Lasers Med Sci (2010) 25:511–516

DOI 10.1007/s10103-009-0682-3

ORIGINAL ARTICLE

Effects of erbium:yttrium–aluminum–garnet
and neodymium:yttrium–aluminum–garnet laser
hypersensitivity treatment parameters on the bond strength
of self-etch adhesives
E. Yazıcı & S. Gurgan & N. Gutknecht & S. Imazato

Received: 2 February 2009 / Accepted: 1 May 2009 / Published online: 28 May 2009
# Springer-Verlag London Limited 2009

Abstract This in vitro study evaluated the shear bond
strength (SBS) of two self-etch adhesives to coronal and
root dentin treated with erbium:yttrium–aluminum–garnet
(Er:YAG) or neodymium:yttrium–aluminum–garnet (Nd:
YAG) lasers for dentin hypersensitivity. The coronal and
root dentin surfaces of 60 extracted human cuspids were
divided into three groups (n=20): (1) control (without
treatment); (2) treated with Er:YAG; (3) treated with Nd:
YAG laser and a one-step (S3) or two-step self-etch
adhesive (SE). A nano-composite was applied and SBS
tests were performed. The mean SBS values were calculat-
ed, failure modes were determined, and data were subjected
to statistical analysis (P=0.05). Control/SE exhibited higher
values than did control/S3 and Nd:YAG/S3 on coronal
dentin (P<0.05). No significant differences were observed
between the SE and S3 groups in root dentin (P>0.05).
Comparisons of two dentin substrates did not show any
E. Yazıcı (*) : S. Gurgan
Department of Conservative Dentistry, Hacettepe University,
School of Dentistry,
Ankara, Turkey
e-mail: esra.yazici@hacettepe.edu.tr
N. Gutknecht
Department of Conservative Dentistry,
Periodontology and Preventive Dentistry,
RWTH Aachen University, School of Dentistry,
Aachen, Germany
S. Imazato
Department of Restorative Dentistry and Endodontology,
Osaka University Graduate School of Dentistry,
Osaka, Japan
difference except control/SE (P<0.05). The failure modes
were mainly adhesive. The SBSs of self-etch adhesives to
Er:YAG or Nd:YAG laser-treated surfaces were comparable
with control for both coronal and root dentin.
Keywords Dentin hypersensitivity .
Erbium:yttrium–aluminum–garnet (Er:YAG) laser .
Neodymium:yttrium–aluminum–garnet (Nd:YAG) laser .
Bond strength . Self-etch adhesive
Introduction
Dentin hypersensitivity is one of the most common com-
plaints in clinical dentistry for which there is still no effective
solution. It is characterized by short, sharp, pain arising from
exposed dentin in response to stimuli, typically thermal,
evaporative, tactile, osmotic, or chemical, which cannot be
ascribed to any other form of dental defect or abnormality [1].
The most widely accepted explanation for dentin hypersen-
sitivity is the hydrodynamic theory, which suggests that
dentin tubules act as capillary tubes and the fluid within them
acts in accordance with the law of fluid movement. The rapid
movement of fluid in dentin tubules, in response to certain
stimuli might produce deformation of nerve fibers wrapped
around the odontoblast cells, which may cause distortion of
intradental nerves and generate pain response [2, 3].
The presence of tubules in dentin makes the tissue
permeable, especially when the outer protective layer of
enamel or cementum is removed. Many dental procedures,
such as root planing, cavity preparation, and veneer and
crown preparation, involve the stripping off of the
cementum or enamel layer to expose the dentinal tubules.
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Consequently, this situation may lead to post-operative
sensitivity [1, 3].
To eliminate such discomforts for patients, several methods
have been tested to date (calcium hydroxide, cavity varnishes,
topical fluorides, fluoride iontophoresis, strontium chloride
and potassium nitrate dentifrices) [4]. Most of the treatments
have aimed to block exposed dentin tubules, but none of
them has produced consistently effective or long-lasting
results [5]. Laser therapy was introduced as an alternative for
the management of dentin hypersensitivity [1, 6].
Treatment of dentin hypersensitivity by erbium:
yttrium–aluminum–garnet (Er:YAG) laser revealed high
efficacy in reducing the diameters of dentin tubules under
some specific conditions, with the partial obliteration of the
tubules below the ablation threshold [7]. Depending on the
hydrodynamic theory, the decrease of dentinal fluid move-
ments would result directly in a decrease of dentin
hypersensitivity. Because of its high absorption by water
and hydroxyapatite, Er:YAG laser was anticipated to
decrease these fluid movements by evaporating the super-
ficial layers of the dentinal fluid or by sealing the tubule
orifices below the ablation threshold [2].
