Restorative Dentistry

Restoration longevity and anaiysis of reasons for the

placement and replacement of restorations provided by
vocational dentai practitioners and their trainers in the
United Kingdom
RJ.TrevorBurke. DDS, MSc, MDSVSau Wan Cheung, BSc, MSc"/
Ivar A, Mjör, Dr Odont, BDS, MSD, MS'*VNairn H. F. Wilson, PhD, M S c " "

Objective: This study Qxaminod the reasons given by vocational dental practitioners and their trainers for
placement and repiacement of restorations. Method and materials: Each participant was asked to record
the reason for placement or replacement of restorations. The age and class of the restoration being re-
placed were also recorded, as was the material being used and the material being replaced (if known).
Results: Details of the reason for placemen! or replacement was received on 9,031 restorations. Of the
restorations placed. 53.9% were amalgam. 29.8% were resin composite, and 16.3% were glass-ionomer
cement The reasons for placemen! or replacement of the restorations were principaiiy primary caries
(41.3%). secondary caries (21.9%). tooth fracture (6.4%), marginal fracture or degradation (6.1%). and
noncarious defects (5.8%). Of the amalgam restorations, most were placed to restore Class I! and Class I
preparations (65.8% and 29.9%, respectively). Qf Ihe composite restorations, most were placed in Ciass III
and Class V cavities (35.5% and 26.3%. respectively). Glass-ionomer cement was used predominantly to
restore Class V cavities (63.5%). Conclusion: Secondary caries was Ihe most prevalent reason for re-
placement of restorations, regardless of material. Statistical analysis indicated that amalgam provided sig-
nificantly greater longevity than composite or glass-ionomer materials. (Quintessence Int 1999;30:234-242)

Key words: amalgam, glass-ionomer cement, primary caries, resin composite, restoration,
secondary caries

ong-lasting dental restorations foster patient confi-

CLINICAL RELEVANCE: Amalgam restorations provided
greater (ongevity than did resin composite or giass-
ionomer restorations, and glass-ionomer restorations
were replaced because ol secondary caries as frequently
as composite restorations but less trequently than amal-
gam restorations.
'Professor oí Dentai Primary Care, University of Giasgow, Dertai
Seil ooi, Giasgow, Scotianä
"Department of Meüicai Compulallor, Uniuersitii of Manchester Man-
ctiestei. Eng i and.
•"Protessor, Deparlment of Operatiue Dentislry. Unweisity of Fiorida,
College oí Oenlistry, iHealth Science Cenier, Gainesviiie, Florida.
'"•Proiessor and Head, Unit oí Operative Derlistrii and Endcdontoiogy,
Turner Dentai Sohooi, Unii/ersity Dental Hospitai oí Manchester, Man-
chester, Engiand.
Reprint requests: Proi F.J.T. Buri<e, Professor of Déniai Primary Care,
university ot Glasgow, Denial Scfiool, 378 Sauchieliaii Streel, Giasgow G3
3JZ, Scotland. E-rnaii: f.j.t.burke®dental.gia.ac.ji(
L dence and reassure those who fund third-party in-
surance systems that a cost-effeetive serviee is being
provided. It is therefore important to research restora-
tion longevity and to seek ways to extend the in-
service durability of restorations and delay their pre-
tTtature removal. To this end, studies on reasons for
the placement and replacetnent of restorations may be
eonsidered to tuake a useful eontributlon, notably in
relation to insight into treatment decisions and patient
managetnent (by one or more dentists). In addition,
such studies provide real-life data on the rnode of fail-
ure of different types of restorative tnaterials in their
various appheations.
Until reeently, and in contrast to the data available
on certain European countries,'-^ there has been little
infortnalion available on restoration longevity in eon-
temporary clinieal practice in the United Kingdom
and reasons for the placement and replacement of
restorations. The information available is limited to
data on restoration longevity eollected by a selected
group of UK practitioners^ and subsequently by voca-
tional dental practitioners (VDPs) and their trainers.'

