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Operative Dentistry, 2014, 39-6, E231-E240

Clinical Decision Making on

Extensive Molar Restorations
T Laegreid ! NR Gjerdet ! A Johansson
A-K Johansson

Clinical Relevance
Extensive loss of posterior tooth substance, which traditionally was restored with amalgam
or indirect restorations, is more commonly being restored with resin-based composite
restorations. The choice between prescribing direct or indirect techniques when restoring
extensive posterior defects has challenged clinical decision making.

SUMMARY the different associations. Most of the respon-

Extensive loss of posterior tooth substance, dents preferred a direct composite restoration
which traditionally was restored with amal- when one cusp was missing, while indirect
gam or indirect restorations, is more common- restorations were most preferred when replac-
ing three or four cusps. Younger dentists and
ly being restored with resin-based composite
dentists working in the private sector had a
restorations. Using a questionnaire, we aimed
greater tendency to choose an indirect tech-
to survey dentists’ clinical decision making
nique compared with older colleagues. Gener-
when restoring extensive defects in posterior
ally, the most important influencing factor in
molar teeth. The questionnaire, which includ-
clinical decision making was the amount of
ed questions on background information from
remaining tooth substance. Factors that ap-
the dentists, clinical cases with treatment
peared to be less important were dental adver-
options, and general questions about restoring tisements, use of fluoride, and dietary habits.
extensive posterior defects, was sent to 476 Female dentists perceived factors such as oral
dentists. The response rate was 59%. Multiple hygiene, patient requests, and economy to be
logistic regressions were used to investigate more important than did their male col-
*Torgils Laegreid, DDS, PhD, University of Bergen, Depart- leagues.
ment of Clinical Dentistry–Cariology, Bergen, Norway
Nils Roar Gjerdet, DDS, PhD, University of Bergen, Depart- INTRODUCTION
ment of Clinical Dentistry–Biomaterials, Bergen, Norway
Clinical decision making is an important component
Anders Johansson, DDS, PhD, University of Bergen, Depart- of everyday dentistry, and its outcome depends on a
ment of Clinical Dentistry–Prosthodontics, Bergen, Norway
large number of different crucial factors. Improved
Ann-Katrin Johansson, DDS, PhD, University of Bergen, biological and mechanical properties of composite
Department of Clinical Dentistry–Cariology, Bergen, Nor-
restorative materials have broadened their indica-
way
tions during the past few decades.1 Extensive loss of
*Corresponding author: Postboks 7804, Bergen, N-5020,
Norway; e-mail: torgils.lagreid@iko.uib.no
posterior tooth substance, which traditionally was
restored with amalgam or indirect restorations, is
DOI: 10.2341/13-069-C
more commonly being restored with resin-based
E232 Operative Dentistry

