Journal of Dentistry 122 (2022) 104120

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Universal Simplified Adhesive applied under different bonding technique’s:

36-month Randomized Multicentre Clinical Trial
Elisa Gomes de Albuquerque a, Flavio Warol b, Chane Tardem c, Fernanda Signorelli Calazans c,
Luiz Augusto Poubel c, Thalita P. Matos d, Jullian J. Souza d, Alessandra Reis d, Marcos
O. Barceleiro c, Alessandro D. Loguercio d, *
a
Department of Restorative Dentistry, School of Dentistry, Juiz de Fora Federal University, Rua José Lourenço Kelmer, s/n - São Pedro, Juiz de Fora, MG, Brazil, CEP
36036-900
b
Department of Restorative Dentistry, School of Dentistry, UNIGRANRIO, Rua Prof. José de Souza Herdy, 1.160, bloco C, 2◦ andar, 25 de Agosto, Duque de Caxias, RJ,
Brazil. CEP 25071-202
c
Department of Restorative Dentistry, School of Dentistry, Fluminense Federal University, Rua Mario Santos Braga, 28, 3◦ andar, Centro, Niterói, RJ, Brazil. CEP 24020-
140
d
Department of Restorative Dentistry, School of Dentistry, State University of Ponta Grossa, Avenida General Carlos Cavalcanti, 4748, Ponta Grossa, PR, Brazil. CEP
84010-330

A R T I C L E I N F O S U M M A R Y

Keywords: Objectives: To evaluate the clinical performance of a new dual-cure universal adhesive system (Futurabond U,
Clinical trial, Dental bonding, Dentin-bonding Voco) when applied using different application strategies in non-carious cervical lesions (NCCLs) after 36
agents, Non-carious cervical lesions, Adhesive months.
techniques
Material and Methods: Futurabond U was applied in NCCLs of 50 subjects using four adhesion strategies (n = 50
Self etching
Dental restorations
restorations per group): only self-etch (SEE); selective enamel etching + self-etch (SET); etch-and-rinse with dry
Clinical longevity dentin (ERDry); and etch-and-rinse with wet dentin (ERWet). All cavities were restored using Admira Fusion
composite resin (Voco). Restorations were evaluated after 36 months using the World Federation criteria (FDI)
and the modified United States Public Health Service (USPHS) criteria.
Results: The after 36-month retention rates were 87% (75–92%) for SEE, 94% (83–98%) for SET, 91% (80–97%)
for ERDry, and 94% (83–98%) for ERWet. Forty-three restorations were considered to have minor discrepancies
in marginal adaptation at the 36-month recall (18 for SEE, 12 for SET, 7 for ERDry, and 6 for ERWet; p > 0.05).
One restoration was detected as a minor marginal discoloration at the 36-month recall (1 for SET; p > 0.05). No
restorations showed postoperative sensitivity and caries recurrence at 36 months.
Conclusion: The clinical performance of the Futurabond U did not depend on the employed bonding strategy, and
it was considered reliable after 36 months of clinical evaluation. However, greater marginal discrepancy was
observed in the self-etch groups.
Clinical Relevance: NCCLs restorations using a dual-cure universal adhesive in self-etch and etch-and-rinse modes
showed satisfactory clinical performance after 36 months.

1. Introduction most relevant tooth wear problems is the formation of non-carious

cervical lesions (NCCLs). Teixeira et al. [2], in a recent published sys­
With the improvement of the population’s life expectancy, there has tematic review of prevalence of NCCLs in adult people, showed that the
been an increase in teeth longevity [1]. Thus, tooth wear became an overall prevalence of NCCLs was approximately 46% and higher in older
important clinical issue mainly in adult and older population. One of the populations. As NCCLs expose dentin, it is common for patients to

Abbreviations: SEE, Self-etch; SET, selective enamel etching+self-etch; ERDry, etch-and-rinse with dry dentin; ERWet, etch-and-rinse with wet dentin; FDI, World
Federation criteria; USPHS, United States Public Health Service.
* Corresponding author at: Alessandro Dourado Loguercio, Department of Restorative Dentistry, School of Dentistry, Ponta Grossa State University. Avenida
General Carlos Cavalcanti, 4748, Ponta Grossa, PR, Brazil. CEP 84010-330
E-mail address: aloguercio@hotmail.com (A.D. Loguercio).

