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The replacement or repair of posterior
amalgam restorations: when is it indicatedin the permanent dentition?
An Evidence-Based Literature Review
Submitted to:
Dr. Carlos Quiñonez and Dr. James Leake
Department of Community Dentistry, Faculty of Dentistry, University of Toronto
Submitted by:
Ji Hoon Hyun Hon. B.Sc.
Danielle Musselman Hon. B.Sc.
Kaveh Nedamat Hon. B.Sc.
Natascha Rodrigues
Michelle WongRobert Wong
In fulfillment of DEN207Y Community Dentistry academic requirements.
Contact:
Michelle Wong
Faculty of Dentistry, University of Toronto
124 Edward Street, Toronto, Ontario, Canada M5G 1G6(416) 979- 4750 ext. 3559
March 20, 2008
Word Count: 2778
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Table of Contents
Abstract ........................................................................................................................................... 3 Introduction..................................................................................................................................... 4 Methods........................................................................................................................................... 6
Search Strategy ............................................................................................................................... .......... 6 Inclusion Criteria ............................................................................................................................... ....... 7 Exclusion Criteria ............................................................................................................................... ...... 7 Validity Instrument ............................................................................................................................... .... 7 Literature Search Results .......................................................................................................................... 8
Results........................................................................................................................................... 10 Discussion..................................................................................................................................... 14 Conclusion .................................................................................................................................... 18 Appendix A:.................................................................................................................................. 19 Checklist to Assess Evidence of Efficacy of Therapy or Prevention ........................................... 19 Appendix B: Evidence Tables ..................................................................................................... 20 Appendix C: Paterson FM et al. Criteria ..................................................................................... 22 Appendix D: Hickel R et al.’s Criteria to evaluate restorations .................................................. 24 Acknowledgements....................................................................................................................... 27 References..................................................................................................................................... 28
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Abstract
Dental practitioners are constantly faced with the decision to replace or repair a failed
posterior amalgam restoration yet no set guidelines exist. The purpose of this paper is to conduct
an evidence-based literature review of when to replace or repair failed posterior amalgam
restorations in the permanent dentition. Eleven scientific electronic databases including Pubmed
and Ovid were searched using MeSH and relevant keywords. The search yielded a total of 4015
articles. Of these, 310 were found to be relevant after screening at the title stage and this number
was further reduced to 53 based on the inclusion/exclusion criteria. Three articles were selected
for critical appraisal and validity scoring; ultimately, two articles were accepted to be of
reasonable quality and study design. The studies indicate that repair is an acceptable and
conservative method of treating failed amalgam restorations; however, no comparative data on
longevity of repair versus replacement of amalgam is available. Unfortunately, there is an
insufficient body of evidence-based literature to make a recommendation as to when a posterior
amalgam should be replaced or repaired. Future work must be conducted.
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Introduction
Dental amalgam is generally regarded as an ideal restorative material due to its high
strength, longevity and cost-effectiveness (1). Yet, a common phrase within the dental
community is “if you build it, it will fail.” This is true for dental amalgam restorations, with one
study claiming that replacing restorations occupies 72% of a dental practitioner’s time (2). In
this regard, there is debate amongst dental professionals as to when an amalgam should be
repaired or replaced. Does a cracked isthmus call for complete removal or simply repair? What
about a deficient margin or a restoration that has suffered recurrent decay? These situations are
routinely encountered in dental practices, but are the clinical treatments based on the literature or
existing dogmas?
According to the literature, the most frequently reported reason for failure of an amalgam
restoration is recurrent or secondary caries (3, 4). The second most frequently reported factor is
fracture, which included isthmus/bulk fracture, marginal fracture and tooth fracture (3-9). Bulk
fractures were predominant in restorations that had three or four surfaces, whereas marginal gaps
or marginal leakage were more frequent in restorations with one or two surfaces (3). Other
factors include esthetic concerns, marginal defects, poor anatomy, excessive wear, marginal
discolouration, pain, sensitivity, and colour changes (5, 10).
According to this literature, amalgam repair should be used more often since it is more
conservative, as it removes less tooth structure, and especially with newer amalgam bonding
adhesives that provide a stronger bond between the old and new amalgam (11, 12). Nonetheless,
the literature is conflicted in terms of the success of many of these approaches (11).
In this study, replacement of amalgam was defined as the complete removal of the
existing amalgam restoration and its replacement with another dentin substitute or prosthesis.
