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Repair vs replacement of direct composite restorations: a survey of teaching and operative techniques in Oceania
Accepted Manuscript Title: Repair vs replacement of direct composite restorations: A survey of teaching and operative techniques in Oceania Author: Paul. A. Brunton Amna Ghazali Zahidah H. Tarif Carolina Loch Christopher Lynch Nairn Wilson Igor R. Blum PII: DOI: Reference:
S0300-5712(17)30038-6 http://dx.doi.org/doi:10.1016/j.jdent.2017.02.010 JJOD 2739
To appear in:
Journal of Dentistry
Received date: Revised date: Accepted date:
17-11-2016 29-1-2017 15-2-2017
Please cite this article as: Brunton PlA, Ghazali A, Tarif ZH, Loch C, Lynch C, Wilson N, Blum IR, Repair vs replacement of direct composite restorations: A survey of teaching and operative techniques in Oceania, Journal of Dentistry (2017), http://dx.doi.org/10.1016/j.jdent.2017.02.010 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
REPAIR VS REPLACEMENT OF DIRECT COMPOSITE RESTORATIONS: A
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SURVEY OF TEACHING AND OPERATIVE TECHNIQUES IN OCEANIA
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Paul. A. Brunton1*, Amna Ghazali1, Zahidah H. Tarif1, Carolina Loch1, Christopher Lynch2,
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Nairn Wilson3, Igor R. Blum4
1- Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago. Dunedin
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9054, New Zealand.
2- University Dental School & Hospital, Wilton, Cork, Ireland.
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3- Emeritus Professor of Dentistry, King's College London Dental Institute, London, UK.
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4- King’s College Hospital and King’s College London Dental Institute, London, UK.
Journal of Dentistry
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Corresponding author. Email: [email protected], Phone +64 3 479 7039
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ABSTRACT Objectives: To evaluate the teaching and operative techniques for the repair and/or replacement of direct resin-based composite restorations (DCRs) in dental schools in Oceania. Methods: A
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14-item questionnaire was mailed to the heads of operative dentistry in 16 dental schools in Oceania (Australia, New Zealand, Fiji and Papua New Guinea). The survey asked whether the
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repair of DCRs was taught within the curriculum; the rationale behind the teaching; how
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techniques were taught, indications for repair, operative techniques, materials used, patient acceptability, expected longevity and recall systems. Results: All 16 schools participated in the
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study. Thirteen (81%) reported the teaching of composite repairs as an alternative to replacement. Most schools taught the theoretical and practical aspects of repair at a clinical
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level only. All 13 schools (100%) agreed on tooth substance preservation being the main reason for teaching repair. The main indications for repair were marginal defects (100%), followed by
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secondary caries (69%). All 13 schools that performed repairs reported high patient
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acceptability, and considered it a definitive measure. Only 3 schools (23%) claimed to have a recall system in place following repair of DCRs. Most respondents either did not know or did not answer when asked about the longevity of DCRs. Conclusion: Repair of DCRs seems to be a viable alternative to replacement, which is actively taught within Oceania. Advantages include it being minimally invasive, preserving tooth structure, and time and money saving. However, standardised guidelines need to be developed and further clinical long-term studies need to be carried out.
Clinical Significance: The decision between replacing or repairing a defective composite restoration tends to be based on what clinicians have been taught, tempered by experience and judgement. This study investigated the current status of teaching and operative techniques of repair of direct composite restorations in dental schools in Oceania. 2
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INTRODUCTION Composite resins are widely used in dentistry for a variety of purposes, including, amongst others, restorative materials, cavity liners, pit and fissure sealants, cores and inlays and
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onlays [1]. The properties of adhesive bonding systems and composite resins have improved over the years, increasing the popularity of composite resins both with dentists and patients [2].
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Direct composite restorations (DCRs) are tooth-coloured, do not require extensive tooth
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preparation and show good performance provided the directions for use are followed meticulously during placement. Modern bonding technologies and techniques have reduced
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polymerisation shrinkage, microleakage and the occurrence of secondary caries [3]. For these reasons, composite resins are the first choice for a large and increasing number of practitioners
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when placing both anterior and posterior restorations [1].
Dental restorations tend to have limited service life and be prone to failure. Biological,
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mechanical and or aesthetic factors might be involved in composite failure, generating the need
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for replacement. When defective composite restorations require intervention, clinicians are often challenged to whether replacement or repair should be undertaken. Based on traditional teaching approaches, complete removal is required if the restorations do not satisfy strict quality requirements [4]. However, in recent years there has been an increasing change in practice to perform repair of defective composites as an alternative to complete removal [5-9]. There are many financial and biological reasons to retain sound parts of the old restoration in place. These include reduction in costs, unnecessary removal of tooth structure, and avoidance of repetitive trauma from restorative procedures [5, 6, 9]. The decision between replacing or repairing a defective composite restoration is more often than not at the discretion of the clinician. This decision tends to be based on what they have been taught, tempered by clinical experience and judgement. Trends in current dental 3
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practice are now shifting to more conservative approaches and consequently many dental schools throughout the world teach repair of restorations to undergraduate students either in preclinical and/or clinical years [4, 10, 11].
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Despite increasing popularity and application among dentists, no practice guidelines are currently available on the indications and operative techniques for the repair of restorations.
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Past investigations performed in different regions such as UK and Ireland [10, 12], Germany
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and Scandinavia [4, 13, 14], USA and Canada [11, 15] have found no consensus in regards to operative techniques and the teaching of this concept as it applies to DCRs. This paper reports
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an investigation into the current status of teaching and operative techniques of repair and
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replacement of direct composite restorations in dental schools in Oceania.
METHODS
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A previously trialled and validated questionnaire [10] comprising 14 questions (see
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Supplementary material) was mailed to the Heads of Operative/Restorative Dentistry in the16 Dental Schools in Oceania (Table 1). Ethical approval for the study was obtained from the University of Otago Human Ethics Committee (D16/099). TABLE 1
In addition to the questionnaire, each respondent was sent a glossary of terms. The questionnaire included questions regarding whether the repair of DCRs was taught in the undergraduate programme; plans for the teaching repair of DCRs in the next five years; grounds behind the teaching; how they were taught (theoretical versus practical); the indications for repair; patients acceptability; operative techniques and materials used; expected longevity and monitoring of repaired restorations. Responded and returned questionnaires were
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de-identified and the data collected was collated and analysed anonymously using Excel. Average percentages were calculated to all variables analysed.
