Dental cements: A review and update

By Randy S. Weiner, DMD, FAGD, FACD, FPFA

Featured in General Dentistry, July/August 2007
Pg. 357-364

Posted on Friday, June 22, 2007

Abstract
This article presents an in-depth review of the literature regarding dental cements.

Received: October 5, 2006

Final revisions: December 19, 2006
Accepted: January 18, 2007

A 2005 article reported that more than 25 manufacturers produced short-term or temporary
cements; some of these companies marketed more than one cement.1 This figure is an
indication of the importance of these materials in clinical dentistry.
A telephone communication with the ADA�s Council on Scientific Affairs (September 2006)
revealed that the ADA does not have an official description as to what a dental cement is or
needs to be. It has been suggested that dental cements have three applications: as a luting
agent to bond preformed restorations and orthodontic appliances in or on the tooth, as a cavity
liner or base to protect the pulp, and as a restorative material.2
The process of selecting appropriate cement/luting materials can be complicated by the fact
that certain product descriptors can be misleading. For example, some products use the words
lining cement in their name even though the product is not designed for use as a cement.
Others are called cements (specifically, when referring to glass ionomers) even when the
product is intended to be used as a restorative material and not as a luting agent. Clinicians
must be careful when choosing a new product and must make their selection based on the
product�s intended use rather than its name.3
It should be noted that even dental schools cannot agree on the best material for a given
clinical scenario. A 2005 survey of U.S. and Canadian dental schools concluded that there was
no agreement as to which material was best for a given clinical situation.4
This article reviews dental cements as a cementing medium or luting agent rather than as a
liner, base, or restoration material. With that in mind, a cement can be defined as a material
that serves to retain restorations or appliances in a fixed position in the mouth.5 A dental
cement, also known as a luting agent, acts as a barrier against microleakage by sealing the
interface between the tooth and restoration and holding the two together by a mechanical or
chemical attachment (or a combination of the two).6
Sealing the interface is an important aspect of cementation as it reduces or eliminates
postoperative sensitivity and makes patients more comfortable. This sealing ability is inherent
in some materials; cements containing acid (zinc phosphate, zinc polycarboxylate, and glass
ionomer) have self-etching properties that are effective to some degree at removing the smear
layer and promoting close adaptation to dentin surfaces.7
Dentists also may place a desensitizing agent directly on the preparation prior to
cementation. According to a 1997 report by Swift et al, these products have no negative effect
on the retention of crowns that have been cemented with zinc phosphate or glass ionomer.8
Conversely, Johnson et al reported seven years later that sealers decreased the retentive
stress of zinc phosphate by 42% (while increasing the retention) when a glass ionomer or resin-
modified glass ionomer is used.9
In addition to the desensitizing agents, clinicians also can place a dentin bonding agent
directly and immediately on the newly prepared dentin. This immediate dentin sealing appears
to improve bond strength, decrease bacterial leakage, and lead to fewer gap formations.10
To eliminate post-treatment sensitivity associated with cementation, Leinfelder recommends
removing any debris on the internal surface of the casting that might prevent complete seating,
lining (as opposed to filling the whole casting) the internal aspect of the casting with cement,
and gently placing and seating the casting into position to prevent any deformation of the
underlying dentinal tubules that might result in a negative pressure on the odontoblasts.11
 Dental cements can be divided into two categories: either a temporary, short-term, or a
weak cement or a permanent, long-term, or final material. They can be classified further into
one of six groups, depending on their basic chemistry: calcium hydroxide-based, zinc oxide
eugenol (ZOE)-based, zinc phosphate-based, zinc polycarboxylate-based, glass ionomer-
based, or resin-based. Clinicians will find that materials from some of these groups are used for
temporary cements, while others are used as final cements. In some cases, materials from the
same group can be used as both temporary and permanent cements. The table lists examples
of both types of cements and describes the important characteristics of each.

