Amalgam Safety

Overview
History of amalgam Mercury exposure Forms of mercury Amalgam concerns Alternative materials Summary

Amalgam
An alloy of mercury with another metal.

Click here for slide presentation on amalgam

Debut of Amalgam
Introduced in 1800s in France
alloy of bismuth, lead, tin and mercury plasticized at 100 C poured directly into cavity

1826 - Traveau
compounded a silver paste amalgam
mixture of silver shavings from coins and mercury

condensed into tooth at room temperature

Mackert JADA 1991

Amalgam War I
1833 - Crawcour brothers
heavily marketed their amalgam of silver and mercury

1843 - American Society of Dental Surgeons

declared use of amalgam malpractice
mercury is a poison

threatened to expel users

Amalgam use declined

Mackert JADA 1991

Amalgam War I
1895 - G.V. Black
developed effective amalgam
improved handling and performance similar to contemporary low-copper amalgam

Popularity of amalgam increased

failure of adverse health effects to materialize
Black Dent Cosmos 1896

Amalgam War II
1924 - Alfred Stock
German professor of chemistry became poisoned with mercury
25 years of laboratory research

published papers on the dangers of mercury in dentistry

Created considerable public concern

Stock Med Klin 1296

Amalgam War II
1934 - German physicians
studied patients
occupationally exposed to mercury
with and without amalgams

published papers
no health risk from amalgams

1941 - Stock recanted his position

Mackert JADA 1991

Amalgam War III

1970 - 1990
concern over occupational exposure of mercury vapor to dentists excess levels in 10% of dental offices
> threshold limit of 50 ug/mm3

urinary mercury levels high

mild functional effects found

ADA institutes mercury hygiene campaign

Mandel JADA 1991

Amalgam War III

1970 - 1990
urinary mercury levels lowered 50 % a shift in concerns
from occupational risk to dentists to patient risk
2 0 u g /L1 0 0 1 9 8 0

U rin a ryM e rc u ryL e v e lsinD e n tis ts

ability to measure mercury release from amalgam restorations in expired air

early tests grossly overestimated

1 9 8 6

1 9 9 1

Mandel JADA 1991 Naleway J Pub Healt Dent 1991

Anti-Amalgamists
Dentists specialize in treating purported mercury toxicity
becomes a marketing tool

Hal Huggins
publications, videotapes and seminars removal of amalgam purportedly cures
Leukemia Hodgkins disease Multiple Sclerosis

website: Hugnet
The Amalgam Scare Campaign

Evidence-Based Care
Critically evaluating research literature and clinical data
lay population unfamiliar with peer-reviewed dental literature rely on media stories and internet

Survey by ADA in 1991

1000 adults
nearly 50% believed health problems possible from dental amalgams
click here for details
Guyatt JAMA 1993 Dodes JADA 2001

Why Amalgam?
Inexpensive Ease of use Proven track record
>100 years

Familiarity Resin-free
less allergies than composite
Ten Clinical and Legal Myths of Anti-Amalgam

Amalgamation
Alloy (Ag-Sn-Cu) mixed with approximately 50% mercury (Hg)
within several hours, no free mercury remains
stable intermetallic compounds

Ag-Sn-Cu + Hg Ag-Sn-Cu + AgHg + Cu-Sn

alloy undissolved alloy matrix copper phase

Liquid Mercury
Hydrargyrum (Hg) Activates amalgamation reaction Only pure metal that is liquid at room temperature

Click here for ADA Mercury Hygiene Recommendations

Amalgam Restorations
Half-billion restorations per year
75 tons of mercury

Mercury vapor released

chewing and brushing
Berglund J Dent Res 1990

removal of amalgam
reduced 90% with high-volume evacuation
Pohl Acta Odontol Scand 1995

difficult to determine vapor levels accurately

Olsson J Dent Res 1992

Mercury Dose from Amalgam

Average daily dose from 8 10 amalgam surfaces
1-2 ug per day well below threshold levels

