Pedodontics

Original Article

PEDIATRIC DENTISTS’ CHOICES OF RESTORATIVE MATERIALS FOR

PRIMARY MOLARS
YOUSEF H AL-DLAIGAN
ABSTRACT
The aim of the study was to examine selection of various restorative materials in children; and
the basis for the selection in a group of pediatric dentists in Riyadh, Saudi Arabia. A self-administered
questionnaire was utilized to obtain demographic information and present the respondents with six
hypothetical clinical scenarios for selection of the restorative materials in primary teeth. A total of
forty four pediatric dentists (52% males and 48% females) completed the questionnaire. Two-third of
the respondents were seeing children between age 6 to 14 years. A great majority (89%) reported that
a successful alternative of amalgam is available. More than two-third (68%) were using tooth-colored
restorative materials more frequently than amalgam. Almost half (45%) of the respondents reported
that the most influencing factor in the choice of restorative material for vital primary teeth is cavity
design. The choice of restorative materials was discussed more with parents (84%) than children
(43%). For Class I and II cavity preparations in primary molars; amalgam was used by 43% and 50%
of the respondents respectively. For restoring two proximal lesions in primary molars; 66% preferred
Stainless Steel Crown (SSC) followed by amalgam (29%). It can be concluded that amalgam is still
popular for deep Class I and II cavities; whereas SSC is the most common choice for restoring primary
teeth with multiple surfaces carious lesions.
Key words: Children, Restorative Material, Pediatric Dentists, Primary Teeth

INTRODUCTION modified glass ionomers and compomers restorations

Many changes have occurred in the development have shown similar longevity compared with amal-
and availability of dental restorative materials for gam, whereas conventional glass ionmer restorations
pediatric patients over the last 60 years.1 Amalgam showed significantly shorter longevity.7 Recently, den-
has been used for over 120 years and is still being used tists have been moving away from amalgams towards
extensively in restorative dentistry.2 It is still taught esthetic restorations. Guelmann and Mjör1 reported
as the material of choice for Class I and II restorations that the pediatric dentists in Florida (USA) mostly
in many dental schools in the USA and Canada; also used resin-based materials for primary teeth Class I
it remains the best direct restorative option for larger and II restorations, while SSCs were the predominant
restorations3 or when used to restore interproximal choice when three or more surfaces were involved.
carious lesions.4,5 However, amalgam was the most common material
used for Class II restorations by Californian pediatric
Composite resins are the most desirable esthetic dentists.8 In Japan, Fukuyama et al9 reported that
materials with excellent physical and mechanical prop- the use of composites has increased primarily due to
erties.6 Compomers are a polyacid modified composite patients’ esthetic desires. More parents and children
resins and considered to be composite resins with now prefer tooth colored restorations as compared to
modest incorporation of glass ionomer cement (GIC). amalgam restorations.10
These materials are easy to handle, stronger and more
esthetic than GICs.4 GICs however have a high fluoride Pediatric dentists’ at the University of Minnesota,
release, good physical properties and biocompatibility; USA found that parental concerns about restorative
with lesser esthetic properties than composites.4 Resin materials in decreasing order were: esthetics, cost,
toxicity and durability. Similarly, parents’ greatest

Yousef H Al-Dlaigan, BDS, MS, Cert Pedo, PhD, Associate Professor,
Division of Pediatric Dentistry, Department of Pediatric Dentistry concerns about SSCs were esthetics and cost.11 Several
and Orthodontics, College of Dentistry, King Saud University, studies have compared durability and lifespan of SSCs
Riyadh, Saudi Arabia
Correspondence: Dr. Yousef H Al-Dlaigan, PO Box 60169, Riyadh and Class II amalgams restorations demonstrating the
11545, Saudi Arabia. Telephone: +966 11 4677228 superiority of SSCs for both the parameters.12, 13 Seale14
Fax: +966 11 4679017 E-mail: yaldlaigan@hotmail.com has recommended that the SSC is the most successful
Received for Publication: February 2, 2015 restoration in children with high caries rate. Several
Revision Received: March 10, 2015
Revision Approved: March 15, 2015 studies have found SSCs as superior restorations for

