Teaching of composite restoration repair: Trends and quality of teaching over the past 20 years

Journal Pre-proof Teaching of composite restoration repair: Trends and quality of teaching over the past 20 years Philipp Kanzow, Annette Wiegand

PII:

S0300-5712(20)30040-3

DOI:

https://doi.org/10.1016/j.jdent.2020.103303

Reference:

JJOD 103303

To appear in:

Journal of Dentistry

Received Date:

9 December 2019

Revised Date:

18 February 2020

Accepted Date:

19 February 2020

Please cite this article as: Kanzow P, Wiegand A, Teaching of composite restoration repair: Trends and quality of teaching over the past 20 years, Journal of Dentistry (2020), doi: https://doi.org/10.1016/j.jdent.2020.103303

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. 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. © 2019 Published by Elsevier.

Teaching of composite restoration repair: Trends and quality of teaching over the past 20 years Running title: Teaching of composite repair

Philipp Kanzowa,* [email protected], Annette Wieganda a

Department of Preventive Dentistry, Periodontology and Cariology, University Medical

Center Göttingen, Germany *Corresponding author at: Dr. Dr. Philipp Kanzow Department of Preventive Dentistry, Periodontology and Cariology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075 Göttingen (Germany).

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Abstract Objectives: Repairs are frequently taught at dental schools around the world. Various studies regarding the teaching of composite repairs were performed over the past 20 years. However, it is unclear if teaching reflects current evidence and if clinical recommendations

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have changed over time.

Sources: Electronic databases (Embase, Scopus, PubMed) were searched.

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Study selection: Studies reporting on teaching concepts (i.e. recommended treatment steps)

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were included. Teaching was analysed regarding key treatment steps for conditioning of the repair surface (use of [1] diamond burs, [2] air abrasion/silica coating, [3] application of silane or universal primers, and [4] application of adhesives) using random-effects meta-analyses,

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meta-regressions, and an overall quality score.

Data: 63 records were assessed, and 12 studies having surveyed 331 dental schools were

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included. The mean (95%CI) proportion of dental schools teaching the use of diamond burs for roughening of the repair surface amounted to 83.0% (71.0-90.7%). Air abrasion / silica

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coating, the use of silane / universal primers and adhesives was taught by 29.8% (18.744.1%), 32.4% (21.1-46.2%), and 86.4% (73.5-93.6%), respectively. In recent years, dental schools more often taught the use of adhesives (padj.=0.012) and the mean overall quality score of teaching improved (p=0.007). Conclusions: Share of dental schools recommending most of the key treatment steps did not significantly increase over the past 20 years. However, the overall quality of teaching

–1–

improved,

and

teaching

is

nowadays

more

consistent

with

recently

published

recommendations. Clinical Significance: Repairs are not only frequently taught, but the mean overall quality score did improve in recent years. Keywords: Minimally invasive dentistry, Restoration Repair, Systematic review, Teaching

1. Introduction

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Partially defective restorations might be repaired instead of replaced. Repair of partially defective composite restorations is frequently taught at dental schools: Meanwhile, 83% of dental schools around the world have included teaching repairs within their undergraduate dental curriculum [1]. Since 2000, various surveys regarding the teaching of composite

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repairs were performed. Besides quantitative data regarding the teaching of repairs, also qualitative aspects (e.g. recommended / mandatory treatment steps, materials, and

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across studies and dental schools.

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procedures) were assessed. However, results are very heterogeneous and vary widely both

Up to now, long-term randomized controlled trials regarding repairs are still missing. Based

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on numerous in-vitro studies, a large variety of protocols recommending clinical procedures when repairing partially defective restorations has been published. Available protocols have been collocated by a recent systematic review [2]. Also, the FDI World Dental Federation

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adopted a policy statement on the repair of restorations in 2019 [3]. Despite missing

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guidelines, recommendations regarding “key treatment steps” when performing repairs can be taken from these publications. Treatment steps being recommended by the majority of available repair protocols [2] and being included in the FDI statement [3] might be considered as key treatment steps. Based on these criteria, the following treatment steps can be considered as mandatory when performing repairs of partially defective composite restorations: (1) Surface roughening using diamond burs, (2) air abrasion or silica coating,

(3) application of a silane coupling agent or universal primer, and (4) application of an adhesive. Currently, it is unclear whether the teaching of composite restoration repair is consistent to recent recommendations regarding these clinical treatment steps and if teaching has changed over time. Therefore, we aimed to systematically review studies reporting on the teaching concepts of composite restoration repair and to analyze the quality of teaching based on recommendation of the following treatment steps: (1) use of diamond burs, (2) air

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abrasion / silica coating, (3) application of silane / universal primers, and (4) application of adhesives.