https://doi.org/10.1016/j.jdent.2022.104120
Received 21 September 2021; Received in revised form 25 February 2022; Accepted 2 April 2022
Available online 8 April 2022
0300-5712/© 2022 Elsevier Ltd. All rights reserved.
E.G. de Albuquerque et al.
complain of compromised esthetics caused by the cervical lesion, as well
as dentin hypersensitivity. A recent estimate indicates that approxi­
mately 33.5% of NCCLs showed some degree of dentin hypersensitivity
[3], which could affect the patients’ quality of life [4].
Therefore, in several cases, some kind of restorative intervention
may be necessary. Unfortunately, the restoration of NCCLs with adhe­
sive materials is challenging because of several factors: difficulty
restoring the margins of these lesions located in the cementum or dentin,
jeopardizing moisture control and access to the gingival margins [5,6],
and involving a high index of sclerotic dentin [7,8], which reduces
bonding efficacy when compared to sound dentin [8]. In fact, restora­
tions inserted in NCCLs have a high number of restoration losses, as well
as marginal defects, representing one of the least durable restorations [9,
10].
NCCL restorations are recommended for clinical trials of different
adhesives available in the market because restoration loss is more likely
to occur in NCCLs than in cavities surrounded by enamel (i.e., class IV)
or in self-retained cavities (i.e., classes I and II) [9,11]. Additionally, due
to the presence of NCCLs in several teeth of the same patient, it is easy to
compare adhesive systems in a split-mouth study design [9,11].
To improve the adhesive performance and simplify the adhesive
procedure in direct and indirect adhesive restorations, a new generation
(8th.) of adhesives has been launched [6]. Universal adhesives have been
introduced to allow clinicians more versatility during adhesive pro­
cedures, following a trend of manufacturers to provide one product for
application in different clinical situations [6]. The addition of specific
functional monomers facilitates chemical bonding to the enamel and
dentin and to multiple indirect substrates, including composites, metals,
zirconia, and silica-based ceramics [12,13]. The best known of these
monomers is 10-methacryloyloxydecyl dihydrogen phosphate (MDP)
[6]. However, several universal adhesives available in the market do
contain other functional monomers such as PENTA (dipentaerythritol
penta-acrylate monophosphate) or GPDM (glycero-phosphate dimetha­
crylate) [14,15].
Furthermore, in terms of direct restorations, dentists have the op­
portunity to decide which strategy to use (i.e., self-etch [SE], with or
without selective etching of enamel, and etch-and-rinse [ER]), with the
possibility of keeping the dentin dry or moist after the phosphoric acid
application. ER strategy involves complete removal of the smear layer
and superficial dentin demineralization by a phosphoric acid followed
by infiltration of resin monomers that permeate the micro-porosities
forming the hybrid layer. [6,11,15]. Unfortunately, the incomplete
impregnation of collagen fibers makes this region susceptible to
degrading mechanism present in the oral cavity environment, and it has
been considered the main disadvantage of the ER strategy. In contrast, in
the SE strategy, the acidic resin monomers infiltrates through the smear
layer, without requiring a separate phosphoric acid etching step. This
overcomes the disadvantages of ER strategy. However, due to the lack of
enamel etching with phosphoric acid, in the SE protocol occurs a
reduction in enamel bonding effectiveness [6,11,15].
Unfortunately, there is not a consensus about which is the better
adhesive strategy [10]. Before the universal adhesives were available,
usually, different adhesive compositions had to be evaluated when
etch-and-rinse and self-etch strategies were compared [10]. Only after
universal adhesives were launched in the market that it became possible
to evaluate the same adhesive composition in both adhesive strategies
(etch-and-rinse and self-etch mode) [15]. In the case of universal ad­
hesives, although randomized clinical trials have shown that the
bonding strategy used with them does not influence retention rate
[16–20], other studies have shown that the ER approach resulted in
higher retention rates and lower marginal discoloration when compared
to SE strategy [21,22]. Also, there is not a consensus regarding dentine
moisture (to keep the dentin moist or dry) after acid etching [23–25]. To
guarantee that functional monomers provide stable and durable in­
terfaces, all universal adhesives must contain water because water is
essential for ionizing the acidic functional monomers that make
2
Journal of Dentistry 122 (2022) 104120
chemical bonding possible [6]. Therefore, it is expected that this water
will be responsible for re-expanding the air-dried and collapsed collagen
mesh, thus facilitating adhesive resin infiltration [26], leading the
manufacturer’s claim that keeping the dentin dry or moist after the
phosphoric acid application does not make a difference in the universal
adhesive’s bonding quality. However, Choi et al. [23] and Sugimura
et al. [24] showed that the moisture of dentin surface is still a significant
factor for some universal adhesive bonding in the ER strategy, therefore
deserving more studies.
Also, a closer look at these previous studies showed that, despite
universal adhesives having been launched in the market in 2012, the
majority of clinical results in the literature are short-term follow-ups (6
to 24 months) [13, 15-22, 27-31], and the few medium-term clinical
studies evaluating universal adhesives have primarily evaluated the first
universal adhesive available on the market [16, 32-35]. Therefore, it is
important to have more medium-term clinical studies evaluating
different universal adhesives available in the market, as recognized by a
recent published review [15], to assess which adhesion strategy may
optimize clinical outcomes.
Considering what was presented, the objective of this multicenter,
double-blind, randomized clinical trial was to evaluate the clinical
behavior of a new dual-cure universal adhesive when applied using
different application strategies during 36 months of clinical evaluation.
The tested null hypothesis was that bonding to NCCLs using the SE
strategy (regardless of whether or not it was associated with selective
enamel etching) or using the ER strategy (applied on dry or moist
dentin) would result in similar retention levels over 36 months of clin­
ical service.
2. Material and methods
2.1. Study design
The description of the experimental design followed the Consoli­
dated Standards of Reporting Trials (CONSORT) statement [36].
2.2. Ethics approval
The State University of Ponta Grossa (protocol 165.357; 2016) and
Federal Fluminense University (protocol 1.618.895; 2016) Ethics Com­
mittees reviewed and approved the protocol and issued a consent form
for this study. Written informed consent was obtained from all partici­
pants prior to starting the treatment.
2.3. Protocol registration
This clinical trial was registered in clinical registry (www.clinical
trial.gov; #NCT03244124). All participants were informed about the
nature and objectives of the study, but they were not aware of which
tooth received the specific treatments under evaluation.
2.4. Trial design, settings, and location of data collection
This was a multicenter, double-blind, superiority, split mouth ran­
domized clinical trial. The study was carried out in the clinics of the
School of Dentistry of both Universities and the restorations were placed
in October 2016 and November 2016.
2.4.1. Recruitment
Patients were recruited as they seek for treatment in the clinics of
Dentistry of both Universities. No advertisement was made for partici­
pant recruitment. Patients were recruited in the order in which they
reported for the screening session, thus forming a sample of
convenience.
E.G. de Albuquerque et al.
2.4.2. Eligibility criteria
A total of 120 participants were examined by two calibrated dental
residents to check if they met the inclusion and exclusion criteria in each
University (70 in the 1st. University and 50 in the 2nd. University;
Figure 1). The evaluations were performed using a mouth mirror, an
explorer, and a periodontal probe. Participants had to be in good general
health, be at least 18 years old, have an acceptable oral hygiene level,
and present at least 20 teeth under occlusion.
Participants were required to have at least four NCCLs to be restored
in four different teeth. These lesions had to be non-retentive, deeper
than 1 mm, and involve both the enamel and dentin of vital teeth
without mobility. The cavosurface margin could not involve more that
50% of enamel [37]. Patients with extremely poor oral hygiene or using
orthodontic devices, severe or chronic periodontitis, or with more than
10 teeth with occlusal facets (premolars and molars) were excluded from
the study as they would receive other treatments before restorative
intervention. Also, participants with known allergy to resin-based ma­
terials or any other material used in this study, pregnant or breast­
feeding women, or participants under chronic use of anti-inflammatory,
analgesic, and psychotropic drugs were not included in the study.
Fig. 1. - Flow chart, np number of patients, nr number of restorations.
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Journal of Dentistry 122 (2022) 104120
2.5. Sample size calculation
The annual failure rate (AFR) of one-step self-etch adhesives in
NCCLs was reported to be 4.4% in a systematic review [10] published
when this study was being planned. Considering that this decline follows
a linear trend, the overall retention rate of one-step self-etch adhesives
will be approximately 78% after 5-year of clinical service. With an α of
0.05, a power of 80%, and a two-sided test, the minimal sample size was
50 restorations in each group in order to detect a difference of 25%
among the tested groups.
2.6. Random sequence generation and allocation concealment
The randomization was done on an intra-individual basis so that
each subject ended up with four restorations, each one resulting from
one of all possible combinations of adhesive strategy. These randomi­
zation schemes were performed using software available at http://www.
sealedenvelope.com.
A staff member not involved in the research protocol performed the
randomization process with computer-generated tables. Details of the
allocated groups were recorded on cards contained in sequentially
numbered, opaque, and sealed envelopes. Opening the envelope only on
the day of the restorative procedure guaranteed the concealment of the
E.G. de Albuquerque et al. Journal of Dentistry 122 (2022) 104120

random sequence. In all cases, the tooth with the highest tooth number Table 2
received the treatment described first, while the tooth with the next Composition and batch number of materials used in the restorative procedures
number in sequence received the treatment mentioned second, with Material Batch Number Composition
placement continuing in a similar manner until the fourth tooth. All (Manufacturer)
restorations in the same subject were always placed in different sextants. VOCOCID (VOCO 123523 35% Phosphoric Acid
GmbH, Cuxhaven,
Germany)
2.7. Interventions: restorative procedure Futurabond U (VOCO 1609415 Adhesive: HEMA, Bis-GMA,
GmbH, Cuxhaven, HEDMA, acidic adhesive
All the patients selected for this study received dental prophylaxis Germany) monomer (*), urethane
dimethacrylate, catalyst, silica
with a suspension of pumice and water in a rubber cup and signed an
nanoparticles, etanol and water
informed consent form two weeks before the restorative procedures. The Admira Fusion (VOCO - shade A2: 1607524; Resin matrix: aromatic and
degree of sclerotic dentin from the NCCLs was measured according to GmbH, Cuxhaven, - shade A3: 1606252; aliphatic dimethacrylates,
the criteria described by Swift et al. [38] (Table 1). The cavity di­ Germany) -shade A3,5: 1605482 methacrylate-functionalized
mensions in millimeters (height, width, and depth), the geometry of the polysiloxane Inorganic filler:
Ba-Al-glass, pyrogenic SiO2,
cavity (evaluated by profile photograph and labeled at <45o, 45o-90o, filler load: 78 mass %.
90o<135o, and >135o) [39], the presence of an antagonist, and the Photoinitiator:
presence of attrition facets were observed and recorded. Pre-operative camphorquinone. Synergist: NI
sensitivity was also evaluated by applying air for 10 s from a dental Abbreviations: HEMA: 2-hydroxyethyl methacrylate; Bis-GMA: Bisphenol-A-
syringe placed 2 cm from the tooth surface and with an explorer. These glycidyl dimethacrylate; HEDMA: 1,6-hexanediol dimethacrylate;
features were recorded to allow comparison of the baseline features of (*) Acidic adhesive monomer in the composition of Futurabond U is 10-MDP: 10-
the dentin cavities among experimental groups. Half of the cavities were methacryloyloxydecyl dihydrogen phosphate according to personal communi­
selected for each center. cation with Dr. Martin Danebrock
Both centers were calibrated together. For this purpose, the study
director placed one restoration of each group to identify all steps
involved in the application technique. Then, the four operators, who Table 3
were resident dentists with more than five years of clinical experience in Application mode of the adhesive system in the groups (*)
operative dentistry, two in each center, placed four restorations, one of Group Application mode
each group, under the supervision of the two study supervisors, one for Etch Adhesive Resin composite

