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MANAGEMENT OF DEFECTIVE DENTAL

AMALGAM RESTORATIONS – A MIXED-METHODS

STUDY

Razia Z Adam

A thesis submitted in fulfilment of the requirements for the degree of

Doctor of Philosophy in Dental Public Health,
Faculty of Dentistry,
University of the Western Cape

July 2016

Supervisor: Professor Sudeshni Naidoo

Co-Supervisor: Professor Greta Geerts
MANAGEMENT OF DEFECTIVE DENTAL
AMALGAM RESTORATIONS – A MIXED
METHODS STUDY

Razia Zulfikar Adam

KEYWORDS
South Africa

Dental amalgam

Treatment patterns

Clinical decision-making

Repair

Refurbishment

Replacement

Defective restorations

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ABSTRACT

MANAGEMENT OF DEFECTIVE DENTAL AMALGAM

RESTORATIONS – A MIXED-METHODS STUDY
RZ Adam, PhD Thesis, Faculty of Dentistry, University of the Western Cape

Aim: Much variation exists in the practice of dentistry with regard to the
diagnosis of caries and the recommendations for treatment. Even though criteria
for the selection of ‘faulty’ restorations often appear ill-defined, subjective and/or
variable restoration replacement is a major component of dental practice in
developed countries (Brennan and Spencer, 2006). While the prevalence of caries
is decreasing in developed countries, low- and middle-income countries are
experiencing an increase. The investigation of factors influencing the clinical
decision-making process has identified and compared the roles of technical (e.g.
oral health factors), patient and dentist factors (Brennan and Spencer, 2006; Bader
and Shugars, 1995a; 1995b). A recent trend for a more conservative approach to
restorative dentistry has led to the alternative management of defective dental
restorations. Repair and refurbishment of defective dental restorations have been
established as viable options. The purpose of this study was to provide
information regarding the practices, knowledge and attitudes of South African
dentists with regard to the management of defective dental amalgam restorations.

Methodology: A mixed-methods study with an online survey administered to all

members of the South African Dental Association was conducted and followed by
in-depth interviews of 15 purposefully selected dentists in the Western Cape. The
online data included demographic data, education level, continuing education
practices, attitudes and use of dental amalgam as a restorative material and a
clinical vignette. The in-depth interviews comprised two patient cases in which
dentists were asked to explain their treatment decisions with regard to the
management of defective dental amalgam restorations. The interviews were
coded, transcribed and analysed using the Atlas.ti ® software package. Responses

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were analysed using the Framework Method. Ethics approval was received from
the Senate Research Committee of the University of the Western Cape.

Results: This study found that almost two-thirds of dentists reported repairing
defective dental restorations in their practices. The majority of those who did not
repair restorations felt that there was a lack of predictability in the technique. The
interview findings also suggested that it was not an ‘appropriate treatment’
although the majority of dentists learnt their repair technique through their own
clinical experience. Dentists had outdated concepts regarding the diagnosis of
micro-leakage and secondary caries. Results from the vignettes indicated that the
majority of the dentists in the study were more inclined to replace defective
restorations, while the presence of a marginal gap (OR=0.594, 0.311–1.133) and
secondary caries (OR=0.434, 0.224–0.842) were significant predictors for the
repair of a defective restoration. Dentists with more than 21 years of experience
were more likely to repair defective restorations (p<0.0001). Cost to patient,
uncertainty in diagnosis and dental school were the most influential non-clinical
factors.

Conclusion: The findings of this study suggest that there is a lack of translation of
evidence-based information to everyday general practice dentistry in South
Africa. This results in the use of outdated knowledge to make treatment decisions
that affect patient outcomes. As a result, there is a need for updated teaching,
specifically regarding secondary caries and micro-leakage. This study also
suggests that the influence of non-clinical factors such as dental schools and
uncertainty in diagnosis are influential in the clinical decision-making process.

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DECLARATION

I declare that the thesis entitled Management of Defective Dental Amalgam

Restorations – A Mixed-Methods Study is my own work, that it has not been
submitted before for any degree or examination at any other university, and that
all the sources I have used or quoted have been indicated and acknowledged as
complete references.

__________________________ __________________

Razia Zulfikar Adam Date

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ACKNOWLEDGEMENTS

• I wish to thank my supervisor, Professor Sudeshni Naidoo and my

co-supervisor, Professor Greta Geerts, for their continued support and
encouragement before and during the period of this PhD work.

• My sincere thanks go to HWSETA, which contributed financially to the

completion of this research project.

• I wish to thank the University of the Western Cape, particularly Professor

Lawack’s office, for providing a grant that supported a replacement and
allowed me to take a six-month sabbatical to complete this PhD work.

• I wish to thank Professor Richard Madsen from the University of Missouri

for his tremendous support, advice and assistance with the data analyses.

• I wish to thank my husband and children for their unwavering patience,

understanding and support during this PhD journey.

• Finally, thank you to my parents for their encouragement.

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CONTENTS
ABSTRACT _____________________________________________________ iii

DECLARATION _________________________________________________ v

ACKNOWLEDGEMENTS _________________________________________ vi

CONTENTS ____________________________________________________ vii

LIST OF FIGURES ______________________________________________ xvi

LIST OF APPENDICES __________________________________________ xvii

DEFINITION OF TERMS ________________________________________ xviii

CHAPTER 1: INTRODUCTION ____________________________________ 19

CHAPTER 2: LITERATURE REVIEW ______________________________ 24

2.1 INTRODUCTION _______________________________________ 24

2.2 SECTION 1: CONCEPTUAL FRAMEWORK _________________ 24

2.2.1 Understanding the process _________________________________ 26

2.2.2 Patient factors ___________________________________________ 26

2.2.3 Dentist factors ___________________________________________ 27

2.3 SECTION 2: CLINICAL DECISION-MAKING________________ 27

2.3.1 Clinical decision-making models ____________________________ 28

2.3.2 Restorative treatment variation in practice _____________________ 33

2.3.3 Patient factors ___________________________________________ 35

2.3.4 Tooth level _____________________________________________ 36

2.3.5 Dentist factors ___________________________________________ 37

2.4 SECTION 3: AMALGAM AS A RESTORATIVE MATERIAL ___ 40

2.4.1 Regulation of dental amalgam as a restorative material ___________ 40

2.4.2 Use of dental amalgam in clinical practice internationally _________ 42

2.4.3 Use and teaching of dental amalgam in clinical practice in Africa___ 43

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2.4.4 Longevity of restorations __________________________________ 44

2.4.5 Replacement of restorations ________________________________ 58

2.4.5.1 Diagnosis for restoration replacement ________________________ 59

2.4.6 Management of defective restorations ________________________ 61

2.4.7 Treatment options for defective dental restorations ______________ 63

2.4.7.1 Refurbishing a defective dental amalgam restoration ____________ 65

2.4.7.2 Sealing defective margins __________________________________ 66

2.4.7.3 Repairing a defective restoration ____________________________ 66

2.4.7.3.1 Clinical procedure for the repair of a defective dental amalgam

restoration ____________________________________________________ 68

2.5 SECTION 4: CLINICAL DECISION-MAKING FOR RESTORATION

REPLACEMENT OR REPAIR ___________________________________ 69

2.5.1 Factors affecting the decision to replace or repair defective

restorations ___________________________________________________ 70

2.5.1.1 Patient factors ___________________________________________ 70

2.5.1.2 Dentist factors ___________________________________________ 72

Summary _____________________________________________________ 73

CHAPTER 3: HYPOTHESIS, RESEARCH AIMS AND OBJECTIVES _____ 74

3.1 PROBLEM STATEMENT _________________________________ 74

3.2 HYPOTHESES __________________________________________ 74

3.3 AIM ___________________________________________________ 74

3.4 OBJECTIVES ___________________________________________ 74

CHAPTER 4: METHODOLOGY ___________________________________ 76

4.1 INTRODUCTION _______________________________________ 76

4.2 RESEARCH DESIGN AND METHODS _____________________ 76

4.2.1 Mixed-methods research ___________________________________ 76

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4.2.2 Research methodology ____________________________________ 76

4.2.3 Sampling _______________________________________________ 78

4.2.4 Research setting _________________________________________ 78

4.3 QUANTITATIVE DATA COLLECTION AND ANALYSIS _____ 79

4.3.1 Study design and study population ___________________________ 79

4.3.1.1 Sample _________________________________________________ 79

4.3.1.2 Inclusion and exclusion criteria _____________________________ 79

4.3.2 Data collection __________________________________________ 79

4.3.2.1 Using an online questionnaire ______________________________ 80

4.3.2.2 The research instrument ___________________________________ 80

4.3.2.3 Clinical vignettes_________________________________________ 80

4.3.3 Pilot study ______________________________________________ 82

4.3.4 Ethical considerations _____________________________________ 82

4.3.5 Validity ________________________________________________ 82

4.3.6 Data analyses ____________________________________________ 83

4.3.6.1 Analysis of vignette responses_______________________________ 83

4.3.6.2 Questions for which only one response could be selected _________ 84

4.3.6.3 Questions for which more than one response could be selected _____ 84

4.4 QUALITATIVE DATA COLLECTION AND ANALYSIS _______ 85

4.4.1 Study design and study population ___________________________ 85

4.4.2 Sample _________________________________________________ 85

4.4.3 Data collection __________________________________________ 86

4.4.3.1 Semi-structured interviews _________________________________ 86

4.4.3.2 Clinical vignettes_________________________________________ 86

4.4.3.3 The think-aloud technique __________________________________ 87

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4.4.3.4 Data recording procedures _________________________________ 88

4.4.3.5 Self-administered questionnaire _____________________________ 88

4.4.3.6 Treatment log ___________________________________________ 88

4.4.3.7 Field notes ______________________________________________ 88

4.4.4 Qualitative data analysis ___________________________________ 89

4.4.4.1 Framework analysis ______________________________________ 89

4.4.4.2 Stages of thematic analysis _________________________________ 89

Stage 1: Transcription ___________________________________________ 89

Stage 2: Familiarisation with the interview __________________________ 89

Stage 3: Coding ________________________________________________ 90

4.4.5 Generalisation, validity and reliability of qualitative research ______ 92

4.4.6 Pilot study ______________________________________________ 92

4.4.7 Ethical considerations _____________________________________ 92

Summary _____________________________________________________ 93

CHAPTER 5: RESULTS __________________________________________ 94

5.1 QUALITATIVE STUDY: DEMOGRAPHY OF THE SAMPLE ___ 94

5.2 GEOGRAPHIC LOCATION _______________________________ 94

5.3 QUANTITATIVE COMPONENT: DEMOGRAPHY OF THE

SAMPLE _____________________________________________________ 97

5.3.1 Gender _________________________________________________ 97

5.3.2 Age ___________________________________________________ 97

5.3.3 Highest qualification ______________________________________ 97

5.3.4 Dental-practice profile and years of experience in private practice __ 97

5.4 CONTINUING PROFESSIONAL DEVELOPMENT ____________ 98

5.5 AMALGAM AS A RESTORATIVE MATERIAL ______________ 98

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5.6 DISCUSSION WITH PATIENT REGARDING CHOICE OF DENTAL
RESTORATIVE MATERIAL ___________________________________ 100

5.7 REPAIR OF DEFECTIVE DENTAL AMALGAM

RESTORATIONS ____________________________________________ 100

5.8 AMALGAM REPAIR TECHNIQUE USED __________________ 102

5.9 ORIGIN OF TECHNIQUE USED __________________________ 103

5.10 RESTORATIVE MATERIAL OF CHOICE FOR REPAIRING A

DEFECTIVE DENTAL AMALGAM RESTORATION _______________ 104

5.11 RESTORATIVE MATERIAL OF CHOICE FOR REPLACING A

DEFECTIVE DENTAL AMALGAM RESTORATION _______________ 105

5.12 FACTORS TAKEN INTO CONSIDERATION WHEN MANAGING

A DEFECTIVE DENTAL AMALGAM RESTORATION _____________ 107

5.13 KNOWLEDGE REGARDING THE MANAGEMENT OF

DEFECTIVE DENTAL AMALGAM RESTORATIONS ______________ 108

5.14 DIAGNOSIS OF SECONDARY CARIES ___________________ 110

5.15 FACTORS AFFECTING TREATMENT DECISIONS__________ 110

5.16 FUTURE OF AMALGAM ________________________________ 112

5.17 RELATIONSHIPS BETWEEN DEMOGRAPHIC VARIABLES, USE

OF AMALGAM, FUTURE USE OF DENTAL AMALGAM, REPAIRING
DEFECTIVE DENTAL AMALGAM RESTORATIONS AND REPLACING
DEFECTIVE DENTAL AMALGAM RESTORATIONS ______________ 113

5.17.1 Relationship between repair of dental amalgam and future use of dental
amalgam as a restorative material _________________________________ 114

5.17.2 Relationship between contracted to medical aid and repair or

replacement of defective dental amalgam restorations _________________ 114

5.17.3 Relationship between age and repair of defective dental amalgam

restorations __________________________________________________ 114

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5.17.4 Relationship between years of experience and choice of

material to repair ______________________________________________ 115

5.17.5 Relationship between use of amalgam as a restorative material and

repair of defective dental amalgam restorations ______________________ 115

5.17.6 Relationship between use of amalgam as a restorative material and

discussion of material choice with a patient _________________________ 115

5.18 ANALYSIS OF CLINICAL VIGNETTE RESPONSES IN THE

ONLINE SURVEY ____________________________________________ 115

5.18.1.1 Secondary Caries as a factor _____________________________ 116

5.18.1.2 Marginal Gap as a factor ________________________________ 117

5.18.2 Refurbishment versus Repair ______________________________ 118

5.18.2.1 Secondary Caries as a factor _____________________________ 118

5.18.2.2 Marginal Gap as a factor ________________________________ 119

5.18.3 Analysis of effects of Secondary Caries and Marginal Gap as predictor

variables ____________________________________________________ 119

5.18.4 Mechanism of reimbursement ______________________________ 120

5.18.5 Self-administered questionnaire ____________________________ 122

5.18.6 Data from treatment logs __________________________________ 125

CHAPTER 6: DISCUSSION ______________________________________ 127

6.1 INTRODUCTION ______________________________________ 127

6.2 THE PROPOSED MODEL FOR TREATMENT DECISIONS OF

DEFECTIVE DENTAL AMALGAM RESTORATIONS ______________ 128

6.3 CONTEXT OF THE STUDY ______________________________ 129

6.4 MANAGEMENT PRACTICES OF DEFECTIVE DENTAL

AMALGAM RESTORATIONS BY SOUTH AFRICAN DENTISTS ____ 130

6.5 FACTORS TAKEN INTO CONSIDERATION WHEN MANAGING

A DEFECTIVE DENTAL AMALGAM RESTORATION _____________ 134

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6.5.1 Tooth factors ___________________________________________ 134

6.5.2 Patient factors __________________________________________ 135

6.5.3 Dentist factors __________________________________________ 136

6.5.4 Knowledge of dentists in managing defective dental amalgam

restorations __________________________________________________ 138

6.5.5 Dentists’ attitudes towards repairing defective dental amalgam

restorations __________________________________________________ 139

6.6 LIMITATIONS OF THE STUDY __________________________ 141

CHAPTER 7: CONCLUSION AND RECOMMENDATIONS ___________ 142

7.1 SUMMARY OF KEY FINDINGS __________________________ 142

7.2 IMPLICATIONS FOR TEACHING AND PRACTICE _________ 144

7.3 IMPLICATIONS FOR POLICY ___________________________ 145

7.4 RECOMMENDATIONS FOR FURTHER RESEARCH ________ 145

REFERENCES _________________________________________________ 146

APPENDICES _________________________________________________ 175

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LIST OF TABLES

Table 1: A classification of issues and questions relevant to treatment

decision-making in general dental practice _____________________________ 39

Table 2: Longevity of dental restorations (1969−2015) ___________________ 47

Table 3: Factors influencing the longevity of dental restorations ____________ 56

Table 4: Clinical situations with recommendations for repair or replacement __ 64

Table 5: Factors affecting replacement of defective dental amalgams ________ 71

Table 6: Glossary ________________________________________________ 91

Table 7: Summary of profiles of interview participants ___________________ 95

Table 8: Frequency distribution of highest qualification __________________ 98

Table 9: Frequency of continuing professional development activities _______ 99

Table 10: Frequency of reasons for not repairing defective dental amalgam
restorations. ____________________________________________________ 101

Table 11: Frequency of techniques __________________________________ 103

Table 12: Frequency of individual items chosen for learning resources _____ 104

Table 13: Frequency of times individual items were chosen for restorative
material of choice _______________________________________________ 105

Table 14: Frequency of restorative material choice for replacing a defective dental
amalgam restoration _____________________________________________ 107

Table 15: Response categories for factors taken into consideration when managing
a defective dental amalgam restoration _______________________________ 108

Table 16: Ranking frequencies for factors taken into consideration when
managing a defective dental amalgam restoration ______________________ 108

Table 17: Responses to statements __________________________________ 109

Table 18: Frequencies for diagnosis of secondary caries _________________ 110

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Table 19: Factors affecting treatment decision: Percentages of individual factors
chosen ________________________________________________________ 111

Table 20: Factors affecting treatment decisions: Ranking of factors ________ 112

Table 21: Factors tested for their association __________________________ 113

Table 22: Repair of dental amalgam and future use of the material _________ 114

Table 23: Replacement versus Repair ________________________________ 117

Table 24: Refurbishment versus Repair ______________________________ 119

Table 25: Analysis of effects_______________________________________ 120

Table 26: Summary of profiles of patients treated at the respective practices _ 123

Table 27: Choice of material for ‘new restorations’. ____________________ 125

Table 28: Reasons for a ‘new restoration’ ____________________________ 126

Table 29: Reason for replacement of a restoration ______________________ 126

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LIST OF FIGURES

Figure 1: Conceptual model of dentists’ caries-related treatment decisions......... 25

Figure 2: Clinical decision-making in dentistry .................................................... 30
Figure 3: Dental decision-making ..................................................................... 31
Figure 4: Hypothetical decision model ................................................................. 32
Figure 5: Workflow diagram for the research process .......................................... 77
Figure 6: Geographic location of interviewees’ practices..................................... 94
Figure 7: Adapted model for caries-related treatment decisions ........................ 128

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LIST OF APPENDICES

Appendix A: Summary of studies conducted on reasons for replacement of

restorations 176

Appendix B: Clinical studies on repair and refurbishment of restorations ____ 180

Appendix C: FDI criteria and gradings _______________________________ 182

Appendix D: Questionnaire (with informed consent) ____________________ 186

Appendix E: Ethics approval ______________________________________ 197

Appendix F: Case Study 1 and Case Study 2 __________________________ 199

Appendix G: Self-administered questionnaire for qualitative sample _______ 216

Appendix H: Treatment log _______________________________________ 220

Appendix I: Research-participant consent form ________________________ 221

Appendix J: Origin of technique used ________________________________ 223

Appendix K: Restorative material of choice for repairing a defective dental

amalgam restoration _____________________________________________ 224

Appendix L: Diagnosis of secondary caries ___________________________ 226

Appendix M: Relationships between demographic variables, use of amalgam,

future use of dental amalgam, repairing defective dental amalgam restorations and
replacing defective dental amalgam restorations _______________________ 228

Appendix N: Summary of proposed treatment for clinical vignettes ________ 231

Appendix O: Summary table of all treatment logs ______________________ 232

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DEFINITION OF TERMS (Mjör et al., 2000)

Secondary caries:
Frank caries: Clearly visible caries adjacent to the existing restoration.
Limited caries: Evidence of limited caries whether visible or not associated
with marginal defects or discoloration.
Marginal discoloration: Discoloration at the tooth/restoration interface sufficient to
warrant replacement of the restoration.
Bulk discolouration: Mismatch of shade between the body of the restoration and the
tooth, which justifies replacement of the restoration.
Marginal fracture/degradation: Refers only to those restorations that are well adapted
to the remaining tooth structures but with marginal fractures or defective margins with
no evidence of caries.
Bulk fracture: Includes isthmus fracture or any fracture through the main body of the
restoration.
Fracture of tooth: Tooth fracture adjacent to the restoration, for example, the fracture
of a cusp.
Poor anatomic form: Loss of substance due to material degradation and wear,
sufficient to result in loss of restoration form and possibly function.

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CHAPTER 1: INTRODUCTION

Worldwide, dental caries is the most common chronic disease that affects nearly
all adults (Petersen, 2003) and is the “primary cause of oral pain and tooth loss”
(Selwitz et al., 2007). Although there has been a widespread decline in the
prevalence of caries in permanent teeth in high-income countries, there are reports
of a growing burden of dental caries for adults in low- and middle-income
countries (Petersen et al., 2009). This is attributed to increasing urbanisation and
changes in living conditions (Petersen et al., 2009). Once sound tooth structure is
destroyed through the caries process, a “lifelong cycle of repair and maintenance”
awaits (Elderton and Nuttall, 1983; Selwitz et al., 2007).

A recent study, “Global Economic Burden of Dental Diseases”, estimated the cost
of dental disease in 2010 at $442 billion, of which $298 billion was attributable to
direct treatment costs and $144 billion to indirect costs in terms of productivity
losses due to caries, periodontitis and tooth loss (Listl et al., 2015).

It is widely accepted that dental caries is an “initially reversible, chronic, disease

process with a known multi-factorial aetiology”(Pitts, 2004). However, since the
20th century, dentists have regarded dental restorations as a cure for dental caries
(Selwitz et al., 2007). With a focus on caries lesion detection and the fee for
service remuneration systems, there is a bias towards operative dentistry
(Fejerskov and Kidd, 2009). However, in recent years, there has been a trend in
caries management to move away from the operative model towards a more
preventive approach – minimum intervention dentistry (Petersen, 2003; Petersen
et al., 2009). This includes strategies that curb the disease process and conserve
tooth structure. However, restorative treatment as a method of caries management
dominates in many countries such as the United States of America (USA) (Ismail
et al., 2001; Elderton, 2003) although in some regions such as Scandinavia, a
more preventive approach has been adopted (Selwitz et al., 2007).

The establishment of effective preventive programmes at country and community

levels has yielded a decline in the levels of dental caries in children and an
improved dentate status in adult populations (Petersen et al., 2009). Research has
identified high-caries risk groups to include:

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[P]eople living in poverty, people with poor education or low
socioeconomic status, ethnic minority groups, individuals with
developmental disabilities, recent immigrants, individuals with human
immunodeficiency virus (HIV) or acquired immunodeficiency syndrome
(AIDS), elderly people who are frail and people with several lifestyle
factors. (Selwitz et al., 2007)

However, a lack of these preventive programmes in middle- and low-income

countries has meant that these populations are in need of comprehensive oral
healthcare, including restorative treatment (Selwitz et al., 2007; Petersen et al.,
2009). Using amalgam, an estimated cost of between US$1 618 and US$3 513 per
1 000 children would be required to restore the permanent teeth of the child
population between the ages of 6 and 18 years of low-income countries
(Kathmandu, 2002). The prevalence and recurring nature of dental caries and
periodontal disease “makes the mouth among the most expensive parts of the
body to treat” (Listl et al., 2015).

A wide variety of dental restorative materials exists today. The principal material
types for direct restorations include dental amalgam, composites, glass ionomers
and resin ionomers (Rekow et al., 2013). The use of dental amalgam for the
restoration of posterior teeth has decreased because of the need for a more
aesthetic material as well as concerns regarding its safety; however, it remains an
effective restorative material (Petersen et al., 2009). A number of tooth-coloured
materials are also currently available. The use of composite restorations is limited
by the technique sensitivity and the intention for use in patients with excellent oral
hygiene (Rekow et al., 2013). The use of glass ionomers as a group of restorative
materials is best suited for long-term provisional restorations (Rekow et al.,
2013).

The last available data records dental amalgam being used by 85.8% of dentists in
South Africa (Lombard et al., 2009). Extensive research has been conducted over
the years to investigate the longevity of direct restorations (Elderton, 1976; Hickel
and Manhart, 2001; Mitchell et al., 2007; Moraschini et al., 2015) and indirect
restorations. Studies conducted by Manhart et al. (2004) and Opdam et al. (2007)

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found that newer resin composite restorations have an improved longevity.
However, a Cochrane Review published in 2014 concluded that the failure rate for
composite restorations was twice that of amalgam restorations (Hurst, 2014).
Despite this, increasing concern over aesthetics, the recent Minamata Convention
on Mercury (Mackey et al., 2014) and advances in adhesive dentistry have
globally decreased the favourability of dental amalgam among dentists and
patients alike (Burke et al., 2003).

Hurst (2014) surmised that the failure rate of composite restorations could be four
times more than that of amalgam restorations in a patient with a high caries
experience. In addition, if dental amalgam were no longer available as a
restorative material, populations with high caries rates could be disadvantaged as
the composite restorations replace dental amalgam restorations (Hurst, 2014). It is
in these instances that extending the longevity of defective dental amalgam
restorations with a repair or refurbishment may be an excellent alternative for
increasing the longevity of the restoration and ultimately, the tooth.

South Africa is classified as an upper- to middle-income country with a

population of approximately 54 million people (Gray and Vawda, 2015). A legacy
of apartheid has left South Africa with many disparities, including access to health
care in both public and private health care sectors. The South African
Demographic and Health Survey (2014) reported that only 14% of the population
has access to medical aid or some form of health benefit. This means that the
majority of individuals seeking dental treatment need to pay for the service.

There are 5 856 dentists and 611 dental therapists registered with the Health
Professions Council of South Africa (HPCSA) (Gray and Vawda, 2015) and of
these, 1 137 and 309 respectively work in the public sector. Most of the treatment
delivered at public health facilities is for pain relief and the treatment of sepsis.
These statistics imply that more than 80% of trained dentists are employed in the
private sector. There has been very little research conducted on the range of
services provided by oral health care workers and specifically, on the management
of defective dental amalgam restorations.