234 Quintessence international


In common with other studies of tbis type, stemming
from tbe work of Mjör,'* sucb research suffers from a
number of inberent limitations, and some of these
have been the subject of recent editorial correspon-
dence.^"" However, tbe autbors remain resolute in
their view that "real-world" data are necessary to un-
derstand and tackle real-world issues.
Tbe purposes of tbis article are to further examine
current restoration longevity in tbe United liingdom.
lo report the reasons for tbe piacement and replace-
ment of restorations provided by VDPs and their
trainers in the United Kingdom, and to determine
whether there are diflerences in prescribing patterns
between the VDPs and tbe trainers.
VOCATIONAL DENTAL PRACTICE
Since 1993. it bas been mandatory in tbe United King-
dom for newly qualified dentists to work for 1 year as
VDPs in specially selected "training" practices, if they
subsequently wish to practice under National Health
Ser\'ice Regulations. Vocational dental practitioners
work in practice 4 days per week, and 1 day is set
aside for structured learning, comprising iectures. sem-
inars, and so on. Eacb course is organized by a VDP
Adviser. The principal aim of vocationai training is to
give new graduates a controlled entry to general den-
tal practice. Results of a survey, in 1992. comparing
tiew graduates who had participated in a vocafional
training scheme with those who had not, indicated
that the vocational dentai practitioners gained less
ciinieai experience after 1 year than their counterparts
without vocational training. However, results also in-
dicated that the support and guidance of a more expe-
rienced colleague was essential during the first year of
pracfice for all dentists, so that patients' welfare is
safeguarded while necessary skills and knowledge are
developed.'^
METHOD AND MATERIALS
The methodology of data collection has previously
been described in detail.' All 1996 to 1997 VDPs and
their trainers (667 VDPs and 712 trainers) were in-
vited to take part in tbe study. Tbe VDPs and trainers
were given an introductory letter and instruction
sheet, including descriptions of tbe various reasons for
the placement and the repiacement of restorations
(Table 1).
Each VDP and trainer was asked to record a reason
for the placement or the replacement of consecutive
restorations completed during February 1997, up to a
maximum of 100 restorations. Tbe participants were
Quintessenca International
Burke et al •
also asked to record, for eacb restoration replaced, the
age of tbe restoration, the class of restoration, the ma-
terial forming the restoration (if known), and the ma-
terial selected for the replacement restoration. The
participants were requested to record "compomer"
materials as resin composites and resin-modified glass-
ionomer materials as glass-ionomer cements for the
purpose of the study.
A form was designed to enable participants to
record the information required with minimal disrup-
tion to tbeir practice. These were distributed to tbe
participants witb instructions for their use. In cases
where more than one reason for replacement was evi-
dent, participants were asked to record the principal
reason for intervetition. The trainers of the VDPs were
also invited to participate.
The data thereby collected were computerized and
analyzed using the statistical package SPSS for
Windows 6.1.3 (SPSS). Basic descriptive statistics, in-
cluding cross-tabulafion tables, were carried out, and,
where appropriate, nonparametric tests, such as the
Mann-Whitney U test and Kruskai-Wailis tests, were
performed.
RESULTS
Eighteen VDP groups participated; data were pro-
vided for a total of 9.031 restorations." Of the 73 den-
tists who provided data, 56 were VDPs and 17 were
trainers. Seventy-two percent of the restorations were
placed by VDPs. the remainder by trainers. A mean of
88 restorations (range: 25 to 130) was placed by eacb
participating denfist (Fig 1). Sixty percent of tbe par-
ficipating dentists were men. Witb regard to practice
locafion, 23% of participants practiced in an urban io-
cation, 24% in a rural location, and 53O.Û in a town or
city center practice.
Of tbe 9,031 restorations, 4,423 (49.0%) were initial
placements and 4,608 (51.0%) were replacements.
Overall, 53.9% of tbe restorations placed were amal-
gam, 29.8% were resin composite, and 16.3% were
glass-ionomer cement. Tbe distribution of the teeth re-
stored, by quadrants, was as foliows: maxiliary right,
28.4%; maxillary left, 28.4%; mandibular right, 20.8%;
and mandibular left, 22.3%.
Tbe ratio of new to replacement restorations was
found to be 1 to 1.1 overall. The rafio of new to re-
placement restorations was 1 to 1.3 for amalgam, 1 to
1.1 for composite, and 1 to 0.7 for glass-ionomer. Tbe
principal reasons for the placement of the 9,031
restorations have previously been reported'; these
were primary caries (n = 3,726, 41.3%), secondary
caries (n = 1,975, 21.9%), and tooth fracture (n = 580,
6.4%) (Table 2). "Other reasons" comprised princi-
235
Butke el al

