The Role of Glass-Ionomer Cements in Minimum Intervention (MI) Caries Management

  • Avijit BanerjeeEmail author


This chapter aims to discuss the evidence available to date from various laboratory and clinical studies about the use of glass-ionomer cements (GICs) in the management of deep caries. The contemporary minimally invasive approach to the operative management of cavitated deep lesions approaching the pulp relies on the selective removal of infected and/or affected dentine close to the pulp, followed by the use of a suitable adhesive restorative material to seal and bond to the underlying peripheral cavity margins/walls. In order to optimize the clinical outcome, an appreciation is required as to how this physico-chemical interaction occurs between GIC and sound as well as caries-affected substrates. The ionic transfer between GIC and tooth structure is described and discussed, with a particular emphasis on its anti-caries and remineralizing potential and also any effects, deleterious or otherwise, on the dental pulp when placed in close proximity to it. The clinical techniques available to restore teeth using high-viscosity GICs are outlined, including Atraumatic Restorative Treatment (ART) and the layered/laminate/sandwich restoration with resin composite. The findings of studies assessing the clinical longevity of such restorations in comparison to other direct plastic restorative materials are analyzed, both in the primary and secondary dentition. From the evidence presented, it is clear that GIC and its derivatives, whilst not perfect, have a major role to play in the minimally invasive restorative management of deep caries lesions.


Minimum Intervention care Minimally invasive dentistry Caries Enamel Dentine Pulp Adhesion Glass-ionomer cement Resin-modified glass-ionomer ART 


  1. Alves FBT, Hesse D, Lenzi TL, et al. The bonding of glass ionomer cements to caries-affected primary dentin. Pediatr Dent. 2013;35(4):320–4.PubMedGoogle Scholar
  2. Arends J, ten Bosch JJ. In vivo de- and remineralization of dental enamel. In: Leach SA, editor. Factors relating to demineralization and remineralization of the teeth. Oxford: IRL Press; 1986. p. 1–11.Google Scholar
  3. Attar N, Önen A. Artificial formed caries-like lesions around esthetic restorative materials. J Clin Pediatr Dent. 2002;26:289–96.CrossRefPubMedGoogle Scholar
  4. Banerjee A, Watson TF. Pickard’s guide to minimally invasive operative dentistry. 10th ed. London: Oxford University Press; 2015.Google Scholar
  5. Berry EA, Powers JM. Bond strength of glass ionomers to coronal and radicular dentin. Oper Dent. 1994;19:122–6.PubMedGoogle Scholar
  6. Bezerra AC, Novaes RC, Faber J, et al. Ion concentration adjacent to glass-ionomer restorations in primary molars. Dent Mater. 2012;28:e259–63.CrossRefPubMedGoogle Scholar
  7. Bissoto Calvo AF, Alves FBT, Lenzi TL, et al. Glass ionomer cements bond stability in caries-affected primary dentin. Int J Adhes Adhes. 2014;48:183–7.CrossRefGoogle Scholar
  8. Bjørndal L, Reit C, Bruun G, et al. Treatment of deep caries lesions in adults: randomised clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy. Eur J Oral Sci. 2010;118(3):290–7.CrossRefPubMedGoogle Scholar
  9. Bonecker M, Toi C, Cleaton-Jones P. Mutans streptococci and lactobacilli in carious dentine before and after atraumatic restorative treatment. J Dent. 2003;31(6):423–8.CrossRefPubMedGoogle Scholar
  10. Bonifácio CC, Kleverlaan CJ, Raggio DP, et al. Physical-mechanical properties of glass ionomer cements indicated for atraumatic restorative treatment. Aust Dent J. 2009;54:233–7.CrossRefPubMedGoogle Scholar
  11. Bonifácio CC, van Amerongen WE, Meschini TG, et al. Flowable glass ionomer cement as a liner: improving marginal adaptation of atraumatic restorative treatment restorations. J Dent Child. 2010;77:12–6.Google Scholar
