Review Article

Universal dental adhesives: Current status, laboratory testing,

and clinical performance

Sanket Nagarkar ,1 Nicole Theis-Mahon,2 Jorge Perdigão 3

1
Park Dental Group, Minneapolis, Minnesota, and Clinical Research Assistant Professor (affiliated), Department of Restorative
Sciences, University of Minnesota, Minneapolis, Minnesota
2
Bio-Medical Library, University of Minnesota, Minneapolis, Minnesota
3
Division of Operative Dentistry, Department of Restorative Sciences, University of Minnesota, Minneapolis, Minnesota

Received 29 August 2018; revised 11 December 2018; accepted 19 December 2018

Published online 00 Month 2019 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jbm.b.34305

Abstract: Increasing demand for simplified and user-friendly
adhesive systems has led to the development of a new class of
adhesives termed as Universal Adhesives (UAs). The term
“Universal” reflects manufacturers’ claims that these adhesives
can be applied with any adhesion strategy and offer the versatil-
ity of use with a variety of direct and indirect restorative mate-
rials. The aim of this review was to synthesize the literature
regarding the current status of UAs, their adhesion potential to
various substrates and their performance in different restorative
situations. In vitro studies, clinical trials and systematic reviews
were identified utilizing controlled vocabulary and keyword
searches in Medline and EMBASE databases. About 282 studies
(272 in vitro studies; 11 clinical studies) were included. Available
laboratory and clinical evidence does not support the claim that
UAs can be used with any adhesive strategy. Although, they can
chemically bond to various tooth and direct/indirect restorative
substrates, the stability of this bond is material-dependent and
subject to hydrolytic degradation. Hence, additional measures
are still needed to ensure long-term durability. which under-
mines the versatility of UAs. The lack of long-term data regarding
the clinical performance of UAs further complicates clinical
decision-making. © 2019 Wiley Periodicals, Inc. J Biomed Mater Res B
Part B: 00B: 000–000, 2019.
Key Words: universal adhesives, multi-mode adhesives, clinical
performance, laboratory performance, review

How to cite this article: Nagarkar S, Theis-Mahon N, Perdigão J. 2019. Universal dental adhesives: Current status, laboratory test-
ing, and clinical performance. J Biomed Mater Res B Part B. 2019:9999B:9999B:1–11.

INTRODUCTION most adhesive joints involve two interfaces, dental adhesive

Scientific advances in cardiology and dental adhesive tech-
nology have extensively influenced and revolutionized many
aspects of restorative dentistry.1–5 The restorative principle
of “Extension for Prevention” suggested by GV Black6 has
evolved into “Prevention of Extension” or more commonly
known as “Minimal Intervention Dentistry”.1,7,8 Minimally
invasive interventions aim to minimize cavity preparation
size by preventing unnecessary removal of sound tooth
structure. Preparations are limited to the removal of friable
enamel and soft dentin only while unnecessary extensions or
undercuts are minimized.7 Subsequent proper sealing of
these preparations with an adhesive restorative material
prolongs tooth survival.9,10
Adhesive restorations bond to tooth structure by means
of dental adhesives which are solutions of resin monomers
in an organic solvent with polymerization initiators. While
joints are more complex such as the one encountered with a
bonded porcelain restoration that involves enamel/dentin–
adhesive–luting composite–adhesive–porcelain interfaces.11
Success of adhesive restorations thus depends on achieving
a strong bond with these substrates. Fundamentally, the
bond with dental substrates is based on an exchange process
in which minerals removed from the dental hard tissues
after acid conditioning are replaced by resin monomers that
become micromechanically interlocked in the porosities
upon polymerization.1,12 Main challenge for current dental
adhesives is to provide an equally effective bond to dental
substrates of differing nature.2 The interlocking of resin tags
within the acid-etched enamel surface can be predictably
achieved12 and can effectively seal the restoration margins
in the long-term.13,14 On the other hand, bonding to dentin is
intricate and less predictable due to the presence of signifi-
cant amount of water and organic material in the