each center, in a clinical setting. The restoration failures were shown to Self-etch No Keep 1. Activate Insert in the
the operators prior to starting the study. At this point, the operators were (SEE) dentin single dose cavity increases
Self-etch Apply dry (do adhesive of up to 1 mm and
considered calibrated to perform the restorative procedures. The oper­
associated etchant not package; light-cure each
ators restored all teeth. All participants received four restorations, one of to selective ONLY in overdry) 2. Apply area of the
each experimental group in different lesions previously selected ac­ enamel enamel (30 adhesive to surface of the
cording to the inclusion criteria. etching s), rinse for the cavity restoration with a
Before restorative procedures, the operators anesthetized the teeth (SET) 30s, air dry surface with dental curing
to remove Voco Single light appliance
with a 3% mepivacaine solution (Mepisv, Nova DFL, Rio de Janeiro, RJ,
excess of Tim Brush for (wavelength of
Brazil) and cleaned all lesions with pumice and water in a rubber cup water 20 s with 470 nm, light
(ref #8040RA and #8045RA, KG Sorensen, Barueri, SP, Brazil), fol­ Etch-and- Apply vigorous power of 1200
lowed by rinsing and drying. Then, shade selection was made using a rinse, etchant in agitation; mW/cm2) for 20
dentin dry enamel (30 3. Gently air s.
shade guide. After rubber dam was placed, the universal adhesive sys­
(ERDry) s) and dentin thin for 5 s;
tem Futurabond U (Voco, GmbH, Cuxhaven, Germany) was applied as (**) (15 s), rinse 4. Light cure
described below. The compositions, application modes, and batch Etch-and- for 30s, air Keep for 10 s at
numbers are described in Table 2 and Table 3. rinse, dry to dentin 1200 mW/
dentin wet remove wet cm2.
(ERWet) excess of
- Self-Etch group (SEE) – One coat of adhesive was gently scrubbed on
water
the entire enamel and dentin surface for approximately 20 s, ac­
cording to the manufacturer’s recommendations (Table 3). Then, the (*) According to the manufacturer’s instructions.
adhesive was evaporated by gentle air stream for 5 s and light cured (**) Manufacturer does not indicate application in dry dentin.
for 10 s at 1200 mW/cm2 (Bluephase, Ivoclar Vivadent, Schaan,
Liechtenstein). applied for 30 s only in enamel. Then, cavities were rinsed, and air-
- Self-Etch associated to Selective Enamel Etching group (SET) - The 35% dried, keeping dentin visible dry. The adhesive system was applied as
phosphoric acid (Vococid, Voco GmbH, Cuxhaven, Germany) was described in the self-etch group (Table 3). Solvent evaporation and
light curing procedures were also the same.
Table 1
- Etch-and-rinse Dry dentin group (ERDry) – The 35% phosphoric acid
Dentin sclerosis scale (*) (Vococid) was applied for 30 s (enamel) and 15 s (dentin). Then,
cavities were rinsed, and air-dried, keeping dentin visible dry. The
Category Criteria
adhesive system was applied as described in the self-etch group
1 No sclerosis present; dentin is light yellowish or whitish, with little (Table 3). Solvent evaporation and light curing procedures were also
discoloration; dentin is opaque, with little translucency or transparency
the same.
2 More sclerosis than in category 1 but less than halfway between
categories 1 and 4 - Etch-and-rinse Wet dentin group (ERWet) – The 35% phosphoric acid
3 Less sclerosis than in category 4 but more than halfway between (Vococid) was applied for 30 s (enamel) and 15 s (dentin). Then,
categories 1 and 4 cavities were rinsed, and slightly air-dried, keeping dentin visible
4 Significant sclerosis present; dentin is dark yellow or even discolored moist. The adhesive system was applied as described in the self-etch
(brownish); glassy appearance, with significant translucency or
transparency evident
group (Table 3). Solvent evaporation and light curing procedures
were also the same.
(*) Adapted from Swift et al.[33]

4
E.G. de Albuquerque et al. Journal of Dentistry 122 (2022) 104120

After adhesive application, the resin composite Admira Fusion uni­
doses (Voco) was used, usually with 2 increments, but in a few numbers
of cases up to three increments were used. The resin composite was
inserted directly in the cavity with a Centrix device (Centrix, Shelton,
CT, USA), each increment being lightly cured for 20 s at 1200 mW/cm2.
The restorations were finished immediately with fine and extra-fine
#2200 diamond burs (KG Sorensen) and polished with Jiffy polisher
(Ultradent, South Jordan, Utah, USA) under constant water-cooling.
2.8. Calibration procedures for clinical evaluation
For training purposes, two experienced and calibrated examiners for
each center observed 10 photographs that were representative of each
score for each criterion, under supervision of study director. Then, they
evaluated 10 to 15 patients each on two consecutive days. These subjects
had cervical restorations but were not part of this project. An intra-
examiner and inter-examiner agreement of at least 85% was necessary
before beginning the evaluation for all evaluators [40].
group at baseline and after 6, 12, 18 and 36 months were evaluated
using the Wilcoxon test.
3. Results
3.1. General results
The restorative procedures were implemented exactly as planned,
and no modification was performed. Seventy out of 120 subjects were
excluded from the study because they did not fulfil the inclusion criteria.
Thus, a total of 50 subjects (23 men and 27 women), 25 for each center,
were selected. Two hundred restorations were placed, 50 for each group
(Figure 1). All baseline details relative to the research subjects and
characteristics of the restored lesions are displayed in Table 4.
The overall Cohen kappa statistics showed excellent agreement be­
tween the examiners in the 6-, 12-, 18- and 36-month (0.82) follow-ups.
All research subjects were evaluated at baseline and at the 6-month
recall. Unfortunately, one subject moved to a new city (center 1) and

2.8.1. Blinding
The examiners were not involved with the restoration procedures Table 4
and therefore blinded to the group assignment. Patients were also Characteristics of the research subjects and the non-carious cervical lesions
blinded to group assignment in a double-blind randomized clinical trial (NCCL) per each experimental group (*).
design. Characteristics of research subjects Number of patients

Gender distribution
2.8.2. Clinical evaluation Male 23
An individual standardized paper case report form was used for each Female 27
Age distribution (years)
evaluator at each recall time so that evaluators were kept blinded to
20-29 3
earlier evaluations during the follow-up recalls. The restorations were 30-39 3
evaluated by World Federation criteria (FDI) [40,41] and the classical 39-49 20
United States Public Health Service (USPHS) adapted criteria [37,42] at > 49 24
baseline and after 6,12, 18 and 36 months of clinical service. Only the Characteristics of NCCLs lesions Number of lesions
SEE SET ERDry ERWet
clinically relevant measures for evaluation of adhesive performance Shape (degree of angle)
were used and scored. The primary clinical endpoint was restoration < 45 0 0 0 0
retention/fracture, but the following secondary endpoints were also 45-90 8 10 13 6
evaluated: marginal staining, marginal adaptation, postoperative 90-135 17 13 15 17
> 135 25 27 22 27
sensitivity, and recurrence of caries. The evaluation of the spontaneous
Cervico-incisal height (mm)
postoperative sensitivity was performed one week after the restorative < 1.5 14 17 17 15
procedure by asking the patient if he experienced any pain during the 1.5-2.5 15 13 14 17
period. 2.5-4.0 12 8 12 11
These variables were ranked according to FDI criteria into clinically > 4.0 9 12 7 7
Degree of sclerotic dentin
very good, clinically good, clinically sufficient/ satisfactory, clinically 1 29 28 28 31
unsatisfactory but repairable, and clinically poor (replacement required) 2 13 14 11 11
[[40][41], ]. In the case of marginal staining and marginal adaptation, 3 6 7 9 6
the semiquantitative criteria (SQUACE) proposed by Hickel et al. [40, 4 2 1 2 2
Presence of antagonist
41] was used. Each evaluator outlined the extent of the observed event
Yes 41 49 42 44
on the sketch of each restoration using a pen according to defined No 9 1 8 6
criteria (marginal staining and marginal adaptation); after that, each Attrition facet
margin was assessed quantitatively as a proportion of the total length of Yes 37 38 40 43
the margin. Also, all mentioned variables previously described were No 13 12 10 7
Pre-operative sensitivity (spontaneous)
evaluated by USPHS criteria into alfa, bravo, and Charlie [42]. Yes 13 11 11 13
Both examiners evaluated all the restorations once and indepen­ No 37 39 39 37
dently. When disagreements occurred during the evaluations, they had Pre-operative sensitivity (air dry)
to reach a consensus before the participant was dismissed. The average Yes 17 13 13 15
No 33 37 37 35
AFR per adhesive strategy was calculated [10].
Tooth distribution
Anterior
2.9. Statistical Analysis Incisor 9 12 10 11
Canines 8 5 10 9
The statistical analyses followed the intention-to-treat protocol ac­ Posterior
Premolar 21 24 23 21
cording to CONSORT (Consolidated Standards of Reporting Trials) Molar 12 9 7 9
suggestion [36]. Descriptive statistics were used to describe the distri­ Arc distribution
butions of the evaluated criteria. Statistical analysis for each individual Maxillary 25 27 24 26
item was performed for each evaluation criteria (FDI and USPHS Mandibular 25 23 26 24
criteria). The differences in the ratings of the four groups after 6, 12, 18 (*) SEE, self-etch without selective enamel etching; SET, self-etch with selective
and 36 months were tested with the Friedman repeated-measures enamel etching; ERWet, etch-and-rinse, wet dentin; ERDry, etch-and-rinse, dry
analysis of variance by rank, and differences in the ratings of each dentin.

