The Glass Ionomer Comeback with Dr. Brian Nový

I remember the first CE course I went to was a dentist from UCLA talking about glass ionomer. And I talked to the dentist at the table with me and I said, so do you use this? And like, no, no one uses this stuff. No, no, no, this is, this stuff doesn't work here in the United States. Here in the United States, we use composite. And this stuff works on the other side of the world. But if you add a little bit of composite to it, then maybe it starts working a little bit better. But no, it's too difficult. It's easier to just have one thing in your office. And really what those dentists were saying to me, Phil, was I want to use materials that are easy for me, not what's best for my patient. Welcome to the Phil Klein Dental Podcast. Today, we're talking about direct restorative materials that can truly change the trajectory of your patient's dental health. And no, I'm not talking about composite. I'm talking about glass ionomer and resin modified glass ionomer. These materials aren't simply filling cavities. When used strategically, they can help keep patients out of a lifetime of fillings, crowns, and endless dental work. And here's the best part. Taking this conservative approach, which is best for the patient, doesn't mean sacrificing revenue. In fact, building a practice around preservation of tooth structure and non-aggressive dental treatment will attract more patients than you can handle because patients want dentists who are conservative and care only about what's best for them. Joining us is Dr. Brian Novy, a leading cariologist at Virginia Commonwealth University with faculty appointments at Harvard and Western University. In addition, he's a private practice owner in Salem, Massachusetts. Dr. Novy is here to explain glass ionomer and resin-modified glass ionomer, how they bond to teeth. He'll walk us through the clinical applications of each and address concerns about strength and aesthetics and show why using glass ionomer and RMGI can have a real impact on your patient's long-term oral health. So if you're ready to rethink restorative dentistry and you're looking to save your patients from decades of dental treatment, This episode is packed with insights you won't want to miss. Before we bring in our guest, I do want to say that if you're enjoying these episodes and want to support the show, please follow us on Apple Podcasts or Spotify. You'll be the first to know about our new releases and our entire production team will really appreciate it. Dr. Novy, pleasure to have you on the show. Thank you very much, Dr. Klein. It's always fun to talk to you. Yeah, you've done so much for Viva Learning. And again, we want to thank you for your contributions over the years. This is an interesting topic because, you know, some doctors love composite and there's so many good composites out there and they love aesthetics and they want the strength. They're great at bonding and so forth. So, you know. When you have a hammer in your hand, everything looks like a nail. And this is the way it is with composite. But there are other direct restorative materials out there. And there are really good applications for them. And I think it's important once in a while outside of... dental school to review some of the benefits of these materials, what they are and so forth. So when we talk about glass ionomers, glass ionomers, we know bond to teeth and they do it chemically. We call it an ionic bond because basically the carboxyl group from the chemical links inside that acid chain, they bond chemically with the positive charged calcium ions that are in hydroxychloroquine. Fuse. Some might say fuse. Right. Oh, yeah. Okay, fuse. Very different than composite. Yes. And they take advantage of the calcium that's in the hydroxyapatite. That's our tooth structure. So we get this really true permanent chemical bond, which has a tremendous advantage over a mechanical bond. And you could talk about that. And then... On the other side, plus we have the fluoride release, the recharging and all the other stuff, and the better behavior under moist conditions. We get this stuff all to work fairly well, even if we can't isolate as well. Composite resin, let's talk about that. That could be beautiful, aesthetic, strong. We do not get any chemical bond whatsoever with composite resin. We rely on the micromechanical retention via the bonding agents. And of course, we're taking advantage of the resin tag formation. We end up with a micromechanical bond. So those are the two basic category of materials that we use for direct restorative. And then we have to complicate matters a little bit. We have a resin modified glass ionomer, which I'm going to let you talk about. But to begin this podcast, talk about the importance of having both glass ionomer and composite resin at hand in our toolkits as we treat our patients. And then I want to bring in the resin modified glass ionomer category so you can explain to us what that is and how we should be using that material. Wow. I have a question before we begin, Phil. Who taught you dental materials? I was actually a material science engineer undergrad. That's how I got into materials, just because I did material science as an undergrad. Okay. That's it. So you and I were kind of like, you were, because as I hear you describe. glass nanomers and resin modified glass nanomers and composite there aren't very many dentists who can explain it at that level just kind of off the cuff the way you did because i i know you're not you're not reading it so no i'm sitting here going wow this can be a very very fun conversation for you and i to have and your listeners will listen to this going oh please i don't i can't i can't listen to you to pontificate about carboxyl groups and and and chemical bonding and and fuse and and i'm like fusion uh so And I hear a lot of dentists say, come to my lectures, and they want to know more about glass ionomers. They want to know how they can use them, where they're in an office environment where they're not using them, where they don't have them. Because let's be honest, even if you talk