Posterior Composite Restorations – Theoretical and Practical Teaching of Undergraduate Students in Serbia and Abroad

Introduction Due to the educational process inertia based on textbook literature, teaching of undergraduate students in dental schools is often behind modern practice. From the aspect of minimally invasive dentistry, composites are materials of choice for the reconstruction of most lesions in posterior teeth. The objective of the study was to systematize data about theoretical and practical teaching of undergraduate students regarding the application of posterior resin composites in the world’s dental schools and compare it with the data obtained from the School of Dental Medicine, University of Belgrade. Material and Methods MEDLINE database was searched for articles based on keywords dental education and posterior composites. Only articles published in the last five years and those which used the same questionnaire were included in the study. Results Data were analyzed for the dental schools from the UK and Ireland, Spain, Japan, United States and Canada. Increased theoretical and practical teaching of students regarding posterior composites is noted in most schools. The dominant contraindication for using resin composite is allergy to its ingredients. Rubber dam is the most common method of providing aseptic conditions and dry field in the world, whereas in our school it is used in negligible number of cases. In a number of schools, metal matrices and wooden wedges are recommended for the proximal cavity restoration. Glass-ionomer cement is commonly used as a liner. Polishing and finishing of restorations is performed in the same session in 90-100% of the schools except in Japan, where it is carried out after 24 hours. Conclusion Theoretical and practical teaching of posterior composite restorations is increasing in the world’s dental centers. It is necessary to harmonize teaching in our school with international trends in the use of rubber dam, certain aspects of cavity design and protocols for the treatment of deep caries lesions.


INTRODUCTION
Contemporary knowledge in dentistry, as in most other areas, is transferred following the "top down" principle.The knowledge generated in academic centers from sci entific research is transferred to the users, general prac titioners through the continuous education, as well as to students, future practitioners, through undergraduate and graduate studies.In medical sciences the flow of scien tific knowledge from academic centers to daily practice is measured in years [1].At least two reasons have an impact on this phenomenon.The first reason is the need to con firm new knowledge through a number of "repetitions" or experimental studies of different researchers, before scientific truth is generally accepted.Even then, scientific truth has a temporary, not a permanent character and can be modified or even completely rejected in the light of new experimental findings and technological advances.Rarely, individual studies can contribute to great and rapid knowledge shift from academy to practice.
Another reason is the inertia of educational system based primarily on textbook literature.Textbooks adjust more slowly to developing science whereas scientific jour nals are more dynamic and more current due to more frequent "updates".Leading scientific journals are com monly published monthly while new editions of textbooks are published after several years.Not only that students are exposed to outdated knowledge, they also develop a model of slow acceptance of new knowledge.Current un dergraduate students will be practicing by mid 21 st cen tury.It is therefore important that they acquire uptodate knowledge at the beginning of their professional career.Also, they need to become aware of continuous and rapid changes in their work field so they can quickly and easily adapt new knowledge to their practice.Although aware ness of rapid development of science in modern society is more or less empirical, it should be professionally focused while critical thinking actively encouraged.
As a rule, the transfer of knowledge from academy to practice is faster than to education; therefore, there is a trend of dental education lag behind modern practice.An example is found in posterior composite restorations.The study done by Wilson and Setcos [2] showed that 10 years after introducing posterior composite restorations into the dental practice in Western countries, education about this new practice was rare.In as many as 90% of schools, posterior composites were not taught whereas in the rest of schools teaching was mainly at preclinical level.
Even today, the problem of educational lag behind practice has not been changed.Contemporary knowl edge suggests that composites possess adequate me chanical properties to be the material of choice for most cavities in posterior teeth.One of few contraindications is bruxism [3].A retrospective study of Opdam et al. [4] showed that composite restorations lifetime is similar to amalgam.However, a recent study done by Lynch et al. [5] revealed that majority of dental practitioners in the UK and Ireland still consider amalgam as material of choice for posterior teeth restorations.Even though the current study confirmed that both theoretical and practical teach ing of undergraduate students regarding composites has been significantly improved in the British and Irish dental schools in the last five years, it is clear that most of dental practitioners still work influenced by the knowledge ac quired in dental school.
Current literature confirms that researchers are inter ested in theoretical and practical teaching of posterior composite restorations.Studies in different countries in vestigate trends at regular intervals [6,7,8], while simi larly designed studies from different countries [2,711] allow comparison and identification of global trends.
The aim of this study was to systematize data from several international dental centers about theoretical and practical teaching of undergraduate students on the appli cation of posterior composite restorations and compare it with teaching at the School of Dental Medicine, University of Belgrade.

