Longevity of Restorations

7/31/2019 Longevity of Restorations

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EffectiveHealth CareDental restoration:

what type of filling?s Tooth decay is one of the

most common diseases andaccounts for almost half ofall tooth extractions. Thetreatment of tooth decay bythe placement of simple,direct restorations (fillings)alone costs the NHS inEngland & Wales 173million per year.

s Dental restorations do notlast forever; over 60% of allrestorative dentistry is forthe replacement ofrestorations.

s New restorative materialsare often marketed and

introduced into practicewith limited evidence ontheir long-term clinicalperformance.

s Overall, amalgam is thedirect restorative materialof choice unless aestheticsare important. It lastslongest and is the cheapest.

s The newer generationdentine bonding agents forcomposite restorations usesome form of acidic primerand have better retentionrates than earlier generations.

s The use of cermet cements,and the composite andglass ionomer sandwichtechnique in class IIcavities, had high failurerates and cannot berecommended.

s There is significantvariation in decision makingbetween dentists.Appropriate criteria forreplacement of restorationsare needed and dentalschools should traindentists in their use in orderto reduce unnecessaryprocedures and improve

quality.s The longevity of

restorations carried out inthe better quality researchstudies suggests thatroutine clinical practicemay be producing sub-optimal results. Work isneeded to establish meansof improving the quality ofroutine practice, putting inplace incentives to promotecost-effective care andidentifying the resourceimplications.

Bulletin on the effectiveness

of health service interventions

for decision makers

Bulletin on the effectiveness

of health service interventions

for decision makers

NHS C ENTRE FOR REVIEWS AND DIS SEMINATION

APRIL 1999 VOLUME 5 NUMBER 2 ISSN: 0965-0288

This bulletin reviews theevidence of the relativelongevity and cost-effectiveness of routine

dental restorations.


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or extra-coronal, when they areplaced around (outside) the toothas in the case of a crown. Intra-coronal restorations are usuallyplaced directlyinto the toothcavity and normally consist of amouldable material that sets andbecomes rigid; the material isretained by the surrounding wallsof the remaining tooth tissue. Analternative intra-coronalrestoration uses an indirecttechnique: here an impression ofthe cavity is taken and alaboratory constructed inlay isproduced and subsequentlycemented into the prepared cavity.

The materials currently used torestore intra-coronal preparationsare: dental amalgam, compositeresins, glass ionomer cements,resin-modified glass ionomer

cements, compomers and cermets,cast gold and other alloys, andporcelain.

C.1. Dental amalgam:Dentalamalgam is an alloy of mercurywith silver and other metals suchas tin and copper to give a setmaterial that does not adhere totooth tissue and is not toothcoloured. It has been available forover 100 years, but the originalformulation of the material hasbeen modified considerably; inparticular, the addition of copperand zinc to the alloy powder hasenhanced its physical properties.The choice of alloy will have abearing on the way the material ishandled clinically and mayinfluence its long-termperformance.

There have been concerns overthe safety of amalgam, most ofwhich appear to be unjustified.The British Dental Associationhave recently concluded that:

To date, extensive research has failedto establish any links betweenamalgam use and general ill health.

Those countries which are limitingthe use of amalgam are doing so to

lower environmental mercurylevels.19

The Department of HealthsCommittee on Toxicity reviewedthe evidence on the safety ofamalgam in response to an expertreport from the EuropeanCommission and concluded thatdental amalgam is free from risk ofsystemic toxicity and only a veryfew cases of hypersensitivityoccur.20

C.2. Composite resin:There areseveral groups of composite

materials that can be classified onthe basis of their resin and fillercomponents. All are toothcoloured and are essentially amixture of filler particles,consisting of various types oftranslucent glass, embedded in amatrix of resin that binds the fillerparticles together. The originalgeneration of materials that set bya chemical reaction have beenlargely superseded by compositesthat set on the application of a

bright light. These light-curedmaterials contract (shrink) duringthe curing process. The loading of

the material with filler particlesand the size of the particles as wellas other factors have a bearing onthe physical properties of thematerial and may influence itslong-term performance. Compositeresins have also been used forinlay restorations.

The use of composite materials hasbeen supplemented with pre-treatment of tooth tissue prior toplacement. Thus, the enamelsurrounding the preparation isusually treated with a mild acidand coated with a thin resinwetting agent to improve themarginal seal and aid retention.

More recently, application of acidsand other agents to dentine hasbeen advocated to reduce leakageand further improve retention.These dentine bonding agents arerapidly evolving.

