This work is a literature review on the use of Glass Ionomer Cement (GIC) for Atraumatic Restorative Treatment (ART) of elderly patients. The research was conducted online, using available academic database platforms, such as a PubMed. It was concluded that the ART is an adequate treatment approach for caries in elderly patients. It presents similar efficiency to the conventional treatment and advantages, such as biocompatibility, anticariogenic action, simplicity, no anesthesia or rotary equipment. Furthermore, it is both cost and time effective while more teeth can be treated per session. However, clinical evidence on the technique being applied to elderly patients is still relatively scarce.

Keywords: aging, odontogeriatrics, glass ionomer cement, root caries

This work aims at a bibliographical review on the efficacy of Glass Ionomer Cement (GIC) and its feasibility in a traumatic restorative treatments (ART) for geriatric patients. The research was conducted online, primarily at PubMed - the academic database platform. Due to its focus on a specific age group, the terms of research were divided in three parts: i) “Elderly AND atraumatic restorative treatment AND root caries”; ii) “Elderly AND atraumatic restorative treatment AND glass ionomer cement”; and iii) Glass ionomer cement AND root caries”. Out of all the works found, 21 tackled the issue specifically. The existing literature, thus, has indicated that glass ionomer cements are ideal because of their advantages in terms time, costs, and clinical application. Nevertheless, more randomized and controlled studies are needed to offer more conclusive answers on its efficacy in the treatment of cavity lesions in elderly patients, as well as the advantages of using such technique.

The last decades have witnessed a substantial growth of the aging population in the world. Estimates show that the number of people over 65 will reach 1,5 billion by 2050. Thus, the projected population trends require more attention to health care, including oral health for the elderly.¹ Nowadays, due to the betterment in oral health care and increase in life expectancy, many elderly citizens have been aging without losing their natural teeth.^2-5 Among this age group, the reduction of salivary flow, development of systemic diseases, changes in local conditions, and many other unfavorable factors may lead to a number of different oral conditions, among which cavities and periodontal diseases are the most common.⁶

A dental cavity continue to be a major public health issue across the globe and has been confirmed as the most prevalent chronic condition among 291 investigated diseases between 1990 and 2010 (global prevalence of 35% for all ages).⁷ Studies estimate that 60% of individuals over 60 present root caries or uncovered dental restorations.⁸ Root caries represent a progressive, multi factorial chronic lesion, with irregular, darkened and softened tissue involving the root surface and can affect the cement, dentin, and enamel; it is very common among elderly patients, especially those with cognitive or physical disabilities.^9-12 Burrow & Stacey⁹ highlight that the high root carie rates in elders has been growing and the philosophy centered on a conservative treatment will likely provide these patients more chances to keep their teeth.⁹ Besides, oral bacterias can be introduced in the circulatory system through infected teeth or caries, forming vegetations in compromised cardiac valves. The Staphylococcus aureus and the Streptococcus viridans can be present in the oral cavity and are the organism most commonly responsible for infectious endocarditis. Dental infections have been implicated in more than a third of infectious endocarditis cases. Therefore, it is of the utmost importance to treat caries and periodontitis as soon as possible in order to avoid deterioration once heart diseases can be fatal or affect other organs.^13,14

However, depending on how these people age and live, the dentist’s plan of action can change. In the aging process, patients not rarely lose physical abilities, such as vision, motor skills, and mobility, which can all present challenges to their autonomy and maintenance of their own oral health. At other times, there may also be cognitive loss stemming from some kind of dementia. In all of the aforementioned situations, these elders will need caregiver’s attention. Sometimes, however, instead of a trained professional, a family member or a somewhat informally hired person without proper know-how performs this role.