MATERIALS AND METHODS
In December 2012, MEDLINE database was searched for articles based on keywords dental education and posterior composites.Only articles published in the last five years in English in peerreviewed international journals indexed in the Journal Citation Report and journals with impact factors were taken into account.For easier comparison only studies which used surveys with the same questions were selected.

RESULTS
Of 34 studies found searching for two keywords, only five met given criteria.These five studies about composite res torations on posterior teeth were related to the teaching in dental schools in the UK and Ireland [5], Spain [12], Japan [13], United States and Canada [6].
The following aspects of theoretical and practical teaching were analyzed: (1) position of resin composite restorations in the curriculum (order and frequency of lectures and practice); ( 2 Tables 1-9 systematize data on certain theoretical and practical aspects of undergraduate teaching.Some schools indicated more than one answer; the difference to 100% can be attributed to the implementation of selfetch adhe sives.Japan is the only country where 4% of dental schools use "plasmaarc" lamps.
In the next five years it is expected that the order of lectures "amalgam and then composite" would still exist in 23% of dental schools in the UK and Ireland.Average time of preclinical teaching dedicated to composites is now about equal the time devoted to amalgams.In the next five years it is expected that the time dedicated to teaching composites will be twice longer than the time dedicated to amalgams.In Spain, the order of teaching "composite and then amalgam" is expected in 47% of schools, 27% state and 100% of private dental schools.Japan does not expect any changes in the next five years regarding the order of lectures.In US and Canada it is projected that 55% of dental schools will continue to teach amalgam first, and then composite.Currently, longer time is dedicated to techniques for amalgam placement in pre clinical teaching; however, it is expected to shorten time for teaching amalgam placement in favor of time for com posite restorations placement.School of Dental Medicine  in Belgrade had a practice to teach cavity preparation for amalgam first and then for composites, and in the sec ond semester to do clinical teaching in the same order.However, this year composite restorations were done first followed by amalgam.

