Retrospective Evaluation of the Clinical Status of Direct Posterior Composite Restorations in Selected Institutions in Nairobi, Kenya

Retrospective Evaluation of the Clinical Status of Direct Posterior Composite Restorations in Selected Institutions in Nairobi, Kenya | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Retrospective Evaluation of the Clinical Status of Direct Posterior Composite Restorations in Selected Institutions in Nairobi, Kenya Umaru Kizito, Hazel Orengo Simila, Fred Odera Otieno, Lincoln Abraham Tentena, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7991828/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background: Dental resin composite, a tooth-coloured restorative material, is used to restore carious teeth. With its inception being for aesthetic reasons, the demand from patients, newer materials demand from clinicians and the amalgam phasedown have led to increased placement in load bearing posterior teeth. This study aimed at evaluating the clinical status of direct posterior resin composite restorations placed over a 5-year period in selected institutions in Nairobi, Kenya. Methods: Using 286 posterior resin composite restorations (RCRs) from 95 participants, a cross-sectional study was conducted at a public dental facility; Kenyatta National Hospital Dental Department (KNHDP), a teaching dental clinic; University of Nairobi Dental School (UoNDS), and a private dental facility; University of Nairobi Dental Plaza (UoNDP). Clinical evaluation was done visually using the United States Public Health Survey (USPHS) tool and data was analysed using STATA version 15(College Station TX, USA). Descriptive statistics, Pearson Chi-square and Fischer’s Exact tests were utilized for association between variables. Results: The study respondents were aged between 18- 66 with 50.5% (48/95) of them being male. The RCRs were between 0.25 and 5 years with 36% (103/286) from UoNDP, due to demand of private patients for more tooth-coloured restorations. RCRs in the maxillary arch were 55.6% (159/286) with 71.3% (204/286) being restorations in molars. Mesial-Occlusal/Distal Occlusal (MO/DO) dominated the surfaces restored at 50.7% (145/286) and the least restored surface found to be occlusal-buccal (OB) at 0.7% (2/286). General clinical status of the restorations assessed scored Bravo, followed by Alpha and the least being Charlie. Of the 7 USPHS parameters, Carvo-surface Marginal discolouration and surface texture showed a statistically significant association with the clinical status of the RCRs (p<0.005). Conclusions: The majority of the RCRs in this study had Alpha and Bravo restorations, which are clinically acceptable. Compared to UoNDP and KNHDD, there were more unsuccessful (Charlie) restorations reported at UoNDS. Restorations placed in mandibular teeth showed higher rates of failure than restorations placed in maxillary teeth. Restorations inserted into molar teeth performed better than those inserted into premolar teeth. The performance of occlusal restorations was superior to that of MOD, OB, and MO/DO restorations. Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Posterior teeth are vital to the normal masticatory function of an individual’s oral structures. Their position in the dental arches gives them a mechanical advantage as they require less muscular effort to exert the same force as compared to the anterior teeth. [ 1 ] It however places them at a disadvantage as they experience the majority of the load bearing occlusal forces and therefore any restorative work done on them must take this into consideration because they must withstand significant biting forces, resist fracture, and maintain their integrity over time. [ 2 ] Consequently, restorative materials used in these teeth must demonstrate high durability, wear resistance, and the ability to maintain marginal adaptation under stress. [ 3 ][ 4 ] Historically, amalgam was the go-to-choice for restorations in posterior teeth. This was because of its durability, cost effectiveness, ease of use and longevity. In spite of this, there has been a shift in preference among clinicians and patients towards alternatives to amalgam [ 5 ]. In the present “amalgam phase down” period, composite resins are increasingly being used for the restoration of both posterior primary and permanent teeth. This is in part due to the improved systems mentioned above and also the 2013 Minamata Convention of Mercury resolution and subsequent implementation. [ 6 ] Currently, direct posterior resin composites are the more preferred restorations for posterior teeth. A multinational survey spanning thirteen countries revealed that dentists overwhelmingly choose composites over alternatives like amalgam or glass ionomer cement (GIC), with an odds ratio of 997.4. [ 7 ] In the past, there were problems that hindered the adoption of their use among clinicians which included shrinkage, contraction stress, poor mechanical properties, wear, and secondary caries. [ 8 ] Advances in the field of materials science continue to reduce these drawbacks associated with resin composites. Innovations include modification of the chemical composition of resins, insertion techniques, instrumentation, and photo polymerization. [ 6 ] As a result, composite systems now have superior mechanical properties and maintain good margins under clinical conditions. The rapid evolution of composite resin systems is however associated with a paucity of long-term clinical studies evaluating the restorations placed under various clinical conditions. In the African context, African data is largely limited to South Africa; trends in other African nations remain understudied. The failure of resin composite restorations and in particular posterior RCRs the world over is becoming a burden to the dental health care system. This is due to the increasing number of patients presenting for replacement of the restorations and/or root canal treatment of the involved teeth. This gap is especially notable for the early manifestations of failures which include postoperative hypersensitivity, marginal discoloration, and secondary caries. [ 9 ] This is not only expensive to the patients and the system but it is also a time-consuming procedure. A systematic review by Opdam revealed the Annual Failure Rate of posterior composite restorations to be between 0 and 6%. [ 2 ] This concurred with a study by Manhurt et al [ 32 ] but had a 1% difference with the AFR in a 2012 study by Heinze and Rousson. [ 33 ] A different meta-analysis by Leite concluded from 12 clinical studies that the caries risk size and dimensions of the restorations (surfaces restored) have a significance in the survival of the restoration [ 34 ]. Furthermore, it revealed that the AFR for posterior composites is 1.8% at 5 years and 2.4% at 10 [ 34 ]. In a meta-analysis by Moraschini et al [ 35 ], the mean rate of survival of RCRs was found to be 86.2% with an average of 55 months of follow up. This data was similar to other reviews that reported the failure in terms of AFR of around 23.7% [ 2 ], [ 36 ], [ 37 ], [ 38 ] In addition to the aforementioned burden, no current data is available in the region to describe the status of posterior resin composites or their failure rates. MATERIALS AND METHODS Study design This was a cross-sectional study to assess the clinical state, factors associated, and the mean annual failure rate of the direct posterior resin-composite restorations placed over a 5-year period in selected institutions in Nairobi, Kenya. Study setting and population The study was conducted in Nairobi County, which is one of the 47 counties of Kenya. The capital of the county is Nairobi city which is the largest and also the capital city of Kenya. Nairobi city is estimated to have a population of 5 million. Three dental clinics located in two institutions namely the University of Nairobi (UoN) and Kenyatta National Hospital (KNH) were conveniently sampled for the study. A teaching hospital, UoN Dental School, the UoN Dental Plaza, a private dental facility, and Kenyatta National Hospital dental department, a public hospital formed the study sites. The study population consisted of posterior resin composite restorations placed in patients at the three dental clinics in the period between 2014 and 2019. Documentation and patient records were used for the determination of who and when they had the restorations done to limit it to the 5-year time frame Sample size calculation and participant selection Sample size was calculated using Kish Leslie’s method for single proportion N= [Z 2 α/2 pq/d 2 ]. Using a prevalence of 50% of all posterior restorations being resin composite restorations from a study in the United States of America [ 12 ]. Where N is the sample size, Z-score corresponding to 95% of confidence interval which is 1.96, p is the prevalence = 0.5, q = 1-p = 0.5. d is the estimated error expected = 0.05. But with a finite population of 1000 at the 3 study sites, the required sample size was estimated using nf = N/ (1 + N/n) which yielded a minimum sample size of 278. The participants were selected using stratified random sampling by site and year of composite placement. The respective dental clinic’s daily work registers were used to access individual patient’s records on posterior restorations done to the limit of the 5-year time frame. The selected patients were identified, contacts retrieved and then contacted by phone. Those who responded were given an appointment by the principal investigator for clinical examination, evaluation and assessment of their restorations. Subsequently RCRs in the patients who consented to the study and attended for examination were included. Data collection Tools Data collection tool An interviewer-administered questionnaire was used to collect data regarding the clinical status of the RCR from the patients they were placed in. Other information collected included patients’ socio-demographic data, oral hygiene practices, dietary habits, frequency of dental visits, medical history of systemic illnesses and any other information that came from the patients’ dental records. The USPHS tool was used for the Alpha (A) Bravo (B) Charlie (C) charting of the posterior RCRs. A modified version of the USPHS tool for tooth-colored restorations was used and details were recorded using visual observation and clinical examination of the restorations. Location of the restorations, the restoration surface, the anatomical shape of the restorations, the colour match of the restoration to the shade of the tooth or difference there of the cavosurface marginal discoloration, the marginal adaptation and presence or absence of secondary caries. Digital Photographs Using a Nikon DSLR (D5300), a sigma macro lens and a ring flash, intraoral dental photographs were taken for post clinical analysis of the restorations and for documentation of peculiar findings. This was done under natural lighting, with the patient comfortable on the dental chair in a semi recumbent position Data collection procedure: The clinical status of the RCRs