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Direct composite resin fillings versus amalgam fillings for

permanent posterior teeth (Review)
Worthington HV, Khangura S, Seal K, Mierzwinski-Urban M, Veitz-Keenan A, Sahrmann P,

Schmidlin PR, Davis D, Iheozor-Ejiofor Z, Rasines Alcaraz MG
Worthington HV, Khangura S, Seal K, Mierzwinski-Urban M, Veitz-Keenan A, Sahrmann P, Schmidlin PR, Davis D, Iheozor-Ejiofor Z,
Rasines Alcaraz MG.
Direct composite resin fillings versus amalgam fillings for permanent posterior teeth.
Cochrane Database of Systematic Reviews 2021, Issue 8. Art. No.: CD005620.
DOI: 10.1002/14651858.CD005620.pub3.
www.cochranelibrary.com
Direct composite resin fillings versus amalgam fillings for permanent posterior teeth (Review)
Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.
Library Better health. Cochrane Database of Systematic Reviews
TABLE OF CONTENTS
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 4
BACKGROUND.............................................................................................................................................................................................. 6
OBJECTIVES.................................................................................................................................................................................................. 7
METHODS..................................................................................................................................................................................................... 7
RESULTS........................................................................................................................................................................................................ 9
Figure 1.................................................................................................................................................................................................. 10
Figure 2.................................................................................................................................................................................................. 13
DISCUSSION.................................................................................................................................................................................................. 16
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 17
ACKNOWLEDGEMENTS................................................................................................................................................................................ 17
REFERENCES................................................................................................................................................................................................ 18
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 23
DATA AND ANALYSES.................................................................................................................................................................................... 36
Analysis 1.1. Comparison 1: Composite resin fillings versus amalgam fillings, Outcome 1: Failure rate......................................... 37
Analysis 1.2. Comparison 1: Composite resin fillings versus amalgam fillings, Outcome 2: Secondary caries............................... 38
Analysis 1.3. Comparison 1: Composite resin fillings versus amalgam fillings, Outcome 3: Fracture of restorations..................... 38
ADDITIONAL TABLES.................................................................................................................................................................................... 38
APPENDICES................................................................................................................................................................................................. 46
WHAT'S NEW................................................................................................................................................................................................. 60
HISTORY........................................................................................................................................................................................................ 60
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 60
DECLARATIONS OF INTEREST..................................................................................................................................................................... 60
SOURCES OF SUPPORT............................................................................................................................................................................... 61
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 61
NOTES........................................................................................................................................................................................................... 61
INDEX TERMS............................................................................................................................................................................................... 62
Direct composite resin fillings versus amalgam fillings for permanent posterior teeth (Review) i
Informed decisions.
[Intervention Review]
Direct composite resin fillings versus amalgam fillings for permanent

posterior teeth
Helen V Worthington1, Sara Khangura2, Kelsey Seal2, Monika Mierzwinski-Urban2, Analia Veitz-Keenan3, Philipp Sahrmann4, Patrick
Roger Schmidlin4, Dell Davis5, Zipporah Iheozor-Ejiofor6, María Graciela Rasines Alcaraz7
1Cochrane Oral Health, Division of Dentistry, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of
Manchester, Manchester, UK. 2Canadian Agency for Drugs and Technologies in Health (CADTH), Ottawa, Canada. 3Department of Oral
Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry, New York, USA. 4Clinic of Conservative and
Preventive Dentistry, Center for Dental and Oral Medicine and Maxillo-Facial Surgery, University of Zurich, Zurich, Switzerland. 5Texas
Medical Center Library, Houston Academy of Medicine, Houston, USA. 6School of Medicine, University of Central Lancashire, Preston, UK.
7Argentine Dental Association (AOA), Buenos Aires, Argentina
Contact: María Graciela Rasines Alcaraz, [email protected].
Editorial group: Cochrane Oral Health Group.

Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 8, 2021.
Citation: Worthington HV, Khangura S, Seal K, Mierzwinski-Urban M, Veitz-Keenan A, Sahrmann P, Schmidlin PR, Davis D, Iheozor-
Ejiofor Z, Rasines Alcaraz MG. Direct composite resin fillings versus amalgam fillings for permanent posterior teeth. Cochrane Database of
Systematic Reviews 2021, Issue 8. Art. No.: CD005620. DOI: 10.1002/14651858.CD005620.pub3.
ABSTRACT
Background
Traditionally, amalgam has been used for filling cavities in posterior teeth, and it continues to be the restorative material of choice in some
low- and middle-income countries due to its effectiveness and relatively low cost. However, there are concerns over the use of amalgam
restorations (fillings) with regard to mercury release in the body and the environmental impact of mercury disposal. Dental composite resin
materials are an aesthetic alternative to amalgam, and their mechanical properties have developed sufficiently to make them suitable for
restoring posterior teeth. Nevertheless, composite resin materials may have potential for toxicity to human health and the environment.
The United Nations Environment Programme has established the Minamata Convention on Mercury, which is an international treaty
that aims "to protect the [sic] human health and the environment from anthropogenic emissions and releases of mercury and mercury
compounds". It entered into force in August 2017, and as of February 2021 had been ratified by 127 governments. Ratification involves
committing to the adoption of at least two of nine proposed measures to phase down the use of mercury, including amalgam in dentistry.
In light of this, we have updated a review originally published in 2014, expanding the scope of the review by undertaking an additional
search for harms outcomes. Our review synthesises the results of studies that evaluate the long-term effectiveness and safety of amalgam
versus composite resin restorations, and evaluates the level of certainty we can have in that evidence.
Objectives
To examine the effects (i.e. efficacy and safety) of direct composite resin fillings versus amalgam fillings.
Search methods
An information specialist searched five bibliographic databases up to 16 February 2021 and used additional search methods to identify
published, unpublished and ongoing studies
Selection criteria
To assess efficacy, we included randomised controlled trials (RCTs) comparing dental composite resin with amalgam restorations in
permanent posterior teeth that assessed restoration failure or survival at follow-up of at least three years.
Direct composite resin fillings versus amalgam fillings for permanent posterior teeth (Review) 1
Informed decisions.
To assess safety, we sought non-randomised studies in addition to RCTs that directly compared composite resin and amalgam restorative
materials and measured toxicity, sensitivity, allergy, or injury.
Data collection and analysis

We used standard methodological procedures expected by Cochrane.
Main results
We included a total of eight studies in this updated review, all of which were RCTs. Two studies used a parallel-group design, and six used
a split-mouth design. We judged all of the included studies to be at high risk of bias due to lack of blinding and issues related to unit of
analysis. We identified one new trial since the previous version of this review (2014), as well as eight additional papers that assessed safety,
all of which related to the two parallel-group studies that were already included in the review.
For our primary meta-analyses, we combined data from the two parallel-group trials, which involved 1645 composite restorations and
1365 amalgam restorations in 921 children. We found low-certainty evidence that composite resin restorations had almost double the risk
of failure compared to amalgam restorations (risk ratio (RR) 1.89, 95% confidence interval (CI) 1.52 to 2.35; P < 0.001), and were at much
higher risk of secondary caries (RR 2.14, 95% CI 1.67 to 2.74; P < 0.001). We found low-certainty evidence that composite resin restorations
were not more likely to result in restoration fracture (RR 0.87, 95% CI 0.46 to 1.64; P = 0.66).
Six trials used a split-mouth design. We considered these studies separately, as their reliability was compromised due to poor reporting,
unit of analysis errors, and variability in methods and findings. Subgroup analysis showed that the findings were consistent with the results
of the parallel-group studies.
Three trials investigated possible harms of dental restorations. Higher urinary mercury levels were reported amongst children with
amalgam restorations in two trials, but the levels were lower than what is known to be toxic. Some differences between amalgam
and composite resin groups were observed on certain measures of renal, neuropsychological, and psychosocial function, physical
development, and postoperative sensitivity; however, no consistent or clinically important harms were found. We considered that the vast
number of comparisons made false-positive results likely. There was no evidence of differences between the amalgam and composite
resin groups in neurological symptoms, immune function, and urinary porphyrin excretion. The evidence is of very low certainty, with most
harms outcomes reported in only one trial.
Authors' conclusions
Low-certainty evidence suggests that composite resin restorations may have almost double the failure rate of amalgam restorations. The
risk of restoration fracture does not seem to be higher with composite resin restorations, but there is a much higher risk of developing
secondary caries. Very low-certainty evidence suggests that there may be no clinically important differences in the safety profile of
amalgam compared with composite resin dental restorations.
This review supports the utility of amalgam restorations, and the results may be particularly useful in parts of the world where amalgam
is still the material of choice to restore posterior teeth with proximal caries. Of note, however, is that composite resin materials have
undergone important improvements in the years since the trials informing the primary analyses for this review were conducted. The global
phase-down of dental amalgam via the Minamata Convention on Mercury is an important consideration when deciding between amalgam
and composite resin dental materials. The choice of which dental material to use will depend on shared decision-making between dental
providers and patients in the clinic setting, and local directives and protocols.
PLAIN LANGUAGE SUMMARY
Tooth-colored resin fillings compared with amalgam fillings for permanent teeth at the back of the mouth
Review question
This review, carried out within Cochrane Oral Health, describes the effects of tooth-coloured (composite resin) fillings compared with
amalgam fillings when placed directly into cavities (holes) in permanent teeth in the back of the mouth.
Background
Traditionally, metal fillings made of a silver-coloured material known as amalgam have been used to treat tooth decay in the back
permanent teeth effectively and cheaply; however, due to unhappiness with their metallic look and concerns about the mercury they
contain, they are being used less often, particularly in high-income countries. The Minamata Convention on Mercury is a global agreement
that has promoted a worldwide reduction in the use of mercury (including amalgam fillings) in order to reduce the impact of mercury on
the environment. Tooth-colored fillings made of a composite resin material have been used as an alternative to amalgam fillings. Initially,
they were used only in the front teeth, but as their quality has improved, they have been used in permanent teeth at the back of the mouth.
Study characteristics
Informed decisions.
We searched scientific databases until 16 February 2021 and found eight relevant studies. The studies evaluated 3285 composite fillings
and 1955 amalgam fillings; however, it is unclear how many participants received these fillings. The exact age of participants was unclear
in some studies, but the studies included both children and adults. The studies took place in the UK, the USA, Portugal, Sweden, the
Netherlands, Belgium, Germany, and Turkey.
Participants in six studies received composite and amalgam fillings in different teeth (known as 'split-mouth design'), whilst participants
in the other two studies received either composite or amalgam fillings ('parallel-group' design).
Key results
Our main analysis focused on the two parallel-group studies that treated 921 children (aged 6 to 12 years) who had their teeth restored
with amalgam (1365) or composite resin (1645) fillings. We found that composite resin fillings were significantly more likely to fail
than amalgam fillings when used to fill cavities in permanent teeth at the back of the mouth. Tooth decay after a filling was placed (known as
'secondary caries') occurred more frequently with composite resin compared to amalgam fillings. There was no suggestion of a difference
between the materials in the likelihood of filling breaking.
Six of the trials used a 'split-mouth' design, which means that each participant had both types of fillings in different teeth. These studies
were less reliable, as they did not explain fully how they conducted the studies, and it was unclear how many people received the fillings.
We analysed the split-mouth studies separately from the parallel-group studies, and undertook a statistical approach known as 'subgroup
analysis'. This showed that the findings of these studies were compatible with the results from the two parallel-group studies.
Three studies reported negative side effects. Although we found that there were some possible side effects with each material used, this
information is unreliable because the study authors carried out so many analyses that 'false positive' results were likely to be found. Overall,
it seems that the materials may differ in terms of how safe they are, but the level of the differences identified in the studies may not be
important.
To summarise, we found that composite resin fillings may be almost twice as likely to fail compared with amalgam fillings when used
for filling permanent teeth at the back of the mouth. Composite fillings do not seem more likely to break, but do seem more likely than
amalgam fillings to develop further tooth decay. The current evidence suggests there are no important differences in the safety of amalgam
compared with composite resin dental fillings.
Certainty of the evidence
We judge the available evidence to be 'low certainty', which means that the results may change with future research. As the colour of
the amalgam and composite resin fillings differed, it would not have been possible to 'blind' those involved in the study from knowing
the treatment administered, so there was a high risk of bias in all of the included studies. In addition, the findings were imprecise and
sometimes inconsistent, so we cannot be sure that the evidence is reliable.
Implications of the evidence
Overall, the evidence suggests that amalgam restorations are effective, enduring, and safe, while composite resin restorations are more
likely to fail and lead to secondary caries. However, the studies in this review were quite old, and composite resin materials have likely
improved since the included studies were conducted. Patients and dental providers can discuss together which material they want to use
when permanent teeth in the back of the mouth require fillings in the dental clinic. Governments around the world are trying to reduce
the use of dental amalgam (according to the Minamata Convention on Mercury), and so each local area will have their own regulations
and guidance.
SUMMARY OF FINDINGS
Summary of findings 1. Direct resin composite versus amalgam fillings for permanent or adult posterior teeth
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Direct resin composite versus almalgam fillings for permanent or adult posterior teeth
Population: people with permanent or adult posterior teeth

Setting: outpatients
Intervention: composite
Better health.
Informed decisions.
Trusted evidence.
Control: amalgam
Outcomes Illustrative comparative risks* Relative effect Number of Certainty of Comments

(95% CI) (95% CI) teeth the evidence
(studies) (GRADE)
Assumed risk Corresponding
risk
Amalgam Composite
Failure rate 75 per 1000 142 per 1000 RR 1.89 3010 ⊕⊕⊝⊝ Reasons for failure included secondary caries, frac-
Follow-up: 5 to 7 (114 to 176) (1.52 to 2.35) (2 studies) low 1,2 ture, restoration loss.
years
Secondary 57 per 1000 122 per 1000 RR 2.14 3010 ⊕⊕⊝⊝

caries (95 to 156) (1.67 to 2.74) (2 studies) low 1,3
Follow-up: 5 to 7
years
Fracture of 14 per 1000 12 per 1000 RR 0.87 3010 ⊕⊕⊝⊝

restorations (6 to 23) (0.46 to 1.64) (2 studies) low 1,4
Follow-up: 5 to 7
years

Harms See comments 3 studies ⊕⊝⊝⊝ Data were reported for physical development, neuro-
Follow-up: 2 very low 1,4,5 logical and psychological effects, neurobehavioural
weeks to 7 years and psychosocial function, kidney function, immune
function, urinary mercury, urinary porphyrin excre-
tion, and postoperative sensitivity. Most outcomes
were reported in only 1 study. Overall, there was a
mixed picture that was not easy to interpret, but did
not seem to suggest that either composite resin or
amalgam restorations are more likely to lead to clini-
cally important harms.
4
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is
based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio
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GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is
substantially different.
Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.
Better health.
Informed decisions.
Trusted evidence.
Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.
1Downgraded one level for performance, detection, and selection bias (unclear allocation concealment).
2Downgraded one level for heterogeneity: I2 = 87%.
3Downgraded one level for heterogeneity: I2 = 92%.
4Downgraded one level for imprecision.
5Downgraded one level for heterogeneity.