C.3. Glass ionomer cements:Glass ionomer cements are toothcoloured and adhere chemically totooth tissue. They are similar tocomposite resins in that theyconsist of a matrix and embeddedfiller particles; however, their

formulation and setting reactiondiffer.

C.4. Resin-modified glassionomer cement and compomers:New generations of materials areessentially glass ionomer cementsthat contain resin. The resin-modified materials are more akinto glass ionomer cements, whilstthe compomers are more likecomposite. Again, these materialsare tooth coloured and areavailable in a variety of differentformulations.

C.5. Cast gold and other alloys:Cast gold or alloy restorations arecalled inlays and are made outsidethe mouth in an indirecttechnique that requires laboratoryfacilities. The advantage of castinlays is their strength in thinsections; they can be used toprotect weak tooth tissue. Castrestorations are inherently moreexpensive because of the cost of

the alloy and the laboratoryinvolvement. They are cementedin place with either traditional

General patient factors

Exposure to fluoride

Caries status General health Parafunction Age (particularly child/adult) Xerostomia Socio-economic status Diet

Table 1 Factors influencing the decision to restore

a) Possible objective influences

Incentives (payment structure: salaried,government funded, private, insurance)

Clinical setting (university, privatepractice, general dental practice,specialist practice, field trial)

Country (local treatment fashions) Clinicians diagnostic, treatment and

maintenance philosophy (influenced bytraining) Patient preferences

b) Subjective factors

Tooth factors

Tooth locat ion/type/size Cavity design/type Dentition Occlusal load Tooth quality e.g. hypoplasia

Operator and restoration processfactors

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

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dental cements or can be usedwith more modern bondingsystems.

C.6. Porcelain:Porcelain crownshave been made for many yearsfor the anterior part of the mouth.With the introduction of new andstronger porcelains, and thedevelopment of cementingsystems, it is now possible toconstruct inlays from porcelainthat can be cemented into theprepared cavity. A variety ofporcelains are available along witha variety of production processes,all of which can be used with anumber of cementing agents.

D. Direct methodsThis section reports on thelongevity of directly placedmaterials: amalgam, composite andothers materials such as glassionomer cements (GIC).

The findings from the review,presented below, report longevityfrom studies generally carried out

under optimal conditions. Theseare reported in order to makesensible comparisons of thelongevity of different materials.The longevity reported from thesestudies is unlikely to be achievedin the conditions of routine generaldental practice (see Section G).

D.1. Amalgam restorations:Thestudies of amalgam show goodrates of survival compared withmost of the other materials

examined in this review.

15

At threeyears, no study showed failure andat 10 years, less than 10% ofrestorations had been replaced (Fig1), although by this time therewere no data on 52% ofrestorations. In addition, theseresults may shed the mostfavourable light on amalgambecause patients were often pre-selected before entry into the studyon criteria such as intact dentition,good oral hygiene and absence ofactive periodontal disease.

The longevity was also affected bythe skill of the operator in placing

the restoration and by the level ofagreement on whether to replace arestoration.27,38,61

There appeared to be no greaterreduction in survival of largeramalgam restorations than smallerones.33,63,64 The evidence that twosurface restorations survive longerthan three surface restorations wasinconclusive.27,65,66 There were nodifferences in survival betweenpolished and unpolishedamalgams over the 36 months offollow-up, but this is a relativelyshort time to assess this factor.50,6769

There was some evidence tosuggest that dispersed phase, highcopper alloy amalgams wereassociated with greater survivalthan other amalgams.27,30,38,53,60,65,66

D.2. Composite restorations:Forty-eight studies involvedcomposite restorations but withoutuse of dentine adhesives.15 Twenty-five studies involved dentinebonding systems. In the vastmajority of cases, these studiesinvestigated cervical cavities

where retention of the restorationrelied exclusively on the bondingmechanism to resist loss. Thesestudies rarely reported the site ofthe filling and thus it is impossibleto assess whether survival isdifferent for composites placed inthe front or back teeth.

Composite without dentine bonding

Many studies poorly cataloguedthe numbers of subjects, teeth, thetooth types, the materials and

types of cavities and also failed todescribe correctly and simply thesurvival data.