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Research regarding the knowledge and the preferences for restorative dental
materials and treatment as well as whether or not they conform to evidence-based
dentistry is scarce.

It is reported that two-thirds of all restorative work completed in dental practice

involves the replacement of existing restorations (Wilson et al., 2004). In a bid to
break the “restorative cycle” of a tooth, recent research has focused on the
management of defective restorations (Henry, 2009). The restorative cycle has
been described as a sequence of three events in which there is loss of tooth
structure: (i) trauma or the original disease process; (ii) tooth preparations to
receive a restoration; and (iii) the eventual failure of the restoration and
replacement thereof. Research has shown that the replacement of restorations
results in larger restorations or a choice between complex restorations, costly
indirect restorations or extraction of the offending teeth (Mjör et al., 1998). Little
research has been conducted on patient outcomes with the repair and
refurbishment of restorations. Initial reports suggest that these procedures are
more time-efficient, require no local anaesthetic and could potentially cost the
patient less (Javidi et al., 2015). Other research conducted has affirmed that the
repair of a defective restoration increases the longevity of the restoration (Gordan
et al., 2015; Moncada et al., 2015a; 2015b).

Current management options for the management of defective amalgam

restorations include repair, refurbishing and sealing of the restoration (Gordan et
al., 2011). The clinical decision-making process for determining the treatment
approach in the management of defective dental restorations is naturally complex.
The decision to intervene is influenced by patient factors, tooth factors, material
factors and dentist factors. Studies conducted around the world confirm that there
is much variation in clinicians’ decisions to intervene and although the repair and
refurbish approach has been included in teaching curricula, there is a slow
translation to the dental practice (Blum et al., 2002; Blum et al., 2003a, 2003b;
Blum and Lynch, 2011; Gordan, 2013; Hasan and Khan, 2013).

It is clear that dentists perform repair restorations but the factors that they
consider when deciding to repair or replace a restoration are unclear. In addition,

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most of the research is conducted in countries in which patients have access to a
well-run health care system and where caries risk levels are low.

There has been a limited number of studies focusing on clinical decision-making

and the management of defective amalgam restorations (Gordan et al., 2009;
Gordan et al., 2012a; 2012b). Little research has reported on the factors
influencing clinical decision-making, specifically in the context of South Africa
where “generations of heavy metal patients have multiple restorations that are
likely to need replacement or maintenance throughout their lifetime”(Rekow et
al., 2013). This gap in the knowledge provides a unique opportunity to understand
the influence dentists have on treatment choices.

Significance of the study

The significance of this study was to explore and to understand the treatment
decisions regarding the management of defective dental amalgam restorations in
South Africa. Inappropriate, clinical decision-making adversely affects patient
outcomes, and it was anticipated that this study would yield a summary of the
varying restorative treatments that dentists are providing for the South African
population and compare them with best practice. Furthermore, this study identifies
inappropriate decision-making behaviour, which would be important in
developing appropriate and continuing education as well as informing curricula in
South African dental schools.

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CHAPTER 2: LITERATURE REVIEW

2.1 INTRODUCTION

This chapter is presented in four sections and describes the key concepts of the
study. Section 1 introduces the conceptual framework used in the present study.
Section 2 explores clinical decision-making in dentistry and restorative treatment
variation among dentists as well as discusses certain factors influencing treatment
decisions in general. Section 3 reviews the literature on the use of amalgam as a
restorative material, longevity of restorations, replacement of restorations and
current techniques in the management of defective dental amalgam restorations.
Lastly, Section 4 focuses on clinical decision-making for the replacement or repair
of defective restorations and the factors that affect this.

2.2 SECTION 1: CONCEPTUAL FRAMEWORK

Bader and Shugars (1992) proposed a model of the decision-making process in

order to assist in the investigation of factors associated with dentists’ treatment
decisions. According to this model, assessment, decision to treat and the selection
of treatment are separate steps in the decision-making process. A variety of dentist
and patient factors were identified from the literature and included in the model
because they were known or expected to affect dentists’ intervention decisions
and treatment (Bader and Shugars, 1992).

In 1997, the model was amended to focus on caries-related treatment decisions

(Bader and Shugars, 1997). In order to understand the clinical decision-making
process regarding the management of defective dental amalgam restorations, the
present study used Bader and Shugars’ (1997) conceptual model on caries-related
treatment decisions (Figure 1).

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Figure 1: Conceptual model of dentists’caries-related treatment decisions (Bader and Shugars, 1997)
2.2.1 Understanding the process

Bader and Shugars (1997) proposed that dentists do not ‘diagnose’ caries in the
classic sense but rather evaluate a single hypothesis whenever a tooth is examined
for caries. Depending on the opinions or experiences of the dentist, the hypothesis
could be the tooth has caries or the tooth does not have caries. This process is
repeated for every tooth and every surface, and the result of the process is
expressed as a decision to intervene. The recognition of caries depends on the
similarity to previous encounters by the dentist. Bader and Shugars (1992) liken
this pattern recognition to illness scripts.

Bader and Shugars (1992) describe illness scripts as “summaries of a provider’s

cumulative experiences with similar clinical presentations of health and disease”.
However, the important difference is that pattern recognition ends in a decision to
intervene rather than a diagnosis. However, not all caries scripts end in a decision
to intervene, and these events of uncertainty are often noted in patients’ folders
and monitored for change. Bader and Shugars (1997) cite Kahneman and
Tversky's (1982) hypothesis of uncertainty as a possible explanation. The
hypothesis states, “the more uncertainty is tolerated, the less likely a decision to
intervene will be made” (Bader and Shugars, 1997).

In addition to the description of the decision-making process, the model also

included a variety of patient and dentist factors that may influence the decision to
intervene. The following paragraphs summarise these factors.

2.2.2 Patient factors

Three types of patient factors are included in this model: (i) those involving a
specific tooth or tooth surface; (ii) those describing intra-oral conditions; and
(iii) those related to patient history, behaviour preferences and socioeconomic
status (Bader and Shugars, 1997). Bader and Shugars (1997) suggest that tooth
and intra-oral factors are included in caries scripts, but patient-level factors
influence the decision and the eventual treatment selection. For the purpose of this
study, the diagnosis of secondary caries, the presence of a marginal gap and the
cost to patient were the only factors explored.

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2.2.3 Dentist factors

There are three types of dentist factors included in the model (Bader and Shugars,
1997). Biases, including dentists’ beliefs of treatment preferences, utilities and
preferred diagnostic methods are believed to play a role in the decision to
intervene as well as in the nature of the intervention. The personal characteristics
of a dentist, including age/experience, skill/diligence, knowledge and tolerance for
uncertainty are also part of the model. In this instance, knowledge is referred to as
“accurate information describing the epidemiology and pathophysiology of caries
and the outcomes of its treatments” (Bader and Shugars, 1997). Practice-related
characteristics such as busyness, scale, personnel and equipment are also
included. Outlier experiences are defined as “unexpected outcomes of treatment
decisions which may then influence subsequent treatment decisions” (Bader and
Shugars, 1997). In this study, the influence of knowledge, age/experience and
treatment preferences on the clinical decision-making process were investigated.

In summary, this conceptual model was used to frame the investigation of the
present study into the clinical decision-making process for the management of
defective dental amalgam restorations. Section 2 reviews the literature on clinical
decision-making in dentistry, restorative treatment variations in practice and the
influence of patient and dentist factors.

2.3 SECTION 2: CLINICAL DECISION-MAKING

Clinical decision-making is defined as a “multifactorial process involving the

assimilation of information from clinical experience, relevant research, and patient
preferences and goals for anticipated outcomes” (Matthews, 1994). Grembowski
et al. (1988) suggested that clinical decision-making is a social process that
includes the dentist, the patient and sometimes, family members and insurers as
well.

Previous studies in clinical decision-making concentrated on the cognitive

processes in medical diagnosis and treatment planning, while very little research
was done in dentistry (Higgs et al., 2008; Maupomé et al., 2010).

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Decision-making is an important component of the clinical activities of a dentist,
whether deciding to extract a tooth or to replace a defective restoration. Formal
decision-making methods and techniques have been applied to studies addressing
radiology, caries prevention and treatment (Kay et al., 1992; Nuttall et al., 1993;
Kay and Nuttall, 1994; White and Maupome, 2001; Doméjean-Orliaguet et al.,
2009; Gordan et al., 2010; Weber et al., 2011; Buchalla et al., 2011), variation in
decisions among dentists (Maryniuk, 1990; Kay et al., 1992; Bader and Shugars,
1995a; Bader and Shugars, 1995; Kay and Locker, 1996; Lewis et al., 1996; Choi
et al., 1998; Brennan and Spencer, 2007; Maidment et al., 2010) and factors that
influence dentists’ decisions (Eisenberg, 1979; Kay and Blinkhorn, 1996; Brennan
and Spencer, 2002; Brennan and Spencer, 2006). In addition, they have been
applied to studies addressing the extraction of third molars, full mouth extractions
(Bouma et al., 1987) and the specialities of geriatrics, prosthodontics (Soderfeldt
et al., 1996; Kronström, 1999), endodontics, orthodontics, oral medicine and
paedodontics (McCreery and Truelove, 1991a, 1991b).

2.3.1 Clinical decision-making models

As early as 1979, Eisenberg concluded that socio-cultural factors also influence

medical decision-making (Eisenberg, 1979). The report identified five factors.
The factors included: sociologic characteristics of the patient; the sociologic
characteristics of the physician; the physician’s interaction with his profession and
the health care system; and the physician’s interpersonal relationship with the
patient (Eisenberg, 1979). The author believed that clinical decisions are
influenced by interactions between the dentist and the patient, the sociocultural
environment and biomedical considerations.

The cognitive theoretical framework of Gale and Marsden (1983) described

clinical decision-making through the identification of the specific psychological
processes that occurred as the resolution of a clinical problem progressed. These
processes are referred to as diagnostic thinking processes (DTP). The authors
suggest that the perception of a problem is dependent on the way knowledge is
structured in memory.

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The link between knowledge structure and a clinical situation is formed by
significant features within pieces of information called “forceful features” (Gale
and Marsden, 1983) or “caries scripts” as referred to by Baders and Shugars
(1997). These are derived from experience and are part of the memory structure.
Gale and Marsden (1983) identified 14 DTPs.

A model such as suggested by Ettinger (1984) represents the types of

decision-making related to diagnosis, treatment planning and maintenance
decisions as seen in Figure 2. It combines elements of the anatomical model and
medical model of diagnosis. In the anatomical model of diagnosis, the emphasis is
on disease identification. Once the disease has been identified, it can be linked
with a specific curative treatment. However, in dentistry, dentists are confronted
by mainly two diseases, dental caries and periodontal disease. These are not
linked to any specific therapeutic treatment, so dentists are more concerned with
the alternatives related to treatment planning. In the medical model, the clinician
collects three sets of data. The first set is about the host and the host’s
environment, the second set is descriptive and related to the morphology or
microbiology of the disease, and the third set describes the interaction between the
disease and its environmental host.

Kay and Nuttall (1997) proposed a Rational Decision-Making Model (Figure 3).
The advantages of using this technique were that it focused the dentists’ thinking
on factors that truly influenced the decision to treat and thus helped structure the
thought process. It also ensured that all possible options were explored (Kay and
Nuttall, 1997).

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Figure 2: Clinical decision-making in dentistry (Ettinger, 1984)

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Figure 3: Dental decision-making (Adapted from Kay and Nuttall, 1997)

Bader and Shugars (1997) improved on their 1992 conceptual model for the
decision-making process of dentists regarding treatment (Figure 1). The authors
admit that the model is not based on any theoretical framework but borrows from
several theories of decision-making and incorporates the authors’ empirical
observations. The model reflects decision-making processes employed by
experienced dentists as opposed to learners or novices. The model suggests that
dentists do not use a hypothetico-deductive reasoning process but rather identify
caries through pattern recognition that is linked to decisions to intervene. The
scripts comprise salient factors that are dependent on individual characteristics
and biases and thus, they vary among dentists (Bader and Shugars, 1997).

Maupome and Sheiham (2000) argued that previous studies described what
clinicians ought to be doing, how they process information while making
decisions can be replicated by numeric algorithms and what clinicians seem to be
doing when making sense of information. Actual research on what clinicians do
while processing information for diagnostic/management applications was rare.
Maupome and Sheiham (2000) proposed the use of the Gale and Marsden
cognitive theoretical framework (Gale and Marsden, 1983) in an educational
setting. In contrast to other studies, there was no significant differences in the
range of DTPs available to either experienced or novice clinicians (Maupomé and
Sheiham, 2000). A key finding of this research was that non-clinical, non-
biological issues affected the appraisal of needs (Maupomé and Sheiham, 2000).

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Following on from this, Maupome and Sheiham (2002) shifted their conceptual
framework to case-study research of explanatory models (EM) of illness using
simulated patients. The decision was based on the assumption that EMs are the
personal representations of a specific illness entity – the cultural models used to
interpret some aspect of reality. The authors acknowledged, however, that the
findings from their study could not be transferred to practising dentists or to other
dental-education settings but encouraged researchers to judge the applicability or
to reproduce the work (Maupome and Sheiham, 2002).

Figure 4: Hypothetical decision model (White and Maupomé, 2003)

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Decision-analysis methods include Bayes theorem, decision tree design,
receiver-operating-characteristic curves, sensitivity analysis and utilities
assessment (McCreery and Truelove, 1991a). A hypothetical decision model is
another clinical example of applying the clinical decision framework as seen in
Figure 4.

It is apparent from the evidence that the decision-making process is complex but
generally involves several important steps in which patient involvement is
essential (Kay and Nuttall, 1997; White and Maupomé, 2003; Hajjaj et al., 2010).
These steps involve:

• Recognising and clarifying the problem

• Identifying potential solutions
• Discussing the options and uncertainties
• Providing tailor-made information
• Checking understanding and reactions
• Checking patient’s preferences
• Exploring the patient’s view
• Agreeing with the patient about a course of action
• Implementing the chosen course of action
• Arranging follow-up with the patient
• Evaluating the outcome

2.3.2 Restorative treatment variation in practice

Internationally, there is a growing body of literature describing variation in rates

and practice patterns among dental practices (Bader and Shugars, 1995a; Palotie,
2009; Alexander et al., 2014). Measuring these differences among practices
usually includes descriptive rates of procedures viz. number of extractions per 100
patient visits or income for a specific procedure. These are useful in comparing
procedures regionally or nationally.

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It is accepted that not all dentists will make the same treatment choice when
confronted with the same clinical situation (Maryniuk, 1990; Bader and Shugars,
1992; Bader and Shugars, 1995b). The differences among professionals are
commonly accepted as reflections of the “art of dentistry” and are described as
natural variations in dentists’ “clinical judgments” (Maryniuk, 1990).

Maryniuk (1990) attempted to explain the variation in dentists’ treatment

decisions, exclusive of clinical data. The author rationalised that the development
of clinical judgement during dental school training ultimately shapes the way they
think, solve problems and make decisions. Two explanatory models of practice
variation were suggested. The first model that depicted the dentist as a self-
fulfilling practitioner proposed that a large proportion of dental care was driven by
the dentist’s desire for an income. This model of financial gain meant that dentists
were acting for self-gain, which included a desire for a certain style of practice,
their own preferences, practice setting and influence over fellow professionals.
The second model that depicted the dentist as the patient’s agent had several
components. Dentists would primarily defend patients’ economic well-being,
which may be in conflict with their own self-interests. This may be explained
where cast restorations are recommended over conventional amalgam or
composite restorations because the dentists’ profit margins would be greater.

These variations in judgement highlight the aspects of dentistry in which there is

uncertainty or disagreement concerning the most effective approaches to
treatment, and this may also compromise the effectiveness of the care. Kay and
Nuttall (1997) suggested that differences in treatment variations could stem from
two main sources, perceptual variation and judgemental variation. Perceptual
variation is when people perceive things differently. For example, when dentists
examining the same tooth disagree about what they are observing, they ‘see’
different conditions (Kay and Nuttall, 1997). Consequently, their treatment
decisions will differ because they think they are seeing different levels of the
disease. Judgemental variations occur when people have different opinions, for
example, dentists examining the same tooth may agree about what they see but
disagree about how it should be treated.

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This variability in treatment decisions and the consequences have encouraged the
development of guidelines that aim to reduce variation and assure quality of care
for all patients (Kay and Nuttall, 1997; Weber et al., 2011)

Marinho et al. (2001) reported that evidence chronicled yearly by the Dartmouth
Atlas of Healthcare indicated that variation in healthcare is associated with three
factors: (i) poor quality of science underlying clinical care; (ii) poor quality of
clinical decision-making; and (iii) variations in clinical skill.

A review of patient and dentist factors associated with restorative treatment

variation in practice follows.

2.3.3 Patient factors

Several characteristics of the patient have been associated with the decision to
treat. Patients who changed dentists received twice as many restorations as those
who did not (Bader and Shugars, 1992). In a study conducted in Dutch adults,
more restorations were classified as requiring replacement among older patients
and patients who visited the dentist regularly (Bader and Shugars, 1992). This
supports the Elderton and Nutall (1983) finding that placing a restoration “invites
lifelong repair and maintenance”.

Alternative treatments varying in effectiveness, permanence, appearance and cost

usually exist for most dental problems (Grembowski et al., 1988). Similarly, in
the USA, patient choice often influences treatment selection, mainly because
caries and periodontal disease are not life-threatening and because the majority of
dental costs are paid out-of-pocket by the patient (Grembowski et al., 1988).
Dentists recommend various levels of restorative care based on the patient’s
ability to pay (Maryniuk, 1990). The availability of dental insurance has been seen
to influence treatment decisions by dentists (Bader and Shugars, 1992). Dentists
may choose not to prescribe the best course of treatment and deny certain services
to those who cannot afford them or make judgements about patients’ preferences
and abilities to pay.

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However, selecting treatment alternatives primarily on the basis of cost raises
issues of the appropriateness of care. This may be because dentistry has been
regarded as a discretionary service, and dentists and patients are sensitive to cost
considerations. This variation in treatment decisions may also introduce
inappropriate treatment such as over- and under-treatment, both of which have
long-term economic health implications (Bader and Shugars, 1992).

In a study conducted by Brennan and Spencer (2002), cost emerged as a major

determinant of treatment choice where significantly cheaper alternatives existed.
In a subsequent study by Brennan and Spencer (2006), the factors considered in
the choice of alternative treatments by dentists were investigated. Dentists were
asked to list the five main factors when choosing an alternative treatment for the
following treatment pairs: ‘crown v. build-up’, ‘root canal v. extraction’, ‘bridge
v. denture’ and ‘prophylaxis v. scaling’ (Brennan and Spencer, 2006).

2.3.4 Tooth level

Dentists’ decisions with respect to caries vary in the diagnosis and detection
phase. Evidence that differences in the criteria for diagnosis exist are found in
studies involving diagnosis and identification (Maryniuk, 1990). Variation in
diagnosis due to differences in tactile skills is also demonstrated in a few studies
(Maryniuk, 1990). This can influence both the detection of disease and the
evaluation of an existing restoration. Baders and Shugars (1995b) suggested that
these differences could be attributed to two factors: skill and diligence in the
examination; and the definition and criteria employed for the identification of
disease.

Findings from a study conducted by Grembowski et al. (1988) found that

technical factors such as age of patient, caries rate, extent of tooth damage and
future plans for the tooth dominated over patient considerations when choosing
alternative treatments.

There is ample evidence of variation among dentists’ decisions to intervene, and

this may be associated with the dentists’ knowledge of the course of the disease
(Nuttall et al., 1993). Most dentists also accept the notion that the course of the

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disease and the effectiveness of any treatment are heavily influenced by a number
of risk factors (Bader and Shugars, 1995b).

Since restorations and replacement of teeth account for large portions of practice
time and dental expenditures, variations in treatment decisions may have
substantial cost and policy implications (Bader and Shugars, 1997). Differences in
how dentistry is practised locally or regionally are acknowledged but have not
been studied frequently in South Africa.

2.3.5 Dentist factors

Research has indicated that factors specific to dentists such as age, education,
practice arrangement and gender have also affected clinical decision-making and
practice patterns. Dentists who were solo practitioners were more inclined to be
more patient orientated (Grembowski et al., 1988).

In a study conducted in Brazil to assess the treatment decisions of clinicians in the

Public Health Service regarding deep carious lesions, it was observed that
younger dentists were more likely to adopt a more conservative treatment (Weber
et al., 2011).

Other research focusing on productivity and gender implied that female dentists
worked fewer hours, saw fewer patients and provided less services to the
community (Spencer and Lewis, 1988; Atchison et al., 2002). A practice-based
study investigating differences in male and female practice patterns found that
female dentists adopted a more conservative restorative treatment approach.
However, this finding was related to females in the sample who had fewer years
since graduation and were prone to restoring at a greater depth when compared
with their male counterparts (Riley et al., 2011).

Grembowski et al. (1988) also presented dentist-practice beliefs that they

maintained could influence clinical decision-making. These beliefs were divided
into five main categories: patient characteristics, practice characteristics, volume
of services, manpower and the dental market. Dentists with preventive practice
beliefs took fewer patient factors into consideration in their decision-making,

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whereas patient-oriented dentists tended to work longer hours, be solo
practitioners and have lower fees (Grembowski et al., 1988).

Kay and Blinkhorn (1996) conducted a qualitative investigation of factors

governing the treatment-decision philosophies of dentists and found that clinical
decision-making relied on a number of factors, not only on the disease process
and treatment options. This paper presented a list of non-clinical factors that are
considered when formulating treatment options (Table 1) (Kay and Blinkhorn,
1996).

Similarly, Brennan and Spencer (2001) referred to “belief scales”, where attitudes,
values and habits could lead to the development of preferences for particular
techniques or procedures. Their study revealed that patient expectations were
matched with practice beliefs and service patterns of dentists (Brennan and
Spencer, 2001).

It is important to note that the selection of restorative materials is also influenced

by dentists’ educational background and experience. Dental training experiences
have a major impact on the development of clinical judgement and practice
patterns (Maryniuk, 1990). Dentists prescribe treatment based not only on
principles and experience learnt during dental school but also on other sources
following graduation, such as continuing education, dental journals, advice from
colleagues or simply experiences in dental practice (Grembowski et al., 1989;
McCreery and Truelove, 1991b; Kay and Nuttall, 1994; Bader and Shugars, 1997;
White and Maupomé, 2003; Doméjean-Orliaguet et al., 2009). In addition, their
decisions are influenced by fear of malpractice and financial self-interest
(Grembowski et al., 1989).

A review on posterior amalgam restorations reported on changes to teaching

approaches with regard to amalgam and resin composite (Mitchell et al., 2007).
There was an increase in the teaching of resin composites for posterior
restorations, and one dental school in the Netherlands reduced the time devoted to
dental amalgam (Mitchell et al., 2007). In 2001, the Nijmegen dental school
became the first amalgam-free dental school (Roeters et al., 2004).

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Table 1: A classification of issues and questions relevant to treatment
decision-making in general dental practice (Kay and Blinkhorn, 1996)
Practitioner Patient Profession
Cost and How long will it Will the patient Will the patient
benefits take to do this ‘gain’ anything by think dentistry is
treatment? having this beneficial if I take
treatment? this option?

Will this treatment How well does the Am I providing

be difficult to do? patient cope with society with the
the process of benefits that they
treatment? pay for?

Is it financially How much can the

viable to undertake patient realistically
this treatment? afford to spend?
Attitudes Am I doing what is Will the patient feel Does this treatment
and values morally right? as if I’ve made a decision fit with
good judgement? what is generally
regarded as ‘right’
by my peers?

Is it ethical to Does this patient Would my peers

undertake this trust me? think that this was
treatment? the best option?
Will the patient like
me/my practice?
Actualisation Am I behaving in What does the Am I doing my
of the way I believe to patient expect as a professional duty?
expectations be the best? result of this
treatment?

How will this Will this treatment Am I providing the

decision affect the give the patient the treatment that the
way I feel about outcome he/she will profession would
myself? value most highly? expect to be
provided?

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2.4 SECTION 3: AMALGAM AS A RESTORATIVE MATERIAL

Dental caries is one of the most common diseases in the world, with
approximately 80% of the population having experienced the condition (Sheldon
and Treasure, 1999). In clinical practice today, dental restorations are regarded as
a treatment for this disease. Currently, there are a number of restorative materials
available on the market, with dental amalgam being one of the most controversial
materials used. Numerous papers have reported on the trends of dental amalgam
use (Widström et al., 1997; Widström and Forss, 1998; Ylinen and Löfroth, 2002;
Burke et al., 2003; Du Preez et al., 2003; Rosenstiel et al., 2004; Burke, 2004;
Wilson et al., 2004; Mitchell et al., 2007; Norlund et al., 2009; Kovarik, 2009;
Khalaf et al., 2014). Dental amalgam continues to be used because of its low cost,
durability and ease of manipulation and placement.

According to Alexander et al. (2014), the advantages of dental amalgam

compared with resin-based composite include:

• increased wear resistance;

• reduced micro leakage;
• less effect on subgingival microflora and biofilm;
• less risk of enlarging the original cavity preparation during removal; and
• less time-consuming.

The disadvantages are that the material is not tooth-coloured, it cannot adhere to
the tooth and so requires a macro-mechanical retention, and it contains mercury
(Petersen, 2003). Opposition to the use of dental amalgam has centred around two
issues, the potentially negative effect on a person’s health and the environmental
issues regarding dental amalgam waste management and disposal.

