Dental Restoration

APRIL 1999 VOLUME 5 NUMBER 2 ISSN: 0965-0288 Effective

Bulletin on the effectiveness Health Care of health service interventions forfor decisiondecision makersmakers Dental restoration:

This bulletin reviews the what type of filling?

evidence of the relative ■ Tooth decay is one of the ■ The use of cermet cements, longevity and cost- most common diseases and and the composite and accounts for almost half of glass ionomer sandwich effectiveness of routine all tooth extractions. The technique in class II dental restorations. treatment of tooth decay by cavities, had high failure the placement of simple, rates and cannot be direct restorations (fillings) recommended. alone costs the NHS in ■ There is significant England & Wales £173 variation in decision making million per year. between dentists. ■ Dental restorations do not Appropriate criteria for last forever; over 60% of all replacement of restorations restorative dentistry is for are needed and dental the replacement of schools should train restorations. dentists in their use in order ■ New restorative materials to reduce unnecessary are often marketed and procedures and improve introduced into practice quality. with limited evidence on ■ The longevity of their long-term clinical restorations carried out in performance. the better quality research ■ Overall, amalgam is the studies suggests that direct restorative material routine clinical practice of choice unless aesthetics may be producing sub- are important. It lasts optimal results. Work is longest and is the cheapest. needed to establish means ■ The newer generation of improving the quality of dentine bonding agents for routine practice, putting in composite restorations use place incentives to promote some form of acidic primer cost-effective care and and have better retention identifying the resource rates than earlier generations. implications.

NHS CENTRE FOR REVIEWS AND DISSEMINATION patient’s lifetime – the ‘restorative makers and industry. A summary A. Background cycle’.8 Studies in the UK suggest of the research methods used is A.1. Tooth decay is a common that much of restorative dentistry given in Appendix A. A glossary of problem: Dental caries (tooth is replacement of existing terms is provided in Appendix B. decay) is one of the most common restorations, accounting for diseases with approximately 80% around 60% of all restorative work 9 of the population in developed carried out. Similar figures have countries having experienced the been found in other parts of B. Replacing 10,11 12,13 condition. In England and Wales, Europe and the USA. dental caries accounts for almost restorations half of all tooth extractions.1 The treatment of carious teeth by the placement of simple, direct The reasons for replacing a A.2. Preventing and treating restorations alone costs the NHS in restoration are numerous, and vary caries: The aim of prevention and England & Wales £173 million per with tooth type and restorative 16 treatment is to maintain a year.14 The provision of crowns material. Once inserted, functioning set of teeth. costs an additional £156 million.14 restorations may fail at variable Interventions can halt and even Restorations are also provided in rates due to a number of ‘objective’ reverse the development of caries the private sector, for which factors affecting both the failure of and its progression through enamel reliable data are unavailable. the filling material and further by reducing the frequency of decay of the tooth around the exposure to sugar, and by exposure The life of a restoration depends filling. These factors include the to fluoride either topically (e.g. in on factors such as the age of the characteristics of the filling material toothpaste) or systemically (e.g. in patient, the properties of the filling and effect modifiers related to the water supply). and the rate of progression of operator skill and technique, caries in the filled tooth. patients’ dental characteristics, and Through interventions at an Successive restorations of the sort the environment around the tooth individual level, caries can be which are placed inside the tooth (Table 1). managed by the use of topical (intra-coronal) tend to increase in and/or systemic fluoride, and the size, leading to increased risk of The decision to replace a use of fissure sealants on the pits subsequent tooth fracture. restoration is also influenced by and fissures of back teeth to Replacement restorations tend to more subjective factors such as prevent them acting as stagnation be more complex and sometimes dentists’ interpretation of the areas for plaque.2–7 more expensive than the initial restoration’s condition and the restorations. They may have a health of the tooth, the criteria If decay has not been prevented, shorter life-span and can have a used to define failure and patient cavities develop and progression of detrimental effect on the pulp, demand. These decisions are caries into the dentine and dental occasionally leading to the need subject to a great deal of 8,17 pulp (‘the nerve’) allows the micro- for root canal treatment involving variation. There is a lack of organisms within lesions to further expense and also cost to standardisation and no generally produce acute inflammation which the patient. agreed criteria are used to decide may lead to severe toothache, when a restoration requires abscess formation and occasionally There is a large choice of materials replacement.18 facial swelling. In order to prevent which can be used for fillings. considerable pain and tooth loss it Many are introduced into the Whilst it is likely in routine may be necessary to remove the market place and used on patients practice that subjective factors diseased tissues and restore the with very limited evidence that have a greater impact on longevity cavities (a filling). The decision to they are more effective or efficient than the physical properties and restore will depend on the likely than existing materials. biocompatibility of a material, rate of progression of caries and Consequently, one of the key there are limited data on the the age of the child or adult. questions is, all other things being relative importance of objective Restorations are also undertaken equal, what type of filling is best? and subjective factors. for other reasons such as trauma, wear and erosion. This issue of Effective Health Care summarises the results of a Several restorative materials are systematic review of the relative available at different costs longevity and cost-effectiveness of C. Types of requiring varying amounts of routine intra-coronal dental expertise to prepare and complete restorations.15 The bulletin aims to restoration a filling. Restorations have a provide information which can be Tooth restorations may be limited life-span and once a tooth used to improve the cost- classified as intra-coronal, when is restored, the filling is likely to be effectiveness of restorations and is they are placed within a cavity replaced several times in the of use to dentists, patients, policy prepared in the crown of a tooth,