Overall, the studies demonstratedgood short-term survival (two andthree years).31,32,7072 Studiesshowing poor results wereexplained on the grounds of poortechnique or unconventionalcavity design.7376 However, the fewstudies with at least five yearsfollow-up showed signs ofsignificant failure, particularly themulti-centre studies.77,78

Survival of composite wasinfluenced significantly bymaterial type, with light-curedmicrofilled and densified filledmaterials being more successfulbetween 6.5 years and 8.5 years,

while the older autopolymerisingmacrofilled composites were mostsuccessful up to 6.5 years. Thestudies did not present dataneeded to analyse the impact ofoperator factors and other effectmodifiers.

Composite with dentine bonding

In the systematic review, dentinebonding agents were classified intothree main groups:79 those evolvedfrom the earliest resin materialswhich simply impregnated the

smear layer (group 3), thosemodified to enhance impregnationand to alter the smear layer (group2), and the more modern materialswhich use an acidic primer (group1). Dentine bonding materials haveoften been tested in cervical cavitiesand in this situation the failure ofthese materials is rapid, beginningwithin one year (Fig 2).8083 Thisfigure is based on a combinationof included studies of cervicalrestorations by the type of dentine

bonding agent used. Unfortunatelyit is not possible to presentadditional figures showing othervariables because of the lack ofdata reported.

More recent materials that usesome form of acidic primer (groups1a and 1b) demonstrate improvedsurvival compared to groups 2 and3. There appeared to be littledifference between materialsclassed in group 1a (those whichuse phosphoric acid) and group 1b

(those using other acids). Studiesof group 1a have shorter follow-up. The reason for the enhanced

4 EFFECTIVE HEALTH CARE Dental restoration: what type of filling?

Fig 1 Survival of amalgam restorations forpermanent teeth (paired and unpaired studies) 2263

1

0.9

0.8

0.7

0.6

0.50 12 24 36 48 60 72 84 96

Follow up time in months

Unpaired Paired


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performance of group 1 comparedto the other groups may be theimprovements in the dentinebonding system but could also bethe etching of enamel that may bea side effect of using acids.

The results of these studiessuggest that enamel etching (withor without enamel bevel) isclinically effective for long-termretention.81,111 Mechanical retentionis also effective for the retention ofrestorations.112 Newer materials(group 1) appear to perform betterthan older materials (groups2/3).92,102 Use of all dentine bonding

systems reduced patient pain afterplacement.

Significant problems of inter-pretation have been encounteredbecause of poorly designedstudies, the appreciation thatocclusal factors may have aninfluence on retention, and lack ofdetail in papers, especially relatingto losses to recall and techniqueused.

D.3. Comparison of amalgamwith composite:Twenty-sixstudies in this review comparedamalgam and compositerestorations.15 In studies comparingthe two materials in an unpaireddesign (teeth from differentpatients), amalgam was superior,always having greater survival. Insimilar studies using a paireddesign (teeth in the same person)the differences in favour ofamalgam were less but stillstatistically significant.

D.4. Other materials:Forty-fourstudies which compared a number

of different materials wereincluded in the review.15 Many ofthese studies were of small sizeand short duration. Only the keyfindings are summarised in thisbulletin.

Overall it appears that indeveloping countries, glassionomer cement inserted with atechnique which removes cariesusing hand instruments (ART) hasreasonable retention rates butother factors have yet to beassessed. Conditioning of dentineprior to placement of glassionomer cement does not seem toaffect longevity (although this is

based on only two studies).113115

Several restorative materials werereported as having low survivalrates. These include cermetcement when used to restoreeither deciduous or permanentteeth 116118 and GIC when used inthe composite/GIC sandwichtechnique.75,119 Improvements inthe physical properties of GIC mayimprove the potential for thesuccess of this type of restoration.Gallium also had high failure rates

and cannot be recommended.120

E. Indirectmethods: inlaysTwenty-seven studies wereincluded which examined thelongevity of inlays using ceramics,gold and composites.15 Thesestudies often had few patients andwere of a weaker design. Inaddition, few undertook any formof comparison.

Overall, there is no importantdifference between porcelain andcomposite inlays (see Fig 3).However, these studies (one ofwhich compares both materials)121,122

suggested that some types ofporcelain inlays were significantlybetter than composite inlays.

There is limited evidence to

support the use of a resincompared with a GIC as lutingcements.123126 There is some

evidence, although limited, tosupport the use of heat cure inaddition to light cure in compositeinlays.127 There are some reports ofpost-operative pain, for example,with inlays and these need furtherinvestigation.128131

One small study comparedporcelain inlays with amalgam andfound identical survival at twoyears.47 There are no long-term data.