Correspondence to: Jorge Perdigão; e-mail: perdi001@umn.edu

© 2019 Wiley Periodicals, Inc. 1

substrate.1,15,16 Furthermore, mechanical instrumentation of
tooth structure during cavity preparation leaves behind a
uniform layer of debris on the tooth surface. This layer
called as the “Smear Layer” is composed primarily of
hydroxyapatite and altered collagen that plugs the entrance
of dentinal tubules reducing its permeability.11,17
Current adhesion strategies depend on how dental adhe-
sives interact with the smear layer and are grouped into two
basic categories: Etch-and-rinse (ER) strategy and self-etch
(SE) strategy. ER strategy involves complete removal of the
smear layer and superficial hydroxyapatite through etching
with a separate acid gel (commonly phosphoric acid)11,14 fol-
lowed by infiltration of adhesive monomers that permeate
the micro-porosities forming hybrid tissue known as the
resin–dentin inter-diffusion zone or the “Hybrid Layer”.18,19
In contrast, the SE strategy makes the smear layer perme-
able without removing it completely. This does not require a
separate phosphoric acid-etch step as acidic adhesive mono-
mers are utilized to partially dissolve the smear layer and
demineralize the underlying dentin/enamel while infiltration
is achieved simultaneously.14
Although, clinical studies suggest that adhesives utilizing
the ER strategy have superior clinical performance for load
bearing restorations,20 many clinicians demand materials or
strategies that are simpler and less technique-sensitive.2 This
demand has urged manufacturers to develop more user-
friendly adhesive systems. The newest of these are “Universal”
or “Multi-mode” adhesives which provide dentists with the
choice of selecting the adhesion strategy – ER, SE, or an
alternative “selective enamel etching” (SEE) strategy, which is
a combination of ER strategy on enamel and SE strategy on
dentin.21–24 Additionally, these adhesives offer the versatility
of use for bonding various direct and indirect restorative mate-
rials such as composite resins, glass-matrix ceramics, zirconia,
and metals.21,25–27 Though there is no official definition for
what qualifies as a Universal Adhesive (UA), literature
describes it as a single-bottle, no-mix adhesive system that
performs equally well with any adhesion strategy and bonds
adequately to tooth structure as well as to different direct and
indirect restorative materials.28,29 The present review aims
to synthesize the literature regarding the current status of
UAs, their adhesion potential to different substrates and
performance in different restorative situations.
METHODS
Information sources and search strategy
A trained librarian (NT-M) developed the search algorithms
and conducted the literature searches. Search strategies uti-
lizing controlled vocabulary (Medical Subject Headings) and
keywords were developed for the Medline database
(National Library of Medicine) via the Ovid interface (Epub
Ahead of Print, In-Process & Other Non-Indexed Citations,
Ovid MEDLINE(R) Daily, Ovid MEDLINE and Versions(R)
1946 to June 27, 2018) and translated to EMBASE
(1947–2018 June 29) on July 2, 2018. No restrictions
were placed on publication type or language. The search
results were exported to EndNote X8 (Clarivate Analytics,
Philadelphia, PA) for de-duplication and were then exported
2 NAGARKAR, THEIS-MAHON AND PERDIGÃO
TABLE I. Search Strategy for Medline via Ovid
Universal Adhesives:
(adhesive* adj3 universal).ti,ab. OR (all-bond adj3 universal).
ti,ab. OR (ambar adj3 universal).ti,ab. OR (clearfil adj3
universal).ab,ti. OR futurabond.ab,ti. OR gaenial.ab,ti. OR
(g-aenial adj3 bond).ti,ab. OR g-premio.ab,ti. OR ibond.
ab,ti. OR optibond adj3 universal.ab,ti. OR (one coat
adj3 universal).ab,ti. OR parkell.ab,ti. OR prime&bond.
ab,ti. OR scotchbond adj3 universal.ab,ti. OR (xeno adj3
select).ab,ti. OR (multi-mode adj3 bond).ab,ti. OR single
bond universal.ab,ti.
AND
Methods for testing or analyses (mechanical, morphological,
or chemical):
Exp Dental Bonding/OR (bond adj3 strength*).ab,ti.
OR fatigue.ab,ti. OR fracture*.ab,ti. OR
push-out.ab,ti. OR SEM.ab,ti. OR FESEM.ab,ti. OR TEM.
ab,ti. OR CLSM.ab,ti. OR
CONFOCAL.ab,ti. OR micro-ct.ab,ti. OR microct.ab,ti. OR
nanoleakage.ab,ti. OR exp Dental
Leakage/OR contact angle.ab,ti. OR exp X-Ray Diffraction/OR
XRD.ab,ti. OR EDS.ab,ti.
OR EDAX.ab,ti. OR NMR.ab,ti. OR exp Magnetic Resonance
Spectroscopy/OR MAS.ab,ti.
OR magic angle spinning.ab,ti. OR qcm-d.ab,ti. OR raman.ab,ti.
to Microsoft Excel (Version 2013). Details of the search strat-
egy are listed in Table I.
Inclusion and exclusion criteria
Both clinical and laboratory studies comparing properties of
UAs used with different application strategies (ER vs. SE
vs. SEE), against other SE and ER adhesives and with different
substrates (enamel, coronal and root dentin, composite resins,
glass-matrix ceramics, zirconia, and other materials) in primary
and permanent human or animal dentitions were included.
Systematic reviews of clinical and in vitro studies were also
included. The following studies were excluded: case reports,
case series, abstracts, thesis/dissertations, and editorials.
Study selection and data collection
Two reviewers Sanket Nagarkar and Jorge Perdigão
reviewed the title and abstracts of studies. Full-texts of these
screened studies were assessed for eligibility. Any disagree-
ments at the title, abstract or full-text screening stages were
resolved through mutual discussion. Extracted information
included: first author and publication year; study design
(systematic review vs. clinical vs. in vitro); type of teeth
(human vs. animal; permanent vs. primary teeth); types of
adhesives (UA vs. ER vs. SE); adhesion strategy (ER vs. SE
vs. SEE); type of substrates (enamel, coronal/root dentin,
glass-matrix ceramics such as lithium disilicate, zirconia,
other materials such as composite resins including pre-
polymerized resin composites for indirect restorations, and
metals); type of outcome measures for clinical studies
(survival/retention, restoration fracture, marginal adapta-
tion, secondary caries, and marginal discoloration); types of
outcomes/tests for in vitro studies (bond strength testing,
fracture toughness, fatigue testing, morphological analysis,
UNIVERSAL ADHESIVES
 REVIEW ARTICLE