to someone about what kind of sealant material they have, most offices don't have more than one sealant material. Everyone just brushes on the teeth and then light cures it. And it's so different than the scene material I would recommend, which is a glass ionomer. And many offices, or not many, I hope every office actually, every office that listens to this, I hope starts thinking seriously about getting glass ionomer in the armamentarium if they don't have it. And I would imagine many people who are listening to this actually already do and are probably going to appreciate what... What's the difference between a resin-modified glass ionomer and a glass ionomer in terms of clinical indications and how do you use them? And I think for anyone who's picking up these products and using them, number one, you got to realize there's a learning curve. If you're a composite dentist and you're even thinking about using glass ionomers or you are a glass ionomer user and you're going to start using resin-modified glass ionomer because I was the guy who... Did some sandwich restorations early on in my career. Dr. Tanner, Dr. David Tanner, if you're listening to this, you remember seeing those early sandwich restorations and you and I having a conversation about what is the bond between the glassionomer to the composite with the bonding agent that you're using? And are you sure that this is the clinical longevity? And thank you, Dr. Tanner, for getting me to start thinking really, really critically about, listen, kid, if you're going to do this on my patients, I want to make sure you know what you're doing. I remember the first CE course I went to was a dentist from UCLA talking about glass ionomer. And I talked to the dentist at the table with me and I said, so do you use this? And like, no, no one uses this stuff. No, no, no. This is, this stuff doesn't work here in the United States. Here in the United States, we use composite. And this stuff works on the other side of the world. But if you add a little bit of composite to it, then maybe it starts working a little bit better. But no, it's too difficult. It's easier to just have one thing in your office. And really what those dentists were saying to me, Phil, was I want to use materials that are easy for me, not what's best for my patient. I mean, that's really what I, that's now what I understand they're saying to me is I don't want to, I don't want to actually take up more space in my drawers for material, which is not, which isn't easier for me. When in fact, I now know, my gosh. I, I work with composite and very rare. occasions when i do i'm like oh i hate this stuff it's so difficult to work with compared to glass ionomer glass ionomer just works so well in my hands and resin modified glass ionomer I used ResModified glass ionomer, and now, like you mentioned, I'm more of a true glass ionomer guy. But I realized that if people who deal with the problems of, and not problems, I shouldn't say problems, people who deal with the limitations of glass ionomer, who don't know what they're dealing with, who go, I hate this material, it falls out. Okay, no, it doesn't fall out. It's breaking down. And it's sacrificing itself in the most extreme environments of your very high-carious risk patients' mouths. And aren't you glad it did? Because if it didn't do that, your restoration is going to get recurrent decay. Now, I know there are those dentists out there who say, recurrent decay? Well, just... That's just a bigger restoration that means more money. And I'm not that dentist. I'm the dentist who goes, please just stay away after I do this. This one time we got through it, let's move on with our lives. And I don't want them coming back. My patients are very fearful and they're very high risk patients. So you have a tremendous respect for glass onomer and you know how to use it and you've been... Absolutely I do. Yes. Tremendous respect. Right. So tell us first, before we get into... more details on how you do use it. Tell us when you don't use it and why you don't use it in those cases. If you ask me to explain why I don't use, when I don't use glass ionomer, I have a really hard time figuring out a case where I don't use glass ionomer. I want to use glass ionomer every chance I possibly get. The times when I can't are when I'm doing a class for anterior restoration and you just need to make it look. absolutely perfect. Let's be honest. I wanted to be that dentist early on in my career. I'm not that dentist now. That's the dentistry that Pam does in our office. That's the dentist that the prosthodontist do in our office. I'm the preventive guy who handles the really high-risk patients who most people find very, very challenging. I find them very unique and quirky and kind of fun to be with. But the people who I work with go, I don't know how you do it. Are we talking about kiddos now? You're working on young kids. We're talking about kiddos and adults and elderly patients and everything in between that has been traumatized in some way, shape or form. I'm thinking about the kiddo I saw yesterday. I had a nine year old tell me that he was papoosed three years ago, not because he was being uncooperative, but and I don't want to get in. Sorry, Phil. But it's just I meet more patients who have been traumatized. And I want to say, are you kidding me? All they needed to do is squirt this stuff on two fingers and smash it on your tooth. And someone could have stopped this from affecting you right now. I can't. I just want to smack some of my colleagues upside the head because we come up with these ridiculously complicated treatment plans and tell our patients, you got to come back next time to do this. And you're going to come back next time to do this and next time to do this. I'm like, just treat the disease and be done with it. And how do you treat the disease? You ensure it doesn't come back and you ensure it doesn't come back by fusing. your restoration to the tooth and that's what glass ion ever does right so let me ask you that let me ask you this now so you said you have getting me really worked up though yeah so you sorry dr so