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Factors influencing Saudi dental students'

preference of amalgam or composite for
posterior dental restorations

Article January 2014

DOI: 10.4103/WKMP-0056.124183

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Saudi Journal of Oral Sciences

ORIGINAL ARTICLE

Factors influencing Saudi dental students

preference of amalgam or composite for
posterior dental restorations
Sharat Chandra Pani, Mohammad Fawaz Al Abbassi1, Abdulrahman Daham Al Saffan1, Maged Abdulrahman
AlSumait1, Ahmed Nassir Shakir1
Department of Preventive Dentistry, Riyadh Colleges of Dentistry and Pharmacy, 1Intern, Riyadh Colleges of Dentistry and
Pharmacy, Riyadh, Kingdom of Saudi Arabia

Abstract
Aim: The aim of this study was to tabulate the factors effecting Saudi dental students selection of a posterior restorative dental
material and compare those factors between a private and a government dental school in Riyadh.
Materials and Methods: The sample comprised of 267 students studying in both the private dental college (67 males, 75 females)
and the government dental college (55 males, 70 females) in their last 3 years of clinical training. The students were administered
a structured questionnaire specifically designed for the purpose after obtaining informed consent. Responses were compared
between the students of each school using the chi-square and Mann-Whitney U test. Each students responses to amalgam
and composite were measured using the Wilcoxon signed rank test.
Results: Overall composite resin was the material preferred by a majority of the students regardless of the type of school.
Students in both the private and the government college were likely to give higher scores for composite than amalgam. A
majority of students in both schools felt that amalgam could not be completely replaced with composite. When asked to list
the main drawbacks of amalgam and composite most of the respondents answered lack of esthetics for amalgam, while they
listed micro-leakage as the greatest drawback of composites.
Conclusion: The findings of our study suggest that dental students in the Kingdom of Saudi Arabia seem to possess the ability
to work confidently with posterior composite resins and seem to be comfortable in doing so; however, there is a significant
difference in the factors influencing their choice of material.

Key words: Amalgam, composite, dental students

Introduction
Advances in composites have revolutionized the management
of posterior teeth affected by caries, facilitating a minimal
invasive approach.[1,2] As dentists the world over switch to
minimal invasive restorative procedures and as patients get
more demanding with their esthetic demands, composites
have slowly begun to replace amalgam as the posterior
restoration of choice in many private practices.[1-5] Surveys
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in the USA, Europe and Brazil suggest that despite a greater
acceptance of the use of composite resins in posterior teeth,
teaching of newer restorative techniques has not kept pace
with advances in the materials sciences.[6,7] There have also
been reports of a need to address the potential conflict
between restorative techniques taught in dental schools and
the materials used by dental practitioners.[8-10]
Preference for amalgam or composite as a posterior
restorative material has been said to depend upon
patient preference, ease of use, time taken and
perceptions of durability.[11] While there is a vast pool
of data for clinicians reasons for choice of material,[12]
Address for correspondence:
Dr. Sharat Chandra Pani, Department of Preventive Dentistry
Riyadh Colleges of Dentistry and Pharmacy, PO Box 84891,
Riyadh 11681, Kingdom of Saudi Arabia.
E-mail: sharat@riyadh.edu.sa