DISCUSSION
Traditional approach to cavity preparation and posterior amalgam restorations teaching followed by lectures about the modification of Black's principles for posterior com posite restorations still exists in most schools in North America and Spain as well as in our country, whereas the BritishIrish and Japanese dental schools changed this approach in favor of composite.Interestingly, fewer private compared to public dental schools in Spain re tain a traditional approach indicating faster adjustment of private schools to everyday practice in order to reach competitiveness.
Education about composites may have a negative ef fect on the perception of students, future dentists, that mechanical principles of restoration have advantage over modern principles of minimally invasive dentistry.Lynch et al. [5] reported that most of British dentists still con sider amalgam as material of choice for posterior teeth.Teaching cavity preparation for composite restorations as a modification of classical Black's preparation puts clas   sical preparation for amalgam in the position of "gold standard" due to the decades of domination.Actually, minimally invasive preparation should be modern "gold standard" for reconstruction of occlusal and proximal le sions in posterior teeth, and not an alternative to Black's preparation [14].Adhesive type of preparation has its own principles [15,16] that should not be derived from Black's but should be considered separately and in accordance with their position in modern dentistry.
The most common contraindication for composite restorations is sensitivity to certain ingredients.Moisture control is given much more importance in North Ameri can schools where impossibility of placing rubber dam and subgingival cavity edges more often contraindicated composites than in other surveyed schools.Despite the theoretical understanding of the importance of rubber dam to control moisture, in our school this is not a con traindication for the placement of composites.Subgingival cavity edges do not represent contraindication for com posite restorations either; in such cases combined use of glassionomer cements and composites is recommended.Cavity size related to mechanical resistance of compos ites is listed as a contraindication in a number of North American and Japanese dental schools.This contraindica tion may be associated with lower resistance of composite to abrasion [17] compared to amalgam and enamel even though the addition of nanofillers significantly reduced vertical and total volumetric wear of composite [18].Caries risk is a contraindication in nearly half of North American dental schools whereas in other countries caries risk is not a contraindication.This is somewhat surprising given that the most common reason for replacing com posite restorations is caries [4,19].
Moisture control using rubber dam is present in most of dental schools, while the most appropriate replacement are cotton rolls and a special type of insulation splint (so called "dry guard").Opdam et al. [19] followed a fiveyear success of composite restorations class I and II placed by students and concluded that acceptable annual failure was 2.8% (in most cases rubber dam was used).There has not been any similar study in our country to assess the effect of moisture control with cotton rolls and aspirator on the success of posterior composite restorations.
In terms of margin design, low percentage of schools teach beveling of cavity edges.Earlier recommendation for beveling was based on better adhesive and enamel bond due to greater microretentive area.However, it has been confirmed that beveling did not improve bonding [20].In addition, there may be a thin layer of composite hinge on the inclined edge of enamel in areas that oc clude with antagonists raising the possibility of marginal discoloration and need for restoration correction.When a composite filling should be corrected or replaced, a bev eled marginal edge can make it difficult to identify cav ity walls leading to unnecessary removal of healthy hard dental tissue [6].
In most schools metal matrices and wooden wedges are used for reconstruction of proximal portion of the cavity.In a significant percentage transparent matrices and wedges are used which reduces the need for subse quent polymerization after the removal of metal matrices.While there is no perfect system, some studies have shown that metal matrices and wooden wedges provide better adaptation of composites and stronger proximal contact [21,22,23].
Lining the cavity using glassionomer cements with or without medicament based on calcium hydroxide is commonly used in North American, and rarely in Span ish dental schools.In majority of surveyed dental schools, glassionomer lining is used in deep cavity only.In our school, combined use of calcium hydroxide and glass ion omer lining is accepted for dentin protection in deep cav ity.Observed difference in theoretical teaching suggests that modern protocols are insufficient in the treatment of deep caries lesions.According to the former view, calcium hydroxide is a medicament of choice for the treatment of deep caries lesion [24].However, recent literature review has confirmed no difference in quantitative pulp response after lining deep cavities with resinmodified glass iono mer cement and calcium hydroxide [25].
Between 90% and 100% dental schools accept the concept of immediate polishing and finishing of com posite restorations, except in Japan, where nearly 50% of schools favor polishing and finishing after 24 hours.It is interesting that 40% of Japanese school support both concepts.Delayed polishing and finishing of composite restorations was previously explained by hygroscopic ex pansion of the material which compensates polymeriza tion contraction.However, a recent study of Versluis et al. [26] confirmed that this compensatory effect takes up to 4 weeks to occur.

CONCLUSION
Education on posterior composite restorations has an im portant place in the curriculum of undergraduate studies in accordance with modern understanding of minimally invasive dentistry.Theoretical and practical aspects of education common to the most of surveyed dental schools in the world are related to reduction of contraindications, moisture control using rubber dam, adhesive type of cav ity preparation with the exception of preventive extension, use of metallic matrices and wooden wedges, halogen and LED lamps, lining deep cavities and polishing and finish ing of composite restorations in the same session.There is a need for harmonization of education in our school with international trends in the use of rubber dam, certain aspects of cavity design and protocols for the treatment of deep caries lesions.

