journal of dentistry 43 (2015) 765–776

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Review

Bond strength of universal adhesives: A systematic

review and meta-analysis

Wellington Luiz de Oliveira da Rosa, Evandro Piva,

Adriana Fernandes da Silva *
Department of Restorative Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas, RS, Brazil

article info abstract

Article history: Objectives: A systematic review was conducted to determine whether the etch-and-rinse or
Received 1 December 2014 self-etching mode is the best protocol for dentin and enamel adhesion by universal adhesives.
Received in revised form Data: This report followed the PRISMA Statement. A total of 10 articles were included in the
14 March 2015 meta-analysis.
Accepted 5 April 2015 Sources: Two reviewers performed a literature search up to October 2014 in eight databases:
PubMed, Web of Science, Scopus, BBO, SciELO, LILACS, IBECS and The Cochrane Library.
Study selection: In vitro studies evaluating the bond strength of universal adhesives to dentin
Keywords: and/or enamel by the etch-and-rinse and self-etch strategies were eligible to be selected.
Adhesives Statistical analyses were conducted using RevMan 5.1 (The Cochrane Collaboration, Copen-
Dental bonding hagen, Denmark). A global comparison was performed with random-effects models at a
Dental materials significance level of p < 0.05.
Systematic review Results: The analysis of dentin micro-tensile bond strength showed no statistically signifi-
cant difference between the etch-and-rinse and self-etch strategies for mild universal
adhesives ( p  0.05). However, for the ultra-mild All-Bond Universal adhesive, the etch-
and-rinse strategy was significantly different than the self-etch mode in terms of dentin
micro-tensile bond strength, as well as in the global analysis of enamel micro-tensile and
micro-shear bond strength ( p  0.05).
Conclusions: The enamel bond strength of universal adhesives is improved with prior
phosphoric acid etching. However, this effect was not evident for dentin with the use of
mild universal adhesives with the etch-and-rinse strategy.
Clinical significance: Selective enamel etching prior to the application of a mild universal
adhesive is an advisable strategy for optimizing bonding.
# 2015 Elsevier Ltd. All rights reserved.

dental substrates: the etch-and-rinse and self-etch systems.1,2

1. Introduction The etch-and-rinse strategy involves the prior application
of phosphoric acid, which, at enamel, produces deep etch-pits
Dental adhesive systems can be classified into two main in the hydroxyapatite (HAp)-rich substrate and, at dentin,
categories according to different bonding techniques to the demineralizes up to a depth of a few micrometers to expose an

* Corresponding author. Tel.:+55 53 32256741x134.

E-mail addresses: wellington.xy@gmail.com (W. Rosa), evpiva@gmail.com (E. Piva), adriana@ufpel.edu.br (A.F.d. Silva).
http://dx.doi.org/10.1016/j.jdent.2015.04.003
0300-5712/# 2015 Elsevier Ltd. All rights reserved.
766 journal of dentistry 43 (2015) 765–776