2 EFFECTIVE HEALTH CARE Dental restoration: what type of filling? APRIL 1999 Table 1 Factors influencing the decision to restore C.1. Dental amalgam: Dental the material with filler particles a) Possible objective influences amalgam is an alloy of mercury and the size of the particles as well with silver and other metals such as other factors have a bearing on General patient factors as tin and copper to give a set the physical properties of the • Exposure to fluoride • Caries status material that does not adhere to material and may influence its • General health tooth tissue and is not tooth long-term performance. Composite • Parafunction coloured. It has been available for resins have also been used for • Age (particularly child/adult) over 100 years, but the original inlay restorations. • Xerostomia formulation of the material has • Socio-economic status The use of composite materials has • Diet been modified considerably; in particular, the addition of copper been supplemented with pre- Tooth factors and zinc to the alloy powder has treatment of tooth tissue prior to • Tooth location/type/size enhanced its physical properties. placement. Thus, the enamel • Cavity design/type surrounding the preparation is • Dentition The choice of alloy will have a • Occlusal load bearing on the way the material is usually treated with a mild acid • Tooth quality e.g. hypoplasia handled clinically and may and coated with a thin resin wetting agent to improve the Operator and restoration process influence its long-term factors performance. marginal seal and aid retention. • Material type More recently, application of acids • Physical properties There have been concerns over and other agents to dentine has • Quality of finish the safety of amalgam, most of been advocated to reduce leakage • Moisture control which appear to be unjustified. and further improve retention. • Anaesthesia during restoration The British Dental Association These dentine bonding agents are • Expertise • Training have recently concluded that: rapidly evolving.

b) Subjective factors ‘To date, extensive research has failed C.3. Glass ionomer cements: • Incentives (payment structure: salaried, to establish any links between Glass ionomer cements are tooth government funded, private, insurance) amalgam use and general ill health. coloured and adhere chemically to • Clinical setting (university, private Those countries which are limiting tooth tissue. They are similar to practice, general dental practice, the use of amalgam are doing so to composite resins in that they specialist practice, field trial) • Country (local treatment fashions) lower environmental mercury consist of a matrix and embedded 19 • Clinician’s diagnostic, treatment and levels.’ filler particles; however, their maintenance philosophy (influenced by formulation and setting reaction training) The Department of Health’s differ. • Patient preferences Committee on Toxicity reviewed the evidence on the safety of C.4. Resin-modified glass or extra-coronal, when they are amalgam in response to an expert ionomer cement and compomers: placed around (outside) the tooth report from the European New generations of materials are as in the case of a crown. Intra- Commission and concluded that essentially glass ionomer cements coronal restorations are usually dental amalgam is free from risk of that contain resin. The resin- placed directly into the tooth systemic toxicity and only a very modified materials are more akin cavity and normally consist of a few cases of hypersensitivity to glass ionomer cements, whilst mouldable material that sets and occur.20 the compomers are more like becomes rigid; the material is composite. Again, these materials retained by the surrounding walls C.2. Composite resin: There are are tooth coloured and are of the remaining tooth tissue. An several groups of composite available in a variety of different alternative intra-coronal materials that can be classified on formulations. restoration uses an indirect the basis of their resin and filler technique: here an impression of components. All are tooth C.5. Cast gold and other alloys: the cavity is taken and a coloured and are essentially a Cast gold or alloy restorations are laboratory constructed inlay is mixture of filler particles, called inlays and are made outside produced and subsequently consisting of various types of the mouth in an indirect cemented into the prepared cavity. translucent glass, embedded in a technique that requires laboratory matrix of resin that binds the filler facilities. The advantage of cast The materials currently used to particles together. The original inlays is their strength in thin restore intra-coronal preparations generation of materials that set by sections; they can be used to are: dental amalgam, composite a chemical reaction have been protect weak tooth tissue. Cast resins, glass ionomer cements, largely superseded by composites restorations are inherently more resin-modified glass ionomer that set on the application of a expensive because of the cost of cements, compomers and cermets, bright light. These light-cured the alloy and the laboratory cast gold and other alloys, and materials contract (shrink) during involvement. They are cemented porcelain. the curing process. The loading of in place with either traditional