composite restorations. In some countries, the use of The primary aim of this study was to survey
dental amalgam has been restricted,2 and direct Norwegian dentists’ clinical decision making when
composite restorations are often considered to be the restoring extensive defects in posterior molar teeth.
most viable treatment alternative. These changes A secondary aim was to evaluate the importance of
have challenged the clinical decision making of influencing factors when it comes to the choice of
dentists and, specifically, the choice between pre- treatment. Finally, the third aim was to study the
scribing direct or indirect techniques when restoring associations between treatment choice, operator, and
extensive posterior defects has been rendered diffi- patient-related factors.
cult. Suggested treatment options must primarily be
based on an individual clinical assessment, but other METHODS AND MATERIALS
factors such as patient requests and economy may Questionnaire
also contribute to the decision making.3,4
A questionnaire was designed to obtain information
While there is little scientific information avail- from dentists regarding their clinical decision mak-
able concerning the choice of restorative treatment ing when restoring extensive posterior defects. The
for extensive loss of tooth substance in posterior first part included background factors such as sex,
teeth, more research has been carried out on age, dental education, workplace, and type of
treatment options for intracoronal Class I and II patients attending their clinic.
cavities in posterior teeth.5-12 These studies focus on
The second part comprised descriptions of four
the differences and changes in the use of amalgam
different clinical cases with details of medical history
and composite but generally do not distinguish
and clinical examination, and the dentists were
between the different outline forms and designs of asked to rank the three most appropriate treatment
the restorations. options, based on their own clinical judgment. The
From a clinical decision-making point of view, the cases were illustrated by photographs of a lower first
choice between direct and indirect restorative tech- molar with one to four missing cusps (Figure 1).
niques has several dimensions. First, the use of Finally, the third part included questions about
direct restoratives is increasingly based on adhesion different possible factors influencing the treatment
and the principle of minimally invasive dentistry, planning, frequency of use of the different restor-
and this procedure minimizes the risk of iatrogenic ative options, and clinical problems deemed associ-
damage to the tooth and surrounding tissues.13 On ated with the treatment.
the other side, the mechanical strength of direct
A pilot of the questionnaire was sent to 10
restoratives can be inferior to that of indirect
dentists, and final corrections were made after
restoratives in many situations,14 and this may call
feedback from respondents.
into question the use of such materials in extensive
posterior defects. Finally, the immediate costs of
doing an indirect restoration are higher compared Subjects
with those of a direct restoration,15 and in addition, The names and addresses of all 768 members of the
indirect work is more time-consuming. Bergen branch of the Norwegian Dental Association
(Bergen Dental Association) were received from the
The available literature is sparse concerning the
local membership administrator. Retired dentists,
choice between direct and indirect restorative treat-
dental students, orthodontists, and oral surgeons
ment of extensive defects in posterior teeth. While
were excluded from the study, and the final selection
most studies concentrate on the choice between
comprised 476 dentists who were included in the
composite and amalgam, a few studies discuss the
survey.
direct/indirect approach.4,8,16-19 A recent report
concluded that ‘‘there is no high quality evidence The questionnaires, together with a cover letter
that supports or rejects the practice of placing an and a stamped return envelope, were sent to the
indirect restoration on a heavily restored vital molar recipients by mail. Three weeks after the initial
rather than a direct restoration to ensure longer mailing, a reminder announcement was published in
tooth survival.’’20 While some authors suggest that the local dental journal. Six weeks after the initial
the restorative treatment of posterior teeth is mailing, a reminder letter with a questionnaire was
moving toward a direct technique,14 others predict sent to the nonresponders.
an enhanced future use of indirect restorations in To achieve anonymity, each subject in the mailing
posterior teeth.8 list was assigned a code. The coded mailing list was
Laegreid & Others: Clinical Decision Making E233

Figure 1. Four clinical situations for the lower right first molar as presented in the questionnaire, seen from an occlusal (O), lingual (L), and distal (D)
view. In the presented situations, the amalgam restoration is removed. An extracted molar was prepared to illustrate the cases. Patient-related
information (right) was also given in the questionnaire.

used to send out the reminders to nonrespondents. It dentists remained available for the survey. The final
was not possible to identify the respondents from the response constituted 270 dentists (59%).
returned questionnaires without the coded mailing
list. The respondents were free to withdraw from the The respondents (142 women and 128 men) had a
survey at any time. mean age of 46.4 years (range, 25-71 years). Eight
respondents reported that they did not work clini-
Privacy Protection cally and were therefore excluded from the statisti-
The study was reported to the commission of privacy cal analyses. The distribution of the respondents
protection at the Norwegian Social Science Data according to age, sex, and employment sector is
Services. shown in Table 1. Sixty-two percent of the respon-
dents reported that their practice was located in the
Statistical Methods City of Bergen, which has about 250,000 inhabitants.
The chi-square goodness-of-fit test was used to
evaluate the representativity of the sample of Table 1: Distribution of the Responders according to Sex,
responding dentists. The treatment choices were Age, and Employment Sector
dichotomized into direct and indirect treatment Age Group, y Public Dental Private Dental Total
alternatives to simplify the statistical calculations. Sectora Sector
Multiple logistic regressions were used to investigate Women Men Women Men
the different associations presented in this article. p ,30 7 0 10 6 23
values less than 0.05 were considered statistically 30-39 25 0 25 16 66
significant. All statistical analyses were performed 40-49 18 2 18 18 56
using the PASW Statistics 18.0 software (SPSS, Inc, 50-59 11 13 12 38 74
Somers, NY). "60 4 12 5 18 39
Total 65 27 70 96 258b
RESULTS a
Included in the category ‘‘Public dental sector’’ are dentists working full-
time or part-time in the Public Dental Service, staff at the Dental University
Response and Background Data Clinic in Bergen, at hospitals, or at other public services in Hordaland
County, Norway.
b
Nineteen of the questionnaires were returned be- Of the 262 dentists available for statistical analysis, three did not report
their age and one did not report employment status.
cause of unknown addresses. Consequently, 457
E234 Operative Dentistry

Figure 2. The proportionate distribution of the respondents’ first Figure 3. The proportionate distribution of the respondents’ first
treatment choice in case 1 (n=266), case 2 (n=267), case 3 (n=266), treatment choice (dichotomized into direct and indirect restorations) in
and case 4 (n=264). The ‘‘nonclinical’’ respondents are included. case 1 (n=266), case 2 (n=267), case 3 (n=266), and case 4
(n=264). The ‘‘nonclinical’’ respondents are included.

