collagen within carious dentin.108 After
chlorination and cleavage of the partially degraded collagen fibrils in the carious lesion, the resultant friable collagen fibrils could be more easily removed with a spoon
excavator.13
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However, this new caries-removing system, first commercialized as Caridex (National Patent Medical Products; New
Brunswick, NJ, USA), was not fully successful in clinical practice. Not only its efficacy in caries removal was contested,
but technical problems – such as the need of a specific apparatus to deliver the solution into the cavity, short shelf-life,
longer treatment time, and higher treatment cost – were advanced as reasons why it was not adopted extensively by
dental practitioners.11
Renewed interest in chemomechanical caries removing
agents was associated with the emerging concept of minimally invasive dentistry. A new caries removing system, also
based on sodium hypochlorite, was introduced in the form
of a gel (Carisolv, MediTeam Dental; Sävedalem, Sweden)
which contained 0.5% w/v sodium hypochlorite, 0.1M of an
amino acid mixture (glutamic acid, leucine and lysine), and
water. The gel is applied in the cavity, after which the carious
dentin is scraped off using specially designed noncutting
hand instruments. The method has been shown to effectively remove caries and was readily accepted by patients.
However, compared with conventional drilling, a substantially longer treatment time was reported.38 In fact, the operative steps in chemomechanical caries excavation include: (1) application of the solution, (2) scrapping off the
carious dentin with possible change of instrument size, (3)
rinsing, and (4) repetition of the procedures until all caries
is removed.38,73 However, if the use of local anaesthesia can
be omitted, the total treatment time can be shortened.97.
Carisolv has proven its efficacy in establishing the endpoint of caries excavation by removing carious dentin to the
same extent as the auto-fluorescence signature of carious
tissue when measured using confocal microscopy.8 However, histological evaluation using toluidine blue as a staining
agent still revealed a higher percentage of teeth presenting
bacteria invading the dentinal tubules. A great amount of
residual bacteria was also detected at the DEJ, where direct
access of the gel and the hand instruments is difficult.117
The presence of bacteria at the bottom of the cavity was explained by the relative absence of smear layer formation
when Carisolv was used,9,98 and presumably resulted from
“pushing” bacteria into the dental tubules.117 On the other
hand, the viability of such residual bacteria should be very
low, because Carisolv has some bactericidal activity due to
formation of chloramine compounds. In fact, Carisolv has
proven to be somewhat superior in reducing the counts of viable bacteria in residual dentin, as compared to conventional bur excavation.70
The chemical composition and microstructure of dentin
after excavation with Carisolv does not seem to be significantly altered. The calcium and phosphorus content remain
similar after excavation, while the hardness values of residual dentin left at the cavity bottom approximate those obtained for sound dentin.51,99 Actually, the chloride present
in the gel does not seem able to interact with the collagen
fibrils of sound dentin, since they are protected by mineral
crystals.104
Although the etch pattern of dentin in Carisolv-excavated
lesions is deeper than that in dentin from which caries was
removed with a conventional bur guided by a caries-staining
dye,117 the bonding effectiveness of adhesives to Carisolv-
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treated dentin did not appear to be affected.20,36,47
r CarisolvPu
excavated dentin has good bonding receptiveness, meaning
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that it is not covered by a smear layer, exhibits patent dentii
46
47
nal tubules and an irregular surface topography
te with im- on
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ce
have
proved wetting potential.35 Acceptable bond strengths
been reported after caries was excavated with Carisolv and
a self-etching adhesive was employed.105 In other studies,
bond strengths obtained with both etch-and-rinse and selfetching adhesives to dentin from which caries was excavated with Carisolv were even found to be similar to that of
sound dentin.20,104
Pepsin-based caries excavation
A new experimental gel consisting of pepsin in a phosphoric acid/sodium biphosphate buffer is being considered as an alternative chemomechanical caries excavation
agent (SFC-VIII, 3M ESPE; Seefeld, Germany). The main advantage of this new enzyme-based solution is that it can
be more specific by digesting only denatured collagen
(after the triple-helix integrity is lost) than the sodium
hypochlorite-based agents.1 According to the manufacturer, the phosphoric acid dissolves the inorganic component of carious dentin, while it at the same time gives
pepsin access to the organic part of the carious biomass
to selectively dissolve the denatured collagen. To avoid
overexcavation, the SFC-VIII gel should be used in combination with a prototype plastic instrument having hardness
between that of sound and infected dentin. Heavily pigmented, arrested dentin caries is known to be more resistant to pepsin digestion,109 but this does not seem to
present a major drawback to the method.
