Direct composite resin fillings versus amalgam fillings for permanent posterior teeth.

BACKGROUND: Traditionally, amalgam has been used for filling cavities in posterior teeth, and it continues to be the restorative material of choice in some low- and middle-income countries due to its effectiveness and relatively low cost. However, there are concerns over the use of amalgam restorations (fillings) with regard to mercury release in the body and the environmental impact of mercury disposal. Dental composite resin materials are an aesthetic alternative to amalgam, and their mechanical properties have developed sufficiently to make them suitable for restoring posterior teeth. Nevertheless, composite resin materials may have potential for toxicity to human health and the environment. The United Nations Environment Programme has established the Minamata Convention on Mercury, which is an international treaty that aims "to protect the [sic] human health and the environment from anthropogenic emissions and releases of mercury and mercury compounds". It entered into force in August 2017, and as of February 2021 had been ratified by 127 governments. Ratification involves committing to the adoption of at least two of nine proposed measures to phase down the use of mercury, including amalgam in dentistry. In light of this, we have updated a review originally published in 2014, expanding the scope of the review by undertaking an additional search for harms outcomes. Our review synthesises the results of studies that evaluate the long-term effectiveness and safety of amalgam versus composite resin restorations, and evaluates the level of certainty we can have in that evidence. OBJECTIVES: To examine the effects (i.e. efficacy and safety) of direct composite resin fillings versus amalgam fillings. SEARCH METHODS: An information specialist searched five bibliographic databases up to 16 February 2021 and used additional search methods to identify published, unpublished and ongoing studies SELECTION CRITERIA: To assess efficacy, we included randomised controlled trials (RCTs) comparing dental composite resin with amalgam restorations in permanent posterior teeth that assessed restoration failure or survival at follow-up of at least three years. To assess safety, we sought non-randomised studies in addition to RCTs that directly compared composite resin and amalgam restorative materials and measured toxicity, sensitivity, allergy, or injury. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We included a total of eight studies in this updated review, all of which were RCTs. Two studies used a parallel-group design, and six used a split-mouth design. We judged all of the included studies to be at high risk of bias due to lack of blinding and issues related to unit of analysis. We identified one new trial since the previous version of this review (2014), as well as eight additional papers that assessed safety, all of which related to the two parallel-group studies that were already included in the review. For our primary meta-analyses, we combined data from the two parallel-group trials, which involved 1645 composite restorations and 1365 amalgam restorations in 921 children. We found low-certainty evidence that composite resin restorations had almost double the risk of failure compared to amalgam restorations (risk ratio (RR) 1.89, 95% confidence interval (CI) 1.52 to 2.35; P < 0.001), and were at much higher risk of secondary caries (RR 2.14, 95% CI 1.67 to 2.74; P < 0.001). We found low-certainty evidence that composite resin restorations were not more likely to result in restoration fracture (RR 0.87, 95% CI 0.46 to 1.64; P = 0.66). Six trials used a split-mouth design. We considered these studies separately, as their reliability was compromised due to poor reporting, unit of analysis errors, and variability in methods and findings. Subgroup analysis showed that the findings were consistent with the results of the parallel-group studies. Three trials investigated possible harms of dental restorations. Higher urinary mercury levels were reported amongst children with amalgam restorations in two trials, but the levels were lower than what is known to be toxic. Some differences between amalgam and composite resin groups were observed on certain measures of renal, neuropsychological, and psychosocial function, physical development, and postoperative sensitivity; however, no consistent or clinically important harms were found. We considered that the vast number of comparisons made false-positive results likely. There was no evidence of differences between the amalgam and composite resin groups in neurological symptoms, immune function, and urinary porphyrin excretion. The evidence is of very low certainty, with most harms outcomes reported in only one trial. AUTHORS' CONCLUSIONS: Low-certainty evidence suggests that composite resin restorations may have almost double the failure rate of amalgam restorations. The risk of restoration fracture does not seem to be higher with composite resin restorations, but there is a much higher risk of developing secondary caries. Very low-certainty evidence suggests that there may be no clinically important differences in the safety profile of amalgam compared with composite resin dental restorations. This review supports the utility of amalgam restorations, and the results may be particularly useful in parts of the world where amalgam is still the material of choice to restore posterior teeth with proximal caries. Of note, however, is that composite resin materials have undergone important improvements in the years since the trials informing the primary analyses for this review were conducted. The global phase-down of dental amalgam via the Minamata Convention on Mercury is an important consideration when deciding between amalgam and composite resin dental materials. The choice of which dental material to use will depend on shared decision-making between dental providers and patients in the clinic setting, and local directives and protocols.

