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Prevalence of unsatisfactory dental restorations in posterior primary teeth and associated factors

Abstract

The aim of this study was to investigate the prevalence of unsatisfactory dental restorations on posterior primary teeth and associated factors in school children aged six to ten years. A cross-sectional study was conducted with children randomly selected from public schools in a small Brazilian town. Questionnaires were sent to the guardians addressing socioeconomic and behavioral aspects of the child. Oral examinations were performed at the schools to determine the quality of dental restorations, visible biofilm, and presence of moderate/extensive untreated caries (scores 3-6 ICDAS). This examination was performed by two previously trained and calibrated examiners. Associations were tested using multilevel logistic regression. Among the 400 children evaluated, 98 had restorations (217 teeth). The prevalence of unsatisfactory restorations was 34.6%. Restorations in amalgam were less likely to fail compared to those in glass ionomer cement (OR = 0.11; 95%CI: 0.02–0.49; p = 0.005). Children with moderate/extensive untreated caries were more likely to have unsatisfactory restorations (OR = 6.79; 95%CI: 2.20–20.93; p = 0.001). Children with a visible plaque index ≥ 20% were also more likely to have unsatisfactory restorations (OR = 2.28 95%CI: 1.05–4.92; p = 0.036). The prevalence of unsatisfactory restorations was high. The occurrence of this outcome was associated with restorative material, presence of caries, and visible plaque.

Cross-Sectional Studies; Dental Restoration Failure; Longevity; Child

Introduction

Direct dental restorations on primary teeth are common procedures11. Franzon R, Opdam NJ, Guimarães LF, Demarco FF, Casagrande L, Haas AN, Araújo FB. Randomized controlled clinical trial of the 24-months survival of composite resin restorations after one-step incomplete and complete excavation on primary teeth. J Dent. 2015 Out;43(10):1235-41. https://doi.org/10.1016/j.jdent.2015.07.011
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,22. Pinto GS, Oliveira LJC, Romano AR, Schardosim LR, Bonow MLM, Pacce M, et al. Longevity of posterior restorations in primary teeth: results from a paediatric dental clinic. J Dent 2014 Out;42(10):1248-54. https://doi.org/10.1016/j.jdent.2014.08.005
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that aim to restore the shape and function of the tooth,33. Finucane D. Restorative treatment of primary teeth: an evidence-based narrative review. Aust Dent J 2019 Jun;64 Suppl 1:S22-S36.018;52(5):406-19. https://doi.org/10.1111/adj.12682.
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,44. Yengopal V, Harnekar SY, Patel N, Siegfried N. Withdrawn: dental fillings for the treatment of caries in the primary dentition. Cochrane Database Syst Rev. 2016 Oct;10(10):CD004483. https://doi.org/10.1002/14651858.CD004483.pub2
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prevent the progression of caries, and maintain the tooth in the arch until its natural exfoliation.55. Subramanyam D, Somasundaram S. Clinical and radiographic evaluation of aloe vera vs formocresol as a pulpotomy medicament in primary molars: a double blinded randomized controlled trial. Int J Clin Pediatr Dent. 2020 Mar-Apr;13(2):138-43. https://doi.org/10.5005/jp-journals-10005-1724
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However, restorations are subject to failure, leading to a cycle of reinterventions that weakens the dental structure and results in the need for increasingly complex procedures.66. Blum IR, Özcan M. Reparative dentistry: possibilities and Limitations. Curr Oral Health Rep. 2018;5(4):264-9. https://doi.org/10.1007/s40496-018-0191-1
https://doi.org/10.1007/s40496-018-0191-...
The most common reasons for failure of dental restorations are recurrent caries77. Chisini LA, Collares K, Cademartori MG, Oliveira LJ, Conde MC, Demarco FF, et al. Restorations in primary teeth: a systematic review on survival and reasons for failures. Int J Paediatr Dent. 2018 Mar;28(2):123-39. https://doi.org/10.1111/ipd.12346
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,88. Collares K, Opdam NJ, Peres KG, Peres MA, Horta BL, Demarco FF, et al. Higher experience of caries and lower income trajectory influence the quality of restorations: a multilevel analysis in a birth cohort. J Dent. 2018 Jan;68:79-84. https://doi.org/10.1016/j.jdent.2017.11.009
https://doi.org/10.1016/j.jdent.2017.11....
and fracture of the tooth or restoration.88. Collares K, Opdam NJ, Peres KG, Peres MA, Horta BL, Demarco FF, et al. Higher experience of caries and lower income trajectory influence the quality of restorations: a multilevel analysis in a birth cohort. J Dent. 2018 Jan;68:79-84. https://doi.org/10.1016/j.jdent.2017.11.009
https://doi.org/10.1016/j.jdent.2017.11....
A retrospective study demonstrated a 37.7% failure rate among restorations on primary teeth.99. Ávila NM, Bottezini PA, Nicoloso G, Araujo FB, Ardenghi TM, Lenzi TL, et al. Prevalence of defective restorations and factors associated with re-intervention in primary teeth: a retrospective university-based study. Int J Paediatr Dent. 2019 Sep;29(5):566-72. https://doi.org/10.1111/ipd.12493
https://doi.org/10.1111/ipd.12493...