HAp-deprived collagen mesh.1,3 Thus, etch-and-rinse adhe-
sives are available for use in three steps (acid etching, primer
and adhesive) or two steps (primer and adhesive joined into
one single material). For these total etching adhesive systems,
hybrid layer formation relies on the demineralization of
superficial dentin by inorganic acids, which exposes collagen
fibrils that are then infiltrated by hydrophilic monomers.2–4
Although etch-and-rinse adhesives are still the gold standard
for dental adhesion and the oldest of the marketed adhesives,
the current trend is to develop simplified self-etching
materials.1,2,5,6
Thereby, self-etch adhesives can involve two steps or a
single step, depending on how the acidic primer and adhesive
resin are provided by the manufacturer.1,4 Thus, manipulation
has been simplified by reducing the number of steps to a one-
step system, with all components (etchant, primer, and
bonding resin) incorporated into a single dental material.5,7
They are a blend of hydrophilic and hydrophobic monomers,
polymerization initiators, solvents, stabilizers, and filler
particles.8 Additionally, self-etch adhesives contain specific
monomer molecules with carboxylate or phosphate acidic
groups that simultaneously act as conditioner (that allow
dental superficial demineralization) and primer agents (resin
monomers that infiltrates into the dentin) upon the dental
substrates.8,9 Thus, these adhesives are easy-to-use, have a
faster application procedure and are less susceptible of
differences in the operator’s technique when compared with
multi-step etch-and-rinse adhesives.1,10
Contemplating these two bonding strategies, adequate
bonding to dentin can be completely achieved with either
etch-and-rinse or self-etch adhesives; however, at enamel, the
etch-and-rinse approach using phosphoric acid remains the
preferred choice.1,11,12 The main challenge for current dental
adhesives is to provide an equally effective bond to dental
substrates of different natures (i.e., sound, carious, sclerotic
dentin, as well as enamel).1 Considering the differences in
professional judgment regarding the selection of the adhesive
strategy and the number of steps, some manufacturers have
released more versatile adhesive systems that give the dentist
the opportunity to decide which adhesive strategy to use: etch-
and-rinse or self-etch. This new family of dental adhesives is
known as ‘‘universal’’ or ‘‘multi-mode’’ and represents the
latest generation of adhesives on the market.13–16 They are
designed under the ‘‘all-in-one’’ concept of the already existing
one-step self-etch adhesives but also incorporate the versatili-
ty of being adaptable to the clinical situation.16 An adhesive
that can be applied both ways enables the practitioner to decide
on a specific adhesive protocol that is most suited for the cavity
being prepared.14
Despite manufacturers’ efforts to develop and market
new materials, the question still remains whether clinicians
should consider using these new adhesives with prior acid
etching over the self-etch strategy. Which adhesive protocol
is best for multi-mode adhesives cannot be indisputably
answered based on the scarce clinical evidence available
and with the short follow-up periods that have been
assessed. Nevertheless, in vitro evaluations of the bonding
efficacies of these new adhesives by application under
different etching modes are already available in the
literature. Thus, the aim of this study was to systematically
review the literature to evaluate whether the bond strength
to dentin and enamel is improved by universal adhesives
with prior acid etching. The hypothesis tested was that there
is no difference in bond strength to dental substrates using
multi-mode adhesives by the etch-and-rinse or self-etch
strategy.
2. Methods
This systematic review was conducted in accordance with the
guidelines of the PRISMA statement.17 The research question
was as follows: does the etch-and-rinse strategy improve the
bond strength of universal adhesives to dentin and/or enamel?
2.1. Systematic literature search
The literature search was performed by two independent
reviewers until 30 October 2014 (considering unlimited
publication years). Eight databases were screened: MEDLINE
(PubMed), ISI Web of Science, Scopus, SciELO, LILACS, IBECS,
BBO (Biblioteca Brasileira de Odontologia) and the Cochrane
Library. The keywords related to the search strategy are listed
in Table 1. The reviewers hand-searched the reference lists of
included articles for additional papers, and the cited articles
were also tracked using SCOPUS citation tools. After the

Table 1 – Search strategy used in PubMed (MEDLINE).