TABLE 1 Instructions given to survey participants regarding reasons for

placement or replacement of restorations

Diagnosis and codes used tor piacement ol the first restorations on a tootii surface'
Primary caries is decay on a surlace not directiy associated with any existing restorations, if
interproximal caries results in the removal of an existing sound restoration, primary caries is
recorded,
Noncarious defects are lypicaliy wedge-shaped toothbrush abrasions, eroded sites, or in-
tact teeth without caries or restorations that have been subjected to trauma.
Other reasons include any other reasons for placing a restoration in a previously unrestored
tooth.

Diagnosis and codes used for replacement of restorations'

Secondary/recurrent caries is that wiiich is detected at tine margins ot an existing
restoration.
Margir>al discoloration leading \o replacement of a tooth-coiored restoration is found at the
tootli/restoration interface.
Bulk discoloration inciudes any mismatch between the coior of the body of the lestoration
and the tooth that leads to repiacement ol the restoration.
Marginal fracture/degradation is often referred to as "ditching" of restorations. Only those
restorations with marginai fractures o< degraded margins but without canes shouid be
recorded in this category of faiiuie.
Bulk fracture of a restoration includes isthmus fracture or any fracture through the mam
body of the restoration.
Fracture of the tooth is any i<ind of tooth fracture adjacent to a restoration, for example, the
fracture of a cusp cr an enamel margin.
Poor anatomic form (wear) as a diagnosis for replacement of a restoration includes any
iess of substance resuiting from materiai degradation and wear.
Pain/sensitivity of any kind requiring repiacement of a restoration is iisted under this
category.
Change of material is used to denote repiacement of serviceabie restorations where the
change per se was the reason for the repiacement rather than the failure of a restoration.

TABLE 2 Reasons for placement and replacement of

the 9,031 restorations in the survey
Reason No. %
Primary caries 3726 41,3
Secondary caries 1975 21.9
Fractured tooth 580 6.4
Maiginai fracture 546 6,0
f^Joncarious defects 527 5,8
Buik fracture 461 5,1
Pain 379 4.2
filargin discoloration 163 1.8
Buik discoloration too 1.1
30 40 &0 60 70 80 90 100 110 120 130 Poor anatomic form 56 0.6
No al (esloralions piaced by eacli dentisl Change of materiai 54 o.e
Other reasons 464 5,t

Fig 1 Distribution of restorations piacea by participating

dentists.

236 Volume 30, Number 4,1999

 1C0'

80'

60

y'
40

20

Tí! il ^ ^ - ^
1395 3562 1245 555 1774 1458 3207 70 3 133
No. No
n Class 1 ED Cl SE II • class III • class IV • Class V Dciassl Dciassil •ciasslll BciassIV • ClassV

Fig 2 Classification ot the 9,031 restorations according tc Fig 3 Amalgam reslorations by class of cavity
Biack's ciassification.

TABLE 3 Amalgam restorations by class of cavity TABLE 4 Principal reasons for placement of
amalgam restorations
Ciass No.
Reason No. %
1 1456 29.9
II 3207 65.8 Primary caries 2033 41.7
ill 70 1.4 Secondary caries 1355 27.8
IV 3 0.1 Marginal fracture degradation 334 6.9
V 133 2.7 Bulk fracture 324 6,7
Total 4871 100 0 Tootti tracture 316 6.5
Pam/sensitivity 212 4.4
Other 138 2.8
Noncarious detects 71 1.5
Marginal disco i oration 34 0.7