5
E.G. de Albuquerque et al. Journal of Dentistry 122 (2022) 104120

was not included in the 12-month recall rate, another three subjects did
not attend the 18 and 36-month recall (one in center 1 and 2 in center 2).
3.2. Retention/fracture
All the data regarding follow-up times are depicted in the Tables 5
and 6. However, only the 36-month data are described here. After 36-
month of clinical evaluation, 17 restorations were lost (6 for SEE, 3
for SET, 4 for ERDry, and 4 for ERWet). According to both evaluation
criteria, the 36-month retention rates (95% confidence interval [CI])
were 87% (75–92%) for SEE, 94% (83–98%) for SET, 91% (80–97%) for
ERDry, and 94% (83–98%) for ERWet (Table 7). The average AFR per
adhesive strategy was: 4.3% for SEE, 2.0% for SET, 3.0% for ERDry, and
2.0% for ERWet.
The Kaplan Meier curves showed no significant differences (Log-rank
test, p = 0.7534) among the cumulative probability of the primary
endpoint, which was loss of retention/fracture (Figure 2). The paired
comparisons among the groups are showed in Table 8, meaning that
cavities receiving each group have the same chance to loss of retention.
In addition, after the 36-month recall, one restoration of the ERDry
group showed some small fracture (Table 5). No significant difference
was detected between groups at the 36-month recall for FDI and USPHS
criteria (p = 1.0; Tables 5 and 6).
3.3. Marginal adaptation
Forty-three restorations were considered to have minor discrep­
ancies in marginal adaptation at the 36-month recall using the FDI
criteria (18 for SEE, 12 for SET, 7 for ERDry, and 6 for ERWet; Table 5).
Significant difference was detected between groups at the 36-month
recall in the FDI criteria (p< 0.001; Table 5). A significant and lower
marginal adaptation was observed for SEE and SER when compared to
ERWet (p< 0.001) and ERDry (p< 0.001; Table 5) in the FDI criteria.
The etch-and-rinse groups (ERWet and ERDry) showed a better perfor­
mance than the self-etch groups (SEE and SET) at 36-month recall in the
FDI criteria. No significant difference was observed in the USPHS
criteria (p > 0.05; Table 6).
3.4. Marginal Discoloration
After 36 months of clinical evaluation, 1 restoration was detected as
a minor marginal discoloration using the FDI criteria (1 for SET, Table 5)
and no significant difference was detected in the FDI and USPHS criteria
(p > 0.05; Tables 5 and 6).
3.5. Other parameters
No restorations had postoperative sensitivity to air or recurrence of
caries at the 6-, 12-, 18- and 36-month recalls in the FDI and USPHS
criteria (Tables 5 and 6).
4. Discussion
The present study’s results showed no significant difference in the
retention rate when different adhesive strategies were compared after a
36-month follow-up, which means that the use of phosphoric acid only
in enamel or in enamel and dentin does not determine the restoration
retention when Futurabond U (FBU) was indicated. Therefore, we failed
to reject the null hypothesis.
Actually, when universal adhesives are evaluated, the assertion that
there is no consensus about which is the better adhesive strategy is based
on short-term clinical studies [17–20]. When medium-term (at least 3
years of follow-up) results are evaluated, no significant difference was
observed when the SE strategy, regardless of whether or not it was
associated with selective enamel etching or the ER strategy (applied on
dry or moist dentin), was evaluated [16, 32-35]. This highlights the
importance of performing medium-term clinical evaluations to observe
any clinically important difference when different adhesive strategies
are compared.
It is worth mentioning that the overall retention rate for FBU, after
36 months of clinical evaluation in the present study, is closer to the
retention rate of previous studies evaluating universal adhesives [16,
32-35]. For example, Loguercio et al.’s [16] and Perdigão et al.’s studies
[34] evaluated Scotchbond Universal (SBU; 3M Oral Care, St. Paul, MN,
USA), the first universal adhesive available in the market, and the

Table 5
Number of evaluated restorations for each experimental group (*) classified according to the World Dental Federation (FDI) criteria [35, 36]]
6 months 12 months 18 months 36 months
FDI Criteria (**) SEE SET ERDry ERWet SEE SET ERDry ERWet SEE SET ERDry ERWet SEE SET ERDry ERWet

Marginal staining A 48 49 49 47 42 41 45 44 36 37 42 41 40 42 42 42
B – – – – 03 04 01 01 06 06 01 01 – 01 – –
C – – – – – – – – – – – – – – – –
D – – – – – – – – – – – – – – – –
E – – – – – – – – – – – – – – – –
Fractures and retention A 48 49 49 47 45 45 46 45 42 43 43 42 40 43 41 42
B – – – – – – – – – – – – – – – –
C – – – – – – – – – – – – – – 01 –
D – – – 01 – – 01 01 – – – – – – – –
E 02 01 01 02 02 03 01 02 04 03 03 04 06 03 04 04
Marginal adaptation A 40 40 45 44 33 35 41 41 29 30 37 36 22 31 35 36
B 08 09 04 03 12 10 05 04 10 11 06 06 18 12 06 06
C – – – – – – – – 03 02 – – – – 01 –
D – – – – – – – – – – – – – – – –
E – – – – – – – – – – – – – – – –
Post-operative (hyper-) A 48 49 49 47 45 45 46 45 42 43 43 42 40 43 42 42
sensitivity B – – – – – – – – – – – – – – – –
C – – – – – – – – – – – – – – – –
D – – – – – – – – – – – – – – – –
E – – – – – – – – – – – – – – – –
Recurrence of caries A 48 49 49 47 45 45 46 45 42 43 43 42 40 43 42 42
B – – – – – – – – – – – – – – – –
C – – – – – – – – – – – – – – – –
D – – – – – – – – – – – – – – – –
E – – – – – – – – – – – – – – – –

(*) SEE, self-etch without selective enamel etching; SET, self-etch with selective enamel etching; ERWet, etch-and-rinse, wet dentin; ERDry, etch-and-rinse, dry dentin.
(**) A = Clinically very good; B = Clinically good; C = Clinically sufficient / satisfactory; D = Clinically unsatisfactory; E = Clinically poor.

6
E.G. de Albuquerque et al. Journal of Dentistry 122 (2022) 104120

Table 6
Number of evaluated restorations for each experimental group (*) classified according to the USPHS criteria [37,42]
6 months 12 months 18 months 36 months
USPHS Criteria SEE SET ERWet ERDry SEE SET ERDry ERWet SEE SET ERDry ERWet SEE SET ERDry ERWet

Marginal staining Alfa 48 49 49 47 44 44 46 45 40 41 43 42 40 43 42 42

Bravo – – – – 01 01 – – 02 02 – – – – – –
Charlie – – – – – – – – – – – – – – – –
Retention Alfa 48 49 49 48 45 45 45 46 42 43 43 42 40 43 42 42
Bravo – – – – – – – – – – – – – – – –
Charlie 02 01 01 02 02 03 01 02 04 03 03 04 06 03 04 04
Fractures Alfa 48 49 49 47 45 45 46 45 42 43 43 42 40 43 41 42
Bravo – – – – – – – – – – – – – – 01 –
Charlie – – – 01 – – 01 01 – – – – – – – –
Marginal Alfa 48 49 49 47 41 42 45 44 36 37 41 40 36 38 39 39
adaptation Bravo 02 01 – – 04 03 01 01 06 06 02 02 04 05 03 03
Charlie – – – – – – – – – – – – – – – –
Post-operative Alfa 48 49 49 47 45 45 46 45 42 43 43 42 40 43 42 42
(hyper-) Bravo – – – – – – – – – – – – – – – –
sensitivity Charlie – – – – – – – – – – – – – – – –
Recurrence of Alfa 48 49 49 47 45 45 46 45 42 43 43 42 40 43 42 42
caries Bravo – – – – – – – – – – – – – – – –
Charlie – – – – – – – – – – – – – – – –

(*) SEE, self-etch without selective enamel etching; SET, self-etch with selective enamel etching; ERWet, etch-and-rinse, wet dentin; ERDry, etch-and-rinse, dry dentin.

