SaudiJOralSci1130-1892253 051522

S J Oral Sci Vol 1 No 1 30 January 2014
Saudi Journal of Oral Sciences

Factors infuencing Saudi dental students
preference of amalgam or composite for
posterior dental restorations
Sharat Chandra Pani, Mohammad Fawaz Al Abbassi
1
, Abdulrahman Daham Al Safan
1
, Maged Abdulrahman
Al Sumait
1
, Ahmed Nassir Shakir
1
Department of Preventve Dentstry, Riyadh Colleges of Dentstry and Pharmacy,
1
Intern, Riyadh Colleges of Dentstry and
Pharmacy, Riyadh, Kingdom of Saudi Arabia
Abstract
Aim: The aim of this study was to tabulate the factors efectng Saudi dental students selecton of a posterior restoratve dental
material and compare those factors between a private and a government dental school in Riyadh.
Materials and Methods: The sample comprised of 267 students studying in both the private dental college (67 males, 75 females)
and the government dental college (55 males, 70 females) in their last 3 years of clinical training. The students were administered
a structured questonnaire specifcally designed for the purpose afer obtaining informed consent. Responses were compared
between the students of each school using the chi-square and Mann-Whitney U test. Each students responses to amalgam
and composite were measured using the Wilcoxon signed rank test.
Results: Overall composite resin was the material preferred by a majority of the students regardless of the type of school.
Students in both the private and the government college were likely to give higher scores for composite than amalgam. A
majority of students in both schools felt that amalgam could not be completely replaced with composite. When asked to list
the main drawbacks of amalgam and composite most of the respondents answered lack of esthetcs for amalgam, while they
listed micro-leakage as the greatest drawback of composites.
Conclusion: The fndings of our study suggest that dental students in the Kingdom of Saudi Arabia seem to possess the ability
to work confdently with posterior composite resins and seem to be comfortable in doing so; however, there is a signifcant
diference in the factors infuencing their choice of material.
Key words: Amalgam, composite, dental students
Introducton
Advances in composites have revolutonized the management
of posterior teeth afected by caries, facilitatng a minimal
invasive approach.
[1,2]
As dentsts the world over switch to
minimal invasive restoratve procedures and as patents get
more demanding with their esthetc demands, composites
have slowly begun to replace amalgam as the posterior
restoraton of choice in many private practces.
[1-5]
Surveys
in the USA, Europe and Brazil suggest that despite a greater
acceptance of the use of composite resins in posterior teeth,
teaching of newer restoratve techniques has not kept pace
with advances in the materials sciences.
[6,7]
There have also
been reports of a need to address the potental confict
between restoratve techniques taught in dental schools and
the materials used by dental practtoners.
[8-10]
Preference for amalgam or composite as a posterior
restorative material has been said to depend upon
patient preference, ease of use, time taken and
perceptons of durability.
[11]
While there is a vast pool
of data for clinicians reasons for choice of material,
[12]

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ORIGINAL ARTICLE
Address for correspondence:
Dr. Sharat Chandra Pani, Department of Preventive Dentistry
Riyadh Colleges of Dentistry and Pharmacy, PO Box 84891,
Riyadh 11681, Kingdom of Saudi Arabia.
E-mail: sharat@riyadh.edu.sa
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Pani, et al.: Students preference of posterior restorative material
relatvely less is known about factors infuencing these
choices among students or their level of comfort with
each of these materials. In the past few years there
have been a series of papers focusing on the teaching
of posterior restoratve techniques in schools across the
world.
[6,10,13]
While these papers have focused on the
curricula of diferent schools, few have atempted to
study the impact they have had on student percepton
and preference of posterior restoratve material.
The system of dental educaton in Saudi Arabia has
undergone a rapid expansion in past decade with the
establishment of several new government, as well as
private dental schools. While the topics covered in both
government and private schools are similar, with the
syllabus being regulated by the same higher authority,
there are diferences in the structure of the clinical hours
as well as the method of teaching these courses. While
the course in the government school is taught over
5 years in additon to 1 preparatory year, the course in
the private school is taught over 12 semesters spanning
a total of 6 academic years. The government school in
queston had a traditonal distributon of students across
departments, with students performing required tasks in
each department; whereas the private school followed
a system of comprehensive clinics where the entre
dental treatment of a patent was carried out by the
same student on a single clinical foor with all specialists
available for consultaton and supervision rather than
fxed departments dealing with only specifc procedures.