Threshold urine mercury levels

subtle, pre-clinical effects
30 ug per day

considered dangerous
82 ug per day
Olsson J Dent Res 1995 Mackert Crit Rev Oral Biol Med 1997 Berdouses J Dent Res 1995

Exposure to Mercury
Food
fish, grain

Occupational
dentistry factory workers

Air, water
naturally occurring

Commercial products
antiseptics ointments thermometers

Sources of Mercury
Ubiquitous in environment
30,000 to 150,000 tons/year released worldwide

Natural
volcanic emissions degassing of soil volatilization from oceans
WHO 1989

Sources of Mercury
Anthropogenic
fossil fuels
coal

industrial processes
waste incineration boilers

products
fluorescent lamps batteries thermometers amalgam

Fate and Transport of Mercury

Continuously mobilized, deposited and remobilized
atmosphere
global circulation
transferred to surface wet or dry deposition

terrestrial
soil deposition

aquatic
may enter food chain
concentrates in fish greatest source of human exposure
www.epa.gov/mercury/exposure.htm

Forms of Mercury
Elemental Inorganic Organic

Osborne J Esthet Rest Dent 2004

Elemental Mercury
Un-ionized mercury High vapor pressure
significant to dentistry

Absorption
readily from lungs poorly from GI and skin
< 0.1% not toxic when swallowed
Clarkson Crit Rev Clin Lab Sci 1987

Mercury Vapor
Accounts for most occupational and home exposures
mercury spills
thermometers fluorescent light bulbs

Significant toxicity when inhaled

80% absorbed by lungs

Acute toxicity is rare

Hursh Arch Environ Health 1976

Inorganic Mercury
Highly toxic as inorganic salts Hg2+ mercuric ion
mercuric oxide
swallowed batteries by children

mercuric sulfide
red tattoos

Hg1+ mercurous ion

mercurous chloride
laxatives teething powder
Wands Am J Med 1974 Litovitz Pediatrics 1992

Organic Mercury
Alkyl
methyl - most toxic form
95% absorbed in gut responsible for several mass poisonings
Minamata Bay, Japan - 1950 inorganic mercury dumped in bay methylated by aquatic organisms concentrates up food chain

ethyl preservative
Thimerosal
anti-microbial in pharmaceuticals

Aryl highly toxic

antifungal on seeds
Renzoni Environ Res 1998

Mercury Monitoring
Exhalation
difficult to perform reliably

Urine
best method for chronic exposure
symptoms 300 ug/L normal < 25 ug/L

Goldfranks Toxicologic Emergencies 1990

Mercury Monitoring
Blood
normal < 6 ug/L reflects recent exposure
3-day half-life

reliable measurement of methylmercury exposure

Hair
not a reliable method
WHO Environmental Health Criteria

Biologic Activity of Mercury

Binds to protein sulfhydryl groups
loses structure and function

No carcinogenicity Teratogenicity

Symptoms of Toxicity
Acute high-level exposure
hypersalivation cough dyspnea bronchitis Pneumonia vomiting gastroenteritis

Chronic low-level exposure

depression irritability weakness tremor insomnia renal failure memory loss

Concerns with Amalgam

Dental occupational exposure Amalgam waste Hypersensitivity Mercury accumulation Multiple sclerosis Alzheimers disease Renal toxicity Reduced immunocompetence Amalgam illness
Ten Medical Myths of Anti-Amalgam

Dental Occupational Exposure

Higher mercury level found in providers with poor mercury hygiene
screening of dentists
2% had elevated urinary mercury levels
avg. 36 ug/L

evidence of adverse preclinical effects

Echeverria Neurotoxicol Teratol 1995

Dental Occupational Exposure

Poor mercury hygiene
in-office dispensing
mercury and alloy powder

mercury spills use of squeeze cloths inadequate suction and water spray during amalgam removal

Minimizing Office Exposure

Pre-capsulated amalgam Store scrap amalgam in tightly-closed unbreakable container
recap capsules

Water spray and high-volume evacuation when polishing or removing amalgam Close cover on triturator when in use Use care when handling amalgam
avoid skin contact
Click here for slide presentation on Mercury Hygiene Click here for ADA Mercury Hygiene Recommendations