1999 APRIL EFFECTIVE HEALTH CARE Dental restoration: what type of filling? 3 dental cements or can be used 1 Overall, the studies demonstrated

with more modern bonding 0.9 good short-term survival (two and three years).31,32,70–72 systems. 0.8 Studies showing poor results were 0.7 C.6. Porcelain: Porcelain crowns explained on the grounds of poor have been made for many years 0.6 technique or unconventional for the anterior part of the mouth. 0.5 cavity design.73–76 However, the few With the introduction of new and 0 12 24 36 48 60 72 84 96 studies with at least five years stronger porcelains, and the Follow up time in months follow-up showed signs of development of cementing Unpaired Paired significant failure, particularly the systems, it is now possible to multi-centre studies.77,78 construct inlays from porcelain Fig 1 Survival of amalgam restorations for that can be cemented into the permanent teeth (paired and unpaired studies) 22–63 Survival of composite was prepared cavity. A variety of influenced significantly by porcelains are available along with material type, with light-cured the restoration and by the level of a variety of production processes, microfilled and densified filled agreement on whether to replace a all of which can be used with a materials being more successful restoration.27,38,61 number of cementing agents. between 6.5 years and 8.5 years, while the older autopolymerising There appeared to be no greater macrofilled composites were most reduction in survival of larger successful up to 6.5 years. The amalgam restorations than smaller studies did not present data ones.33,63,64 The evidence that two D. Direct methods needed to analyse the impact of surface restorations survive longer This section reports on the operator factors and other effect than three surface restorations was longevity of directly placed modifiers. inconclusive.27,65,66 There were no materials: amalgam, composite and differences in survival between others materials such as glass Composite with dentine bonding polished and unpolished ionomer cements (GIC). In the systematic review, dentine amalgams over the 36 months of bonding agents were classified into follow-up, but this is a relatively The findings from the review, three main groups:79 those evolved short time to assess this factor.50,67–69 presented below, report longevity from the earliest resin materials from studies generally carried out which simply impregnated the There was some evidence to under optimal conditions. These smear layer (group 3), those suggest that dispersed phase, high are reported in order to make modified to enhance impregnation copper alloy amalgams were sensible comparisons of the and to alter the smear layer (group associated with greater survival longevity of different materials. 2), and the more modern materials than other amalgams.27,30,38,53,60,65,66 The longevity reported from these which use an acidic primer (group studies is unlikely to be achieved 1). Dentine bonding materials have D.2. Composite restorations: in the conditions of routine general often been tested in cervical cavities Forty-eight studies involved dental practice (see Section G). and in this situation the failure of composite restorations but without these materials is rapid, beginning use of dentine adhesives.15 Twenty- D.1. Amalgam restorations: The within one year (Fig 2).80–83 This five studies involved dentine studies of amalgam show good figure is based on a combination bonding systems. In the vast rates of survival compared with of included studies of cervical majority of cases, these studies most of the other materials restorations by the type of dentine 15 investigated cervical cavities examined in this review. At three bonding agent used. Unfortunately where retention of the restoration years, no study showed failure and it is not possible to present relied exclusively on the bonding at 10 years, less than 10% of additional figures showing other mechanism to resist loss. These restorations had been replaced (Fig variables because of the lack of studies rarely reported the site of 1), although by this time there data reported. were no data on 52% of the filling and thus it is impossible restorations. In addition, these to assess whether survival is More recent materials that use results may shed the most different for composites placed in some form of acidic primer (groups favourable light on amalgam the front or back teeth. 1a and 1b) demonstrate improved because patients were often pre- survival compared to groups 2 and selected before entry into the study Composite without dentine bonding 3. There appeared to be little on criteria such as intact dentition, Many studies poorly catalogued difference between materials good oral hygiene and absence of the numbers of subjects, teeth, the classed in group 1a (those which active periodontal disease. tooth types, the materials and use phosphoric acid) and group 1b types of cavities and also failed to (those using other acids). Studies The longevity was also affected by describe correctly and simply the of group 1a have shorter follow- the skill of the operator in placing survival data. up. The reason for the enhanced

