Factors influencing dentists’ choice of restorative materials for occlusal cavities: a cross-sectional study from Palestine

Abstract

Objective

To assess the factors influencing dentists’ choice of restorative materials for posterior restorations, with a particular emphasis on the perceived influence of social media on patient preferences among general dental practitioners in Palestine.

Design

Cross-sectional web-based survey.

Participants/Setting

A total of 550 general dentists practising in Palestine were invited between May and December 2023 through convenience and snowball sampling via social media platforms; 390 responded, and 350 complete responses were included in the final analysis.

Intervention

No specific intervention was applied; this was an observational, questionnaire-based study.

Main outcome measures

Dentists’ selection of restorative materials (composite, amalgam or high-viscosity glass-ionomer cement (HVGIC)) for posterior restorations in relation to tooth type, patient age, oral hygiene, moisture control, financial status and social media influence.

Statistical analysis was performed

Descriptive statistics, χ² tests and multinomial logistic regression were used to examine associations and control for potential confounders.

Results

Material selection varied significantly by tooth type (p<0.001), patient age (p<0.001), oral hygiene (p<0.001) and financial status (p<0.001). In the multivariable analysis, financial influence remained the only significant predictor of material choice, whereas gender, clinical experience, postgraduate training and perceived social media influence were not independent determinants. Composite resin was preferred for premolars and aesthetically driven cases, whereas amalgam was favoured for molars and for patients with poor hygiene or inadequate moisture control. HVGICs were selected for mainly children (60%) and elderly patients (39%). Most dentists perceived that social media strongly influenced their patients’ preferences (p<0.0001), with 97% of dentists reporting believing that their patients’ preferences were due to social media.

Conclusion

Patient-related factors were the main determinants of material selection, whereas practitioner demographics played a minimal role. HVGICs are preferred for paediatric and elderly patients because of their suitability for age-specific clinical needs. The influence of social media, assessed in this study as dentists’ perceptions rather than direct measures of patient behaviour, underscores its growing role in shaping dentists’ impressions of patient expectations and highlights the importance of evidence-based guidance and public education to support patient-centred, clinically appropriate restorative decisions.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study is the first to investigate restorative material selection among general dental practitioners in Palestine and the first to incorporate the perceived influence of social media into this decision-making context.

• The use of a structured, pretested online questionnaire ensured standardisation, clarity and reliable data capture.

• Methodological rigour was strengthened through adherence to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines and the inclusion of stratified and subgroup analyses to explore potential confounding factors and effect modifications.

• The use of convenience and snowball sampling may introduce selection bias and limit the generalisability of the findings, particularly towards more digitally active practitioners.

• The cross-sectional design limits causal inference and reflects clinical practice at a single point in time, preventing assessment of temporal changes or evolving trends.

Introduction

Restoration of posterior teeth is a fundamental component of clinical dentistry, as it re-establishes function, maintains occlusal stability and contributes to the long-term preservation of dentition.¹ The choice of restorative material is a critical determinant of clinical success and must balance mechanical performance, aesthetic expectations and economic feasibility.² For decades, dental amalgam has been widely used for posterior restorations because of its longevity, ease of use and cost-effectiveness, particularly in high-load situations.^{3 4} In recent decades, however, there has been a global shift toward mercury-free alternatives such as resin composites and high-viscosity glass-ionomer cements (HVGICs), driven by patient demand for tooth-coloured restorations and efforts to phase down amalgam under the Minamata Convention.^{5 6} Accordingly, several countries have restricted the use of amalgam, particularly for vulnerable groups such as children and pregnant women.

HVGICs have emerged as alternatives offering chemical adhesion, fluoride release and ease of placement, which may be advantageous for high-caries-risk groups such as children and older adults. Although they perform well in small to moderate restorations, durability under high-stress conditions remains a limitation.⁶,⁹

However, the adoption of mercury-free alternatives is not uniform. Research has shown that clinical outcomes depend not only on material properties but also on patient-related and operator-related factors.^{3 10 11} In low- and middle-income countries, the implementation of Minamata-related recommendations may be constrained by limited resources, training, infrastructure and material availability.¹²,¹⁴ Consequently, restorative decision-making often reflects clinical and aesthetic priorities alongside contextual constraints such as technique sensitivity, cost and durability.¹⁴,¹⁷