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RESULTS The response rate was 100%. All 16 respondents (100%) had performed repairs to
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DCRs themselves and considered the treatment to have been successful. Most of the dental
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schools in Oceania (81%, n=13) taught repair of direct composite restorations as an alternative to replacement in their undergraduate programmes.
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The three schools that did not teach students how to repair DCRs reported that this procedure was not intended to be introduced in the curriculum within the next five years. The
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main reasons for not teaching composite repair were its absence from the current recommended curriculum, perceived lack of evidence and its absence in recommended textbooks. Other
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reasons reported included perceptions about insufficient adhesion of new increments of
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composite to cured “aged” composite.
The most common grounds for teaching composite repair were clinical experience (92%, n= 12) and existing evidence (62%, n=8) (Fig. 1). Among other reasons reported were ‘prosthodontic opinion’ and the fact that ‘this is a topic described and examined in several studies’.
FIGURE 1
Most schools taught both the theoretical and practical aspects of composite repair at a clinical level only (61% and 69% of the schools, respectively), while teaching at a preclinical level was not common (15%, n= 2). Among the main factors that were indicated as reasons for teaching repair of DCR were tooth substance preservation (100% of the respondents),
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promotion of minimal intervention dentistry (69%, n= 9), and a desire to minimise the adverse effects of the restorative cycle (46%, n = 6) (Fig. 2). FIGURE 2
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Concerning the restoration-related failures that were considered to justify the teaching DCR repairs, all respondents reported marginal defects (100%, n = 13) as the main reason,
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followed by secondary caries (69%, n= 9) and marginal discolouration, superficial colour
FIGURE 3
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correction and labial/buccal restoration discoloration (61%, n= 8) (Fig. 3).
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Bulk fractures of restorations, considered to indicate repair were predominantly incisal (62%, n= 8) and proximal-incisal (38%, n= 5) fractures in anterior teeth; and marginal ridge
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(46%, n= 6), followed by isthmus and occlusal fractures (38%, n= 5) in posterior restorations. Other indications included repair in cases of fracture of tooth tissue adjacent to existing
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composites- incisal (46%, n= 6) and proximal-incisal (38%, n= 5) fractures in anterior teeth and
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cusp fractures (54%, n= 7) in posterior teeth.
With respect to patient acceptance, 100% of the respondents that teach repair of DCRs (n = 13) reported that patients are willing to accept this procedure as an alternative to replacement. Most schools (77%, n= 10) considered the repair of DCRs to be a definitive measure, with expected longevity varying between 1 and 10 years. Respondents indicated that the expected longevity was multifactorial and case-dependent. Common surface treatment methods used included acid etching with phosphoric acid (92%, n= 12) and cleaning with slurry pumice (85%, n= 11). Acid etching with hydrofluoric acid and Al2O3 air-abrasion were less popular (8%, n = 1) (Fig. 4). FIGURE 4
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The most common materials used in the repair of composites were dentin/enamel bonding systems (92%, n= 12) followed by hybrid composites (62%, n= 8) and flowable composites (62%, n= 8) (Fig. 5).
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FIGURE 5 The main instruments reported to be used in finishing composite repairs were diamond
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finishing instruments (100%, n = 13), followed by tungsten carbide finishing instruments (77%,
FIGURE 6
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n= 10) and finishing discs (69%, n= 9) (Fig. 6).
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In relation to monitoring systems, the majority of the schools (77%, n= 10) reported that no recall system was implemented and only 3 schools (23%) claimed to have a recall system in
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place following repair of direct composite restorations. Almost half of the respondents either did not know or did not answer in regards to the longevity of composite repairs placed by their
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to 100% (15%, n= 2).
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students (46%, n= 6), while the others estimated an increase in longevity from 30% (15%, n=2)
DISCUSSION
The aim of the present study was to investigate the teaching and operative techniques
for the repair, rather than replacement, of failing DCRs in dental schools in Oceania. The excellent response rate (100%), while possibly related, at least in part to the small number of dental schools surveyed, may be considered to be an indication of the importance of the topic and the willingness of the dental schools in Oceania to engage in research. Although online data collection is typically found to be efficient, effective and relatively inexpensive, it has been reported to yield lower response rates than paper-based/postal surveys [16]. In addition, respondents may be found to provide less considered answers online, compared to when they 7
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respond to questions via paper-based/postal methods [16]. Despite the perceived limitations of postal surveys in terms of response rate, the present study achieved 100% response rate. As a consequence, the data presented provides a complete overview of attitudes to, and the extent of
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composite repair teaching provided throughout the Oceania region. In this way the findings are considered to add to existing knowledge and understanding on techniques and the teaching of
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repairs to DCR.
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Even though all 16 respondents reported that they had clinically performed repairs to DCRs with successful outcomes, three dental schools in Oceania did not teach this technique to
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undergraduate students and did not plan to introduce it into the curriculum the near future. A similar study undertaken in UK and Irish dental schools [4] found that only one dental school
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did not teach the technique; however, that school planned to include it in the curriculum within the next five years. It is suggested that the schools included in the present study which
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presently do not teach repairs to DCRs will be very quickly become exceptional with the
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international shift to the teaching of repairs to restorations which historically would have been replaced on the basis of the outdated dogma of ‘if in doubt, take it out’[17]. The specific techniques used for the repair of DCRs in each school were not investigated in this study. Those schools that did not teach the repair of DCRs cited lack of evidence and the absence of descriptions of relevant techniques in recommended textbooks as the main factors. In contrast, 61% of the respondents chose existing evidence as one of the reasons for teaching repair. Recent publications (e.g. [5-9]) have reported on the success of repairs to DCRs and analysed the techniques used to ensure longevity and optimum results. The limited body of work in the area of repair of dental composites was recently the subject of a review [9]. Clinical studies of 2-3 years in duration have found positive outcomes for composite repairs. A 7-year
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recall study by Gordan et al. [6] indicated the longer term
success of this conservative
intervention strategy. Previous studies conducted in the US and Canada [11, 15] UK and Ireland [10, 12], common justification for
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Germany [13] and Scandinavia [4, 14] reported that the most
teaching repair was clinical experience, as observed in the present study. Our results revealed
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that the theoretical and practical teaching of repair in Oceania was most common at a clinical
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level, as found in a survey of North American dental schools [15]. This may be because the decision to repair or replace is case-dependent, and possibly difficult to teach theoretically.
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However, it would be beneficial for students to be familiar with guidelines in terms of the theory of repair vs. replacement before entering clinical studies.
