Position Paper: Amalgam Vs.

Other Restorative Materials

Position Paper: Do Silver Amalgam Restorations Have Greater

Longevity Vs. Composite Resin Materials
EVBP- 5500-01
Carry Maynard RDH
Due Date: July 29 2016
Candace Volpe, Emily Hartin, Erin Whitney

Position Paper: Amalgam Vs. Other Restorative Materials

Introduction:
Inadequate oral hygiene can cause many major problems in the oral cavity including
gingival infection, halitosis, tooth staining and caries. It has been noted that the vast majority of
the public, 92% (STATS Canada, 2014) have had a caries experience in the past, thus needing the
tooth/teeth to be restored. Since the majority of the public needs dental restorations, it is
important to use a material that will be affordable, easy to place, doesnt require a lot of the tooth
structure to be removed in order to be placed, and be able to withstand the chewing forces of the
posterior teeth. The topic that we chose to do our position paper on is concerning the longevity of
dental restorations in posterior teeth. There are many different types of materials used for
restorative dental work in today's modern dental clinics such as amalgam, glass ionomer,
composite resin, ceramic, porcelain, these are just a few examples that dental offices use to
fabricate tooth restorations. We chose to compare amalgam and composite resin materials. Under
normal circumstances do silver amalgam fillings provide more longevity than composite resin
restorative materials? From the research that we have conducted we believe that the lifespan of
all dental restorations is limited, but amalgam fillings will last longer than composite resins or
glass ionomer restorative materials. Amalgam restorations excel in all of the previous stated
categories especially with regards to contracting forces while chewing and this is why we believe
that amalgam material has increased longevity over composite resin restorative materials.
Strength:
One of the main advantages to amalgam is it's mechanical properties and its ability to
withstand chewing forces and resist fracture (Monga, Sharma, Kumar, 2009). This is one of the
main reasons why, although new and improved dental materials are making their way into the
dental community, amalgam has stuck around for over 100 years (Monga et al., 2009). However,

Position Paper: Amalgam Vs. Other Restorative Materials

one problem with amalgam is the lack of adhesion to the tooth structure (Monga et al., 2009).
There is a solution to this problem being studied. A product that has made its way into the dental
field to further improve restoration materials is an adhesive system that bonds restoration
material to tooth structure (Monga et al., 2009). When amalgam restorations are placed without
the bonding system, they often result in fracture of the tooth (Monga et al., 2009). This is due to
the lack of adaptation of amalgam to tooth structure in addition to repetitive loading causing
fatigue (Monga et al., 2009). When amalgam is placed in addition with a bonding system, the
benefit of amalgam's notorious compressive strength as well as the ability for the material to
adapt to the tooth are combined, largely improving the efficacy of the restoration (Monga et al.,
2009). In one study, various materials were tested for compression strength when paired with an
adhesive system. The purpose of the study was to evaluate the effect of bonded restorations on
fracture resistance of endodontically treated teeth. Endodontically treated teeth must be restored
with the most fracture resistant restoration because of the lack of vascularity to the tooth (Monga
et al., 2009). Once the pulp and blood supply have been removed from the tooth, the dentin can
become dehydrated and therefore more susceptible to fracture (Monga et al., 2009). The study
compared the compressive strength of endodontically treated teeth with the following types of
restorations: bonded composite, bonded amalgam, and amalgam without an adhesive system.
The results of the study showed amalgam without a bonding system was the weakest, however
the amalgam with the bonding system was the strongest. Another factor that contributes to
fracture and weakness of restoration or tooth structure is the size of the restoration (Kemaloglu,
Pamir, Tezel, 2016). According to one study, the larger the restoration, the more susceptible it, or
the tooth surrounding it, is to fracture (Kemaloglu et al., 2016). The results of a randomized
control trial evaluating the effects of bonded composite resin restorations and bonded amalgam

Position Paper: Amalgam Vs. Other Restorative Materials

restorations concluded that breakage of larger restorations is more evident in composite resin
restorations than in bonded amalgam fillings (Kemaloglu et al., 2016). Based on this
information, amalgam is the superior restoration material in comparison with composite resin, as
it is more resistant to fracture.
Micro-leakage:
When teeth experience dental caries, the caries causing bacteria begins to break down the
enamel, causing the tooth to lose its integrity. This can be very painful to the client experiencing
the decay, therefore the tooth needs to be restored in order to distinguish the discomfort the client
is experiencing and to eliminate the decay that is causing the tooth to break down. Once the tooth
has been restored, there is a possibility of the restoration failing. One reason for failure can be
micro-leakage. Micro-leakage is when there are voids in the margins of the restoration, meaning
that saliva and bacteria can get in and around the restoration that has been placed in the tooth.
Once that happens the bacteria can cause more damage resulting in recurrent decay and the
restoration to fail. Micro-leakage reduces the longevity of the tooth and the restoration. It is
evident that this problem is more prevalent in composite resin restorations. In one study it stated
that one of the reasons microleakage is more evident in composite resin restorations is due to the
composition of the composite resin material. Composite resin consists of polymer chains. While
the material is setting, its polymeric material contracts (Mahrous, Eltiti, Ahmed, & Alagha,
2015). This is called polymer shrinkage (Vanishree, Shanthala, Bobby, 2015). A study we looked
at compared fracture resistance and microleakage in amalgam, bonded amalgam, and bonded
composite resin restorations. For the study method, 30 primary molar teeth were divided into 3
groups relating to the material they would be restored with, and were then prepped at the
gingival third and restored. The results of the study showed that bonded amalgam showed the