5
Informed decisions.
BACKGROUND down measures (UNEP 2013). The Convention entered into force
internationally on 16 August 2017 (UNEP 2017a), and as of February
Description of the condition 2021 had been ratified by 127 governments worldwide (UNEP
2017b).
Dental caries (tooth decay) is a dynamic and continuous process
composed of cycles of demineralisation of the hard tissue of Dental resin composites were developed in response to
the teeth followed by cycles of remineralisation. The balance demands for tooth-coloured restorations. Dental resin composites
between the two cycles determines the stage of the disease are particle-reinforced resins. The field of composite dental
(ICDAS 2011). There is a close relationship between oral health restoratives continues to advance, for example, in resin
and quality of life; socioeconomic status and home environment formulation, filler loading and modification, and curing
have been shown to impact on oral condition (Gomes 2009; methodologies and mechanisms (Cramer 2011). The indications of
Paula 2012). Despite the great accomplishments in oral health resin composites have expanded from anterior teeth to restricted
obtained globally, caries is still a serious problem, particularly posterior restorations and even to stress-bearing posterior
amongst underprivileged groups in low-, middle-, and high-income restorations as amalgam substitutes or alternatives (Lutz 1999;
countries, affecting 60% to 90% of schoolchildren and the vast Moraschini 2015). Other advantages of dental resin composite
majority of adults (Costa 2012). It is also the most prevalent oral restorations include their conservative design and reparability.
health problem in several Asian and Latin American countries (WHO
2012). How the intervention might work
Modern management of dental caries involves making a diagnosis Dental amalgam and composite resin restorations are still the
to determine the person's caries risk status, followed by the most commonly used materials for restoring permanent molar and
application of intervention strategies focused on preventing, premolar cavities. The choice of amalgam as the preferred material
arresting, and possibly reversing the caries process to delay to restore posterior teeth has been gradually replaced by resin
restorative treatment until it becomes absolutely necessary composite, which is likely due to a host of factors that include
(Ferreira Zandona 2012). When the damage on the tooth structure is patient and clinician preference (Espelid 2006), cost, environmental
permanent, the most commonly used treatment involves cleaning and ethical issues, and context (CADTH 2018).
the cavity and filling it with a restorative material to restore the
shape and function of the tooth. Nevertheless, concerns about the potential toxicity of both dental
amalgam and composite resin materials have been raised. For
Primary caries seems to be the most frequent reason for instance, the use of dental amalgam has been restricted or banned
the placement of restorations (fillings), and caries lesions are in several countries due to its mercury content (Handzel 2017; UNEP
most commonly found on occlusal surfaces of posterior teeth 2013; UNEP 2016). Concerns have been raised about the potential
(Nascimento 2010). Secondary caries is responsible for 60% of all toxicity of materials used in some composite resin restorations that
replacement restorations in the typical dental practice, but the may contain derivatives of bisphenol A (BPA), such as "…bisphenol
association between the type of restoration materials and location A diglycidyl methacrylate (bis-GMA) especially, but also bisphenol
of caries and the composition of the microflora has not been found A dimethacrylate (bis-DMA), polycarbonate-modified bis-GMA (PC
to be statistically significant (Mo 2010). bis-GMA), ethoxylated bisphenol A glycol dimethacrylate (bis-EMA)
and 2,2-bis [(4-methacryloxy polyethoxy) phenyl]propane (bis-
Description of the intervention MPEPP)]" (Dursun 2016).
The obturation and filling of occlusal cavities is an issue that has When addressing safety concerns of dental amalgam and
been long studied. The choice of the best material for restoring the composite resin restorative materials, it is first important to
anatomical structures that also achieves acceptable resistance to make the distinction between the restorations themselves and the
the forces of mastication is still controversial. This review compared compounds of which they are composed. Despite concerns about
dental amalgams and resin composites, the two main categories of potential health risks from mercury in dental amalgam fillings and
dental restorative fillings used in posterior tooth restorations today. BPA (or other toxins) in composite resin restorations, evidence has
not been generated to definitively implicate dental amalgam or
Dental amalgams are metallic alloys. They have been predictable
composite resin restorations as harmful to human health.
and inexpensive restorative materials for over 150 years. Their
use and success rate have been well documented, and they are A 2018 Canadian cost-consequence analysis comparing amalgam
the most cost-effective materials in posterior teeth restorations. and composite resin restorations of permanent posterior teeth
However, they are declining in use in dentistry mainly due to their found that, on average, amalgam restorations last longer and cost
unaesthetic appearance and concerns about their mercury content less (amalgam CAD 171.00 versus composite CAD 219.00; CADTH
(Kelly 2004; Mitchell 2007; Roulet 1997). 2018). Because time to failure, on average, was longer for amalgam
restorations, the estimated lifetime cost for amalgam restorations
Because mercury is a substance that can be toxic to both human
was half that of composite resin restorations (assuming that a
health and the environment, the United Nations Environment
failed restoration would be replaced by another of the same size
Programme has established the Minamata Convention on Mercury,
and material). Moreover, crown installation or tooth extraction
which aims "to protect the human health and the environment from
may occur later in life with amalgam than with composite resin
anthropogenic emissions and releases of mercury and mercury
restorations. Whilst composite resin restorations take slightly more
compounds" (UNEP 2013). The Minamata Convention recommends
time to place, the impact of this on patient or caregiver productivity
a phase-down of the use of mercury, including the use of amalgam
was found to be minimal. For dental clinics that install amalgam
in dentistry; specifically, parties who have ratified the Convention
separators to ensure that mercury from the dental amalgam
commit to the adoption of at least two of nine proposed phase-
Informed decisions.
materials used is not introduced into the environment, additional marginal adaptation, anatomical form, and secondary caries
costs will be incurred. (Cvar 2005)), and tooth fracture
Why it is important to do this review Search methods for identification of studies

This topic was identified as a priority through a comprehensive Electronic searches
Cochrane Oral Health prioritisation exercise. It was intended to
Cochrane Oral Health’s Information Specialist conducted
inform policy and decision-making in light of changes in the use of
systematic searches in the following databases for RCTs and
dental amalgam as a result of the Minamata Convention, as well
controlled clinical trials. There were no language, publication year,
as to update and expand the assessment of the safety of dental
or publication status restrictions.
amalgam relative to composite resin. Since adhesive dentistry
remains one of the fastest-changing fields (Tanimoto 2015), there is • Cochrane Oral Health Trials Register (searched 16 February
a need to provide a comprehensive update on the effects of dental 2021) (Appendix 1)
composite resin materials in comparison with amalgam.
• Cochrane Central Register of Controlled Trials (CENTRAL; 2021,
OBJECTIVES Issue 1) in the Cochrane Library (searched 16 February 2021)
(Appendix 2)
To examine the effects (i.e. efficacy and safety) of direct composite • MEDLINE Ovid (1946 to 16 February 2021) (Appendix 3)
resin fillings versus amalgam fillings. • Embase Ovid (1980 to 16 February 2021) (Appendix 4)
• LILACS BIREME Virtual Health Library (Latin American and
METHODS
Caribbean Health Science Information database; from 1982 to 16
Criteria for considering studies for this review February 2021) (Appendix 5)
Types of studies Review author MM undertook a supplementary search on safety,

using strategies she designed for a Canadian Agency for Drugs and
For the outcome of efficacy, we included randomised controlled Technologies in Health (CADTH) health technology assessment. We
trials (RCTs) comparing dental composite resin with dental searched MEDLINE (1946 to 20 February 2019), Embase (1974 to
amalgam restorations in permanent posterior teeth (dating back to 20 February 2019), and CENTRAL (January 2019 edition) with one
1946). We excluded studies that had less than a three-year follow- broad search in Ovid (see Appendix 6). We also searched PubMed
up period. (1950 to 21 February 2019, see Appendix 6). There was no language
restriction, but we restricted studies of the safety of composite
For the outcome of safety, we included RCTs and non-randomised
resin fillings to 2006 onwards, in accordance with feedback from
studies that directly compared composite resin and amalgam
clinical experts that composite resin materials have developed
restorations in people requiring dental caries treatment (dating
considerably over recent years, and studies using earlier materials
back to 2007).
would not be comparable.
Types of participants
Searching other resources
For efficacy, participants were people with permanent posterior
Cochrane Oral Health's Information Specialist searched the
teeth with dental caries requiring direct restorations that were
following trial registries for ongoing studies:
suitable for treatment with either composite resin or amalgam, or
both. • US National Institutes of Health Ongoing Trials Register
ClinicalTrials.gov (clinicaltrials.gov; searched 16 February 2021)
For safety, participants were people with dental caries treated with
(Appendix 7);
direct dental restorations made of composite resin or amalgam.
• World Health Organization International Clinical Trials Registry
Types of interventions Platform (WHO ICTRP) (apps.who.int/trialsearch; searched 16
February 2021) (Appendix 8).
• Intervention: direct dental restorations made from composite
resin We checked the reference lists of all eligible trials and relevant
• Control: direct dental restorations made from amalgam review articles for additional studies. We contacted the authors of
unpublished studies; however, we did not received any replies.
Types of outcome measures
We checked that none of the studies included in this review were
We chose outcomes that would allow us to asssess clinical efficacy
retracted due to error or fraud.
and safety.
For the first version of this review, we contacted the major
Primary outcomes
manufacturers of dental materials (GC and 3M ESPE) in June 2012 to
• Restoration failure (or survival) obtain information on published and unpublished studies that may
• Harms, including toxicity, sensitivity, allergic reaction, injury have involved their products. We were informed that no studies
comparing resin composite materials and amalgam materials had
Secondary outcomes been carried out. We also contacted Ivoclar Vivident, Kerr, and
Dentsply at the same time, but received no reply.
• Reason for failure (according to the evaluation categories of the
US Public Health Service (USPHS), which includes colour match,
Informed decisions.
Data collection and analysis After taking into account additional information provided by the
authors of some of the included trials, we grouped the studies into
Selection of studies the following categories:
Two review authors (SK, KS) independently screened the titles
and abstracts of all citations using standardised criteria. We • overall low risk of bias (plausible bias unlikely to seriously alter
retrieved the full text for any titles and abstracts that either review the results);
author deemed potentially relevant. The same review authors then • overall high risk of bias (plausible bias that weakens confidence
independently applied the study selection criteria to each full-text in the results), if one or more domains were assessed as at high
report and compared their selections, resolving all discrepancies risk of bias;
through discussion and consensus or by involving a third review • overall unclear risk of bias, if one or more domains were
author (SM) as necessary. Ongoing discussion amongst review assessed as unclear.
authors occurred during both phases of screening to consider
discrepancies and establish consensus on the application of Measures of treatment effect
selection criteria. We tabulated excluded studies with our reasons We considered whether to pool quantitative outcome data
for exclusion (see Characteristics of excluded studies table). separately for the outcomes of efficacy and safety. We considered
several factors, including the number of included studies
Data extraction and management
and the amount of between-study clinical and methodological
The review authors piloted tailored data extraction forms and heterogeneity.
modified them before use. One review author extracted data
from each included study, and a second review author verified We undertook statistical syntheses using Review Manager 5
the extracted data, with any disagreements resolved through software (Review Manager 2020), with forest plots presented for
discussion. summary estimates. We used random-effects meta-analyses unless
there were fewer than four studies included in a meta-analysis.
We collected the following data from the included reports.
We pooled dichotomous outcomes using risk ratios (RRs) and 95%
• First author’s name, publication year, country, and funding confidence intervals (CIs). We calculated mean difference (MD) or
sources standardised mean difference (SMD) for continuous data. In the
• Study design, analytical approach, and any subgroup analyses case of studies with a split-mouth design, we aimed to calculate log
of interest risk ratio separately for each outcome.
◦ for the outcome of efficacy:
▪ number and types of restorations; For the safety outcome, we presented the findings narratively
by study. We planned to calculate RRs or odds ratios (ORs),
▪ a description of the intervention, comparator, and (where converting to a common effect measure to facilitate meta-analysis,
reported) the application technique(s) used to place the if appropriate. For time-to-event data such as restoration failure,
restoration; we planned to calculate pooled hazard ratios (HRs) and 95% CIs.
▪ restoration failure rate and reasons for failure (i.e. We planned to meta-analyse continuous data using MD or SMD
secondary caries, tooth fracture). with corresponding 95% CIs. We intended to pool data on the same
◦ for the outcome of safety: outcomes from RCTs and non-randomised studies separately.
▪ number, age, sex, remote/rural/urban settings,
socioeconomic status, and restoration; Unit of analysis issues
▪ types of study participants (where reported); The 2014 review identified a unit of analysis problem in several of
▪ a description of the intervention, comparator, and (where the included studies in terms of participants versus restorations.
reported) the numbers of surface areas and/or surface This update aimed to address this issue by undertaking appropriate
years; analyses for each outcome taking into account the units of analysis
▪ description of outcomes reported, follow-up duration, where possible, following the recommendations in Section 16.3
and study loss to follow-up findings and conclusions of the Cochrane Handbook for Systematic Reviews of Interventions
regarding the outcomes and subgroups of interest. (Higgins 2011).
Assessment of risk of bias in included studies Dealing with missing data
Two review authors independently and in duplicate undertook risk In the case of missing individual data, we analysed only the
of bias assessment for each included study using the Cochrane available data. Where possible, we performed an intention-to-
risk of bias assessment tool (Higgins 2017). We assessed seven treat (ITT) analysis. In the previous version of this review, we
domains for each included study: sequence generation (selection contacted study authors when we required additional information.
bias), allocation sequence concealment (selection bias), blinding We addressed the potential impacts of missing data on the findings
of participants and personnel (performance bias), blinding of of the review in the Discussion section.
outcome assessment (detection bias), incomplete outcome data
(attrition bias), selective outcome reporting (reporting bias), and Assessment of heterogeneity
other potential sources of bias. We assessed risk of bias as 'low', We aimed to assess statistical heterogeneity using the I2 statistic
'high', or 'unclear', with the last category indicating either lack of (Higgins 2003), which quantifies the percentage of the variability
information or uncertainty over the potential for bias. in effect estimates that is due to heterogeneity rather than
sampling error (i.e. chance). We planned to observe heterogeneity
Informed decisions.
by analysing the point estimates and CIs on the forest plots. We • socioeconomic status;
also planned to assess statistical heterogeneity using Cochran's test • remote, rural or urban setting;
for heterogeneity and quantified using the I2 statistic. Based on • developmental/special need;
the Cochrane Handbook for Systematic Reviews of Interventions, we
• numbers of restorations/surface areas/surface years;
considered values of I2 as follows:
• application technique used to place the restoration.
• 0% to 40% might not be important;
Sensitivity analysis
• 30% to 60% may represent moderate heterogeneity;
• 50% to 90% may represent substantial heterogeneity; and We had planned to conduct sensitivity analyses (particularly for the
question addressing safety) to evaluate the robustness of findings
• 75% to 100% represents considerable heterogeneity (Deeks
by methodological and statistical factors, including (but not limited
2017).
to): the impact of varying study risk of bias assessments, alternative
We considered heterogeneity to be statistically significant if the P study designs (e.g. cohort versus case control), types of analysis
value was less than 0.1. (e.g. unadjusted versus adjusted), and effect measures (e.g. RR
versus OR).
Assessment of reporting biases
Summary of findings and assessment of the certainty of the
Only a proportion of research projects conducted are ultimately evidence
published in an indexed journal and become easily identifiable
for inclusion in systematic reviews (Easterbrook 1991). Reporting We have presented a summary of findings table to show the
biases arise when the reporting of research findings is influenced findings of the most important outcomes (Summary of findings 1).
by the nature and direction of the findings of the research. We We assessed the certainty of the body of evidence by following
attempted to avoid time lag bias, multiple (duplicate) publication the GRADE framework with reference to the overall risk of bias of
bias, and language bias by conducting a detailed, sensitive search, the included studies, directness of the evidence, consistency of the
including searching for ongoing studies. We did not restrict the results, precision of the estimates, and risk of publication bias. We
search by language (other than the search for the safety outcomes), categorised the quality of the body of evidence for each of the
and review authors translated non-English studies. outcomes as high, moderate, low, or very low.
Data synthesis RESULTS

We combined RRs for dichotomous data of studies we considered Description of studies
appropriate for inclusion in meta-analysis. We intended to combine
the treatment effects from split-mouth trials with those from Results of the search
parallel-group trials where appropriate as outlined in the Cochrane The previous version of this review included seven eligible RCTs
Handbook for Systematic Reviews of Interventions, Deeks 2017, and reported across 14 articles. Our update identified one additional
in Elbourne 2002; however, this was not possible because of poor RCT that addressed both efficacy and safety (Kemaloglu 2016),
reporting. We therefore treated the split-mouth trials as a subgroup and our supplementary search identified eight articles addressing
so that we could examine the results either in isolation or in safety that related to the two parallel-group RCTs used in our
combination with the parallel-group studies. This was aimed in primary analyses (Casa Pia 2007; NECAT 2007).
particular at providing a broader view and 'bottom-line' to the
review question. We used random-effects models where there were The updated electronic literature search identified 595 citations,
more than three studies in any given meta-analysis, and fixed-effect which was reduced to 208 after the removal of duplicates.
models when combining data from two or three studies. Where Twenty-one were potentially relevant and retrieved for full-text
meta-analysis was inappropriate, we presented data in Additional scrutiny. Most citations returned by the bibliographic searches
tables. were in English, with a small proportion in German, Spanish, and
Portuguese (the review author team translated these). We retrieved
Subgroup analysis and investigation of heterogeneity one report from the grey literature. Of these 21 potentially eligible
Depending on the amount of available data and the degree of reports, we found one to be eligible and included it in the review
observed statistical heterogeneity, we had intended to explore (Kemaloglu 2016). There was complete agreement at the full-text
the following potential sources of heterogeneity using subgroup phase of screening (weighted overall Kappa statistic of 1.0). We
analyses: have presented a PRISMA flow diagram illustrating the results of
this search, screening, and selection process in Figure 1 (Moher
• participant age; 2009).
• genetic susceptibility to mercury;
Informed decisions.
Figure 1. Updated flow diagram 2021
The supplementary search designed to investigate safety identified Included studies