Pakistan Oral & Dental Journal Vol 35, No. 1 (March 2015) 83
 Pediatric dentists’ choices of restorative materials

badly broken down primary molars.13,15 Pre-veneered tionnaire was pilot tested in 10 dentists in King Saud
SSCs were developed to serve as a convenient durable, University College of Dentistry Clinics. The ques-
reliable, and an esthetic solution to the challenge of tionnaire was subsequently modified to make it more
restoring severely carious primary incisors.16 These comprehensive. All the data were entered and analyzed
crowns are commonly used to restore primary anterior using SPSS (Version 16.0). Descriptive statistics and
teeth by pediatric dentists at Detroit, USA. 17 Paren- tables were generated.
tal satisfaction is greater with pre-veneered SSCs for
RESULTS
primary anterior teeth.18
Forty-four pediatric dentists (52% males and 48%
Dentist needs to make wise decisions about the type
females) completed the questionnaire with a response
of restorative material they choose to restore primary
rate of 80%. The respondents’ age ranged from 31-50
teeth. The decisions are becoming more challenging due
years with mean age of 40.5 (SD 7.7) years. Half (50%)
to advancement and availability of newer materials19.
of the participants had Certificate and Master of Science
The purpose of the present study was to examine the
degree, while slightly more than one-third (36%) had
selection of restorative materials in primary teeth by
PhD degree. A majority (77%) of the participants had 11
a group of specialist pediatric dentists in Riyadh city,
years or longer experience. More than half (59%) were
Saudi Arabia.
graduates from Saudi Arabia, 16% from Arab countries,
METHODDOLOGY and the rest were from different countries including
A sample of pediatric dentists was chosen on the USA, UK, Canada, France, and Pakistan. Among the
basis of their membership in the Saudi Dental Society participants; 46% work in government hospitals, 25%
and working in Riyadh city, Saudi Arabia. They includ- in private clinics and others in private hospitals and
ed pediatric dentists (having a specialist training in academic institutions. Most of respondents (39%) see
pediatric dentistry) working in teaching institutions, 31 or more children per week mainly aged between
government hospitals, private hospitals and private 6-10 years.
dental clinics. Majority (91%) of the children were treated on a
A self-administered questionnaire was designed dental chair with or without local anesthesia and rest
for the study. The questionnaire had four sections: with local anesthesia and N2O (9%) and no one used
a general anesthesia approach. A great majority of
1 Demographic information; respondent’s gender, the participants (89%) found a successful alternative
age, qualification, years of experience, place of material to amalgam for posterior teeth; and the ma-
graduation, place of work, number of children seen jority (68%) reported using tooth colored materials
per week, age range of children treated, and main more frequently than amalgam (Table 1). None of
behavior management approaches used. the pediatric dentists used amalgam as only choice of
2 Factors affecting the choice of restorative materials; restorative material for posterior teeth. The two most
pattern of amalgam usage, other materials used frequently reasons for selecting a particular tooth-col-
including SSCs, reason for using tooth colored ma- ored material in posterior teeth were fluoride release
terial for posterior teeth, and the most influential (34%) and longevity similar to amalgam (32%). The
factor in choosing a restorative material. two most influential factors in material choice were
cavity extension or depth (45%) and research reports
3 Influence of parents and child patients in the re- or journal articles (41%).
storative material selection.
Majority of the respondents (84%) discussed restor-
4 The final section had six hypothetical clinical ative material selection with parents and the parental
scenarios (brief descriptions with diagrams and preferences were actually considered by 64% of the
material options) presenting lesions of various sizes, pediatric dentists. Most respondents (57%) did not
location and depth in primary molars. Participants discuss the choice of restorative material with children.
were asked for their choices of materials including
Hypothetical clinical scenarios (Tables 2 & 3)
fissure sealant with unfilled resin (FS), preventive
resin restoration with resin plus unfilled resin Scenario 1: Preferred material for occlusal
(PRR), GICs, composite resins, amalgam, SSCs, and lesions (just into enamel) on a primary molar.
others. These material choices and six hypothetical Preventive resin restoration with resin plus un-
clinical scenarios were adopted from work of Tran filled resin (PRR) was the first choice (64%) followed
and Messer. 20 It was assumed that all hypothetical by fissure sealant (FS) using unfilled resin (39%).
situations were in co-operative children with good
Scenario 2: Preferred material for occlusal
oral hygiene and using a fluoridated tooth paste.
lesions (half way to dentino-enamel junction) on
Prior to undertaking the main study, the ques- primary molar.

