Teaching the placement of posterior resin-based composite restorations in U.S. dental schools

Teaching of posterior composites for the restoration of permanent teeth in undergraduate dental training programmes: Systematic review and meta-analysis

OBJECTIVES

To systematically assess aspects of teaching of posterior composite restorations (PCRs) in permanent teeth in dental schools.

STUDY SELECTION

Quantitative studies reporting on dental schools' teaching regarding the placement of PCRs in permanent teeth. Random-effects meta-analyses and meta-regressions were performed. Risk of bias was assessed based on the Medical Education Research Study Quality Instrument (MERSQI).

SOURCES

Electronic databases (MEDLINE via PubMed, EMBASE via Ovid, Web of Science, and Scopus) were searched in January 2023.

DATA

Forty sources reporting on 34 studies having surveyed 1,286 dental schools were included. Overall, 92.7% (95%-CI: 88.2-95.5) of dental schools reported to teach PCRs. PCRs in three-surface Class II cavities are taught by 82.0% (95%-CI: 70.4-89.7). The mandatory use of liners in deep cavities is taught by 78.3% (95%-CI: 68.9-85.5), and 44.0% (95%-CI: 34.3-54.2) reported to teach bulk-fill composites. While most posterior restorations placed by students were composites (56.1%; 95%-CI: 46.0-65.8), 94.7% (95%-CI: 86.6-98.0) of dental schools (still) teach posterior amalgam restorations. The proportion of dental schools teaching PCRs in three-surface Class II cavities increased and the mean proportion of PCRs among all posterior restorations increased over time (padj.≤0.003).

CONCLUSIONS

The teaching of PCRs in dental schools around the world reflects the increased use of resin composite in clinical practice, with students in countries where dental amalgam continues to be used, placing more posterior composites than restorations of dental amalgam. The teaching of PCRs, which is anticipated to increase, will continue to be refined with further developments in adhesive materials, devices, instrumentation, and techniques.

CLINICAL SIGNIFICANCE

Graduating dentists can be expected to be familiar with the use of resin composites for the restoration of posterior teeth.

Teaching of composite restoration repair in Brazilian dental schools

OBJECTIVES

The aim was to investigate aspects of the teaching of restoration repair as a minimally invasive alternative to replacing defective direct composite restorations in undergraduate curricula teaching programs in Brazilian dental schools.

METHODS

A 14-item validated survey questionnaire was mailed to directors/coordinators of operative/restorative dentistry teachers of Brazilian Dental Schools. Data were collected on demographic characteristics of the teachers and institutions, together with questions on the teaching of the repair of defective resin-based composite restorations as part of the school curriculum; the rationale behind the teaching; the nature of the teaching (preclinical and/or clinical); how techniques were taught, indications for repair, operative techniques, materials used, patient acceptability and expected longevity of completed repairs.

RESULTS

Two hundred and twenty-two (94%) directors/ coordinators of dental curricula in Brazil were contacted. One hundred and thirty-one directors/coordinators (59%) replied, providing the e-mail address from the teacher responsible for the operative/restorative dentistry program in their school. Of these, 104 responded to the questionnaire (79% response rate). Ninety-three (89%) of the participating schools reported teaching composite repairs as an alternative to replacing restorations. Of the theoretical content, 43% was taught at preclinical and clinical levels, whereas most practical experience (53%) was acquired at clinical levels. Eighty-eight schools (95%) reported tooth substance preservation being the main reason for teaching repair techniques. All schools that taught repairs reported high patient acceptability.

CONCLUSIONS

The teaching of composite restoration repair as an alternative to restoration replacement is established in undergraduate programs in most of the Brazilian dental schools surveyed.

CLINICAL SIGNIFICANCE

The reasons for teaching restoration repair in Brazil were found to be quite unanimous among teachers, especially regarding the preservation of tooth structure. Variations were found in the clinical indications for repair, suggesting the need for further investigations. Monitoring repaired restorations should be encouraged and could contribute to future studies.

Evidence-based fact checking for selective procedures in restorative dentistry

OBJECTIVES

Similar to other dental specialties, there are many clinical procedures in restorative dentistry that may or may not be supported by good evidence. Thus, the effectiveness of these procedures is uncertain. The aim of this paper is to reduce this knowledge gap by critically inspecting selective procedures in restorative dentistry and exploring if these well-established or widely advocated treatment modalities are necessary for improving treatment outcomes based on the best available evidence.

MATERIALS AND METHODS

A MEDLINE search was conducted to identify research on selective procedures while focusing on clinical trials and systematic reviews. Due to their practical relevance in the decision-making process, cost-effectiveness analyses were also included.

RESULTS

Mixed results were identified regarding the included interventions. Some procedures had adequate evidence supporting them while others were mostly based on beliefs.

CONCLUSIONS

A critical review of the available literature indicates that some common restorative procedures lack adequate support from high-quality research evidence.

CLINICAL RELEVANCE

This paper attempts to highlight the need to critically examine the scientific validity of traditional knowledge and techniques through the context of current research evidence. This will not only help generate consensus between educators, clinicians, and researchers regarding restorative procedures but will also lead to improved patient care and outcomes.

Resin Composite Versus Amalgam Restorations Placed in United States Dental Schools

OBJECTIVES

To investigate the latest teaching policies for posterior resin composite placement versus amalgam and to determine the actual numbers of posterior resin composites versus amalgam restorations placed in American dental schools from 2008 to 2018.

