Repair or replacement of restorations: do we accept built in obsolescence or do we improve the evidence? M. O. Sharif, 1 Z. Fedorowicz, 2 M. Tickle 3 and P. A. Brunton 4 VERIFIABLE CPD PAPER of restorations by ever larger and more complex restorations has been called the restorative cycle, spiral or staircase. 7 Although recurrent caries is still consid- ered to be the most common reason for the failure of amalgam restorations, 8-12 fracture of the filling or the tooth itself are also con- sidered to be major causes. 11,13-18 Composite resin restorations fail for many of the same reasons although poor aesthetics as a con- sequence of material degradation and dis- colouration has been highlighted as one of the principal reasons which are important to patients. 19 Other factors that result in the replacement of resin composite resto- rations include the loss of marginal integ- rity due to breakdown often causing pain and discomfort. 20 The traditional and possibly most widely accepted treatment option for a defective restoration has favoured total replacement rather than their repair. 21 However, a criti- cal and at times difficult balance needs to be struck between the perceived benefits and the potential harm of each of these options. The unwarranted replacement of a restoration can result in not only a sub- stantial loss of tooth tissue 22-24 but may INTRODUCTION In the UK amalgam continues to be the most popular option 1 to restore posterior teeth, although its use has declined recently, and there has been a corresponding steady increase in the use of direct composite resin restorations. 2,3 Considerable resources in terms of time and money are spent restoring teeth 4-6 and as restorations have a limited lifespan periodic costly inter- ventions are required eg patch and repair or even complete replacement of restora- tions. With each intervention less and less tooth structure remains and eventually the tooth may become unrestorable or even suffer catastrophic fracture and may need to be extracted. This serial replacement Introduction Controversy surrounds decisions on whether to repair or replace defective dental restorations. The concept of built-in obsolescence, ie periodic replacement of dental restorations, is largely accepted as the modus operandi if not the default mode in restorative care. In this article we examine the current best available evidence underpinning the effective- ness of replacement versus repair of direct amalgam and resin composite restorations. Method This article builds on two recent Cochrane systematic reviews which have reported on the evidence base supporting the effectiveness of replacement versus repair of amalgam and direct resin composites and translates the results of their research conclusions into recom- mendations for the dental clinician. Results As no relevant randomised controlled trials (RCTs) were identified in either of these systematic reviews, the evidence regarding the effectiveness of repair versus replacement of amalgam and composite restorations is weak and incomplete. The evidence as it currently stands seems to favour repair over replacement, but this is insufficient to make firm recommendations. Conclusion In view of the absence of high level evidence there is a need for further well designed RCTs. To add value to the evidence base these trials should be conducted in a general practice setting which will strengthen the generalisability and applicability of the research conclusions and enable dentists and patients to make informed decisions. also lead to additional and unnecessary insult to the pulp. The often less traumatic approach of repair may be perceived as being more acceptable by patients, whereas clinicians may see this as a financially less attractive option or indeed even consider it to be substandard care. Although the most common reason for the replacement of any restoration is recurrent caries, the term ‘recurrent car- ies’ remains ill-defined. 25 It can encom- pass extensive carious lesions which have completely undermined a restoration in which the only solution is the removal of caries and complete replacement of the restoration; minimal carious lesions adjacent to restoration margins and also non-carious defects adjacent to restora- tions. 26 Often restorations with a marginal gap, a fracture or with an associated tooth fracture but without any evidence of car- ies are included under this catch-all term. These scenarios often provide dilemmas for clinicians in deciding whether some of these lesions are treated more appropri- ately by means of repair rather than total replacement. The repair of restorations is in general considered a more conservative 1* NIHR In-Practice Research Fellow, 3 Professor of Dental Public Health and Primary Care, Oral Health Unit, School of Dentistry, University of Manchester, Manchester, M15 6LP; 2 Director - The Bahrain Branch of the UK Cochrane Centre, The Cochrane Collabora- tion; 4 Professor of Restorative Dentistry, Leeds Dental Institute, University of Leeds, Leeds *Correspondence to: Mr Mohammad Sharif Email: mohammad.owaise.sharif@googlemail.com Refereed Paper Accepted 30 April 2010 DOI: 10.1038/sj.bdj.2010.722 © British Dental Journal 2010; 209: 171–174 • Demonstrates the evidence base for the replacement and repair of amalgam and resin composite restorations enabling practitioners to make an evidence-based decision. • Discusses the implications of the evidence on clinical practice. • Discusses the implications of current evidence on future research. IN BRIEF PRACTICE BRITISH DENTAL JOURNAL VOLUME 209 NO. 4 AUG 28 2010 171 © 20 Macmillan Publishers Limited. All rights reserved 10