6535 citations, 90 of which we considered to be potentially relevant
We included eight RCTs, which were reported in 23 articles. For
and retrieved for full-text assessment (Appendix 6). We retrieved
details on each included study, see Characteristics of included
one report from the grey literature. Of these potentially eligible
studies.
reports, we found nine to be eligible for inclusion, eight of which
related to two RCTs that were already included (Casa Pia 2007; Design
NECAT 2007). The weighted overall Kappa statistic indicated initial
agreement at the full-text phase of screening as generating a value Two RCTs used a parallel-group design (Casa Pia 2007; NECAT
of 0.49 (95% CI 0.39 to 0.79), indicating moderate agreement. 2007), whilst the other six RCTs used a split-mouth design
Informed decisions.
(Cunningham 1990; Hendriks 1986; Kemaloglu 2016; Letzel 1989; Casa Pia 2007 presented trial results on the effects of mercury
Norman 1990; Robinson 1988). The split-mouth studies were on the nervous system and potential damage to the renal system
not conducted, reported, or analysed using methodologically or in children. They carried out tests at baseline and at seven years
clinically consistent approaches and did not always clearly report after a filling placement to explore intelligence, nerve conduction
study initiation and end dates. velocity, memory, attention, and visuomotor function. To study
renal function, they recorded creatinine-adjusted urinary albumin
The two parallel-group RCTs reported data from large studies that levels at years one, two, three, four, five, six, and seven.
were designed to compare amalgam with composite to restore
posterior teeth. The Casa Pia Study of Health Effects of Dental NECAT 2007 focused on the effect of restorations on psychosocial
Amalgam in Children started in 1996 and followed participants for function and physical development in children after five
seven years (Casa Pia 2007). The New England Children’s Amalgam years of follow-up. Study authors measured the effect of
Trial (NECAT) was conducted between September 1997 and March restorations on psychosocial function using two validated
2005 (NECAT 2007). instruments: Child Behavior Checklist (CBCL) parent report
and Behavior Assessment for Children Self Report (BASC-SR).
Casa Pia 2007 and NECAT 2007 were funded by research grants. Degree of exposure to restorations was expressed in surface
Three studies were funded by the same dental industry source, ICI years (SY); however, no direct comparison was made between
(Letzel 1989; Norman 1990; Robinson 1988), whilst the remaining children in the composite and amalgam arms. The BASC-SR
three studies did not state their funding sources (Cunningham 1990; measured emotional symptoms, clinical maladjustment, school
Hendriks 1986; Kemaloglu 2016). maladjustment, personal adjustment, and core syndromes such
as anxiety, depression, attitude to school, and interpersonal
Participants
relations. The CBCL measured competence, total problem
The two parallel-group trials randomised a total of behaviours, internalising problems, externalising problems, and
1041 participants (Casa Pia 2007 randomised 507; NECAT core syndromes such as attention problems, withdrawal, anxiety/
2007 randomised 534), and analysed 921 participants. We analysed depression, delinquent behaviours, and aggression. The growth
data from 871 participants in this review. The participants in these outcomes NECAT 2007 considered were body fat percentage, body
two trials were aged six to 12 years at baseline. Follow-up periods mass index (BMI), and height.
were seven and five years, respectively.
Kemaloglu 2016 assessed postoperative sensitivity after restoration
The split-mouth trials reported data on 2230 restorations (ranging placement at two weeks (baseline), six months, one year, and three
from 27 to 932 per trial), but did not specify the number of years using a visual analogue scale completed by participants. The
participants recruited or their ages. study publication did not report raw data.
Two studies were conducted in the UK (Cunningham 1990; We listed all references to studies under the relevant study ID;
Robinson 1988), one in Portugal (Casa Pia 2007), one in Turkey however, we did not include data from five of the articles assessing
(Kemaloglu 2016), one in the USA (NECAT 2007), and one harms outcomes, as we judged them to be secondary analyses that
multicentre trial was conducted in the USA and Europe (Belgium, did not compare the originally randomised treatment groups (Geier
Germany, the Netherlands, Sweden, and the UK; Letzel 1989). 2011; Geier 2012; Geier 2013; Maserejian 2012; Woods 2013).
Two studies did not clearly report their locations (Hendriks 1986;
Norman 1990). Excluded studies
We rejected most records from the updated efficacy search based
Interventions
on title or abstract. We retrieved the full texts of 22 articles
Participants in the eight included studies received amalgam and rejected 21 on the basis of ineligible study design (i.e. not
restoration or composite resin restoration, or both. In NECAT randomised or controlled); population (e.g. not dental caries);
2007, participants received amalgam, compomer, or composite intervention (e.g. not direct dental restorations); outcome (i.e. not
restoration; data on compomer restorations are not included in this efficacy); or publication (e.g. time frame, type, or availability).
review.
We rejected most records from the safety search based on title
Outcomes or abstract. We retrieved 67 full-text articles for more detailed
evaluation and rejected 59 because they evaluated an ineligible
The primary outcome was restoration failure, which all eight population (i.e. secondary analyses not considering originally
included trials reported. Seven trials reported secondary caries randomised treatment groups); intervention (i.e. not direct dental
(Casa Pia 2007; Cunningham 1990; Hendriks 1986; Kemaloglu 2016; restorations); comparison (i.e. no direct comparison of amalgam
NECAT 2007; Norman 1990; Robinson 1988), whilst two studies and composite resin); outcome (i.e. not safety); publication (i.e. not
reported fracture outcome data (Casa Pia 2007; NECAT 2007). a report of study findings); or time frame (i.e. published prior to
Three RCTs reported data on harms (Casa Pia 2007; Kemaloglu 2007).
2016; NECAT 2007). No studies reported on outcomes of In the 2014 version of this review, we excluded 43 articles for the
relevance to allergic reaction or injury. Casa Pia 2007 and NECAT following reasons (see Characteristics of excluded studies tables).
2007 described multiple outcomes relevant to toxicity,
whilst Kemaloglu 2016 reported an outcome relevant to sensitivity. • The study design was not randomised or controlled (Allan 1977;
See Table 1. Bryant 1994; Busato 1996; Cloyd 1997; Collins 1998; Eames 1974;
Fukushima 1988; Hendriks 1985; Johnson 1992; Knibbs 1992;
Kopperud 2012; Mjör 1993a; Mjör 1993b; Pieper 1991; Powers
Informed decisions.
1974; Prati 1988; Rowe 1989; Rytömaa 1984; Samaha 1982; 1993b; Leinfelder 1980; Mair 1998; Mannocci 2005; Nell 1994;
Smales 1992; Tobi 1999; Van Nieuwenhuysen 2003). Roulet 1978; Shenker 2008; Smales 1992; Wilson 1996).
• Randomisation was broken (Welbury 1990). • We contacted one study author to obtain data for an
• Follow-up was less than three years (Borgmeijer 1991; Kreulen unpublished trial (Koray), but received no reply.
1993a; Lambrechts 1984; Leinfelder 1975; Roulet 1977; Walls • We were unable to obtain the full-text article of Solano 1984 for
1988). critical appraisal.
• There was a lack of clarity regarding methodology (comparison
between amalgam and composite unclear; not stated if the Risk of bias in included studies
materials were tested in permanent posterior teeth; lack We judged all of the included studies to be at high risk of bias
of clarity on evaluation of longevity and impossibility of overall, primarily due to lack of blinding (Figure 2). The main risk
obtaining useful data) (Bellinger 2006; Dilley 1990; Kreulen of bias for the split-mouth studies was related to failure to take the
clustering effect into account in the analysis.
Informed decisions.
Figure 2. Risk of bias summary: review authors' judgments about each risk of bias item for each included study.
Blinding of participants and personnel (performance bias): All outcomes

Blinding of outcome assessment (detection bias): All outcomes
Incomplete outcome data (attrition bias): All outcomes
Random sequence generation (selection bias)
Allocation concealment (selection bias)
Selective reporting (reporting bias)

Other bias
Casa Pia 2007 ? ? - - + + +

Cunningham 1990 ? + - - ? + -
Hendriks 1986 ? + - - ? + -
Kemaloglu 2016 + + - - + + +
Letzel 1989 ? + - - ? - -
NECAT 2007 + + - - + + +
Norman 1990 + + - - ? + -
Robinson 1988 + + - - ? + -
Informed decisions.
Allocation Effects of interventions

Random sequence generation See: Summary of findings 1 Direct resin composite versus
We considered four studies to be at low risk of selection bias amalgam fillings for permanent or adult posterior teeth
(Kemaloglu 2016; NECAT 2007; Norman 1990; Robinson 1988), Due to the poor reporting in five split-mouth trials which rendered
whilst the other four studies were at unclear risk of bias as there the reported data unreliable, we decided that the primary analyses
was a lack of detail on the randomisation process (Casa Pia 2007; should be based on the two parallel-group trials. We undertook a
Cunningham 1990; Hendriks 1986; Letzel 1989). secondary analysis of all included trials.
Allocation concealment Failure rate
We judged the six split-mouth studies to be at low risk of bias The parallel-group trials recorded failure rate in the amalgam
because a lack of allocation concealment would neither make a and composite groups over a period of five years in NECAT
difference nor introduce bias to a split-mouth study (Cunningham 2007 and seven years in Casa Pia 2007. The trials analysed a total
1990; Hendriks 1986; Kemaloglu 2016; Letzel 1989; Norman 1990; of 1365 amalgam restorations and 1645 composite restorations.
Robinson 1988). We judged NECAT 2007 to be at low risk of bias, Our pooled estimate showed that composite restorations had a
as they described an acceptable allocation concealment process. significantly higher risk of failure than amalgam (risk ratio (RR) 1.89,
We judged Casa Pia 2007 to be at unclear risk of selection bias 95% confidence interval (CI) 1.52 to 2.35; P < 0.001; fixed-effect
because we could not find any explicit description of the allocation model; Analysis 1.1). There was indication of heterogeneity (P =
concealment process in any of the included articles (including
0.005; I2 = 87%), but, as there were only two studies, this could not
those that the study authors referenced for more details describing
be investigated. As the effect estimates for both studies were in the
methods).
same direction, we decided to present the meta-analysis.
Blinding
Subgroup analysis of the split-mouth trials found an imprecise
We judged all of the included studies to be at high risk of result that was inconclusive (RR 1.33, 95% CI 0.84 to 2.11; P = 0.23;
performance bias and detection bias, since the dental restorations random-effects model; analysis not shown). There was no evidence
look different, and therefore blinding of operators and participants of heterogeneity (P = 0.57; I2 = 0%). A test for subgroup differences
was not possible. Even though some studies indicated that showed no evidence of a significant difference between the
outcome assessment was carried out by evaluators independent of parallel-group and split-mouth trials (P = 0.26). The parallel-group
the operators (NECAT 2007; Norman 1990; Robinson 1988), we did and split-mouth trials combined showed more precise results than
not consider this sufficient to minimise detection bias. either alone, and suggested that composite restorations may have
a significantly higher risk of failure than amalgam restorations (RR
Incomplete outcome data 1.65, 95% CI 1.13 to 2.40, P = 0.009; random-effects model; analysis
We judged three studies to be at low risk of attrition bias: dropout not shown). There was some evidence of heterogeneity (P = 0.05; I2
rates were similar in the intervention and comparator groups = 52%).
in Casa Pia 2007 and NECAT 2007, and the split-mouth study
Kemaloglu 2016 evaluated all participants who were assessed at Because the additional split-mouth trial identified in this 2021
baseline. The other five split-mouth studies reported an overall update reported zero events of failure in both arms of the study (and
dropout rate (Cunningham 1990; Hendriks 1986; Letzel 1989; described data for only 40 restorations), its incorporation into the
Norman 1990; Robinson 1988); as we were unable to determine subgroup and combined analyses would have had no impact on the
whether the dropout rate was differential, we judged the risk of bias original findings (Kemaloglu 2016).
to be unclear. Analysis of subgroups
Selective reporting One study reported failure rates separately in molars and premolars
We judged Letzel 1989 to be at high risk of reporting bias, as it (Casa Pia 2007), but the results were not sufficient to determine
reported all data for composite resin but not for amalgam. All of the whether there was an association between location of the
other studies presented data for their planned outcomes and were restorations in different teeth and failure rate.
therefore judged to be at low risk of reporting bias. Data were insufficient to consider any of our other planned
Other potential sources of bias subgroup or sensitivity analyses.
We judged three studies as at low risk of bias for this domain as Reason for restoration failure
they had no other apparent biases (Casa Pia 2007; Kemaloglu 2016; Secondary caries
NECAT 2007).
Secondary caries was the most common reason for failure in
We assessed five split-mouth studies as being at high risk of other the included studies. Meta-analysis of the parallel-group studies
bias due to a unit of analysis error (Cunningham 1990; Hendriks showed a higher risk of secondary caries in permanent posterior
1986; Letzel 1989; Norman 1990; Robinson 1988). In addition, teeth with composite restoration compared with teeth with
Letzel 1989 reported that there were notable variations in results amalgam restoration (RR 2.14, 95% CI 1.67 to 2.74; P < 0.001;
across the different centres involved in the trial, but provided no fixed-effect model; Analysis 1.2). There was once again evidence
explanation for this. of heterogeneity (P < 0.001; I2 = 92%), but, as there were only two
studies, this could not be investigated. As the effect estimates for
Informed decisions.
both studies were in the same direction, we decided to present the Psychosocial function
meta-analysis. NECAT 2007 evaluated psychosocial function in a subset of children
Outcome data from the split-mouth studies alone provided an using the CBCL (n = 395) and the BASC-SR (n = 426) analyses.
imprecise result that did not provide evidence of a significant The CBCL has four main composite scores, measured as changes
difference in secondary caries when composite restorations were between baseline and five years; there was no difference between
compared with amalgam restorations (RR 1.30, 95% CI 0.34 to groups in the competence or externalising behaviour scores, but
4.97, P = 0.7; random-effects model; analysis not shown). There the resin composite group had higher scores for total problem
was no evidence of heterogeneity (P = 0.64; I2 = 0%). However, a behaviour and for internalising behaviour (Table 3). This means
test for subgroup differences showed no evidence of a significant adjustment and behaviour were poorer in children with composite
difference between the parallel-group and split-mouth trials (P = fillings after five years' follow-up.
0.58), and combined results of all trials indicated there may be
an increased risk of secondary caries with composite restorations The BASC-SR assessed four global scores and showed no difference
compared to amalgam restorations (RR 1.93, 95% CI 0.98 to 3.80; P between groups for school or clinical maladjustment. The study
= 0.06; random-effects model; analysis not shown). There was some found a difference between groups in favour of the amalgam
evidence of heterogeneity (P = 0.02; I2 = 64%). group for the other two scores, personal adjustment and emotional
symptoms (Table 3).
The additional RCT identified in this update reported zero events
of secondary caries in both study arms (and described data for NECAT 2007 concluded that greater exposure to composite
only 40 restorations), so its incorporation into the subgroup and restorations was associated with impaired psychosocial function
combined analyses would have had no impact on the original in children, whereas no adverse psychosocial outcomes were
findings (Kemaloglu 2016). observed with greater amalgam treatment levels.
Fracture of the restoration Physical development
Only the two parallel-group trials reported fracture of the NECAT 2007 assessed physical development in 474 of the 534
restorations (Casa Pia 2007; NECAT 2007). It was not a common children originally randomised. They reported no between-group
reason for failure. There was no evidence of a difference in risk of differences in age-adjusted, mean BMI-for-age Z scores, body fat
fracture between the two materials (RR 0.87, 95% CI 0.46 to 1.64, P percentage, or height throughout the five-year study follow-up
= 0.66; fixed-effect model; Analysis 1.3). There was no evidence of (Table 4). Additional, exploratory analyses of menarche outcomes
heterogeneity (P = 0.44; I2 = 0%). in females investigated 113 participants and were restricted to one
study site. These analyses indicated that girls in the composite
Harms resin group were less likely to have reached menarche during study
follow-up compared with those in the amalgam group (48% versus
Five studies did not assess this outcome. Three studies explored
67%; hazard ratio 0.57, 95% CI 0.35 to 0.95; P = 0.03). Nevertheless,
potential harms from toxicity (Casa Pia 2007; NECAT 2007) or
an examination of age at first menarche indicated no statistically
sensitivity (Kemaloglu 2016) (see Table 1). We did not find
significant difference between treatment groups amongst those
any eligible studies that evaluated allergic reaction or injury.
who had reached first menarche (composite group mean age in
The large number of comparisons carried out by the studies,
years = 12.5 (standard deviation (SD) ± 1.1); amalgam group mean
particularly NECAT 2007, means that false-positive results were
age in years = 12.3 (SD ± 1.0)); mean difference 0.20 (95% CI −0.19
likely.
to 0.59).
Toxicity
Immune function
Neuropsychological function
A subset of children were invited to take part in a substudy of NECAT
NECAT 2007 reported that there was no difference 2007 to measure immune function. The substudy analysed data
between composite and amalgam restorations for overall from 59 of 257 children (31 in the composite resin group, 35 in
neuropsychological function (see Table 2). Significant differences the amalgam group). The paper reported that the characteristics of
for some of the subscales were found in both directions, giving children in the substudy were similar to those of the overall study
inconsistent results. This trial made a large number of comparisons population; it is not entirely clear if they were selected randomly.
(more than 60). With a 5% level of significance being used for each, No significant difference was found between groups at any time
we would expect some statistically significant differences to be point for total white cell counts, T cell, B cell, neutrophil, and
found by chance, when no true differences exist. monocyte responsiveness.
Casa Pia 2007 found no statistically significant differences in Renal effects