Search terms
No. 3 Search no. 1 and no. 2
No. 2 Search (Universal adhesive) OR (adhesive, universal) OR (universal adhesives) OR (adhesives, universal) OR (Multimode
adhesive) OR (multi-mode adhesive) OR (multimode adhesives) OR (multi-mode adhesives) OR (G Bond Plus) OR (Adhese
Universal) OR (All-Bond Universal) OR (One-step Universal Dental adhesive) OR (One-step plus universal) OR (Peak Universal
Bond) OR (Clearfil Universal Bond) OR (iBond Self Etch) OR (FuturaBond U) OR (Prime&Bond Elect) OR (Universal bond) OR
(Universal bonding agent) OR (multi-mode bond) OR (multimode bond) OR (multi-mode bonding agent) OR (multimode bonding
agent)
No.1 Search (Dental Bonding) OR (Bonding, Dental) OR (Dental Bonding, Chemically-Cured) OR (Chemically-Cured Dental Bonding)
OR (Dental Bonding, Chemically Cured) OR (Dental Bonding, Self-Cured) OR (Dental Bonding, Self Cured) OR (Self-Cured Dental
Bonding) OR (Chemical-Curing of Dental Adhesives) OR (Chemical Curing of Dental Adhesives) OR (Dental Bonding, Dual-Cure)
OR (Dentin-Bonding Agents) OR (dental primer) OR (Dental Materials) OR (Materials, Dental) OR (Dental Material) OR (Material,
Dental) OR (dental resin) OR (Dental Resins) OR (Resin, Dental) OR (Resins, Dental) OR (bonding interface) OR (adhesive) OR
(Dentin-Bonding Agents) OR (Agents, Dentin-Bonding) OR (Bonding Agents, Dentin) OR (Agents, Dentin Bonding) OR (Dentin
Bonding Agents)
 journal of dentistry 43 (2015) 765–776
identification of articles in the databases, the articles were
imported into Endnote X7 software (Thompson Reuters,
Philadelphia, PA, USA) to remove duplicates.
2.2. Study selection
Two of the review authors independently assessed the titles
and abstracts of all of the studies. The eligibility criteria
consisted of selecting only studies related to universal
adhesives systems that evaluated dentin and/or enamel
bond strength by the self-etch and etch-and-rinse techniques
(Fig. 1). Full copies of all of the potentially relevant studies
were assessed. Those appearing to meet the inclusion criteria
or with insufficient data in the title and abstract to make a
clear decision were selected for full analysis. Studies in which
the secondary outcome was to evaluate the bond strength to
enamel and dentin by multi-mode adhesives were also
included. The full-text papers were independently assessed
in duplicate by two review authors. Any disagreement
regarding the eligibility of the included studies was resolved
through discussion and consensus or by a third reviewer.
Only papers that fulfilled all of the eligibility criteria were
included.
2.3. Data extraction
The data were extracted using a standardized form in the
Microsoft Office Excel 2013 software (Microsoft Corporation,
Redmond, WA, USA), with all of the trial documents contain-
ing demographic data (year, country), the outcomes evaluated,
the number of teeth, the universal adhesive system used, the
predominant failure mode and the composite used (Table 2).
Data related to the bond strength to dentin and enamel was
also tabulated (micro-tensile and micro-shear bond strength)
(Tables 3 and 4). If any information was missing, the authors of
the included papers were contacted via e-mail to retrieve the
missing data. If no answer was received within 2 weeks after
the first e-mail message was sent, then a second e-mail was
sent. If authors had not given an answer by one month after
the first contact, the missing information was not included in
this systematic review.
Fig. 1 – Eligibility criteria.
767
2.4. Quality assessment
The methodological quality of each included study was
independently assessed by the two reviewers, as adapted
from another systematic review of in vitro studies.18 Thus, the
risk of bias was evaluated according to the articles’ description
of the following parameters: teeth randomization, teeth free of
caries, blinding of the examiner, the presence of a control
group, samples with similar dimensions, evaluation of the
failure mode, analysis by a single observer, description of
coefficient of variation and sample size calculation. If the
authors reported the parameter, the article had a ‘‘Yes’’ on
that specific parameter; if it was not possible to find the
information, the article received a ‘‘No.’’ Articles that reported
one to three items were classified as having a high risk of bias,
four or five items as a medium risk of bias, and six to eight
items as a low risk of bias (Table 5).
2.5. Statistical analysis
Each possible comparison of the bond strength of the
universal adhesive using the self-etch and etch-and-rinse
techniques was carried out; i.e., a study that evaluated the
bond strength of one adhesive to dentin and enamel resulted
in two possible comparisons. For dentin: we compared etch-and-
rinse with the self-etch mode; similarly, for enamel: etch-and-rinse
with the self-etch mode. Additionally, for studies that evaluated
the samples before and after aging, both data sets were
analysed. Pooled-effect estimates were obtained by comparing
the standardized mean difference of each multi-mode adhe-
sive and were expressed as the weighted mean difference
between groups. A p value 0.05 was considered statistically
significant. Statistical heterogeneity of the treatment effect
among studies was assessed using the Cochran’s Q test and
the inconsistency I2 test, in which values greater than 50%
were considered as indicative of substantial heterogeneity.19
The first global analysis of dentin and enamel bond
strength was carried out using a random-effect model, and,
for adhesives that were evaluated in at least two different
studies, the analyses were carried out independently. All
analyses were conducted using Review Manager Software
 768
Table 2 – Demographic data of the included studies.
Study Year Country Number Primary Secondary outcome Predominant Universal adhesives Composite Type of
of teeth outcome 1 failure mode composite
(per group)
De Goes 13 2014 Brazil 30 (8) Enamel mTBS Interfacial morphology Adhesive Scotchbond Universal (3 M Filtek Supreme Plus Nanocomposite
Espe, St. Paul, MN, USA) (3 M Espe, St. Paul, MN,
USA)
Goracci 32 2013 Italy 133 (20) Enamel mSBS Microleakage Adhesive/Mixed G-Bond Plus (GC, Tokyo, G-aenial Universal Flo Flowable
measurements and Japan) (GC, Tokyo, Japan) composite
scanning electron
microscopy
Hanabusa 14 2012 Belgium 25 (5) Enamel and Ultra-structural Mixed G-Bond Plus (GC, Tokyo, Clearfil AP-X (Kuraray, Microhybrid
dentin mTBS analysis (Transmission Japan) Tokyo, Japan) composite
electron microscopy)
Marchesi 7 2014 Italy 60 (15) Dentin mTBS Interfacial Adhesive Scotchbond Universal (3 M Filtek Z250 (3 M Espe, Microhybrid

