The Approach to Dental Caries Prevention in a Case of Agenesis of the Major Salivary Glands: A Case Report

Xerostomia leads to great challenges for patients and dentists in managing and maintaining oral health due to the high risk of developing dental caries. We discuss a case of a 10-year-old male patient who presented with complaints of decayed teeth and difficulty chewing and swallowing food. He had bilateral congenital stenosis and stricture of lacrimal ducts and a family history of lacrimal gland agenesis and Hashimoto's disease. The diagnosis reached was agenesis of all major salivary glands confirmed by saliva testing and ultrasound examination of the glands. Comprehensive preventative, restorative, and maintenance protocols based on caries management by risk assessment (CAMBRA) were implemented, including fissure sealants, amalgam and composite resin restorations, professional and home-applied fluoride, chlorhexidine mouthwash, frequent water consumption, and two-monthly recalls. We were able to stabilize the patient's risk of dental caries for over three years. The implementation of stringent restorative, preventive, and maintenance protocols is key to improving and maintaining oral health in severe cases of xerostomia.

Health economic evaluation of endodontic therapies

Healthcare is an expensive endeavour, and it is likely that costs for endodontic treatment will grow over the next decade. The assessment of costs and, in most cases, health outcomes, and the comparison of the cost-health ratio of interventions, is at the heart of health economics. The present review aims to introduce the main concepts of health economic analysis, to systematically review the existing economic endodontic literature, and to deduce further action for the community. Overall, the identified body of evidence on the health economics of endodontic therapies is heterogenous and has several limitations: Not all studies identified robust data to inform their analyses and many relied on a wide range of assumptions, which were only explored for their impact in a limited way. However, a number of themes were identified from the review: (1) Maintaining pulpal vitality is preferable over root canal treatment if possible when it comes to cost-effectiveness. (2) Retaining teeth is usually more cost-effective than removing and replacing them. (3) Endodontic retreatment may be clinically indicated, but not always cost-effective, and should hence be considered carefully. In conclusion, the general sparsity of economic analyses is a concern, as decision makers such as commissioners or those funding dental care increasingly rely on them. The endodontic community is called to action to improve the competency of both researchers to conduct such analyses and consider them when planning research, but also clinicians who should factor in health economics when assigning interventions. Health economics should become an accepted pillar of endodontic research.

Resin Composites in Posterior Teeth: Clinical Performance and Direct Restorative Techniques

Resin composites are the most versatile restorative materials used in dentistry and the first choice for restoring posterior teeth. This article reviews aspects that influence the clinical performance of composite restorations and addresses clinically relevant issues regarding different direct techniques for restoring posterior teeth that could be performed in varied clinical situations. The article discusses the results of long-term clinical trials with resin composites and the materials available in the market for posterior restorations. The importance of photoactivation is presented, including aspects concerning the improvement of the efficiency of light-curing procedures. With regard to the restorative techniques, the article addresses key elements and occlusion levels for restoring Class I and Class II cavities, in addition to restorative strategies using different shades/opacities of resin composites in incremental techniques, restorations using bulk-fill composites, and shade-matching composites.

Public Valuation of Direct Restorations: A Discrete Choice Experiment

Direct posterior dental restorations are commonly provided following management of dental caries. Amalgam use has been phased down and the feasibility of a phase-out by 2030 is being explored. Alternative direct restorative materials differ in their outcomes and provision. This research aimed to elicit the UK population's preferences for different attributes of restorations and their willingness to pay (WTP) for restorative services and outcomes. A discrete choice experiment (DCE) was designed with patient and public involvement and distributed to a representative sample of the UK general population using an online survey. Respondents answered 17 choice tasks between pairs of scenarios that varied in levels of 7 attributes (wait for filling, clinician type, filling color, length of procedure, likely discomfort after filling, average life span of filling, and cost). An opt-out (no treatment) was included. Mixed logit models were used for data analysis. Marginal WTP for attribute levels and relative attribute importance were calculated. In total, 1,002 respondents completed the DCE. Overall, respondents were willing to pay £39.52 to reduce a 6-wk wait for treatment to 2 wk, £13.55 to have treatment by a dentist rather than a therapist, £41.66 to change filling color from silvery/gray to white, £0.27 per minute of reduced treatment time, £116.52 to move from persistent to no postoperative pain, and £5.44 per year of increased restoration longevity. Ability to pay affected willingness to pay, with low-income respondents more likely to opt out of treatment and value restoration color (white) and increased longevity significantly lower than those with higher income. Clinicians should understand potential drivers of restoration choice, so they can be discussed with individual patients to obtain consent. It is important that policy makers consider general population preferences for restorative outcomes and services, with an awareness of how income affects these, when considering the potential phase-out of amalgam restorations.

