1.

Burke FJ, Wilson NH, Cheung SW, Mjor IA Influence of patient factors on age of restoration failure and reasons for their replacement and replacement Journal Dentistry 29:317-324. 2. Lavelle C.L A cross sectional longitudinal survey into the durability of amalgam restorations. Journal Dentistry 4:139-143. 3. Tveit AB, Espelid I Class II amalgam: inter observer variations in replacement decisions diagnosis of caries and crevices International Dental Journal 42: 12-18. 4. Forss H, Widstrom E Reasons for restorative therapy and the longevity of restorations in adults Acta Odonologica Scandinevica 62: 82-86.

Dental Amalgam Overview

Amalgam Use and Benefits

Dental amalgam, in widespread use for over 150 years, is one of the oldest materials used in oral health care. Its use extends beyond that of most drugs, and is predated in dentistry only by the use of gold. Dental amalgam is the end result of mixing approximately equal parts of elemental liquid mercury (43 to 54 percent) and an alloy powder (57 to 46 percent) composed of silver, tin, copper, and sometimes smaller amounts of zinc, palladium, or indium. Because of a general decline of dental caries among school children and young adults, the use of dental amalgam began to decrease in the 1970s. There are also changes in patterns of dental caries, largely the result of topical and systematic fluoride, sealant use, improved oral hygiene practices and products and possibly dietary modifications. In 1990, over 200 million restorative procedures were provided in the United States; of these, dental amalgam accounted for roughly 96 million, a 38 percent reduction since 1979. This trend is expected to continue. There are also reports that carious lesions today are generally smaller, easier to treat, and managed by more conservative treatment that retains tooth structure. Because of this decrease in the frequency and size of dental caries, there has been a relative increase in the use of alternative dental restorative materials. The most commonly used and less expensive of the alternate materials, however, cannot be used for large lesions and need more frequent replacement. Also, there are currently many serviceable dental amalgam restorations that will need replacing in the future. Approximately 70 percent of the resotrations placed annually are replacements. Most of these replacements will require amalgam or other metallic materials, because compositie materials often lack sufficient strength or durability to be considered adequate substitutes.

Today, dental amalgam is used in the following situations:

in individuals of all ages, in stress-bearing areas and in small-to moderate-sized cavities in the posterior teeth, when there is severe destruction of tooth structure and cost is an overriding consideration,

as a foundation for cast-metal, metal-ceramic, and ceramic restorations, when patient commitment to personal oral hygiene is poor, when moisture control is problematic with patients, when cost is an overriding patient concern.

It is not used when:

esthetics are important, such as in the anterior teeth and in lingual endodontic-access (root canal) restorations of the anterior teeth, patients have a hisotry of allergy to mercury or other amalgam components, a large restoration is needed and the cost of other restorative materials is not a significant factor in the treatment decision.

Highlights of the Report on Dental Amalgam

Dental amalgam has been used as a dental restorative material for over 150 years. Amalgam remains popular because it is strong, durable and relatively inexpensive. Roughly 200 million restorative procedures performed in 1990 used amalgam. Nonetheless, amalgam use is declining because the incidence of caries is decreasing and because improved substitute materials are now available for certain applications. Dental amalgam, an inter-metallic compound, contains elemental mercury that is emitted in minute amounts as vapor. Becuase vapor emitting from amalgam restorations can be absorbed by the patient through inhalation, ingestion, or by other means, concerns have been raised about possible toxicity. At present, there is scant evidence that the health of the vast majority of people with amalgam is compromised, nor that removing amalgam filings has a beneficial effect on health. It also is recognized that a total conversion from dental amalgam to alternative materials would cause a significant increase in U.S. health care costs. Nonetheless, the possiblity that this material, as well as currently available alternatives, could pose health risks cannot be totally ruled out becuase of the paucity of definitive human studies. Given the limitations of existing scientific data, a research program should be designed and implemented to fill as many gaps as possible in current knowledge about the potential long-term biological effects of dental amalgam and alternative restorative materials. The Public Health Service (PHS) should be a leader in this effort. The PHS should also educate dental personnel and consumers about the risks and benefits of dental amalgam. An educational program should include information on all restorative materials to help dentists and their patients make informed dental treatment decisions, and encourage dental care providers to report adverse reactions. Such a program should promote the use of preventative measures such as fluoride and dental sealants to prevent caries and thus further reduce the need for dental restorations. To exert greater control over dental amalgam use, the Food and Drug Administration (FDA) should regulate elemental mercury and dental alloy as a single product. To help dentists identify patients who may exhibit allergic hypersensitivity to all restorative materials, including dental amalgam, the FDA should require manufacturers to disclose the ingredients of these materials in product labeling. Sweden, Denmark, and Germany have proposed restrictions on dental amalgam use to diminish both human exposure to and environmental release of mercury and not becuase of any documented health effects associated with exposure to dental amalgam. The U.S. Public Health Serice believes it is inappropriate at this time to recommend any restrictions on the use