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In this study, the most important general factor for teaching of repairs to DCRs was the preservation of tooth substance. The same was observed in similar surveys done elsewhere (e.g.
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[10-13, 15]. The promotion of minimal intervention dentistry was also an important factor in
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our study. This minimal approach has been widely recognised for its advantages, primarily the opportunity to avoid unnecessary removal of sound tooth structure to increase mechanical retention [18]. Similarly, as in most previous studies on this topic we found that the most important restoration-related failure which justified the teaching of repairs to DCRs was marginal defects. Poor marginal adaptation exposes the dentine-pulp complex to the oral environment, which in turn can lead to complications such as microleakage, marginal discoloration, plaque accumulation, secondary caries, postoperative sensitivity, pathologic pulp changes and restoration failures [19]. Therefore, marginal defects are very important
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predicting the clinical success of a restoration [20]. Concerning surface treatment techniques prior to composite repair, most previous studies reported that mechanical surface treatment is crucial to enhancing bonding between 9
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new and existing composite resin (e.g. [10-13, 15]). Improvements in bond strength tend to be achieved through increased surface roughness to promote mechanical interlocking, in particular when chemical bonding might not be sufficient [21]. Dental schools in Oceania (this study)
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and Germany [13], in contrast to dental schools in the US and Canada (11) and the UK and Ireland (4,12) performed limited aluminium oxide air abrasion. Aluminium oxide air abrasion
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enhances bond strength between composite and tooth structure [22].
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was uncommon in dental schools in Scandinavia [14], despite it being a technique which
There was limited use of acid etching with hydrofluoric acid in the present study, as the study in the US and Canada [11]. Although a few studies have
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was the case in
demonstrated beneficial effects when applying this approach, other studies suggested the
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technique to be ineffective and one which should not be recognised as the standard of care [23]. As suggested by Loomans [24], composites should not be seen as materials which have
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identical properties when it comes to repair procedures. Hence, the effect of etching will largely
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depend on the composition of the filler particles in the composite forming the substrate. During the repair of a composite restoration, preparation usually exposes enamel and dentine. Thus, the use of bonding systems is required to obtain adequate bond strength to tooth structures [25]. To create an effective seal between tooth structure and composite and along composite-to-composite interfaces, the use of a flowable composite [26] may enhance the effect of the selected adhesive bonding system [27]. In the absence of evidence-based guidelines, the technique to be applied in each case requires careful judgement and, whatever materials and approach are selected, strict adherence to directions for use and meticulous attention to detail. As with all other forms of minimum intervention dentistry, the effective repair of restorations requires good knowledge and understanding of the effects of the various operative interventions and materials used. Future clinical studies should investigate the factors 10
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affecting the clinical performance of repairs, including the effects of bonding new composite to composite which has been exposed to the oral environment for some time. All respondents that participated in the US and Canada study [11] used finishing disks
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and composite polishing points to finish repairs to DCRs. However, these two finishing devices were not as popular in the dental schools in Oceania. Also, composite polishing paste was more
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than three-fold less popular in Oceania than in the US and Canada [11]. The reason for these
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differences are unclear from the data collected, but would appear to reflect either different understanding or acceptance of existing information on the efficacy of different composite
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finishing devices and instruments. Presumably, the selection of finishing regimen for repairs, at least in dental schools in Oceania, is presently based more on experience and personal
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preference than best available evidence.
In the present study the predicted longevity of the repairs placed by students varied
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widely, with no obvious consensus on how successful repairs may be in clinical service.
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Similar findings were reported in the studies undertaken in North America, UK and Ireland, Germany and Scandinavia [10-13, 15], in which most respondents considered repairs to restorations as a definitive measure, with varied views on longevity. Yet, there was a common consensus in the previous studies that patient acceptance of repairs to restorations is very high because of the ease and speed of the procedures, let alone the biological and financial advantages. Although it is expected that the operator’s experience plays an important role in the longevity of restorations, with restorations placed by inexperienced operators having a higher chance of repair, this study did not analyse the effects of factors such as patient, operator and materials in the longevity of composite restorations. Unfortunately, it is likely that, at best, limited data will be available on how long composite repairs undertaken in dental schools in Oceania will last in clinical service, as the 11
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majority of the schools in the region reported no recall system to monitor clinical performance. Only 20% of the schools we surveyed had a recall system in place for repaired restorations, with no indication of any intentions to research the longevity of repairs to DCRs. Given the
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many advantages of repair over restoration replacement, it is suggested that high priority should be given to performing clinical studies on the efficacy of repairs. Such research would
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hopefully encourage the much needed shift to more minimum intervention forms of operative
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dentistry in members of the aging population are to have ‘teeth for life’, and contribute toward a worldwide consensus on DCR guidelines instead of the current regional bias. Future research
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should also address clinical factors such as the role of the original restoration’s length in the success of DCR repairs, and the effect of grinding, bruxism and other parafunctional habits in
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the survival of repairs placed on incisal edges and marginal ridges.
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CONCLUSION
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To date, there is no consensus on guidelines for the repair of composite restorations, despite the repair rather than the replacement of a restoration being minimally invasive, cost effective and popular with patients. The decision to repair or replace is very subjective, and currently depends on the clinician’s knowledge, experience and preferences. This investigation and other similar studies done elsewhere emphasised the need for clinical studies on repairs. Mapping trends in the teaching of operative dentistry helps inform clinical teachers, drives postgraduate dental education and helps develop research agendas in restorative dentistry.