An x-ray micro-CT evaluation of carious teeth excavated
with SFC-V revealed that the new enzymatic caries-removing
gel was able to remove equivalent volumes of carious dentin
as Carisolv.25 Figure 6 shows volume-rendering slices based
on micro-CT data of a carious tooth before and after caries
excavation with SFC-VIII aided by the prototype plastic instrument. SFC-VIII selectively removed carious dentin, leaving residual dentin with an acceptably high mineral density
(1.18 to 1.44g/cm3). Figure 7 shows the prototype plastic instrument (Star v 1.8, 3M ESPE) before and after caries excavation.
Others have found partially demineralized intertubular
collagen fibrils and some tubule occlusion upon treatment
of artificially-formed dentin caries with a pepsin-based
caries-excavation agent.1 However, further laboratory studies and clinical trials are still lacking.
Excavation by sono-abrasion
Caries excavation by “sono-abrasion” is based on the use
of cutting tips coupled to high-frequency, sonic, air-scaler
handpieces under water cooling. The handpiece oscillates
in the sonic region (< 6.5 kHz), while the tips perform an
elliptical motion. A maximum 2-N torque force should be
applied, otherwise the cutting efficiency is reduced due to
damping of the oscillations.10
Sono-abrasion excavation with diamond-coated tips appeared as efficient (time required for excavation) as conventional hand excavation using dental spoons, but still taking more time than the carbide-bur excavation method.8 Re13
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Fig 7A Plastic single-use instrument intended to be used with the enzymatic pepsinbased gel (SFC-VIII, 3M ESPE).
Fig 7B The same instrument after use in the
tooth depicted in Fig 6, showing complete
dulling after the excavation procedure.
Fig 8A Cariex diamond-coated tips for
enamel preparation.
Fig 8B Cariex tungsten carbide tips for
dentin excavation.
garding caries removal, the effectiveness of sono-abrasion
based on its auto-fluorescence signature has shown a tendency to underprepare carious cavities. Some authors speculated that the oscillation of the diamond-coated tip is transferred to only a slight vibration at the dentin surface, impairing effective tissue cutting and resulting only in a compacting effect on the carious dentin substrate.8 No chemical or structural changes were observed in sono-abraded
dentin, the surface characteristics of which resembled those
of conventionally bur-cut dentin.113 The surface topography
of dentin after sono-abrasion excavation with diamond-coated tips revealed relatively little9 or even no evidence of
smear layer formation.116 According to another study, any
smear layer produced tends to be thinner than the one yielded by diamond/carbide burs,95 which may be advantageous
for the bonding effectiveness of so-called mild self-etching
adhesives in particular.39
More recently, the Cariex system (Kavo Dental; Biberach,
Germany) was launched, including two sets of cutting tips:
two diamond-coated tips with different diameters for enamel preparation and two tungsten-carbide tips with different
diameters for dentin excavation (Fig 8). The effectiveness
and efficacy of these new tungsten carbide tips in removing
carious dentin have, however, not yet been explored.