  12. Bonifácio CC, Hesse D, Bönecker M, et al. A preliminary clinical trial using flowable glass-ionomer cement as a liner in proximal-ART restorations: the operator effect. Med Oral Patol Oral Cir Bucal. 2013;18(3):e529–32.PubMedCentralCrossRefPubMedGoogle Scholar
  13. Burke F, Lynch E. Glass polyalkenoate bond strength to dentine after chemo-mechanical caries removal. J Dent. 1994;22:283–91.CrossRefPubMedGoogle Scholar
  14. Carvalho TS, Sampaio FC, Diniz A, et al. Two years survival rate of Class II ART restorations in primary molars using two ways to avoid saliva contamination. Int J Paediatr Dent. 2010;20:419–25.CrossRefPubMedGoogle Scholar
  15. Cattani-Lorente MA, Godin C, Meyer JM. Early strength of glass ionomer cements. Dent Mater. 1993;9:57–62.CrossRefPubMedGoogle Scholar
  16. Cehreli ZC, Akca T, Altay N. Comparison of bonding ability of single-step self- etching adhesives with different etching aggressiveness to root dentin. Am J Dent. 2013;16:47A–50.Google Scholar
  17. Cho S, Cheng AC. A review of glass ionomer restorations in the primary dentition. J Can Dent Assoc. 1999;65:491–5.PubMedGoogle Scholar
  18. Creanor SL, Awawdeh LA, Saunders WP, et al. The effect of a resin-modified glass ionomer restorative material on artificially demineralized dentine caries in vitro. J Dent. 1998;26(5–6):527–31.CrossRefPubMedGoogle Scholar
  19. Czarnecka B, Deregowska-Nosowicz P, Limanowska-Shaw H, et al. Shear bond strengths of glass-ionomer cements to sound and to prepared carious dentine. J Mater Sci. 2007;18(5):845–9.Google Scholar
  20. Da Franca C, Colares V, Van Amerongen E. Two-year evaluation of the atraumatic restorative treatment approach in primary molars class I and II restorations. Int J Paediatr Dent. 2011;21:249–53.CrossRefPubMedGoogle Scholar
  21. Davidson CL. Advances in glass-ionomer cements. J Applied Oral Sci. 2006;14:3–9.CrossRefGoogle Scholar
  22. De Amorim RG, Leal SC, Frencken JE. Survival of atraumatic restorative treatment (ART) sealants and restorations: a meta-analysis. Clin Oral Investig. 2012;16:429–41.PubMedCentralCrossRefPubMedGoogle Scholar
  23. De Munck J, Inoue S, Suzuki K, et al. Four-year water degradation of a resin-modified glass-ionomer adhesive bonded to dentin. Eur J Oral Sci. 2004;112(1):73–83.CrossRefPubMedGoogle Scholar
  24. Deepa G, Shobha T. A clinical evaluation of two glass ionomer cements in primary molars using a traumatic restorative treatment technique in India: 1 year follow up. Int J Paediatr Dent. 2010;20:410–8.CrossRefPubMedGoogle Scholar
  25. Eden E, Topaloglu-Ak A, Frencken JE, et al. Survival of self-etch adhesive Class II composite restorations using ART and conventional cavity preparations in primary molars. Am J Dent. 2006;19:359–63.PubMedGoogle Scholar
  26. Ersin NK, Candan U, Aykut A, et al. A clinical evaluation of resin-based composite and glass ionomer cement restorations placed in primary teeth using the ART approach: results at 24 months. J Am Dent Assoc. 2006;137:1529–36.CrossRefPubMedGoogle Scholar
  27. Es-Souni M, Zimehl R, Fischer-Brandies H. Microscopic and electron spectroscopic characterization of dental enamel surfaces. Colloid Polym Sci. 1999;277:382–7.CrossRefGoogle Scholar
  28. Fagundes TC, Toledano M, Navarro MF, et al. Resistance to degradation of resin-modified glass-ionomer cements dentine bonds. J Dent. 2009;37(5):342–7.CrossRefPubMedGoogle Scholar
  29. Felton DA, Cox CF, Odom M, et al. Pulpal response to chemically cured and experimental light-cured glass ionomer cavity liners. J Prosthet Dent. 1991;65:704–12.CrossRefPubMedGoogle Scholar
  30. Foley J, Evans D, Blackwell A. Partial caries removal and cariostatic materials in carious primary molar teeth: a randomised controlled clinical trial. Br Dent J. 2004;197(11):697–701.CrossRefPubMedGoogle Scholar