Efficacy of 8% arginine on dentin hypersensitivity: A multicenter clinical trial in 273 patients over 24 weeks.

OBJECTIVES: To assess the efficacy of 8% arginine containing prophylaxis products over 24 weeks in subjects with dentin hypersensitivity (DH). METHODS: 297 patients with established DH (Schiff score 2, 3) in three European study centers were randomly assigned to either 8% arginine and calcium carbonate in-office prophylaxis paste and the respective toothpaste (test group) or fluoride-free prophylaxis paste and sodium monoflourophosphate toothpaste as a negative control group. Air blast (Schiff Score) and tactile (Visual Analog Scale) sensitivity scores were assessed at baseline (BL_0), after single application of the prophylaxis paste (BL_1) and after 4, 8, and 24 weeks of continuous at-home use of the toothpaste. RESULTS: 273 subjects completed the study. Test and control group presented statistically significant percentage reductions (t-test, p < 0.05) in Schiff Score at BL_1 and at 24 weeks relative to BL_0 (difference in %; test group: -23.6, -44.9, control group: -8.8, -32.7). The pooled Schiff Score for the two evaluated teeth yielded a significantly greater alleviation of DH in the test group than in the control group at all evaluation appointments (Ancova, p < 0.05; difference in %: 15.3, 7.4, 10.6, 17.2). CONCLUSIONS: A significant relief of DH was demonstrated after application of the 8% arginine prophylaxis products over 24 weeks compared to a negative control. CLINICAL SIGNIFICANCE: Whilst DH is influencing patients' eating, drinking and tooth brushing habits as well as social life interactions it is important that clinicians are able to offer evidence based immediate and long-lasting treatment methods in order to manage their patients' discomfort.

Evaluation of a novel repetitive gas-enhanced permeation test for restoration leakage determination after thermo-mechanical loading.

OBJECTIVES: To assess leakage of class-I restorations using a gas-enhanced permeation test (GEPT) as compared with conventional SEM or dye analysis. MATERIALS AND METHODS: Pressure differences over time and penetrating water volumes were measured simultaneously in a two-chamber system (GEPT) before and after class I cavity preparation in 30 molars. Ten teeth were restored with a composite restoration without bonding (A1), a composite restoration with bonding (A2) or a ceramic indirect restoration (B). Five intact teeth served as controls (C). Another GEPT measurement was performed and impressions were taken. Teeth were subjected to thermodynamic loading (1 200 000 cycles) and final GEPT measurements and impressions were made. SEM evaluation of the marginal continuity was performed and teeth were subjected to a Fuchsin dye penetration test. Spearman's rank test was used to compare results from different tests. RESULTS: The GEPT and SEM values did not correlate before loading (0.359, p = 0.051), but significantly correlated afterwards (0.662, p < 0.0001). The correlations between the Fuchsin dye penetration test and GEPT and SEM surface marginal analysis were significant (0.777 and 0.534, p-values < 0.0001 and 0.002, respectively). CONCLUSIONS: SEM marginal analysis was mainly limited in reflecting the surface restoration integrity. GEPT evaluation may, therefore, serve as a tool to non-destructively assess restoration sub-surface integrity over time. CLINICAL RELEVANCE: The current study provided proof that restoration margin quality does not necessarily reflect its leakage behaviour.

Impact of Dynamic Loading on the Implant-abutment Interface Using a Gas-enhanced Permeation Test In Vitro.

PURPOSE: To assess implant leakage under static conditions as well as during and after dynamic loading. Materials and methods : Implants (Astra Tech (A), Biomet 3i (B) and Nobel Biocare (C)) were evaluated for leakage (n=8/group). Testing to assess the gas pressure change over time (hPa/min) and infiltrated fluid volume, was performed in a Gas Enhanced Permeation Test (GEPT) to qualify embedding. Implant apexes were then drilled, abutments were mounted and resin build-ups were fabricated. GEPT was reassessed. Samples were afterward mounted in a computer-controlled masticator while tested to bacterial leakage, they were daily observed for turbidity. Samples were then reassessed using GEPT. Dunnett's and Fisher's exact tests were utilized to compare implant and to analyze bacterial leakage. Results : Significant differences in GEPT values were shown after loading (p=0.034). Leakage resistance was best for B when compared to C (p=0.023). Samples with higher GEPT values demonstrated earlier bacterial leakage, occurring after 1 or 2 days (A=4, B=0, C=6) and showing favorability for implant system B (p=0.009). Conclusion : Implants leaking under static conditions had increased potential for bacterial leakage under dynamic conditions. As strongly correlating to sophisticated analytical methods, GEPT is a promising technique for assessing the overall implant system leakage resistance.