Restoration longevity depends on factors related to clinical aspects, dental material properties, dentist skills, and patient characteristics, such as age, socioeconomic status, risk of caries, caries activity/severity, and oral hygiene.1010. Demarco FF, Corrêa MB, Cenci MS, Moraes RR, Opdam NJ. Longevity of posterior composite restorations: not only a matter of materials. Dent Mater. 2012 Jan;28(1):87-101. https://doi.org/10.1016/j.dental.2011.09.003
https://doi.org/10.1016/j.dental.2011.09...
,1111. Sande FH, Collares K, Correa MB, Cenci MS, Demarco FF, Opdam N. Restoration survival: revisiting patients’ risk factors through a systematic literature review. Oper Dent. 2016 Sep;41 S7:S7-26. https://doi.org/10.2341/15-120-LIT
https://doi.org/10.2341/15-120-LIT...
Some studies found that restoration failure on permanent teeth is associated with socioeconomic, individual, and behavioral factors.1111. Sande FH, Collares K, Correa MB, Cenci MS, Demarco FF, Opdam N. Restoration survival: revisiting patients’ risk factors through a systematic literature review. Oper Dent. 2016 Sep;41 S7:S7-26. https://doi.org/10.2341/15-120-LIT
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,1212. Correa MB, Peres MA, Peres KG, Horta BL, Barros AJ, Demarco FF. Do socioeconomic determinants affect the quality of posterior dental restorations? A multilevel approach. J Dent 2013 Nov;41(11):960-967. https://doi.org/10.1016/j.jdent.2013.02.010
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However, few studies have investigated such associations among children in the primary dentition phase,99. Ávila NM, Bottezini PA, Nicoloso G, Araujo FB, Ardenghi TM, Lenzi TL, et al. Prevalence of defective restorations and factors associated with re-intervention in primary teeth: a retrospective university-based study. Int J Paediatr Dent. 2019 Sep;29(5):566-72. https://doi.org/10.1111/ipd.12493
https://doi.org/10.1111/ipd.12493...
,1313. Omidi BR, Naeini FF, Dehghan H, Tamiz P, Savadroodbari MM, Jabbarian R. Microleakage of an enhanced resin-modified glass ionomer restorative material in primary molars. J Dent (Tehran). 2018 Jul;15(4):205-13. especially population-based studies. Identifying and minimizing factors that influence the quality of dental restorations is fundamental to enhancing restoration longevity. Moreover, monitoring dental restorations is important to detect failures and repairs them (when possible) rather than replacing the restoration.66. Blum IR, Özcan M. Reparative dentistry: possibilities and Limitations. Curr Oral Health Rep. 2018;5(4):264-9. https://doi.org/10.1007/s40496-018-0191-1
https://doi.org/10.1007/s40496-018-0191-...
Replacing a restoration not only weakens the structure of the tooth, but can also lead to the need for more complex dental procedures, generating higher costs and consuming oral health resources in the public sector.66. Blum IR, Özcan M. Reparative dentistry: possibilities and Limitations. Curr Oral Health Rep. 2018;5(4):264-9. https://doi.org/10.1007/s40496-018-0191-1
https://doi.org/10.1007/s40496-018-0191-...

Therefore, the aim of the present study was to investigate the prevalence of unsatisfactory dental restorations on primary teeth and associated factors in schoolchildren aged six to ten years. The hypothesis is that the prevalence of unsatisfactory restorations is associated with the type of restorative material, the child’s risk of caries, and poor oral hygiene.