pally lost restorations and endodontic access. For the
4,423 initial restorations placed, the principal reasons
for operative intervention were primary caries (n =
3,624, 78.70/0 of total), noncarious defects [n = 384,
8.3% of total), and tooth fracture (n = 198, 4.3% of
total).
More Class If restorations were piaced than any
other class (Fig 2). Amalgam restorations were pre-
dominantly placed in Class !! preparafions (Fig 3 and
Table 3), principally as a result of primary caries
(Table 4), while composite restorations tended to be
placed in Ciass III, Class V, and Class fV preparations
(Fig 4), again principally as a consequence of primary
caries. Glass ionomer cement restorations were pre-
dominantly placed in Class V cavifies (Fig 5), most fre-
quently for the reason primary caries (Table 5).
The proportions of restorations placed are summa-
rized, hy class, in Fig 6. Amalgam (n = 4,871) tended
to he used to restore Class II and Class I preparations
(65.8% and l^.^^i%, respectively). Of the composite
restorations (n - 2,690), most were used for Class III
and Class V cavities (35.50/0 and 26.3''/o, respectively}.
while glass-ionomer cement (n = 1,470) was used pre-
dominantly to restore Class V cavities (63.5%),
The previous restorative material was recorded for
4,189 of the replacement restorafions (amalgam 2,924;
composite 1,003; and glass-ionomer, 262), allowing
the reason for replacement to be analyzed according
to the restorative material. Overall, secondary caries
was the most common reason for the repiacement of
restorations, accounfing for 46,0%. 39.6o.'o, and 39.8%
of the replaced restorations of amalgam, composite,
and glass-ionomer restorations, respectively. When the
incidence of secondary caries was compared with that
of all other reasons for the repiacement of restora-
tions, a highly significant difference was apparent
(Pearson chi-square value f4.227: P < 0.001). A greater
proportion of restorations of amaigam than of compos-
ite or glass-ionomer cement had been replaced hecause
of secondary caries.
For amalgam restorations, while secondary caries
was the most common reason for restorafion replace-
ment (n = 1,340; 46% of restorations), marginal frac-
ture or degradation accounted for 390 (13%), bulk

237
Quintessence Inte
• Burke et al

100

eo
60
il
40

20
II
fr\
X\y
^
11/ II
175 108 220 993
No
D Class 1 D Class II • Class 1 • Class IV • Class V

Fig 4 Resin composite restorations by Class ol cavity. Fig 5 Glass-ionomer restorations by class ol cavity.

TABLE 5 Principal reasons for placement of glass-

ionomer restorations
Reason No. %
Primary caries 659 44.9
Ncncarious delects 208 14.2
Seccndary caries 190 12.9
Other B9 6.1
Pain/sensitivity 80 5.4
Tooth fracture 78 5.3
Marginal fracture degradation 77 5.2

Fig 6 All restorations by ciass cf cavity ana materiai used

fracture for 341 (12%), and tooth fracture for 306
(llf/ü) of cited reasons. By contrast, for composite
restorations, while secondary caries was also the most
common reason for the replacement of restorations {n
= 594; 40''/o of restorations}, marginai discoloration
accounted for 117 (120/0), marginai fracture or degra-
dation for 92 (9%), isthmus fracture for 78 (go/o), tooth
fracture for 55 (6%), and other reasons for 108 {\Vk)
replacements. For restorations of glass-ionomer ce-
ment, while secondary caries was again the most com-
mon reason for restoration replacement [n = 104; 40%
of restorations), tnarginal fracture or degradation ac-
counted for 37 (14%), pain or sensitivity for 20 (8%),
bulk discoloration for 18 (7%), buik fracture for 17
(7%), and other reasons for 22 (8%) replacements.
Further analysis of the data has shown that amal-
gam was used for the management of primary caries
significantly more often than other materials (Pearson
chi-square = 113.42; P < 0.0001). Amalgam restora-
tions were placed for the reason primary caries in
54.6% of cases, composite was placed in 38.4% of
cases, and glass-ionomer was placed in 44.8% of cases.
For noncarious defects, amalgam was used in 13.5% of
cases, composite was used in 47.1% of cases, and glass-
ionomer cement was used in 39.5% of cases, a highly
significant difference (P < 0.001) indicating that the
respondent dentists used composite more frequently
than glass-ionomer for the restoration of noncarious
defects.
Among the failed restorations, the mean age of the
amalgam restorations was 6.8 years; the composite
and glass-ionomer cement restorations had mean sur-
vival ages of 4.5 and 3.8 years, respectively. Because
longevity is not normally distributed, a nonparametric
test, Kruskal-Wallis one-way analysis of variance,
was carried out to determine whether any differences
in longevity existed between the three materials. The
results indieated a highly significant difference
{P < 13.0001); the longevity of amalgam restorations
exceeded that of composite or glass-ionomer cement
restorations. The medians and ranges for the restora-
tions of amalgam, composite, and glass-ionomer

