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P R A C T I C E
IO
N
ABSTRACT
CON
he performance of dental
restorations is influenced
by several factors,
including the restorative
materials used,1-3 the
clinicians level of experience,4 the
type of tooth,5,6 the tooths position
in the dental arch,7,8 the restorations design,9 the restorations
size,6 the number of restored surfaces10,11 and the patients age.4,11
Failure occurs when a restoration
reaches a level of degradation that
precludes proper performance
either for esthetic or functional reasons or because of inability to prevent new disease.
Failure of dental restorations is
of major concern in dental practice.
It has been estimated that the
replacement of failed restorations
constitutes about 60 percent of all
operative work.12 Survival and
failure rates may be used as measures of clinical performance. The
reason why a restoration fails also
is important, because it points to a
specific weakness of the restorationtooth system.
The two direct dental restorative
materials most commonly used
today are silver-mercury amalgam
and resin-based composites. Amalgam is not suitable for visible resto-
Dr. Bernardo is an associate professor of community and preventive dentistry, Faculdade de Medicina Dentria, Universidade de Lisboa, Portugal.
Mr. Lus is a faculty member, Faculdade de Medicina Dentria, Universidade de Lisboa, Portugal.
Dr. Martin is an associate professor, Departments of Oral Medicine, Dental Public Health Sciences, and Epidemiology, University of Washington, Health Sciences
Building, 1958 N.E. Pacific St., Room B316, Seattle, Wash. 98195-6370, e-mail mickeym@u.washington.edu. Address reprint requests to Dr. Martin.
Dr. Leroux is an associate professor, Department of Dental Public Health Sciences and Department of Biostatistics, University of Washington, Seattle.
Ms. Rue is a research scientist, Department of Dental Public Health Sciences and Department of Biostatistics, University of Washington, Seattle.
Dr. Leito is a cathedratical professor, Institute of Health Sciences, Portuguese Catholic University, Lisbon, Portugal.
Dr. DeRouen is a professor, Department of Dental Public Health Sciences and Department of Biostatistics, and the executive associate dean for research and
academic affairs, University of Washington, Seattle.
http://jada.ada.org
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Children
Randomized
N = 507
Children in
Composite Group
n = 233
Baseline
Composite
Restorations
n = 891
Baseline
Amalgam
Restorations
n = 2
Children in
Amalgam Group
n = 239
Baseline
Composite
Restorations
n=1
Baseline
Amalgam
Restorations
n = 854
same person. The failure rates we used to calculate the RR consisted of the ratio of the number of
events (frequency of failures) to the number of
restoration-years. We followed restorations from
the time of placement to the last examination at
which each restoration was found either to be
sound or to have failed. The time to failure for the
two kinds of restorations was displayed through
Kaplan-Meier survival curves.
RESULTS
The study dentists placed 1,748 posterior restorations during the baseline phase of the Casa Pia
study, which we followed for a period of up to seven
years. Table 1 shows the number of restorations
placed by restorative material, tooth and restoration
characteristics.
Overall, 177 (10.1 percent) restorations failed
during the course of the study. The survival rate of
the amalgam restorations was 94.4 percent at seven
years (Table 2). The survival rate for composite restorations was 85.5 percent. Amalgam restorations
with only one surface or of small size had the
highest survival rates, of 98.8 percent and 98.9 percent, respectively. We found that among the
amalgam restorations, large restorations and restorations with three or more restored surfaces had the
lowest survival rates. Survival rates of the composite restorations followed the same trend
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TABLE 1
TABLE 2
Mean annual failure rates and survival at seven years, by arch, tooth
type and restoration characteristics.