Is amalgam removal in patients with medically unexplained physical symptoms cost-effective? A prospective cohort and decision modelling study in Norway

There are many patients in general practice with health complaints that cannot be medically explained. Some of these patients attribute their health complaints to dental amalgam restorations. This study examined the cost-effectiveness of the removal of amalgam restorations in patients with medically unexplained physical symptoms (MUPS) attributed to amalgam fillings compared to usual care, based on a prospective cohort study in Norway. Costs were determined using a micro-costing approach at the individual level. Health outcomes were documented at baseline and approximately two years later for both the intervention and the usual care using EQ-5D-5L. Quality adjusted life year (QALY) was used as a main outcome measure. A decision analytical model was developed to estimate the incremental cost-effectiveness of the intervention. Both probabilistic and one-way sensitivity analyses were conducted to assess the impact of uncertainty in costs and effectiveness. In patients who attribute health complaints to dental amalgam restorations and fulfil the inclusion and exclusion criteria, amalgam removal is associated with modest increase in costs at societal level as well as improved health outcomes. In the base-case analysis, the mean incremental cost per patient in the amalgam group was NOK 19 416 compared to the MUPS group, while mean incremental QALY was 0.119 with a time horizon of two years. Thus, the incremental costs per QALY of the intervention was NOK 162 680, which is usually considered cost effective in Norway. The estimated incremental cost per QALY decreased with increasing time horizon, and amalgam removal was found to be cost saving over both 5 and 10 years. This study provides insight into the costs and health outcomes associated with the removal of amalgam restorations in patients who attribute health complaints to dental amalgam fillings, which are appropriate instruments to inform health care priorities.

Application of choosing by advantages to determine the optimal site for solar power plants

Solar energy is a critical component of the energy development strategy. The site selection for solar power plants has a significant impact on the cost of energy production. A favorable situation would result in significant cost savings and increased electricity generation efficiency. California is located in the southwest region of the United States of America and is blessed with an abundance of sunlight. In recent years, the state's economy and population have expanded quickly, resulting in an increased need for power. This study examines the south of California as a possibly well-suited site for the constructing large solar power plants to meet the local electricity needs. To begin, this article imposed some limits on the selection of three potential sites for constructing solar power plants (S1, S2, and S3). Then, a systematic approach for solar power plant site selection was presented, focusing on five major factors (economic, technological, social, geographical, and environmental). This is the first time that the choosing by advantages (CBA) method has been used to determine the optimal sites for solar power plant construction, with the possible sites ranked as S2 > S1 > S3. The results were then compared with traditional methods such as the multi-criteria decision-making method. The findings of this study suggest that the CBA method not only streamlines the solar power plant site selection process but also closely aligns with the objectives and desires of the investors.

Long-term cost-effectiveness of glass hybrid versus composite in permanent molars

OBJECTIVES

We assessed the long-term cost-effectiveness of glass hybrid (GH) versus composite (CO) for restoring permanent molars using a health economic modelling approach.

METHODS

A multi-national (Croatia, Serbia, Italy, Turkey) split-mouth randomized trial comparing GH and CO in occlusal-proximal two-surfaced cavities in permanent molars (n=180/360 patients/molars) provided data on restoration failure and allocation probabilities (i.e. failure requiring re-restoration, repair or endodontic therapy). Using Markov modelling, we followed molars over the lifetime of an initially 12-years-old individual. Our health outcome was the time a tooth was retained. A mixed-payers' perspective within German healthcare was used to determine costs (in Euro 2018) using fee item catalogues. Monte-Carlo-microsimulations, univariate and probabilistic sensitivity analyses were conducted. Incremental cost-effectiveness ratios (ICER)s and cost-effectiveness-acceptability were quantified.

RESULTS

In the base-case scenario, CO was more effective (tooth retention for a mean (SD) 54.4 (1.7) years) but also more costly (694 (54) Euro) than GH (53.9 (1.7) years; 614 (56 Euro). The ICER was 158 Euro/year, i.e. payers needed to be willing to invest 158 Euro per additional year of tooth retention when using CO. In a sensitivity analysis, this finding was confirmed or GH found more effective and less costly.