238 Voiume 30, Number 4, 1999

 Burke et al •

TABLE 6 Reasons for placement or replacement of A cross-tabulation table was performed on the five
restorations by vocational dental practitioners main reasons for placement or replacement of restora-
tions {primary caries, secondary caries, fractured
Reason No % tooth, marginal fracture, and noncarious defects), with
Primary caries 2729 42 0 VDP courses divided into England, Seotland, and
Secondary caries t518 23.3 Northern Ireland. A statistically significant difference
Tootti tracture 371 5.7 was noted [at the 1% level with Pearson chi-square
tJoncarious detects 369 5.7 value - 114.708; and P < 0.0001); the respondent den-
Bulk tracture 350 5.4 tists in England and Scotland provided a higher pro-
Marginal fracture degradation 339 5.2
Pain/se nsilivity
portion of restorations for primary caries than did
255 3.9
Marginal dtscoioration 106
those in Northern Ireland. Northern Ireland was
1.6
Buik discoloration 75 1.2
found to have the fewest number of restorations
Change ot material 36 0.6 placed for marginal fracture.
Poor anatomic term 35 0.5 Finally, the data also included information on re-
Other 316 4.9 placement of 7 gold restorations. While this number is
Total 6501 100.0 too small for statistical analysis, the results indicated
that 5 of these gold restorations were replaced as a re-
sult of secondary caries but that the mean longevity of
the restorations was 18.5 years.

DISCUSSION

cement were 6 years (0 to 40 years), 4 years (0 to 34
years), and 3 years (0 to 17 years), respectively.
A total of 268 Class 1 amalgam and 27 Class I com-
posite restorations were identified in the data for
which longevity was known. The mean longevity of
these restorations was found to be 7.4 and 3.3 years,
respectively. A total of 1.142 Class II amalgam and 71
Class II composite restorations were available for
analysis; the mean longevity of these restorations was
6.6 and 4.6 years, respectively. A total of 243 Class III
composite and 53 Class 111 glass-ionomer restorations
were available for analysis; the mean longevity of
these restorations was 5.0 and 4.8 years, respectively.
A total of 151 Class IV composite and 10 Class IV
glass-ionomer restorations were available for analysis;
the mean longevity of these restorations was 3.9 and
3.7 years, respectively. A total of 115 Class V amal-
gam, 101 Class V composite, and 130 Class V glass-
ionomer restorations were available for analysis; the
mean longevity of these restorations was 70, 4.6, and
3,2 years, respectively.
With regard to the prescribing patterns of the VDPs
and the trainers, the principal reasons given for place-
ment/replacement of restorations is shown in Table 6.
Further analysis of the data has indicated that there
was a relationship between the level of experience of
the dentist and the number of restorations placed with
respect to primary and secondary caries and the rest
of the reasons for placement or replacement; this was
highly significant (P < 0.001). For primary and sec-
ondary caries, VDPs carried out significantly greater
numbers of restorations than trainers.
The methodology used in this project was derived from
previous projects." " The data collection sheets were
redesigned to allow more complete collection of infor-
mation. Few adverse comments were received from
participants.
Vocational dental practitioners were iniated to par-
ticipate in a research project that is organized annually
for them by the Faeultj' of General Dental Practitioners
(UK). The participation rate may be considered disap-
pointing, given that only 10% of VDPs took part.
However, this was not considered surprising, because
many VDP groups organize their o\vn research projects,
leaving little time for participation in a national project.
Nevertheless, the volume of data collected is considered
sufficient to provide useful informafion about patterns
of restoration placement in dental practice in the
United Kingdom and to allow some comparison be-
tween prescribing patterns of more mature general den-
tal praetifioners (the trainers) and more recently quali-
fied general dental pracfifioners (the VDPs).
No differences in prescribing were apparent be-
tween VDPs and trainers, other than for the number
of restorations placed for caries (primary and second-
ary); the VDPs carried out greater numbers of restora-
tions for these reasons than the trainers. This may
indicate a difference in diagnostic criteria used by the
two groups. Alternatively, this finding may indicate
that VDPs see more of the new patients attending
a practice, who may be less motivated, less dentally
aware, and more caries active, than do the trainers,
whose patient base may be expected to contain more
regular attenders.