TABLE II. Common Universal Adhesives (references listed

below)

Classification Functional
Universal Adhesive by pH Monomer(s)
All-Bond Universal (ABU) Ultra-mild 10-MDP
(BISCO Inc.) 3.1–3.2
AdheSE Universal (AU) Ultra-mild 10-MDP, MCAP
(Ivoclar Vivadent) 2.5–3.0
Optibond Universal (OBU) Ultra-mild GPDM
(Kerr) 2.5–3.0
One Coat 7 Universal (OC7U) Ultra-mild 10-MDP
(Coltene) 2.8
Scotchbond Universal (SBU) Ultra-mild 10-MDP, PAC
(3M Oral Care) 2.7
Prime&Bond Elect (PBE) Ultra-mild PENTA
(Dentsply Sirona) 2.5
Clearfil Universal Mild 10-MDP
Bond (CFU) 2.3
(Kuraray Noritake
Dental Inc.)
Futurabond U (FBU) Mild 10-MDP
(VOCO GmbH) 2.3
iBOND Universal (IBU) Intermediate 10-MDP, 4-MET
(Kulzer GmbH) strong
FIGURE 1. Study flow diagram. 1.6–1.8
G-Premio Bond (GPB) Intermediate 10-MDP, 4-MET
(GC Corp) strong
1.5
chemical analysis, micro/nanoleakage, and artificial-aging);
10-MDP, 10-methacryloyloxydecyl dihydrogen phosphate; MCAP,
and common UAs tested. One review author (Sanket methacrylated carboxylic acid polymer; GPDM, glycero-phosphate
Nagarkar) extracted the data, which was double-checked by dimethacrylate; PAC, Polyalkenoic acid copolymer; PENTA, dipentaery-
a second reviewer (Jorge Perdigão). If discrepancies were thritol penta acrylate monophosphate; 4MET, 4-methacryloxyethyl tri-
mellitic acid.
identified, they were resolved through mutual discussion.
References
Aggregate data was used for qualitative synthesis. Findings 1. Rosa WL, Piva E, Silva AF. Bond strength of universal adhesives: A
from laboratory tests and clinical performance were summa- systematic review and meta-analysis. J Dent 2015;43(7):765–776.
rized separately. Quantitative synthesis (meta-analysis) was 2. Perdigão J, Swift EJ, Jr. Universal Adhesives. J Esthet Restor Dent
2015;27(6):331–334.
not undertaken due to wide variations in study design, 3. Kaczor K, Gerula-Szymanska A, Smektala T, Safranow K,
substrates, adhesives, and testing methods. Lewusz K, Nowicka A. Effects of different etching modes on the nano-
leakage of universal adhesives: A systematic review and meta-analysis.
J Esthet Restor Dent 2018;30:287-298.
RESULTS 4. de Albuquerque EG, Santana FW, Calazans FS, Poubel LA, Marins
The initial database searches identified 1250 articles. Eight SS, de Paris Matos T, Hanzen TA, de Oliveira Barceleiro M, Loguercio
additional records were identified by manual searches of AD. A new universal simplified adhesive: 6-month randomized multi-
center clinical trial. Rev Bras Odontol 2017;74(4):251–260.
reference lists and other sources. A total of 285 studies were 5. Gutiérrez MF, Sutil E, Malaquias P, de Paris Matos T, de Souza LM,
included for the final data syntheses. Majority of the Reis A, Perdigão J, Loguercio AD. Effect of self-curing activators and
included studies (273 studies) were in vitro or systematic curing protocols on adhesive properties of universal adhesives bonded
to dual-cured composites. Dent Mater 2017;33(7):775–787.
reviews of in vitro studies. Only 12 clinical studies (11 ran-
6. Saikaew P, Chowdhury AF, Fukuyama M, Kakuda S, Carvalho RM,
domized trials; 1 systematic review of randomized trials) Sano H. The effect of dentine surface preparation and reduced applica-
were identified and included. Figure 1 describes the study tion time of adhesive on bonding strength. J Dent 2016;47:63–70.
flow in detail. 7. iBOND Universal Dental Science: Scientific Compendium. Kulzer
GmbH, Hanau, Germany 2017: 12. Available at: https://www.kulzer.com/
media/webmedia_local/downloads_new/ibond_8/ibond_universal_2/
Mechanism of adhesion of UAs iBOND_Universal_Compendium_GB.pdf [accessed August 26, 2018].
When UAs are applied with the SE strategy, they basically work
as traditional one-step SE adhesives30 and differ in their aggres-
siveness (pH of acidic monomers). Most UAs fall under the bonds ionically to dentin forming hydrolytically stable
ultra-mild (pH ≥ 2.5), mild (pH ≈ 2) and intermediately strong calcium salts on hydroxyapatite in the form of “nanolayer-
(pH between 1 and 2) categories.22,30,31 Despite similar compo- ing”.32,33 Chemical bonding promoted by 10-MDP is more effec-
sition to older SE adhesives, UAs contain specific carboxylate tive and stable in water than that provided by other functional
and/or phosphate functional monomers (Table II). The most monomers.2,34 Additionally, 10-MDP has been shown to chemi-
notable of these monomers is 10-methacryloyloxydecyl dihydro- cally bond with the oxides in zirconia while copolymerizing with
gen phosphate (10-MDP or MDP), a phosphate monomer that resin monomers of the luting cement.35–37 Glycero-phosphate