Globally, studies have examined factors influencing material selection, including tooth type, oral hygiene status, patient demographics and practitioner experience, with variations across regions due to local economic conditions, material availability and cultural preferences.¹⁷,²⁴ Disparities in dental education may further contribute to these differences, as some curricula continue to emphasise amalgam, whereas others prioritise contemporary alternatives aligned with minimally invasive dentistry.²²²⁵,³¹

An additional contemporary influence is social media and digital communication.³² Platforms such as Instagram, TikTok, Snapchat and Facebook frequently portray idealised aesthetic outcomes,³³ which dentists may perceive as shaping patients’ expectations for tooth-coloured restorations.³⁴ In Palestine, although social media exposure is increasing, it remains unclear how these perceived influences interact with the economic and infrastructural constraints that shape restorative material selection in daily practice. To date, no empirical studies have examined this issue in the Palestinian context.^{14 35}

In this study, restorative material selection was viewed as the product of both contextual influences (eg, cost, availability, training and perceived external pressures) and case-specific clinical factors (eg, cavity characteristics and patient needs). Accordingly, we assessed tooth-level, patient-level, practitioner-level and practice-level determinants of material selection in posterior occlusal restorations.

This study aims to explore how Palestinian dentists select restorative materials for posterior occlusal restorations, considering tooth-related factors (tooth type, moisture control), patient-related factors (age, oral-hygiene status, financial capacity) and operator-related factors (experience, postgraduate training). We also examined contextual influences, including perceived social media impacts on patient expectations and awareness of Minamata-related regulatory pressure, to provide region-specific evidence to support restorative decision-making in Palestine.

Materials and methods

This cross-sectional, questionnaire-based study investigated the factors influencing Palestinian general dentists’ choice of restorative materials for posterior occlusal restorations. The primary outcome was the dentist’s preferred restorative material. Independent variables were grouped into clinical (tooth type, oral hygiene and moisture control), patient-related (age and financial capacity), contextual (perceived social media influence and awareness of Minamata Convention-related regulatory changes) and dentist-related (gender, years of experience and postgraduate training) domains. Years of experience were categorised into four non-overlapping groups, defined as inclusive at the lower bound and exclusive at the upper bound (<5 = 0–<5; 6–9 = 5–<10; 10–15 = 10–<16; ≥16 = ≥16 years). For analysis, age was categorised as children (≤12 years), adults (13–64 years) or older adults (≥65 years). Oral hygiene was classified as good when minimal visible plaque or calculus was present and poor when visible plaque or calculus was observed. Moisture control was defined as adequate when effective isolation was feasible and inadequate when isolation was ineffective or absent.

Study setting, recruitment and data collection

This study was conducted in Palestine and is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.³⁶ Participants were recruited via convenience and snowball sampling through professional networks and social media platforms (WhatsApp and Facebook). A web-based, anonymous questionnaire (Google Forms) was distributed via an invitation link and was completed voluntarily without incentives. The survey comprises 20 close-ended items and requires approximately 10–15 min to complete. The target sample size was calculated via Raosoft (estimated population: 4000; 95% confidence level; 5% margin of error), yielding a minimum of 350 participants; to account for non-response, 550 dentists were invited and the response rate was 65%. Eligible participants were general dentists actively practising in Palestine; interns, undergraduate students and dentists enrolled in formal postgraduate programmes (residency, master’s or doctoral) were excluded. Because the survey was anonymous, reasons for non-participation and partial responses could not be systematically recorded.

Survey development and testing

A structured, standardised online questionnaire was developed on the basis of a literature review.^{18 20 28 30} Two experts in operative dentistry reviewed the draft for relevance and clarity, supporting content validity. A pilot test with 20 general dentists assessed item clarity and online functionality, leading to minor revisions and supporting face validity.