was assessed based on the following parameters: Color match, restoration anatomy, marginal integrity, cavosurface discoloration, surface texture, secondary caries, restoration fracture, and proximal contact tightness of the posterior RCRs. Each of the parameters was scored ( Alpha = excellent result ; Bravo = acceptable result ; Charlie = unacceptable). Quality control Prior to commencement of the study, the study tools were pilot tested among a convenient sample of 10 RCRs (n = 10) attending the University of Nairobi dental hospital and these were not included in the main study. This was done in order to gain feedback on the overall acceptability of the tools in terms of length, language clarity, validity and reliability. Based on the participants’ feedback, minor modifications were made to the tools. Ethical considerations Ethical approval to conduct the study was obtained from the Kenyatta National Hospital-University of Nairobi Ethics and Research Committee, Protocol No. P760/08/2019 . Permission was sought from the hospital administration to access the patients’ records. Informed consent was voluntarily given by the participants after providing them with detailed information about the study, the expected benefits, and confidential management of the medical and dental data captured. Confidentiality was maintained all through the study. Taking part in the study was purely voluntary and the subjects were informed of the freedom to terminate participation without any repercussions or victimization. Where unique treatment needs were identified, the patients were referred for appropriate care by dental professionals. Statistical analyses Numerical variables were summarized using means/SD or medians/IQR. Categorical variables were summarized as proportions. Clinical status was summarized as a percentage for each of the parameters used. To assess factors associated with the clinical status, clinical status was categorized as a binary variable (successful status Vs failed status). Successful RCRs were the combined Alpha or Bravo frequencies except for secondary caries where Bravo indicated restoration failure. Restoration failure was taken to be Charlie for all the USPHS parameters in addition to Bravo scores for secondary caries. Associations were determined using both binary and multivariate logistic regression analysis. RESULTS Socio-demographic characteristics of the study participants A total of 286 posterior RCRs distributed among 95 patients were examined. The participants were equitably distributed among the three study sites. The demographic data showed that most of the participants, 41 (43.2%) were between the ages of 41 and 46, 35 (36.8%) had tertiary education as the highest level of learning while 65 (68.4%) were in formal employment. Table 1 below summarizes the results. Table 1 Distribution of the socio-demographic characteristic of the patients whose RCRs were examined at the 3 dental facilities in Nairobi county placed between 2014 and 2019 Variable Overall n (%) UoNDS n (%) UoNDP n (%) KNHDD n (%) Statistical test result Age (years) 18–30 28 (29.5) 10 (22.7) 9 (32.1) 9 (39.1) Fishers = 9.000 df = 4 p = 0.061 31–40 26 (27.4) 13 (29.6) 11 (39.3) 2 (8.7) 41–66 41 (43.2) 21 (47.7) 8 (28.6) 12 (52.2) Gender Male 48 (50.5) 23 (52.3) 14 (50.0) 11 (47.8) X 2 = 0.12 df = 2, p = 0.940 Female 47 (49.5) 21 (47.7) 14 (50.0) 12 (52.2) Occupation Employed 45 (47.4) 20 (45.5) 17 (60.7) 8 (34.8) Fishers = 4.140 df = 4 p = 0.387 Self employed 35 (36.8) 18 (40.9) 7 (25.0) 10 (43.5) Unemployed 15 (15.8) 6 (13.6) 4 (14.3) 5 (21.7) Education Primary 4 (4.2) 3 (6.8) 0 (0.0) 1 (4.4) Fishers = 6.308 df = 4 p = 0.387 Secondary 26 (27.4) 12 (27.3) 5 (17.9) 9 (39.1) Tertiary 65 (68.4) 29 (65.9) 23 (82.1) 13 (56.5) Chronic diseases Diabetes Mellitus 3 (3.8) 1 (3.3) 2 (7.4) 0 (0.0) Fishers = 4.662 df = 4 p = 0.324 Hypertension 5 (6.3) 1 (3.3) 1 (3.7) 3 (13.0) None 72 (90.0) 28 (93.3) 24 (88.9) 20 (87.0) Pearson Chi-Square (χ 2 ) test for association was used for gender variables . Fisher’s Exact (Fisher’s) test was used for age, occupation and education. df; Degrees of Freedom. Table 2 ; Distribution of the oral cavity characteristic of the Resin Composite Restorations examined at the 3 dental facilities in Nairobi County placed between 2014 and 2019 Variable Overall n (%) UoNDS n (%) UoNDP n (%) KNHDD n (%) Statistical test result Restoration age (years) 0–2 43 (45.3) 18 (40.9) 16 (57.1) 9 (39.1) Fishers = 3.096 df = 4 p = 0.542 2–4 34 (35.8) 17 (38.6) 9 (32.1) 8 (34.8) 4–5 18 (19.0) 9 (20.5) 3 (10.7) 6 (26.1) Dental arch Maxillary 159 (55.6) 51 (56.0) 57 (55.3) 51 (55.4) X 2 = 0.011 df = 2 p = 0.994 Mandibular 127 (44.4) 51 (56.0) 46 (44.7) 41 (44.6) Tooth type Premolar 82 (28.7) 31 (34.1) 25 (24.3) 26 (28.3) X 2 = 2.277 df = 2 p = 0.32 Molar 204 (71.3) 60 (65.9) 78 (75.7) 66 (71.7) Restoration surface Occlusal 125 (43.7) 29 (31.9) 52 (50.5) 44 (47.8) Fisher’s = 7.987 df = 4 p = 0.092 MO/DO 145 (50.7) 55 (60.4) 47 (45.6) 43 (46.7) MOD 14 (4.9) 5 (5.5) 4 (3.9) 5 (5.4) OB 2 (0.7) 2 (2.2) 0 (0.0) 0 (0.0) Pearson Chi-Square (χ 2 ) test for association was used for dental arch and tooth type. Fisher’s Exact (Fisher’s) test was used for restoration age and restoration surface. df; Degrees of Freedom. Clinical status of direct posterior resin-composite restorations When the clinical status of the RCRs was scored, Bravo restorations were more prevalent in the following four parameters; surface texture 69.6% (200/286), anatomical contour 69.2% (198/286), marginal integrity 59.1% (169/286), and colour match 46.9%(134/286). On the contrary, Alpha restorations were more prevalent for gross fracture 79.4%(227/286), secondary caries 76.2%(218/286), and cavo surface marginal discoloration 50.3%(144/286). Restorations with secondary caries 23.8%(68/286) were captured as Bravo and regarded as failed treatment, and thus no Charlie restorations for that parameter. Figure 1 illustrates the overall clinical status of the RCRs evaluated. Table 3 Clinical status of the direct posterior composite restorations at the 3 dental facilities Variable Overall n (%) UoNDS n (%) UoNDS n (%) KNHDD n (%) Statistical test result Color match Alpha 110 (38.5) 34 (37.4) 40 (38.8) 36 (39.1) X 2 = 2.571 df = 4 p = 0.632 Bravo 134 (46.9) 44 (48.4) 44 (42.7) 46 (50.0) Charlie 42 (14.7) 13 (14.3) 19 (18.4) 10 (10.9) Anatomical contour Alpha 68 (23.8) 25 (27.5) 26 (25.2) 17 (18.5) X 2 = 4.512 df = 4 p = 0.341 Bravo 198 (69.2) 57 (62.6) 71 (68.9) 70 (76.1) Charlie 20 (7.0) 9 (9.9) 6 (5.8) 5 (5.4) Cavosurface Marginal discoloration Alpha 144 (50.3) 49 (53.8) 43 (41.7) 52 (56.5) X 2 = 9.944* df = 4 p = 0.041 Bravo 122 (42.7) 32 (35.2) 55 (53.4) 35 (38.0) Charlie 20 (7.0) 10 (11.0) 5 (4.9) 5 (5.4) Marginal integrity Alpha 88 (30.8) 32 (35.2) 30 (29.1) 26 (28.3) X 2 = 2.498 df = 4 p = 0.645 Bravo 169 (59.1) 49 (53.8) 65 (63.1) 55 (59.8) Charlie 29 (10.1) 10 (11.0) 8 (7.8) 11 (12.0) Secondary caries Alpha 218 (76.2) 66 (72.5) 80 (77.7) 72 (78.3) X 2 = 1.205 df = 4, p = 0.877 Bravo 68 (23.8) 25 (27.5) 23 (22.3) 20 (21.7) Surface texture Alpha 69 (24.1) 32 (35.2) 16 (15.5) 21 (22.8) X 2 = 13.109* df = 4 p = 0.011 Bravo 199 (69.6) 51 (56.0) 82 (79.6) 66 (71.7) Charlie 18 (6.3) 8 (8.8) 5 (4.9) 5 (5.4) Gross fracture Alpha 227 (79.4) 73 (80.2) 84 (81.6) 70 (76.1) X 2 = 4.374 df = 4 p = 0.358 Bravo 37 (12.9) 10 (11.0) 10 (9.7) 17 (18.5) Charlie 22 (7.7) 8 (8.8) 9 (8.7) 5 (5.4) Pearson Chi-Square (χ 2 ) test for association was used for all variables. df; Degrees of Freedom. *p < 0.05 Since the success of posterior direct posterior resin-composite restorations was taken as a combined Alpha and Bravo score, 66.8% (191/286) of the RCRs were successful. The rest which were Charlie restorations were 33.2%(95/286). For subgroup analysis, participants aged 18–30 years had higher 42.9% (82/191) successful RCRs compared to patients older than 40. The male gender exhibited a higher 60.7% (116/191) frequency of successful RCRs compared to the female gender. The maxillary arch, molar tooth type, and MO/DO restoration surfaces had higher frequencies of successful RCRs i.e., 59.7% (114/191), 72.8%(139/191) and 48.7%(93/191) respectively as shown in Figs. 2 , 3 and 4. Annual Failure Rate The overall AFR was 12.39% (95%CI = 10.1%-14.9%). UoN Dental plaza had the highest AFR at 14.46% (95%CI = 10.3%-19.4%) followed by UoN dental school and the least was KNH. (Table 4 ) The mean AFR was calculated at 2.63% with the lowest being 2.56% from KNHDD. (Table 5 ) Table 4 Summary of AFR at 5 years Overall UoNDS UoNDP KNHDD AFR at 5 years 12.39% 12.60% 14.46% 10.16% 95% Confidence Interval 10.1%- 14.9% 8.8% − 17.2% 10.3%-19.4% 6.7% − 14.5% Table 5 Mean AFR Overall UoNDS UoNDP KNHDD Mean AFR 2.63% 2.63% 2.68% 2.56% Discussion 5.1 Clinical status of the Posterior Resin Composite Restorations This study evaluated 286 restorations distributed among 95 patients in the three dental clinics. The results thereof revealed that, overall, 1 in every 3 posterior resin composite restorations had a bravo or Alpha score while 1 in 13 had a Charlie score. Various studies in Brazil and the Netherlands had similar findings showing the highest frequency of Bravo restorations, followed by Alpha and the lowest being Charlie restorations [ 2 ] [ 10 ]. A twelve-year prospective study showed a related trend of Alpha having the highest, followed by Bravo, Charlie and Delta values at baseline, 3 and 12-year intervals [ 11 ]. However, these significantly differed in distribution with higher proportions being scored alpha in the Derchi study. The difference in distribution of the scores may be attributed to differences in the study design and setting. The current study was conducted in Kenya while the 12 years prospective study was conducted in Italy. A 3-year prospective study by Moura et. al concurred with Derchi’s findings showing the highest values for Alpha, followed by Bravo and the lowest being Charlie [ 8 ]. This trend may be attributed to the fact that this was a double-blinded randomized clinical trial (RCT) and carried out in a shorter time of 3 years compared to the retrospective nature of the current study of 5 years [ 8 ]. Another possible reason for the reduced Alpha frequency in the current study may be the fact that there is increased failure of RCRs placed by dental students since this study was carried in Dental School (UoNDS) and post Dental School setting (KNHDP) [ 8 ], [ 12 ], [ 13 ]. A review by Cazzaninga [4)] highlighted that factors related to the patient and operator are of great importance to the success or failure of the restoration. For the individual parameters, this study revealed that, for every 1 in 3 restorations, there was an Alpha score for colour match. This finding differed from that in a study by Cetin et al. that showed 100% well colour matched restorations at 5 years [ 15 ], [ 16 ]. Other studies [ 7 , 18 ] showed that 1 in 2 showed acceptable colour match in the restorations. The difference in this observation compared to the current study may be explained by the differences in the status of the teeth that were