JOURNAL OF BIOMEDICAL MATERIALS RESEARCH PART B: APPLIED BIOMATERIALS | MONTH 2019 VOL 000B, ISSUE 0 3
dimethacrylate (GPDM) is another functional monomer that
forms a calcium salt with hydroxyapatite though the bond is not
stable.38 A polyalkenoic acid copolymer (PAC; also known as
Vitrebond copolymer) is a component of some adhesives
(Scotchbond Universal; 3M Oral Care) that chemically binds to
calcium ions in hydroxyapatite39,40 and may contribute to long-
term bond stability.39
Overview of methods for testing performance of UAs
Randomized controlled trials (RCTs) with long-term follow-
ups are the best study designs to evaluate clinical effectiveness
of restorative materials including dental adhesive systems.
RCTs evaluating performance of UAs have compared clinical
outcomes such as restoration retention/survival, restoration
fracture, marginal discoloration, post-operative sensitivity,
marginal adaptation, and secondary caries.41–52
Laboratory studies are predominantly used during the
development phase of restorative materials to define guide-
lines for application procedures and predict clinical behavior
to some extent.22 The micro-tensile bond strength (μTBS) test
developed by Sano et al.53 is the current standard for bond
strength testing54,55 and has a larger discriminative power
than the traditional macro-shear test.56 Although μTBS tests
provide useful information regarding the bonding ability of
adhesives, the stresses applied to the adhesive interfaces are
different from those that occur in the oral cavity where resto-
rations are subjected to cyclic loading over time, including
compressive, flexural, or tensile stresses. For this reason,
mechanical fatigue testing has been used to dynamically chal-
lenge the bonding effectiveness of adhesive-tooth inter-
faces.57,58 Interfacial fracture toughness testing has also been
suggested for evaluating the bonding effectiveness59 but it is
more laborious and requires specific equipment.56 Though
the fracture toughness test is more valid than the μTBS test,
the latter is more versatile and universal.54
While laboratory studies mostly evaluate immediate
bond characteristics, durability of adhesion under aged con-
ditions is considered more clinically relevant.54 Thermal
fatigue (thermocycling) and storage in water or artificial
saliva are the most popular artificial-aging methods.55 A cor-
relation has also been shown between in vitro dentin bond
strengths of 6-month, water-aged specimens, and marginal
discoloration of restorations in the oral cavity.60
The ultra-morphology of the interface between UAs
(or respective functional monomers) and tooth structure or
restorative materials has been characterized using several
imaging methods. Due to its ease of use, the most predomi-
nant technique is Scanning electron microscopy (SEM), either
in secondary mode,39,61,62 or backscattered mode.63–66 The
secondary mode is more common in the literature and is used
to analyze the ultra-morphology of the dentin hybrid layer.
SEM has also been used to measure the surface roughness of
zirconia specimens prior to several bonding procedures67 as
well as to evaluate the ultra-morphology of lithium disilicate
after bonding.68 Other tools for ultra-morphological evalua-
tion of adhesive interfaces include Transmission electron
microscopy,33,38,69–71 Confocal laser scanning microscopy,61,72
and Atomic force microscopy.61,72 Methods used to identify
4 NAGARKAR, THEIS-MAHON AND PERDIGÃO
and analyze interfacial chemical reactions include Energy
dispersive X-ray spectroscopy,33,73 X-ray diffraction,33,66
Nuclear magnetic resonance spectroscopy,40,71,74 X-ray photo-
electron spectroscopy,71,75 Fourier-transform infrared
spectroscopy,40,71,75,76 and Raman spectroscopy.61,77
Laboratory performance of UAs
Adhesion to enamel. It is well known that phosphoric acid
etching produces most durable resin–enamel bonds.78
Hence, when UAs are used with the SE strategy, their lower
aggressiveness reduces their potential to fully demineralize
enamel thereby resulting in inadequate retentive micro-
porosities. A meta-analysis of in vitro studies by Rosa et al.22
confirmed that UAs utilizing the SE strategy (vs. ER) resulted
in significantly lower enamel micro-shear and μTBS values.
Several other in vitro studies not included in the above
meta-analysis have reported improved enamel bond
strength values when ER strategy was utilized.79–82 Simi-
larly, studies utilizing artificial-aging for testing enamel bond
durability of SE adhesives (including UAs) concluded that
the ER strategy resulted in significantly better long-term
bond characteristics.57,58,83,84
In vitro studies have suggested several methods to improve
the resin–enamel bond characteristics with UAs. Some studies
have suggested use of an active85,86 and prolonged applica-
tion86 of the adhesive with the SE strategy as a practical alter-
native to enamel etching. One study indicated that double
application of UAs may be effective in enhancing enamel bond
strengths with the SE strategy possibly due to the increased
thickness and improved mechanical properties of the adhesive
layer.87 Another in vitro study reported improved enamel
bonding with the use of an additional hydrophobic resin coat-
ing (Heliobond, Ivoclar Vivadent) after SEE.88
Adhesion to dentin. While acid etching benefits resin–
enamel bonds, removal of smear layer and exposed dentinal
collagen with the ER strategy or with aggressive SE adhe-
sives results in an increase fluid flow onto the exposed den-
tin surface.89 Furthermore, it makes the bonding interface
highly vulnerable to hydrolytic and possibly enzymatic
degradation processes2,90,91 resulting in decreased short-
and long-term dentin bond strengths. However, for UAs,
results from in vitro studies indicate that the adhesive strat-
egy does not affect immediate dentin bonding. Meta-analysis
of in vitro studies by Elkaffas et al.92 reported statistically
similar average dentin μTBS values of about 37 MPa for ER
versus 35 MPa for SE strategies. Rosa, et al. meta-analysis
also did not find any statistically significant difference in the
μTBS of UAs (SBU, GPB, PBE, and FBU) with the ER versus
SE strategies. For ABU, however, the ER strategy resulted in
higher bond strengths although considerable heterogeneity
was noted among the included studies.22 Contrastingly, stud-
ies utilizing artificial-aging for testing dentin bond durability
of UAs concluded that the SE strategy resulted in more sta-
ble long-term bond characteristics.39,64,93,94 Studies have
attributed this to the stable chemical bonding produced by
10-MDP.39,66,95 Another meta-analysis of in vitro studies
assessing nanoleakage with UAs found inconsistent results
UNIVERSAL ADHESIVES