METHODS

Emails were sent to the deans of all 66 dental schools in the United States to collect data in the forms of: 1) Questionnaire on current teaching policies of posterior composite and amalgam restorations; and 2) Data entry form to collect the actual numbers of posterior composite and amalgam restorations placed in their clinics. Descriptive statistics were used to summarize ratios of posterior restorations. Inferential analysis (chi-square test and z-test) was employed to compare posterior restoration proportions over time and within each year. Level of significance was set at 0.05.

RESULTS

For the teaching questionnaire, the response rate was 52% (n=34). Seventy-six per cent of the responding schools reported that they assign 50% or more of their preclinical restorative teaching time towards posterior resin composite placement, while 50% of the responding schools devoted 25% or less towards amalgam teaching. Data entry response rate was 26% (n=17). In 2008, amalgam and resin composite restorations were placed almost equally. However, resin composite restorations were placed significantly more frequently from 2009 onwards in all responding schools. The results revealed a significant ongoing increasing trend in placing posterior resin composites in all responding schools over time (p<0.05).

CONCLUSIONS

Data analysis revealed a clear trend towards an increase in posterior resin composite restoration placement and a decrease in the number of amalgam restorations. However, the time assigned for posterior resin composite teaching is not aligned with quantity of restorations placed. Review and adjustment of the time allocated for teaching and training of each material are suggested.

Composite versus Amalgam Restorations Placed in Canadian Dental Schools

OBJECTIVES

To investigate the latest teaching policies of posterior composite placement versus amalgam and to determine the actual numbers of posterior composites versus amalgam restorations placed in Canadian dental schools, over the years from 2008 to 2018.

METHODS

Emails were sent to Chairs/Heads of Restorative Departments and Clinic Directors of all 10 Canadian dental schools to collect data in the forms of: 1) Questionnaire on current teaching policies of posterior composite and amalgam restorations; 2) data entry form to collect the actual numbers of posterior composite and amalgam restorations placed in their clinics.

RESULTS

For the teaching questionnaire, the response rate was 90% (n=9). Seven (78%) of the responding schools reported that they assign 25%-50% of their preclinical restorative teaching time towards posterior composite placement. While, three (33%) of the responding schools allocated 50%-75% of their restorative teaching towards amalgam placement. Data entry response rate was 80% (n=8). Amalgam material was dominant in the restoration distribution from 2008 to 2012. While from 2013 to 2018, resin composite material was dominant in all eight responding schools. Linear regression analysis revealed a significant increasing trend in placing posterior composites in all the responding schools over time (p<0.05).

CONCLUSIONS

Data analysis revealed a clear trend towards an increase of posterior composite restoration placement and a decrease in the number of amalgam restorations placed. However, the teaching time assigned for posterior composite is not aligned with quantity placed. Review and adjustment of time allocated for teaching and training of each material are recommended.

Current trends in removable partial prosthodontics education in dental colleges of Pakistan

OBJECTIVE

The objective of this study was to investigate the current trends in undergraduate teaching of removable partial prosthodontics in various dental colleges of Pakistan.

METHODOLOGY

A cross-sectional study was conducted in which a questionnaire was sent by email to head of Prosthodontics department of thirty-one dental institutes of Pakistan. The survey included multiple questions regarding current trends in removable partial prosthodontics education in undergraduate dental colleges.

RESULTS

Out of thirty-one questionnaires, twenty-six were completely filled and returned. In 19 (73%) dental colleges, removable partial denture is taught over a period of at least two years of undergraduate education. Students of only six dental colleges fabricate 10-12 removable partial dentures during their Prosthodontic rotation. Lectures and live clinical demonstration for construction of removable acrylic dentures are reported to be carried out in all the dental schools. Simple hinge articulator is the articulator of choice in 22 (84.6%) colleges. Even though twenty-four out of twenty-six colleges (92.3%) teach fabrication of cast partial dentures in lectures, none of the student fabricate these dentures during their Prosthodontic rotation.

CONCLUSION

This survey is the first to comprehensively report the teaching practices of removable denture Prosthodontics in undergraduate dental colleges of Pakistan. Faculty of all twenty-six colleges give clinical demonstrations of acrylic partial denture construction before students start working in the dental OPD. Most of the dental colleges report use of similar impression materials and techniques in removable partial denture fabrication. More than 90% of dental colleges teach cast partial dentures theoretically, but their construction is grossly neglected in all the dental colleges. It is important that this skill is taught and practised by students in order to have the necessary skill set, so they can provide comprehensive treatment to partially dentate patients once they graduate.

Dental educators' attitudes towards the teaching of dental amalgam

OBJECTIVE

To ascertain dental educators' attitudes towards the teaching of dental amalgam at dental schools in Australia and identify preferred curricular approaches in a potentially "amalgamless" profession.

METHODS

A mixed methods analysis was employed based on an open-ended response survey followed by a closed-ended questionnaire. Identification of key issues from the survey helped frame the questionnaire. Participants included those with expertise in operative and restorative dentistry, with direct involvement in curriculum development or delivery, at Australian dental schools.

