R E S T O R AT I O N O F R O O T S U R FA C E C A R I E S

ARTICLE

ABSTRACT Restoration of root surface caries

The authors conducted a review to eval-
uate the current literature addressing
root surface caries treatment in the
in vulnerable elderly patients:
vulnerable elderly, to identify any gaps
in the literature that will need to be a review of the literature
addressed in the future. The authors
conducted a literature search of the
electronic databases using MEDLINE, R. S. Amer, DDS, MS;1* J.L. Kolker, DDS, MS, PhD2
PubMed, to identify original clinical
research articles regarding treatment of 1
Assistant Professor, Division of Restorative, Prosthetics and Primary Care Dentistry at the College of
root caries lesions, with emphasis on Dentistry at The Ohio State University, Columbus, Ohio; 2Associate Professor, Department of Operative
research focused on the vulnerable Dentistry at the College of Dentistry at The University of Iowa, Iowa City, Iowa.
elderly. Five articles were clinical stud- *Corresponding author e-mail: [email protected]
ies of root caries restorations. Only one
was conducted on a vulnerable elderly Spec Care Dentist 33(3): 141-149, 2013
population. The results of the literature
review show that there is a need for fur-
ther studies addressing the restorative
needs of the vulnerable elderly. With the Int r od uct ion
aging of the American population, more In the U.S. between 2000 and 2010, there was a 15.1% increase in population among
research is needed to provide adequate individuals 65 years of age and older, with approximately a 30% increase in elderly
care to this population. At this time, individuals aged 80–99 years.1 Among this population is a segment of the population,
glass ionomers are a good treatment termed the “vulnerable elderly,” defined as individuals over the age of 65 who have any
option. of the following clinical findings: limited mobility, limited resources or a complex
health status.2 When considering oral health among this population, there has been a
KEY WORDS: access/barriers to substantial decline in edentulism.3,4 Ekstrand et al. have stated that a significant
care, geriatric dentistry, root caries amount of required dental treatment will be on exposed root surfaces.5 In determining
the most appropriate treatment for root caries there are multiple gaps in the literature;
even less is known about the outcomes of such restorations among the vulnerable eld-
erly. However, in an attempt to summarize known information on restoring root caries,
with emphasis on the vulnerable elderly, this manuscript’s purpose was to discuss cur-
rent restorative options and identify gaps in the literature regarding the most
appropriate approach for root caries in vulnerable elderly.

Ap p r oa ch t o t h e r ev iew clinical trials, regarding restoration of

root caries in general.7,10-18
o f l it er a t ur e There are no long-term clinical trials
A comprehensive Pub Med search for in excess of two years on root restorations’
clinical literature, published in English, longevity specifically among the vulnera-
on root caries restorations, with the ble elderly. Clinical trial outcomes that
limits on age set to 65+ years, returned may be applicable to root restorations in
four relevant citations.6-9 One of the the vulnerable elderly are few and vary
citations contained descriptions of substantially by the population observed,
specific restorative techniques.7 One types of restorative materials, types of pro-
article9 was only a summarization of cedures, and observation period. Although
a paper previously published in another many of the studies use similar evaluation
journal.6 criteria, definitions of success varied
Therefore, to expand the literature greatly. Due to the paucity of clinical trials
search, the age limit was removed, and addressing the outcome of root caries res-
the search for root caries restorations was toration in the vulnerable elderly, the
not limited to the vulnerable elderly. This authors also expanded the evaluation of
new literature search yielded additional the literature, to include laboratory studies.

©2012 Special Care Dentistry Association and Wiley Periodicals, Inc. S p e c C a r e D e n t i s t 3 3 ( 3 ) 2 0 1 3 141
doi: 10.1111/j.1754-4505.2012.00302.x