Table 7 Table 8
Absolute risk (95% CI) and relative risk (95% CI) for outcome retention for Retention loss hazard ratio (95% confidence interval) for pairwise
different groups after 3-years of clinical evaluation comparison of different groups
Absolute risk (95% CI) Relative risk (95% CI)* Pairwise comparison Hazard ratio (95% CI)

ERWet 93.6 (82.84 – 97.8) 1.3 (0.3 – 5.6) SEE vs. SET 0.87 (0.38 to 1.98)
ERDry 91.5 (80.0 – 96.6) SEE vs. ERDry 0.64 (0.28 to 1.45)
SET 93.6 (82.84 – 97.8) 1.0 (0.2 – 4.7) SEE vs. ERWet 0.78 (0.34 to 1.77)
SEE 87.2 (74.8 – 94.0) 2.0 (0.5 – 7.5) SET vs. ERDry 0.73 (0.32 to 1.66)
SET vs. ERWet 0.89 (0.39 to 2.03)
Related to group ERWet. ERDry vs. ERWet 1.22 (0.54 to 2.76)

Both are higher when compared to AFR of SE (3.1%) and ER (2.3%)

Fig. 2. - Kaplan–Meier survival rate at 3 years obtained for the adhesive stra­
tegies tested
retention rates after 36 months were 89% and 86% for restorations in
the SE group, respectively, which is similar to the retention rate for FBU
applied through SE (87%) in the present study. When ER results are
compared, the retention rate for FBU was 93%, closer than the results
observed by Loguercio et al. [16] and Atalay et al. [32] after a 36-month
follow-up using SBU, which was 98% for both studies. More than that,
the results of the present study in terms of retention rate showed better
results when compared to the old version of simplified adhesives (ER
and SE). According to Peumans et al. [10], the percentage of AFR of
1-step SE and 2-step ER adhesives were 4.4% and 5.8%, respectively.
observed in the present study.
Primarily, the exemplary retention rate patterns observed for FBU, as
well as for SBU, can be explained because both universal adhesives
present a similar pH (i.e., 2.3 for FBU and 2.7 for SBU) and both contain
10-methacryloyloxydecyl dihydrogen phosphate (10-MDP) in their
composition. The molecule atomic relation of 10-MDP favors its chem­
ical interaction with the tooth substrate [43–45]. Due to this interaction,
the monomer produces highly hydrolytically stable 10-MDP-Ca salts
that promote stable chemical bonding with dental substrates [46,47].
The produced salt contributes to the protection of the collagen fibers, as
well as to its etching potential, when compared to other functional
monomers. The intense chemical interaction established between
10-MDP and hydroxyapatite is assigned to the superficial dissolution of
hydroxyapatite, induced by the adsorption of 10-MDP, and the subse­
quent deposition of MDP-Ca salts with lower solubility than of the salts
produced by other functional monomers [46].
It is important to mention that, when the etch-and-rinse strategy was
used, FBU was applied under dry or wet demineralized dentin (ERDry
and ERWet). To be considered as an ideal universal adhesive, the ad­
hesive would be one for which bonding to the tooth would not be
influenced by clinically plausible variations in the surface moisture [48].
When traditional simplified etch-and-rinse adhesives are applied, it is
important to keep the dentin moist after phosphoric acid etching to
avoid the collapse of the exposed collagen matrix and guarantee the
infiltration of the resin monomer into the demineralized dentin [49].
However, as described in the introduction section, to keep the 10-
MDP ionized and to enable the self-etching potential [6] water was
added in the composition of the universal adhesive. Although the exact
amount of water content of the universal adhesives are not disclosed by
the manufacturers, several studies have already claimed that universal
adhesives contain approximately 10–25%wt of water [48,50,51].