  31. Fonseca RB, Branco CA, Quagliatto PS, et al. Influence of powder/liquid ratio on the radiodensity and diametral tensile strength of glass ionomer cements. J Appl Oral Sci. 2010;18:577–84.PubMedCentralCrossRefPubMedGoogle Scholar
  32. Frencken JE, Holmgren CJ. How effective is ART in the management of dental caries? Community Dent Oral Epidemiol. 1999;27:423–30.CrossRefPubMedGoogle Scholar
  33. Frencken JE, Leal SC. The correct use of the ART approach. J Appl Oral Sci. 2010;18:1–4.CrossRefPubMedGoogle Scholar
  34. Frencken JE, Van’t Hof MA, Van Amerongen WE, et al. Effectiveness of single-surface ART restorations in the permanent dentition: a meta-analysis. J Dent Res. 2004;83:120–3.CrossRefPubMedGoogle Scholar
  35. Frencken JE, Taifour D, Van’t Hof MA. Survival of ART and amalgam restorations in permanent teeth of children after 6.3 years. J Dent Res. 2006;85:622–6.CrossRefPubMedGoogle Scholar
  36. Fuks AB, Araujo FB, Osorio LB, et al. Clinical and radiographic assessment of Class II aesthetic restorations in primary molars. Pediatr Dent. 2000;22(6):479–85.PubMedGoogle Scholar
  37. Gwinnett AJ. Chemically conditioned dentin: a comparison of conventional and environmental scanning electron microscopy findings. Dent Mater. 1994;10:150–5.CrossRefPubMedGoogle Scholar
  38. Hashem D, Mannocci F, Patel S, et al. Efficacy of calcium silicate indirect pulp capping; a randomized controlled clinical trial. J Dent Res. 2015;94(4):562–8.PubMedCentralCrossRefPubMedGoogle Scholar
  39. Hatibovic-Kofman S, Suljak JP, Koch G. Remineralization of natural carious lesions with a glass ionomer cement. Swed Dent J. 1997;21:11–7.PubMedGoogle Scholar
  40. Hickel R, Kaaden CH, Paschos E, et al. Longevity of occlusally-stressed restorations in posterior primary teeth. Am J Dent. 2005;18(3):198–211.PubMedGoogle Scholar
  41. Hilgert LA, de Amorim RG, Leal SC, et al. Is high-viscosity glass-ionomer-cement a successor to amalgam for treating primary molars? Dent Mater. 2014;30:1172–8.CrossRefPubMedGoogle Scholar
  42. Hilton TJ. Keys to clinical success with pulp capping: a review of the literature. Oper Dent. 2009;34:615–25.PubMedCentralCrossRefPubMedGoogle Scholar
  43. Holmgren CJ, Roux D, Doméjean S. Minimal intervention dentistry: part 5. Atraumatic restorative treatment (ART) – a minimum intervention and minimally invasive approach for the management of dental caries. Br Dent J. 2013;214:11–8.CrossRefPubMedGoogle Scholar
  44. Hosoya Y, Garcia-Godoy F. Bonding mechanism of Ketac-Molar Applicap and Fuji IX GP to enamel and dentin. Am J Dent. 1998;11:235–9.PubMedGoogle Scholar
  45. Hume WR, Mount GJ. In vitro studies on the potential for pulpal cytotoxicity of glass-ionomer cements. J Dent Res. 1988;67:915–8.CrossRefPubMedGoogle Scholar
  46. Jang KT, Garcia-Godoy F, Donly KJ, et al. Remineralizing effects of the glass ionomer restorations on adjacent interproximal caries. ASDC J Dent Child. 2001;68:125–8.PubMedGoogle Scholar
  47. Kemoli AM, van Amerongen WE, Opinya G. Influence of the experience of operator and assistant on the survival rate of proximal ART restorations: two-year results. Eur Arch Paediatr Dent. 2009;10:227–32.CrossRefPubMedGoogle Scholar
  48. Lenzi TL, Bonifácio CC, Bönecker M, et al. Flowable glass ionomer cement layer bonding to sound and caries affected primary dentin. J Dent Child (Chic). 2013;80:20–4.Google Scholar
  49. Marchi JJ, de Araujo FB, Froner AM, et al. Indirect pulp capping in the primary dentition: a 4 year follow-up study. J Clin Pediatr Dent. 2006;31(2):68–71.CrossRefPubMedGoogle Scholar
  50. Marquezan M, Corrêa FN, Sanabe ME, et al. Artificial methods of dentine caries induction: a hardness and morphological comparative study. Arch Oral Biol. 2009;54(12):1111–7.CrossRefPubMedGoogle Scholar
