Journal of Dentistry 58 (2017) 67–73

Contents lists available at ScienceDirect

Journal of Dentistry
journal homepage: www.intl.elsevierhealth.com/journals/jden

Light curing procedures – performance, knowledge level and safety

awareness among dentists
S.E. Kopperud, H.V. Rukke, H.M. Kopperud, E.M. Bruzell*
Nordic Institute of Dental Materials (NIOM), Norway

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: This study aimed to investigate dentists’ exposure to curing light and to obtain information
Received 1 December 2016 about the dentists’ knowledge on practical use and technical features of their curing lights as well as their
Received in revised form 19 January 2017 safety awareness.
Accepted 4 February 2017
Methods: A pre-coded questionnaire was sent electronically to all dentists (n = 1313) in the Public Dental
Service (PDS) in Norway in 2015.
Keywords: Results: The Response rate was 55.8%. The dentists spent on average 57.5% of their working days placing
Dental curing lights
restorations, ranging from 1 to 30 (mean 7.7, SD 3.6) restorations per day. The average length of light
Maximum permissible exposure time
Visible light
curing one normal layer of composite was 27 s. The longest individual mean curing time per day was
Dental restoration about 100 times higher than that of the lowest. The mean curing time for lamps of the lower reported
Resin composite irradiances was similar to the time representing exceedance of international guidelines for limit values
for blue light to the eyes. Almost one-third of the dentists used inadequate eye protection against blue
light. The odds of using adequate eye protection were significantly higher among young dentists
(p < 0.01). The majority of the respondents (78.3%) were unaware of the irradiance value of their curing
lights, thus rendering the curing time uncertain. More dentists in this group did not perform regular
maintenance of their curing lights compared with all respondents (17.1% vs. 3.3%, p < 0.01).
Conclusions: This study revealed considerable variations among Norwegian dentists in the Public Dental
Service with respect to performance of light curing of restorations, safety awareness and technical
knowledge of the curing light.
Clinical significance: The questionnaire study identifies specific knowledge gaps among Norwegian
dentists with regard to curing lights and use of personal protection. Today’s dependence on technology in
dentistry necessitates that the operator possesses knowledge of essential technical specifications and
safe use of devices and instruments routinely used in dental treatment.
© 2017 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction
In many parts of the world, dental amalgam is being phased out
and replaced by adhesive materials in restorative treatment of
dental caries [1–6]. Most adhesive materials found on the market
today contain photoinitiators that require absorption of optical
radiation in the wavelength range 350–500 nm to set. Light
emitting diode (LED)-based curing lights are the most used light
sources. The emission peak for these dental LED lights is in the
blue/blue-green range (430–490 nm), and some curing lights emit
a second peak around 400 nm, i.e. in the transition between
* Corresponding author at: Nordic Institute of Dental Materials (NIOM),
Sognsveien 70a, NO 0855 Oslo, Norway.
E-mail addresses: s.e.kopperud@niom.no (S.E. Kopperud), ebr@niom.no
(E.M. Bruzell).
ultraviolet (UV) and visible radiation. Both UV- and visible
radiation may induce biological hazards. The light emission,
radiant flux [7], being transmitted from the output area of the
curing device has the quantity irradiance [7]. The unit of irradiance
is watts (W) per square metre (m2), frequently expressed as
milliwatts per square centimetre (mW/cm2). The quantity radiant
exposure [7], popularly expressed as “light dose” or “energy
output”, is the product of irradiance and exposure (curing) time
with the unit (milli-)joules per m2 (cm2), ((m)J/cm2). A typical
radiant exposure range required to sufficiently cure a layer of
composite polymer is reported to be about 8–50 J/cm2 [8–10]. The
radiant exposure required is dependent on material character-
istics. Recommended irradiance by educational institutions and
manufacturers of curing lights and restorative materials may vary
from about 300 mW/cm2 to more than 2000 mW/cm2, with
corresponding recommended curing times in the range 100 s to
<5 s. Theoretically, these values can give light doses outside the

http://dx.doi.org/10.1016/j.jdent.2017.02.002
0300-5712/© 2017 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
68 S.E. Kopperud et al. / Journal of Dentistry 58 (2017) 67–73

