[Downloaded free from http://www.jresdent.org on Tuesday, June 23, 2020, IP: 49.207.141.

16]

Review Article

S i l v e r a m a l g a m : A   c l i n i c i a n’ s
perspective
Treville Pereira
Department of Oral and Maxillofacial Pathology and Microbiology, School of Dentistry, D. Y. Patil University, Navi Mumbai, Maharashtra, India

Address for correspondence: Dr. Treville Pereira, Department of Oral and Maxillofacial Pathology and Microbiology, School of Dentistry, D. Y. Patil University, Sector 7, Nerul,
Navi Mumbai ‑ 400 706, Maharashtra, India. E‑mail: trevillepereira@gmail.com

ABSTRACT Caries persists throughout the world, and patients have multiple restorations that are likely to need
replacement throughout the remainder of their lives. The selection of the best restorative material that can
be used in the oral cavity is a challenging job for both the dentist and the manufacturer. While material
properties and clinical performance are critically important, local economies, health care systems, will
be important determinants of whether and where new materials can be easily adopted. Challenges
exist not only in specifying how the material should be manipulated and perform clinically but also in
understanding and incorporating implications of the skill of the operator placing the restoration. Many
restorative materials currently exist like amalgam, composites, glass ionomers, and resin ionomers. It
is important that the dentist must make the selection of the material with great care because, in future
years, those restorations needing replacement will result in the loss of increasing amounts of tooth
structure. Amalgam has a lot of disadvantages such as lack of adhesion, toxicity, poor esthetics, and
marginal leakage; however, the advantages score better over other materials.

Keywords: Amalgam, clinician, operative dentistry, restoration

INTRODUCTION of tooth extractions. It was in 1896 that G.V. Black

developed a standard for cavity preparation and
Operative dentistry has been considered to be the experimented with various mixtures of amalgam thus
entirety of the clinical practice of dentistry, however, contributing immensely to the dental profession. Black’s
today many of the past subject areas in operative son, Authur Black (1870–1937) continued the legacy of
dentistry have become specialty areas. Operative his father through dental research.[2]
dentistry has been recognized as the foundation of
dentistry and the base from which most other aspects In recent times, there has been astonishing progress
of dentistry evolved.[1] in materials and methods of restoring teeth. Dental
materials, as ever before, are available in a great number
Dentistry originated in the United States in the and variety to the dental profession. Faced with a surfeit
17th century when several “barber‑dentists” were sent of choices, a dental surgeon must necessarily know what
from England. The practice then consisted mainly to choose and how to choose it.

Access this article online This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
Quick Response Code: others to remix, tweak, and build upon the work non‑commercially, as long as the
Website: author is credited and the new creations are licensed under the identical terms.
www.jresdent.org

For reprints contact: reprints@medknow.com

DOI:
10.4103/2321-4619.181000 How to cite this article: Pereira T. Silver amalgam: A clinician's
perspective. J Res Dent 2016;4:25-30.

© 2016 Journal of Restorative Dentistry | Published by Wolters Kluwer - Medknow • 25

[Downloaded free from http://www.jresdent.org on Tuesday, June 23, 2020, IP: 49.207.141.16]

Pereira: Silver amalgam: A clinician’s perspective

Intense environmental concerns recently have prompted A BRIEF REVIEW OF CURRENTLY

dentists to evaluate the performance and environmental
impact of existing restoration materials. Doing so
entices us to explore the “what if?” innovation in
materials science to create the best restorative material.
Articulating a specification for the design and evaluation
methods is proving to be more complicated than
originally anticipated. Challenges exist not only in
specifying how the material should be manipulated
and perform clinically but also in understanding and
incorporating implications of the skill of the operator
placing the restoration, economic considerations,
expectations patients have for their investment,
cost‑effectiveness, influences of the health care system
on how and for whom restorations are to be placed,
and global challenges that limit the types of materials
available in different areas of the world. The quandary is
to find ways to focus on future directions on the creation
of more ideal restorative materials that can be available
throughout the world.
The “Holy Grail” for dentistry is to eliminate dental
caries entirely. Unfortunately, caries remains ubiquitous.
A major proportion of the population needs or already
has restorations. Once restorations are placed, their
lifetimes are influenced by an array of factors and vary
enormously. To decide which material is the best, one
must know the properties of different materials available.
AVAILABLE MATERIALS
Four classes of direct‑placement restorative materials
currently exist amalgam, composites, glass ionomers,
and resin ionomers.[3] Advantages and disadvantages
of each class are summarized in Table 1. Together, they
present interesting choices.
SELECTION OF A DENTAL RESTORATIVE
MATERIAL
The selection of the type of dental restorative material
is dependent on many factors, among them the
characteristics of the tooth itself, the patient, the
dentist, and the material. The dentist must make this
selection with great care because, in future years, those
restorations needing replacement will result in the loss
of increasing amounts of tooth structure. This sets up a
cycle where the increasing cavity size limits the selection
of the materials that may be used effectively. There are
numerous factors to consider when restoring a tooth,
for example, the extent of the lesion, the strength of
the remaining tooth structure, the preference of the
dentist in using the material, and the financial cost of
the procedure, both out‑of‑pocket costs borne directly
by the patient and those covered by insurance.[4] In
considering the characteristics of an ideal restorative