depending on the UA used.31 SBU showed comparable effi-
cacy with both strategies whereas ABU showed significantly
less nanoleakage with the SE strategy. The reviewers specu-
lated that the lower nanoleakage with these adhesives may
be due to their lower aggressiveness and incorporation of
10-MDP.31
Several methods have been proposed to preserve the
resin–dentin bonds. In vitro studies have demonstrated
improved immediate and long-term resin–dentin bond charac-
teristics of UAs with the SE strategy by applying an additional
hydrophobic resin coat possibly due to improvement in the
degree of monomer conversion at the resin–dentin inter-
faces.63,88,96 Active application (scrubbing) of the adhesive on
the dentin surface has also been shown to increase its imme-
diate bonding effectiveness97 as well as long-term bond stabil-
ity irrespective of the adhesion strategy.98 Other studies have
demonstrated improved long-term bond stability by applica-
tion of matrix metalloproteinases (MMPs) inhibitors such as
Chlorhexidine, Benzalkonium chloride, polymerizable benzalk-
onium methacrylate, and ethylenediaminetetraacetic acid
(EDTA).99,100 Preconditioning with EDTA using a sonic device
has also been shown to improve bonding performance of UAs
with the SE strategy on sclerotic dentin.101 Since residual
water and/or solvent may compromise the performance of
UAs, studies have demonstrated prolonged air-blowing after
adhesive application for 15–30 s versus manufacturer recom-
mended 5–10 s to enhance immediate adhesive properties of
UAs.102,103 Caries-affected dentin is a more challenging sub-
strate for bonding than sound dentin where ER adhesives
work better than SE adhesives.104,105 However, with UAs, the
adhesive strategy did not make a significant difference in
bond strengths of caries-affected dentin.106–109 Similarly,
eroded dentin-UA bonding properties did not depend on the
adhesive strategy.110–112
For primary teeth, the ER strategy resulted in better
dentinal bond strengths with UAs.113–115 Studies evaluating
UA-root dentin bond strengths have presented conflicting
evidence with some advocating the use of SE strategy116,117
while others recommending the ER strategy118,119 for luting
fiber-reinforced composite posts.
Contamination of bonding surfaces with saliva, blood or
hemostatic agents impairs bonding of adhesives.120–122 Several
decontamination methods have been proposed to regain den-
tin adhesion with UAs. These include drying the contaminants
and adhesive re-application;123 rinsing and drying followed by
re-application;123–125 and re-etching and re-bonding.126
Adhesion to glass-matrix ceramics. Successful bonding of
resin cements to glass-matrix ceramics such as lithium disilicate
can be achieved by hydrofluoric acid (HF) etching followed by
application of a silane solution, γ-methacryloxypropyl tri-
methoxysilane (MPTMS).127–129 Silane application increases the
ceramic wettability130 while promoting chemical interaction
between the silica in the ceramic and the methacrylate groups
of the adhesive or luting resin.131,132 Therefore, some manufac-
turers have incorporated a silane in their UAs (e.g., CFU and
SBU) with an intention to simplify the glass–ceramic bonding
protocol.30 However, studies have demonstrated that the
JOURNAL OF BIOMEDICAL MATERIALS RESEARCH PART B: APPLIED BIOMATERIALS | MONTH 2019 VOL 000B, ISSUE 0
REVIEW ARTICLE
presence of a Bis-GMA monomer in the silane solution signifi-
cantly reduces the contact angle of the solution decreasing its
surface wettability.133 In addition, silanols are more stable and
reactive when used separately and not when combined with
resin monomers.129 Furthermore, the acidic pH of UAs reduces
the bonding effectiveness of the incorporated silane.134
Kalavacharla et al.135 recommended the use of 9.5% HF for 60 s
(vs. 5% for 20 s) if an additional silane step were to be avoided
prior to UA application. The higher concentration and pro-
longed application perhaps increase the micromechanical reten-
tion and thus the bond strength due to the enhanced etch
pattern. The authors further recommended that a separate
silane should always be applied to lithium disilicate since the
silane and 10-MDP in the composition of UAs were not effective
in optimizing the ceramic-resin bond.135 Studies utilizing
artificial-aging also advocate a separate silane application step,