required range for adequate curing. Thus, decision on the duration
of curing time requires knowledge of the irradiance level.
Blue light, such as that emitted from curing lights, can cause eye
damage [11,12]. The risk is dependent on lamp emission and
radiative geometry, exposure time, the degree to which light is
reflected as well as the use of adequate eye protection [13]. Limit
values for exposure of blue light to the eyes are provided by the
International Commission on Non-Ionizing Radiation Protection
(ICNIRP) [11]. When these guidelines are applied to the reflected
light from today’s curing lights, the limit value denoted “maximum
permissible exposure time” (tmax) [11] can theoretically be
exceeded after 5 min of exposure during a workday [13]. In
modern dental practice, safety concerns are crucial to avoid work
injury. Nevertheless, in a survey among Norwegian dentists in
2009, one-third of all dentists reported that they refrained from
using any personal eye protection when light curing restorations
[14].
With respect to patient safety and radiation protection
principles, dentists should optimise the curing procedure. Too
long exposure may cause thermal damage to the pulp and other
tissues exposed to the light [15]. For example if, unintentionally,
higher irradiance than usual is applied while keeping the curing
time constant, thermal injury may be induced in the patient’s oral
tissues. Contrary, applying too low irradiance or too short curing
time can cause inadequate curing of restorations [16] leading to
possible early restoration failures and/or monomer leakage [17].
Low irradiance may be caused by scratches, spots or remains of
restorative material on the light output area [18]. Further, although
LEDs are generally regarded as stable and long-lasting compared to
halogen lamps, the irradiance of LEDs may decrease over time due
to e.g. technical failure or battery drain [19]. Thus, all curing lights
require regular maintenance and monitoring to control that the
irradiance is relatively stable.
The current investigation was part of a larger survey which
aimed to evaluate dentists’ treatment choices in operative
dentistry [20]. One aim of the present study was to assess
Norwegian dentists’ exposure to curing light and whether any
curing procedures lead to exposure times exceeding radiation limit
values. Another aim was to obtain information about the dentists’
knowledge about practical use and technical features of their
curing lights, routines for maintenance and use of personal eye
protection when light curing restorations.
2. Material and methods
2.1. Questionnaire
A pre-coded questionnaire (Supplementary material) was sent
electronically to all dentists (n = 1313) employed in the Public
Dental Service (PDS) in Norway in February 2015, using the
Internet-based software Questback (Oslo, Norway). The question-
naire software was configured to automatically send reminders to
all participants who did not reply within 2, 10 and 14 weeks.
Information was collected on the respondents’ age, gender, clinic
size, rural or urban work site, and to which extent the respondents
were using restorative materials on a daily basis. The participants
were asked questions related to light curing of dental restorations,
such as average time of light curing a normal layer (defined here as
2 mm) of resin composite and the average number of restorations
placed during a working day. Furthermore, questions were asked
about the survey participants’ use of eye protection when light
curing, their knowledge of age and irradiance of their light curing
unit, routines for maintenance of the device and which curing time
recommendations they followed.
2.2. Ethical considerations
Participation was voluntary, and no remuneration was given to
the respondents. Anonymity of the participants was ensured by
Questback. The study was registered with The Norwegian Data
Protection Authority (ID: 70269).
2.3. Estimations
Curing times data were divided into four ranges (8–19 s (n = 30);
20–29 s (n = 275); 30–39 s (n = 87); 40–60 s (n = 153)). Radiant

Table 1
Associations between selected variables and the odds of the dentist using adequate eye protection when light curing restorations. The results are calculated using logistic
regression analyses. Unadjusted results were obtained by performing separate regression analyses for each selected variable. Adjusted results were obtained by including all
the selected variables in one regression analysis. Thus, in the adjusted analysis the result for each variable is adjusted for all the other variables listed in Table 1.