F. Cost-

effectivenessThe 30 economic studies that wereidentified were of poor quality15

and did not provide sufficientinformation to enable the cost ofrestorations to be constructed withany degree of confidence. The datawere, therefore, supplemented byinformation provided by dentistson the time taken to carry outrestorations in order to undertakea cost-effectiveness comparison ofthe filling materials (see Appendix

A). A summary of the results isshown in Table 2.

Whilst these results areapproximate and should be treatedwith caution, amalgam clearlydominates composite and inlaysacross all time periods consideredbecause it is cheaper and hasbetter survival, and thisdominance was robust to a widerange of changes in theassumptions. Composite was

between 1.7 and 3.5 times moreexpensive than amalgam togenerate one tooth year, a finding

Fig 2 Survival of composites in cervical cavitiesby type of bonding agent48,80110

1

0.8

0.6

0.4

0.2

00 6 12 18 24 30 36 42 48


1a 1b 2 3

Fig 3 Survival of porcelain and compositeinlays 47,123,125, 126, 130150

1

0.9

0.8

0.7

0.6

0.5

0 6 12 18 24 30 36 42 48 54 60


Composite Porcelain


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which is in line with previousestimates from better qualityeconomic evaluations149,150

Composite would provide morevalue for money than amalgamover the first five years only ifpatients valued tooth years withcomposite nearly twice as highlyas with amalgam for aestheticreasons. However, the studiesincluded in the review did notmeasure patients quality of life or

valuations of tooth years withdifferent restorations.

G. Generalapplicability offindingsThe majority of studies ofsufficiently high quality to beincluded in this review were

undertaken in dental schools,whereas virtually all restorationsare treated in a primary dentalcare setting. This affects the extentto which individual studies can begeneralised to the widerpopulation. The advantage of theacademic setting is that it is easierto control the study as well astrain and calibrate operators andexaminers. In addition, many ofthe financial and time factors thatbeset practitioners are removed.

The data on the relative longevityare likely, therefore, to be morevalid. However, using a setting

that is quite different from thatunder which most patients aretreated has disadvantages. It mayresult in different types of patientsbeing included, different amountsof time being taken, differentexpertise and payment systemsetc. Any one or combination ofthese factors may affect longevityto a greater or lesser extent.

Studies not included in thesystematic review which used

subjective criteria, and are morerepresentative of the situationprevailing in general dentalpractice, make it clear that thelongevity of amalgams151153 andcomposite152 is considerably lessthan that achieved in theprospective studies included in thesystematic review. Glass ionomerrestorations have been in use for amuch shorter time but they, too,have a high replacement rate incross-sectional studies.150

Wide variation both within andbetween dentists treatmentdecisions has been reported, and isobviously an important issue whentrying to identify the point at whicha restoration is replaced.8,17,154,155

This is an issue that could beappropriately addressed by dentalschools.18 There is a differencebetween identifying how long arestoration could last if objectiveoutcome measures were used, andhow long it is allowed to last when

individual practitioners use theirown criteria. It is claimed that thelikelihood of having a restoration

replaced is more than doubledwhen a patient changespractitioner.156

H. ImplicationsH.1. Implications for policy and

practice:

The dental manufacturingindustry is constantlypromoting the use of newmaterials. These are marketedand introduced into practicetypically without reliable andcomprehensive trials involvingpeople in everyday situations.

This has created a high level ofuncertainty about the absoluteand relative merits of differentmaterials. Mechanisms shouldbe sought to ensure that theintroduction of dental materialsinto clinical practice isincorporated into any new NHSregulatory structures designedto promote the quality ofhealth care.157

The good results in terms oflongevity of restorations

achieved in the optimallydesigned studies demonstratethat routine clinical practicemay be producing sub-optimalresults. This raises the issue ofhow clinical practice can beimproved so that restorationlongevity in all settingsapproaches the best that can beachieved and what the resourceimplications of this may be.

Appropriate incentives(including the fee structure)

which reward cost-effectivepractice should be exploredand evaluated. This is an areathat might be worthconsidering for inclusion in theNational PerformanceFramework.

There is insufficientinformation to be able to assessthe likely impact of bettertraining, more care whencarrying out a restoration,protocols to ensure the optimal

process of restoration, theimpact of the time spent, andremuneration systems etc.