Table 1: Direct placement restorative materials ‑ brief overview

Factor Amalgam Glass ionomers Resin ionomers Composites
Cavity preparation Sound tooth structure to Adhesive bonding allows Adhesive bonding allows Adhesive bonding
be removed for material removal of less tooth removal of less tooth allows removal of less
manipulation structure structure tooth structure
Restoration use Especially posterior teeth Nonload bearing areas Nonload bearing areas Esthetic zone
Clinical conditions Wide range tolerance Well controlled field of Well controlled field of Well controlled field of
operation operation operation
Resistance to fracture Brittle, chips at the edge Low Low to moderate Moderate
Durability Good to excellent Good in nonload bearing, Moderate to good in Good in small to
poor in load bearing nonload bearing moderate restorations
Wear resistance High Low on occlusal surfaces Low on occlusal surfaces Moderate
Moisture tolerance during Moderate Very low Very low Very low
placement
Leakage Moderate Low Low with proper bonding Low with proper bonding
Recurrent decay Similar to other materials Similar to other materials Similar to other materials Dependant on
tooth‑material bond
Esthetics Poor Good Good Excellent
Fluoride release No Yes Yes No
Placement time compared to 1X 2X 2X 2X
amalgam
Material cost compared to 1X 30% more approximately 30% more approximately 30% more
amalgam approximately
Failure rate (%) 2.2 7.6 3.1 3.5
Approx. life of restoration (years) 10 4 2 7
Potential environmental impact Yes Not known Not known Not known
Operator skill Material predictable Material unforgiving, Material unforgiving, Material unforgiving,
and forgiving, dentist dentists experience dentists experience dentists experience
comfortable with usage required while using required while using required while using

