|Year : 2014 | Volume
| Issue : 1 | Page : 30-36
Factors influencing Saudi dental students' preference of amalgam or composite for posterior dental restorations
Sharat Chandra Pani1, Mohammad Fawaz Al Abbassi2, Abdulrahman Daham Al Saffan2, Maged Abdulrahman Al Sumait2, Ahmed Nassir Shakir2
1 Department of Preventive Dentistry, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia
2 Department of Intern, Riyadh Colleges of Dentistry and Pharmacy, Riyadh, Saudi Arabia
|Date of Web Publication||2-Jan-2014|
Sharat Chandra Pani
Department of Preventive Dentistry Riyadh Colleges of Dentistry and Pharmacy, PO Box 84891, Riyadh 11681
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study was to tabulate the factors effecting Saudi dental students' selection of a posterior restorative dental material and compare those factors between a private and a government dental school in Riyadh.
Materials and Methods: The sample comprised of 267 students studying in both the private dental college (67 males, 75 females) and the government dental college (55 males, 70 females) in their last 3 years of clinical training. The students were administered a structured questionnaire specifically designed for the purpose after obtaining informed consent. Responses were compared between the students of each school using the chi-square and Mann-Whitney U test. Each student's responses to amalgam and composite were measured using the Wilcoxon signed rank test.
Results: Overall composite resin was the material preferred by a majority of the students regardless of the type of school. Students in both the private and the government college were likely to give higher scores for composite than amalgam. A majority of students in both schools felt that amalgam could not be completely replaced with composite. When asked to list the main drawbacks of amalgam and composite most of the respondents answered lack of esthetics for amalgam, while they listed micro-leakage as the greatest drawback of composites.
Conclusion: The findings of our study suggest that dental students in the Kingdom of Saudi Arabia seem to possess the ability to work confidently with posterior composite resins and seem to be comfortable in doing so; however, there is a significant difference in the factors influencing their choice of material.
Keywords: Amalgam, composite, dental students
|How to cite this article:|
Pani SC, Al Abbassi MF, Al Saffan AD, Al Sumait MA, Shakir AN. Factors influencing Saudi dental students' preference of amalgam or composite for posterior dental restorations. Saudi J Oral Sci 2014;1:30-6
|How to cite this URL:|
Pani SC, Al Abbassi MF, Al Saffan AD, Al Sumait MA, Shakir AN. Factors influencing Saudi dental students' preference of amalgam or composite for posterior dental restorations. Saudi J Oral Sci [serial online] 2014 [cited 2020 Jun 6];1:30-6. Available from: http://www.saudijos.org/text.asp?2014/1/1/30/124183
| Introduction|| |
Advances in composites have revolutionized the management of posterior teeth affected by caries, facilitating a minimal invasive approach. , As dentists the world over switch to minimal invasive restorative procedures and as patients get more demanding with their esthetic demands, composites have slowly begun to replace amalgam as the posterior restoration of choice in many private practices. ,,,, Surveys in the USA, Europe and Brazil suggest that despite a greater acceptance of the use of composite resins in posterior teeth, teaching of newer restorative techniques has not kept pace with advances in the materials sciences. , There have also been reports of a need to address the potential conflict between restorative techniques taught in dental schools and the materials used by dental practitioners. ,,
Preference for amalgam or composite as a posterior restorative material has been said to depend upon patient preference, ease of use, time taken and perceptions of durability.  While there is a vast pool of data for clinicians' reasons for choice of material,  relatively less is known about factors influencing these choices among students or their level of comfort with each of these materials. In the past few years there have been a series of papers focusing on the teaching of posterior restorative techniques in schools across the world. ,, While these papers have focused on the curricula of different schools, few have attempted to study the impact they have had on student perception and preference of posterior restorative material.