RESULTS

Participants numbered fifteen and represented seven of the nine dental schools in Australia. Key themes identified and explored included the following: (in)consistency of approach to teaching restorative dentistry; a perceived disconnect between undergraduate study and the "real world"; a need for a focus on teaching of alternatives to dental amalgam (80 per cent (strongly) agreeing); the contradictory nature of the evidence base and literature that is not readily understood; the need for more post-graduate education relating to adhesive restorative materials (86 per cent (strongly) agreeing); the need for dental amalgam to continue to be available; formal understandings (guidelines) as to the use of dental amalgam; dental schools in Australia being heard on these issues; and the relevance of this issue (100 per cent (strongly) agreeing the issue is topical and important).

CONCLUSION

There is a broad consensus of dental educators at Australian dental schools as how best to approach the teaching of amalgam if a phase-down is to occur and the issues any such approach may face.

The Dental Amalgam Phasedown in New Zealand: A 20-year Trend

BACKGROUND AND OBJECTIVES

Information on the choice of material and performance of restorations placed in a dental practice annually is limited. The Minamata Convention on Mercury is likely to affect the use of amalgam worldwide. The objective of this research was to investigate the use of restorative materials at the University of Otago Faculty of Dentistry in New Zealand from 1998 to 2017.

METHODS

Data from the Faculty of Dentistry's database from the years of interest were compiled. These data included information on the characteristics of restorations, including information on the material used and number of surfaces involved for each restoration. The tooth in which each restoration was placed was categorized by arch, tooth type, and deciduous or permanent dentition.

RESULTS

Records identified 227,514 permanent restorations placed from January 1998 to December 2017, of which 91.7% were direct restorations. Among direct restorations, composite resin was the most commonly used material, followed by amalgam, glass ionomer, and compomer. The use of amalgam for direct restorations decreased from 52.3% of direct restorations in 1998 to 7.1% in 2017. A corresponding increase was observed in the use of tooth-colored direct restorations, particularly composites. Among indirect restorations, porcelain fused to metal, gold, and stainless steel (in pediatric applications) were the materials most frequently used.

CONCLUSIONS

Despite having no official policy on reducing the use of dental amalgam, the Faculty of Dentistry is following the global trend in reducing its use, with composite resin now well established as the predominant restorative material used. If the current rate of decline persists unchecked, the Faculty of Dentistry could transition to being amalgam free by 2020, although it seems likely that the characteristics and principles of use of the material (and its removal) will be taught for some time to come. This knowledge is important to planning curriculum changes needed to prepare graduates for clinical practice.

The transition from amalgam to other restorative materials in the U.S. predoctoral pediatric dentistry clinics

Increased concerns about the safety of amalgam restorations in children have resulted in many dental schools emphasizing the teaching of alternative dental materials. This study investigated the current teaching of different dental materials for use in posterior teeth in the United States predoctoral pediatric dentistry programs. In 2011, the authors invited the chairs of the predoctoral pediatric dentistry departments in all accredited dental schools at that time (N = 57) to participate in an internet-based survey. Descriptive statistics were calculated to describe the frequency of using different restorative materials. Regression models were developed to explore the factors related to the use of dental restorations in predoctoral pediatric clinics. Among the 44 dental schools that responded (77% response rate), 74% used amalgam, and 93% used composite in primary posterior teeth. Glass ionomer was used by 61% of the schools in primary posterior teeth. Placing amalgam in primary posterior teeth was associated with programs that treated more 3-5-year-old patients (β = .302, p < .043), whereas the use of glass ionomer was associated with having students serving at off-site satellite dental clinics (β = .015, p < .012). In general, having departments with chairs who had positive attitudes towards Minimal Invasive Dentistry (MID) used composite (β = .091, p < .0001) and glass ionomer (β = 103, p < .0001) more frequently and were less likely to use amalgam (β = -.077, p < .005) in primary posterior teeth. Although teaching MID concepts in predoctoral pediatric clinics in dental schools is increasing, the use of amalgam in posterior primary and permanent teeth is still widely practiced.

Dental cavity liners for Class I and Class II resin-based composite restorations

BACKGROUND

Resin-based composite (RBC) is currently accepted as a viable material for the restoration of caries for posterior permanent teeth requiring surgical treatment. Despite the fact that the thermal conductivity of the RBC restorative material closely approximates that of natural tooth structure, postoperative hypersensitivity is sometimes still an issue. Dental cavity liners have historically been used to protect the pulp from the toxic effects of some dental restorative materials and to prevent the pain of thermal conductivity by placing an insulating layer between restorative material and the remaining tooth structure. This is an update of the Cochrane Review first published in 2016.

OBJECTIVES

The objective of this review was to assess the effects of using dental cavity liners in the placement of Class I and Class II resin-based composite posterior restorations in permanent teeth in children and adults.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 12 November 2018), the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 10) in the Cochrane Library (searched 12 November 2018), MEDLINE Ovid (1946 to 12 November 2018), Embase Ovid (1980 to 12 November 2018) and LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 12 November 2018). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomized controlled trials assessing the effects of the use of liners under Class I and Class II posterior resin-based composite restorations in permanent teeth (in both adults and children). We included both parallel and split-mouth designs.

DATA COLLECTION AND ANALYSIS

We utilized standard methodological procedures prescribed by Cochrane for data collection and analysis. Two review authors screened the search results and assessed the eligibility of studies for inclusion against the review inclusion criteria. We conducted risk of bias assessments and data extraction independently and in duplicate. Where information was unclear we contacted study authors for clarification.