SURVIVAL AT
SEVEN YEARS (%)
RESTORATION
CHARACTERISTIC
MEAN ANNUAL
FAILURE RATES (%)
Amalgam
Composite
Amalgam
Composite
Arch
Maxillary
Mandibular
95.2
93.5
84.5
86.6
0.70
0.95
2.37
2.04
Tooth Type
Premolar
Molar
94.5
94.4
85.7
85.5
0.80
0.82
2.18
2.21
Restored Surfaces
1
2
3
4 or more
98.8
90.5
88.5
81.8
93.6
80.6
66.2
50.0
0.17
1.41
1.74
2.83
0.95
3.03
5.72
9.43
Size
Small
Medium
Large
98.9
93.3
89.5
93.6
84.9
74.3
0.16
0.99
1.58
0.94
2.31
4.15
ALL
94.4
85.5
0.82
2.21
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TABLE 3
RESTORATION
CHARACTERISTIC
Amalgam
Secondary Caries
Composite
Fracture
Secondary Caries
Fracture
Arch
Maxillary
Mandibular
15 (3.4)
17 (4.1)
6 (1.4)
10 (2.4)
64 (14.1)
49 (11.2)
6 (1.3)
10 (2.3)
Tooth Type
Premolar
Molar
5 (5.5)
27 (3.5)
0 (0)
16 (2.1)
16 (14.3)
97 (12.4)
0 (0)
16 (2.1)
Restored Surfaces
1
2
3
4+
2 (0.5)
22 (6.5)
6 (7.7)
2 (18.2)
3 (0.7)
10 (3)
3 (3.8)
0 (0)
26
59
23
5
3
10
2
1
Size
Small
Medium
Large
2 (0.8)
23 (5)
7 (5.3)
1 (0.4)
8 (1.7)
7 (5.3)
16 (5.7)
57 (13.2)
40 (22.3)
2 (0.7)
8 (1.9)
6 (3.4)
ALL
32 (3.7)
16 (1.9)
113 (12.7)
16 (1.8)
(5.8)
(16.6)
(31.1)
(41.7)
(0.7)
(2.8)
(2.7)
(8.3)
TABLE 4
restorations. Table 5 presents the same
information for failures due to fracture.
Relative risk of secondary caries in
The RR of developing secondary caries
was significantly higher in composite resto- composite restorations compared with
rations for both arches, for molars, for resamalgam restorations, by arch, tooth type
torations involving up to three surfaces
and restoration characteristics.
and for all restoration sizes (P < .05). The
risks were not significantly different in res- RESTORATION
95%
P VALUE
RELATIVE
CONFIDENCE
RISK
CHARACTERISTIC
torations with four or more surfaces
INTERVAL
involved (owing to small numbers) or in
Arch
premolars. The overall risk of secondary
4.3
< .0001
(2.4-7.5)
Maxillary
caries was 3.5 times greater in composite
2.8
.0003
(1.6-4.8)
Mandibular
restorations than in amalgam restorations.
Tooth Type
Even after adjustment for sex, baseline
2.6
.0639
(0.9-7.1)
Premolar
3.6
< .0001
(2.4-5.5)
Molar
age, and tooth and restoration characteristics, the RR was still 3.4 (95 percent CI,
Restored Surfaces
12.4
.0006
(2.9-52.1)
1
2.1-5.4). Figure 2A (page 781) shows the
2.7
< .0001
(1.6-4.3)
2
diverging survival curves due to secondary
4.3
.0015
(1.7-10.5)
3
2.6
.2482
(0.5-13.5)
4 or more
caries.
On the other hand, the overall risk of
Size
7.4
.0075
(1.7-32.3)
Small
fracture for composite restorations was
2.7
< .0001
(1.6-4.3)
Medium
slightly (0.9 times) lower than that for
4.8
.0001
(2.1-10.7)
Large
amalgam restorations. After adjustment,
3.5
< .0001
(2.3-5.1)
ALL
the RR was 1.1 (95 percent CI: 0.5-2.4), but
neither risk ratio is significantly different
DISCUSSION
from a no-effect ratio of 1.0. Figure 2B (page
781), in which the survival curves for fractures in
Our study used data collected in a randomized,
the two kinds of restorations are superimposed,
controlled clinical trial designed to assess the
shows the lack of effect.
safety of low-level mercury exposure arising from
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TABLE 5
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1.0
0.8
0.6
0.4
0.2
0.0
PROPORTION SURVIVING
0.8
0.6
0.4
0.2
0.0
PROPORTION SURVIVING
1.0
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