of dnetal amalgam, for several reasons. First, current scientific evidence does not show that exposure to mercury from amalgam restorations poses a serious health risk in humans, except for an exceedingly small number of allergic reactions. Second, there is insufficient evidence to assure the public that components of alternative restorative materials have fewer potential health effects than dental amalgam including allergictype reactions. Third, there are significant efforts underway in the U.S. to reduce the amount of mercury in the environment. And finally, as stated previously, amalgam use is declining due to a lessening of the incidence of dental caries and the increasing use of alternative materials. [Dental Amalgam] [Amalgam Safety] [Amalgam Facts] [Amalgam Overview]

Amalgam Menu | Dental Information Menu

Stuart A. Greene, DDS-FAGD 2009 Birdcreek Terrace Temple, TX 76502 254.773.9007 | Fax 254.773.8051 2004 Stuart A. Greene, DDS-FAGD | Online since 1996 | Updated Continuously

Knowledge and attitude of dentists toward amalgam bonding systems in Riyadh area

By

DR. WEDAD Y. AWLIYA

Assistant Professor Department of Restorative Dental Sciences, College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia

And

DR. HODA ABDELLATIF

Assistant Professor Department of Preventive Dental Sciences, College of Dentistry, King Saud University, Riyadh, Kingdom of Saudi Arabia

ABSTRACT The aim of this study was to assess knowledge and attitude of dentists toward amalgam bonding systems in Riyadh area, Kingdom of Saudi Arabia. 250 questionnaire papers were distributed in a dental meeting, which was held in Riyadh, October 2001. The questionnaire includes questions regarding the utilization of bonding systems, the source of getting information about these systems, and the reasons from using the bonding systems with amalgam restorations. The results indicated that 46% of the respondents did not use amalgambonding systems and the main reason was unavailability of the material followed by lack of knowledge regarding the material. 87% of the respondents from the private practice used bonded amalgam restorations in comparison to 50% from the governmental sector. From the amalgam bonding system user, 83% indicated that to make the amalgam retentive in the cavity is the main reason from their utilization of the bonding systems.

INTRODUCTION Amalgam was used as a restorative material as early as 1826 and it remains as one of the most versatile restorative materials in use today (1). It has a myriad of uses, ease of manipulation, long clinical service life, and low cost. However, amalgam has certain disadvantages such as its color, and lack of adhesion to tooth structure, the latter which could result in microleakage and sensitivity. Retention of amalgam restorations must rely also upon cavity preparation with undercuts, retentive grooves, slots and even pins placed in sound tooth tissues to prevent dislodgement of the restoration. The presence of these retentive undercuts and pins increases the tooths susceptibility to fracture (2, 3). Copal varnish has served as the standard cavity liner under amalgam to control microleakage at the amalgam tooth interface. Varnish, however, exhibits some breakdown in oral fluids and its benefit may be relatively short-lived. (4,5) Late 1980s, the efficacy of using an adhesive resin to bond amalgam to tooth structure has been demonstrated by Vargat et al. (6), Shimizv et al. (7) and Staninec & Holt (8). Bonding amalgam to tooth structure offers several advantages. Conservation of tooth structure because mechanical retention by means of slots and grooves can be eliminated. Also, further damage to tooth structure by using pins or amalpins will be reduced. Adhesive dentistry, including bonding amalgam to tooth structure, is a relatively new field and not all dentists practicing today are trained in treatments involving the use of adhesive systems in general or to bond amalgam to tooth structure in specific. Those practitioners have had to study adhesive materials on a postgraduate or voluntary basis.

The aim of this study is to assess knowledge and attitude towards the utilization of amalgam adhesive among practitioners in Riyadh, Saudi Arabia.