you have an associate dr pam who handles the aesthetic dentistry and the patients that come in that are doing an interview on tv next week and they need yeah whatever they need direct restorative veneers because they don't have time to do indirect or whatever they do indirect and they get stuff and then when she's not there i have to deal with those patients right i do i work in glass ionomer people you're in a different right you're in a different sphere of dentistry yeah but what i'm saying is try to put your shoes on now that you're a dentist who has both You have a practice where you have those high caries risk patients that you know will have recurrent problems if you go the composite route. You know that. You've done not only scientific research, you've done it clinically for decades. You know that as good as you could be with a composite resin restoration, if that patient is extremely prone to caries in that area, it is highly unlikely without the benefit of glasonomer. you will have as successful as a clinical outcome as you can get with glass onomer compared to composite resin. But now put your shoes on and you're the dentist where the patient demands aesthetics. They want that thing to look beautiful. Do you go with a, in that case, do you go with a resin modified glass onomer or do you use a composite? And what do you do differently with a composite when you know there's high risk carriers? Or is that even possible? Well, first of all, let me say, I have worked with, I'm going to call them legacy assistants, who have worried about me doing my glass on or restorations in a patient's mouth, and they are concerned about how it's going to turn out. And I have always convinced my legacy assistants that... oh wow you can make that look really nice oh my wow you're right it does look it's just like composite so in the right hands and when you know how to use the materials they can be very aesthetic if you don't know what you're doing and you don't know how to work with the material, I can see why many people try it one time clinically. And let's be honest, how many times did you do composite restorations and for the new graduates coming out now, how many times did you do composite restorations in lab? How many times did you do glass ionomer, resin-modified glass ionomer restorations in lab? As I tell my students at VCU, please don't judge glass ionomer as a material. because of your dental school experience with it it's best when you're in private practice and you know you've got the composite technique down and now you're ready to say look i realize this material is not the best to put in a high carousest patient's mouth and you're right i'm challenged by this patient continuing to come in with recurrent decay and i don't want to deal with it anymore What material should I use to make sure that doesn't happen or at least minimize that from happening? Because, you know, you know, you know how to use composites, but you also realize, no, this is not the right material for a high risk patient. You may want to use conventional glassionomy because it has some wonderful anticarious benefits. The problem is if you put it in that patient's mouth, it's going to dissolve away under that acidic biofilm, which isn't being removed. I mean, thinking about those elderly patients who. they're not the most cariogenic, but they don't remove the interproximal vial film. And so if that's marinating on a margin, you get recurrent decay. So if you put glass ionomer in there, you're going to eat away at the glass ionomer and you get these ditching glass ionomers that people think, why would I want to use that material? It's ditching away and it's falling away from the tooth. Yeah, the patient's biofilm and the oral environment adjacent to that restoration is so darn caustic that it's literally eating away at something. Would you rather eat away at the restoration or would you rather eat away at the tooth? I'd rather eat away at the restoration. I can patch that up. How am I going to patch it up? I'll probably patch it up with more glass ionomer. Or if I really knew that might happen, I would use resin-modified glass ionomer because that's not going to ditch. Not the same way. So now do you get the fusion, what you mentioned earlier, with resin-modified glass ionomer where you can get a very similar benefit to glass ionomer and hopefully some fluoride and remineralization and so forth? Now, if you don't get that deterioration of the surface of the restoration with resin-modified glass ionomer, you actually don't know where. where that attack is taking place. But you think that's a good compromise between the two materials? Well, it's interesting you ask that question. I don't think most... Well, no, it's a very... It's a good question to ask. Do you get the same gosh darn chemical fusion to the tooth with resin-modified glass ionomer that you get with glass ionomer? And the reality is... I mean, is this a safe... space phil yeah sure this is a safe space really can we talk off the record that's what this episode that's what this podcast is all about then maybe this isn't the place to talk off the record um about the nefarious things that go on within dental research um and what we actually what the dental what the really really really smart smart dental materials gurus out there who run these who run the last remaining dental research labs of the dental schools that are that have disappeared and yet They're still heavily funded dental research materials labs. Those folks, and you know who I'm talking about, or maybe you don't know who I'm talking about, but the guy who one time showed up in my lecture and my crown, this is a funny story, Phil. I'm going to get on a funny story. This has a point. I was lecturing in Chicago and in the middle of my lecture, my crown broke. My Empress II crown broke in the middle of my lecture. And the fortune of my crown was rolling around in my vestibule. And I, And so I finished the lecture. I went up to the back of the room, was talking to the sponsor about, I think my crown broke in the middle of the lecture. And she made a comment about, well, what