A review of the current debate with regard to the use of dental amalgam both
globally and in the South African context follows.

2.4.1 Regulation of dental amalgam as a restorative material

Following the distribution of the WHO/FDI Consensus Statement on Dental

Amalgam in 1995, the World Health Organization (WHO) received numerous

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requests from WHO member states, organisations and individuals on various
aspects related to the use of dental amalgam (Mitchell et al., 2007).

The United States Public Health Service (USPHS) issued a comprehensive report
on the risk management of dental amalgam in 1993. The report concluded that
there was no need to place restrictions on the use of dental amalgam. This was
reaffirmed in 1995 (Widström et al., 1997). At the time that the WHO report was
being prepared, available data indicated a 38% decrease in the number of dental
amalgam procedures (Mitchell et al., 2007). This was attributed to a declining
incidence in caries, widespread use of fluoridated water, availability of fluoride-
containing toothpastes, rinses and gels, wider use of dental sealants and a greater
public awareness of the need for and access to dental healthcare (Listl et al.,
2015).

Recommendations for the use of dental amalgam emerged in some Nordic

countries together with a requirement for the use of amalgam separators in dental
surgeries (Ylinen and Löfroth, 2002; Burke et al., 2003). The safety of dental
amalgam was emphasised, and it was recommended that use be avoided in
pregnant women and children. In Norway, a general ban on the use of dental
amalgam was introduced in 2008 and a complete ban in January 2011 (Burke,
2004; Lynch and Wilson, 2013b). Sweden and Denmark joined the ban due to
concerns regarding the environmental impact (Lynch and Wilson, 2013b).
Growing global concern around the environmental effects of the continued use of
dental amalgam, a shift towards minimally invasive dentistry and patients’
increasing demands for more aesthetic dentistry expressed the need for a
world-wide reduction in the use of dental amalgam.

In Geneva (Switzerland), the recent Minamata Convention on Mercury (named

after a city in Japan where serious health damage occurred as a result of mercury
pollution in the mid-20th century) saw 90 nations undertaking to reduce and
ultimately to cease the global production and use of mercury-containing products
by 2020 (Mackey et al., 2014). The major highlights of the Minamata Convention
on Mercury included a ban on new mercury mines, the phasing-out of existing
mercury mines, control measures for air emissions and the international regulation

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of the informal sector for artisanal and small-scale gold mining. Dental amalgam
fillings are exempt from the 2020 ban, but delegates agreed to a “phase-down in
the use of dental fillings using mercury amalgam” (Lynch and Wilson, 2013a).
Some of the measures to reach that goal include (Mackey et al., 2014):

• minimising the need for dental restoration by setting national objectives

aimed at dental caries prevention and health promotion;
• setting national objectives aimed at minimising its use;
• promoting the use of cost-effective and clinically effective mercury-free
alternatives for dental restoration;
• promoting research and development of quality mercury-free materials for
dental restoration;
• encouraging representative professional organisations and dental schools
to educate and train dental professionals and dental students in the use of
mercury-free dental restoration alternatives and to promote best
management practices;
• discouraging insurance policies and programmes that favour dental
amalgam use over mercury-free dental restorations;
• encouraging insurance policies and programmes that favour the use of
quality alternatives to dental amalgam for dental restorations;
• restricting the use of dental amalgam to its encapsulated form; and
• promoting the use of best environment practices in dental facilities to
reduce releases of mercury and mercury compounds to water and land.

The FDI (Federation Dentaire Internationale) and the ADA (American Dental
Association) have given their support to the Minamata Convention. It is envisaged
that this could result in a fundamental change in the clinical practice of dentistry
and the training of future dentists.

2.4.2 Use of dental amalgam in clinical practice internationally

A questionnaire was developed from the questionnaire used by Widström and

Forss (1998) in Finland to determine dentists’ attitudes towards the use of dental

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amalgam and resin-based composite (RBC) restorations in general practice
(Burke, 1992). Fifty-nine percent of respondents reported a decrease in the use of
amalgam over the previous five years, and 44% reported that their use of amalgam
remained stable (Burke, 1992). In the USA, dental amalgam was considered the
most commonly used posterior tooth restorative material in 2001 (Burke et al.,
2003). Despite the various local, regional and global research projects by different
expert groups, about 250 000 dentists within the European Union continued to
treat their patients using amalgam restorations (Burke et al., 2003). There was
little evidence to indicate whether this trend was also apparent in the United
Kingdom (UK) (Burke et al., 2003).

When the data from the study of Burke et al. (2003) is compared with that of
Widström and Forss (1998), the use of amalgam decreased by 58% in Finland
between 1996 and 2001, and only 2% of British dentists reported not using
amalgam compared with 37% of Finnish dentists. These differences may be due
to the guidance issued by the Ministry of Social Affairs and Health in 1994, which
recommended that the use of dental amalgam be decreased due to environmental
reasons, as well as the different methods of funding in oral health care in the two
countries. A 2007 review by Mitchell et al. (2007) on posterior amalgam
restorations between 1996 and 2006 indicated a decline in the use of dental
amalgam and an increase in the use of resin composites worldwide.

2.4.3 Use and teaching of dental amalgam in clinical practice in Africa

In low-resource communities, oral health services are either not available or poor,
especially in rural and remote areas (Gray and Vawda, 2015). Where oral health
services do exist, dental amalgam is a still the best choice in restorative dental
care because of its affordability, ease of use and longevity (Rekow et al., 2013).
Composites are favoured by private practitioners and patients for aesthetic reasons
(Rekow et al., 2013). However, dental amalgam is regarded as a more forgiving
and predictable material.

In 1997, Thorpe reported to the WHO that in the African region, dental amalgam
is the most extensively used restorative material for the repair of decayed
posterior teeth, mainly because of its advantages (Petersen et al., 2009).

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A paper by Oginni and Olusie published in 2002 on the longevity of restorations
in Nigeria stated that “[i]n Nigeria … dental amalgam has been used extensively
as a tooth restorative material”. However, no data was presented to support the
statement. Burke (2004) reported that there was very little data available regarding
the usage of amalgam in Africa.

In a 1999 survey regarding the use of dental materials by dentists in South Africa,
it was found that 85.8% of respondents were still using amalgam as a restorative
material (DuPreez et al., 2003). This was lower than the 99,7% reported in 1990
(DuPreez et al., 2003). In 2009, Lombard et al. (2009) conducted a study to
investigate and compare the teaching approaches regarding direct restorative
techniques and materials in dental schools in South Africa with the teaching
approaches in American, Canadian, Irish and United Kingdom schools. All four
South African dental schools agreed that dental amalgam should still be included
in teaching as a restorative dental material (Lombard et al., 2009). This was in
accordance with research conducted at Canadian, Irish and United Kingdom
dental schools (Lombard et al., 2009). Equal time was spent on the preclinical
teaching of composites and dental amalgam. Conversely, five out of the eight
dental schools in Canada placed a greater emphasis on silver amalgam.

2.4.4 Longevity of restorations

Evidence suggests that dental restorations have a limited lifespan and that once a
tooth is restored, the filling is likely to be replaced many times in the patient’s
lifetime – “the restorative cycle” (Chadwick et al., 2001). The durability or
longevity of a dental restoration is a salient factor in determining its effectiveness
as a treatment for caries (Downer et al., 1999). Long-lasting dental restorations
foster patient confidence in the practitioner and the profession and reassure that a
cost-effective service is being provided.

The examination of patients for treatment needs frequently reveals restorations

that do not conform to criteria for successful restorations but are capable of further
clinical service and do not necessarily require replacement. A comparison of the
longevity of dental amalgam restorations in different studies reported by different
authors is problematic for various reasons (Downer et al., 1999).

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The variables in the study designs are often poorly described or omitted.
Differences in clinical procedures, materials used and variations in study
characteristics make direct comparisons impossible (Hickel and Manhart, 2001).
Similar sentiments were published by Chadwick et al. (2001) with regard to the
challenges when conducting systematic reviews about the longevity of
restorations.

In a clinical trial, a new restoration is the initial event, which is followed by a

subsequent event, a replacement. The time between these two events is called
survival time. The results of longevity of restorations can be represented in
different ways, but the difference is that the subsequent event (i.e. the
replacement) may not have occurred for all restorations. Controlled clinical trials
are a necessary part of long-term evaluation, but they are time-consuming and
costly. Controlled clinical trials do not adequately portray the general dental
practice setting. Cross-sectional studies differ from longitudinal studies in which
clinicians operate under ideal conditions for the materials investigated. Downer et
al. (1999) pointed out that cross-sectional studies involving retrospective case
record examinations by non-standardised examiners can give insights into effect
modifiers such as the dental care system, but such studies do not rate highly in the
hierarchy of acceptable evidence. The authors have also cautioned about the
confusion in the nomenclature; median survival time is the life-time that any
individual restoration has a 50% change of exceeding. The expression is routinely
used in cross-sectional studies, but it would be more correct to speak of median
functional periods of failed restorations (Downer et al., 1999; Forss and
Widström, 2001; Chadwick et al., 2001). As a result, cross-sectional studies give
an underestimation of the average lifespan of routine restorations. The value of
the cross-sectional study is that it clarifies the decisions made by ordinary dentists
in general dental practice.

In an attempt to investigate the treatment patterns of dentists more accurately,

studies have been conducted to determine restoration longevity by using dental
insurance-claim databases (Bogacki et al., 2002) and more recently, practice-
based research (Mjor et al., 2005; Gilbert et al., 2011 and Gilbert et al., 2013).
Despite these limitations, certain trends are apparent.

Study design
First author

GV Black

Remarks
Year

specified)

I Conventional 25 5.8 Zinc and copper content of

zinc-free, 70 the alloy contributed to the
II conventional 70 2.3 corrosion resistance of the
zinc 2.3 amalgams
1997 Letzel 13 containing, 3119 85 Main failure reasons:
high copper 1.2 fractures, marginal ditching,
zinc-free, high recurrent caries
copper zinc-
containing
I Amalgam 9 Main failure reasons:
Cross-
1997 Mjor >25 II (alloys not 282 secondary caries (50%),
sectional
specified) fracture (29%)
I 87, 2, Kaplan-Meier method.
Cross-
1997 Roulet 6 II 163 43 5 1 Main reasons for
sectional
replacement: fracture

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Table 2: Longevity of dental restorations (continued)

Median Survival Time (yrs.)

Number of restorations (n)
Observation period (yrs.)

Annual failure rate (%)

Number of patients (n)
Restorative materials

Survival Rate (%)

Study design
First author

GV Black

Remarks
Year

II Amalgam 77.6 4.5 14, Extensive amalgam

5, Cross-
1997 Smales (alloys not 160 66.7 3.3 6 restorations with cusp
10 sectional
specified) 47.8 3.5 replacement

1998 Kreulen 15 II New True 1117 183 Longitudinal 83 1, Replacement risk for MOD
Dentalloy, 1 is significantly higher than
Tytin, Cavex for MO/OD replacement
II New True 94,3 0,6
1998 Mair 10 Dentalloy, 35 Longitudinal
Solila Nova
Large amalgam restorations
1998 Plasmans 8 II Cavex (non- 266 130 Longitudinal 88 1,5 in molars with cusp
gamma-2) replacement
I 268 Cross- 7.4
1999 Burke
II 1142 sectional 6.6

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Table 2: Longevity of dental restorations (continued)

Median Survival Time (yrs.)

Number of restorations (n)
Observation period (yrs.)

Annual failure rate (%)

Number of patients (n)
Restorative materials

Survival Rate (%)

Study design
First author

GV Black

Remarks
Year

1,2, Amalgam 80 2.5 Severe mentally and/or

3 (alloys not 73.2 3.4 physically handicapped
S specified) Cross- 71.1 3.6 patients
1999 Circhon 8 820
sectional

I 62 83.9 2.7 Main failure reasons:

1999 Kamann 6 Longitudinal
II 21 66.7 5.6 secondary caries
Need for replacement
2007 Soncini 5 509 534 Longitudinal 15, increased with the size of
Amalgam 9 the restoration
I Amalgam 912 89.6
5
2007 Opdam II Dispersed 621 Longitudinal 79.2
10
phase
Amalgam
2007 Bernado 7 1,2, Dispersed Longitudinal Study conducted in
3,4 phase 0,8,2 subjects aged 8–12 years
Data mining of 4 patient
2009 Kakilehto 20 19892
Retrospective record centres in Finland

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Table 2: Longevity of dental restorations (continued)

Median Survival Time (yrs.)

Number of restorations (n)
Observation period (yrs.)

Annual failure rate (%)

Number of patients (n)
Restorative materials

Survival Rate (%)

Study design
First author

GV Black

Remarks
Year

0.9
5 II 8 Practice-based research of 1
2010 Opdam Dispersalloy 1202 Retrospective
12 4/5 2.0 dentist
5
Amalgam,
93 %
compomer,
(Hg), Practice-based research of
2012 Kopperud 4 II resin 4030 1873 Practice based
88% 27 dentists
composite,
(Au)
glass ionomer
4.5,
Composite,
5.1,
amalgam, Longitudinal Practice-based research of
2015 Laske 15 432044 76071 7.1,
compomer, descriptive 67 dentists
10.
glass Ionomer
7

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Some disparity also exists in the results from longitudinal clinical trials, which
present a more comparable or slightly better longevity of amalgam restorations as
opposed to cross-sectional retrospective studies. Furthermore, practice-based
research found that the longevity of amalgam restorations was twice as much as
the composite restorations (Opdam et al., 2007). This could be explained by the
fact that in longitudinal studies, operators are well trained and calibrated whilst in
cross-sectional studies, they may have more experience in working with amalgam
than with posterior composites (Opdam et al., 2007).

The longevity of restorations is dependent on a variety of factors such as patient- ,

dentist- and material-related factors as summarised in Table 3. Studies have also
reported that proportionally, more resin composite restorations failed (77.9%)
because of secondary caries than amalgam restorations (22.1%)
(VanNieuwenhuysen et al., 2003; Hurst, 2014). Reasons for this include the
formation of oxides at the amalgam-tooth interface that seal the margin, thereby
reducing caries, as well as adhesive failures in the resin composite restorations
that increase the development of recurrent caries, thus creating a difference in
caries risk in the amalgam and resin-composite sample groups (Moraschini et al.,
2015).

The number of surfaces involved in the restoration may also influence the
longevity of the restoration. Lucarotti et al. (2005b) found that 58% of
single-surface amalgam restorations survived better compared with 43% of
mesial-occlusal-distal (MOD) amalgams. Similarly, Bernardo et al. (2007) found
that large restorations and those with three or more surfaces had the lowest
survival rate. Findings from the New England Children’s Amalgam Trial were
consistent with previous reports that in permanent teeth, the need for replacement
increased significantly with the size of the restoration (Soncini et al., 2007).

In everyday clinical practice, several factors relating to the patient and the
clinician may have an unfavourable effect on the survival of a restoration, but
there is very little information available regarding this. The factors may include
the age of the patient, the gender of the clinician, operator skill, the materials and

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techniques used, patient compliance with oral hygiene advice, caries susceptibility
and possibly, the means by which the treatment is funded (Table 3).

Burke et al. (2001) confirmed that although the influence of high caries activity
was not clear, good oral hygiene enhanced restoration longevity, heavy occlusal
function decreased the restoration longevity, increased patient age improved
restoration longevity and the patient’s gender had no effect.

Table 3: Factors influencing the longevity of dental restorations (Hickel and

Manhart, 2001)

Patient Dentist Material

Oral hygiene Correct indication Strength (fractures)

Preventive measures Cavity preparation (size, Fatigue/degradation
type, finishing)
Compliance in recall Handling and Wear resistance (occlusal
application (e.g. contact areas, contact-free
Oral environment incremental vs. bulk areas)
(quality of tooth placement) Bond strength
structure, saliva, etc.) Curing mode (device,
Size, shape, location of time, light intensity) Chemical compatibility of
the lesion and tooth Mode of finishing and restorative systems (DBA,
(number of surfaces, polishing the restoration composite)
vital vs. non-vital,
premolar vs. molar)
Technique sensitivity
Cooperation during Correct occlusion Caries-inhibiting effects
treatment Experience (with (release of substances)
Bruxism/habits material)

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A practice-based study that included three private practices with twenty dentists
was conducted by Hawthorne and Smales (1997). This study examined the effects
on restoration longevity of dental practice, age of patient when restoration was
placed, frequency of attendance for treatment, change of dentist, experience or
graduation age of dentist and restoration placement (initial or replacement). The
study reported excellent survival times for all the restorative materials, possibly
due to the regular attendance of motivated patients, the fairly low turnover of
dentists and the remuneration system in which the majority of the cost was borne
by the patient. Hawthorne and Smales (1997) determined that a change of dentist
had no effect on the longevity of restorations. Conversely, Bogacki et al. (2002)
used an insurance-claim database and observed that amalgam and resin composite
restorations had a greater chance of failure when patients changed dentists.

Dobloug and Grytten (2015) estimated dentist-specific variation in the longevity

of restorations in first permanent molars for children aged 6–18 years over a
12-year period. The authors reasoned that if the dentist variation was
considerable, then the focus should shift to reassessing the teaching practices in
restorative dentistry. If the patient variation was large, then the focus should be on
strategies to improve their dental behaviour. The results of the study confirmed
that variation between dentists was low and, therefore, most of the variation was
attributed to patient factors such as secondary caries and the age of the patient
(Dobloug and Grytten, 2015). These findings may be difficult to extrapolate to the
South African context since the study was conducted in Norway. In Norway, all
children under the age of 18 years receive free dental treatment, and there are no
economic incentives that could influence treatment decisions (Dobloug and
Grytten, 2015).

A more recent retrospective, practice-based study reported on the largest dataset

of 400 000 restorations placed by general dental practitioners between 1996 and
2011 (Laske et al., 2016). The research focused on the longevity of restorations
and explored the effect of practice/operator, patient and tooth/restoration factors
on restoration survival. Considerable variation in longevity of restorations among
the practices was found, with the annual failure rate (AFR) showing values
between 2.1% and 6.4% (Laske et al., 2016). A lower restoration survival was

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recorded for larger team practices (Laske et al., 2016). One could assume that in
large practices, patients are more often seen by different dentists and hence,
changing dentists could lead to a higher replacement rate of fillings (Laske et al.,
2016).

2.4.5 Replacement of restorations

Dental restorations are often described as “permanent” but in reality, do not last a
lifetime (Fejerskov and Kidd, 2009). Each time an amalgam restoration is
replaced, there is loss of healthy tissue, thus increasing the size of both the
preparation and the restoration (Gordan, 2000; Gordan, 2001 and Gordan et al.,
2004). Although the cost of replacing an existing restoration is about the same as
the original restoration, the complete replacement of large restorations is time-
consuming, technically difficult and may be potentially damaging to the pulp
(Moncada et al, 2008).

Approximately 72% of amalgam restorative treatment is performed to replace

existing restorations, and the two primary reasons are recurrent caries and faulty
margins (Gordan et al., 2009). Dentists are frequently faced with a clinical
decision either to replace or repair a defective amalgam restoration. However,
there is evidence to suggest that the replacement restoration may incorporate
many of the inherent faults of the original restoration (Smales and Yip, 2012).

A recent study in the USA revealed that 30% of posterior restorations are replaced
within a two-year period (Palotie and Vehkalahti, 2012). The data reviewed in
previous studies indicate that every day, clinical practice in Scandinavia, the UK
and the USA included and continue to include more replacements than new
restorations (Burke et al., 1999; Deligeorgi et al., 2001). In one of the few studies
conducted in Africa, only 24.8% of amalgam restorations placed were
replacements (Oginni and Olusile, 2002), which is in contrast to studies conducted
elsewhere. These findings could possibly be attributed to a decrease in caries
incidence in developed countries and an increase in developing countries.

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2.4.5.1 Diagnosis for restoration replacement

Numerous studies have been conducted in different countries and in different

settings to record the reasons for restoration replacements (Appendix A).
Information from these types of studies is important in order to determine
treatment patterns and to prevent future failures. Maupomé and Sheiham (1998)
cited Boyd (1989) who maintained that “reasons of failure” included different
concepts assembled according to the judgement of a given clinician.

The principal reason for the replacement of amalgam and resin composite
restorations has been secondary caries (Mjör and Toffenetti, 2000). Deligeorgi et
al. (2001) reviewed findings of the last two decades concerning the placement and
replacement of restorations. In order to clarify dentists’ diagnoses of secondary
caries, Mjor et al. (2000) sought to differentiate between frank and limited caries
in their study of the replacement of restorations in student clinics in Manchester,
England and Athens, Greece. Recurrent caries refers to caries of the tooth at the
margin of restorations, and although secondary caries is histologically similar to
primary caries, diagnostically, it is a challenge for dental practitioners because
many lesions are not always at the interface of the tooth and restoration (Gordan
et al., 2009).

Micro-leakage has been traditionally linked to the presence of secondary caries,

but research has proved that it is not a predictor of secondary caries (Dennison
and Sarrett, 2012). This uncertainty in diagnosis often means that a clinical
diagnosis is made when the probe catches any gap between the enamel and a
restoration. Recent research suggests that operative intervention be delayed unless
“there is clear evidence of soft dentin in marginal gaps larger than 250 µm”
(Ozer,1997 and Dennison and Sarrett, 2012).

The majority of surveys regarding the reasons for replacement of amalgam

restorations indicated the frequency of secondary caries diagnosis as being
between 50% and 60% (Mjor, 1981; Klausner and Charbeneau, 1985; Klausner et
al., 1987; Mjör and Toffenetti, 1992; Friedl et al., 1994; Mjör, 1997; Mjor et al.,
2000). Dennison and Sarrett (2012) reported that the diagnosis of secondary caries

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and the determination of appropriate treatment are among the most clinically
challenging tasks.

The visual, tactile and radiographic information used by dentists is often not
linked to the diagnostic criteria that are universally accepted or taught in dental
schools (Dennison and Sarrett, 2012). Ongoing research has described secondary
caries as a combination of an outer lesion and a wall lesion (Mjör and Toffenetti,
2000; Fejerskov and Kidd, 2009). The outer lesion is typically found as primary
caries in the tooth structure adjacent to the restoration. Histologically, there is no
difference between primary and secondary caries. Clinically, secondary caries is
found most often on the gingival margins of restorations and less frequently at
occlusal margins (Mjör, 2005).

Although more recent studies have reported lower frequencies (Oginni and
Olusile, 2002; Tyas, 2005; Olaleye, 2013; Bahsi et al., 2013; Silvani et al., 2014),
the decline in frequency could be attributed to an improved diagnostic ability of
dentists or a decrease in the use of amalgam. Findings from a cross-sectional,
retrospective, records-based study in Nigeria contradicted earlier studies when it
was found that secondary caries was not a major reason for the amalgam
replacements, with a frequency of only 11.6% (Olaleye, 2013).

Other common reasons to replace a defective amalgam restoration include bulk

fracture of the amalgam as well as marginal fracture and marginal degradation.
Tooth fracture accounted for 10–15% of the reasons for amalgam replacement in
other controlled and longitudinal studies (Burke, 1992; Mjör, 1997). Tooth
fracture is a common clinical problem, which may vary from a minimal enamel
fracture to the fracture of an entire cusp or a longitudinal fracture that may lead to
the eventual loss of the tooth (Burke, 1992). It may be caused by a faulty cavity
preparation in which insufficient, unsupported enamel has been removed or in
which the remaining enamel is too thin (Burke, 1992). Food and the patient’s
chewing habits may also contribute to the development of restoration or tooth
fractures (Akerboom et al., 1986). In the study conducted by Oginni and Olusile
(2002), bulk amalgam fracture was the most frequent reason for amalgam
replacement at 47%.

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There have been conflicting reports on the value of marginal degradation as a
good predictor of loss of amalgam restorations. Hamilton and Moffa (1983)
reported marginal failure was not a predictor for restoration longevity. As early as
1988, the replacement criteria developed clearly stated that the “the presence of a
marginal gap alone is not a criterion for restoration replacement” (Anusavice,
1988). In 1991, Osborne maintained it was a good predictor for the loss of
amalgams, while Mjor (1997) concluded that marginal degradation as a reason for
replacement of amalgam remained controversial.

It is anticipated that restorations with limited defects but with many serviceable
years left will not be replaced (Mjor and Toffenetti, 2000). The recommendation
is that the defective margins should be ground and polished and repaired with
amalgam or sealed with fissure sealant (Mjor and Toffenetti, 2000). In addition,
“marginal defects without visible evidence of soft dentin on the wall or the base of
the defect should be monitored for change or repaired or sealed and then
monitored” (Dennison and Sarrett, 2012). Dennison and Sarrett (2012) also
advocate removing some of the existing restorative material to visualise the walls
and base of the defect better prior to repair or sealing.

Interestingly, only one paper reported aesthetics as a main reason for the
replacement of dental amalgam restorations (Silvani et al., 2014). In this study,
which was performed in a dental clinic at a Brazilian university, 36.59% of
amalgam restorations were replaced for aesthetic purposes based on the patients’
desires to have restorations similar to the tooth structures, despite the restorations
being clinically satisfactory.

2.4.6 Management of defective restorations

Clinical studies conducted provide evidence for clinicians that repair is a safe
alternative to replacement for restorations that present with localised defects in
marginal areas, including gaps with exposed dentin, loss of anatomic form, altered
contact or secondary caries (Moncada et al., 2008; Moncada et al., 2009;
Moncada et al., 2010; Fernández et al., 2011; Martin et al., 2013; Moncada et al.,
2015a, 2015b) (Appendix B).