measures of memory, attention, visuomotor function, or nerve Both Casa Pia 2007 and NECAT 2007 measured kidney function and
conduction velocities. reported this outcome in one article relating to each study. NECAT
Neurological symptoms 2007 included 490 children in the primary analyses and found no
difference in biomarker levels or prevalence of high biomarker
In Casa Pia 2007, neurologists evaluated participants' neurological values. NECAT 2007 reported that the composite group had
symptoms (hard signs, soft signs, and positional tremor) annually. lower odds of microalbuminuria (MA) at years 3 or 5 (repeat-
They found no statistically significant differences between resin measures logistic regression analysis; number with MA/number
composite and amalgam groups at any time point. analysed, year 3: composite resin group = 15/148 (9.5%), amalgam
Informed decisions.
group = 18/135 (13%); number with MA/number analysed, year 5: consider this to be a clinically important difference. There was no
composite resin group = 18/186 (9.7%), amalgam group = 30/193 difference between groups at the earlier time points.
(16%); P = 0.03). The study authors suggest that this finding may
be due to chance or confounding and required corroboration, DISCUSSION
since albuminuria is common in the general population, including
children, and can result from everyday exposures like extreme Summary of main results
physical exertion or infections causing fever. Casa Pia 2007 reported We identified eight RCTs assessing the efficacy of amalgam versus
microalbuminuria in yearly age cohorts and found no difference resin composite fillings, and have presented a summary of our
between the treatment groups (Table 5), nor did they did find any findings in Summary of findings 1. We judged the certainty of
evidence for differences between resin composite and amalgam the evidence to be low due to high risk of bias, inconsistency, or
restorations for any other renal biomarkers. imprecision in the results. Our primary analysis of two parallel-
Urinary mercury
group trials suggests that restoration failure and secondary
caries may be almost twice as likely with composite restorations
NECAT 2007 found a significantly higher level of mean urinary compared to amalgam restorations. We added the data from split-
mercury in children in the amalgam group at five-year follow-up mouth studies and conducted a subgroup analysis, which showed
(0.9 μg/g creatinine; range 0.1 to 5.7 μg/g creatinine), as compared that the split-mouth study results were consistent with our primary
with children in the composite group (0.6 μg/g creatinine; range 0.1 findings. The evidence suggests that there may be no difference in
to 2.9 μg/g creatinine; P < 0.001; 95% CIs not reported). In Casa Pia fracture rates between amalgam and composite restorations.
2007, urinary mercury levels were reported as a primary outcome
of interest. Children in both treatment groups had comparable Both parallel-group trials assessed potential harms related
urinary mercury levels at baseline: 1.5 μg/L (SD ± 1.2; range 0.1 to toxicity, and one split-mouth trial evaluated postoperative
to 7.7) for amalgam and 1.4 μg/L (SD ± 1.1; range 0.0 to 8.6) sensitivity. It is possible that differences were identified due to
for composite resin. Urinary mercury levels became significantly the large number of comparisons undertaken at 0.05 level of
higher in children assigned to amalgam through years 2 to 6, with significance, which could make false-positive results more likely.
a peak level of 3.2 μg/L in year 2 postintervention (P < 0.001; 95% The evidence was mixed, and a clear pattern did not emerge. In
CIs not reported); levels for the composite resin group were only terms of toxicity, two trials reported that urinary mercury excretion
reported graphically. We were unable to pool data due to poor was lower in the composite resin compared to the amalgam group
reporting in both studies. up to five- or six-year follow-up. At seven-year follow-up, one trial
did not find a difference between groups, suggesting that mercury
By follow-up year 7, urinary mercury in the amalgam group exposure from dental amalgam restorations may attenuate over
had dropped to around baseline level (reported narratively and time. Moreover, the levels identified were not toxic. Some
graphically only), and there was no evidence of a difference differences between amalgam and composite resin groups were
between groups, which suggests that urinary mercury excretion observed on certain measures of renal, neuropsychological and
reduces over time in those with dental amalgam restorations. psychosocial function, physical development, and postoperative
sensitivity; however, no consistent or clinically important harms
Casa Pia 2007 found no significant group differences in creatinine- were found. There was no evidence of differences between the
adjusted urinary albumin over the seven years of follow-up. A re- amalgam and composite resin groups in neurological symptoms,
analysis of the data published in 2011, based on amalgam size immune function, and urinary porphyrin excretion. In terms of
and years of exposure, found a significant association between sensitivity, postoperative sensitivity to cold was higher for people
amalgam and the porphyrin biomarkers for mercury-related with amalgam restorations than those with resin composite
enzyme blockage, which suggests that amalgams are a significant restorations at three years. The trial authors did not comment on
contributor to mercury body burden. A further investigation of the clinical significance of this, but did discuss whether variability
a subgroup of children with genotyping assays demonstrated a in bonding materials may have played a role in the postoperative
genetic susceptibility to the adverse neurobehavioural effects of sensitivity findings.
mercury exposure in children, predominantly in boys.
Overall, there were some differences noted between composite
Urinary porphyrin excretion
and amalgam fillings with respect to other potential harms, but
Another report generated from Casa Pia 2007 presented the we judged these as unlikely to be of any clinical importance.
urinary porphyrin excretion in 479 children (i.e. all those for The evidence is of very low certainty, with most harms outcomes
whom porphyrin data were available). No statistically significant reported in only one trial.
differences were found in any of the primary analyses comparing
the randomised treatment groups, nor in a series of subgroup Overall completeness and applicability of evidence
analyses (i.e. by age, race, and sex). Trial authors noted that The eight included studies were RCTs that compared resin
although they observed "incipient increases" in a subgroup composite restorations with amalgam restorations in permanent
analysis of eight- and nine-year-old participants, these were much posterior teeth, with follow-up periods ranging between three and
lower than the level at which renal function is likely to be affected. seven years. We reported results for failure rate, secondary caries,
fracture of restorations, and adverse effects in this review. The
Sensitivity
event of a failure is reported rather than the 'non-event' of survival.
Postoperative sensitivity
Only three trials reported on adverse effects associated with either
Kemaloglu 2016 found a between-group difference at three years amalgam or composite restorations, and the generalisability of
in favour of composite resin restorations (P < 0.05), but we did not the findings from these trials to populations other than healthy
Informed decisions.
children (e.g. children or adults with potentially mercury-sensitive 2020 found both composite resin and amalgam materials were
health conditions such as chronic kidney disease) is unclear. There widely recommended for restorative treatment of early childhood
is recent research exploring genetic susceptibility to the adverse carious lesions (Correa-Faria 2020). A systematic review conducted
neurological effects of mercury exposure in children, with effects in 2020 identified one RCT, which showed that class II composite
manifested predominantly amongst boys. It is acknowledged that a restorations may have a higher risk of failure compared with
comprehensive systematic review of adverse events would include amalgam restorations (Splieth 2020).
observational studies, which were not part of this review.
AUTHORS' CONCLUSIONS
The dental material industry is continuously evolving and
improving the products that clinicians use. All but one of the Implications for practice
included studies were conducted more than 10 years ago. Some of
Low-certainty evidence suggests that fillings made of resin
the materials used in the studies included in this review may no
composite lead to higher failure rates and secondary caries risk
longer be in use or may have been replaced by products with better
than amalgam restorations. The international commitment to
mechanical properties and better resistance to wear, shrinkage,
reducing mercury will increasingly restrict the use of amalgam
and fracture. In this respect, the results of this review may not be a
fillings, but there are still many parts of the world where it is
true reflection of the quality of restorations that are currently in use.
the material of choice for the restoration of posterior teeth with
Quality of the evidence proximal caries. Safety data is very limited for both types of filling
material, but very low-certainty evidence suggests there may be no
We assessed the evidence on effectiveness as low certainty due clinically important differences in the safety profile of composite
to high risk of bias (lack of blinding) and inconsistency, and the resin and amalgam dental restorations.
harms data provide only very low certainty evidence. Differences in
oral hygiene may have contributed to the inconsistency observed Implications for research
in failure rate and secondary caries outcomes owing to age
This review suggests that there are higher failure rates with
differences of participants in the two trials (mean ages 7.9 and 10.2
resin composite than with amalgam restorations. However, the
years). Inconsistency may have also resulted from the difference
included studies are from 2007, and composite dental restorative
in adhesives used for composite restoration in the studies. The
materials have advanced considerably in the last 10 years.
trial that found an association between composite restoration and
Since the proposed discontinuation of amalgam use depends on
impaired psychosocial function reported that participants received
quality improvement of non-mercury-based alternative restorative
additional composite restoration in cases where any anterior
materials (BDA 2013), there is a need for new research to
teeth needed restoration. This may have amplified the effects of
demonstrate long-term effectiveness and safety of the latest
composite restoration on psychosocial function.
improved composite materials, techniques, and instruments for
Potential biases in the review process placing them. If split-mouth trial design is to be used in future
studies, data should be analysed and reported appropriately,
There were unit of analysis issues with all of the included studies, taking into account the clustering of sites within participants
as even the parallel-group studies had more than one filling per (Lesaffre 2009).
person, and the data were analysed without taking the clustering
into account. This meant that the confidence intervals for the effect ACKNOWLEDGEMENTS
estimates were smaller than they should be; however, this effect
will be very small. The effect for the split-mouth studies is unknown, For this update, we thank Cochrane Oral Health, especially Laura
as there is a lack of clarity in their reporting, which is why we did MacDonald, Anne Littlewood, Professor Anne-Marie Glenny, and
not include them in the primary analysis. Jennifer Hilgart. We also thank CADTH for their contribution to
initiating and brokering the collaborative update, in particular
Agreements and disagreements with other studies or Dr. Julie Polisena, Chris Kamel and Dr. Laura Weeks. For
reviews the original protocol and previous versions of the review, we
thank: Krishna Aravamudhan and Julie Frantsve-Hawley (American
The results obtained in the process of the current systematic Dental Association); Aronita Rosenblatt (University of Pernambuco,
review are consistent with the conclusions of the systematic review Brazil); Luisa Fernandez Mauleffinch, Anne Littlewood, Helen
performed by the Canadian Agency of Drugs and Technologies Worthington and Tanya Walsh (Cochrane Oral Health); Marta
in Health (CADTH 2018), which presented safety, efficacy, and Roqué-Figuls (Iberoamerican Cochrane Center); Agustin Ciapponi
cost-effectiveness, although the duration of follow-up in the two (Argentine Cochrane Centre IECS, Institute for Clinical Effectiveness
studies presenting efficacy data was inadequate to permit inclusion and Health Policy); Huan Lu.
of these studies in our review. A scoping review carried out in
Informed decisions.
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CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]
Casa Pia 2007

Methods Study design: parallel-group RCT
Conducted in: Lisbon, Portugal
Number of centres: 1 at Lisbon Faculty of Dental Medicine
Recruitment period: started in 1996
Funding source: National Institute of Dental & Craniofacial Research
Participants Inclusion criteria: children born from 1986 through 1989. At least 1 carious lesion in a permanent pos-
terior tooth. Urinary mercury concentration < 10 μg/L. Blood lead concentration of < 15 μg/dL. An IQ
score at least 67 on Comprehensive Test of Nonverbal Intelligence
Exclusion criteria: prior exposure to dental amalgam, interference health condition
Age: 8 to 12 years
Caries risk status: unclear
Location of teeth filled: 1545 permanent molars and 203 premolars
Informed decisions.
Casa Pia 2007 (Continued)

Type of cavity filled: 879 Class I restorations and 869 Class II restorations
Number randomised: 507 children
Number evaluated: 472 children
Interventions Comparison: composite vs amalgam
Group A: 233 children received 892 composite restorations
Group B: 239 children received 856 amalgam restorations
Type of moisture control: restorations were placed using rubber dam isolation whenever possible.
Duration of follow-up: 7 years
Outcomes • Failure rate, estimated at 7 years

• Secondary caries, estimated at 7 years
• Fracture of restoration, estimated at 7 years
• Adverse sentinel health events
• Neurobehavioural assessment of memory, attention concentration, and motor/visuomotor domains,
as well as nerve conduction velocities, estimated at year 1, 2, 3, 4, 5, 6, and 7
Notes Sample size calculation: selected to ensure adequate power for detecting 2 potential scenarios
The first scenario was a small but near-uniform effect of 0.3 SD for the 3 neurobehavioural outcomes,
and half of that (0.15 SD) for the nerve conduction outcome. The effect size of 0.3 SD represents a shift
that would cause the proportion of abnormally low values in a normally distributed population to in-
crease from 2.5% to 5.0%, thus doubling the proportion classified as abnormally low.
For the second scenario, a potential effect in only 1 of the 4 outcomes was of interest, so an effect size
of 0.5 SD in the nerve conduction outcome was used, with no effects in the others.
A sample size of 400 (200 in each group) through 5 years of follow-up provided adequate power (97%)
to detect both scenarios.
Risk of bias
Bias Authors' judgement Support for judgement
Random sequence genera- Unclear risk Children were randomly assigned to 1 of the 2 treatment groups, but study au-
tion (selection bias) thors did not explain the method of randomisation.
Allocation concealment Unclear risk No information provided.

(selection bias)
Blinding of participants High risk Not reported. Blinding was not possible due to the clinical characteristics of
and personnel (perfor- the interventions.
mance bias)
All outcomes
Blinding of outcome as- High risk Restorative procedures were standardised, and dentists were calibrated be-
sessment (detection bias) fore starting the trial, but there is no indication that assessors were blinded or
All outcomes different from the operators.
Incomplete outcome data Low risk Of 507 children initially randomised, 19 had no dental exam after baseline, and
(attrition bias) 16 had no restoration to posterior teeth at baseline. None of the children who
All outcomes had fillings placed were lost to follow-up, and all of them were analysed in the
group that they had been allocated to by randomisation. 472 children (93%)
were followed up for 1 year.
Informed decisions.
Casa Pia 2007 (Continued)
Selective reporting (re- Low risk Expected outcomes reported.

porting bias)
Other bias Low risk No other bias apparent.
Cunningham 1990
Methods Study design: RCT, split-mouth design
Conducted in: Liverpool, UK
Number of centres: 3 dentists, 1 based at Liverpool Dental Hospital, 2 general practitioners
Recruitment period: not reported
Funding source: unclear
Participants Inclusion criteria: teeth requiring the treatment of Class I and Class II carious lesions
Exclusion criteria: unclear
Age: not reported
Location of teeth filled: not reported
Type of cavity filled: O: 83 cavities, MO: 140 cavities, DO: 164 cavities, MOD: 122 cavities
Number randomised: 605 cavities (Class I or Class II lesions) were randomly assigned to be restored
with 2 different amalgams and 3 different composites
Number evaluated: 509 restorations
Group A: 309 composite restorations
Group B: 200 amalgam restorations
Type of moisture control: unclear
Outcomes • Failures and fractures of the restorations, estimated at year 3

• Contact points, estimated at 6, 12, 24, and 36 months
• Gingival inflammation, estimated at 6, 12, 24, and 36 months
• Marginal stain and caries, estimated at year 3
• Color match, estimated at year 3
Notes Sample size calculation: unclear
Risk of bias
Informed decisions.
Cunningham 1990 (Continued)
Random sequence genera- Unclear risk Teeth were randomly assigned to treatment groups, but study authors did
tion (selection bias) not explain the method of randomisation used to generate the allocation se-
quence.
Allocation concealment Low risk There was no information regarding the method used to conceal the allocation
(selection bias) sequence; however, due to the study design (split-mouth), a lack of allocation
concealment was unlikely to introduce bias.
mance bias)
All outcomes
Blinding of outcome as- High risk Blinding was not possible due to the clinical characteristics of the interven-
sessment (detection bias) tions.
All outcomes
Incomplete outcome data Unclear risk Of the original 605 restorations, 509 could be examined at 3 years, and the
(attrition bias) losses were reported to have been evenly distributed across the trial arms,
All outcomes though numbers per group were not explicitly given. Follow-up 84.1%
Selective reporting (re- Low risk All data were well reported.
porting bias)
Other bias High risk Unit of analysis error - the total number of participants was not indicated in
the paper. There were 5 materials under consideration, and each tooth was
randomised to 1 of them, but the number of restorations per participant is not
clear.
Hendriks 1986
Conducted in: unclear
Number of centres: 3 operators
Recruitment period: unclear
Participants Inclusion criteria: not reported
Exclusion criteria: not reported
Age: adults
Location of teeth filled: 108 permanent molars and 124 premolars
Type of cavity filled: not reported
Number randomised: 242 cavities
Number evaluated: 232 cavities
Informed decisions.
Hendriks 1986 (Continued)
Type of moisture control: rubber dam
Outcomes Failures of restorations estimated at year 3
Notes Sample size calculation: not reported
Risk of bias
Random sequence genera- Unclear risk The 4 materials within each series were distributed at random over the teeth
tion (selection bias) selected for restoration, and the participants were assigned at random to 1 of
3 operators. Study authors did not describe the method of randomisation.
Allocation concealment Low risk Information in the paper regarding allocation concealment was unclear; how-
(selection bias) ever, due to the design of the study (split-mouth), a lack of allocation conceal-
ment was unlikely to introduce bias.
mance bias)
All outcomes
All outcomes
Incomplete outcome data Unclear risk The 3-year retrieval percentage of both the participants and restorations was
(attrition bias) 96%; however, dropout rate was not reported by trial arm.
All outcomes
porting bias)
Other bias High risk Unit of analysis error - number of restorations per participant not reported
Kemaloglu 2016
Methods Study design: RCT
Quote: "The study was conducted according to the ethical standards stated in the Helsinki Declaration
and approved by the Institutional Review Board/Ethics Committee of Ege University."
Participants 20 people in need of at least 2 posterior restorations
Inclusion criteria: teeth asymptomatic, occlusal and adjacent teeth in contact, cavity sizes exceeding
the 1/3 of the faciolingual distance between cuso tips
Informed decisions.
Kemaloglu 2016 (Continued)