The final questionnaire comprised 20 closed-ended items across three sections. The first section captured demographics (gender, years of experience and postgraduate training). The second section assessed restorative material preferences using clinical scenarios varying by tooth type, patient age group, oral hygiene status and moisture control. For each scenario, respondents selected the preferred material (amalgam, resin composite or HVGIC) and the primary reason for their choice from a predefined list (eg, durability, aesthetics, cost, patient preference and clinical requirements), including ‘Minamata Convention and environmental safety’. Patient financial capacity was assessed via a five-point scale. The final section assessed perceived social media influence via three items addressing its perceived effect on patients’ preferences, the material most commonly requested due to social media exposure and the frequency with which dentists felt pressured to meet these expectations. The full questionnaire is provided in online supplemental appendix A.

Patient and public involvement

None. Patients and/or the public were not involved in the design, conduct, reporting or dissemination plans of this research.

Statistical analysis

Data analysis was performed via descriptive and inferential methods in IBM SPSS Statistics V.28 (IBM, Armonk, New York, USA), with a significance threshold set at p<0.05. Categorical variables, including gender, years of clinical experience and postgraduate training, were summarised as frequencies and percentages. Associations between demographic and clinical characteristics and restorative material selection were examined via χ² tests.

Subgroup analyses were conducted to explore differences in material preferences according to specific exposures: tooth type (molars vs premolars), patient age group (children, adults, elderly), oral-hygiene status (good vs poor) and moisture-control conditions (adequate vs inadequate). χ² tests were used for preliminary bivariate analyses to explore associations between clinical scenarios and material preferences. To provide a more comprehensive assessment, multinomial logistic regression was employed to control for potential confounders, with ORs and 95% CIs reported to quantify the strength and precision of associations. To control for potential confounding factors, multinomial logistic regression analyses were performed with amalgam as the reference category. The independent variables included gender and postgraduate training (as categorical factors) and years of experience, financial influence and social media influence (as covariates). Five models were estimated to evaluate preferences for (1) the primary restorative material and (2–5) the same outcome across subgroups—molars, premolars, good oral hygiene and poor oral hygiene. A Bonferroni-adjusted significance level (α=0.05/10 tests (5 predictors×2 outcome contrasts) = 0.005) was applied to control for multiple comparisons. Model fit was assessed via the likelihood ratio χ² test and Nagelkerke R². χ² tests were applied solely for preliminary bivariate assessment of associations. Effect size statistics (such as Cramér’s V) were not calculated, as the primary inferential analyses relied on multinomial logistic regression, which generated adjusted effect estimates with corresponding 95% CIs.

Given the use of convenience and snowball sampling via online platforms, potential selection bias was acknowledged, including the possible overrepresentation of digitally active dentists. Because no national demographic registry exists for Palestinian dentists, statistical weighting was not feasible. Missing data were handled via complete-case analysis: partially completed or early-terminated questionnaires were excluded before analysis. Of the 390 responses received, 40 incomplete questionnaires (10.3%) were removed, leaving 350 complete questionnaires for analysis; no imputation was performed.

The internal consistency of the material-preference items was evaluated via Cronbach’s α (α=0.83), which indicated good reliability. Test–retest reliability was assessed in a pilot sample of 20 dentists by readministering key questions after 2 weeks. The resulting Cohen’s κ values were 0.612 (95% CI 0.47 to 0.75) for molars, 0.754 (95% CI 0.62 to 0.89) for poor oral hygiene and 0.752 (95% CI 0.61 to 0.89) for children, demonstrating moderate to substantial agreement and confirming the overall stability of the responses.

Results

A total of 550 dentists were invited to participate, of whom 390 submitted responses. After 40 incomplete questionnaires (10.3%) were excluded, 350 fully completed surveys were retained for analysis; therefore, item-level missing data were not present in the analysed dataset. Because the survey was administered anonymously online, reasons for non-participation and partial completion could not be systematically recorded. Although excluding incomplete responses improved the data quality, selection bias is possible if non-completers differ systematically from completers. However, because incomplete submissions represented a small proportion of responses, their exclusion is unlikely to materially affect the overall findings.

The demographic and professional characteristics of the 350 respondents revealed a gender distribution of 55.71% males and 44.29% females. In terms of clinical experience, the largest proportion of respondents had more than 16 years of experience (29.14%), followed by those with 10−15 years (24.86%), 6−9 years (24%) and 0−5 years (22%). With respect to postgraduate training in restorative dentistry, 53.43% of the respondents reported no formal training, whereas 46.57% indicated that they had received such training. These findings highlight diverse samples in terms of gender, experience level and training background. Table 1 summarises the demographic and professional characteristics of the respondents included in the analysis.

