Direct composites represent an ever-increasing percentage of procedures in the 21st century dental office. In fact, they represent a procedure that restorative dentists do in their practice on a daily basis.

dentin adhesives

In spite of the frequency with which they are performed, they can occasionally be problematic because of tooth sensitivity following treatment. This sensitivity can be caused by pulpal inflammation, but in most instances I believe it is from inadequate sealing of the dentin.

Martin Branstrom taught us years ago that open dentinal tubules lie at the heart of sensitivity, and eliminating sensitivity requires the tubules be sealed. There are many products that are capable of this, but two approaches I have used that have been very effective have involved either a self etching two-step system, such as Clearfil SE bond, or a total etch two-step system, such as 3M single bond.

Here are the steps I follow in order to eliminate sensitivity and obtain an adequate bond to enamel and dentin, recognizing that others may use different products and techniques and get excellent results as well.

  1. Etch enamel: Whenever I use a self-etch 2-step in the posterior, I etch the enamel first to ensure a good bond to it. I know several friends who don’t pre etch the enamel with self-etching systems and have great success, but I still prefer a 15-second enamel pre etch. If some acid gets on the dentin, which it will, I am not overly concerned about it. With the total etch 2-step systems I etch the enamel and dentin for 15 seconds. For either system the acid is then rinsed off and the tooth lightly dried.
  2. Apply desensitizer: Since 1987 I have used Gluma desensitizer following my etching prior to then applying the dentin adhesive, the Gluma contains 5% Glutaraldehyde and 35% HEMA. It has been shown to disinfect the preparation and coagulate proteins in the dentinal tubules, this slows down the flow of fluid in the tubules reducing sensitivity. Bottom line for me is that it has been incredibly successful at eliminating most post-operative sensitivity. Some question whether it is necessary with self-etching dentin adhesives, but I still choose to use it because of the results I get. I lightly dry the Gluma prior to applying the dentin adhesive, others leave it wet with success as well.
  3. Apply dentin adhesive: I then apply the dentin adhesive according the manufacturer’s instructions. It’s important to make sure the adhesive dries properly and all of the solvent is thoroughly vaporized. In my experience, the typical water/air syringe does not produce clean, dry air. I like using an ADEC air-drying unit that attaches to a four hole handpiece hose to ensure the area is dried without contamination. The one thing I am very aware of is that different adhesives must be applied with different protocols, and often dentists don’t read the instructions as to how to apply the adhesive, whether to agitate it or not, number of layers, etc. Whatever product you use, definitely follow the manufacturers instructions for application. After drying, the dentin adhesive is the light cured.
  4. Verify adequate coverage: After light curing the bonding agent, it’s essential to verify adequate coverage. A tooth that is adequately covered will have a shiny surface all over the dentin. If you don’t see any shine, apply another layer of adhesive on top and repeat the process of drying and light curing until it yields the results you want. Remember we have to seal the tubules to prevent post-op sensitivity.
  5. Place first increment of composite: There is ample evidence that bulk filling techniques are successful, and with the newer low shrink materials likely even better then ever, but I personally like to use incremental placement. I start off by placing the composite along the buccal and lingual walls of the proximal box and extend up and along the buccal and lingual walls of the occlusal as well. Essentially leaving the middle of the prep unfilled. This layer is cured completely prior to the second increment.
  6. Place second increment of composite and cure: The second increment fills up the center but I don’t place the composite all the way to the top. If desired, I’ll add a little colorant to the top of this layer to give the composite a more natural appearance. Again curing completely prior to the final increment. At this point, I place the final increment of composite and build it up to the correct contour for proper shaping.

I recognize that there are more products and techniques available for placing direct posterior restorations than we have ever had in dentistry, many which are very successful, but hopefully the recipes I presented may help you if you are having sensitivity problems with your direct composites. 