The remaining 38% had their practices in surround-

ing smaller towns or rural areas. greater proportion of the younger dentists (#50
The chi-square goodness-of-fit test indicated that years) chose to restore the tooth with an indirect
there were no significant differences in the distribu- restoration compared with their older colleagues
tion of responding dentists in this survey compared (odds ratio [OR]=1.9, 1.0-3.7). A significantly greater
proportion of the dentists working in the private
with the distribution of dentists in Norway according
sector chose an indirect restoration compared with
to age, sex, and employment sector.
those from the public sector (OR=5.7, 3.1-10.6).
Clinical Cases
Use of Restorative Materials in General
Figure 2 shows the distribution of the first treatment
The frequency of use of different restorative mate-
choice of the respondents in each of the four cases. In
rials in extensive posterior defects in general,
the following statistics, these treatment choices were
reported by the respondents, is shown in Table 3.
dichotomized into direct and indirect treatment
Direct composite restorations and metal-ceramic
alternatives (Figure 3). Composite was the only
crowns are the most reported treatment alterna-
direct material preferred by the respondents when
tives. Most of the respondents reported that they, to
restoring the four cases.
a slight extent or seldom, used restorative materials
Most of the respondents chose a direct composite
restoration for case 1. This is in contrast to cases 3
and 4, in which indirect restorations were the Table 2: Multiple Logistic Regression Analysis with the
preferred treatment option. A more even distribution Treatment Choices Made by the Respondents in
between direct and indirect treatment was present Case 2 as a Dependent Variable (Direct
Technique=0; Indirect Technique=1) and the
in case 2, and this was chosen as the indicator case Dentist-Related Factors Sex, Age, Employment
for further statistical analyses. Status, and Practice Area as Independent
Variablesa
Age, Sex, Workplace, and Location of Practice Independent Variable b p Value OR 95% CI for OR
When including age, sex, workplace, and location of Sex (female) 0.2 0.519 1.3 0.6-2.5
the practice as independent variables in a logistic Age ("50 years) 0.7 0.041 1.9 1.0-3.7
regression analysis with the treatment choice in case Employment status
2 (direct or indirect treatment as a dependent (private sector) 1.7 ,0.001 5.7 3.1-10.6
variable), only age and employment status were Practice area (urban) 0.5 0.071 1.7 1.0-3.1
found to have a significant influence on the restor- Abbreviations: CI, confidence interval; OR, odds ratio.
a
Nagelkerke R2=0.23.
ative decision making (Table 2). A significantly
Laegreid & Others: Clinical Decision Making E235

Table 3: Distribution of Answers to the Question, ‘‘How Often Do You Use the Listed Treatment Options in Your Clinical Work
when Restoring Molars with Extensive Defects?’’
n Always (%) Often (%) Occasionally (%) Little (%) Seldom or Never (%)
Glass ionomer 256 0.4 4.7 22.3 25.0 47.7
Composite 260 1.9 83.5 10.0 3.8 0.8
Composite inlay/onlay 255 0.0 1.6 10.2 23.1 65.1
Gold inlay/onlay 256 0.0 1.6 9.8 28.5 60.2
Ceramic inlay/onlay 256 0.0 6.3 20.3 32.8 40.6
All-ceramic crown 260 0.4 32.3 36.9 22.3 8.1
Metal-ceramic crown 260 1.2 77.7 17.7 3.1 0.4
Metal crown 259 0.0 4.2 22.8 29.0 44.0