7
E.G. de Albuquerque et al.
Unfortunately, this is a controversial topic. For instance, one study
showed that while one universal adhesive showed higher bond strength
when applied in dry dentin, other one showed lower bond strength when
applied in dry dentin [25]. The huge variability in the amount of water
among universal adhesives could be partially responsible for the
controversial results observed in the literature [23-25,52]. Unfortu­
nately, the manufacturer did not disclose the exact water content of FBU.
However, the amount of water is speculated to range from 10–25%wt.
Therefore, keeping the dentin wet or dry after the phosphoric acid
application theoretically would not make a difference in the retention
rate when using FBU in the etch-and-rinse approach, which was also
observed in different clinical trials in NCCLs evaluating dry and wet
dentin associated with the etch-and-rinse strategies for universal adhe­
sives [33, [50]].
Although retention is considered a primary outcome to evaluate
restorations in NCCLs, some secondary outcomes, such as marginal
adaptation and marginal discoloration, can indicate important infor­
mation about the degradation of the adhesive interface. A usual concern
regarding universal adhesives when they are used in the SE mode relates
to the risk of a higher number of marginal defects and, consequently,
higher potential of marginal staining at medium-term follow-ups
because of the lower potential of etching enamel [51,52].
In fact, the present study’s results partially confirm this concern
when using FDI criteria. It was observed that, in the ER mode, FBU had
fewer marginal defects (15%) than when it was used in the SE mode
(45%), which is consistent with the observations in other medium-term
studies that evaluated universal adhesives [32,34]. Similar results were
also observed in posterior restorations [53,54].
Application of selective enamel etching before applying a universal
adhesive in the SE mode is a useful tool to improve the marginal
adaptation of adhesive restorations [55]. It must be noted that the
number of restorations with some degree of marginal defects decreased
from 45% (SE mode) to 27% (SE associated to enamel etching) when
evaluated by FDI criteria. However, the number of restorations with
marginal defects in the SE mode, associated or not with selective enamel
etching, is still significantly different when compared to the ER strategy.
The reason for these differences, even after application of selective
enamel etching before adhesive application, is not clear.
Furthermore, it is difficult to compare the results of the present study
with previous ones because, although FDI criteria is more sensitive to
small variations in the clinical outcomes of NCCLs than the USPHS-
modified criteria is [56], several recently published clinical trials have
continued to use USPHS [26,28,29], instead of FDI criteria. A unique
exception is the paper published by Loguercio et al. [16]. In Loguercio
et al. [16], after a 36-month follow-up, 17%, 18% and 24% of the res­
torations in the ER, selective enamel etching and SE groups, respec­
tively, presented some marginal discrepancy in comparison to 15%, 27%
and 45% of the restorations in the ER, selective enamel etching and SE
groups, respectively, in the present study.
At first glance, the marginal defects observed with FBU in the SE and
SEE modes (i.e., 45% and 27%, respectively) were higher than those
observed in a previous study [16], when SBU in the SE and SEE modes (i.
e., 24% and 18%, respectively) were evaluated. Although it may seem to
be a clinical concern, a closer view of the results shows that these
slightly marginal defects were not clinically relevant, primarily when
analyzing the marginal staining results. In the previous study [16], 8%
of the restorations in the SEE group and 16% of the restorations in the SE
group presented some kind of marginal staining after 36 months. This is
different from the observations in this study, in which only one resto­
ration presented some marginal staining, once again showing the good
clinical performance of FBU after 36 months of clinical evaluation.
The restorations in this study were also evaluated by USPHS criteria.
As previously mentioned, when comparing the USPHS and FDI results, it
could be seen that a few restorations were observed with marginal de­
fects when evaluated by USPHS criteria in the present study, in agree­
ment with previous studies [16,17,53]. Using USPHS criteria, FBU
8
Journal of Dentistry 122 (2022) 104120
presented approximately 9% of restorations with marginal discrep­
ancies, which was also comparable with previous medium -term studies
that used this same criterion [32,35].
In both situations, the identified marginal defects and staining were
considered clinically acceptable according to the FDI and USPHS criteria
[40,41], which means that they could be easily resolved with a new
finishing and polishing procedure. As these restorations continue to be
evaluated, finishing and polishing procedures were not conducted
because we intend to observe the performance of the restorations in
longer term follow-ups.
This study has some limitations. Only one universal adhesive was
used, and the conclusions should not be extrapolated for all universal
adhesives available in the market. In the present study, all restorations
were performed with an ORganically MOdified CERamics (Ormocer)
[57], which is a material with a resin matrix containing aromatic and
aliphatic dimethacrylates in addition to methacrylate-functionalized
polysiloxane, instead of a methacrylate-based filling. Despite the first
version of the ORMOCER materials showed a tendency of poor clinical
performance when compared to methacrylate-based composite in pos­
terior restorations [57], nowadays, the improvement of pure silicate
matrix technology combined with nano-hybrid fillers resulted in
nano-ormocer with a better clinical performance in posterior and ante­
rior restorations when compared to methacrylate-based filling [57–60].
Also, additional operatory procedures as a dentin roughening or the
application of a flowable resin as a liner were not performed in the
present study. At the time when this clinical study was started, the
dentin roughening and the application of flowable resin composite
showed nonsignificant clinical benefits [61,62]. However, a recent
randomized clinical trial evaluated clinical performance of restorations
placed in NCCLs, using different cavity preparation designs and flowable
resin composite. The authors showed better performance after 7.7 years
of clinical evaluation for restorations performed with a combination of
dentin preparation (groove or dentin roughening) associated to the
application of a flowable resin composite [63]. Therefore, future clinical
studies need to be done to evaluate the effect of these variables in the
clinical performance of universal adhesives in NCCLs.
5. Conclusion
The clinical performance of the Futurabond U did not depend on the
bonding strategy employed, and it was considered reliable after 36
months of clinical evaluation. However, greater marginal discrepancy
was observed in the self-etch group.
Credit author statement
Elisa Gomes de Albuquerque: Conceptualization, Methodology,
Formal analysis, Investigation, Data Curation
Flavio Warol: Conceptualization, Methodology, Formal analysis,
Investigation, Data Curation.
Chane Tardem3 Conceptualization, Methodology, Formal analysis,
Investigation, Data Curation.
Fernanda Signorelli Calazans: Conceptualization, Methodology,
Investigation.
Luiz Augusto Poubel: Conceptualization, Methodology,
Investigation.
Thalita de Paris Matos: Conceptualization, Methodology,
Investigation.
Jullian J. Souza: Conceptualization, Methodology, Investigation.
Alessandra Reis: Conceptualization, Writing - Review & Editing.
Marcos O. Barceleiro: Conceptualization, Methodology, Formal
analysis, Investigation, Data Curation, Writing - Original Draft, Writing -
Review & Editing, Funding acquisition.
Alessandro D. Loguercio: Conceptualization, Methodology, Formal
analysis, Investigation, Data Curation, Writing - Original Draft, Writing -
Review & Editing, Funding acquisition.
E.G. de Albuquerque et al.
CRediT authorship contribution statement
Elisa Gomes de Albuquerque: Conceptualization, Methodology,
Formal analysis, Investigation, Data curation. Flavio Warol: Concep­
tualization, Methodology, Formal analysis, Investigation, Data curation.
Chane Tardem: Conceptualization, Methodology, Formal analysis,