ACKNOWLEDGEMENTS Thanks are extended to all study participants for their time and cooperation with data collection. 12
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REFERENCES
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[1] J.L. Ferracane, Resin composite—state of the art, Dental Materials 27(1) (2011) 29-38. [2] B.S. Bohaty, Q. Ye, A. Misra, F. Sene, P. Spencer, Posterior composite restoration update: focus on factors influencing form and function, Clinical, Cosmetic and Investigational Dentistry, 5 (2013) 33–42. [3] A.V. Ritter, Posterior Resin Based Composite Restorations: Clinical Recommendations for Optimal Success, Journal of Esthetic and Restorative Dentistry 13(2) (2001) 88-99. [4] I. Blum, A. Schriever, D. Heidemann, I. Mjör, N. Wilson, The repair of direct composite restorations: an international survey of the teaching of operative techniques and materials, European Journal of Dental Education 7(1) (2003) 41-48. [5] V.V. Gordan, C. Shen, J. Riley, I.A. Mjör, Two Year Clinical Evaluation of Repair versus Replacement of Composite Restorations, Journal of Esthetic and Restorative Dentistry 18(3) (2006) 144-153. [6] V.V. Gordan, C.W. Garvan, P.K. Blaser, E. Mondragon, I.A. Mjör, A long-term evaluation of alternative treatments to replacement of resin-based composite restorations: results of a seven-year study, The Journal of the American Dental Association 140(12) (2009) 1476-1484. [7] G. Moncada, E. Fernández, J. Martin, C. Arancibia, I. Mjör, V. Gordan, Increasing the longevity of restorations by minimal intervention: a two-year clinical trial, Operative Dentistry 33(3) (2008) 258-264. [8] G. Moncada, J. Martin, E. Fernández, M.C. Hempel, I.A. Mjör, V.V. Gordan, Sealing, refurbishment and repair of Class I and Class II defective restorations, The Journal of the American Dental Association 140(4) (2009) 425-432. [9] M.O. Sharif, M. Catleugh, A. Merry, M. Tickle, S.M. Dunne, P. Brunton, V.R. Aggarwal, Replacement versus repair of defective restorations in adults: resin composite, Australian Dental Journal 55(3) (2010) 351-352. [10] I.R. Blum, A. Schriever, D. Heidemann, I.A. Mjör, N. Wilson, Repair versus replacement of defective direct composite restorations in teaching programmes in United Kingdom and Irish Dental Schools, The European Journal of Prosthodontics and Restorative Dentistry 10(4) (2002) 151-155. [11] C.D. Lynch, I.R. Blum, K.B. Frazier, L.D. Haisch, N.H. Wilson, Repair or replacement of defective direct resin-based composite restorations: contemporary teaching in US and Canadian dental schools, The Journal of the American Dental Association 143(2) (2012) 157-163. [12] I.R. Blum, C.D. Lynch, N. Wilson, Teaching of direct composite restoration repair in undergraduate dental schools in the United Kingdom and Ireland, European Journal of Dental Education 16(1) (2012) e53-e58. [13] I.R. Blum, C.D. Lynch, A. Schriever, D. Heidemann, N. Wilson, Repair versus replacement of defective composite restorations in dental schools in Germany, The European Journal of Prosthodontics and Restorative Dentistry 19(2) (2011) 56-61. [14] I.R. Blum, C.D. Lynch, N. Wilson, Teaching of the repair of defective composite restorations in Scandinavian dental schools, Journal of Oral Rehabilitation 39(3) (2012) 210216. [15] V.V. Gordan, I.A. Mjör, I.R. Blum, N. Wilson, Teaching students the repair of resin-based composite restorations: a survey of North American dental schools, The Journal of the American Dental Association 134(3) (2003) 317-323. [16] H. McDonald, S. Adam, A comparison of online and postal data collection methods in marketing research, Marketing Intelligence & Planning 21(2) (2003) 85-95. 13
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[17] N. Wilson, C. Lynch, P.B. Brunton, R. Hickel, H. Meyer-Lueckel, S. Gurgan, U. Pallesen, A. Shearer, Z. Tarle, E. Cotti, Criteria for the replacement of restorations: Academy of Operative Dentistry European Section, Operative Dentistry (2015) S48-S57. [18] J. Van Amerongen, W. Van Amerongen, T. Watson, N. Opdam, D. Roeters, D. Bittermann, E. Kidd, Restoring the tooth:‘the seal is the deal’, Fejerskov O & Kidd E: Dental Caries: The Disease and its Clinical Management. Copenhagen, Blackwell Munksgaard (2003) 275-291. [19] K.H. Neppelenbroek, The clinical challenge of achieving marginal adaptation in direct and indirect restorations, Journal of Applied Oral Science 23(5) (2015) 448-449. [20] A.D.C. Medina, A.B.d. Paula, S.B.P.d. Fucio, R.M. Puppin-Rontani, L. Correr-Sobrinho, M.A.C. Sinhoreti, Marginal adaptation of indirect restorations using different resin coating protocols, Brazilian Dental Journal 23(6) (2012) 672-678. [21] P.A. Oskoee, S. Kimyai, E. Talatahari, S. Rikhtegaran, F. Pournaghi-Azar, J.S. Oskoee, Effect of mechanical surface treatment on the repair bond strength of the silorane-based composite resin, Journal of Dental Research, Dental clinics, Dental prospects 8(2) (2014) 61. [22] A. Rathke, Y. Tymina, B. Haller, Effect of different surface treatments on the composite– composite repair bond strength, Clinical Oral Investigations 13(3) (2009) 317-323. [23] S.A.R. Junior, J.L. Ferracane, Á. Della Bona, Influence of surface treatments on the bond strength of repaired resin composite restorative materials, Dental Materials 25(4) (2009) 442451. [24] B. Loomans, M. Cardoso, N. Opdam, F. Roeters, J. De Munck, M. Huysmans, B. Van Meerbeek, Surface roughness of etched composite resin in light of composite repair, Journal of Dentistry 39(7) (2011) 499-505. [25] F. Staxrud, J.E. Dahl, Role of bonding agents in the repair of composite resin restorations, European Journal of Oral Sciences 119(4) (2011) 316-322. [26] R. Frankenberger, N. Krämer, J. Ebert, U. Lohbauer, S. Käppel, S. Ten Weges, A. Petschelt, Fatigue behavior of the resin-resin bond of partially replaced resin-based composite restorations, American Journal of Dentistry 16(1) (2003) 17-22. [27] N. Oztas, A. Alacam, Y. Bardakcy, The effect of air abrasion with two new bonding agents on composite repair, Operative Dentistry 28(2) (2003) 149-154.