Air-abrasion Excavation
Air-abrasion systems for cavity preparation use the kinetic
energy of abrasive particles to cut tooth structure in a less
invasive way, while rounding off internal and cavosurface
angles to the direct benefit of the subsequent adhesive
restoration. Pure aluminium oxide particles (alumina) have
been most frequently used as the abrading agent, thanks
14
to their high cutting effectiveness, chemical stability, low
cost, low affinity for water, and neutral color.16
Air-abrasion systems using 27-μm diameter alumina particles are currently available to remove tooth staining or to
prepare shallow cavities. Aside from the type and size of the
abrasive particles, other variables which also directly influence the cutting effectiveness of air-abrasion systems are
the particle speed and the angle of surface approach, and
naturally the properties of the substrate itself. The major
drawback of air-abrasion excavation of carious dentin is that
sound dentin is more efficiently removed than carious
dentin.92 Although 27-μm alumina particles have proven to
remove more carious dentin than particles with larger dimensions (50- and 125-μm diameter), cavities produced in
sound dentin were still considerably deeper than in carious
dentin.82 As carious dentin has a softer consistency, the energy of the particles is absorbed during the impact, reducing
the cutting ability.
Other types of particles were tested in order to improve
the effectiveness of caries removal with air-abrasion systems. Spherical glass beads with different diameters improved removal of artificially softened dentin, but although
at lower rates, sound enamel and dentin were still removed.
Polycarbonate resin-crushed powder removed artificially
softened dentin more selectively without cutting sound
dentin or enamel,45 but further clinical investigations with
these particles are still lacking. A mixture of alumina and hydroxyapatite in a volume ratio of 3:1, with particle sizes ranging from 3 to 60 μm, was shown to be as efficient as conventional hand excavation with dental spoons, and was positively rated when related to the auto-fluorescence signature
of the lesion.8 An air-abrasion system that makes use of a
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Excavation Aided by Laser-induced Fluorescence
Based on the above-mentioned fact that caries-induced
changes lead to increased fluorescence of dentin at the
n
Fluorescence-aided Caries Excavation (“FACE”)
This technique was developed as a direct method to clinically differentiate between infected and affected carious
dentin. Based on the fact that several oral microorganisms
produce orange-red fluorophores as by-products of their
metabolism (porphyrins), infected carious tissue will fluoresce especially in the red fraction of the visible spectrum2
due to the presence of proto- and meso-porphyrins.76 In
this way, continuous visual detection of orange-red fluorescence during caries excavation was thought to be convenient for clinicians.
By feeding a slow-speed handpiece with a fiber-optic violet light source (370 to 420 nm) and allowing the operator
to use a 530-nm yellow glass filter, areas exhibiting orangered fluorescence can be selectively identified and removed
with the bur. Compared to Caries Detector or the visual-tactile method for establishing the caries removal endpoint, the
FACE method showed the highest sensitivity, specificity, percentage correct score, and predictive values for residual
caries detection, as evaluated using confocal microscopy.71
Histological examination after staining with ethidium bromide revealed fewer samples presenting bacteria in dentin
when the FACE method was used than was the case with
conventional bur excavation.72 Others failed to find differences in the number of infected samples between FACE and
conventional bur excavation, but observed a significant reduction in the number of samples presenting residual bacteria after excavation with FACE, when compared to Carisolv
or bur excavation guided by Caries Detector.73
The FACE method also proved to be very efficient, with
less time needed to excavate caries and without a need to
change instruments, apply chemical agents, orto test the
cavity with an explorer.73 Another important aspect is that
the increased caries-removal efficacy of FACE was apparently not associated with an increased cavity size or overexcavation.74
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bioactive glass powder (Bioglass, Novamin Technology;
Alachua, USA) with a particle diameter between 25 and 32
μm was also explored. Although still removing sound dentin,
the risk of unnecessary sound dentin removal was reduced
because of the difference in cutting rate between sound and
carious dentin.93 The authors suggested that other bioactive
glasses with different hardness should be evaluated for their
caries-removal selectivity.