Table 1. Demographic and professional characteristics of the 350 respondents.

Gender	Count	%
Male	195	55.71
Female	155	44.29
Years of experience
0−5 years	77	22
6−9 years	84	24
10−15 years	87	24.86
More than 16 years	102	29.14
Postgraduate training in restorative dentistry
No	187	53.43
Yes	163	46.57

Initial bivariate analyses (online supplemental appendix B, table B1) revealed no significant associations between dentist demographics (gender, clinical experience, postgraduate training) and restorative material selection (all p values >0.05). To assess whether these demographic factors were significant independent predictors after accounting for other key influences, a multinomial logistic regression was performed. The multinomial logistic regression models, which controlled for financial and perceived social media influence, confirmed that the demographic variables remained non-significant (all p>0.05 after Bonferroni correction; see online supplemental tables C1–C5). In contrast, financial influence was statistically significant in multiple models and remained a consistent predictor of material selection.

Online supplemental table B1 reveals distinct material preferences for posterior restorations. For molars, composite resin was selected by 48% of respondents (n=169), closely followed by amalgam at 47% (n=164), with HVGIC being the least common at 6% (n=17). For premolars, the composite was selected by 67% (n=235), amalgam by 21% (n=73) and HVGIC by 12% (n=42). A χ² analysis confirmed a significant association between the type of tooth and the choice of restorative material (χ² = 56.32, p<0.001). No significant associations were found between material choice and dentist gender, experience or postgraduate training.

Data stratified by patient age revealed distinct trends in restorative material preferences. For children, HVGIC was selected in 60% of cases (n=211), composite in 25% (n=89) and amalgam in 15% (n=50). For adults, amalgam was selected in 50% of cases (n=173), composite in 41% (n=145) and HVGIC in 9% (n=32). Among the elderly patients, amalgam accounted for 45% (n=159), HVGIC accounted for 39% (n=138) and the composite accounted for 15% (n=53). Material selection differed significantly by age group (χ² = 243.73, p<0.001), with no significant associations observed between material choice and dentist demographics within any age category.

Material preference also varies according to oral hygiene status. For patients with good oral hygiene, amalgam was selected in 49% of the patients (n=173), composite in 42% (n=148) and HVGIC in 8% (n=29). For patients with poor oral hygiene, amalgam was selected in 65% of the patients (n=228), whereas composite and HVGIC were selected in 17% of the patients (n=61). This association was statistically significant (χ² = 55.14, p<0.001). No significant differences were detected across the demographic subgroups. When moisture control was inadequate, amalgam was selected in 69% of the cases (n=243), HVGIC in 24% (n=83) and composite in 7% (n=24). Dentist gender, years of experience and postgraduate training had no significant effect on any moisture control condition.

Online supplemental table B2 presents the reported reasons for selecting restorative materials by tooth type and patient age. For premolars, amalgam was selected for durability in 100% of the cases (n=73). The composite was selected for aesthetic appeal in 50% (n=118) and for patient preference in 19% (n=45) of the cases. HVGICs were selected for specific material properties of 36% (n=15) and for ease of use of 31% (n=13). For molars, amalgam was selected for durability in 74% (n=122) of cases and for clinical requirements in 22% (n=36) of cases. The composite was selected for aesthetic appeal in 44% (n=74), patient preference in 26% (n=44) and Minamata-related concerns in 13% (n=22). HVGIC was selected for specific properties in 100% of the cases (n=17). For children, amalgam was selected for ease of use in 56% (n=28) and durability in 28% (n=14) of the cases. The composite was selected for patient preference in 44% (n=39) and Minamata-related concerns in 28% (n=25). The HVGIC was selected for recommendations in 34% (n=72) and durability in 25% (n=52) of the cases. For adults, amalgam was selected for durability in 48% (n=83) and clinical requirements in 21% (n=36) of patients. The composite was selected for patient preference in 48% (n=69) and aesthetic appeal in 26% (n=37) of patients. The HVGIC was selected for 41% (n=13) of the recommendations, and specific properties were selected for 28% (n=9) of the recommendations. For elderly patients, amalgam was selected for clinical requirements in 34% (n=54) and ease of use in 30% (n=48) of patients. The composite was selected for patient preference in 28% (n=15) and aesthetic appeal in 23% (n=12) of patients. The HVGIC was selected for specific properties in 28% (n=38) and for recommendations in 25% (n=35) of the samples.