UNADJUSTED ADJUSTED

% (n) OR 95 % CI P–value OR 95 % CI P–value

Dentist’s age (years)
52–75 24.4 (174)
39–51 25.0 (178) 1.63 1.05–2.53 0.03 1.41 0.86–2.29 0.17
32–38 24.1 (172) 2.47 1.55–3.94 <0.01 2.07 1.24–3.47 0.01
25–31 26.1 (189) 2.72 1.71–4.31 <0.01 2.26 1.34–3.83 <0.01
Dentist’s gender
Male 30.4 (217)
Female 69.6 (496) 1.81 1.29–2.55 0.00 1.42 0.96–2.12 0.08
Size of dental clinic
1–3 dentists 45.8 (326)
>3 dentists 54.2 (387) 1.36 0.98–1.88 0.06 1.17 0.78–1.76 0.44
Work site
Rural 36.3 (259)
Urban 63.7 (454) 1.44 1.03–2.01 0.03 1.42 0.94–2.16 0.09
Age of curing light (years)
Do not know 23.6 (168)
New (1–5 yrs) 55.5 (377) 0.64 0.42–0.97 0.03 0.83 0.53–1.31 0.42
Old (>5 yrs) 16.3 (168) 0.65 0.38–1.11 0.11 0.85 0.48–1.49 0.56
Irradiance of curing light (mW/cm2)
Do not know 78.3 (549)
1000–1499 12.4 (87) 0.77 0.48–1.25 0.29 0.88 0.53–1.48 0.64
1500–1999 4.9 (34) 0.92 0.43–1.98 0.84 1.06 0.47–2.39 0.88
2000 4.4 (31) 0.81 0.37–0.59 0.59 1.02 0.43–2.42 0.96
 S.E. Kopperud et al. / Journal of Dentistry 58 (2017) 67–73
exposure (light dose) received by one layer of composite was
estimated by multiplying the reported mean curing time for each
irradiance range by the midpoint of that irradiance range. The
highest and lowest radiant exposure values were calculated
similarly, by using the longest and shortest curing times,
respectively, reported for each irradiance range. For estimations
of the total curing time of a restoration, it was assumed that a
restoration consisted of three layers of composite resin and that an
additional bonding layer on each restoration was cured for 20 s.
A risk analysis of eye hazard due to blue light exposure from
curing light was performed. In the absence of spectral information
of the curing lights of the respondents, theoretical light exposures
were approximated based on the reported information on
irradiance levels and curing times. In a recent study [13], spectral
characteristics of curing lights (LEDs) were used to estimate
“maximum permissible exposure time” (tmax) for reflected blue
light to eyes based on a limit value [11]. Based on corresponding
irradiance data from this study, the mean tmax for each of the
irradiance options in the questionnaire was estimated to be 17 min,
16 min and 8 min for curing lights providing 1000–1499 mW/cm2
(n = 3), 1500–1999 mW/cm2 (n = 2) and  2000 mW/cm2 (n = 4),
respectively. In order to assess whether exposure to the lamp
irradiances, reported by the questionnaire respondents, would
exceed limit values, the above estimated tmax values for each
irradiance group were compared with the daily curing light
exposure time reported.
2.4. Statistics
Statistical analyses were performed by descriptive statistics
with chi-square tests and logistic regression analyses. The latter
were performed with the dependent variable: “Dentist using
adequate eye protection when light curing restorations”. Indepen-
dent variables are listed in Table 1. Collinearity was checked using
the criterion variance inflation factor <5, and no independent
variables were found to invalidate the analyses. Statistical analyses
were performed with IBM SPSS Statistics version 20.0.0.1
(Statistical Package for the Social Sciences; SPSS, Chicago, IL,
USA). A significance level of 5% was used throughout.
3. Results
3.1. Demography
Of 1313 dentists invited to participate in the study, a total of 748
dentists had responded after three reminders. Respondents who
stated that they did not normally work with restorative treatment
(n = 35) were excluded from the statistical analyses. A response
rate of 55.8% was calculated according to Standard Definitions of
the American Association for Public Opinion Research [21]. The age
of the respondents varied from 25 to 77 years (mean 42, SD 12),
69.6% were females and 30.4% males. Similar data for all PDS-
employed dentists were extracted from Statistics Norway, Dental
Health [22]. The present sample was found not to be significantly
different from all Norwegian dentists regarding age (p = 0.08) and
gender (p = 0.68). Regarding size of the dental clinics, 45.8% of the
respondents worked in a small dental practice with 1–3 practicing
dentists, while 54.2% worked in larger practices (>3 dentists).
3.2. Light exposure and dose during restoration procedures
The respondents stated that on average 57.5% of their working
day was spent placing restorations (range 10–100%, SD 17).The
majority of dentists light-cured a normal layer of resin composite
for 20–29 s independent of the irradiance of their curing lights
(p = 0.91) (Fig. 1). Estimations of the mean and the range of daily
69
Fig. 1. Left y-axis; coloured symbols: Distribution of curing time ranges of one
composite layer among respondents for different irradiance ranges (Supplementary
material). Right y-axis; black symbols: Estimated radiant exposure (light dose) to
one layer of composite for different irradiance ranges. Bars indicate highest and
lowest values.
curing times are given in Table 2. The longest mean curing time per
day among all respondents was about 100 times higher than that of
the lowest. Fifteen dentists reported that they placed more than 20
restorations each day, and five dentists reported that they light-
cured a normal layer of resin composite for 60 s (Table 2). The 31
dentists with curing lights of the highest irradiance light-cured a
normal layer of composite for a mean time of 28 s (range: 10–60 s,
SD 11). The highest estimated light dose applied to cure one layer of
composite material was 15 times higher than the lowest value
(Fig. 1). The lowest estimated light dose (radiant exposure: 8 J/cm2)
was in the lower part of the range reported to be required to
sufficiently cure a layer of composite polymer [8–10] (Fig. 1).
3.3. Risk assessment of reflected blue light to the dentist’s eyes
The mean curing time was close to the tmax estimated for the
two lowest irradiance ranges and exceeded it when curing lights
above 2000 mW/cm2 were used (Tables 2 and 3). The subgroup
(n = 15) that placed the highest mean number of restorations
(Table 2) was exposed to curing light on the average three times
longer than the group of all dentists (n = 748). This situation caused
exceedance of tmax independent of the curing light irradiance range
(Table 3). Likewise, the group of dentists that reported 60 s curing
time (Table 2) exceeded the tmax independent of the number of
restorations placed and the irradiance range reported (Table 3).
The light exposure limit time (tmax) will theoretically be
exceeded after placement of 34–38 layers when using curing lights
of irradiance in the range 1000–2000 mW/cm2 given a mean
curing time of one layer of 27 s and estimated tmax for this
irradiance range [13]. For curing lights of irradiance  2000 mW/
cm2 the corresponding estimated number of layers is 18 assuming
a tmax of 8 min [13] (Table 2).
3.4. Use of eye protection
When light curing restorations, almost one-third of the dentists
used what is considered inadequate eye protection against blue
light: 1.7% of the respondents reported that they did not use any
type of eye protection against blue light, 7.7% tried to look away
from the light and 19.7% used a protection shield mounted to the
70 S.E. Kopperud et al. / Journal of Dentistry 58 (2017) 67–73