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Amalgam repair was defined as the replacement of the defective or fractured aspect of the dental
amalgam restoration with new amalgam.
In turn, this paper is an evidence-based literature review of the replacement or repair of
failed posterior amalgam restorations in the permanent dentition.
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Methods
Search Strategy
An initial search for relevant academic papers was performed using eleven electronic
databases, which can be seen in Table 1. The MeSH terms used were:
a) Dental Amalgam OR Dental Restoration Failure AND posterior AND replace* repair*
NOT implant NOT denture
b) Dental Amalgam OR Dental Restoration Failure AND posterior AND repair* NOT
implant NOT denture
Additionally when MeSH was not applicable, four keyword search phrases were used:
a) Amalgam AND Posterior AND Restor* AND Replace*
b) Amalgam AND Posterior AND Restor* AND Repair
c) Amalgam AND Posterior AND Restor* AND Remov*
d) Amalgam AND Posterior AND Restor* AND Fail*
To finalize the literature search, titles of articles were screened based on relevance to the
research question: “when is the replacement or repair of posterior amalgam restorations indicated
in the permanent dentition?” Abstracts were acquired for the accepted titles. They were
screened based on the inclusion/exclusion criteria presented below. Duplicates were removed at
this stage. Subsequently, full articles were also collected and screened based on the
inclusion/exclusion criteria.
To further achieve a comprehensive search, reference lists of accepted articles were
scanned. Dr. A. Jokstad, Faculty of Dentistry, University of Toronto was also consulted for
additional resources and references.
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Inclusion Criteria
Articles selected for this report met the following criteria:
1. English
2. Available through Local Holdings (University of Toronto Library Resources)
3. Publication date of January 1964 to present
4. Human subjects with permanent dentition
Exclusion Criteria
Articles selected for this report excluded the following criteria:
1. Personal or expert opinion
2. In vitro trials
3. Topic focused solely on the longevity of the amalgam restoration and not of replacement
or repair
4. Languages other than English
Validity Instrument
Abstracts and full text titles were assessed by two independent reviewers using the
inclusion/exclusion criteria. Any discrepancies between the two reviewers were discussed
between all group members. The validity and quality of the resultant three articles was assessed
using “Checklist to Assess Evidence of Efficacy of Therapy or Prevention” developed by J.L.
Leake (Appendix A). Each article was scored by two independent reviewers and could receive a
maximum score of fifteen. When a discrepancy in the article score of two or more points was
demonstrated, a final score was determined after discussion between all six group members. All
studies receiving a score of 9 or more were retained.
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Literature Search Results
The literature search resulted in a total yield of 4015 articles. The total number of
relevant articles yielded after the title stage was 310 (Table 2 provides details). The 310
abstracts were further reduced to 53 based on the inclusion/exclusion criteria. Three articles
were ultimately selected for validity scoring. Upon reviewing reference lists located at the back
of the accepted articles, no additional articles were accepted. The consultation with Dr. Jokstad
yielded no additional resources and references.
Table 1: Electronic Literature Search of Internet and Academic Sources
Literature Search
Method Sources Total #Hits # Abstractsretrieved
Academic Literature Database Search (accessed through U of T Library Resources)
Pubmed 189 30
Ovid:MEDLINE, CINAHL (Cumulative Index to Nursing & Allied
Health Literature), EMBASE, All Evidence Based Medicine
Reviews (Cochrane Database of Systematic Reviews (CDSR),American College of Physicians (ACP) Journal Club, Database
of Abstracts of Reviews of Effects (DARE), and CCTR
(formerly Cochrane Controlled Trials Register), Cochrane
Methodology Register (CMR), Health Technology Assessment(HTA), and NHS Economic Evaluation Database (NHSEED).