MAIN RESULTS

Eight studies, recruiting over 700 participants, compared the use of dental cavity liners to no liners for Class I and Class II resin-based composite restorations.Seven studies evaluated postoperative hypersensitivity measured by various methods. All studies were at unclear or high risk of bias. There was inconsistent evidence regarding postoperative hypersensitivity (either measured using cold response or patient-reported), with a benefit shown at some, but not all, time points (low-quality evidence).Four trials measured restoration longevity. Two of the studies were judged to be at high risk and two at unclear risk of bias. No difference in restoration failure rates were shown at 1 year follow-up, with no failures reported in either group for three of the four studies; the fourth study had a risk ratio (RR) 1.00 (95% confidence interval (CI) 0.07 to 15.00) (low-quality evidence). Three studies evaluated restoration longevity at 2 years follow-up and, again, no failures were shown in either group.No adverse events were reported in any of the included studies.

AUTHORS' CONCLUSIONS

There is inconsistent, low-quality evidence regarding the difference in postoperative hypersensitivity subsequent to placing a dental cavity liner under Class I and Class II posterior resin-based composite restorations in permanent posterior teeth in adults or children 15 years or older. Furthermore, no evidence was found to demonstrate a difference in the longevity of restorations placed with or without dental cavity liners.

Enhancing Dental Student Learning and Skill with Dental Bonding Utilizing a Shear Bond Strength Test

Teaching dental students the proper protocol and application of bonding agents for improved composite restorations in the preclinical setting can be challenging due to difficulty in translating their bonding technique to clinical outcomes. The aim of this study was to examine the effectiveness of utilizing a shear bond strength test and to evaluate if it improved student performance and confidence in adhesive dentistry. All 106 third-year and 106 fourth-year dental students (total N=212) at the University of California, Los Angeles, School of Dentistry were invited to participate in a shear bond strength workshop in 2016. The hands-on workshop used a bond strength testing instrument to demonstrate the various principles and techniques of adhesive dentistry. A total of 54 third-year and 34 fourth-year students (total N=88) participated, for response rates of 51% and 32%, respectively. For the total students, there was a significant difference in the mean bond strength between the first and second attempts (p<0.001). For the third-year students, an increase in the mean shear bond strength was seen but was not significant (p=0.097). For the fourth-year students, there was a significant difference between the first and second attempts (p<0.001). A significant difference was also found in the aggregate self-ratings before and after the exercise (p<0.001). The students rated the exercise as an enjoyable way to learn about adhesive dentistry and agreed that it increased their confidence in performing bonding procedures. This exercise served as an innovative method of emphasizing proper technique with adhesive dentistry, while helping to build student confidence in the preclinical laboratory.

Attitudes of dentists and interns in Riyadh to the use of dental amalgam

Background

Studies investigating the attitudes of Saudi dentists to the use of amalgam for restorations are relatively rare. Considering the goals set forth by the Minamata Convention on Mercury, it appears prudent to investigate the attitudes of experienced dentists and fresh dental graduates to the use of amalgam. The aim of this study was to assess the attitudes of Saudi dentists and interns working in Riyadh, Saudi Arabia to the use of amalgam. Using a convenience sampling methodology, a total of 400 Saudi dentists and interns were contacted to request their participation in this cross-sectional questionnaire-based study. The questionnaire consisted of socio-demographic and practice characteristics such as gender, type of practice, as well as their service sector and questions related to the use of dental amalgam. The data obtained was analyzed using Chi square tests to compare differences in distribution between groups. P values of less than 0.05 were considered statistically significant.

Results

The overall response rate was 84% (336 of 400 potential participants). The majority of the participants (80.7%) did not use dental amalgam for restorations in their clinical practice frequently. A significantly higher number of participants working in private sector did not use amalgam frequently (P = 0.004), agreed on replacing good amalgam restoration with composite resin (P < 0.000) and on stopping the use of amalgam as a final restoration (P = 0.017) compared to participants working in public sector. A significantly higher number of interns did not use amalgam in their clinical practice frequently (P < 0.000), agreed on replacing good amalgam restoration with composite resin (P = 0.002) and on stopping the use of amalgam as a final restoration (P < 0.000) compared to dentists.

Conclusions

Within the limitations of this study, dental amalgam seems to be less frequently used among the surveyed Saudi dentists and interns working in Riyadh. Fresh dental graduates used amalgam less frequently compared to experienced dentists. Furthermore, private dental practitioners showed a propensity to replace existing well-placed amalgam restorations with resin composite which reinforces their market-oriented attitude reported in earlier studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-016-2294-x) contains supplementary material, which is available to authorized users.

Dental cavity liners for Class I and Class II resin-based composite restorations

BACKGROUND

Resin-based composite (RBC) is currently accepted as a viable material for the restoration of caries for posterior permanent teeth requiring surgical treatment. Despite the fact that the thermal conductivity of the RBC restorative material closely approximates that of natural tooth structure, postoperative hypersensitivity is sometimes still an issue. Dental cavity liners have historically been used to protect the pulp from the toxic effects of some dental restorative materials and to prevent the pain of thermal conductivity by placing an insulating layer between restorative material and the remaining tooth structure.