The topography of residual dentin caries after removal
with 50-μm alumina particles exhibits a porous, sponge-like
appearance caused by the impact of the particles under
compressed air. Remnants of alumina powder were also
identified and tubules were fully occluded with surface debris.116 Although air abrasion produces a more irregular, imbricate surface pattern and a thinner smear layer when compared to bur-cut dentin, it does not seem to affect bonding
performance of adhesives to dentin on the condition that it
is still acid-etched if etch-and-rinse adhesives are employed.113
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655-nm (red) wavelength,2 a laser-fluorescence
r Pdevice
ubdethat irradiates at this particular wavelength has been
lica
veloped to diagnose “hidden” occlusal carious lesions
ti
(DIAGNOdent, Kavo Dental; Biberach, Germany).
te A photo- on
ss e nthe
ce
diode attached to the tip of the handpiece measures
feedback of fluorescence after initial irradiation, where the
intensity of fluorescence at the occlusal surface is directly
related to the degree of caries progression into dentin.76
Based on a diagnostic scale correlating the readings of fluorescence with the histological presence of caries, values
above 30 should be considered a stage of caries progression demanding operative intervention.75
Beyond using laser-induced fluorescence for occlusal
caries diagnosis, these readings are currently being investigated as a possible end-point guide to caries excavation.
Based on a comparison with histological examination in the
confocal microscope after staining with ethidium bromide,
a DIAGNOdent reading of 15 was seen to best predict the
presence of residual caries at the bottom of the cavity.71 Later, this value was correlated to the absence of detectable
bacteria, and thus set as the endpoint for complete caries
removal.54 It is interesting to note that when Caries Detector was used as caries removal endpoint, a threshold of 11
was found,19 corroborating previous findings that the staining method invariably leads to overexcavation. When combined with caries removal using an erbium laser, a DIAGNOdent threshold between 11 and 20 was shown to best
predict removal of infected carious dentin.121 Others who
used a threshold value of 30 for dentin caries have found acceptable sensitivity values (ability to correctly diagnose
caries) for DIAGNOdent when used to determine the caries
removal endpoint.118 One should, however, realize that the
DIAGNOdent readings increase with the proximity to the pulp
as well as with stained, sclerotic dentin,66 which thus could
lead to a false-positive threshold for caries removal.
Laser Excavation
The word “laser” is an acronym for “Light Amplification by
Stimulated Emission of Radiation”, which means that
laser devices produce beams of coherent and high-intensity light. The indications for the use of lasers in dentistry
are nowadays broad, varying from caries diagnosis, disinfection of periodontal pockets or root canals, photodynamic therapy of oral tumors, soft-tissue surgery, caries
removal, and cavity preparation.114 Especially in the field
of operative dentistry, erbium lasers have been pointed
out as most promising due to their specificity in ablating
enamel and dentin without side effects to the pulp and
surrounding tissues when the approprate parameters are
employed.114
The erbium-loaded yttrium-aluminum-garnet (Er:YAG) and
the erbium,chromium: yttrium-scandium-gallium-garnet
(Er,Cr:YSGG) lasers are the two types of erbium-based devices currently available on the market. Both devices present
very similar wavelengths (2.78 μm for Er,Cr:YSGG and 2.94
μm for Er:YAG), although the Er,Cr:YSGG laser is discretely
more absorbed by hydroxyapatite than Er:YAG.114 Despite
this difference, both wavelengths are very close to the absorption peak of water in the infrared spectrum, which
makes their interaction with dental hard tissues very similar.
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Fundamentally, the mechanism by which enamel and
dentin are removed during Er:YAG irradiation consists of explosive subsurface expansion of water interstitially trapped
in the dental hard tissues. During irradiation, the water molecules absorb the incident radiation, causing sudden heating and water evaporation. As a result, a high-stream pressure is formed, inducing a violent, yet controlled expansion
and ejection of dental hard tissue components.50 In contrast, the Er,Cr:YSGG laser system, usually known as a “laserpowered hydrokinetic system”, delivers photons straight into an air-water spray directed to the target tissue. This phenomenon induces micro-explosive forces into water droplets,
which is said to contribute significantly to the mechanism of
hard-tissue removal.44 Unfortunately, no systematic studies
comparing these two types of erbium lasers have been performed so far, especially considering their particular effects
on cavity morphology and on the characteristics of the residual dentin after caries removal.