studied. The current study assessed all teeth irrespective of clinical status. The difference can also be attributed to the possible elimination of operator error through careful matching of resin composite shade [ 17 ], [ 18 ]. The current study, being a retrospective study, could not examine whether this was done which can be a possible explanation for the low Alpha frequency. Colour match failure has been reported to be due both clinician’s incompetence to colour match the restoration to the tooth shade or failure of the restoration to resist discoloration from coloured food and drinks. In Kenya, most clinicians use visual assessment for colour matching, rather than a resin composite shade guide which might be more accurate in colour matching but not readily available to the students and clinicians. Furthermore, the resin composite types with dentine and enamel shades yield superior restorations than most available single resin composite for all which are more commonly used in the region. More Bravo restorations were recorded with regards to restoration anatomy, surface texture and marginal integrity in this study. This was followed by Alpha and least being Charlie restorations. This trend has also been noted in a number of studies and systematic reviews that evaluated the performance of resin composite restorations between 3–8 years [ 2 ], [ 19 ], [ 20 ]. The restoration of anatomical reproduction demands experienced and artistic hands with an eye for detail, a skill that is not easy to come by, and this could explain the trend noted in this study. Surface texture is a product of the finishing protocol of a dental restoration according to a study by Wheeler J et al [ 21 ]. The recommended polishing protocol for resin composite is use of a mylar strip on the last cure, soflex discs or white stone [ 21 ], [ 22 ], [ 23 ]. These are not readily available to some dentists in Kenya leading to inadequate finishing of the final restoration. This is another probable reason why this study recorded higher scores for Bravo than Alpha for surface texture. General performance for cavosurface marginal discoloration and gross fracture followed a different trend with more Alpha restorations than Bravo and least being Charlie restorations (Fig. 1 ). A similar trend was noted in a 3-year evaluation of resin composites in Brazil [ 2 ]. Marginal discoloration is an indication of defective restoration margins but if RCRs are placed according to protocol by bonding the resin composite to the tooth and sealing the margins, marginal discoloration or fracture of the restoration is rare [ 2 ]. Moura et al. in the aforementioned study mentions that it is not common for posterior resin composite restorations to fracture to the point of losing the restoration which explains why the Charlie score is low for restoration fracture for this study [ 2 ]. This finding is similar to that revealed by Lempel et al [ 17 , 18 ] Secondary caries was assessed with Alpha and Bravo scores alone for absence or presence of secondary caries respectively. The study showed that 1 in every 5 restorations had a Bravo score. Similar studies in Brazil and the Netherlands revealed the same trend where between 5–20% of resin composite restorations developed secondary caries between 5–15 years [ 14 ], [ 24 ], [ 25 ]. Astvaldsdo ́ttir et al . reported a 75% higher chance of RCRs developing secondary caries after 3 years in service. [26]. Another study by Durão MdA [27] revealed that 1 in 36 people developed secondary caries after a 3 year follow up period. However, the higher incidence of caries in the Kenyan population could be explained by the fact that the population studied is one with a high caries incidence. [28] The result observed in the present study may be attributed to the failure of the bond between the restoration and the tooth structure with the inadequate adhesive interface influencing the caries development [20]. Another possible reason for development of the secondary caries may be attributed to the gap formation during incremental placement of resin composite leading to marginal failure [ 26 ], [ 27 ] Lopes e t al. assessed restorations on several teeth and found gap formation of up to 6.1% for teeth restored with the incremental placement technique and 18.7% for teeth restored with the bulk placement technique [ 27 ], [ 29 ]. Turkun et al. concluded that one of the main modes of failure of RCRs is loss of marginal adaptation in addition to secondary caries [ 30 ]. Furthermore, clinical status was evaluated for either successful or failed restoration. The current study revealed that 1 in every 2 restorations was successful. This finding was similarly reported by Alvanforoush et al . when he analysed published clinical studies on success and failure of direct resin composites [ 30 ]. The overall mean AFR was calculated to be 2.63% (Table 3 ). Similar studies that reported mean AFR of RCRs at five years reported it to be between 1.7% − 3.5% [ 39 ], [ 2 ], [ 35 ], [ 40 ], [ 41 ]. The highest mean AFR% is usually seen up to 5 years, which reduces over time having lower rates at over 15 years of evaluation of RCRs [ 42 ]. A systematic review by Opdam et al. [ 2 ] concluded that mean AFR at 5 and 10 years was 1.8% and 2.4% for posterior RCRs respectively. A study in Brazil, after 8-year follow-up, revealed that the AFR of restorations placed by dental students was 2.62% which is almost similar to what was noted for UoNDS (2.63%) for this study [ 19 ]. On the other hand, a five-year study evaluating RCRs placed in a dental school in the Netherlands, Opdam et al. [ 10 ] calculated a mean AFR of 2.8% which is also close to the results in this study. The almost similar mean AFR may be explained by the fact that both studies were carried out in a Dental School setting. Downer et al. [ 43 ] pointed out that cross-sectional studies give an underestimation of the average lifetime of routine restorations and randomized clinical trials produce lower values for mean AFR than retrospective cross-sectional studies like the present study [ 40 ]. An example is a study by Cetin et al. [ 13 ] who found a mean AFR of 2.2% for direct composite resin fillings at five years which is slightly lower than that of this study because it was a longitudinal study. The value for the current study was however within the reported values of AFR. UoNDP had the highest mean AFR (2.68%) compared to UoNDS at 2.63% and least being KNHDD with (2.56%). This trend may be explained by the fact that teaching hospitals are strict on procedures with supervision compared to private practice [ 19 ]. Conclusion The clinical status of RCRs in this study showed that the majority of the posterior direct RCRs were Alpha and Bravo restorations which are clinically acceptable. The Mean AFR for this study was calculated as 2.63% at 5 years. The lowest AFR was noted to be in KNHDP a public dental clinic (2.56%) and highest at UoNDP which is a private clinic (2.68%). Study limitations . The retrospective nature of this study limited accurate recording of the types of resin composites that were used. This made it hard to ascertain the relation between resin composite material used and the success/failure (clinical status) of posterior RCRs. In addition, some of the contacted participants for the study were unable or unwilling to come for the study due to dissatisfaction or change of contacts. This however did not affect the target sample size for the study. Declarations Ethics approval and consent to participate Ethical approval to conduct the study was obtained from The Kenyatta National Hospital- University of Nairobi Ethics and Research Committee, Protocol No. P760/08/2019. Informed consent was voluntarily given by the participants after providing them with detailed information about the study, the expected benefits and confidential management of the medical and dental data captured. Confidentiality was maintained all through the study. Consent for publication Availability of data and materials Funding ; Self-funded Clinical trial number : not applicable. Author Contribution Dr. Umaru Kizito is the primary author and principal investigator of this manuscript. He coordinated the research team during data collection, led the writing process, and secured all necessary approvals for the study. The manuscript was primarily written by Dr. Kizito, with input and corrections from all co-authors.Dr. Hazel Orengo Simila and Dr. Fred Odera Otieno served as secondary supervisors. They ensured that the study adhered to ethical standards and provided critical feedback during the manuscript’s development.Dr. Lincoln Abraham Tentena was responsible for organizing the overall structure and flow of the manuscript. He contributed significantly to the literature review and background sections, assisted in drafting the discussion, and conducted substantive editing throughout the manuscript.Dr. Bernina Kyale Kisumbi was the main supervisor for this study. She worked closely with the principal investigator in guiding the research process, reviewing drafts, and providing essential input in the editing and formulation of the final manuscript. Her supervision was instrumental to the successful completion of this study. Acknowledgement Mr. Thomas Kakairo, Mr. K’Owino Desmond Otieno and Ms. Grace Nabagala for their statistical work done. 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Heintze SD, Rousson V. Clinical effectiveness of direct class II restorations-a meta-analysis. J Adhes Dent. 2012;14(5):407–31. Leite S. Restoration survival in the composite resin age: [Sl: sn]; semanticscholar.org/paper: 2016; 40–44. Moraschini V, Fai CK, Alto RM, Dos Santos GO. Amalgam and resin composite longevity of posterior restorations: A systematic review and meta-analysis. J Dent. 2015;43(9):1043–50. Demarco FF, Corrêa MB, Cenci MS, Moraes RR, Opdam NJ. Longevity of posterior composite restorations: not only a matter of materials. Dent Mater. 2012;28(1):87–101. Opdam N, Bronkhorst E, Loomans B, Huysmans M-C. 12-year survival of composite vs. amalgam restorations. J Dent Res. 2010;89(10):1063–7. Loomans B, Opdam N, Roeters F, Bronkhorst E, Burgersdijk R, Dörfer C. A randomized clinical trial on proximal contacts of posterior composites. J Dent. 2006;34(4):292–7. Brunthaler A, König F, Lucas T, Sperr W, Schedle A. 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Supplementary Files Appendix1.docx Appendixtwo.docx Appendix4.docx Appendix5.docx Appendix6.docx Appendix7.