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12 Glass-Ionomer Cements as Restorative and Preventive Materials

12 Glass-Ionomer Cements as Restorative and Preventive Materials

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Glass-IonomerCements asRestorative andPreventive Materials
Hien Ngo,
BDS, MDS, PhD, FADI, FICD, FPFA
This article will focus on glass-ionomer cement (GIC) and its role in the clinicalmanagementofcaries.ItbeginswithabriefdescriptionofGIC,themechanismoffluo-ride release and ion exchange, the interaction between GIC and the external environ-ment, and finally the ion exchange between GIC and the tooth at the internal interface.The importance of GIC, as a tool, in caries management, in minimal interventiondentistry, and Caries Management by Risk Assessment (CAMBRA) also will behighlighted.The philosophy of minimal intervention density (MI) and the CAMBRA approach isgaining popularity worldwide as both integrate the new understanding that caries isa biofilm-related, multifactorial and lifestyle-associated bi-directional disease. Thereis now an acceptance that to manage caries disease effectively, it is important tomove from the surgical approach to a combined surgical—medical approach, withspecial focus on engaging patients in changing their lifestyle. The following statementis a consensus of 165 experts, comprising of clinicians, scientists, educators, andhealth service managers from 15 countries, who gathered in Bangkok for a consulta-tive meeting to discuss the MI philosophy (personal communication, 2009):
‘‘The current surgical model of caries management does not fully address the multi-factorial nature of dental caries. This model often results in unnecessary  removal of tooth structure, can impact negatively on general health and quality of life and can impose substantial cost.’’
Glass-ionomer cement (GIC) is an important tool in the fight against caries. It can bethought of as a reservoir of fluoride and other ions in the oral cavity, a mechanicalbarrier that protects the tooth surface against bacteria; most importantly, it canprovide a long-lasting seal under the most challenging clinical circumstances.
General Dental Practice, School of Dentistry, The University of Queensland, 200 Turbot Street,Brisbane, QLD 4000, Australia
E-mail address:
KEYWORDS
Glass-ionomer cement
Therapeutic coating
Internal remineralisation
Caries
Dent Clin N Am 54 (2010) 551–563doi:10.1016/j.cden.2010.04.001
0011-8532/10/$ – see front matter
ª
2010 Published by Elsevier Inc.
 