such as glass ionomer cement, gold/composite/ce- Multiple logistic regression (Table 6) after dichot-
ramic inlays or onlays, and full metal crowns. omizing the categories into ‘‘very much influence’’
and ‘‘much, neither much or little, little and no
Multiple logistic regression (Table 4) showed that
influence,’’ showed that female dentists perceived
dentists working in the public sector used signifi-
factors such as oral hygiene (OR=3.5, 1.3-9.3),
cantly more glass ionomer cement than those in
patient requests (OR=2.0, 1.0-3.8), and patient’s
private practice (OR=14.8, 2.3-93.1), while private
economy (OR=2.2, 1.1-4.4 ) to be significantly more
dentists used significantly more ceramic (OR=3.3, important than their male colleagues did.
1.6-6.5) and metal-ceramic crowns (OR=6.7, 3.2-
14.1). Male dentists used significantly more ceramic A significantly greater proportion of dentists aged
inlays or onlays compared with female dentists 50 years or younger reported that factors such as
remaining tooth substance (OR=1.9, 1.1-3.3) and
(OR=3.9, 1.0-14.7). Dentists working in urban areas
moisture control (OR=2.6, 1.3-5.1) were more im-
used significantly more ceramic crowns than did
portant, compared with their older colleagues, while
dentists in rural areas (OR=2.6, 1.4-5.0).
scientific literature was more important (OR=2.3,
1.0-5.3) for the older dentists (Table 6).
Influencing Factors
A significantly greater proportion of dentists
The factors reported to influence the choice of working in urban areas reported a very important
restorative material in extensive posterior defects influence of factors such as secretion of saliva
are shown in Table 5. (OR=2.6, 1.1-6.3) and moisture control (OR=2.0,
Generally, the most important factor reported was 1.1-3.7) compared with their colleagues from more
the amount of remaining tooth substance. Other rural areas.
important factors were patient request, presence of
parafunctional oral habits, caries activity, and DISCUSSION
lectures. Factors that were less important for the The dental health care system in Norway is
respondents were advertisements, use of fluoride, organized in two different sectors: a public dental
and dietary habits. health care sector and a private sector. The public

Table 4: Significant Findings in the Multiple Logistic Regression Analyses with the Frequency of Use of Different Materials as a
Dichotomized Dependent Variable* (Treatment Choice: Always or Often=1; Sometimes, Little, Seldom, or Never=0)
and the Dentist-Related Factors Sex, Age, Employment Status, and Practice Area as Independent Variablesa
Independent Variable Treatment Choice* b p Value OR 95% CI for OR
Employment status (public sector) Glass ionomer cement 2.7 0.004 14.8 2.3-93.1
Employment status (private sector) Ceramic crown 1.2 0.001 3.3 1.6-6.5
Metal-ceramic crown 1.9 ,0.001 6.7 3.2-14.1
Sex (male) Ceramic inlay/onlay 1.4 0.044 3.9 1.0-14.7
Practice area (urban) Ceramic crown 1.0 0.002 2.6 1.4-5.0
Abbreviations: CI, confidence interval; OR, odds ratio.
a
The nonsignificant findings are not shown.
E236 Operative Dentistry

Table 5: Distribution of Answers when the Respondents Were Asked, ‘‘How Do You Feel the Listed Factors Influence Your
Treatment Choice when Restoring Molars with Extensive Defects?’’
n Very Much (%) Much (%) Neither Much nor Little (%) Little (%) No Influence (%)
Acquirement factors
Advertisements 259 0 3.1 24.3 51.7 20.8
Scientific literature 259 13.1 49.4 29.7 7.7 0
Courses/lectures 258 20.9 58.9 17.8 2.3 0
Patient-related factors
Age of the patient 259 7.3 49.0 30.5 12.4 0.8
Oral hygiene 259 13.1 61.4 22.0 3.5 0
Caries activity 260 21.9 62.3 15.0 0.8 0
Secretion of saliva 259 13.9 47.5 31.7 6.2 0.8
Diet 258 3.5 22.1 56.6 14.3 3.5
Use of fluoride 259 2.7 22.4 52.9 17.4 4.6
Patient requests 260 28.8 56.5 13.5 1.2 0
Patient economy 259 25.5 51.7 19.7 2.7 0.4
Tooth-related factors
Occlusion 260 16.2 54.2 23.8 5.4 0.4
Remaining tooth substance 259 46.3 51.7 1.9 0 0
Available cervical enamel 259 15.8 46.7 29.0 6.9 1.5
Parafunctional habits 259 23.9 59.5 14.7 1.9 0
Moisture control 260 28.1 49.2 18.5 3.8 0.4

dental health system provides free care for all geons, and dentists reporting that they did not work
children aged 0-20 years, all mentally and physically clinically were excluded from the study. The study
handicapped people, and institutionalized and elder- population was considered representative for Nor-
ly people. All other people have to pay the costs for wegian dentists in general, based on statistical
dental care themselves. There are almost 5000 comparison with available official statistics.21 Very
dentists in Norway, and that represents about 1000 limited information could be retrieved about the
inhabitants per dentist. nonresponders, so a meaningful nonresponse analy-
The target group for this questionnaire survey was sis could not be performed.
dentists providing restorative treatment as a main The questionnaire used in the present study is
activity in their clinical practice. Therefore, retired based on the Paper Patient Cases method, which has
dentists, dental students, orthodontists, oral sur- been found to be useful in studies dealing with