journal of dentistry 43 (2015) 765–776

nanoleakage and MMP (Cohesive in Espe, St. Paul, MN, USA) St. Paul, MN, USA) composite
expression composite only
with etch-and-rinse
strategy)
Munoz 29 2013 Brazil 40 (5) Dentin mTBS Interfacial Adhesive/Mixed Peak Universal Adhesive Opallis (FGM, Joinville, Microhybrid
nanoleakage and (Ultradent, South Jordan, UT, SC, Brazil) composite
degree of conversion USA); Scotchbond Universal
(3 M Espe, St. Paul, MN, USA);
All-Bond Universal (Bisco
Inc., Schaumburg, IL, USA)
Munoz 15 2014 Brazil 60 (5) Dentin mTBS Interfacial Adhesive/Mixed Scotchbond Universal (3 M Filtek Z350 (3 M Espe, Nanocomposite
nanoleakage and Espe, St. Paul, MN, USA); All- St. Paul, MN, USA)
degree of conversion Bond Universal (Bisco Inc.,
Schaumburg, IL, USA); G-
Bond Plus (GC, Tokyo, Japan)
Perdigão 30 2012 United States 36 (6) Dentin mTBS Ultra-morphologic Adhesive Scotchbond Universal (3 M Filtek Z250 (3 M Espe, Microhybrid
evaluation Espe, St. Paul, MN, USA) St. Paul, MN, USA) composite
Luque- 2014 Brazil 140 (5) Dentin mTBS Interfacial Adhesive All-Bond Universal (Bisco Filtek Z350 (3 M Espe, Nanocomposite
Martinez 31 nanoleakage Inc., Schaumburg, IL, USA); St. Paul, MN, USA)
Prime&Bond Elect (Dentsply
Caulk, Milford, DE, USA);
Scotchbond Universal (3 M
Espe, St. Paul, MN, USA)
Perdigão 10 2014 United States 60 (5) Enamel mSBS Dentin mTBS and Adhesive/Mixed G-Bond Plus (GC, Tokyo, Filtek Z350 (3 M Espe, Nanocomposite
degree of conversion Japan) St. Paul, MN, USA)
Wagner 16 2014 Germany 20 (12) Dentin mTBS Resin penetration Adhesive Futurabond U (Voco, GrandioSO (Voco, Nanohybrid
Cuxhaven, Germany); All- Cuxhaven, Germany) composite
Bond Universal (Bisco Inc.,
Schaumburg, IL, USA);
Scotchbond Universal (3 M
Espe, St. Paul, MN, USA)
1
mTBS: micro-tensile bond strength; mSBS: micro-shear bond strength.
 journal of dentistry 43 (2015) 765–776 769

Table 3 – Dentin bond strength of universal adhesives with aging/storage procedures.

Study Adhesive system Aging/storage Dentin micro-tensile bond strength
(MPa)

Etch-and-rinse SD Self-etch SD
Hanabusa14 G-Bond Plus 24 h of storage in distilled water at 37˚ C 29.4* 8.2 30.5 7.6
Marchesi7 Scotchbond Universal 24 h of storage in artificial saliva at 37˚ C 34.8* 9.4 35.5 9.7
1 year of storage in artificial saliva at 37˚ C 21.9* 9.5 26.8 9.5
Munoz29 Peak Universal Adhesive 24 h of storage in distilled water at 37˚ C 43.6 4.6 39.9 4.5
Scotchbond Universal 35.1 6.6 32.4 4.5
All-Bond Universal 39.3 3.7 13.4 1.9
Munoz15 Scotchbond Universal 24 h of storage in distilled water at 37˚ C 32.3 3.7 34.7 5.8
All-Bond Universal 40.8 5.0 22.0 5.1
G-Bond Plus 20.5 3.2 11.5 3.3
Perdigão30 Scotchbond Universal 24 h of storage in solution** at 4˚ C 54.0* 18.8 54.4 18.5
Perdigão10 G-Bond Plus 24 h of storage in distilled water at 37˚ C 19.1 0.7 13.4 1.3
Luque-Martinez31 All-Bond Universal 24 h of storage in distilled water at 37˚ C 40.8* 5.0 22.0* 5.1
Prime&Bond Elect 16.8* 2.4 18.9* 2.6
Scotchbond Universal 36.2* 3.3 32.3* 4.8
Wagner16 Futurabond U 24 h of storage in distilled water at 37˚ C 41.2 10.7 37.9 14.0
All-Bond Universal 44.8 10.8 52.6 12.7
Scotchbond Universal 49.1 11.1 44.0 21.9
Futurabond U After thermo-cycled for 5000 cycles 46.0 12.9 36.6 18.7
All-Bond Universal (cyclic immersion for 30 s at 5.5˚ C/55˚ C, 54.6 11.7 44.7 12.7
Scotchbond Universal 7 s dwelling time) 46.8 15.1 48.3 13.8
*
Values were in accordance with the manufacturer’s instructions.
**
Immersed in 2.5% glutaraldehyde/2% paraformaldehyde in 0.1 M sodium cacodylate buffer at pH 7.4.

Table 4 – Enamel bond strength of universal adhesives with aging/storage procedures.