OBJECTIVES

The objective of this review was to assess the effects of using dental cavity liners in the placement of Class I and Class II resin-based composite posterior restorations in permanent teeth in children and adults.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 25 May 2016), the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 4) in the Cochrane Library (searched 25 May 2016), MEDLINE Ovid (1946 to 25 May 2016), Embase Ovid (1980 to 25 May 2016) and LILACS BIREME Virtual Health Library (Latin American and Caribbean Health Science Information database; 1982 to 25 May 2016). We searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

We included randomized controlled trials assessing the effects of the use of liners under Class I and Class II posterior resin-based composite restorations in permanent teeth (in both adults and children). We included both parallel and split-mouth designs.

DATA COLLECTION AND ANALYSIS

We utilized standard methodological procedures prescribed by Cochrane for data collection and analysis. Two review authors screened the search results and assessed the eligibility of studies for inclusion against the review inclusion criteria. We conducted risk of bias assessments and data extraction independently and in duplicate. Where information was unclear we contacted study authors for clarification.

MAIN RESULTS

Eight studies, recruiting over 700 participants, compared the use of dental cavity liners to no liners for Class I and Class II resin-based composite restorations.Seven studies evaluated postoperative hypersensitivity measured by various methods. All studies were at unclear or high risk of bias. There was inconsistent evidence regarding postoperative hypersensitivity (either measured using cold response or patient-reported), with a benefit shown at some, but not all, time points (low-quality evidence).Four trials measured restoration longevity. Two of the studies were judged to be at high risk and two at unclear risk of bias. No difference in restoration failure rates were shown at one year follow-up, with no failures reported in either group for three of the four studies; the fourth study had a risk ratio (RR) 1.00 (95% confidence interval (CI) 0.07 to 15.00) (low-quality evidence). Three studies evaluated restoration longevity at two years follow-up and, again, no failures were shown in either group.No adverse events were reported in any of the included studies.

AUTHORS' CONCLUSIONS

There is inconsistent, low-quality evidence regarding the difference in postoperative hypersensitivity subsequent to placing a dental cavity liner under Class I and Class II posterior resin-based composite restorations in permanent posterior teeth in adults or children 15 years or older. Furthermore, no evidence was found to demonstrate a difference in the longevity of restorations placed with or without dental cavity liners.

Do clinical experience time and postgraduate training influence the choice of materials for posterior restorations? Results of a survey with Brazilian general dentists

The aims of this study were to evaluate the materials available for posterior restorations and to assess whether clinical experience time and post-graduate training influence dentists' choices. A cross-sectional study was conducted using a questionnaire with closed questions applied to dentists (n=276) of a mid-sized city of the southern Brazil. Information was collected regarding sociodemographic variables, level of specialization, time since graduation and working place. In addition, options regarding posterior restorations including the first choice of material, type of composite resin (if used) and use of rubber dam were also collected data. Data were submitted to descriptive analysis and the associations were evaluated using chi-square and Fisher's exact tests (α=0.05). The response rate was 68% (187). Direct composite resin was broadly indicated (73.2%) as the first-choice for posterior restorations. Most professionals used microhybrid composite (74.5%) and 42.6% of the participants used rubber dam for placement of posterior composite restorations. Dentists with more time of clinical practice used less composite (p=0.014). Specialists used more frequently rubber dam to restore posterior teeth than did non-specialists (p=0.006). The results of this survey revealed that direct composite was the first choice of dentists for posterior restorations; microhybrid was the preferred type of composite and the use of rubber dam for composite resin placement in posterior teeth was not frequent; time since graduation and level of specialization affected dentists' choices.

Managing the phase-down of amalgam: Part I. Educational and training issues

Following the recently agreed Minamata Convention, a phase-down in the use of dental amalgam will become a priority for the profession. With a lead-in period of a number of years, important changes in the mind-set of the profession are required to ensure that patient safety is not compromised. Posterior composites have been a viable, and in many cases preferable, alternative to amalgam for many years. However, notwithstanding considerable developments in dental school teaching on the application and placement of posterior composites, growing evidence to support the use of composites in the restoration of posterior teeth and advances in composite systems, many practitioners remain reluctant to place composite rather than amalgam. This paper considers the present and future use of posterior composites and highlights ways in which dental school teaching and continuing professional development (CPD) may contribute to the successful phase-down, and now inevitable discontinuation, in the use of dental amalgam.

Managing the phase-down of amalgam: part II. Implications for practising arrangements and lessons from Norway

The announcement of the Minamata Convention has triggered the lead into a phase-down in the use of dental amalgam. This paper considers aspects of this development in the context of the experience of banning the use of dental amalgam in Norway. It is suggested that strong top-down leadership and joined-up working by all relevant stakeholders, including patients, may be one of the most important keys to an effective, seamless transition to the provision of preventatively orientated, patient-centred, minimally interventive operative dentistry, based on state-of-the-art selection and application of tooth-coloured restorative materials. The benefits of such a transition are considered to be an important goal for dentistry in the UK.

Teaching New Materials and Techniques for Fixed Dental Prostheses in Dental Schools in the United States and Canada: A Survey

PURPOSE

Tooth-supported fixed dental prostheses (FDPs) remain an extensive therapeutic option, with new materials and a digital fabrication process gradually replacing traditional methods. The variety of advances calls for dental schools to expand the teaching of this field. Our aim was to examine the nature and the amount of theoretical and practical training in clinical FDP courses, and the extent to which new methods and innovations in the field are being integrated.

MATERIALS AND METHODS

Data were collected using an online questionnaire including theoretical and practical teaching regarding clinical courses, restorative materials, and new fabrication methods, which was sent to 58 dental schools in North America.