Desirable properties of dental cements include the absence of adverse effects on the pulp;
low solubility in oral fluids; and high tension, shear, and compressive strengths.12 If the cement
dissolves or deteriorates to the point that it washes out, leakage can result, with subsequent
adverse effects including caries and sensitivity.13 Cements also should have adequate working
and setting times.2
In a 2005 article, Farah listed the ideal features of temporary cements as controlled
dispensing, compact kit (resulting in minimal waste), easy mixing and cleanup, and rapid
setting.14 That same year, Abrams suggested that temporary cements also should allow for
easy removal of the material from around the margins upon cementation, provide a good
marginal seal to help minimize postoperative sensitivity, and offer good retention but easy
removal of the temporary prosthesis.15 With the exception of the latter point, all of the items
from both lists would apply to permanent cements as well.

Calcium hydroxide
Calcium hydroxide (CaOH) usually is thought of as either a liner or a base, although it also can
be used for short-term cementation. It is available in both chemical and photocured versions.
The catalyst component gives CaOH an alkaline pH of 12, which accounts for the antibacterial
properties of this material by neutralizing the bacterial acids.16 Additional advantages related
to cementation include easy manipulation, rapid hardening in thin layers, low strength, and good
sealing characteristics. Unfortunately, CaOH dissolves when it makes contact with saliva,
indicating that sealed margins are a must when CaOH is used as a temporary cement.2 CaOH
does not bond to dentin, making it easy to remove the material from the preparation.17 For
those operators who use a resin-based final cement, calcium hydroxide is a non-eugenol zinc
oxide material. Therefore, there should be no concern about a negative interaction.

ZOE/noneugenol zinc oxide

ZOE products have a pH of approximately 7. Like zinc phosphate and zinc polycarboxylate,
these products should be mixed on a dry, cool glass slab to slow the reaction. Doing so makes
it possible to incorporate more powder into the liquid, which will improve the mixture�s
properties. Any moisture that enters the mixture will cause the reaction to speed up to
completion, as will increasing the powder/liquid ratio.
The powder contains zinc oxide (70% by weight) with rosin added to reduce the brittleness
of the final mixture. Some formulations are made with polymethylmethacrylate (PMMA) to
strengthen the product. Aluminum oxide particles may be added to reinforce it. ZOE (Type 1)
has low strength and is highly soluble in the mouth, which makes it ideal for temporary
cementation.17
The liquid portion of ZOE contains eugenol, which comes from oil of cloves, one of the
essential oils. Eugenol is bactericidal by itself but becomes more effective when it is combined
with zinc oxide, which has no inhibitory effect.18
ZOE provides an excellent seal at the restoration-tooth interface.13 This seal prevents
dietary substrate from reaching any microorganisms under the crown, reducing their metabolism
and decreasing the tendency of caries to develop and spread. Essentially, ZOE inhibits
bacterial cell metabolism.19 This inhibition, along with the fact that ZOE has inherent
antibacterial properties, explains the low incidence of postoperative sensitivity. In addition,
while ZOE is considered an obtundent material, it actually is a mild irritant (that is, the eugenol
portion). This irritation may cause the pulp to form more reparative dentin. This thicker, denser
dentin can reduce the amount of bacteria that reaches the pulp, reducing postoperative
sensitivity as a result.20
One manufacturer has added potassium nitrate to the ZOE (Preservetemp, Healex
Products, Providence, RI; 401.421.3252); according to a 1993 study, this combination results in
less postoperative sensitivity than ZOE alone.21
As a permanent cement, two different versions of ZOE Type 2 are available: one with
orthoxybenzoic acid liquid (in place of some of the eugenol) and alumina added to the powder
and the other with polymer particles added to the powder.13
It appears that this type of material is not very popular as a final cement; only one school
from the 2005 dental school survey reported using it and a review of the literature shows no
comparative studies that include ZOE Type 2 materials.4
It has been reported that ZOE materials have an adverse effect on resin-based
products.22,23 This is relevant only when a temporary cement containing ZOE is used prior to
final cementing with a resin-based material. Other reports do not support this conclusion.24,25
Products that replace the eugenol with carboxylic acid are available, resulting in the noneugenol
zinc oxide formula. In addition, teeth cleaned with a prophy cup and flour of pumice exhibited
the smallest amount of residual provisional cement.26
According to Christensen, manufacturer�s recommendations to use an noneugenol zinc
oxide provisional cement in place of a final resin cement are more commercial hype than they
are a documented necessity, based on studies conducted by Clinical Research Associates, in
which as much as one week elapsed between tooth preparation and final cement.27
Compared to ZOE products, noneugenol materials do not have a sedative effect on the
pulp.27 Noneugenol zinc oxide products are slower to set and do not soften provisional acrylic
crowns.5
In recent years, dental manufacturers have been marketing noneugenol zinc oxide
temporary cements with additives like chlorhexidine (to make their product more antibacterial)
and fluoride and potassium nitrate (to help reduce postoperative sensitivity).