are you going to do? And I was like, I don't know. No, I think my crown actually has a hole in it. And this guy walks up behind me and he goes, what happened to your tooth? I can fix it for you. And I went, I looked at him. I was like, I don't even know your name, dude. And he goes, hi, I'm Alan. And I was like, oh, hi, nice to meet you, Alan. He wound up being. quite a very well-known and well-respected dental materials researcher. And he invited me back to his office, high up in a Chicago high-rise. And we had, we geeked out on dental materials and he gets me in the chair and he's going to fix my tooth. And he goes, all right, Mr. Smarty Pants, what do I fix your tooth with? And I said, do you have any glass ionomer? And he said, I knew I liked you. That's what I would pick for my own tooth. I'm like, oh. Thank goodness, because here I am, this young, cocky, kind of cocky dental material, not kind of cocky, cocky dental materials speaker early on in my career, and this guy is agreeing with me. And dentists disagreed with me back then, and now people don't disagree with me. Because people who use it know it works. You had a hole in the crown, the actual ceramic empress fractured? Yeah, my empress tooth, the distal cusp of my empress tooth crown fractured off. It was bound to happen. Fractured off and it was left with no distal contact. And so we put a matrix on it and we cleaned it up and he actually fixed it with resin-modified glass ionomer. And that was really my indication because he didn't have any glass ionomer and he really opened my eyes to, you know, no, you should respect resin-modified glass ionomer. And I am a conventional glass ionomer guy, but I know that dentists worry about... these things dissolving away in high-risk patients' mouths. And they see that as a failure when I don't see that as a failure. I see it as a tremendous success because it's patchable at that point. And who the heck wants to anesthetize a patient and chase recurrent decay closer to Big Red? I mean, who wants to do that? I do not find that. Maybe some people enjoy doing that. I don't enjoy doing that. Well, they're looking at the glass ionomers falling apart because it doesn't have the wear resistance. They're not looking at it from any other standpoint. They're just saying this is a weaker material and now I got to redo something, right? And I'm saying no, no, colleagues, please. You've got to free your mind from that mindset of this material is inferior. It's breaking down because your patient's caries has not been controlled. And you have one of two options at that point. Either you get recurrent decay around your restorations and that patient is going to need endo and crowns and more and more and more services, which I can see why you might want to drive that business model. But I don't think it's on every patient. Right. But you're talking about the breakdown in approximately or maybe in a class five cervical area. But I'm talking about breakdown occlusally. They're chewing, they're grinding, whatever they're doing, and it's starting to break apart. And they're saying composite can resist those. forces much better than glass onomer. You're talking about it as an acid attack. I don't know that I would make that. Yeah, I'm talking about that acid attack. Right, but I'm talking about it as an occlusal wear. Occlusal forces? Yeah. You can't say that you could rely more on glass onomer than composite when it comes to occlusal wear. Well, you know, Phil, I'm going to challenge you on that because why then can orthodontists open bites? Why do they open bites with resin-modified glasonomer? When they need to get some sort of distal contact during orthodontic treatment, they will do it with resin-modified glasonomer. No, resin-modified glasonomer, I agree. I'm talking about straight glasonomer. I'm talking about pure glasonomer. I want to hear more about resin-modified glasonomer as much as you can tell us. I think a lot of dentists out there know your position on glasonomers. Absolutely. I'm one that agrees with you. I think you know that over the years. We've done many of these. I'm a big minimally intervention guy. I love medically treating teeth as much as possible. And by fusing to the teeth and the actual remineralization that could occur, the ongoing fluoride deposition into the hydroxyapatite, all that stuff to me is very important. Just fighting the potential for... recurrent decay is a huge thing for me because i think it's the responsibility of the dentist to do that as a dental health care provider that's why the patient is going to you they want to be healed they want they want some material that's going to help them from this happening again so if you're putting a material in that is kind of a proponent of this happening again versus just because it looks good and they they like using the material like you said earlier in this podcast that's not a in my opinion that's not a responsible health care provider so i'm Totally on your side on this one. But when it comes to resin modified glass ionomers, are we compromising in any way by using that versus using pure glass ionomer for one thing and pure composite resin for another? Is there a place for resin modified glass ionomer? It's been around a long time. And what are the indications? And could someone say, I'll just use that? It's got good aesthetics. Yeah. Well, I absolutely think there's an indication of a resin-modified glass ionomer. And so I think that's how we started this podcast was, but Brian, when do you use which one? That was 20 minutes ago. Yeah. I'm sorry. I told you when we did this, when we did the pre-production call, I wasn't going to make, I wasn't going to do this to you. I promised. And here I am. But my rule of thumb is if it's in an aesthetic area, a class three or class five, I use resin-modified glass ionomer. If it's in a posterior area or class two, I tend to use conventional glass ionomer. But I then, on top of it, place composite. Now, when I say I place composite on top of my glass ionomer, it sounds like I'm doing a sandwich. No. What I'm saying is I'm impregnating the surface of my