Study Adhesive Aging/Storage Enamel micro-tensile bond strength Enamel micro-shear bond strength
system
Etch-and-rinse SD Self-etch SD Etch-and-rinse SD Self-etch SD
14
Hanabusa G-Bond Plus 24 h of storage 34.5 13.8 23.1 9.8 – – – –
in distilled
water at 37˚ C
Perdigão10 G-Bond Plus 24 h of storage – – – – 15.9 2.8 14.7 1.1
in distilled
water at 37˚ C
De Goes13 Scotchbond 24 h of storage 33.6 9.3 27.4 8.5 – – – –
Universal in distilled
water at 37˚ C
Goracci32 G-Bond Plus 24 h of storage – – – – 15.2 4.4 10.1 2.7
in distilled
water at 37˚ C

Table 5 – Quality assessment and risk of bias.

Study Teeth Teeth Control Samples Evaluation Description Sample Blinding Risk of bias
randomization free of group with similar of failure of coefficient size of the
caries dimensions mode of variation calculation examiner
Hanabusa14 Yes Yes Yes Yes Yes No No No Medium
Marchesi7 Yes Yes Yes Yes Yes No No No Medium
Munoz29 Yes Yes Yes Yes Yes No No Yes Low
Wagner16 Yes Yes Yes Yes Yes No No No Medium
Perdigão30 Yes Yes Yes Yes Yes No No No Medium
Munoz15 Yes Yes Yes Yes Yes No No Yes Low
De Goes13 Yes Yes Yes Yes Yes No No No Medium
Goracci32 Yes Yes Yes Yes Yes No No No Medium
Luque- Yes Yes Yes Yes Yes No No No Medium
Martinez31
Perdigão10 Yes Yes Yes Yes Yes No No No Medium
770 journal of dentistry 43 (2015) 765–776

Fig. 2 – Search flowchart according to the PRISMA Statement.17

version 5.1 (The Nordic Cochrane Centre, The Cochrane excluded because they did not meet the eligibility criteria, and
Collaboration, Copenhagen, Denmark). The influence of 19 articles were assessed by full-text reading. Of the 19 studies
bonding strategies among studies on the bond strength of retained for detailed review, 9 were not included; of the 9, 2
universal adhesives was analysed using descriptive statistics. were clinical trials20,21, 6 were studies that performed
evaluations different than assessing the bond strength to
dentin and/or enamel by the self-etch and etch-and-rinse
3. Results techniques22–27 and 1 was a case report.28 A total of 10 studies
fulfilled all of the selection criteria and were included in this
3.1. Search strategy review.

A total of 6578 potentially relevant records were identified
from all of the databases. Fig. 2 is a flowchart that summarizes
the article selection process according to the PRISMA
Statement.17 After the removal of duplicates, 5573 records
were examined by the titles and abstracts; 5554 studies were
3.2. Descriptive analysis
Six different types of universal adhesives were evaluated in
this review, considering all of the included clinical trials
(Table 6). Of the studies included in the review, a total of seven

Table 6 – Composition and classification of universal adhesives.