especially utilizing silane solutions with 10-MDP77,136 speculat-
ing that this additional step may enhance the hydrolytic stabil-
ity and the capability of UAs to form strong bonds with
different substrates at the same time.136 Thus, additional silane
pretreatment can effectively improve the bond strength and
marginal sealing of UAs to glass-matrix ceramics and is still
recommended even if the UA contains a silane in its
composition,68,134,135,137,138 as silane incorporated in the com-
position of universal adhesives is not expected to bond chemi-
cally to glass ceramics.137
Adhesion to zirconia. Several mechanical and chemical pre-
treatment methods have been suggested for bonding zirconia
restorations.139–141 Mechanical methods such as aluminum
oxide air-abrasion, tribochemical silica coating, laser irradia-
tion, chemical etching and ceramic coating can increase the
bond strengths by increasing the surface roughness and
micromechanical interlocking.140,142 Chemical pretreatments
with silane solutions/zirconia primers containing functional
monomers such as 10-MDP, phosphonic acid acrylate, or
anhydride containing primers promote chemical bonding
to zirconia.140,143 Recommended strategies for durable
resin–zirconia bonding are tribochemical silica coating
followed by silanization; aluminum oxide air-abrasion fol-
lowed by preconditioning with a MDP-containing primer; or
silica/ceramic coating followed by a MDP-primer.139,140,144
Many MDP-based UAs have also been recommended for
effectively bonding zirconia.26,30,75 Adequate bonding with
UAs still requires prior abrasive surface treatment26,37,145,146
and although acceptable bond strengths were achieved in
the short-term, their durability after artificial-aging was
found to be questionable.67,73 One study suggested silica
coating followed by heat treated ceramic primer or a
MDP-based UA to improve the bond durability.147 Xie et al.75
tested the effect of preconditioning with a MDP-primer
(Z-Prime Plus; BISCO Inc.) prior to UA application on resin-
zirconia bonding. Although, this repeated application of MDP
did not increase the chemical bonding, one group (Z-Prime
Plus and CFU) exhibited better bond stability after aging.75
Overall, laboratory studies suggest that achieving reliable
long-term bonds to zirconia is challenging with most bond-
ing strategies. Hence, Bömicke et al.67 recommended that
5
clinicians should not solely rely on adhesion for retention of
zirconia restorations.
Adhesion to other materials. Few laboratory studies evalu-
ated bonding of UAs with other materials such as pre-
polymerized resin composites for indirect restorations, aged
direct resin composites, and metals. Studies evaluating use
of UAs for repairing aged pre-polymerized resin composites
for indirect restorations recommend prior air-abrasion for
effective bonding.136,148–150 For aged direct composites,
either airborne-particle abrasion or grinding with a diamond
bur were recommended for improving the repair bond
strengths.151,152 For bonding composite resins to stainless
steel crowns, Hattan et al.153 reported superior shear bond
strengths and lesser adhesive failures with a UA versus tra-
ditional one-bottle ER adhesive. Ghadimi et al.154 advocated
use of air-abrasion or diamond bur roughening along with a
UA for improving the shear bond strengths.
Clinical performance of UAs
Very few RCTs have evaluated the clinical performance of
UAs in restoring non-carious cervical lesions (NCCLs), Class II
cavity preparations and for luting partial ceramic crowns.41–52
Vogl et al.41 compared the clinical performance of partial
ceramic crowns (feldspathic ceramic; CEREC blocks) cemen-
ted using a self-adhesive resin cement (no separate etch or
adhesive used) versus UA plus resin cement with a SEE or a
SE strategy. Although, the cumulative survival at 18 months
for restorations in the UA-resin cement-SEE group was
slightly higher (about 98% vs. 96% for SE group), this differ-
ence was not statistically significant. Interestingly, since the
UA (SBU) already had silane in its composition, no separate
silane application step was utilized for the UA-resin cement
groups with either adhesion strategy.41
van Dijken et al.42 compared clinical performance of
Class II composite resin restorations placed with an UA
(ABU) using the SEE strategy versus those placed with a
two-step SE adhesive (Optibond XTR; Kerr) and demon-