Despite the rapid growth of dental educaton in Saudi
Arabia, there is scant data on student attudes toward
the placement of posterior restoratve materials in the
Kingdom in partcular or the Middle East in general.
Given the current scenario, we decided to tabulate the
factors effecting Saudi dental students selection of a
posterior dental material and compare those factors
between a private and a government dental school in Riyadh.
Materials and Methods
The study was conducting after obtaining ethical
clearance from the research center of the Riyadh
Colleges of Dentstry and Pharmacy.
Development of the questonnaire
A pool of questons was prepared afer reviewing the
literature and interviewing both fnal year students
and instructors of the private college. Using the most
common responses the questionnaire was then
reduced to 11 items that were thought to most refect
the concerns of both students and instructors alike.
These were then framed in the form of a structured
questonnaire and then administered to fve students
who were blinded as to the purpose of the study. Afer
minor modifcatons in the format the questonnaire was
fnalized. The fnal questonnaire comprised of 11 main
questons, excluding demographic data. The questons
concerned with the factors afectng preference for
amalgam (Q5) and composite (Q6) were further
subdivided, using the most common factors cited in the
queston pool. The responses to both these questons
were standardized and scored on a four-point Likert type
scale, with 1 indicatng that the factor had no infuence
and 4 indicatng that the factor was very infuental.
A pilot questonnaire was administered as a pilot to
20 students and re-administered to those students afer
1 month to test for reliability using the Cronbachs alpha
test.
[14,15]
Once the reliability of the questonnaire had
been established, the questonnaire was distributed to
the study populaton.
Data collecton
The sample comprised of 267 students studying in both
the private dental college (67 males, 75 females) and
the government dental college (55 males, 70 females)
in their last 3 years of clinical training. The students
were administered the questonnaire by one of the
investgators afer obtaining informed consent.
Statstcal analyses
All data was coded and analyzed using SPSS ver.19 data
processing sofware. The responses between groups
to questons with categorical answers were compared
using the chi-square test, with the z test used to measure
specifc responses between students of the government
and private school. The questons which were scored on
the Likert scale were compared using the Mann-Whitney
U test. The responses of each student for amalgam were
paired with their responses for composite and signifcant
diferences were measured using the Wilcoxon signed
rank test. The test was run separately for the students
of the government and the private school and was
tabulated so as to ascertain a diference in the reasons, if
any, for the students preference of a partcular material.
Results
When the questions regarding theoretical and pre-
clinical training in amalgam were considered there was a
signifcant diference in the responses of the students in
the government and private schools. While the students
in the government school felt that their studies in both
amalgam and composite were equal, students in the
private school reported that their studies on amalgam
were greater than their studies on composite [Table 1] .
When the questons regarding clinical skill and comfort
while using each material were compared we found
that overall composite resin was the material preferred
by a majority of the students regardless of the type of
school, with most respondents saying that it took less
tme to prepare a cavity for composite resin. However,
students in the government school were more likely to
state that their preference of material did not mater,
or that they took the same tme in preparing a cavity for
both amalgam and composite [Table 2].
When the responses for factors influencing their
preference of material were compared between the
private and the government school [Table 3], we found
that the diference in percepton difered according
to the material used. When it came to amalgam, a
signifcantly higher number of students in government
school believed that they would choose amalgam
because it was an easier material for them to handle,
while the only reason where students in the private
school assigned a higher score to amalgam was the
consideraton of cost. Students in the government
school tended to assign higher scores to amalgam
than students in the government school for most
other questons, even though this diference was not
Table 1: Students responses on questons regarding their training in the use of amalgam and composite
Type Chi- square Sig
Government Private
Theoretcal knowledge of dental restoratve
materials:
My studies on amalgam are more comprehensive 6 57
My studies on composite are more comprehensive 21 28 52.26 0.0001
*
My studies on both are equal 98 57
Pre-clinical training for handling dental
restoratve materials:
I have had more training with amalgam 20 88
I have had more training with composite 17 36 95.16 0.0001
*
My training for both is equal 88 18
*Signifcant at P < 0.05
Table 2: Students responses on questons regarding their clinical ease in the use of amalgam and composite
Type Chi-square Sig
Government Private
How long does it take for you to prepare a
simple class I restoraton using amalgam or
composite?