Table 6: Statistically Significant Findings of Multiple Logistic Regression Analyses with the Influence of Different Factors to the
Treatment Choice as a Dichotomized Dependent Variable* (Influencing Factor: Much, Neither Much nor Little, Little or
No=0; Very Much Influence=1) and the Dentist-Related Factors Sex, Age, and Practice Area as Independent
Variablesa
Independent Variable Influencing Factor* b p Value OR 95% CI for OR
Sex (female) Oral hygiene 1.3 0.013 3.5 1.3-9.3
Patient request 0.7 0.040 2.0 1.0-3.8
Patient economy 0.8 0.029 2.2 1.1-4.4
Age (.50 years) Scientific literature 0.8 0.045 2.3 1.0-5.3
Age (#50 years) Remaining tooth substance 0.6 0.031 1.9 1.1-3.3
Moisture control 0.9 0.007 2.6 1.3-5.1
Practice area (urban) Secretion of saliva 1.0 0.034 2.6 1.1-6.3
Moisture control 0.7 0.032 2.0 1.1-3.7
Abbreviations: CI, confidence interval; OR, odds ratio.
a
No significant differences were found according to employment status.
Laegreid & Others: Clinical Decision Making E237

clinical decision making in restorative dentistry.22 explained by the age group of patients. The dental
Realistic and illustrative clinical cases with back- care of patients aged up to 20 years is a public
ground information were presented to a large responsibility in Norway, and this is a major patient
number of dentists, who were then asked questions group in the Norwegian Public Dental Service. The
about their educational and professional background use of indirect restorations in children and adoles-
and their clinical decision making. cent is not very common and is often complicated
The treatment options available for the respon- and involves higher direct costs. The same differ-
dents in this study could all be tentatively viable ences between private and public dentists’ treat-
options as restorative materials and techniques for ment choices, as found in this study, were also
posterior teeth.14 To simplify statistical analyses, the reported in a Finnish study from 2002.18 In Kuwait,
options were dichotomized into direct and indirect dental treatment is free of charge in public clinics,8
restoratives. Dental amalgam was left out because and this lack of financial constraint can be an
its use is forbidden by law in Norway. explanatory factor for the increased use of indirect
alternatives among public sector dentists. In addi-
The results from the present study indicate, in tion, public clinics in Kuwait do not only treat
general, good agreement in clinical decision making children but also have a substantially greater
among the respondents when restoring a deficient proportion of adult patients compared with Norway,
molar lacking one, three, or four cusps. The which, in turn, may explain the increased use of
borderline between direct and indirect technique indirect restorations (Professor R. Omar, Faculty of
selection seems to be concentrated on restorations Dentistry, Kuwait University, Kuwait, personal
involving two cusps. For that reason, case 2 was communication).
considered to be the most interesting clinical
situation for studying the decision making among Patient-related factors such as preference and
dentists and can be considered as an indicator case costs were also considered important by the respon-
in the analysis. dents in this study. This indicates that the patient
request has an influence on the treatment, which is
As mentioned before, there is a lack of scientific in accordance with some but not with other stud-
information concerning the choice of restorative ies.16,17,19
treatment for extensive loss of tooth substance in
posterior teeth. In a Kuwaiti questionnaire survey Another finding in the present study is that female
from 2010,8 the authors found that fewer than 20% dentists consider factors such as patient requests
of the respondents would have preferred a direct and economy to be more important than do their
restoration for the retreatment of a failed molar male colleagues in clinical decision making. This is
restoration involving two cusps. Although the re- comparable with the results of a 1996 study3 in
spondents could have chosen between both amalgam which it was reported that female dentists sought
and composite as direct alternatives, this proportion their patient’s opinion more frequently than male
is much lower than the results of the present study, dentists did. It was suggested that female dentists
which shows that 36% of the respondents would have had a greater interest in esthetics than did their
chosen a direct composite restoration in a compara- male counterparts.
ble clinical situation. Another finding from the In the present study, the amount of remaining
Kuwaiti study mentioned above was that male tooth substance was clearly considered the most
dentists, older dentists, and dentists working in the important factor influencing the treatment choice.
public sector each had a greater tendency to place The perceived importance of such a technical tooth-
indirect restorations when the molar needed a related factor has been reported in other studies16,19
restoration that involved two cusps. These results and is confirmed by the present study.
contrast with our results, showing that a greater Resin-based composite has replaced amalgam as
proportion of younger dentists and dentists working the primary direct restorative material in posterior
in the private sector would prefer indirect restora- teeth in countries such as Sweden and Norway, since
tions compared with their older colleagues. The fact amalgam is no longer an available option. An issue is
that older dentists use direct composite more to what extent the governmental restrictions on the
frequently in extensive molar defects has also been use of dental amalgam have influenced the clinical
found in another study.6 decision making among dentists. In Norway, the use
The tendency among dentists in the public sector of amalgam was banned in 2008. Nevertheless, the
to use a direct technique in our study may be decrease in use of amalgam was noticeable begin-
E238 Operative Dentistry