Table 2
Estimated total daily light curing time based on the number of restorations placed per day and the curing time per layer shown for three groups of the respondents with
different behaviour: all dentists in the material (n = 713); the group placing the highest number of restorations (n = 15); the group spending the longest light curing times
(n = 5). n.a.: not applicable.

“ALL DENTISTS” “MANY RESTORATIONS” “LONG CURING TIME”

Mean Mean Mean
[Range] [Range] [Range]
(Median; SD)
Number of restorations/day 8 21 11
[1–30] [20–30] [5–20]
(7.0; 3.6)
Curing time per layer (s) 27 28 60
[8–60] [10–60] [n.a.]
(20.0; 9.8)
Total curing time/daya (min) 13 37 38
[1–100] [17–100] [17–67]
(n.a.)
a
Each restoration is based on three layers of composite in addition to a bonding layer cured for 20 s.

Table 3 Table 4
Indication of whether the daily curing/exposure time (i.e. total curing time) of Associations between dentist’s age and reported source of recommendations for
reflected emission from curing lights of irradiances of three ranges will be below, light curing time of composite resin restorations. Multiple replies were allowed to
close to (within irradiance value uncertainty) or above the “maximum permissible this question.
exposure time” (tmax) for reflected blue light to eyes. Previously estimated tmax are
based on selected curing lights with known spectral characteristics (1000– University Manufacturer of restorative material
1499 mW/cm2: n = 3; 1500–1999 mW/cm2: n = 2; 2000 mW/cm2: n = 4). “Close to” n % %
is within 20%, based on a 20% measurement uncertainty in curing light irradiance Age (years)
[13]. 25–31 189 60.1 51.6
32–38 172 47.1 57.0
Estimated tmax for comparison (min) 18 16 8
39–51 178 25.0 67.0
Curing light irradiance range (mW/cm2)
52–75 174 21.3 68.6
Total exposure time/day (min) 1000–1499 1500–1999 2000 Gender
Male 217 31.8 70.6
1 below below below
Female 496 42.0 56.6
13 below close to above
17 close to above above
>17 above above above