The system of dental education in Saudi Arabia has undergone a rapid expansion in past decade with the establishment of several new government, as well as private dental schools. While the topics covered in both government and private schools are similar, with the syllabus being regulated by the same higher authority, there are differences in the structure of the clinical hours as well as the method of teaching these courses. While the course in the government school is taught over 5 years in addition to 1 preparatory year, the course in the private school is taught over 12 semesters spanning a total of 6 academic years. The government school in question had a traditional distribution of students across departments, with students performing required tasks in each department; whereas the private school followed a system of 'comprehensive clinics' where the entire dental treatment of a patient was carried out by the same student on a single clinical floor with all specialists available for consultation and supervision rather than fixed departments dealing with only specific procedures.
Despite the rapid growth of dental education in Saudi Arabia, there is scant data on student attitudes toward the placement of posterior restorative materials in the Kingdom in particular or the Middle East in general.
Given the current scenario, we decided to tabulate the factors effecting Saudi dental students' selection of a posterior dental material and compare those factors between a private and a government dental school in Riyadh.
| Materials and Methods|| |
The study was conducting after obtaining ethical clearance from the research center of the Riyadh Colleges of Dentistry and Pharmacy.
Development of the questionnaire
A pool of questions was prepared after reviewing the literature and interviewing both final year students and instructors of the private college. Using the most common responses the questionnaire was then reduced to 11 items that were thought to most reflect the concerns of both students and instructors alike. These were then framed in the form of a structured questionnaire and then administered to five students who were blinded as to the purpose of the study. After minor modifications in the format the questionnaire was finalized. The final questionnaire comprised of 11 main questions, excluding demographic data. The questions concerned with the factors affecting preference for amalgam (Q5) and composite (Q6) were further subdivided, using the most common factors cited in the question pool. The responses to both these questions were standardized and scored on a four-point Likert type scale, with 1 indicating that the factor had no influence and 4 indicating that the factor was very influential.
A pilot questionnaire was administered as a pilot to 20 students and re-administered to those students after 1 month to test for reliability using the Cronbach's alpha test. , Once the reliability of the questionnaire had been established, the questionnaire was distributed to the study population.
The sample comprised of 267 students studying in both the private dental college (67 males, 75 females) and the government dental college (55 males, 70 females) in their last 3 years of clinical training. The students were administered the questionnaire by one of the investigators after obtaining informed consent.
All data was coded and analyzed using SPSS ver.19 data processing software. The responses between groups to questions with categorical answers were compared using the chi-square test, with the z test used to measure specific responses between students of the government and private school. The questions which were scored on the Likert scale were compared using the Mann-Whitney U test. The responses of each student for amalgam were paired with their responses for composite and significant differences were measured using the Wilcoxon signed rank test. The test was run separately for the students of the government and the private school and was tabulated so as to ascertain a difference in the reasons, if any, for the students' preference of a particular material.
| Results|| |
When the questions regarding theoretical and pre-clinical training in amalgam were considered there was a significant difference in the responses of the students in the government and private schools. While the students in the government school felt that their studies in both amalgam and composite were equal, students in the private school reported that their studies on amalgam were greater than their studies on composite [Table 1] .
|Table 1: Students responses on questions regarding their training in the use of amalgam and composite |
Click here to view
When the questions regarding clinical skill and comfort while using each material were compared we found that overall composite resin was the material preferred by a majority of the students regardless of the type of school, with most respondents saying that it took less time to prepare a cavity for composite resin. However, students in the government school were more likely to state that their preference of material did not matter, or that they took the same time in preparing a cavity for both amalgam and composite [Table 2].
|Table 2: Students responses on questions regarding their clinical ease in the use of amalgam and composite |
Click here to view
When the responses for factors influencing their preference of material were compared between the private and the government school [Table 3], we found that the difference in perception differed according to the material used. When it came to amalgam, a significantly higher number of students in government school believed that they would choose amalgam because it was an easier material for them to handle, while the only reason where students in the private school assigned a higher score to amalgam was the consideration of cost. Students in the government school tended to assign higher scores to amalgam than students in the government school for most other questions, even though this difference was not statistically significant. In the case of composite resins the students in the private school assigned higher scores to composite for all questions when compared to those in the government school. The scores were significantly higher when it came to the questions that pertained to patient perception, ease of use, cost of the material and cavity preparation.
