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 .

lead.Debut of Amalgam ‡ Introduced in 1800¶s in France ± alloy of bismuth.Traveau ± compounded a silver paste amalgam ‡ mixture of silver shavings from coins and mercury ± condensed into tooth at room temperature Mackert JADA 1991 . tin and mercury ± plasticized at 100 ºC ± poured directly into cavity ‡ 1826 .

Crawcour brothers ± heavily marketed their amalgam of silver and mercury ‡ 1843 .Amalgam War I ‡ 1833 .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 .

Stock recanted his position Mackert JADA 1991 .German physicians ± studied patients ‡ occupationally exposed to mercury ± with and without amalgams ± published papers ‡ no health risk from amalgams ‡ 1941 .Amalgam War II ‡ 1934 .

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 .

Amalgam War III ‡ 1970 .1990 ± urinary mercury levels lowered 50 % ± a shift in concerns ‡ from occupational risk to dentists to patient risk 20 ug/L 10 0 1980 Urinary Mercury Levels in Dentists ± ability to measure mercury release from amalgam restorations in expired air ‡ early tests grossly overestimated 1986 1991 Mandel JADA 1991 Naleway J Pub Healt Dent 1991 .

videotapes and seminars ± removal of amalgam purportedly cures ‡ Leukemia ‡ Hodgkin¶s disease ‡ Multiple Sclerosis ± website: Hugnet The Amalgam Scare Campaign .Anti-Amalgamists ‡ Dentists specialize in treating purported mercury toxicity ± becomes a marketing tool ‡ Hal Huggins ± publications.

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-SnAg-Sn-Cu + Hg   Ag-Sn-Cu + AgHg + Cu-Sn Ag-SnCualloy 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 .

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 .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.

water ± naturally occurring ‡ Commercial products ± antiseptics ± ointments ± thermometers .Exposure to Mercury ‡ Food ± fish. grain ‡ Occupational ± dentistry ± factory workers ‡ Air.

000 to 150.000 tons/year released worldwide ‡ Natural ± volcanic emissions ± degassing of soil ± volatilization from oceans WHO 1989 .Sources of Mercury ‡ Ubiquitous in environment ± 30.

Sources of Mercury ‡ Anthropogenic ± fossil fuels ‡ coal ± industrial processes ‡ waste incineration ‡ boilers ± products ‡ ‡ ‡ ‡ fluorescent lamps batteries thermometers amalgam .

epa.htm .gov/mercury/exposure. 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.Fate and Transport of Mercury ‡ Continuously mobilized.

Forms of Mercury ‡ Elemental ‡ Inorganic ‡ Organic Osborne J Esthet Rest Dent 2004 .

1% ‡ not toxic when swallowed Clarkson Crit Rev Clin Lab Sci 1987 .Elemental Mercury ‡ Un-ionized mercury ‡ High vapor pressure ± significant to dentistry ‡ Absorption ± readily from lungs ± poorly from GI and skin ‡ < 0.

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 .

most toxic form ‡ 95% absorbed in gut ‡ responsible for several mass poisonings ± Minamata Bay.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 .Organic Mercury ‡ Alkyl ± methyl . Japan .

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 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 Alzheimer¶s disease Renal toxicity Reduced immunocompetence Amalgam illness Ten Medical Myths of Anti-Amalgam .

36 ug/L ‡ evidence of adverse preclinical effects » Echeverria Neurotoxicol Teratol 1995 .Dental Occupational Exposure ‡ Higher mercury level found in providers with poor mercury hygiene ± screening of dentists ‡ 2% had elevated urinary mercury levels ± avg.

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 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 .

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 ‡ Non-contact amalgam ± store in sealed container ‡ Contact amalgam ± disinfect and dry ‡ non-chlorine disinfectant ± combine with non-contact amalgam ‡ Used amalgam capsules ± recap.

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. Finland. Denmark. 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 .

6%) Storrs J Am Acad Dermatol 1989 .Hypersensitivity ‡ Double-blind study ± 660 subjects ± tested with 1% ammoniated mercury ± 3% positive skin response ‡ only 20% of these had true allergy (0.

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 .Mercury Accumulation ‡ Studies found higher mercury levels in various organs ± in sheep and monkeys with amalgam placement ± Hahn FASEB 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 ³60 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 .

poor study design. and placebo effect ‡ Wahl Quintessence Int 2001 .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.

1993 ± ± ± ± ± ± ± ± Henningsson 1996 Bjorkman 1996 Anneroth 1992 Langworth 1997 Lindberg 1994 Meurman 1990 Michel 1989 Stromberg 1999 .Amalgam Illness ‡ Studies finding no relationship between amalgam illness and mercury levels or amalgam restorations ± ± ± ± ± ± ± ± Bergland 1996 Molin 1987 Stenman 1997 Bratel 1997 Bratel 1997 Sandborgh-Englund 1994 Melchart 1998 Ahlqwist 1988.

³ ‡ American Dental Association ³Dental amalgam (silver filling) is considered a safe.´ ‡ Food and Drug Administration (FDA) ³«no valid scientific evidence has ever shown that amalgams cause harm to patients with dental restorations. affordable and durable material«´ .Major Health Organizations ‡ Alzheimer¶s Association ³«no connection between Alzheimer¶s and mercury-containing dental fillings«´ ‡ National MS Society ³There is no scientific evidence to connect the development of MS or other neurological diseases with dental fillings containing mercury.

Alternative Materials ‡ Typically higher cost and/or greater technique sensitivity ± composite resin ± glass ionomer ± ceramic ± metal alloys How Dental Materials Compare .

but many components have allergic potential Isolated cases Slight to high Certain components mutagenic in vitro Yes None Not verified Extremely rare mp i Gl I m Anaph laxi xi i ag ni i arcinog nici Lich noid reactions None so far Low None Yes None so far Slight to high Slight mutagenicity None WHO 1997 .Comparison of Toxic Effects Am lg m S .h All gi R i i mi T xi i None Not verified Rare None Not verified Rare.

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%

Am g m

r

ompo i

Indir

ompo i

Oh r

12% 8%

3%

Amalgam Free

Haj-Ali Gen Dent 2005

77%

Profile of Amalgam Users Civilian Practitioners Do you use amalgam in your practice? 22% Do you place fewer amalgams than 5 years ago? 12% No Yes No Yes 78% 88% 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 .

S.Online Fact Sheets ‡ Dental Amalgam Use and Benefits U. December 2001. Centers for Disease Control Resource Library Fact Sheet. 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. 129:494-501. Accessed Nov 2005 Dental Watch Website Accessed Nov 2005 . 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.

David Charlton ‡ Dr. Walt Thomas ‡ Dr.mil .navy. John Osborne Questions/Comments Col Kraig Vandewalle ± DSN 792-7670 ± ksvandewalle@nidbr.Acknowledgements ‡ Dr.med.

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