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Pani, et al.: Students preference of posterior restorative material
relatively less is known about factors influencing these
choices among students or their level of comfort with
each of these materials. In the past few years there
have been a series of papers focusing on the teaching
of posterior restorative techniques in schools across the
world.[6,10,13] While these papers have focused on the
curricula of different schools, few have attempted to
study the impact they have had on student perception
and preference of posterior restorative material.
The system of dental education in Saudi Arabia has
undergone a rapid expansion in past decade with the
establishment of several new government, as well as
private dental schools. While the topics covered in both
government and private schools are similar, with the
syllabus being regulated by the same higher authority,
there are differences in the structure of the clinical hours
as well as the method of teaching these courses. While
the course in the government school is taught over
5years in addition to 1 preparatory year, the course in
the private school is taught over 12 semesters spanning
a total of 6 academic years. The government school in
question had a traditional distribution of students across
departments, with students performing required tasks in
each department; whereas the private school followed
a system of comprehensive clinics where the entire
dental treatment of a patient was carried out by the
same student on a single clinical floor with all specialists
available for consultation and supervision rather than
fixed departments dealing with only specific procedures.
Despite the rapid growth of dental education in Saudi
Arabia, there is scant data on student attitudes toward
the placement of posterior restorative materials in the
Kingdom in particular or the Middle East in general.
Given the current scenario, we decided to tabulate the
factors effecting Saudi dental students selection of a
posterior dental material and compare those factors
between a private and a government dental school in Riyadh.
Materials and Methods
The study was conducting after obtaining ethical
clearance from the research center of the Riyadh
Colleges of Dentistry and Pharmacy.
Development of the questionnaire
A pool of questions was prepared after reviewing the
literature and interviewing both final year students
and instructors of the private college. Using the most
common responses the questionnaire was then
reduced to 11 items that were thought to most reflect
S J Oral Sci Vol 1 No 1 31
the concerns of both students and instructors alike.
These were then framed in the form of a structured
questionnaire and then administered to five students
who were blinded as to the purpose of the study. After
minor modifications in the format the questionnaire was
finalized. The final questionnaire comprised of 11 main
questions, excluding demographic data. The questions
concerned with the factors affecting preference for
amalgam (Q5) and composite (Q6) were further
subdivided, using the most common factors cited in the
question pool. The responses to both these questions
were standardized and scored on a four-point Likert type
scale, with 1 indicating that the factor had no influence
and 4 indicating that the factor was very influential.
A pilot questionnaire was administered as a pilot to
20 students and re-administered to those students after
1 month to test for reliability using the Cronbachs alpha
test.[14,15] Once the reliability of the questionnaire had
been established, the questionnaire was distributed to
the study population.
Data collection
The sample comprised of 267 students studying in both
the private dental college (67 males, 75 females) and
the government dental college (55 males, 70 females)
in their last 3 years of clinical training. The students
were administered the questionnaire by one of the
investigators after obtaining informed consent.
Statistical analyses
All data was coded and analyzed using SPSS ver.19 data
processing software. The responses between groups
to questions with categorical answers were compared
using the chi-square test, with the z test used to measure
specific responses between students of the government
and private school. The questions which were scored on
the Likert scale were compared using the Mann-Whitney
U test. The responses of each student for amalgam were
paired with their responses for composite and significant
differences were measured using the Wilcoxon signed
rank test. The test was run separately for the students
of the government and the private school and was
tabulated so as to ascertain a difference in the reasons, if
any, for the students preference of a particular material.
Results
When the questions regarding theoretical and pre-
clinical training in amalgam were considered there was a
significant difference in the responses of the students in
the government and private schools. While the students
in the government school felt that their studies in both
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Pani, et al.: Students preference of posterior restorative material

amalgam and composite were equal, students in the
private school reported that their studies on amalgam
were greater than their studies on composite [Table 1] .
When the questions regarding clinical skill and comfort
while using each material were compared we found
that overall composite resin was the material preferred
by a majority of the students regardless of the type of
school, with most respondents saying that it took less
time to prepare a cavity for composite resin. However,
students in the government school were more likely to
state that their preference of material did not matter,
or that they took the same time in preparing a cavity for
both amalgam and composite [Table 2].
When the responses for factors influencing their
preference of material were compared between the
private and the government school [Table 3], we found
that the difference in perception differed according
to the material used. When it came to amalgam, a
significantly higher number of students in government
school believed that they would choose amalgam
because it was an easier material for them to handle,
while the only reason where students in the private
school assigned a higher score to amalgam was the
consideration of cost. Students in the government
school tended to assign higher scores to amalgam
than students in the government school for most
other questions, even though this difference was not

Table 1: Students responses on questions regarding their training in the use of amalgam and composite
Type Chi- square Sig
Government Private
Theoretical knowledge of dental restorative My studies on amalgam are more comprehensive 6 57
materials: My studies on composite are more comprehensive 21 28 52.26 0.0001*
My studies on both are equal 98 57
Pre-clinical training for handling dental I have had more training with amalgam 20 88
restorative materials: I have had more training with composite 17 36 95.16 0.0001*
My training for both is equal 88 18
*Significant at P < 0.05

