Community social responsibility of continued and appropriate use of silver amalgam as dental restorative material in southern India: A cross-sectional study

Background For more than 150 years, dental amalgam (DA) has been popular as a dental restorative material. Many organizations oppose its use due to perceived toxicity and environmental concerns. Hence, this study aimed to explore the continued use of DA from a South Indian dental practitioners’ perspective. Methods This cross-sectional study was conducted among fifty-two private and public dental practitioners of Udupi district in Southern India. A self‑administered questionnaire was distributed, that involved assessment of their preferences, continuation of use and concerns of using DA as a restorative material. The percentage contribution of each variable was calculated. Preferences for continuation of use of silver amalgam based upon the age, experience and mercury toxicity as a risk factor were analyzed using Students-t test and Fisher’s Exact Test test. Results Most dentists were satisfied (87%) with the results of the DA, found minimal failures (96%) and found DA more economical (89%). More than half (54%) of the participants reported that they would not continue the use of DA owing to mercury toxicity and environmental concerns. Dentists with higher age and longer clinical experience preferred continuation of DA. Conclusions Despite satisfaction with DA for its minimal failure, longevity and affordability, the authors found that most practitioners did not prefer its continued usage. This highlights their concerns over mercury toxicity and soft tissue lesions and accentuates their community social responsibility. There is also an urgent need to educate dentists on mercury hygiene, mercury waste management and disposal.


Introduction
Dental amalgam (DA) has been popular as a restorative material for more than 150 years particularly in large cavities, owing to tremendous mechanical properties and durability.It makes up for seventy-five percent of all dental restorations performed across the world [Bharti et al., 2010].DA is a combination of alloy particles and elemental mercury.The usage of the "silver paste" was first found in the Chinese medical texts written by Su Kung in 659 AD [Hsi-T'ao, 1958].
In early 1800s, D'Arcet Mineral Cement was developed in France, which is regarded as the first dental amalgam [Magkert, 1991].The use of room temperature mixed amalgam as a dental restorative material was formerly advocated by Bell in England (1819) and Traveau in France ( 1826) [Frykholm, 1957 andGreener, 1979].
Functionally and financially, DA has been a source of great comfort for the common man.The plasticity and strength of the restorative material is a quality that has made dental practitioners utilize it not just for regular restorative work, but also for the making of dental Inlays and Onlays [Bharti et al. 2010].
In recent times, we have noticed a 'phase-down' of DA in many parts of the world [Espelid et al., 2006;Al-Asmar et al., 2019;Spencer, 2000;Brennan and Spencer, 2003] have reported reducing use of DA in recent times [Brennan and Spencer, 2003].In a study conducted by Al-Asmar et al., shift to aesthetic restorations were seen among the dentists.
In another study, DA usage was reduced, yet constituted more than half of the restorations during the 5-year period under review [Umesi, Oremosu and Makanjuola, 2020].
Since the beginning there have been debates around its usage.In 1833, the Crawcour brothers introduced a newer version of DA "The Royal Mineral Succedaneum" to America that resulted in multiple failed amalgam restorations that sparked the "First Amalgam War" in 1845 [Molin, 1992].The American Society of Dental Surgeons condemned amalgam usage as malpractice and if used, member would be expelled from the society [Mosteller, 1961].The criticism of amalgam gradually muted with improved handling and performance of the amalgam versions put forth by Elisha Townsend, J Foster Flagg and G.V. Black [Flagg, 1843;Cannon et al., 1985].The "Second Amalgam War" resulted from the writings of Dr Alfred Stock, who was poisoned with mercury through the twenty-five years of exposure to the metal [Weiner, Nylander and Berglund, 1990].A committee was appointed to study allegations, which concluded that amalgam has a rightful place in dentistry and that there was no reason to stop its use [Eames, 1959].The current controversy popularly known as "Third Amalgam War" stemmed from the words of HA Huggins in 1973 who suspected that everything from leukemia to bowel disorders could be due to patient's reaction to mercury [Huggins, 2007].The Consumer Report of 1986 exposed this anti -amalgam movement that subsided this controversy.Again, the "60 Minutes" TV program re-intensified the issue again thereby creating considerable public alarm [Dodes, 2001].
Mercury is present in abundance in the natural environment and a substantial number of people are exposed to it in various ways [Dodes, 2001].Yet, any symptoms of unknown etiology have been frequently linked to water fluoridation and dental amalgam restorations [Boyd et al., 1991;Huggins, 2007].
In recent times, various organizations around the world have attempted to reduce the usage of DA.Its usage is brought down after the Minamata convention, a global health and environment treaty that governs the mining, usage and trade in mercury.It entreats for "phase down of dental fillings using mercury amalgam".It included various strategies like "aiming at dental caries prevention and use of mercury-free dental restoration alternatives and on promoting best management practices.As well as promoting the use of best environmental practices in dental facilities to reduce release of mercury and mercury compounds to water and land" [Minamata Convention, 2014].
The European Commission's Scientific Committee on Health and Environmental Risks ("SCHER") authenticates that "dental amalgam in the environment can methylate (forming methylmercury, which is the most toxic form of mercury)" [SCHER, 2014].In 2015 the European Commission's Scientific Committee on Emerging and Newly Identified Health Risks ("SCENIHR") changed their stance from amalgam is "a safe and effective restorative material" to that amalgam is only "an effective restorative material" [SCENIHR, 2014[SCENIHR, , 2015]].Based on these, the European Union has accorded the "Berlin declaration" in 2017 to end amalgam use in Europe by 1 July 2022 [Berlin Declaration, 2017].