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2. Methods

Prior to its initiation, registration of this review was submitted to PROSPERO. The reporting

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is in accordance with the PRISMA and the ENTREQ statements [4, 5].

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2.1 Eligibility criteria

Observational studies reporting on repair concepts taught by dental schools within the

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undergraduate dental curricula. Qualitative studies reporting on recommended / mandatory treatment steps (e.g. materials and procedures) were assessed. Also, quantitative studies

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(i.e. surveys) reporting qualitative data were eligible. There were no language, time, or quality restrictions.

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2.2 Outcomes

The primary outcome of this review was the quality of teaching measured by the proportion of dental schools teaching the use of (1) diamond burs, (2) air abrasion / silica coating, (3) silane / universal primers, and (4) adhesives. These key treatment steps were derived from a recent systematic review on repair protocols [2] (treatment steps recommended by the majority of protocols) and the 2019 FDI World Dental Federation policy statement on the repair of restorations [3].

Secondary outcome was an overall quality score combining the recommendation of the four identified key treatment steps. 2.3 Information sources Three electronic databases (Embase, Scopus, and Medline via PubMed) were searched in November 2019. Additionally, hand searches using Google and Google Scholar were conducted, and reference lists of identified full texts screened and cross-referenced.

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2.4 Search strategy For the database search, the following strategy was used for PubMed and adapted for the other databases: Search ((((((repair) OR refurbish) OR refurbishment) OR repolish) OR reseal) OR sealing) AND ((dental) OR dentists) AND ((composite) OR composites) AND

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((((filling) OR fillings) OR restoration) OR restorations) AND ((((teaching) OR teach) OR education) OR curriculum). For non-databases (i.e. Google and Google Scholar), different

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combinations of the terms included in the search strategy were used.

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2.5 Study records

Two reviewers independently screened the identified records and compared their findings.

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Both reviewers independently performed the data extraction using a pilot-tested spreadsheet. There were no disagreements during screening or data extraction.

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2.6 Data items

If available, the following items were collected: Authors; year in which study was performed;

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year of publication; study type (e.g. questionnaire survey, qualitative study); characteristics of the dental schools being investigated (e.g. country); number of responding dental schools; number of dental schools teaching repairs; response rate; absolute and relative numbers of dental schools recommending the use of (1) diamond burs, (2) air abrasion / silica coating, (3) silane / universal primers, and (4) adhesives. 2.7 Data synthesis

As all included studies were quantitative in nature (i.e. questionnaire surveys) without employing truly qualitative methods, qualitative data was gathered from surveys. Proportions of dental schools teaching the use of (1) diamond burs, (2) air abrasion / silica coating, (3) silane / universal primers, and (4) adhesives were assessed by meta-analyses using the software R (version 3.6.1, www.r-project.org) and the packages “meta” (version 4.9-7) and “metafor” (version 2.1-0). Cochrane’s Q and I2-statistics were used to assess heterogeneity [6]. Due to high heterogeneity being present in the analyses, random-effect

funnel plots as well as Egger’s regression intercept tests [7].

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meta-analyses were used throughout the study. Potential publication bias was verified using

To assess potential changes in the teaching regarding the management of partially defective

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restorations, random effects meta-regressions using the DerSimonian-Laird estimator were performed. The level of significance was set at p<0.05 and p-values were adjusted according

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to Bonferroni-Holm for multiple testing.

The overall quality score (ranging from 0 to 100) was calculated as the average proportion of

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dental schools teaching the use of (1) diamond burs, (2) air abrasion / silica coating, (3) silane / universal primers, and (4) adhesives. To assess potential changes of the overall

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quality score over time, linear regression analysis of the sample-size weighted means of each study was performed. As not all studies reported the year in which the survey was

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actually performed, the year of publication was used as predictor during regression analyses. 2.8 Quality assessment and confidence in data

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Quality of included studies was assessed based on the modified Newcastle-Ottawa Scale for cross-sectional studies. The scale allowed for a maximum of 10 points (“stars”). Studies with high risk of bias were judged with 0-3, moderate risk resulted in 4-6 points, and low risk of bias in 7-10 points. Further details are described in the appendix (appendix Tab. S1). Quality assessments were derived from a previous systematic review [1] and jointly updated by both reviewers.

3. Results 3.1 Search and included studies In total, 23 articles were identified via PubMed, 15 via Embase, and 19 via Scopus. Additionally, 6 articles were identified via cross-referencing and hand search. From all identified articles, 17 were screened in full-text and 12 included (Table 1). Details on excluded studies can be found in the appendix (appendix Tab. S2). All of the included studies were surveys. A total of 331 dental schools had been surveyed.