Pakistan Oral & Dental Journal Vol 35, No. 1 (March 2015) 84
 Pediatric dentists’ choices of restorative materials

TABLE 1. PEDIATRIC DENTISTS’ RESPONSE TO VARIOUS QUESTIONS ABOUT RESTORATIVE

MATERIAL SELECTION
Questions N (%)
Posterior teeth: Successful alternatives to amalgam
Yes 39 (89)
No 5 (11)
Posterior teeth: Patterns of usage of dental materials (other than stainless
steel crown)
Amalgam only 0 (0)
More amalgam than tooth-colored material 13 (30)
More tooth-colored materials than amalgam 30 (68)
Tooth colored materials only 1 (2)
Posterior teeth: Main reason for use of tooth-colored materials
Aesthetic superior to amalgam 11 (25)
Fluoride release 15 (34)
Longevity as good as amalgam 14 (32)
Tooth does not need pulp therapy 4 (9)
Most influential factors in choosing a restorative material:
Cavity preparation 20 (45)
Previous success with material 6 (14)
Research reports and journal articles 18 (41)
Colleague appraisal 0 (0)

TABLE 2: VARIOUS HYPOTHETICAL CLINICAL SCENARIOS20

Scenario Lesion on mandibular primary second molar Material choices
(1) 4 - years- old child Occlusal lesions just into FS, PRR, GIC, RMGIC,
enamel CR, A, SSC, Comp

(2) 5- years-old child Occlusal lesions half way FS, PRR, GIC, RMGIC,
to dentine enamel junc- CR, A, SSC, Comp
tion

(3) 6- years -old child Occlusal lesion just into FS, PRR, GIC, RMGIC,
dentin CR, A, SSC, Comp

(4) 5- years -old child Occlusal lesion half way FS, PRR, GIC, RMGIC,
to the pulp CR, A, SSC, Comp

(5) 8- years -old child Proximal lesion half way FS, PRR, GIC, RMGIC,
to the pulp CR, A, SSC, Comp

(6) 8- years - old child Two proximal lesions half FS, PRR, GIC, RMGIC,
way to the pulp CR, A, SSC, Comp

Abbreviations: FS= Fissure sealant; PRR= Preventive resin restoration; GIC= Glass ionomer cement; RMGIC=
Resin modified glass ionomer cement; CR= Composite resin; A= Amalgam; SSC= Stainless steel crown; Comp=
Compomer
Pakistan Oral & Dental Journal Vol 35, No. 1 (March 2015) 85
 Pediatric dentists’ choices of restorative materials