ning in the 1990s,11 and amalgam constituted fewer dependent on both the initial price and the expected
than 10% of the restorations in 2002.23 However, in a longevity of the restoration.
study carried out between 2001 and 2004, most of Historically, amalgam has been regarded as the
the participating dentists still preferred amalgam in most cost-effective treatment in posterior teeth
more challenging restorations with respect to caries compared with other direct and indirect restor-
activity, lesion depth, and tooth type.24 This indi- atives.31-37 Some studies have also concluded that
cates that many Norwegian dentists were forced to it is not cost beneficial to replace failed extensive
change their treatment strategies when restoring amalgam restorations with indirect alterna-
extensive posterior defects after 2008. tives.32,37,38 Internal differences in long-term costs
As the present study indicates a shift toward the between the direct alternatives amalgam, resin-
use of direct resin-based composite when restoring based composite, and glass ionomers are also
extensive posterior defects in Norway, an important reported, with amalgam as the least expensive.36
question concerning longevity and socioeconomic None of these studies include extensive cusp-
effects arises. Comparative clinical studies of exten-
covering resin-based restorations. For that reason,
sive posterior restorations are few, but interesting.
the information about the cost-effectiveness of
In a prospective longitudinal evaluation of extensive
extensive direct posterior composite restorations
restorations in permanent teeth,25 it was found that
in relation to indirect prosthetic alternatives is
the median survival times were 12.8 years for
sparse.
amalgam, 7.8 years for resin-based restorations,
and 14.6 years for crowns. The authors concluded The reparability of resin-based composite restora-
that ‘‘extensive amalgam restorations but not com- tions is documented,39,40 and such repair procedures
posite resin restorations can be used as appropriate are less expensive than total replacements, and they
alternatives to crowns.’’ Other studies have reported thus reduce the long-term costs. This may contribute
the same conclusion as the above-mentioned to an opinion that extensive direct posterior compos-
study.26,27 On the other side, a recently published ite restorations are more cost-effective than their
retrospective study28 showed better survival of indirect counterparts, although the latter have
composite restorations compared with amalgam better survival rates.
after 12 years.
CONCLUSION
In a review from 2004,14 the mean annual failure
rate (AFR) for different indirect posterior restora- The results of this study indicate that the choice of
tions was calculated: indirect composite inlays and restorative technique in posterior teeth (direct vs
onlays (2.9%), ceramic inlays and onlays (1.9%), indirect) is influenced by a range of factors related
computerized designed and manufactured (CAD/ both to the patient and the operator. In addition,
CAM) ceramic inlays and onlays (1.7%), and cast they reveal a variation in clinical decision making
gold inlays and onlays (1.4%). Another review from among dentists.
2007 estimated the mean AFR for crowns, which Since clinical decision making has an influence on
varied from 1.0% to 3.4%, depending on what type of oral health care, both economically and biologically,
material was used.29 The mean AFR calculated further research on this topic is needed.
from these long-term studies involving indirect
restorations is lower than the failure rate calculat-
Conflict of Interest
ed for extensive direct composite restorations
(4.2%).30 The authors of this manuscript certify that they have no
proprietary, financial, or other personal interest of any nature
The choice between direct techniques, in which the or kind in any product, service, and/or company that is
restoration is inserted and set directly into the tooth, presented in this article.
and indirect techniques, in which the restoration is
(Accepted 5 December 2013)
produced outside the mouth, has a great impact on
the initial cost of the treatment. An indirect REFERENCES
technique may enhance the price of the restoration
1. Hickel R, Manhart J, & Garcia-Godoy F (2000) Clinical
multifold.31,32 For the patient and eventually a third results and new developments of direct posterior restora-
party such as insurance companies and governmen- tions American Journal of Dentistry 13(Spec No)
tal institutions, it is also important to have informa- 41D-54D.
tion about the cost-effectiveness in the long term. 2. Scientific Committee on Health and Environmental
Such long-term costs of dental restorations are Risks, European Commission (2008) Scientific opinion
Laegreid & Others: Clinical Decision Making E239