REVISED Amendments from Version 4
We have now applied Fisher's Exact Test as a replacement of Chi-square test, since the expected frequencies of few cells were less than 5 (Table 5).We have also mentioned Confidence Intervals for proportions (Tables 1 & 2).
In contrast, there is vast research done that supports DA usage and provides scientific evidence for its safety [Heggland et al., 2011;Melchart et al., 2008;Woods et al., 2008].Many other organizations too contradict the above standpoint of SCHER and SCENIHR [U.S.Food and Drug Administration, 2020; National Institute of Health, 2006; Alzheimer's myths; Uçar and Brantley, 2017].No correlations were found between exposure to DA and neuropsychological and renal functions in many randomized trials done all over the world [Bellinger et al., 2006;Barregard, Trachtenberg, and McKinlay, 2008;Lauterbach et al., 2008].A systematic review and meta-analysis conducted by Aminzadeh and Etminan did not provide evidence for or against an association between the presence of DA restorations and multiple sclerosis [Aminzadeh and Etminan, 2007].
Studies did not find any association between urinary mercury concentrations among dentists and dental nurses with selfreported memory disturbance or mercury vapors in the dental office with cytogenetic damage to leukocytes [Ritchie et al., 2004;Atesagaoglu et al., 2006].
The U.S. Given the dual stance of dental amalgam usage by various organizations around the world, and notable reduction in DA usage over the years by dental practitioners, we wanted to explore the continued usage of silver amalgam as a tooth restorative material, from South Indian dental practitioners' perspectives in an unbiased manner.

Ethics statement
This study was initiated after approval from the Kasturba Medical College and Kasturba Hospital Institutional Ethics Committee [dated 12/2018; Reference No. 569], which is the ethical committee for MAHE University.The study was conducted in agreement with the World Medical Association Declaration of Helsinki, 1975.Prior to the start of study, a signed informed consent for participating in the study and reuse of anonymized data was received from each participant.