Position Paper: Amalgam Vs. Other Restorative Materials

least microleakage out of all types of tested restoration materials. Composite resin material
consists of polymers that are highly susceptible to shrinkage when cured (Vanishree et al., 2015).
This can lead to poor marginal adaptation. When a bonding system is used in conjunction with
amalgam, the risk of polymer shrinkage is eliminated as amalgam does not consist of polymers,
and marginal adaptation is excellent as the bonding system assists in closing the microscopic gap
between the restoration and the tooth surface. These factors together lead to less microleakage
(Antony, Genser, Hiebinger, & Windisch, 2008). To confirm these findings, we looked at
another study. In the article, An in vitro Evaluation of Micro-leakage of Posterior Teeth Restored
with Amalgam, Composite and Zirconomer A Stereomicroscopic Study, it discusses a study
that was comparing micro-leakage of amalgam and composite resin restorative materials in
posterior teeth. There were 10 teeth for each group and the results show that amalgam has less
micro-leakage than composite resin. Only 20% of the teeth filled with amalgam experienced
micro-leakage, while 47.5% of the teeth restored with composite material experienced microleakage. With this information, it is evident that composite resin restorations, due to the
composition of the material and its polymers being susceptible to polymer shrinkage, are inferior
to amalgam restorations.
Placement:
One problem with composite resin is its lack of ability to adhere to surfaces of the tooth
other than enamel (Mahrous, Eltiti, Ahmed, & Alagha, 2015). There are multiple reasons as to
why adhesion of composite resin to dentin or cementum is challenging. One study stated that
dentin and cementum is heterogeneous (Mahrous, Eltiti, Ahmed, & Alagha, 2015). It's
components consist of hydroxyapatite, collagen, smear layer, dentinal tubules, and fluids
(Mahrous, Eltiti, Ahmed, & Alagha, 2015). The heterogeneous nature of dentin and cementum

Position Paper: Amalgam Vs. Other Restorative Materials

poses a challenge to the bonding system of composite resin as it is difficult to simultaneously
adhere to all of these components (Mahrous, Eltiti, Ahmed, & Alagha, 2015). Bonding to the
enamel is not as challenging as the enamel is highly mineralized and consists of 90%
hydroxyapatite (Mahrous, Eltiti, Ahmed, & Alagha, 2015). This problem does not occur with
amalgam restorations as there is no absolute need for a bonding system. Amalgam can be placed
and function adequately with or without an adhesive system. Another challenge with placing
composite resin restorations on dentin and cementum surfaces is keeping the area isolated and
free from contamination with saliva (Mahrous, Eltiti, Ahmed, & Alagha, 2015). It is important
that composite resin restorations be isolated adequately as they are a very technique-sensitive
material. Small disruption in the technique could cause failure of the restoration, where as
amalgam materials are not technique-sensitive and can function adequately when placed on
dentin or cementum surfaces (Vanishree, Shanthala, Bobby, 2015). This inability for composite
resin to adhere effectively to the surface of dentin and cementum is a problem in itself but it also
leads to another problem, microleakage (Mahrous, Eltiti, Ahmed, & Alagha, 2015). One study
we read tested the effectiveness of composite resin restorations on three different tooth surfaces;
the enamel, the cemento-enamel junction, and the cementum. The results of the study showed
that most of the micro-leakage due to lack of proper adhesion to the tooth surface, occurred in
the cementum, followed by the cemento-enamel junction, followed by the enamel. None of the
restorations could completely eliminate microleakage, however the most effective restorative
material tested was in the enamel. Because of this information, we believe that composite resin
restorations, due to their lack of ability to adhere effectively to all tooth surfaces, are inferior to
amalgam restorations.