MATERIALS AND METHODS

The survey reported on here was conducted on a sample of dentists working in both private and government sector attending the Saudi Dental Society Meeting in January 2001.
To ascertain dentists knowledge and attitudes towards the utilization of adhesive amalgam restorations bonding amalgam to tooth structure among dental practitioners, a questionnaire was developed and pre-tested for use. The first part of the questionnaire contained personal data such as age, sex, and educational degree. The second part of the questionnaire included items related to type of practice dentist are engaged in, utilization of bonding agent, source of bonding agent instruction, and purposes of using a bonding agent. Two hundred and fifty questionnaire forms were distributed among attendee and collected at the end of the day of the two days annual meeting. Data were collected by means of a self-administered questionnaire. Not all questions in the questionnaire form were answered by respondents. Data were entered into a computer and analyzed by the statistical package SPSS version 10.0. The data, being categorical, were subjected to frequency tabulations and crossclassifications. Cross-classification significance was evaluated with Chi-square test. The sole continuous scaled data item, age, was analyzed by subgroup using the two-sample t-test. For all analysis, a size = 0.005 test was used to conclude statistical significance.

RESULTS
The overall response rate for this survey was 80.4%. From among the respondents, all but 19 indicated their age. The range was 21 to 54 years, with a median of 29 years old. All but two indicated their sex, and 42% and 58% were male and female respectively. Regarding their academic degrees only two respondents failed to provide information; the distribution was 13% (undergraduate), 58% (BDS), 7% (clinical certificate), 19% (MSc.), 7% (PhD), and 3% (other). Ninety-six percent of respondents provided data on their type of

practice with 92% working in government, 8% working in solo private practice, and one respondent with group practice.

With respect to the use of amalgam bonding systems, 106 (54%) respondents indicated that they are using the systems in their clinics compared to 91 (46%) not using them and 4 respondents did not indicate either. Among those who are not using bonding system, Table 1 shows the reasons. It is clear that the unavailability of the material was the major reason followed by the lack of knowledge regarding the material.
Among those who have been instructed on the use of the material, the source of instruction is tabulated in Table 2. The major source of instruction was undergraduate dental school. All but 16 responded to the question regarding the importance of amalgam bonding system, and 78% of the sample subjects felt that it was important. Approximately 90% indicated that they are willing to attend instructional seminars/workshops and that they would use the knowledge gained in their practice. In cross tabulating age with source of instruction on the use of the amalgam bonding system, results indicated that the average age of respondents with undergraduate instruction are significantly younger (p<.0001) compared to the average age of respondents who received their instruction from graduate studies or dental seminars (p<0.04 and p <0.02 respectively)

In comparing the rates of amalgam bonding system use between male and female, the rate among males (64%) was significantly higher than that among females (46%) (p = 0.020). When comparing the rates of amalgam bonding system utilization among different types of practice, the rate of amalgam use in government was 50%, in solo private practice was 87%, and the single group practice respondent did not use amalgam bonding. In comparing the government with solo private practice with respect to amalgam bond utilization, the difference was statistical significance (p < 0.050). The average age of respondents who used amalgam was 28 years of age ( 0.6 SEM), and this was significantly less than that for those who did not use amalgam 33 ( 0.7) years old (p < 0.001). Among those who used amalgam bonds, 58% reported that they did not know enough about materials. Furthermore, among those who did not use it, 23% reported that they have not used the materials despite their knowledge about it. The brands used in Table 3 indicated types of bonding agent utilized, note that several users reported the use of multiple brands. The distribution of purposes for use of amalgam is given in Table 4. Again several respondents gave multiple purposes. It is clear that to make the restoration retentive was the major reason followed by preventing microleakage. The type of tooth to which the bonding was applied is given in Table 5, the results indicated that most of the respondents used the bonding only for badly broken teeth. When the users were asked if they used other means of retention with the bonding agent, 60% indicated the use of other means of retention.