strated good short-term efficacy (annual failure rate of 1.8%
for UA vs. 2.9% for SE adhesive) after 36 months of clinical
use. Oz et al.43 demonstrated excellent retention rates
(97–100%) of composite restorations in NCCLs placed using
three different UAs with the SEE strategy after 18 months. A
systematic review/meta-analysis of eight RCTs evaluating
composite restorations in NCCLs155 found no difference in
marginal adaptation, marginal discoloration, post-operative
sensitivity and secondary caries when UAs were used with
the ER or SE strategy. However, ER or SEE strategy resulted
in higher retention rate and lesser incidence of restoration
fractures. There was no significant difference between any of
the clinical parameters when ER strategy was used with dry
versus moist dentin.155 A recently published RCT not
included in the previous systematic review, showed no dif-
ference between the ER and SE strategies after 18 months of
clinical use but reported a fairly high incidence of marginal
discoloration when the UA (SBU) was used with the SE strat-
egy.44 However, this RCT was at high risk of bias due to its
high loss to follow-up (22% loss to follow-up). Dentin
6 NAGARKAR, THEIS-MAHON AND PERDIGÃO
roughening has earlier been recommended to increase resto-
ration retention rates in NCCLs irrespective of the type of
adhesive used.156 However, a recent RCT of UAs in NCCLs
with ER and SE strategies found no difference between the
retention rates in roughened vs. unprepared dentin.45
Table III summarizes the findings from laboratory and
clinical studies.
DISCUSSION
Overall, for durable bonding with UAs, laboratory studies
recommend the use of SEE strategy for permanent teeth
and ER strategy for primary teeth. For glass-matrix ceramic
restorations, such as lithium disilicate, an additional silane
application step is necessary even if the UA contains a
silane in its composition. In addition, the use of an MDP-
based silane solution may increase the bond durability.
For zirconia restorations, relying solely on bonding for
retention should be avoided even though laboratory studies
suggest the use of air-abrasion with aluminum oxide or
silica-coated aluminum oxide particles (tribochemical silica
coating) or ceramic coating for acceptable bonding using an
MDP-based UA. For repair of direct composite resins and
pre-polymerized composite resins for indirect restorations,
the use of air-abrasion with aluminum oxide and UA appli-
cation is recommended.
Clinical studies recommend ER or SEE strategy for
improving survival rates of composite restorations in NCCLs;
and SEE strategy for Class II composite restorations. For
glass-matrix ceramics, the adhesive strategy was not rele-
vant. Except for NCCLs, clinical studies were sparse and
results should be interpreted with caution. There were no
clinical studies evaluating the bonding performance of UAs
to zirconia or other restorative materials.
Strategies to improve adhesion of UAs to tooth structure
advocated by laboratory studies include preventing contami-
nation while bonding, utilizing decontamination procedures,
use of MMP inhibitors, additional hydrophobic resin coating,
active and prolonged adhesive application, double adhesive
application, and prolonged air blowing of the adhesive.
The review has several limitations. Majority of the
included studies were in vitro studies, which have major
drawbacks. Accurate replication of clinical factors in the lab-
oratory is not possible. In addition, factors such as type of
test used, degree of dentin sclerosis, dentin depth, tooth age,
artificial-aging of the interface, and dentin roughness are fre-
quently not controllable.157,158 Hence, validity of laboratory
tests to predict clinical behavior is questionable. Although,
RCTs with long-term follow-ups are the best study designs
to evaluate clinical performance of adhesives, their validity
relies heavily on rigorous study design and completeness of
patient follow-up. This makes them difficult, time-consuming
and thus expensive. Additionally, rapid development and fre-
quent introduction of new dental adhesive materials makes
existing materials obsolete within a few years of their intro-
duction. This often tempts manufacturers to release succes-
sor products even before its precursor has been clinically
evaluated.54
UNIVERSAL ADHESIVES
 REVIEW ARTICLE