26 • Journal of Restorative Dentistry / Vol ‑ 4 / Issue ‑ 2 / May‑Aug 2016

[Downloaded free from http://www.jresdent.org on Tuesday, June 23, 2020, IP: 49.207.141.16]
Pereira: Silver amalgam: A clinician’s perspective
material, it is apparent that no single material can fulfill
all of the clinical needs.
Factors which govern the success of a restoration are
diagrammatically represented in Figure 1.
FACTORS WHICH INFLUENCE THE
PERFORMANCE OF A MATERIAL
These include:
• Physical properties (thermal, electrical, optical, and
mass properties)
• Chemical properties  (water adsorption, chemical
corrosion, and biodegradation)
• Mechanical properties  (toughness, fracture
resistance, fatigue resistance)
• Biological properties  (especially existence of any
ingredients worrisome for adverse patient reactions
or environmental impact)
• Clinical manipulation  (minimum isolation, bulk
placement, bulk cure, low shrinkage, minimal
recycling, minimal waste, minimal packaging,
operator skill)
• Clinical properties (no recurrent caries, good wear
resistance, fracture resistance, and retention).
Three items on this long list are most influential in defining
the performance of the material/restoration: Crack
tolerance, ease of delivery, and clinical performance.[5]
CHALLENGES THAT ASSESS THE
PERFORMANCE PROPERTIES OF A
MATERIAL
In vitro laboratory research, while important, has not yet
been shown to correlate highly with short‑term (2–5 years)
or long‑term (10–20 years) clinical   performance. There
are numerous reasons for this.    In vitro laboratory
tests tend to evaluate a single property representing
physical, chemical, mechanical, or biological properties
and generally are unable to account for variables that
influence clinical performance, such as dentist skill,
Figure 1: Factors influencing the success of a restoration
Journal of Restorative Dentistry / Vol ‑ 4 / Issue ‑ 2 / May‑Aug 2016 • 27
recurrent caries, ever‑changing oral environment, and
loading. In vitro laboratory testing, while important, is
also vulnerable to differences in results based on the
operator, research design, materials tested, interfaces,
environment, and specimen geometry.[5]
Assessing clinical outcomes is even more challenging.
Here, 5 interacting categories of factors complicate the
understanding and ability to predict outcomes:
• The operator (his/her skill – not judgment)
• Design  (operator judgments relative to cavity
preparation features for the restorative material
being evaluated)
• Material (laboratory properties)
• Intra‑oral location  (variations in saliva, stress,
temperature, and other effects relating to anterior
vs. posterior, maxillary vs. mandibular arches, and
primary vs. permanent tooth) and
• Patient factors (caries risk, fluoride history, diet, bites
force, etc.).[6]
Interestingly, the operator is considered to have the
most influence on clinical performance (at least 50% of
the risk for outcomes). The material itself contributes
the least to risk. A skilled operator can make even
a poor material work relatively well. An unskilled
operator cannot make even the best material work
well. [7] Thus, operator skill is critically important.
Consequently, an ideal material should be as simple
to use as possible!
Restorative filling materials are used to “fill the hole”
that is left in a tooth after your dentist removes decay
from the tooth. Silver amalgam, composite resins, and
glass ionomers are commonly used. They are usually
placed in one visit.
Dental amalgam was probably first introduced
by  Monsieur Travaux  of Paris in the year 1826. At that
time, dental amalgam was usually made by triturating
fillings from silver coins, with mercury. Dr. G.V.
Black of the USA is credited with the introduction of
a dental amalgam alloy in the year 1895, with a silver
tin composition which is the precursor of modern
day dental alloys. This is in the form of fine particles,
which when mixed with a specific amount of pure
mercury, forms a plastic mass in its initial stage of
the reaction, and gradually hardens, as the reaction
progresses. Because of its initial plastic behavior, the
amalgam at this stage, can be molded to any form and
allowed to harden. In dentistry, amalgam is extensively
used to restore tooth structures destroyed by dental
caries. In the hands of a competent clinician, it is still
the cheapest, most durable and satisfactory material,
even today.[8]
[Downloaded free from http://www.jresdent.org on Tuesday, June 23, 2020, IP: 49.207.141.16]
Pereira: Silver amalgam: A clinician’s perspective
WHAT IS DENTAL AMALGAM?
Dental amalgam is a dental filling material used to fill
cavities caused by tooth decay. It has been used for more
than 150 years in hundreds of millions of patients. Dental
amalgam is a mixture of metals, consisting of liquid
mercury and a powdered alloy composed of silver, tin,
and copper. Approximately, 50% of dental amalgam
is elemental mercury by weight. Dental amalgam
fillings are also known as “silver fillings” because of
their silver‑like appearance.[9] In deciding, what filling
material can be used to treat dental decay, a choice must