DISCUSSION
The high response rate for this survey (80.4%) can be attributed to the selective characteristics of study population who attended the scientific meeting. These selective factors such as being young, dynamic, motivated, showing interest in continuing education and in research may make the sample not representative of the total population of dentists in Saudi Arabia. It was clear from the results that around half of the respondents did not use amalgambonding systems in their practice. The most identified reason was the unavailability of material (57%), which indicated that they might have the knowledge of amalgam adhesive system without being able to practice it. The second reason was lack of knowledge about the bonding system (26%). Hence, 87% believed they want to attend seminars and workshops about amalgam adhesive restorations. This study showed that age influences significantly the use of amalgam bonding system. Younger dentists use the bonding system more than the older ones. Their training and their recent graduation may explain this difference. The source of getting knowledge about adhesive dentistry, as reflected in the results, was influenced also by age. Dentists younger than 28 years

old received instruction during their undergraduate study from the dental school where they were trained to use the systems. One may assume that they are more confident in utilizing the systems since they know the systems indications and contraindications. Older dentists received amalgam adhesive instruction in their graduate studies or from other sources such as dental seminars. This difference in source of knowledge can be explained by the time of the availability of amalgam bonding systems in the market, which was in the early 1980s. Regarding gender, female dentists tend to use amalgam-bonding system less frequently than male dentists. The difference reflects that probably more women work in public and primary care dental health services thus carrying out relatively few treatments involving amalgam-bonding systems. In this study, dentists working in private practices bond their amalgam restorations to tooth structure significantly more than dentists in the governmental sectors. This finding is in agreement with findings of Peutzfeldt (9). In this study, the reason could be attributed to unavailability of the materials in some of the governmental sectors as shown in Table 1. One may say that dentists working in private practice have to provide the recent dental materials as an advertisement to their clinics. Also, bonding amalgam restorations to tooth structure could be a reason to increase the fee from the type of patients attending their clinics. Although All Bond 2 system is a multi-step system, it was the most amalgam bonding system used (53%) and the second used bonding system was Amalgabond (26%). This preference may reflect that those dentists are trained to use these two systems before or during their graduate studies or they are the systems provided in their place of practice. However, the usage of a certain brand of amalgam bonding system may be underestimated in that some dentists may use more than one brand of amalgam bonding system and they recall only the brand they often use.

In response to the reasons from bonding amalgam to tooth structure, the majority (60%) think that adhesive systems make the amalgam restoration retentive. In fact, this reason is in agreement with substantial body of supportive evidence for the advantages of bonding amalgam derived from in vitro investigations (10).

CONCLUSIONS
From this study, one may conclude that:

1. Amalgam bonding systems were not used by around 50% of the respondents in this study. The unavailability of the material was the major reason followed by the lack of knowledge regarding the material. 2. Dentists working in private practice bond amalgam restorations to tooth structure significantly more than dentists in governmental sector. 3. Making amalgam retentive was the most reason from using the adhesive systems by majority of the respondents.

RECOMMENDATIONS Given the potential advantages of bonded amalgam restoration over the non-bonded restorations, it is suggested that more seminars and workshops are held especially for general practitioners in governmental sectors. These seminars and workshops will provide the knowledge regarding the bonding systems and subsequently will help to increase the utilization of these systems.

This research (NF 1721) is registered with college of dentistry, Research Center (CDRC), King Saud University.

REFERENCES: 1. Anderson MH, McCoy RB. Dental amalgam. The state of art and science. 3rd ed. Philadelphia: Saunders, 1993 2. Larson TD, Douglas WH, Geistfeld RE. (1981) Effect of prepared cavities on the strength of teeth. Operative Dentistry, 6:2-5 3. Blaser PK, Lund MR, and Cocharn MA. (1983) Effect of designs of class II preparations on resistance of tooth to fracture. Operative Dentistry, 8:6-10 4. Sneed WD, Hembree JH, and Welsh El. (1984). Effectiveness of three cavity varnishes in reducing leakage of high-cooper amalgam. Operative Dentistry, 9(1):32-4 5. Powell GL, Daines DT. Solubility of cavity varnish: a study in vitro. (1987) Operative Dentistry, 12(2):48-52 6. Varga J, Matsumura H, Masuhara E. (1986) Bonding of amalgam filling to tooth cavity with adhesive resin. Dental material, 2;158-164 7. Shimizu A, Ui T, Kawakami M. (1987) Micro leakage of amalgam restoration with adhesive resin cement lining, glass ionomer cement and fluoride treatment. Dental Material, 6:64-69 8. Staninec M, and Holt M. (1988) bonding of amalgam to tooth structure: Tensile adhesion and microleakage test. Journal Prosthetic Dentistry, 59:397-402. 9. Peutzfeldt A, and Vigild M. A survay of the use of dentin-bonding systems in Denmark. Dent Mater 17:211-216 2001 10. Setcos JC, Staninec M, And Wilson NHF. (2000) Bonding of amalgam restorations: existing Knowledge and future prospects. Operative Dentistry, 25,121-129