Another laser suggested to be used to treat dentin
hypersensitivity was neodymium:yttrium–aluminum–garnet
(Nd:YAG) laser. The effects of Nd:YAG laser on relieving
the pain of hypersensitive dentin had been demonstrated by
a number of clinical investigations [6, 8–10]. As Nd:YAG
laser can partially close the dentinal tubules and decrease
hydraulic conductance by melting the hydroxyapatite
structure, it reduces dentin hypersensitivity without harm-
ing the dentinal surface [1, 6]. Its mechanism is also based
on the coagulation and precipitation of plasma proteins in
dentinal fluid. Additionally, the thermal energy delivered
from Nd:YAG laser was reported to alter interdental nerve
activity and create a biostimulative effect [11].
The use of self-etch adhesives on patients suffering from
dentin hypersensitivity has gained popularity in the past
few years [12]. As these systems do not completely resolve
or remove the smear layer, they are partially integrated into
the hybrid layer, reducing the post-operative sensitivity
associated with removal of the smear layer and smear plugs.
Besides, as there is no need for rinsing, the clinical procedure
is less complicated and time consuming for the operators and
less painful for the patients with hypersensitive teeth [13, 14].
Current self-etch adhesive systems are generally divided into
two types [15]. The first are termed two-step self-etch
systems, which combine the demineralizing agent and primer
with a separate adhesive resin. The most recent type
combines all components into the liquid, and these have
been referred to as “all-in-one” or “one-step self-etch”
systems. Although low technique sensitivity and consistent
performance are expected to be achieved with one-step self-
etch adhesives due to their simplified application procedures,
Lasers Med Sci (2010) 25:511–516
some previous studies have indicated controversies on the
performance of these newly introduced adhesives [16].
Dentin hypersensitivity treatments do not always have
permanent effects, and patients may continue to suffer from
pain caused by external stimuli. At this point clinicians
usually restore lesions on coronal or root dentin with resin
composites. However, there is a lack of information on the
effects of lasers on the performance of adhesive restorations
when lasers are used to treat dentin hypersensitivity prior to
bonding procedures. Thus, the aim of this in vitro study
was to evaluate the effects, during hypersensitivity treat-
ment, of Nd:YAG and Er:YAG laser parameters on shear
bond strength (SBS) of either one-step or two-step self-etch
adhesives to coronal and root dentin.
Materials and methods
The materials used in the study are presented in Table 1. We
scaled 60 extracted intact human cuspids with a periodontal
scaler to remove organic debris before cleaning them with a
water/pumice slurry. Each tooth was examined under a
stereomicroscope (Leica DM-IL, Heerbrugg, Switzerland)
at ×25 magnification so that we could eliminate the ones
with cracks or hypoplastic defects. The superficial enamel
and cementum were abraded from the buccal tooth surfaces
with a 180-grit silicon carbide (SiC) paper under running
water to expose both coronal and root dentin within the
same tooth. The prepared surfaces were polished with 220-
grit, 320-grit and 400-grit SiC papers under copious water
for 10 s each and, finally, with a 600-grit SiC paper for 60 s, to
create a standard and clinically relevant smear layer. We
examined all specimens under the stereomicroscope at ×25
magnification to ensure that no enamel and cementum
remained and that no pulp had been exposed. Each tooth
was then mounted in a plexiglass mold with an auto-
polymerizing acrylic resin (Meliodent, Heraeus Kulzer,
Hanau, Germany) so that the flattened surface of the tooth
was positioned parallel to the base. The specimens were
placed in distilled water to reduce the temperature from the
exothermic polymerization reaction of the embedding resin.
After ultrasonic cleaning with distilled water for 3 min to
remove the debris, the surfaces were washed and dried with
oil-free compressed air. The teeth were then randomly
allocated into three groups (n=20):
1. Control group. The specimens in this group received no
treatment. Specimens with polished surfaces served as
the control.
2. Er:YAG group. A circle of diameter 5 mm was marked
on the coronal and root dentin surfaces of each
specimen to indicate the test site. The dentin surfaces
Lasers Med Sci (2010) 25:511–516
Table 1 Materials used in the study
Materials Composition
(batch no.)