Table 2 summarises the distribution of restorative material selection by patient financial status (p<0.0001). Amalgam was selected in 56.9% of the cases involving patients with significant financial constraints (n=41), 38.2% with moderate constraints (n=34), 35.9% with slight constraints (n=23) and 37.6% with no financial constraints (n=47). Direct composite was selected for 43.1% of the significantly constrained cases (n=31), 58.4% of the moderately constrained cases (n=52), 64.1% of the slightly constrained cases (n=41) and 38.4% of the cases involving patients with no constraints (n=48). HVGIC was selected in 9.1% of the moderately constrained cases (n=3) and 24% of the cases with no financial constraints (n=30). No respondents reported selecting HVGICs for patients with significant or slight financial constraints.

Table 2. Influence of financial status on patients’ preferences for restorative materials.

Restorative material	Significantly constrained (n=72)	Moderately constrained (n=89)	Slightly constrained (n=64)	Not at all constrained (n=125)	P value
Amalgam (n=145)	41 (56.9)	34 (38.2)	23 (35.9)	47 (37.6)	p<0.0001
Direct composite (n=172)	31 (43.1)	52 (58.4)	41 (64.1)	48 (38.4)
HVGIC (n=33)	0 (0.0)	3 (9.1)	0 (0.0)	30 (90.9)

Note: the data are presented as n (%). The p value from the χ² test indicates a significant association between patient financial status and material preference.

HVGIC, high-viscosity glass-ionomer cement.

Table 3 presents the distribution of dentists’ reported perceptions of the influence of social media on patient preferences for restorative materials. Most respondents reported some level of perceived influence, with 38.6% (n=135) describing it as moderate, 23.4% (n=82) as slight and 21.1% (n=74) as significant. Smaller proportions perceived either extreme influence (8.6%, n=30) or no influence at all (8.3%, n=29). The difference in perceived levels of influence was statistically significant (χ², p<0.0001). When asked which material they believed patients preferred due to social media exposure, 97% (n=340) selected composite, 2% (n=6) selected amalgam and 1% (n=4) selected HVGIC (p<0.0001). Regarding the frequency of perceived pressure to align with social media-driven patient expectations, 18.9% of respondents (n=66) reported consistent pressure, 56.3% (n=197) reported occasional pressure and 24.8% (n=87) reported no pressure (p<0.0001).

Table 3. Dentists’ perceptions and reports regarding social media and patient preferences.

Question	Answer	N (%)	P value
Perceived influence of social media on patient preferences	Moderately	135 (38.6)	<0.0001
	Slightly	82 (23.4)
	Significantly	74 (21.1)
	Not at all	29 (8.3)
	Extremely	30 (8.6)
Material perceived to be most requested by patients due to social media	Composite resins	340 (97)	<0.0001
	Amalgam	6 (2)
	HVGICs	4 (1)
Frequency of feeling pressured to align with perceived social media-driven expectations	Felt consistent pressure	66 (18.9)	<0.0001
	Felt occasional pressure	197 (56.3)
	Did not feel any pressure	87 (24.8)

HVGIC, high-viscosity glass-ionomer cement.

Multinomial logistic regression analyses were performed to assess independent predictors of restorative material selection while controlling for gender, clinical experience, postgraduate training, financial influence and perceived social media influence. ORs with 95% CIs were calculated. Amalgam was used as the reference category in all the models. Five dependent outcomes were assessed: primary restorative material, molars, premolars, good oral hygiene and poor oral hygiene. The full model outputs are provided in online supplemental appendix C, tables C1–C5.

The primary restorative material model (online supplemental appendix C table C1) demonstrated good fit (Nagelkerke R² = 0.165, χ² = 52.586, p<0.001). Financial influence significantly reduced the odds of selecting HVGIC over amalgam (OR=0.186, 95% CI 0.090 to 0.386, p<0.001). No other predictors were significant after Bonferroni correction (p<0.005). Perceived social media influence was not associated with material choice (p=0.226 for composite vs amalgam; p=0.602 for HVGIC vs amalgam).