CONCLUSION

CO was more costly and limitedly more effective than GH, and while there is uncertainty around our findings, GH is likely a cost-effectiveness option for restoring permanent molars.

CLINICAL SIGNIFICANCE

When considering the long-term (life-time) cost-effectiveness, GH showed cost savings but CO was limitedly more effective. Overall, cost-effectiveness differences seems limited or in favour of GH.

[Amalgam and alternatives-discussions on mercury reduction in the environment]

Dental amalgam has been successfully used for the restoration of carious lesions for more than 180 years. It is clinically characterized by high longevity and low technique sensitivity. For decades, dental amalgam has been discussed in the public, especially due to its roughly 50% mercury content. Since the Minamata Convention was published in 2013 with the primary goal of reducing the anthropogenic mercury release into the environment, the previously muted amalgam discussion has received fresh impetus. Another considerable disadvantage of amalgam is its silver/greyish color, which simply no longer matches patients' esthetic demands.The present paper describes the basic problems with amalgam against the background of multiple biological, clinical, and health policy factors. Possible consequences of the Minamata Convention concerning legal regulations as well as the use of dental biomaterials and therefore also relating to the future national healthcare system are discussed. Finally, possible amalgam alternatives and the urgent need for biomedical research towards restorative dentistry are presented, embedded into the crucial question of whether we are actually conducting the correct debate.

Cost-effectiveness of glass hybrid versus composite in a multi-country randomized trial

OBJECTIVES

We assessed the cost-effectiveness of two amalgam alternatives, glass hybrid (GH) and composite (CO) in a multi-country randomized controlled split-mouth trial.

MATERIALS

University clinics in Croatia, Serbia, Italy and Turkey participated. Pairs of GH (EQUIA Forte, GC) and a nano-hybrid CO (TetricEvoCeram, IvoclarVivadent) were randomly placed in occlusal-proximal two-surfaced cavities in permanent molars of adults (n = 180/360 patients/molars). We used 3-years interim data for this evaluation. FDI-2 criteria were applied and teeth requiring repair, re-restoration, endodontic treatment or extraction recorded. Our outcome was the time until any or major complications (requiring endodontic treatment or extraction) occurred. Costs were calculated in US Dollar (USD) 2018, with the local currencies being converted using Purchasing Power Parities. To estimate initial and re-treatment costs, a payers' perspective was taken and direct medical costs estimated from fee item catalogues. Incremental-cost-effectiveness ratios (ICER) were used to express the cost difference per gained or lost effectiveness.

RESULTS

Overall costs were lower for GH than CO in Croatia, Turkey and Serbia, while this difference was minimal in Italy. GH tended to survive longer than CO in Croatia and Italy, and shorter in Serbia and Turkey; overall survival time was not significantly different (p = 0.67/log-rank). The cost-effectiveness differences indicated CO to be more expensive at limited (ICER: 268.5 USD/month without any complications) or no benefit at all (-186.2 USD/month without major complications).

CONCLUSIONS

GH was less costly than CO both initially and over 3 years. Efficacy differences were extremely limited.

CLINICAL SIGNIFICANCE

Given their low initial costs and as efficacy between GH and CO did not differ significantly, GH had a high chance of being more cost-effective within this specific trial.

Secondary Caries Adjacent to Bulk or Incrementally Filled Composites Placed after Selective Excavation In Vitro

Objectives: selective caries excavation (SE) is recommended for deep carious lesions. Bulk fill composites (BF) may be considered to restore SE-cavities. We compared the susceptibility for secondary caries adjacent to BF versus incrementally filled composites (IF) in SE and non-selectively excavated teeth (NS) in vitro. Methods: in 72 extracted human premolars, artificial caries lesions were induced on pulpo-axial walls of standardized cavities. The lesions were left (SE) or removed (NS), and teeth were restored using two BF, GrandioSO x-tra/Voco (BF-Gra) and SDR/Dentsply (BF-SDR), and an IF, GrandioSO/Voco (IF-Gra) (n = 12/group for SE and NS). After thermo-mechanical cycling (5–55 °C, 8 days), teeth were submitted to a continuous-culture Lactobacillus rhamnosus biofilm model with cyclic loading for 10 days. Mineral loss (ΔZ) of enamel surface lesions (ESL), dentin surface lesions (DSL), and dentin wall lesions (DWL) was analyzed using transversal microradiography. Results: ΔZ was the highest in DSL, followed by ESL, and it was significantly lower in DWL. There were no significant differences in ΔZ between groups in DSL, ESL, and DWL (p > 0.05). Regardless of lesion location, ΔZ did not differ between SE and NS (p > 0.05). Conclusions: BF and IF both showed low risks for DWL (i.e., true secondary caries) after SE in vitro, and surface lesion risk was also not significantly different between materials. SE did not increase secondary caries risk as compared with NS. Clinical Significance: the risk of secondary caries was low after selective excavation in this study, regardless of whether bulk or incrementally filled composites were used