UVOD
Sa vre me ni tok zna nja u sto ma to lo gi ji, kao i ve ći ni dru gih obla sti, od vi ja se po prin ci pu "od vr ha na do le" (engl.top down).Zna nje stvo re no kroz na uč no i stra ži vač ki rad u aka dem skim cen tri ma pre no si se na ko ri sni ke -sto ma to lo ge prak ti ča re kroz kon ti nu i ra nu edu ka ci ju, a i na stu den te, bu du će prak ti ča re, kroz osnov ne i post di plom ske stu di je.U me di cin skim na u ka ma tok na uč nog sa zna nja od aka dem skog cen tra do sva ko dnev ne prak se me ri se go di na ma [1].Mo gu se iz dvo ji ti naj ma nje dva raz lo ga ko ji uti ču na ovu po ja vu.Pr vi raz log je neo p hod nost po tvr de no vog sa zna nja kroz ve li ki broj "po na vlja nja", od no sno eks pe ri men tal nih stu di ja raz li či tih is tra ži va ča, pre ne go što se pro gla si na uč nom isti nom.Čak i ta da, na uč na isti na ima pri vre me ni, a ne traj ni, ka rak ter i mo že se mo di fi ko va ti ili čak pot pu no od ba ci ti u sve tlu no vih eks pe ri men tal nih sa zna nja i teh no lo škog na pret ka.Vr lo ret ko po je di nač na is tra ži va nja do pri no se ve li kom i br zom po ma ku u zna nju od aka de mi je do prak se.
Dru gi raz log je tro most obra zov nog si ste ma, ko ji se za sni va pre te žno na udž be nič koj li te ra tu ri.Udž be ni ci se spo ri je pri la go đa va ju raz vo ju na u ke od na uč nih ča so pi sa, ko ji su znat no di na mič ni ji i ak tu el ni ji jer če šće "ažu ri ra ju" po dat ke.Vo de ći na uč ni ča so pi si obič no iz la ze na me seč nom ni vou, dok se no va iz da nja udž be ni ka ob ja vlju ju na kon ne ko li ko go di na.Osim što do stu de na ta mo gu sti ći "pre va zi đe na" zna nja, ova kvim si ste mom se pre u zi ma i mo del spo rog usva ja nja no vih sa zna nja.Stu den ti ko ji su da nas na osnov nim stu di ja ma bi će rad no ak tiv ni do sre di ne 21. ve ka.Za to je ve o ma va žno da se stek nu naj sa vre me ni ja zna nja na po čet ku pro fe si o nal nog pu ta, ali i da se raz vi je svest o stal nim i br zim pro me na ma u obla sti ko jom se ba ve, ka ko bi mo gli br že i lak še da ih pri la go de svo joj prak si.Iako je svest o br zom raz vo ju na u ke u sa vre me nom dru štvu ma njevi še em pi rij ska, tre ba lo bi da bu de i pro fe si o nal no usme re na, a kri tič ko mi šlje nje ak tiv no po dr ža no.
Tran sfer zna nja iz aka de mi je je, po pra vi lu, br ži u prak su ne go u na sta vu, pa po sto ji i trend za o sta ja nja sto ma to lo ške edu ka ci je za sa vre me nom prak som.Pri mer za to je re sta u ra ci ja boč nih zu ba kom po zit nim ma te ri ja li ma.Stu di ja Vil so na (Wil son) i Set ko sa (Set cos) [2] je po ka za la da je to kom pr vih de se tak go di na otkad je po če la ova prak sa u za pad nim ze mlja ma na sta va u sve tu bi la vr lo skrom na.U čak 90% ško la ni je bi lo pre da va nja o kom po zit nim is pu ni ma na boč nim zu bi ma, dok je u pre o sta lim ško la ma ona bi la pre te žno na pret kli nič kom ni vou.
Pro blem za o sta ja nja edu ka ci je za prak som ni je se pro me nio ni do da nas.Sa vre me na sa zna nja uka zu ju na to da kom po zi ti ima ju od go va ra ju ća me ha nič ka svoj stva, da se mo gu ko ri sti ti kao ma te ri jal iz bo ra za ve ći nu ka vi te ta na boč nim zu bi ma, pri če mu iz ra zi to op te re će nje, po put bruk si zma, pred sta vlja jed nu od ret kih pre o sta lih kon tra in di ka ci ja [3].Re tro spek tiv na stu di ja Op da ma (Op dam) i sa rad ni ka [4] po ka zu je da je vek tra ja nja kom po zit nih is pu na sli čan amal gam skim.Ipak, ne dav na stu di ja Lin ča (Lynch) i sa rad ni ka [5] ot kri va da ve ći na sto ma to lo ga prak ti ča ra u Ve li koj Bri ta ni ji i Ir skoj i da lje sma tra amal gam ma te ri ja lom iz bo ra za re sta u ra ci ju boč nih zu ba.Iako ova stu di ja po ka zu je da su i na sta va i prak ti čan rad s kom po zi ti ma zna čaj no na pre do va li u bri tan skim i ir skim ško la ma u po sled njih pet go di na, ja sno je da ve ći na sto ma to lo ga prak ti ča ra još ni je pro me ni la shva ta nja ste če na na stu di ja ma.Do sa da šnja li te ra tu ra po ka zu je in te re so va nje is tra ži va ča za te o rij sku i prak tič nu na sta vu o pri me ni kom po zi ta na boč nim zu bi ma.Stu di je u po je di nim ze mlja ma pra te tren do ve u pra vil nim vre men skim in ter va li ma [6,7,8], a slič no osmi šlje ne stu di je iz raz li či tih ze ma lja [2,711] omo gu ća va ju po re đe nje i uoča va nje glo bal nih tren do va.Cilj ra da je bio da se si ste ma ti zu ju po da ci iz ne ko li ko svet skih cen ta ra o te o rij skoj i prak tič noj na sta vi stu de na ta osnov nih stu di ja sto ma to lo gi je o pri me ni kom po zi ta u boč noj re gi ji i upo re de s edu ka ci jom na Sto ma to lo škom fa kul te tu Uni ver zi te ta u Be o gra du.