be made by the patient and the dentist.
However, the following points should be kept in mind:
Potential benefits
Dental amalgam fillings are strong and long‑lasting, so
they are less likely to break than some other types of
fillings. It is the least expensive type of filling material.
Potential risks
Dental amalgam contains elemental mercury. It releases
low levels of mercury vapor that can be inhaled. High
levels of mercury vapor exposure are associated with
adverse effects in the brain and the kidneys. Food and
Drug Administration (FDA) has reviewed the best
available scientific evidence to determine whether the
low levels of mercury vapor associated with dental
amalgam fillings are a cause for concern. Based on
this evidence, FDA considers dental amalgam fillings
safe for adults and children ages 6 and above. Even in
adults and children ages 6 and above who have fifteen
or more amalgam surfaces, mercury exposure due to
dental amalgam fillings has been found to be far below
the lowest levels associated with  harm.[10,11]
There is limited clinical information about the potential
effects of dental amalgam fillings on pregnant women
and their developing fetuses, and on children under
the age of 6, including breastfed infants. However, the
estimated amount of mercury in breast milk attributable
to dental amalgam is low and falls well below general
levels for an oral intake that the Environmental
Protection Agency (EPA) considers safe.   FDA concludes
that the existing data support a finding that infants are
not at risk for adverse health effects from the breast
milk of women exposed to mercury vapor from dental
amalgam. The estimated daily dose of mercury vapor
in children under age 6 with dental amalgams is also
expected to be at or below levels that the EPA and the
Centers for Disease Control and Prevention consider
safe.[12]
28 • Journal of Restorative Dentistry / Vol ‑ 4 / Issue ‑ 2 / May‑Aug 2016
Dental amalgam is not inert and small amounts of
mercury vapor are released during the functional life
of the restoration. Mercury vapor is released in greater
amounts when the restoration is mixed and placed
or replaced. Such things as number of filled teeth, the
number of surfaces per filling, eating habits including
gum chewing, tooth brushing, oral breathing habits,
and bruxism can influence the amount of mercury
released. The World Health Organization and World
Dental Federation state, “No controlled studies have
been published demonstrating systemic adverse health
effects from amalgam restorations.” The World Health
Organization issued this consensus statement in March
1997 that dental amalgam is considered to be “safe and
effective.”[12]
Allergic reactions to the mercury in amalgam are very
rare. Fewer than 100 cases have ever been reported. Mild
symptoms of the allergic reaction, similar to typical skin
allergies, usually disappear in 2–3 weeks.[13]
Approximately, half of a dental amalgam filling is liquid
mercury, and the other half is a powdered alloy of
silver, tin, and copper. Mercury is used to bind the alloy
particles together into a strong, durable, and solid filling.
Mercury’s unique properties (it is the only metal that is
a liquid at room temperature and that bonds well with
the powdered alloy) make it an important component
of dental amalgam that contributes to its durability.[14,15]
There are several different chemical forms of
mercury: Elemental mercury, inorganic mercury, and
methylmercury. The form of mercury associated with
dental amalgam is elemental mercury, which releases
mercury vapor. The form of mercury found in fish is
methylmercury, a type of organic mercury. Mercury
vapor is mainly absorbed by the lungs. Methylmercury
is mainly absorbed through the digestive tract. The
body processes these forms of mercury differently and
has different levels of tolerance for mercury vapor and
methylmercury. It is more toxic than mercury vapor.
If the fillings are in good condition, and there is no decay
beneath the filling, FDA does not recommend that the
amalgam fillings be removed or replaced. Removing
sound amalgam fillings results in unnecessary loss of
healthy tooth structure, and exposes the patient and the
dentist to additional mercury vapor released during the
removal process.[12,16‑19]
INDICATIONS FOR SILVER AMALGAM
It seems sensible to restrict the use of amalgam to clinical
situations that justify its use.
[Downloaded free from http://www.jresdent.org on Tuesday, June 23, 2020, IP: 49.207.141.16]
Pereira: Silver amalgam: A clinician’s perspective
They may include:
• Large Class I and Class II cavities, involving more
than the middle 3rd of the occlusal surface of the
posterior teeth, where indirect restorations are
contraindicated
• Class II cavities where the cervical margin of the box
finishes subgingivally and is composed entirely of
dentin
• Extensive cores, where the majority of coronal tooth
structure is missing
• Where definite restorations must be placed but care
or moisture cannot be controlled
• Where cost is a major patient concern and
esthetic  unimportant.[20,21]
CONTRAINDICATIONS FOR SILVER
AMALGAM