from the dental schools compared with all other responding

dentists (48.4% vs. 36.2%, p < 0.01).
curing light. Adequate eye protection, such as a separate hand-held
3.6. Knowledge related to the curing light
shield and protection eyewear was used by 63.4% and 7.5%,
respectively. The odds of using adequate eye protection were
The majority of the respondents (78.3%) were unaware of the
significantly higher among young dentists (p < 0.01) (Table 1).
irradiance value of their curing lights as new. The distribution of
There was no significant difference in the mean daily exposure
the respondents who knew their irradiance value is given in
time of curing light between the dentists who used inadequate eye
Table 1. The mean curing time per day of the dentists who were
protection and all the responding dentists (p = 0.34).
unaware of the irradiance of their curing lights did not differ
significantly from that of all responding dentists (p = 0.91). A
3.5. Compliance with advice
significantly higher percentage of the dentists who did not know
the irradiance value reported that they did not check their device
A percentage of 60.9% of the respondents stated that they
regularly (17.1% vs. 3.3%, p < 0.01). A total of 14.5% stated that they
followed recommendations from the manufacturer of the restor-
had no routines for regular maintenance of their curing lights.
ative material when deciding the curing time for a normal layer of
Visual control of the lamp’s lens or light guide for scratches, spots
composite resin. Recommendations from the dental schools were
or foreign bodies (e.g. remains of restorative material) was
followed by 38.9%, while 17.9% followed recommendations from
performed habitually by 26.0% of the respondents, while 46.8%
the manufacturer of the curing lights and 5.2% had specific
applied a curing light meter regularly to monitor the irradiance. A
guidelines provided by their dental clinic. There was a significant
total of 36.2% of the respondents reported that their curing light
(p < 0.01) steady increase in the number of dentists who followed
was controlled regularly during service of the dental unit.
recommendations given by the manufacturer of the restorative
Significantly fewer of the dentists who had new curing lights
material from the lowest to the highest age quartile (Table 4).
(5 years) checked their device regularly compared with dentists
Similarly, there was a significant (p < 0.01) steady decrease in the
with devices older than 5 years (p = 0.02). About a quarter (24.7%)
number of dentists who followed recommendations given by the
of the respondents did not know when their clinic’s curing light
dental schools from the lowest to the highest age quartile (Table 4).
was purchased. The remaining respondents reported that the
The majority (71.0%) of the dentists who used curing lights with
mean age of the curing light was 3.8 years (range 1–10, SD 2.6).
irradiances higher than 2000 mW/cm2 (n = 31) reported that they
followed recommendations for curing times given by the
4. Discussion
manufacturer of the restorative material. Of the dentists who
were unaware of age and irradiance of their curing lights (n = 155),
The questionnaire study identifies specific knowledge gaps
significantly more reported that they followed recommendations
among Norwegian dentists with regard to curing lights and use of
 S.E. Kopperud et al. / Journal of Dentistry 58 (2017) 67–73
personal protection. The adequately high response rate (55.8%) and
the matching age and gender distribution of the respondents
indicate that the present sample was representative of all PDS-
employed dentists in Norway.
4.1. Light exposure and safety aspects
The present study revealed that one third of the dentists used
inadequate eye protection when light curing restorations. This
percentage was disappointingly similar to that reported in a
questionnaire study performed nine years earlier [14]. Looking
away from the light and thereby the site of restoration placement is
not recommended, since this behaviour in many cases causes the
curing light operator to move the light away from the restoration
area resulting in decreased light dose to the material. Such a
decrease may compromise restoration quality [18]. In the authors’
opinion, filter eyewear (spectacles, goggles, visors) or hand-held
shields held correctly are the only safe measures in order to
achieve both sufficient eye protection and at the same time
verifying that the restoration receives sufficient amount of light. A
discussion of exposure conditions in relation to safety measures
can be found elsewhere [23].
The use of eye protection in the present study was independent
of the reported irradiance of the curing light. This situation is
unfavourable since one-fourth of the dentists who reported having
curing lights with the highest irradiance (above 2000 mW/cm2)
used the shield mounted to the curing light as their only eye
protection. These shields are too small to protect the reflected light
that are spread in all directions and, thus, may provide none or less
than optimal protection. The finding that fewer dentists in the
higher (39–75 years) compared to the lower (25–38 years) age
groups used protective eyewear may be ascribed the time since