Methodology

Ethical aspects

This study was developed following the “Strengthening the Reporting of Observational Studies in Epidemiology” guidelines (STROBE statement) and was approved by the Human Research Ethics Committee of the School of Dentistry under protocol numbers 11350919.4.0000.5108 and 3.366.387. The guardians of eligible participants received written information about the purpose of this study and informed consent was obtained from all mothers. Children who required dental treatment were referred to the pediatric clinic of the postgraduate program.

Study design and population

A cross-sectional study was conducted between August 2019 and March 2020 in Diamantina, a city located in southeastern Brazil. The city had an estimated population of 47,825 residents in 2020, with 6206 children enrolled in primary school in 2018. The proportion of individuals aged six to 14 years attending school was 97.8% in 2010.1414. Instituto Brasileiro de Geografia e Estatística. Brazilian Government Portal; 2017 [cited 2021 May]. Available from: https://cidades.ibge.gov.br/brasil/mg/diamantina/panorama
https://cidades.ibge.gov.br/brasil/mg/di...

The inclusion criteria were enrolment in public schools in the city, six to ten years of age, with at least one deciduous posterior teeth, and authorization from a legal guardian to participate in the study. Children who declined participation and those with neuropsychomotor disabilities were excluded.

The sample size was calculated considering a 95% confidence level, 80% test power, and frequencies of unsatisfactory restorations determined in the pilot study (39.21% among non-exposed individuals [teeth restored with glass ionomer cement] and 60% among exposed individuals [teeth restored with other material]). A minimum sample of 198 restorations was required, to which 40 (20%) were added to compensate for possible dropouts, leading to a sample of 238 restorations.

Randomization

Participant selection was performed in two stages. In the first stage, the schools in the city were selected using a random number method. Three schools were randomly selected from a total of twelve public schools that met the age group of interest and that accepted to participate in the research. In the second stage, children who met the eligibility criteria were randomly selected from each school. If the guardians of a selected child did not authorize the child’s participation, another drawing was performed for the replacement of the child.

Training and calibration

Training (theory and practice) was conducted with two researchers and calibration was performed for the criteria used to determine the clinical diagnosis of the following variables: restoration quality1515. Cvar JF, Ryge G. Reprint of criteria for the clinical evaluation of dental restorative materials. 1971. Clin Oral Investig. 2005 Dec;9(4):215-32. https://doi.org/10.1007/s00784-005-0018-z
https://doi.org/10.1007/s00784-005-0018-...
(inter-examiner Kappa: 0.78; intra-examiner Kappa: 0.81 and 0.83) and dental caries1616. Ekstrand KR, Gimenez T, Ferreira FR, Mendes FM, Braga MM. The International Caries Detection and Assessment System - ICDAS: a systematic review. Caries Res. 2018;52(5):406-19. https://doi.org/10.1159/000486429
https://doi.org/10.1159/000486429...
[inter-examiner Kappa: 0.79; intra-examiner Kappa: 0.78 and 0.80)]. The calibration involved the clinical examination of 30 children on two occasions with a one-week interval between evaluations. Training and calibration involved the two researchers who were to perform the data collection and were conducted by an experienced researcher who served as the “gold standard”.

Data collection

The guardians of the selected children were invited to participate in the study and answered a questionnaire sent home addressing socioeconomic and behavioral characteristics of the children. The dental examinations of the children were performed in the schools under natural light after tooth brushing. Unsatisfactory restoration was the main outcome and the independent variables were organized at two levels: tooth (1) and individual (2).

Dependent variable: quality of dental restorations

Dental restorations were assessed with regard to each clinical characteristic: marginal adaptation, surface defects, presence of recurring caries, marginal staining, and anatomic shape, following the modified criteria of the United States Public Health Service (USPHS).1515. Cvar JF, Ryge G. Reprint of criteria for the clinical evaluation of dental restorative materials. 1971. Clin Oral Investig. 2005 Dec;9(4):215-32. https://doi.org/10.1007/s00784-005-0018-z
https://doi.org/10.1007/s00784-005-0018-...
Restorations categorized as Alpha (no defect) and those categorized as Bravo (localized defect that could be repaired) were considered satisfactory, whereas those categorized as Charlie (clinically unacceptable defect requiring replacement of restoration) were considered unsatisfactory.