Exclusion criteria: with < 20 teeth, poor oral hygiene, bruxism, periodontitis, a history of allergic reac-
tions to any of the materials used
Interventions Composite restorations
Bonded amalgam restorations
50 restorations (2 in each participant) placed by 2 dentists who practised the technique before the first
restoration (5 people did not return for 2-week appointment)
Outcomes Performance of restoration measured using modified US Public Health Service criteria for retention,
marginal adaptation, anatomic form, surface texture, and secondary caries.
Postoperative sensitivity (response to cold) using VAS
Measured at baseline (2 weeks), 6 months, 1 year, and 3 years
Notes Trial authors concluded that posterior resin composite can be used even in large cavities.
Risk of bias
Random sequence genera- Low risk Quote: "The randomization of the restorations was obtained by flipping a coin
tion (selection bias) to choose the first teeth to be restored by the resin composite."
Allocation concealment Low risk Split-mouth study

(selection bias)
Blinding of participants High risk Blinding was not possible, as the interventions looked different.
and personnel (perfor-
mance bias)
All outcomes
Blinding of outcome as- High risk Quote: "Two examiners who were not involved in the placement of the restora-
sessment (detection bias) tions evaluated the restorations after 2 weeks (baseline), 6 months, 1 and 3
All outcomes years. In case of disagreement, the examiners reevaluated the restorations un-
til they reached a consensus."
Quote: "Postoperative sensitivity evaluation was blindly conducted by trained

examiner after 2 weeks (baseline), 6 months, 1 and 3 years."
The study attempted to reduce bias, but as the restorations looked different,
blinding was not possible.
Incomplete outcome data Low risk 5 people did not return for baseline assessment at 2 weeks, but those who em-
(attrition bias) barked on the study completed it.
All outcomes
Selective reporting (re- Low risk Outcomes were reported as planned.

porting bias)
Other bias Low risk None noted.
Letzel 1989
Informed decisions.
Letzel 1989 (Continued)
Methods Study design: multicentre RCT, split-mouth design
Conducted in: Liverpool (UK), London (UK), Manchester (UK), North Carolina (USA), Indianapolis (USA),
South Illinois (USA), Philadelphia (USA), Gothenburg (Sweden), Nijmegen (Netherlands), Leuven (Bel-
gium), Louvain (Belgium), Bonn (Germany)
Number of centres: 12
Funding source: ICI Dental (Imperial Chemical Industries), Macclesfield, UK
Participants Inclusion criteria: adults with teeth requiring posterior Class I or II restorations. Sound tooth or a sound
restored tooth in proximal contact with each of the teeth were included.
Exclusion criteria: people who may have been unable to return for 5 years or who required special man-
agement, extensive restorative care, or cuspal replacement. Teeth requiring Class II restorations that
had no proximal contact. Pairs of opposing teeth
Age: adults, age not reported
Location of teeth filled: posterior teeth
Type of cavity filled: Class I and II restorations
Number randomised: 447 adults, 1164 cavities
Number evaluated: 338 adults, 693 cavities
Type of moisture control: unclear
Outcomes Primary outcome: failure
In order to trace the causes of failure in each case, reasons for failure were classified according to a sys-
tem described by Letzel and colleagues in 1988. This system was designed for an evaluation of the in-
fluence of experimental variables and operators on the survival rate of restorations included in con-
trolled clinical trials of dental amalgams.
The system distinguishes between 3 types of restoration failure:
• Type 1: failures directly related to the restoration (i.e. the material and the way it is manipulated into
a restoration);
• Type 2: failures related to the restorative process (i.e. the result of the decision-making process of the
operator);
• Type 3: failures caused by external factors.
12 centres were involved in the trial, but data from 10 centres were used in the review because these
centres complied with the condition of fully reviewing the restorations after at least 4 years.
Risk of bias
Informed decisions.
Letzel 1989 (Continued)
Random sequence genera- Unclear risk The study authors declared that randomisation was done in 5 centres, but do
tion (selection bias) not state if the sequence generation had been at random in the other centres.
Allocation concealment Low risk Information in the paper regarding allocation concealment was unclear; how-
(selection bias) ever, due to the design of the study (split-mouth), a lack of allocation conceal-
ment was unlikely to introduce bias.
mance bias)
All outcomes
All outcomes
Incomplete outcome data Unclear risk Follow-up at 4 years was 76% for composite restorations. Dropout rate for
(attrition bias) amalgam was not clearly reported.
All outcomes
Selective reporting (re- High risk Data seemed to be well reported for composite, but only partially reported for
porting bias) amalgam, in particular follow-up data.
Other bias High risk There were variations in practice and dropout rate amongst the centres, and
the reason for these variations was not clearly explained.
Unit of analysis error - number of restorations reported but not number of

restorations per participant
NECAT 2007
Methods Study design: parallel-group RCT
Conducted in: USA
Number of centres: 5 community centres in Boston and Maine, USA
Recruitment period: 1997 to 2005
Participants Inclusion criteria: children fluent in English
Had ≥ 2 posterior teeth with dental caries. Primary and permanent teeth
Exclusion criteria: had known prior or existing amalgam restorations. Had a physician-diagnosed psy-
chological behavioural, neurologic, immunosuppressive, or renal disorder
Age: 6 to 10 years
Caries risk status: not reported
Location of teeth filled: posterior teeth
Type of cavity filled: Class I and Class II restorations
Informed decisions.
NECAT 2007 (Continued)

Number randomised: 534 children
Number evaluated: 449 children
Type of moisture control/tooth isolation: rubber dam
Duration of follow-up: 5 years. Evaluation every 6 months
Outcomes Rate of replacement and repair of the restorations, psychosocial function (5-year follow-up), physical
development (5-year follow-up)
Notes Sample size calculation: not reported. Only data from permanent teeth were used in the review.
Risk of bias
Random sequence genera- Low risk Quote: "Randomization was stratified by geographic location (Boston/Cam-
tion (selection bias) bridge vs Farmington) and number of teeth with caries (2 to 4 versus 5 or
more), using randomly permuted blocks within each of the 4 strata..."
Allocation concealment Low risk Quote: "Randomization was stratified...using randomly permuted blocks with-
(selection bias) in each of the four strata to achieve balance...Assignment was made via tele-
phone, using software and encrypted files at New England Research Institutes
by staff personnel not involved in data collection."
Blinding of participants High risk Participants and dentists could not be blinded to treatment assignment due to
and personnel (perfor- the clinical characteristics of the interventions.
mance bias)
All outcomes
Blinding of outcome as- High risk Blinding was not possible for efficacy outcomes due to the clinical characteris-
sessment (detection bias) tics of the interventions.
All outcomes
Quote: "Participants and dentists could not be blinded to treatment assign-
ment, but all individuals who collected outcome data (e.g., neuropsychologi-
cal tests) or analyzed specimens (e.g., for mercury) were blinded to children’s
treatment assignments" (Bellinger and colleagues 2007)
Incomplete outcome data Low risk Follow-up at 3 years was 84%, and losses were similar in both groups.
(attrition bias)
All outcomes
porting bias)
Other bias Low risk No other apparent biases
Norman 1990
Informed decisions.
Norman 1990 (Continued)
Conducted in: unclear
Funding source: ICI (Imperial Chemical Industries), Macclesfield, UK
Participants Inclusion criteria: individuals in need of posterior Class I and II restorations. Maximum of 4 restorations
was allowed. Selection of the teeth required that there be a sound tooth or a sound restored tooth in
proximal contact to the restoration. At least a portion of the restoration was required to be in contact
with an opposite tooth or restoration.
Exclusion criteria: not reported
Age: 28 to 40 years
Location of teeth filled: molars and premolars
Number randomised: 62 participants, 160 restorations
Group A: 80 Occlusin composite. Light-cured, highly filled hybrid posterior composite resin
Group B: 43 Dispersalloy amalgam
Type of moisture control: rubber dam was used to isolate the teeth
Outcomes Primary outcomes: failure and recurrent caries
Secondary outcomes: wear, marginal adaptation, anatomic form, interproximal contacts
Risk of bias
Random sequence genera- Low risk All restorations were placed by following a random selection chart for compos-
tion (selection bias) ite resins and amalgam.
(selection bias) sequence; however, due to the design of the study (split-mouth), a lack of allo-
cation concealment was unlikely to introduce bias.
mance bias)
All outcomes
Informed decisions.
Norman 1990 (Continued)
All outcomes
Incomplete outcome data Unclear risk Follow-up at 5 years was 80.6%; however, dropout rate was not reported by tri-
(attrition bias) al arm.
All outcomes
porting bias)
Other bias High risk Unit of analysis error - number of restorations reported but not number of par-
ticipants
Robinson 1988
Conducted in: Guy's Hospital, London, UK
Recruitment period: not clear
Funding source: ICI Dental, Macclesfield, UK
Participants Inclusion criteria: adults who required O and proximo-O restorations in vital premolars and molars
Exclusion criteria: mental and physical disabilities likely to prevent continued co-operation, people
who would not be available for the long-term follow-up visits over the 5 years, and restorations requir-
ing cuspal replacement
Age: 19 to 66 years
Location of teeth filled: molars and premolars
Number randomised: 58 participants, 98 composites and 27 amalgams
Group A: 70 Occlusin composite
Group B: 20 Aristaloy amalgam
Type of moisture control/tooth isolation used: rubber dam isolation in 82.4% of cases
Outcomes Failure rate in terms of the following criteria: gingival condition, interproximal contacts, colour match,
anatomic form, surface roughness
Informed decisions.
Robinson 1988 (Continued)
Risk of bias
Random sequence genera- Low risk Participants were allocated to receive composite or amalgam restoration in
tion (selection bias) the ratio 3:1 from a randomised table.
(selection bias) sequence; however, due to the design of the study (split-mouth), a lack of allo-
cation concealment was unlikely to introduce bias.
mance bias)
All outcomes
All outcomes
Incomplete outcome data Unclear risk Follow-up at 36 months was 78.4%, but it was unclear whether dropout was
(attrition bias) balanced between trial arms.
All outcomes
porting bias)
Other bias High risk Unit of analysis error - number of restorations reported but not number of par-
ticipants
DO: distal and occlusal; IQ: intelligence quotient; MO: mesial and occlusal; MOD: mesial, occlusal, and distal; O: occlusal; RCT: randomised
controlled trial; SD: standard deviation; VAS: visual analogue scale
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Allan 1977 Non-RCT. Retrospective analysis of dental records
Bellinger 2006 This article reports data from the New England Children's Amalgam Trial. As the data for perma-
nent and temporary dentition were not informed separately, it was not possible to extract the data
for permanent posterior teeth.
Borgmeijer 1991 Insufficient follow-up and incomplete data
Bryant 1994 Not an RCT. No randomisation
Busato 1996 Not an RCT. No randomisation
Cloyd 1997 Not an RCT. No randomisation
Collins 1998 Not an RCT. No randomisation
Informed decisions.
Dilley 1990 Did not evaluate longevity correctly
Eames 1974 Not an RCT. No randomisation
Fukushima 1988 Not an RCT. No randomisation
Hendriks 1985 Not an RCT. No randomisation
Johnson 1992 Not an RCT. No randomisation
Knibbs 1992 Not an RCT. No randomisation
Kopperud 2012 Not an RCT
Koray Unpublished. Study author did not respond to request for data.
Kreulen 1993a No long-term follow-up. No caries and fracture reporting
Kreulen 1993b Intervention did not correspond with the aims of this review.
Lambrechts 1984 Follow-up 18 months
Leinfelder 1975 Follow-up 24 months
Leinfelder 1980 As the study considered anterior and posterior restorations, it is not possible to be certain that the
failures occurred in Class I and II restorations.
Mair 1995 No data could be extracted.
Mair 1998 No data could be extracted.
Mannocci 2005 Intervention did not correspond with the aims of this review.
Mjör 1993a Not an RCT. No randomisation
Mjör 1993b Not an RCT
Nell 1994 Intervention did not correspond with the aims of this review.
Pieper 1991 Not an RCT. Retrospective study
Powers 1974 Not an RCT. No randomisation
Prati 1988 Not an RCT. No randomisation
Roulet 1977 Follow-up 12 months
Roulet 1978 Same data as Roulet 1977
Rowe 1989 Not an RCT. No randomisation
Rytömaa 1984 Not an RCT. No randomisation
Samaha 1982 Not an RCT. No randomisation
Informed decisions.
Shenker 2008 This article reported data from the New England Children's Amalgam Trial. As the data for perma-
nent and temporary dentition were not informed separately, it was not possible to extract the data
for permanent posterior teeth.
Smales 1991 Not an RCT. No randomisation
Smales 1992 Intervention did not correspond with the aims of this review.
Solano 1984 Study data were unpublished (master's dissertation) and could not be found for critical appraisal.
Tobi 1999 Randomised at tooth level, but only partially analysed and reported
Van Nieuwenhuysen 2003 Not an RCT. No randomisation
Walls 1988 Follow-up 24 months
Welbury 1990 Randomisation broken by ignoring it in 20/150 pairs of teeth.
Wilson 1996 Did not compare amalgam versus composite
RCT: randomised controlled trial
DATA AND ANALYSES
Comparison 1. Composite resin fillings versus amalgam fillings
Outcome or subgroup title No. of studies No. of partici- Statistical method Effect size
pants
1.1 Failure rate 7 5200 Risk Ratio (M-H, Fixed, 95% CI) 1.78 [1.47, 2.17]
1.1.1 Failure rate - parallel-group 2 3010 Risk Ratio (M-H, Fixed, 95% CI) 1.89 [1.52, 2.35]
studies
1.1.2 Failure rate - split-mouth 5 2190 Risk Ratio (M-H, Fixed, 95% CI) 1.42 [0.90, 2.24]
studies
1.2 Secondary caries 6 4036 Risk Ratio (M-H, Fixed, 95% CI) 2.11 [1.66, 2.69]
1.2.1 Secondary caries - paral- 2 3010 Risk Ratio (M-H, Fixed, 95% CI) 2.14 [1.67, 2.74]
lel-group studies
1.2.2 Secondary caries - split- 4 1026 Risk Ratio (M-H, Fixed, 95% CI) 1.50 [0.43, 5.21]
mouth studies
1.3 Fracture of restorations 2 3010 Risk Ratio (M-H, Fixed, 95% CI) 0.87 [0.46, 1.64]
Informed decisions.
Analysis 1.1. Comparison 1: Composite resin fillings versus amalgam fillings, Outcome 1: Failure rate
Composite Amalgam Risk Ratio Risk Ratio

Study or Subgroup Events Total Events Total Weight M-H, Fixed, 95% CI M-H, Fixed, 95% CI
1.1.1 Failure rate - parallel-group studies

Casa Pia 2007 (1) 129 892 48 856 33.2% 2.58 [1.88 , 3.54]
NECAT 2007 112 753 55 509 44.5% 1.38 [1.02 , 1.86]
Subtotal (95% CI) 1645 1365 77.7% 1.89 [1.52 , 2.35]
Total events: 241 103
Heterogeneity: Chi² = 7.89, df = 1 (P = 0.005); I² = 87%
Test for overall effect: Z = 5.76 (P < 0.00001)
1.1.2 Failure rate - split-mouth studies

Cunningham 1990 21 309 14 200 11.5% 0.97 [0.51 , 1.86]
Hendriks 1986 7 174 1 58 1.0% 2.33 [0.29 , 18.57]
Letzel 1989 54 932 6 232 6.5% 2.24 [0.98 , 5.14]
Norman 1990 6 107 3 53 2.7% 0.99 [0.26 , 3.81]
Robinson 1988 2 98 0 27 0.5% 1.41 [0.07 , 28.61]
Subtotal (95% CI) 1620 570 22.3% 1.42 [0.90 , 2.24]
Total events: 90 24
Test for overall effect: Z = 1.49 (P = 0.14)
Total (95% CI) 3265 1935 100.0% 1.78 [1.47 , 2.17]