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 30 Dec, 2025 Reviewers agreed at journal 21 Dec, 2025 Reviewers invited by journal 12 Dec, 2025 Editor invited by journal 18 Nov, 2025 Editor assigned by journal 14 Nov, 2025 Submission checks completed at journal 14 Nov, 2025 First submitted to journal 30 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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arch\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7991828/v1/3975d4f2bd4f96d1966e6ef2.png"},{"id":98753563,"identity":"f4550643-bb04-4324-b283-18ae5aa734e9","added_by":"auto","created_at":"2025-12-22 09:22:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":77374,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eClinical status of direct posterior resin-composite restorations by tooth type\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7991828/v1/0e44439231d199f86f50bc5a.png"},{"id":98753566,"identity":"30fa86c9-0f23-45cd-be45-70a7a4866b41","added_by":"auto","created_at":"2025-12-22 09:22:25","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":94298,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eClinical status of direct posterior resin-composite restorations by surface restored\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-7991828/v1/70541a86da9340837dc46905.png"},{"id":98783255,"identity":"2aa9dbac-bf6a-46ed-931f-18a162b669db","added_by":"auto","created_at":"2025-12-22 12:41:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1544848,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7991828/v1/73eb842f-5bb2-4382-9913-f19215fe8a03.pdf"},{"id":98753558,"identity":"3de6d913-6680-4280-8433-28546682d5f7","added_by":"auto","created_at":"2025-12-22 09:22:25","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24107,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-7991828/v1/adc67bb4374845ebe1e1498e.docx"},{"id":98779948,"identity":"c8263987-ac6d-44ca-ba69-aebd5d4741f4","added_by":"auto","created_at":"2025-12-22 12:30:57","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":15518,"visible":true,"origin":"","legend":"","description":"","filename":"Appendixtwo.docx","url":"https://assets-eu.researchsquare.com/files/rs-7991828/v1/0656ba2db79b1bd9a69a0f95.docx"},{"id":98778966,"identity":"66ab20af-acc1-46fc-abc5-2e9462f2ce3d","added_by":"auto","created_at":"2025-12-22 12:29:51","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":15128,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix4.docx","url":"https://assets-eu.researchsquare.com/files/rs-7991828/v1/bee5fd70054f362ac9bae481.docx"},{"id":98753565,"identity":"46d065d7-f885-4b33-be0f-6d7c18c25046","added_by":"auto","created_at":"2025-12-22 09:22:25","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":20266,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix5.docx","url":"https://assets-eu.researchsquare.com/files/rs-7991828/v1/4c5688983e1049d9dfb61929.docx"},{"id":98753578,"identity":"1d083d53-70cf-4efe-93bb-ca5dd843d29a","added_by":"auto","created_at":"2025-12-22 09:22:26","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":2212868,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix6.docx","url":"https://assets-eu.researchsquare.com/files/rs-7991828/v1/d5398592b7aef72485bd87c4.docx"},{"id":98753582,"identity":"6079d7b2-2235-42d2-9409-269b218d1593","added_by":"auto","created_at":"2025-12-22 09:22:27","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":28938120,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix7.docx","url":"https://assets-eu.researchsquare.com/files/rs-7991828/v1/25e27dde175aae1a75977985.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eRetrospective Evaluation of the Clinical Status of Direct Posterior Composite Restorations in Selected Institutions in Nairobi, Kenya\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003e Posterior teeth are vital to the normal masticatory function of an individual\u0026rsquo;s oral structures. Their position in the dental arches gives them a mechanical advantage as they require less muscular effort to exert the same force as compared to the anterior teeth. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] It however places them at a disadvantage as they experience the majority of the load bearing occlusal forces and therefore any restorative work done on them must take this into consideration because they must withstand significant biting forces, resist fracture, and maintain their integrity over time. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] Consequently, restorative materials used in these teeth must demonstrate high durability, wear resistance, and the ability to maintain marginal adaptation under stress. [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e][\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eHistorically, amalgam was the go-to-choice for restorations in posterior teeth. This was because of its durability, cost effectiveness, ease of use and longevity. In spite of this, there has been a shift in preference among clinicians and patients towards alternatives to amalgam [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In the present \u0026ldquo;amalgam phase down\u0026rdquo; period, composite resins are increasingly being used for the restoration of both posterior primary and permanent teeth. This is in part due to the improved systems mentioned above and also the 2013 Minamata Convention of Mercury resolution and subsequent implementation. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eCurrently, direct posterior resin composites are the more preferred restorations for posterior teeth. A multinational survey spanning thirteen countries revealed that dentists overwhelmingly choose composites over alternatives like amalgam or glass ionomer cement (GIC), with an odds ratio of 997.4. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] In the past, there were problems that hindered the adoption of their use among clinicians which included shrinkage, contraction stress, poor mechanical properties, wear, and secondary caries. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] Advances in the field of materials science continue to reduce these drawbacks associated with resin composites. Innovations include modification of the chemical composition of resins, insertion techniques, instrumentation, and photo polymerization. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] As a result, composite systems now have superior mechanical properties and maintain good margins under clinical conditions.\u003c/p\u003e \u003cp\u003eThe rapid evolution of composite resin systems is however associated with a paucity of long-term clinical studies evaluating the restorations placed under various clinical conditions. In the African context, African data is largely limited to South Africa; trends in other African nations remain understudied.\u003c/p\u003e \u003cp\u003eThe failure of resin composite restorations and in particular posterior RCRs the world over is becoming a burden to the dental health care system. This is due to the increasing number of patients presenting for replacement of the restorations and/or root canal treatment of the involved teeth. This gap is especially notable for the early manifestations of failures which include postoperative hypersensitivity, marginal discoloration, and secondary caries. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] This is not only expensive to the patients and the system but it is also a time-consuming procedure.\u003c/p\u003e \u003cp\u003e A systematic review by Opdam revealed the Annual Failure Rate of posterior composite restorations to be between 0 and 6%. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] This concurred with a study by Manhurt et al [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] but had a 1% difference with the AFR in a 2012 study by Heinze and Rousson. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] A different meta-analysis by Leite concluded from 12 clinical studies that the caries risk size and dimensions of the restorations (surfaces restored) have a significance in the survival of the restoration [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Furthermore, it revealed that the AFR for posterior composites is 1.8% at 5 years and 2.4% at 10 [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In a meta-analysis by Moraschini et al [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], the mean rate of survival of RCRs was found to be 86.2% with an average of 55 months of follow up. This data was similar to other reviews that reported the failure in terms of AFR of around 23.7% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e], [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn addition to the aforementioned burden, no current data is available in the region to describe the status of posterior resin composites or their failure rates.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003e \u003cstrong\u003eStudy design\u003c/strong\u003e \u003cp\u003eThis was a cross-sectional study to assess the clinical state, factors associated, and the mean annual failure rate of the direct posterior resin-composite restorations placed over a 5-year period in selected institutions in Nairobi, Kenya.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eStudy setting and population\u003c/strong\u003e \u003cp\u003eThe study was conducted in Nairobi County, which is one of the 47 counties of Kenya. The capital of the county is Nairobi city which is the largest and also the capital city of Kenya. Nairobi city is estimated to have a population of 5\u0026nbsp;million. Three dental clinics located in two institutions namely the University of Nairobi (UoN) and Kenyatta National Hospital (KNH) were conveniently sampled for the study. A teaching hospital, UoN Dental School, the UoN Dental Plaza, a private dental facility, and Kenyatta National Hospital dental department, a public hospital formed the study sites. The study population consisted of posterior resin composite restorations placed in patients at the three dental clinics in the period between 2014 and 2019. Documentation and patient records were used for the determination of who and when they had the restorations done to limit it to the 5-year time frame\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSample size calculation and participant selection\u003c/h2\u003e \u003cp\u003eSample size was calculated using Kish Leslie\u0026rsquo;s method for single proportion N= [Z\u003csup\u003e2\u003c/sup\u003e\u003csub\u003eα/2\u003c/sub\u003e pq/d\u003csup\u003e2\u003c/sup\u003e].\u003c/p\u003e \u003cp\u003eUsing a prevalence of 50% of all posterior restorations being resin composite restorations from a study in the United States of America [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Where N is the sample size, Z-score corresponding to 95% of confidence interval which is 1.96, p is the prevalence\u0026thinsp;=\u0026thinsp;0.5, q\u0026thinsp;=\u0026thinsp;1-p\u0026thinsp;=\u0026thinsp;0.5. d is the estimated error expected\u0026thinsp;=\u0026thinsp;0.05. But with a finite population of 1000 at the 3 study sites, the required sample size was estimated using nf\u0026thinsp;=\u0026thinsp;N/ (1\u0026thinsp;+\u0026thinsp;N/n) which yielded a minimum sample size of 278. The participants were selected using stratified random sampling by site and year of composite placement. The respective dental clinic\u0026rsquo;s daily work registers were used to access individual patient\u0026rsquo;s records on posterior restorations done to the limit of the 5-year time frame. The selected patients were identified, contacts retrieved and then contacted by phone. Those who responded were given an appointment by the principal investigator for clinical examination, evaluation and assessment of their restorations. Subsequently RCRs in the patients who consented to the study and attended for examination were included.