208 82
Scopus 1483 74
Web of Science 110 44
BIOSIS 24 16
Grey Literature Internet Search
American Assoc. Operative
Dentistry Guidelineshttp://www.jopdent.org/ 1 0
National Institutes for Health and
Clinical Evidence (NICE) http://www.nice.org.uk/ 0 0
Google Scholar http://scholar.google.ca/ 843 27
National Institute of Dental and
Craniofacial Research (NIDCR)http://www.nidcr.nih.gov/ 44 3
Journal of the Canadian Dental
Association (JCDA)
http://www.cda-adc.ca/jcda/311 7
Journal of American Dental
Association (JADA)http://jada.ada.org/ 802 27
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Table 2: Number of Abstracts selected after rejection at title stage
Search Terms:
P u b m
e d
O v i d
A m
e r . A s s o
c . O p e
r a t i v e
D e n t i s t r y
G u i d
e l i n e s
N I C
E
W e b
o f S c i e n
c e
B i o s i s
G o o
g l e
S c h
o l a r
N I D
C R
J C D
A
A D
A
S c o p u
s
MeSH: Dental Amalgam or
Dental Restoration Failure
AND posterior AND (replace*
OR repair*) NOT implant
NOT denture
7 17 N/A N/A N/A N/A N/A 3 0 23 N/A
Amalgam AND PosteriorAND Restor* AND
Replace*
10 22 1 0 17 5 8 0 7 4 28
Amalgam AND Posterior
AND Restor* AND Repair1 4 0 0 4 1 4 0 0 0 5
Amalgam AND Posterior
AND Restor* AND
Remov*
0 6 0 0 6 2 8 0 0 0 8
Amalgam AND Posterior
AND Restor* AND Fail*12 33 0 0 17 8 7 0 0 0 33
Table 3: Summary of Literature Search Results
YieldAfter Rejecting at
Title Stage
After Rejecting At
Abstract Stage
After Rejecting At
Full Text StageAccepted
4015 310 53 3 2
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Results
Two studies were identified that investigated the effectiveness of alternative treatments
for replacing defective amalgam restorations, one randomized controlled trial (13) and one
prospective cohort clinical trial (14).
Both studies were abstracted into evidence tables
(Appendix 1).
Moncada et al. (13) studied patients treated at the Operative Dentistry Clinic at the
College of Dentistry, Univeridad de Chile. Sixty-six patients with 271 defective amalgam and
composite resin restorations were randomly assigned to five groups: sealant (etch and resin-
based sealant), refurbish (smooth and polish), repair (removal of restorative material adjacent to
defect and repair with amalgam or resin-based filling), replacement (complete removal of
defective restoration and complete replacement) and no treatment. Sixty-four of the sixty-six
(97%) patients returned after a 12-month period and were assessed by two independent
examiners; examiners performed calibration exercises at baseline (Kappa 0.74) and upon recall
evaluation (Kappa 0.81). The authors found all treatment groups showed improvements from
baseline, based on ten clinical characteristics using Ryge USPHS criteria (Table 4). A change
from bravo to alfa was considered an improvement, while a change from alfa to bravo or charlie
indicated deterioration. Most improvements from bravo to alfa were from the sealant group,
representing a 16-fold improvement (p<0.0001). A four-fold (p<0.0001), three-fold (p=0.003)
and two-fold (p<0.0001) increase in alfa rating was observed in the replaced, repaired and
refurbished groups, respectively. The no treatment group was the only one to show a reduced
rating from alfa to either bravo or charlie (p=0.242). The authors concluded that repairing
defective restorations, instead of complete replacement, is an acceptable, economical and
efficient technique causing minimal loss of tooth structure and increasing the longevity of the
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restoration; longevity, however, was not actually measured as the authors only collected data at
the 1-year recall examinations. Moreover, the authors failed to report the results for the resin-
based and amalgam restorations separately; this study was still included in the report due to the
lack of data on this subject (13).
Table 4: Modified Ryge USPHS clinical criteria.Clinical
Characteristics Alfa Bravo Charlie
Color The restoration matches
in color and translucency
to adjacent tooth structure
The mismatch in color and
translucency is within the
acceptable range of toothcolor and translucency
The mismatch is
outside the acceptable
range of color andtranslucency
Marginal adaptation Explorer does not catch or
has one-way catch when
drawn across therestoration/tooth interface
Explorer falls into crevice
when drawn across the
restoration/tooth interface
Dentin or base is
exposed along the
margin
Anatomic form The general contour of the
restoration follows the
contour of the tooth
The general contour of the
restoration does not follow
the contour of the tooth
The restoration has an
overhang
Surface roughness The surface of the
restoration has no surface
defects
The surface of the
restoration has minimal
surface defects
The surface of the
restoration has severe
surface defects
Marginal staining There is no discoloration
between the restoration
and tooth
There is discoloration on
less than half of the
circumferential margin
There is discoloration
on more than half the
circumferential margin
Interfacial staining There is no stain on the
restoration, or the stain isequal on both the tooth
and restoration
There is more stain on the
restoration than on thesurrounding tooth structure
The stain cannot be
polished off therestoration (body
discoloration)
Contact Normal Light None
Postoperative
sensitivity
No sensitivity when an air
syringe is activated for 2
seconds at a distance of 0.5 in. from the
restoration with the facial
surface of the proximal
tooth covered with gauze
Sensitivity is present when
an air syringe is activated
for 2 seconds at a distanceof 0.5 in. from the
restoration with the facial
surface of the proximal
tooth covered with gauze
and ceases when thestimulus is removed
Sensitivity is present
when an air syringe is
activated for 2 secondsat a distance of 0.5 in.