MATERIJAL I METODE RADA
U de cem bru 2012.pre tra že na je ba za po da ta ka ME DLI NE pre ma ključ nim re či ma den tal edu ca tion i po ste ri or com po si tes.Ana li zi ra na su sa mo is tra ži va nja ob ja vlje na na en gle skom je zi ku u po sled njih pet go di na u me đu na rod nim ča so pi si ma s re cen zi jom ko ji su in dek si ra ni u Jo ur nal Ci ta tion Re port, od no sno u ča so pi si ma s im paktfak to rom.Ra di po re đe nja po da ta ka, oda bra na su is tra ži va nja ra đe na u vi du an ke te u ko ji ma su po sta vlja na ista pi ta nja.

REZULTATI
Od 34 stu di je do bi je ne pre tra ži va njem po dve ma ključ nim re či ma, pet je od go va ra lo za da tim kri te ri ju mi ma.Ove stu di je se od no se na edu ka ci ju o po sta vlja nju kom po zi ta na boč ne zu be u ško la ma u Ve li koj Bri ta ni ji i Ir skoj [5], Špa ni ji [12], Ja pa nu [13], Sje di nje nim Ame rič kim Dr ža va ma i Ka na di [6].
Tra že ni po da ci se od no se na sle de će aspek te te o rij ske i prak tič ne na sta ve: 1) po zi ci ja edu ka ci je o kom po zi ti ma u na sta vi (re do sled pre da va nja i uče sta lost prak se); 2) kon tra in di ka ci je za po sta vlja nje kom po zi ta u po ste ri or noj re gi ji; 3) me to de za kon tro lu vla ge; 4) ob ra da ka vi te ta; 5) ma tri ce i ko či ći; 6) za šti ta eks po ni ra nog den ti na; 7) ma te ri ja li; 8) sve tlo sni iz vo ri; 9) za vr šna ob ra da is pu na; 10) in di rekt ni is pu ni i 11) ce ne uslu ga na stu dent skim ve žba ma.
Ta be le 1-9 si ste ma ti zu ju po dat ke o po je di nim te o rij skim ili prak tič nim aspek ti ma obra zo va nja stu de na ta.Ne ke ško le su na ve le vi še od go vo ra; raz li ka do 100% se mo že pri pi sa ti pri me ni sa mo na gri za ju ćih ad he zi va.Ja pan je je di na is pi ti va na ze mlja gde se u 4% ško la pri me nju ju i tzv.pla sma-arc lam pe.
U na red nih pet go di na u Ve li koj Bri ta ni ji i Ir skoj se oče ku je da će re do sled pre da va nja o amal ga mu pa o kom po zi ti ma i da lje po sto ja ti u 23% ško la.Pro seč no vre me na pret kli nič kim pre da va nji ma po sve će no kom po zi ti ma sa da je pri bli žno vre me nu ko je je po sve će no amal ga mi ma.U na red nih pet go di na se oče ku je da će vre me po sve će no pre da va nju o kom po zi ti ma u od no su na vre me po sve će no amal ga mi ma bi ti 2:1.U Špa ni ji se re do sled pre da va nja o kom po zi ti ma pa o amal ga mu oče ku je u 47% ško la (27% dr žav nih i 100% pri vat nih).U Ja pa nu se ne oče ku je pro me na ak tu el nog re do sle da pre da va nja u na red nih pet go di na.U SAD i Ka na di se pred vi đa da će 55% ško la na sta vi ti s pre da va nji ma pr vo o amal ga mu, a za tim o kom po zi ti ma.Tre nut no se vi še vre me na po sve ću je teh ni ka ma po sta ve amal gam skih is pu na na pret kli nič kim ve žba ma, ali se oče ku je skra će nje edu ka ci je o amal ga mu u ko rist vre me na za ve žba nje po stav ke kom po zit nih is pu na.Na Sto ma to lo škom fa kul te tu u Be o gra du je do ove škol ske go di ne bi la prak sa da se pr vo pre da je pre pa ra ci ja ka vi te ta za amal gam, za tim za kom po zit, a da se u dru gom se me stru spro vo di re sta u ra ci ja pre pa ri sa nih zu ba istim re dom, dok je u ovoj škol skoj go di ni ra đe na re sta u ra ci ja zu ba pr vo kom po zi tom, a na kon to ga amal ga mom.

