Enhanced CPD DO C RestorativeDentistry

Petros Mylonas

Jing Zhang and Avijit Banerjee

Conventional Glass-ionomer
Cements: A Guide for Practitioners
Abstract: Glass-polyalkenoate cements, also known as glass-ionomer cements (GICs), are one of the most commonly used bio-interactive
restorative dental materials, having been available since the 1970s. With the promotion of minimally invasive operative dentistry (MID), and
the reduction in the use of dental amalgam worldwide, the popularity of these materials has grown significantly in recent years. This article
outlines the basics and clinical importance of GIC material science, and provides an overview of their use in restorative dentistry.
CPD/Clinical Relevance: GICs are versatile dental biomaterials that require correct case selection, material handling and placement
technique to ensure optimal clinical success.
Dent Update 2021; 48: 643–650

Glass-polyalkenoate cements, also known powder, and are defined by this acid–base silicate (FAS) glass.8,9 The polyalkenoic acid
as glass-ionomer cements (GICs), were setting reaction. However, by altering the polymer could be polyacrylic, polymaleic
invented in the UK by Wilson and Kent polymeric acids, alkaline glasses, or by or polyitaconic acid, or a combination.
in 1965, and commercially introduced in adding different components, different The reaction is split into three overlapping
1972 as ASPA (alumino-silicate polyacrylic types of modified GICs with significantly stages: dissolution; gelation; and
acid) cements.1,2 All GICs consist of the different properties related to their maturation (Figure 1).
same generic formulation of a polymeric proposed clinical use have been created.3,4 Clinically, the acid–base reaction
acid, from the polyalkenoate acid family GICs are self-adhesive, self-curing, begins as soon as the material is mixed.
of polymer acids, and an alkaline glass possess fluoride uptake and release Care must be taken to ensure minimal
properties, can interact with adjacent moisture loss or contamination to
enamel and dentine resulting in prevent the loss of the ions involved in
Petros Mylonas, BDS, MMedEd, PhD exchange of ions, and exhibit cariostatic the setting reaction. If water is gained or
(Lond), MJDF RCS (Eng) MFDS RCPS properties.5,6 GICs do not require specific lost during the setting reaction, this will
(Glasg), FHEA (UK), Clinical lecturer, StR in tooth preparation or modifications, such lead to substantially reduced physical and
Restorative Dentistry, Cardiff University as acid-etching or bonding steps that are mechanical properties and, ultimately,
School of Dentistry, Cardiff and Vale needed for resin-based composites, but premature restoration failure.6
University Health Board, University their physical and mechanical properties The pH of freshly mixed GICs is
Hospital of Wales, Cardiff, UK. Jing are generally weaker when compared with reported to be between 0.9 and 210,11
Zhang, BEng, MEng, PhD (Lond), Suzhou resin composites.5,7 The ionic interaction immediately after mixing, rising to pH
Science and Technology Town, Huqiu, of GICs with adjacent dentine is not as 2.8–4.310,11 after 10 minutes, and pH 5.4–
Suzhou, Jiangsu, China. Avijit Banerjee, active as that of calcium silicate cements 6.710,11 after 24 hours. Previous laboratory
BDS, MSc, PhD (Lond), LDS, FDS (Rest such as mineral trioxide aggregate (MTA) studies suggested a critical pH of 2 (or
Dent), FDS RCS (Eng), FHEA, Chair in or Biodentine (Septodont, Saint-Maur-des- less) for the setting cement to cause
Cariology and Operative Dentistry, Fossés, France).
pulp irritation.10 However, the clinical
Honorary Consultant, Restorative
implication of the initial low pH remains
Dentistry, Faculty of Dentistry, Oral and Acid–base setting reaction controversial because the degree of pulp
Craniofacial Sciences, King’s College
GICs are defined by the acid–base setting reaction to setting GIC is dependent
London, London, UK.
reaction between the polyalkenoic acid on a number of factors, including
email: mylonasp@cardiff.ac.uk
polymer and the alkaline fluoro-alumino- the following:10,12–14
September 2021 DentalUpdate 643
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carboxyl groups (of the polyalkenoic acid)