4 EFFECTIVE HEALTH CARE Dental restoration: what type of filling? APRIL 1999 performance of group 1 compared of different materials were evidence, although limited, to to the other groups may be the included in the review.15 Many of support the use of heat cure in improvements in the dentine these studies were of small size addition to light cure in composite bonding system but could also be and short duration. Only the key inlays.127 There are some reports of the etching of enamel that may be findings are summarised in this post-operative pain, for example, a side effect of using acids. bulletin. with inlays and these need further investigation.128–131 Overall it appears that in 1 developing countries, glass One small study compared 0.8 ionomer cement inserted with a porcelain inlays with amalgam and technique which removes caries 0.6 found identical survival at two using hand instruments (ART) has years.47 There are no long-term data. 0.4 reasonable retention rates but other factors have yet to be 0.2 assessed. Conditioning of dentine 0 prior to placement of glass 1 0 6 12 18 24 30 36 42 48 Follow up time in months ionomer cement does not seem to 0.9 1a 1b 2 3 affect longevity (although this is 0.8 based on only two studies).113–115 0.7 Fig 2 Survival of composites in cervical cavities 48,80–110 0.6 by type of bonding agent Several restorative materials were reported as having low survival 0.5 0 6 12 18 24 30 36 42 48 54 60 The results of these studies rates. These include cermet Follow up time in months suggest that enamel etching (with cement when used to restore Composite Porcelain or without enamel bevel) is either deciduous or permanent clinically effective for long-term teeth 116–118 and GIC when used in Fig 3 Survival of porcelain and composite retention.81,111 Mechanical retention the composite/GIC sandwich inlays 47,123,125, 126, 130–150 is also effective for the retention of technique.75,119 Improvements in restorations.112 Newer materials the physical properties of GIC may (group 1) appear to perform better improve the potential for the than older materials (groups success of this type of restoration. F. Cost- 2/3).92,102 Use of all dentine bonding Gallium also had high failure rates systems reduced patient pain after and cannot be recommended.120 effectiveness placement. The 30 economic studies that were identified were of poor quality15 Significant problems of inter- and did not provide sufficient pretation have been encountered E. Indirect information to enable the cost of because of poorly designed restorations to be constructed with studies, the appreciation that methods: inlays any degree of confidence. The data occlusal factors may have an were, therefore, supplemented by influence on retention, and lack of Twenty-seven studies were information provided by dentists detail in papers, especially relating included which examined the on the time taken to carry out to losses to recall and technique longevity of inlays using ceramics, 15 restorations in order to undertake used. gold and composites. These studies often had few patients and a cost-effectiveness comparison of D.3. Comparison of amalgam were of a weaker design. In the filling materials (see Appendix with composite: Twenty-six addition, few undertook any form A). A summary of the results is studies in this review compared of comparison. shown in Table 2. amalgam and composite restorations.15 In studies comparing Overall, there is no important Whilst these results are the two materials in an unpaired difference between porcelain and approximate and should be treated design (teeth from different composite inlays (see Fig 3). with caution, amalgam clearly patients), amalgam was superior, However, these studies (one of dominates composite and inlays always having greater survival. In which compares both materials)121,122 across all time periods considered similar studies using a paired suggested that some types of because it is cheaper and has design (teeth in the same person) porcelain inlays were significantly better survival, and this the differences in favour of better than composite inlays. dominance was robust to a wide amalgam were less but still range of changes in the statistically significant. There is limited evidence to assumptions. Composite was support the use of a resin between 1.7 and 3.5 times more D.4. Other materials: Forty-four compared with a GIC as luting expensive than amalgam to studies which compared a number cements.123–126 There is some generate one tooth year, a finding

1999 APRIL EFFECTIVE HEALTH CARE Dental restoration: what type of filling? 5 Table 2 Cost per tooth year of three main classes of restoration (discounted at 5%) replaced is more than doubled when a patient changes 5-year time period 10-year time period practitioner.156 Tooth £ Cost per Tooth £ Cost per years tooth year years tooth year