The molar model (online supplemental appendix C table C2) showed marginal overall significance (Nagelkerke R² = 0.071, χ² = 20.950, p=0.021). Financial influence increased the odds of selecting composite over amalgam (OR=1.418, 95% CI 1.169 to 1.721, p<0.001). The premolar model (online supplemental appendix C table C3) was not significant (Nagelkerke R² = 0.047, χ² = 13.620, p=0.191). Financial influence did not remain significant after the Bonferroni correction (OR=0.773, 95% CI 0.614 to 0.974, p=0.029).

For good oral hygiene (online supplemental appendix C table C4), the model was significant (Nagelkerke R² = 0.100, χ² = 30.838, p=0.001). Financial influence increased the odds of selecting composite over amalgam (OR=1.679, 95% CI 1.370 to 2.059, p<0.001). The poor oral hygiene model (online supplemental appendix C table C5) was not significant (Nagelkerke R² = 0.055, χ² = 16.282, p=0.092), and no predictors reached significance after Bonferroni correction.

Discussion

This study examined factors influencing restorative material selection among Palestinian general dentists. According to the results of the multinomial logistic regression, financial influence was the strongest independent predictor, whereas clinical factors (tooth type, age group and oral hygiene) were significantly associated in the stratified analyses. Greater financial influence increased the odds of choosing composite over amalgam for molars and in good oral hygiene scenarios, whereas it reduced the odds of selecting HVGIC over amalgam as the primary restorative material. Dentist characteristics (gender, experience, postgraduate training) were not independently associated with material choice, indicating that patient-related and case-related factors predominated.

Because patient attitudes and behaviours are not measured directly, social media influence should be interpreted as dentists’ perceptions. Although most respondents believed that social media shapes patient preferences (97% attributed composite requests to social media and >75% reported pressure), perceived social media influence was not an independent predictor of material selection in multivariable models. This suggests that while social media may intensify expectation management and negotiation during consultations, the material ultimately placed is driven primarily by clinical considerations (tooth type, oral hygiene, moisture control) and financial constraints.

Because platform-specific use was not assessed, we could not identify which channels most shaped expectations; however, prior studies provide context. In Saudi Arabia, Snapchat and Instagram are the most commonly used platforms among individuals seeking aesthetic dental treatments.³⁷ In Spain, although many patients view dental practice social media, a smaller proportion reported using it to choose a dentist, with traditional factors (eg, facilities and recommendations) remaining more influential.³⁸ Similarly, a 2024 survey revealed that a minority of university students reported that social media influences the pursuit of aesthetic treatment, with Instagram predominating.³⁹ Overall, this evidence supports our interpretation that social media primarily creates aesthetic/communication pressure rather than acting as a direct determinant of restorative material choice, reinforcing the distinction between perceived influence and measurable behaviour.

Subgroup regression analyses revealed variation in predictor effects. The premolar and poor oral hygiene models were not significant, which may reflect limited power and sparse cells (particularly the small number of HVGIC cases). Gender showed a borderline association with HVGIC selection under poor oral hygiene conditions, but this association did not remain significant after Bonferroni adjustment and should be interpreted cautiously.

Tooth type significantly influenced material selection (p<0.0001). The composite was preferred for premolars (67%), which is consistent with its aesthetic advantages and favourable performance in less stress-bearing regions.⁴⁰,⁴² In contrast, amalgam (21%) and HVGIC (12%) were less commonly chosen for premolars. For molars, composite (48%) and amalgam (47%) were selected at similar rates, reflecting the balance between functional demands and aesthetic expectations. HVGICs are used infrequently overall but may be selected in specific situations where fluoride release and chemical bonding are advantageous. Overall, dentists appeared to integrate tooth-related functional requirements with patient expectations and material properties when selecting restorations.

Material selection differed significantly by age group (p<0.0001). HVGICs are preferred for children (60%), which is consistent with their fluoride release and practical advantages in paediatric care.^{43 44} Among adults, amalgam (50%) and composite (41%) were selected most often, reflecting the balance between durability and aesthetic expectations. In elderly patients, amalgam and HVGIC predominated, with HVGIC potentially favoured for ease of placement and fluoride release in patients with xerostomia or reduced dexterity.^{45 46} Overall, these findings indicate that dentists tailor material choices to address age-related clinical needs and constraints.