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These laboratory studies, provided very challenging.29,30 Additionally, bond- been shown to be proportional to the
information on characteristics of cari- ing to caries-affected dentin is even more acidity level of the environment.34 There
ous root structure, and root caries difficult due to its lower hardness and is evidence that glass-ionomer restora-
progression, as well as evaluations of presence of mineral deposits in the denti- tions may make root surfaces resistant to
different types of restorative materials nal tubules.31 Moreover, in addressing the cariogenic effect of mixed-species
(Table 1). recurrent caries on the root, preparations oral biofilm, found in and around roots.35
could involve a combination of dentin Yet, there are inconsistent reports of
and the prior restoration, such as a GICs preventing secondary caries with or
without exposure to fluoride denti-
Root mo r pho logy and crown, amalgam, composite or glass-ion-
omer cement (GIC). frices.36,37 Another benefit of GICs is that
car ies progre ssi o n they bond well to moist and even con-
Gingival Recession within the elderly taminated dentin.34 Additionally, the
quality of glass-ionomer adhesion
population is very common.19 Exposed
root surfaces are areas where biofilm
T y p es of r es t or a t ive increases with time, thus possibly
often stagnates and can result in caries m a t er ia ls making glass-ionomers more reliable
initiation. Primary demineralization of When a patient is unable to properly than composite resin restorations for
the root exposes collagen fibrils, which clean a tooth surface lesion and it restoring root caries.34 The setting reac-
can lead to greater breakdown of progresses to a point that restoration is tion of conventional glass ionomer is a
dentin.20 Root caries can also occur necessary, there are many issues for clini- complex acid-base reaction that involves
when root structure is exposed and cians to consider regarding choice of a short initial setting reaction (3–5 min-
cementum has been removed (either tooth preparation and restoration. Before utes), followed by a prolonged
due to abrasion, erosion, or abfraction) choosing the restorative material, the maturation reaction (months to years).38
and bacteria enter directly into dentinal amount and location of the remaining This prolonged setting time in addition
tubules without demineralization.21,22 sound tooth structure must be evaluated. to the low initial strength of conven-
To assess root caries progression on Unfortunately, little is known regard- tional GICs was one of disadvantages of
cementum and dentin root surfaces ing optimal methods for restoring root glass-ionomer restorations.
without cementum, Smith et al. carried caries. In the past, amalgam was rou- To improve the physical properties of
out an in-vitro lesion formation study.23 tinely used to restore root lesions. glass-ionomer, resin-modified GIC was
Carious lesion depths were significantly However, amalgam’s lack of adhesive developed, by adding monomers to the
greater on root samples without cemen- properties require the removal of healthy liquid. Resin-modified glass-ionomer set
tum than on samples with intact tooth structure to obtain adequate resist- by a combined acid-base ionomer reac-
cementum, suggesting that cementum ance and retention form. Ideal retention tion, like conventional glass-ionomer, in
reduces mineral loss from root sur- in the prepared cavity is not easy to addition to a light-cured resin polymeri-
face.23 Regardless of what tooth surface achieve, especially in the small and zation. This results in earlier strength
the root caries lesion started from, root narrow root structure that is difficult to allowing immediate and easier finishing.11
caries lesions often spread by covering access. Amalgam’s lack of adhesive and Due to these advantages, in 2006 The
a larger surface area (i.e. encircling the therapeutic qualities no longer makes it World Dental Federation (FDI) recom-
entire cervical root surface) vs. deep the material of choice for restoring root mended the use of glass ionomers
penetration.21,24 Histologically root surface caries.10 Currently, GICs and (conventional or resin-modified) as the
caries has a slightly demineralized resin composite restorations are more material of choice for the restoration of
dentin surface lesion with bacterial frequently used to restore root lesions, root caries lesions, especially in subgingi-
penetration (surface zone) covering a and cavities restored with GICs have val areas.39
more pronounced demineralized sub- resulted in fewer recurrent carious Unfortunately, glass ionomers are not
surface lesion and translucent dentin lesions than cavities restored with amal- ideal restorative materials, since they are
deep to the body of the lesion (frontal gam.32 The term GIC in this manuscript difficult to manipulate, are often brittle,
zone).25-27 will be used to describe the restorative and have low wear resistance. One of the
While enamel is a predominantly material and not the luting agents. drawbacks of glass ionomers is the lim-
mineralized tissue (70% inorganic), GICs are useful for managing dental ited amount of finishing that can be
dentin contains a significant amount of caries according to the principles of min- completed immediately after placing this
water (10%) and organic material (20%), imally invasive dentistry because they restorative material. Care should be
mainly type I collagen.28 The physiologi- chemically adhere to the mineral content taken to protect recently placed glass
cal content of dentin must be understood of tooth structure via calcium bonds, cre- ionomer restorations from both dehydra-
when restoring root caries lesions, ating a seal.33 The main benefit of tion and water uptake from saliva.34
because the moisture and organic compo- glass-ionomer materials is that they When glass ionomer restorations become
nents of dentin make adhesive bonding actively release fluoride and release has dehydrated during initial setting, they

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Table 1. Root caries restoration, published clinical studies.

