Clinical evaluation of EBS dentine bonding agent:one year results
Michael Burrow2000, Australian Dental Journal
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There are numerous dentine bonding agents c u r r e n t l y on the market, the majority of which adhere by means of infiltration of a hydrophilic p o l y m e r i z a b l e diacrylate into dentinal collagen exposed by acid treatment. The purpose of the present study was to evaluate the clinical performance of one such product, EBS dentine bonding, in nonundercut caries-free cervical lesions. Forty cavities were restored in eight patients of mean age 53 years. The manufacturer's instructions were followed, which involved essentially etching the enamel and dentine for 20 seconds with 32 per cent phosphoric acid, application and evaporation of EBS Primer, followed by placement and curing of EBS Bond, and restoring the cavity with Pertac II (ESPE) hybrid resin composite. Restorations were photographed at base line and one year for evaluation of marginal discolouration on a continuous linear rating scale. A t six months, one patient with four restorations was not available; the remaining 36 restorations were all present. At one year, one restoration was missing, giving a cumulative retention rate of over 97 per cent. One of the 36 restorations exhibited very mild marginal discolouration.
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SCIENTIFIC A R T I C L E
Australian Dental Journal 2000;45:(2):115-117
Clinical evaluation of EBS dentine bonding agent:one
year results
Martin J Tyas,* Michael F Burrow†
Abstract
There are numerous dentine bonding agents
currently on the market, the majority of which
adhere by means of infiltration of a hydrophilic
polymerizable diacrylate into dentinal collagen
exposed by acid treatment. The purpose of the present
study was to evaluate the clinical performance of
one such product, EBS dentine bonding, in nonundercut caries-free cervical lesions. Forty cavities
were restored in eight patients of mean age 53
years. The manufacturer’s instructions were followed,
which involved essentially etching the enamel and
dentine for 20 seconds with 32 per cent phosphoric
acid, application and evaporation of EBS Primer,
followed by placement and curing of EBS Bond, and
restoring the cavity with Pertac II (ESPE) hybrid
resin composite. Restorations were photographed
at base line and one year for evaluation of marginal
discolouration on a continuous linear rating scale. At
six months, one patient with four restorations was
not available; the remaining 36 restorations were all
present. At one year, one restoration was missing,
giving a cumulative retention rate of over 97 per
cent. One of the 36 restorations exhibited very mild
marginal discolouration.
Key words: Dental bonding, dentine bonding agents,
acid etching, tooth abrasion therapy.
(Received for publication October 1999. Revised January
2000. Accepted February 2000.)
Introduction
The bonding of resin composite to enamel is now
a well established clinical procedure, achieved by
treating the enamel with acid,commonly 32 per cent
phosphoric acid, which selectively etches either the
prisms or the interprismatic substance to leave a
high energy, porous surface. Bonding of resin
composite to dentine is much more challenging, due
to its heterogeneous, low energy and relatively wet
nature.1 The early dentine bonding agents were
designed to bond chemically to the dentine,2 but this
*Reader, School of Dental Science,The University of Melbourne.
†Senior Lecturer, School of Dental Science, The University of
Melbourne.
Australian Dental Journal 2000;45:2.
did not occur in practice and clinical failure rates were
high in non-undercut non-carious cervical lesions.3
Following the work of Nakabayashi et al.,4 almost
all the current dentine bonding agents achieve
adhesion mechanically by infiltration into the dentinal
collagen, exposed by acid treatment of the dentine,
by a hydrophilic polymerizable monomer (a
‘primer’). The infiltrated collagen is termed the
‘ hy b ri d ’ or ‘resin-reinforced’ layer, and the
methacrylate groups on its surface can then bond
chemically to the subsequently placed resin composite,
assisted by an intermediate layer of ‘adhesive’ or
‘bond’ which acts as a wetting agent.2 Commercial
products commonly employ simultaneous enamel
and dentine etching, in order to enhance the efficiency
of the bonding procedure.