Several advantages have been related to the use of laser
irradiation in operative dentistry, such as a more conservative cavity design, an alleged antibacterial activity,111 and a
significant decrease of enamel solubility, therefore also possibly playing a role in the prevention of recurrent caries.23
Moreover, laser ablation apparently provides more comfort
to the patient due to the absence of vibration57 and a lower
pain sensation. In fact, the need for local anaesthesia is reported to be lower when compared to the use of conventional rotary instruments.58 On the other hand, the major
drawback related to their use in operative dentistry is the relatively long time needed for cavity preparation. The time required for a complete excavation is, in general, twice that
with rotary instruments,4,12,58 Recently, one study succeeded in reducing the overall cavity preparation time by using
considerably high energies (700 mJ).80 However, it should
be noted that such high energies can also induce irreversible
chemical and structural alteration to the dental hard tissues7 and even damage the pulp.114
Irrespective of the parameters used during laser irradiation, the effectiveness of carious dentin removal with erbium
lasers has been questioned. SEM has shown that the laser
produces an undefined and random excavation pattern in
dentin, with deep overprepared and wide underprepared
zones present in the same cavity. For optimal irradiation, a
noncontact beam emission mode is usually recommended,
thus rendering caries excavation more difficult to control due
to the lack of tactile sensation.12 Moreover, the irregular
dentin surface left after laser ablation hampers an accurate
tactile feedback when an ordinary probe is used for detecting the status of excavation.12,116 Despite this, some studies have relied upon visual/tactile methods44,57 or staining
with 1% acid-red solution to evaluate the thoroughness of
caries removal,4 obtaining residual dentin hardness values
similar to sound dentin. Histological observations have also
disclosed the same degree of bacterial removal by an Er:YAG
laser and conventional bur excavation.4 Additionally, better
DIAGNOdent scores of residual dentin were obtained after
excavation with an Er,Cr:YSGG laser than with Carisolv.63
Although Er:YAG laser ablation is not selective for carious
dentin, it has been described that the popping sound emitted by these lasers when operating in dental hard tissues
pyrig
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changes according to the presence or absence
r Pof caries.
ub
This change in sound could assist the user in determining
lica
when caries removal is complete.114 This approach is, howtio
ever, not very objective or practical, and is tsusceptible
ess c eto n
misinterpretation. An improvement in the caries-removal
en
ot
Neves et al
ability of erbium lasers is to combine it with laser-fluorescence technology for caries detection. In one unit (Key III, Kavo Dental), Er:YAG laser irradiation is controlled by the feedback response provided by the red-infrared diagnostic diode
laser, resulting in a self-limiting laser ablation. Actually, the
laser ablation is activated only if the fluorescence emitted
from the dental tissue exceeds a pre-determined threshold.32 An initial threshold value of 7 for the laser fluorescence detection system removed all bacteria at the bottom
of the cavity, as was detected histologically.32 This threshold
value was corroborated by clinical studies in permanent31
and primary teeth,67 in which only clinically insignificant
amounts of bacteria could be detected at the bottom of the
excavated cavities. Beyond appropriate removal of infected
dentin, this laser also precluded less sound dentin removal,
resulting in smaller cavities compared to conventional bur
excavation.33
Absence of smear layer is very often mentioned as an advantage of laser irradiation of tooth surfaces, in particular for
bonding procedures.5,56,63 However, while relatively high
bond strengths have been reported with either an etch-andrinse or a self-etching adhesive after caries removal with an
Er:YAG laser,101 other authors found lower bond strengths to
laser-irradiated dentin when compared to a conventionally
bur-cut substrate.21,105,113 Such disappointing results have
been related to the presence of subsurface microcracks produced in dentin during laser ablation, rendering it more
prone to cohesive failures.21 Moreover, laser-irradiated
dentin has also been reported to change the composition
and conformation of the organic matrix of dentin,7 which
may impair adhesive penetration and facilitate collagen
degradation.