from the restoration
with the facial surface
of the proximal tooth
covered with gauze anddoes cease when the
stimulus is removed
Secondary caries There is no clinical
diagnosis of caries
N/A There is clinical
diagnosis of cariesLuster of restoration The restoration surface is
shiny and has an enamel-
like, translucent
The restoration surface is
dull and somewhat opaque
The restoration surface
is distinctly dull and
opaque and isesthetically displeasing
Reproduced from: Moncada, GC, Martin, J, Fernandez, E, Vildosola, PG, Caamano, C, Caro, MJ, Mjor, IA, Gordon,
VV. Alternative treatments for resin-based composite and amalgam restorations with marginal defects: A 12-month
clinical trial. General Dentistry 2006;50(5):314-8.
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The second study by Gordan et al. (14) was very similar in methodology and analysis;
however the study type was a prospective cohort clinical trial. Gordan et al. recruited forty-five
patients with 113 defective amalgam restorations from the Operative Dentistry Clinic, College of
Dentistry, University of Florida and randomly assigned them to five groups: repair, sealing,
refurbishing, total replacement and no treatment. The aim of this study was to assess the
longevity of defective amalgam restorations treated by repair, sealant or refurbishing, rather than
complete replacement. Contrary to their objective, the authors failed to report any significant
period of longevity; outcomes after 1-year and 2-year recalls were reported. Loss to follow-up
was 30% and 35% at the 1- and 2-year recall appointments, respectively. Te authors also fail to
mention if the returning patients were the same at both recall exams. Two independent
examiners evaluated the clinical quality of the restorations at baseline and after the assigned
treatment, with inter-examiner agreement ratio of 92%. Similar to Moncada et al., this study
used the Ryge USPHS clinical criteria and alfa, bravo and charlie assignments; however, Gordan
et al. used only eight clinical characteristics for comparisons: 1) occlusal marginal adaptation, 2)
proximal adaptation, 3) occlusal anatomic form, 4) proximal anatomic form, 5) occlusal contact,
6) proximal contact, 7) secondary caries and 8) post-operative sensitivity (Table 4). All
restorations received a score for each clinical characteristic at baseline and post-treatment, except
for those restorations receiving no treatment. Four outcomes were used to assess the change in
clinical condition at 1- and 2-year recall exams: a grade of 1 signifying an upgrade from bravo to
alfa, 0 as no change, -1 a downgrade from alfa the bravo or bravo to charlie, or –2 a downgrade
from alfa to charlie. The authors reported a statistically significant improvement in “all
alternative groups when compared to the no treatment group for marginal adaptation and
anatomical form characteristics. (14)” The refurbishing and sealant groups showed “statistically
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significant downgrading on marginal adaptation and anatomic form compared to the replacement
group and the repair group at both 1- and 2-year recalls. (14)” Compared to the repair and
replacement groups the no treatment group was significantly more likely to downgrade in
marginal adaptation. The repair group “showed no significantly different outcome when
compared to the replacement group. (14)” The authors concluded that repair or replacement of
defective restorations with a bravo rating for marginal adaptation or anatomical form would
result in the most predictable outcomes, and that repairing defective restorations offers the most
conservative treatment (14).
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Discussion
The lack of clinical evidence is apparent in regard to the when to replace or repair
posterior amalgam restorations; the majority of the literature pertaining to this topic consists of
cross-sectional surveys ascertaining the reasons for replacement or repair of posterior amalgams.