FIGURE LEGENDS
Figure 1. Grounds for teaching the repair of composite restorations in Oceania. Figure 2. General factors that indicate the reasons for teaching composite repairs in Oceania. Figure 3. Restoration-related failures that indicate reasons for teaching repair of composites in Oceania. Figure 4. Surface treatments performed prior to placement of composite in Oceania. Figure 5. Materials used in the teaching of composite repairs in Oceania. Figure 6. Use of instruments for composite repair procedures in Oceania. 14
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Table 1 - List of dental schools in Oceania. Dental Schools
New Zealand
Auckland University of Technology University Of Otago
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Countries
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Melbourne University Griffith University University of Western Australia Curtin University Australia University of Newcastle Central Queensland University University Of Adelaide Charles Sturt University University of Sydney La Trobe University University of Queensland James Cook University
Fiji
Fiji National University
University of Papua New Guinea
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Papua New Guinea
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Australia
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S0300-5712(17)30038-6 http://dx.doi.org/doi:10.1016/j.jdent.2017.02.010 JJOD 2739
To appear in:
Journal of Dentistry
Received date: Revised date: Accepted date:
17-11-2016 29-1-2017 15-2-2017
Please cite this article as: Brunton PlA, Ghazali A, Tarif ZH, Loch C, Lynch C, Wilson N, Blum IR, Repair vs replacement of direct composite restorations: A survey of teaching and operative techniques in Oceania, Journal of Dentistry (2017), http://dx.doi.org/10.1016/j.jdent.2017.02.010 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
REPAIR VS REPLACEMENT OF DIRECT COMPOSITE RESTORATIONS: A
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SURVEY OF TEACHING AND OPERATIVE TECHNIQUES IN OCEANIA
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Paul. A. Brunton1*, Amna Ghazali1, Zahidah H. Tarif1, Carolina Loch1, Christopher Lynch2,
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Nairn Wilson3, Igor R. Blum4
1- Sir John Walsh Research Institute, Faculty of Dentistry, University of Otago. Dunedin
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9054, New Zealand.
2- University Dental School & Hospital, Wilton, Cork, Ireland.
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3- Emeritus Professor of Dentistry, King's College London Dental Institute, London, UK.
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4- King’s College Hospital and King’s College London Dental Institute, London, UK.
Journal of Dentistry
*
Corresponding author. Email: [email protected], Phone +64 3 479 7039
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ABSTRACT Objectives: To evaluate the teaching and operative techniques for the repair and/or replacement of direct resin-based composite restorations (DCRs) in dental schools in Oceania. Methods: A
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14-item questionnaire was mailed to the heads of operative dentistry in 16 dental schools in Oceania (Australia, New Zealand, Fiji and Papua New Guinea). The survey asked whether the
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repair of DCRs was taught within the curriculum; the rationale behind the teaching; how
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techniques were taught, indications for repair, operative techniques, materials used, patient acceptability, expected longevity and recall systems. Results: All 16 schools participated in the
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study. Thirteen (81%) reported the teaching of composite repairs as an alternative to replacement. Most schools taught the theoretical and practical aspects of repair at a clinical
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level only. All 13 schools (100%) agreed on tooth substance preservation being the main reason for teaching repair. The main indications for repair were marginal defects (100%), followed by
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secondary caries (69%). All 13 schools that performed repairs reported high patient
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acceptability, and considered it a definitive measure. Only 3 schools (23%) claimed to have a recall system in place following repair of DCRs. Most respondents either did not know or did not answer when asked about the longevity of DCRs. Conclusion: Repair of DCRs seems to be a viable alternative to replacement, which is actively taught within Oceania. Advantages include it being minimally invasive, preserving tooth structure, and time and money saving. However, standardised guidelines need to be developed and further clinical long-term studies need to be carried out.
Clinical Significance: The decision between replacing or repairing a defective composite restoration tends to be based on what clinicians have been taught, tempered by experience and judgement. This study investigated the current status of teaching and operative techniques of repair of direct composite restorations in dental schools in Oceania. 2
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INTRODUCTION Composite resins are widely used in dentistry for a variety of purposes, including, amongst others, restorative materials, cavity liners, pit and fissure sealants, cores and inlays and
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onlays [1]. The properties of adhesive bonding systems and composite resins have improved over the years, increasing the popularity of composite resins both with dentists and patients [2].
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Direct composite restorations (DCRs) are tooth-coloured, do not require extensive tooth
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preparation and show good performance provided the directions for use are followed meticulously during placement. Modern bonding technologies and techniques have reduced
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polymerisation shrinkage, microleakage and the occurrence of secondary caries [3]. For these reasons, composite resins are the first choice for a large and increasing number of practitioners
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when placing both anterior and posterior restorations [1].
Dental restorations tend to have limited service life and be prone to failure. Biological,
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mechanical and or aesthetic factors might be involved in composite failure, generating the need
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for replacement. When defective composite restorations require intervention, clinicians are often challenged to whether replacement or repair should be undertaken. Based on traditional teaching approaches, complete removal is required if the restorations do not satisfy strict quality requirements [4]. However, in recent years there has been an increasing change in practice to perform repair of defective composites as an alternative to complete removal [5-9]. There are many financial and biological reasons to retain sound parts of the old restoration in place. These include reduction in costs, unnecessary removal of tooth structure, and avoidance of repetitive trauma from restorative procedures [5, 6, 9]. The decision between replacing or repairing a defective composite restoration is more often than not at the discretion of the clinician. This decision tends to be based on what they have been taught, tempered by clinical experience and judgement. Trends in current dental 3
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practice are now shifting to more conservative approaches and consequently many dental schools throughout the world teach repair of restorations to undergraduate students either in preclinical and/or clinical years [4, 10, 11].
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Despite increasing popularity and application among dentists, no practice guidelines are currently available on the indications and operative techniques for the repair of restorations.
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Past investigations performed in different regions such as UK and Ireland [10, 12], Germany
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and Scandinavia [4, 13, 14], USA and Canada [11, 15] have found no consensus in regards to operative techniques and the teaching of this concept as it applies to DCRs. This paper reports
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an investigation into the current status of teaching and operative techniques of repair and
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replacement of direct composite restorations in dental schools in Oceania.
METHODS
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A previously trialled and validated questionnaire [10] comprising 14 questions (see
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Supplementary material) was mailed to the Heads of Operative/Restorative Dentistry in the16 Dental Schools in Oceania (Table 1). Ethical approval for the study was obtained from the University of Otago Human Ethics Committee (D16/099). TABLE 1
In addition to the questionnaire, each respondent was sent a glossary of terms. The questionnaire included questions regarding whether the repair of DCRs was taught in the undergraduate programme; plans for the teaching repair of DCRs in the next five years; grounds behind the teaching; how they were taught (theoretical versus practical); the indications for repair; patients acceptability; operative techniques and materials used; expected longevity and monitoring of repaired restorations. Responded and returned questionnaires were
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de-identified and the data collected was collated and analysed anonymously using Excel. Average percentages were calculated to all variables analysed.
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RESULTS The response rate was 100%. All 16 respondents (100%) had performed repairs to
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DCRs themselves and considered the treatment to have been successful. Most of the dental
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schools in Oceania (81%, n=13) taught repair of direct composite restorations as an alternative to replacement in their undergraduate programmes.