Amalgam 4.85 21.56 4.44 9.31 32.93 3.54

(5.05) (3.92) H. Implications H.1. Implications for policy and Composite 4.37 33.01 7.54 7.35 91.66 12.47 practice: (8.19) (11.87) • The dental manufacturing industry is constantly 3.30 130.00 39.39 - - - Inlay promoting the use of new (41.26) materials. These are marketed and introduced into practice Tooth year = the average number of years a restoration survives before failure over 5 or 10 years typically without reliable and £ = cost of initial restoration + cost of replacement at time of failure with the same material comprehensive trials involving people in everyday situations. which is in line with previous that is quite different from that This has created a high level of estimates from better quality under which most patients are uncertainty about the absolute economic evaluations149,150 treated has disadvantages. It may and relative merits of different result in different types of patients materials. Mechanisms should Composite would provide more being included, different amounts be sought to ensure that the ‘value for money’ than amalgam of time being taken, different introduction of dental materials over the first five years only if expertise and payment systems into clinical practice is patients valued tooth years with etc. Any one or combination of incorporated into any new NHS composite nearly twice as highly these factors may affect longevity regulatory structures designed as with amalgam for aesthetic to a greater or lesser extent. to promote the quality of 157 reasons. However, the studies health care. included in the review did not Studies not included in the • The good results in terms of measure patients’ quality of life or systematic review which used longevity of restorations valuations of tooth years with subjective criteria, and are more achieved in the optimally different restorations. representative of the situation designed studies demonstrate prevailing in general dental that routine clinical practice practice, make it clear that the may be producing sub-optimal longevity of amalgams151–153 and results. This raises the issue of composite152 is considerably less how clinical practice can be G. General than that achieved in the improved so that restoration prospective studies included in the longevity in all settings applicability of systematic review. Glass ionomer approaches the best that can be restorations have been in use for a achieved and what the resource findings much shorter time but they, too, implications of this may be. have a high replacement rate in The majority of studies of • Appropriate incentives sufficiently high quality to be cross-sectional studies.150 (including the fee structure) included in this review were which reward cost-effective undertaken in dental schools, Wide variation both within and practice should be explored whereas virtually all restorations between dentists’ treatment and evaluated. This is an area are treated in a primary dental decisions has been reported, and is that might be worth care setting. This affects the extent obviously an important issue when considering for inclusion in the to which individual studies can be trying to identify the point at which 8,17,154,155 National Performance generalised to the wider a restoration is replaced. population. The advantage of the This is an issue that could be Framework. academic setting is that it is easier appropriately addressed by dental • There is insufficient to control the study as well as schools.18 There is a difference information to be able to assess train and calibrate operators and between identifying how long a the likely impact of better examiners. In addition, many of restoration could last if objective training, more care when the financial and time factors that outcome measures were used, and carrying out a restoration, beset practitioners are removed. how long it is allowed to last when protocols to ensure the optimal The data on the relative longevity individual practitioners use their process of restoration, the are likely, therefore, to be more own criteria. It is claimed that the impact of the time spent, and valid. However, using a setting likelihood of having a restoration remuneration systems etc.

6 EFFECTIVE HEALTH CARE Dental restoration: what type of filling? APRIL 1999 • Currently, variations between periods of greater than 10 restoration was replaced because it dentists in the way they judge years. It has been suggested had failed or because a clinician existing restorations increases that “pragmatic clinical studies” subjectively deemed it to have the probability of replacement using a representative group of failed. For example, one clinician restorations when patients practitioners, on a large sample may have decided to replace an change dentists. In order to of their patients, may be one old corroded amalgam filling while reduce unjustified variation in way to obtain the internal another may have polished it. For the diagnostic level at which validity of a randomised these reasons studies were restorations are replaced there controlled trial and the required to have measured is a need for clarification of generalisability of purely outcome (the decision to replace a appropriate criteria for observational clinical studies restoration) using stated criteria. replacement of restorations. which this review has largely For example, the criterion “failure Dental schools should train ignored because of their due to secondary caries” was not dentists in using standardised subjective nature!158 With accepted unless the paper clearly definitions of what constitutes appropriate clinical and stated how secondary caries was a failed restoration and to economic evaluation such diagnosed. adopt appropriate maintenance studies would allow an policies. This would protect the overview of a material’s Study design public against unnecessary spectrum of performance in Whilst new restorative materials procedures, reduce costs and different clinical environments. are tested using laboratory-based improve the quality of • In order to obtain more reliable studies and animal experiments to professional decision-making. cost and relevant outcome examine the chemical, physical • Dental amalgam is the direct estimates, a long-term and biological properties of restorative material with the prospective cohort study is materials, these studies cannot be longest duration and from the needed across different dental used to predict their performance perspective of the NHS is of settings. The cost profile for in practice. Thus, only studies lower cost. Unless there is a each material type for different which looked at performance in contra-indication (which is types of restorations could be either experimental or clinical usually aesthetics or constructed and used in settings were included. The review pregnancy), it is recommended conjunction with the evidence included randomised controlled for routine use wherever relating to the longevity of trials (RCTs), quasi-experimental possible. All NHS dental each restorative material. designs and non-experimental treatment provided by general studies which surveyed the dental practitioners in England longevity of restorations in a cohort and Wales is reported to the Appendix A – Research methods of patients with good follow-up. Dental Practice Board. Whilst This bulletin is based on a this database provides a record systematic review15 which used a of actual patterns of practice, it Cost-effectiveness wide search for studies in any is of limited use for comparing language using a large number of In order to compare the cost- the longevity of different general and specialist databases, effectiveness of different filling restorative and other hand searching of key dental materials a review of the economic influences because subjective journals and searching of abstracts literature was undertaken. This criteria are used which vary from conference proceedings.21 Of was supplemented by information between practitioners. the 652 relevant papers, 253 from nine general dental practitioners in Wales who H.2. Implications for research: (representing 195 studies) had the minimum core of data required for provided data on the time taken to • Co-ordinated research in inclusion. place a restoration and subsequent primary dental care is needed replacements. These times were to assess the effects of multiplied by the estimated Inclusion criteria clinicians’ skill, tooth type, average hourly cost of dental staff cavity type and material type Use of objective outcome measures (£62.50) preparing and completing on restoration survival, taking Many authors did not state or use a restoration. The cost of a filling into account the evolving criteria for deciding when a was calculated by adding staff disease patterns. restoration had failed and needed costs to the different material • This requires the establishment to be replaced. In these studies it is costs. Thus the costs used in the of multi-centre, multi-operator therefore impossible to distinguish economic model were developed studies with stratification of between the objective factors from the bottom up rather than by tooth type, cavity type and influencing longevity (the main using the fee schedules. The costs other effect modifiers (such as aim of the review) and subjective for the initial filling were fluoride availability and oral influences. In other words it is not combined in an economic model hygiene), for assessment possible to establish whether a with estimates of the number of