ADHESION TO CARIOUS DENTIN
Sound human dentin is most convenient to test the performance of dental adhesives by means of standard bondstrength protocols. This “model” dentin is, however, far
from the clinically more relevant substrate remaining after
caries removal, which exhibits “mixed” chemical and mechanical characteristics and includes caries-infected,
caries-affected, sclerotic, eroded, and sound dentin.79
In general, the presence of carious dentin results in thicker hybrid layers and lower bond strengths.83,84,123,124 The
bond strength of adhesives to carious dentin has been reported to be inversely proportional to the degree of caries
progression, with caries-infected dentin presenting the lowest bond strength.30 The thickness of the hybrid layer is indirectly correlated to the degree of caries progression, with
caries-infected dentin presenting thicker hybrid layers, followed by caries-affected and sound dentin.52,123,124 Like in
sound dentin, hybrid layers in caries-affected dentin are
thicker using etch-and-rinse than self-etching adhesives.52,123 For caries-infected dentin, however, the thickThe Journal of Adhesive Dentistry
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ness of the hybrid layer tends to be similar, irrespective of
the adhesive approach.52 Thicker hybrid layers in caries-affected dentin are explained by the increased porosity of intertubular dentin, which promotes diffusion of resin
monomers.53,83
The lower bonding effectiveness to caries-infected dentin
is related to its extremely low cohesive strength, due to its
low degree of mineralization and the collagen-matrix disorganization.83 Although resulting in thicker hybrid layers, this
type of dentin allows only superficial monomer penetration,
keeping many dentin tubules completely free from tag formation.52,123,124 Considering the poor interaction with the
substrate, bonding to caries-infected dentin is seldom indicated, except when aiming to prevent further caries progression in uncooperative patients while implementing behavior control.
The lower bonding effectiveness to caries-affected dentin
than to sound dentin is related to the alterations that occur
in this substrate as a consequence of caries progression.
First, the reduction in mineral content and loss of crystallinity of the remaining mineral phase, coupled to the
changes in the secondary structure of collagen,115 result in
a dentin substrate with a lower hardness89 and modulus of
elasticity than those of sound dentin,78 performing poorer in
mechanical tests. Secondly, the deposition of mineral casts,
namely of β-tricalcium phosphates (whitlockites),26,115 in
the dentin tubules during caries progression also alters the
etch pattern and thus the penetration capacity of resin
monomers into the tubules. When bonding using the moist
bonding technique with etch-and-rinse adhesives, some
studies were able to achieve similar bond strengths to residual dentin after caries excavation (guided by Caries Detector) as to sound dentin.83,85,86 While one of these studies83
with sound dentin achieved a relatively “low” bond strength
(20 to 30 MPa) compared to what is achieved nowadays with
modern adhesives (40 to 50 MPa),29 the others may have
achieved these favorable results by using a rather aggressive threshold to establish the endpoint of caries removal,
that is, by having produced a substrate that is more receptive for bonding than that obtained in other studies. It was
also demonstrated that acetone-based etch-and-rinse adhesives bonded better to caries-affected dentin than did
ethanol-based adhesives, although both were able to produce acceptable bond strengths to non-stained (with Caries
Detector) dentin left after excavation.86
Although other studies were not able to produce similar
results in bond strength to sound as to caries-affected
dentin for many materials tested,22,88,102,122 it became
clear that the chemical composition of the adhesive could
strongly influence the bond strength to caries-affected
dentin. Apparently, the immediate bond strength of etchand-rinse adhesives to caries-affected dentin is higher than
that of self-etching adhesives.22,37,122 However, no differences in bond strength of etch-and-rinse and self-etching adhesives to carious dentin was observed after the specimens
were stored for 6 months in water.37
In summary, although the bond strength at caries-affected dentin interfaces is lower than that at sound dentin interfaces, they are both continually improving and have now
reached relatively high values. Table 1 offers an overview of
opyretigal
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Fig 9 Pooled data from Table 1 (Nakajima et al;84-86 Yoshiyama
et al;122-124 Tachibana et al105) regarding carious dentin surfaces
that were prepared with 600-grit SiC-paper and when Caries Detector was used as caries removal endpoint following two different thresholds: non-stained vs lightly pink-stained dentin. The
more “aggressive” threshold (non-stained) shows only slightly
higher bond strength values than the more conservative threshold (light pink). The 3-step etch-and-rinse adhesives achieved the
highest values, followed by the 2-step etch-and-rinse and the 2step self-etching adhesives. Horizontal lines represent the mean
values and bars represent the upper and lower standard deviations.
bond-strength values in relation to different caries removal
endpoints employed, different methods used to produce the
carious substrate, and different types of adhesives used.