Oral hygiene significantly influenced material selection (p<0.001), which is consistent with evidence that composite restorations are technique sensitive and perform best when isolation and patient risk factors are favourable.⁴⁷,⁵⁰ For patients with good oral hygiene, amalgam (49%) and composite (42%) were selected at similar rates, suggesting a balance between durability and aesthetic considerations. In contrast, for poor oral hygiene, amalgam predominated (65%), whereas composite and HVGICs were each selected less often (17%). Given reports of higher failure rates for composites in high-risk oral conditions, this level of composite use in poor hygiene scenarios warrants further evaluation.⁵¹ Overall, oral hygiene appeared to be a key determinant of material choice, whereas dentist demographics were not.

Under inadequate moisture control, material preferences were consistent across gender, experience and postgraduate training, indicating that choices were driven mainly by procedural demands rather than practitioner characteristics. Most respondents selected amalgam (69.4%), followed by HVGIC (23.7%), whereas composites were rarely chosen (6.9%), which is consistent with their need for effective isolation for reliable bonding.⁵²

Dentist demographics (gender, experience, postgraduate training) were not associated with material selection, reinforcing the predominance of clinical and patient-related determinants. These findings suggest a need for continuing professional development that emphasises evidence-based use of contemporary restorative materials and techniques to support consistent, up-to-date decision-making in general practice.

Despite the Minamata Convention’s goal of phasing down amalgam, our findings suggest a limited influence on routine decision-making. A proportion of dentists still selected amalgam for paediatric patients, and only a minority cited Minamata-related considerations when preferring composite, indicating that practical factors (eg, durability, ease of use and patient-driven aesthetic demand) remain more influential than policy. This highlights the need for coordinated strategies—curricular updates, accessible mercury-free alternatives and targeted awareness efforts—to better align environmental objectives with clinical and economic realities, which is consistent with reports from Jordan.²⁹

In general, the high cost of dental care can influence patient decisions, often directing patients toward more affordable options that may be less aligned with preferred clinical or aesthetic goals.^{30 53 54} Patient financial status was strongly associated with material preference (p<0.0001). Under significant financial constraints, amalgam was most commonly preferred (56.9%), whereas composite was predominant with moderate (58.4%) and slight (64.1%) constraints, which is consistent with its balance of aesthetics and relative affordability. The HVGIC was selected primarily in the ‘no financial constraints’ category, suggesting that when cost is less limiting, other material considerations may play a greater role. Overall, these findings highlight the central role of socio-economic context in restorative decision-making in Palestine and the need to align material recommendations with both clinical requirements and patients’ financial capacity.

Prior studies suggest that social media can shape patients’ aesthetic expectations and may influence dentists’ perceptions of patient preferences.³⁹⁵⁵,⁵⁷ Consistent with this, most respondents in our study perceived some degree of social media influence, although the reported magnitude of influence varied across dentists. These findings support the need for evidence-based patient communication, including professionally managed digital engagement, to address misinformation and calibrate expectations.

Most dentists perceived that patients prefer composite resins because of social media exposure (97%), whereas very few attributed patient preference to amalgam (2%) or HVGIC (1%).^{40 56} This perception is consistent with the aesthetic emphasis of social media content and may contribute to perceived clinical pressure: 75.2% reported feeling pressured to meet these expectations (18.9% ‘always’ and 56.3% ‘sometimes’). Overall, these findings suggest that social media operates mainly as an indirect contextual influence on dentists’ perceptions and consultation dynamics rather than as a direct measure of patient behaviour.

These findings underscore the need for communication strategies that balance patient autonomy with evidence-based care. Clinicians can address misinformation and align expectations through effective chairside counselling, public education and professionally managed social media engagement.⁵⁸,⁶⁰ Further research should examine how social media-driven expectations influence long-term outcomes and identify effective approaches to support appropriate, patient-centred restorative decisions.

