Glass Ionomer and Urgent Care Situations with Andrew Johnston, RDH – TIPisode

• A look at Glass Ionomer
• Glass Hybrids
• Importance of Instructions for Use
• What Andrew loves about EQUIA Forte
• Ways to use EQUIA Forte in today’s ops. 

Michelle Strange: A Tale of Two Hygienists presents this week’s TIPisode: Quick and easy tips to keep you up to date and presented by the experts in the dental profession. Now, get ready for your unofficial TIPisode, this week brought to you by GC America.

Andrew Johnston: Hello, everyone. This is Andrew bringing you the TIPisode this week, sponsored by GC. I am super excited about being here delivering this TIPisode for you guys today and for a couple of reasons. One, this is the first TIPisode that I’ve ever done by myself, and so that’s completely amazing. But, two, I’m excited about being able to deliver on a topic and about a product that I’ve been using since day two in the real world after I’ve graduated in hygiene school. 

The product is glass ionomer. And we’re going to talk a little bit today about kind of the differentiation between some of the glass ionomers of old but really focusing on one particular product called EQUIA Forte. And, after we do the review of the EQUIA Forte, I do want to talk about some of the things that are happening in this world and some ways to use the product that’s maybe a little bit different based on what’s going on. 

Okay. So let’s jump right on into it. So, first of all, my background. I’m a restorative dental hygienist. What that means is I’ve been able to place restorations since licensure. And that has really given me the opportunity to handle the different types of materials as they’re coming out and utilize them in different types of preps and different locations in the mouth and different handling, different techniques. It’s been a real wonderful opportunity for me. 

Traditionally, glass ionomers have been used in situations where moisture control has been problematic. In pediatrics — when I worked in pediatrics, that was a good place to use it. In special needs situations, that’s a good place to use it. And, also, people have used it as a temporary fill or a stop gap in between treatment. But, as things have evolved, especially newer generations of the glass hybrids which we’re going to talk about in a little bit, they are more of a permanent restoration than ever before. 

In 2009, EQUIA was launched by GC, and it was brought about in a time when the world was very much used to using composite or RMGI. EQUIA was really the first self-adhesive posterior restorative system. It balanced a quick and easy handling and delivery with the aesthetics and the physical properties that they were looking for, and it was the first of its class to have long-term indications for class I and class II preps. 

Glass ionomers were known for having this huge upside of fluoride release, which the clinicians loved, hygienists loved that, but also virtually no post-op sensitivity. So, as EQUIA was establishing its stellar reputation, GC kept working on ways to improve the clinical outcomes and develop the next generation, which was going to be this EQUIA Forte that’s a glass hybrid, and that was released in 2014. 

So EQUIA Forte works in tandem with EQUIA Forte Coat, again, building a stronger, more superior bulk fill GI restoration. So, for the super nerdy people like me who care about flexural strength and wear resistance, this new improved formula is higher flexural strength, higher wear resistance, higher resistant to acid, and higher fluoride release than the previous EQUIA. 

And it’s interesting, though, because as I mentioned, EQUIA Forte is considered a glass hybrid — glass hybrid meaning that it’s a mixture of two types of glass particles; they have larger and smaller sizes all fitting within the same matrix — and this is something that, to my knowledge, only GC is doing. It’s pretty next-level thinking. 

Now, before we get into the next step, which is a step-by-step application of the EQUIA Forte into a prep, I think that one of the most important things that we cannot leave out and that I really hope that you’ll take away is how important it is to use the instructions for use, the IFUs. 

I think that many clinicians figure that since the product looks the same and it comes in similar packaging from the same company that it is more or less the same product, and it is not. So please, please, please read the instructions for use, follow them, and please make sure that everyone on your team is also doing the same. As I’ve mentioned before, I’m a restorative hygienist, so it’s going to look a little bit differently, the step-by-step for the EQUIA Forte, but let me go through this really quick. 