Tooth year = the average number of years a restoration survives before failure over 5 or 10 years

= cost of initial restoration + cost of replacement at time of failure with the same material

Amalgam

Composite

Inlay

Toothyears

4.85

4.37

3.30

21.56

33.01

130.00

Cost pertooth year

4.44

(5.05)

7.54

(8.19)

39.39

(41.26)

Toothyears

9.31

7.35

-

32.93

91.66

-

Cost pertooth year

3.54

(3.92)

12.47

(11.87)

-

5-year time period 10-year time period

Table 2 Cost per tooth year of three main classes of restoration (discounted at 5%)


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Currently, variations betweendentists in the way they judgeexisting restorations increasesthe probability of replacementrestorations when patientschange dentists. In order toreduce unjustified variation inthe diagnostic level at whichrestorations are replaced thereis a need for clarification ofappropriate criteria forreplacement of restorations.Dental schools should traindentists in using standardiseddefinitions of what constitutesa failed restoration and toadopt appropriate maintenancepolicies. This would protect the

public against unnecessaryprocedures, reduce costs andimprove the quality ofprofessional decision-making.

Dental amalgam is the directrestorative material with thelongest duration and from theperspective of the NHS is oflower cost. Unless there is acontra-indication (which isusually aesthetics orpregnancy), it is recommendedfor routine use whereverpossible. All NHS dentaltreatment provided by generaldental practitioners in Englandand Wales is reported to theDental Practice Board. Whilstthis database provides a recordof actual patterns of practice, itis of limited use for comparingthe longevity of differentrestorative and otherinfluences because subjectivecriteria are used which varybetween practitioners.

H.2. Implications for research: Co-ordinated research in

primary dental care is neededto assess the effects ofclinicians skill, tooth type,cavity type and material typeon restoration survival, takinginto account the evolvingdisease patterns.

This requires the establishmentof multi-centre, multi-operatorstudies with stratification oftooth type, cavity type and

other effect modifiers (such asfluoride availability and oralhygiene), for assessment

periods of greater than 10years. It has been suggestedthat pragmatic clinical studiesusing a representative group ofpractitioners, on a large sampleof their patients, may be oneway to obtain the internalvalidity of a randomisedcontrolled trial and thegeneralisability of purelyobservational clinical studieswhich this review has largelyignored because of theirsubjective nature!158 Withappropriate clinical andeconomic evaluation suchstudies would allow anoverview of a materials

spectrum of performance indifferent clinical environments.

In order to obtain more reliablecost and relevant outcomeestimates, a long-termprospective cohort study isneeded across different dentalsettings. The cost profile foreach material type for differenttypes of restorations could beconstructed and used inconjunction with the evidencerelating to the longevity of

each restorative material.

Appendix A Research methods

This bulletin is based on asystematic review15 which used awide search for studies in anylanguage using a large number ofgeneral and specialist databases,hand searching of key dental

journals and searching of abstractsfrom conference proceedings.21 Ofthe 652 relevant papers, 253(representing 195 studies) had theminimum core of data required forinclusion.

Inclusion criteria

Use of objective outcome measures

Many authors did not state or usecriteria for deciding when arestoration had failed and neededto be replaced. In these studies it istherefore impossible to distinguishbetween the objective factorsinfluencing longevity (the main

aim of the review) and subjectiveinfluences. In other words it is notpossible to establish whether a

restoration was replaced because ithad failed or because a cliniciansubjectively deemed it to havefailed. For example, one clinicianmay have decided to replace anold corroded amalgam filling whileanother may have polished it. Forthese reasons studies wererequired to have measuredoutcome (the decision to replace arestoration) using stated criteria.For example, the criterion failuredue to secondary caries was notaccepted unless the paper clearlystated how secondary caries wasdiagnosed.

Study design

Whilst new restorative materialsare tested using laboratory-basedstudies and animal experiments toexamine the chemical, physicaland biological properties ofmaterials, these studies cannot beused to predict their performancein practice. Thus, only studieswhich looked at performance ineither experimental or clinicalsettings were included. The reviewincluded randomised controlledtrials (RCTs), quasi-experimental

designs and non-experimentalstudies which surveyed thelongevity of restorations in a cohortof patients with good follow-up.