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The three schools that did not teach students how to repair DCRs reported that this procedure was not intended to be introduced in the curriculum within the next five years. The
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main reasons for not teaching composite repair were its absence from the current recommended curriculum, perceived lack of evidence and its absence in recommended textbooks. Other
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reasons reported included perceptions about insufficient adhesion of new increments of
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composite to cured “aged” composite.
The most common grounds for teaching composite repair were clinical experience (92%, n= 12) and existing evidence (62%, n=8) (Fig. 1). Among other reasons reported were ‘prosthodontic opinion’ and the fact that ‘this is a topic described and examined in several studies’.
FIGURE 1
Most schools taught both the theoretical and practical aspects of composite repair at a clinical level only (61% and 69% of the schools, respectively), while teaching at a preclinical level was not common (15%, n= 2). Among the main factors that were indicated as reasons for teaching repair of DCR were tooth substance preservation (100% of the respondents),
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promotion of minimal intervention dentistry (69%, n= 9), and a desire to minimise the adverse effects of the restorative cycle (46%, n = 6) (Fig. 2). FIGURE 2
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Concerning the restoration-related failures that were considered to justify the teaching DCR repairs, all respondents reported marginal defects (100%, n = 13) as the main reason,
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followed by secondary caries (69%, n= 9) and marginal discolouration, superficial colour
FIGURE 3
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correction and labial/buccal restoration discoloration (61%, n= 8) (Fig. 3).
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Bulk fractures of restorations, considered to indicate repair were predominantly incisal (62%, n= 8) and proximal-incisal (38%, n= 5) fractures in anterior teeth; and marginal ridge
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(46%, n= 6), followed by isthmus and occlusal fractures (38%, n= 5) in posterior restorations. Other indications included repair in cases of fracture of tooth tissue adjacent to existing
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composites- incisal (46%, n= 6) and proximal-incisal (38%, n= 5) fractures in anterior teeth and
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cusp fractures (54%, n= 7) in posterior teeth.
With respect to patient acceptance, 100% of the respondents that teach repair of DCRs (n = 13) reported that patients are willing to accept this procedure as an alternative to replacement. Most schools (77%, n= 10) considered the repair of DCRs to be a definitive measure, with expected longevity varying between 1 and 10 years. Respondents indicated that the expected longevity was multifactorial and case-dependent. Common surface treatment methods used included acid etching with phosphoric acid (92%, n= 12) and cleaning with slurry pumice (85%, n= 11). Acid etching with hydrofluoric acid and Al2O3 air-abrasion were less popular (8%, n = 1) (Fig. 4). FIGURE 4
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The most common materials used in the repair of composites were dentin/enamel bonding systems (92%, n= 12) followed by hybrid composites (62%, n= 8) and flowable composites (62%, n= 8) (Fig. 5).
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FIGURE 5 The main instruments reported to be used in finishing composite repairs were diamond
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finishing instruments (100%, n = 13), followed by tungsten carbide finishing instruments (77%,
FIGURE 6
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n= 10) and finishing discs (69%, n= 9) (Fig. 6).
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In relation to monitoring systems, the majority of the schools (77%, n= 10) reported that no recall system was implemented and only 3 schools (23%) claimed to have a recall system in
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place following repair of direct composite restorations. Almost half of the respondents either did not know or did not answer in regards to the longevity of composite repairs placed by their
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to 100% (15%, n= 2).
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students (46%, n= 6), while the others estimated an increase in longevity from 30% (15%, n=2)
DISCUSSION
The aim of the present study was to investigate the teaching and operative techniques
for the repair, rather than replacement, of failing DCRs in dental schools in Oceania. The excellent response rate (100%), while possibly related, at least in part to the small number of dental schools surveyed, may be considered to be an indication of the importance of the topic and the willingness of the dental schools in Oceania to engage in research. Although online data collection is typically found to be efficient, effective and relatively inexpensive, it has been reported to yield lower response rates than paper-based/postal surveys [16]. In addition, respondents may be found to provide less considered answers online, compared to when they 7
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respond to questions via paper-based/postal methods [16]. Despite the perceived limitations of postal surveys in terms of response rate, the present study achieved 100% response rate. As a consequence, the data presented provides a complete overview of attitudes to, and the extent of
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composite repair teaching provided throughout the Oceania region. In this way the findings are considered to add to existing knowledge and understanding on techniques and the teaching of
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repairs to DCR.
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Even though all 16 respondents reported that they had clinically performed repairs to DCRs with successful outcomes, three dental schools in Oceania did not teach this technique to
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undergraduate students and did not plan to introduce it into the curriculum the near future. A similar study undertaken in UK and Irish dental schools [4] found that only one dental school
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did not teach the technique; however, that school planned to include it in the curriculum within the next five years. It is suggested that the schools included in the present study which
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presently do not teach repairs to DCRs will be very quickly become exceptional with the
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international shift to the teaching of repairs to restorations which historically would have been replaced on the basis of the outdated dogma of ‘if in doubt, take it out’[17]. The specific techniques used for the repair of DCRs in each school were not investigated in this study. Those schools that did not teach the repair of DCRs cited lack of evidence and the absence of descriptions of relevant techniques in recommended textbooks as the main factors. In contrast, 61% of the respondents chose existing evidence as one of the reasons for teaching repair. Recent publications (e.g. [5-9]) have reported on the success of repairs to DCRs and analysed the techniques used to ensure longevity and optimum results. The limited body of work in the area of repair of dental composites was recently the subject of a review [9]. Clinical studies of 2-3 years in duration have found positive outcomes for composite repairs. A 7-year
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recall study by Gordan et al. [6] indicated the longer term
success of this conservative
intervention strategy. Previous studies conducted in the US and Canada [11, 15] UK and Ireland [10, 12], common justification for
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Germany [13] and Scandinavia [4, 14] reported that the most
teaching repair was clinical experience, as observed in the present study. Our results revealed
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that the theoretical and practical teaching of repair in Oceania was most common at a clinical
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level, as found in a survey of North American dental schools [15]. This may be because the decision to repair or replace is case-dependent, and possibly difficult to teach theoretically.
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However, it would be beneficial for students to be familiar with guidelines in terms of the theory of repair vs. replacement before entering clinical studies.
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In this study, the most important general factor for teaching of repairs to DCRs was the preservation of tooth substance. The same was observed in similar surveys done elsewhere (e.g.
