Amalgam Safety

Col Kraig S. Vandewalle

USAF Dental Evaluation & Consultation Service
 Official Disclaimer
• The opinions expressed in this presentation are
those of the author and do not necessarily
reflect the official position of the US Air Force or
the Department of Defense (DOD)
• Devices or materials appearing in this
presentation are used as examples of currently
available products/technologies and do not
imply an endorsement by the author and/or the
USAF/DOD
 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 1800’s in France
– alloy of bismuth, lead, tin
and mercury
– plasticized at 100 ºC
– 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 UrinaryMercuryLevelsinDentists
– urinary mercury levels
lowered 50 % 20
– a shift in concerns
ug/L10
• from occupational risk to
dentists to patient risk
0
– ability to measure mercury 1980 1986 1991

release from amalgam

restorations in expired air
• early tests grossly
overestimated
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
• Hodgkin’s 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 matrix copper
alloy 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 • Occupational
– fish, grain – dentistry
• Air, water – factory workers
– 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

Goldfrank’s 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 • Chronic low-level
exposure exposure
– hypersalivation – depression
– cough – irritability
– dyspnea – weakness
– bronchitis – tremor
– Pneumonia – insomnia
– vomiting – renal failure
– gastroenteritis – memory loss
 Concerns with Amalgam
• Dental occupational exposure
• Amalgam waste
• Hypersensitivity
• Mercury accumulation
• Multiple sclerosis
• Alzheimer’s 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
Dental Occupational Exposure
• No negative reproductive effects
– Ericson Int Arch Occup Environ Health 1989
– Brodsky JADA 1985
– Sundby J Women’s Health 1994
– Dahl Scand J Work Environ Health 1999
– Heidam J Epidemiol Community Health 1984
– Warfvinge Br Dent J 1995
 Amalgam Waste
• Mercury is a naturally occurring metal
• Half of environmental mercury comes
from human activity
– < 1% dentistry

13% <1%
Fuel Combustion
Waste Combustion
52% Manufacturers
34% Dentistry
 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
 Multiple Sclerosis
• Studies found no relationship between
amalgam restorations and MS
– McGrother Br Dent J 1999
– Bangsi Int J Epidemiol 1998
• Study found no difference in
mercury levels between autopsied
brains in patients with and without MS
– Clausen Acta Neurol Scand 1993
 Multiple Sclerosis
• Overnight cure claimed after amalgam
removal
– highlighted on “60 Minutes” and
by Hal Huggins
• Huggins Dent Assist 1985
– not logical
• mercury burden increases after mercury removal
• strong placebo effect
 Alzheimer’s Disease
• Mercury from dental amalgam can accumulate in
many body tissues, including brain
– Eggleston J Prosthet Dent 1987
– Nylander Lancet 1986
• Studies evaluating mercury
levels in autopsied brains
of Alzheimer’s patients
– higher
• Wenstrup Brain Res 1990
– no correlation
• Saxe JADA 1999
 Alzheimer’s Disease
• Controlled human studies fail to find link
between amalgam or mercury levels and
Alzheimer’s
– Saxe JADA 1995
• 129 nuns
• existing amalgams not associated with low performance
on neuropsychological tests
– Fung Gen Dent 1996
• found no significantly higher levels of mercury in urine,
blood or brain tissue of Alzheimer’s patients

Q&A About Dental Fillings and Alzheimer's Disease

 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
 Amalgam Illness
• Studies finding no relationship between amalgam
illness and mercury levels or amalgam restorations
– Bergland 1996 – Henningsson 1996
– Molin 1987 – Bjorkman 1996
– Stenman 1997 – Anneroth 1992
– Bratel 1997 – Langworth 1997
– Bratel 1997 – Lindberg 1994
– Sandborgh-Englund 1994 – Meurman 1990
– Melchart 1998 – Michel 1989
– Ahlqwist 1988, 1993 – Stromberg 1999
 Major Health Organizations
• Alzheimer’s Association
“…no connection between Alzheimer’s 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 Composite Glass Ionomers
Systemic Toxicity
- acute None None None

- chronic Not verified Not verified Not verified

Allergic Reactions Rare Rare, but many Extremely rare

components have
allergic potential
Anaphylaxis None so far Isolated cases None so far

Cytotoxicity Low Slight to high Slight to high

Mutagenicity or None Certain components Slight mutagenicity

mutagenic in vitro
Carcinogenicity
Lichenoid reactions Yes 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 Amalgam
Free 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% 3%
8%
Amalgam Free

Haj-Ali Gen Dent 2005 77%

 Profile of Amalgam Users
Civilian Practitioners
Do you use amalgam in Do you place fewer amalgams
your practice? than 5 years ago?

22% 12%
No No
Yes
Yes

78%
88%

DPR 2005
 Review of Clinical Studies
(Failure Rates in Posterior Permanent Teeth)
% Annual Failure
8

0
Amalgam Direct Comp Ceramic CAD/CAM Gold GI
Comp Inlays Inlays Inlays Inlays &
Onlays

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

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Manhart Oper Dent 2004

Click here for abstract
 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 H
ealth 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