Table 2: Students responses on questions regarding their clinical ease in the use of amalgam and composite
Type Chi-square Sig
Government Private
How long does it take for you to prepare a Preparing for amalgam is more time consuming 68 106 12.012 .002*
simple class I restoration using amalgam or than composite
composite? Preparing for composite is more time consuming 21 13
than amalgam
It takes me about the same amount of time for both 36 23
Which material do you personally prefer? I prefer using amalgam 27 10
I prefer using composite 62 116 30.928 .000*
It does not matter to me 36 16
*Significant at P < 0.05

Table 3: Differences between students in the influences affecting usage of amalgam and composite
Type of school Amalgam Composite
Mean rank Mann-whitney U Sig Mean rank Mann-whitney U Sig
More lectures taken on this material Government 131.41 8551.500 127.25 8031.500 .166
Private 136.28 .591 139.94
Instructors prefer that I use this material more often Government 137.54 126.92 7990.500 .143
Private 130.88 8432.500 .467 140.23
Patients prefer this material Government 136.11 117.70 6838.000 .000*
Private 132.14 8611.000 .663 148.35
This material is easier for me to use and handle Government 151.51 101.76 4844.500 .000*
Private 118.59 6686.500 .000* 162.38
The properties of this material make it more ideal Government 131.47 127.17 8021.000 .159
Private 136.23 8558.500 .599 140.01
The cost of this material makes it a better choice Government 115.94 121.10 7262.000 .008*
Private 149.89 6618.000 .000* 145.36
Cavity preparation is much easier with this material Government 141.11 112.72 6214.500 .000*
Private 127.74 7986.500 .133 152.74
*Significant at P < 0.05

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Pani, et al.: Students preference of posterior restorative material

statistically significant. In the case of composite resins
the students in the private school assigned higher
scores to composite for all questions when compared
to those in the government school. The scores were
significantly higher when it came to the questions that
pertained to patient perception, ease of use, cost of
the material and cavity preparation.
When the responses of each student to the questions
regarding amalgam and composite were paired and
analyzed it was found that the students in both the private
and the government college were likely to give higher
scores for composite than amalgam [Table 4]. In the
private schoo,l a significantly higher number of students
felt that they had more lectures taken on composite,
their instructors preferred they use composite, their
patients preferred composite restorations and that
composite was an easier material to use and prepare
cavities for. They perceived no significant difference
in the cost of the amalgam or composite restoration.
However, they felt that the properties of composite were
significantly inferior to those of amalgam.
The responses of the students in the government school
were similar with regards to the lectures taken, patient
preference, cost and ease of cavity preparation and
material properties. However, unlike the students in
the private school, they did not feel that composite was
easier for them to use and handle. A greater number of
them felt that amalgam was easier to handle, though
this difference was not statistically significant.
When the students attitude toward the restorative
materials and their views on the future of amalgam
were compared [Table 5], we found that a majority
of students in both schools felt that amalgam could
not be completely replaced with composite. However,
the z test showed that a significantly higher number
of students in the private school felt that amalgam
would be replaced by composite resin restorations. A
greater number of students felt that composite was a
good substitute for amalgam although this difference
was significant only in the private school. There was
a significant difference in the perception of longevity
of composite resin restorations in the mouth of a
patient with good oral hygiene. While students in the
private school felt that in such a patient a posterior
composite restoration would last as long as amalgam,
a significantly higher number of students in the
government school felt the opposite.