1999 APRIL EFFECTIVE HEALTH CARE Dental restoration: what type of filling? 7 years a restoration survives (tooth Erosion – irreversible loss of tooth years) based on survival substance by a chemical process References probabilities derived from the that does not involve bacterial 1. Agerholm DM, Sidi AD. Reasons given for systematic review. The economic action. the extraction of permanent teeth by evaluation was undertaken from general dental practitioners in England and Wales. Br Dent J 1988;164:345-8. the perspective of the NHS and Extra-coronal restoration – a used tooth years as the outcome crown. 2. Kay E, Locker D. Effectiveness of oral health measure for each material type promotion: a review. London: Health Education Authority, 1997. and the cost per tooth year as the Fissure – a small groove or trough 15 cost-effectiveness ratio. in the enamel of the tooth. 3. Simonsen R. Glass ionomer as fissure sealant - a critical review. J Public Health Table 2 also presents the discounted Dent 1996;56(3 Spec Issue):146-9. cost per tooth year which takes GIC lute – a cement used in the into account the fact that benefits placement of an inlay. 4. Sprod A, Anderson R, Treasure E. Effective and costs are spread over time. oral health promotion. Cardiff: Health Indirect inlay – method of Promotion Wales, 1996. construction of an inlay by using 5. Pitts N, Evans D, Nugent Z. The dental Appendix B – Glossary an impression of the tooth. caries experience of 12-year-old children Indirect technique is more suitable in the United Kingdom. Surveys Carious – describes a tooth coordinated by the British Association for affected by caries (decay). for complex cavities, preparations the Study of Community Dentistry in with veneers, and full crowns. 1996/97. Community Dent Health 1998;15:49-54. Cavity – carious lesion or area of destruction in a tooth. Occlusal load – the load on a tooth 6. 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8 EFFECTIVE HEALTH CARE Dental restoration: what type of filling? APRIL 1999 18. Maupome G. A comparison of senior 33. Kusner W, Markitziu A, Hirschfeld Z, et al. 48. Jordan RE, Suzuki M. Early clinical dental students and normative standards Four-year follow-up of occlusal amalgam evaluation of four new bonding resins with regard to caries assessment and restorations in extended vs. nonextended used for conservative restoration of treatment decisions to restore occlusal cavity preparation. Is J Dent Sci 1988;2:90-3. cervical erosion lesions. J Can Dent Assoc surfaces of permanent teeth. J Prosthet 1993;59:81-4. Dent 1998;79:596-603. 34. Walls AW, Murray JJ, McCabe JF. The management of occlusal caries in 49. Gibson GB, Richardson AS, Patton RE, et al. 19. BDA. Dental amalgam safety. London: permanent molars. A clinical trial A clinical evaluation of occlusal composite British Dental Association Fact File, comparing a minimal composite and amalgam restorations: one- and two- January, 1999. restoration with an occlusal amalgam year results. J Am Dent Assoc restoration. Br Dent J 1988;164:288-92. 1982;104:335-7. 20. Committee on Toxicety of Chemicals in Food, Consumer Products and the 35. Robinson AA, Rowe AH, Maberley ML. A 50. Corpron RE, Straffon LH, Dennison JB, et Environment. Statement on the toxicity of three-year study of the clinical al. A clinical evaluation of polishing dental amalgam. London: Department of performance of a posterior composite and amalgams immediately after insertion: 18 Health, December, 1997. a lathe cut amalgam alloy. Br Dent J month results. Pediatr Dent 1982;4:98-105. 1988;164:248-52. 21. NHS Centre for Reviews and Dissemination. 