Journal of Minimum Intervention in Dentistry 2012; 5: 186 - 9 Available online at www.jmid.

org

Midentistry cc - ISSN 1998-801X

Minimal intervention in dentistry: Glass-ionomers, composite resins and CPP-ACP

Graham Mounta
a

13 MacKinnon Parade, North Adelaide, South Australia 5006 Australia, e-mail: gjmount@ozemail.com.au

ABSTRACT
There have been many papers published over the years, which attempt to draw a comparison between the physical properties of the members of the composite resin family and the glass-ionomer family. It is suggested that there is little to be gained from these exercises and it is far more valuable to recognize that there are significant differences between the two groups and to then use each group in the area where it is best suited. - A new remineralisation technology has been developed that is based upon phosphopeptides from milk casein and this is capable of penetration to the depths of the porosities. Casein phosphopeptides (CPP) contain multiphosphoseryl sequences and these have the ability to stabilize calcium phosphate in nano-complexes in solution in the form of amorphous calcium phosphate (ACP). Keywords: Operative dentistry; tooth restoration; minimal intervention

There have been many papers published over the years, which attempt to draw a comparison between the physical properties of the members of the composite resin family and the glass-ionomer family. It is suggested that there is little to be gained from these exercises and it is far more valuable to recognize that there are significant differences between the two groups and to then use each group in the area where it is best suited. The following properties are often compared: Wear Factor - the ability of composite resins to combat wear from occlusal load is controlled entirely by the percentage loading of filler. The higher the filler content the greater the resistance to wear and vice versa. It has little or no bearing on the type of filler incorporated apart from the fact that the coarser fillers are likely to lead to heavy wear on the opposing tooth structure. The opposite is also true in that micro-fine filler particles cannot be loaded to the same level as the regular sized particles and will therefore not withstand load as well as a combination of different sizes such as found in the so-called "hybrid composite resins. In a similar manner the wear factor for glass-ionomers is directly related to the powder to liquid ratio that is used so the lower the powder content the greater the wear factor. In addition it is important to recognize that the setting reaction of the glass-ionomers is a chemical reaction that takes place over time and is therefore not dissimilar to amalgam. The initial set will occur within three minutes and within one hour it will be resistant to further water uptake. However, it will take up to one week to achieve a level of set that can be regarded as mature and it should not be subject to meaningful laboratory testing prior to this time. As mentioned above there will be a fluoride ion release from the surface of the set material and the ions so lost will be replaced by calcium and phosphate ions from the saliva. This means that the material will continue to mature over time and examination of restorations after many years in function will demonstrate that they resist wear very satisfactorily in the oral environment (Figure 1 and 2).

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Journal of Minimum Intervention in Dentistry 2012; 5: 186 - 9 Available online at www.jmid.org

Midentistry cc - ISSN 1998-801X

Figure 1. Tooth photographed approximately 12 years after placement of the fissure seal suggesting the longevity of such a seal is satisfactory.

Figure 2. A similar fissure seal in an upper molar photographed approximately 14 years after placement. Shrinkage - The basic resins used in the composite resins are long molecular chains that will shrink as they polymerize. The inclusion of fillers of various sizes and combinations of sizes will assist in reducing the quantity of shrinkage but cannot eliminate it entirely. It would seem that as long as the basic resin shrinks it will not be possible to develop a composite resin that is dimensionally stable. This is particularly significant with the light activated composites because the setting reaction will take place over a matter of seconds and therefore will exert significant stress on the adhesive bonds and the surrounding tooth structure. A chemically activated resin will set more slowly and evenly and it is possible that water uptake will compensate to a limited degree and offer some level of stress release. As with most chemically set materials the glass-ionomers will also show a small degree of shrinkage as they set. However, as the setting mechanism is rather prolonged over a period of hours, and in fact days, there will be some level of stress release over this period. Glass-ionomer cements are water based materials and therefore capable of taking up further water whilst immersed within a wet environment. As more water is taken up there will be a small amount of expansion and this appears to be sufficient to compensate for any setting shrinkage. Adhesion - As discussed above adhesion between composite resin and tooth structure is micro-mechanical, that is to say the tooth structure needs to be etched and demineralised to some degree to allow the resin component to seep in to the porosities in the tooth and subsequently set thus locking the two together. With the enamel it is straightforward because it is heavily mineralized and the process of demineralisation will simply allow penetration down between the enamel rods. The remainder of the rods will maintain their intrinsic strength and the union will therefore be as strong as the enamel providing it is supported by sound dentine. However, demineralisation of dentine is designed to expose the collagen fibers that make up the basic framework of the dentine. 187

Journal of Minimum Intervention in Dentistry 2012; 5: 186 - 9 Available online at www.jmid.org