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Studies were conducted between 2000 and 2018. Sample sizes ranged between 6 and 67 dental schools per study. Response rates ranged between 66% and 100% (mean 86.6%). In total, data from 237 dental schools in 16 countries were included. Due to repetitive surveys

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among the same countries, the same dental schools might have been surveyed at different timepoints. These duplications were not excluded as this study aimed at assessing a change

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in teaching over time. Moreover, included studies did allow for identification of specific dental

3.2 Study quality assessment

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schools that were assessed.

Risk of bias of included studies is shown in the appendix (appendix Tab. S3). Most of the

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included studies yielded representative samples of dental schools. No study reported on sample size calculations. The validity of the surveys was not assessed, and the original

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questionnaire was not published by the majority of studies. Overall, risk of bias was classified as high in 10 studies and moderate in 2 studies.

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3.3 Meta-analyses and meta-regression All 12 studies were included in meta-analyses (Fig. 1). Both the use of diamond burs and adhesives are frequently taught. The mean (95% CI) proportions of dental schools teaching the use of diamond burs and adhesives was 83.0% (71.0-90.7%) and 86.4% (73.5-93.6%), respectively. Air abrasion / silica coating (29.8% [18.7-44.1%]) and application of silane / universal primers (32.4% [21.1-46.2%]) was only taught by the minority of dental schools.

However, one study did not assess the teaching of silane / universal primers. Risk of publication bias was present in some analyses (appendix Fig. S2). Regarding potential changes in the teaching of repairs over time, the teaching of adhesives was significantly associated with the year of study publication (padj.=0.012). Recommendation of other treatment steps did not change over time (Fig. 2). 3.4 Overall quality score The averaged mean overall quality score of included studies amounted to 57.1%. More

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recent studies presented a significantly higher mean overall quality score (p=0.007). The mean overall quality score increased by 1.7% (0.6-2.8%) per year (Fig. 3).

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4. Discussion

Based on the included studies, our results indicate that most dental schools not only teach

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repairs but also comply with recent recommendations regarding required clinical treatment steps. Both mechanical and adhesive surface conditioning methods are performed by the

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majority of dental schools. Therefore, undergraduate dental students can be expected to be adequately taught the repair of partially defective composite restorations.

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Surveys are frequently performed in dental education research [8]. As part of this research, teaching concepts and dental curricula are frequently assessed. For example, teaching of

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posterior composites has frequently been assessed since the 1980s [9]. Other aspects of interest include teaching in Cariology [10-12], Endodontics [13-15], pediatric dentistry [16-

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18], and geriatric dentistry [19-21]. However, most of these surveys were only conducted in a single country or countries within a close geographic region (e.g. US/Canada, UK/Ireland, Germany/Austria/Switzerland). Only few studies represent multinational questionnaire surveys [22-25]. Therefore, results are often based on a low number of dental schools, thus transferability to other countries remains questionable. To overcome these limitations, systematic reviews of multiple survey studies with data from different countries and over a broad range of time are necessary. Such systematic reviews are already available for some

aspects of teaching / dental school curricula, e.g. the teaching of posterior composite restorations [9]. Research on the teaching on various aspects of contemporary dentistry should be recognized as a means to help harmonize the teaching within and between countries. Comprehensive studies regarding qualitative aspects of teaching repairs are still missing. However, teaching repairs in undergraduate programs of dental schools has been assessed in various national studies from all around the world over the past 20 years [1]. While no

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study utilized true qualitative research methods, qualitative data regarding teaching concepts can be derived from questionnaire studies. As outlined above, it seemed necessary to systematically assess the qualitative aspects of teaching repairs at an international level and to assess potential changes over time.

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Most of the included studies used questionnaires based on the survey originally designed by

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Blum et al. [24]. Therefore, survey design was similar and allowed for better comparison. However, not all studies reported on absolute numbers but rather used relative numbers

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regarding certain treatment steps. In the majority of studies, results were based on responding dental schools teaching repairs instead of the total number of participating dental schools. If possible, data was transformed and results uniformly entered into meta-analyses

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(number of dental schools teaching certain treatment steps, number of dental schools teaching repairs). However, raw data of one study [26] was not available and data based on

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the total number of responding dental schools was entered into meta-analyses. Therefore, our results might be slightly biased and proportions of dental schools teaching certain

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treatment steps might be under-estimated. Also, the true overall quality score might be higher. Due to missing information for individual dental schools, calculation of the overall quality score at the level of participating dental schools was not possible. Despite published recommendations regarding survey research [8], future studies regarding the teaching of repairs should use true qualitative methods to gain a deeper insight into teaching concepts. Irrespective of the research method to be used, recommendation of all four identified key treatment steps should be assessed, results should be based on dental

schools teaching repairs, and the proportion of dental schools teaching certain treatment steps should be stated as absolute numbers. To contribute to the harmonization of teaching, scientific societies in Operative Dentistry should produce guidelines on relevant topics, such as the repair of partially defective restorations. Uniform protocols would allow for state-of-the-art teaching with both students and patients being joint beneficiaries.