|Table 3: Differences between students in the influences affecting usage of amalgam and composite |
Click here to view
When the responses of each student to the questions regarding amalgam and composite were paired and analyzed it was found that the students in both the private and the government college were likely to give higher scores for composite than amalgam [Table 4]. In the private schoo,l a significantly higher number of students felt that they had more lectures taken on composite, their instructors preferred they use composite, their patients preferred composite restorations and that composite was an easier material to use and prepare cavities for. They perceived no significant difference in the cost of the amalgam or composite restoration. However, they felt that the properties of composite were significantly inferior to those of amalgam.
|Table 4: Differences between government and private students in factors affecting usage of amalgam and composite |
Click here to view
The responses of the students in the government school were similar with regards to the lectures taken, patient preference, cost and ease of cavity preparation and material properties. However, unlike the students in the private school, they did not feel that composite was easier for them to use and handle. A greater number of them felt that amalgam was easier to handle, though this difference was not statistically significant.
When the students' attitude toward the restorative materials and their views on the future of amalgam were compared [Table 5], we found that a majority of students in both schools felt that amalgam could not be completely replaced with composite. However, the z test showed that a significantly higher number of students in the private school felt that amalgam would be replaced by composite resin restorations. A greater number of students felt that composite was a good substitute for amalgam although this difference was significant only in the private school. There was a significant difference in the perception of longevity of composite resin restorations in the mouth of a patient with good oral hygiene. While students in the private school felt that in such a patient a posterior composite restoration would last as long as amalgam, a significantly higher number of students in the government school felt the opposite.
When asked to list the main drawbacks of amalgam and composite [Table 6], most of the respondents answered lack of esthetics for amalgam, while they listed micro-leakage as the greatest drawback of composites.
|Table 5: Comparison of students' opinion about the greatest drawback of both amalgam and composite |
Click here to view
|Table 6: Comparison of students' perception of the future of amalgam and the viability of composite |
Click here to view
| Discussion|| |
The debate to use amalgam or not is as old as dentistry itself;  however, with the availability of a viable alternate in posterior composite resins the debate in literature seems to be moving toward when, rather than if, amalgam can be completely replaced.  As the use of posterior composite resins has been increasing in practices the world over, the question of whether our education of students in these materials have kept place has also been studied in literature. ,,,, The primary aim of this study was to view this debate from the perspective of the student rather than the educator.
Given the trends among patients as well as dentists the world over, ,,,,, it is perhaps not surprising that students in both the schools we studied tended to favor composite over amalgam in posterior teeth. This finding is similar to those reported from several European and American dental schools in the past few years. ,,,,,
We found that students in the private school felt they had more emphasis on amalgam than composite, while those in the government school felt that their training in both materials was equal. The curriculum of both schools is regulated by the Ministry of Higher Education, Kingdom of Saudi Arabia; ensuring that though mildly different, the overall structure of the courses is similar. Given this fact a possible reason for this difference could be the nature of the clinical environment of the schools. While the government school has a free clinic, the patients pay for treatment in the private school, thus perhaps indirectly influencing the type of restorative material placed. It was interesting to note that in both schools students agreed that composite resin was the material the patient was likely to prefer over amalgam. The findings of this study suggest that exposing students to a situation where they have to convince patients, not only of the need for treatment, but also of the need to pay for it places them in a position where they are more likely to be in tune with the demands and needs of the patients they are likely to encounter in their practices.
Given the above argument it is perhaps natural then that the students in the government school were ambivalent as to their preference of material, while those in the private school were significantly more in favor of composite resin restorations over amalgam. While one can appreciate the comfort of the students with the use of composite resin, a lack of ease with amalgam in the students of the private college is a worrisome trend. While the concept of an "amalgam"-free dental school has been floated in literature,  amalgam still comprises a significant portion of the restorations placed in Saudi Arabia, and the country is far from the stage of "amalgam-free" dentistry.