on the environmental risks and indirect health effects of Sweden. I: The choice between crown therapy and filling
mercury in dental amalgam; Retrieved online from: http:// International Journal of Prosthodontics 12(5) 426-431.
ec.europa.eu/health/ph_risk/committees/04_scher/docs/
18. Heinikainen M, Vehkalahti M, & Murtomaa H (2002) Re-
scher_o_089.pdf
treatment decisions for failed posterior fillings by Finnish
3. Forss H, & Widström E (1996) Factors influencing the general practitioners Community Dental Health 19(2)
selection of restorative materials in dental care in Finland 98-103.
Journal of Dentistry 24(4) 257-262.
19. Brennan DS, & Spencer AJ (2002) Factors influencing
4. Brennan DS, & Spencer AJ (2006) Longitudinal compar- choice of dental treatment by private general practitioners
ison of factors influencing choice of dental treatment by International Journal of Behavioral Medicine 9(2) 94-110.
private general practitioners Australian Dental Journal
20. Hurst D (2010) Indirect or direct restorations for heavily
51(2) 117-123.
restored posterior adult teeth? Evidence-Based Dentistry
5. Burke FJ, McHugh S, Hall AC, Randall RC, Widström E, 11(4) 116-117.
& Forss H (2003) Amalgam and composite use in UK
21. Statistics Norway (2008; cited 11 August 2011). Retrieved
general dental practice in 2001 British Dental Journal
online from: http://statbank.ssb.no/statistikkbanken
194(11) 613-618.
22. Söderfeldt B, Palmqvist S, Eriksson T, Kronström M, &
6. Burke FJ, McHugh S, Randall RC, Meyers IA, Pitt J, &
Carlsson GE (1996) A questionnaire instrument to assess
Hall AC (2004) Direct restorative materials use in
Australia in 2002 Australian Dental Journal 49(4) clinical decision-making in prosthodontics among general
185-191. practitioners Acta Odontologica Scandinavica 54(5)
314-319.
7. Haj-Ali R, Walker MP, & Williams K (2005) Survey of
general dentists regarding posterior restorations, selec- 23. Gimmestad AL, Holst D, Grytten J, & Skau I (2004) Exit
tion criteria, and associated clinical problems General amalgam? Use of amalgam in dental practice in Norway
Dentistry 53(5) 369-375. 2002 Journal of the Norwegian Dental Association 114(6)
284-286.
8. Alomari Q, Al-Kanderi B, Qudeimat M, & Omar R (2010)
Re-treatment decisions for failed posterior restorations 24. Vidnes-Kopperud S, Tveit AB, Gaarden T, Sandvik L, &
among dentists in Kuwait European Journal of Dentistry Espelid I (2009) Factors influencing dentists’ choice of
4(1) 41-49. amalgam and tooth-colored restorative materials for
Class II preparations in younger patients Acta Odonto-
9. Mjör IA (1997) Selection of restorative materials in logica Scandinavica 67(2) 74-79.
general dental practice in Sweden Acta Odontologica
Scandinavica 55(1) 53-57. 25. Van Nieuwenhuysen JP, D’Hoore W, Carvalho J, & Qvist
V (2003) Long-term evaluation of extensive restorations
10. Mjör IA, & Moorhead JE (1998) Selection of restorative in permanent teeth Journal of Dentistry 31(6) 395-405.
materials, reasons for replacement, and longevity of
restorations in Florida Journal of the American College 26. Bernardo M, Luis H, Martin MD, Leroux BG, Rue T,
of Dentists 65(3) 27-33. Leitao J, & DeRouen TA (2007) Survival and reasons for
failure of amalgam versus composite posterior restora-
11. Mjör IA, Moorhead JE, & Dahl JE (1999) Selection of tions placed in a randomized clinical trial. Journal of the
restorative materials in permanent teeth in general American Dental Association 138(6) 775-783.
dental practice Acta Odontologica Scandinavica 57(5)
257-262. 27. Simecek JW, Diefenderfer KE, & Cohen ME (2009) An
evaluation of replacement rates for posterior resin-based
12. Mjör IA, Shen C, Eliasson ST, & Richter S (2002) composite and amalgam restorations in U.S. Navy and
Placement and replacement of restorations in general marine corps recruits Journal of the American Dental
dental practice in Iceland Operative Dentistry 27(2) Association 140(2) 200-209.
117-123.
28. Opdam NJ, Bronkhorst EM, Loomans BA, & Huysmans
13. Ericson D (2004) What is minimally invasive dentistry? MC (2010) 12-year survival of composite vs. amalgam
Oral Health & Preventive Dentistry 2(Supplement 1) restorations Journal of Dental Research 89(10)
287-292. 1063-1067.
14. Manhart J, Chen H, Hamm G, & Hickel R (2004) 29. Pjetursson BE, Sailer I, Zwahlen M, & Hämmerle CH
Buonocore Memorial Lecture. Review of the clinical (2007) A systematic review of the survival and complica-
survival of direct and indirect restorations in posterior tion rates of all-ceramic and metal-ceramic reconstruc-
teeth of the permanent dentition Operative Dentistry tions after an observation period of at least 3 years. Part I:
29(5) 481-508. single crowns Clinical Oral Implants Research
15. Mjör IA (1992) Long term cost of restorative therapy 18(Supplement 3) 73-85.
using different materials. Scandinavian Journal of 30. Laegreid T, Gjerdet NR, & Johansson AK (2012) Exten-
Dental Research 100(1) 60-65. sive composite molar restorations: 3 years clinical
16. Grembowski D, Milgrom P, & Fiset L (1988) Factors evaluation Acta Odontologica Scandinavica 70(4)
influencing dental decision making Journal of Public 344-352.
Health Dentistry 48(3) 159-167.
31. Mjör IA (1992) Long term cost of restorative therapy
17. Kronström M, Palmqvist S, & Söderfeldt B (1999) using different materials Scandinavian Journal of Dental
Prosthodontic decision making among general dentists in Research 100(1) 60-65.
E240 Operative Dentistry