Clearfil SE Primer: 10-MDP, HEMA, hydrophilic dimethacrylate,
Bond N,N-diethanol, p-toluidine, water. Adhesive: 10-MDP,
(#41538) bis-GMA, HEMA, hydrophilic dimethacrylate, CQ,
N,N-diethanol, p-toluidine, silanated colloidal silica
Clearfil Tri-S 10-MDP, bis-GMA, HEMA, initiator, ethanol, water,
Bond stabilizer, filler, hydrophobic dimethacrylate
(#41138)
Clearfil Silanated barium glass powder, pre-polymerized organic
Majesty filler, bis-GMA, hydrophobic aromatic dimethacrylate,
Esthetic di-camphorquinone
(#003BB)
10-MDP 10-methacryloyloxydocyl dihydrogen phosphate; HEMA hydroxyethylmethacrylate; Bis-GMA bis-phenol A diglycidylmethacrylate; CQ
dil-camphorquinone
were manually irradiated to simulate the clinical
conditions, in scanning movements, perpendicular to
the surface, at defocus mode (approximately 6 mm
away from the surface) with an Er:YAG laser (Fidelis
III, Fotona Medical Lasers, Ljubljana, Slovenia) for
60 s/cm2 at 3 Hz and 100 mJ, with air-cooling, two
times, in very long pulse (VLP) mode (300 μs) using
an R14 handpiece [2, 10].
3. Nd:YAG group. The coronal and root dentin surfaces to
be treated with Nd:YAG laser were also demarcated as in
the Er:YAG group. The Nd:YAG laser device (Fidelis III,
Fotona Medical Lasers) had a 300 μm quartz fiber optic
delivery system. The coronal and root dentin surfaces
were manually irradiated by scanning movements, per-
pendicular to the surface, approximately 1 mm away from
the dentin surface, for 60 s/cm2 at 15 Hz and 1 W,
without coolant, two times, in very short pulse (VSP)
mode (100 μs) [10, 17].
After storage in artificial saliva for 14 days at 37°C, all the
specimens were rinsed with distilled water. The coronal and
root dentin of ten teeth from each group were treated with a
two-step self-etch (SE) adhesive (Clearfil SE Bond, Kuraray
Medical, Tokyo, Japan) according to the manufacturer’s
instructions. The primer was applied to the dentin surfaces
for 20 s. The primed dentin surface was then dried with oil-
free compressed air. The bonding agent was applied, air
spread until a homogeneous layer was observed on the
surface, and light cured for 10 s with a standard curing light
(Bluephase C8, Ivoclar Vivadent, Schaan, Liechtenstein).
The remaining ten teeth on each group were treated with a
one-step self-etch adhesive (S3) (Clearfil Tri-S Bond, Kuraray
Medical) according to the manufacturer’s instructions. The
adhesive was applied to the dentin surface for 20 s, air blown
for 5 s to remove water and solvent, and light cured for 10 s.
513
Manufacturer Application procedure
Kuraray Apply primer and leave for 20 s. Dry with mild
Medical, air blow. Apply bond, air blow gently. Light
Tokyo, cure for 10 s
Japan
Kuraray Apply bond and leave for 20 s. Dry with high-
Medical, pressure air blow for more than 5 s. Light
Tokyo, cure for 10 s
Japan
Kuraray Apply in 1.5 mm thick increments. Light cure
Medical, for 20 s
Tokyo,
Japan
After the respective pretreatment and adhesive sequen-
ces, a Teflon jig (Ultradent, Salt Lake City, USA) with an
inner diameter of 2.3 mm and a height of 3 mm was
attached to the prepared dentin surfaces. Resin composite
(Clearfil Majesty Esthetic, Kuraray Medical, A3 shade) was
placed as two increments (1.5 mm thick each), and each
increment was light cured for 20 s. After curing, the Teflon
jig surrounding the composite resin was carefully removed.
The specimens were stored in distilled water at 37°C for 24
h, and then loaded by a metal rod parallel with and close to
the bonding interface at 1 mm/min in the shear mode until
rupture occurred, on a universal testing machine (Lloyd,
Hampshire, UK). SBS values were calculated as the ratio of
fracture load to bonding area and expressed in megapascals.
The fractured surface of each specimen was examined
with a stereomicroscope (Leica DM-IL,) at ×80 magnifica-
tion to determine the mode of failure. The failure mode was
classified as either adhesive (between dentin and adhesive),
cohesive (within the adhesive or dentin) or mixed (a
combination of adhesive and cohesive failures).