conventional glass ionomer with an unfilled resin so that I get the acid dissolution imparted to the occlusal surface of my restoration. So I can make my conventional glass ionomers. They do have a resin. top if you will to them now people hear me say that and then they come to my lectures and say i thought you said that when you coat glass ionomer that floor it i'm like i guess i did say that but the reality is when a patient starts wearing away a little wear facet or when you polish it at all and you get any little window open through that surface sealer which could be interproximal as the teeth kind of shift a little bit and then and i don't usually seal my interproximal surfaces because i want to see If the interproximal surfaces break down, I get those class two lesions in my in my restorations. I know my patient carries risk is not maintained. And it's so easy. And it's so funny to me that people say, well, why would you want that to happen? If I used composite, it would get recurrent decay. I have to anesthetize and I have to remove the whole gosh darn thing cut down. to a new gingival box probably expand buccal lingually put a freaking sectional matrix in there put a and get the bleeding controlled when why don't i want to just cut a little slot prep right in the occlusal slip in a little mylar strip or something if even that clean it out with some with some polycrylic acid rinse it out the key is getting it's figuring out the right moisture content of that of that tooth and also to realize how much material is going to come out of that capsule and so i would rely on a really good assistant who can who can tell is this you know going back to you know it's a single spill a double spill or triple spill restoration because glass ionomer capsules have a limited amount it's not like composite where you can just keep you know adding more to it you're you want to move quickly and And I mean, granted, if you don't move quickly, you can repair them. But as you get better and better, you're going to want to do a bulk fill with glass ionomer. Maybe it's one, two, three capsules, depending on how large a restoration that is. And then condense each one. each capsule into the other very without drying them out without adding any bonding agent you got to work really quickly are these capsules resume resin modified glass ionomer yeah okay we're talking about resin modified because you said glass either or okay because you i mean we're either talking about ionostar or ionolux ionolux is a is a resin modified glass ionomer ionostar is a conventional glass ionomer um do you need to treachery either one of them You do. It's still, it's an acid-base reaction with resin. So it's not pre-mixed. It's not pre-mixed. It's not pre-mixed. Okay, so you need to triturate it. Yeah. And having, and I know people, and the other thing is, I think with their hygienists listening to this, please really consider using. a resin modified glass ionomer as a sealant material like ionolux but the reality is you need a triterator in your operatory to be able to do that or you need and i've had dentists say i don't want people running through my office from one operatory to another well so what again here we are saying i don't want to buy i don't want to put a triterator in my hygiene operatory because i don't want to i don't i don't know i just don't want to do it so i want my my my team to use an inferior sealant material because I don't want to buy a triterator? Seriously. Yeah, see, that's my whole point, and I think you nailed it right there. Why can't you take up some counter space for the mixer of the material which is best for your patient? We took a footprint to put a display for bleaching, which may or may not be good for your patient. We'll be having a discussion about that some other time. So you're saying that if the triterator is in the hygiene... department, the hygiene op. Well, what I'm saying is I have heard dentists say that I don't want, I don't want to encourage my dental hygienist to do composite or I don't want, I don't want to discourage them from doing composite sealants because it's easy for them and they don't have triterators in their operatories. So I don't want them to move switching to glass ionomer because I don't want to buy them triterators. Okay. You're talking about for the sealants. I see for the sealants. And so then, and I'm thinking what. What office, what's an easy transition for an office to get to do more resin modified glass ionomer? What I would do is encourage your hygienist to do glass ionomer sealants or resin modified glass ionomer sealants and do your resin modified glass ionomer sealants on your lower risk patients. I know that sounds weird. And do your glass ionomer sealants on your higher risk patients. Because we all know the beauty of glass ionomer is a very forgiving material. And we all know that. composite resin sealant should be put on under rubber dam so let's start having that conversation about what's the best technique for these patients to be getting sealants applied when we have hygienists working alone who are not putting rubber dams on kids teeth to place sealants when that's what we should be doing when we place composite sealants period end of story i will not have further discussion on that issue You don't need to do that with glass eye honor because it's so freaking forgiving. And you can literally smash the stuff in kids' teeth. And I sound like a heretic. I sound like someone who wants to do ridiculously, ridiculous preventive procedures. No, I want to do preventive procedures which help patients avoid any traumatic experience and make them go, oh my gosh, that wasn't bad at all. If I just need to get that so smashed in my teeth every six months, I will come back and get that done. and that's a that to me is a practice builder because if you're replacing sealants every six months and granted we need payers to get on board to realize when you use certain sealant materials and it's having its preventive effect you need to replace them on an annual basis you can't say no i'll only replace a sealant every three years and so we need