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[10-13, 15]. The promotion of minimal intervention dentistry was also an important factor in
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our study. This minimal approach has been widely recognised for its advantages, primarily the opportunity to avoid unnecessary removal of sound tooth structure to increase mechanical retention [18]. Similarly, as in most previous studies on this topic we found that the most important restoration-related failure which justified the teaching of repairs to DCRs was marginal defects. Poor marginal adaptation exposes the dentine-pulp complex to the oral environment, which in turn can lead to complications such as microleakage, marginal discoloration, plaque accumulation, secondary caries, postoperative sensitivity, pathologic pulp changes and restoration failures [19]. Therefore, marginal defects are very important
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predicting the clinical success of a restoration [20]. Concerning surface treatment techniques prior to composite repair, most previous studies reported that mechanical surface treatment is crucial to enhancing bonding between 9
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new and existing composite resin (e.g. [10-13, 15]). Improvements in bond strength tend to be achieved through increased surface roughness to promote mechanical interlocking, in particular when chemical bonding might not be sufficient [21]. Dental schools in Oceania (this study)
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and Germany [13], in contrast to dental schools in the US and Canada (11) and the UK and Ireland (4,12) performed limited aluminium oxide air abrasion. Aluminium oxide air abrasion
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enhances bond strength between composite and tooth structure [22].
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was uncommon in dental schools in Scandinavia [14], despite it being a technique which
There was limited use of acid etching with hydrofluoric acid in the present study, as the study in the US and Canada [11]. Although a few studies have
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was the case in
demonstrated beneficial effects when applying this approach, other studies suggested the
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technique to be ineffective and one which should not be recognised as the standard of care [23]. As suggested by Loomans [24], composites should not be seen as materials which have
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identical properties when it comes to repair procedures. Hence, the effect of etching will largely
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depend on the composition of the filler particles in the composite forming the substrate. During the repair of a composite restoration, preparation usually exposes enamel and dentine. Thus, the use of bonding systems is required to obtain adequate bond strength to tooth structures [25]. To create an effective seal between tooth structure and composite and along composite-to-composite interfaces, the use of a flowable composite [26] may enhance the effect of the selected adhesive bonding system [27]. In the absence of evidence-based guidelines, the technique to be applied in each case requires careful judgement and, whatever materials and approach are selected, strict adherence to directions for use and meticulous attention to detail. As with all other forms of minimum intervention dentistry, the effective repair of restorations requires good knowledge and understanding of the effects of the various operative interventions and materials used. Future clinical studies should investigate the factors 10
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affecting the clinical performance of repairs, including the effects of bonding new composite to composite which has been exposed to the oral environment for some time. All respondents that participated in the US and Canada study [11] used finishing disks
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and composite polishing points to finish repairs to DCRs. However, these two finishing devices were not as popular in the dental schools in Oceania. Also, composite polishing paste was more
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than three-fold less popular in Oceania than in the US and Canada [11]. The reason for these
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differences are unclear from the data collected, but would appear to reflect either different understanding or acceptance of existing information on the efficacy of different composite
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finishing devices and instruments. Presumably, the selection of finishing regimen for repairs, at least in dental schools in Oceania, is presently based more on experience and personal
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preference than best available evidence.
In the present study the predicted longevity of the repairs placed by students varied
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widely, with no obvious consensus on how successful repairs may be in clinical service.
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Similar findings were reported in the studies undertaken in North America, UK and Ireland, Germany and Scandinavia [10-13, 15], in which most respondents considered repairs to restorations as a definitive measure, with varied views on longevity. Yet, there was a common consensus in the previous studies that patient acceptance of repairs to restorations is very high because of the ease and speed of the procedures, let alone the biological and financial advantages. Although it is expected that the operator’s experience plays an important role in the longevity of restorations, with restorations placed by inexperienced operators having a higher chance of repair, this study did not analyse the effects of factors such as patient, operator and materials in the longevity of composite restorations. Unfortunately, it is likely that, at best, limited data will be available on how long composite repairs undertaken in dental schools in Oceania will last in clinical service, as the 11
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majority of the schools in the region reported no recall system to monitor clinical performance. Only 20% of the schools we surveyed had a recall system in place for repaired restorations, with no indication of any intentions to research the longevity of repairs to DCRs. Given the
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many advantages of repair over restoration replacement, it is suggested that high priority should be given to performing clinical studies on the efficacy of repairs. Such research would
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hopefully encourage the much needed shift to more minimum intervention forms of operative
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dentistry in members of the aging population are to have ‘teeth for life’, and contribute toward a worldwide consensus on DCR guidelines instead of the current regional bias. Future research
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should also address clinical factors such as the role of the original restoration’s length in the success of DCR repairs, and the effect of grinding, bruxism and other parafunctional habits in
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the survival of repairs placed on incisal edges and marginal ridges.
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CONCLUSION
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To date, there is no consensus on guidelines for the repair of composite restorations, despite the repair rather than the replacement of a restoration being minimally invasive, cost effective and popular with patients. The decision to repair or replace is very subjective, and currently depends on the clinician’s knowledge, experience and preferences. This investigation and other similar studies done elsewhere emphasised the need for clinical studies on repairs. Mapping trends in the teaching of operative dentistry helps inform clinical teachers, drives postgraduate dental education and helps develop research agendas in restorative dentistry.