The students in both schools felt at ease with the use of composite resin restorations. One of the reasons for this could be the fact that the specialty of dentistry is relatively young in the Kingdom of Saudi Arabia. Thus, traditional "barriers" to the teaching of posterior composite restorations , may be less applicable. An argument supported by the fact that students from both schools reported that a majority of their instructors preferred them to use composite over amalgam. The findings also support the argument that the instructor plays an important role in influencing the students' preference of material.
The difference in the cost of placing either amalgam or composite posterior restorations is a subject that has been discussed in literature. Traditionally, amalgam restorations have always been cheaper than composite; however, recent advances in composite resins along with increasing prices of silver have meant that today an amalgam restoration costs as much to place as a composite resin restoration. ,,, However, it has been suggested that the long-term viability of amalgam reduces overall cost to the patient. , Restorative care in the government college was free, whereas the private school charged the same price for similar amalgam and composite restorations. Our study suggests that while students were aware of the short-term costs of placing a restoration, they did not give much thought to the long term cost of placement of a restoration. Interestingly, although many of the students surveyed felt that composites could replace amalgam in the mouth of a patient with good oral hygiene, questions about the durability of composite still remained.
The debate of whether composite will ever replace amalgam is at least two decades old, and yet the view that we can move toward an "amalgam-free" practice is not the one that is universally accepted.  One of the greatest objections to amalgam in the West, especially in Europe, has been the threat of mercury toxicity , a view that has been criticized. , The respondents in our study however ranked mercury toxicity way below the concerns of esthetics and excessive tooth preparation. The significantly higher number of students in the private school who objected to amalgam on the grounds of destructive tooth preparation seems to suggest that students, who are encouraged in the use of composite, may subconsciously assimilate the principles of minimal intervention better than students who routinely use amalgam.
Data on the use and preference of posterior restorative materials in the Middle East remains scant.  A recent study from Iran highlighted that the education on restorative techniques in that country are compatible with standards practiced in the West.  Our study suggests that while curricula and education standards certainly form the core of education, students with very similar curricula may have different perceptions based on the clinical setting they work in.
| Conclusions|| |
The findings of our study suggest that dental students in the Kingdom of Saudi Arabia seem to possess the ability to work confidently with posterior composite resins and seem to be comfortable in doing so. However, the reasons for choosing composite resin restorations over dental amalgam vary, and seem to be influenced by the clinical setting in which the student worked. Given the scant data on the subject in the Middle East, similar studies in different colleges in the region can greatly help to understand student perception, attitude and comfort in using posterior composite resin restorations.
| References|| |
|1.||Christensen GJ, Child PL Jr. Has resin-based composite replaced amalgam? Dent Today 2010;29:108, 110. |
|2.||Roulet JF. Benefits and disadvantages of tooth-coloured alternatives to amalgam. J Dent 1997;25:459-73. |
|3.||Domejean-Orliaguet S, Tubert-Jeannin S, Riordan PJ, Espelid I, Tveit AB. French dentists' restorative treatment decisions. Oral Health Prev Dent 2004;2:125-31. |
|4.||Gilmour AS, Evans P, Addy LD. Attitudes of general dental practitioners in the UK to the use of composite materials in posterior teeth. Br Dent J 2007;202:E32. |
|5.||Espelid I, Cairns J, Askildsen JE, Qvist V, Gaarden T, Tveit AB. Preferences over dental restorative materials among young patients and dental professionals. Eur J Oral Sci 2006;114:15-21. |