better tracking systems we need better measurement systems but hey that's coming that's that is so we are so we are on there is this tidal wave about to hit the dental ecosystem when it comes to caries management and prevention. So I'm sealants and resin modified glass vinyl restorations and conventional glass vinyl restorations in the posterior are all part of better caries management strategies, in my opinion. And to the dentist who says, I don't, my patients don't get caries. Okay, well continue using composite resin. But I know all of us get to a point where we start seeing our composite restorations break down. And we need a material which is going to withstand the test of time. And the test of time is not, are you going to be able to continue? Is it going to wear away a little bit over time? No, I want the test of time to be, it doesn't get recurrent decay. And it seems to me that most patients end up not taking better care of their teeth towards the end of life. Let me ask you about core buildups. Is there a benefit to use resin-modified glass anomers for core buildups, given its anticarious properties? Is that a... argument to be made where it still has the strength to support a crown, but you, you are preventing, hopefully preventing some recurrent decay there. That's a really good question because I think people remember, um, my, my colleagues had been doing this longer than I have. We'll remember a time when crowns were popping off with glass anomer and res-monfect glass anomer buildups underneath them. And so you bring up a really, really, really good point. And naturally, I think that Before you start doing a core buildup, before you start doing any big restorations where you want longevity, if you know what you're doing, absolutely, yes. Use resin off the glass onward as a core buildup. Use conventional glass onward as a core buildup. That's absolutely what I would want under any indirect restoration of my own mouth. I also know what type of indirect restorations I'm doing and I know how I'm doing them. And then my assistant knows not to dry them out. And we know exactly the moisture content I want on the tooth surface because, and thank you for bringing this up again because I didn't answer this question the first time. We know that with resin modified glass on where you want the tooth to be slightly. on the drier side, because that resin component, if you leave the tooth as wet as you would with conventional glass ionomer, it's going to repel that resin component of the resin modific glass ionomer. You're not going to get that bond. And to your point or to your question about, do you get the same bond strength? If you know what you're doing, I think you can. And if I can just take a step back and say, this is the point I just drove home to my students at VCU this week in class, because There's a student in my class who's very vocal about how much he dislikes evidence-based dentistry. And every time we bring up the evidence, he groans. And it's quite comical, actually. But it's not unlike the reaction everyone has when you start boring people with the evidence. And so I had my students read a paper this week where it's actually a paper that says, how should we evaluate and use evidence to improve population oral health? And I would say you can whittle that down to patient oral health and whittle that down further to tooth health. And what that means, and this paper actually argues that evidence production is not enough to stimulate evidence use. And we need to particularly highlight the importance of carefully considering the theoretic underpinnings of change and the role of the context. when we implement what we see in the evidence. And I bring that up because when you read the systematic reviews that compare glass ionomers to resin-modified glass ionomers to composite in terms of Kerry's preventive effects, I'm referring to the ADA systematic review in 2016. That evidence is still the best we have for the Kerry's preventive effect. And it clearly demonstrates, despite the fact that the abstract says, if you look at figure... and seven and figure eight or table seven and table eight if you look at those tables and you look at the the hierarchy of the evidence you can clearly see there's a difference in the anti-carious benefits of this material if you put it on sound enamel or whether you put it on carious enamel and so there is one material which when we talk about when you seal things in the teeth yes the disease stops That is not the same as certain materials that we claim seal. Glass ionomer truly seals. Resin-modified glass ionomer truly seals. Other materials do not truly seal. We all know it. We see it. We see recurrent decay around those. That's why we, anyway. So when you're doing a filling using either glass ionomer or resin-modified glass ionomer, let's get back to doing a filling. We're not talking about sealants here. When you're removing the decay, We were taught in dental school to get down to squeaky sound tooth structure. At this point in time, are you recommending to leave the leathery dentin and just take the infected dentin away, the mush, and not go any further when you're using glass ionomer or resin modified glass ionomer? The short answer is... It's so complicated, Phil. You know restorative dentistry is complicated. You can't make hard and fast rules like this, right? So when we're talking about, do I have really, do I have a cooperative patient? Am I in complete control of the situation? Is my patient, do they have really good oral hygiene? Do they come in with a tooth smattered in biofilm and I had to clean the biofilm off? I didn't even think that there were dentists who didn't. do that if it was there. And now we realize, oh my gosh, there are dentists who say, I don't have enough time to wipe the biofilm off the teeth. Just put the matrix on. I love learning that there are dentists out there advocating for cleaning a patient's teeth before they restore them. Thank you, Dave Clark, for coming to planet earth. And I'm sorry. Yeah, no, these should be minimum requirements for restorative dentists. You want to work on a clean