Quintessence Internaticnal 239

 3urke et al
The resuhs of the present study largely confirmed
the results of a previous study, among selected practi-
tioners,^ which indicated that secondary caries was
most frequently considered to be the reason for
replacement of restorations and primary caries was
most frequently considered to be tbe reason for tbe
placement of restorafions.^' In the previous study," 22
selected practitioners collected information on 2,379
restorations. The results indicated that around 60%
of the restorations were replacements; secondary
caries was the principal reason for replacement of
restorations of amalgam and glass-ionomer cement.
For restorafions of resin composite, secondary caries
and poor appearance accounted for equai proportions
of restorafion replacernents.
The present results also confirmed the findings of a
previous puhiication,^ which reported a pilot study
that has given rise to substantial debate.^"" In tbat
work, tbe most frequent reason given by a group of
Swedish dental practitioners for tbe replacement of
glass-ionomer restorations was secondary caries, a
surprising result, given tbe previous considerafion tbat
fiuoride release of conventionai glass-ionomer cements
was one of tbeir greatest assets" and tbe caries inhibi-
tion demonstrated by some resin-modified glass-
ionomer liners."'' In tbe present study, tbe most pre-
valent reason for the replacetTient of glass-ionomer
restorations was secondary caries (39.8% of cases);
tbis percentage was similar to that for composite
(39.6%) but slightly less tban tbat for amalgam
(46.0%). Interpretation of tbese findings is difficult,
because no data were collected on patient cbaracteris-
fics such as caries activity, oral hygiene, age, and diet,
let alone precise details of tbe material used.
It may be assumed tbat, because the average life of
the glass-ionomer restorations was 3.8 years, the
majority of the restorations were formed in conven-
tional glass-ionomer materials rather than tbe more re-
cently introduced resin-modified glass-ionomer ce-
ments, wbicb may perform better in terms of fluoride
release, color stability, and bonding to dentin.'^
Nevertheless, the results would appear to lend support
to the question that now surrounds the cariostatic ef-
fects of giass-ionomer materials.'"
The vaiidity of the practitioners' stated reasons was
not tested, and it may be that aspects of their diag-
noses were imperfect; this would be expected among a
group of newly qualified practifioners such as those in
the present study. However, it may also be argued that
these denfists have had the benefit of recent teaching
in their undergraduate course. In particular, the diag-
nosis of secondary caries bas been considered to be
difficuh." However, tbe diagnostic criteria were tbe
same for eacb material, tbus allowing comparison
among materials.
240
Tbe mean restoration longevity, at 6.8, 4.5, and 3.8
years, respectiveiy, for amalgam, composite, and glass-
ionomer restorations (median: 6, 4, and 3 years for
amalgam, composite, and glass-ionomer restorafions,
respectively), was less tban previously publisbed data,
which indicated tbat the median age of restorations
placed by a group of general dental practifioners in
Sweden was 9, 6, and 3 years for amalgam, resin com-
posite, and glass-ionomer, respectiveiy.' It is tberefore
apparent tbat tbe UK data indicated a less favorable
performance of restorations tban in Sweden; furtber-
more, the UK data compared unfavorabiy with data
on longevity of composite Class I and Class II restora-
tions placed in private practice in Germany'^ and ex-
tensive amalgam restorations placed in Australia,"
Work is now required to investigate the reasons for
tbe differences in performance of restorations in dif-
ferent countries.
The greater number of Class II than Class I amal-
gam restorations placed for primary caries may be
considered surprising, given tbe potentiai for fluoride
tootbpaste, used predominantly in tbe United
Kingdom, to reduce smooth-surface caries. Further
work may be indicated to investigate whether the data
represent a bigh incidence of interproximal caries
per se, or whether practitioners are using outmoded
concepts for the management of approximal caries,
given tbat longitudinal radiograpbic analysis of carious
lesion progression bas shown tbat 50% of enamel
lesions, if left untreated, would not progress into
dentin for a period of 73 montbs.^"
With regard to restorative material for load-bearing
surfaces, the data indicated that amalgam is still the
most frequently used material; composite restorations
accounted for 262 and 247 Class I and Class II
restorations, respectively, while tbere were 1,458 Class
I and 3,207 Class 11 amalgam restorations. Tbis would
appear to indicate eitber tbat patients in tbe United
Kingdom are not especially concerned to bave estbetic
restorations placed in their posterior teetb and that
tbere are no particuiar anxieties among a substantial
proportion of tbe dental population with regard to
mercury, or tbat concerns about tbe bigher cost of
resin composite restorations predominate."
In this respect, the longevity of composite restora-
tions placed in ioad-bearing areas was shorter than
that of amaigam restorations in similar situations,
given that the mean longevity of Class 1 amalgam and
composite restorations was found to be 7.4 and 3.3
years, respectively. Similarly, tbe data on longevity of
Class II amalgam and Class II composite restorations
indicated that the mean longevity of these restora-
tions was 6.6 and 4.6 years, respectively. It would
therefore appear that a substantial price must be paid
in tenns of restorafion cost effectiveness when, in the
Voiume 30. Number 4.