Midentistry cc - ISSN 1998-801X

The theory is that these collagen fibers can then be maintained in their demineralised form and a low viscosity resin will flow in to the interstices so that, when the resin sets, there will be a mechanical interlock with the collagen. There remain a number of problems with the theory. There are now three materials and two interfaces in the adhesion with first the union between the bond and the collagen and then the union between the bond and the composite resin. There has been little study of the actual area of failure but it could be at either interface or within the resin bond itself which is a low viscosity and therefore of no great strength. Next, is it possible to ensure that the collagen fibers will remain standing upright in their original form? Then is it possible to ensure that the resin will effectively flow around the collagen framework and engage it all? Finally, as collagen is a vital living organ will it remain vital and healthy following acid etching or will there be a layer of collagen that will eventually die and be separated off from the underlying layers of vital mineralized collagen? None of these questions have yet been answered completely but it emphasizes again the need to conduct in vivo research on vital teeth, in the presence of a positive dentine fluid flow, rather than ones that are extracted and are non-vital. Adhesion between tooth structure and glass-ionomer is the result of an ion exchange between the two materials. As the polyalkenoic acid liquid has a very low pH there will be a release of calcium (strontium), phosphate and aluminum ions from the glass powder immediately they are mixed together. As soon as the mixed cement is placed on clean tooth structure, either enamel or dentine, there will be an immediate release of calcium and phosphate ions from that surface also. The surface will be wet from the dentine fluid flow and there will be more water developed from the setting reaction. In the presence of water the released ions will intermingle forming a new material and, over a short period of time, as the chemical reaction is neutralized and the pH rises, this material will begin to set locking the ions together. It has already been shown that, in the presence of demineralised dentine, the free ions are capable of penetrating to the depths of any area that has been deprived of ions in an attempt to restore the ion balance [1]. The result of this chemical activity is the generation of an adhesive interlayer that is well attached to both tooth structure and cement and at the same time a degree of remineralisation to compensate for the damage caused by caries. As the ion exchange layer is stronger than the cement itself any failure will be cohesive in the cement leaving the adhesive layer still protecting the tooth surface. It must again be recognized that tests on adhesion with glass-ionomers have to be carried out in vivo because the ion exchange will only take place in the presence of water on a vital tooth. The above discussion emphasizes the differences between the composite resin and the glass-ionomer families. It shows clearly that there are sufficient significant differences to suggest that there is little or no gain in trying to directly compare the two materials. Both have their advantages and disadvantages and they should only be compared within their own "family group". The primary differences lie in the fact that the resins are anhydrous, will not mix with water and there is a need for a further low viscosity resin to be laid down on the enamel and dentine first to ensure the full development of the micro-mechanical adhesion. With the glass-ionomers the adhesion is entirely a chemical reaction involving an ion exchange between the cement and the tooth structure that can only take place in the presence of water. If a low viscosity resin has to be laid down first then it will interfere with the chemical ion exchange mechanism and eliminate one of the major advantages of the glass-ionomers. It is important that the profession recognize these differences and understands the need to use each of the families in their correct place in operative dentistry. Resistance to caries - for too long the profession has been seeking restorative materials that will resist further attacks of caries. It must be accepted at this point that caries is a bacterial disease and no restorative material is ever likely to have any effect on the caries rate. So-called recurrent caries around the margins of a restoration represents a continuation or recurrence of the disease rather than a failure of the material itself. The answer is to overcome the disease in the first place and whether the material releases fluoride or any other deterrent to caries is no longer relevant. Casein phosphopeptide-amorphous calcium phosphate nano-complexes (CPP-ACP) As discussed above demineralisation of enamel occurs primarily inwards along the surfaces of the enamel rods and these are composed of tightly bunched enamel crystals. The surface crystals are dissolved by acid attack creating spaces down between the rods and making the enamel porous to some depth. The porosity in turn will be filled with saliva and this will alter the transmission of light through the enamel so that it looks opaque. This is then identifiable as a "white spot lesion". Tooth mineral is predominantly composed of calcium phosphate in the form of apatite and if the fluoride ion alone is made available it will lead to the formation of calcium fluorapatite. For every two-fluoride ions, ten calcium ions and six 188

Journal of Minimum Intervention in Dentistry 2012; 5: 186 - 9 Available online at www.jmid.org

Midentistry cc - ISSN 1998-801X

phosphate ions are required to form one unit cell of fluorapatite. Calcium phosphates, and in particular calcium fluoride phosphates, are insoluble so if they are allowed to form on the surface of enamel they will form a strong layer that is resistant to further acid attack. Up to date topical applications of fluoride in varying strength have been the primary method for stabilization of the early caries lesion. It will lead to the development of a layer of fluorapatite on the surface of the enamel that will seal the porosities and maintain a smooth surface that is more resistant to further acid attack. A new remineralisation technology has been developed [2] that is based upon phosphopeptides from milk casein and this is capable of penetration to the depths of the porosities. Casein phosphopeptides (CPP) contain multiphosphoseryl sequences and these have the ability to stabilize calcium phosphate in nano-complexes in solution in the form of amorphous calcium phosphate (ACP). These nano-complexes (CPP-ACP) remain very small and they have two effective functions. They can localize at the tooth surface and prevent enamel demineralization and they are also small enough to be able to penetrate deep into the porous enamel and remineralise the surface of the enamel crystals. At the same time the CPP-ACP will interact with available fluoride ions to produce an amorphous calcium fluoride phosphate and this can be stabilized by the CPP on the tooth surface. The result from the application of CPP-ACP is remineralisation in depth thus eliminating the porosity in the enamel and restoring the light properties and translucency. It is currently available in several forms, mostly through your dentist, and the most common ones are a CPP-ACP containing paste or incorporated in a chewing gum. CPP-ACP paste is for direct application to the tooth crowns with the use of a clear "plastic splint" or a toothbrush. The chewing gum is to be chewed for a given time daily. The prescription will depend upon the specific requirements.

REFERENCES
[1] Ngo HC, Mount GJ, McIntyre J. Tuisuva J, von Doussa J. Chemical exchange between glass-ionomer restorations and residual carious dentine in permanent molars: an in vivo study. J Dent 2006; 34: 608-13. [2] Featherstone JD. Delivery challenges for fluoride, chlorhexidine and xylitol. BMC Oral Health 2006; 15: 6 Suppl 1: S8.

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