51. Fenton RA, Smales RJ. Immediate-polished Undertaking systematic reviews of research 36. Prati C, Montanari G. Three-year clinical and as-carved Tytin restorations after 12 on effectiveness. CRD guidelines for those study of two composite resins and one months. J Dent 1984;12:165-74. carrying out or commissioning reviews: non-gamma 2 conventional amalgam in University of York, 1996. posterior teeth. Schweiz Monatsschr 52. Hendriks FH, Letzel H, Vrijhoef MM. Zahnmed 1988;98:120-5. Composite versus amalgam restorations. A 22. Osborne JW, Gale EN, Ferguson GW. One- three-year clinical evaluation. J Oral year and two-year clinical evaluation of a 37. Knibbs PJ, Plant CG, Shovelton DS, et al. Rehabil 1986;13:401-11. composite resin vs. amalgam. J Prosthet An evaluation of a lathe-cut high-copper Dent 1973;30:795-800. amalgam alloy. J Oral Rehabil 53. Morris ME, Braham RL, Schmutz JR, et al. A 1987;14:465-73. clinical and laboratory study comparing 23. Eames WB, Strain JD, Weitman RT, et al. three amalgam alloys of random particle- Clinical comparison of composite, 38. Letzel H, van’t Hof M, Vrijhoef M. The size, mixed phase with one of amalgam, and silicate restorations. J Am influence of the condensation instrument conventional regular lathe-cut particles. Dent Assoc 1974;89:1111-7. on the clinical behaviour of amalgam Acta de Odontologia Pediatrica 1981;2:41-5. restorations. J Oral Rehabil 1987;14:133-8. 24. Osborne JW, Gale EN. A two-, three-, and 54. Osborne JW, Friedman SJ. Clinical four-year follow-up of a clinical study of 39. Johnson GH, Bales DJ, Gordon GE, et al. evaluation of marginal fracture of the effect of trituration on amalgam Clinical performance of posterior amalgam restorations: one-year report. J restorations. J Am Dent Assoc 1974;88:795-7. composite resin restorations. Quintessence Prosthet Dent 1986;55:335-9. Int 1992;23:705-11. 25. Phillips RW, Avery DR, Mehra R, et al. 55. Bates JF, Douglas WH. A Two-year Field Observations on a composite resin for 40. Johnson GH, Bales DJ, Powell LV. 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Hamilton JC, Moffa JP, Ellison JA, et al. 30. Capel CPE, Gomes MWJ, Ferreira SJF. Low- study. Am J Dent 1993;6:185-8. Marginal fracture not a predictor of silver amalgam restorations: a two-year longevity for two dental amalgam alloys: a clinical evaluation. Dental Materials 45. Wilkie R, Lidums A, Smales R. Class II glass ten-year study. J Prosthet Dent 1989;5:277-80. ionomer cermet tunnel, resin sandwich 1983;50:200-2. and amalgam restorations over 2 years. Am 31. Hoyer I, Gangler P, Niemela S. Composite J Dent 1993;6:181-4. 61. Letzel H, Vrijoef MMA. Experimental and amalgam fillings in a 4-year clinical clinical research on dental amalgam comparison. Zahn-, Mund-, und 46. Wood RE, Maxymiw WG, McComb D. A restorations. In: Winter GD, Gibbons DF, Kieferheilkunde Mit Zentralblatt clinical comparison of glass ionomer Plenk H, editors. Biomaterials 1980. 1988;76:721-6. 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1999 APRIL EFFECTIVE HEALTH CARE Dental restoration: what type of filling? 9 63. Plasmans P, Creugers N, Mulder J. Long- 79. Van Meerbeek B, Bream M, Lambrechts P, 95. Horsted-Bindslev P, Knudsen J, Baelum V. term survival of extensive amalgam et al. Mechanisms of dentine bonding. 3-year clinical evaluation of modified restorations. J Dent Res 1998;77:453-60. Leuven: International Standard Book, 1993. Gluma adhesive systems in cervical abrasion/erosion lesions. Am J Dent 64. Belcher MA, Stewart GP. Two-year clinical 80. Heymann HO, Sturdevant JR, Brunson DW, 1996;9:22-6. evaluation of an amalgam adhesive. J Am et al. Twelve-month clinical study of Dent Assoc 1997;128:309-14. dentinal adhesives in Class V cervical 96. Neo J, Chew CL, Yap A, et al. Clinical lesions. JADA 1988;116:179-83. evaluation of tooth-colored materials in 65. Akerboom HB, Advokaat JG, Van cervical lesions. Am J Dent 1996;9:15-8. Amerongen WE, et al. Long-term 81. Horsted-Bindslev P, Knudsen J, Baelum V. evaluation and rerestoration of amalgam Dentin adhesive materials for restoration 97. Tyas MJ. Clinical evaluation of five restorations. Comm Dent & Oral Epidemiol of cervical erosions. Two- and three-year adhesive systems: three-year results. Int 1993;21:45-8. clinical observations. Am J Dent 1988;1:195-9. Dent J 1996;46:10-4.