TABLE 3: SELECTION OF THE RESTORATIVE DISCUSSION

MATERIALS FOR THE HYPOTHETICAL CLINI- The present study utilized the method sample
CAL SCENARIOS. distribution and size similar to the study by Tran
and Messer in their study.20 The results demonstrate
Hypothetical First choice Second choice
clinical for material/ for material/ that participants were well qualified and experienced,
scenarios procedure procedure thus providing strong confidence to the results of the
(n=44) N (%) (n=44) N (%) study. The high average number of children treated
Occlusal lesions PRR 28 (64) FS 17 (39) by pediatric dentists per week and broad age-range of
(just into the children further strengthened the study.
enamel)
The trend towards finding an alternative to amal-
Occlusal lesions PRR 24 (54) RMGIC 16(36) gam and increasing use of tooth-colored materials as
(half way to shown by the present study were in agreement with
DEJ)
several other previous studies1,20,21 and reflect favorable
Occlusal lesion RMGIC 17 (39) CR 16 (36) scientific reports about these materials from other
(just into organization such as National Health and Medical
dentine)
Research Council.1,20,21
Occlusal lesion Amalgam 19 (43) RMGIC/CR 17
(half way to (39) Fluoride release was selected as one of the most
pulp) important factors in selecting tooth-colored material
Proximal lesion Amalgam 22 (50) CR 16 (36) for restoring posterior teeth. This could be attributed
(half way to to high caries risk that makes the fluoride releasing
pulp) materials the primary choice for restoring posterior
Two proximal SSC 29 (66) Amalgam 12 primary teeth. Using glass ionomer and compomer
lesions (half way (29) had been investigated in the past through different
to pulp) studies. Ample fluoride release and longevity have
Abbreviations: PRR= Preventive resin restoration; been reported for GICs.21,22 It was comforting to note
FS= Fissure sealant; RMGIC= Resin modified glass that the majority of pediatric dentist were considering
ionomer cement; CR= Composite resin; SSC= Stainless parental preference for the restorative materials.
steel crown In the 1st hypothetical scenario; a majority of the
Preventive resin restoration with resin plus unfilled respondents selected PRR as a preferred restoration
resin (PRR) was the first choice (54%) followed by GICs in spite of the fact the carious lesion only involved
restorations (36%). enamel surface. Previous studies have reported that
in preparations which extend very minimally into
Scenario 3: Preferred material for occlusal
enamel are restored with sealants that can be flown
lesion just into dentin on primary molar.
onto an acid-etched surface. PRR can be used when the
GICs were the first material of choice (39%) while preparation extent substantially into enamel or even
the second was composite resins (36%). into dentine.23
Scenario 4: Preferred material for an occlusal In the 2nd scenario; the first choice was PRR for
lesion (half way to the pulp) on primary molar. restoring occlusal lesion that extends half way into
Amalgam restoration was preferred by 43% re- dentino-enamel junction of a primary molar. This is a
spondents followed by resin modified GICs/composite reasonable selection for a carious lesion that is extended
resins (39%). half way into dentino-enamel junction.23
Scenario 5: Preferred material for a proximal

For the 3rd scenario of carious lesion just into
lesion on primary molar. dentin; it was interesting to find that the respondents
selected GICs as the first material of choice followed
Although a wide range of materials were selected,
by composites. High caries rates in Saudi children
amalgam was the first material of choice (50%) while
could be the contributing factor in this decision.4 This
the second was composite resins (36%).
finding was similar to several other studies in various
Scenario 6: Preferred material for two prox- countries.1,21,25
imal lesions (half way to the pulp) on primary
In the 4th scenario, where the lesion was half-way
molar SSCs was the first choice of the pediatric dentists
towards pulp, a majority selected amalgam as the first
(66%) while amalgam was the second (29%).
choice; followed by GICs/Composites. The selection indi-
There were no differences (p>.05) in various re- cates respondents’ continuing trend towards amalgam
sponses in relation to gender, age, experience, place of as a dependable material for deep carious lesions. This
graduation and qualifications of the pediatric dentists.
Pakistan Oral & Dental Journal Vol 35, No. 1 (March 2015) 86
 Pediatric dentists’ choices of restorative materials