Zinc phosphate
Zinc phosphate cement was the gold standard for dental luting agents due to its high modulus
of elasticity.28 Type I (which is used for luting) has a smaller particle size than Type II cement,
which allows for better flow of the mixture.
Zinc phosphate powder consists of zinc oxide with magnesium oxide, silicon dioxide, and
bismuth trioxide. The liquid contains orthophosphoric acid, water, and other minor materials.
Adding powder to the liquid increases the properties of the mixture.
The operator should not dispense the liquid prior to use, as doing so may cause the
properties to change. Working in a dry atmospheric environment will allow some of the water to
evaporate, increasing both the liquid�s viscosity (making it more difficult to seat a casting) and
its acidity (making it less biocompatible).29 To account for evaporation, ADA Specification No.
96 requires manufacturers to place 20% more liquid in the package than the powder requires.
To dissipate the heat that is generated when mixing the powder and liquid, it is best to
spatulate the mixture over a wide area, which will incorporate more powder into the liquid.
Initially, the mixture has a pH of approximately 3.5; over the next 48 hours, that will increase to
approximately 6.9.30
Zinc phosphate has been associated with postoperative sensitivity; originally, this was
attributed to the acidic nature of the material.2 To prevent postoperative sensitivity, some
dentists apply a varnish on the preparation prior to placing the casting. This postoperative
sensitivity is more likely due to the poor sealing ability associated with zinc phosphate. In 1977,
Brannstrom and Nyborg concluded that postoperative sensitivity resulted from bacteria on the
prepared surface.31
Zinc phosphate�s retentive properties are attributed to its ability to fill the irregularities of
both the prepared dentin and the inside of the casting.32 Zinc phosphate cannot adhere to
tooth structure; its retentive seal is obtained by mechanical means only.33 As a result, the
taper, length, and surface area of the tooth preparation are critical to the success of the seal.34
Christensen recommends sandblasting or microabrading the inside of the casting to increase
mechanical retention.35
According to a 2005 study conducted at Montana State University, small amounts of copper
have been shown to have antibacterial properties (unpublished data); as a result, one
manufacturer has added copper to zinc phosphate (in the form of cupric acid) (Doc Red�s Best
Copper Cement, Cooley & Cooley, Houston, TX; 800.215.4487). Conventional zinc phosphate
also has been shown to be an effective bacterial inhibitor.36
Mitchell writes that zinc phosphate cement is a good choice for posts that have adequate
mechanical retention, especially if fluoride release is not considered essential.37 There are
times when a post needs to be removed. A 2001 study by Gomes et al used ultrasound during
post removal and reported that it reduced retention by 39% when zinc phosphate was used.38