• Anterior teeth and clearly visible surfaces of
posterior teeth
• Remaining tooth structure requires support or would
require extensive preparation to accommodate
amalgam
• T r e a t m e n t o f i n c i p i e n t o r e a r l y p r i m a r y
fissure  caries.[20,21]
DISADVANTAGES OF SILVER AMALGAM
IN COMPARISON WITH TOOTH
COLORED RESTORATIVE MATERIALS
• Lack of adhesion to the tooth structure: Since
amalgam does not bond to the tooth structure,
microleakage immediately following the insertion
of the restoration is inevitable; whereas the tooth
colored restorative materials have micromechanical
bond
• Esthetics: The appearance of amalgam is considered
to be a drawback hence its use is limited to the
posterior teeth
• Toxicity: The seemingly constant pronouncements
about the toxic effects of mercury and the suggested
link between dental amalgam and disease have
confused and frightened public. While there is no
scientific evidence whatsoever to support these
claims they continue to flame the “Antiamalgam
fires”
• Marginal deterioration: The “ditching” around
amalgam restorations are considered to be a stress/
corrosion dependent defect occurring in areas
subject to occlusal loading. The magnitude and
extent of ditching are directly proportional to creep
properties. Secondary caries is one of the most
important factors leading to the replacement of
amalgam  restoration.[22]
Journal of Restorative Dentistry / Vol ‑ 4 / Issue ‑ 2 / May‑Aug 2016 • 29
ADVANTAGES OF SILVER AMALGAM
• Inexpensive
• Easy to use
• Strength under occlusal load and durability
• The only restorative material existing nowadays
in which the marginal seal improves with time
due to formation of corrosion products at the
tooth‑amalgam interface
• Quick to place
• Stable: Dental amalgam is still considered to be
the best direct restorative material for posterior
restorations in permanent teeth subject to high
occlusal load.[23]
THE HEALTH CARE SYSTEM
It is tempting to assume that treatment decisions are
a relatively straightforward decision‑making process
between dentists and patients. However, the health
care system in any given situation may have a profound
influence on whether, when, how, and how quickly
alternative restorative materials can be introduced. The
pressure to lower costs will always be there; however,
the pressures may fall in different places, depending on
the health care system, and this may determine whether
a new material is adopted. This is likely to be a critical
factor in the determination of how novel materials are
adopted.
For the patient who is willing to pay, there is no issue.
However, in a global sense, a costly material or technique
will exclude large sections of the population, raising a
question of equity around the availability of very routine
dental care.[24] Put simply, a costly technique or material
may eliminate large sections of the global population
from simple dental care.
CAN A SINGLE MATERIAL “DO IT ALL”?
The answer to this question is complicated. As a first
priority, the exquisite need for care in underdeveloped
and poor countries and areas that lack infrastructure
must be addressed with any material that is available in
that area. At the other extreme, existing materials, when
properly used, are seemingly adequate in developed,
affluent areas served by highly skilled dentists. Notably,
though, the general perception is that amalgam is still the
“best” material, and that is not likely to remain a choice
in many settings. Hence, a compelling question remains:
Should the objective be to define one over‑engineered
material that is highly fracture resistant; extremely
forgiving, permitting relatively unskilled operators to
place it quickly; and that seals  (perhaps even heals)
the remaining tooth structure, eliminating concern for
[Downloaded free from http://www.jresdent.org on Tuesday, June 23, 2020, IP: 49.207.141.16]
Pereira: Silver amalgam: A clinician’s perspective
recurrent caries around the restoration margins, and can
be used in all locations in the mouth in both primary
and permanent teeth while providing excellent esthetics
and long clinical lifetime? If not, what choices should
one make, and how does one justify the compromises?
Moreover, should the aim be only for long‑term solutions,
or the identification of both near term and longer term
improvements and innovations?
WHAT NEXT?
The reality is that caries persists throughout the world,
and whole generations of “heavy metal” patients have
multiple restorations that are likely to need replacement
throughout the remainder of their lives. There are many,
many challenges in, first, specifying, and then creating the
best restorative material of the future.
While materials properties and clinical performance are
critically important, local economies, health care systems,
will be important determinants of whether and where new
materials can be easily adopted. For new technologies to
be globally relevant, managing the cost of the material and
technique will be pivotal.
It is self‑evident that, if the costs associated with a new material
are much higher than for those already present, these costs