ACKNOWLEDGEMENTS Thanks are extended to all study participants for their time and cooperation with data collection. 12
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REFERENCES
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[1] J.L. Ferracane, Resin composite—state of the art, Dental Materials 27(1) (2011) 29-38. [2] B.S. Bohaty, Q. Ye, A. Misra, F. Sene, P. Spencer, Posterior composite restoration update: focus on factors influencing form and function, Clinical, Cosmetic and Investigational Dentistry, 5 (2013) 33–42. [3] A.V. Ritter, Posterior Resin Based Composite Restorations: Clinical Recommendations for Optimal Success, Journal of Esthetic and Restorative Dentistry 13(2) (2001) 88-99. [4] I. Blum, A. Schriever, D. Heidemann, I. Mjör, N. Wilson, The repair of direct composite restorations: an international survey of the teaching of operative techniques and materials, European Journal of Dental Education 7(1) (2003) 41-48. [5] V.V. Gordan, C. Shen, J. Riley, I.A. Mjör, Two Year Clinical Evaluation of Repair versus Replacement of Composite Restorations, Journal of Esthetic and Restorative Dentistry 18(3) (2006) 144-153. [6] V.V. Gordan, C.W. Garvan, P.K. Blaser, E. Mondragon, I.A. Mjör, A long-term evaluation of alternative treatments to replacement of resin-based composite restorations: results of a seven-year study, The Journal of the American Dental Association 140(12) (2009) 1476-1484. [7] G. Moncada, E. Fernández, J. Martin, C. Arancibia, I. Mjör, V. Gordan, Increasing the longevity of restorations by minimal intervention: a two-year clinical trial, Operative Dentistry 33(3) (2008) 258-264. [8] G. Moncada, J. Martin, E. Fernández, M.C. Hempel, I.A. Mjör, V.V. Gordan, Sealing, refurbishment and repair of Class I and Class II defective restorations, The Journal of the American Dental Association 140(4) (2009) 425-432. [9] M.O. Sharif, M. Catleugh, A. Merry, M. Tickle, S.M. Dunne, P. Brunton, V.R. Aggarwal, Replacement versus repair of defective restorations in adults: resin composite, Australian Dental Journal 55(3) (2010) 351-352. [10] I.R. Blum, A. Schriever, D. Heidemann, I.A. Mjör, N. Wilson, Repair versus replacement of defective direct composite restorations in teaching programmes in United Kingdom and Irish Dental Schools, The European Journal of Prosthodontics and Restorative Dentistry 10(4) (2002) 151-155. [11] C.D. Lynch, I.R. Blum, K.B. Frazier, L.D. Haisch, N.H. Wilson, Repair or replacement of defective direct resin-based composite restorations: contemporary teaching in US and Canadian dental schools, The Journal of the American Dental Association 143(2) (2012) 157-163. [12] I.R. Blum, C.D. Lynch, N. Wilson, Teaching of direct composite restoration repair in undergraduate dental schools in the United Kingdom and Ireland, European Journal of Dental Education 16(1) (2012) e53-e58. [13] I.R. Blum, C.D. Lynch, A. Schriever, D. Heidemann, N. Wilson, Repair versus replacement of defective composite restorations in dental schools in Germany, The European Journal of Prosthodontics and Restorative Dentistry 19(2) (2011) 56-61. [14] I.R. Blum, C.D. Lynch, N. Wilson, Teaching of the repair of defective composite restorations in Scandinavian dental schools, Journal of Oral Rehabilitation 39(3) (2012) 210216. [15] V.V. Gordan, I.A. Mjör, I.R. Blum, N. Wilson, Teaching students the repair of resin-based composite restorations: a survey of North American dental schools, The Journal of the American Dental Association 134(3) (2003) 317-323. [16] H. McDonald, S. Adam, A comparison of online and postal data collection methods in marketing research, Marketing Intelligence & Planning 21(2) (2003) 85-95. 13
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[17] N. Wilson, C. Lynch, P.B. Brunton, R. Hickel, H. Meyer-Lueckel, S. Gurgan, U. Pallesen, A. Shearer, Z. Tarle, E. Cotti, Criteria for the replacement of restorations: Academy of Operative Dentistry European Section, Operative Dentistry (2015) S48-S57. [18] J. Van Amerongen, W. Van Amerongen, T. Watson, N. Opdam, D. Roeters, D. Bittermann, E. Kidd, Restoring the tooth:‘the seal is the deal’, Fejerskov O & Kidd E: Dental Caries: The Disease and its Clinical Management. Copenhagen, Blackwell Munksgaard (2003) 275-291. [19] K.H. Neppelenbroek, The clinical challenge of achieving marginal adaptation in direct and indirect restorations, Journal of Applied Oral Science 23(5) (2015) 448-449. [20] A.D.C. Medina, A.B.d. Paula, S.B.P.d. Fucio, R.M. Puppin-Rontani, L. Correr-Sobrinho, M.A.C. Sinhoreti, Marginal adaptation of indirect restorations using different resin coating protocols, Brazilian Dental Journal 23(6) (2012) 672-678. [21] P.A. Oskoee, S. Kimyai, E. Talatahari, S. Rikhtegaran, F. Pournaghi-Azar, J.S. Oskoee, Effect of mechanical surface treatment on the repair bond strength of the silorane-based composite resin, Journal of Dental Research, Dental clinics, Dental prospects 8(2) (2014) 61. [22] A. Rathke, Y. Tymina, B. Haller, Effect of different surface treatments on the composite– composite repair bond strength, Clinical Oral Investigations 13(3) (2009) 317-323. [23] S.A.R. Junior, J.L. Ferracane, Á. Della Bona, Influence of surface treatments on the bond strength of repaired resin composite restorative materials, Dental Materials 25(4) (2009) 442451. [24] B. Loomans, M. Cardoso, N. Opdam, F. Roeters, J. De Munck, M. Huysmans, B. Van Meerbeek, Surface roughness of etched composite resin in light of composite repair, Journal of Dentistry 39(7) (2011) 499-505. [25] F. Staxrud, J.E. Dahl, Role of bonding agents in the repair of composite resin restorations, European Journal of Oral Sciences 119(4) (2011) 316-322. [26] R. Frankenberger, N. Krämer, J. Ebert, U. Lohbauer, S. Käppel, S. Ten Weges, A. Petschelt, Fatigue behavior of the resin-resin bond of partially replaced resin-based composite restorations, American Journal of Dentistry 16(1) (2003) 17-22. [27] N. Oztas, A. Alacam, Y. Bardakcy, The effect of air abrasion with two new bonding agents on composite repair, Operative Dentistry 28(2) (2003) 149-154.
FIGURE LEGENDS
Figure 1. Grounds for teaching the repair of composite restorations in Oceania. Figure 2. General factors that indicate the reasons for teaching composite repairs in Oceania. Figure 3. Restoration-related failures that indicate reasons for teaching repair of composites in Oceania. Figure 4. Surface treatments performed prior to placement of composite in Oceania. Figure 5. Materials used in the teaching of composite repairs in Oceania. Figure 6. Use of instruments for composite repair procedures in Oceania. 14
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Table 1 - List of dental schools in Oceania. Dental Schools
New Zealand
Auckland University of Technology University Of Otago
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Countries
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Melbourne University Griffith University University of Western Australia Curtin University Australia University of Newcastle Central Queensland University University Of Adelaide Charles Sturt University University of Sydney La Trobe University University of Queensland James Cook University
Fiji
Fiji National University
University of Papua New Guinea
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Papua New Guinea
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Australia
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Figure 6
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