Zinc polycarboxylate
In a 2005 survey of dental schools, none of the schools reported teaching about the use of zinc
polycarboxylate cement (ZPC) in their clinics.4 This material has been available for some 40
years and is very similar to zinc phosphate, except that the liquid component contains
polyacrylic acid instead of orthophosphoric acid, resulting in a much more viscous liquid,
although the final mixture still has a very thin film thickness. In some instances, manufacturers
may have added stannous fluoride to the powder to improve its handling characteristics.
It is believed that zinc polycarboxylate (also known as zinc polyacrylate) cements adhere to
the collagen in the tooth structure via hydrogen and ionic bonding.39 Craig and Powers
reported that this bonding involves carboxylate groups of the polymer chelating with calcium.5
The surface of the preparation must be clean to allow for maximum adhesion between the
cement and the tooth. Unlike zinc phosphates, where the weak area is the tooth/cement
interface, the failure location for zinc polycarboxylate is the metal/cement interface.13
Zinc polycarboxylate has an initial pH of 1.7, which is neutralized quickly by the powder.
Even with the initial acidic nature of these materials, they offer little irritation to the pulp, perhaps
because of the large size of the acrylate molecule, which is too large to diffuse into the dentinal
tubule.2,13 There also may be less dentinal fluid movement in response to this material. From
a biocompatibility standpoint, this material is similar to ZOE.2
The liquid also has disadvantages; it requires the powder and liquid to be mixed in less time
and is more difficult to mix as a result. As with zinc phosphate, this material should be mixed on
a cold, dry glass slab. Only the powder should be kept refrigerated; the liquid will become too
viscous to use if it is kept cold.
Unlike zinc phosphate, which incorporates a little powder into the liquid at a time, zinc
polycarboxylate powder can be mixed en masse. The clinician should use the mixture before it
becomes rubbery and loses its glossy appearance, which indicates that the mix is starting to set
and that proper wetting of the preparation surface cannot be obtained.30 In addition, excess
cement should not be removed until after the material has set completely. Removal during the
rubbery stage could tear the cement from under the casting margin, resulting in voids.
Although the solubility of zinc polycarboxylate is greater than that of glass ionomer, it is
approximately equal to zinc phosphate.39

Glass ionomer
Glass ionomer powder contains aluminum fluorosilicate glass and the liquid is composed of
polyacrylicitaconic acid. After mixing, the two adhere to the tooth via ionic bonds with the
calcium in the apatite of the enamel and dentin.6 The adhesion depends on the moisture on the
tooth. Clinicians should be aware that once the mixture loses its shiny appearance, the
availability of loose ions for bonding decreases and the material is much less adhesive as a
result. If the tooth is desiccated, the degree of bonding to the tooth decreases, which may
increase postoperative sensitivity.
To promote adhesion, it is best to clean the surface of the preparation with an acidic
conditioner prior to cementation, as doing so will remove the smear layer. Phosphoric acid and
polyacrylic are the two most common acids used for this task.13
The initial mixture of glass ionomer is quite acidic due to its low powder/liquid ratio;
however, pulpal reactions are considered mild and are similar to those associated with ZOE
materials.5
Another advantage of these materials is the leaching out of fluoride after mixing. This
fluoride supply has been shown to reduce recurrent caries at the margin.40 The fluoride
released from the glass ionomer aids in forming fluorohydroxyapatite on adjacent tooth
structure. This does not prevent new carious lesions but renders the adjacent tooth more
resistant to demineralization, which is important for patients at a high risk for caries.41
According to Peters et al, autocured versions of glass ionomer cement are more effective than
photocured versions for establishing a zone of inhibition.42 Carey et al reported that a low pH
environment led to more fluoride release than a neutral environment.43
Glass ionomer cements are available in a number of different delivery systems (powder-
liquid, encapsulated, automixed, and paste-paste). A 2003 study concluded that the paste-
paste versions released more fluoride than the other types.44 Clinicians also should be aware
that the powder-liquid delivery systems cannot always be dispensed at a constant ratio and that
the capsule, paste-paste, and automix systems are much better for ensuring a cement with
maximum properties.33
Eventually, this fluoride will be depleted; however, it has been reported that the fluoride can
be replenished via toothpastes, topical fluoride, and gels (which are considered to be the most
effective of the three options).45,46
The reduction of microleakage and postoperative sensitivity also are attributed to the
coefficient of thermal expansion of glass ionomer, which is similar to that of dentin.47
One disadvantage of glass ionomers is their sensitivity to moisture during setting.
According to Mojon et al, they should be protected from water and saliva for at least 15 minutes
after they are placed in the mouth.48 A 2001 study recommended coating the margin with a
protective material so that the cement could mature fully.49
The moisture contamination may have a benefit, as it will cause the glass ionomer to
expand. This may result in a better seal at the margin of metallic castings.50 All-ceramic
restorations may fracture when the glass ionomer expands.
Some manufacturers have replaced part of the polyacrylic acid with hydrophilic monomers,
resulting in a resin-modified glass ionomer. These products are considered dual-cured
materials. According to a study that examined the effect of cavity pretreatment on marginal
sealing of glass ionomers, conventional glass ionomer products demonstrated a lower sealing
ability than the photocured (resin-modified) materials.51 The pretreatment step had a positive
effect on only a specific chemical-cured product.
As previously mentioned, zinc phosphate does not adhere to tooth structure, which means
that the junction of the tooth and cement is a favorable environment for bacteria. Glass
ionomers are better suited for orthodontic appliances, since the fluoride release helps to reduce
the decalcification that is associated with orthodontic appliances that are cemented with zinc
phosphate.5 According to an in vitro study by Lindquist and Connelly, glass ionomer is
associated with less microleakage than zinc phosphate.52