The data obtained from the shear bond strength testing
and failure mode evaluation were subjected to statistical
analyses for differences between and within the groups. The
normality of data distribution and the homogeneity of group
variances were evaluated prior to the selection of the
statistical tests. Since the variances of the coronal dentin
groups were not homogeneous, the data from this group
were subjected to Welch analysis of variance (ANOVA)
followed by a Dunnet T3 test. The variances of the root
dentin groups were homogeneous, so the data obtained
from this group were evaluated with ANOVA followed by a
Tukey honestly significant difference (HSD) test. The
differences between dependent variables within each group
(coronal and root dentin) were determined by Student’s t-
test. The differences among the groups for failure mode
distribution were evaluated by chi-square test. In all the
514
tests, the level of significance was set at P<0.05, and
calculations were handled by SPSS 12.0 software for
Windows (SPSS, Chicago, USA).
Results
Control/SE group showed significantly higher SBS values
than those of the control/S3 and Nd:YAG/S3 groups on
coronal dentin (P<0.05). Although the SBS values for the
control/SE group was higher than those for the Er:YAG/SE
and Nd:YAG/SE groups, the differences among these
groups were not significant (P>0.05). There were also no
significant differences among the S3 groups (P>0.05). For
root dentin, no significant differences were observed among
the SE or S3 groups (P>0.05) (Table 2).
Comparisons of SBS to coronal and root dentins in each
group failed to exhibit significant differences (P>0.05),
except for in the control/SE group, which showed higher
values for coronal dentin (P<0.05) (Table 2).
The failure modes of all groups were generally adhesive,
and the fracture distributions among the groups were
similar (P>0.05). There were no statistically significant
differences between coronal and root dentins except for in
the control/SE group (P>0.05). In the control/SE group,
coronal dentin exhibited 40% adhesive and 60% cohesive
and mixed failures, whereas the root dentin showed 90%
adhesive failures (P<0.05) (Fig. 1).
Discussion
Because of the absence of success in routine dentin
hypersensitivity treatments, the use of laser irradiation in
dentin hypersensitivity was proposed in the middle of the
1980s [10]. Several clinical studies have evaluated the
efficacy of lasers in reducing the symptoms of dentin
hypersensitivity [1, 2, 6–10]. While dentin hypersensitivity
treatments with lasers are generally successful in relieving
pain, sometimes they are not effective or their effects are
not permanent, lasting only for a short time. Therefore,
clinicians need to seal these hypersensitive dentin surfaces
Table 2 Shear bond strength values [mean ± standard deviation (sd)] and the comparison of coronal and root dentin within groups. The same
superscript letters indicate no statistical difference (P=0.05)
Groups (n=10) Control/SE Control/S3
Coronal dentin 17.98±4.57ab 8.26±2.01c
Root dentin 10.17±3.21α 8.78±2.54 α
Coronal–root dentin P<0.05 P<0.05
a,b,c
For coronal and root dentin results
α
Only for root dentin values
Lasers Med Sci (2010) 25:511–516
Fig. 1 Failure mode distributions (%) of the coronal and root dentin
specimens
by adhesive procedures following previous unsuccessful
treatments. However, until now, no published data have
been available concerning the effects of desensitizing
treatments with lasers on adhesive procedures.
Our study compared the in vitro SBS of two different
self-etch adhesive systems to human coronal and root
dentin which had been previously treated with Er:YAG or
Nd:YAG lasers for dentin hypersensitivity. A duration of 14
days is considered as a suitable follow-up period to see the
clinical performance of dentin hypersensitivity treatments
by many clinical studies [18, 19]. Therefore, in our study,
after laser application the dentin specimens were stored in
artificial saliva for 14 days at 37°C before the adhesive
procedures, to simulate the clinical conditions.
The effects of Er:YAG laser parameters for surface
pretreatment and cavity preparation (above the ablation
threshold) on dental hard tissues prior to restoration have
been extensively investigated, and the results reported in
the literature were often confusing and even contradictory
[20, 21]. However, the implications of Er:YAG laser
treatment for dentin hypersensitivity (below the ablation
threshold) on human dentin prior to bonding procedures
have not yet been clarified. There are some concerns about
the mechanisms of Er:YAG laser, as this laser is absorbed
by the water molecules in hydroxyapatites, can cause
ablation of dentin surface, and is opposite to the sealing
Er:YAG/SE Er:YAG/S3 Nd:YAG/SE Nd:YAG/S3
10.16±2.14bc 10.93±1.72 bc
11.23±3.16bc 8.58±3.49c
9.76±3.76 α
8.47±2.31 α
9.87±2.14 α
7.29±2.09 α
P<0.05 P<0.05 P<0.05 P<0.05
Lasers Med Sci (2010) 25:511–516
of dentinal tubules [10]. In this study, the Er:YAG laser
parameter—100 mJ/pulse, 3 Hz, defocus mode (approxi-
mately 6 mm away from the surface)—was lower than the
ablation threshold of dentin and it was expected to seal
partially the tubule orifices and decrease these fluid move-
ments by evaporating the superficial layers of the dentinal
fluid [2]. The efficacy of Er:YAG laser for the treatment of
dentin hypersensitivity had been investigated in a number
of studies, and it had been shown to decrease dentin
hypersensitivity [2, 7, 10]. In contrast to previous studies
with higher energy settings—120 mJ/10 Hz, focus mode
[21] or 260 mJ/4 Hz focus mode [22]—in our study the
bond strength values did not significantly differ after dentin
hypersensitivity treatment by Er:YAG laser for both self-
etch adhesives tested.