TABLE III. Summary of Recommendations for Bonding Different Substrates with Universal Adhesives

Recommendations

Substrate Laboratory Findings Clinical Findings Limitations

Enamel/dentin
Permanent teeth SEE strategy NCCLs: ER or SEE strategy Long-term clinical studies
Class II: SEE strategy are lacking
Only one clinical study
evaluated Class II
restorations
Primary teeth ER strategy No studies identified No clinical data available

Root dentin Findings inconclusive No studies identified No clinical data available

Conflicting findings regarding
adhesive strategy
Glass-matrix Separate silane application Tooth: SEE or SE strategy Clinical findings based
ceramics necessary Ceramic: UA with silane; no separate on only one study
silane application
Zirconia Reliance on adhesion should No studies identified No clinical data available
be avoided
Aluminum oxide air-abrasion
methods,
or ceramic coating
and a 10-MDP-based
UA recommended
Direct/indirect Prior aluminum No studies identified No clinical data available
composite resins oxide air-abrasion
ER, Etch-and-rinse; SE, Self-etch; SEE, Selective enamel etching (ER strategy on enamel and SE strategy on dentin); NCCL, Non-carious cervical
lesion; UA, Universal adhesive; MDP, methacryloyloxydecyl dihydrogen phosphate.

CONCLUSIONS 7. FDI policy statement on Minimal Intervention Dentistry (MID) for

Within limitations of the review, available laboratory and
clinical evidence does not support the claim that UAs can be
used with any adhesive strategy. Although, UAs can chemi-
cally bond to various tooth and direct/indirect restorative
substrates, the stability of this bond is material-dependent
and subject to hydrolytic degradation. Hence, additional
measures are still needed to ensure long-term durability
undermining the versatility of UAs. This poses a basic
conundrum—Are universal adhesives truly “Universal”?
These findings should be interpreted with caution
since they are mostly based on laboratory studies and
very few clinical trials with short-term follow-ups. More
long-term RCTs are thus needed to support clinical
decision-making.
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