will need to be met from somewhere. It is also self‑evident
that high costs will be a barrier to voluntary change while
low costs may be a facilitator. Clinicians, materials scientists,
and manufacturers need to collaborate to create the design
specification for future innovations. Agencies such as
International Standards Organization, Federation Dentaire
Internationale, and others can work toward harmonization
of global testing protocols and factors that influence the
availability of materials. Most importantly, however, leaders
of health care systems and third‑party payers need to consider
how preventive care can become more cost‑effective and
incentivizing for practitioners. Until then, undoubtedly the
clinician can safely rely on amalgam as the best restorative
material.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
REFERENCES
1. Strudevant CM, editor. Introduction to operative dentistry. In: The
Art and Science of Operative Dentistry. 2nd ed. U.S.A.: Mosby CV
Company; 1985. p. 1.
2. Joseph R. The father of modern dentistry‑Dr Greene Vardiman
Black (1836‑1915). J Conserv Dent 2005;8:5‑6.
3. Petersen PE. Future Use of Materials for Dental Restoration:
Report of the Meeting Convened at WHO HA, Geneva,
30 • Journal of Restorative Dentistry / Vol ‑ 4 / Issue ‑ 2 / May‑Aug 2016
Switzerland 16‑17 November, 2009. Geneva: World Health
Organization; 2010. Available from: http://www.who.int/oral_
health/publications/en. [Last accessed on 2015 Nov 15].
4. Dental Amalgam: A Scientific Review and Recommended Public
Health Service Strategy for Research, Education and Regulation.
Final Report of the Subcommittee on Risk Management of the
Committee to Coordinate Environmental Health and Related
Programs Public Health Service; January, 1993.
5. Heintze SD, Barkmeier WW, Latta MA, Rousson V. Round robin
test: Wear of nine dental restorative materials in six different wear
simulators – Supplement to the round robin test of 2005. Dent
6.
Mater 2011;27:e1‑9.
Bayne SC. Dental restorations for oral rehabilitation – Testing
of laboratory properties versus clinical performance for clinical
decision making. J Oral Rehabil 2007;34:921‑32.
7. Bayne SC. Correlation of clinical performance with ‘in vitro tests’
of restorative dental materials that use polymer‑based matrices.
Dent Mater 2012;28:52‑71.
8. Hollenback GM. A consideration of amalgam. J Calif Dent Assoc
1969;45:15‑8.
9. FDI Policy Statement/WHO Consensus Statement on Dental
Amalgam. September 1997. [Last accessed on 2015 Nov 15].
10. Lyons K; Ministry of Health. Direct placement restorative materials for
use in posterior teeth: The current options. N Z Dent J 2003;99:10‑5.
11. Klausner LH, Green TG, Charbeneau GT. Placement and
replacement of amalgam restorations: A Challenge for the
profession. Oper Dent 1987;12:105‑12.
12. Dental amalgam: Update on safety concerns. ADA Council on
Scientific Affairs. J Am Dent Assoc 1998;129:494‑503.
13. Saxe SR, Wekstein MW, Kryscio RJ, Henry RG, Cornett CR,
Snowdon DA, et al. Alzheimer’s disease, dental amalgam and
mercury. J Am Dent Assoc 1999;130:191‑9.
14. Clarkson TW, Magos L, Myers GJ. The toxicology of
mercury – Current exposures and clinical manifestations.
N Engl J Med 2003;349:1731‑7.
15. Brownawell AM, Berent S, Brent RL, Bruckner JV, Doull J,
Gershwin EM, et al. The potential adverse health effects of
dental amalgam. Toxicol Rev 2005;24:1‑10.
16. Bellinger DC, Trachtenberg F, Barregard L, Tavares M,
Cernichiari E, Daniel D, et al. Neuropsychological and renal
effects of dental amalgam in children: A randomized clinical
trial. JAMA 2006;295:1775‑83.
17. Bellinger DC, Daniel D, Trachtenberg F, Tavares M, McKinlay S.
Dental amalgam restorations and children’s neuropsychological
function: The New England children’s amalgam trial. Environ
Health Perspect 2007;115:440‑6.
18. DeRouen TA, Martin MD, Leroux BG, Townes BD, Woods JS,
Leitão J, et al. Neurobehavioral effects of dental amalgam in
children: A randomized clinical trial. JAMA 2006;295:1784‑92.
19. European Commission: Scientific Committee on Emerging and
Newly Identified Health Risks. The Safety of Dental Amalgam
and Alternative Dental Restoration Materials for Patients and
Users; 6 May, 2008.
20. Widström E, Forss H. Dental practitioners’ experiences on the
usefulness of restorative materials in Finland 1992‑1996. Br Dent J
1998;185:540‑2.
21. Mjör IA, Moorhead JE, Dahl JE. Selection of restorative materials
in permanent teeth in general dental practice. Acta Odontol Scand
1999;57:257‑62.
22. Bernardo M, Luis H, Martin MD, Leroux BG, Rue T, Leitão J, et al.
Survival and reasons for failure of amalgam versus composite
posterior restorations placed in a randomized clinical trial. J Am
Dent Assoc 2007;138:775‑83.
23. Dunne SM, Gainsford ID, Wilson NH. Current materials and
techniques for direct restorations in posterior teeth. Part 1: Silver
amalgam. Int Dent J 1997;47:123‑36.
24. Sgan‑Cohen HD, Evans RW, Whelton H, Villena RS, MacDougall M,
Williams DM; IADR‑GOHIRA Steering and Task Groups. IADR Global
Oral Health Inequalities Research Agenda (IADR‑GOHIRA(R)):
A call to action. J Dent Res 2013;92:209‑11.