RESULTS

A total of 36 schools responded to the survey for a response rate of 62.1%. All the schools teach theoretical and practical porcelain-fused-to-metal (PFM) restorations, and almost all the schools teach full-metal FDPs. In more than half (57.1%) of the schools, zirconia-based FDPs are placed by students. Students place partial veneer FDPs in less than one-fifth (17.9%) of the schools. The average number of restorations required for completion of the clinical course is 7.3 FDP units. The respondents assessed that of the total FDPs placed by students in the clinical course, tooth-color coping (zirconia/alumina/porcelain) FDPs constituted 16.2%. None of the schools produce computer-assisted design/computer-assisted manufacturing copings or crowns within the school.

CONCLUSIONS

All North American dental schools include teaching and placement of PFM restorations in their curriculum, but only one-third teach ceramic-based crowns. The low average number of required crowns may lead to graduates not being exposed to and trained in up-to-date dental restorative materials and techniques.

Dentists' restorative decision-making and implications for an 'amalgamless' profession. Part 1: a review

The Minamata Convention has agreed to a worldwide reduction and ultimate elimination in the production and use of mercury containing products. This will have implications for the practice of dentistry. Australian organizations' pronouncements on the issue are limited and research examining the Australian context dated. The restoration of teeth with direct materials has changed significantly since the 1980s. Up to this time amalgam was the material of choice for direct posterior restorations. Its properties and guidelines for placement were, and remain, well established. Resin composite has replaced amalgam as the material of choice in many clinical situations. Despite inherent clinical disadvantages compared to amalgam, there continues to be a shift toward greater use of resin composite. There is consensus worldwide that the restoration of posterior teeth using resin composite now exceeds that of amalgam. The reasons for this are reviewed in this article along with current evidence and commentary relating to direct restorative and evidence-based decision-making, minimally invasive approaches, and approaches to education. The implications for these in an 'amalgamless' profession are identified.

Effect of different adhesive strategies on the post-operative sensitivity of class I composite restorations

Objective:

To evaluate the post-operative sensitivity of occlusal restorations using different dentin adhesives performed by an undergraduate and a post-doctorate dentist.

Materials and Methods:

One hundred and eighty-eight molar occlusal restorations were placed in 39 patients (ages between 18 and 30) using 3 different kind of adhesive systems; Optibond FL (OBF), Clearfil Protect Bond (CPB), and iBond (IB) by a post-doctorate dentist or a fifth-year dental student according to the manufacturers’ instructions. Post-operative sensitivity to cold and air was evaluated using a Visual Analog Scale (VAS) after 24 hours, 30, 90, and 180 days. Data were analyzed using the Mann-Whitney U and Friedman tests (P < 0.05).

Results:

Post-operative sensitivity scores for OBF and CPB were higher for the dental student (P < 0.05), while IB scores did not differ statistical significantly according to the operator (P > 0.05).

Conclusion:

Operator skill and experience appears to play a role in determining the outcome of post-operative sensitivity of multi-step adhesive systems although the post-operative sensitivity was low. It is suggested that the less experienced clinicians (rather than experienced clinicians) should better use the self-etching dentin bonding systems with reduced application steps to minimize the potential risk of post-operative sensitivity of dental adhesives.

The Management of Defective Resin Composite Restorations: Current Trends in Dental School Teaching in Japan

Aim:

The aim of this article is to investigate the contemporary teaching of the management of defective direct resin composite restorations in dental schools in Japan.

Methods:

A questionnaire relating to the teaching of the management of defective resin composite restorations was developed and e-mailed to 29 dental schools in Japan in 2010.

Results:

Completed responses were received from 19 of the 29 invited schools (response rate = 66%). Eighteen schools (95%) report that they included the teaching of repair of direct defective resin composite restorations in their dental school programs. Thirteen schools reported that they included both clinical and didactic instruction on the repair of direct resin composite restorations. Fourteen schools did not teach any mechanical roughening of the exposed resin composite restoration surface before undertaking a repair. The most commonly reported treatment was acid etching with phosphoric acid (12 schools). The most commonly taught material for completing repairs was a flowable resin composite (16 schools).

Conclusion:

The teaching of repair of defective resin composite restorations is well established within many Japanese dental schools, to a greater extent than in some other regions of the world. The impact of this teaching on subsequent clinical practices in Japan should be investigated. Furthermore, it is concluded that there is a need for much stronger leadership in operative and conservative dentistry, ideally at the global level, to resolve differences in key aspects of operative procedures such as repairs.

Teaching the placement of posterior resin-based composite restorations in Spanish dental schools

Objectives: In an area of esthetic dentistry such as posterior composites, in which new materials and techniques are being devolved continuously, it is important to confirm that dental students have a clear understanding of the basic principles of clinical application of this knowledge. Considering that the preparation of dental graduates in Spain may be of interest to competent dental authorities and employers with whom they can work worldwide, this study investigated the teaching of posterior composite restorations in Spanish dental schools. Study design: In late 2009⁄ early 2010, a questionnaire seeking information on the teaching of posterior composites was emailed to the professor responsible for teaching operative dentistry in each of the fifteen dental schools having complete undergraduate dental degree programs in Spain. Results: The response rate was 100%. Most investigated topics did not show noteworthy differences depending on whether the schools were public or private. Variations were found among Spanish dental schools in both the amount and content of the teaching programs concerning posterior composite restorations. Differences were recorded in the teaching of cavity design, contraindications to composite placement, indications for liners and bases, matrix and wedging techniques, composite and bonding systems, light curing and finishing procedures for composite restorations. More consistency was observed in teaching methods of moisture-control, indirect composites and amalgam bonding. Conclusions: As recommended in previously surveyed countries, efforts must be made to promote harmonization of dental curricula to make it easier for graduates to work elsewhere, and to ensure they meet the needs of their patients on entering independent practice.