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J Esthet Dent follow-up study. Acta Odontol Scand 90. Tyas MJ. One-year clinical performance of 1990;2:100-3. 1986;44:357-67. PMDM-based dentine bonding agents. Aust Dent J 1992;37:445-8. 107. Bohm BE, Schutze ER, Klimm WH, et al. 75. Welbury RR, Murray JJ. A clinical trial of [The symptomatic therapy of cervical the glass-ionomer cement-composite resin 91. Hansen EK. Five-year study of cervical hard-substance defects with dentin- “sandwich” technique in Class II cavities in erosions restored with resin and dentin- adhesive-composite systems]. Schweiz permanent premolar and molar teeth. bonding agent. Scan J Dent Res Monatsschr Zahnmed 1991;101:1549-58. Quintessence Int 1990;21:507-12. 1992;100:244-7. 108. Matis BA, Carlson T, Cochran M, et al. 76. Heymann HO, Wilder AD, May KN, et al. 92. Van Meerbeek B, Peumans M, Gladys S, et How finishing affects glass ionomers. Two-year clinical study of composite al. Three-year clinical effectiveness of four Results of a five-year evaluation. 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1999 APRIL EFFECTIVE HEALTH CARE Dental restoration: what type of filling? 11 Acknowledgements: ■ Peter Nicklin, University of York ■ Effective Health Care would like to Hideo Ogura, The Nippon Dental Effective University, Japan acknowledge the helpful Health Care assistance of the following who ■ Colin Pollock, Wakefield HA commented on the text: ■ Jim Ralph, Postgraduate Dental Dean, ■ Paul Batchelor, UMDS of Guy’s and Northern & Yorkshire This bulletin is based on a systematic St Thomas’s ■ review15 of the longevity of dental John Renshaw, GDP, Scarborough ■ John Beal, Leeds HA restorations commissioned by the ■ Elizabeth Roberts-Harry, University Scottish Office and carried out by a team ■ Linda Davies, University of York of Leeds at the Dental School, University of Wales ■ ■ College of Medicine led by Professor Alison Evans, University of Leeds Stephen Singleton, Northumberland HA Paul Dummer. Team members: Barbara ■ Tony Fuge, GDP, Cardiff Chadwick, Frank Dunstan, Alan Gilmour, ■ Mary Turner-Boutle ■ Rhiannon Jones, Ceri Philips, Jeremy Tony Hawkes, Department of Health ■ Martin Tyas, University of Melbourne Rees, Stephen Richmond, Julia Stevens ■ Paul Hodgkin, Centre for Innovation School of Dental Science, Australia and Elizabeth Treasure. in Primary Care, Sheffield ■ Colin Waine, Sunderland HA The bulletin was written by Professor ■ David Landes, County Durham HA Trevor Sheldon and Dr Elizabeth ■ Nairn Wilson, University of Manchester ■ Ivar Mjör, University of Florida College Treasure and edited and produced by of Dentistry, USA staff at the NHS Centre for Reviews and Dissemination, University of York. Effective Health Care Bulletins The Effective Health Care bulletins are based on systematic review and Vol. 2 Vol. 3 Vol. 4 synthesis of research on the clinical 1. The prevention and treatment 1. Preventing and reducing the 1. Cholesterol and coronary effectiveness, cost-effectiveness and of pressure sores adverse effects of unintended heart disease: screening and acceptability of health service 2. Benign prostatic hyperplasia teenage pregnancies treatment 3. Management of cataract 2. The prevention and treatment 2. Pre-school hearing, speech, interventions. This is carried out by of obesity language and vision a research team using established 4. Preventing falls and subsequent injury 3. Mental health promotion in screening methodological guidelines, with advice in older people high risk groups 3. Management of lung cancer from expert consultants for each topic. 5. Preventing unintentional 4. Compression therapy for 4. Cardiac rehabilitation Great care is taken to ensure that the injuries in children and venous leg ulcers 5. Antimicrobial prophylaxis in work, and the conclusions reached, young adolescents 5. Management of stable colorectal surgery 6. The management of breast angina 6. Deliberate self-harm fairly and accurately summarise cancer 6. The management of the research findings. The University of 7. Total hip replacement colorectal cancer Vol. 5 York accepts no responsibility for any 8. Hospital volume and health 1. Getting evidence into care outcomes, costs and consequent damage arising from the practice use of Effective Health Care. patient access Full text of previous bulletins available on our web site: www.york.ac.uk/inst/crd

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12 EFFECTIVE HEALTH CARE Dental restoration: what type of filling? APRILAPRIL 1999