completed DDS degree. The authors speculate that the habit of not
using protection may originate from a time when the light curing
units had lower irradiance. Thus, the focus on protective eyewear,
although addressed at the time [24,25], was less pertinent. The fact
that there was no significant difference in protection pattern
between the group of 31 dentists having curing lights of the
highest irradiance and all the responding dentists (p = 0.61),
indicated that the consciousness is low with respect to the
relationship between strong light sources and potential eye
damage. The group of dentists with curing lights of the highest
irradiance may exceed the tmax for reflected light to eyes after
restoring about five fillings when no eye protection is used. The
subgroup of respondents who reported that they either did not use
eye protection or just looked away from the light during curing,
spent a similar amount (p = 0.34) of time light curing per day as the
mean time for all respondents (Table 2; “all dentists”). Thus, the
total exposure time per day was close to or above the tmax value for
all irradiances reported (Table 3).
The assumption that all dentists used three layers of
composite in each restoration was a rough estimate based on
clinical guidelines [26–29]. The number of layers in a restoration
will depend on factors such as the tooth, size and shape of cavity,
and probably also personal preferences. There are uncertainties in
the estimations of the tmax for reflected blue light to eyes caused
by the curing lights reported in use. Obviously, simplifications are
made in the estimations of hypothetically reflected light, i.e. light
originating from a curing light, reaching a tooth surface and being
reflected to the eye of the lamp operator [13,23,30,31]. Further,
although the irradiance values of the characterized curing lights
used in the tmax estimations were comparable to the irradiances
reported in the questionnaire, other light emission properties,
such as solid angle of emitted light and spectral shape may have
been different. Other uncertainties or points for discussion
include the biological basis for the limit values set by ICNIRP
71
[32], which was a study on primate retinas, as well as the practical
problem of accurate measurement of radiance (the light flux
divided by area and solid angle) used in the exposure dose limit
(100 J/cm2  sr (sr: steradian)) [11]. The measured radiance of the
curing lights may be associated with uncertainties of up to 21%
[13]. Further, the previously estimated tmax values were compared
with reported irradiances grouped into three arbitrary ranges (
Supplementary material; Table 3). It is reasonable to expect
discrepancies between the irradiance values of the curing lights
as new that were reported and the actual values of the curing
lights used in the various clinics. Further, it is unlikely that a
dentist who is placing 20 restorations per day light-cures each
layer for 60 s. Therefore, owing to the above-mentioned
uncertainties, the indications of exceeding tmax (Table 3) must
be interpreted with caution. Nevertheless, since the total daily
curing times were categorised as “close to limit value” (Table 3),
the use of eye protection is strongly encouraged as a precaution-
ary attitude in order to protect the eyes sufficiently throughout
the workday and many years of occupation.
4.2. Curing time recommendations
Curing time should be varied according to relevant parameters
such as factors influencing lamp irradiance and material proper-
ties. In the Norwegian dental school curriculum, it is stated that
recommendations from the manufacturer of the restorative
material should be followed. This view is shared by several
experts in the field of light curing of dental materials [33]. A
simplified schematic of the relationship between curing time and
distance to restoration can be found in a one-page list of
recommendations of light curing decided upon in a consensus
statement [34].
4.3. The “do not know” group
Knowledge of the irradiance is essential, on one side to ensure
sufficient curing of the composite, on the other side to avoid
possible thermal damage to tissues. Therefore, a large “do not
know irradiance”- group (n = 549) indicates a high possibility for
incorrect curing procedures. The finding that more dentists
without knowledge of the irradiance value of their curing light
as new did not monitor the irradiance regularly compared with all
the respondents, may be explained by the fact that light
measurement services are performed by e.g. a radiation safety
officer or the unit manufacturer. Some curing lights have irradiance
value indicators in the form of colour display, thereby curing lights
can be monitored to a reasonable extent without knowing the
numerical irradiance value. Reasons for not knowing age and/or
irradiance of the curing lights could be that the respondents were
outside clinic when answering the questionnaire, as experienced
in a previous questionnaire about curing lights [14] or that dentists
working in a public clinic were not involved in the selection and
purchase of the curing lights. The fact that no dentists reported to