So the prep is now done, and I am entering the room. If I need a matrix system, I put one on. If there is visible contamination of the prep area — so meaning heme, saliva, or particulates — then I make sure I use a cavity conditioner. Now, in the IFU, this is listed as an optional step, but it is one that I recommend for people like me where, as people are moving in and out of the rooms, there is a chance for contamination.

Another great tip for this, though, if you have the patient gently biting on the cotton roll longways over the exposed prep or even like a 2×2, that might work also. It’ll help prevent a large amount of the saliva getting in there. It’ll also help some of the particulates, some of the tooth matter and things like that, from finding its way back into that opening. Probably it’s not going to help so much with the heme, but hopefully there’s not a lot of heme to begin with. 

And then, at this point, I start having my assistant mixing. So they will tap or shake the capsule first, they’ll push in the plunger, and then mixing for ten seconds in the triturator. Now, while they are doing that, I’m monitoring the field. I’m keeping it clean. Occasionally I will do a gentle air dry being sure that we’re not desiccating that tooth, collapsing the tubules, et cetera. They will insert it into the capsule applier that we in my office affectionately call “the clicker” for after some triturating, clicks it until it’s about to be dispensed, and hands it over to me. 

At that point, I apply the same technique that I would with other similar products where I’m keeping the nozzle as close to the tooth as possible for at least that first layer and slowly applying the pressure. Now, there is some back pressure that is happening that I am allowing that to guide me up and out of the prep, and I am very, very careful that I don’t underfill. So it’s not going to be a perfect situation, but just doing your best. The great thing, though, about EQUIA Forte is that it does have some resistance to its handling, which makes it easy to gently condense. So, even if you do have a little bit of excess, it’s fine. 

So, at this point, this is where I find that myself and many of my colleagues have made this similar mistake, and some continue to make the same mistake. In the IFUs, the instructions for use, step number eight states to pack and contour and void moisture contamination. This is one of the main reasons why I wanted to bring out the importance of using the instructions for use. Please do not use a wet cotton pellet or a wet cotton swab at this point in the procedure. It specifically states to avoid moisture contamination. 

So, after about two and a half minutes, you may begin the final finishing. And, for this, I personally don’t care to use a bur if I don’t have to. I learned a great technique from one of my doctors, which is basically treat this as an alloy. I use a T3 for larger preps and a Cleoid-Discoid for smaller preps and also the occasional premolar class II to kind of help with some of the anatomy. 

If you haven’t heard of a T3 before, it has a tip on one side that’s similar to the Half Hollenback, and then you flip it around and the other side has a larger Beavertail, which is great because it has good surface area. It’s good for scooping and bulk reducing. It’s really is a great tool [sic]. I like it quite a bit. 

When I have used burs, I prefer the light touch of a carbide football. I found that I was a little bit heavy handed with a diamond bur. But the choice is completely yours on what you want to use to reduce it. But using these carvers I find that the EQUIA Forte ends up shaving off in nice, easy-to-manage layers. 

I also, as a huge helpful hint for this one, really strongly recommend that you check the occlusion before you apply the next step, which is applying the coat. The white stones that I’ve used after applying the coat ends up turning a black color. This coat, after it’s set, is just so incredibly hard that it ruins the white stone, but it also ruins the restoration. It discolors it pretty badly. And, also, I find that my carbide and my diamond football have a really hard time reducing it, which really just goes to prove how durable and strong this coat is. But it’s a word of advice or word of caution to make sure that you’re very sure that you’re ready to apply the coat. 

The next step or the last step to this is applying the EQUIA Forte Coat, a very, very thin layer. Because all of us are so used to air-thinning everything we do, or air drying, it is not uncommon that I have seen people make this mistake as well. But do not air thin. It’s in the instructions for use. Do not air thin, and just light cure for 20 seconds after you apply the coat. 

A quick note about that coat, too, is because this is an easy, thin application of the surface, all of my patients after I’ve applied that if they haven’t been numb have really appreciated how smooth it ends up being.