Table 4: Differences between government and private students in factors affecting usage of amalgam and composite
Ranksa Private Government
N Mean rank Z Sig N Mean rank Z Sig
More lectures taken on Composite - Negative Ranksb 27 30.96 15 19.00
More lectures taken on Amalgam Positive Ranksc 49 42.65 3.302c .001 36 28.92 3.722c .000
Ties 66 74
Total 142 125
Instructors prefer that I use Negative Ranksb 32 44.16 23 23.65
Composite more often - Instructors Positive Ranksc 66 52.09 3.656c .000 36 34.06 2.678c .007
prefer that I use Amalgam Ties 44 66
Total 142 125
Patients prefer Composite - Patients Negative Ranksb 11 23.45 12 29.33
prefer Amalgam Positive Ranksc 89 53.84 7.897c .000 71 44.14 6.406c .000
Ties 42 42
Total 142 125
Composite is easier for me to use and Negative Ranksb 8 13.50 32 33.30
handle - Amalgam is easier for me to Positive Ranksc 91 53.21 8.377c .000 39 38.22 1.248c .212
use and handle Ties 43 54
Total 142 125
The properties of composite - The Negative Ranksb 54 45.61 43 33.55
properties of Amalgam make it more Positive Ranksc 39 48.92 1.084b .278 22 31.93 2.548b .011
ideal Ties 49 60
Total 142 125
The cost of composite - The cost of Negative Ranksb 45 43.62 30 25.50
Amalgam makes it a better choice Positive Ranksc 33 33.88 2.141b .032 24 30.00 .201b .841
Ties 64 71
Total 142 125
Cavity preparation is much easier Negative Ranksb 12 22.79 14 25.64
with composite - Cavity preparation is Positive Ranksc 92 56.38 8.124c .000 62 41.40 5.821c .000
much easier with Amalgam Ties 38 49
Total 142 125
a
Ranks tabulated using Wilcoxon Signed Rank Test, bNegative Ranks indicate a preference for Amalgam, cPositive ranks indicate a preference for composite

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Pani, et al.: Students preference of posterior restorative material

When asked to list the main drawbacks of amalgam and
composite [Table 6], most of the respondents answered
lack of esthetics for amalgam, while they listed micro-
leakage as the greatest drawback of composites.
Discussion
The debate to use amalgam or not is as old as dentistry
itself; [16] however, with the availability of a viable
alternate in posterior composite resins the debate in
literature seems to be moving toward when, rather
than if, amalgam can be completely replaced.[1] As the
use of posterior composite resins has been increasing
in practices the world over, the question of whether
our education of students in these materials have kept
place has also been studied in literature.[8,9,17-19] The
primary aim of this study was to view this debate from
the perspective of the student rather than the educator.
those in the government school felt that their training
in both materials was equal. The curriculum of both
schools is regulated by the Ministry of Higher Education,
Kingdom of Saudi Arabia; ensuring that though mildly
different, the overall structure of the courses is similar.
Given this fact a possible reason for this difference
could be the nature of the clinical environment of the
schools. While the government school has a free clinic,
the patients pay for treatment in the private school, thus
perhaps indirectly influencing the type of restorative
material placed. It was interesting to note that in both
schools students agreed that composite resin was the
material the patient was likely to prefer over amalgam.
The findings of this study suggest that exposing students
to a situation where they have to convince patients, not
only of the need for treatment, but also of the need to
pay for it places them in a position where they are more
likely to be in tune with the demands and needs of the
patients they are likely to encounter in their practices.

Given the trends among patients as well as dentists
the world over,[3-5,20-22] it is perhaps not surprising that
students in both the schools we studied tended to favor
composite over amalgam in posterior teeth. This finding
is similar to those reported from several European and
American dental schools in the past few years.[4,8,9,12,18,19]
We found that students in the private school felt they
had more emphasis on amalgam than composite, while
Given the above argument it is perhaps natural then that
the students in the government school were ambivalent
as to their preference of material, while those in the
private school were significantly more in favor of
composite resin restorations over amalgam. While one
can appreciate the comfort of the students with the
use of composite resin, a lack of ease with amalgam
in the students of the private college is a worrisome
trend. While the concept of an amalgam-free dental

Table 5: Comparison of students opinion about the greatest drawback of both amalgam and composite
Type of school Chi-square Sig
Government Private
In your opinion, what is the greatest drawback Non-esthetic 86a 91a
(negative aspect) of Amalgam Destructive preparation 16a 35b
Thermal expansion 7a 1b 15.014 .005*,a
Corrosion 7a 12a
Mercury toxicity 9a 3b
In your opinion, what is the greatest drawback Micro-leakage 46a 68a
(negative aspect) of Composite Technique sensitive 59a 68a 13.934 .003*,a
Takes more time 4a 3a
Poor clinical survival 15a 2b
Values in the same row and subtable not sharing the same subscript are significantly different at P < 0.05 in the two-sided test of equality for column proportions. Cells with no
subscript are not included in the test. Tests assume equal variances.