Variables at tooth level (Level 1)

At tooth level (1), unsatisfactory dental restorations on posterior primary teeth were assessed according to (1) dental arch (maxillary or mandibular), (2) restoration class (Class I or II), and (3) type of restorative material (glass ionomer cement [conventional/resin modified], amalgam, composite resin, or zinc oxide with eugenol).

Variables at individual level (Level 2)

At individual level (2), unsatisfactory dental restorations on posterior primary teeth were assessed according to (1) sex (female or male) (2) age, (3) family income (using the monthly minimum wage (MMW) as reference [≥ two times MMW or < two times MMW), (4) mother’s schooling (≥ 12 or < 12 years of study), (5) consumption of sweetened foods or beverages between meals (< twice or ≥ twice per day), (6) last dental appointment (< one year or > one year earlier), (7) tooth brushing frequency (≥ twice or < twice per day), (8) use of dental floss (yes or no), (9) sleep bruxism according to parental report (absent or present), (10) risk of dental caries according to the American Dental Association criteria1717. American Dental Association - ADA. Caries Risk Assessment Form (Age >6); 2009, 2011 [cited 2021 Jan 3]. Available form: http://www.ada.org/~/media/ADA/Science%20and%20Research/Files/topic_caries_over6.ashx
http://www.ada.org/~/media/ADA/Science%2...
for children older than six years (low or moderate/high risk), (11) moderate/extensive untreated caries according to the International Caries Detection and Assessment System (scores 3-6 ICDAS)1616. Ekstrand KR, Gimenez T, Ferreira FR, Mendes FM, Braga MM. The International Caries Detection and Assessment System - ICDAS: a systematic review. Caries Res. 2018;52(5):406-19. https://doi.org/10.1159/000486429
https://doi.org/10.1159/000486429...
(absent or present), visible plaque, and gingival bleeding index (< 20% or ≥ 20%).1818. Ainamo J, Bay I. Problems and proposals for recording gingivitis and plaque. Int Dent J. 1975 Dec;25(4):229-35.,1919. Casagrande L, Seminario AT, Correa MB, Werle SB, Maltz M, Demarco FF, et al. Longevity and associated risk factors in adhesive restorations of young permanent teeth after complete and selective caries removal: a retrospective study. Clin Oral Investig. 2017 Apr;21(3):847-55. https://doi.org/10.1007/s00784-016-1832-1
https://doi.org/10.1007/s00784-016-1832-...

Data analysis

Descriptive statistics were performed to determine the distribution of the variables and respective frequencies at tooth (1) and individual (2) levels. A multilevel regression model was employed for the analysis of factors related to failed restorations on posterior teeth. The data were organized at (1) tooth level (teeth) and (2) individual level (children). Estimates considered the restricted maximum likelihood method and the predictive quasi-likelihood estimation. A null model was first run to evaluate the partition of the variability in the data between levels. Next, the characteristics were considered at both levels. The variance partition coefficient (VPC) was calculated to quantify the extent to which the variance in the response variable was the result of differences between groups or intra-group differences.

Variables at tooth level (1) were incorporated into the model individually before being tested together. Next, variables at individual level (2) were incorporated one by one based on the results of the Student’s t-test and considering a p-value < 0.05. The multilevel model was constructed with variables that achieved a p-value < 0.25. Odds ratios (OR) and respective 95% confidence intervals (CI) were estimated for each analysis. The reliability estimate, which comprised only variables with a p-value < 0.05, was used to determine the fit of the final model. The Hierarchical Linear and Nonlinear Modeling Software (HLM 6.08 statistical package) was used for the multilevel analysis.

Results

Among the 400 children examined, 98 had restored teeth and 217 restorations were analyzed. The response rate was 91.18%. Losses (8.82%) were due to incomplete questionnaires. The description of the sample and frequencies of the variables were organized on two levels: tooth (Table 1) and individual (Table 2). The prevalence of unsatisfactory dental restorations on primary teeth was 34.6%. The power of the sample for the main independent variable (type of restorative material) was 83%.

Table 1
Descriptive analysis of the sample according to variables at tooth level (1) (total number of restorations evaluated: 217).