Study design
A cross-sectional study was conducted over a duration of sixteen weeks in 2019 from second week of January to second week of May across various dental practices in the district of Udupi in alliance with Indian Dental Association, Udupi district branch, in Southern India.The inclusion criteria for the study participants were (i) Government or private practitioners (ii) Dental practitioners who have the willingness and who consented to participate in the study.The exclusion criteria for the study were: (i) those practicing for less than 5 years; and (ii) inability/unwillingness to participate in the study.
A total of one hundred and thirty-four (134) dental practices encompassing all the seven 'Taluks' were identified.Since it was a small population size, a complete enumeration of the study population was done.They were assessed on questions relating to their opinions of using DA.
Private dental clinics: The list of registered practitioners in Udupi district as per the Karnataka State Dental Council Registration list was used as a reference document for contacting the clinics individually.Access to this list was granted after the authors submitted a request to the Karnataka State Dental Council.Names and mail addresses were also obtained from the list of the largest non-governmental dental organization in India, namely the Indian Dental Association, Udupi branch.Access to this list was granted after the authors submitted a request to the Indian Dental Association.
Public health care centers: Oral health delivery in public sector is unified into the existing public hospital setups and is available from community health centers and district hospitals.So, we included practitioners from six Community Health Centers (CHCs) and the district hospital, details of the same obtained from official portal of Karnataka State Health Ministry (District wise Hospital details with facilities).
After excluding those not fulfilling the inclusion criteria, ninety-two (92) participants were available for the study.Due to the small population size, we included all the practitioners, public and private, in the study.
Questionnaires were distributed through email and communication network of IDA Udupi District branch.We attempted to contact non-respondents during the conduct of four Continuing Dental Education programs for dental practitioners to ensure maximum participation of respondents.
A self-administered questionnaire [Nayak, 2022] assessing the practitioners' preferences, continuation of use and concerns of using DA as a restorative material was developed based on similar studies [Brennan and Spencer, 2003;Maciel et al., 2017;Espelid et al., 2006].Four subject experts checked the face validity and content validity of questions and finalized the questionnaire.A pilot survey was conducted among 15 dentists working in an academic setting to confirm the needed background preparations and clarity of specific terms in questionnaire that could seem unclear.
The findings and responses of pilot study were found to be favorable, facilitating the initiation of the larger planned study.
Their responses, however are not included in the study results.
The questionnaire consisted of two sections: (a) Four questions on respondents' demographic and professional particulars: age, gender, qualification and type of practice and (b) fourteen closed-ended questions regarding duration of DA usage and preferences for DA over other restorative materials, preferred type of cavity for DA usage, experiences regarding ease of use, longevity, failures, soft tissue lesions and mercury toxicity during DA usage as well as on patient affordability and satisfaction of DA.

Statistical analysis
Responses were documented on Microsoft Excel and data analysis was performed using IBM Statistical Package for the Social Sciences (SPSS) version 26 (IBM Corp., Armonk, N.Y., USA).The percentage contribution was obtained for each significant variable.Preferences for continuation of use of silver amalgam based upon the age of dentists has continuous variables, so analysis was done using Students t-test.Since the sample was small, Shapiro Wilk test was done was performed, which did not show evidence of non-normality (W = 0.78, p-value = 0.26).Results of preferences for the use of DA by practitioners, duration and satisfaction of usage of DA, experiences regarding longevity, their perceptions on the risks associated with DA and patient satisfaction of restorations were analyzed using Fisher's Exact test at 5% level of significance.