The social component is relevant to the establishment of a treatment plan. A lot of patients demand home care because of their vulnerability or inability to go to the office. Either at home, a retirement community, or an institution, the treatment needs to take into consideration efficacy, time, costs, and maintenance of the patient’s health, focusing on their life as a whole. Bearing in mind that this patient might be terminal or in advanced age, professionals should avoid oral rehabilitation plans with prostheses, implants, or any complex restorative treatments. Nowadays, the concerns regarding institutionalized patients have been rising, given the numerous barriers for the dental treatment. Therefore, there is a recurrent need for more conservative, cost and time effective materials that can be utilized outside the dentist’s office. Thus, a traumatic restorative treatment (ART) has been discussed and recommended since the 1980s. It consists of the removal of carious tissue (infected dentin) with manual instruments under relative isolation and use of glass ionomer cements.^15,16 At first, ART became a highly accepted line of treatment for pediatric patients, once there is no need of anesthesia and rotative instruments.^17,20 Throughout time, ART has also proved to be successful in systemic reviews that do not show differences in longevity in relation to conventional treatments that utilize resins or amalgam. Because of that, ART has been suggested as an alternative strategy of cavity control in elderly patients, once it is simple and more cost-effective in comparison to conventional techniques.^21,23 Even though the use of ART and its success rates in permanent teeth have been documented in the literature,^24,21 many dentists are still reluctant to its adoption in their daily practice, especially when it comes to adults and elders.⁹ The method is promising as a way of dealing with cavity lesions of root caries and can be a useful alternative for institutionalized patients who are incapable of paying a visit to the dentist’s office on a regular basis, proving to be a better kind of treatment in elderly after one year in comparison to conventional restorations.^12,23-25 Another advantage of ART is the possibility of conducting multiple restorations in different quadrants, once local anesthesia is not needed. Mata et al.²⁶ compared ART’s durability to a conventional restorative technique in elders after 5 years. The results show an 85% survival rate for ARTs, demonstrating its place as an efficient tool to provide dental treatment for vulnerable elders, particularly in non-clinical environments. Gonzalez & Zuluaga⁹ Balgi et al.²⁷ Serpa et al.²⁸ Dornellas et al.²⁹ Amer & Kolker,⁴ Amorim et al.²¹ also concluded that ART restorations were considered clinically well succeeded with excellent results.

Glass Ionomer Cement (GIC), which was developed in 1969 by Wilson and Kent^3-5,30 is the material used for this technique and has shown good results. Ever since, many researchers have studied and modified its composition to improve the mechanical properties involving adhesion to the dental substrate and anti-carious properties due to the liberation of fluorine ions.^17,25,31-34 Besides, GIC presents thermal expansion coefficient similar to the tooth's structure, biocompatibility, low cytotoxicity,^32,35 favorable work time, low cost, minimum contraction of polymerization, good marginal sealing properties, easy application, antimicrobial activity³⁴ and easy manipulation.²⁵ Davidson³³ had already mentioned that GIC could become the most reliable restorative material in less invasive dentistry. According to him, GIC can be called active as it liberates fluorine and can also be called an intelligent material once it releases fluorine according to acidity, acting somewhat as a pH controller.

The GIC of high viscosity presented better performance than the low or medium viscosity ones in ART,²⁵ and in some works, the GICs modified by resin presented compatible mechanical properties to composite resins, being as efficient as the conventional technique.^22,24,36 The encapsulated GICs present superior numbers when it comes to resistance to compression compared to the powder/liquid system because the proportions are pre-balanced in the factory.^37,38 According to Cajazeira et al.¹⁹ another advantage of GICs is that their longevity is not influenced by the use of a dental dam, making its use even easier, both in children and elders. However, some factors may contribute to the failure of the ARTs with glass ionomers cement, such as quality of the material and operator. ^20,33-35

Based on the available literature online, ART is an adequate treatment approach for caries in elderly patients. It presents similar efficiency to the conventional treatment and advantages, such as biocompatibility, anti cariogenic action, simplicity, no anesthesia or rotary equipment. Furthermore, it is both cost and time effective while more teeth can be treated per session. However, clinical evidence on the technique being applied to elderly patients is still relatively scarce.

None.

The authors of this manuscript have no competing interests.

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