have curing lights with irradiance less than 1000 mW/cm2, does
not imply that such lights are not in use [9]. Since multiple options
were available in answering questions related to maintenance,
there may have been overlap between some of the 36.2% of dentists
who reported that the curing lights was controlled by the unit
service and the 48.8% dentists who applied a light meter regularly.
If so, it implies that up to about 50% of the dentists did not check
the irradiance regularly.
4.4. Respondent bias
There are intrinsic limitations to questionnaire studies as
discussed by Norton et al. [35]. Response bias is subjected to social
72 S.E. Kopperud et al. / Journal of Dentistry 58 (2017) 67–73
desirability, such as replying in line with the prevailing expert
opinion. Another type of bias is non-validated self-reports which
may not reflect the actual behaviour. Strengths of the present study
are the adequate response rate and the fact that the replies
regarding the use of eye protection were similar to a questionnaire
study [14] performed seven years earlier, indicating frank replies
from the respondents. Furthermore, the large variations in
reported curing light durations, as well as the high respondent
percentage admitting not knowing the curing light irradiance, both
point in the direction of non-biased replies. A weakness of the
study is the participation by PDS-dentists only. This group
comprises about a third of all dentists in Norway [22]. It cannot
be ascertained whether the respondents’ replies are representative
for private practitioners. The authors were not able to obtain email
addresses of private practitioners, excluding this group of dentists
to participate in the survey. However, 90–95% of all practicing
dentists in Norway are members of the only national dental
association and thus, both public and private practitioners have
access to the same information on the present topic, through the
national dental journal and post-graduate courses directed by the
association.
5. Conclusions
This study revealed considerable variations among Norwegian
dentists in the Public Dental Service with respect to performance of
light curing of restorations, safety awareness and technical
knowledge. According to the survey data collected, one normal
layer of restoration would receive light doses ranging from the
lowest to about twice the doses reported to cure it sufficiently.
Typical curing times with light of irradiance equal to or above
1000 mW/cm2 combined with a typical number of restorations
performed per day may exceed the hazard limit values for reflected
blue light to eyes. This is alarming, considering that one third of the
responding dentists did not protect their eyes sufficiently from
blue light. Today’s dependence on technology in dentistry
necessitates that the operator possesses knowledge of essential
technical specifications and safe use of devices and instruments
routinely used in dental treatment.
Declaration of interest
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the paper.
Acknowledgements
The present study was part of a collaboration between all Oral
Health Centres of Expertise (OHCE) in Norway, the University of
Oslo and Nordic Institute of Dental Materials (NIOM). Particular
thanks are due to Directors Hilde Vogt Toven (OHCE/East), Magne
Audun Kloster (OHCE/West), Ellen Berggren (OHCE/West) and
Anne Brit Skjetne (OHCE/Mid), and Research Managers Ewa A. Sz.
Hovden (OHCE/South), Vibeke Ansteinsson (OHCE/East) and Nils
Oscarsson (OHCE/North) who all made valuable contributions to
collect email addresses of the dentists.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/j.
jdent.2017.02.002.
References
[1] F.F. Demarco, M.B. Correa, M.S. Cenci, R.R. Moraes, N.J. Opdam, Longevity of
posterior composite restorations: not only a matter of materials, Dent. Mater.
28 (2012) 87–101.
[2] S. Domejean, S. Leger, M. Maltrait, I. Espelid, A.B. Tveit, S. Tubert-Jeannin,
Changes in occlusal caries lesion management in France from 2002 to 2012: a
persistent gap between evidence and clinical practice, Caries Res. 49 (2015)
408–416.
[3] S.A. Eklund, Trends in dental treatment, 1992 to 2007, J. Am. Dent. Assoc. 141
(2010) 391–399.
[4] C.D. Lynch, R.J. McConnell, N.H. Wilson, Trends in the placement of posterior
composites in dental schools, J. Dent. Educ. 71 (2007) 430–434.
[5] N.J.M. Opdam, E. Bronkhorst, J. Roeters, B.A.C. Loomans, Longevity and reasons
for failure of sandwich and total-etch posterior composite resin restorations, J.
Adhes. Dent. 9 (2007) 469–475.
[6] S. Vidnes-Kopperud, A.B. Tveit, I. Espelid, Changes in the treatment concept for
approximal caries from 1983 to 2009 in Norway, Caries Res. 45 (2011) 113–120.
[7] CIE International Electrotechnical Vocabulary, Lighting, International
Commission on Illumination, Genève, Switzerland, 1987.
[8] N. Ilie, S. Bucuta, M. Draenert, Bulk-fill resin-based composites: an in vitro
assessment of their mechanical performance, Op. Dent. 38 (2013) 618–625.
[9] Nordic Institute of Dental Materials Tested depth of cure and curing lamps.
URL: http://niom.no/tested-depth-of-cure-and-curing-lamps/, 2011 (Assessed
17 November 2016).
[10] L. Musanje, B.W. Darvell, Polymerization of resin composite restorative