Strengths and limitations

This study has several notable strengths. This is the first study to explore the factors influencing restorative material choice among general dental practitioners in Palestine, addressing a significant gap in the literature. The use of a structured and pretested online questionnaire enhanced data consistency and reliability. The internal consistency (Cronbach’s α=0.83) and test–retest reliability confirmed the stability and reproducibility of the responses. Adherence to the STROBE guidelines ensured methodological rigour. Stratified and subgroup analyses were employed to control for confounding factors and assess effect modification, thereby strengthening the validity of the observed associations.

However, as an exploratory study, several limitations should be considered when the findings are interpreted. The convenience and snowball sampling strategy may have affected representativeness, with possible over-representation of digitally active practitioners, which could overestimate preferences for contemporary tooth-coloured materials. Because incomplete questionnaires were excluded (complete-case analysis), selection bias is possible if non-completers differ systematically from completers; this could not be assessed owing to the anonymous survey design. In addition, the study relied on self-reported responses to hypothetical scenarios, which may be influenced by reporting and social desirability bias; dentists may overreport preferred or guideline-concordant materials (eg, composites) and under-report less favoured materials (eg, amalgam).

Notably, the questionnaire did not directly measure patient behaviour or external social pressure. Rather, the social media-related items assessed dentists’ perceptions of how social media influences their patients’ preferences and the extent to which they feel pressure to align with these perceived expectations. Accordingly, the construct of social media influence should be interpreted as reflective of perceived contextual influence rather than of observed patient behaviour. This distinction limits causal inference and the ability to draw conclusions about actual patient influence or broader societal trends. While we retained this variable because it is central to the study question, its operationalisation may reflect indirect or mediated pathways (eg, via financial or aesthetic preferences). Future studies should employ validated instruments, direct patient surveys and mediation analyses to assess these constructs more precisely and clarify the pathways through which social media affects restorative decisions.

Furthermore, the cross-sectional design captures data at a single point in time and does not account for external factors, such as evolving clinical guidelines, regulatory changes or material availability, that may affect restorative decisions over time. In addition, no formal sensitivity analyses were performed. Although subgroup stratification and complete-case analysis enhanced internal validity, formal sensitivity analyses, such as variable reclassification or alternative model testing, could have provided further insight into the robustness of the findings. Future studies should incorporate such analyses to validate these results under varying assumptions.

The Bonferroni correction (α=0.005) controlled the familywise error rate but reduced statistical power, likely obscuring borderline associations—such as financial influence (p=0.014) and gender (p=0.033) in the HVGIC subgroup—that would have been significant at α=0.05. The small number of HVGIC cases (n=17–42) also limited the estimation precision and may have contributed to model instability. Larger samples or alternative adjustment methods may help clarify these effects in future studies. Finally, the generalisability of these findings beyond Palestine should be approached cautiously because of context-specific factors such as socio-economic conditions, dental healthcare infrastructure and the regional prominence of social media. Nonetheless, the results may offer valuable insights for other low- and middle-income countries facing similar challenges, where financial constraints, patient expectations shaped by global media trends and limited access to advanced training collectively influence restorative decision-making. Broader sampling strategies, comparative research across diverse contexts and longitudinal designs are recommended to enhance the external validity of future investigations.

Conclusion

The findings of this study underscore the complex interplay of clinical, socio-economic and sociocultural factors influencing restorative material selection among Palestinian dentists. Patient-related determinants remain central to decision-making, whereas financial constraints exert the strongest independent effect. The study also identifies a notable sociocultural layer: the widespread perception among dentists that social media influences their patients’ expectations for tooth-coloured, aesthetic restorations. The findings highlight social media as a growing, unregulated driver of patient demand that now intersects with and at times challenges evidence-based restorative decision-making. Although many dentists report feeling pressured to respond to these expectations, the multivariate analysis shows that this perceived influence does not independently override clinical or financial considerations.

This distinction is especially relevant in lower socio-economic settings, where patient demand for composite restorations, amplified by social media, may conflict with evidence-based, cost-appropriate treatment options such as amalgam or HVGIC. This tension highlights the need for improved patient communication strategies, clearer public education about material suitability and longevity, and professional support for dentists navigating aesthetic pressures within resource-limited contexts. Strengthening dentists’ ability to manage social media-driven expectations while upholding clinically sound, context-sensitive and patient-centred care represents a key priority for future policy and training initiatives.

Data availability statement

Data are available upon reasonable request.