and the water in the tooth surface. Over
time, these bonds are replaced by ionic
bonds between the polyalkenoic acid
polymer and calcium in the hydroxyapatite
of the tooth surface, forming an ion-
exchange layer.9,17 This ion-exchange
layer (reportedly 1–15 μm thick) is a
blended interface between the GIC and
the underlying dentine, which can take
between 1 and 10 days to form18 and
only forms in an aqueous environment.
Within this ion-exchange layer, there is an
exchange of fluoride, calcium, phosphate
and other ions between the dentine and
GIC,18 with the ionic bonds being capable
of dynamically breaking and reforming over
the lifetime of the GIC restoration.18
The clinical importance is that GICs
adhere chemically to enamel and dentine.
In vitro bond strengths have been shown
to be similar to both sound dentine and
caries-affected dentine.19 Additionally, the
initially hydrophilic and acidic properties of
GICs result in excellent marginal adaptation
at the tooth–restoration interface.20,21 As
a result of the ion-exchange layer, the
GIC can exhibit antibacterial and bio-
interactive properties when placed on
carious dentine.18
Measuring bond strengths of GICs to
dentine and enamel has been notoriously
difficult because GICs tend to fail
cohesively, rather than adhesively, and
a true comparison with other materials,
Figure 1. Simplified representation of the GIC setting process. Dissolution occurs within the first few such as resin composites, may not be
seconds after mixing, gelation occurs within first couple of minutes, while maturation occurs from possible or appropriate.9,18 However, values
24 hours to up to a couple weeks after placement. for GIC bond strengths have varied from
2.6 to 9.6 MPa (to enamel) and 1.1–4.1
MPa (to dentine), with 80% of the bond
strength achieved 15 minutes after GIC
 Quantity of free acid available within Self-adhesive and self- placement, and this increases as maturation
the setting GIC; etching properties continues.9,22 Clinical studies have indicated
 Setting rate and duration;
Chemical bonding occurs between the GIC that, depending on the GIC manufacturer,
 Existing histological condition of
and the tooth surface. Adhesion of GIC to pre-conditioning of dentine improves
the pulp and the proximity of the
dentine (and enamel) occurs in different GIC adhesion and restoration seal 23–25
GIC material; (see section on GIC conditioners).
stages (Figure 2), consisting of surface
 Degree of bacterial load in the wetting, self-etching and micromechanical
remaining dentine; interlocking, true chemical bonding and Antibacterial properties
 Quality of seal of the final restoration. ion-exchange layer formation. The initial low pH of GICs may confer
Owing to advances in their chemistry GIC is hydrophilic and self-etching, antibacterial activity, particularly when
compared with older GICs, modern GICs therefore, there is initially both surface placed over caries-affected dentine.
are advocated for use in the restoration of wetting and surface etching leading Additionally, laboratory testing indicated
large and deep cavity types, particularly to micromechanical interlocking. True that freshly mixed or set GIC and mature GIC
where selective caries removal techniques chemical bonding occurs where hydrogen inhibit the growth of Streptococcus mutans
are used.15,16 bonds rapidly form between the free and affect the acidogenicity of the overlying
644 DentalUpdate September 2021
 RestorativeDentistry

Figure 2. Simplified representation of the GIC adhesion process.