Cost-effectiveness

In order to compare the cost-effectiveness of different fillingmaterials a review of the economicliterature was undertaken. Thiswas supplemented by informationfrom nine general dentalpractitioners in Wales who

provided data on the time taken toplace a restoration and subsequentreplacements. These times weremultiplied by the estimatedaverage hourly cost of dental staff(62.50) preparing and completinga restoration. The cost of a fillingwas calculated by adding staffcosts to the different materialcosts. Thus the costs used in theeconomic model were developedfrom the bottom up rather than byusing the fee schedules. The costs

for the initial filling werecombined in an economic modelwith estimates of the number of


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years a restoration survives (toothyears) based on survivalprobabilities derived from thesystematic review. The economicevaluation was undertaken fromthe perspective of the NHS andused tooth yearsas the outcomemeasure for each material typeand the cost per tooth year as thecost-effectiveness ratio.15

Table 2 also presents the discountedcost per tooth year which takesinto account the fact that benefitsand costs are spread over time.

Appendix B Glossary

Carious describes a toothaffected by caries (decay).

Cavity carious lesion or area ofdestruction in a tooth.

Cervical (Class V) concerning theneck of the tooth, near the gum.

Dental caries (tooth decay)disease resulting in thedemineralisation, cavitation andbreakdown of calcified dentaltissue by microbial activity.

Direct inlay method ofconstruction of an inlay using awax pattern taken directly from atooth preparation and not from amodel.

Direct intra-coronal restorationinvolves a direct insertion of apliable material (such as dentalamalgam, composites and glassionomer cement) into thepreparation which subsequentlybecomes rigid and is retained by

the surrounding walls.

Dispersed phase a specificformulation of amalgam alloypowder.

Effect modifier factor whichmodifies the effect of anintervention.

Enamel bevel a sloping surface, ata cavity margin.

Etching partial demineralisation

of a selected area of toothsubstance.

Erosion irreversible loss of toothsubstance by a chemical processthat does not involve bacterialaction.

Extra-coronal restoration acrown.

Fissure a small groove or troughin the enamel of the tooth.

GIC lute a cement used in theplacement of an inlay.

Indirect inlay method ofconstruction of an inlay by usingan impression of the tooth.Indirect technique is more suitable

for complex cavities, preparationswith veneers, and full crowns.

Occlusal load the load on a toothor filling due to the forces of bitingor clenching.

Parafunction abnormal occlusalloads placed on teeth because ofhabits or function of a patient.

Pit a small depression in theenamel of a tooth.

Recurrent caries dental cariesthat extends either beneath orbeyond the margins of arestoration.

Resin a low viscosity liquidmonomer that is applied tothe cavity usually to improveadaptation of the material.

Root canal (or endodontic)treatment the treatment of adamaged necrotic pulp in atooth to allow the tooth toremain functional in thedental arch.

Secondary caries see recurrentcaries.

Smear layer the loosely attachedmineral and organic debris left onthe surface, particularly of dentine,after it has been mechanicallyinstrumented.

Xerostomia dryness of the mouthdue to a lack of saliva.

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APRIL 1999APRIL 1999

This bulletin is based on a systematic

review15 of the longevity of dentalrestorations commissioned by the

Scottish Office and carried out by a teamat the Dental School, University of WalesCollege of Medicine led by Professor

Paul Dummer. Team members: BarbaraChadwick, Frank Dunstan, Alan Gilmour,Rhiannon Jones, Ceri Philips, Jeremy

Rees, Stephen Richmond, Julia Stevensand Elizabeth Treasure.

The bulletin was written by ProfessorTrevor Sheldon and Dr ElizabethTreasure and edited and produced bystaff at the NHS Centre for Reviews andDissemination, University of York.

Acknowledgements:

Effective Health Carewould like toacknowledge the helpfulassistance of the following who

commented on the text:

s Paul Batchelor, UMDS of Guys and

St Thomass

s John Beal, Leeds HA

s Linda Davies, University of York

s Alison Evans, University of Leeds

s Tony Fuge, GDP, Cardiff

s Tony Hawkes, Department of Health

s Paul Hodgkin, Centre for Innovation

in Primary Care, Sheffield

s David Landes, County Durham HA

s Ivar Mjr, University of Florida College

of Dentistry, USA

s Peter Nicklin, University of York

s Hideo Ogura, The Nippon Dental

University, Japan

s Colin Pollock, Wakefield HA

s Jim Ralph, Postgraduate Dental Dean,

Northern & Yorkshire

s John Renshaw, GDP, Scarborough

s Elizabeth Roberts-Harry, University

of Leeds

s Stephen Singleton, Northumberland

HA

s Mary Turner-Boutle

s Martin Tyas, University of Melbourne

School of Dental Science, Australia

s Colin Waine, Sunderland HA

s Nairn Wilson, University of Manchester


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