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTools\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eData collection tool\u003c/strong\u003e \u003cp\u003eAn interviewer-administered questionnaire was used to collect data regarding the clinical status of the RCR from the patients they were placed in. Other information collected included patients\u0026rsquo; socio-demographic data, oral hygiene practices, dietary habits, frequency of dental visits, medical history of systemic illnesses and any other information that came from the patients\u0026rsquo; dental records.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe USPHS tool was used for the Alpha (A) Bravo (B) Charlie (C) charting of the posterior RCRs. A modified version of the USPHS tool for tooth-colored restorations was used and details were recorded using visual observation and clinical examination of the restorations. Location of the restorations, the restoration surface, the anatomical shape of the restorations, the colour match of the restoration to the shade of the tooth or difference there of the cavosurface marginal discoloration, the marginal adaptation and presence or absence of secondary caries.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDigital Photographs\u003c/strong\u003e \u003cp\u003eUsing a Nikon DSLR (D5300), a sigma macro lens and a ring flash, intraoral dental photographs were taken for post clinical analysis of the restorations and for documentation of peculiar findings. This was done under natural lighting, with the patient comfortable on the dental chair in a semi recumbent position\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection procedure:\u003c/h3\u003e\n\u003cp\u003eThe clinical status of the RCRs was assessed based on the following parameters: Color match, restoration anatomy, marginal integrity, cavosurface discoloration, surface texture, secondary caries, restoration fracture, and proximal contact tightness of the posterior RCRs. Each of the parameters was scored (\u003cem\u003eAlpha\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u003cem\u003eexcellent result\u003c/em\u003e; \u003cem\u003eBravo\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u003cem\u003eacceptable result\u003c/em\u003e; \u003cem\u003eCharlie\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u003cem\u003eunacceptable).\u003c/em\u003e\u003c/p\u003e\n\u003ch3\u003eQuality control\u003c/h3\u003e\n\u003cp\u003ePrior to commencement of the study, the study tools were pilot tested among a convenient sample of 10 RCRs (n\u0026thinsp;=\u0026thinsp;10) attending the University of Nairobi dental hospital and these were not included in the main study. This was done in order to gain feedback on the overall acceptability of the tools in terms of length, language clarity, validity and reliability. Based on the participants\u0026rsquo; feedback, minor modifications were made to the tools.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003eto conduct the study was obtained from the Kenyatta National Hospital-University of Nairobi Ethics and Research Committee, Protocol No. \u003cb\u003eP760/08/2019\u003c/b\u003e.\u003c/p\u003e \u003c/p\u003e \u003cp\u003ePermission was sought from the hospital administration to access the patients\u0026rsquo; records. Informed consent was voluntarily given by the participants after providing them with detailed information about the study, the expected benefits, and confidential management of the medical and dental data captured. Confidentiality was maintained all through the study. Taking part in the study was purely voluntary and the subjects were informed of the freedom to terminate participation without any repercussions or victimization. Where unique treatment needs were identified, the patients were referred for appropriate care by dental professionals.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStatistical analyses\u003c/h3\u003e\n\u003cp\u003eNumerical variables were summarized using means/SD or medians/IQR. Categorical variables were summarized as proportions. Clinical status was summarized as a percentage for each of the parameters used. To assess factors associated with the clinical status, clinical status was categorized as a binary variable (successful status Vs failed status). Successful RCRs were the combined Alpha or Bravo frequencies except for secondary caries where Bravo indicated restoration failure. Restoration failure was taken to be Charlie for all the USPHS parameters in addition to Bravo scores for secondary caries. Associations were determined using both binary and multivariate logistic regression analysis.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic characteristics of the study participants\u003c/h2\u003e \u003cp\u003eA total of 286 posterior RCRs distributed among 95 patients were examined. The participants were equitably distributed among the three study sites. The demographic data showed that most of the participants, 41 (43.2%) were between the ages of 41 and 46, 35 (36.8%) had tertiary education as the highest level of learning while 65 (68.4%) were in formal employment. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e below summarizes the results.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of the socio-demographic characteristic of the patients whose RCRs were examined at the 3 dental facilities in Nairobi county placed between 2014 and 2019\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUoNDS\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUoNDP\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKNHDD\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStatistical test\u003c/p\u003e \u003cp\u003eresult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28 (29.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (22.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9 (39.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFishers\u0026thinsp;=\u0026thinsp;9.000\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.061\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u0026ndash;40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13 (29.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e11 (39.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2 (8.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u0026ndash;66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e41 (43.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21 (47.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8 (28.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12 (52.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48 (50.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23 (52.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11 (47.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.12\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;2, p\u0026thinsp;=\u0026thinsp;0.940\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e47 (49.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21 (47.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e14 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e12 (52.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eOccupation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e45 (47.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20 (45.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e17 (60.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8 (34.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFishers\u0026thinsp;=\u0026thinsp;4.140\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.387\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSelf employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35 (36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (40.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e7 (25.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10 (43.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6 (13.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5 (21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eEducation\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4 (4.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (6.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFishers\u0026thinsp;=\u0026thinsp;6.308\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.387\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (27.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (27.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (17.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9 (39.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65 (68.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29 (65.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23 (82.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e13 (56.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eChronic diseases\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiabetes Mellitus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2 (7.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFishers\u0026thinsp;=\u0026thinsp;4.662\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.324\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHypertension\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1 (3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1 (3.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e3 (13.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e72 (90.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28 (93.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e24 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20 (87.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePearson Chi-Square (χ\u003csup\u003e2\u003c/sup\u003e) test for association was used for gender variables .\u003c/p\u003e \u003cp\u003eFisher\u0026rsquo;s Exact (Fisher\u0026rsquo;s) test was used for age, occupation and education.\u003c/p\u003e \u003cp\u003edf; Degrees of Freedom.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e; Distribution of the oral cavity characteristic of the Resin Composite Restorations examined at the 3 dental facilities in Nairobi County placed between 2014 and 2019\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUoNDS\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUoNDP\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKNHDD\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStatistical test\u003c/p\u003e \u003cp\u003eresult\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eRestoration age (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e43 (45.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (40.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16 (57.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e9 (39.