Key words:Aesthetic dentistry, composite restoration, dental education, teaching program, undergraduate dental student.

Teaching of direct composite restoration repair in undergraduate dental schools in the United Kingdom and Ireland

AIM

To investigate aspects of the teaching of restoration repair as a minimally invasive alternative to the replacement of defective direct composite restorations in teaching programmes in undergraduate curricula in dental schools in the United Kingdom and Ireland.

METHODS

An online questionnaire which sought information in relation to the current teaching of composite restoration repair was developed and distributed to the 17 established UK and Irish dental schools with undergraduate teaching programmes in Spring 2010.

RESULTS

Completed responses were received from all 17 schools (response rate= 100%). Fifteen schools reported that they included teaching of repair techniques for defective direct composite restorations in their programme. Of the two remaining schools, one indicated that it would introduce teaching of repair techniques during the next five years. The most common indication for a composite repair was that of 'tooth substance preservation' (15 schools). The defects in restorations considered appropriate for repair rather than replacement by the largest number of schools included partial loss of restoration (13 schools) and marginal defects (12 schools). The most commonly taught surface treatment when performing a repair was mechanical roughening of the existing composite with removal of the surface layer (14 schools). Thirteen schools taught etching and the application of an adhesive bonding agent to the prepared surfaces, while the most commonly taught material for completing the repair was a hybrid composite resin (12 schools). Popular finishing implements included diamond finishing instruments (13 schools) and finishing discs (11 schools).

CONCLUSION

Not withstanding reluctance amongst general dental practitioners, the teaching of repair of a defective composite restoration, rather than total restoration replacement, is firmly established within UK and Irish dental school programmes. Repair techniques have clear advantages for patients, not least including a minimally invasive approach to treatment and avoidance of unnecessary loss of tooth tissue and pulpal damage. Dental practitioners should look more to repair techniques when managing defective composite restorations and clinical dental teachers should continue to research and refine composite repair techniques.

Attitudes of some European dental undergraduate students to the placement of direct restorative materials in posterior teeth

The aim of this article was to report on the attitudes, opinions and confidences of final year dental students in three European schools towards the restoration of posterior teeth and in particular towards the use of amalgam and resin composite. One hundred and twenty-eight pre-piloted questionnaires were distributed to final year dental students in Cardiff, Dublin and Malmö. The questionnaire sought information relating to various opinions and attitudes towards the use of amalgam and resin composite in posterior teeth. Information was returned anonymously. Ninety-one completed questionnaires were returned (response rate=71%; Cardiff: n =40, Dublin: n=24, Malmö: n=27). Ninety-three per cent of Malmö students (n=24), 67% of Dublin students (n=16) and 60% of Cardiff students (n=24) reported that they feel confident when placing posterior resin composites. One hundred per cent of Malmö students (n=27), 75% of Cardiff students (n=30) and 33% of Dublin students (n=8) would prefer to have a resin composite rather than amalgam, placed in one of their own posterior teeth. Eighty-five per cent of Malmö students (n=23), 30% of Cardiff students (n=12) and 25% of Dublin students (n=6) perceive amalgam as being harmful to the environment. For the restoration of a posterior tooth in a pregnant female, 44% of students (n=40) would place a resin composite restoration, and 7% (n=6) would place an amalgam restoration, while 32% (n=29) would place a temporary restoration. Students at Malmö report that they place more posterior resin composites and have greater confidence at placing posterior resin composites than students at Cardiff or Dublin. There was confusion relating to the choice of restorative materials for pregnant females. Large variations in restorative strategies among graduates must be considered as dental professionals can practice in all countries within the European Union.

Association between caries location and restorative material treatment provided

OBJECTIVES

This cross-sectional study by the Northwest PRECEDENT practitioners correlated the location of caries diagnosed in the past 12 months with treatment provided.

METHODS

An oral health survey was conducted on up to 20 patients per practice for 101 practises in the Northwest PRECEDENT network. A total of 1943 eligible patients were randomly assessed for the location of and treatment provided for caries lesions diagnosed within the past 12 months. Regression analysis using generalized estimating equations (GEE) was performed to assess association of treatment to tooth location and surface characterization, adjusting for age, practice location (urban/rural), dentist gender, and experience level. The analysis accounts for clustering by practice using robust variance estimates.

RESULTS

Overall, 55.4% of patients exhibited recent caries and 42.8% received treatment for at least one permanent tooth. 18% of treated teeth were treated with amalgam, and 72% were treated with composite. This percentage varied as a function of tooth surface characteristics, patient characteristics, and dentist characteristics. The results suggest that restoration selection does depend on tooth type and which surfaces are being restored. The odds of a molar receiving an amalgam restoration are 2.44 (95% CI=1.81-3.30) times higher as compared to a bicuspid, adjusting for all other covariates. When the restoration includes the occlusal surface of a tooth the odds are 0.42 (95% CI=0.20-0.89) times as great that amalgam will be placed. When the restoration includes the mesial or distal surface of the tooth the odds for amalgam restoration are 2.49 (95% CI=1.25-4.95) times higher compared to when it does not include these surfaces.