Investigation, Data curation. Fernanda Signorelli Calazans: Concep­
tualization, Methodology, Investigation. Luiz Augusto Poubel:
Conceptualization, Methodology, Investigation. Thalita P. Matos:
Conceptualization, Methodology, Investigation. Jullian J. Souza:
Conceptualization, Methodology, Investigation. Alessandra Reis:
Conceptualization, Writing – review & editing. Marcos O. Barceleiro:
Conceptualization, Methodology, Formal analysis, Investigation, Data
curation, Writing – original draft, Writing – review & editing, Funding
acquisition. Alessandro D. Loguercio: Conceptualization, Methodol­
ogy, Formal analysis, Investigation, Data curation, Writing – original
draft, Writing – review & editing, Funding acquisition.
Declarations of interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influence
the work reported in this paper.
Acknowledgements
This study was partially supported by the National Council for Sci­
entific and Technological Development (CNPq) under grants 303332/
2017-4 and 308286/2019-7 and Coordenação de Aperfeiçoamento de
Pessoal de Nível Superior - Brasil (CAPES) - Finance Code 001.
References
[1] MA Peres, LMD Macpherson, RJ Weyant, B Daly, R Venturelli, MR Mathur, S Listl,
RK Celeste, CC Guarnizo-Herreño, C Kearns, H Benzian, P Allison, RG Watt, Oral
diseases: a global public health challenge, Lancet (London, England) 394 (2019)
249–260, https://doi.org/10.1016/s0140-6736(19)31146-8.
[2] DNR Teixeira, RZ Thomas, PV Soares, MS Cune, MMM Gresnigt, DE Slot,
Prevalence of noncarious cervical lesions among adults: A systematic review,
J. Dent. 95 (2020), 103285, https://doi.org/10.1016/j.jdent.2020.103285.
[3] L Favaro Zeola, PV Soares, J Cunha-Cruz, Prevalence of dentin hypersensitivity:
Systematic review and meta-analysis, J. Dent. 81 (2019) 1–6, https://doi.org/
10.1016/j.jdent.2018.12.015.
[4] DW Douglas-de-Oliveira, GP Vitor, JO Silveira, CC Martins, Costa FO, LOM Cota,
Effect of dentin hypersensitivity treatment on oral health related quality of life - A
systematic review and meta-analysis, J. Dent. 71 (2018) 1–8, https://doi.org/
10.1016/j.jdent.2017.12.007.
[5] AD Loguercio, I Luque-Martinez, AH Lisboa, C Higashi, VA Queiroz, RO Rego,
A Reis, Influence of Isolation Method of the Operative Field on Gingival Damage,
Patients’ Preference, and Restoration Retention in Noncarious Cervical Lesions,
Oper. Dent. 40 (2015) 581–593, https://doi.org/10.2341/14-089-c.
[6] B Van Meerbeek, K Yoshihara, K Van Landuyt, Y Yoshida, M Peumans, From
Buonocore’s Pioneering Acid-Etch Technique to Self-Adhering Restoratives. A
Status Perspective of Rapidly Advancing Dental Adhesive Technology, J. Adhes.
Dent. 22 (2020) 7–34, https://doi.org/10.3290/j.jad.a43994.
[7] K Karan, X Yao, C Xu, Y Wang, Chemical characterization of etched dentin in non-
carious cervical lesions, J. Adhes. Dent. 14 (2012) 315–322, https://doi.org/
10.3290/j.jad.a22766.
[8] FR Tay, DH Pashley, Resin bonding to cervical sclerotic dentin: a review, J. Dent.
32 (2004) 173–196, https://doi.org/10.1016/j.jdent.2003.10.009.
[9] J De Munck, K Van Landuyt, M Peumans, A Poitevin, P Lambrechts, M Braem,
B Van Meerbeek, A critical review of the durability of adhesion to tooth tissue:
methods and results, J. Dent. Res. 84 (2005) 118–132, https://doi.org/10.1177/
154405910508400204.
[10] M Peumans, J De Munck, A Mine, B Van Meerbeek, Clinical effectiveness of
contemporary adhesives for the restoration of non-carious cervical lesions. A
systematic review, Dent. Mater. 30 (2014) 1089–1103, https://doi.org/10.1016/j.
dental.2014.07.007.
[11] RM Carvalho, AP Manso, S Geraldeli, FR Tay, DH Pashley, Durability of bonds and
clinical success of adhesive restorations, Dent. Mater. 28 (2012) 72–86, https://
doi.org/10.1016/j.dental.2011.09.011.
[12] J Perdigao, AD Loguercio, Universal or Multi-mode Adhesives: Why and How?
J. Adhes. Dent. 16 (2014) 193–194, https://doi.org/10.3290/j.jad.a31871.
[13] G Alex, Universal adhesives: the next evolution in adhesive dentistry?, in:
Compend. Contin. Educ. Dent., 36 Dental Learning Systems Co., Inc., 2015,
pp. 15–26, quiz 28, 40.
9
Journal of Dentistry 122 (2022) 104120
[14] S Jacker-Guhr, J Sander, AK Luehrs, How “Universal” is Adhesion? Shear Bond
Strength of Multi-mode Adhesives to Enamel and Dentin, J. Adhes. Dent. 21 (2019)
87–95, https://doi.org/10.3290/j.jad.a41974.
[15] S Nagarkar, N Theis-Mahon, J Perdigao, Universal dental adhesives: Current status,
laboratory testing, and clinical performance, J. Biomed. Mater. Res. Part B, Applied
biomaterials 107 (2019) 2121–2131, https://doi.org/10.1002/jbm.b.34305.
[16] AD Loguercio, EA de Paula, V Hass, I Luque-Martinez, A Reis, J Perdigao, A new
universal simplified adhesive: 36-Month randomized double-blind clinical trial,
J. Dent. 43 (2015) 1083–1092, https://doi.org/10.1016/j.jdent.2015.07.005.
[17] J Perdigao, C Kose, AP Mena-Serrano, EA De Paula, LY Tay, A Reis, AD Loguercio,
A new universal simplified adhesive: 18-month clinical evaluation, Oper. Dent. 39
(2014) 113–127, https://doi.org/10.2341/13-045-c.
[18] NC Lawson, A Robles, CC Fu, CP Lin, K Sawlani, JO Burgess, Two-year clinical trial
of a universal adhesive in total-etch and self-etch mode in non-carious cervical
lesions, J. Dent. 43 (2015) 1229–1234, https://doi.org/10.1016/j.
jdent.2015.07.009.
[19] VC Ruschel, S Shibata, SC Stolf, Y Chung, LN Baratieri, Heymann HO, R Walter,
Eighteen-month Clinical Study of Universal Adhesives in Noncarious Cervical
Lesions, Oper. Dent. 43 (2018) 241–249, https://doi.org/10.2341/16-320-c.
[20] RF Zanatta, TM Silva, M Esper, E Bresciani, S Goncalves, T Caneppele, Bonding
Performance of Simplified Adhesive Systems in Noncarious Cervical Lesions at 2-
year Follow-up: A Double-blind Randomized Clinical Trial, Oper. Dent. 44 (2019)
476–487, https://doi.org/10.2341/18-049-c.
[21] LS Lopes, FS Calazans, R Hidalgo, LL Buitrago, F Gutierrez, A Reis, AD Loguercio,
MO Barceleiro, Six-month Follow-up of Cervical Composite Restorations Placed
With a New Universal Adhesive System: A Randomized Clinical Trial, Oper. Dent.
41 (2016) 465–480, https://doi.org/10.2341/15-309-c.
[22] FD Oz, E Ergin, S Canatan, Twenty-four-month clinical performance of different
universal adhesives in etch-and-rinse, selective etching and self-etch application
modes in NCCL - a randomized controlled clinical trial, J. Appl. Oral Sci. 27 (2019),
e20180358, https://doi.org/10.1590/1678-7757-2018-0358.
[23] AN Choi, JH Lee, SA Son, KH Jung, YH Kwon, JK Park, Effect of Dentin Wetness on
the Bond Strength of Universal Adhesives, Materials (2017) 10, https://doi.org/
10.3390/ma10111224.
[24] FFS Siqueira, TF Pinto, EM Carvalho, J Bauer, LM Gonçalves, AL Szesz, A Reis,
AF Millan Cardenas, AD Loguercio, Influence of dentinal moisture on the properties
of universal adhesives, Int. J. Adhes. Adhes. 101 (2020), 102633, https://doi.org/
10.1016/j.ijadhadh.2020.102633.
[25] R Sugimura, A Tsujimoto, Y Hosoya, NG Fischer, WW Barkmeier, T Takamizawa,
MA Latta, M Miyazaki, Surface moisture influence on etch-and-rinse universal
adhesive bonding, Am. J. Dent. 32 (2019) 33–38.
[26] DH Pashley, FR Tay, RM Carvalho, FA Rueggeberg, KA Agee, M Carrilho,
A Donnelly, F García-Godoy, From dry bonding to water-wet bonding to ethanol-
wet bonding. A review of the interactions between dentin matrix and solvated
resins using a macromodel of the hybrid layer, Am. J. Dent. 20 (2007) 7–20.
[27] AD Loguercio, IV Luque-Martinez, S Fuentes, A Reis, MA Muñoz, Effect of dentin
roughness on the adhesive performance in non-carious cervical lesions: A double-
blind randomized clinical trial, J. Dent. 69 (2018) 60–69, https://doi.org/
10.1016/j.jdent.2017.09.011.
[28] P Manarte-Monteiro, J Domingues, L Teixeira, S Gavinha, MC Manso, Multi-Mode
adhesives performance and success/retention rates in NCCLs restorations:
randomised clinical trial one-year report, Biomater. Investig. Dent. 6 (2019) 43–53,
https://doi.org/10.1080/26415275.2019.1684199.
[29] TP Matos, MF Gutiérrez, TA Hanzen, P Malaquias, AM de Paula, JJ de Souza,
V Hass, E Fernández, A Reis, AD Loguercio, 18-month clinical evaluation of a
copper-containing universal adhesive in non-carious cervical lesions: A double-
blind, randomized controlled trial, J. Dent. 90 (2019), 103219, https://doi.org/
10.1016/j.jdent.2019.103219.
[30] A Mena-Serrano, C Kose, EA De Paula, LY Tay, A Reis, AD Loguercio, J Perdigão,
A new universal simplified adhesive: 6-month clinical evaluation, J. Esther. Restor.
Dent. 25 (2013) 55–69, https://doi.org/10.1111/jerd.12005.
[31] FD Oz, ZB Kutuk, C Ozturk, R Soleimani, S Gurgan, An 18-month clinical