Results
As the population size was small, a complete enumeration of all the 134 dental practitioners was done.Of these, only Ninety-two practitioners fulfilled the inclusion criteria, and hence were included in the study.Out of them, 52 dental practitioners responded (Response rate 55.9%).About the gender distribution, there were equal number of male and female participants (26 out of 52 each).The mean age group of study population was 34.9 years.
Table 1 describes the experience and satisfaction for DA use among practitioners.About 77% of participants reported that they have been using DA for less than ten years and 87% participants were very satisfied/satisfied with its use.The longevity of DA is highly appreciated by the dental practitioners as 44% and 48% participants found the longevity "Very Good" and "Good" respectively.Most of them reported that their patients were 'very satisfied' and 'satisfied' (76.9% and 15.4% respectively) of the DA restorations.Table 2 describes the opinions and preferences of practitioners for DA usage.Regarding the ease of use, equal number (48% each) of participants found it "easy to use" and "difficult and cumbersome".When asked about the type of cavity for which they would prefer to use DA, 46 (59.6%) participants responded that they would use it for medium and large cavities.They also reported that DA is the material of choice economically as 89% of participants found it economical and 98% found it affordable by patients.Yet, 54% of the participants reported that they would not suggest the use of DA compared to other tooth-colored restorations.Table 3 elucidates the perception and awareness for DA use as a risk factor.It was found that nearly 94% were aware of mercury toxicity concerns.Moreover, 46% and 37% participants felt that using DA as a restorative material could pose a risk factor for pregnant women and children respectively.
Preference for continued usage of DA based upon the age of dentists, showed statistically significant differences, with older practitioners preferring DA more (Table 4).Likewise, a significantly greater number of experienced practitioners preferred continued use of DA as well as being very satisfied with DA usage (Table 5).

Discussion
Silver amalgam as a dental restorative material has survived time and has successfully competed with various toothcoloured restorations in the market [Roulet, 1997;Antony et al., 2008].The longevity of the restoration, an extensive record of minimal failures in addition to being one of the most economic dental materials in the market, makes dentists and patients opt for the product especially in developing nations like India [Ukrainian Religious Studies, 1996;Maciel et al., 2017;Peretz and Ram, 2002].Hence, this study was conducted to explore the continued use of silver amalgam for dental restorations, from a South Indian dental practitioner's perspective in an unbiased manner.
In our study we witnessed that although most dentists were satisfied with longevity, minimal failures of DA restorations and cost-effectiveness, more than 50% of them reported that they would not suggest dental amalgam over other toothcolored restorations.Reported continuation of DA usage is lesser in our study as compared to previous studies [Maciel et al., 2017;Peretz and Ram, 2002].This can be owed to their concerns over mercury toxicity, as 94% of practitioners were aware of its impact on the environment.Presence of environmental Mercury results in microbial antibiotic resistance, which in turn propounds health risk to humans and animals [Rahman and Singh, 2018].This is in line with Minamata Convention that calls for reduction of DA usage [Minamata Convention, 2014].Moreover, it was found from our study that tooth-colored restorations were preferred mostly by younger dentists as compared to older practitioners which could be due to comfortable working time and better aesthetics.
In contrast, more dentists with higher age and longer clinical experience preferred continuation of DA.This could be due to greater experience and confidence in handling DA.Other reasons for their preferences for DA usage could be cost effectiveness, minimal failures and patient affordability.These findings are comparable with other studies conducted by Maciel et al. [2017], Espelid et al. [2006] and Peretz and Ram [2002].In our study, more than half of them preferred DA usage in medium and large cavities.This is in accordance with studies that show ineffectiveness of DA in very large cavities owing to higher chances of overhanging margins in proximal restorations [Ghulam and Fadel, 2018].This could be due to the exceptional mechanical properties of DA over others as well as aggravation of pain and sensitivity with composite restorations in deeper cavities.However, a shift in the concept of 'extension for prevention' to a modern 'minimally invasive approach' with newer self-adhesive materials has further reduced the use of DA.This could be the reason for significantly lower preference for DA among younger practitioners.Further, not being aesthetic as compared to other restorations, DA also causes local soft tissue lesions like amalgam tattoo and lichenoid reaction and can trigger hypersensitivity and autoimmune disorders [Ghulam and Fadel, 2018].This was like the results in our study, where 40% of practitioners had experienced soft tissue lesions due to DA restorations.
We observed that in the government run CHCs, none of the dentists are currently using DA.This can be attributed to (i) low rates of dental auxiliary recruitment at the CHCs, who are very much needed for handling of DA. (ii) nonavailability of amalgam triturators in the government hospitals, (iii) Government's support for the Minamata convention.
There is also an attempt to move towards phase-down of DA restorations in the governmental sector.
Moreover, the study results show that the practitioners lacked extensive knowledge on mercury toxicity, as not many of them felt that they could pose a risk factor for pregnant women and children.However, more than 90% of them expressed their concerns over mercury toxicity on environment.This highlights their concerns over mercury toxicity and soft tissue lesions and accentuates their community social responsibility.That is, even though DA demonstrates cost effectiveness, minimal failures and patient affordability, dental practitioners are reducing its usage.This substantiates the dental practitioners' awareness of community well-being and environmental safety.Yet, as older practitioners still preferred DA, there is a need to sensitize them to the precautions to be taken on mercury hygiene as well as mercury waste management, its environmental effects, and guidelines of Minamata Convention.This also necessitates adopting and disseminating evidence on the use of dental restorative materials through continuing education programs.
Consequently, as our study and various authors [Al-Asmar et al., 2019;Umesi, Oremosu and Makanjuola, 2020] report, a majority of dental practitioners across the globe do not advise the use of DA over other tooth-coloured restorative materials.There is a prevailing notion that placing dental amalgam restorations can cause adverse health effects like impairing kidney function [Eggleston, 1994 anddecreasing T-lymphocyte counts [Boyd et al., 1991], although studies by Berglund [1990], University of Umea in Sweden found no evidence of kidney impairment in subjects with amalgam restorations.
Also, the hype generated from the three Amalgam Wars [Molin, 1992;Weiner, Nylander and Berglund, 1990;Huggins, 2007] raised considerable concerns about mercury toxicity amongst the patients and dentists, in spite of being disproved repeatedly.This discussion is still a relevant debate and different countries have laid down their guidelines regarding the use or restriction of amalgam as a dental restoration with many places where amalgam phase down is moving from a debatable domain to a legislative domain [Al-asmar et al., 2019;Umesi, Oremosu and Makanjuola, 2020].
However, our study had certain limitations; a modest study population significant reduction in sample size occurred due to a minimum of five years of experience as inclusion criteria.Also, certain practitioners had completely shifted to toothcoloured restorations, precluding them from the study.Among those included in the study, a significant number of participants did not respond, despite repeated reminders, citing busy patient schedules, making it a limitation of this study.