Amalgam Waste
Mercury is a naturally occurring metal Half of environmental mercury comes from human activity
< 1% dentistry
13% <1% Fuel Combustion Waste Combustion Manufacturers Dentistry

34%

52%

Wastewater Discharge
Primary source of mercury in water is air However, increased regulatory pressure to control mercury in wastewater Dental offices become easy identifiable source Municipal water treatment authorities
attempt to regulate mercury wastewater from dental offices
Click here for ADA Summary of Amalgam in Wastewater Click here for ADA Best Management Practices for Amalgam Waste

Amalgam Waste
Non-contact amalgam
store in sealed container

Contact amalgam
disinfect and dry
non-chlorine disinfectant

combine with non-contact amalgam

Used amalgam capsules

recap, if possible store in sealed container
Click here for USAF Best Management Practices for Amalgam Waste Click here for slide presentation on Mercury Hygiene

Amalgam Waste
Extracted teeth
disinfect and dry
non-chlorine disinfectant

store in sealed container

Chairside traps
disinfect and dry store with used amalgam capsules

Amalgam Restrictions
Typically to reduce the amount and sources of mercury by various countries
in the environment exposure to children and pregnant women

Examples
Belgium, Denmark, Finland, Sweden
Rowland Occup Environ Med 1994

Hypersensitivity
Type IV or cell-mediated immune response Contact dermatitis Lichenoid lesions adjacent to amalgam Most reactions subside
amalgam removal usually not necessary

True allergy is rare

< 1%
Anneroth Acta Odontol Scand 1992 Duxbury Br Dent J 1982 McGiven Br Dent J 2000

Hypersensitivity
Double-blind study
660 subjects tested with 1% ammoniated mercury 3% positive skin response
only 20% of these had true allergy (0.6%)

Storrs J Am Acad Dermatol 1989

Mercury Accumulation
Studies found higher mercury levels in various organs
in sheep and monkeys with amalgam placement
Hahn FASEB 1989, 1990

critical review of studies

Eley Br Dent J 1997 probable result of swallowed scrap amalgam no controls

in dental staff
Nylander Swed Dent J 1989

Renal Toxicity
Study evaluating kidney function
Boyd AM J Physiol 1991
6 sheep with 12 amalgams 2 sheep with glass ionomers (control) reported 60% loss of renal function compared to control

study reviewed by renal physiologists Malvin Am J Physiol 1992

poor model data support improved renal function

Renal Toxicity
Studies showing no renal dysfunction due to amalgam restorations
Molin Acta Odontol Scand 1990 Sandborgh-Englund Am J Physiol 1996 Herrstrom Arch Environ Health 1995 Naleway J Public Health 1991 Langworth J Dent Res 1997

Reduced Immunocompetence
Study showing drop in lymphocyte level with amalgam placement
Eggleston J Prosthet Dent 1983
baseline CBC on 2 patients
placed amalgams and new CBC removed amalgams and new CBC

However, change was consistent with normal diurnal variation in cell counts and measuring error
Mackert JADA 1991

Reduced Immunocompetence
Studies show no damage to immune system from amalgam restorations
Herrstrom Scand J Prim Health Care 1994 Loftenius J Toxicol Environ Health 1998 Herrstrom Arch Environ Health 1994 Mackert JADA 1991

Amalgam Illness
Multitude of conditions reportedly caused by the presence of amalgam
symptoms may be due to mental disorders

Studies found reduction of symptoms after amalgam removal

70% of patients reported reduction
Siblerud J Orthomol Med 1990

patients reported 88% reduction

Lichtenberg J Orthomol Med 1993

Critics site lack of control groups, poor study design, and placebo effect
Wahl Quintessence Int 2001

Major Health Organizations

Alzheimers Association
no connection between Alzheimers and mercury-containing dental fillings

National MS Society
There is no scientific evidence to connect the development of MS or other neurological diseases with dental fillings containing mercury.

Food and Drug Administration (FDA)

no valid scientific evidence has ever shown that amalgams cause harm to patients with dental restorations.

