Glass Ionomers: More Than Just Geriatric Treatment

You're listening to The Dr. Phil Klein Dental Podcast from Viva Learning.com. Welcome to the show. I'm Dr. Phil Klein. The next generation glass ionomers, known as glass hybrids, have become an ideal treatment option for geriatric and high-risk caries patients. Today we'll be discussing how the improved physical properties of these materials make them a cost-effective, long-term restorative option where there is virtually no risk of recurrent decay. Our guest is Dr. Lou Graham, an internationally recognized lecturer extensively involved in continuing education for dental professionals. His lectures focus on incorporating current clinical advancements through conservative dentistry. Dr. Graham, it's a pleasure to have you back on Dental Talk. Great to be here. What a great topic. So we have an aging population. going on and i guess getting old is a good thing right because the alternative isn't isn't that great so uh and me and you are no youngsters anymore although i know we feel well we're active and we try to convince ourselves we're still young but we're getting old too as is a lot of the country i don't know what the percentages are of people that are over 60 these days but it's it's way more than it was when we were young so having a good idea of how to treat some of these geriatric patients is really important for the practitioner so we're glad we have you on our show today So let me begin with this question. What are the specific challenges in direct restorations when it comes to geriatric patients? Well, you know, it's interesting, Phil, and thanks again for having me on your podcast. We're talking generally the way I term geriatrics, Phil, is anybody who's 10 years older than me, and it used to be 20. So now I'm going to label them at 75-year-olds and up. And what's interesting... As patients have aged in this generation, more have teeth, far more have teeth than in previous generations. Usually, back in the day, people come in with no teeth and with dentures. Today, they're dentulists. So to your question, what has changed? And what's changed is really their oral environment. There's so many compromised issues. So let's start out with the first and foremost one is xerostomia dry mouth. We know that patients are on so many medications. And we know that xerostomia is a problem. And if xerostomia is around, much higher caries rate. In addition, when we're working on these patients and seeing them, their teeth have shifted. And they've shifted based on occlusion and periodontal disease. They've got crowding. They've got larger embrasures due to bone loss and tissue loss. They've got poorer diets, very high in sugar. And they've got poor dexterity. So they've got poor oral hygiene, Phil. So as a result, it's like this is a perfect kitchen in their mouth for recurrent caries, new caries, and periodontal issues. So I think those are an accumulation of how I look at those would be what we're seeing today in patients' mouths of 75-year-olds and above. I didn't know that the sugar content in their diet was much higher. I know their diet can be compromised, but what makes you say that their sugar intake is more? You know, it's amazing. What we have found in our practice and when I'm doing courses is that they have like developed even more of a sweet tooth, probably because of a changing taste buds. But we actually see them having more sugar, sugar at night before they go to bed. And as a result, higher caries. You definitely see that overall in the geriatric population. Yeah. Yeah. It sounds like the perfect storm. tooth retention rate is improving versus fully edentulous. So now that we have that improved retention rate where there's more teeth in these geriatric patients, now we have to make sure these teeth maintain a good environment where they could sustain themselves. So what are the advantages of glass ionomers? Now I know from dental school, and I went to dental school a long time ago, we talked about glass ionomers as favorable to high risk patients, high caries risk patients. Talk to us about the glass ionomers used in these situations with geriatric treatment and how have they improved over the years if they have? So first off, they have improved. I think glass ionomers were amazing even back in the day when I started practicing 35 plus years ago. The first and foremost topic that we should discuss with glass ionomers is they don't need isolation. They can bond chemically to teeth in the presence of saliva. So whether xerostomic or not, routinely what we're seeing in advanced aging patients are root caries, and root caries aren't just buccal or lingual, they're proximal. And so we're not seeing coronal caries, we're seeing proximal caries along the necks of the teeth. So there you are, Phil, as an endodontist, saving teeth now, as you did in your career. And now I'm trying to re-restore them with previous crowns, lower bone levels. And so as a result, I'm dealing with gingival cavicular fluid, subgingival margins. And whether it's reparative dentistry or non-reparative dentistry, that's what I'm looking at. So to add to this. You know, and the beauty of glass animus has always been their long-term fluoride release. That has always been their mainstay. And so I think, obviously, bonding in the presence of saliva or placing without the need for a bonding agent makes this far more of a simplistic placement. And I think with these difficult-to-access areas, man, reparative dentistry for geriatrics is key. Absolutely key. Yeah, so it brings to light the cycle of life because you start with a pediatric patient and glass onomers do very well with pediatric patients. And then as you go through life and end up being a geriatric patient, the same thing applies. Isolation issues are a problem with kids and also with older patients as well. It's something you got to have in your toolbox as a practicing dentist. No question. Phil, I can't understand how dentists, you know, they used to say, well, I gave up amalgam, so no treacherators. and glass ionomers um have long been a mainstay uh using triturators now we'll talk about some of the advancements but you know there are so many great reasons like you just said to really touch on glass ionomers and why they are so let me just touch on a few things before we get into the improvements because that was one of your that was your question so the first pearl that I would tell your listeners is you don't want a phosphoric etch. You want to use a cavity conditioner to etch the dentin. That's what you're going to want to do. Now, the reason why is you don't want to use phosphoric etch because it really creates what I would call resin tags and the dentin becomes hypomineralized from phosphoric etching. And if you think about it, and this is a key point. If you use a cavity conditioner for 10 seconds, what you then do is you're just removing the smear layer and allowing a glass ionomer to chemically bond to the dentin, which will be the calcium in the tooth structure. And now you allow a calcium release internally, which only strengthens your glass ionomer. So I think phosphoric etching is out. Cavity conditioners