Universal adhesives Classification Composition*
according to pH
Scotchbond Universal Mild (pH = 2.7) 10-MDP phosphate monomer, Vitrebond copolymer, HEMA, BISGMA,
(3 M Espe, St. Paul, MN, USA) dimethacrylate resins filler, silane, initiators, ethanol, water
G-Bond Plus (GC, Tokyo, Japan) Mild (pH = 1.5) Acetone, dimethacrylate, TEGDMA, 4-MET, phosphoric acid ester
monomer, silicon dioxide, photo initiator
All-Bond Universal Ultra-mild (pH = 3.1) 10-MDP phosphate monomer, HEMA, BISGMA, ethanol
(Bisco, Schaumburg, IL, USA)
Prime&Bond Elect Mild (pH = 2.5) Mono-, di- and trimethacrylate resins, PENTA, diketone, organic
(Dentsply Caulk, Milford, DE, USA) phosphine oxide, stabilizers, cetylamine hydrofluoride, acetone, water
Futurabond U Mild (pH = 2.3) Liquid 1: acidic adhesive monomer, HEMA, BISGMA, HEDMA, UDMA,
(Voco, Cuxhaven, Germany) catalyst; Liquid 2: ethanol, Initiator, catalyst
Peak Universal Adhesive Mild (pH = 1.2–2.0) Methacrylic acid, ethyl alcohol, HEMA, chlorhexidine di(acetate)
(Ultradent, South Jordan, UT, USA)
*
HEMA: 2-hydroxyethyl methacrylate; PENTA: dipentaerythritol pentaacrylate monophosphate; TEGDMA: triethylene dimethacrylate; 4-MET:
4-methacryloyloxyethyl trimellitic acid; BISGMA: Bisphenol A-glycidyl methacrylate; HEDMA: 2-hydroxyethyl dimethacrylate; UDMA: urethane
dimethacrylate.
 journal of dentistry 43 (2015) 765–776
evaluated the multi-mode adhesive Scotchbond Universal
(3 M Espe, St. Paul, MN, USA).7,13,15,16,29–31 Four studies
evaluated the bond strength of G-Bond Plus (GC, Tokyo,
Japan),10,14,15,32 and 4 evaluated the bond strength of All-Bond
Universal (Bisco, Schaumburg, IL, USA).15,16,29,31 The other
universal adhesives evaluated were Peak Universal Adhesive
(Ultradent, South Jordan, UT, USA), Futurabond U (Voco,
Cuxhaven, Germany) and Prime&Bond Elect (Dentsply, Caulk,
Milford, DE, USA).16,29,31 Only one universal adhesive was
ultra-mild (All-Bond Universal). The different compositions
and classifications according to pH of these universal
adhesives are described in Table 6.
Furthermore, different types of restorative materials were
used by each study, including the microhybrid composites
Filtek Z250 (3 M Espe, St. Paul, MN, USA), Opallis (FGM,
Joinville, SC, Brazil) and Clearfil AP-X (Kuraray, Tokyo,
Japan).7,14,29,30 Additionally, three studies used the nanocom-
posites Filtek Z350 (3 M Espe, St. Paul, MN, USA),10,15,31 and one
study used Filtek Supreme Plus (3 M Espe, St. Paul, MN, USA).13
The other restorative materials used were a nanohybrid
composite (GrandioSO, Voco, Cuxhaven, Germany)16 and a
flowable composite (G-aenial Universal Flo, GC, Tokyo,
Japan).32
Each study used its own protocol for aging and storing the
samples, and most studies stored the samples for 24 h in
distilled water at 37 8C. Thermocycling for 5000 cycles (cyclic
immersion for 30 s at 5.5 8C/55 8C, 7 s dwelling time) was also
used by one in vitro study.16 In this study, the bond strength
results were similar before and after thermocycling. Long-
term storage over 1 year in artificial saliva was used by one
study.7 The results for the dentin bond strength after 1 year
were inferior to those after 24 h; however, they were similar
for the etch-and-rinse and self-etch techniques. Although
aging seemed to reduce the bond strength, the overall results
among the different adhesives strategies (self-etch or etch-
and-rinse) did not seem to be influenced by the aging protocol.
3.3. Meta-analysis
A meta-analysis was performed with 24 data sets, although
only 10 studies were included.7,10,13–16,22,29,31,32 For the dentin
micro-tensile bond strength (mTBS), eight studies that includ-
ed 20 data sets were included in the analysis. Four studies
evaluated the dentin bond strength with 3 types of universal
adhesives. Additionally, one study evaluated the dentin bond
strength before and after thermo-cycling,16 and another study