Comments

Commenter's Profile Image Sarat
March 20th, 2013
Some techniques suggest use of a first layer of flowable composite at the base of the box, and consequently filling up with hybrid composite, would you recommend that, any other comments. Thank you
Commenter's Profile Image Chris Mast
March 20th, 2013
love the pre-etch, I think that is super important. thanks for this!!
Commenter's Profile Image Gerald Benjamin
March 20th, 2013
As per the photo, the single MOST important factor in avoiding post operative sensitivity is the use of the rubber dam. Frank Spear's over riding message has been to pursue excellence and the best way to place a direct posterior resin restoration is by placing a rubber dam. One of my endodontists has told me that he routinely finds retained caries under direct posterior resins which means that there is no adhesive bond and therefore sensitivity is likely even if Frank's adhesive protocol is utilized. If a dentist cannot manage the patient's tongue, lips, cheeks or saliva, there is no way to insure that caries are removed and that the adhesive protocol has been successful.
Commenter's Profile Image Kurt
April 4th, 2013
I have used the same protocol as Dr. Spear for the past 10 years (total etch, Gluma, Singlebond) with what I feel is good success. I recently switched to 3M Scotchbond Universal and eliminated the Gluma step (still total etch). It seems to work quite well. I remember Dr. Spear expressing optimism over this new product a year ago at a workshop. I wonder how he and others feel about it now that it's been on the market for a year.
Commenter's Profile Image Susan Christensen
April 4th, 2013
I use a rubber dam but occasionally use an isolite instead for patients that object to rubber dam's comfort. Do you think and isolite is acceptable? Thank you
Commenter's Profile Image Susan Christensen
April 4th, 2013
Do you think an isolite is acceptable to use when a patient objects to a rubber dam?
Commenter's Profile Image David Hoyle
April 4th, 2013
Dear Dr Spear- Sometimes I think we are doing our patients a disservice when we do a "permanent " restoration that is not cario-static for a tooth when we know that it will reliably last only 5-8 years before it starts to debond. Most patients do not treat the composite as a temporary filling...should we market it as "temporary"? Should we move to doing more dense composites (CAD CAM, lab fabricated or office fabricated indirect composites)? And I am sure that if you look at the photo you provided with this posting, you would prefer to build up the distal contact of the tooth wider and tighter anyway, which you could have better done with an indirect composite.--Thanks, David
Commenter's Profile Image Chad L.
April 4th, 2013
David- In response to your comments, I think indirect restorations are very acceptable if you're having to replace a lot of missing tooth structure. However, one way the direct composite case above could have been improved would be to have used a better, more updated matrix system. I never use a wood wedge for anything and the photo above demonstrates the old palodent system and clearly the contact is not ideal. A triodent matrix system would have provided a more optimal result in the above case along with a wave wedge, IMHO.
Commenter's Profile Image DR FARHAN DURRANI
May 30th, 2013
THANK YOU DR SPEAR ,I HAVE BEEN USING THE ABOVE MENTIONED TECHNIQUE AND QUITE SUCCESSFUL WITH MOST OF MY PATIENTS,IS RUBBER DAM ESSENTIAL OR CAN IT BE MANAGED WITHOUT IT?
Commenter's Profile Image Emilio
June 4th, 2013
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Commenter's Profile Image Dr.Haytham El-Fawal
May 12th, 2015
Thanks for this article Can we use 3M universal self etch adhesive with any type of composite ( eg: tetric Evo ceram or Tetric N-ceram ) or it must be used with the 3M composite only thanks
Commenter's Profile Image Dr.Haytham El-Fawal
May 12th, 2015
Thanks good article Can we use 3M universal self etch adhesive with any type of composite ( eg: tetric Evo ceram or Tetric N-ceram ) or it must be used with the 3M composite onlyhanks . Good article
Commenter's Profile Image Dr.Haytham El-Fawal
May 12th, 2015
Good topic . Thanks Can we use 3M universal self etch adhesive with any type of composite ( eg: tetric Evo ceram or Tetric N-ceram ) or it must be used with the 3M composite only
Commenter's Profile Image Bojana B.
April 7th, 2018
My associates continue to have issues in this area however in my 6 years I have only had one case of sensitivity. I do not use Gluma, liners or any time-consuming added steps. Here is my protocol: 1) Use plenty of water when preparing the tooth 2) Total etch 10 seconds 3) Do not over dry dentin 4) ObtiBond Solo- 20 second micro brush rub 5) Make sure no water in air-water syringe. Dissolve solvent and thin the bond gently for 5 seconds, cure 10 seconds. 6) Make sure each layer of composite is cured 20s. If you do not over heat the tooth, over dry the dentin and make sure that the solvent is evaporated and each layer of composite is cured to manufacturer instructions you will not have any issues.