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eFishers\u0026thinsp;=\u0026thinsp;3.096\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.542\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34 (35.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17 (38.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (32.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e8 (34.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u0026ndash;5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (20.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e3 (10.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e6 (26.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eDental arch\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMaxillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e159 (55.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51 (56.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e57 (55.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e51 (55.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.011\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;2 p\u0026thinsp;=\u0026thinsp;0.994\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMandibular\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e127 (44.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51 (56.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e46 (44.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e41 (44.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eTooth type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePremolar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82 (28.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25 (24.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26 (28.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2.277\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;2 p\u0026thinsp;=\u0026thinsp;0.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMolar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e204 (71.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60 (65.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e78 (75.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e66 (71.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003eRestoration surface\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOcclusal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e125 (43.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29 (31.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e52 (50.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e44 (47.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eFisher\u0026rsquo;s\u0026thinsp;=\u0026thinsp;7.987 df\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.092\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMO/DO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e145 (50.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e55 (60.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e47 (45.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e43 (46.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMOD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5 (5.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e4 (3.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5 (5.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0 (0.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePearson Chi-Square (χ\u003csup\u003e2\u003c/sup\u003e) test for association was used for dental arch and tooth type.\u003c/p\u003e \u003cp\u003eFisher\u0026rsquo;s Exact (Fisher\u0026rsquo;s) test was used for restoration age and restoration surface.\u003c/p\u003e \u003cp\u003edf; Degrees of Freedom.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eClinical status of direct posterior resin-composite restorations\u003c/h2\u003e \u003cp\u003eWhen the clinical status of the RCRs was scored, Bravo restorations were more prevalent in the following four parameters; surface texture 69.6% (200/286), anatomical contour 69.2% (198/286), marginal integrity 59.1% (169/286), and colour match 46.9%(134/286). On the contrary, Alpha restorations were more prevalent for gross fracture 79.4%(227/286), secondary caries 76.2%(218/286), and cavo surface marginal discoloration 50.3%(144/286). Restorations with secondary caries 23.8%(68/286) were captured as Bravo and regarded as failed treatment, and thus no Charlie restorations for that parameter. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e illustrates the overall clinical status of the RCRs evaluated.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical status of the direct posterior composite restorations at the 3 dental facilities\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUoNDS\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eUoNDS\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eKNHDD\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStatistical test result\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eColor match\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlpha\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e110 (38.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e34 (37.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e40 (38.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e36 (39.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2.571\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.632\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBravo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e134 (46.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e44 (48.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e44 (42.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e46 (50.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharlie\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42 (14.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e19 (18.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e10 (10.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eAnatomical contour\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlpha\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68 (23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25 (27.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e26 (25.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17 (18.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;4.512\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.341\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBravo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e198 (69.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e57 (62.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e71 (68.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e70 (76.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharlie\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (9.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6 (5.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5 (5.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eCavosurface\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eMarginal\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003ediscoloration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlpha\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e144 (50.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e43 (41.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e52 (56.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;9.944*\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.041\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBravo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e122 (42.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32 (35.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e55 (53.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35 (38.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharlie\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (7.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5 (5.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eMarginal integrity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlpha\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88 (30.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32 (35.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30 (29.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26 (28.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2.498\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.645\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBravo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e169 (59.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e49 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e65 (63.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e55 (59.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharlie\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (10.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e8 (7.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e11 (12.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSecondary caries\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlpha\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e218 (76.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e66 (72.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e80 (77.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e72 (78.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;1.205\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;4, p\u0026thinsp;=\u0026thinsp;0.877\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBravo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e68 (23.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25 (27.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e23 (22.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e20 (21.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eSurface texture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlpha\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69 (24.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32 (35.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e16 (15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e21 (22.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;13.109*\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBravo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e199 (69.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e51 (56.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e82 (79.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e66 (71.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharlie\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e5 (4.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5 (5.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eGross fracture\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAlpha\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e227 (79.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e73 (80.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e84 (81.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e70 (76.