analysed the bond strength after both 24 h and 1 year of
storage.7 For these studies, both results were included in the
analysis to obtain the overall results (Fig. 3). The character-
istics of these studies (20 data sets) are summarized in Table 3.
For the enamel bond strength, four studies were included in
two different analyses: two studies for the micro-shear bond
strength (mSBS) and the other two for the micro-tensile bond
strength (mTBS). The characteristics of these four studies (4
data sets) are described in Table 4.
The analysis of the dentin micro-tensile bond strength
(Fig. 3) showed no statistically significant difference between
the etch-and-rinse and self-etch strategies for the following
mild universal adhesives ( p  0.05): Scotchbond Universal, G-
Bond Plus, Prime&Bond Elect, Peak Universal and Futurabond
771
U. Considerable heterogeneity was observed in the analysis of
G-Bond Plus (I2 = 83%); this heterogeneity was not observed for
the analysis of Scotchbond Universal (I2 = 0%). However, for
All-Bond Universal, the etch-and-rinse mode was significantly
different than the self-etch strategy ( p = 0.02), and the value of
the I2 test was 87%, which demonstrated substantial hetero-
geneity.
Moreover, in the global analysis for the enamel micro-
tensile bond strength using a random-effect model (Fig. 4), the
etch-and-rinse strategy was significantly different than the
self-etch strategy ( p  0.05). The value of the I2 test was 0%. For
the enamel micro-shear bond strength (Fig. 5), the random-
effect model demonstrated that the etch-and-rinse strategy
was also significantly different than the self-etch mode
( p  0.05), and the I2 test value was 26%, representing low
heterogeneity.
3.4. Quality assessment
Of the 10 studies included, 8 presented a medium risk of bias,
and 2 studies showed a low risk of bias. The results are
described in Table 5, according to the parameters considered
in the analysis. The studies scored particularly poorly on the
following items: sample size calculation, description of
coefficient of variation and blinding of the examiner.
4. Discussion
The performance of the multi-mode adhesives evaluated by
in vitro studies was dependent on the adhesive strategy. All of
the new adhesive systems tested had the same versatility of
being used in both the etch-and-rinse and self-etch
approaches; the differences in their compositions might be
the reason for their different performances in bond strength,
as evaluated by in vitro studies. Despite the substantial
heterogeneity found in this meta-analysis, the in vitro
literature suggests that the prior acid etching to universal
adhesives improves the bond strength to enamel but not to
dentin for mild universal adhesives. Nevertheless, for enamel,
it was not possible to perform analysis by each material due to
the small number of studies that evaluated this condition for
the same universal adhesive. However, it was possible to
analyse both the micro-shear and micro-tensile bond
strengths, which showed an improvement in the bond
strength to enamel with the etch-and-rinse approach in all
analyses. Thus, the hypothesis was partially accepted, as only
an ultra-mild multi-mode adhesive (All-Bond Universal)
demonstrated an improvement in the dentin bond strength
with prior phosphoric acid etching; for enamel, this strategy
improved the bond strength of all universal adhesives
evaluated.
The general mechanisms for adhesive bonding to enamel
and dentin are essentially based on superficial demineraliza-
tion, followed by infiltration of resin monomers, which upon
polymerization become micro-mechanically interlocked in
the created porosities.1 On dentin, this process is called
‘hybridization’ and involves the formation of the hybrid layer
that contain with resin-infiltrated collagen fibrils.1,2 Phospho-
ric acid etching (30–40%) of dentin promotes superficial dentin
772 journal of dentistry 43 (2015) 765–776