Preparing for amalgam is more tme consuming
than composite
68 106 12.012 .002
*
Preparing for composite is more tme consuming
than amalgam
21 13
It takes me about the same amount of tme for both 36 23
Which material do you personally prefer? I prefer using amalgam 27 10
I prefer using composite 62 116 30.928 .000
*
It does not mater to me 36 16
Table 3: Diferences between students in the infuences afectng usage of amalgam and composite
Type of school Amalgam Composite
Mean rank Mann-whitney U Sig Mean rank Mann-whitney U Sig
More lectures taken on this material Government 131.41 8551.500 127.25 8031.500 .166
Private 136.28 .591 139.94
Instructors prefer that I use this material more ofen Government 137.54 126.92 7990.500 .143
Private 130.88 8432.500 .467 140.23
Patents prefer this material Government 136.11 117.70 6838.000 .000*
Private 132.14 8611.000 .663 148.35
This material is easier for me to use and handle Government 151.51 101.76 4844.500 .000*
Private 118.59 6686.500 .000* 162.38
The propertes of this material make it more ideal Government 131.47 127.17 8021.000 .159
Private 136.23 8558.500 .599 140.01
The cost of this material makes it a beter choice Government 115.94 121.10 7262.000 .008*
Private 149.89 6618.000 .000* 145.36
Cavity preparaton is much easier with this material Government 141.11 112.72 6214.500 .000*
Private 127.74 7986.500 .133 152.74
statstcally signifcant. In the case of composite resins
the students in the private school assigned higher
scores to composite for all questons when compared
to those in the government school. The scores were
signifcantly higher when it came to the questons that
pertained to patent percepton, ease of use, cost of
the material and cavity preparaton.
When the responses of each student to the questons
regarding amalgam and composite were paired and
analyzed it was found that the students in both the private
and the government college were likely to give higher
scores for composite than amalgam [Table 4]. In the
private schoo,l a signifcantly higher number of students
felt that they had more lectures taken on composite,
their instructors preferred they use composite, their
patients preferred composite restorations and that
composite was an easier material to use and prepare
cavites for. They perceived no signifcant diference
in the cost of the amalgam or composite restoraton.
However, they felt that the propertes of composite were
signifcantly inferior to those of amalgam.
The responses of the students in the government school
were similar with regards to the lectures taken, patent
preference, cost and ease of cavity preparaton and
material propertes. However, unlike the students in
the private school, they did not feel that composite was
easier for them to use and handle. A greater number of
them felt that amalgam was easier to handle, though
this diference was not statstcally signifcant.
When the students attude toward the restoratve
materials and their views on the future of amalgam
were compared [Table 5], we found that a majority
of students in both schools felt that amalgam could
not be completely replaced with composite. However,
the z test showed that a signifcantly higher number
of students in the private school felt that amalgam
would be replaced by composite resin restoratons. A
greater number of students felt that composite was a
good substtute for amalgam although this diference
was signifcant only in the private school. There was
a signifcant diference in the percepton of longevity
of composite resin restorations in the mouth of a
patent with good oral hygiene. While students in the
private school felt that in such a patent a posterior
composite restoraton would last as long as amalgam,
a significantly higher number of students in the
government school felt the opposite.