Figure 9 summarizes the bond strength values depicted in
Table 1, when the caries removal endpoint was obtained
with two different thresholds for staining (no staining vs lightpink staining) and after the carious dentin substrate was
produced with a standardized surface-preparation method
using 600-grit SiC paper. Figure 10 depicts the bond
strength results for the studies presented in Table 1 that
used a conventional bur and Carisolv to excavate caries. In
both cases, essentially no differences in bond strength between etch-and-rinse and self-etching approach were found.
Altogether, irrespective of the caries excavation method
chosen, it remains clinically recommended to finish the cavity margins in clean/sound tooth tissue in order to achieve
the best performance of adhesives, while being at the same
time least invasive with regard to caries excavation and most
conservative with regard to sound-tissue preservation.
REFERENCES
1. Ahmed AA, Garcia-Godoy F, Kunzelmann KH. Self-limiting caries therapy
with proteolytic agents. Am J Dent 2008;21:303-312.
2. Alfano RR, Yao SS. Human teeth with and without dental caries studied by
visible luminescent spectroscopy. J Dent Res 1981;60:120-122.
17
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Table 1 Bond strength related to the different caries removal endpoints, type of caries-affected substrate, andfo
adhesive
rP
ub
material used
lica
tio
n
te
Method of caries
Type of caries-affected Type of adhesive (brand name)
μTBS
Reference
e
s
s
c
en
excavation endpoint
substrate
Neves et al
by N
ht
Q ui
fo r
Non-stained dentin
remaining after using
Caries Detector
220-grit SiC paper
600-grit SiC paper
320-grit SiC paper
Conventional bur
Er,Cr:YSGG Laser
Carisolv
Light-pink staining
remaining after using
Caries Detector
18
600-grit SiC paper
2-step etch-and-rinse
(Prime & Bond NT, Dentsply)
2-step etch-and-rinse
(Scotchbond 1, 3M ESPE)
2-step self-etch
(Clearfil SE Bond, Kuraray)
1-step self-etch
(Prompt L-Pop, 3M ESPE)
3-step etch-and-rinse
(Scotchbond MP, 3M ESPE)
3-step etch-and-rinse
(ART Bond, VITA)
2-step etch-and-rinse
(One-Step, Bisco)
2-step etch-and-rinse
(Single Bond, 3M ESPE)
2-step etch-and-rinse
(Single Bond, 3M ESPE)
2-step etch-and-rinse
(Single Bond, 3M ESPE)
2-step self-etch
(Clearfil SE Bond, Kuraray)
2-step self-etch
(Clearfil Liner Bond 2, Kuraray)
2-step self-etch
(Clearfil Liner Bond 2, Kuraray)
2-step self-etch
(Clearfil Protect Bond, Kuraray)
2-step self-etch
(Tenure ABS System, Denmat)
2-step self-etch
(FluoroBond, Shofu)
3-step etch-and-rinse
(Scotchbond MP, 3M ESPE)
3-step etch-and-rinse
(All Bond 2, Bisco)
2-step self-etch
(Clearfil Liner Bond 2, Kuraray)
2-step self-etch
(Clearfil SE Bond, Kuraray)
2-step self-etch
(Clearfil SE Bond, Kuraray)
2-step self-etch
(Clearfil SE Bond, Kuraray)
2-step etch-and-rinse
(Scotchbond 1, 3M ESPE)
2-step etch-and-rinse
(Optibond Solo Plus, Kerr)
2-step self-etch
(Clearfil Protect Bond, Kuraray)
2-step self-etch