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Moncada et al. (2015a, 2015b) in their 10-year longitudinal study noted that all
repaired restorations experienced deterioration over the period of time, but they
were still clinically acceptable. Reasons for the downgrade of scores were not
explored and are opportunities for further research. The findings of this study are
in contrast to a similar study conducted by Smales and Hawthorne (2004). The
data in the study by Smales and Hawthorne (2004) was collected from established
private practices because the authors believed it provided a more stable
environment to evaluate the success of dental treatments. Another difference was
that treatment decisions were based on the clinical judgements of the individual
dentists and not on calibrated clinicians and USPHS criteria (Smales and
Hawthorne, 2004).

Although there was no statistically significant difference between the survival of

replaced and repaired amalgams (p=0.37), approximately 63% of the replaced
amalgams were still present at 10 years and 50% at 15 years, while only 37% of
the repaired amalgams were still present at 10 years (Smales and Hawthorne,
2004). It could be postulated that in the study by Smales and Hawthorne (2004),
only dental amalgam restorations with an actual clinical failure were repaired as
opposed to criteria on a specific list. Similar findings were reported in a
longitudinal, retrospective, practice-based study on repaired restorations by
Opdam and Bronkhorst (2012).

The lack of standardised criteria may be a failing of practice-based studies, but

they offer unique opportunities for follow-up restorations in real-world settings. In
addition, using standardised criteria required that restorations that may not have
been ordinarily treated were treated, as in the studies by Moncada et al. (2015a,
2015b), Martin et al. (2013), Moncada et al. (2010) and Moncada et al. (2009).
This could imply a potential for overtreatment.

Cochrane Reviews evaluating the evidence for effectiveness of replacement

versus repair of defective amalgam and composite restorations in permanent
molar and premolar teeth found that none of the studies reviewed provided
reliable evidence (Sharif et al., 2010). They called for more methodologically
sound, randomised controlled trials to be conducted. Balevi (2014) acknowledged

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that “while Sharif et al. (2014) ‘s updated review is relevant and appropriate, it is
unlikely that any future study would ever meet the strict criteria”. It would be
unethical randomly to assign a patient with obvious caries around an amalgam
restoration to the ‘no treatment’ group.

It is accepted that more clinical studies are required to support the current
evidence regarding the benefits of repairing defective dental amalgam
restorations. However, the present study focused on the clinical decision-making
process of selecting a treatment option in the management of defective dental
amalgam restorations.

2.4.7 Treatment options for defective dental restorations

The current management options for defective dental amalgam restorations are
repair, refurbishing and replacement of the restoration. These options are in line
with the contemporary, minimally invasive concept in restorative dentistry (Mjör,
2007). Setcos et al. (2004), in their study of treatment decisions of repair or
replacement of amalgam restorations at a school in the USA and the UK,
described sealing, refurbishment and repair together with indications for each
approach. These were redefined and published by the Word Dental Federation in
2010 (Hickel et al., 2010) (Appendix C). In addition, a helpful guide for clinical
situations with recommendations regarding repair or replacement was published
in 2013 (Hickel et al., 2013) (Table 4).

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Table 4: Clinical situations with recommendations for repair or replacement
(Hickel et al., 2013)

Clinical Problem Repair Replacement

1. Marginal Problems Pronounced localised marginal Deep marginal staining, not
Marginal Staining staining accessible
Marginal adaptation -Gap >250 µm or dentine/base -Restoration (complete or
exposed partial) is loose but in situ
-Severe ditching or marginal -Generalised major gaps or
fractures (tooth or restorative irregularities
material)
-Larger irregularities or
(negative) steps
Caries adjacent to Severe marginal Deep caries or exposed
restoration demineralisation or caries with dentine that is not
(secondary caries) cavitation and suspected accessible for repair
undermining caries but
localised and accessible
2. Surface problems Voids or rough surface, cannot Generalised very rough and
Surface lustre be masked by saliva film, unacceptable plaque
simple polishing is not retentive surface
sufficient
Aesthetic anatomical Form is affected and Form is unsatisfactory
form unacceptable aesthetically and/or lost
Intervention/correction is Repair not feasible or
necessary reasonable
Approximal Contact form too weak and Contact form too weak
anatomical form possible damage due to food and/or clear damage due to
impaction or inadequate food impaction and repair
contour not feasible/possible
Occlusal contour and Wear considerably exceeds Generalised excessive
wear normal enamel wear, occlusal wear, repair not feasible
contact points are lost
3. Fractures and bulk
loss
Closure of access Remaining restoration (larger Remaining restoration is
cavity after endodontic filling or crown) is sufficient insufficient, repair not
treatment feasible.
Fracture of restorative -Chip fractures that damage Partial or complete loss of
material marginal quality or proximal restoration and/or multiple
contact or contour fractures
-Bulk fractures with partial
loss (less than one-half) of the
restoration
Tooth integrity -Larger cracks >250 µm, probe Large cusp or tooth fracture
(enamel cracks, tooth penetrates
fracture) -Large enamel chipping or
wall fracture
-Cusp fractures (that are easily
accessible for repair)
4. Patient’s view Desire for improvement in Completely dissatisfied
aesthetics or function e.g. and/or adverse effects,
tongue irritation and reshaping including pain
of anatomic form or
refurbishing
impossible/insufficient
64

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There are four management options for defective restorations as first introduced
by Mjor and Gordan (2002) and more recently by Hickel et al. (2010):

1. No treatment (monitoring): indicated if minor shortcomings are present

(e.g. unfavourable colour/staining or sub-optimal margins) with no clinical
disadvantages if untreated.
2. Refurbishment: can be done if shortcomings are adjustable without
damage to tooth (e.g. removal of overhangs, recontouring of surface,
removal of discoloration, smoothening or glazing of surface including
sealing of pores and small gaps), which can be improved without adding
new restorative material (except glaze or bonding).
3. Repair: is indicated mainly in cases of localised shortcomings that are
clinically unsatisfactory and no longer acceptable. Repair is a minimally
invasive approach that implies the addition of new restorative material (not
only glaze or adhesive) with or without a preparation in the restoration
and/or dental hard tissues.
4. Replacement: is indicated for generalised or severe problems in which
intervention is necessary, and a repair is not reasonable or feasible.
Replacement is the complete removal of the restoration, usually combined
with more loss of tooth structure.

A brief summary of the current available evidence and preferred clinical

techniques is introduced below.

2.4.7.1 Refurbishing a defective dental amalgam restoration

Refurbishment is considered when there is poor anatomic form or marginal

ditching. Refinishing of defective areas is done using carbide burs, and
silicone-impregnated points are used for polishing. Proximal areas may be
smoothed with aluminium oxide finishing strips. In the case of dental amalgam
restorations where there is some expansion, recontouring and polishing of the
restoration, specifically the marginal areas, could extend the lifetime of the
restoration. This would also mean that the plaque retentive areas are reduced since
the surface is smooth. In vitro studies confirmed that sealing marginal, non-
carious defects in dental amalgam restorations significantly reduced marginal

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microleakage compared with control groups, delaying the need for replacement of
the old amalgams and potentially providing protection for the tooth from
secondary marginal caries (Cassin et al., 1991; Roberts et al., 2001). Results from
a five-year clinical trial confirm that refinishing defective restorations with
localised anatomic form defects is a useful and minimally invasive treatment
option (Martin et al., 2013).

2.4.7.2 Sealing defective margins

This procedure is defined as the application of a resin-based sealant on the

defective site or margin. Previous in vitro studies have indicated that the sealed
margins of a defective restoration may perform better than those that are not
sealed (Cassin et al., 1991; Roberts et al., 2001). All defective amalgam
restorations that received sealants did not show signs of significant degradation in
a two-year longitudinal study (Gordan et al., 2006). A three-year clinical trial
conducted by Moncada et al. (2009) supported this. The authors noted that sealed
margins may deteriorate over time and encouraged dentists to check them
regularly. However, no investigation into the cause of deterioration has been
conducted. When defective margins are sealed, a median survival time of three
years can be expected (Martin et al., 2013). The placement of sealants on
marginal gaps that are not larger than 1mm is a simple, non-invasive strategy to
improve the overall clinical properties of a restoration (Moncada et al., 2015b).

2.4.7.3 Repairing a defective restoration

The repair of a defective restoration rather than the replacement of the entire
restoration is not widely accepted as an alternative treatment (Christensen, 2007).
The rationale for repairing a defective restoration is aligned with the current,
minimally invasive approach in dentistry. The repair of a defective dental
restoration preserves existing sound tooth structure and conserves the pulp, which
could mean less treatment time and cause less anxiety for the patient since most
repair procedures may be completed without local anaesthesia (Javidi et al.,
2015). Other advantages include reduced costs and increased longevity of the
restoration (Strassler, 2012; Hickel et al., 2013; Blum et al., 2014).

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Once the decision has been made that the restoration is unsuitable, the dentist
needs to distinguish the conditions and determine repair or replacement. The
following conditions are more suited to repairing a dental restoration: large
marginal opening/ditching (250 µm); severe (localised) marginal staining
(aesthetically unacceptable); secondary caries (also known as caries adjacent to a
restoration) without deep undermining caries (can be controlled after opening);
marginal fracture of restorative material; chipping or partial fracture of restorative
material; marginal breakdown of enamel; erosive/abrasive loss of tooth structure
at a restoration margin; wear of restoration; minor cusp fracture; and filling of
access cavity after endodontic treatment (Hickel et al., 2007; Hickel et al., 2010;
Hickel et al., 2013) (Table 4).

However, more recent studies have investigated the longevity between alternative
treatments and replacement of defective dental amalgam restorations. Gordan et
al. (2006) published two-year longitudinal results assessing the longevity of
amalgam restorations that had been clinically diagnosed as defective and treated
by repair, sealant or refurbishment. The final outcome of this study showed there
was no difference between the repair and replacement groups. This implies that
repair would be a more conservative treatment option, given that tooth structure is
preserved. Gordan et al. (2015) reported that repaired restorations (7%) were more
likely to receive additional treatment compared with 5% of replaced restorations.
However, the replaced restorations were more likely to require endodontic
treatment (29%) compared with the repaired restorations. Another significant
finding was that molar teeth received more additional treatment than premolars or
anterior teeth (Gordan et al., 2015).

Similarly, Moncada et al. (2015a) published results from a prospective blind,

randomised, ten-year clinical trial conducted at a dental clinic at the University of
Chile on the effectiveness of repair of localised clinical defects in amalgam
restorations. Limited and localised defects, which were clinically and
radiographically detected, were defined as the presence of secondary caries,
under-contoured or over-contoured anatomic form and marginal failures of
occlusal, proximal and cervical areas. Significant findings from this study confirm
the findings of previous studies, which state that repair is a safe alternative to

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restoration replacement and could increase the longevity of the restoration by an
additional 10 years. The authors acknowledged that selection criteria in the
clinical decision-making for repair have yet to be determined (Moncada et al.,
2015a).

2.4.7.3.1 Clinical procedure for the repair of a defective dental amalgam

restoration

According to data from laboratory and clinical studies, the following

recommendations for repair were made by Blum et al. (2014);

• administer local analgesia as indicated;

• remove any unsupported, undermined tooth tissue and the surface of the
amalgam restoration adjacent to the fracture to provide a fresh surface as a
potential bonding substrate;
• prepare retention features within the amalgam restoration to provide
mechanical retention for the composite material;
• ensure adequate moisture control by using a rubber dam, cotton rolls and
salivary ejectors;
• prepare adjacent amalgam and tooth tissue surfaces using intraoral
aluminum oxide sandblaster or a diamond bur;
• provide pulp protection if indicated;
• acid etch the tooth surface for 1–30 seconds and wash and dry the tooth
surface;
• apply an adhesive bonding system to the conditioned tooth surface;
• apply an alloy-resin bonding agent to the prepared amalgam surface;
• place the repair composite, using an incremental technique and light curing
each increment fully prior to applying subsequent layers of material;
• finish working from composite to amalgam carefully; and
• check the occlusion and remove any interferences.

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2.5 SECTION 4: CLINICAL DECISION-MAKING FOR
RESTORATION REPLACEMENT OR REPAIR

There are only a small number of publications available regarding how dentists
determine the need for replacement of restorations (Moncada et al., 2008; Gordan
et al., 2009; Doméjean-Orliaguet et al., 2009). In order for dentists to diagnose a
defective restoration, there is a need for clear criteria of what constitutes an
unacceptable restoration and guidance on how to evaluate the quality of dental
restorations. Two clinical evaluation systems have been widely used in research.
The original Criteria for the clinical evaluation of dental restorative materials
was developed by Cvar and Ryge in 1971 for use by the USPHS. A similar system
regarding the standards of quality of dental care was published by the California
Dental Association. Both systems have been widely used in research and since
been modified. However, these systems were criticised because they only
described deviations from an “ideal restoration” and due to all the modifications,
comparisons between studies became increasingly difficult (Jokstad et al., 2001).

In 1988, the symposium, Criteria for placement and replacement of dental

restorations, was convened in which criteria for the replacement of restorations
were introduced, and a recommendation was made that the California Dental
Association evaluation system should be introduced into the dental curriculum.
Paterson et al. (1995) attempted to develop a policy document with valid criteria
for the replacement of amalgam restorations using a modified Delphi technique in
collaboration with dental schools and experts in health services research. There
was unanimous agreement that lost amalgam restorations should be replaced and
that fractured amalgam should be repaired/replaced. The group also agreed that
‘catching’ of the probe was not an indication for replacement of dental amalgam
restorations (Paterson et al., 1995).

In 2001, the FDI published a comprehensive report reviewing all factors that
affect the quality of dental restorations as well as reviewing the studies that
investigated these issues (Jokstad et al., 2001). Hickel et al. (2007) proposed new
clinical evaluation criteria for direct and indirect restorations with a more
discriminant scale. This system was consequently updated in 2010 (Hickel et al.,

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2010) (Appendix C). These criteria are suitable for teaching in dental schools, as
well as when patients are recruited for clinical trials to evaluate a new restorative
material or operative technique. They may also be used by practitioners who
experience problems deciding reproducibly when a filling is unacceptable and
should be repaired or replaced.

Despite this attempt to guide clinical decision-making around defective dental

amalgam restorations, Sharif et al. (2014) suggest that:

In the absence of any high quality evidence, clinicians should base their
decisions on clinical experience (anecdotal evidence), individual
circumstances and in conjunction with patients’ preferences where
appropriate. (Sharif et al., 2014)

2.5.1 Factors affecting the decision to replace or repair defective

restorations

There are a variety of factors that affect dentists’ decisions to replace defective
restorations. The decision to replace a restoration is often influenced by subjective
factors such as the dentist’s interpretation of the restoration condition, health of
the tooth, criteria used to define failure and patient demand (NHS, 1999) (Table
5). These may be divided into operator factors, material factors, tooth factors
(number of surfaces, tooth type) and patient factors. Some of the evidence related
to this is briefly summarised below.

2.5.1.1 Patient factors

The type of tooth and the number of tooth surfaces involved are significant
variables in the clinical decision-making process of repairing restorations. Two
studies found that dentists were more likely repair a restoration in a molar tooth
(Gordan et al., 2012b; Gordan et al., 2015). Gordan et al. (2012b) also reported
that dentists were more likely to repair teeth with a single surface restoration than
teeth with multiple restored surfaces. However, the converse was found in their
2015 study (Gordan et al., 2015).

One of the first studies to report the impact of repair versus replacement of failed
restorations clinically with patient-related outcomes was published in 2015 (Javidi

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et al., 2015). Although the sample was small (n=38), some significant findings
were reported. The authors concluded that patients were more uneasy and anxious
when having a restoration replaced compared with having it repaired. Fewer
patients who underwent a repair required a local anaesthetic, and the procedure
was completed in a significantly smaller time interval (Javidi et al., 2015).
Despite this, fewer repairs of restorations are performed in dental practice
compared with replacements (Sharif et al., 2010).

Table 5: Factors affecting replacement of defective dental amalgams (NHS,

1999)

POSSIBLE OBJECTIVE INFLUENCES

General patient factors Subjective factors
Exposure to fluoride Incentives
Caries status Clinical setting
General health Country
Parafunction Clinician’s diagnostic, treatment and
Age maintenance philosophy

Tooth factors
Tooth location/type/size
Cavity design/type
Dentition
Occlusal load
Tooth quality
Operator and restoration process

Material type
Physical properties
Quality of finish
Moisture control
Anaesthesia during restoration
Expertise
Training

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2.5.1.2 Dentist factors

Gordan et al. (2009) conducted a cross-sectional study in order to determine how

dentists evaluate and manage existing restorations. Dentists from the Dental
Practice-Based Research Network (DPBRN) formed the sample for this study.
Participants were asked to assess photographs of defective amalgam and
composite restorations. Potential variables were selected from the literature and
analyses conducted. Dentists in solo or small group practices chose replacement
for all the scenarios more often than dentists in large group practices or public
health practices (Gordan et al., 2009). These results were confirmed by a
subsequent study involving the same study population (Gordan et al., 2012b).

Javidi et al. (2015) investigated the relationship between repair versus

replacement and the type of dental practice. In contrast to other studies, the repair
and replacement rates of National Health Service (NHS) dental practices were
comparable with private dental practices, with repair rates being approximately
30% and replacement rates being approximately 40%. Because dentists are service
providers who may directly benefit from their professional actions, it could be
assumed that private dentists would increase the treatment prescribed to private
patients. A study by Tuominen et al. (2012) confirmed “that dentists working on a
fee-for-service basis classify their treatment mix in a way that provides financial
rewards”.

No relationship has been reported among variables such as dental-insurance status

of the patient and dentist’s decision to treat. However, significant differences have
been reported for gender and full-time versus part-time practice.

Dentists who did not determine the caries risk of patients were more likely to
choose a surgical intervention than a preventative treatment (Gordan et al., 2009).
Studies have also proved that dentists were more likely to replace restorations that
were not placed by themselves (Bader and Shugars, 1992; Gordan et al., 2009;
Gordan et al., 2012b). However, dentists who recently graduated from dental
school were more likely to repair defective restorations (Gordan et al., 2009). This
could be due to changes in the dental school curriculum as teaching shifts to a
more minimally invasive approach.

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Experiences of a dental student during training form the foundation of all future
clinical behaviour. Thus, the quality and content of the learning material should be
current and relevant. There are few studies recording the teaching practices of
repair and refurbishment of amalgam restorations compared with composite
restorations as amalgam use dwindles in developed countries.

Findings from a study conducted by Setcos et al. (2004) suggest that students with
little clinical experience were more confident with the choice to replace than to
repair despite having been taught both repair and refurbishment of defective
dental amalgam restorations. These findings are consistent with a study conducted
in the UK, which found that despite being taught repair techniques, these were
lost on entering private practice (Burke and Lucarotti, 2009). A more recent study
of dental schools in Pakistan reports that 60% of dental faculties teach the repair
of dental amalgams, and those who were not advocating the technique cited the
lack of an established technique as the main reason (47%) for not adopting it
(Hasan and Khan, 2013). There is no information currently available with regard
to the teaching practices at South African dental schools concerning the repair and
replacement of amalgam or composite restorations.

Summary

This chapter introduced clinical decision-making in dentistry. It also explained the

variety of factors that may influence a dentist in selecting the appropriate
treatment for a patient. In this specific study, the clinical decision-making process
and the factors involved are discussed in reference to the management of defective
dental amalgam restorations.

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CHAPTER 3: HYPOTHESIS, RESEARCH AIMS AND
OBJECTIVES

3.1 PROBLEM STATEMENT

Much has been published internationally about the reasons for the replacement of
defective amalgam restorations and the longevity of amalgam restorations (Burke
et al., 1999; Maupomé and Sheiham, 2000; AlNegrish and AlNegrish, 2001;
Udoye and Aguwa, 2008; Alomari et al., 2010). Clinical procedures with respect
to repair and replacement of restorations have largely evolved in a piecemeal and
anecdotal way, and there is little understanding of how widely repair of
restorations has been adopted by dentists in South Africa (Sharif et al., 2010).

3.2 HYPOTHESES

1. South African dentists routinely replace all defective dental amalgam

restorations.
2. Practises of South African dentists with regard to defective dental amalgam
restorations vary in their personal and dental practice characteristics.
3. Attitudes of South African dentists towards amalgam as a restorative material
influence their decisions to replace defective dental amalgam restorations.

3.3 AIM

The aim of this study was to provide information concerning the practices,
knowledge and attitudes of South African dentists with regard to the management
of defective dental amalgam restorations.

3.4 OBJECTIVES

• To examine the knowledge of South African dentists with regard to the

management of defective dental amalgam restorations

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• To evaluate the practices of South African dentists in the diagnosis and
management of defective dental amalgam restorations using vignettes
• To explore the attitude of South African dentists regarding the management
of defective dental amalgam restorations
• To explore the extent to which the presence of a marginal gap, secondary
caries and the mechanism of reimbursement affects the dentist’s decision to
manage defective dental amalgam restorations.
• To make recommendations to enhance the decision-making in the
management of defective dental amalgam restorations.

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CHAPTER 4: METHODOLOGY

4.1 INTRODUCTION

In this chapter, an overview of the research design and research setting is

provided. This section is divided into a quantitative and a qualitative segment. For
each segment, addition detail regarding the study design, research participants,
data collection methods, mechanisms for ensuring rigour, approach to data
analysis and ethical considerations are discussed.

4.2 RESEARCH DESIGN AND METHODS

4.2.1 Mixed-methods research

Creswell and Plano Clark (2011) described mixed methods as: “A research design
where the use of quantitative and qualitative approaches, in combination, provides
a better understanding of research problems than either approach alone”.
Combining qualitative and quantitative methods in a single study is not
uncommon in social research. Within health research, there has been an upsurge
of interest in the combined use of qualitative and quantitative methods, commonly
referred to as mixed-methods research (Creswell et al., 2004; Borkan, 2004;
O’Cathain, 2009).

Research in dentistry has been largely quantitative in nature, mainly because of

the need for evidenced-based research. Yet it is now widely recognised that
qualitative research methods such as in-depth interviews can offer dentistry more
unique insights into the understanding of knowledge and attitudes than a self-
administered questionnaire. A mixed-method approach was used in the study to
give a comprehensive view of decision-making in the management of defective
dental amalgam restorations.

4.2.2 Research methodology

An Explanatory Sequential Design with two distinct interactive phases was used
as shown in Figure 5 below. The quantitative component, that is, the electronic
survey of general dentists comprised the first phase.

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Figure 5: Workflow diagram for the research process (Adapted from Creswell
and Plano Clark, 2011)

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Quantitative data was collected in order to reach the objective of exploring the
treatment patterns of defective dental amalgam restorations. The second phase of
the study included qualitative data. Semi-structured interviews explored the
factors that influence the management of defective dental amalgam restorations,
including the participants’ attitudes towards amalgam as a restorative material and
the practice of repair and replacement. Finally, the findings of both the qualitative
and quantitative components of the study were integrated.

4.2.3 Sampling

In mixed-method research, sampling schemes must be selected for each phase of

the research project. Currently, there are many mixed-method research designs in
existence, and their typologies differ in levels of complexity (Onwuegbuzie and
Collins, 2007; Tashakkori and Teddlie, 2010). In this research project, a parallel
sampling design relationship was used. This specifies that the samples of the
quantitative and qualitative phases of the research are different but are drawn from
the same population of interest (Onwuegbuzie and Collins, 2007). A detailed
explanation of the sampling is provided in each phase.

4.2.4 Research setting

If we want more evidenced-based practice, we need more practice-based

evidence. (Green, 2008)

The primary aim of conducting research is to provide a scientific basis for the best
possible patient care. Major research achievements have been made relating to
dental caries and periodontal disease, but there has been a significant delay
between the generation of breakthroughs and the transfer of these to individual
patients. One of the ways to accelerate this translation of research is to create an
environment in which the researchers and the end users, that is, the dentists,
collaborate to find solutions to key issues in the field. Practice-based research
(PBR) is an appropriate vehicle for this because it has two advantages: it
generates evidence-based knowledge with a broad spectrum that can be more
readily generalised to the public; and it accelerates translation of research findings

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since passive absorption of knowledge is usually ineffective or is very slow (Mjör
et al., 2005).

The management of defective dental amalgam restorations is an important health

concern for patients, dentists and healthcare funders. Longitudinal studies are
appropriate for providing insight into the longevity of dental amalgam
restorations. However, in order to understand the clinical decision-making process
for the management of defective dental amalgam restorations, it is only logical to
proceed to a practice-based research approach because it reports on ‘real world
dentistry’.

4.3 QUANTITATIVE DATA COLLECTION AND ANALYSIS

4.3.1 Study design and study population

A cross-sectional quantitative survey with purposive sampling was completed.

The study population consisted of 3 076 general practice dentists who were
members of the South African Dental Association (SADA) at the time of the
study.

4.3.1.1 Sample

There were 388 dentists who participated in the online survey, resulting in a
response rate of 12.6%.

4.3.1.2 Inclusion and exclusion criteria

The membership of SADA includes active specialists and dentists in the public or
private sector. The main purpose of the study was to determine the treatment
patterns among general practice dentists in private practice. The dentists who
indicated that they were employed in the public sector or at an academic
institution were excluded. This resulted in a final sample of 324 dentists.

4.3.2 Data collection

A cross-sectional survey was conducted using a self-administered online

questionnaire. Responses were collected through the Survey Monkey® program

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and automatically generated into a spreadsheet. The South African Dental
Association distributed the link to the online survey to all its members. Responses
were collected for three months and reminders were emailed at 14-day intervals
for two months.

4.3.2.1 Using an online questionnaire

The use of the commercial website, SurveyMonkey®, allowed the researcher to

present a variety of item types such as multiple-choice questions, ranking and
open-ended responses.