Table 2
Descriptive analysis of the sample according to variables at individual level (2) (number of patients evaluated: 98).

The results of the multilevel logistic regression analysis are displayed in Table 3, with odds ratios (ORs) presented separately for each level. This cross-sectional study found that 98 children had dental restorations in posterior primary teeth. After the adjustments on the tooth level (1), restorations in amalgam were less likely to fail compared to those in glass ionomer cement (OR = 0.11; 95%CI: 0.02–0.49; p = 0.005). After adjustments on the individual level (2), children with moderate/extensive untreated caries (OR = 6.79; 95%CI: 2.20–20.93; p = 0.001) and those with a visible plaque index ≥ 20% (OR = 2.28; 95%CI: 1.05–4.92; p = 0.036) were more likely to have unsatisfactory restorations. A total of 29.3% of the variance in unsatisfactory restorations could be attributed to variables at the individual level (2).

Table 3
Null model (random effect) and multilevel models (unadjusted and adjusted) for variables at tooth level (n = 217) and individual level (n = 98) associated with unsatisfactory dental restorations in children aged six to ten years.

Discussion

The present cross-sectional study evaluated the effect of clinical and individual variables on the quality of restorations on posterior primary teeth. The results demonstrated that restorative material, presence of moderate/extensive untreated caries, and a high visible plaque index were associated with failed restorations on posterior primary teeth. Therefore, the tested hypothesis was partially accepted.

The prevalence of unsatisfactory dental restorations was relatively high in this study (34.6%). This result is compatible with findings described in a retrospective study addressing defective restorations and factors associated with dental reinterventions, in which the prevalence of defects in restorations on primary teeth was 37.7%.99. Ávila NM, Bottezini PA, Nicoloso G, Araujo FB, Ardenghi TM, Lenzi TL, et al. Prevalence of defective restorations and factors associated with re-intervention in primary teeth: a retrospective university-based study. Int J Paediatr Dent. 2019 Sep;29(5):566-72. https://doi.org/10.1111/ipd.12493
https://doi.org/10.1111/ipd.12493...

At tooth level, amalgam was the restorative material with the lowest likelihood of failure compared to glass ionomer cement in both the unadjusted and adjusted models. This may be attributed to the good mechanical properties of amalgam.2020. World Dental Federation. FDI policy statement on dental amalgam and the Minamata Convention on Mercury: adopted by the FDI General Assembly: 13 September 2014, New Delhi, India. Int Dent J. 2014 Dec;64(6):295-6. https://doi.org/10.1111/idj.12151
https://doi.org/10.1111/idj.12151...
Currently, however, this material is often not inadvisable due to the toxicity of mercury to human health and the environment,2020. World Dental Federation. FDI policy statement on dental amalgam and the Minamata Convention on Mercury: adopted by the FDI General Assembly: 13 September 2014, New Delhi, India. Int Dent J. 2014 Dec;64(6):295-6. https://doi.org/10.1111/idj.12151
https://doi.org/10.1111/idj.12151...
,2121. Jenkins N. Materials for paediatric dentistry. Part 1: background to the treatment of carious primary teeth. Dent Update. 2015 Dec;42(10):905-8. https://doi.org/10.12968/denu.2015.42.10.905
https://doi.org/10.12968/denu.2015.42.10...
which has led to a reduction in the use of amalgam.2222. Cumerlato CB, Demarco FF, Barros AJ, Peres MA, Peres KG, Morales Cascaes A, et al. Reasons for direct restoration failure from childhood to adolescence: A birth cohort study. J Dent. 2019 Oct;89:103183. https://doi.org/10.1016/j.jdent.2019.103183
https://doi.org/10.1016/j.jdent.2019.103...
Moreover, tooth preparation for restorations with this material is less conservative, which goes against current recommendations for minimal interventions. Thus, adhesive materials, such as glass ionomer cement and composite resins, are widely employed due to the less invasive cavity preparation, which is restricted to the removal of the carious tissue.2323. Dias AG, Magno MB, Delbem AC, Cunha RF, Maia LC, Pessan JP. Clinical performance of glass ionomer cement and composite resin in Class II restorations in primary teeth: a systematic review and meta-analysis. J Dent. 2018 Jun;73:1-13. https://doi.org/10.1016/j.jdent.2018.04.004
https://doi.org/10.1016/j.jdent.2018.04....
,2424. Dhar V, Hsu KL, Coll JA, Ginsberg E, Ball BM, Chhibber S, et al. Evidence-based update of pediatric dental restorative procedures: dental materials. J Clin Pediatr Dent. 2015;39(4):303-10. https://doi.org/10.17796/1053-4628-39.4.303
https://doi.org/10.17796/1053-4628-39.4....
,2525. Pires CW, Pedrotti D, Lenzi TL, Soares FZ, Ziegelmann PK, Rocha RO. Is there a best conventional material for restoring posterior primary teeth? A network meta-analysis. Braz Oral Res. 2018 Mar;32(0):e10. https://doi.org/10.1590/1807-3107bor-2018.vol32.0010
https://doi.org/10.1590/1807-3107bor-201...
Considering these results, more frequent monitoring of restorations performed with glass ionomer cement is warranted.