(AdheSE, Ivoclar Vivadent)
2-step self-etch
(Clearfil SE Bond, Kuraray)
2-step self-etch
(Mac-Bond II, Tokuyama)
2-step self-etch
(UniFil Bond, GC)
41.3±10.7
ot
n
Staining with 0.5% fuchsin
Ceballos et al22
36.3±12.2
21.5±5.5
13.4±1.9
48.2±3.9
Nakajima et al85
30.2±13.4
Nakajima et al84
45±7.2
Nakajima et al86
40.2±11.1
28.8±6.3
Yoshiyama et al123
27.1±6.5
Yoshiyama et al122
30.3±11.9
Tachibana et al105
30±10
Yoshiyama et al124
29.7±10.3
Nakajima et al84
29.4±7.5
Nakajima et al87
25.3±5
Yoshiyama et al123
17.5±2.1
Yoshiyama et al122
18.49±4.04
Nakajima et al83
13.01±3.64
13.97±4.3
29±10.3
Tachibana et al105
18.4±11
21.5±10
34.5±6.8
Erhardt et al37
29.2±4.3
Say et al102
28.7±5
Erhardt et al37
24.2±7
21.5±5.3
Doi et al30
20.2±5.8
19.6±6
The Journal of Adhesive Dentistry
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Table 1 Bond strength related to the different caries removal endpoints, type of caries-affected substrate, and adhesive
rP
ub
material used (continued)
lica
tio
n
Method of caries
Type of caries-affected Type of adhesive (brand name) μTBS
Referencet e
e
s
s
c
en
excavation endpoint
substrate
fo r
600-grit SiC paper
Conventional bur
Er:YAG laser
Visual-tactile method
Hand excavation
Conventional bur
Carisolv
Smart Prep bur
2-step etch-and-rinse
(Optibond Solo Plus, Kerr)
2-step self-etch
(Clearfil Protect Bond, Kuraray)
2-step etch-and-rinse
(Optibond Solo Plus, Kerr)
2-step self-etch
(Clearfil Protect Bond, Kuraray)
2-step etch-and-rinse
(Optibond Solo Plus, Kerr)
2-step self-etch
(Clearfil Protect Bond, Kuraray)
2-step etch-and-rinse
(Prime & Bond NT, Dentsply)
2-step self-etch
(Tenure ABS System, Denmat)
2-step etch-and-rinse
(Single Bond, 3M ESPE)
2-step self-etch
(Clearfil SE Bond, Kuraray)
2-step etch-and-rinse
(Prime & Bond NT, Dentsply)
2-step self-etch
(Clearfil SE Bond, Kuraray)
2-step self-etch
(One Coat Bond, Coltene)
2-step self-etch
(Tenure ABS System, Denmat)
2-step etch-and-rinse
(Single Bond, 3M ESPE)
2-step self-etch
(Clearfil SE Bond, Kuraray)
25.7±5.9
ot
n
Diagnodent value = 20
Sattabanasuk et al101
35.4±9.7
21.3±7.5
12.2±3.1
26.6±9.4
32.5±7.1
25.06±10.16
Sonoda et al104
22.33±6.9
24.8±15.9
Silva et al103
31.4±12.7
26.99±11.69
Sonoda et al104
28.7±6.9
Burrow et al20
27.4±6.4
31.1±9.21
Sonoda et al104
13.9±7.1
Silva et al103
10.5±6.6
Fig 10 Pooled data from Table 1 (Burrow et al;20 Sattabanasuk
et al;101 Silva et al;103 Tachibana et al105) comparing the bond
strength results when caries was excavated with a conventional
bur (left) or Carisolv (right). Similar mean bond strength values
were recorded for etch-and-rinse and self-etching adhesives in
both cases. Horizontal line represents the mean values and bars
represent the upper and lower standard deviations.
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Clinical relevance: The bonding performance to carious dentin is directly related to the caries-excavation
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