Intracanal Antibiotic Medication for Sustained Root Surface Disinfection-A Laboratory Evaluation.

PURPOSE: To measure the release of an antibiotic mixture of ciprofloxacin, cerfuroxim and metronidazole (TreVitaMix, TVM) through human dentine and to assess the growth inhibition of Fusobacterium nucleatum. MATERIAL AND METHODS: Twenty-four extracted human incisors were scaled and endodontically treated. Root canals were either filled with antibiotic tri-mixture (TVM) or with the carrier material alone (propylene glycol, PG) and were coronally and apically sealed with a flowable composite. Transradicular medicament release was spectrophotometrically measured at 277 nm in simulated body fluid for up to 21 days. In a second part, an agar diffusion assay (F. nucleatum) with representative TVM concentrations as determined in the first part was performed to study the growth inhibition. Samples were anaerobical incubated for 48 h and inhibition zones were measured. RESULTS: TVM was spectrophotometrically detectable in the immersion solution and released in decreasing concentrations up to 21 days (222.5 ± 65.2 mg/ml at day 1 and 35.1 ± 15.6 mg/ml at day 21). In addition, inhibition zones were shown in the agar diffusion assay at representative TVM concentrations. The carrier material showed no antibacterial effect. CONLUSION: TVM showed the potential to penetrate through dentine and to inhibit bacterial growth. Therefore, it might have the potential to disinfect the outer root surface in perio-endo lesions, but further research is needed to confirm these observations.

Direct composite resin fillings versus amalgam fillings for permanent or adult posterior teeth.

BACKGROUND: Amalgam has been the traditional material for filling cavities in posterior teeth for the last 150 years and, due to its effectiveness and cost, amalgam is still the restorative material of choice in certain parts of the world. In recent times, however, there have been concerns over the use of amalgam restorations (fillings), relating to the mercury release in the body and the environmental impact following its disposal. Resin composites have become an esthetic alternative to amalgam restorations and there has been a remarkable improvement of its mechanical properties to restore posterior teeth.There is need to review new evidence comparing the effectiveness of both restorations. OBJECTIVES: To examine the effects of direct composite resin fillings versus amalgam fillings for permanent posterior teeth, primarily on restoration failure. SEARCH METHODS: We searched the Cochrane Oral Health Group's Trials Register (to 22 October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9), MEDLINE via OVID (1946 to 22 October 2013), EMBASE via OVID (1980 to 22 October 2013), and LILACs via BIREME Virtual Health Library (1980 to 22 October 2013). We applied no restrictions on language or date of publication when searching the electronic databases. We contacted manufacturers of dental materials to obtain any unpublished studies. SELECTION CRITERIA: Randomized controlled trials comparing dental resin composites with dental amalgams in permanent posterior teeth. We excluded studies having a follow-up period of less than three years. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: Of the 2205 retrieved references, we included seven trials (10 articles) in the systematic review. Two trials were parallel group studies involving 1645 composite restorations and 1365 amalgam restorations (921 children) in the analysis. The other five trials were split-mouth studies involving 1620 composite restorations and 570 amalgam restorations in an unclear number of children. Due to major problems with the reporting of the data for the five split-mouth trials, the primary analysis is based on the two parallel group trials. We judged all seven trials to be at high risk of bias and we analyzed 3265 composite restorations and 1935 amalgam restorations.The parallel group trials indicated that resin restorations had a significantly higher risk of failure than amalgam restorations (risk ratio (RR) 1.89, 95% confidence interval (CI) 1.52 to 2.35, P value < 0.001 (fixed-effect model) (low-quality evidence)) and increased risk of secondary caries (RR 2.14, 95% CI 1.67 to 2.74, P value < 0.001 (low-quality evidence)) but no evidence of an increased risk of restoration fracture (RR 0.87, 95% CI 0.46 to 1.64, P value = 0.66 (moderate-quality evidence)). The results from the split-mouth trials were consistent with those of the parallel group trials.Adverse effects of dental restorations were reported in two trials. The outcomes considered were neurobehavioral function, renal function, psychosocial function, and physical development. The investigators found no difference in adverse effects between composite and amalgam restorations. However, the results should be interpreted with caution as none of the outcomes were reported in more than one trial. AUTHORS' CONCLUSIONS: There is low-quality evidence to suggest that resin composites lead to higher failure rates and risk of secondary caries than amalgam restorations. This review reinforces the benefit of amalgam restorations and the results are particularly useful in parts of the world where amalgam is still the material of choice to restore posterior teeth with proximal caries. Though the review found insufficient evidence to support or refute any adverse effects amalgam may have on patients, new research is unlikely to change opinion on its safety and due to the decision for a global phase-down of amalgam (Minamata Convention on Mercury) general opinion on its safety is unlikely to change.