One such material is EBS (ESPE Dental AG,
Seefeld, Germany).The etch consists of 32 per cent
phosphoric acid, the Primer is an aqueous solution
of hydroxyethylmethacrylate (HEMA) and
methacryl magnesium chelate (MMC), and the
Bond is malonic acid alkyl methacrylate (MAM)
and bis-methacrylates. There are limited published
data on EBS. A tensile bond strength of 9.8 MPa,5
and shear bond strengths of 17.2 MPa5 and 33.6
MPa,6 have been reported. In a clinical study, van
Dijken7 reported a zero one year loss rate of zero for
Pertac (ESPE Dental AG, Seefeld, Germany) resin
composite restorations bonded with EBS in noncarious cervical lesions (NCCL). However, this
appears to be the only study of this type available.
The purpose of the present study was to evaluate
the clinical performance, with respect to retention
and marginal discolouration, of the EBS bonding
system in NCCLs, using Pertac II as the resin
composite. The data can then be used to assess the
external validity of van Dijken’s study7 and to confirm
the efficacy of the chemistry of the system.
Materials and methods
Eight patients (age range 24-75 years; mean age
53 years) gave informed consent for inclusion in the
115
study. Forty teeth were restored according to the
manufacturer’s instructions: 1 upper molar; 8 upper
premolars; 7 upper anteriors; 2 lower molars; 15
lower premolars; 7 lower anteriors.
The teeth were cleaned for a few seconds with a
pumice/water slur ry on a rubber cup at slow speed,
then washed and dried. Etching gel was applied to
the cavity and surrounding tooth structure for 20
seconds and washed off with a copious air/water
spray. The cavity was dried with oil-free air and the
EBS Primer (B/N 002) applied for 20 seconds with
a scrubbing action with the sponge-ended applicator
supplied.The (water) solvent was evaporated by air,
and EBS Bond (B/N 022) applied in the same way
as the Primer, followed by gentle air-thinning and
photopolymerization for 20 seconds. Pertac II resin
composite was applied in a single increment,
photocured, and the final restoration polished using
fine diamonds and Soflex discs (3M Dental
Products, St Paul, MN, USA).
Restorations were photographed on colour slide
film for evaluation of marginal discolouration on a
continuous linear rating scale of zero to eight against
a standard set of photographs.8 Patients were
recalled at six months and one year for evaluation of
r e s t o r ation integrity and for photographs for
assessment of marginal discolouration.
Results
At six months all examined restorations were
present, however, one patient with four restorations
was lost to the study.The retention rate, using survival
analysis, was therefore 100 per cent.At one year,one
restoration was missing from an upper right canine,
giving a retention rate of 97.7 per cent. At six
months no marginal discolouration was visible. At
one year one restoration exhibited a score of 2 for
marginal discolouration, that is, it was clinically
hardly detectable.
Discussion
The two published bond strength values of EBS5,6
are widely different at 17.2 MPa and 33.6 MPa .T h e
disparity between bond strength measurements of
the same material in different laboratories has been
discussed previously9 and is inherent in dentine bond
strength testing. In any case, laboratory bond strength
may not be indicative of clinical performance.10
EBS is claimed to bond to dentine by diffusion of
the primer into the collagen to form a hybrid layer,
facilitated by the HEMA, which is water soluble and
polymerizable, and this has been observed on
s c a n n i n g electron micrographs. 6 However, the
manufacturers also suggest that the additional
component in the EBS Primer,methacryl magnesium
chelate, may react with dentinal calcium to form
116
methacryl calcium chelate, and thus some chemical
bonding may also occur. This possibility does not
appear to have been confirmed analytically.
The study reported here is essentially a pilot
study, based on a relatively small number of
restorations. No attempt was made to select teeth or
patients based on specific criteria, and the design of
the study is therefore analogous to the way the
materials might be used in a general practice. The
effectiveness of the bond is demonstrated clinically
by the high retention rate in NCCLs, which were
non-undercut, and thus restoration retention
depended mainly on the adhesive efficacy of the
EBS.The one year retention rate of over 97 per cent is
in agreement with that of van Dijken,7 who reported a
100 per cent retention rate of the 52 EBS/Pertac
restorations in his study. The single restoration which
showed slight marginal discolouration in the present
study may be a result of a technique failure, for
example, inadequate etching of the enamel or excessive
drying of the Primer. If there was a fundamental
problem with the material, more restorations would
probably have been affected. Thus,the results of this
study contribute to the external validity of van
Dijken’s study,7 and the two studies together,
involving the restoration of 92 NCCLs, confirm the
good clinical performance of EBS.