evaluation of three different universal adhesives used with a universal flowable
composite resin in the restoration of non-carious cervical lesions, Clin. Oral
Investig. 23 (2019) 1443–1452, https://doi.org/10.1007/s00784-018-2571-2.
[32] C Atalay, G Ozgunaltay, AR Yazici, Thirty-six-month clinical evaluation of different
adhesive strategies of a universal adhesive, Clin. Oral Investig. 24 (2020)
1569–1578, https://doi.org/10.1007/s00784-019-03052-2.
[33] T de Paris Matos, J Perdigão, Paula E de, F Coppla, V Hass, RF Scheffer, A Reis,
AD Loguercio, Five-year clinical evaluation of a universal adhesive: A randomized
double-blind trial, Dent. Mater. 36 (2020) 1474–1485, https://doi.org/10.1016/j.
dental.2020.08.007.
[34] J Perdigão, L Ceballos, I Giráldez, B Baracco, MV Fuentes, Effect of a hydrophobic
bonding resin on the 36-month performance of a universal adhesive-a randomized
clinical trial, Clin. Oral Investig. 24 (2020) 765–776, https://doi.org/10.1007/
s00784-019-02940-x.
[35] VC Ruschel, SC Stolf, S Shibata, Y Chung, LW Boushell, LN Baratieri, R Walter,
Three-year clinical evaluation of universal adhesives in non-carious cervical
lesions, Am. J. Dent. 32 (2019) 223–228.
[36] KF Schulz, DG Altman, D Moher, CONSORT 2010 statement: Updated guidelines
for reporting parallel group randomised trials, Int. J. Surg. 9 (2011) 672–677,
https://doi.org/10.1016/j.ijsu.2011.09.004.
[37] C Zander-Grande, SQ Ferreira, TR da Costa, AD Loguercio, A Reis, Application of
etch-and-rinse adhesives on dry and rewet dentin under rubbing action: a 24-
month clinical evaluation, J. Am. Dent. Assoc. 142 (1939) (2011) 828–835,
https://doi.org/10.14219/jada.archive.2011.0272.
E.G. de Albuquerque et al.
[38] EJ Swift Jr., J Perdigão, HO Heymann, AD Wilder Jr., SC Bayne, KN May Jr.,
JR Sturdevant, TM Roberson, Eighteen-month clinical evaluation of a filled and
unfilled dentin adhesive, J. Dent. 29 (2001) 1–6, https://doi.org/10.1016/s0300-
5712(00)00050-6.
[39] TR Da Costa, AD Loguercio, A Reis, Effect of enamel bevel on the clinical
performance of resin composite restorations placed in non-carious cervical lesions,
J. Esther. Restor. Dent. 25 (2013) 346–356, https://doi.org/10.1111/jerd.12042.
[40] R Hickel, JF Roulet, S Bayne, SD Heintze, IA Mjör, M Peters, V Rousson, R Randall,
G Schmalz, M Tyas, G Vanherle, Recommendations for conducting controlled
clinical studies of dental restorative materials, Clin. Oral Investig. 11 (2007) 5–33,
https://doi.org/10.1007/s00784-006-0095-7.
[41] R Hickel, A Peschke, M Tyas, I Mjör, S Bayne, M Peters, KA Hiller, R Randall,
G Vanherle, SD Heintze, FDI World Dental Federation - clinical criteria for the
evaluation of direct and indirect restorations. Update and clinical examples,
J. Adhes. Dent. 12 (2010) 259–272, https://doi.org/10.3290/j.jad.a19262.
[42] D Dalton Bittencourt, IG Ezecelevski, A Reis, JW Van Dijken, AD Loguercio, An 18-
months’ evaluation of self-etch and etch & rinse adhesive in non-carious cervical
lesions, Acta Odontol. Scand. 63 (2005) 173–178, https://doi.org/10.1080/
00016350510019874.
[43] VP Feitosa, FA Ogliari, B Van Meerbeek, TF Watson, K Yoshihara, AO Ogliari,
MA Sinhoreti, AB Correr, G Cama, S Sauro, Can the hydrophilicity of functional
monomers affect chemical interaction? J. Dent. Res. 93 (2014) 201–206, https://
doi.org/10.1177/0022034513514587.
[44] VP Feitosa, S Sauro, FA Ogliari, AO Ogliari, K Yoshihara, CH Zanchi, L Correr-
Sobrinho, MA Sinhoreti, AB Correr, TF Watson, B Van Meerbeek, Impact of
hydrophilicity and length of spacer chains on the bonding of functional monomers,
Dent. Mater. 30 (2014) e317–e323, https://doi.org/10.1016/j.
dental.2014.06.006.
[45] K Yoshihara, S Hayakawa, N Nagaoka, T Okihara, Y Yoshida, B Van Meerbeek,
Etching Efficacy of Self-Etching Functional Monomers, J. Dent. Res. 97 (2018)
1010–1016, https://doi.org/10.1177/0022034518763606.
[46] D Fukegawa, S Hayakawa, Y Yoshida, K Suzuki, A Osaka, B Van Meerbeek,
Chemical interaction of phosphoric acid ester with hydroxyapatite, J. Dent. Res. 85
(2006) 941–944, https://doi.org/10.1177/154405910608501014.
[47] Y Yoshida, K Nagakane, R Fukuda, Y Nakayama, M Okazaki, H Shintani, S Inoue,
Y Tagawa, K Suzuki, J De Munck, B Van Meerbeek, Comparative study on adhesive
performance of functional monomers, J. Dent. Res. 83 (2004) 454–458, https://
doi.org/10.1177/154405910408300604.
[48] M Hanabusa, A Mine, T Kuboki, Y Momoi, A Van Ende, B Van Meerbeek, J De
Munck, Bonding effectiveness of a new ‘multi-mode’ adhesive to enamel and
dentine, J. Dent. 40 (2012) 475–484, https://doi.org/10.1016/j.
jdent.2012.02.012.
[49] TL Lenzi, FZ Soares, DP Raggio, GK Pereira, RO Rocha, Dry-bonding Etch-and-
Rinse Strategy Improves Bond Longevity of a Universal Adhesive to Sound and
Artificially-induced Caries-affected Primary Dentin, J. Adhes. Dent. 18 (2016)
475–482, https://doi.org/10.3290/j.jad.a36670.
[50] EG de Albuquerque, F Warol, FS Calazans, LA Poubel, SS Marins, T Matos, JJ de
Souza, A Reis, M de Oliveira Barceleiro, AD Loguercio, A New Dual-cure Universal
Simplified Adhesive: 18-month Randomized Multicenter Clinical Trial, Oper. Dent.
45 (2020) E255–e270, https://doi.org/10.2341/19-144-c.
10
Journal of Dentistry 122 (2022) 104120
[51] AD Loguercio, MA Muñoz, I Luque-Martinez, V Hass, A Reis, J Perdigão, Does
active application of universal adhesives to enamel in self-etch mode improve their
performance? J. Dent. 43 (2015) 1060–1070, https://doi.org/10.1016/j.
jdent.2015.04.005.
[52] T Sato, T Takagaki, N Matsui, H Hamba, A Sadr, T Nikaido, J Tagami,
Morphological Evaluation of the Adhesive/Enamel interfaces of Two-step Self-
etching Adhesives and Multimode One-bottle Self-etching Adhesives, J. Adhes.
Dent. 18 (2016) 223–229, https://doi.org/10.3290/j.jad.a36135.
[53] AD Loguercio, M Rezende, MF Gutierrez, TF Costa, A Armas-Vega, A Reis,
Randomized 36-month follow-up of posterior bulk-filled resin composite
restorations, J. Dent. 85 (2019) 93–102, https://doi.org/10.1016/j.
jdent.2019.05.018.
[54] ILM de Oliveira, TA Hanzen, AM de Paula, J Perdigão, MAJR Montes,
AD Loguercio, GQM Monteiro, Postoperative sensitivity in posterior resin
composite restorations with prior application of a glutaraldehyde-based
desensitizing solution: a randomized clinical trial, J. Dent. 5 (2021), 103918,
https://doi.org/10.1016/j.jdent.2021.103918.
[55] A Szesz, S Parreiras, A Reis, A Loguercio, Selective enamel etching in cervical
lesions for self-etch adhesives: A systematic review and meta-analysis, J. Dent. 53
(2016) 1–11, https://doi.org/10.1016/j.jdent.2016.05.009.
[56] T Marquillier, S Doméjean, J Le Clerc, F Chemla, K Gritsch, JC Maurin, P Millet,
M Pérard, B Grosgogeat, E Dursun, The use of FDI criteria in clinical trials on direct
dental restorations: A scoping review, J. Dent. 68 (2018) 1–9, https://doi.org/
10.1016/j.jdent.2017.10.007.
[57] P Monsarrat, S Garnier, JN Vergnes, K Nasr, B Grosgogeat, S Joniot, Survival of
directly placed ormocer-based restorative materials: A systematic review and meta-
analysis of clinical trials, Dent. Mater. 33 (2017) e212–e220, https://doi.org/
10.1016/j.dental.2017.01.019.
[58] CRG Torres, MC Mailart, RS Rocha, PLB Sellan, SCM Contreras, R Di Nicoló,
AB Borges, The influence of a liner on deep bulk-fill restorations: Randomized
clinical trial, J. Dent. 102 (2020), 103454, https://doi.org/10.1016/j.
jdent.2020.103454.
[59] CR Torres, AL Jurema, MY Souza, R Di Nicoló, AB Borges, Bulk-fill versus layering
pure ormocer posterior restorations: A randomized split-mouth clinical trial, Am. J.
Dent. 34 (2021) 143–149.
[60] TP Matos, JJ Souza, ML Méndez-Bauer, A Núñez, LJF Duarte, MO Barceleiro,
A Reis, AD Loguercio, Influence of viscosity and chemical composition of
composite resins in non-carious cervical restorations: 12-month randomized
clinical trial, Braz. Dent. Sci. 24 (4 supl 2) (2021), https://doi.org/10.4322/
bds.2021.e2792, 2021.
[61] JW van Dijken, Clinical evaluation of three adhesive systems in class V non-carious
lesions, Dent. Mater. 16 (2000) 285–291, https://doi.org/10.1016/s0109-5641
(00)00019-1.
[62] A Szesz, S Parreiras, E Martini, A Reis, A Loguercio, Effect of flowable composites
on the clinical performance of non-carious cervical lesions: A systematic review
and meta-analysis, J. Dent. 65 (2017) 11–21, https://doi.org/10.1016/j.
jdent.2017.07.007.
[63] AK Lührs, S Jacker-Guhr, H Günay, P Herrmann, Composite restorations placed in
non-carious cervical lesions-Which cavity preparation is clinically reliable? Clin.
Exp. Dent. Res. 6 (2020) 558–567, https://doi.org/10.1002/cre2.310.