plaque biofilm.26,27 Ions released from the GIC and adjacent tooth structure.17,39 failure of a tooth-restoration complex. In
GICs, including fluoride, aluminium and The calcium and fluoride ions found within vitro laboratory studies have found that the
strontium, have exhibited antimicrobial the GIC can aid in tooth remineralization colour stability of GICs differs for several
effects.28–32 Some studies have suggested and provide cariostatic properties reasons, including the additives in the
that the antibacterial properties of GICs that are not observed in conventional formulation, contamination from extrinsic
could be related to fluoride release,33 the resin composites.39 sources and the storage solution.43,44
acidity,33,34 or even zinc.35 Given there are Clinical trials have also found good
conflicting reports on this matter, the Physical properties long-term colour stability for GICs. In a
exact mechanism by which fresh and set As GICs have been refined, they have 2-year study, EQUIA (GC Corp, Tokyo, Japan)
GIC exhibit antibacterial properties is still been successfully used across a wide was found to rarely show distinct colour
not fully understood.34 range of clinical scenarios, such as the mismatch (less than 1%) in class I and II
definitive restoration of primary teeth, restorations in permanent teeth.45 This was
Bio-interactive properties and stabilization in adults with high caries later confirmed by a series of studies in
The terms 'bio-active' and 'bio-interactive' susceptibility.40 However, in comparison which EQUIA (GC) exhibited no significant
describe two different properties for a to resin composites, the reduced colour match or margin discolouration
given dental material. Bio-active dental mechanical properties of GICs have issues at any recall up to 5 years, with no
materials can induce apatite-containing traditionally limited their comprehensive differences found compared to the hybrid
material formation (eg hydroxyapatite) clinical application as definitive resin composite Gradia Direct Posterior
in simulated body fluid, or induce a long-term restorations, especially as (Dentsply, PA, USA).46,47
pulpal response to simulate reparative posterior, load-bearing restorations.9,41
Compressive and flexural strength are
dentine formation. Bio-interactive dental GlC classification
materials contain and release ions most commonly used to describe GIC
and presentation
similar to those found within the tooth mechanical properties because they have
suitable in vitro analogues that allow All GICs can be categorized according
structure (eg calcium) that can interact
the replication of typical masticatory to how they are formulated, designed,
with adjacent tooth structure to drive
loading seen clinically.41 Wear resistance marketed, and sold.
remineralization.36–38 GICs therefore belong
in the bio-interactive category because of is another requirement in load-bearing
their ability to release calcium and fluoride scenarios. Conventional GICs have Clinical use
into the surrounding tooth structure been demonstrated to exhibit lower  Restorative: GICs for restorative and/or
and environment. wear resistance compared with dental preventive purposes;
Polyalkenoic acids are both ionic amalgam and resin composites; however,  Luting: GICs for luting/cementation
and polymeric in nature. Clinically, this their physical and mechanical properties purposes, both temporary
is important because GICs are both improve as maturation proceeds.42 and definitive;
hydrophilic and acidic, and can interact  Pulp protection: GICs for the purpose
chemically with dentine and enamel, Aesthetic properties of protecting the pulp floor of cavity
resulting in chemical adhesion and ion Aesthetics is a key property that preparations, overlying caries-affected
exchange (calcium and fluoride) between determines the overall clinical success or or infected dentine.
September 2021 DentalUpdate 645
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Delivery systems and dentine. Many manufacturers use layer of polymer on the GIC surface.9 Light-
GICs are presented with different delivery polyacrylic acid in their tooth conditioning cured resin coatings generally consist of a
systems according to their clinical use and protocols at different concentrations mixture of methacrylate monomers, photo-
formulation, and are available in a powder/ (10–25%) and for differing times (10–25 s) initiators, with/without filler particles.9
liquid combination, either hand-mixed or before being rinsed off with water.5,24,54 Comparisons between GIC surface
encapsulated and auto-dispensed. Most As GIC conditioner consists of polyacrylic coats have been undertaken primarily in
manufacturers provide the same GICs with acid, it is sufficiently acidic to remove laboratory-based studies studying water
different delivery systems. For example, Fuji the smear layer after rinsing, but, not too loss or gain, or the penetration of dyes
IX GP (GC) and Chemfil Rock (Dentsply) are acidic to completely remove the smear into the surface of GIC samples coated
available both as encapsulated and manually plugs. The significance of this is that the with different GIC surface coats. Surface
mixed powder/liquids. GICs with the same conditioning helps expose more calcium emollients have been reported to have
brand name and overall formulation do have in the hydroxyapatite enamel/dentine limited success in protecting GICs because
subtle differences in the filler:liquid ratio surface, which in turn plays a key role in GIC they can be easily wiped or washed off.
according to their clinical delivery system.5,9 adhesion.9,55 Using 37% phosphoric acid in They do, however, offer some protection
Hand-mixed GICs allow the clinician to a total-etch technique on dentine would where no GIC coat is available.57,60 No
control the quantity of final GIC required for remove all remnants of smear layer and differences between the protective effects
their restoration. It is easier to restore a large plug and decalcify the underlying dentine. of solvent-based varnishes and light-cured
cavity using a large quantity of hand-mixed This would reduce the number of exposed resin-based coats have been reported.
GIC compared with using multiple capsules, calcium ions available for GIC ionic bonding, All coatings that were tested performed
some of which may not be used in their and possibly increase the risk of post- equally well in minimizing dye penetration
entirety. However, previous research has operative sensitivity because the GIC itself is and preventing water loss, and both types
indicated that there are large inconsistencies also acidic.24 were significantly better than no coating
in the mixing ratios of powder/liquid and If the pH of the freshly mixed GIC is at all.57,61 A previous study indicated that
mixing techniques that can influence the sufficiently acidic, then the smear layer will varnishes might peel from the GIC surface
mechanical properties and setting time/ be dissolved/incorporated into the GIC itself, and the use of a light-cured resin-based
handling properties of the GIC.48–52 Pre-dosed and a GIC conditioner is not required.5,56 This coat may be preferred.62 In 1990, the
encapsulated GICs (powder/liquid) offer the is entirely brand dependent, and clinicians American Dental Association (ADA) stated
advantage of improved consistency and should always check the instructions before the importance of coating conventional
repeatability of mixing and dispensing. using any GIC material to ensure their correct GICs with either a varnish or a light-cured
use and placement. resin-based coat to limit water movement
Conditioners and during the maturation stage.63
surface coatings GIC surface coatings Improved clinical survival rates have
Some GICs may require the use of a During the setting reaction, GICs are been demonstrated for GICs protected with
conditioner before placement, and the susceptible to excess water loss or gain, light-cured coats compared with no surface
application of a surface coat after the GIC which can significantly affect the chemical coat.64 However, the mechanism by which
has been placed, shaped and cured.5 and mechanical properties of the set this occurs is not fully understood.65,66
material.5,57,58 The concept of surface
GIC conditioners protection for conventional GICs was Clinical indications
GIC tooth conditioners (also known as first investigated in 1993, using the then-
The use of conventional GICs include among
surface or cavity conditioners) are not available dental adhesives to investigate
others, the definitive restoration of all
the same as acid-etchants used prior to their adhesion in vitro.59 As a result,
paediatric cavity types, definitive restoration
resin composite placement. They differ manufacturers may recommend the use of
of adult class III and V restorations, temporary
according to the acid type, strength, and a GIC surface coat after placement to help
restoration of adult class I and II restorations,
effect on the smear layer.5,9 A smear layer protect the GIC. These can be of three types:
core build-ups, endodontic cavity sealing,
is always created after tooth preparation  Emollients, eg petroleum jelly, cocoa; deep margin elevation/acquisition, and
and contains a mixture of bacteria, necrotic butter; coronal perforation repair (supragingival).
organic tooth tissue, minerals, oils from  Solvent-based waterproof varnishes, eg Within paediatric and special care
the dental handpiece and other debris. GC Fuji Varnish (GC), Ketac Glaze (3M, dentistry, GICs can be used for fissure
Over time, this smear layer is susceptible Seefeld, Germany); sealing and restorations in patients with
to dissolution under restorations, which  Light-cured resin-based coatings, limited co-operation, difficulty attaining
encourages microleakage, microbial ingress eg EQUIA Coat (GC), Riva Coat (SDI, adequate moisture control or for partially
and possibly pulp inflammation.53 Melbourne, Australia). erupted teeth.67
Emollients can be petroleum- or lipid-based Additionally, while there are no
GIC conditioners versus acid etchants products.57 Solvent-based varnishes are companies whose instructions for use
GIC conditioners modify the smear simple solutions of different polymers in state explicitly that their GIC can be used
layer and improve adhesion to enamel solvents that evaporate, leaving behind a for class IV restorations, there is no reason
646 DentalUpdate September 2021
 RestorativeDentistry