Resin
Resin-based products are the last category of materials that can be used as a cement.
Essentially, resin cements, like flowable composites, are a composite resin with a
reduced filler content. They are available for both temporary and permanent cementation
procedures, although the temporary versions have a lower compressive strength. Resin
cements can be classified as either self-cured (Class 1, according to ADA Specification
No. 27), photocured (Class 2), or dual-cured (a combination of both) (Class 3).5
The higher filler content produces a more viscous material, which reduces the flow and
increases the film thickness. As with any cement, these conditions can make it more difficult for
the operator to seat the restoration.
Dental adhesive cements can be classified according to the cementing technique for which
they are intended to be used. Bonded restorations involve indirect tooth-colored restorations
used with a resin cement and a bonding agent. Luting agents are intended for metal-based
restorations that are mechanically retained with cements that do not chemically bond to teeth.
Adhesive cements are those products that bond well with metal substrates and require the use
of a separate primer for bonding to ceramic, metal, and tooth substrates. Self-adhesive resin
cements do not require a separate primer for bonding to any substrate. An esthetic resin
cement is a tooth-colored or translucent cement that requires a separate primer for bonding to
metal and ceramic substrates.53
Chemical-cured resin cements allow for a shorter working time, as the material starts to set
as soon as the components are mixed. These cements are best suited for clinical scenarios
involving metal casting or thick indirect ceramic/composite restorations that the photocuring light
cannot reach.
The photocured products have a longer working time and set on command. They must be
protected from ambient light so as not to start the polymerization reaction.
Dual-cured materials make it possible for the clinician to cure the product along the margin
of the restoration, which secures the restoration in place while the remaining mix cures at its
own pace (set times vary from product to product). Although Caughman et al reported that not
all dual-cured products polymerize adequately in every clinical situation, a subsequent study by
Attar et al concluded that dual-cured cements demonstrated the best combination of mechanical
and physical properties.54,55 According to Simon and Waldemar, the dual-cured systems
achieve lower degrees of conversion and have the shortest shelf life.33 El-Mowafy and Rubo
noted that the hardness value of the cement decreased as the restoration thickness increased,
indicating a weak chemical curing mechanism in areas that the curing light could not access
readily.56
Some resin cement products involve etching, priming/bonding, and luting; other products
combine these steps into one. Dentists who use the multi-step version must be concerned
about the dentin bonding layer, as this is the material that makes contact with the preparation.
The bonding agent should be the type that is not photocured but rather self-cured. The
former may pool prior to photocuring, preventing proper seating of the restoration.
Sixth generation bonding products (those that combine the etchant with the dentin bonding
agent) tend to have a low pH. The acid primers make them incompatible with self-cured and
dual-cured cements. The same incompatibility is associated with seventh generation products
as well.57
There are times when dentists must prepare a tooth �beyond the ideal,� when existing
decay, existing loss of tooth structure (fractured cusp), or the loss of an existing restoration
results in a shorter, narrower, or more tapered preparation. In situations like these, the dentist
may be close to the pulp. The strength of the bond decreases as the remaining dentin
thickness decreases, due to the increased fluid in the deeper dentin.58,59 For a stronger
adhesion, Blatz et al recommend including as much enamel as possible when using a resin
cement, as the enamel can be etched with phosphoric acid.60
Restorations that involve a silica-based ceramic should be coated with a silane coupling
agent on the acid-etched surface to provide a chemical bond between the resin cement and the
restoration. The acid etch provides a true mechanical interlocking feature.61 A 2006 article by
Desai reported that all-ceramic restorations bonded with dual-cure composite luting cements
have a higher resistance to debonding than traditional metal-based crowns.62
Some resin cements contain barium fluorosiliocate filler and reportedly release fluoride,
although the amount of fluoride they release is unconfirmed.6