DISKUSIJA
Tra di ci o nal ni pri stup pre da va nju pre pa ra ci je ka vi te ta i re sta u ra ci ji boč nih zu ba amal ga mi ma iza ko jih sle di pre da va nje o mo di fi ka ci ji Ble ko vih prin ci pa za re sta u ra ci ju boč nih zu ba kom po zi ti ma i da lje po sto ji u ve ći ni ško la u Se ver noj Ame ri ci i Špa ni ji, kao i kod nas, dok je u bri tan skim, ir skim i ja pan skim ško la ma ovaj pri stup pro me njen u ko rist kom po zi ta.Za ni mlji vo je da je ma nje pri vat nih ne go dr žav nih ško la u Špa ni ji za dr ža lo tra di ci o nal ni pri stup, što uka zu je na br že pri la go đa va nje pri vat nih ško la sva ko dnev noj prak si ra di ve će kon ku rent no sti.
Po zi ci ja na sta ve o kom po zi ti ma u od no su na amal gam mo že lo še uti ca ti na shva ta nje stu de na ta, bu du ćih sto ma to lo ga, da me ha nič ki prin ci pi re sta u ra ci je ima ju pred nost nad sa vre me nim prin ci pi ma mi ni mal no in va ziv ne sto ma to lo gi je.Na ovo uka zu je po da tak Lin ča i sa rad ni ka [5] da ve ći na bri tan skih sto ma to lo ga i da lje sma tra amal gam ma te ri ja lom iz bo ra za boč ne zu be.Pre da va nje pre pa ra ci je ka vi te ta za kom po zit kao mo di fi ka ci je kla sič ne Ble ko ve pre pa ra ci je za amal gam sta vlja kla sič nu pre pa ra ci ju u po zi ci ju tzv.zlat nog stan dar da zbog vi še de ce nij ske do mi na ci je.Me đu tim, za pra vo je mi ni mal no in va ziv na pre pa ra ci ja sa vre me ni "zlat ni stan dard" za re kon struk ci ju oklu zal nih i prok si mal nih le zi ja boč nih zu ba, a ne al ter na ti va kla sič noj Ble ko voj pre pa ra ci ji [14].Ad he ziv ni tip pre pa ra ci je ima svo je prin ci pe [15,16], ko je ne bi tre ba lo iz vo di ti iz Ble ko vih, već bi ih tre ba lo raz ma tra ti odvo je no i u skla du s nji ho vim mestom u sa vre me noj sto ma to lo gi ji.
Naj če šća kon tra in di ka ci ja za po sta vlja nje kom po zi ta je pre o se tlji vost pa ci jen ta na po je di ne sa stoj ke ovih ma te ri ja la.Kon tro li vla ge se pri da je znat no ve ći zna čaj u se ver no a me rič kim ško la ma, pa su ta ko ne mo guć nost po sta vlja nja ko fer da ma i sub gin gi val nih rub nih ka vi te ta znat no če šće kon tra in di ka ci je u ovim ne go u dru gim an ke ti ra nim ško la ma.Upr kos te o rij skom shva ta nju zna ča ja ko fer da ma u kon tro li vla ge kod nas, ovo ni je kon tra in di ka ci ja za po sta vlja nje kom po zi ta, kao ni sub gin gi val ni rub ka vi te ta, ka da se pre po ru ču je kom bi no va na pri me na gla sjo no merce men ta (GJC) i kom po zi ta.Ve li či na ka vi te ta ko ja bi se mo gla do ve sti u ve zu s me ha nič kom ot por no šću kom po zi ta na vo di se kao kon tra in di ka ci ja u ve ćem bro ju se ver no a me rič kih i ja pan skih ško la.Ova kon tra in di ka ci ja se mo že do ve sti u ve zu s ma njom ot por no šću kom po zi ta na abra zi ju od amalgama [17] i na ro či to gle đi, iako do da va nje na no pu ni la ca znat no sma nju je ver ti kal no i ukup no vo lu me trij sko tro še nje kom po zi ta [18].Ri zik od ka ri je sa je kon tra in di ka ci ja u sko ro po lo vi ni se ver no a me rič kih ško la, dok je u dru gim ze mlja ma ređi.Ovaj po da tak je do ne kle neo če ki van ima ju ći u vi du da se kao naj če šći raz log za me ne kom po zi ta na vo di upra vo ka ri jes [4,19].