CONCLUSION

Restorative material choice varied based on caries location and practitioner gender.

Posterior amalgam restorations--usage, regulation, and longevity

The use of dental amalgam has declined, but in most of the world, amalgam is the most widely used and widely taught direct restorative material for load-bearing posterior restorations. There are few national regulations on the use of amalgam; however, there are several nations where few amalgam restorations are placed. Long-term studies have shown that under optimum conditions, posterior restorations of amalgam and resin composite last longer than reported previously and that amalgam restorations outlast composite restorations. In general practice settings, posterior amalgam and composite restorations both have lower longevities.

Evidence-based care and the curriculum

An evidence-based (EB) approach has been a significant driver in reforming healthcare over the past two decades. This change has extended across a broad range of health professions, including oral healthcare. A key element in achieving an EB approach to oral healthcare is educating our practitioners, both current and future. This involves providing opportunities integrated within simulated and actual clinical settings for practitioners to learn and apply the principles and processes of evidence-based oral healthcare (EBOHC). Therefore, the focus of this discussion will be on ways in which EBOHC and associated research activities can be implemented into curricula, with the aim of improving patient care. This paper will initially define the scope of EBOHC and research, what these involve, why they are important, and issues that we need to manage when implementing EBOHC. This will be followed by a discussion of factors that enable successful implementation of EBOHC and research into curricula. The paper concludes with suggestions on the future of EBOHC and research in curricula. Key recommendations related to curricula include strengthening of the culture of a scientific approach to education and oral healthcare provision; complete integration of EBOHC into the curriculum at all levels; and faculty development to implement EBOHC based on their needs and evidence of effective approaches. Key recommendations to support implementation and maintenance of EBOHC include recognition and funding for high-quality systematic reviews and development of associated methodologies relevant for global environments; building global capacity of EBOHC researchers; research into improving translation of effective interventions into education and healthcare practice, including patient-reported outcomes, safety and harms, understanding and incorporation of patient values into EB decision-making, economic evaluation research specific to oral healthcare and effective methods for changing practitioner (faculty) behaviours; and extend access to synthesized research in 'user friendly' formats and languages tailored to meet users' needs. Realizing these recommendations may help to improve access to effective healthcare as a basic human right.

Amalgam and composite posterior restorations: curriculum versus practice in operative dentistry at a US dental school

This study recorded the number of preclinical lecture and simulation laboratory sessions spent teaching the preparation and placement of amalgam and resin composite posterior restorations. These data were compared to the use of both materials in the operative clinic as placed by third- and fourth-year students. The number of posterior restorations inserted by the students, expressed as a function of the number of restoration surfaces, was also evaluated. The results show that the teaching of posterior restorations pre-clinically has consistently favored amalgam 2.5 to 1 during the last three years. However, clinically, resin composite is being used for posterior restorations 2.3 times more often than amalgam. The only instance that favored amalgam over composite during the last year was in the placement of four surface posterior restorations. This shift in emphasis from amalgam to composite needs to be addressed within dental educational institutions so that newly graduated dentists are prepared to place composite restorations properly.

The teaching of removable partial dentures in Ireland and the United Kingdom

AIM

The aim of this paper is to investigate methods employed for teaching removable partial dentures in dental schools in Ireland and the United kingdom.

MATERIALS AND METHODS

A questionnaire was distributed by email in May 2005 to each of the 15 dental schools with undergraduate dental degree programmes in Ireland and the UK. The questionnaire sought information relating to the preclinical and clinical teaching of removable partial dentures (both acrylic and cobalt-chromium based dentures).

RESULTS

Eleven completed questionnaires were returned. The average duration of a preclinical course in removable partial dentures was 67 hours (range = 24-200 hours). This course was directed by a senior clinical academic alone in eight schools, by a senior clinical academic in collaboration with a dental technician in two schools, and solely by a dental instructor technician in one school. The median number of cobalt-chromium and acrylic removable partial dentures provided by undergraduate dental students was 3 (range = 2-5) and 2 (range = 0-3), respectively. Four schools reported that their patient pool is not entirely satisfactory for clinical teaching of undergraduate dental students.

CONCLUSION

Variations were noted between dental schools in both the amount and content of teaching programmes. Experience gained by undergraduate students in dental schools is limited, and appears to be hampered by limited access to patients suitable for undergraduate teaching.

Challenges to teaching posterior composites in the United Kingdom and Ireland

Recent surveys from general dental practice have found increased placement of direct composite resin restorations in occlusal (Class I) and occlusoproximal (Class II) cavities in permanent teeth by general dental practitioners. This has been matched, and possibly driven, at least in part, by the development of new composite resin materials and bonding technologies. Recent studies by the authors have found an increase in the teaching of Class I and Class II composite resin restorations in the UK, Ireland, the US, and Canada. The increased teaching in the UK and Ireland, however, was not as great as in North America, and several worrying trends were observed. The aim of this paper is to discuss these trends and related factors considered important to the necessary further development of the teaching of Class I and Class II direct composite resin restorations, let alone modern operative dentistry in general, in the UK and Ireland.