field. It's like doing heart surgery and it's a mess. Yeah. It's not a septic environment. Yeah. But again, the mouth is not a perfect place to do operative dentistry, but removing biofilm in an area where you're restoring a tooth does make sense. So there's no real answer for this, you're saying. Well, I think there is. I mean, I can whittle it down to a flow chart, which people might be able to imagine as they're driving their cars listening to this podcast. And that flow chart is if I've... I'm assuming living in a perfect world, and I want margins. First of all, my margins, if I've got really nice margins that I'm happy with, that I know are going to be sound, I'm comfortable leaving more and more affected dentin. Definitely not infected dentin, unless I'm treating that infected dentin with something like silver diamine fluoride or nanosilver. And there's a lot of controversy out there about nanosilver now, and I don't think there's any controversy at all. You're a big fan of SDF? Oh, I'm a huge fan of silver modified atraumatic restorative technique, which is smart. So in the cariology world, we call it smart, silver modified atraumatic restorative technique. I love silver diamine fluoride. I was one of the first adopters of silver diamine fluoride back when we couldn't even read the instructions on the bottle. And yet we were meeting at the California General Association to get some. Yeah, I like silver diamine fluoride a lot. So we were talking about leaving the affected dentin alone. And SDF is a great material to put on top of that. And that's not a bad idea to add conventional glass anomer directly on top of that and the patient goes home, right? Because now you've got... silver that's that's doing this i mean it's it's antimicrobial as it gets right in that and it's so freaking basic you basically cauterize the lesion and you precipitate both silver phosphate and silver chloride and the more and more we learn about it in fact i learned I learned something about it the other day from students who helped me realize we've hammered home the fact that silver reduces to silver phosphate. Well, actually what's happening is first the silver diamond fluoride is oxidized by any organic matter that's there, and then it further reduces into these black precipitates that we see. So understanding that science allows us to get away from everyone's worst fear with SDF, which is ill-founded in my opinion. Is that, you know, oh, it's going to stain the lesion darker. Well, do you want a darker lesion that's not going anywhere? Or do you want a lesion which is brown and penetrating down to the nerve? That continues to destroy your tooth. It continues to fester. Right, right. It's crazy talk. I see on Reddit. I see dentists on Reddit who post pictures of... white aesthetic restorations with the dark line around it going, I'm taking this out, but there's no decay. And people are going, no, don't do that. That's smart. Someone put silver diamond in floor and then put restorative material in over the top. Don't touch that thing. And like, well, yeah, there's not, but how come no one taught me this? I'm like, oh, you were so programmed to see a dark, any darkness. Well, we're dentists. We're dentists. What about using resin modified glass ionomer on top of SDF instead of conventional glass ionomer? Can you do that? Yes. At the same visit. I'm talking about the same visit. If you did that, what I would do is I would make sure you look at the chemistry of what type of silver solution you're using, because there are lots of different types out there now. And the question becomes, do you want to put your polycrylic acid conditioner on first? And then your silver diamine fluoride. Do you want to use your cavity conditioner at all? We haven't even gotten into that issue. Or do you want to do the silver diamine fluoride? first and then your cavity conditioner do you want to and do you want to rinse the silver diamond for it off do you want to and here's the thing if you don't understand the chemistry of what you're doing you really shouldn't be combining these materials until you've read more papers or go to some courses given by the wonderful dentist who have perfected the hall technique and if you're not familiar with the hall technique i think that's the best technique to use to say any any crown form where you're basically on a on a primary tooth you're doing as much decay removal as is comfortable for the patient without anesthesia usually, and then just filling a crown with glasionomer. And they do very well. They do very well. They do. There's some really, really fascinating stuff coming out of pediatrics on what we can actually do to help patients with really minimal interventions. Right, without drilling. We need to get into medically treated caries, caries management through medicine. more than picking up a drill all the time. I mean, we already know that that stuff works. Well, that's Canberra. That's what Canberra, and everyone thinks Canberra is a risk assessment form, and Canberra isn't a risk assessment form. Canberra has always been carries management by risk assessment, and risk assessment leads you to figure out why the patient can get carries. And of course, everyone goes, But I don't want to fill out a risk assessment form. I don't want to fill out a risk assessment form either. And Canberra's coffin looks like it carries risk assessment form to me. But if I can give a plug for Canberra, Canberra is where the clinicians who do this stuff and are asking questions about, okay, so wait, I want to do SMART. Should I do it like this? You'll be able to talk to clinicians who actually have that experience and say, okay, this is what I would do. And we've got some, the dentists, we geek out on this once a month on our National Canberra Coalition meeting call. And everyone is welcome to join us. um and there's a lot of stuff happening in cariology right now with diagnostic Diagnostics. Oh, my gosh. Just the field of salary diagnostics is exploding all of a sudden. So, Phil, you're getting me all worked up and to a lather about. All right. So as we wrap up this, you have