Conclusions
To draw inferences from this study, it is important to take a calculated decision while selecting the right restorative material based on individual case scenario and economics of the patient.India is a developing country where emphasis on oral health is minimal, and majority of the population is incapable of meeting increased expenses on dental treatment.Hence, dental amalgams still stand as a good restorative material for low-middle income countries.
However, there is an urgent need to educate dentists about the precautions to be taken on mercury hygiene as well as mercury waste management and disposal, which by itself can help in reducing mercury toxicity and subsequent effects.
There is an imperative need to sensitize the dentists on the guidelines of Minamata Convention.Patients too have to be alerted about the dental materials based on evidence so that they do not instinctively believe in biased publicity of products.
The continued and appropriate use of DA is a decision that needs careful consideration in the times of newer dental cements and the spectrum of Composites.DA is a material that has been tried and tested.The newer materials too will face the test of time and will have to prove their efficacy in the coming decades.

Extended data
Open Science Framework: Community Social Responsibility of continued and appropriate use of Silver Amalgam as dental restorative material in Southern India.https://doi.org/10.17605/OSF.IO/NUC5J [Nayak, 2022].
This project contains the following extended data: -Questionnaire -Copy.docxData are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication). 1.

Focus on Dental Amalgam and Its Health Impacts controversies: Current Status:
The manuscript currently emphasizes the official position on dental amalgam without a comprehensive review of its health impacts.enhance the manuscript's comprehensiveness and relevance and guarantees its neutrality.