GIC is very versatile. It may be utilized as a definitive restorative material, a prepara-tion liner, a restorative base material, a luting cement, or a fissure sealant. Recently, itwas suggested that GIC also could be useful in the preventive arena as therapeuticcoating. This new terminology is utilized to describe a material that can be paintedon a susceptible surface and form a long-lasting coat to protect, both mechanicallyand chemically, against accumulation of plaque where patients are unable to rendereffective hygiene in certain parts of the oral cavity. Clinical examples of these applica-tions will be given at the end of the article.
HISTORICAL PERSPECTIVE
There is a spectrum of tooth-colored restorative materials, spanning from GIC at oneend to the resin-based materials at the other end. Wilson and McLean introduced theGICfamilyofmaterialstothedentalprofessionin1988.
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Thefourfamiliesofacid–basematerials used in dentistry are: silicate, zinc phosphate, polycarboxylate, and glass-ionomer. They all utilize acid and base components ( 
 ). It was over 100 yearsago when silicate cements were introduced to dentistry as a restorative material.There was anecdotal evidence that silicate cements were an effective anticaries agentthatwas attributedmainly tothehigh leveloffluoride releasefromthesilicate material.The material’s solubility was high, however, and the search for its replacement led tothe development of polycarboxylate cements, and eventually GIC. Currently, glass-ionomeristheonlyrestorativematerialthatiswater-basedandlikesilicatehasananti-caries effect.
Current esthetic high-strength GICs are considered to be durablerestorative dental cements.
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HOW DO GIC ACQUIRE THEIR ANTICARIES EFFECT?
GICs are true acid–base cements where the base is the fluoroaluminosilicate glasspowder and the liquid containing acid comes from the polyalkenoic family. In someglass formulations, the F rich phase of the glass can be visible ( 
 ) and physicallydistinct. Apart from the base and acid, the third major component is water, the majorcomponent of the liquid. The total water content of the set cement is somewherebetween 11% and 24%. Being a true water-based material, GIC also is recognizedas the only biological active restorative material that is currently available.
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The precise glass composition varies from one material to another. Traditionally,GIC powder was based on calcium (Ca); however, there are several materials wherethe calcium has been substituted by strontium (Sr). This was done to impart radiopac-ity to the material. It is interesting to note that because of their similarity in polarity andatomic size, these two elements are interchangeable in the composition of GIC as wellas hydroxyapatite (HAP). Some of the Ca in HAP can be substituted with Sr withoutany significant disadvantage.
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It is interesting to note that, at a population level, thereis some evidence to show that Sr has anticariogenic properties. Curzon reported onthecaries-reducingeffectofdrinkingwatercontainingstrontium.Henotedareduction
Table 1The acid and base components used in the various dental cementsAcid-Base Cement Acid Base
Silicate Calcium-fluoro-alumino-silicate Phosphoric acidZinc Phosphate Zinc oxide Phosphoric acidPolycarboxylate Zinc oxide Polyalkenoic acidGlass-Ionomer Calcium-fluoro-alumino-silicate Polyalkenoic acid
Ngo
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in DMFT in a population exposed to drinking water containing strontium.
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The impor-tance of this information will become apparent in the discussion of a study relating tothe internal remineralization technique, where both F and Sr from GIC were found tomigrate from GIC to the soften dentine left at the base of cavities.For restorative GIC, approximately 60% of the liquid is water, which plays an impor-tant role in the setting reaction and in the final structure of the set cement, as well ascontributing to the observed biocompatibility and the well known ionic exchange.Water allows the acid–base reaction to occur and the migration of the various ionsout of and into the matrix of the set cement. When the powder is brought into contactwith the liquid, the acidity allows the matrix-forming cations, Ca or Sr and Al, to leachout of the glass. These will cross-link with the polyalkenoic chains to form metal poly-acrylate salts, which form the matrix and solidify the mix.
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MOISTURE CONTROL AND THE CLINICAL PERFORMANCE OF GIC
The setting reaction of GIC is a two-phase process.
In the first phase, immediatelyafter mixing, there is cross-linking of the poly-acid chains by either the Ca or Sr ions.This cross-linking during this first phase is not stable and can be easily affected byexcessive water loss or gain. Clinically, this means that the restoration must be pro-tected, against initial water contamination and desiccation, immediately after place-ment. In the second phase, within the solidified cement, the poly-acid chains arefurther cross-linked by trivalent Al ions. This second phase gives the materialincreased physical properties and reduced solubility.In the set GIC, water molecules can be classified as either loosely bound or tightlybound.Asthematerialmatures,theratiobetweenthelooselyboundandtightlyboundwater decreases, and the material will show increased in physical properties. This isimportant for two reasons. First, the loosely bound water is essential for ion releaseand uptake, and second, it is important to maintain the water balance right throughthe life of a GIC restoration. Early exposure to excess water during setting and desic-cation, at any stage, will lead to poor clinical performance.
ION EXCHANGE BETWEEN GIC AND THE EXTERNAL ENVIRONMENT
Becauseofthecombinedeffectofreleaseanduptakeofions,GICisarichreservoirof apatite forming ions such as fluoride, calcium, strontium, and phosphate. In the
Fig. 1.
Scanning electron microscope view of a set GIC showing a reacted glass particle ina set cement. The three areas of interest are: the silica ion–depleted gel phase, the glasscore with its fluoride-rich phase (dense white droplets), and the matrix of the cement.The minor crack is an artifact.
Glass-Ionomer Cements
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