a d g

b e h

c
f i

Figure 3. Clinical example of GIC placement using a cavity conditioner and GIC coat placement. (a) Caries identification in maxillary premolar, rubber dam
isolation. (b) Cavity preparation and caries removal following minmally invasive principles. (c) Cavity isolation ensuring tight margins. (d) GIC cavity conditioner
(20% polyacrylic acid used in this example). (e) Encapsulated GIC placed under pressure ensuring minimal bubble formation and maximizing cavity fill. (f) While
the GIC is setting, excess is quickly removed and gross shaping achieved. (g) Interproximal margins are flossed and checked for overhangs and cleansibility. (h)
Occlusion checked and any adjustments made. (i) GIC varnish or light-cured coat placed. (Courtesy of Dr B Fleitman, Fuji IX, GC Cavity Conditioner and G Coat
Plus (GC Corp, Japan).

that any restorative GIC type could not be according to their intended clinical purpose A clear distinction is therefore
used for stabilizing carious lesions in the – as 'stabilizing restorations'. For example, required, and a discussion to be had with
anterior dentition. a restoration for caries control and disease the patient, to ensure full understanding
There is controversy, however, regarding stabilization would be any restoration with and appreciation of the use of GICs. The
the use of any GIC for load-bearing areas sufficient chemical and physical properties, patient who has undergone a phased,
in permanent teeth, and whether these and clinical longevity, to allow patients (and personalized care plan will therefore
restorations are deemed 'definitive' or clinicians) to control the patient risk factors have already been informed of the
'provisional'. Rather than considering them for caries progression, before re-evaluating initial stabilization of disease, followed
according to their supposed longevity, it and either replacing them or using them as by a review, and if required, definitive
would be prudent to describe restorations part of the definitive restoration. restorative treatment.
September 2021 DentalUpdate 647
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Conflict of Interest: The authors declare that
the material is being used and what will based Class V restorations: in vitro study. Eur J Dent 2019;
they have no conflict of interest. 13: 599–606.
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650 DentalUpdate September 2021