Heterogeneity: Chi² = 12.44, df = 6 (P = 0.05); I² = 52% 0.01 0.1 1 10 100
Test for overall effect: Z = 5.80 (P < 0.00001) Favours composite Favours amalgam
Test for subgroup differences: Chi² = 1.25, df = 1 (P = 0.26), I² = 19.7%
Footnotes
(1) Fixed-effect model displayed as primary result is for parallel group subgroup
Informed decisions.
Analysis 1.2. Comparison 1: Composite resin fillings versus amalgam fillings, Outcome 2: Secondary caries

1.2.1 Secondary caries - parallel-group studies

NECAT 2007 (1) 95 753 46 509 59.8% 1.40 [1.00 , 1.95]
Casa Pia 2007 113 892 32 856 35.6% 3.39 [2.31 , 4.96]
Subtotal (95% CI) 1645 1365 95.4% 2.14 [1.67 , 2.74]
Test for overall effect: Z = 6.06 (P < 0.00001)
1.2.2 Secondary caries - split-mouth studies

Hendriks 1986 1 174 1 58 1.6% 0.33 [0.02 , 5.24]
Robinson 1988 2 98 0 27 0.8% 1.41 [0.07 , 28.61]
Norman 1990 3 107 1 53 1.5% 1.49 [0.16 , 13.95]
Cunningham 1990 3 309 0 200 0.7% 4.54 [0.24 , 87.40]
Subtotal (95% CI) 688 338 4.6% 1.50 [0.43 , 5.21]
Total events: 9 2
Test for overall effect: Z = 0.64 (P = 0.52)
Total (95% CI) 2333 1703 100.0% 2.11 [1.66 , 2.69]

Test for overall effect: Z = 6.07 (P < 0.00001) Favours composite Favours amalgam
Test for subgroup differences: Chi² = 0.30, df = 1 (P = 0.58), I² = 0%
Footnotes
(1) Fixed-effect model displayed as primary result is for parallel group subgroup
Analysis 1.3. Comparison 1: Composite resin fillings versus amalgam fillings, Outcome 3: Fracture of restorations

Casa Pia 2007 16 892 16 856 82.0% 0.96 [0.48 , 1.91]

NECAT 2007 2 753 3 509 18.0% 0.45 [0.08 , 2.69]
Total (95% CI) 1645 1365 100.0% 0.87 [0.46 , 1.64]

Total events: 18 19
Test for overall effect: Z = 0.44 (P = 0.66) Favours composite Favours amalgam
Test for subgroup differences: Not applicable
ADDITIONAL TABLES
Table 1. Harms
Study Report Type of harm Outcome
NECAT 2007 Bellinger 2007 Toxicity Neuropsychological function
Urinary mercury
Informed decisions.
Table 1. Harms (Continued)
Bellinger 2008 Psychosocial status
Shenker 2008 Immune function
Barregard 2008 Renal effects
Maserejian 2012 Physical development
Casa Pia 2007 Lauterbach 2008 Neurological symptoms
DeRouen 2006 Neurobehavioural effects
Woods 2007 Urinary mercury
Woods 2008 Renal effects
Woods 2009 Urinary porphyrin excretion
Kemaloglu 2016 Sensitivity Postoperative sensitivity
Table 2. Neuropsychological function
Memory
Library
Cochrane
Method of measurement - RAVLT memory test
Resin composite Amalgam
n Mean SD n Mean SD MD 95% CI P value
Better health.
Informed decisions.
Trusted evidence.
At 7 years 176 9.73 2.79 172 9.65 2.86 0.08 −0.51, 0.68 0.79
Method of measurement - WRAML visual memory (1) WMS-III reproductions delayed (2)
At 7 years (2) 176 32.98 6.24 172 33.02 6.24 −0.03 −1.35, 1.28 0.96
Method of measurement - WRAML visual learning (1) WMS-III reproductions immediate (2)
At 7 years (2) 176 35.79 3.68 172 35.15 4.47 0.64 −0.22, 1.50 0.15
Method of measurement - RAVLT total learning test

At 7 years 176 47.36 9.48 172 46.06 9.09 1.30 −0.65, 3.25 0.19
Attention/concentration
Method of measurement - coding (1) WAIS-III digit symbol (2)

40
Table 2. Neuropsychological function (Continued)
Library
Cochrane
At 7 years (2) 176 9.45 2.98 172 9.45 2.86 0.00 −0.61, 0.61 1.00
Method of measurement - symbol search (1) WAIS-III symbol search (2)
Better health.
Informed decisions.
Trusted evidence.
At 7 years (2) 176 9.40 2.85 172 9.77 3.08 −0.37 −0.99, 0.25 0.25
Method of measurement - digit span (1) WAIS-III digit span (2)
At 7 years (2) 176 7.64 2.17 172 7.70 2.21 −0.06 −0.52, 0.40 0.80
Method of measurement - finger windows (1) WAIS-III spatial span (2)
At 7 years (2) 176 9.03 2.96 172 9.34 2.99 −0.31 −0.94, 0.32 0.33
Method of measurement - trial A, seconds (1) adult trial A, seconds (2)

At 7 years (2) 176 28.94 12.06 172 28.72 11.26 0.22 −2.23, 2.67 0.86
Method of measurement - trial B, seconds (1) adult trial B, seconds (2)

41
At 7 years (2) 176 63.84 25.5 172 65.34 25.07 −1.50 −6.81, 3.81 0.58
Library
Cochrane
Method of measurement - Stroop word
Better health.
Informed decisions.
Trusted evidence.
At 7 years 176 41.7 8.09 172 41.41 8.04 0.29 −1.40, 1.98 0.74
Method of measurement - Stroop colour
At 7 years 176 41.59 8.16 172 42.67 8.14 −1.08 −2.79, 0.63 0.22
Method of measurement - Stroop colour-word
At 7 years 176 46.99 9.71 172 48.42 9.41 −1.43 −3.44, 0.58 0.16
Visuomotor
Method of measurement - WRAVMA matching (1) WASI matrices (2)

At 7 years (2) 176 24.44 5.33 172 24.83 5.02 −0.39 −1.48, 0.70 0.48
Method of measurement - WRAVMA pegs (dominant)

42
At 7 years 176 119.38 15.83 172 119.01 15.55 0.37 −2.93, 3.67 0.83
Library
Cochrane
Method of measurement - WRAVMA pegs (non-dominant)
Better health.
Informed decisions.
Trusted evidence.
At 7 years 176 119.38 15.83 172 119.01 15.55 0.37 −2.93, 3.67 0.83
Method of measurement - standard reaction time
At 7 years 176 0.76 0.14 172 0.77 0.15 −0.01 −0.04, 0.02 0.52
Method of measurement - finger tapping (dominant)
At 7 years 176 50.5 6.56 172 50.51 6.56 −0.01 −1.39, 1.37 0.99
Method of measurement - finger tapping (non-dominant)

At 7 years 176 44.49 6.33 172 44.48 6.34 0.01 1.32, 1.34 0.99
Nerve conduction velocity
Method of measurement - tibial, m/s

43
At 7 years 140 50.15 5.09 140 50.78 5.07 −0.63 −1.82, 0.56 0.30
Library
Cochrane
Method of measurement - ulnar, m/s
Better health.
Informed decisions.
Trusted evidence.
At 7 years 140 57.58 6.52 140 59.26 6.41 −1.68 −3.19, 0.17 0.03
Intelligence
Method of measurement - CTONI
At 7 years 176 81 12 173 81 12 0.00 −2.52, 2.52 1.00
Method of measurement - WASI
At 7 years 176 92 13 173 94 14 −2.00 −4.84, 0.84 0.17
CI: confidence interval; CTONI: Comprehensive Test of Non-Verbal Intelligence; MD: mean difference; RAVLT: Rey Auditory Verbal Learning Test; SD: standard deviation; WAIS-
III: Wechsler Adult Intelligence Scale - Third Edition; WASI: Wechsler Abbreviated Scale of Intelligence; WMS-III: Wechsler Memory Scale - Third Edition; WRAML: Wide Range

Assessment of Memory and Learning; WRAVMA: Wide Range Assessment of Visual Motor Abilities
44
Informed decisions.
Table 3. Psychosocial function

Composite (permanent/pos- Amalgam (permanent/poste- Composite versus
terior occlusal SY) rior occlusal SY) amalgam
Mean (SE) Mean (SE) P value
BASC-SR Composite Scorea, adjusted mean
Emotional symptoms indexb 46.3 (0.6) 44.6 (0.6) 0.05
Clinical maladjustment 45.7 (0.6) 44.0 (0.6) 0.08
School maladjustment 50.4 (0.7) 50.8 (0.8) 0.29
Personal adjustment 51.3 (0.6) 53.3 (0.6) 0.005
CBCL Change Score, adjusted mean
Competence −0.9 (0.6) 0.8 (0.6) 0.13
Total problem behaviours −2.1 (0.7) −3.3 (0.7) 0.007
Internalising problems −2.1 (0.6) −3.8 (0.6) 0.03
Externalising problems −1.5 (0.8) −1.8 (0.6) 0.06
BASC-SR: Behavior Assessment for Children Self Report; CBCL: Child Behavior Checklist parent report; SE: standard error; SY: surface years
aBASC-SR scores reported in the table above reflect the scores of children aged 6 to 10 years. However, the BASC-SR was developed for
children ≥ 8 years. Change in BASC-SR was therefore assessed amongst children aged ≥ 8 years as a subgroup.
bHigher score is worse for school adjustment, clinical maladjustment, and emotional symptoms index; a lower score is worse for personal
adjustment.
Table 4. Physical development

Composite Amalgam Composite versus amalgam
5-year change (SE) 5-year change (SE) β (SE) P value
Growth outcome in girls
Body fat percentage 8.8 (0.7) 7.7 (0.8) 0.05 (0.83) 0.95
BMI-for-age z-score 0.36 (0.06) 0.21 (0.07) 0.08 (0.12) 0.49
Height 30.7 (0.5) 31.2 (0.5) 0.77 (1.18) 0.51
Growth outcome in boys
Body fat percentage 4.9 (0.9) 5.7 (0.9) 0.57 (0.82) 0.49
BMI-for-age z-score 0.13 (0.08) 0.25 (0.07) −0.21 (0.23) 0.36
Height 34.4 (0.6) 33.5 (0.6) 0.48 (0.83) 0.56
BMI: body mass index; SE: standard error

Informed decisions.
Table 5. Kidney function

Creatinine-adjusted urinary albumin levels
Composite Amalgam
Mean 95% CI Mean 95% CI
Year 1 7.4 4.2 to 12.5 7.7 3.1 to 11.5
Year 2 9.4 5.3 to 16.1 8.6 5.5 to 13.4
Year 3 9.9 6.8 to 16.7 9.0 5.5 to 17.9
Year 4 9.25 5.8 to 20.8 8.7 5.6 to 14.5
Year 5 8.2 5.1 to 14.3 8.0 5.4 to 12.5
Year 6 7.5 4.8 to 14.3 7.3 4.8 to 14.0
Year 7 6.8 4.4 to 13.7 6.5 4.3 to 12.3
CI: confidence interval
APPENDICES
Appendix 1. Cochrane Oral Health Trials Register search strategy

Cochrane Oral Health’s Trials Register is available via the Cochrane Register of Studies. For information on how the register is compiled,
see https://oralhealth.cochrane.org/trials
From October 2013, searches of Cochrane Oral Health's Trials Register were conducted using the Cochrane Register of Studies and the
search strategy below:
#1 ((tooth or teeth or molar* or bicuspid* or "Class I" or "Class II"):ti,ab) AND (INREGISTER)
#2 ((fill* or restor*):ti,ab) AND (INREGISTER)
#3 (#1 and #2) AND (INREGISTER)
#4 (amalgam*:ti,ab) AND (INREGISTER)
#5 ((resin* and composite*):ti,ab) AND (INREGISTER)
#6 (("bisphenol A-Glycidyl methacrylate" or compomer* or Bis-GMA):ti,ab) AND (INREGISTER)
#7 (("enamel bond*" or (concise and resin*) or (white and sealant*) or "conclude resin*" or Adaptic or Delton or Epoxylite-9075 or (Kerr
and seal*) or Nuva-seal or Panavia or Retroplast or Silux):ti,ab) AND (INREGISTER)
#8 (#5 or #6 or #7) AND (INREGISTER)
#9 (#3 and #4 and #8) AND (INREGISTER)
In May 2012, a search of the Cochrane Oral Health Group's Trials Register was conducted using the Procite software and the search strategy
below:
(((tooth or teeth or molar* or bicuspid* or "Class I" or "Class II") and (fill* or restor*)) and (amalgam and ((resin* and composite*) or
"bisphenol A-Glycidyl methacrylate" or compomer* or Bis-GMA or "enamel bond*" or (concise and resin*) or (white and sealant*) or
"conclude resin*" or Adaptic or Delton or Expoylite-9075 or (Kerr and seal*) or Nuva-seal or Panavia or Retroplast or Silux)))
Appendix 2. Cochrane Central Register of Controlled Clinical Trials (CENTRAL) search strategy
#1 MeSH descriptor Dental Restoration, Permanent explode all trees
#2 MeSH descriptor Dental Restoration, Temporary explode all trees
#3 ( (tooth in All Text or teeth in All Text or molar* in All Text or bicuspid* in All Text or "Class I" in All Text or "Class II" in All Text) and (restor*
in All Text or fill* in All Text) )
Informed decisions.
#4 (#1 or #2 or #3)
#5 MeSH descriptor Dental amalgam this term only
#6 amalgam* in Title, Abstract or Keywords
#7 (#5 or #6)
#8 MeSH descriptor Composite resins explode all trees
#9 ( (resin* in Title, Abstract or Keywords near/3 composite* in Title, Abstract or Keywords) or "bisphenol A-Glycidyl methacrylate" in Title,
Abstract or Keywords or compomer* in Title, Abstract or Keywords or Bis-GMA in Title, Abstract or Keywords)
#10 ("enamel bond*" in Title, Abstract or Keywords or (concise in Title, Abstract or Keywords near/3 resin* in Title, Abstract or Keywords)
or (white in Title, Abstract or Keywords near/3 sealant* in Title, Abstract or Keywords) or "conclude resin*" in Title, Abstract or Keywords
or Adaptic in Title, Abstract or Keywords or Delton in Title, Abstract or Keywords or Epoxylite-9075 in Title, Abstract or Keywords or (Kerr
in Title, Abstract or Keywords near/5 seal* in Title, Abstract or Keywords) or Nuva-seal in Title, Abstract or Keywords or Panavia in Title,
Abstract or Keywords or Retroplast in Title, Abstract or Keywords or Silux in Title, Abstract or Keywords)
#11 (#8 or #9 or #10)
#12 (#4 and #7 and #11)
Appendix 3. MEDLINE Ovid search strategy

1. Dental restorations, permanent/
2. Dental restorations, temporary/
3. ((tooth or teeth or molar$ or bicuspid$ or "Class I" or "Class II") and (restor$ or fill$)).ti,ab.
4. or/1-3
5. Dental amalgam/
6. amalgam$.ti,ab.
7. or/5-6
8. exp Composite resins/
9. ((resin$ adj3 composite$) or "bisphenol A-Glycidyl methacrylate" or compomer$ or Bis-GMA).ti,ab.
10. ("enamel bond$" or (concise adj3 resin$) or (white adj3 sealant$) or "conclude resin$" or Adaptic or Delton or Epoxylite-9075 or (Kerr
adj5 seal$) or Nuva-seal or Panavia or Retroplast or Silux).ti,ab.
11. or/8-10
12. 4 and 7 and 11
Appendix 4. Embase Ovid search strategy

1. Tooth filling/
2. ((tooth or teeth or molar$ or bicuspid$ or "Class I" or "Class II") and (restor$ or fill$)).ti,ab.
3. 1 or 2
4. Dental alloy/
5. amalgam$.ti,ab.
6. or/4-5
7. exp Resin/
8. ((resin$ adj3 composite$) or "bisphenol A-Glycidyl methacrylate" or compomer$ or Bis-GMA).ti,ab.
9. ("enamel bond$" or (concise adj3 resin$) or (white adj3 sealant$) or "conclude resin$" or Adaptic or Delton or Epoxylite-9075 or (Kerr
adj5 seal$) or Nuva-seal or Panavia or Retroplast or Silux).ti,ab.
10. or/7-9
11. 3 and 6 and 10
Appendix 5. LILACS BIREME Virtual Health Library search strategy

(Mh dental restorations, permanent or Mh dental restorations, temporary or (tooth or teeth or diente$ or dente$ or molar$ or premolar
$ or bicuspid$ or "Class I" or "Class II") and (restor$ or restaura$ or fill$)) [Words] and (Mh Dental amalgam or amalgam$) AND (Mh
Composite resins or (resin$ and composite$) or (resin$ and compuesta$) or (resin$ and composta$) or "bisphenol A-Glycidyl methacrylate"
or compomer$ or Bis-GMA or "enamel bond$" or (concise$ and resin$) or (white and sealant$) or "conclude resin$" or Adaptic or Delton
or Epoxylite-9075 or (Kerr and seal$) or Nuva-seal or Panavia or Retroplat or Silux or Compómeros or Compômeros) [Words]
Appendix 6. Supplementary searches