Kon tro la vla ge ko fer da mom se na vo di u na sta vi u naj ve ćem bro ju ško la, a naj pri hva tlji vi je za me ne su va te rol ne i po se ban tip izo la ci o nog splin ta (tzv.dry gu ard).Op dam (Op dam) i sa rad ni ci [19] su ana li zi ra li pe to go di šnji uspeh stu de na ta u po sta vlja nju kom po zit nih is pu na I i II kla se i za klju či li da je pri hva tljiv go di šnji pro ce nat ne u spe ha od 2,8%, pri če mu je u ve ći ni slu ča je va ko ri šćen ko fer dam.Kod nas ne po sto ji slič na stu di ja ko ja bi uka za la u ko joj me ri kon tro la vla ge va te rol na ma i si salj kom uti če na uspeh kom po zit nih is pu na na boč nim zu bi ma.
U po gle du ob li ko va nja ka vi te ta, naj ma nji pro ce nat an ke ti ra nih ško la po dr ža va za ko ša va nje ru bo va ka vi te ta.Ra ni je pre po ru ke za za ko ša va nje su is ti ca le bo lju ve zu ad he zi va i gle đi zbog ve će mi kro re ten tiv ne po vr ši ne, ali je po ka za no da za ko ša va nje ne uti če na kva li tet rub nog zap ti va nja [20].Osim to ga, mo že do ći do od la ma nja tan kog slo ja kom po zi ta na za ko še nom gleđ nom ru bu u zo na ma ko je oklu di ra ju s an ta go ni sti ma, što po ve ća va mo guć nost mar gi nal ne dis ko lo ra ci je i po tre bu za ko rek ci jom is pu na.Pri li kom ko rek ci je ili za me ne is pu na za ko ša va nje gleđ nog ru ba mo že ote ža ti iden ti fi ka ci ju pra vih di men zi ja ka vi te ta i do ve sti do ne po treb nog ukla nja nja zdra vog zub nog tki va [6].
U naj ve ćem bro ju ško la se za re kon struk ci ju prok si mal nih de lo va ka vi te ta ko ri ste me tal ne ma tri ce i dr ve ni ko či ći.U znat nom pro cen tu ko ri ste se i tran spa rent ne ma tri ce i ko či ći ko ji pro vo de sve tlost, či me se sma nju je po tre ba za na knad nim pro sve tlja va njem na kon ski da nja me tal nih ma tri ca.Iako ne po sto ji ide a lan si stem, is tra ži va nja po ka zu ju da me tal ne ma tri ce i dr ve ni ko či ći omo gu ća va ju bo lju adap ta ci ju kom po zi ta i ja či prok si mal ni kon takt [21,22,23].
Pod la ga nje ka vi te ta sa GJC sa me di ka ment nom pod lo gom na ba zi kal ci jumhi drok si da ili bez nje naj če šće se pri me nju je u se ver no a me rič kim, a naj re đe u špan skim ško la ma.U naj ve ćem pro cen tu an ke ti ra nih ško la u sve tu kod du bo kih ka vi te ta se pri me nju je sa mo pod lo ga na ba zi GJC.Kod nas se pri me nju je pro to kol kom bi no va ne kal ci jumhi drok sid ne i GJC za šti te den ti na kod du bo kih ka vi te ta.Uoče ne raz li ke u na sta vi uka zu ju na iz o sta nak sa vre me nog pro to ko la za le če nje du bo kog ka ri je sa.Pre ma ra ni jem shva ta nju, kal ci jumhi drok sid je me di ka ment na pod lo ga iz bo ra u te ra pi ji du bo kih ka ri je sa [24].Me đu tim, ne dav ni pre gled li te ra tu re po ka zao je da ne ma raz li ke u kvan ti ta tiv nom od go vo ru pul pe na kon pod la ga nja du bo kih ka vi te ta GJC mo di fi ko va nim smo lom i kal ci jumhi drok si dom [25].
Iz me đu 90% i 100% an ke ti ra nih ško la za stu pa kon cept neo d lo žne za vr šne ob ra de kom po zit nih is pu na, osim u Ja pa nu, gde se u sko ro 50% ško la fa vo ri zu je is klju či vo za vr šna ob ra da na kon 24 ča sa.Za ni mlji vo je da 40% ja pan skih ško la za stu pa oba kon cep ta.Od lo že na za vr šna ob ra da kom po zit nog is pu na ima la je svo je upo ri šte u shva ta nju o hi gro skop noj eks pan zi ji ma te ri ja la ko jom se kom pen zu je po li me ri za ci o na kon trak ci ja, me đu tim, ne dav no is tra ži va nje Ver slu i ja (Ver slu is) i sa rad ni ka [26] po ka zu je da su za ovaj kom pen za tor ni efe kat po treb ne če ti ri ne de lje.