Effect of titanium tetrafluoride and amine fluoride treatment combined with carbon dioxide laser irradiation on enamel and dentin erosion.

OBJECTIVE: This in vitro study aimed to analyze the influence of carbon dioxide (CO(2)) laser irradiation on the efficacy of titanium tetrafluoride (TiF(4)) and amine fluoride (AmF) in protecting enamel and dentin against erosion. METHODS: Bovine enamel and dentin samples were pretreated with carbon dioxide (CO(2)) laser irradiation only (group I), TiF(4) only (1% F, group II), CO(2) laser irradiation before (group III) or through (group IV) TiF(4) application, AmF only (1% F, group V), or CO(2) laser irradiation before (group VI) or through (group VII) AmF application. Controls remained untreated. Ten samples of each group were then subjected to an erosive demineralization and remineralization cycling for 5 days. Enamel and dentin loss were measured profilometrically after pretreatment, 4 cycles (1 day), and 20 cycles (5 days) and statistically analyzed using analysis of variance and Scheffe's post hoc tests. Scanning electron microscopy (SEM) analysis was performed in pretreated but not cycled samples (two samples each group). RESULTS: After 20 cycles, there was significantly less enamel loss in groups V and IV and significantly less dentin loss in group V only. All other groups were not significantly different from the controls. Lased surfaces (group I) appeared unchanged in the SEM images, although SEM images of enamel but not of dentin showed that CO(2) laser irradiation affected the formation of fluoride precipitates. CONCLUSION: AmF decreased enamel and dentin erosion, but CO(2) laser irradiation did not improve its efficacy. TiF(4) showed only a limited capacity to prevent erosion, but CO(2) laser irradiation significantly enhanced its ability to reduce enamel erosion.

Histological, morphological, profilometric and optical changes of human tooth enamel after microabrasion.

PURPOSE: To determine the loss of enamel after a single 20-secondsapplication of a microabrasion slurry and to evaluate structural changes by means of laser fluorescence, and microscopic and optical measurements. METHODS: Defined buccal areas with a diameter of 2 mm from 16 extracted human molars were demineralized for 12 weeks using a demineralization gel (pH 4.8). The created artificial white-spot lesions were divided corono-apically in control and test sites, using a rubber cement that prospectively covered the untreated control site. Teeth were divided into two groups of eight teeth each. One group was treated with an abrasive cleaning paste (Pell-ex) and the other group with a commercially available microabrasion slurry (Opalustre) for 20 seconds, applying a load of 200 g. Before and after treatment, standardized photographs were taken for the determination of luminescence and profilometric tracings of the surface, and these were recorded for the determination of enamel loss. The grade of demineralization was quantified using a laser fluorescence method (Diagnodent). Statistical differences were checked using a Mann Whitney and student t-test. Replicas of the treated areas were made for scanning electron microscopy (SEM) analysis, and teeth were histologically investigated by polarized light microscopy. RESULTS: Loss of tooth substance was significantly higher (P < or = 0.001) for the microabrasion group (134.8 +/- 35.5 microm) compared with the abrasive cleaning paste group (4.5 +/- 1.2 microm). After treatment, statistically significant differences in fluorescence and luminescence measurements could only be detected for microabraded teeth. No significant changes were noted for teeth treated with an abrasive cleaning paste. Histological findings confirmed removal of the demineralized surface zone when microabrading the enamel, whereas no changes were observed in the test group treated with an abrasive cleaning paste. Polarized light microscopy did not indicate any changes in the mineralization pattern, for example compaction, in the treated subsurface zone.