First author Study Specific Mean Initial no. of Initial no. of Eval No. of resto- Outcome rates
(publication compared population age participants restorations period rations @ end
year) (range) (months) of evaluation
period
Levy CGI vs. CR None 52.4 50 (26 104 (59 24 77 (44 CR, Clinically Acceptable (not
(1990)15 (25–76) female, CR,45 GI) 33 GI) requiring replacement): CR
24 male) (73%), CGI (45%)
Recurrent caries: CR (6%),
CGI (0%)
Extensive loss of marginal
integrity: CR (9%),CGI
(30%)
Lo (2006)5 ART w/ CGI Institutionalized 78.6 103 (72 162 (78 ART/ 12 122 (59 ART/ Survival (sound restora-
vs. RP w/ Elders female, 31 CGI, 84 RP/ CGI, 63 RP/ tions, including those with
RMGI male) RMGI) RMGI) less than 0.5 mm marginal
defect): ART+CGI (86.4%),
RP + RMGI (92.1%)
Recurrent caries: ART+CGI
(3.6%), RP + RMGI (1.7%)
Extensive loss of marginal
integrity: ART+CGI
(11.9%), RP + RMGI
(7.9%)
Hu (2002)18, ART vs. RP, Xerostomic 63 (37– 15 (7 146 (74 ART, 24 125 (65 ART, Success (Not missing,
(2005)17 and CGIs head and neck 76) female, 8 72 RP) (73 60 RP) (60 lost, or unacceptable): ART
(Ketec-Molar radiation male) Ketac-Molar, Ketac-Molar, (66.2%), Rotary (65.2%),
vs. Fuji IX) patients 73 Fuji IX) 65 Fuji IX) Ketac-Molar (66.7%), Fuji
IX (86.2%)
McComb CGI vs. Xerostomic >17 50 144 (44 CGI, 24 69 (28 CGI, Success (non-failure): CR
(2002)19 RMGI vs. CR head and neck 50 RMGI, 50 21 RMGI, 20 (20%), RMGI (33%), CGI
CF vs. NCF radiation CR) CR) (11%)
patients
Overall recurrent caries:
CR (44%), RMGI (11%),
CGI (0%)
CF recurrent caries: CR
(0%), RMGI (0%), CGI
(0%)
NCF recurrent caries: CR
(67%), RMGI (12.5%), CGI
(0%)
Failure due to marginal
adaptation and/ or anatom-
ical form: CR (41%), RMGI
(67%), CGI (89%)
CF Failure due to marginal
adaptation and/ or anatom-
ical form: CR (0%), RMGI
(88%), CGI (100%)
NCF Failure due to mar-
ginal adaptation and/ or
anatomical form: CR
(64%), RMGI (54%), CGI
(75%)
Continued

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Table 1. Continued.
First author Study Specific Mean Initial no. of Initial no. of Eval No. of resto- Outcome rates
(publication compared population age participants restorations period rations @ end
year) (range) (months) of evaluation
period
De Moor CGI vs. Xerostomic ~45 35 105 (35 CGI, 24 81 (27 CGI,27 Success (non-failure):
(2011)16 RMGI vs. CR head and neck (7 female, 35 RMGI, RMGI, 27 CR) CR (52%), RMGI (22%),
CF vs. NCF radiation 28 male) 35 CR) CGI (4%)
patients
Overall recurrent caries:
CR (26%), RMGI (26%),
CGI (7%)
CF recurrent caries:
CR (8%), RMGI (15%),
CGI (8%)
NCF recurrent caries:
CR (36%), RMGI (36%),
CGI (7%)
Failure due to marginal
adaptation and/or anatomi-
cal form: CR (33%), RMGI
(78%), CGI (96%)
CF Failure due to marginal
adaptation and/or anatomi-
cal form: CR (8%), RMGI
(92%), CGI (100%)
NCF Failure due to
marginal adaptation and/
or anatomical form:
CR (50%), RMGI (71%),
CGI (93%)
CGI = conventional glass ionomer; RMGI = resin-modified glass ionomer; CR = composite resin; ART = atraumatic restorative technique;
RP = rotary preparation; CF = compliant use of daily neutral sodium fluoride gel in trays; NCG = noncompliant use of daily neutral sodium
fluoride gel in trays.