Efficacy search conducted on 26 June 2017, with monthly updates to 1 February 2019
Database(s): EBM Reviews - Cochrane Central Register of Controlled Trials May 2017, Embase 1974 to 2017 June 23, Ovid MEDLINE(R) Epub
Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid MEDLINE(R) 1946 to present
Informed decisions.
# Searches
1 exp Dental restoration, permanent/
2 Dental restoration, temporary/
3 ((tooth or teeth or molar$ or bicuspid$ or "Class I" or "Class II") and (restor$ or fill$)).ti,ab,kf.
4 or/1-3
5 Dental amalgam/
6 amalgam$.ti,ab,kf.
7 or/5-6
8 exp Composite resins/
9 ((resin$ adj3 composite$) or "bisphenol A-Glycidyl methacrylate" or compomer$ or Bis-

GMA).ti,ab,kf.
10 (enamel bond$ or (concise adj3 resin$) or (white adj3 sealant$) or conclude resin$ or Adaptic or
Delton or Epoxylite-9075 or (Kerr adj5 seal$) or Nuva-seal or Panavia or Retroplast or Silux).ti,ab,kf.
11 or/8-10
12 4 and 7 and 11
13 12 use ppez
14 exp Dental Restoration, Permanent/
15 exp Dental Restoration, Temporary/
16 ((tooth or teeth or molar$ or bicuspid$ or "Class I" or "Class II") and (restor$ or fill$)).af.
17 or/14-16
18 Dental amalgam/
19 amalgam$.ti,ab,kw.
20 or/18-19
21 exp Composite resins/

GMA).ti,ab,kw.
23 (enamel bond$ or (concise adj3 resin$) or (white adj3 sealant$) or conclude resin$ or Adaptic or
Delton or Epoxylite-9075 or (Kerr adj5 seal$) or Nuva-seal or Panavia or Retroplast or Keywords or
Silux).ti,ab,kw.
24 or/21-23
25 17 and 20 and 24
Informed decisions.
(Continued)
26 25 use cctr
27 Tooth filling/
28 ((tooth or teeth or molar$ or bicuspid$ or "Class I" or "Class II") and (restor$ or fill$)).ti,ab,kw.
29 or/27-28
30 exp Dental alloy/
31 amalgam$.ti,ab,kw.
32 or/30-31
33 exp Resin/

GMA).ti,ab,kw.
35 (enamel bond$ or (concise adj3 resin$) or (white adj3 sealant$) or conclude resin$ or Adap-
tic or Delton or Epoxylite-9075 or (Kerr adj5 seal$) or Nuva-seal or Panavia or Retroplast or
Silux).ti,ab,kw.
36 or/33-35
37 29 and 32 and 36
38 37 use oemezd
39 13 or 26 or 38
40 limit 39 to yr="2012 -Current"
41 remove duplicates from 40
Safety search, last conducted on 20 February 2019
Database(s): EBM Reviews - Cochrane Central Register of Controlled Trials January 2019, Embase 1974 to 2019 February 20, Ovid
MEDLINE(R) ALL 1946 to February 20, 2019
Search Strategy:
# Searches
1 Dental amalgam/
2 (exp Dental Restoration, Permanent/ or Dental Restoration, Temporary/ or Dental Materials/tu

or exp Dental caries/th) and (Silver/ or Mercury/ or (amalgam or amalgams or silver or mer-
cury).ti,ab,kf,kw.)
3 ((silver or mercury) and (dental or dentist* or tooth or teeth or filling* or premolar* or molar* or bi-
cuspid* or incisor* or cuspid*)).ti,ab,kf,kw.
Informed decisions.
(Continued)
4 (amalgam or amalgams).ti,ab,kf,kw. and (Silver/ or Mercury/ or (dental or dentist* or tooth or teeth

or silver or mercury or filling* or restor* or premolar* or molar* or bicuspid* or incisor* or cus-
pid*).ti,ab,kf,kw.)
5 (amalgam or amalgams).ti. and (dentist* or dental or oral biology or oral bioscience* or oral health
or oral research or endodont* or oral science or caries research or oral medical or dentaire or stom-
atolog*).jw.
6 or/1-5
7 6 use medall
8 6 use cctr
9 Dental amalgam/
10 Dental alloy/ and Amalgam/
11 (Dental restoration/ or Dental Material/ or Tooth Filling/ or exp Dental Caries/th) and (Silver/ or
Mercury/ or (amalgam or amalgams or silver or mercury).ti,ab,kw.)
12 ((silver or mercury) and (dental or dentist* or tooth or teeth or filling* or premolar* or molar* or bi-
cuspid* or incisor* or cuspid*)).ti,ab,kw.
13 (amalgam/ or (amalgam or amalgams).ti,ab,kw.) and (Silver/ or Mercury/ or (dental or dentist* or

tooth or teeth or silver or mercury or filling* or restor* or molar* or bicuspid* or incisor* or cus-
pid*).ti,ab,kw.)
14 (amalgam or amalgams).ti. and (dentist* or dental or oral biology or oral bioscience* or oral health
or oral research or endodont* or oral science or caries research or oral medical or dentaire or stom-
atolog*).jx.
15 or/9-14
16 15 use oemezd
17 (conference review or conference abstract).pt.
18 16 not 17
19 7 or 8 or 18
20 exp safety/
21 equipment safety/
22 exp equipment failure/
23 consumer product safety/
24 "product recalls and withdrawals"/
25 medical device recalls/
26 "safety-based medical device withdrawals"/
27 product surveillance, postmarketing/
Informed decisions.
(Continued)
28 postmarketing surveillance/
29 clinical trial, phase iv.pt.
30 phase 4 clinical trial/
31 clinical trials, phase iv as topic/
32 "phase 4 clinical trial (topic)"/
33 exp postoperative complications/
34 exp postoperative complication/
35 exp intraoperative complications/
36 peroperative complication/
37 exp side effect/
38 "side effects (treatment)"/
39 exp adverse drug reaction/
40 exp drug safety/
41 exp "drug toxicity and intoxication"/
42 exp "drug-related side effects and adverse reactions"/
43 exp drug-induced liver injury/
44 exp drug hypersensitivity/
45 drug recalls/
46 drug recall/
47 safety-based drug withdrawals/
48 abnormalities, drug-induced/
49 exp "side effects (drug)"/
50 (hazard* or defect* or misuse* or failure* or malfunction* or error*).ti,kf,kw.
51 (safe* or adverse* or undesirable or harm* or injurious or risk or risks or reaction* or complication*

or poison*).ti,kf,kw.
52 (side effect* or safety or unsafe).ti,ab,kf,kw.
53 ((adverse or undesirable or harm* or toxic or injurious or serious or fatal) adj3 (effect* or reaction*
or event* or outcome* or incident*)).ab.
54 ((drug or chemically) adj induced).ti,ab,kf,kw.
Informed decisions.
(Continued)
55 (toxic or toxicit* or toxologic* or intoxication or noxious or tolerability or teratogen*).ti,ab,kf,kw.
56 (warning* or recall* or withdrawn* or withdrawal*).ti,kf,kw.
57 (death or deaths or fatal or fatality or fatalities).ti,kf,kw.
58 exp environmental exposure/
59 or/20-58
60 19 and 59
61 Dental amalgam/ae, ct, po, to
62 exp Dental Restoration, Permanent/ or Dental Restoration, Temporary/ or Dental Materials/ or exp
Dental caries/th or Dental amalgam/ or (amalgam or amalgams or dental or dentist* or tooth or
teeth or filling* or premolar* or molar* or bicuspid* or incisor* or cuspid*).ti,ab,kf,kw.
63 Silver/ae, ct, to or Mercury/ae, to, bl or exp Mercury poisoning/ or exp Mercury poisoning, nervous
system/
64 62 and 63
65 exp Dental Restoration, Permanent/ae, ct, mo or Dental Restoration, Temporary/ae, ct or Dental

Materials/ae, co, ct, po, to
66 Dental amalgam/ or Silver/ or Mercury/ or (amalgam or amalgams or silver or mercury).ti,ab,kf,kw.
67 65 and 66
68 61 or 64 or 67
69 68 use medall
70 68 use cctr
71 Dental amalgam/ae, ct, to
72 Dental alloy/am, ae, to and amalgam/am, ae, to
73 Dental restoration/ or Dental Material/ or Tooth Filling/ or exp Dental Caries/th or Dental alloy/ or
dental amalgam/ or (amalgam or amalgams or dental or dentist* or tooth or teeth or filling* or pre-
molar* or molar* or bicuspid* or incisor* or cuspid*).ti,ab,kw.
74 Silver/ae, to or Mercury/ae, to or Mercurialism/
75 73 and 74
76 amalgam/am, ae, to and (dental or dentist* or tooth or teeth or silver or mercury or filling* or
restor* or molar* or bicuspid* or incisor* or cuspid*).ti,ab,kw.
77 Dental procedure/ae or Dental Material/am, ae, to
78 Amalgam/ or Dental amalgam/ or (amalgam or amalgams or silver or mercury).ti,ab,kw.
79 77 and 78
Informed decisions.
(Continued)
80 71 or 72 or 75 or 76 or 79
81 80 use oemezd
82 81 not 17
83 69 or 70 or 82
84 60 or 83
85 exp Composite Resins/
86 (exp Dental Restoration, Permanent/ or Dental Restoration, Temporary/ or Dental Materials/tu or

exp Dental caries/th) and composite*.ti,ab,kf,kw.
87 (composite* adj3 (resin* or restor* or filling* or dental or dentist* or conventional or microfilled or

macrofilled or hybrid or flowable or packable or nanofilled or direct or indirect or small particle* or
condensable or bonded or non-bonded or nonbonded)).ti,ab,kf,kw.
88 (composite* adj3 (poly-acid or polyacid or polyacrylate or polyacrylic or acrylic)).ti,ab,kf,kw.
89 ((resin or resins) adj3 (filled or unfilled or synthetic* or dental or restor*)).ti,ab,kf,kw.
90 ((tooth-colored or tooth-coloured) adj3 (filling* or restor*)).ti,ab,kf,kw.
91 (White adj3 filling*).ti,ab,kf,kw.
92 exp Dental Restoration, Permanent/ or Dental Restoration, Temporary/ or Dental Materials/tu or

exp Dental caries/th or (composite* or resin or resins).ti,ab,kf,kw.
93 Bisphenol A-Glycidyl Methacrylate/ or (alumino silicate polyacrylic acid or "bisphenol A-Glycidyl

methacrylate" or Bis-GMA or BisGMA or triethylene glycol dimethacrylate or urethane dimethacry-
late*).ti,ab,kf,kw.
94 92 and 93
95 Compomer*.ti,ab,kf,kw.
96 composite*.ti. and (dentist* or dental or oral biology or oral bioscience* or oral health or oral
research or endodont* or oral science or caries research or oral medical or dentaire or stoma-
tolog*).jw.
97 or/85-91,94-96
98 97 use medall
99 97 use cctr
100 exp Resin/ and composit*.ti,ab,kw.
101 (Dental restoration/ or Dental Material/ or Tooth Filling/ or exp Dental Caries/th) and compos-
ite*.ti,ab,kw.
102 (composite* adj3 (resin* or restor* or filling* or dental or dentist* or conventional or microfilled or
macrofilled or hybrid or flowable or packable or nanofilled or direct or indirect or small particle* or
condensable or bonded or non-bonded or nonbonded)).ti,ab,kw.
Informed decisions.
(Continued)
103 (composite* adj3 (poly-acid or polyacid or polyacrylate or polyacrylic or acrylic)).ti,ab,kw.
104 ((resin or resins) adj3 (filled or unfilled or synthetic* or dental or restor*)).ti,ab,kw.
105 ((Tooth-colored or tooth-coloured) adj3 (filling* or restor*)).ti,ab,kw.
106 (White adj3 filling*).ti,ab,kw.
107 Dental restoration/ or Dental Material/ or Tooth Filling/ or exp Dental Caries/th or (composite* or
resin or resins).ti,ab,kw.
108 "bisphenol A bis(2 hydroxypropyl) ether dimethacrylate"/ or (alumino silicate polyacrylic acid or
"bisphenol A-Glycidyl methacrylate" or Bis-GMA or BisGMA or triethylene glycol dimethacrylate or
urethane dimethacrylate*).ti,ab,kw.
109 107 and 108
110 Compomer*.ti,ab,kw.
111 composite*.ti. and (dentist* or dental or oral biology or oral bioscience* or oral health or oral
research or endodont* or oral science or caries research or oral medical or dentaire or stoma-
tolog*).jx.
112 or/100-106,109-111
113 112 use oemezd
114 113 not 17
115 98 or 99 or 114
116 59 and 115
117 exp Composite Resins/ae, ct, to
Materials/ae, co, ct, po, to
119 Composite resins/ or (composite* or resin or resins).ti,ab,kf,kw.
120 118 and 119
Materials/ae, ct, co, po, to
122 ("bisphenol A-Glycidyl methacrylate" or Bis-GMA or BisGMA).ti,ab,kf,kw.
123 121 and 122
124 117 or 120 or 123
125 124 use medall
126 125 use cctr
127 exp Resin/am, ae, to and composit*.ti,ab,kw.
Informed decisions.
(Continued)
129 exp Resin/ or (composite* or resin or resins).ti,ab,kw.
130 128 and 129
132 ("bisphenol A-Glycidyl methacrylate" or Bis-GMA or BisGMA).ti,ab,kw.
133 131 and 132
134 127 or 130 or 133
135 134 use oemezd
136 135 not 17
137 125 or 126 or 136
138 116 or 137
139 84 or 138
140 limit 139 to yr="2016 -Current"
141 remove duplicates from 140
PubMed search, conducted 21 February 2019
Clinical efficacy
Recent queries
Search Add to builder Query Items found Time
#11 Add Search #9 AND #10 3 08:41:24
#10 Add Search publisher[sb] OR 546179 08:41:16

2019/02/17:2019/02/21[edat]
#9 Add Search #3 AND #4 AND #8 1807 08:40:37
#8 Add Search #5 OR #6 OR #7 30990 08:39:48
#7 Add Search enamel bond*[tiab] OR (concise[tiab] 6715 08:39:36

AND resin*[tiab]) OR (white[tiab] AND sealan-
t*[tiab]) OR conclude resin*[tiab] OR Adap-
tic[tiab] OR Delton[tiab] OR Epoxylite-9075 OR
(Kerr[tiab] AND seal*[tiab]) OR Nuva-seal[tiab]
OR Panavia[tiab] OR Retroplast[tiab] OR
Silux[tiab]
Informed decisions.
(Continued)
#6 Add Search (resin*[tiab] AND composite*[tiab]) OR 17337 08:39:29

“bisphenol A-Glycidyl methacrylate”[tiab] OR
compomer*[tiab] OR Bis-GMA[tiab]
#5 Add Search Composite resins[mh] 24218 08:39:22
#4 Add Search Dental amalgam[mh] OR amalgam*[tiab] 13020 08:39:10
#3 Add Search #1 OR #2 50119 08:39:00
#2 Add Search (tooth[tiab] OR teeth[tiab] OR mo- 33949 08:38:48

lar*[tiab] OR bicuspid*[tiab] OR "Class I"[tiab]
OR "Class II"[tiab]) AND (restor*[tiab] OR fil-
l*[tiab])
#1 Add Search Dental restoration, permanent[mh] OR 24862 08:36:41

Dental restoration, temporary[mh]
Safety
Search Add to builder Query Items found Time
#45 Add Search #43 AND #44 123 10:52:29
#44 Add Search publisher[sb] OR 546179 10:52:15

2019/02/17:2019/02/21[edat]
#43 Add Search #27 OR #42 8682 10:51:44
#42 Add Search #35 OR #41 2162 10:51:24
#41 Add Search #36 OR #38 OR #40 858 10:50:07
#40 Add Search #32 AND #39 76 10:49:15
#39 Add Search "bisphenol A-Glycidyl methacry- 1221 10:49:00

late"[tiab] OR Bis-GMA[tiab] OR BisGMA[tiab]
#32 Add Search Dental Restoration, Permanent[mh]/ad- 2570 10:48:53

verse effects OR Dental Restoration, Permanen-
t[mh]/contraindications OR Dental Restoration,
Permanent[mh]/mortality OR Dental Restora-
tion, Temporary[mh]/adverse effects OR Den-
tal Restoration, Temporary[mh]/contraindica-
tions OR Dental Materials[mh]/adverse effects
OR Dental Materials[mh]/complications OR Den-
tal Materials[mh]/contraindications OR Dental
Materials[mh]/poisoning OR Dental Material-
s[mh]/toxicity
#38 Add Search #32 AND #37 857 10:48:45
Informed decisions.
(Continued)
#37 Add Search Composite resins[mh] OR compos- 192063 10:48:30

ite*[tiab] OR resin[tiab] OR resins[tiab]
#36 Add Search Composite Resins[mh]/adverse effects 476 10:48:15