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5. Conclusion Teaching of repairs is roughly consistent with recently published recommendations. Further development in the teaching of repairs is required to fully comply with these

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recommendations. Especially the share of dental schools teaching the use of air abrasion / silica coating and application of silane / universal primers remains low.

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Declarations of interest None.

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Acknowledgements

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This study was funded by the authors and their institution.

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Figure 1: The proportion (%) of dental schools teaching the use of (1) diamond burs, (2) air abrasion / silica coating, (3) silane / universal primers, and (4) adhesives. Pooled proportions and 95 % confidence intervals (CI) from random-effects meta-analyses are shown as

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diamonds. Heterogeneity was assessed using χ2-test and I2-statistics.

Figure 2: Association between the year of study publication and the logit of the share of dental schools teaching the use of (1) diamond burs, (2) air abrasion / silica coating, (3)

silane / universal primers, and (4) adhesives. Regression lines and corresponding 95% confidence intervals (CI) bounds are shown. P-values were adjusted according to BonferroniHolm for multiple testing. Meta-regression indicates that the use of adhesives is significantly

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more often taught in recent years (p adj. = 0.012).

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Figure 3: Sample-size weighted linear regression of the mean overall quality score of each study. Regression line and corresponding 95% confidence interval (CI) bounds are shown.

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The mean overall quality score significantly increased in recent years (p = 0.007).

Table 1: Included studies reporting the teaching of composite restoration repair. Study

Method

Country

Year

Sample

n repair / n

Response

Physical

repair

Chemical

repair

rate

measures

[%]

Diamond

Air

Silane

Adhesive

quality

bur [%]

abrasion

coupling

[%]

score

measures

Mean overall

responders

/

silica

agent

/

coating

universal

[%]

primer [%]

Blum

et

Questionnaire

al. 2002

England,

2000

14/15

100.0

92.9

28.6

14.3

92.9

57.0

2000

9/ 9

90.9

88.9

0.0

0.0

100.0

47.2

20.8

20.8

45.8

33.3

Ireland

[27] Blum

et

Questionnaire

Sweden,

al. 2003

Finland,

[28]

Denmark, Norway

Schriever

Germany

2000

12/24

75.0

45.8

Questionnaire

USA,

2001

37/52

81.3

70.3

2009

6/ 6

75.0

50.0

22/25

al.

2003* [26]

al.

et

Questionnaire

Brazil (State of

[30]

Grande

Questionnaire

Germany

2009

Questionnaire

England,

2010

al. 2012

Ireland

Questionnaire

al. 2012

al. 2012

Questionnaire

86.4

59.1

45.5

86.4

69.4

100.0

93.3

20.0

33.3

86.7

58.3

83.3

2010

42/48

71.6

100.0

31.0

28.6

100.0

64.9

Sweden,

2010

11/12

100.0

100.0

9.1

27.3

100.0

59.1

Finland,

Denmark,

Jo

[34]

USA,

ur

et

41.7

Canada

[33] Blum

15/17

na

[32] Lynch et

66.7

lP

[31] et

16.7

do

al. 2011

Blum

33.3

Rio

Sul) et

51.4

Puerto Rico

al. 2011

Blum

56.8

Canada,

2003 [29] Toyo

–

-p

et

27.0

re

Gordan

ro of

et

Questionnaire

Lynch et

Norway

Questionnaire

Japan

2010

18/19

65.5

88.9

22.2

83.3

94.4

72.2

Questionnaire

Australia,

unknown

13/16

100.0

100.0

7.7

15.4

92.3

53.9

2018

26/29

96.7

76.9

84.6

50.0

96.2

76.9

al. 2013 [35]

Brunton et

al.

New

2017 [36]

Zealand, Fiji, Papua

New

Guinea Kanzow

Questionnaire

Germany

et

al.

2018** [37]

The proportions (%) of dental schools teaching the use of (1) diamond burs, (2) air abrasion / silica coating, (3) silane / universal primers, and (4) adhesives within each study. Unless otherwise noted, data is based on participating dental schools having stated to include repairs within their undergraduate dental curricula. *Results are based on all participating

Jo

ur

na

lP

re

-p

ro of

dental schools. **Results were adjusted based on raw data supplied by the authors.