United Kingdom, resin composite is used for restora-
tions in load-bearing situations, confirming an earlier
conclusion,-"
It would therefore appear that research is required
to determine the reasons for the less satisfactory per-
formance of these restorations (at least, in comparison
to amalgam), given that a mcta-anaiysis of cotnposite
restorations indicated that their performance was, in
general, satisfactory.-- and that a sttidy comparing the
performance of resin composite and amalgam restora-
tions concluded that the resin composite was as effec-
tive as amalgam.-^ However, the differences that have
been identified may simply reflect the difference be-
tween restorations placed in general dental practice
and those placed in the highly controlled conditions
prevailing for clinical trials.
Finally, a total of 243 Class III composite and 53
Class HI glass-ionomer restorations were available for
analysis; the mean longevity' of these restorations was
fotind to be 5.0 and 4.8 years, respectively. Given that
there was little difference in longevity between these
materials when used in Class HI cavities, it would ap-
pear that it is for the clinician to weigh the potential
benefits of good esthetics (for composite) against the
possible benefits of fluoride release and adhesion to
tooth substance (for glass-ionomer) for a particular
patient and clinical situation.
A total of 115 Class V amalgam, 101 Class V com-
posite, and 130 Class V glass-ionomer restorations
were available for analysis; the mean iongevity of
these restorations was found to be 7.0, 4.5, and 3.2
years, respectively. It would tberefore appear that, in
situations where appearance is not of relevance, amal-
gam should be used. However, given tbat a substantial
proportion of Class V restorations are placed in non-
carious, nonretentive cavities, tbe benefits of minimal
preparation and the adhesive nature of composite
(when used with a dentin bonding system) and glass-
ionomer may weigh highly in their favor.
CONCLUSION
The results indicated that primary caries was the
most common reason for placement of restorations
by the participating dentists and that secondary
caries was the most prevalent reason for the replace-
ment of amalgam, composite, and glass-ionomer
restorations. Amaigam restorations were found to
have significantly greater longevity than composite or
glass-ionomer restorations. No differences were
noted in prescribing patterns, except that tbe VDPs
carried out significantly greater numbers of restora-
tions because of primary and secondary caries than
did the trainers.
Quintessence International
Burke et al •
ACKNOWLEDGMENTS
The authors wish lo thank the participating dentists for their diligence
and lime in completing the data collection forms. The project could
iim have been carried oui without their help.
This project was organized by the authors under the auspices of Ihe
Research Commiliee of (lie Faculty of General Dental Practitioners;
thanks are Jue lo the members of the Research Commillee for Iheir
helpful cummenls on the project at Ihe protocol stage. Thanks are also
due to BUPA Denial Cover for providing secretarial suppon for Ihe
itudy and for dismbuling the dala colleclion sheets and associated ma-
terials. The authors also actjiuwledge the assistance from Mr George
Smilh in producing Figs 2 to 7.
REFERENCES