Fig. 3 – Results for the analysis of the micro-tensile bond strength of different universal adhesives to dentin using random-
effects models. No statistically significant differences between the etch-and-rinse and self-etch strategies for Scotchbond
Universal, G-Bond Plus, Prime&Bond Elect, Peak Universal, and Futurabond U ( p I 0.05) were observed. For All-Bond
Universal, the etch-and-rinse mode was significantly different than the self-etch strategy ( p = 0.05).

demineralization and collaborates in the removal of the smear
layer, leading to the exposure of the collagen fibrils.2,29 The
presence of the smear layer acts as a physical barrier against the
penetration of adhesive monomers.33 Thus, prior phosphoric
acid etching helps to increase the impregnation of monomers,
which leads to the formation of a hybrid layer integrated with the
dentin.15,33–35 On the other hand, self-etch adhesives contain
acid resin monomers that simultaneously ‘‘condition’’ and
‘‘prime’’ the dental substrates and do not require a prior
phosphoric acid etching step.1 These types of adhesive only
dissolve the smear layer and do not remove the dissolved
calcium phosphates.1 Furthermore, self-etch adhesives differ

Fig. 4 – Results for the analysis of the micro-tensile bond strength to enamel using a random-effects model. The etch-and-
rinse mode was significantly different than the self-etch strategy ( p = 0.05).
 journal of dentistry 43 (2015) 765–776
Fig. 5 – Results for the analysis of the micro-shear bond strength to enamel using a random-effects model. The etch-and-
rinse mode was significantly different than the self-etch strategy ( p = 0.05).
from each other in many aspects, especially in their resin
monomer composition, water content and acidity.7 All-Bond
Universal was the only universal adhesive that demonstrated
an improvement in the bond strength with the etch-and-rinse
technique, probably due to its ultra-mild acidity (pH = 3.1),
which was not able to rightly ‘‘condition’’ and ‘‘prime’’ the
dentin substrate. Our systematic review demonstrated that
prior acid etching did not influence the dentin bond strength
for universal adhesives with mild acidity. However, the
content of acidic monomers could affect the bond strength;
for the sake of bond stability, a mild self-etch adhesive is
currently recommended for adhesion to dentin.1,36–38 Consid-
ering that the universal adhesives evaluated that are classified
as mild adhesive systems demonstrated no differences in the
dentin bond strength between the etch-and-rinse and self-etch
approaches, the more superficial interaction of these materials
with the dentin substrate without prior phosphoric acid
etching might reduce the risk of post-operative sensitivity
and the chance that the collagen fibrils will undergo degrada-
tion phenomena, which could compromise the bond stability
over time.7,32,36,37
For self-etch adhesives, a disadvantage of the self-etch
protocol is the reduction in enamel bonding efficacy,29,39,40
which was also observed with the universal adhesives in this
meta-analysis. One of the problems of self-etching adhesives
is that the increase in the surface area of the intact and ground
enamel is lower than that achieved with phosphoric acid; this
effect is dependent on the pH of the adhesive.29,40–50 Indeed,
the mechanism of bonding to enamel etched with phosphoric
acid is based on the micro-mechanical interlocking of
adhesives into etch pits through selective demineralization
of prismatic and aprismatic dental substrates.51 A recent 18-
month clinical trial21 that evaluated a multi-mode adhesive
with and without selective enamel etching revealed that the
clinical retention of Scotchbond Universal did not depend on
the bonding strategy, but a deterioration of marginal adapta-
tion from baseline to 18 months was observed with the self-
etching application. However, this occurrence was not
deemed as a clinical failure, as it could usually be solved by
repolishing the restoration.52,53 Despite manufacturers’ efforts
to improve the enamel bond strength with these new
universal adhesives, this meta-analysis reveals that the use
of prior acid etching increases the enamel bond strength, and
the etch-and-rinse strategy can be suggested for use to
improve the adhesion to enamel.
Beyond the different application techniques, the different
formulations among the adhesive systems might play an
773
important role on the dental material performance (see
Table 6). In this context, self-etch and universal adhesives
have a less acidic composition compared with phosphoric
acid, thus reducing their potential to demineralize the full-
mineral phase of enamel and, consequently, to create
appropriate micro-retentive porosities.2 For dentin bond
strength, differences among the self-etch or etch-and-rinse
strategy were not observed for the mild universal adhesives. In
general, the demineralization ability of self-etching systems is
limited20 and might compromise the adhesion to enamel;13,54
this was also found in our global analysis of enamel bond
strength with multi-mode adhesives.
Regarding the quality of the studies included, all of them
had a medium or low risk of bias. One limitation of this review
was the degree of scientific evidence obtained by the in vitro
studies. Bond strength tests are capable of ranking dental
adhesive systems according to their bond strength values.
However, some factors must be taken into consideration that
could influence the bond strength in clinical situations,
including masticatory stresses, pH and temperature cycling,
as well as the wet environment, which might lead to rapid
degradation of the adhesive interface.55–59 Thus, the validity of
bond strength tests to predict the clinical performance of
dental adhesives is questionable;60–62 however, some studies
evidenced that clinical results could, to some extent, be
predicted based upon laboratory results such as the those of
the bond strength tests.63–65 Moreover, mechanical tests can
provide valuable information in terms of identifying substrate
variables,64–67 which helps to define guidelines for application
procedures.61,68 In this way, systematic reviews are also
invaluable tools for clinical practice, providing a critical
approach of the scientific knowledge regarding certain
subjects, with the aims of answering a clinically relevant
question based on the best scientific evidence available and
pointing out improvements and standardized methodologies
for further research.69,70 Thus, there is a lack of data for the
long-term storage and thermal fatigue in the bond strength
analysis of universal adhesives, which might correlate better
with clinical behaviour.10 Over time, it was demonstrated both
in vitro71 and in vivo72 that the hybrid layer created by etch-
and-rinse adhesives could undergo degradation within 6
months to 3–5 years. This is manifested by a loss of cross-
banding of collagen fibrils, a large increase in water uptake,
and a loss of heavy metal staining.2 Future studies are required
to analyse the effect of long-term water storage on the in vitro
performance of universal adhesives. Additionally, studies on
different substrates such as carious dentin in association with
774 journal of dentistry 43 (2015) 765–776
in vivo tests are needed to assess the long-term clinical
behaviour of these new simplified adhesives.
Clinical studies pointed out that enamel pre-etching
resulted in a more durable marginal integrity of restorations
bonded with self-etch adhesives.21,73 Nevertheless, it is a
challenge in clinical situations to use phosphoric acid only on
enamel margins, as accidental dentin etching might occur,
especially if a low-viscosity etchant is used.29,47 For dentin,
considering that there is not an improvement in the bond
strength with prior acid etching in mild universal adhesives, a
self-etch approach might reduce the risk of post-operative
sensitivity.7,32,36,37 Therefore, based on this meta-analysis,
selective enamel etching prior to the application of a mild
universal adhesive is an advisable strategy for optimizing
bonding.
5. Conclusions
Although the studies showed heterogeneity, the in vitro
literature seems to suggest that bond strength is improved by
the use of multi-mode adhesives with prior acid etching only
for enamel; this effect was not evident for dentin with the use
of mild universal adhesives. The only ultra-mild universal
adhesive evaluated (All-Bond Universal) showed an improve-
ment in the dentin bond strength with the etch-and-rinse
strategy. Based on this meta-analysis, selective enamel
etching could be considered the best strategy for optimizing
the bond strength of mild universal adhesives.
Acknowledgements
The present research was financially supported by National
Counsel of Technological and Scientific Development (CNPq,
Process: 131462/2014-8).
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