|6.||Gordan VV, Abu-Hanna A, Mjor IA. Esthetic dentistry in North American dental schools. J Can Dent Assoc 2004;70:230. |
|7.||Lynch CD, Wilson NH. Teaching of direct posterior resin composite restorations in UK dental therapy training programmes. Br Dent J 2010;208:415-21. |
|8.||Lynch CD, McConnell RJ, Wilson NH. Teaching of posterior composite resin restorations in undergraduate dental schools in Ireland and the United Kingdom. Eur J Dent Educ 2006;10:38-43. |
|9.||Lynch CD, McConnell RJ, Wilson NH. Teaching the placement of posterior resin-based composite restorations in U.S. dental schools. J Am Dent Assoc 2006;137:619-25. |
|10.||Ottenga ME, Mjor I. Amalgam and composite posterior restorations: Curriculum versus practice in operative dentistry at a US dental school. Oper Dent 2007;32:524-8. |
|11.||De MR, Delme K. Black or white - Which choice for the molars? Part 2. Which does one choose for the restoration of posterior teeth: Amalgam or composite?. Rev Belge Med Dent 2008;63:135-46. |
|12.||Burke FJ, McHugh S, Hall AC, Randall RC, Widstrom E, Forss H. Amalgam and composite use in UK general dental practice in 2001. Br Dent J 2003;194:613-8. |
|13.||Lynch CD, Guillem SE, Nagrani B, Gilmour AS, Ericson D. Attitudes of some European dental undergraduate students to the placement of direct restorative materials in posterior teeth. J Oral Rehabil 2010;37:916-26. |
|14.||Johnston JM, Leung GM, Fielding R, Tin KY, Ho LM. The development and validation of a knowledge, attitude and behaviour questionnaire to assess undergraduate evidence-based practice teaching and learning. Med Educ 2003;37:992-1000. |
|15.||Adams ME, Dollard J, Hollins J, Petkov J. Development of a questionnaire measuring student attitudes to working and living in rural areas. Rural Remote Health 2005;5:327. |
|16.||Hyson JM Jr. Amalgam: Its history and perils. J Calif Dent Assoc 2006 Mar;34:215-29. |
|17.||Fukushima M, Iwaku M, Setcos JC, Wilson NH, Mjor IA. Teaching of posterior composite restorations in Japanese dental schools. Int Dent J 2000;50:407-11. |
|18.||Gordan VV, Mjor IA, Veiga Filho LC, Ritter AV. Teaching of posterior resin-based composite restorations in Brazilian dental schools. Quintessence Int 2000;31:735-40. |
|19.||Lynch CD, Frazier KB, McConnell RJ, Blum IR, Wilson NH. State-of-the-art techniques in operative dentistry: Contemporary teaching of posterior composites in UK and Irish dental schools. Br Dent J 2010;209:129-36. |
|20.||Mackert JR Jr., Wahl MJ. Are there acceptable alternatives to amalgam? J Calif Dent Assoc 2004;32:601-10. |
|21.||Shugars DA, Bader JD. Cost implications of differences in dentists' restorative treatment decisions. J Public Health Dent 1996;56:219-22. |
|22.||Vidnes-Kopperud S, Tveit AB, Gaarden T, Sandvik L, Espelid I. Factors influencing dentists' choice of amalgam and tooth-colored restorative materials for Class II preparations in younger patients. Acta Odontol Scand 2009;67:74-9. |
|23.||Roeters FJ, Opdam NJ, Loomans BA. The amalgam-free dental school. J Dent 2004;32:371-7. |
|24.||Bharti R, Wadhwani KK, Tikku AP, Chandra A. Dental amalgam: An update. J Conserv Dent 2010;13:204-8. |
|25.||Sjogren P, Halling A. Survival time of Class II molar restorations in relation to patient and dental health insurance costs for treatment. Swed Dent J 2002;26:59-66. |
|26.||Langworth S, Sallsten G, Barregard L, Cynkier I, Lind ML, Soderman E. Exposure to mercury vapor and impact on health in the dental profession in Sweden. J Dent Res 1997;76:1397-404. |
|27.||Mutter J. Is dental amalgam safe for humans? The opinion of the scientific committee of the European Commission. J Occup Med Toxicol 2011;6:2. |
|28.||Berry TG, Summitt JB, Chung AK, Osborne JW. Amalgam at the new millennium. J Am Dent Assoc 1998;129:1547-56. |
|29.||Al-Samhan A, Al-Enezi H, Alomari Q. Clinical evaluation of posterior resin composite restorations placed by dental students of Kuwait University. Med Princ Pract 2010;19:299-304. |
|30.||Sadeghi M, Lynch CD, Wilson NH. Trends in dental education in the Persian Gulf--an example from Iran: Contemporary placement of posterior composites. Eur J Prosthodont Restor Dent 2009;17:182-7. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]