will likely develop fractures that result ionomer restorations was evaluated in a In efforts to develop a restorative
in measurable gaps between restorations laboratory study, no significant differ- material that prevents secondary root
and tooth preparation. There has been ences in microtensile bond strengths caries, laboratory studies have reported
one report that has demonstrated that between younger and older teeth were promising results regarding the use of
resin-modified glass ionomer restorative reported, when bonding to enamel or the anti-bacterial monomer 12-methacry-
materials have the potential for closure dentin.41 Another laboratory study found loyloxydodecylpyridinium bromide
of this type of fracture after rehydra- that the age of dentin did not have a sig- (MDPB) in adhesive and composite
tion.40 Glass ionomer restorations are nificant influence on bond strengths of resins. Experimental adhesive systems
also sensitive to low pH. When exposed resin bonding systems.31 With the bond- containing MDBP have been found to
to low pH environments, such as soda- ing systems currently on the market inhibit the progression of root-surface
pop, glass ionomer erosion is (both etch-and-rinse and self-etch), caries in-vitro, through a combination of
enhanced.34 resin-impregnated layer quality is its antimicrobial activity and sealing of
Unlike glass ionomers, current resin believed to be more important for obtain- the demineralized dentin.42 Thom et al.
composite restorative materials depend ing high tensile bond strengths than the studied the use of MDPB in composite
on advanced technique-sensitive dentin age of the tooth structure.31 Regardless of resin restorations and reported that
adhesive methods for restoration reten- the age of dentin, bonding composite MDPB in the tested composite resins was
tion. Changes in oral environment and resins to dentin is still very technique- comparable to the results associated with
dentin associated with aging may also sensitive and the manufacturers’ conventional resin modified glass iono-
affect this process. When the effect of a instructions and/or steps are different for mer restorations in inhibiting secondary
subject’s age on the bonding of compos- almost every commercially available caries formation in-vitro.43 Imazato et al.
ite resin and resin-modified glass bonding system. also demonstrated the anti-bacterial

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Table 2. Root caries restorative materials.

Material Class How much Fluoride release Esthetics Advantages Disadvantages
affected by
contamina-
tion before
setting
Resin-Modified Low High High Bulk placement of restorative material. Less aesthetic than composite
Glass Ionomer Can be contoured and finished in the resins.
same visit. No separate bonding agent
needed. Adheres well to slightly contami-
nated (moist) tooth structure. Better wear
and aesthetics than conventional GI.
Long-term fluoride release.
Glass Ionomer Low A little higher Medium Bulk placement of restorative material. More wear than any other root
than RMGI No separate bonding agent needed. caries restorative material.
Adheres well to slightly contaminated Finishing of restoration not possi-
(moist) tooth structure. Long-term fluo- ble in same appointment.
ride release Restoration highly affected by dry-
mouth. Not highly aesthetics.
Amalgam Low None Low One step bulk placement of the filling No adhesive properties. Requires
makes it a fast treatment option. Not more tooth structure removal to
affected by dry-mouth. Forgiving material achieve macro-mechanical reten-
when absolute field dryness cannot be tion. No fluoride release. Very low
achieved. esthetics.
Composite High Usually none Very high Superior aesthetics. Easier placement Multiple steps needed for place-
Resin and finishing than GI or RMGI. Not ment of restorative material.
affected by dry-mouth. Requires separate bonding agent
to adhere to tooth. Absolute field
control necessary for long-term
success. No fluoride release.