materials: exposure reciprocity, Dent. Mater. 19 (2003) 531–541.
[11] International Commission on Non-Ionizing Radiation Protection. Guidelines
on limits of exposure to incoherent visible and infrared radiation. Health Phys.
105 (2013) 74–96. http://www.icnirp.org/cms/upload/publications/
ICNIRPVisible_Infrared2013.pdf, 2013 (Assessed 17 November 2016).
[12] A.R. Wielgus, J.E. Roberts, Retinal photodamage by endogenous and xenobiotic
agents, Photochem. Photobiol. 88 (2012) 1320–1345.
[13] E.M. Bruzell, T. Christensen, B. Johnsen, Sufficient øjenbeskyttelse reducerer
risikoen for øjenskader fra hærdelamper, Tandlaegebladet 119 (2015) 367–378
In Danish with English summary, http://www.tandlaegebladet.dk/sites/
default/files/articles-pdf/TB052015-368-381.pdf, 2015 (Assessed 17
November 2016).
[14] I.H.R. Hauge, A. Widmark, E.M. Bruzell, Use of diagnostic x-ray among
Norwegian dentists. A survey and inspection based on new radiation
protection regulations, Norwegian Radiation Protection Authority, Østerås,
Norway, 2009 In Norwegian with English abstract. http://www.nrpa.no/
publikasjon/straalevernrapport-2009-2-bruk-av-roentgendiagnostikk-blant-
norske-tannlegar.pdf, 2009 (Assessed 17 November 2016).
[15] P. Runnacles, C.A. Arrais, M.T. Pochapski, F.A. Dos Santos, U. Coelho, J.C. Gomes,
et al., In vivo temperature rise in anesthetized human pulp during exposure to
a polywave LED light curing unit, Dent. Mater. 31 (2015) 505–513.
[16] P.L. Fan, R.M. Schumacher, K. Azzolin, R. Geary, F.C. Eichmiller, Curing-light
intensity and depth of cure of resin-based composites tested according to
international standards, J. Am. Dent. Assoc. 133 (2002) 429–434.
[17] H.M. Kopperud, G.F. Johnsen, S. Lamolle, I.S. Kleven, H. Wellendorf, H.J. Haugen,
Effect of short LED lamp exposure on wear resistance, residual monomer and
degree of conversion for Filtek Z250 and Tetric EvoCeram composites, Dent.
Mater. 29 (2013) 824–834.
[18] R.B. Price, A.C. Shortall, W.M. Palin, Contemporary issues in light curing, Op.
Dent. 39 (2014) 4–14.
[19] M.M. Al Shaafi, J.E. Harlow, H.L. Price, F.A. Rueggeberg, D. Labrie, M.Q. Al
Qahtani, et al., Emission characteristics and effect of battery drain in budget
curing lights, Op. Dent. 41 (2016) 397–408.
[20] F. Staxrud, A.B. Tveit, H.V. Rukke, S.E. Kopperud, Repair of defective composite
restorations. A questionnaire study among dentists in the Public Dental
Service in Norway, J. Dent. 52 (2016) 50–54.
[21] American Association for Public Opinion R. Standard Definitions. http://www.
aapor.org/Education-Resources/For-Researchers.aspx, 2010 (Assessed 17
November 2016).
[22] Statistics Norway Dental Health. StatBank, Norway. https://statbank.ssb.no/
en/statistikkbanken, 2010 (Assessed 17 November 2016).
[23] E.M. Bruzell, B. Johnsen, T.N. Aalerud, T. Christensen, Evaluation of eye
protection filters for use with dental curing and bleaching lamps, J. Occup.
Environ. Hyg. 4 (2007) 432–439.
[24] H. Moseley, R. Strang, I. MacDonald, Evaluation of the risk associated with the
use of blue light polymerizing sources, J. Dent. 15 (1987) 12–15.
[25] P.L. Fan, W.T. Wozniak, S. McGill, J.B. Moser, J.W. Stanford, Evaluation of light
transmission characteristics of protective eyeglasses for visible light-curing
units, J. Am. Dent. Assoc. 113 (1986) 770–772.
[26] R.W. Nash, R.A. Lowe, K. Leinfelder, Using packable composites for direct
posterior placement, J. Am. Dent. Assoc. 132 (2001) 1099–1104.
[27] J.S. Rees, D.C. Jagger, D.R. Williams, G. Brown, W. Duguid, A reappraisal of the
incremental packing technique for light cured composite resins, J. Oral Rehabil.
31 (2004) 81–84.
[28] A.H. Tjan, B.H. Bergh, C. Lidner, Effect of various incremental techniques on the
marginal adaptation of class II composite resin restorations, J. Prosthet. Dent.
67 (1992) 62–66.
[29] R.D. Jackson, M. Morgan, The new posterior resins and a simplified placement
technique, J. Am. Dent. Assoc. 131 (2000) 375–383.
 S.E. Kopperud et al. / Journal of Dentistry 58 (2017) 67–73
[30] E.M. Bruzell, B. Johnsen, T.N. Aalerud, J.E. Dahl, T. Christensen, In vitro efficacy
and risk for adverse effects of light-assisted tooth bleaching, Photochem.
Photobiol. Sci. 8 (2009) 377–385.
[31] R.B. Price, D. Labrie, E.M. Bruzell, D.H. Sliney, H.E. Strassler, The dental curing
light: A potential health risk, J. Occup. Environ. Hyg. 13 (2016) 639–646.
[32] W.T. Ham Jr., H.A. Mueller, D.H. Sliney, Retinal sensitivity to damage from short
wavelength light, Nature 260 (1976) 153–155.
[33] R.B. Price, Light curing guidelines for practitioners: a consensus statement
from the 2014 symposium on light curing in dentistry, Dalhousie University,
Halifax, Canada, J. Can. Dent . Assoc. 80 (2014) e61.
73
[34] Price R. B. Fast Curing with High Power Curing Lights: Is this a Good Idea?
http://conference.capd-acdp.org/wp-content/uploads/2015/01/Dr.-Richard-
Price-Course-Outline.pdf, 2015 (Assessed 17 November 2016).
[35] W.E. Norton, E. Funkhouser, S.K. Makhija, V.V. Gordan, J.D. Bader, D.B. Rindal, D.
J. Pihlstrom, T.J. Hilton, J. Frantsve-Hawley, G.H. Gilbert, Concordance between
clinical practice and published evidence: findings from The National Dental
Practice-Based Research Network, J. Am. Dent. Assoc. 145 (2014) 22–31.