4.3.2.2 The research instrument

The questionnaire consisted of closed and open-ended questions (Appendix D). It

elicited information such as age, gender, years of experience in practice and
highest qualification achieved. The questionnaire also gathered information
regarding the dentists’ practices in the management of defective dental amalgam
restorations, their knowledge and attitudes and the factors affecting the decision-
making in the management of defective dental amalgam restorations. A clinical
vignette with a clinical photograph was included. The questionnaire was adapted
from research conducted by Moncada et al. (2008), Dental PBRN (Gordan et al.,
2009) and Palotie and Vehkalahti (2012) (Appendix D).

4.3.2.3 Clinical vignettes

Researchers agree that vignettes, as any other research tool, can never recreate the
reality and dynamism of people’s lives, but they do provide valuable insights into
decision-making (Gould, 1996; Hughes and Huby, 2002; Green et al., 2003).
Research findings have shown that people exhibit the same behaviour that they
would exhibit when faced with real-life information needs (Donnell et al., 2013).

The last question of the survey was a vignette with a clinical photograph
(Appendix D). Each respondent was randomly allocated a clinical vignette with a
brief explanation and a clinical photograph. The clinical photograph was the same
in each vignette. Each respondent was presented with one of eight scenarios. The
vignette examined three factors relating to the effects of dentists’ treatment

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decisions. The factors were: presence and absence of a marginal gap; presence and
absence of secondary caries; and the patient’s ability to pay for treatment. There
were three response categories, repair, replace or refurbish. The vignette was
randomly allocated to the participants by the online programme, Survey
Monkey®.

1. A 35-year-old unemployed patient presents at your practice for a routine

visit. The 37 has an amalgam restoration occlusally and buccally. On
clinical examination, you find that there is a marginal gap on the 37
between the restoration occlusally. There is no evidence of caries
radiographically or clinically. What would your treatment for the 37
entail?

2. A 35-year-old unemployed patient presents at your practice for a routine

visit. The 37 has an amalgam restoration occlusally and buccally. On
clinical examination, you find caries on the mesial surface. The occlusal
restoration has no marginal gaps. What would your treatment for the 37
entail?

3. A 35-year-old unemployed patient presents at your practice for a routine

visit. The 37 has an amalgam restoration occlusally and buccally. On
clinical examination, you find an occlusal marginal gap between the tooth
and the restoration, and you detect caries occlusally. What would your
treatment for the 37 entail?

4. A 35-year-old unemployed patient presents at your practice for a routine

visit. The 37 has an amalgam restoration occlusally and buccally. The
restorations on the 37 are intact and caries free. What would your
treatment for the 37 entail?

5. A 35-year-old patient on medical aid presents at your practice for a routine

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6. A 35-year-old patient on medical aid presents at your practice for a routine
visit. The 37 has an amalgam restoration occlusally and buccally. On
clinical examination, you find caries on the mesial surface. The occlusal
restoration has no marginal gaps. What would your treatment for the 37
entail?
7. A 35-year-old patient on medical aid presents at your practice for a routine
visit. The 37 has an amalgam restoration occlusally and buccally. On
clinical examination, you find an occlusal marginal gap between the tooth
and the restoration, and you detect caries occlusally. What would your
treatment for the 37 entail?

8. A 35-year-old patient on medical aid presents at your practice for a routine

visit. The 37 has an amalgam restoration occlusally and buccally. The
restorations on the 37 are intact and caries free. What would your
treatment for the 37 entail?

4.3.3 Pilot study

The questionnaire was piloted among 10 dentists who were sessional employees
of the University of the Western Cape. They were not included in the final study
sample.

4.3.4 Ethical considerations

Each participant was asked to complete an online informed consent form

(Appendix D). Ethics approval was received from the Senate Research Committee
of the University of the Western Cape (Project registration: 11/1/46) (Appendix
E).

4.3.5 Validity

Both the questionnaire and clinical vignettes were validated by members of the
Restorative Dentistry Department at the University of the Western Cape. In
addition, the results of the pilot study were analysed to ensure that face validity of
the questionnaire and vignette was achieved.

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4.3.6 Data analyses

The Survey Monkey® program collected responses and automatically converted

them into an Excel spreadsheet. Data analyses are explained in three sections: (i)
analysis of the responses to the vignettes; (ii) responses to the close-ended
questions where only one response was selected; and (iii) questions where more
than one response could be selected.

The data was analysed in the following steps:

• Sample size calculation after application of the exclusion criteria and

analysis of cases

• The frequency distributions of all the demographic variables, dental

practice profile, continuing professional development, selection of
restorative materials and attitudes to repair and replacements of defective
amalgam restorations

There were several different statistical tests used for this analysis. When both
variables were categorical, a Chi-square test was used. When one variable was
categorical and the other was ordinal, then a Wilcoxon Rank-Sum test or a
Kruskal-Wallis test was used. When both variables were ordinal, the Spearman’s
correlation was used. Results are presented as frequency distributions and mean
scores. For the Analysis of Variance (Anova) tests, Chi-square tests and paired
t-tests, a p-value of <0.05 was considered as statistically significant.

4.3.6.1 Analysis of vignette responses

In the vignette study, the effects of the three factors on the decision of the dentist
relative to the hypothetical patient needing treatment were examined. The three
factors each had two levels. The factors were: presence of a marginal gap with
levels of yes and no; presence of secondary caries with levels of yes and no; and
the patient’s ability to pay with levels of yes and no. Consequently, there were
eight factor combinations that could be presented. Each respondent was randomly
presented with one of the eight scenarios. The response was a categorical,
multinomial variable with three choices, repair, replace or refurbish. With this
type of response, an appropriate method of analysis is to use a generalised logistic

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model. The design is similar to a three-way analysis of variance, but since the
response variable is multinomial rather than continuous and normally distributed,
the standard analysis of variance is not appropriate. The analysis was performed
using the logistic procedure in the statistical software SAS (SAS Institute Inc.,
Cary, NC, USA). The initial analysis included two-way and three-way interaction
terms for the factors. If any of these interactions were not significant, simpler
models for the main effects were used. In addition to determining which factors
demonstrated coefficients in the model that were significantly different from zero,
various odds ratios and their corresponding confidence intervals were given as an
indication of the impact of the factor.

Analysis of the vignette responses were stratified on the eight scenarios and the
Cochran-Mantel-Haenszel tests used. These are stratified versions of the tests
described above (Chi-Square Test of Association, Kruskal-Wallis test and
Spearman’s correlation). Since one of the three responses, repair, was considered
to be the best alternative, a secondary analysis was done with the outcome being
dichotomous, namely ‘best option chosen’ and ‘best option not chosen’. In this
case, a simpler logistic regression model could be used for analysis. As with the
generalised logit model, the initial analysis was done considering all interaction
terms. If appropriate, simpler models were then analysed. Odds ratios and their
confidence intervals were given as well.

4.3.6.2 Questions for which only one response could be selected

A frequency of responses for each question was completed.

4.3.6.3 Questions for which more than one response could be selected

In some cases, participants were able to select more than one appropriate
response. The analyses explain how frequently each item was chosen. To
determine whether or not these proportions were significantly different from each
other, the Friedman’s test was used to determine these differences. The Friedman
test is a non-parametric test for testing the differences between several related
samples. The null hypothesis for the Friedman test is that there are no differences
between the proportions of times the items were chosen. If the calculated p-value

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is low (p is less than the selected significance level), the null-hypothesis is
rejected, and it can be concluded that at least two of the items have proportions
that are significantly different from each other. Pairwise differences and adjusted
p-values for multiple testing were also determined. The data analyses and
re-codings were carried out using statistical software SAS (SAS Institute Inc.,
Cary, NC, USA).

4.4 QUALITATIVE DATA COLLECTION AND ANALYSIS

4.4.1 Study design and study population

The case-study method was used as a research strategy for this phase. Case studies
may be regarded as limiting because no generalisations can be made (Yin, 2009;
Darke et al., 1998; Rule and Vaughn, 2011; Crowe et al., 2011). Lack of
calibration and lack of verification and validation of actual diagnoses are inherent
difficulties in this type of survey, but it has the advantage of reflecting real-life
dentistry.

4.4.2 Sample

The key focus of this research was to obtain insights into the factors affecting a
dentist’s treatment choice when managing a defective dental amalgam restoration.
In order to appreciate the complexities of clinical decision-making in private
practice, the unit of analysis was a dentist in private practice in the Western Cape.
Purposive sampling was used to select dentists to participate in the semi-
structured interviews. The criteria that were considered were:

• Age: to ensure a balanced demographic sample

• Gender: to ensure balance and because treatment patterns/choices
differ slightly between men and women
• Fee structure of practice: it was hypothesised that the mechanism
of reimbursement could affect treatment pattern/choice of the
dentist

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Sample size in qualitative studies is determined not by statistical power
considerations but by reaching a complete understanding of the problem being
studied, and this is referred to as saturation (Rubin and Rubin, 1995). Central
concepts have reached saturation when the researcher finds that new interviews do
not add new information and the central concepts are understood (Guest, 2006).

4.4.3 Data collection

In this phase of the research, multiple data sources in the form of semi-structured
interviews, a self-administered questionnaire, a log of treatment procedures
provided over a two-week period and field notes were used as a strategy to
enhance data credibility (Patton, 1990; Yin, 2009). A summary of each method
follows.

4.4.3.1 Semi-structured interviews

Qualitative interviewing is a way of uncovering and exploring the meanings that

underpin people's lives, routines, behaviours, feelings, etc. (Rubin and Rubin,
1995; Britten, 1995; Gill et al., 2008). Semi-structured interviews are defined by
DiCicco-Bloom and Crabtree (2006) as usually scheduled in advance and
organised around a set of predetermined, open-ended questions, with other
questions emerging from the dialogue between the interviewer and interviewee.
The semi-structured interviews consisted of a clinical vignette that elicited
specific responses from the dentists in order to gather information regarding the
dentists and their decision-making.

4.4.3.2 Clinical vignettes

Two clinical case vignettes were created apropos the management of defective
dental amalgam restorations using two actual patient records. These clinical
vignettes were presented to academic staff in the Restorative Dentistry
Department at the University of the Western Cape for validation. Each case had a
panoramic radiograph and bitewings taken as per routine visits to the Faculty of
Dentistry for treatment. Intraoral images were collected of each arch and the
individual teeth that were restored with amalgam. The teeth were dried prior to
imaging. After being captured, each picture was reviewed and once it was deemed

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appropriate, it was saved to a data file and subsequently serialised in an MS
Office PowerPoint® presentation (Appendix F).

Each dentist examined both cases and reported a diagnosis and treatment plan for
tooth 26 in each case. Conventional audio-recording equipment was used to
record the treatment planning until terminated by the dentist. This recording of the
dentist’s thoughts was carried out in the presence of the researcher to gather
information regarding the strategies used in the treatment planning and relevant
knowledge about the diagnosis and treatment plan. The think-aloud technique was
used to elicit information about underlying thinking processes and actions.

4.4.3.3 The think-aloud technique

Think aloud is a technique that allows for the examination of an individual’s

thinking processes and decisions that are being considered at that point in time;
health professionals are confronted with large volumes of information that can
only be partially processed at any one time. Think-aloud research is widely used
in nursing, and it has focused on the approaches that nurses use to decide on a
diagnosis, with little emphasis on the management of the problem. Payne (1994)
also suggested that the think aloud technique may be useful for:

• Providing early insight into behaviours

• Pre-testing questionnaires to improve clarity
• Comparing data with data collected by other methods
• Testing an hypothesis about behaviour
• Building and testing models of behaviour such as expert systems

Participant numbers in think-aloud studies are generally low due to the depth and
richness of the data usually gained from each participant, with some reports
suggesting that as few as five or six participants may produce stable results
(Gerrish and Lacey, 2010; Lundgrén-Laine and Salanterä, 2010).

Limitations of this technique include reactivity, verbal participants, verbal

abilities and data validity ( Hughes and Huby, 2002; Young, 2009). Reactivity
relates to the ability of the participant to think and attend to a task simultaneously.
Most often, the participant is required to verbalise their thoughts during an

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activity that is normally performed in silence. The technique also draws attention
to the underlying cognitive processes of a task.

Training participants in the technique is an important component of data

collection and provides the researcher with an opportunity to explain to the
participants that they should only be attempting to verbalise and not rationalise
their thinking processes. One of the most common exercises requested is an
arithmetic exercise such as asking them to ‘count the number of windows in their
home’ since this requires sequential progression through the various rooms in
their home.

4.4.3.4 Data recording procedures

The participants were given training in the think-aloud technique as described

above. An interview protocol was used to keep the discussion focused. The
semi-structured interviews were audio taped and supplemented with the field
notes.

4.4.3.5 Self-administered questionnaire

A self-administered questionnaire was chosen to collect information from the

participants to ensure standardisation of information (Appendix G). The
questionnaire was adapted from that used in the Dental PBRN study (Gordan et
al., 2009). The questionnaire was piloted prior to its administration.

4.4.3.6 Treatment log

Participants were also asked to complete a patient log form for each restoration
placed over a two-week period (Appendix H) .The data collected included the
patient’s age, gender, tooth number, cavity classification, the new restorative
material choice, possible reasons for placement, reasons for replacement and the
previous restorative material used. The patient log form was adapted from the
Dental PBRN study (Gordan et al., 2009).

4.4.3.7 Field notes

Field notes are defined as the notes of observations or conversations taken during
the conduct of qualitative research (Thorpe, 2008). They may be taken throughout

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the research process. As each interview was being conducted at the practice of the
participating dentist, field notes were made, including descriptions of the context
of the conversation and interpretations of the data.

4.4.4 Qualitative data analysis

4.4.4.1 Framework analysis

The Framework approach was developed by researchers, Jane Ritchie and Liz
Spencer, from the Qualitative Research Unit at the National Centre for Social
Research in the UK in the late 1980s for use in large-scale policy research
(Ritchie and Lewis, 2003). It has gained popularity in health research largely due
its effectiveness in managing qualitative data and analyses systematically (Smith
and Firth, 2011). The approach is inductive but allows for the inclusion of a priori
as well as emergent concepts. Its characteristic feature is the matrix output: rows
(cases), columns (codes) and cells of summarised data, providing a structure into
which the researcher can systematically reduce the data in order to analyse it by
code. This allows the researcher to explore the data at great depths whilst
maintaining transparency. This in turn contributes to the rigour of the study and
enhances the credibility of the findings (Ritchie and Lewis, 2003).

4.4.4.2 Stages of thematic analysis

A glossary of terms is provided to assist in understanding the stages of analysis in

this method (Table 6).

Stage 1: Transcription

The verbal data was converted from an audio recording into a verbatim
transcription using ATLAS.ti®. In this programme, each transcript is called a
Primary document.

Stage 2: Familiarisation with the interview

All the recordings were listened to again together with the field notes made by the
researcher and amendments were made if necessary. A random sample of
transcripts was checked by a more experienced researcher for accuracy.

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Stage 3: Coding

Coding is a process that provides the researcher with a formal system to organise
the data, uncovering and documenting additional links within and between
concepts and experiences described in the data (Braun and Clarke, 2006; Bradley
et al., 2007). Codes are tags or labels that are assigned to whole documents or
segments of documents (i.e. paragraphs, sentences or words) to help catalogue key
concepts while preserving the context in which these concepts occur (Miles and
Huberman, 1994).

In the ATLAS.ti® package, a typical screen has the transcript on the left-hand
side, with a wide margin on the right-hand side to allocate codes or notes/memos.
The researcher highlights the relevant passage of text and using the ATLAS.ti®
package, applies a label (a ‘code’) that describes what they have interpreted in the
passage as important.

Stage 4: Developing a working analytical framework

After coding the first few transcripts, the codes were grouped together into
categories. These categories formed the analytical framework. The categories
were drawn from the literature as well as from the interviews. A search for
patterns and explanations was performed to determine, for example, whether or
not certain codes could be grouped together under a more general code. This
process was constantly refined throughout the data analysis process and as new
insights emerged, theoretical saturation was reached (Bradley et al., 2007).

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Table 6: Glossary (Gale et al., 2013)

Analytical framework: A set of codes organised into categories that have been jointly
developed by researchers involved in analysis that can be used to manage and organise
the data. The framework creates a new structure for the data (rather than the full,
original accounts given by participants) that is helpful to summarize/reduce the data in a
way that can support answering the research questions.
Analytic memo: A written investigation of a particular concept, theme or problem,
reflecting on emerging issues in the data that captures the analytic process.
Categories: During the analysis process, codes are grouped into clusters around similar
and interrelated ideas or concepts. Categories and codes are usually arranged in a tree
diagram structure in the analytical framework. While categories are closely and
explicitly linked to the raw data, developing categories is a way to start the process of
abstraction of the data (i.e. towards the general rather than the specific or anecdotal).
Charting: Entering summarized data into the Framework Method matrix.
Code: A descriptive or conceptual label that is assigned to excerpts of raw data in a
process called ‘coding’.
Data: Qualitative data usually needs to be in textual form before analysis. These texts
can either be elicited texts (written specifically for the research, such as food diaries), or
extant texts (pre-existing texts, such as meeting minutes, policy documents or weblogs),
or can be produced by transcribing interview or focus group data, or creating ‘field’
notes while conducting participant-observation or observing objects or social situations.
Indexing: The systematic application of codes from the agreed analytical framework to
the whole dataset.
Matrix: A spreadsheet contains numerous cells into which summarized data are entered
by codes (columns) and cases (rows).
Themes: Interpretive concepts or propositions that describe or explain aspects of the
data, which are the final output of the analysis of the whole dataset. Themes are
articulated and developed by interrogating data categories through comparison between
and within cases. Usually a number of categories would fall under each theme or sub-
theme.
Transcript: A written verbatim (word-for-word) account of a verbal interaction, such as
an interview or conversation.

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Stage 5: Applying the analytical framework

The framework was applied to all subsequent transcripts.

Stage 6: Charting data into the framework matrix

A spreadsheet was used to generate a matrix into which the data was charted.
Codes that specifically referred to the objectives of the study, demographic
attributes and practice-profile attributes were charted against the specific cases.
This allowed the researcher to assess both the patterns of association (how often
features vary under different circumstances) and the nature of the associations (in
what ways certain features might vary under particular or different circumstances)
(Bazeley, 2009).

Stage 7: Interpreting the data

Gradually, connections between themes and other data were mapped.

4.4.5 Generalisation, validity and reliability of qualitative research

In this study, the process of peer review was adopted whereby another suitably
experienced researcher reviewed and explored the transcripts, data analyses and
emergent themes. The reliability of data collection may be affected by the timing
of the data collection. Retrospective data collection is more open to error through
inaccurate memory of the decision task or the requirement to explain a long
procedure.

4.4.6 Pilot study

A pilot study was conducted at two dental practices to determine the length of the
interviews, appropriate questions and the feasibility of data-collection strategies.

4.4.7 Ethical considerations

Ethics approval was granted by the Senate Research Committee of the University
of the Western Cape (Project Registration 11/1/46) (Appendix E). In this research
project, participants were asked to complete an informed consent form that
outlined the research objectives and recorded their permission to participate in the
study (Appendix H).

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Participants were informed on how confidentiality was to be maintained
throughout the project. The information gathered was only to be used for
academic purposes, and research findings would be reported to the institution and
other researchers in the field. In order to protect the identity of the participants,
their names would be removed, and they would only be identified by Dr J, Dr S,
Dr LD, etc. Participants were informed of the use of a recording device and
verbatim transcriptions, and written interpretations were made available to the
participants. All records were securely stored in a lockable filing cabinet in a
locked office. All electronic records were stored on a computer with a password.

Summary

In this chapter, the research design was introduced. The mixed-methods approach
and the rationale for the research setting was explained. An overview of the
research methodology with its quantitative and qualitative components was
presented.

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CHAPTER 5: RESULTS

In this section, the research findings of both the quantitative and qualitative
phases are presented. Firstly, a description of the samples for the quantitative and
qualitative components are given. Secondly, excerpts of the semi-structured
interviews regarding Case Study 1 are presented alongside the quantitative data.
The interview data enriches the findings of the national survey. Lastly, a summary
of the findings from the treatment log sheets is presented.

5.1 QUALITATIVE STUDY: DEMOGRAPHY OF THE SAMPLE

Because the number of participants in the qualitative component is small, a

summary table of the demographic details is provided (Table 7).

5.2 GEOGRAPHIC LOCATION

Dentists across Cape Town were selected to participate in interviews (Figure 6).

Figure 6: Geographic location of interviewees’ practices

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Table 7: Summary of profiles of interview participants

Dentist Gender Age Graduation Highest Practice arrangement Full or

group year qualification part-time
(years)

Dr J M 36-45 2001 BChD Self-employed as a partner in a complete partnership Full time

Dr S F 36-45 2000 BChD Self-employed without partners (solo practice) Part-time

Dr A M 56-65 1991 BChD Self-employed without partners (solo practice) Full time

Dr LD M 36-45 2000 BChD Self-employed without partners but share costs Full time

Dr M F 20-25 2012 BChD Employed by Group Full time

Dr LA F 36-45 2001 PDD Other (please specify) Full time

Dr LE F 26-35 2006 BChD Employed by another dentist Full time

Dr K F 36-45 1993 BChD Employed by another dentist Full time

Dr F M >66 1980 BChD Self-employed as a partner in a complete partnership Full time

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Dentist Gender Age Graduation Highest Practice arrangement Full or
group year qualification part-time
(years)

Dr LI M 26-35 2009 BChD Other (please specify) Full time

Dr RI F 26-35 2005 BChD Other (please specify) Full time

Dr RA M 46-55 1991 BChD Self-employed without partners (solo practice) Full time

Dr N F 36-45 1997 PDD Employed by another dentist Part-time

Dr Y M 36-45 1993 BChD Self-employed without partners (solo practice) Full time

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5.3 QUANTITATIVE COMPONENT: DEMOGRAPHY OF THE
SAMPLE

The electronic survey was distributed to 3 607 dentists who are members of
SADA. A total of 388 dentists completed the online questionnaire, a response rate
of 10.7%. Of the 388, six respondents did not agree to participate in the study.
Another seven respondents agreed but did not answer any of the survey questions.
Only 375 responses could be used. However, with the application of the exclusion
criteria, all dentists with a qualification of MChD (n=13) were excluded. Dentists
who were employed at a public health institution (n=28) or academic institution
(n=7) were also excluded. Retired dentists (n=3), a postgraduate student (n=1) and
a consultant geologist (n=1) were also excluded. Note that some dentists met more
than one exclusion criteria. A final sample of 324 dentists was included in the
study.

5.3.1 Gender

Females accounted for 36% (n=112) of the sample.

5.3.2 Age

A high percentage (78%) of the respondents were younger than 55 years old, with
almost one-third (32%) of the sample being in the age group of 26–35 years.

5.3.3 Highest qualification

More than two-thirds of the sample (67.7%) of dentists had a BChD degree as
their highest qualification, and some (26.7%) had a postgraduate diploma as
shown in Table 8.

5.3.4 Dental-practice profile and years of experience in private practice

Only respondents who were currently employed as dentists in the private sector
were included in the sample. More than one-half of the sample (55%) were
self-employed without partners, and less than one-half (41%) of the sample had at
least 21 years in private practice. One-third (33%) of all respondents were not
contracted to medical aid or third-party funders.

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Table 8: Frequency distribution of highest qualification (n=322)

Highest qualification Frequency (n) %

PhD/DSc 2 0.62

MSc 16 4.97

PG Dip 86 26.71

BChD/BDS 218 67.70

5.4 CONTINUING PROFESSIONAL DEVELOPMENT

Thirty-three per cent (n=33) of the dentists reported reading a dental journal more
than once a month, and 40% (n=122) spent between five and ten days a year
attending postgraduate meetings or courses. Dentists were asked to select all the
activities they had completed for their Continuing Professional Development
(CPD) portfolio for the previous year.

From Table 9, it is clear that participants preferred to attend lectures and answer
journal questionnaires as CPD activities. There was a statistically significant
difference in how Continuing Education Units (CEU) was earned, which was
determined by the selection, X²(2) = 649.73, p<0.0001*. From pairwise
comparisons, participants preferred answering journal questionnaires significantly
more than all the other activities, apart from attending lectures organised by the
profession (p<0.0001*).

5.5 AMALGAM AS A RESTORATIVE MATERIAL

A high percentage of respondents (62%) seldom used amalgam as a restorative

material in their practice, while only a small group (7%) reported using amalgam
as a rule.

Data from the interviews indicated that most of the participants were generally in
favour of the use of dental amalgam because of its excellent lifespan as a
restorative material.

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Table 9: Frequency of Continuing Professional Development activities
(n=303)

Item Frequency %

Answering journal questionnaires 219 72

Attending lectures organised by dental companies 218 72

Attending lectures organised by my profession 222 73

Attending refresher courses 128 42

Attending congresses 150 50

Enrolling in a postgraduate course 42 14

Attending small study groups 65 21

Teaching 23 8

I am for amalgams. They have proved themselves over and over (Dr LD).

I have such a huge faith in amalgams. They last for very long. It doesn’t
look fantastic but it doesn’t leak, it doesn’t break and if it does, then you
address it (Dr RI).

The interview data also suggested that the increase in complications following the
placement of posterior composite restorations could be attributed to the continued
use of dental amalgam as a restorative material.

We have seen so many times … the disasters of large posterior composite

space and big cavities … and from my experience, this is where the people
who are still using amalgams, use amalgams because of failed composites
(DR Y).

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5.6 DISCUSSION WITH PATIENT REGARDING CHOICE OF
DENTAL RESTORATIVE MATERIAL

Approximately one-half of the respondents (57%) indicated that generally, they

discussed the choice of dental material with the patient, whilst only 11% (n=33)
seldom did.