effect of MDBP in an in-vivo dog comes of the materials.15 Although not with 103 elderly patients (mean age =
model.44 However, at the time this review significantly different, glass ionomers 78.6 years) living in care homes. The
was conducted, resin composite contain- had higher rates of loss of retention ART technique involves using hand
ing MDBP was not color stable.42 No (39%), extensive loss of integrity (30%), instruments in the removal of carious
studies were published regarding in and being clinically not acceptable (56%) (soft) dental tissue for cavity preparation,
vivo or clinical studies involving human compared to those of the composite instead of rotary instruments.45
subjects. resins (23%, 9%, and 27%, respectively; The ART preparations were restored
Table 2). This study was published in with a conventional glass ionomer (Ketac
1990 and the restorative materials since Molar) and the conventional prepara-
that time have been highly modified and tions made with rotary instruments were
C lin ical tr i als reformulated. Thus, studies completed restored with a resin-modified glass iono-
Despite advances in material science, nei- on outdated materials that are often no mer (Fuji II LC). After 12 months, the
ther glass ionomers nor composite resins longer available have limited validity. conventional glass ionomer restorations
are considered to be ideal restorative However, Levy et al. concluded that the using the ART technique had a compara-
materials for root caries, especially high failure rates of both of the materials ble survival rate (86.4%) to the resin
among the vulnerable elderly. In addition may be due to difficulty in achieving modified glass ionomer restorations pre-
to different types of restorative materials, proper isolation due to inaccessibility,15 pared using rotary instruments (92.1%).6
different methods of restoring have been which is a problem that has not changed Although there was no control group in
evaluated. or been improved upon. this study and two different cavity prepa-
After 24 months of observing con- In a 12 month clinical trial by Lo ration methods and two different types of
ventional glass ionomer (Ketac-Fil) and et al.,6 root caries was restored using restorative materials were evaluated, the
microfill composite (Silux) restorations Atraumatic Restorative Treatment (ART) study gives evidence that, in limited
treating root caries, Levy et al. found few versus the conventional method of using dental access locations without the tradi-
significant differences between the out- rotary-instruments for cavity preparation, tional dental operatory, the ART