OR Composite Resins[mh]/contraindications OR
Composite Resins[mh]/toxicity
#35 Add Search #28 OR #31 OR #34 1400 10:47:18
#34 Add Search #32 AND #33 536 10:46:55
#33 Add Search Dental amalgam[mh] OR Silver[mh] OR 116392 10:46:08

Mercury[mh] OR amalgam[tiab] OR amalgam-
s[tiab] OR silver[tiab] OR mercury[tiab]
#31 Add Search #29 AND #30 986 10:39:36
#30 Add Search Silver[mh]/adverse effects OR Sil- 8327 10:39:26

ver[mh]/contraindications OR Silver[mh]/tox-
icity OR Mercury[mh]/adverse effects OR Mer-
cury[mh]/toxicity OR Mercury[mh]/blood OR
Mercury poisoning[mh] OR Mercury poisoning,
nervous system[mh]
#29 Add Search Dental Restoration, Permanent[mh] OR 508967 10:39:18

Dental Restoration, Temporary[mh] OR Dental
Materials[mh]/therapeutic use OR Dental Mate-
rials[mh]/therapy OR Dental caries[mh]/thera-
py OR Dental amalgam[mh] OR amalgam[tiab]
OR amalgams[tiab] OR dental[tiab] OR den-
tist*[tiab] OR tooth[tiab] OR teeth[tiab] OR fill-
ing*[tiab] OR premolar*[tiab] OR molar*[tiab]
OR bicuspid*[tiab] OR incisor*[tiab] OR cus-
pid*[tiab]
#28 Add Search Dental amalgam[mh]/adverse effects OR 392 10:39:10

Dental amalgam[mh]/contraindications OR Den-
tal amalgam[mh]/poisoning OR Dental amal-
gam[mh]/toxicity
#27 Add Search #18 AND #26 7588 10:38:47
#26 Add Search #19 OR #20 OR #21 OR #22 OR #23 OR #24 3573266 10:38:34
OR #25
#25 Add Search warning*[ti] OR recall*[ti] OR with- 185785 10:37:31

drawn[ti] OR withdrawal*[ti] OR death[ti] OR
deaths[ti] OR fatal[ti] OR fatality[ti] OR fatali-
ties[ti]
#24 Add Search toxic[tiab] OR toxicit*[tiab] OR toxolog- 699502 10:37:25

ic*[tiab] OR intoxication[tiab] OR noxious[tiab]
OR tolerability[tiab] OR teratogen*[tiab] OR Poi-
son*[tiab]
#23 Add Search (adverse[tiab] OR undesirable[tiab] OR 767293 10:37:18

harm*[tiab] OR toxic[tiab] OR injurious[tiab]
OR serious[tiab] OR fatal[tiab]) AND (effec-
Informed decisions.
(Continued)
t*[tiab] OR reaction*[tiab] OR event*[tiab] OR
outcome*[tiab] OR incident*[tiab])
#22 Add Search side effect[tiab] OR safety[tiab] OR un- 484394 10:37:09

safe[tiab]
#21 Add Search Hazard*[ti] OR defect*[ti] OR misuse*[ti] 1320653 10:37:01

OR failure*[ti] OR malfunction*[ti] OR error*[ti]
OR safe*[ti] OR adverse[ti] OR undesirable[ti]
OR harm*[ti] OR injurious[ti] OR risk[ti] OR
risks[ti] OR reaction*[ti] OR complication*[ti]
OR poison*[ti]
#20 Add Search "Drug-related side effects and adverse 398050 10:36:55
reactions"[mh] OR Drug-Induced Liver Injury,
Chronic[mh] OR drug hypersensitivity[mh]
OR drug recalls[mh] OR safety-based drug
withdrawals[mh] OR abnormalities, drug-in-
duced[mh] OR environmental exposure[mh]
#19 Add Search Safety[mh] OR Equipment Safety[mh] 692020 10:36:48

OR Equipment Failure[mh] OR Consumer Prod-
uct Safety[mh:noexp] OR “Product Recalls and
Withdrawals”[mh:noexp] OR Medical Device Re-
calls[mh] OR Safety-Based Medical Device With-
drawals[mh] OR Product Surveillance, Post-
marketing[mh:noexp] OR Clinical Trial, Phase
IV[pt] OR Clinical Trials, Phase IV as Topic[mh]
OR Postoperative Complications[mh] OR Intra-
operative Complications[mh]
#18 Add Search #5 OR #17 64969 10:35:58
#17 Add Search #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR 54639 10:35:24

#12 OR #15 OR #16
#16 Add Search Compomer*[tiab] 801 10:33:49
#15 Add Search #13 AND #14 4228 10:33:43
#14 Add Search Bisphenol A-Glycidyl Methacrylate[mh] 5131 10:33:29

OR alumino silicate polyacrylic acid[tiab] OR
"bisphenol A-Glycidyl methacrylate"[tiab] OR
Bis-GMA[tiab] OR BisGMA[tiab] OR triethyl-
ene glycol dimethacrylate[tiab] OR urethane
dimethacrylate*[tiab]
#13 Add Search Dental Restoration, Permanent[mh] OR 209804 10:33:23

Dental Restoration, Temporary[mh] OR Den-
tal Materials[mh:noexp]/therapy OR Dental Ma-
terials[mh:noexp]/therapeutic use OR Dental
caries[mh]/therapy OR composite*[tiab] OR
resin[tiab] OR resins[tiab]
#12 Add Search White[tiab] AND filling*[tiab] 752 10:33:15
#11 Add Search (tooth-colored[tiab] OR tooth- 546 10:33:08

coloured[tiab]) AND (filling*[tiab] OR
restor*[tiab])
Informed decisions.
(Continued)
#10 Add Search (resin[tiab] OR resins[tiab]) AND 19427 10:33:03

(filled[tiab] OR unfilled[tiab] OR synthetic*[tiab]
OR dental[tiab] OR restor*[tiab])
#9 Add Search composite*[tiab] AND (poly-acid[tiab] OR 1809 10:32:55

polyacid[tiab] OR polyacrylate[tiab] OR poly-
acrylic[tiab] OR acrylic[tiab])
#8 Add Search composite*[tiab] AND (resin*[tiab] OR 36165 10:32:48

restor*[tiab] OR filling*[tiab] OR dental[tiab]
OR dentist*[tiab] OR conventional[tiab] OR
microfilled[tiab] OR macrofilled[tiab] OR hy-
brid[tiab] OR flowable[tiab] OR packable[tiab]
OR nanofilled[tiab] OR direct[tiab] OR indirec-
t[tiab] OR small particle*[tiab] OR condens-
able[tiab] OR bonded[tiab] OR non-bonded[tiab]
OR nonbonded[tiab])
#7 Add Search (Dental Restoration, Permanent[mh] OR 1569 10:32:40

caries[mh]/therapy) AND composite*[tiab]
#6 Add Search Composite Resins[mh] 24218 10:32:32
#5 Add Search #1 OR #2 OR #3 OR #4 13439 10:32:16
#4 Add Search (amalgam[tiab] OR amalgams[tiab]) AND 7208 10:31:50

(Silver[mh] OR Mercury[mh] OR dental[tiab] OR
dentist*[tiab] OR tooth[tiab] OR teeth[tiab] OR
silver[tiab] OR mercury[tiab] OR filling*[tiab]
OR restor*[tiab] OR premolar*[tiab] OR mo-
lar*[tiab] OR bicuspid*[tiab] OR incisor*[tiab]
OR cuspid*[tiab])
#3 Add Search (silver[tiab] OR mercury[tiab]) AND (den- 4949 10:31:44

tal[tiab] OR dentist*[tiab] OR tooth[tiab] OR
teeth[tiab] OR filling*[tiab] OR premolar*[tiab]
OR molar*[tiab] OR bicuspid*[tiab] OR in-
cisor*[tiab] OR cuspid*[tiab])
#2 Add Search (Dental Restoration, Permanent[mh] OR 894 10:31:37

caries[mh]/therapy) AND (Silver[mh] OR Mer-
cury[mh] OR amalgam[tiab] OR amalgams[tiab]
OR silver[tiab] OR mercury[tiab])
#1 Add Search Dental amalgam[mh] 8299 10:31:30
Appendix 7. ClinicalTrials.gov search strategy

Expert search interface:
amalgam AND (resin OR "bisphenol A-Glycidyl methacrylate" OR compomer* OR Bis-GMA OR "enamel bond*" OR "white sealant*" OR
Adaptic OR Delton OR Epoxylite-9075 OR Kerr OR Nuva-seal OR Panavia OR Retroplast OR Silux)
Informed decisions.
Appendix 8. WHO ICTRP search strategy

amalgam AND resin OR amalgam AND "bisphenol A-Glycidyl methacrylate" OR amalgam AND compomer* OR amalgam AND Bis-GMA OR
amalgam AND "enamel bond*" OR amalgam AND "white sealant*" OR amalgam AND Adaptic OR amalgam AND Delton OR amalgam AND
Epoxylite-9075 OR amalgam AND Kerr OR amalgam AND Nuva-seal OR amalgam AND Panavia OR amalgam AND Retroplast OR amalgam
AND Silux
WHAT'S NEW
Date Event Description
6 August 2021 New citation required but conclusions Conclusions remain the same after the addition of one new effi-
have not changed cacy trial and eight new papers assessing safety (drawn from the
two parallel-group trials already included in the review).
16 February 2021 New search has been performed Search modified and updated to 16 February 2021. Additional
searches undertaken for the outcome of harms. New review au-
thors added and author order changed.
HISTORY
Protocol first published: Issue 1, 2006
Review first published: Issue 3, 2014
Date Event Description
21 May 2014 Amended Conclusions edited to reflect received feedback.
CONTRIBUTIONS OF AUTHORS
Conceiving the review: María Graciela Rasines Alcaraz (GR), Patrick Roger Schmidlin (PRS)
Co-ordinating the review: GR
Leading the 2021 update: Sara D Khangura (SDK)
Revising the methods for update: SDK, Kelsey Seal (KS), Monika Mierzwinski-Urban (MMU), Helen V Worthington (HW)
Developing search strategy: Dell Davis (DD), MMU
Handsearching of relevant journals: GR
Retrieve from literature references list: GR
Contacting authors: GR
Obtaining and screening data on unpublished studies: Analia Veitz-Keenan (AVK), Philipp Sahrmann (PS), PRS, GR, SDK, KS
Screening search results: AVK, GR, SDK, KS, HW
Screening retrieved papers against inclusion criteria: PS, PRS, SDK, KS
Appraising risk of bias in studies: AVK, PS, PRS, GR, SDK, KS
Extracting data from studies: HW, AVK, PS, PRS, GR, SDK, KS
Entering data into Review Manager 5: GR, HW
Analyses of data: HW, GR, SDK, SMM
Interpretation of data: HW, AVK, PS, PRS, GR, SDK, SMM
Writing the review: HW, AVK, PS, PRS, GR, SDK, ZIE
DECLARATIONS OF INTEREST
Helen V Worthington: none known. I am an Editor (and former Co-ordinating Editor) with Cochrane Oral Health.
Sara D Khangura: none known. I was employed by CADTH when working on the review.
Kelsey Seal: none known. I was employed by CADTH when working on the review.
Monika Mierzwinski-Urban: none known. I was employed by CADTH when working on the review.
Analia Veitz-Keenan: none known.
Philipp Sahrmann: none known
Informed decisions.
Patrick Roger Schmidlin: none known

Dell Davis: none known
Zipporah Iheozor-Ejiofor: none known. I was employed by Cochrane Oral Health when working on the review.
María Graciela Rasines Alcaraz: none known
SOURCES OF SUPPORT
Internal sources
• Canadian Agency for Drugs and Technologies in Health (CADTH), Canada
Several members of the author team were employed by CADTH when they worked on this review update.
External sources
• Cochrane Oral Health Group Global Alliance, UK
The production of Cochrane Oral Health reviews has been supported financially by our Global Alliance since 2011
(oralhealth.cochrane.org/partnerships-alliances). Contributors over recent years have been the American Association of Public Health
Dentistry, USA; British Association for the Study of Community Dentistry, UK; the British Society of Paediatric Dentistry, UK; the Canadian
Dental Hygienists Association, Canada; the Centre for Dental Education and Research at All India Institute of Medical Sciences, India;
the National Center for Dental Hygiene Research & Practice, USA; New York University College of Dentistry, USA; and Swiss Society for
Endodontology, Switzerland.
• National Institute for Health Research (NIHR), UK
This project was supported by the NIHR, via Cochrane Infrastructure funding to Cochrane Oral Health. The views and opinions expressed
therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS, or the
Department of Health.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW
Differences between the original review and this update

• We updated the Background section.
• We expanded the scope of the review to search specifically for data on harms.
• Typograpical errors in abstract corrected.
Differences between protocol and the original review

• The participant inclusion criterion in the protocol was originally restricted to adults and adolescents. However, we considered tooth
type (permanent posterior teeth) as a more important criterion than age group, therefore we included studies on children. We only
reported data on permanent posterior teeth in this review.
• We modified the title slightly.
• We could not analyse participant satisfaction, as none of the randomised controlled trials provided data for this variable.
• Partial reporting precluded a calculation of cost-effectiveness.
• In the protocol, survival rate was listed as the primary outcome; however, this review lists failure rate as primary outcome. Failure rate
is reported in this review as a proxy for survival rate.
• We had planned to assess potential reporting biases (including publication bias, time lag bias, multiple (duplicate) publication bias,
and language bias) by constructing a funnel plot; however, this was not possible as we had fewer than 10 studies.
• Only dichotomous data were available.
• The review used random-effects models, unless there were fewer than four studies, in which case we used fixed-effect models; this was
the general policy for Cochrane Oral Health. Our protocol had stated random-effects models only.
• We did not find sufficient data to conduct any of the subgroup or sensitivity analyses we had planned.
NOTES
This is an update of 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
Informed decisions.
INDEX TERMS
Medical Subject Headings (MeSH)

Bias; Composite Resins [*therapeutic use]; Dental Amalgam [*therapeutic use]; Dental Caries [*therapy]; Dentition, Permanent;
Randomized Controlled Trials as Topic
MeSH check words

Child; Humans

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Cochrane

Direct composite resin fillings versus amalgam fillings for

Worthington HV, Khangura S, Seal K, Mierzwinski-Urban M, Veitz-Keenan A, Sahrmann P,

Direct composite resin fillings versus amalgam fillings for permanent

Contact: María Graciela Rasines Alcaraz, [email protected].

Editorial group: Cochrane Oral Health Group.

Data collection and analysis

PLAIN LANGUAGE SUMMARY

Certainty of the evidence

Implications of the evidence

Population: people with permanent or adult posterior teeth

Outcomes Illustrative comparative risks* Relative effect Number of Certainty of Comments

Secondary 57 per 1000 122 per 1000 RR 2.14 3010 ⊕⊕⊝⊝

Fracture of 14 per 1000 12 per 1000 RR 0.87 3010 ⊕⊕⊝⊝

Cochrane Database of Systematic Reviews

Cochrane Database of Systematic Reviews

Why it is important to do this review Search methods for identification of studies

Types of studies Review author MM undertook a supplementary search on safety,

Assessment of risk of bias in included studies Dealing with missing data

Data synthesis RESULTS

Figure 1. Updated flow diagram 2021

The supplementary search designed to investigate safety identified Included studies

Blinding of participants and personnel (performance bias): All outcomes

Selective reporting (reporting bias)

Casa Pia 2007 ? ? - - + + +

Allocation Effects of interventions

Fracture of the restoration Physical development

Casa Pia 2007 found no statistically significant differences in Renal effects

Tobi 1999 {published data only} Cvar 2005

Geier 2013 Maserejian 2012

Higgins 2011 Moraschini 2015

Kelly 2004 Review Manager 2020 [Computer program]

Tanimoto 2015 tabid/3428/language/en-US/Default.aspx (accessed 17 February

Characteristics of included studies [ordered by study ID]

Casa Pia 2007

Methods Study design: parallel-group RCT

Conducted in: Lisbon, Portugal

Number of centres: 1 at Lisbon Faculty of Dental Medicine

Recruitment period: started in 1996

Funding source: National Institute of Dental & Craniofacial Research

Exclusion criteria: prior exposure to dental amalgam, interference health condition

Caries risk status: unclear

Location of teeth filled: 1545 permanent molars and 203 premolars

Casa Pia 2007 (Continued)

Number randomised: 507 children

Number evaluated: 472 children

Interventions Comparison: composite vs amalgam

Group A: 233 children received 892 composite restorations

Group B: 239 children received 856 amalgam restorations

Duration of follow-up: 7 years

Outcomes • Failure rate, estimated at 7 years

Bias Authors' judgement Support for judgement

Allocation concealment Unclear risk No information provided.

Casa Pia 2007 (Continued)

Selective reporting (re- Low risk Expected outcomes reported.

Other bias Low risk No other bias apparent.

Methods Study design: RCT, split-mouth design

Conducted in: Liverpool, UK