American Dental Association

Dental amalgam (silver filling) is considered a safe, affordable and durable material

Alternative Materials
Typically higher cost and/or greater technique sensitivity
composite resin glass ionomer ceramic metal alloys

How Dental Materials Compare

Comparison of Toxic Effects

Amalgam
Systemic Toxicity - acute - chronic Allergic Reactions
None Not verified Rare None Not verified Rare, but many components have allergic potential None Not verified Extremely rare

Composite

Glass Ionomers

Anaphylaxis
Cytotoxicity Mutagenicity or Carcinogenicity Lichenoid reactions

None so far
Low None

Isolated cases
Slight to high Certain components mutagenic in vitro Yes

None so far
Slight to high Slight mutagenicity

Yes

None
WHO 1997

Risk vs. Benefit Relationship

Benefits and detriments to the use of any material Unbalanced risk assessments may lead to the waste of limited health resources
deny public access to beneficial therapies

ADA Council on Scientific Affairs JADA 1998 Corbin JADA 1994

Survey of Practice Types

Civilian General Dentists

32%

Amalgam Free

Amalgam Users

68%

Haj-Ali Gen Dent 2005

Frequency of Posterior Materials

by Practice Type
3% 7% 39%

Amalgam Users
51%

Amalgam

Direct Composite

Indirect Composite

Other

12% 8%

3%

Amalgam Free

Haj-Ali Gen Dent 2005

77%

Profile of Amalgam Users

Civilian Practitioners
Do you use amalgam in your practice?
2 2 %

Do you place fewer amalgams than 5 years ago?

1 2 %

No Yes

No
Yes

7 8 %

8 8 %

DPR 2005

Review of Clinical Studies

(Failure Rates in Posterior Permanent Teeth)
% Annual Failure

8 6 4 2 0

Amalgam

Direct Comp

Comp Inlays

Ceramic CAD/CAM Inlays Inlays

Gold Inlays & Onlays

GI

Longitudinal

Cross-Sectional
Hickel J Adhes Dent 2001

Review of Clinical Studies

(Failure Rates in Posterior Permanent Teeth)
% Annual Failure

15
Standard Deviation

10
Longitudinal and Cross-Sectional Data

5 0

GI

Am al ga Di m re ct Co Co mp m po m Co er m p Ce In la ra ys m ic In la CA ys D/ CA M Ca st G ol d

Tu nn el

Manhart Oper Dent 2004 Click here for abstract

AR T

Summary
Dental amalgam
releases minute amounts of elemental mercury
no evidence of systemic health problems
limited cases of allergy

Mercury absorbed from many sources

no demonstration of clinical effects from additional burden from amalgam
Click here for Talking Paper on Amalgam Safety (PDF)

Summary
No cure or health benefit from amalgam removal Dentists must inform patients
risks and benefits of restorative materials

Research needed on specific health effects of low-level mercury exposure

determine effects of amalgam-derived mercury
need large-scale human studies
Click here for Talking Paper on Amalgam Safety (PDF)

Summary
Materials research
alternatives to amalgam reduce mercury emission from amalgams

Amalgam will eventually be replaced by composite and other materials

esthetics environment

Online Fact Sheets

Dental Amalgam Use and Benefits U.S. Centers for Disease Control Resource Library Fact Sheet, December 2001; Accessed Nov 2005 California Dental Materials Fact Sheet Accessed Nov 2005

Online Video
FDA Confirms Safety of Amalgam Accessed Nov 2005

Online References
Dental Amalgam: A Scientific Review and Recommended Public Health Strategy for Research, Education and Regulation US Public Health Service 1993; Accessed Nov 2005

American Academy of Pediatrics Web site Accessed Nov 2005

Dental Amalgam: Update on Safety Concerns JADA 1998; 129:494-501; Accessed Nov 2005 Dental Watch Website Accessed Nov 2005

Acknowledgements
Dr. David Charlton Dr. Walt Thomas Dr. John Osborne

Questions/Comments
Col Kraig Vandewalle
DSN 792-7670
ksvandewalle@nidbr.med.navy.mil