  51. Marquezan M, Osório Ciamponi AL, Toledano M. Resistance to degradation of bonded restorations to simulated caries-affected primary dentin. Am J Dent. 2010;23(1):47–52.PubMedGoogle Scholar
  52. Mhaville RJ, van Amerongen WE, Mandari GJ. Residual caries and marginal integrity in relation to Class II glass ionomer restorations in primary molars. Eur Arch Paediatr Dent. 2006;7:81–4.CrossRefPubMedGoogle Scholar
  53. Mickenautsch S, Yengopal V, Banerjee A. Atraumatic restorative treatment versus amalgam restoration longevity: a systematic review. Clin Oral Invest. 2010;14:233–40.CrossRefGoogle Scholar
  54. Mount GJ. Clinical placement of modern glass ionomer cements. Quintessence Int. 1993;24:99–107.PubMedGoogle Scholar
  55. Mount GJ, Hume WR. Preservation and restoration of tooth structure, chapter 8. St Louis: Mosby; 1998. p. 80–2.Google Scholar
  56. Müller J, Bruckner G, Kraft E, et al. Reaction of cultured pulp cells to eight different cements based on glass ionomers. Dent Mater. 1990;6:172–7.CrossRefPubMedGoogle Scholar
  57. Nakajima M, San H, Burrow MF, et al. Tensile bond strength and SEM evaluation of caries-affected dentin using dentin adhesive. J Dent Res. 1995;74:1679–88.CrossRefPubMedGoogle Scholar
  58. Ngo H. Remineralization of artificial carious dentine exposed to two glass ionomers. J Dent Res. 2002a;81(Special Issue):386.Google Scholar
  59. Ngo HC. Biological potential of glass-ionomer. In: Mount GJ, editor. An atlas of glass-ionomer cements. London: Martin Dunitz; 2002b. p. 43–55.Google Scholar
  60. Ngo HC, Mount GJ, Peters MC. A study of glass-ionomer cement and its interface with enamel and dentin using a low-temperature, high resolution scanning electron microscopic technique. Quintessence Int. 1997a;28:63–9.PubMedGoogle Scholar
  61. Ngo HC, Ruben J, Arends J, et al. Electron probe microanalysis and transverse microradiography studies of artificial lesions in enamel and dentin: a comparative study. Adv Dent Res. 1997b;11:426–32.CrossRefPubMedGoogle Scholar
  62. Ngo HC, Mount G, McIntyre J, et al. Chemical exchange between glass-ionomer restorations and residual carious dentine in permanent molars: an in vivo study. J Dent. 2006;34(8):608–13.CrossRefPubMedGoogle Scholar
  63. Olivia A, Della Ragione F, Salerno A. Biocompatibility studies on glass ionomer cements by primary cultures of human osteoblasts. Biomaterials. 2000;17:1351–6.CrossRefGoogle Scholar
  64. Ostlund J, Möller K, Koch G. Amalgam, composite resin and glass ionomer cement in Class II restorations in primary molars – a three year clinical evaluation. Swed Dent J. 1992;16(3):81–6.PubMedGoogle Scholar
  65. Peez R, Frank S. The physical–mechanical performance of the new Ketac Molar Easymix compared to commercially available glass ionomer restoratives. J Dent. 2006;34:582–7.CrossRefPubMedGoogle Scholar
  66. Qvist V, Laurberg L, Poulsen A, et al. Eight-year study on conventional glass ionomer and amalgam restorations in primary teeth. Acta Odontol Scand. 2004;62:37–45.CrossRefPubMedGoogle Scholar
  67. Raggio DP, Hesse D, Lenzi TL, et al. Is atraumatic restorative treatment an option for restoring occluso-proximal caries lesions in primary teeth? A systematic review and meta-analysis. Int J Paediatr Dent. 2013;23:435–43.PubMedGoogle Scholar
  68. Ricketts DNJ, Lamont T, Innes P et al (2013) Operative caries management in adults and children. Cochrane Database Syst Rev (3):CD003808Google Scholar
  69. Roeleveld AC, van Amerongen WE, Mandari GJ. Influence of residual caries and cervical gaps on the survival rate of Class II glass ionomer restorations. Eur Arch Paediatr Dent. 2006;7:85–91.CrossRefPubMedGoogle Scholar