Amalgam Phase-Down Part 1: UK-Based Posterior Restorative Material and Technique Use

Introduction:

A European Union amalgam phase-down has recently been implemented. Publicly funded health care predominates in the United Kingdom with the system favoring amalgam use. The current use of amalgam and its alternatives has not been fully investigated in the United Kingdom.

Objectives:

The study aimed to identify direct posterior restorative techniques, material use, and reported postoperative complication incidence experienced by primary care clinicians and differences between clinician groups.

Methods:

A cross-sectional survey was distributed to primary care clinicians through British dentist and therapist associations (11,092 invitations). The questionnaire sought information on current provision of direct posterior restorations and perceived issues with the different materials. Descriptive statistical and hypothesis testing was performed.

Results:

Dentists’ response rate was 14% and therapists’ estimated minimum response rate was 6% (total N = 1,513). The most commonly used restorative material was amalgam in molar teeth and composite in premolars. When placing a direct posterior mesio-occluso-distal restoration, clinicians booked on average 45% more time and charged 45% more when placing composite compared to amalgam (P < 0.0001). The reported incidences of food packing and sensitivity following the placement of direct restorations were much higher with composite than amalgam (P < 0.0001). Widely recommended techniques, such as sectional metal matrix use for posterior composites, were associated with reduced food packing (P < 0.0001) but increased time booked (P = 0.002).

Conclusion:

Amalgam use is currently high in the publicly funded sector of UK primary care. Composite is the most used alternative, but it takes longer to place and is more costly. Composite also has a higher reported incidence of postoperative complications than amalgam, but time-consuming techniques, such as sectional matrix use, can mitigate against food packing, but their use is low. Therefore, major changes in health service structure and funding and posterior composite education are required in the United Kingdom and other countries where amalgam use is prevalent, as the amalgam phase-down continues.

Knowledge Transfer Statement:

This study presents data on the current provision of amalgam for posterior tooth restoration and its directly placed alternatives by primary care clinicians in the United Kingdom, where publicly funded health care with copayment provision predominates. The information is important to manage and plan the UK phase-down and proposed phase-out of amalgam and will be of interest to other, primarily developing countries where amalgam provision predominates in understanding some of the challenges faced.

Secondary caries risk of different adhesive strategies and restorative materials in permanent teeth: Systematic review and network meta-analysis

OBJECTIVES

Secondary caries is a major long-term complication of dental restorations. Different adhesive strategies and restorative materials may affect secondary caries risk. We aimed to systematically review and synthesize the secondary caries risk of different adhesive strategies and restorative materials.

SOURCES

Medline via PubMed 01/2005-10/2019.

STUDY SELECTION

Randomized controlled studies with minimum 2 years follow-up, comparing different adhesive strategies and/or restorative materials in permanent teeth were included. Our outcome was the occurrence of secondary caries. Bayesian pairwise and network-meta-analysis were conducted.

DATA

We included 50 trials; 19 assessing secondary caries depending on different adhesive strategies, 31 on restorative materials. Studies were published between 2005 and 2017, largely of unclear risk of bias, and included a mean of 40 (range: 8-90) participants and 46 (range: 14-200) placed restorations. Mean follow-up was 43 (range: 24-180) months. Secondary caries was a rare event; the majority of studies did not find any lesions. Network meta-analysis found great uncertainty. 3-step etch-and-rinse adhesives showed the lowest risk of secondary caries, 2-step etch-and-rinse the highest. For restorative materials, resin-modified glass ionomer showed the lowest risk of secondary caries. Most resin composites showed similar risks.

CONCLUSION

Data from randomized trials comparing different adhesive strategies or restorative materials are extremely scarce. The differences between materials were limited over the observational period of the included studies. The yielded rankings should be interpreted with caution.

