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.

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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)



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.



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



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)



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



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



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



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)



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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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.



Questions

Online CompletionUse this page to review the questions and answers. Return to www.ineedce.comand sign in. I you have not previously purchased the program select it rom the Online Courses listing and complete theonline purchase. Once purchased the exam will be added to your Archives page where a Take Exam link will be provided. Click on the Take Exam link, complete all the program questions and submit your

answers. An immediate grade report will be provided and upon receiving a passing grade your Verifcation Form will be provided immediately or viewing and/or printing. Verifcation Forms can be viewed

and/or printed anytime in the uture by returning to the site, sign in and return to your Archives Page.

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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Questions Continued

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


16/16

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If not taking online, mail completed answer sheet to

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INSTRUCTIONSAll questions should have only one answer. Grading o this examination is done manually. Participants willreceive conrmation o passing by receipt o a verication orm. Verication o Participation orms will bemailed within two weeks ater taking an examination.

PROVIDER INFORMATIONPennWell is an ADA CERP Recognized Provider. ADA CEROP is a service of the American Dental Association toassist dental proessionals in identiying quality providers o continuing dental education. ADA CERP does notapprove or endorse individual courses or instructors, not does it imply acceptance o credit hours by boards

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COURSE CREDITS/COSTAll participants scoring at least 70% on the examination will receive a verication orm veriying 3 CE credits.The ormal continuing education program o this sponsor is accepted by the AGD or Fellowship/Mastershipcredit. Please contact PennWell or current term o acceptance. Participants are urged to contact their statedental boards or continuing education requirements. PennWell is a Caliornia Provider. The Caliornia Providernumber is 4527. The cost or courses ranges rom $29.00 to $110.00.

RECORD KEEPINGPennWell maintains records o your successul completion o any exam or a minimum o six years. Pleasecontact our ofces or a copy o your continuing education credits report. This report, which will list all creditsearned to date, will be generated and mailed to you within ve business days o receipt.

Completing a single continuing education course does not provide enough inormation to give the participantthe eeling that s/he is an expert in the eld related to the course topic. It is a combination o many educationalcourses and clinical experience that allows the participant to develop skills and expertise.

CANCELLATION/REFUND POLICYAny participant who is not 100% satised with this course can request a ull reund by contacting PennWellin writing.

2011 by the Academy o Dental Therapeutics and Stomatology, a div ision o PennWell

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?

___________________________________________________________________

___________________________________________________________________

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

information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn

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

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