Participants of the interviews were acutely aware of the concern some patients
expressed regarding the safety of dental amalgam as a restorative material:

[A] lot of our patients that come in ... you know patients are becoming very
knowledgeable now, and they have Internet now and smart phones so when
they walk through the door, they can tell you exactly what they want or what
they need, and you are like okay. In the past as well, there was a whole fear
of amalgams and mercury (Dr J).

5.7 REPAIR OF DEFECTIVE DENTAL AMALGAM RESTORATIONS

Almost two-thirds (63%) of the dentists repaired defective dental amalgam

restorations in their practice. Of the 37% (n=112) who did not repair, 81 dentists
provided reasons when asked (Table 10). Most of the respondents (72%) felt there
was a lack of predictability in the technique, and this was a major factor in their
decision not to repair defective dental amalgam restorations.

There was a statistically significant difference in the reasons for repairing

defective dental amalgam restorations depending on the selection, X²(2) = 71.29,
p<0.0001*. From pairwise comparisons for not repairing, lack of predictability of
the technique was chosen significantly more often than all the other reasons
(p<0.0001*). With regard to reasons for not repairing defective dental amalgam
restorations, ‘lack of supporting scientific evidence’ was not significantly
different from ‘the absence of an established technique’ and ‘no professional code
and fee for the procedure’.

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Table 10: Frequency of reasons for not repairing defective dental amalgam
restorations

Reasons Frequency %

Lack of predictability in the technique 58 72

Lack of supporting evidence 16 20

Absence of an established technique 21 26

No professional code and fee for the procedure 7 8.6

Data from the interviews revealed that one interview participant was quite amused
about the idea of repairing a dental amalgam restoration.

(Laughs at the thought. So ridiculous.) I have just never done it [repair an

amalgam restoration]. We were not taught how to (Dr S).

The interviews also suggested that some participants felt that repairing a defective
dental amalgam restoration was a practical solution but had reservations about the
longevity of the repaired restoration and stressed the importance of informing the
patient that it was not a ‘permanent treatment’. There was a lack of confidence in
the technique as a treatment option for the management of defective dental
amalgam restorations. As one participant said, “if that tooth is still symptomatic
after we have worked, then things become questionable”.

I think anything that is practical and it works, I don’t see a reason why it
shouldn’t be done. And it is one of those cases where it is neither right nor
wrong. If it works, and it is a much less expensive option (Dr A).

I don’t see it as a long term or something that is going to last forever. I

explain to them, you can have the patchwork if you want it done (Dr RI).

Interestingly, some participants felt that repairing a defective dental amalgam

restoration was not the ‘right’ thing to do as a health professional. The
appropriateness of the treatment was questioned.

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I just find if I am going to have a breakdown on a tooth or a filling that is
broken down I will ... Maybe the right thing to do is to replace the whole
thing (Dr J).

I don’t think that it [repairing a defective dental amalgam restoration] is

the best you can do (Dr LE).

5.8 AMALGAM REPAIR TECHNIQUE USED

Table 11 indicates that the most commonly used repair technique was a bur to
create mechanical retention (77%). There was a statistically significant
difference in the technique used in repairing defective dental amalgam
restorations depending on the selection, X²(2) = 428.98, p<0.0001*.

When pairwise comparisons were completed, using a bur to create mechanical

retention was chosen significantly more often than all the other technique options
(p<0.0001). The application of a silica coating to the amalgam prior to bonding
was chosen significantly less than the use of dentine bonding agents or placement
of a pin-retained restoration (p<0.0001*). The use of a total-etch dentine-bonding
system was also chosen significantly more often than a self-etch dentine-bonding
system, a glass ionomer as a dentine-bonding system or the placement of a
pin-retained restoration (p< 0.0001).

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Table 11: Frequency of techniques (n=246)

Techniques Frequency %

Use a bur to create mechanical retention 189 77

Apply silica coating to the amalgam prior to

3 1.2
bonding

Apply silane coating to the amalgam prior to

15 6
bonding

Apply total-etch dentine-bonding system 120 49

Apply self-etch dentine-bonding system 53 21.5

Apply glass ionomer as a dentine-bonding

79 32.1
system

Place a pin-retained restoration 81 33

5.9 ORIGIN OF TECHNIQUE USED

More than two-thirds (68%) of the participants learnt their technique through their
clinical experience, while only 27% learnt it through attending a continuing
professional development course or lecture (Table 12).

There was a statistically significant difference in where the technique was learnt
depending on the selection, X²(2) = 343.10, p<0.0001*(Appendix J). From
pairwise comparisons conducted regarding the origin of their repair technique,
undergraduate dental school was chosen significantly more than attending a CPD
course or lecture, reading a journal article, learning from the Internet or learning
from a fellow colleague (p<0.0001*) but chosen significantly less than their
clinical experience.

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Table 12: Frequency of individual items chosen for learning resources
(n=262)

Activities Frequency %

Undergraduate dental school 131 50

CPD course or lecture 70 27

Reading journal 47 18

Internet 7 12.6

Fellow colleague 45 17

My clinical experience 177 68

5.10 RESTORATIVE MATERIAL OF CHOICE FOR REPAIRING A

DEFECTIVE DENTAL AMALGAM RESTORATION

It is evident from Table 13 below that resin-based composites were chosen

significantly more often than all the other dental restorative materials when
repairing a defective dental amalgam restoration. The Friedman test was used to
determine if one dental restorative material was consistently chosen above another
in repairing a defective dental amalgam restoration with a probability of <0.05.
There was a statistically significant difference in the choice of restorative material
used depending on the selection, X²(2) = 259.17, p<0.0001* (Appendix H).

From pairwise comparisons conducted, resin-modified glass ionomer was chosen

significantly less than resin-based composite but significantly more than
silorane-based composite, flowable composite and compomers when choosing a
restorative material to repair a defective dental amalgam restoration. There was no
significant difference found between resin-modified glass ionomer and amalgam
as restorative materials of choice when repairing a defective dental amalgam
restoration (p=0.44).

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Table 13: Frequency of times individual items were chosen for restorative
material of choice (n=250)

Restorative Material Frequency %

Resin-modified glass ionomer 91 36

Resin-based composite 154 62

Silorane-based composite 7 2.8

Flowable composite 57 22.8

Compomer 22 8.8

Amalgam 74 30

Interestingly, data from the interviews revealed there was concern when repairing
a defective dental amalgam restoration with a material other than dental amalgam.
Participants questioned the science behind using two different materials.

It sounds― (hesitant). I don’t like mixing materials. It is not that I am

averse to doing that, but I am not keen on it. Mixing materials like amalgam
and composite simply because the composite is not going to adhere (Dr Y).

Well, I find that if I do that then the filling mostly, it could fail. I don’t want
anybody really to come back with problems and tell me, ‘But you could have
told me, or you could have done something more expensive for me, and why
didn’t you do that in the first place?’ (Dr LE).

5.11 RESTORATIVE MATERIAL OF CHOICE FOR REPLACING A

DEFECTIVE DENTAL AMALGAM RESTORATION

From the data, 56% of the participants (n=20) would replace a defective dental
amalgam restoration with a resin-based composite restoration, and 12% (n=34)
would choose either a resin-based restoration or a crown (Table 14).

From Table 14, it is evident that resin-based composites were the material of
choice when replacing a defective dental amalgam restoration (78%). The

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treatment choice of a crown was also popular, with 58% of the participants
choosing this treatment option. Using the Friedman test, there was a statistically
significant difference in selecting a dental restorative material depending on the
selection, X²(2) = 563.57, p<0.0001*.

When pairwise comparisons were completed, resin-based composites were chosen

significantly more often than all the other possible treatment choices for replacing
a defective dental amalgam restoration (p<0.0001*).

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Table 14: Frequency of restorative material choice for replacing a defective
dental amalgam restoration

Restorative Material Frequency %

Resin-modified glass ionomer 68 24

Resin-based composite 219 78

Silorane-based composite 14 5

Compomer 27 9.6

Amalgam 71 25

Ceramic inlay 75 27

Ceramic onlay 68 24

Crown 164 58

5.12 FACTORS TAKEN INTO CONSIDERATION WHEN MANAGING

A DEFECTIVE DENTAL AMALGAM RESTORATION

Participants were asked to list the three main factors that they considered when
managing a defective dental amalgam restoration. This open-ended question was
analysed by grouping responses into five categories as displayed in Table 15.

From Table 16, it is clear that tooth factors such as remaining tooth structure, the
size and depth of the restoration and the presence of caries are ranked as the most
important considerations when managing a defective dental amalgam restoration.
Material factors were ranked as the least important consideration.

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Table 15: Response categories for factors taken into consideration when
managing a defective dental amalgam restoration

Category Responses

Patient factors Occlusion, finances, presence of pain

Tooth factors Remaining tooth structure, size of restoration, depth of

restoration, presence of caries, etc.

Clinician factors Experience, available time

Material factors Longevity of restorative material, condition of existing

restoration

Do not repair
defective dental
amalgam restorations

Table 16: Ranking frequencies for factors taken into consideration when
managing a defective dental amalgam restoration

First Position % Second Position % Third Position %

Tooth factors 85 Tooth factors 70 Patient factors 47

Patient factors 10 Patient factors 22 Tooth factors 43

Do not repair restorations 2 Material factors 7 Material factors 8

Material factors 2

5.13 KNOWLEDGE REGARDING THE MANAGEMENT OF

DEFECTIVE DENTAL AMALGAM RESTORATIONS

Only 8% of the participants agreed that there is no correlation between a marginal

gap and secondary caries, but 60% agreed that the size of the marginal gap present
is directly related to the chance of secondary caries (Table 17). There was very

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little difference in the response to the statements: ‘I replace faulty margins when
there is no clinically or radiographically datable caries because chances are good
that there is caries below the margins that cannot be detected’ and ‘I replace faulty
margins when there is no clinically or radiographically detectable decay because
chances are good that decay will set in, in the near future’. The majority of the
participants were in favour of repairing defective dental amalgam restorations as a
treatment.

Table 17: Responses to statements

Statements Agree Undecided Disagree

% % %

There is no correlation between a

8 9 83
marginal gap and secondary caries

I replace faulty margins when there is

no clinically or radiographically
detectable decay because chances are 44 16 40
good that decay will set in, in the
near future

The size of the marginal gap between

amalgam and tooth structure is
60 19 21
directly related to the chance of
secondary caries

There is no relationship between the

decision to replace an existing
18 44 38
restoration and refurbishing an
amalgam restoration

I do not repair defective dental

amalgam restoration because it is not
21 14 65
an acceptable form of restorative
dentistry

I replace faulty margins when there is

no clinically or radiographically
detectable caries because chances are 39 19 41
good that there is caries below the
margins that cannot be detected

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5.14 DIAGNOSIS OF SECONDARY CARIES

The most common diagnostic method was the use of radiographs, followed by the
presence of soft, discoloured dentine or enamel and the use of a sharp probe
(Table 18).

Table 18: Frequencies for diagnosis of secondary caries (n=285)

Diagnostic Methods Frequency %

Radiographs 282 99

Probing with a sharp probe 239 84

Probing with a blunt probe 31 11

Intuition or clinical experience based on clinical

178 62
appearance

Discoloured margins of a restoration 181 63

Frank or definite caries cavitation 205 72

Presence of soft, discoloured dentine or enamel 248 87

Exploratory preparation to inspect the lesion 63 22

Using the Friedman test, there was a statistically significant difference in the
diagnosis of secondary caries depending on the selection, X²(2) = 820.79,
p<0.0001*. With the use of pairwise comparisons, radiographs were chosen
significantly more often than any other diagnostic method (p<0.0001*). The use
of a sharp explorer was also chosen significantly more often than all other
diagnostic methods except in the presence of soft, discoloured dentine or enamel.

5.15 FACTORS AFFECTING TREATMENT DECISIONS

Dentists were asked to indicate the three most important factors in replacing a
defective dental amalgam restoration, repairing a defective dental amalgam
restoration and refurbishing a defective dental amalgam restoration. The following
data represents the respondents who included at least three main factors (Table
19).

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Table 19: Factors affecting treatment decision: Percentages of individual factors chosen

tooth
Future plans for tooth

Possibility of caries
Cost to patient

Pt . preference

Age of patient

Visible caries
Caries risk

Remaining
A esthetics

structure
P ain
OH
My decision to REPLACE a defective dental
22 20 22 12 16 5.2 19 42 60 17 48
amalgam restoration

My decision to REPAIR a defective dental

64 27 17 9.5 25 17 4 14 24 15 50
amalgam restoration

My decision to REFURBISH a defective dental

59 23 26 24 30 17 23 5.5 5.5 17 25
amalgam restoration

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Table 20: Factors affecting treatment decisions: Ranking of factors

1st % 2nd % 3rd %

My decision to
Visible 60 Remaining 48 Pain 42
REPLACE a defective caries tooth
dental amalgam structure
restoration

My decision to Cost to 64 Remaining 50 Future 27

REPAIR a defective patient tooth plans for
dental amalgam structure the tooth
restoration

My decision to Cost to 59 Patient 30 Caries 26

REFURBISH a patient preference risk for
defective dental the
amalgam restoration patient

There was a statistically significant difference in the factors taken into

consideration when replacing a defective dental amalgam restoration depending
on the selection, X²(2) = 282.71, p<0.0001* (Table 20). With pairwise
comparisons, the considerations of cost to the patient and future plans for the
tooth were chosen significantly less often than pain, visible caries and remaining
tooth structure (p<0.0001*). Similarly, the cost to the patient was chosen
significantly more often than all the other options when deciding to repair or
refurbish a defective dental amalgam restoration (p<0.0001*) (Appendix M).

5.16 FUTURE OF AMALGAM

More than one-half of the respondents (58%) felt that dental amalgam should be
available for use in the future, and an almost equal number (54%) thought that
dental amalgam posed an environmental risk.

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5.17 RELATIONSHIPS BETWEEN DEMOGRAPHIC VARIABLES,
USE OF AMALGAM, FUTURE USE OF DENTAL AMALGAM,
REPAIRING DEFECTIVE DENTAL AMALGAM
RESTORATIONS AND REPLACING DEFECTIVE DENTAL
AMALGAM RESTORATIONS

Different statistical tests were performed to examine the relationships between

factors in the categories: dentists’ individual characteristics, practice profiles and
biases (Table 21). A Chi-square test was used when both variables were
categorical. When one variable was categorical and the other was ordinal, a
Wilcoxon Rank-Sum test or a Kruskal-Wallis test was used. When both variables
were ordinal, the Spearman’s correlation was used. Cross-tabulations were only
completed for the pairs that were significant at the 0.005 level (Appendix M).

Table 21: Factors tested for their association

Dentists’ Practice Profile Biases

Individual
Characteristics

Age Practice arrangement Use of repair as a treatment

option

Gender Practice location Choice of material to repair

Years of experience Contracted to third-party Future use of amalgam

funders

CPD activities Choice of material to replace

amalgam

Treatment option chosen in

vignette

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5.17.1 Relationship between repair of dental amalgam and future use of
dental amalgam as a restorative material

There was a statistically significant relationship and a trend that dentists who
repair defective dental amalgam restorations are more likely to believe that there
is a future for amalgam as a dental restorative material (p<0.005*) (Table 22).

Table 22: Repair of dental amalgam and future use of the material

Repair amalgams Future use of amalgam

Yes No Do not know Total

Yes Frequency (n) 118 43 12 173

% 68.21 24.86 6.94

No Frequency (n) 43 50 11 104

% 41.35 48.08 10.58

Total 161 93 23 277

Frequency missing = 75

5.17.2 Relationship between contracted to medical aid and repair or

replacement of defective dental amalgam restorations

There was a statistically significant relationship and a trend that dentists who are
contracted to third-party funders are more likely to repair defective dental
amalgam restorations than replace (p<0.005*) (Appendix M).

5.17.3 Relationship between age and repair of defective dental amalgam

restorations

There was a statistically significant relationship and a trend that dentists who
repair defective dental amalgam restorations are more likely to be between the
ages of 56 years and 65 years (p<0.0001). Dentists between the ages of 26 years
and 35 years do not choose amalgam as a restorative material for repair (Appendix
M).

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5.17.4 Relationship between years of experience and choice of material to
repair

There was a statistically significant relationship and a trend that dentists who have
more than 21 years of experience are more likely to use amalgam as a restorative
material when repairing a defective amalgam (p<0.0027) (Appendix M).

5.17.5 Relationship between use of amalgam as a restorative material and

repair of defective dental amalgam restorations

There was a statistically significant relationship and a trend that dentists who
never repair amalgams almost never use amalgam in practice (p<0.0001)
(Appendix M).

5.17.6 Relationship between use of amalgam as a restorative material and

discussion of material choice with a patient

There was a statistically significant relationship and a trend that dentists who
routinely discuss restorative material choice with patients very rarely use
amalgam (p<0.0001) (Appendix M).

5.18 ANALYSIS OF CLINICAL VIGNETTE RESPONSES IN THE

ONLINE SURVEY

The clinical vignettes formed part of the online survey distributed to members of
SADA. The vignette examined the effects of three factors regarding dentists’
treatment decisions. The factors were: presence and absence of a marginal gap;
presence and absence of secondary caries; and the patient’s ability to pay for
treatment. There were three response categories, repair, replace or refurbish. The
vignettes were randomised in SurveyMonkey®, and each dentist answered one
vignette. There were 274 respondents who answered the clinical vignette
questions.

Preliminary analysis indicated that the ability to pay (AP) was not important to
predicting the response, so it was excluded in later stages. The interaction term
between Marginal Gap (MG) and Secondary Caries (SC) was not significant, so a

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simpler main-effect model was fit. There were three choices: Refurbish, Repair
and Replace. Repair was chosen as the best option, and two scenarios were
analysed: Refurbish versus Repair and Replace versus Repair.

5.18.1 Replacement versus Repair

5.18.1.1 Secondary Caries as a factor

The odds ratio for choosing Repair over Replacement when Secondary Caries is
present (SC=1) compared with when Secondary Caries is absent (SC=0) must be
considered. The restoration is less likely to repair when SC=1 (approximately
25% probability) than when SC=0 (approximately 41% probability) (Table 21).
Hence, the odds ratio is expected to be less than 1. The estimated odds ratio from
the model with two factors is 0.434, with a 95% confidence interval of 0.224,
0.842 (Table 22). Since both end points of the confidence interval are less than 1,
the p-value for testing the null hypothesis that the odds ratio equals 1 would be
less than 0.05 (i.e. the odds ratio is significantly different from 1).

Data from the interviews revealed that 2 of the 15 dentists were of the opinion that
the presence of secondary caries necessitated the replacement of the defective
dental amalgam restoration. There was a further suggestion that caries was linked
to the presence of a marginal gap. One dentist was more defensive in his response,
stating that all dentists experience secondary caries.

[B]ut I would prefer to remove the entire restoration and then clean out
under the restoration in case of secondary caries (Dr J).

I think the gap is always a problem for caries (Dr N).

Every dentist experiences secondary caries. Even under the fillings I placed.
Secondary caries will develop if the initial caries was not removed 100%
(Dr RA).

Secondary caries can develop under any restoration, and it’s something we
can’t guarantee (Dr RA).

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5.18.1.2 Marginal Gap as a factor

The odds ratio for choosing Repair over Replacement when Marginal Gap is
present (MG=1) compared to when Marginal Gap is absent (MG=0) must also be
considered. Hence, the odds ratio is expected to be less than 1. From Table 23, the
estimated odds ratio from the model with two factors is 0.594, with a 95%
confidence interval of 0.311, 1.133. Since the lower end point of the confidence
interval is less than 1 and the upper end point is greater than 1, it could be
reasonably concluded that the odds ratio would be 1. Therefore, the test of the null
hypothesis that the odds ratio is equal to 1 would have a p-value greater than 0.05
(i.e. the odds ratio is not significantly different from 1).

The data from the interviews inform that 4 of the 15 participants diagnosed tooth
26 as being a ‘leaky restoration’. This was described as the amalgam restoration
pulling away from the tooth surface and creating a gap where leakage can occur.

Table 23: Replacement versus Repair (MG=0, MG=1; SC=1, SC=0)

Secondary Secondary Marginal Marginal

Caries Caries Gap Gap
Frequency absent present absent present Total
SC=0 SC=1 MG=0 MG=1

37 121 50 108
Replacement 158
62.71% 78.57% 68.49 77.14

22 33 23 32
Repair 55
37.29% 21.43% 31.51 22.86

Total 59 154 73 140 213

Frequency Missing = 50

This was not the same as diagnosing secondary caries but could predispose the
patient to the development of secondary caries. One participant, however, did feel
that “the gap is always a problem for caries” (Dr N).

It looks like a leaky amalgam … the margins are very uneven and pulled
away from the enamel. So I suspect there is a leak (Dr MA).

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It looks like it is a leaking filling … the ridge is broken down around the
tooth over there and there is a bit ... There could be a bit of a micro leakage
over there or saliva could seep down there (Dr J).

Just looking at that tooth … intraorally, there is definitely micro leakage on

that restoration [26]. You can see there is marginal discrepancy as well;
there is decay as well as staining (Dr RA).

Other interview participants felt that the presence of a gap alone was not enough
clinical evidence to warrant intervention. The presence of any clinical symptom,
specifically pain or sensitivity, would indicate the need for an intervention. The
intervention would usually be a complete replacement of the defective dental
amalgam restoration. Suggestions such as burnishing or repolishing the amalgam
restoration were made to improve the appearance of the restoration, specifically
the marginal area.

I think one of the things that would be a factor to me clinically, is if there is

a clinical symptom on a tooth like this, where there is a gap between the
amalgam and the cavity wall. If there is a symptom of sensitivity on it, then I
would feel differently about it, but if it is asymptomatic, and there is a space
like that and we can burnish it down like this one on the other side, then I
would feel … The one thing you don’t want to do is over treat the area also
(Dr Y).

[T]he amalgam is old. Look at the margins. They may be defective. And it’s
quite deep, and she is not complaining of pain, and there is no periapical
area. Honestly, I would not do anything. If the patient does not come in with
a problem, I don’t create a problem (Dr S).

5.18.2 Refurbishment versus Repair

5.18.2.1 Secondary Caries as a factor

The odds ratio for choosing Repair over Refurbishment when SC=1 compared
with SC=0 must be considered. From Table 24, the restoration is more likely to
repair when SC=1 than when SC=0. Hence, the odds ratio is expected to be more
than 1. The estimated odds ratio from the model with two factors is approximately

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53.0 (53.137), with a 95% confidence interval of 11.47, 247. Since both end
points of the confidence interval are more than 1, the p-value for testing the null
hypothesis that the odds ratio is equal to 1 would be less than 0.05.

5.18.2.2 Marginal Gap as a factor

Finally, the ratio of odds for choosing Repair over Refurbishment when MG=1
compared with MG=0 must be considered. Table 24 demonstrates that the
restoration is more likely to repair when MG=1 than when MG=0. Hence, the
odds ratio is expected to be more than 1. The estimated odds ratio from the model
with two factors is 5.62, with a 95% confidence interval of 2.32, 13.63. Since both
end points of the confidence interval are more than 1, the p-value for testing the
null hypothesis that the odds ratio is equal to 1 would be less than 0.05.

Table 24: Refurbishment versus Repair

Secondary Secondary Marginal Marginal

Caries Caries Gap Gap
Frequency absent present absent present Total
SC=0 SC=1 MG=0 MG=1

22 33 33 32
Repair 55
27.16 94.29 33.33 68.09

59 2 46 15
Refurbishment 61
72.84 5.71 66.67 31.91

Total 81 35 79 47
Missing= 50

5.18.3 Analysis of effects of Secondary Caries and Marginal Gap as

predictor variables

Based on a multinomial response model using MG and SC as predictor variables

(not AP since it was not a significant predictor), it was found that both MG and
SC are significant predictors of the outcome (p<0.0001* in each case). The

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magnitude of the effect is characterised by the odds ratio. This is the ratio of the
odds1 for choosing a particular outcome when, for example, SC=1, compared with
the odds for choosing that outcome when SC=0. If the odds ratio is equal to 1,
then both of the individual odds are the same, which mathematically means that
their ratio is 1. A ratio greater than 1 means the odds are higher when SC=1 than
when SC=0. Similarly, a ratio less than 1 means that the odds are lower when
SC=1 than when SC=0 (Table 25).

Table 25: Analysis of effects

Effect DF Wald Chi-square Pr>Chi-square

Marginal Gap 2 27.1587 <0.0001*

Secondary Caries 2 41.2585 <0.0001*

5.18.4 Mechanism of reimbursement

Data from the interviews indicate that 2 of the 15 dentists insisted that the method
of payment did not affect their treatment. However, there was an awareness of the
influence that finances could have when suggesting a treatment plan. Almost all
(12 of the 15) participants asked for confirmation of whether or not the patient had
medical aid cover.

1
If p is the probability of an event, then p/ (1-p) is the odds of the event occurring. For example, if
p=0.6, then the odds are 0.6/ (1-0.6) = 0.6/0.4 = 1.5.

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My decision-making is first clinical. Then we see what you require, and then
costs get discussed last. So if you are on medical aid, I tend not to look at
your medical aid and I tend … if you not on medical aid, either way it
doesn’t matter. So we see what is needed and then we give you the options,
and then you have to decide which way to go. I would first look at what the
patient requires before anything else. In private practice, the one thing that
I try not to do is to look at what the patient can afford (Dr Y).

Look, I will be honest with you, it doesn’t really matter. Even if it was a
medical aid case, we will go the conservative route. If the patient says they
are quite happy to have the amalgam there and just repair the mesial
section, then we go for that. Fine. No issues (DrRA).