a paper coming out on cariology? I do. Yeah. Tell us about that real quick. I and a number of authors have a paper coming out. We have finally, it took years, Phil. I remember when I used to roll my eyes and go, oh, it's going to take me all night to write this paper. Now it takes years to write a paper. And when it gets done, you go, oh, it wasn't that bad. And in reality, the gnashing of teeth that went on behind the scenes writing this paper, but a great group of authors, many of them the executive board of the National Canberra Coalition. We've actually published in the Journal of General Dentistry the November, December 2025 issue, the final issue of the year. We have published the clinical guidelines in the era of Canberra. And so Canberra actually came out and said, everyone, this is what we think we should be doing. And we were able to link, and thank you, thank you, thank you, Academy of General Dentistry for letting us do this and saying, yes, we would love to publish this in our journal. We linked together the American Dental Association and Caries Classification System with what the ORCA Congress has done with ICCMS or the International Caries Classification Management System and the International Caries Classification Management Pathway that's been created. And we took all of that. And we mashed it together with what do dentists who really want to do this stuff, can we give them a framework for, okay, what can I remineralize? What should I be drilling? What should I be restoring with? When do I determine a lesion is active? When do I determine it's inactive? How do I track it over time? And we put all that into a clinical guidelines paper. So why can't we do, can we do like a 45-minute podcast someday in the future, not too far from now, early 2026? go through these? Because that's what I'm looking for. I'm looking for you to guide us based on each clinical situation as it comes into the office and saying, yeah, like I mentioned, do we leave affected dentin and we just take the infected dentin? It's hard to make that. Asking a guy like you to make that generalization is absurd, of course, but maybe you could sum it up for us in a 45-minute episode someday in the future. Could I hold you to that? Yeah, you can hold me to that. I'll pay you less than a million dollars for the episode as an honorarium. No more than a million dollars. That's fine. Heck, I talk about this stuff. I would talk about this stuff for free. Well, I mean, it's such a great service for the dentist to hear from someone like you, like what really is the recommended way of approaching these kinds of cases where it's best for the patient, not what's easiest for the operator, what's best for the patient. And that's sometimes lost in the... routine of dentistry a lot of these doctors are working in corporate dentistry where they're they're held to account on production and they they have to do certain things and whatever it is um so we're going to end this podcast but overall there is a place for resin modified glass anomers i know you like ionolux i think voco makes that that's one of them there are others out there but this particular material is something that's worth looking into and the The clinical applications for it, in summary, you're looking for something where there may be some tendency for that patient to be caries risk, but not super, super high caries risk. But you also need some aesthetics and you need maybe a little bit more occlusal strength. Is that sum it up? And I would sum it up with the Journal of Dental Materials did a systematic review where they said that the longevity of a resin-modified glass ionomer class 5 restoration is... superior to anything else right when it comes to and that's because of the the beautiful array of physical and chemical properties it has which is it's fused to the tooth it has the ability to bond to bend and flex with the tooth um with the same coefficient of thermal expansion and you have the anti-caries property if you're a dentist out there and you're saying yeah but they don't look that aesthetic when i do them Well, what I would encourage you to do is take some of the coating agent that comes, that's sold along with whatever res-modified glass polymer you're using, and use the coating agent and impregnate the surface of that. As you're manipulating the material, the more that coating agent you put into the surface of that, the more enamel-like that outer layer will become because you really will get this layer of very opaque glass polymer underneath, which is... wonderful because it opaques out dark stain from any silver diamond fluoride and then on the top you have this translucent layer just like enamel and isn't that what we're isn't that what the the um the pascal mannier's and the and the and the real dental gurus talk about is we really need to start creating the DEJ, right? And when you restore a tooth, why are we not restoring the physiologic structure of the tooth? And when you start thinking about resin-modified glass and glass acting more like dentin, what is the enamel? Well, the enamel can be composite resin, and that's a sandwich. I'm not talking about sandwiches. I'm just talking about using that coating agent to give you that acid dissolution surface. More so than that, with resin-modified glass armor, you get the aesthetics that you want. And then a dentist who knows what they're doing with microbrushes and everything, you can easily, easily make a resin-modified glass armor look beautiful. Class threes, class fives, class four, I think you want to go for the bond strength of composite resin when you start getting to that. Dr. Novy, amazing. Thank you so much. And we're looking forward to having you on where we can really talk about this paper that you're coming out with. And we could just summarize the workflow for our dental practitioners so that they could listen to it in the car while they're driving to work and they can get right to work when they get there. All right. Yeah. And implement better curious management. That's the idea. All right. You have a great day. Thank you so much. Thank you, Phil. Always fun.