The pulsed Nd:YAG laser has also been demonstrated to
be an effective tool in reducing dentin hypersensitivity [7–
10]. It was reported that Nd:YAG laser was able to reduce
dentin permeability, to remove smear layer, and to melt
hydroxyapatite and totally or partially occlude exposed
dentin tubules with application parameters similar to those
used in this study [7]. However, several studies showed that
dentin irradiation with Nd:YAG laser before the adhesive
procedure resulted in a reduction in bond strength with the
resin composite [23]. This effect was credited to oblitera-
tion of the dentinal tubules by the melting and resolidifi-
cation of the irradiated dentin [23, 24]. On the other hand,
another study reported that laser did not have a negative
influence on bond strength [25]. In our study the bond
strength values did not differ after dentin hypersensitivity
treatment with Nd:YAG laser for either self-etch adhesive
tested. Similar to our findings, Rolla et al. [26] reported that
the irregularities formed by Nd:YAG laser irradiation might
have favored greater micromechanical retention for the self-
etch adhesives than non-irradiated dentin.
The regional variability of dentin in terms of morpho-
logical and functional characteristics determines the quality
of resin–dentin interactions achieved with adhesive systems
[27]. Since root dentin surfaces are usually small and are
not generally used as bonding substrates because of
technical difficulties, very little work has been published
on the adhesive properties of resin composites for human
root dentin [28]. It was shown that, as there were fewer
dentinal tubules in root dentin, the permeability of root
dentin was much lower than that of coronal dentin [29].
This might reduce the hydrophilic resin infiltration capacity
of root dentin and result in lower bond strength values than
those of coronal dentin. Similar to previous findings [28,
29], in our study the control/SE group exhibited higher
values for shear bond strength to coronal dentin than that of
root dentin. However, these values in the other five groups
indicated that coronal or root dentin substrates could not be
considered to be superior to the other one.
515
Etch-and-rinse adhesive systems, which include acid-
etching and rinsing steps, might be rather aggressive for
patients suffering from dentin hypersensitivity, as they can
stimulate pain thermally and chemically [30, 31]. Self-etch
adhesive systems use non-rinsed, acidic monomers that can
etch and prime tooth tissues simultaneously. Their bonding
mechanism is based on changing the chemical composition
of the substrate surface, in which the surface layer of dentin
is partially dissolved and the resultant porosity is filled with
adhesive resin. Moreover, the risk of discrepancy between
the depth of dentin demineralization and hybridization is
limited [12–14, 32]. Having these certain advantages, the
use of self-etch adhesives on hypersensitive teeth has
gained popularity in the past years. Thus, in this study,
two self-etch adhesives containing the same functional
monomers and having similar compositions, and from the
same manufacturer, were tested. Clearfil SE Bond, a two-
step self-etch system, has a higher acidity (pH=1.9) than
that of Clearfil Tri-S Bond, which is a one-step self-etch
adhesive (pH=2.7). For this reason, it was expected to
dissolve more mineral content of the dentin. This might
explain the lower bond strength of Clearfil Tri-S Bond to
coronal dentin. However, no significant difference was
observed between the bond strengths of the tested self-etch
adhesives for root dentin.
Although our findings might open a gateway, this in
vitro study could not predict clinical performance under in
vivo conditions, as the absence of dentin fluid in the
extracted teeth may have influenced the bond strengths.
Therefore, further in vivo studies are necessary to clarify
the possible effects of dentin hypersensitivity treatments
with Er:YAG and Nd:YAG lasers on bond strengths of
restorative materials.
Conclusion
Based on the outcomes and within the limitations of this in
vitro study, it may be concluded that parameters used for dentin
hypersensitivity treatment of both coronal and root dentin
substrates, either with Er:YAG laser or Nd:YAG laser, did not
affect the shear bond strength of the self-etch adhesives.
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