Table 4: Diferences between government and private students in factors afectng usage of amalgam and composite
Ranks
a
Private Government
N Mean rank Z Sig N Mean rank Z Sig
More lectures taken on Composite -
More lectures taken on Amalgam
Negatve Ranks
b
27 30.96 15 19.00
Positve Ranks
c
49 42.65 3.302
c
.001 36 28.92 3.722
c
.000
Ties 66 74
Total 142 125
Instructors prefer that I use
Composite more ofen - Instructors
prefer that I use Amalgam
Negatve Ranks
b
32 44.16 23 23.65
Positve Ranks
c
66 52.09 3.656
c
.000 36 34.06 2.678
c
.007
Ties 44 66
Total 142 125
Patents prefer Composite - Patents
prefer Amalgam
Negatve Ranks
b
11 23.45 12 29.33
Positve Ranks
c
89 53.84 7.897
c
.000 71 44.14 6.406
c
.000
Ties 42 42
Total 142 125
Composite is easier for me to use and
handle - Amalgam is easier for me to
use and handle
Negatve Ranks
b
8 13.50 32 33.30
Positve Ranks
c
91 53.21 8.377
c
.000 39 38.22 1.248
c
.212
Ties 43 54
Total 142 125
The propertes of composite - The
propertes of Amalgam make it more
ideal
Negatve Ranks
b
54 45.61 43 33.55
Positve Ranks
c
39 48.92 1.084
b
.278 22 31.93 2.548
b
.011
Ties 49 60
Total 142 125
The cost of composite - The cost of
Amalgam makes it a beter choice
Negatve Ranks
b
45 43.62 30 25.50
Positve Ranks
c
33 33.88 2.141
b
.032 24 30.00 .201
b
.841
Ties 64 71
Total 142 125
Cavity preparaton is much easier
with composite - Cavity preparaton is
much easier with Amalgam
Negatve Ranks
b
12 22.79 14 25.64
Positve Ranks
c
92 56.38 8.124
c
.000 62 41.40 5.821
c
.000
Ties 38 49
Total 142 125
a
Ranks tabulated using Wilcoxon Signed Rank Test,
b
Negatve Ranks indicate a preference for Amalgam,
c
Positve ranks indicate a preference for composite
When asked to list the main drawbacks of amalgam and
composite [Table 6], most of the respondents answered
lack of esthetcs for amalgam, while they listed micro-
leakage as the greatest drawback of composites.
Discussion
The debate to use amalgam or not is as old as dentstry
itself;
[16]
however, with the availability of a viable
alternate in posterior composite resins the debate in
literature seems to be moving toward when, rather
than if, amalgam can be completely replaced.
[1]
As the
use of posterior composite resins has been increasing
in practces the world over, the queston of whether
our educaton of students in these materials have kept
place has also been studied in literature.
[8,9,17-19]
The
primary aim of this study was to view this debate from
the perspectve of the student rather than the educator.
Given the trends among patents as well as dentsts
the world over,
[3-5,20-22]
it is perhaps not surprising that
students in both the schools we studied tended to favor
composite over amalgam in posterior teeth. This fnding
is similar to those reported from several European and
American dental schools in the past few years.
[4,8,9,12,18,19]
We found that students in the private school felt they
had more emphasis on amalgam than composite, while
those in the government school felt that their training
in both materials was equal. The curriculum of both
schools is regulated by the Ministry of Higher Educaton,
Kingdom of Saudi Arabia; ensuring that though mildly
diferent, the overall structure of the courses is similar.
Given this fact a possible reason for this diference
could be the nature of the clinical environment of the
schools. While the government school has a free clinic,
the patents pay for treatment in the private school, thus
perhaps indirectly infuencing the type of restoratve
material placed. It was interestng to note that in both
schools students agreed that composite resin was the
material the patent was likely to prefer over amalgam.
The fndings of this study suggest that exposing students
to a situaton where they have to convince patents, not
only of the need for treatment, but also of the need to
pay for it places them in a positon where they are more
likely to be in tune with the demands and needs of the
patents they are likely to encounter in their practces.
Given the above argument it is perhaps natural then that
the students in the government school were ambivalent
as to their preference of material, while those in the
private school were significantly more in favor of
composite resin restoratons over amalgam. While one
can appreciate the comfort of the students with the
use of composite resin, a lack of ease with amalgam
in the students of the private college is a worrisome
trend. While the concept of an amalgam-free dental
Table 5: Comparison of students opinion about the greatest drawback of both amalgam and composite
Type of school Chi-square Sig
Government Private
In your opinion, what is the greatest drawback
(negatve aspect) of Amalgam
Non-esthetc 86
a
91
a
Destructve preparaton 16
a
35
b
Thermal expansion 7
a
1
b
15.014 .005*,
a
Corrosion 7
a
12
a
Mercury toxicity 9
a
3
b
In your opinion, what is the greatest drawback
(negatve aspect) of Composite
Micro-leakage 46
a
68
a
Technique sensitve 59
a
68
a
13.934 .003*,
a
Takes more tme 4
a
3
a
Poor clinical survival 15
a
2
b
Values in the same row and subtable not sharing the same subscript are signifcantly diferent at P < 0.05 in the two-sided test of equality for column proportons. Cells with no
subscript are not included in the test. Tests assume equal variances.