ZAKLJUČAK
Pre da va nja o kom po zit nim is pu ni ma na boč nim zu bi ma za u zi ma ju zna čaj no me sto u na sta vi osnov nih stu di ja sto ma to lo gi je u skla du sa sa vre me nim shva ta njem mi ni mal no in va ziv ne sto ma to lo gi je.Aspek ti te o rij ske i prak tič ne na sta ve ko ji su za jed nič ki za naj ve ći broj an ke ti ra nih ško la u sve tu od no se se na sma nji va nje kon tra in di ka ci ja, kon tro lu vla ge ko fer da mom, ad he ziv ni tip pre pa ra ci je ka vi te ta sa od stu pa njem od pre ven tiv ne eks ten zi je, ko ri šće nje me tal nih ma tri ca i dr ve nih ko či ća, ha lo ge nih i LED lam pi, pod la ga nje du bo kih ka vi te ta i za vr šnu ob ra du is pu na u is toj se an si.Uoče na je po tre ba za uskla đi va njem na stav nog pro gra ma kod nas s me đu na rod nim tren do vi ma u po gle du upo tre be ko fer da ma, po je di nih aspe ka ta ob ra de ka vi te ta i pro to ko la za le če nje du bo kog ka ri je sa.

Table 1 .
Position of composite education in the curriculum (order of pre-clinical lectures and structure of clinical practice)

Ta be la 1. Mesto
edu ka ci je o kom po zi ti ma u na sta vi (re do sled pre da va nja na pret kli ni ci i struk tu ra kli nič ke prak se)

Table 2 .
Contraindications for the use of composites in occlusal and occluso-proximal cavities Ta be la 2. Kon tra in di ka ci je za pri me nu kom po zi ta na oklu zal nim i oklu zo prok si mal nim ka vi te ti ma

Table 4 .
Cavity designTa be la 4. Ob li ko va nje ka vi te ta

Table 5 .
Application of various types of matrices and wedges in students' clinical work Ta be la 5. Pri me na ra znih vr sta ma tri ca i ko či ća na stu dent skim ve žba ma

Table 6 .
Protection of exposed dentin before placing a composite filling Ta be la 6. Za šti ta eks po ni ra nog den ti na pre po sta vlja nja kom po zit nog is pu na

Table 7 .
Composite materials used in students' clinical work Ta be la 7. Kom po zit ni ma te ri ja li ko ji se ko ri ste na stu dent skim ve žba ma

Table 8 .
Light sources used in students' clinical work Ta be la 8. Sve tlo sni iz vo ri ko ji se ko ri ste u prak tič nom ra du stu de na ta * percentage of Japanese schools that use both type of lamps * procenat japanskih škola koje koriste obe vrste lampi

Table 9 .
Polishing and finishing of composite restorations Ta be la 9. Za vr šna ob ra da kom po zit nih is pu na