Only two relevant studies were retrieved from over 4000 articles found. In addition, the strength
of the two studies is poor. The randomized control trial by Moncada et al., level of evidence I,
failed to report if ethical approval was obtained and moreover, the study failed to differentiate
between amalgam and composite restorations in their analysis and results. Additional
limitations, which were also common to the prospective cohort study by Gordan et al., level of
evidence II-B, include: insufficient duration of the studies; failure to report demographics of the
study group and whether participants were treated equally; failure to report the method of
randomization, the class of restoration being treated and the number of operators providing the
treatment; and failure to control for external dental care. Furthermore, the results are arguably
limited to the specific populations studied, thereby limiting external validity. Ultimately, there is
insufficient evidence to make a recommendation regarding when a posterior amalgam should be
replaced or repaired – a clinical decision that is made by all dentists on a daily basis.
This dilemma in the dentist’s practice prompted Paterson et al. in 1995 (10) to develop
valid criteria for the replacement of amalgam restorations. The first stage of proposals was
developed by a panel of dental academics using a modified Delphi technique which employed
sequential questionnaires in order to aggregate judgments and reach a consensus opinion. The
questionnaires were sent to individual academic dentists and general dental practitioners in
Scotland who were asked to comment on the issues being discussed and to provide reasons for
their choice.
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The first round of the Delphi questionnaire consisted of nineteen advisory statements on
criteria to be adopted when considering whether or not an amalgam restoration should be
replaced. The panel was asked to comment on the format of the statements and to rate the
proposals using the modified Turoff scoring system. Each statement was scored for five key
items: importance, confidence, desirability, probability and feasibility.
The panel reached a unanimous agreement that lost amalgam restorations should be
replaced and amalgams that were fractured required replacement/repair. They also agreed that
ditching at the margins was not an indication for the replacement or repair of the amalgam
restoration. It was also concluded that amalgam restorations should be locally repaired rather
than totally replaced. Consensus was also reached regarding the need to modify defective
contact areas in Class II restorations. They also felt that replacement of amalgam due to allergy
should only occur after specialist testing and advice. Finally, the panel concurred that before a
decision to replace/repair could be made, an assessment of the patient’s caries risk and
consideration of the individual restoration must occur. A consensus view, however, could not
be reached regarding policy statements relating to pain management, white spots adjacent to
restoration margins and dentinal staining of existing amalgam restorations. A reproduction of the
criteria is included in Appendix C. The next stage in the development of the criteria is to send
these statements to a panel of general dental practitioners to obtain their consensus view, again
using the Delphi technique.
To further the research on this topic, future studies addressing this clinical question will
require improved design methods. According to Hickel et al.’s 2007 review on conducting
controlled clinical trials (15), an ideal restorative study is a randomized control trial with proper
randomization and concealment of allocation. Split mouth design or a paired tooth design is
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optimal although not always practical. Alternatively, a prospective cohort clinical trial is
comparable study design but is considered second in the level of evidence ranking. Blinding in
in vivo studies where there are two independent assessors is impossible due to the nature of
restoration evaluation. The sample should be a good representation of the healthy population
and the sample size should have adequate statistical power. Fully standardized procedures
should be preset with regards to who will do the dental procedure, the technique and materials
used, and who will assess the restoration. It is recommended that calibration training and inter-
examiner agreement be at the ≥ 85% level to ensure a reproducible restoration assessment. The
analysis should account for the class of restoration because the dimension and size of the
restoration may have an effect to the outcome.
To adequately address whether clinicians should replace or repair posterior amalgams,
only two intervention groups should be present as direct comparators: replacement or repair of
amalgam restoration with amalgam. Including an untreated control group may be considered
unethical where the standard of care is to provide some form of treatment. The restorations need
to be validly and reliably measured. The Ryge Criteria is considered standard outcome measure
for restorations; however, with the advent of new dental materials, more sensitive assessment or
scoring methods need to be used. Hickel et al. refers to a two-step method of scoring where the
first step evaluates clinical acceptability of the restoration based on the Ryge classification:
Table 5: Overview of Ryge Criteria
Ryge Classification Score Restoration is:
1 Excellent, fulfilling all quality criteria; tooth and/or surroundingtissues are adequately protected
Alpha
2 Highly acceptable, though one or more criteria is not ideal; minor
modifications can be made to the restoration but is not necessary
Bravo 3 Sufficiently acceptable but with minor shortcomings in areas
where any instrumentation may result in damage to the tooth; no
adverse effects are anticipated
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Charlie 4 Unacceptable but repairable
Delta 5 Unacceptable and must be replaced
A Modified Ryge USPHS Criteria (Table 4) has been developed and used in the studies found in
our literature search. The second step is the classification of the restoration into aesthetic,
functional and biological categories (Appendix D). For direct restorations, there is a
recommendation for a three-year observation period involving four recall appointments: baseline
at one-week (maximum one month) post-insertion, and yearly recalls at 12, 24, and 36 months.