finding however was in contrast to the results of study 8 Pair RL, Udin RD, Tanbonliong T. Materials used to restore class
II lesions in primary molars: a survey of California pediatric
by Tran and Messer 20 where the first choice was GICs. dentists. Pediatr Dent. 2004; 26: 501-507.
The respondent’s first choice for restoring proximal 9 Fukuyama T, Oda S, Yamashita H, Sekiguchi H, Yakushiji M.
lesions in primary molars was amalgam followed by Clinical survey on type of restoration in deciduous teeth. Bull
Tokyo Dent Coll. 2008; 49: 41-50.
composites. This finding was in agreement with the
result of Pair et al (2004) who found that the majority 10 Peretz B, Ram D. Restorative material for children's teeth:
preferences of parents and children. ASDC J Dent Child. 2002;
of pediatric dentists in the California used amalgam 69: 243-248, 233.
as the material of choice for restoration the proximal 11 Zimmerman JA, Feigal RJ, Till MJ, Hodges JS. Parental at-
lesions. However, several other studies have reported titudes on restorative materials as factors influencing current
Compomers and GICs as the first choice of pediatric use in pediatric dentistry. Pediatr Dent. 2009; 31: 63-70.
dentists for restoring primary proximal lesions.4,20,25 12 Threlfall AG, Pilkington L, Milsom KM, Blinkhorn AS, Tickle
M. General dental practitioners' views on the use of stainless
In the 6th scenario of multi-surface carious lesions; steel crowns to restore primary molars. Br Dent J, 2005; 199:
SSCs were the clear choice of the respondents. This 453-455.
finding is in agreement with several other studies. 26, 27, 28 13 Attari N, Roberts JF. Restoration of primary teeth with crowns:
SSCs are considered as the most durable restoration for a systematic review of the literature. Eur Arch Paediatr Dent.
2006; 7: 58-62.
multi surface primary lesions and have a high success
14 Seale NS. The use of stainless steel crowns. Pediatr Dent. 2002;
rate than any other type of restoration.28 The present 24: 501-505.
study has provided useful information on the selection
15 MacLean JK, Champagne CE, Waggoner WF, Ditmyer MM,
of restorative materials in various clinical situations for Casamassimo P. Clinical outcomes for primary anterior teeth
restoring primary molars. The author feels that there treated with preveneered stainless steel crowns. Pediatr Dent.
is a need to provide a uniform guidelines to be used for 2007; 29: 377-381.
the selection of restorative materials in primary teeth. 16 Roberts C, Lee JY, Wright JT. Clinical evaluation of and paren-
tal satisfaction with resin-faced stainless steel crowns. Pediatr
CONCLUSIONS Dent. 2001; 23: 28-31.
17 Oueis H, Atwan S, Pajtas B, Casamassimo PS. Use of anterior
• GICs are the pediatric dentists’ first choice to restore veneered stainless steel crowns by pediatric dentists. Pediatr
shallow occlusal carious lesions in primary molars. Dent. 2010; 32: 413-416.

• Amalgam is still a choice for restoring deep occlusal 18 Champagne C, Waggoner W, Ditmyer M, Casamassimo PS,
MacLean J. Parental satisfaction with preveneered stainless
and proximal carious lesions. steel crowns for primary anterior teeth. Pediatr Dent. 2007; 29:
465-469.
• SSC is most common choice for restoring primary
molars with multi-surfaces carious lesions. 19 Uston KA, Estrella MR. The stainless steel crown debate: friend
or foe? J Mich Dent Assoc. 2011; 93: 42-44, 46.
ACKNOWLEDGMENT 20 Tran LA, Messer LB. Clinicians’ choices of restorative materials
for children. Aust Dent J. 2003; 48: 221-232.
The author would like to express his deepest thanks
21 Milsom KM, Tickle M, Blinkhorn A. The prescription and relative
to Drs Ahmed M. Maawadh and Feras A. Al-Halabi for outcomes of different materials used in general dental practice
their help in data collection. Participation of all the in the northwest region of England to restore the primary den-
pediatric dentists is also deeply appreciated. tition. J Dent. 2002; 30: 77-82.
22 Duggal MS, Toumba KJ, Sharma NK. Clinical performance of
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