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;4.374\u003c/p\u003e \u003cp\u003edf\u0026thinsp;=\u0026thinsp;4\u003c/p\u003e \u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.358\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBravo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e37 (12.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10 (9.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17 (18.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCharlie\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e22 (7.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8 (8.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9 (8.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e5 (5.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePearson Chi-Square (χ\u003csup\u003e2\u003c/sup\u003e) test for association was used for all variables.\u003c/p\u003e \u003cp\u003edf; Degrees of Freedom.\u003c/p\u003e \u003cp\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSince the success of posterior direct posterior resin-composite restorations was taken as a combined Alpha and Bravo score, 66.8% (191/286) of the RCRs were successful. The rest which were Charlie restorations were 33.2%(95/286). For subgroup analysis, participants aged 18\u0026ndash;30 years had higher 42.9% (82/191) successful RCRs compared to patients older than 40. The male gender exhibited a higher 60.7% (116/191) frequency of successful RCRs compared to the female gender. The maxillary arch, molar tooth type, and MO/DO restoration surfaces had higher frequencies of successful RCRs\u003c/p\u003e \u003cp\u003ei.e., 59.7% (114/191), 72.8%(139/191) and 48.7%(93/191) respectively as shown in Figs.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and 4.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eAnnual Failure Rate\u003c/h2\u003e \u003cp\u003eThe overall AFR was 12.39% (95%CI\u0026thinsp;=\u0026thinsp;10.1%-14.9%). UoN Dental plaza had the highest AFR at 14.46% (95%CI\u0026thinsp;=\u0026thinsp;10.3%-19.4%) followed by UoN dental school and the least was KNH. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) The mean AFR was calculated at 2.63% with the lowest being 2.56% from KNHDD. (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of AFR at 5 years\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUoNDS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUoNDP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKNHDD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAFR at 5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12.39%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.60%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e14.46%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e10.16%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e95% Confidence Interval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.1%- 14.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.8% \u0026minus;\u0026thinsp;17.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.3%-19.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6.7% \u0026minus;\u0026thinsp;14.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMean AFR\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUoNDS\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUoNDP\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKNHDD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean AFR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.63%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.63%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.68%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.56%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cb\u003e5.1 Clinical status of the Posterior Resin Composite Restorations\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThis study evaluated 286 restorations distributed among 95 patients in the three dental clinics. The results thereof revealed that, overall, 1 in every 3 posterior resin composite restorations had a bravo or Alpha score while 1 in 13 had a Charlie score. Various studies in Brazil and the Netherlands had similar findings showing the highest frequency of Bravo restorations, followed by Alpha and the lowest being Charlie restorations [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A twelve-year prospective study showed a related trend of Alpha having the highest, followed by Bravo, Charlie and Delta values at baseline, 3 and 12-year intervals [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. However, these significantly differed in distribution with higher proportions being scored alpha in the Derchi study. The difference in distribution of the scores may be attributed to differences in the study design and setting. The current study was conducted in Kenya while the 12 years prospective study was conducted in Italy.\u003c/p\u003e \u003cp\u003eA 3-year prospective study by Moura \u003cem\u003eet. al\u003c/em\u003e concurred with Derchi\u0026rsquo;s findings showing the highest values for Alpha, followed by Bravo and the lowest being Charlie [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This trend may be attributed to the fact that this was a double-blinded randomized clinical trial (RCT) and carried out in a shorter time of 3 years compared to the retrospective nature of the current study of 5 years [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Another possible reason for the reduced Alpha frequency in the current study may be the fact that there is increased failure of RCRs placed by dental students since this study was carried in Dental School (UoNDS) and post Dental School setting (KNHDP) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. A review by Cazzaninga [4)] highlighted that factors related to the patient and operator are of great importance to the success or failure of the restoration. For the individual parameters, this study revealed that, for every 1 in 3 restorations, there was an Alpha score for colour match. This finding differed from that in a study by Cetin \u003cem\u003eet al.\u003c/em\u003e that showed 100% well colour matched restorations at 5 years [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Other studies [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e] showed that 1 in 2 showed acceptable colour match in the restorations. The difference in this observation compared to the current study may be explained by the differences in the status of the teeth that were studied. The current study assessed all teeth irrespective of clinical status.\u003c/p\u003e \u003cp\u003eThe difference can also be attributed to the possible elimination of operator error through careful matching of resin composite shade [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The current study, being a retrospective study, could not examine whether this was done which can be a possible explanation for the low Alpha frequency. Colour match failure has been reported to be due both clinician\u0026rsquo;s incompetence to colour match the restoration to the tooth shade or failure of the restoration to resist discoloration from coloured food and drinks.\u003c/p\u003e \u003cp\u003eIn Kenya, most clinicians use visual assessment for colour matching, rather than a resin composite shade guide which might be more accurate in colour matching but not readily available to the students and clinicians. Furthermore, the resin composite types with dentine and enamel shades yield superior restorations than most available single resin composite for all which are more commonly used in the region.\u003c/p\u003e \u003cp\u003eMore Bravo restorations were recorded with regards to restoration anatomy, surface texture and marginal integrity in this study. This was followed by Alpha and least being Charlie restorations. This trend has also been noted in a number of studies and systematic reviews that evaluated the performance of resin composite restorations between 3\u0026ndash;8 years [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The restoration of anatomical reproduction demands experienced and artistic hands with an eye for detail, a skill that is not easy to come by, and this could explain the trend noted in this study.\u003c/p\u003e \u003cp\u003eSurface texture is a product of the finishing protocol of a dental restoration according to a study by Wheeler J et al [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The recommended polishing protocol for resin composite is use of a mylar strip on the last cure, soflex discs or white stone [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These are not readily available to some dentists in Kenya leading to inadequate finishing of the final restoration. This is another probable reason why this study recorded higher scores for Bravo than Alpha for surface texture.\u003c/p\u003e \u003cp\u003e General performance for cavosurface marginal discoloration and gross fracture followed a different trend with more Alpha restorations than Bravo and least being Charlie restorations (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A similar trend was noted in a 3-year evaluation of resin composites in Brazil [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMarginal discoloration is an indication of defective restoration margins but if RCRs are placed according to protocol by bonding the resin composite to the tooth and sealing the margins, marginal discoloration or fracture of the restoration is rare [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Moura \u003cem\u003eet al.\u003c/em\u003e in the aforementioned study mentions that it is not common for posterior resin composite restorations to fracture to the point of losing the restoration which explains why the Charlie score is low for restoration fracture for this study [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This finding is similar to that revealed by Lempel et al [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eSecondary caries was assessed with Alpha and Bravo scores alone for absence or presence of secondary caries respectively. The study showed that 1 in every 5 restorations had a Bravo score. Similar studies in Brazil and the Netherlands revealed the same trend where between 5\u0026ndash;20% of resin composite restorations developed secondary caries between 5\u0026ndash;15 years [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e], [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Astvaldsdo ́ttir \u003cem\u003eet al\u003c/em\u003e. reported a 75% higher chance of RCRs developing secondary caries after 3 years in service. [26]. Another study by Dur\u0026atilde;o MdA [27] revealed that 1 in 36 people developed secondary caries after a 3 year follow up period. However, the higher incidence of caries in the Kenyan population could be explained by the fact that the population studied is one with a high caries incidence. [28] The result observed in the present study may be attributed to the failure of the bond between the restoration and the tooth structure with the inadequate adhesive interface influencing the caries development [20].