1. MjÖr IA, Toftmetti F, Placement and replacement of atnal-
gam restorations in Italy. Oper Dent 1992:17:70-73,
2. Friedl K-H, Hiller KA, Schmalz G. Placement and replace-
ment of amalgam restorations in Germany. Oper Dent 1994;
19:228-232,
3. Mjor IA, The reasons for replacement and the age of failed
restorations in general dental practice. Acta Odontol Scand
1997:55:58-63.
4. Mjör TA. Glass ionomer cement restorations and secondary
caries: A preliminary report Quintessence Int 1996:27:
171-174.
5. Qvist J, Qvist V, Mjör IA, Placement and replacement of
amalgam restorations in Denmark. Acta Odontol Scand
1990;48:297-303.
6. Wilson NHF. Burke FJT, Mjör IA. Reasons for placement
and replacement of restorations of direct restorative materi-
als by a selected group of practitioners in the United
Kingdom. Quintessence Int 1997;28:245-248
7. Burke F|T, Cheung SW, Mjör IA, Wilson NHF Reasons for
the placement and replacement of restorations in Vocational
Training Practices. Primarj' Dent Care (in press).
8. Mjör IA, Placement and repiacement of restorations. Oper
Dent 1981:6:49-54.
9. Swift E), Bader |D. Shugars DA, Glass-ionomer cement
restorations and secondari' caries, A prelitninary report [let-
ter] Quintessence Int 1996:27,581,
10. Forsten L. Glass-ionomer cement restorations and secondary
caries: A preliminary report, [letter]. Quintessence Int 1996;
27:791.
11. Mount GJ. Another letter on glass-ionomer cetnent restora-
tions [letter]. Quintessence Int 1996;27:582.
12. Levine RS Experience, skill and knowledge gained by newly
qualified dentists during their first year of general practice.
BrDent) 1992:172:97-102.
15. Sidhu SS, Walson TF Resin-modified glass ionomer mater-
ials. A status report for the American journal of Dentistry.
AmJ Dent 1995:8:59-67
14. Suoto M, Donly KJ, Caries inhibition of glass ionomers. Am
J Dent 1994,7:122-124,
15. Cao DS, Hollis RA, Hicken CB, Christensen RB. Fluoride
release from glass ionomers, glass ionomer/resins and com-
posites [abstract 260]. J Dent Res 1994;73:184.
16. Randall R, Wilson NHF. Glass ionomers: Systematic review
of a secondary caries treatment effect [abstract 378], J Dent
Res 1997 ;76:1066.
241
f7. Fontana M. Secondary caries: Relation with current criteria
used toreplacerestorations. Gen Dent 1995;43:t45-152,
18. Guertsen W, Schoeler U. A 4-year retrospective clinical
study o[ Class I and Class (1 cotnposite restorations, J Dent
1997;25:229-232.
19. Smales RJ, Hawthorne WS. Long-term survival of extensive
amalgams and posterior crowns. ) Dent 1997 ;25:225-227.
20. Berkey CS, Douglass CW, Valachovic RW, Chauncey HH.
Longitudinal radiographie analysis of carious lesion progres-
sion. Community Dent Oral Epidemiol t988;16:83-90.
21. Mjör [A, Burke FJT. Wilson NHF, Therelativecost of differ-
ent restoradons in tlie UK. Br Dent J 1997;182:285-289,
22. El-Mowafy OM, Lewis DW, Benmergui, Lcvinlon C, Meta-
analysis on long-term clinical performance of posterior com-
posites, ) Dent 1994:22:33-43,
23. Norman RD, Wright JS, Rydberg R|, Felkner LL. A 5-year
study comparing a posterior composite resin and an amal-
gam. J Prosthet Dent 1990;64;523-529,

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w9mjÊ Answers to Ql 1/99 Questions E

5, C 9, C 13, D
2. C 6, A 10. A 14, C
3. C 7. B 11, B 15, A
4. D 8. B 12. A 16, B

242 Volume 3D, Number 4, 1999