Still, follow-up times of longer duration such as for 7-10 years would be more appropriate.
Studies have shown that repair and replace treatments have equivalent longevity after 5 years
while repaired restorations show a lower survival rate compared to replaced restorations after 10
years (15).
Until more research and guidelines are developed, the clinician must consider several
factors prior to deciding when to replace or repair posterior amalgam restorations. The majority
of factors that affect a clinician’s decision is centered around the patient. The dentist must
access and account for the patient’s caries risk, any present or future periodontal conditions, the
size and location of the restoration, the medical history of the patient, in particular, manual
dexterity, and their economic situation. The last factor could potentially be the most significant
factor as whether to repair or replace the restoration. After assessment of the restoration, the
determination of restoration prognosis and the presentation of treatment options to the patient,
the dentist will ultimately perform the preferred treatment of the patient. In the case where the
patient chooses the less expensive treatment of lower prognosis, the dentist will respect the
patient’s decision. This clinical reality makes incorporation of evidence-based care difficult in
instances where finances play a major role in the provision of treatment.
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Conclusion
The evidence-based literature on whether to replace or repair posterior amalgam
restorations in the permanent dentition is scarce and of poor quality. Future studies should be
carried out using the suggested improvements discussed in the paper, including statistically
significant sample size and a high level design study such as a randomly controlled trial or
prospective cohort. Due to the lack of good clinical evidence, we are unable to make an
evidence-based recommendation as to when to replace or repair defective posterior amalgam
restorations in the permanent dentition.
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Appendix A:
Checklist to Assess Evidence of Efficacy of Therapy or Prevention
Citation:
1. Was the study ethical? ___
2. Was a strong design used to assess efficacy? ___
3. Were outcomes (benefits and harms) validly and reliably measured? ___
4. Were interventions validly and reliably measured? ___
5. What were the results?
Was the treatment effect large enough to be clinically important? ___
Was the estimate of the treatment effect beyond chance and relatively precise? ___ If the findings were “no difference” was the power of the study 80% or better ___ 6. Are the results of the study valid?
• Was the assignment of patients to treatments randomised? ___
• Were all patients who entered the trial properly accounted for and attributed at its conclusion?
i) Was loss to follow-up less than 20% and balanced between test and controls ___
ii) Were patients analysed in the groups to which they were randomised? ___
• Was the study of sufficient duration? ___
• Were patients, health workers, and study personnel “blind” to treatment? ___
• Were the groups similar at the start of the trial? ___
• Aside from the experimental intervention, were the groups treated equally? ___
• Was care received outside the study identified and controlled for ___
7. Will the results help in caring for your patients?
Were all clinically important outcomes considered? ___
Are the likely benefits of treatment worth the potential harms and costs? ___
SCORE OUT OF 17 - ___N/A:
Please note for our purposes, “no difference” and “blinding” statements did not apply. Thus, the
score was taken over a denominator of 15.
Adapted from: Fletcher, Fletcher and Wagner. Clinical epidemiology – the essentials. 3rd
ed.
1996, and Sackett et al. Evidence-based medicine: how to practice and teach
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Appendix C: Paterson FM et al. Criteria
Initial propositions on repair/replacement of amalgam agreed by academic group
Table reproduced from: Paterson, FM, Paterson, RC, Watts, A, and Blinkhorn, AS. Initial stages
in the development of valid criteria for the replacement of amalgam restorations. Journal of
Dentistry 1995;23(9): 137-143.
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Appendix D: Hickel R et al.’s Criteria to evaluate restorations
Allocation of criteria to clinical observations
Table reproduced from: Hickel R, Roulet JF, Bayne S, Heintze SD, Mjor IA, Peters M, Rousson
V, Randall R, Schmalz G, Tyas M, Vanherle G. Recommendations for conducting controlledclinical studies of dental restorative materials. Clinical Oral Investigation 2007; 11: 5-33
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Acknowledgements
We would like to thank Dr. Carlos Quiñonez and Dr. James Leake of the Department of
Community Dentistry, Dr. Asbjørn Jokstad of Department of Prosthodontics, and Dr. Dena
Taylor of the Health Sciences Writing Centre, University of Toronto for their guidance and
expertise.
This evidence-based report was conducted as an academic requirement of DEN207Y
Community Dentistry.
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References
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