CLINICAL SIGNIFICANCE

Despite often claimed to be a major complication of restorations, there is surprisingly little data on secondary caries from randomized trials. Longer-term studies may be needed to identify differences in secondary caries risk between materials.

Characterization of low-cost Brazilian resin composites submitted to tooth brushing

This in vitro study aimed to evaluate surface microhardness, roughness, color, gloss and topography of low-cost Brazilian resin composites, compared with an international one. All 120 samples (8mm ø x 2mm height) were prepared and divided into 5 groups: Ultrafill (Biodinâmica), Llis (FGM), Fill Magic (Coltene), Applic (Makira), and Filtek Z250XT (3M Oral Care). Surface microhardness (KHN) (n=10) was analyzed at two time periods: before and after simulated tooth brushing (STB). Other standardized samples of each group (n=10) were analyzed for surface roughness (Ra), color (ΔL, Δa, Δb, ΔE, ΔE00) and gloss unit (GU) at the same two periods. The topography of non-brushed and brushed samples of each group (n=4) was evaluated by scanning electron microscopy. Data were analyzed statistically by two-way repeated measures ANOVA with Bonferroni post-hoc test (KHN, Ra, GU), and one-way ANOVA with Tukey post-hoc test (ΔL, Δa, Δb, ΔE, ΔE00) (α=0.05). Topographic images were submitted to descriptive analysis. The low-cost Brazilian resin composites investigated were compared with the international one and revealed: lower KHN, regardless of before or after STB; statistically similar Ra before STB, except Ultrafill, which presented higher values; lower Ra after STB, except Ultrafill, which presented statistically similar values; statistically similar color change in ΔL, Δa, Δb parameters; statistically similar color change in ΔE, ΔE00 parameters, except Fill Magic, which presented lower values; lower gloss before STB; lower gloss after STB, except Ultrafill, which presented statistically similar values. In a situation of scarce resources, low-cost Brazilian composites might be an acceptable cost-effective restorative alternative.

Secondary caries: what is it, and how it can be controlled, detected, and managed?

OBJECTIVES

To assess how to control, detect, and treat secondary caries. This review serves to inform a joint ORCA/EFCD consensus process.

METHODS

Systematic and non-systematic reviews were performed or consulted and narratively synthesized.

RESULTS

Secondary (or recurrent) caries is defined as a lesion associated with restorations or sealants. While the restorative material itself has some influence on secondary caries, further factors like the presence and size of restoration gaps, patients' caries risk, and the placing dentist's experience seem more relevant. Current detection methods for secondary caries are only sparsely validated and likely prone for the risk of over-detection. In many patients, it might be prudent to prioritize specific detection methods to avoid invasive overtreatment. Detected secondary caries can be managed either by repair of the defective part of the restoration or its complete replacement.

CONCLUSIONS

There is sparse data towards the nature of secondary caries and how to control, detect, and treat it.

CLINICAL SIGNIFICANCE

Despite often claimed to be a major complication of restorations, there is surprisingly little data on secondary caries. Longer-term studies may be needed to identify differences in secondary caries risk between materials and to identify characteristic features of progressive lesions (i.e., those in need of treatment).