Clarity and Repetition:
Recommendation: Avoid repetition and ensure clarity in the language.For example, the phrase "Shapiro-Wilk test was done was performed" should be corrected to "the Shapiro-Wilk test was performed."The revised methods section includes details on the small population size and the use of complete enumeration.
○ Recommendation 1: Explicitly state any limitations related to sample size, potential biases, and the generalizability of findings in a dedicated paragraph in the discussion section.
○ Recommendation 2: Finite Population Correction (FPC): If applicable, include the finite population correction factor in the descriptive statistical analysis section.This adjustment is crucial for small populations and should be transparently reported to strengthen the credibility of the findings.

Statistical Analysis Transparency: T-Test and Chi-Square Test Assumptions: T-Test:
The manuscript now includes information on the assumptions for the ttest.

○
Chi-Square Test: The assumptions for the chi-square test, particularly the need for independence of observations and the requirement that expected frequencies be at least 5, have not been discussed.

○ ○
Recommendation: Please discuss how the assumptions for both the t-test and chisquare test were verified.For the chi-square test, specifically confirm that all expected frequencies met the minimum requirement.

Confidence Intervals for Descriptive Statistics: Current Status:
The response indicates a misunderstanding about the applicability of confidence intervals for proportions.My suggestion was to estimate CIs for the descriptive statistics summarized in the first three tables, not specifically for hypothesis tests.
○ Recommendation: Confidence intervals should be calculated and presented for the descriptive statistics (proportions and means) summarized in Tables 1-3.This will enhance the interpretability and reliability of your estimates.Confidence intervals can and should be calculated for proportions and are a standard practice in statistical analysis to express the precision of an estimate.Providing confidence intervals for proportions, and not only means, would strengthen the presentation of your results by offering a range within which the true population proportion is likely to lie.This enhances the interpretability and reliability of your findings.

3.
If there are specific reasons or constraints that will prevent you from including confidence intervals for proportions, it would be helpful to elaborate on these in the manuscript.Otherwise, I strongly recommend incorporating confidence intervals for the proportions presented in your results section to improve the completeness and robustness of your statistical analysis.

Conclusion:
While the manuscript has shown significant improvements, addressing the above points will further enhance its methodological rigor and overall quality.Including discussions on the chisquare test assumptions, providing confidence intervals for descriptive statistics, and ensuring detailed discussion on the study limitations will make your manuscript more robust and transparent.
Thank you for your attention to these points.I look forward to seeing the revised version of your manuscript.
Best regards,

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Yes

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?Yes Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Epidemiology, Environmental health, Biostatistical modeling I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
Current Status: The revised methods section includes details on the small population size and the use of complete enumeration.Recommendation 1: Explicitly state any limitations related to sample size, potential biases, and the generalizability of findings in a dedicated paragraph in the discussion section.
Recommendation 2: Finite Population Correction (FPC): If applicable, include the finite population correction factor in the descriptive statistical analysis section.This adjustment is crucial for small populations and should be transparently reported to strengthen the credibility of the findings.
enhances the interpretability and reliability of your findings.
If there are specific reasons or constraints that will prevent you from including confidence intervals for proportions, it would be helpful to elaborate on these in the manuscript.Otherwise, I strongly recommend incorporating confidence intervals for the proportions presented in your results section to improve the completeness and robustness of your statistical analysis.
Author Response: Thank you, ma'am, for suggestion.We have now added Confidence Intervals for proportions.(Tables 1 & 2) The revised methods section still lacks essential information regarding the population size and the sampling method.This omission hampers the ability of readers to evaluate the generalizability of the study findings.Including these details is crucial for the overall transparency and robustness of your research.

Statistical Analysis Transparency:
I appreciate the clarity in your statistical analysis section.However, the revised manuscript does not mention whether all assumptions for the t-test and especially for the chi-square test were checked before application.Reporting on these checks and addressing any violations would significantly enhance the methodological transparency of your study.The authors mentioned that perception and awareness for DA use as a risk factor were treated as continuous variables for analysis using Student's t-test.However, the manuscript lacks clarification on the specific transformation method employed to convert these variables into continuous form.Providing details on this transformation process would enhance the transparency and replicability of the study's statistical analysis

Confidence Intervals:
While proportions are presented in the results section, the absence of confidence intervals limits the precision of the estimates.Signaling this limitation in the discussion is not sufficient to accept it.Providing insights into the real reasons behind this absence is crucial and would strengthen the methodological rigor of your study.
On another hand, the revised version of the article has addressed some aspects of the initial concerns, but there are still areas that could be further refined: Neutrality and Balance: The authors have made slight revisions to the language, but there is room for improvement in achieving a more neutral tone.