Glass ionomer cement is the most indicated material for dental restorations in pediatric dentistry22. Pinto GS, Oliveira LJC, Romano AR, Schardosim LR, Bonow MLM, Pacce M, et al. Longevity of posterior restorations in primary teeth: results from a paediatric dental clinic. J Dent 2014 Out;42(10):1248-54. https://doi.org/10.1016/j.jdent.2014.08.005
https://doi.org/10.1016/j.jdent.2014.08....
,2626. Ehlers V, Gran K, Callaway A, Azrak B, Ernst CP. One-year clinical performance of flowable bulk-fill composite vs conventional compomer restorations in primary molars. J Adhes Dent. 2019;21(3):247-54. https://doi.org/10.3290/j.jad.a42519
https://doi.org/10.3290/j.jad.a42519...
due to the release of fluoride, adhesivity to the tooth, and biocompatibility.2525. Pires CW, Pedrotti D, Lenzi TL, Soares FZ, Ziegelmann PK, Rocha RO. Is there a best conventional material for restoring posterior primary teeth? A network meta-analysis. Braz Oral Res. 2018 Mar;32(0):e10. https://doi.org/10.1590/1807-3107bor-2018.vol32.0010
https://doi.org/10.1590/1807-3107bor-201...
Moreover, the restorative technique involves fewer steps compared to composite resin, which reduces the patient’s chair time.22. Pinto GS, Oliveira LJC, Romano AR, Schardosim LR, Bonow MLM, Pacce M, et al. Longevity of posterior restorations in primary teeth: results from a paediatric dental clinic. J Dent 2014 Out;42(10):1248-54. https://doi.org/10.1016/j.jdent.2014.08.005
https://doi.org/10.1016/j.jdent.2014.08....
Therefore, this material was used as a reference for the comparison of other restorative materials in the present study. Indeed, glass ionomer cement was the most frequently used material on the evaluated teeth, accounting for 56.7% of the restorations.

No significant difference was found in restoration failures performed with glass ionomer cement (conventional and resin-modified) and those performed with composite resin. Similar results were reported in a recent systematic review that compared the clinical performance of these materials in restorations on primary molars.2323. Dias AG, Magno MB, Delbem AC, Cunha RF, Maia LC, Pessan JP. Clinical performance of glass ionomer cement and composite resin in Class II restorations in primary teeth: a systematic review and meta-analysis. J Dent. 2018 Jun;73:1-13. https://doi.org/10.1016/j.jdent.2018.04.004
https://doi.org/10.1016/j.jdent.2018.04....
These findings suggest relative freedom in the choice of these restorative materials and dentists should consider other aspects such as the operational technique, the child’s behavior, the individual caries risk, and access when performing restorations in children.1010. Demarco FF, Corrêa MB, Cenci MS, Moraes RR, Opdam NJ. Longevity of posterior composite restorations: not only a matter of materials. Dent Mater. 2012 Jan;28(1):87-101. https://doi.org/10.1016/j.dental.2011.09.003
https://doi.org/10.1016/j.dental.2011.09...
,2323. Dias AG, Magno MB, Delbem AC, Cunha RF, Maia LC, Pessan JP. Clinical performance of glass ionomer cement and composite resin in Class II restorations in primary teeth: a systematic review and meta-analysis. J Dent. 2018 Jun;73:1-13. https://doi.org/10.1016/j.jdent.2018.04.004
https://doi.org/10.1016/j.jdent.2018.04....