Two of the dentists expressed concern in suggesting treatment for patients who
had not reported any symptoms and did not have medical aid and thus, may be
struggling financially. Treatment was seen as an unnecessary expense:

This woman does not have medical aid, and now you want to open up this
thing and you have to put a composite, and it’s going to cost you a lot of
money. All these things. She is coming to us pain free (Dr RA).

Again, like I said, we see some of these patients and if they don’t complain
and they are not financially eager to do anything about it, I wouldn’t do too
much (Dr A).

One participant confirmed that treatments are influenced by funding, whilst two
others remained cognisant about the financial well-being of their patients and
“work according to their budget” (Dr LE).

You know, treatments are influenced by funding (Dr K).

I normally work according to their budget (Dr LE).

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One participant expressed concern that if they were not competitive in the pricing
of their treatment, the patients would consult another colleague.

In our practice, because we are working with people who want economical
dentistry, what tends to happens if I tell a patient that I am going to charge
her R650, they rather go somewhere and have it done for whatever the
cheapest price is (Dr A).

5.18.5 Self-administered questionnaire

A summary of the demographic data of these dentists was presented in Table 7.

Table 26 provides a summary of the responses with regard to the patient profile of
the individual practice. All practices except one reported that more than one-half
of the patient population were members of a medical aid. A summary table of the
recommended treatment for tooth 26 in the clinical vignette is presented in
Appendix N.

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Table 26: Summary of profiles of patients treated at the respective practices

Number of % patients % patients % patients % patients % patients % patients

patients per with private without private 1–18 years 19–44 years 45–64 years 65 years and
week insurance insurance older

Dr J 60 65 35 30 30 20 20

Dr S 50 90 10 60 15 20 5

Dr A 80 70 30 10 60 20 10

Dr LD 50 70 30 10 50 20 20

Dr M 70 85 15 25 25 40 10

Dr LA 80 80 20 25 25 25 25

Dr LE 60 70 30 25 63 10 2

Dr K 50 50 50 20 40 30 10

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Number of % patients % patients % patients 1– % patients % patients % patients
patients per with private without private 18 years 19–44 years 45–64 years 65 years and
week insurance insurance older

Dr F 50 50 50 30 30 25 15

Dr LI 50 0 100 20 60 10 10

Dr RI 40 70 30 20 70 5 5

Dr RA 100 70 30 30 50 15 5

Dr MA 100 85 15 20 10 20 50

Dr N 25 60 30 10 50 30 10

Dr Y 75 75 25 30 30 25 15

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5.18.6 Data from treatment logs

Only 9 out of the 15 dentists submitted treatment logs. Each dentist was asked to
complete an entry for every patient who received a direct restoration during a
two-week period. A total of 300 patients were treated and 468 individual teeth
(Appendix O). The data indicates that the treatment of primary caries was the
main service provided.

Using only the unique responses in which new restorations were placed, resin
composite was the material of choice in most instances (Table 27). Almost
two-thirds of these restorations were due to primary caries (Table 28). However,
when the restorations were replaced, only 12% were due to secondary caries
(Table 29).

Table 27: Choice of material for ‘new restorations’

Material Frequency %

Amalgam 11 2.4

Resin composite 357 78

Glass Ionomer 41 9

Compomer 24 5.2

Other 4 0.8

Not answered 21 4.6

Missing= 10

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Table 28: Reasons for a ‘new restoration’

Reason Frequency %

Primary caries 294 63

Non-carious defects 54 11

Other 23 5

Not answered 97 21

Table 29: Reason for replacement of a restoration

Reason Frequency %

Secondary caries 56 12

Marginal discoloration 2 0.43

Bulk discolouration 2 0.43

Isthmus/ Bulk fracture 12 2.6

Tooth fracture 17 4

Poor anatomic form 1 0.2

Pain/sensitivity 18 3.9

Not answered 355 77

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CHAPTER 6: DISCUSSION

6.1 INTRODUCTION

This chapter discusses the findings of the present study and integrates the findings
of both the quantitative and qualitative phases. The first section discusses the
model of decision-making for defective dental amalgam restorations and is
followed by a discussion on the diagnosis and management practices of South
African dentists, factors influencing treatment decisions and the attitudes of
dentists. The final section discusses the limitations of the study.

While there has been an increase in practice-based studies conducted in dentistry,

this is one of the few studies that focuses on clinical decision-making in South
Africa. A worldwide trend towards minimally invasive dentistry and a dearth of
information on the restorative treatment practices and clinical decision-making of
South African dentists, specifically on how defective dental amalgam restorations
are managed by dentists in private practice, motivated the present study. The
study is anticipated to make an important methodological contribution with the
use of mixed methods and practice-based research in the field of dentistry in
South Africa.

The purpose of the present study was to explore the practices, knowledge and
attitudes of South African dentists with regard to the management of defective
dental amalgam restorations. The findings of the study supported the first
hypothesis that South African dentists routinely replace all defective dental
amalgam restorations.

This study confirmed that clinical decision-making is influenced by a multitude of

factors, not only the disease process. The second hypothesis that dentists’
practices differ with respect to personal and practice characteristics was also
supported. In addition, the present study combined the ‘models’ into a single
framework for a more comprehensive understanding of the extent of the influence
of clinical and non-clinical factors in the management of defective dental
amalgam restorations by South African dentists. In examining the influence of
treatment preferences on the management of defective dental amalgam

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restorations, the research findings supported the third hypothesis that dentists’
attitudes towards dental amalgam influences their decisions to replace defective
dental amalgam restorations.

6.2 THE PROPOSED MODEL FOR TREATMENT DECISIONS OF

DEFECTIVE DENTAL AMALGAM RESTORATIONS

The classification of issues relevant to treatment decision-making in general

dental practice by Kay and Blinkhorn (1996) and the conceptual model of caries-
related treatment decisions of Bader and Shugars (1997) are similar and form the
basis of the new conceptual model proposed by this study and portrayed in Figure
7.

Figure 7: Adapted model for caries-related treatment decisions

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The inner circle represents the decision-making process for managing a defective
dental amalgam restoration, and the outer rings illustrate the influence of dentist
and patient factors (clinical and non-clinical) on the process.

In this study, non-clinical factors such as fear, ethical conscience and dental
school had an influence on the decision process. The caries script process as
described by Baders and Shugars (1997) remains unchanged.

6.3 CONTEXT OF THE STUDY

In South Africa in 2014, a total of 5 824 dentists were registered with the HPCSA
(HPCSA, 2014), of which 3 607 were members of SADA. Despite being
reminded of their participation fortnightly for two months, there was a low
response rate of 10.7% for the quantitative online survey. However, this is
consistent with other studies conducted that used the same study population and
similar electronic survey methods (Botha et al., 2014; Snyman et al., 2016).

This study comprised approximately one-third female participants. A study of the

gender distribution among dental graduates between 2000 and 2005 reported a
two-fold increase in the number of female graduates (Lalloo et al., 2005).
Previous research conducted in South Africa also noted differences in the working
patterns of male and female dentists. A study in 1997, found that gender,
breadwinner status and age of children had a considerable influence on working
patterns (DeWet et al., 1997). The percentage of male to female dentists working
in private practice was 89.7% to 70% respectively (DeWet et al., 1997). However,
the working hours of female dentists dropped from 86% (practising more than 35
hours per week) to 34%, while male dentists’ working patterns remain unchanged
(DeWet et al., 1997). Only 19% of female dentists were the primary
breadwinners, indicating that many female dentists were able to work part-time
(DeWet et al., 1997). In addition, a greater percentage of female than male
dentists worked for a salary in government clinics and at academic institutions
(DeWet et al., 1997). The present study focused on dentists in private practice and
if these working patterns remained unchanged from 1997, this may have
influenced the study population.

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The sample of the present study comprised ‘younger dentists’, with the majority
of participants being under the age of 55 years and more than one-half having
over 15 years of experience. Approximately one-half of the sample was self-
employed without partners, and two-thirds were contracted to medical aids.

6.4 MANAGEMENT PRACTICES OF DEFECTIVE DENTAL

AMALGAM RESTORATIONS BY SOUTH AFRICAN DENTISTS

The findings of the present study were in line with global trends, revealing a
decline in amalgam use, with only 7% of participating dentists using it as a
restorative material in South Africa. Despite this, dentists in this study advocated
its use due to the excellent lifespan and durability, and a significant number
believed it should remain available for clinical use. This is in stark contrast to the
99.7% of dentists who were using dental amalgam in 1990 and the 85.8% in 2003
(Du Preez et al., 2003). It should be noted that the 2003 study conducted by Du
Preez et al. only had 177 respondents as opposed to 324 in this study. The
dramatic decline may be due to dentists’ increasing perception that the material is
outdated and patients’ increasing awareness of the possible harmful effects of
dental amalgam since “they are very knowledgeable, and they have Internet now
and smartphones” (Dr J). It could also be the result of demands for a more
aesthetic restorative material from both dentist and patient (Petersen, 2003).
Concern was also raised with regard to the failure rate of posterior composite
restorations, and this was used as a motivation for using dental amalgam.

In 2009, Lombard et al. compared teaching practices on dental amalgam with

posterior composite restorations in South African dental schools. They reported
that an equal amount of time was spent on the preclinical teaching of both
materials (Lombard et al., 2009). In order to prepare future dentists adequately
with the appropriate skills needed in the South African context, dental schools
need to review the time spent on teaching amalgam and composites. The present
study suggests that more time should be spent on teaching techniques for the
successful placement of posterior composite restorations and the repair of
defective dental restorations.

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Recent studies have confirmed that the repair of defective dental restorations is a
clinically viable option to extend the longevity of a restoration without
compromising tooth structure or incurring huge costs as in the case of indirect
restorations (Gordan et al., 2015; Moncada et al., 2015a, 2015b). Data from the
self-administered questionnaires revealed that the majority of dentists reportedly
repair defective dental amalgam restorations.

Most of the dentists in this study who did not repair restorations felt there was a
lack of predictability in the technique. This lack of knowledge or competence in
the technique potentially means patients are not offered a treatment procedure that
has been shown to require less anaesthetic and conserve more tooth structure
(Javidi et al., 2015). Furthermore, until a decade ago, dental amalgam was the
material of choice in South Africa (Du Preez et al., 2003). Given that the
longevity of dental amalgam restorations varies between 7 years and 20 years, it is
anticipated that South African dentists will be treating more patients with
defective dental amalgam restorations in the near future (Laske et al., 2016).
Recent data on improved patient outcomes when choosing to repair a restoration
and the continued evolution of dental materials and adhesive dentistry signals a
change in the practice of clinical dentistry (Javidi et al., 2015). The lack of
adequate knowledge and skills among South African dentists on how to repair
defective restorations may adversely affect health outcomes for an entire
population. This raises issues of ethics and quality of care.

Approximately two-thirds of dentists who were repairing defective dental

amalgams learnt the technique through their own clinical experience. The lack of
awareness of the accepted repair techniques suggest two possible opinions.
Firstly, clinicians often assume that a treatment is successful based on positive
outcomes reported for a number of treated patients. Secondly, the perception that
the treatment ‘works in my hands’ is often better evidence for general dentists that
the treatment is clinically viable and acceptable as opposed to data from ‘artificial
clinical trial settings’. While dentists are bombarded with information from dental
company representatives, they often lack the ability to evaluate the scientific
information critically. This prevents the incorporation of evidence-based dentistry
into general dental practice.

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While the dentist is responsible for providing appropriate dental care, the
responsibility to implement suitable dental care is shared between dental schools
and professional organisations (Fejerskov and Kidd, 2009). Dental schools should
ensure that their curriculum is based on evidence-based practice. Dentists should
be taught how to access sound resources of evidenced-based dentistry and how to
incorporate these guidelines into clinical practice. An important part of teaching
dental students to think critically includes making them aware of conflicting
evidence or the absence of evidence. The fact that dentists have adapted their own
‘repair technique’ may imply that dental schools in South Africa have not yet
formally included repair techniques into their curricula, as have the UK, USA and
European schools where they teach the repair of direct restorations (Blum et al.,
2002; Blum et al., 2003a, 2003b; Gordan et al., 2003; Setcos et al., 2004; Hasan
and Khan, 2013). Gilmore et al. (2006) stated that “the adoption of evidence-
based practice by dentists has been slow”. The present study suggests that South
African dentists are no different and raises concern regarding the practice of
evidence-based dentistry and the competency of acquiring and maintaining
evidence-based knowledge.

While no consensus has been reached on a repair technique, recent research has
clearly outlined successful and appropriate techniques (Hickel et al., 2013; Blum
et al., 2014). Dental amalgam does not adhere to tooth structure; consequently, in
keeping with recent research, a large percentage of the dentists indicated that they
would use a bur to create mechanical retention (Blum et al., 2014). In addition,
dentists in this study reportedly spend approximately five days annually to
continuing professional education, yet few of them were aware of published repair
techniques or alternatives to the management of defective restorations. This
advocates the need to evaluate existing and continuing professional education
programmes and to investigate the translation of knowledge into everyday
practice. It may also be helpful for professional organisations to advocate the use
of clinical guidelines based on well-conducted systemic reviews by organisations
such as Cochrane and the National Institute for Health and Clinical Excellence.

Once the decision has been taken to repair a restoration, the focus shifts to the
selection of a suitable dental restorative material to repair the defective dental

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amalgam restoration. In the present study, more than one-half of the dentists
reported discussing the choice of dental material with patients even though it is
possible that most patients would not understand the scientific rationale.

Data from the present study was conflicting with regard to the choice of material
used when repairing a defective dental amalgam restoration. Consistent with the
decrease in amalgam usage worldwide and the findings from the National Dental
Practice-Based Research Network (Gordan et al., 2012b), resin composite was the
restorative material of choice when repairing a defective dental amalgam
restoration. However, similar to the findings of Gordan et al. (2012b), a very
small number of dentists were confident to use amalgam to repair an existing
defective dental amalgam restoration. A concern for aesthetics and the perception
of a lack of adequate bond strength between dental amalgam and composite could
explain these results even though laboratory studies confirmed favourable bond
strengths when using resin composite to repair defective amalgam restorations (
Machado et al., 2007; Özcan and Schoonbeek, 2010; Cehreli et al., 2010).

One of the major concerns in repairing a restoration was placing two different
types of restorative material adjacent to each other. Dentists queried the validity
of the technique because their years of dental schooling had not included this. One
particular dentist was extremely shocked at the idea of a single tooth or surface
having two different restorative materials. The idea was not plausible “because we
were not taught how” (Dr S). Another dentist recalled the specific lecturer who
was responsible for teaching dental materials and who had affirmed that it was
indeed possible to repair a restoration. In this case, the effect of dental training on
restorative practice is undoubted and strengthens the argument for a review of
current teaching in dental schools and an update for practitioners (Maryniuk,
1990; Bader and Shugars, 1997; Kay and Nuttall, 1994; Doméjean-Orliaguet et
al., 2009).

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6.5 FACTORS TAKEN INTO CONSIDERATION WHEN MANAGING
A DEFECTIVE DENTAL AMALGAM RESTORATION

Several factors are responsible for the variation in clinical decision-making in

dentistry such as dental training, knowledge of the disease, dentists’ preferences
and specific factors relating to the tooth or restorative material (Bader and
Shugars, 1992; Riley et al., 2011). The present study confirmed the decision-
making model proposed by Bader and Shugars (1997) and indicated a distinct
pattern in the factors taken into consideration when managing a defective dental
amalgam restoration.

6.5.1 Tooth factors

Tooth factors such as remaining tooth structure, size and depth of the restoration
and the presence of caries were ranked higher than patient factors (viz. occlusion,
finances and presence of pain) and material factors. This supports previously
published research in which technical factors dominated patient outcomes
(Grembowski et al., 1988; Brennan and Spencer, 2002). Literature has identified
an emphasis in teaching of the technical aspects without creating an awareness of
the importance of patient outcome as a possible reason for this (Doméjean-
Orliaguet et al., 2009).

There is documented evidence that each time a restoration is replaced, the size of
the cavity increases and the tooth structure is further compromised with an
increased possibility of pulpal involvement (Gordan et al., 2004). Costly,
advanced dental procedures such as root canal treatment and indirect restorations
may be the only alternative to extending the longevity of the tooth. Extraction of
the offending tooth is a viable treatment option if the patient is unable to afford
costly treatment. However, this could be avoided if the dentist has the knowledge
and skills to recommend and perform repairs of defective restorations if
appropriate. This may prolong the longevity of the tooth.

Visible caries was the most important consideration when replacing a restoration.
A statistically significant relationship was found between repair and replacement
and the presence of a marginal gap and secondary caries.

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In contrast to Gordan et al. (2012b), there was only a 25% probability that dentists
would repair a restoration with a diagnosis of secondary caries. Similarly,
participating dentists were less likely to repair in the presence of a marginal gap.
This could mean that dentists were not confident that a repair would yield a
positive treatment outcome in the presence of caries and that caries could recur. In
South Africa, there is a high rate of unemployment, and one of the benefits of a
good job is access to a healthcare fund. As a result, only 14% of the population
are members of a medical scheme (Gray and Vawda, 2015). This means that most
individuals have to pay for any health service, including oral health. It would
appear that dentists will only recommend repairing a defective dental amalgam
restoration if patients are unable to afford an indirect restoration or a complete
replacement of the restoration. Data from the interviews illustrated how dentists
consider the cost and benefits to themselves as operators (i.e. How long it will
take?), to the patient (i.e. Will the patient ‘benefit’ from the treatment?) and to the
profession (i.e. Will the patient perceive dentistry as beneficial?).

It would seem that because recent studies on repairing restorations have reported
positive patient outcomes, the technique may also be capable of improving the
patient’s perception of dentistry (Javidi et al., 2015).

6.5.2 Patient factors

The present study found that dentists ranked ‘cost to patient’ as the most
important consideration in their decision to repair or refurbish a defective dental
amalgam restoration. These findings corroborated those reported by Brennan and
Spencer (2006). Dentists interviewed in the present study who were sensitive to
the financial difficulties that patients experience proposed a treatment plan, and
some dentists “work according to their [patient’s] budget” (Dr LE). Dentists
provided different levels of restorative care based on their perception of the
patient’s ability to pay. This demonstrated their willingness to provide the best
level of care within the financial constraints set by the patient (Maryniuk, 1990).
However, if patients did not experience any symptoms, dentists were reluctant to
suggest treatment, especially if there was concern about the patient’s ability to

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pay. Dentists would recommend that treatment be delayed until absolutely
necessary.

Interestingly, the caries risk of a patient was only considered important when
refurbishing a restoration. The lack of preventive dentistry concepts used in these
treatment decisions may be explained by factors relating to dentists’ knowledge,
patient demand, dental training or the health system. Schwendicke et al. (2015)
cite Black’s (1891) concept of ‘extension for prevention’ that has guided
conventional operative treatment of carious lesions for many decades. In addition,
given that the majority of dentists in this study had more than 15 years of
experience, they may not be familiar or comfortable with the incorporation of
preventive strategies in their practices, strategies that may be more time-
consuming but not necessarily more financially rewarding. In addition, service
health systems in South Africa do not reward dentists for adopting a more
preventive approach in caries management. It is also possible that South African
dental schools do not specifically and actively incorporate preventive methods in
the comprehensive management of adult patients.

Replacement of restorations was only recommended if the patient reported a

symptom such as pain. Insight from the interviews suggest that dentists felt
uneasy with recommending a treatment such as a repair when they were unsure
about the clinical effectiveness.

6.5.3 Dentist factors

The present study was conducted to identify clinical and non-clinical factors that
may act as predictors for the repair or replacement of defective dental amalgam
restorations by South African dentists.

A significant relationship was found between age of the dentist and the repair of
dental amalgam restorations. In contrast to previous studies, older dentists were
found to be more inclined to repair than replace defective dental amalgam
restorations (Gordan et al., 2009; Gordan et al., 2012b). Older dentists may have
more clinical experience.

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In this study, gender did not have any influence on treatment decisions although
previous studies noted a difference in treatment approaches (Brennan and
Spencer, 2005; Riley et al., 2011). Riley et al. (2011) found that female dentists
were more conservative and more inclined to use caries-preventive measures. The
small number of female dentists participating in this study could account for not
detecting a difference in treatment approaches.

Preferences for techniques and materials were found to influence clinical

decision-making; dentists with more than 21 years of experience were more likely
to choose amalgam as the material of choice when repairing a defective dental
amalgam restoration. This was not surprising since the majority of them would
have more clinical experience using amalgam.

Dentists who were interviewed expressed fear of facing patients as a consequence

of an unsuccessful clinical decision and the possibility of incurring additional
costs for the patient when a treatment was unsuccessful. This places dentists in
conflict with their decision to prioritise the patient’s well-being or to benefit
financially from their professional recommendation, which may result in
overtreatment. The concern is that dentists would only recommend repairing a
defective dental amalgam restoration if patients were not able to afford an indirect
restoration or a complete replacement of the restoration.

Three practice-related factors, practice arrangement, practice location and

contracted to third-party funders, were tested for their association with repair and
replacement of defective dental amalgam restorations. The only factor found to
have a significant relationship was ‘contracted to third party funders’.
Surprisingly, dentists who were contracted to medical aids were more likely to
repair defective dental amalgam restorations. Data from the interviews and the
online survey reported concern among participating dentists in placing an
additional financial burden on patients when a defective dental restoration
required treatment. The repair of a defective restoration could be classified as a
restoration, and no additional authorisation or payment would be necessary from
the medical aid. However, if the patient presented with pain, dentists were

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reluctant to repair restorations. In this instance, a root canal or crown would be
more appropriate, which could incur additional costs to be paid by the patient.

6.5.4 Knowledge of dentists in managing defective dental amalgam

restorations

Similar to other studies, dentists in the present study were more likely to replace a
restoration if secondary caries was found (Mjör and Toffenetti, 1992; Burke et al.,
1999; Mjör and Toffenetti, 2000; Setcos et al., 2004; Silvani et al., 2014). While
secondary caries is the most common reason for the replacement of restorations
(Mjör and Toffenetti, 1992), previous research has labelled the diagnosis and
treatment of secondary caries as clinically challenging (Sarrett, 2009). Secondary
caries is histologically similar to primary dental caries (Fejerskov and Kidd,
2009), but because many lesions are not at the interface of the tooth and
restoration, diagnosis may be difficult (Gordan et al., 2009). This uncertainty
means that dentists rely more on radiographs despite the fact that it is not a
reliable predictor of cavitation (Schwendicke et al., 2015). The most common
diagnostic method for secondary caries used in this study was radiographs,
followed by the presence of soft, discoloured dentine or enamel.

Any uncertainty in the diagnosis may force dentists to be more invasive and
replace restorations rather than repair them. The present study found that the
majority of dentists had outdated concepts regarding secondary caries and
marginal gaps. The dentists believed there was a correlation between the presence
of a marginal gap and secondary caries. Participating dentists were more inclined
to replace an entire restoration because of ‘faulty margins’. Replacement criteria
developed in 1988 found that “marginal gap alone was not reason enough for a
replacement of a restoration” (Boyd, 1989). In 2012, Dennison and Sarrett
elaborated on that statement. They maintained “that marginal defects without
visible evidence of soft dentin on the wall or the base of the defect should be
monitored for change or repaired or sealed and then monitored” (Dennison and
Sarrett, 2012).

Related to this misconception is the reference to ‘leaking restorations’ by

participating dentists. Dentists implied a relationship between micro-leakage and

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secondary caries even though it has long since been determined that micro-
leakage is not a predisposing factor nor a predictor for secondary caries (Dennison
and Sarrett, 2012). The present study found a statistically significant relationship
between repair and replacement and marginal gap and secondary caries.

In addition, the dentists believed that in the absence of any clinically or

radiographically detectable decay around faulty margins, caries could be present
below the margins or could develop in the future. They would recommend that
these restorations be replaced; it is almost more acceptable to over diagnose than
misdiagnose. Uncertainty about when it is appropriate to intervene caused dentists
to favour surgical intervention. Gordan et al. (2009) reported similar findings and
attributed this to the lack of standards in determining the failure of a restoration
and the lack of appropriate reimbursement for the procedure. Other possibilities
are that dentists would want to remove all possible causes of infection or they are
unsure of the diagnosis.

Some of the dentists in the present study also recommended replacing restorations
with defective margins. The literature describes this behaviour as “defensive
dentistry” in which a dentist adopts an “if in doubt, replace” attitude as opposed to
a minimal intervention approach (Blum et al., 2014). The effect of these factors
may result in dentists over treating and unnecessarily replacing restorations,
perpetuating the “restorative cycle” (Elderton and Nuttall, 1983; Elderton, 2003;
Alexander et al., 2014). A review of the basic concepts in caries diagnosis at
dental schools and in continuing education courses for practitioners may prevent
this behaviour in the future. Variation in treatment decisions show that positive
and false negative diagnoses and treatments occur because of the uncertainty of
clinical decisions (Choi et al., 1998). It is recommended that dentists are made
aware of these uncertainties and how they may affect clinical decision-making.