Inclusion of Opposing Views:
The manuscript still lacks explicit inclusion of opposing viewpoints or critical studies on dental amalgam use.Enhancing the literature review with such perspectives would contribute to a more balanced overview.

Clarity and Flow:
While the manuscript maintains an acceptable reading flow, some sentences could be simplified for clarity.Revisiting sentence structures and avoiding unnecessary repetition would enhance communication.
While there has been some improvement, it seems that the initial concerns were not fully addressed in the revised submitted manuscript.

Nourdine Attiya
Moulay Ismail University, Meknes, Morocco I have had the opportunity to thoroughly review the research article titled:"Community social responsibility of continued and appropriate use of silver amalgam as dental restorative material in southern India: A cross-sectional study", submitted for consideration to F1000Research and I would like to raise several points that, in my view, require careful consideration and clarification.

Introduction:
The introduction provides a comprehensive historical background on dental amalgam, highlighting its significance and controversies.However, there seems to be a lack of neutrality in the language, particularly in statements like "We observed that DA is receiving undue attention and controversies."This may give the impression of bias and could be addressed for a more balanced tone.

Literature Review:
While the literature review touches upon the controversies surrounding dental amalgam, it appears to be somewhat one-sided.It would be beneficial to include key studies or viewpoints that are critical of amalgam use to provide a more comprehensive overview of the current landscape.Moreover, I observed that the bibliography includes references that are somewhat dated.Given the dynamic nature of research in this field, it is essential to incorporate the most recent and pertinent literature to enhance the credibility and relevance of the study.

Methods:
The methods section is clear, but there is a lack of information regarding the population size and the sampling method.Including these details is crucial for readers to assess the generalizability of the study findings and understand how the sample was selected and if it is representative of the sought population.

○
Additionally, the statistical analysis section does not mention whether assumptions for the t-test (normality, homoscedasticity) and chi-square test (expected frequencies in each cell are not too small, especially for variables with multiple categories) were checked before application.Reporting on these checks and how violations, if any, were addressed would enhance the transparency of the study. ○

Results:
The results section presents proportions without confidence intervals.The absence of confidence intervals limits the ability to gauge the precision of the estimates.In the discussion, it would be beneficial to acknowledge and explain this limitation.

Discussion & conclusion:
While the discussion is comprehensive, it would be helpful to emphasize the strengths and positive aspects of dental amalgam, providing a more balanced view.

○
The use of a specific commercial product name in the conclusion (Ivoclar Cention N) raises ethical considerations.Scientific research should prioritize objectivity, and care should be taken to avoid any perception of endorsing or promoting a specific company's product.

○
The conclusion rightly emphasizes the need for a calculated decision in selecting the right restorative material.However, it would be beneficial to reiterate key recommendations (promoted by the Minamata convention and several organizations), such as the importance of education on mercury hygiene and waste management.

○
Finally, throughout the article, I think that clarity and conciseness could be enhanced by revisiting sentence structures and avoiding unnecessary repetition.Moreover, neutrality in presenting the dental amalgam controversial scientific debate is recommended.Abstract -"This highlights their concerns over mercury toxicity and soft tissue lesions and accentuates their community social responsibility."-How does it accentuate their community social responsibility?This has to be explained in the discussion.

4.
Introduction -is extensive and informative about the stance of dental amalgam usage by various organizations around the world.Since the study is individual dentists, the review demands the addition of such information if there is any in the existing literature and justifies the need for the study.