\u003c/p\u003e \u003cp\u003eAnother possible reason for development of the secondary caries may be attributed to the gap formation during incremental placement of resin composite leading to marginal failure [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] Lopes e\u003cem\u003et al. assessed\u003c/em\u003e restorations on several teeth and found gap formation of up to 6.1% for teeth restored with the incremental placement technique and 18.7% for teeth restored with the bulk placement technique [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Turkun \u003cem\u003eet al.\u003c/em\u003e concluded that one of the main modes of failure of RCRs is loss of marginal adaptation in addition to secondary caries [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFurthermore, clinical status was evaluated for either successful or failed restoration. The current study revealed that 1 in every 2 restorations was successful. This finding was similarly reported by Alvanforoush \u003cem\u003eet al\u003c/em\u003e. when he analysed published clinical studies on success and failure of direct resin composites [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe overall mean AFR was calculated to be 2.63% (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Similar studies that reported mean AFR of RCRs at five years reported it to be between 1.7% \u0026minus;\u0026thinsp;3.5% [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e], [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The highest mean AFR% is usually seen up to 5 years, which reduces over time having lower rates at over 15 years of evaluation of RCRs [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. A systematic review by Opdam et al. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] concluded that mean AFR at 5 and 10 years was 1.8% and 2.4% for posterior RCRs respectively. A study in Brazil, after 8-year follow-up, revealed that the AFR of restorations placed by dental students was 2.62% which is almost similar to what was noted for UoNDS (2.63%) for this study [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. On the other hand, a five-year study evaluating RCRs placed in a dental school in the Netherlands, Opdam et al. [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] calculated a mean AFR of 2.8% which is also close to the results in this study. The almost similar mean AFR may be explained by the fact that both studies were carried out in a Dental School setting. Downer et al. [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] pointed out that cross-sectional studies give an underestimation of the average lifetime of routine restorations and randomized clinical trials produce lower values for mean AFR than retrospective cross-sectional studies like the present study [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. An example is a study by Cetin et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] who found a mean AFR of 2.2% for direct composite resin fillings at five years which is slightly lower than that of this study because it was a longitudinal study. The value for the current study was however within the reported values of AFR. UoNDP had the highest mean AFR (2.68%) compared to UoNDS at 2.63% and least being KNHDD with (2.56%). This trend may be explained by the fact that teaching hospitals are strict on procedures with supervision compared to private practice [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConclusion\u003c/strong\u003e \u003cp\u003eThe clinical status of RCRs in this study showed that the majority of the posterior direct RCRs were Alpha and Bravo restorations which are clinically acceptable. The Mean AFR for this study was calculated as 2.63% at 5 years. The lowest AFR was noted to be in KNHDP a public dental clinic (2.56%) and highest at UoNDP which is a private clinic (2.68%).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eStudy limitations\u003c/b\u003e. The retrospective nature of this study limited accurate recording of the types of resin composites that were used. This made it hard to ascertain the relation between resin composite material used and the success/failure (clinical status) of posterior RCRs. In addition, some of the contacted participants for the study were unable or unwilling to come for the study due to dissatisfaction or change of contacts. This however did not affect the target sample size for the study.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003e Ethical approval to conduct the study was obtained from The Kenyatta National Hospital- University of Nairobi Ethics and Research Committee, Protocol No. \u003cb\u003eP760/08/2019.\u003c/b\u003e\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eInformed consent\u003c/h2\u003e \u003cp\u003ewas voluntarily given by the participants after providing them with detailed information about the study, the expected benefits and confidential management of the medical and dental data captured. Confidentiality was maintained all through the study.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eConsent for publication\u003c/h2\u003e \u003cp\u003eAvailability of data and materials\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003e; Self-funded\u003c/p\u003e \u003cp\u003e \u003cem\u003eClinical trial number\u003c/em\u003e: not applicable.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDr. Umaru Kizito is the primary author and principal investigator of this manuscript. He coordinated the research team during data collection, led the writing process, and secured all necessary approvals for the study. The manuscript was primarily written by Dr. Kizito, with input and corrections from all co-authors.Dr. Hazel Orengo Simila and Dr. Fred Odera Otieno served as secondary supervisors. They ensured that the study adhered to ethical standards and provided critical feedback during the manuscript\u0026rsquo;s development.Dr. Lincoln Abraham Tentena was responsible for organizing the overall structure and flow of the manuscript. He contributed significantly to the literature review and background sections, assisted in drafting the discussion, and conducted substantive editing throughout the manuscript.Dr. Bernina Kyale Kisumbi was the main supervisor for this study. She worked closely with the principal investigator in guiding the research process, reviewing drafts, and providing essential input in the editing and formulation of the final manuscript. Her supervision was instrumental to the successful completion of this study.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eMr. Thomas Kakairo, Mr. K\u0026rsquo;Owino Desmond Otieno and Ms. Grace Nabagala for their statistical work done.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eUmaru, Kizito ; Tentena, Lincoln (2025), \u0026ldquo;Data For CLINICAL PERFORMANCE OF DIRECT POSTERIOR RESIN-COMPOSITE RESTORATIONS PLACED OVER A 5-YEAR PERIOD IN SELECTED INSTITUTIONS IN NAIROBI, KENYA\u0026rdquo;, Mendeley Data, V1, doi: 10.17632/pzxjh5368x.1\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBourdiol P, Hennequin M, Peyron MA, Woda A. Masticatory Adaptation to Occlusal Changes. 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Br Dent J. 1999;187(8):432\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7991828/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7991828/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Background: Dental resin composite, a tooth-coloured restorative material, is used to restore carious teeth. With its inception being for aesthetic reasons, the demand from patients, newer materials demand from clinicians and the amalgam phasedown have led to increased placement in load bearing posterior teeth. This study aimed at evaluating the clinical status of direct posterior resin composite restorations placed over a 5-year period in selected institutions in Nairobi, Kenya.\nMethods: Using 286 posterior resin composite restorations (RCRs) from 95 participants, a cross-sectional study was conducted at a public dental facility; Kenyatta National Hospital Dental Department (KNHDP), a teaching dental clinic; University of Nairobi Dental School (UoNDS), and a private dental facility; University of Nairobi Dental Plaza (UoNDP). Clinical evaluation was done visually using the United States Public Health Survey (USPHS) tool and data was analysed using STATA version 15(College Station TX, USA). Descriptive statistics, Pearson Chi-square and Fischer’s Exact tests were utilized for association between variables.\nResults: The study respondents were aged between 18- 66 with 50.5% (48/95) of them being male. The RCRs were between 0.25 and 5 years with 36% (103/286) from UoNDP, due to demand of private patients for more tooth-coloured restorations. RCRs in the maxillary arch were 55.6% (159/286) with 71.3% (204/286) being restorations in molars. Mesial-Occlusal/Distal Occlusal (MO/DO) dominated the surfaces restored at 50.7% (145/286) and the least restored surface found to be occlusal-buccal (OB) at 0.7% (2/286). General clinical status of the restorations assessed scored Bravo, followed by Alpha and the least being Charlie. Of the 7 USPHS parameters, Carvo-surface Marginal discolouration and surface texture showed a statistically significant association with the clinical status of the RCRs (p\u003c0.005).\nConclusions: The majority of the RCRs in this study had Alpha and Bravo restorations, which are clinically acceptable. Compared to UoNDP and KNHDD, there were more unsuccessful (Charlie) restorations reported at UoNDS. Restorations placed in mandibular teeth showed higher rates of failure than restorations placed in maxillary teeth. Restorations inserted into molar teeth performed better than those inserted into premolar teeth. The performance of occlusal restorations was superior to that of MOD, OB, and MO/DO restorations.","manuscriptTitle":"Retrospective Evaluation of the Clinical Status of Direct Posterior Composite Restorations in Selected Institutions in Nairobi, Kenya","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-22 09:22:20","doi":"10.21203/rs.3.rs-7991828/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-12-30T17:17:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325721725871917659214974258720991026210","date":"2025-12-21T17:29:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-12-12T18:55:24+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-18T10:53:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-14T10:51:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-14T10:48:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-10-30T17:43:14+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"af144ccd-d63d-4a36-b33c-4760861c9942","owner":[],"postedDate":"December 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-22T09:22:21+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-22 09:22:20","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7991828","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7991828","identity":"rs-7991828","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}