Restorative Choices by Drs. Roopwant Kaur and Luis G. Sensi

When to use glass ionomer cement or composite to restore teeth after SDF treatment

by Drs. Roopwant Kaur and Luis G. Sensi

Fig. 1: Silver diamine fluoride “sealants” don’t require a restoration after placement.

Fig. 2: A cavitated lesion on the buccal surface of #31 treated with SDF only (no restoration required).

• Fluoride release. One of the hallmark benefits of GIC is its ability to release fluoride ions over an extended period. This property is particularly advantageous in caries prevention and management because fluoride plays a critical role in remineralizing enamel and dentin. The fluoride release can also be recharged by external sources such as fluoride toothpaste, which sustains its preventive benefits over time.
• Moisture tolerance. GICs exhibit excellent moisture tolerance, making them suitable for use in environments where complete dryness cannot be achieved, such as subgingival restorations or areas with high saliva flow. This property ensures adequate adhesion and longevity of the restoration in challenging conditions.
• Biocompatibility and chemical adhesion. GICs are known for their biocompatibility, causing minimal irritation to the pulp and surrounding tissues. They chemically bond to the tooth structure without the need for a bonding agent, reducing the risk of microleakage and secondary caries.
• Antibacterial properties. The acidic nature of GIC and its fluoride release contribute to an antibacterial environment, further protecting the tooth from carious lesions.

• Aesthetic limitations. While modern GICs have improved in terms of aesthetics, they still cannot match the superior aesthetic qualities of composite resins, especially in terms of color matching and surface finish.
• Mechanical properties. GICs generally have lower tensile and compressive strength compared with composite resins, making them less suitable for restorations in high-stress areas such as posterior teeth.
• Wear resistance. GIC restorations exhibit higher wear rates than composite resins, potentially leading to faster degradation and the need for replacement.

• Superior aesthetics. Composite resins offer exceptional aesthetic qualities, including a wide range of shades and the ability to mimic the natural translucency and texture of tooth enamel. This makes them the material of choice for restorations in visible areas.
• Mechanical properties. Composites possess high tensile and compressive strength, making them suitable for restorations that require durability, especially in areas subjected to high masticatory forces.
• Versatility and conservative preparation. Composite resins allow for minimally invasive preparations and are versatile in their application, suitable for both anterior and posterior restorations. They bond mechanically to the tooth structure, facilitating conservation of tooth material.

• No fluoride release. Unlike GICs, composite resins do not release fluoride, which means they do not contribute to remineralization or offer additional protection against caries after restoration.
• Technique sensitivity. The placement of composite resins is more technique-sensitive, requiring meticulous isolation and layering techniques to prevent contamination and ensure optimal bonding.
• Polymerization shrinkage. Composite resins undergo polymerization shrinkage, which can lead to gap formation at the margins, potentially resulting in microleakage and secondary caries.
• Cost and time. Generally, composite resin restorations are more time-consuming and costly than GIC restorations, primarily because of the labor-intensive placement technique and the material cost.

• Multiple-appointment approach. This involves waiting two to four weeks after the final SDF application before proceeding with resin composite restoration. To mask the darkened dentin in aesthetically sensitive areas, an opaque restorative material such as traditional GIC can be used either for the entire restoration or as a base layer in a sandwich technique. An opaque resin-modified glass ionomer liner is another option to cover dark axial or pulpal dentin before applying a more translucent resin composite.
• Same-day SDF-resin approach. In this scenario, SDF treatment and resin composite restoration occur in the same appointment. It’s crucial to rinse off the SDF before proceeding with bonding to prevent silver staining, especially near the margins. Employing a short burst (1–2 seconds) of a “tac”-style curing light after SDF application and rinsing can help reveal and then selectively and conservatively remove residual silver-stained areas at the enamel margins while keeping the internally stained arrested dentin on axial/pulpal walls. This step may need to be repeated to eliminate visible silver staining at the preparation’s margins before proceeding with opaque layering and restoration as described (Figs. 4 and 5). A study in 2016 by Schwendicke et al. investigated the discoloration of dental hard tissues and restorative materials after SDF application. The research highlighted the importance of clean margins in preventing discoloration, supporting the proposed strategy.²

References
1. https://www.ada.org/resources/ada-library/oral-health-topics/silver-diamine-fluoride
2. Schwendicke F, Frencken JE, Bjorndal L, et al. Managing carious lesions: consensus recommendations on carious tissue removal. Adv Dent Res. 2016;28(2):58-67.

Dr. Roopwant Kaur, BDS, MS, an associate professor and assistant dean at East Carolina University’s School of Dental Medicine, leads in cariology and operative dentistry curriculum. Kaur serves on multiple national and regional executive boards and her accolades include the ADEA Leadership Institute Award, the Heraeus Kulzer Research Award and the Health Sciences Author Recognition Award, reflecting her dedication to dental education and research in caries risk assessment and student learning methodologies.

Dr. Luis G. Sensi received a DDS degree in 2000 from the Pontifical Catholic University of Parana in Brazil. Sensi pursued specialty certifications in endodontics and operative dentistry at the Federal University of Parana, followed by a master’s degree and PhD in operative dentistry from the Federal University of Santa Catarina in Brazil. He taught at the University of Maryland and at the University of Florida before joining the East Carolina University dental faculty in 2013, where he teaches and supervises the operative dentistry course for dental students.