5.
Discussion -there is a need to discuss community social responsibility since it is mentioned in the title. 6.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Yes

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?Yes Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
Reviewer Expertise: Public Health Dentistry I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
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○Recommendation:
The literature review should include a thorough discussion on the health effects of mercury exposure from dental amalgam, especially concerning dental personnel.It is important to acknowledge studies that highlight potential risks, even if they are not aligned with official positions.Some relevant studies (from many others) include: Florina Andreescu C, 2017 (Ref 1) ○ Neghab M, et.al., 2011 (Ref 2) ○ Moen B, et.al., 2008 (Ref 3) ○ ○ A balanced view of the risks and benefits associated with dental amalgam use will ○ 2.
Interests: Authors do not have any competing interests Version 3 Reviewer Report 19 January 2024 https://doi.org/10.5256/f1000research.159529.r229119© 2024 Attiya N.This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Nourdine AttiyaMoulay Ismail University, Meknes, Morocco Dear Authors', I hope this message finds you well.Thank you for your continued efforts in revising the manuscript titled "Community social responsibility of continued and appropriate use of silver amalgam as dental restorative material in southern India: A cross-sectional study."I have thoroughly reviewed the revised version and would like to emphasize certain methodological concerns that, unfortunately, remain unaddressed: Methods:Population Size and Sampling Method: Food and Drug Administration states, "We have reviewed the best available scientific evidence to determine whether the low levels of mercury vapors associated with dental amalgam fillings are a cause for concern.Based on this evidence, U.S. Food and Drug Administration considers dental amalgam fillings safe for adults and children aged six and above.Clinical studies in adults and children ages six and above have found no link between dental amalgam fillings and health problems" [U.S.Food and Drug Administration, 2020].The National Institute of Dental and Craniofacial Research in the U.S. Dept. of Health and Human Services also states that children whose cavities were filled with dental amalgam had no adverse health effects.The findings included no detectable loss of intelligence, memory, coordination, concentration, nerve conduction or kidney function during the 5-7 years the children were followed"[National Institute  of Health, 2006].

Table 1 .
Experience and satisfaction for DA (dental amalgam) use among practitioners.

Table 2 .
Opinion and preference for the use of DA (dental amalgam) by practitioners.

Table 4 .
Preference for continuation of use of silver amalgam based upon the age of dentists.
p value derived by student t test, p < 0.05 considered significant.

Table 3 .
Perception and awareness for DA (dental amalgam) use as a risk factor among practitioners.

Table 5 .
Preference for continuation of use of silver amalgam based upon experience of dentists.

Is the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
https://doi.org/10.5256/f1000research.164158.r275665© 2024 Yadav R. Ramkumar Yadav Department of Biomaterials Science, College of Dentistry,, Dankook University, Yongin-si, Gyeonggi-do, South Korea Why did authors work on DA materials still.Add Dental composite history also.Add current limitations of work.Add futute scope of this work.Why did authors not perform mechanical test.Why did authors not perform physical test.Why did authors not perform thermal test.Why did authors not perform wear test.Reviewer Expertise: Dental composite materials I confirm that I

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Nourdine Attiya Moulay
Ismail University, Meknes, Morocco Dear Authors, I hope this message finds you well.Thank you for your diligent efforts in revising the manuscript titled "Community Social Responsibility of Continued and Appropriate Use of Silver Amalgam as Dental Restorative Material in Southern India: A Cross-Sectional Study."After thoroughly reviewing the revised version, I appreciate the improvements made so far.However, several methodological concerns need to be addressed to ensure the robustness and transparency of your study.Key

the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests:
No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.
This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

the work clearly and accurately presented and does it cite the current literature? No Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? No If applicable, is the statistical analysis and its interpretation appropriate? No Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests:
No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Yes Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes Competing Interests:
No competing interests were disclosed.

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Version 1
Reviewer Report 06 October 2022 https://doi.org/10.5256/f1000research.134713.r150726management and disposal."-Will this help dentists with higher age and longer clinical experience who preferred continuation of DA?This has to be explained in the discussion.