are absolutely in. What everybody also has to understand... glass ionomers, you get far less recurrent decay. I have been using them for 30 years in class ones without occlusion on them. In other words, in the fissures, Phil, I've been using them as core buildups. And when I've taken off crowns that were 25 years old and I did a glass ionomer buildup, I would take out the glass ionomer buildup just to see if there was recurrent decay and rarely was there recurrent decay. So minimizing recurrent decay is what I would say glass animers are all about, along with the latest composites and all their technologies that are coming into dentistry. So I see this all being customized for geriatric care. Absolutely. So what do you say to a dentist that says to you, Dr. Graham, I love glass animers, but I feel they're not strong enough. They don't have the strength that I'm looking for. Now you say you use them in a core buildup and probably your prep design withstood. the stress of normal occlusal forces. So that crown maintained itself. It wasn't so much the material you were relying on, but the ferrule effect in your design. But what do you say to dentists that say, hey, I don't have the confidence in the strength of a glass ionomer compared to a composite? Right. So if I'm rebuilding a Phil Kline endodontically treated tooth, I'm routinely using a dual cure composite core because that tooth has been... decimated from decay and endodontic requirements. If I'm building a wall or I'm at the gingival area and I'm rebuilding a buckle or a proximal wall, it's plenty strong. They've lasted for years. I just don't believe I would use them to rebuild an entire tooth, but a wall, absolutely. Let's talk about that question. So here's GC, GC America launching. They have glass ionomers. and rmgis so it's really interesting that their glass hybrids like let's call it like equia 4khd they have improved physical strength than in previous generations and i have used these in class ones for years that are not load-bearing and you they just look brand new 30 years later and obviously the newer versions are going to be just as long lasting so I think what's interesting, and for your audiences to get even a little bit more information out of this, is that glass ionomers are pure glass, and then you put a resin coating over them. They're actually stronger, Phil, in terms of compressive strength. So they have fluoride release, and they're stronger in terms of compressive strength. Now, the RMGIs, like Fuji Automix LC, that you don't need a treacherator. They're actually greater, Phil, in flexural strength. So what does that mean? They flex more. They have greater strength. That would be ideal for their class fives. And because they're more translucent than previous generations in geriatrics with high recurrent decay issues, man, I see an RMGI like Fuji Automix LC as almost one of the ideal. offerings to our patients for that reason, because it's got higher flexural strength. And again, you don't have to bond them in. It's a chemical bond. What's the Equia Forte clinical application and how is that placed into the tooth? Yeah. So Equia Forte in our practice is still a treacherated technology. It's almost got a variety of different glasses, so to speak. of the floral alumina silicate glass and the strontium floral alumina and different combinations of the glass have made it more translucent but equally have given it further compressive strength so i say it's it's a wonderful reparative it's great for class ones in my practice especially on kids and i don't treat a lot of kids but equia forte you do a small class one prep small class 2-preps, this could be really a new application to many of your listeners versus etching and bonding and putting a composite in. Glass ionomers, believe it or not, have slightly more compressive strength than RMGIs or resin-modified glass ionomers. And the compressive strength is formidable. It really is strong. And the slam on glass ionomers for years has been wear. if it's in occlusion it will wear so i don't really rebuild large class ones with these materials but a small class one minimal occlusal wear on it or minimal occlusal cusp load on that really and then you just put the glaze that comes with equia forte the equia glaze uh you put that basically over the material and you just basically brush it on a very thin layer no airing And that allows the material underneath to fully harden. So it protects it in the first 24 hours and further. I don't believe it adds to the strength. It just allows the material to harden fully and protect it. So with this toolbox of glass ionomers that's available today, and GC is the leading company that makes this stuff, it sounds like to me that for a geriatric patient, someone you define as... As you get older, you always add 10 years on. So I guess it'll never end. Well, soon it'll be 95 years old. But right now it's 75. And we are working further into our life. People are retiring. They used to retire at 62, 65. That was routine. And they worked for a company. They got their watch, their pension, and they were off to Florida. But now people are working longer and they're more active and they need to have teeth that are presentable. The smile has to be, they have to have confidence in their smile. You're saying that. We could use as clinicians glass ionomer pretty much as our main staple product for restoring geriatric patients. I would say this, that the shift in restorative dentistry for geriatric patients, glass ionomers and RMGIs, along with some of the newer, we'll say composite technologies that are coming out that are very innovative. These materials are customized for our geriatric high-risk patients. Absolutely. I couldn't agree more with that statement that you just said. Okay, good. And to wrap up this podcast, Dr. Graham, it's been very, very informative as usual. Which other clinical situations, other than the ones we discussed, would you use these glasinomers? Well, obviously anybody who's high risk, and that could be any age group. uh children are ideal because you're in and out you think about this you prep you do you know a cavity cleanser etch you rinse you pack this material in and then openly all i do is i dip my burnisher in a little bit of water just water not resin i pack it in after 30 seconds let it set and then you finish refinish and polish so i would say patients who are high risk, hard areas to get to of any age, and compromised patients who really just can't sit in this chair, operating room patients. All of these are added virtues. And again, underneath crowns is a wall buildup or anything that can be exposed to recurrent decay. I love these materials. Excellent stuff. We really enjoy talking to you, Dr. Graham. You covered a tremendous amount of material in a short time. I hope you're enjoying working in Chicago and also living in Florida at the same time. It's a great... hybrid lifestyle you have there thank you phil i do enjoy it thank you that's what it's all about all right be well many more years to come of these uh podcasts we we got to keep going here talk to you soon keep smiling bro all right thanks a lot you be well