In the present study, 29.3% of the variance in unsatisfactory restorations was related to individual level variables. In the final model, moderate/extensive untreated caries and visible dental plaque (> 20%) remained associated with unsatisfactory dental restorations. These results are compatible with the findings of previous studies, which suggest that dental caries is an important factor that affects the longevity of restorations.88. Collares K, Opdam NJ, Peres KG, Peres MA, Horta BL, Demarco FF, et al. Higher experience of caries and lower income trajectory influence the quality of restorations: a multilevel analysis in a birth cohort. J Dent. 2018 Jan;68:79-84. https://doi.org/10.1016/j.jdent.2017.11.009
https://doi.org/10.1016/j.jdent.2017.11....
,2222. Cumerlato CB, Demarco FF, Barros AJ, Peres MA, Peres KG, Morales Cascaes A, et al. Reasons for direct restoration failure from childhood to adolescence: A birth cohort study. J Dent. 2019 Oct;89:103183. https://doi.org/10.1016/j.jdent.2019.103183
https://doi.org/10.1016/j.jdent.2019.103...
Moreover, restoration survival is longer in patients who perform better routine biofilm control,88. Collares K, Opdam NJ, Peres KG, Peres MA, Horta BL, Demarco FF, et al. Higher experience of caries and lower income trajectory influence the quality of restorations: a multilevel analysis in a birth cohort. J Dent. 2018 Jan;68:79-84. https://doi.org/10.1016/j.jdent.2017.11.009
https://doi.org/10.1016/j.jdent.2017.11....
,1919. Casagrande L, Seminario AT, Correa MB, Werle SB, Maltz M, Demarco FF, et al. Longevity and associated risk factors in adhesive restorations of young permanent teeth after complete and selective caries removal: a retrospective study. Clin Oral Investig. 2017 Apr;21(3):847-55. https://doi.org/10.1007/s00784-016-1832-1
https://doi.org/10.1007/s00784-016-1832-...
,2727. Ruiz LF, Nicoloso GF, Franzon R, Lenzi TL, de Araújo FB, Casagrande L. Repair increases the survival of failed primary teeth restorations in high-caries risk children: a university-based retrospective study. Clin Oral Investig. 2020 Jan;24(1):71-7. https://doi.org/10.1007/s00784-019-02899-9
https://doi.org/10.1007/s00784-019-02899...
as stagnant biofilm on the tooth surface leads to the development of caries2828. Kidd EA, Fejerskov O. What constitutes dental caries? Histopathology of carious enamel and dentin related to the action of cariogenic biofilms. J Dent Res 2004;83 Spec No C:C35-38. https://doi.org/10.1177/154405910408301s07
https://doi.org/10.1177/154405910408301s...
and restoration failure can occur at the tooth-restoration interface. A wide confidence interval was observed for the presence of moderate/extensive untreated caries in the present study (Table 3). It is suggested that this may be related to the small number of children who did not have moderate/extensive untreated caries (10%). In other words, there was sample homogeneity, in this sense, it is recommended that in future studies this variable be considered as exposure. In the present study, sample calculation considered presence or absence of glass ionomer cement dental restorations as an exposure factor, while the presence of moderate/extensive untreated caries was not considered as an exposure factor.

Studies evaluating the quality of restorations have found a greater occurrence of failure and a reduction in the longevity of Class II restorations compared to Class I restorations.1919. Casagrande L, Seminario AT, Correa MB, Werle SB, Maltz M, Demarco FF, et al. Longevity and associated risk factors in adhesive restorations of young permanent teeth after complete and selective caries removal: a retrospective study. Clin Oral Investig. 2017 Apr;21(3):847-55. https://doi.org/10.1007/s00784-016-1832-1
https://doi.org/10.1007/s00784-016-1832-...
,2323. Dias AG, Magno MB, Delbem AC, Cunha RF, Maia LC, Pessan JP. Clinical performance of glass ionomer cement and composite resin in Class II restorations in primary teeth: a systematic review and meta-analysis. J Dent. 2018 Jun;73:1-13. https://doi.org/10.1016/j.jdent.2018.04.004
https://doi.org/10.1016/j.jdent.2018.04....
However, no significant association was found between the type of restoration (Class I or II) and unsatisfactory restoration in the present investigation. This may have occurred because the restorations had not been in the oral cavity long enough to demonstrate such an association. As the present study had a cross-sectional design, the restorations were not monitored over time.