Table 6: Comparison of students percepton of the future of amalgam and the viability of composite
Type of school Chi-square Sig
Government Private
Do you believe that the usage of amalgam in dental practce should
be completely discontnued and replaced with the contnuously
evolving composite?
Yes 42 65
No 83 76 4.305 .038*
Do you believe composite is a good substtute for amalgam? Yes 69 99 6.006 .014*
No 56 43
In the mouth of a cooperatve patent, do you believe composite
restoratons would last longer than amalgam ones?
Yes 63 82 1.446 .229
No 62 60
*The chi-square statstc is signifcant at the 0.05 level
school has been foated in literature,
[23]
amalgam stll
comprises a signifcant porton of the restoratons placed
in Saudi Arabia, and the country is far from the stage of
amalgam-free dentstry.
The students in both schools felt at ease with the use
of composite resin restoratons. One of the reasons
for this could be the fact that the specialty of dentstry
is relatively young in the Kingdom of Saudi Arabia.
Thus, traditonal barriers to the teaching of posterior
composite restoratons
[8,19]
may be less applicable. An
argument supported by the fact that students from both
schools reported that a majority of their instructors
preferred them to use composite over amalgam. The
fndings also support the argument that the instructor
plays an important role in infuencing the students
preference of material.
The diference in the cost of placing either amalgam
or composite posterior restorations is a subject
that has been discussed in literature. Traditonally,
amalgam restoratons have always been cheaper than
composite; however, recent advances in composite
resins along with increasing prices of silver have meant
that today an amalgam restoraton costs as much to
place as a composite resin restoraton.
[1,2,4,21]
However,
it has been suggested that the long-term viability
of amalgam reduces overall cost to the patent.
[24,25]

Restoratve care in the government college was free,
whereas the private school charged the same price
for similar amalgam and composite restoratons. Our
study suggests that while students were aware of the
short-term costs of placing a restoraton, they did not
give much thought to the long term cost of placement
of a restoraton. Interestngly, although many of the
students surveyed felt that composites could replace
amalgam in the mouth of a patent with good oral
hygiene, questons about the durability of composite
stll remained.
The debate of whether composite will ever replace
amalgam is at least two decades old, and yet the view
that we can move toward an amalgam-free practce
is not the one that is universally accepted.
[23]
One of the
greatest objectons to amalgam in the West, especially
in Europe, has been the threat of mercury toxicity
[26,27]
a
view that has been critcized.
[24,28]
The respondents in our
study however ranked mercury toxicity way below the
concerns of esthetcs and excessive tooth preparaton.
The signifcantly higher number of students in the private
school who objected to amalgam on the grounds of
destructve tooth preparaton seems to suggest that
students, who are encouraged in the use of composite,
may subconsciously assimilate the principles of minimal
interventon beter than students who routnely use
amalgam.
Data on the use and preference of posterior restoratve
materials in the Middle East remains scant.
[29]
A recent
study from Iran highlighted that the education on
restoratve techniques in that country are compatble
with standards practiced in the West.
[30]
Our study
suggests that while curricula and educaton standards
certainly form the core of educaton, students with very
similar curricula may have diferent perceptons based
on the clinical setng they work in.
Conclusions
The fndings of our study suggest that dental students in
the Kingdom of Saudi Arabia seem to possess the ability
to work confdently with posterior composite resins
and seem to be comfortable in doing so. However, the
reasons for choosing composite resin restoratons over
dental amalgam vary, and seem to be infuenced by the
clinical setng in which the student worked. Given the
scant data on the subject in the Middle East, similar
studies in diferent colleges in the region can greatly
help to understand student percepton, attude and
comfort in using posterior composite resin restoratons.
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Cite this artcle as: ***
Source of Support: Nil, Confict of Interest: None declared.

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