There is currently a trend towards so-called ‘onebottle’ systems, although this is strictly incorrect as
almost all products only combine primer and
adhesive (bond) into one bottle and still require a
separate etch.There are some advantages of using a
‘one-bottle’ system, such as simplified stock control
and infection control, but the total time taken for the
bonding procedure is not necessarily less than that for
a ‘two-bottle’ system.11,12 The main issue concerning
EBS (a ‘two-bottle’ system) is that each cavity must
be scrubbed for 20 seconds with the Primer and for
20 seconds with the Bond. The basis for a 20 second
scrub is the bond strength data of May,13 who
reported a tensile bond strength of 9.6 MPa when
the Primer was left undisturbed on the dentine for
60 seconds, and 11.4 MPa when the dentine was
‘scrubbed’ with the Primer for 20 seconds. These
values were not significantly different; however,
when restoring one tooth, the scrubbing technique
would save 40 seconds. Conversely, if there were more
than three cavities being restored simultaneously, the
individual scrubbing technique would take longer
overall than passive placement. The manufacturer
should therefore consider allowing the option of a 60
second passive Primer application, as well as a 20
second scrub.
EBS has now been superseded by EBS-Multi.
The components of EBS-Multi are the same as those
of EBS, except that part of a self-cure polymerization
initiator is included in the Primer. This self-cure
Australian Dental Journal 2000;45:2.
initiator has no function when EBS-Multi is used
with a photocured resin composite, but is important
when used with a resin luting cement (Compolute;
ESPE Dental AG, Seefeld,Germany). When used in
the adhesive restoration of non-carious cervical
lesions, the performance of EBS-Multi would be
expected to be no different from that of EBS.
Acknowledgement
This study was supported by ESPE Dental AG,
Seefeld, Germany.
References
1. Douglas WH. Clinical status of dentine bonding agents. J
Dent 1989;17:209-215.
2. Eick JD, Gwinnett AJ, Pashley DH, Robinson SJ. Current
concepts on adhesion to dentin. Crit Rev Oral Biol Med
1997;8:306-335.
3. Tyas MJ. Clinical testing – has it proved the efficacy of
adhesives? Int Dent J 1993;43:343-347.
4. Nakabayashi N, Nakamura M, Yasuda N. Hybrid layer as a
dentin-bonding mechanism. J Esthet Dent 1991;3:133-138.
5. May KN, Swift JR, Bayne SC. Bond strengths of a new
dentin adhesive system. Am J Dent 1997;10:195-198.
6. El Kalla IH, Garcia-Godoy F. Bond strength and interfacial
micromorphology of four adhesive systems in primary and
permanent molars. J Dent Child 1998;65:169-176.
Australian Dental Journal 2000;45:2.
7 . van Dijken JWV. Clinical effectiveness of nine dentin adhesives
in Class V cervical lesions. J Dent Res 1997;76:185: Abstr
1369.
8. Tyas MJ, Burns GA, Byrne PF, Cunningham PJ, Dobson
BC,Widdop FT. Clinical evaluation of Scotchbond:one-year
results. Aust Dent J 1986;31:159-164.
9. Øilo G, Olsson S. Tensile bond strength of dentin adhesives:
a comparison of materials and methods. Dent Mater
1990;6:138-144.
10. Finger WJ. Dentin bonding agents. Relevance of in vitro
investigations. Am J Dent 1988;1:184-188.
11. Clinical Research Associates. Dentin-resin adhesion, newest
systems. CRA Newsletter 1996;20:1-3.
12. Clinical Research Associates. Dentin-resin adhesion, 5
newest products. CRA Newsletter 1997;21:1-2.
13. May R. Dentin tensile bond strength: effect of different
primer application. J Dent Res 1998;77:638: Abstr 50.
Address for correspondence/reprints:
Associate Professor Martin J. Tyas,
School of Dental Science,
The University of Melbourne,
711 Elizabeth Street,
Melbourne,Victoria 3000
117
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