6.5.5 Dentists’ attitudes towards repairing defective dental amalgam

restorations

Similar to the qualitative investigation into factors affecting treatment decisions

by Kay and Blinkhorn (1996), participating dentists expressed concern over the
ethics, cost and benefits of the repair procedure. Some dentists felt that repairing a

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restoration was “not the best treatment a dentist could offer” (DR LE). This could
be because they personally did not place the original restoration, and research has
demonstrated that dentists are more likely to replace a restoration that they have
not originally placed (Gordan et al., 2009). It is also possible that they are
drawing from their experience as dental students. Most dental schools in South
Africa use the quota system in teaching restorative dentistry, and students are
sometimes asked to replace restorations to gain more experience with a technique
or a restorative material. While this may improve technical ability, the dental
student has also learnt not to trust the work of colleagues by indiscriminately
replacing restorations (Boyd, 1989). Dental schools should be aware that students
also learn informally (Boyd, 1989). Attitudes, preferences and beliefs are co-
curricular activities that students learn consciously and unconsciously. This
behaviour shapes the behaviour of the future dentist and affects practice patterns
(Brennan and Spencer, 2001).

Other participants regarded the repair of defective restorations as “patchwork”

and “not the right thing to do” (DR LE). This supports the findings of Sharif et al.
(2010) and could largely be attributed to a lack of knowledge of alternative
therapies to replacement and outdated beliefs regarding the relationship between
marginal gaps and secondary caries.

Literature has described dentists’ fears to include fear of litigation, fear of

consequences of clinical decisions, fear of cost to patients and fear of cost to
practice/dentists (Fox, 2010). Dentists in this study expressed fear of
consequences of clinical decisions, fear of litigation and fear of recommending
‘costly’ treatment to patients. All of these relate to trust between a dentist and a
patient and the belief that the dentist will always act in the patient’s best interest.
This is an example of Maryniuk’s (1990) explanatory model of practice pattern
variation in which the dentist’s practice patterns are driven by a desire always to
act in their patient’s best interest. Another fear dentists expressed was losing
clientele to colleagues if they were not competitive enough with their costs for
treatment. The dentist has to reach a compromise between providing the best
appropriate treatment and cost effectiveness for the practice and for the patient.

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6.6 LIMITATIONS OF THE STUDY

This study has a number of limitations that the reader should bear in mind:

• Study design: The quantitative phase of the research was a cross-sectional

design. An inherent flaw in this design is the difficulty to make causal
inference and the possibility that the situation may provide different results
in another time frame. The generalisability of the results may be difficult
since the findings may be more specific to dentists practising in South
Africa.

• Sampling: The study population was limited to SADA membership, and

this may not be representative of all dentists in South Africa. It may reduce
the generalisability of the findings. In the qualitative phase, sampling was
non-probability based, purposive and convenience. Interviews were
conducted with dentists in the Western Cape. The purpose of the
interviews was to provide insight and depth to clinical decision-making by
dentists in South Africa. Extrapolating findings from data collected in the
interviews to the national survey is unlikely to bias the study because of
the variation among dentists irrespective of location.

• Data collection: The use of an online survey may have automatically

excluded dentists who were not fully computer literate. Use of the
think-aloud technique is limited by the ability of the participants to think
and talk aloud, including their ability to express themselves. This may
affect data validity. Data collected from only one case study during the
semi-structured interviews was included in the study because the majority
of the participants repeated information for the second case. The
interviews were also restricted in time due to the fact that most dentists
agreed to participate during their lunch time.

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CHAPTER 7: CONCLUSION AND RECOMMENDATIONS

In this chapter, the key findings are highlighted and their implications as they
relate to teaching, practice and policy are discussed. Recommendations are made
and suggestions for further research are outlined.

In recent years, there has been an increase in the number of practice-based studies
conducted, specifically in dentistry. The present study provides important insight
into restorative treatment practices and clinical decision-making of South African
dentists, specifically regarding how defective dental amalgam restorations are
managed by dentists in private practice.

The present study illustrated that a combination of the concepts defined by Bader
and Shugar (1997) in their caries-related conceptual model and the classification
of non-clinical factors by Kay and Blinkhorn (1996) gives a more comprehensive
understanding of the decision-making process for the management of defective
dental amalgam restorations. The findings suggest that South African dentists face
similar challenges to dentists in more well-developed countries where the caries
levels are lower.

7.1 SUMMARY OF KEY FINDINGS

• Dentists were more likely to replace all defective restorations.

• Dentists with more than 21 years of experience were more likely to repair
defective restorations.
• Cost to patient, uncertainty in diagnosis and dental school were the most
influential non-clinical factors.
• Secondary caries and the presence of a marginal gap were significant
predictors for the repair of defective restorations.

Data from the treatment logs submitted indicated that the replacement of
restorations does not account for a major portion of dentists’ time spent in
practice. This is in contrast to studies conducted in the USA, UK and Europe.

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However, it is in keeping with the higher level of caries that is present in the
South African population. In this study, the use of outdated concepts and
knowledge, especially with regard to micro-leakage, secondary caries and the
presence of a marginal gap, had a significant influence on the replacement of
restorations. While the diagnosis of secondary caries and micro-leakage remains a
challenge, dentists had a tendency to diagnose secondary caries and micro-leakage
if they were in doubt about the quality of the restoration. This uncertainty led to
many unnecessary replacements. These findings have implications for teaching
and practice. Dentists are ‘out of touch’ with core knowledge and techniques.
While this may be expected from older clinicians, younger dentists were
exhibiting similar practice patterns. This means that they do not know any better
or are too comfortable with their outdated techniques and too reluctant to change.
Similarly, dentists reportedly replaced restorations to prevent any caries
developing in the future even though it has been proved that a defective
restoration does not imply that the restoration is clinically unacceptable.

This study also supports previous evidence that dental schools and their teachings
not only have a tremendous influence on the initial development of clinical
decision-making skills but also on the eventual treatment decisions of the
professionals in dentistry (Maryniuk, 1990). The challenge is for dental curricula
to be more responsive and contextually appropriate in order to affect the oral
health of the population positively and to equip dentists with skills that will enable
them to make evidence-based decisions. This study does not suggest that
evidence-based dentistry is not taking place in South African dentistry but rather
that the translation of this evidence-based dentistry to everyday clinical practice
be more overt to dentists in practice and to future dentists.

The findings of this study confirmed that dentists are influenced by a number of
non-clinical factors in their decision-making processes. A combination of these
factors often force dentists to perform unnecessary replacement of restorations,
increasing the restorative burden on the tooth and pushing patients into the
‘restorative cycle’. This study also contributed to the small pool of data available
in dentistry for understanding the mechanisms and the degree to which fear may
affect clinical decision-making.

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7.2 IMPLICATIONS FOR TEACHING AND PRACTICE

• The findings of the present study suggest that dentists are not able to use
and implement evidence-based knowledge in their practices, thus
adversely affecting the health outcomes of many. Specific areas include:
determination of the quality of restorations; diagnosis and management of
secondary caries; and marginal gap and repair techniques for defective
restorations.
• The study also suggests that dentists are not equipped with the skills to
search for the necessary information. Undergraduate dental curricula and
continuing professional education should focus on the development of
critical thinking skills.
• Although dentists in the present study were participating in continuing
professional education programmes, it did not appear to translate to their
clinical practice. The value of current continuing professional activities
should be assessed so that dentists, and ultimately patients, may benefit
from them.
• It is evident from this study that dentists’ treatment patterns and clinical
decision-making processes are shaped by the teaching in dental schools.
Their experiences as dental students create the initial caries scripts that
will later mature into their individual practice beliefs and identity as a
clinician. This implies that dental students should be exposed to a greater
variety of cases to develop more scripts that they may draw on during the
clinical decision-making process.
• In addition, the influence of non-clinical factors on clinical
decision-making should remind clinical teachers and creators of curricula
that both the social aspect of patient management and the focus on patient
outcomes are equally important as developing technical competences in
the discipline. Comprehensive management of patient cases should be
investigated in preference over the quota system that is used in South
African dental schools.

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7.3 IMPLICATIONS FOR POLICY

• The current health system in South Africa is a fee-for-service system. In

dentistry, dentists are remunerated for treating caries with restorations.
Incentives for practising preventive dentistry and minimally invasive
dentistry should be instituted to allow patients to assume more
responsibility for their oral health.
• Third-party funders should also evaluate the possibility of creating a fee
structure for the repair and refurbishment of defective restorations as a
more cost-effective measure to retain natural teeth for longer. This could
ultimately improve the oral health outcomes of a population.

7.4 RECOMMENDATIONS FOR FURTHER RESEARCH

Recommendations for further research include:

• Investigating the use of evidence-based restorative treatment principles in
practice.
• Evaluating the current continuing professional activities for dentists with
regard to the translation of evidence-based knowledge to everyday general
practice.
• Reviewing teaching on the diagnosis, management and repair of direct
restorations in dental schools across South Africa as well as in continuing
education programmes.

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Snyman, L., Van der Berg-Cloete, S.Ε. & White, J.G. 2016. The perceptions of
South African dentists on strategic management to ensure a viable dental practice.
South African Dental Journal, 71(1): 12–18.
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Soderfeldt, B., Palmqvist, S., Eriksson, T., Kronstrom, F. & Carlsson, G.E. 1996.
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Spencer, A.J. & Lewis, J.M. 1988. The practice of dentistry by male and female
dentists. Community Dentistry and Oral Epidemiology, 16(4): 202–7.
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Strassler, H.E. 2012. Clinical decision-making for restoration replacement or

repair. Inside Dentistry, (March). https://cdeworld.com/courses/4570-
Clinical_Decision-Making_for_Restoration_Replacement_or_Repair?&q=howard
strassler.

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Tuominen, R., Eriksson, A.L. & Vahlberg, T. 2012. Private dentists assess
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dentists. Community Dentistry Oral Epidemiology, 40(4): 362–8.
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Widström, E. & Forss, H. 1998. Dental practitioners’ experiences on the
usefulness of restorative materials in Finland 1992-1996. British Dental Journal,
185: 540–542.

Widström, E., Mjör, I.A. & Pakhomov, G.N. 1997. In: I.A. Mjor and G.
Pakhomov. Eds. Dental amalgam and alternative direct restorative materials.
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[8 February 2016].

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2004. Contemporary dental practice in the UK: aspects of direct restorations,
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dental amalgam from health and environmental perspectives. Acta Odontologica
Scandinavica, 60(5): 315–20. http://www.ncbi.nlm.nih.gov/pubmed/12418724.

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APPENDICES

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Appendix A: Summary of studies conducted on reasons for replacement of restorations

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Appendix B: Clinical studies on repair and refurbishment of restorations

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Appendix C: FDI criteria and gradings (Hickel et al., 2010)

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Appendix D: Questionnaire (with informed consent)(*Compulsory questions)

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Appendix E: Ethics approval

Office of the Deputy Dean

Postgraduate Studies and Research
Faculty of Dentistry and WHO Collaborating Centre for Oral
Health

UNIVERSITY OF THE WESTERN CAPE

Private Bag X1, Tygerberg 7505
Cape Town
SOUTH AFRICA
Date: 04th March 2011

For Attention: Dr R Adam, Department of Restorative Dentistry

Dear Dr Adam

STUDY PROJECT: Management of defective dental amalgam restorations

PROJECT REGISTRATION NUMBER: 11/1/46

ETHICS: Approved

At a meeting of the Senate Research Committee held on Friday 4th

February 2011 the above project was approved. This project is therefore
now registered and you can proceed with the work. Please quote the
above-mentioned project title and registration number in all further
correspondence. Please carefully read the Standards and Guidance for
Researchers below before carrying out your study.

Patients participating in a research project at the Tygerberg and

Mitchells Plain Oral Health Centres will not be treated free of charge as
the Provincial Administration of the Western Cape does not support
research financially.

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Due to the heavy workload auxiliary staff of the Oral Health Centres
cannot offer assistance with research projects.

Yours sincerely

Professor Sudeshni Naidoo

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Appendix F: Case Study 1 and Case Study 2

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Appendix G: Self-administered questionnaire for qualitative sample (n=15)

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Appendix H: Treatment log

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Appendix I: Research participant consent form

Title of Project: Clinical Decision-making REC Ref No: Project Registration:

11/1/46).

Name of Researcher: Dr Razia Adam

(tick
the appropriate box)
I confirm that I have read and understood the
information sheet for the above study and what Yes No Not applicable
my contribution will be

I have been given the opportunity to ask

questions (face to face, via telephone and Yes No Not applicable
email)

I agree to take part in the interview Yes No Not applicable

I agree to being voice recorded Yes No Not applicable

I agree to take digital images during the Yes No Not applicable

research exercises

I agree to keep a log of

replaced/repaired/refurbished amalgam Yes No Not applicable
restorations for a period of 14 working days

I agree to the researcher disseminating the

information collected in the following formats: Yes No Not applicable
thesis, conference presentations, published
articles(journals and electronically)

I understand that my participation is voluntary

and that I can withdraw from the research at Yes No Not applicable
any time without giving any reason and
without penalty

I agree to take part in the above study Yes No Not applicable

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Name of participant:
Signature:
Date:
Name of researcher taking consent:
Researcher’s email address: [email protected]

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Appendix J: Origin of technique used
Friedman result for outcome y with id and item variables: Pairs significantly different: Adjusted p<0.05

Obs. Effect Item Item Estimate Std Err. DF t-value Probt. Adjustment Adjp.

item 1 2 0.6985 0.1058 1305 6.60 <.0001 Tukey <.0001

item 1 3 0.9618 0.1058 1305 9.09 <.0001 Tukey <.0001
item 1 4 1.4198 0.1058 1305 13.43 <.0001 Tukey <.0001
item 1 5 0.9847 0.1058 1305 9.31 <.0001 Tukey <.0001
KEY
item 1 6 -0.5267 0.1058 1305 -4.98 <.0001 Tukey <.0001
1= Undergraduate Dental School
item 2 4 0.7214 0.1058 1305 6.82 <.0001 Tukey <.0001
item 2 6 -1.2252 0.1058 1305 -11.59 <.0001 Tukey <.0001 2= Attending a CPD course or lecture
item 3 4 0.4580 0.1058 1305 4.33 <.0001 Tukey 0.0002 3= Reading a journal article
item 3 6 -1.4885 0.1058 1305 -14.08 <.0001 Tukey <.0001 4= From the Internet
item 4 5 -0.4351 0.1058 1305 -4.11 <.0001 Tukey 0.0006 5= From a fellow colleague
item 4 6 -1.9466 0.1058 1305 -18.41 <.0001 Tukey <.0001 6= From my clinical experience
item 5 6 -1.5115 0.1058 1305 -14.29 <.0001 Tukey <.0001

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Appendix K: Restorative material of choice for repairing a defective dental amalgam restoration

Pairs significantly different: Adjusted p<0.05

Item _Item Estimate Std Err. DF t-value Probt. Adjustment Adjp.

1 item 1 2 -0.7560 0.1109 1245 -6.81 <.0001 Tukey <.0001

2 item 1 3 1.0080 0.1109 1245 9.09 <.0001 Tukey <.0001
3 item 1 4 0.4080 0.1109 1245 3.68 0.0002 Tukey 0.0033
4 item 1 5 0.8280 0.1109 1245 7.46 <.0001 Tukey <.0001
6 item 2 3 1.7640 0.1109 1245 15.90 <.0001 Tukey <.0001 KEY
7 item 2 4 1.1640 0.1109 1245 10.49 <.0001 Tukey <.0001 1= Resin-modified glass
8 item 2 5 1.5840 0.1109 1245 14.28 <.0001 Tukey <.0001 ionomer
9 item 2 6 0.9600 0.1109 1245 8.65 <.0001 Tukey <.0001
2= Resin-based composite
10 item 3 4 -0.6000 0.1109 1245 -5.41 <.0001 Tukey <.0001
12 item 3 6 -0.8040 0.1109 1245 -7.25 <.0001 Tukey <.0001 3= Silorane-based composite
13 item 4 5 0.4200 0.1109 1245 3.79 0.0002 Tukey 0.0022
4= Flowable composite
15 item 5 6 -0.6240 0.1109 1245 -5.62 <.0001 Tukey <.0001
5= Compomer

6= Amalgam

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Pairs NOT significantly different: Adjusted p>=0.05

Obs. Effect Item _Item Estimate Std Err. DF t-value Probt. Adjustment Adjp.

5 item 1 6 0.2040 0.1109 1245 1.84 0.0662 Tukey 0.4411

11 item 3 5 -0.1800 0.1109 1245 -1.62 0.1050 Tukey 0.5837
14 item 4 6 -0.2040 0.1109 1245 -1.84 0.0662 Tukey 0.4411

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Appendix L: Diagnosis of secondary caries (n=285)
Pairs significantly different: Adjusted p<0.05

Obs. Effect Item _Item Estimate Std Err. DF t-value Probt. Adjustment Adjp.

item 1 2 0.6035 0.1249 1988 4.83 <.0001 Tukey <.0001

item 1 3 3.5228 0.1249 1988 28.21 <.0001 Tukey <.0001 KEY
item 1 4 1.4596 0.1249 1988 11.69 <.0001 Tukey <.0001
1= Radiographs
item 1 5 1.4175 0.1249 1988 11.35 <.0001 Tukey <.0001
item 1 6 1.0807 0.1249 1988 8.65 <.0001 Tukey <.0001 2= Probing with a sharp explorer
item 1 7 0.4772 0.1249 1988 3.82 0.0001 Tukey 0.0034
3=Probing with a blunt explorer
item 1 8 3.0737 0.1249 1988 24.61 <.0001 Tukey <.0001
item 2 3 2.9193 0.1249 1988 23.38 <.0001 Tukey <.0001 4= Clinical experience or intuition based on
item 2 4 0.8561 0.1249 1988 6.86 <.0001 Tukey <.0001 clinical experience
item 2 5 0.8140 0.1249 1988 6.52 <.0001 Tukey <.0001
5= Discoloured margins of a restoration
item 2 6 0.4772 0.1249 1988 3.82 0.0001 Tukey 0.0034
item 2 8 2.4702 0.1249 1988 19.78 <.0001 Tukey <.0001 6= Frank or definite caries cavitation

item 3 4 -2.0632 0.1249 1988 -16.52 <.0001 Tukey <.0001 7= Presence of soft, discoloured dentine or
item 3 5 -2.1053 0.1249 1988 -16.86 <.0001 Tukey <.0001 enamel
item 3 6 -2.4421 0.1249 1988 -19.56 <.0001 Tukey <.0001
8= An exploratory preparation to inspect the
lesion

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item 3 7 -3.0456 0.1249 1988 -24.39 <.0001 Tukey <.0001
item 3 8 -0.4491 0.1249 1988 -3.60 0.0003 Tukey 0.0079
item 4 6 -0.3789 0.1249 1988 -3.03 0.0024 Tukey 0.0499
item 4 7 -0.9825 0.1249 1988 -7.87 <.0001 Tukey <.0001
item 4 8 1.6140 0.1249 1988 12.92 <.0001 Tukey <.0001
item 5 7 -0.9404 0.1249 1988 -7.53 <.0001 Tukey <.0001
item 5 8 1.6561 0.1249 1988 13.26 <.0001 Tukey <.0001
item 6 7 -0.6035 0.1249 1988 -4.83 <.0001 Tukey <.0001
item 6 8 1.9930 0.1249 1988 15.96 <.0001 Tukey <.0001
item 7 8 2.5965 0.1249 1988 20.79 <.0001 Tukey <.0001

Pairs NOT significantly different: Adjusted p>=0.05

Obs. Effect Item _Item Estimate Std Err. DF t-value Probt. Adjustment Adjp.

item 2 7 -0.1263 0.1249 1988 -1.01 0.3119 Tukey 0.9728

item 4 5 -0.04211 0.1249 1988 -0.34 0.7360 Tukey 1.0000
item 5 6 -0.3368 0.1249 1988 -2.70 0.0070 Tukey 0.1239

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Appendix M: Relationships between demographic variables, use of amalgam, future use of dental amalgam, repairing defective
dental amalgam restorations and replacing defective dental amalgam restorations

Categorical with Chi-square test (*significant: p<0.005)

Obs. Table DF Value Prob.

1 Gender * Repair or not 1 5.4413 0.0197

8 Practice arrangement * Repair or not 3 2.5954 0.4583
14 Practice location * Repair or not 3 3.9947 0.2620
27 Contracted to third-party funding * Repair or not 1 9.2106 0.0024*
34 Gender * q29 2 1.0234 0.5995
40 Practice arrangement * q29 6 3.2993 0.7705
46 Practice location * q29 6 12.1938 0.0578
52 Repair or not * q29 2 19.5325 <.0001*
58 Contracted to third-party funding * q29 2 8.1020 0.0174
64 Gender * amalgam 23 1 4.6053 0.0319
71 Practice arrangement * amalgam 23 3 1.0815 0.7816
77 Practice location * amalgam 23 3 4.1819 0.2425
83 Repair or not * amalgam 23 1 8.6737 0.0032*
90 Contracted to third-party funding * amalgam 23 1 3.3144 0.0687
97 Gender * amalgam 24 1 0.0006 0.9811
104 Practice arrangement * amalgam 24 3 2.7246 0.4361
110 Practice location * amalgam 24 3 1.9870 0.5751
116 Repair or not * amalgam 24 1 7.4179 0.0065
123 Contracted to third-party funding * amalgam 24 1 7.9154 0.0049*
130 Gender * tcr24 1 0.0021 0.9634
137 Practice arrangement * tcr24 3 3.2290 0.3576

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143 Practice location * tcr24 3 0.6097 0.8942
149 Repair or not * tcr24 1 0.1934 0.6601
156 Contracted to third-party funding * tcr24 1 0.6177 0.4319
163 Gender * crb24 1 1.2668 0.2604
170 Practice arrangement * crb24 3 7.1555 0.0671
176 Practice location * crb24 3 8.8965 0.0307
182 Repair or not * crb24 1 6.6853 0.0097
189 Contracted to third-party funding * crb24 1 4.7798 0.0288

Ordinal predictor with categorical outcome (*significant: p<0.005)

Obs. Table Statistic Alt Hypothesis DF Value Prob.

2 Table Repair or not * q4 2 Row Mean Scores Differ 1 5.2715 0.0217

5 Table q29 * q4 2 Row Mean Scores Differ 2 2.7712 0.2502
8 Table amalgam 23 * q4 2 Row Mean Scores Differ 1 14.8119 0.0001
11 Table amalgam 24 * q4 2 Row Mean Scores Differ 1 7.5227 0.0061
14 Table tcr24 * q4 2 Row Mean Scores Differ 1 3.5380 0.0600
17 Table crb24 * q4 2 Row Mean Scores Differ 1 1.5945 0.2067
20 Table q19 * q7 2 Row Mean Scores Differ 1 1.9779 0.1596
23 Table q29 * q7 2 Row Mean Scores Differ 2 2.0247 0.3634
26 Table amalgam 23 * q7 2 Row Mean Scores Differ 1 9.0126 0.0027
29 Table amalgam 24 * q7 2 Row Mean Scores Differ 1 4.2222 0.0399
32 Table tcr24 * q7 2 Row Mean Scores Differ 1 1.0214 0.3122
35 Table crb24 * q7 2 Row Mean Scores Differ 1 1.2909 0.2559
38 Table q19 * q15 2 Row Mean Scores Differ 1 2.4106 0.1205
41 Table q29 * q15 2 Row Mean Scores Differ 2 0.6782 0.7124

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44 Table amalgam 23 * q15 2 Row Mean Scores Differ 1 0.2645 0.6071
47 Table amalgam 24 * q15 2 Row Mean Scores Differ 1 1.0716 0.3006
50 Table tcr24 * q15 2 Row Mean Scores Differ 1 2.1727 0.1405 KEY
53 Table crb24 * q15 2 Row Mean Scores Differ 1 2.3656 0.1240 q19 = repair or not
56 Table q19 * q17 2 Row Mean Scores Differ 1 16.0141 <.0001 q29 = future use of amalgam
59 Table q29 * q17 2 Row Mean Scores Differ 2 100.3082 <.0001
62 Table amalgam 23 * q17 2 Row Mean Scores Differ 1 96.8283 <.0001 amalgam 23= choice of material to repair
65 Table amalgam 24 * q17 2 Row Mean Scores Differ 1 134.8118 <.0001 amalgam 24 = choice of material to replace
68 Table tcr24 * q17 2 Row Mean Scores Differ 1 41.3328 <.0001
71 Table crb24 * q17 2 Row Mean Scores Differ 1 0.3070 0.5795 q7= years of experience
74 Table q19 * q18 2 Row Mean Scores Differ 1 2.6989 0.1004
tcr24 = use of amalgam to repair
77 Table q29 * q18 2 Row Mean Scores Differ 2 20.6717 <.0001
80 Table amalgam 23 * q18 2 Row Mean Scores Differ 1 16.2631 <.0001 q4= age
83 Table amalgam 24 * q18 2 Row Mean Scores Differ 1 23.3813 <.0001
86 Table tcr24 * q18 2 Row Mean Scores Differ 1 12.3979 0.0004 crb24= choice of composite to repair
89 Table crb24 * q18 2 Row Mean Scores Differ 1 0.6063 0.4362 q15= cpd activity
q17= use of amalgam
q18= discuss material choice with patient
Ordinal predictor with ordinal outcome (*significant: p<0.005)

Obs. Table Statistic Alt Hypothesis DF Value Prob.

1 Table q4 * q17 1 Non-zero Correlation 1 7.0490 0.0079

4 Table q7 * q17 1 Non-zero Correlation 1 3.1547 0.0757
7 Table q15 * q17 1 Non-zero Correlation 1 0.1935 0.6600
10 Table q18 * q17 1 Non-zero Correlation 1 38.8717 <.0001*

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Appendix N: Summary of proposed treatment for clinical vignettes

No. of participants (n=15)

Treatment plan
recommendation (Case Study 1) (Case Study 2)
Tooth 26 Tooth 26

Crown and bridge 2 2

Repair of restoration 1 0

Replacement of restoration 5 1

Re-examine tooth at next 4 1

recall visit

No treatment indicated 3 12

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Appendix O: Summary table of all treatment logs

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