Table 6: Comparison of students perception of the future of amalgam and the viability of composite
Type of school Chi-square Sig
Government Private
Do you believe that the usage of amalgam in dental practice should Yes 42 65
be completely discontinued and replaced with the continuously No 83 76 4.305 .038*
evolving composite?
Do you believe composite is a good substitute for amalgam? Yes 69 99 6.006 .014*
No 56 43
In the mouth of a cooperative patient, do you believe composite Yes 63 82 1.446 .229
restorations would last longer than amalgam ones? No 62 60
*The chi-square statistic is significant at the 0.05 level

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Pani, et al.: Students preference of posterior restorative material
school has been floated in literature,[23] amalgam still
comprises a significant portion of the restorations placed
in Saudi Arabia, and the country is far from the stage of
amalgam-free dentistry.
The students in both schools felt at ease with the use
of composite resin restorations. One of the reasons
for this could be the fact that the specialty of dentistry
is relatively young in the Kingdom of Saudi Arabia.
Thus, traditional barriers to the teaching of posterior
composite restorations[8,19] may be less applicable. An
argument supported by the fact that students from both
schools reported that a majority of their instructors
preferred them to use composite over amalgam. The
findings also support the argument that the instructor
plays an important role in influencing the students
preference of material.
The difference in the cost of placing either amalgam
or composite posterior restorations is a subject
that has been discussed in literature. Traditionally,
amalgam restorations have always been cheaper than
composite; however, recent advances in composite
resins along with increasing prices of silver have meant
that today an amalgam restoration costs as much to
place as a composite resin restoration.[1,2,4,21] However,
it has been suggested that the long-term viability
of amalgam reduces overall cost to the patient.[24,25]
Restorative care in the government college was free,
whereas the private school charged the same price
for similar amalgam and composite restorations. Our
study suggests that while students were aware of the
short-term costs of placing a restoration, they did not
give much thought to the long term cost of placement
of a restoration. Interestingly, although many of the
students surveyed felt that composites could replace
amalgam in the mouth of a patient with good oral
hygiene, questions about the durability of composite
still remained.
The debate of whether composite will ever replace
amalgam is at least two decades old, and yet the view
that we can move toward an amalgam-free practice
is not the one that is universally accepted.[23] One of the
greatest objections to amalgam in the West, especially
in Europe, has been the threat of mercury toxicity[26,27] a
view that has been criticized.[24,28] The respondents in our
study however ranked mercury toxicity way below the
concerns of esthetics and excessive tooth preparation.
The significantly higher number of students in the private
school who objected to amalgam on the grounds of
destructive tooth preparation seems to suggest that
students, who are encouraged in the use of composite,
may subconsciously assimilate the principles of minimal
S J Oral Sci Vol 1 No 1 35
intervention better than students who routinely use
amalgam.
Data on the use and preference of posterior restorative
materials in the Middle East remains scant.[29] A recent
study from Iran highlighted that the education on
restorative techniques in that country are compatible
with standards practiced in the West.[30] Our study
suggests that while curricula and education standards
certainly form the core of education, students with very
similar curricula may have different perceptions based
on the clinical setting they work in.
Conclusions
The findings of our study suggest that dental students in
the Kingdom of Saudi Arabia seem to possess the ability
to work confidently with posterior composite resins
and seem to be comfortable in doing so. However, the
reasons for choosing composite resin restorations over
dental amalgam vary, and seem to be influenced by the
clinical setting in which the student worked. Given the
scant data on the subject in the Middle East, similar
studies in different colleges in the region can greatly
help to understand student perception, attitude and
comfort in using posterior composite resin restorations.
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Cite this article as: ***
Source of Support: Nil, Conflict of Interest: None declared.
January 2014