Position Paper: Amalgam Vs. Other Restorative Materials

Counterclaims:
It may be difficult to convince a client to have a silver amalgam materials placed in the
oral cavity when composite resin look so much more appealing. Composite resins come in an
array of many different tooth shades so DDS can match the restorative material exactly to the
colour of the tooth being restored. It is obvious that when restoring a tooth, longevity is not the
be all and end all. Esthetics play a large role in restorations, especially in the anterior teeth where
esthetics may be the primary concern. However, it is important to consider the fact that caries is a
disease (Hygiene related diseases: Caries, 2014). When dealing with oral health conditions, one
should consider what the best option is in relation to the overall health and prognosis of the
tooth, rather than the appearance of the tooth. In addition, another study claims that using a
restorative material with elastic properties similar to dentin, like composite resins, the restoration
can have a more favourable performance with teeth under stress because they can expand and
contract with the teeth (Geracci, Ferrari, 2011). A systematic review evaluated how effective
composite resin restorations are compared with conventional amalgam fillings when placed
directly into cavities in permanent teeth in the back of the mouth. The summary of findings in the
article stated that the failure rate of amalgams was 75 out of 1000, whereas the failure rate for
composite resin restorations was 142 out of 1000(M Graciela Rasines Alcaraz, Analia VeitzKeenan, Philipp Sahrmann, Patrick Roger Schmidlin, Dell Davis, Zipporah Iheozor-Ejiofor,
2014). In addition to failure of the restoration, secondary caries was evaluated. The prevalence of
secondary caries in amalgam restorations was 57 out of 1000, where as for composite resin
restorations it was 122 out of 1000 (M Graciela Rasines Alcaraz et al, 2014). Taking this into
consideration, it is evident that although the composite resin material may be more flexible than
amalgam, the failure rate of the material is still greater than amalgam. In addition, if the material

Position Paper: Amalgam Vs. Other Restorative Materials

has a higher prevalence of secondary caries, caries being the general indication for a composite
or amalgam restoration in the first place, the purpose of the restoration is defeated.
Conclusion:
Based on the articles reviewed in this paper, we believe that amalgam is the longer lasting
restoration material in comparison to composite resin. In the studies we reviewed, amalgam
restorations excelled in terms of strength, microleakage, and restoration placement. For these
reasons, we believe amalgam is the superior restorative material when it comes to longevity.

Position Paper: Amalgam Vs. Other Restorative Materials

References:
Antony, K., Genser, D., Hiebinger, C., & Windisch, F. (2008, November 13). Longevity of dental
amalgam in comparison to composite materials. Retrieved July 16, 2016, from
http://europepmc.org/articles/PMC3011298
Dental Caries (Tooth Decay) in Adults (Age 20 to 64). (2014, September 05). Retrieved July 07,
2016,http://www.nidcr.nih.gov/DataStatistics/FindDataByTopic/DentalCaries/DentalCari
esAdults20to64.htm
Goracci, C., & Ferrari, M. (2011, June). Current perspectives on post systems: A literature
review. Australian Dental Journal,56, 77-83. doi:10.1111/j.1834-7819.2010.01298
Hygiene related diseases: Caries. (2014, December 16). Retrieved July 27, 2016, from
http://www.cdc.gov/healthywater/hygiene/disease/dental_caries.html
Kemaloglu, H., Pamir, T., & Tezel, H. (2016). A 3-year randomized clinical trial evaluating two
different bonded posterior restorations: Amalgam versus resin composite. European
Journal of Dentistry, 10(1), 1622. http://doi.org/10.4103/1305-7456.175692
Mahrous, A. I., Eltiti, H. A., Ahmed, I. M., & Alagha, E. I. (2015). Effect of different gingival
margin restorations of class II cavities on microleakage: an in-vitro study. Electronic
Physician, 7(7), 14351440. http://doi.org.dproxy.library.dc-uoit.ca/10.19082/1435
Monga P, Sharma V, Kumar S. Comparison of fracture resistance of endodontically treated teeth
using different coronal restorative materials: An in vitro study. J Conserv Dent [serial
online] 2009 [cited 2016 Jul 10];12:154-9. Available
from: http://www.jcd.org.in/text.asp?2009/12/4/154/58338
Patel, M. U., Punia, S., Bhat, S., Singh, G., Bhargava, R., Goyle, P.Raiyani, C. M. (2015,

Position Paper: Amalgam Vs. Other Restorative Materials

July). An in vitro Evaluation of Microleakage of Posterior Teeth Restored with
Amalgam, Composite and Zirconomer A Stereomicroscopic Study. Journal of Clinical
Diagnostic Research. doi:10.7860/JCDR/2015/13024.6225

Rasines Alcaraz MG, Veitz-Keenan A, Sahrmann P, Schmidlin PR, Davis D, Iheozor-Ejiofor Z.

Direct composite resin fillings versus amalgam fillings for permanent or adult posterior
teeth. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD005620.
DOI: 10.1002/14651858.CD005620.pub2.
Vanishree H S, Shanthala B M, Bobby W. The comparative evaluation of fracture resistance and
microleakage in bonded amalgam, amalgam, and composite resins in primary molars.
Indian J Dent Res [serial online] 2015 [cited 2016 Jul 7];26:446-50. Available
from: http://www.ijdr.in/text.asp?2015/26/5/446/172019