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technique may be a viable alternative, restorations with three different materi- between that of conventional glass iono-
which may benefit the vulnerable elderly. als: a conventional glass ionomer mers and composites. The erosion was
Additionally, a 2010 review of the litera- (Ketac-Fil, in both studies), a resin modi- likely due to the combination of xerosto-
ture reported that the longevity of ART fied glass ionomer (Vitremer17 and mia and use of the fluoride gel. In the
class V restorations was comparable to Photac-Fil12, and a resin composite DeMoor et al. study, there were signifi-
the longevity of amalgam restorations.46 (Z-10017 and Herculite XRV12. cant differences among all of the
Some of the more recent clinical Placement of the restoration in these materials at 24 months; conventional
studies evaluating glass ionomers have studies was based on an allocation table glass ionomers had the highest failure
focused on the treatment of patients with that placed each restorative material the rate (96%), followed by the resin-modi-
xerostomia due to radiation therapy. It is same number of time in the same quad- fied glass ionomer (78%) and the resin
well known that these patients are at rant or sextant of the mouth. All patients composite (48%).12 These reports did not
high risk for developing root caries.12-14,17 in both trials were instructed to use a specifically state the gingival location of
Salivary hypofunction, often referred to neutral sodium fluoride gel in custom the lesions (supra-gingival or sub-gingi-
as xerostomia has been associated with trays, on a daily basis. Patients who val margins), but did report that enamel
various disease processes and a broad use reported that they did not use the fluo- margins of the cavity preparations were
of medications that cause dry mouth as a ride trays at least 50% of the time were beveled for the composites. If the cavity
side effect. considered noncompliant. preparations had some margins on
The prevalence of xerostomia has When defining failure as recurrent enamel, this is a possible explanation for
increased, and it is estimated that caries at 24 months, there were no differ- the favorable outcomes found for the
approximately 30% of adults aged 65 and ences in the failure rates among the three resin composite fillings. Also, it is worth
older now have xerostomia.47 The results restorative materials for the entire study mentioning that De Moor et al. evaluated
of glass ionomer clinical trials in patients sample for the fluoride users in both a conventional, low viscosity glass iono-
with xerostomia due to radiation may be studies (Table 2).12,17 However, among mer (Ketac-Fil) and not a high-viscosity
helpful to determine restorative solutions the noncompliant fluoride users in the glass ionomer (i.e., Ketac-Molar). High
for individuals with xerostomia, includ- McComb et al. study, the failure rate for viscosity glass ionomers tend to be easier
ing the vulnerable elderly, regardless of composites was significantly higher at 6, to manipulate and place, and also exhibit
cause. 12, and 18 months (21%, 39%, and 62%, better wear resistance than do low vis-
Hu et al. conducted a clinical trial respectively) than the failure rate for cosity glass ionomers.49,50 This may be an
which evaluated outcomes of 146 root resin-modified glass ionomers (4%, 6%, additional property that contributed to
surface lesions restored using ART and and 9%, respectively).17 At 24 months, the high failure rate of the conventional
conventional rotary preparations in 15 the sample size became too small to glass ionomers.
patients who had radiation-induced root allow for the detection of any statistical The results of these studies can be
surface caries.13 All preparations were differences; however, 67% of teeth helpful when assessing and determining
restored with a conventional glass iono- restored with resin composite had recur- the most appropriate treatment for the
mer (either Fuji IX or Ketac-Molar). Hu rent caries. None of the teeth restored vulnerable elderly or others with xerosto-
et al. reported that, after 24 months, the with conventional glass ionomer had mia. Under these conditions, it appears
ART technique was as effective (66.2% recurrent caries. In the DeMoor et al. that the outcomes and restorative mate-
survival rate) as the conventional rotary study, teeth restored with resin compos- rial selection are highly dependent on the
cavity preparation method (65.2% sur- ites had significantly more recurrent patient’s compliance with using fluoride
vival rate).13 They also concluded that caries during all time periods, including gel trays on a daily basis. In a compliant
the conventional glass ionomers at 24 months.12 patient who has good oral hygiene and
appeared to prevent secondary caries, The results were much different when routinely uses supplemental fluoride, it
even when the restorations were subse- failure was defined by discrepancies in appears that resin composite would be
quently lost.14 This clinical finding marginal adaptation and anatomical form the most appropriate material.
agreed with an earlier laboratory study (loss of restoration). In the McComb Unfortunately, many of the vulnerable
by Ten Cate that reported the formation et al. study, for the noncompliant fluo- elderly may have poor oral hygiene, may
of hypermineralized tooth structure due ride users, there were no significant not have the means or ability to be com-
to the effect of glass ionomer.48 differences in failure between the materi- pliant fluoride-tray users, or may not
Two 24-month clinical studies evalu- als. However, the compliant fluoride have access to fluoride trays. Therefore,
ated class V restorations in head and users had significantly higher failure it may be most appropriate to use
neck cancer patients who had radiation rates of the conventional glass ionomer conventional glass ionomers and
therapy and suffered from xerosto- vs. composite.17 The conventional glass resin-modified glass ionomers in the
mia.12,17 The protocols for the McComb ionomers displayed a large amount of vulnerable elders. De Moor et al. recom-
et al.17 and DeMoor et al.12 studies were erosion, while the erosion levels for mended that, if the conventional
very similar. Each patient received three resin-modified glass ionomers was glass ionomer experiences surface

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deterioration due to erosion or dehydra- not only need to adapt to the dry envi- is needed to provide adequate care to this
tion, then repair may be completed by ronment, but ideally would also need to population. At this time, GIC restora-
placing composite on top of (veneering) be anti-bacterial and demonstrate resist- tions are a good treatment option.
the remaining glass ionomer to prolong ance to secondary caries.
the service life of the restoration.12 This An ideal root caries restorative mate-
procedure is known as the closed sand- rial for the vulnerable elderly, should:
wich technique. 1. have a strong bond to root dentin;
C onf lict of in t e r e st
The authors report no conflict of interest.
The open sandwich technique may 2. have good flexural strength to pre-
also be beneficial in restoring root caries. vent dislodgement and high strength
This would involve placing a resin-modi- to sustain both tensile and compres-
fied glass ionomer on the gingival floor
of the preparation and then adhesively
sive intra-oral loading forces;
3. possess cariostatic properties that
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(some of which are outdated), different Gerodontology 2008;25(2):67-75.
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reflect the time required to render appro-
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priate care.56 Also, due to time
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