Although socioeconomic variables influence health-related issues,2929. Bor J, Cohen GH, Galea S. Population health in an era of rising income inequality: USA, 1980-2015. Lancet. 2017 Apr;389(10077):1475-90. https://doi.org/10.1016/S0140-6736(17)30571-8
https://doi.org/10.1016/S0140-6736(17)30...
,3030. Zarzar PM, Ferreira EF, Kawachi I. Can social capital contribute to the improvement of oral health? Braz Oral Res. 2012 Sep-Oct;26(5):388-9. https://doi.org/10.1590/S1806-83242012000500002
https://doi.org/10.1590/S1806-8324201200...
no associations were found between unsatisfactory restorations and family income or mother’s schooling. The lack of statistically significant associations in this respect may have been due to the homogeneity of the sample, which was composed of public school students mainly from low-income families and little schooling.

This study has the limitations inherent to the cross-sectional design, as the restorations were not followed up from the beginning, the initial quality of all restorations was assumed to be the same,1212. Correa MB, Peres MA, Peres KG, Horta BL, Barros AJ, Demarco FF. Do socioeconomic determinants affect the quality of posterior dental restorations? A multilevel approach. J Dent 2013 Nov;41(11):960-967. https://doi.org/10.1016/j.jdent.2013.02.010
https://doi.org/10.1016/j.jdent.2013.02....
and the technique employed was not known. Therefore, these variables were not controlled. Despite the high prevalence of unsatisfactory dental restorations, this number may have been underestimated, as the dental examination was not conducted under ideal conditions in terms of lighting, prophylaxis, and drying of the teeth. Thus, longitudinal studies should be conducted in which dental restorations are monitored long-term from the onset so that these variables can be controlled. Another limitation of the study was that only students from public schools were included. Future studies with representative samples of the general population are recommended.

This study has strong points that should be highlighted. Multilevel statistical analysis is the most recommended for situations in which the variables interact with the outcome on different levels, as occurred in the present study.1212. Correa MB, Peres MA, Peres KG, Horta BL, Barros AJ, Demarco FF. Do socioeconomic determinants affect the quality of posterior dental restorations? A multilevel approach. J Dent 2013 Nov;41(11):960-967. https://doi.org/10.1016/j.jdent.2013.02.010
https://doi.org/10.1016/j.jdent.2013.02....
Moreover, the population-based design enables the determination of the prevalence of a health condition and associated factors in the population studied. Another relevant point of this study is its originality. Previous studies addressing the quality of dental restorations using the modified USPHS criteria on the population level are scarce.

Based on the findings of the present study, amalgam restorations are less likely to fail than glass ionomer cement restorations. Moreover, patients with moderate/extensive untreated caries and a dental plaque index higher than 20% were more likely to have unsatisfactory restorations. These results underscore the importance of monitoring dental restorations and employing an integral preventive approach for the control of etiological factors of caries. In addition, this cross-sectional study helps to identify the factors associated with failure of dental restorations, so that they can be worked on, aiming to increase the longevity of restorations and reduce the spending of public resources on oral health in the country.1212. Correa MB, Peres MA, Peres KG, Horta BL, Barros AJ, Demarco FF. Do socioeconomic determinants affect the quality of posterior dental restorations? A multilevel approach. J Dent 2013 Nov;41(11):960-967. https://doi.org/10.1016/j.jdent.2013.02.010
https://doi.org/10.1016/j.jdent.2013.02....

Conclusions

Restoration failure was associated with the restorative material, presence of moderate/extensive untreated caries, and visible plaque. Dentists should be aware not only of factors related to the restored tooth, but also those related to the patient, which are important aspects in the failure of dental restorations.

Acknowledgments

The authors are grateful to the Brazilian fostering agency Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES [Coordination for the Advancement of Higher Education Personnel] – Financing Code 001). The authors are also grateful to the school staff and parents/guardians of the children who contributed to this study.

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Publication Dates

  • Publication in this collection
    11 Nov 2022
  • Date of issue
    2022

History

  • Received
    17 Nov 2021
  • Accepted
    4 July 2022
  • Reviewed
    25 July 2022
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