32. Kelly PG, & Smales RJ (2004) Long-term cost-effective- 37. Kolker JL, Damiano PC, Flach SD, Bentler SE, Arm-
ness of single indirect restorations in selected dental strong SR, Caplan DJ, Kuthy RA, Warren JJ, Jones MP,
practices British Dental Journal 196(10) 639-643. & Dawson DV (2006) The cost-effectiveness of large
33. Smales RJ, & Hawthorne WS (1996) Long-term survival amalgam and crown restorations over a 10-year period
and cost-effectiveness of five dental restorative materials Journal of Public Health Dentistry 66(1) 57-63.
used in various classes of cavity preparations Interna- 38. Maryniuk GA, Schweitzer SO, & Braun RJ (1988)
tional Dental Journal 46(3) 126-130. Replacement of amalgams with crowns: a cost-effective-
34. Smales RJ, & Hawthorne WS (1997) Long-term survival ness analysis Community Dentistry and Oral Epidemiol-
of extensive amalgams and posterior crowns Journal of ogy 16(5) 263-267.
Dentistry 25(3-4) 225-227. 39. Fernandez EM, Martin JA, Angel PA, Mjör IA, Gordan
35. Tobi H, Kreulen CM, Vondeling H, & van Amerongen WE VV, & Moncada GA (2011) Survival rate of sealed,
(1999) Cost-effectiveness of composite resins and amal- refurbished and repaired defective restorations: 4-year
gam in the replacement of amalgam Class II restorations follow-up. Brazilian Dental Journal 22(2) 134-139.
Community Dentistry and Oral Epidemiology 27(2) 40. Gordan VV, Garvan CW, Blaser PK, Mondragon E, &
137-143. Mjör IA (2009) A long-term evaluation of alternative
36. Sjögren P, & Halling A (2002) Long-term cost of direct treatments to replacement of resin-based composite
Class II molar restorations Swedish Dental Journal 26(3) restorations: results of a seven-year study Journal of
107-114. the American Dental Association 140(12) 1476-1484.