  70. Sidhu SK. Clinical evaluations of resin-modified glass-ionomer restorations. Dent Mater. 2010;2:7–12.CrossRefGoogle Scholar
  71. Sidhu SK. Glass-ionomer cement restorative materials: a sticky subject? Aust Dent J. 2011;56 Suppl 1:23–30.CrossRefPubMedGoogle Scholar
  72. Six N, Lasfargues JJ, Goldberg M. In vivo study of the pulp reaction to Fuji IX, a glass ionomer cement. J Dent. 2000;28:413–22.CrossRefPubMedGoogle Scholar
  73. Smith DC. Development of glass-ionomer cement systems. Biomaterials. 1998;19:467–78.CrossRefPubMedGoogle Scholar
  74. Thompson V, Craig RG, Curro FA, et al. Treatment of deep carious lesions by complete excavation or partial removal: a critical review. J Am Dent Assoc. 2008;139(6):705–12.PubMedCentralCrossRefPubMedGoogle Scholar
  75. Toh SL, Messer LB. Evidence-based assessment of tooth-colored restorations in proximal lesions of primary molars. Pediatr Dent. 2007;29(1):8–15.PubMedGoogle Scholar
  76. Topaloglu-Ak A, Eden E, Frencken JE, et al. Two year survival rate of class II composite resin restorations prepared by ART with and without a chemomechanical caries removal gel in primary molars. Clin Oral Investig. 2009;13:325–32.PubMedCentralCrossRefPubMedGoogle Scholar
  77. United Nations Environment Programme (2013) Minamata Convention on Mercury UNEP(DTIE)/Hg/CONF/3Google Scholar
  78. Van Dijken JW. A 6-year evaluation of a direct composite resin inlay/onlay system and glass ionomer cement-composite resin sandwich restorations. Acta Odontol. 1994;52:368–76.CrossRefGoogle Scholar
  79. Van Gemert-Schriks MC, van Amerongen WE, ten Cate JM, et al. Three-year survival of single- and two-surface ART restorations in a high-caries child population. Clin Oral Investig. 2007;11:337–43.PubMedCentralCrossRefPubMedGoogle Scholar
  80. Van Noort R. Introduction to dental materials. 4th ed. Edinburgh/New York: Mosby Elsevier; 2013. p. 113.Google Scholar
  81. Vlietstra JR, Plant CG, Shovelton DS, et al. The use of glass ionomer cement in deciduous teeth. Br Dent J. 1978;145:164–6.CrossRefPubMedGoogle Scholar
  82. Watson TF. Bonding glass-ionomer cements to tooth structure. In: Davidson CL, Mjör IA, editors. Advances in glass-ionomer cements. Germany: Quintessence Publishing Co Inc.; 1999.Google Scholar
  83. Way JL, Caputo AA, Jedrychowski JR. Bond strength of light-cured glass ionomers to carious primary dentin. ASDC J Dent Child. 1996;63(4):261–4.PubMedGoogle Scholar
  84. Welbury RR, Walls AW, Murray JJ, McCabe JF. The 5-year results of a clinical trial comparing a glass polyalkenoate (ionomer) cement restoration with an amalgam restoration. Br Dent J. 1991;170:177–81.CrossRefPubMedGoogle Scholar
  85. Wilson AD, Kent BE. The glass ionomer cement. A new translucent dental filling material. J Appl Chem Biotechnol. 1971;21:313.CrossRefGoogle Scholar
  86. Woolford M. Composite resin attached to glass polyalkenoate (ionomer) cement—the laminate technique. J Dent. 1993;21:31–8.CrossRefPubMedGoogle Scholar
  87. Yip HK, Tay FR, Ngo HC, et al. Bonding of contemporary glass ionomer cements to dentin. Dent Mater. 2001;17(5):456–70.CrossRefPubMedGoogle Scholar
  88. Yiu CK, Tay FR, King NM, et al. Interaction of glass-ionomer cements with moist dentin. J Dent Res. 2004;83(4):283–9.CrossRefPubMedGoogle Scholar
  89. Yoshida Y, Van Meerbeek B, Nakayama Y, et al. Evidence of chemical bonding at biomaterial-hard tissue interfaces. J Dent Res. 2000;79(2):709–14.CrossRefPubMedGoogle Scholar
  90. Zoergiebel J, Ilie N. An in vitro study on the maturation of conventional glass ionomer cements and their interface to dentin. Acta Biomater. 2013;9:9529–37.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Conservative & MI DentistryKing’s College London Dental Institute at Guy’s Hospital, King’s Health Partners, Guy’s Dental HospitalLondonUK

Personalised recommendations