Now, one thing that people do get concerned about is delamination, right? So thinking that that coat is going to peel off the top of your restoration. Do not worry. It will not do that. It takes about six months for the coating to wear off. It’s really dependent upon acids and the occlusion. And, before I forget, another concern that has been brought up is that after that six months, what is underneath that coat? During that time that it takes to wear down, the EQUIA Forte beneath it has had a secondary maturation phase occur in which the layer below it is found to be exceptionally hard. So you’re in the clear there as well. 

So, for the last few minutes, I want to talk a little bit about urgent care settings and specifically about the times that are happening now. If you’re listening to this in the future, we are smack-dab in the middle of the COVID-19 pandemic, and we’re trying to figure out ways for us to safely treat our patients specifically, as we understand it currently, through a reduction of aerosolization. 

And so triaging is the most important factor in determining which treatment route you should be taking, and these tests should only be performed by trained, licensed professionals operating within their scope of practice. And, if the case is determined to be an emergency, which is usually defined by having pain and swelling and infection, follow your normal protocol for treatment. But, if the case is not an emergency and it is allowable in your area to perform non-emergency services, consider a few of these ideas as alternative to or maybe in addition to your normal drill-and-fill method. 

One of these things is called ART. Atraumatic restorative technique, sometimes also referred to as “scoop and fill,” is a process of decay removal using hand instrumentation only. Right now, dental professionals worldwide are trying to do their part in reducing opportunities that might contribute to the spread of the virus, and using ART technique is a great way to reduce aerosols. The clinical simply needs to use the HVE and gently begin excavation. Once all the infected material is removed, follow normal procedures for EQUIA Forte. 

As mentioned earlier, EQUIA Forte does not require the use of air-thinning the coat, nor does it require the use of a high-speed handpiece to finish it. A carver generally used for alloy does a great job in these situations. And so the ART technique fits hand-in-hand with improved infection control and reducing transmitting of disease. 

For ART to work, a dental professional will need to feel comfortable and agree with the concepts of infected versus affected dentin, removing only the infected portion and trusting the glass hybrid to deliver remineralizing fluoride to the area. 

There needs to be a short mention about case selection and prioritizing here. During urgent care, a dental team should have a prioritizing system which focuses first on pain and symptomatic teeth, then classifying teeth that need priority care, followed by asymptomatic then cosmetic concerns. We know that dental caries is a communicable condition, so priority should be given to causal agents for high levels of caries including bacteria, which oddly enough, big holes in one’s teeth could perpetuate that cycle. 

If there is not much time or there are other limiting factors, focus on removal of decay first with consideration to quadrant dentistry and glass hybrids as a quicker solution. Again, reduction of aerosols through decreased use of hand pieces even if you do it only for the excavation portion. It is not needed for the finishing steps, and every little bit helps.

Glass hybrids reduce chair time and get more work finished so that the patient lowers their bacterial levels in their mouths thereby reducing the chances for reinfection or escalation of current dental needs. 

Another tool in our toolkit is called silver diamine fluoride or SDF. We do not have time in this episode to cover this in detail, but using it underneath EQUIA Forte has shown to reduce sensitivity and potentially aid in the remineralization of teeth. Just remember to take caution using it with materials that need light cure as the darkness could show through. There’s also a lot of good science being done in this space, so feel free to research it on your own. 

GC has another product that came out last year, which we’re also not going to be able to get to today, but I did at least want to mention it before we end. It’s called EQUIA Forte HT, which stands for “higher translucency.” So, as they move from EQUIA to EQUIA Forte, the trade-off was a decreased translucency, which they improved upon with this latest iteration.

Man, I cannot believe how quick the time goes doing these TIPisodes. I hope that you learned a little bit of something here whether it was something that you’d forgotten and just remembered or a brand-new concept. I really hope to be able to do this again sometime with you guys. 

Please visit the show notes to find out more about this amazing line of products from GC. Thank you, everyone. Take care. 

 Michelle Strange: Thanks for listening to another TIPisode, this week brought to you by GC America. Head over to their website or ask your dealer about some of their products. Be sure to follow us on Facebook, Instagram, and head over to our website to sign up for our newsletter. We appreciate all ratings and reviews. Thank you for listening to your unofficial dental hygiene podcast.

[CLOSING MUSIC]