Other factors associated with dental cements

A number of delivery systems are available for these products, including powder-liquid, auto-
dispensed syringes, automix syringes, capsules, and paste-paste.
Proper mixing is vital to successful cementation. Dentists who find hand mixing a problem
might prefer a different delivery system; many materials are available in different systems.
Should an encapsulated product be used, the clinician needs to remember to adjust the timer in
the triturator after use so that it is correct for amalgam.
It also is important for the clinician to understand and follow the manufacturer�s
instructions. According to Peutzfeldt and Viglid, the degree to which dentists complied with the
manufacturer�s instructions for use was influenced by the degree that dentists were satisfied
with those instructions.63
At the restoration insertion visit, the dentist may find some black stain on the preparation
after removing the temporary restoration. These stains are caused by iron pigments in the
blood contacting bacteria in the saliva and sulcular fluid. It is thought that these bacteria
produce hydrogen sulfide gas, which reacts with the iron and forms the dark stain.64 This stain
can be removed using acid etching and (if necessary) a green stone. To prevent staining,
dentists must be sure that the margins of the temporary restoration are sealed; an antibacterial
temporary cement also can be used.64
It is important to remove excess cement for long-term patient comfort. Mitchell et al showed
that subclinical cement retention occurred after crown cementation, which was influenced by the
cement, crown type, and tooth morphology but not by the method of cement removal.65
Clinicians must be vigilant when removing subgingival cement�especially tooth-colored
products, which may be difficult to see. Cement also should be removed from any contact
areas prior to setting, when it is easier to do so. In addition, placing a releasing agent around
the restoration margin will enable the operator to remove any excess cement with less struggle,
resulting in less discomfort for the patient.
 To confirm that all cement has been removed, a postoperative bitewing radiograph can be
exposed. For that reason, it would be best if the cement used was radiopaque. Radiopaque
cement also would be helpful at the recall visits in diagnosing recurrent decay, enabling the
clinician to distinguish between the cement and the decay, which appears radiolucent.

Summary
A number of different materials are available for cementation procedures and no one type of
material is best for all clinical scenarios. Dentists should be familiar with each type of cement
so that they can choose the ones that are most appropriate.

Disclaimer
The author has acted and currently acts as a consultant for several manufacturers (GC America
and Heraeus Kulzer) and has received honoraria for his service.

Author information
Dr. Weiner is in private practice in Millis, Massachusetts.

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