A Propósito del Acuerdo de Minamata y la eliminación de la amalgama dental

Contamos hoy con evidencia contundente sobre los efectos lesivos que genera el mercurio para la salud humana y el medio ambiente (1). Esto condujo, en 2013, a que en la quinta sesión del Comité Intergubernamental de Negociación sobre el mercurio, en Ginebra, se acordara el “Convenio de Minamata” (2); el cual fue adoptado el mismo año en Kunamoto, Japón. El 16 de agosto de 2017 entró en vigor este convenio, que busca controlar las emisiones antrópicas de mercurio a lo largo de su ciclo de vida. “Los aspectos más destacados del Convenio de Minamata incluyen la prohibición de nuevas minas de mercurio, la eliminación gradual de las existentes, la reducción del uso del mercurio en una serie de productos y procesos, la promoción de medidas de control de las emisiones a la atmósfera y de las emisiones a la tierra y al agua, así como la regulación inexistente del sector de la minería artesanal y a pequeña escala” (3). El Congreso de Colombia aprobó el Convenio de Minamata mediante la Ley 1892 de mayo de 2018, al considerarlo compatible con la Ley 1658 de 2013, la cual busca solucionar la problemática del uso de mercurio en el país. La Ley colombiana limita y pone término a las importaciones de mercurio, el cual, de acuerdo con el decreto 1041 de junio de 2018, del ministerio de Comercio Industria y Turismo deberá dejarse de importar en el mes de julio de 2023. La discusión surge cuando aduciendo el cumplimiento del Convenio, el Estado colombiano pretende, sin dialogar con la Academia, eliminar el uso de la amalgama dental en el país. El artículo 4 del mencionado convenio hace referencia a los productos con mercurio añadido, y el parágrafo 3 de este artículo establece que: “las Partes adoptarán medidas en relación con los productos con mercurio añadido incluidos en la parte II del anexo A de conformidad con las disposiciones establecidas en dicho anexo”. Al respecto, el anexo establece que: “las medidas que ha de adoptar la Parte para reducir el uso de la amalgama dental tendrán en cuenta las circunstancias nacionales de la Parte y las orientaciones internacionales pertinentes…” Lo anterior da discrecionalidad al Estado (la Parte) en lo referente a la eliminación del uso de la amalgama dental. Vale aquí recordar que los resultados del último Estudio Nacional de Salud Bucal (ENSAB IV), mostraron que la caries dental sigue siendo una enfermedad altamente prevalente en la población colombiana. La experiencia modificada de caries (incluye lesiones iniciales no cavitadas) fue del 66.9% en niños de 1 a 5 años, 60.5% entre los 5 y 12 años, y 98.6% en dentición permanente, siendo estos porcentajes mayores en las poblaciones rurales dispersas. Además, el Convenio de Minamata presenta nueve medidas que las Partes pueden implementar para poner en marcha el convenio; la tercera de ellas reza: “Promover el uso de alternativas sin mercurio eficaces en función de los costos y clínicamente efectivas para la restauración dental”. No existen hoy en el mercado materiales dentales para obturaciones directas, con los mismos niveles de desempeño clínico que la amalgama dental. Al respecto, un trabajo publicado en junio de 2018 por Schwendicke et al. realiza un análisis de costo-efectividad de algunas alternativas a la amalgama dental, como composites puestos incrementalmente, composites puestos en bloque, cementos de ionómero de vidrio, e inlays de composites. Los autores concluyen que todas estas alternativas son inferiores a la amalgama (4). Por su parte, la Asociación Dental Americana (ADA) emitió en agosto de 2009 su “Statement on Dental Amalgam”, este documento inicia diciendo lo siguiente: “La amalgama dental es considerada segura, es un material económico y duradero que ha sido usado para restaurar los dientes de más de 100 millones de americanos. Contiene una mezcla de metales como plata, cobre y estaño, en adición con mercurio, el cual une estos componentes en una sustancia dura, estable y segura. La amalgama dental ha sido estudiada y revisada extensivamente, y ha establecido un record de seguridad y efectividad” (5). El mismo documento concluye: “el Consejo de Asuntos Científicos de la ADA soporta las investigaciones en curso sobre la seguridad de los materiales existentes y el desarrollo de nuevos materiales, y continua creyendo que la amalgama es valiosa, viable y una alternativa segura para los pacientes odontológicos” (5). Finalmente, la profesión odontológica nacional ha generado una voz de alerta ante la inminente desaparición de la amalgama dental, en un país con altos índices de caries y para la cual hoy no contamos con materiales sustitutos que ofrezcan mejores o por lo menos iguales niveles de desempeño clínico a mediano y largo plazo.Sin embargo esto no resulta coherente con una evidente disminución en la enseñanza y uso de la amalgama dental en las Facultades de Odontología del país, y con la práctica diaria, tanto privada como institucional, de los profesionales de la odontología quienes ante la avalancha de las exigencias estéticas, han olvidado que la decisión clínica sobre el material restaurador debe obedecer además de la estética a otros factores como el pronóstico del desempeño clínico del material, relacionado con el riesgo de caries del paciente, la extensión de la cavidad y la ubicación del diente en boca, entre otros. Las Facultades y la Profesión se encuentran en mora de dar una profunda y académica discusión sobre este aspecto, que afecta la salud de nuestros pacientes. En conclusión, nos enfrentamos a una decisión que bajo las condiciones actuales, afectará negativamente en el mediano y largo plazo la salud buco-dental de la población colombiana. Corresponde a la Academia acompañar al Estado para que considere todos los aspectos relacionados con la desaparición de la amalgama dental como material restaurador.