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Amalgam, risk, benefits and the

precautionary principle

Derek Richards
Editor, Evidence-based Dentistry
Evidence-Based Dentistry (2008) 9, 2. doi: 10.1038/sj.ebd.6400556

In this issue of Evidence-based Dentistry, we Dalhousie University, Halifax, Canada, writ- examination of the full range of alternatives,
are publishing our first Dental Evidence- ing in a Journal of Dental Research editorial, including no action.” (
based Topic (DEBT) on the use of dental describes this as a, “bureaucratic travesty” caution.html)
amalgam in children. As we are hoping to for the following reasons:7 Although the COT decision to advise
develop this feature, I encourage readers to • At least 50% of environmental mercury that amalgam use should be avoided in preg-
submit articles for this new element of the pollution comes from natural sources. nant women is probably justified, it is more
journal. • Some 42% of environmental mercury difficult to reconcile the Norwegian govern-
The bottom line of the amalgam DEBT pollution comes from the burning of ment’s view with their failure to ban some
is that it is safe to use in children, although fossil fuels. of the larger contributors to environmental
current research suggests that resin-modi- • No valid scientific studies have ever mercury pollution. What I do find interesting
fied glass ionomer cements (and compom- shown that dental amalgam poses a about that precautionary principle is that it
ers) are now showing durability comparable health hazard to patients, to dentists, or seems just a modern restatement of the risk
to amalgams, at least for occlusal and mod- to the environment. to benefit balance that scientists have been
erate sized class II cavities,1 with preformed weighing up for years. What that precaution-
metal crowns showing superiority for larger He goes on further to calculate, “that ary principle now does is shift the balance of
restorations.2 the environmental impact of mercury from proof too far. To me, this is a symptom of an
The continuing use of amalgam in den- 800 000 dental offices world-wide would increasingly risk-averse society which is gen-
tistry has been challenged for many years represent between 0.04 and 0.20% of the erating higher and higher barriers to much-
because of concerns that its use is associ- total world-wide environmental mercury needed good quality research.
ated with a range of conditions such as pollution from all sources”, pointing out
Alzheimer’s, Parkinson’s disease and mul- that this would be significantly reduced by 1. Chadwick BL, Evans DJP. Restorations of class II cavities
tiple sclerosis. Several reviews in the area the use of amalgam traps. in primary molar teeth with conventional and resin
have found that current evidence for a role Although the use of dental amalgam is on modified glass ionomer cements: a systematic review
of the literature. Eur Arch Paed Dent 2007; 8:14–21
for amalgam in these diseases is inconclu- the decline, it is still an effective filling mate- 2. Attari N, Roberts JF. Restoration of primary teeth with
sive, however.3–5 The latest of these, a pre- rial that is longlasting, cost-effective and less crowns: a systematic review of the literature. Eur
Arch Paed Dent 2006; 7:58–63
liminary report by the Scientific Committee technique-sensitive than the majority of the
3. Bates MN. Mercury amalgam dental fillings: an
on Emerging and Newly Identified Health newer dental restorative materials.8,9 The epidemiologic assessment. Int J Env Health 2006;
Risks,6 concluded that there are no increased COT and Norwegian Government decisions 209:309–316
4. National Health and Medical Research Council,
risks of adverse systemic effects; the on amalgam are based on the increasingly Australia. Dental Amalgam and Mercury in Dentistry.
Committee does not therefore consider that prevalent use of the precautionary principle, Report of a National Health and Medical Research
Council Working Party. 1999.
the current use of dental amalgam poses a articulated following the 1998 Wingspread
5. Department of Health. Committee on Toxicity of
risk of systemic disease. Conference (, Chemicals in Food, Consumer Products and the
Even without evidence of any adverse “When an activity raises threats of harm to Environment. Statement on the Toxicity of Dental
Amalgam. London: Department of Health; 1998.
health effects, the Committee on Toxicity human health or the environment, precau- 6. Scientific Committee on Emerging and Newly
of Chemicals in Food UK (COT) advised tionary measures should be taken even if Identified Health Risks. Preliminary Report on the
that it was prudent, where clinically reason- some cause and effect relationships are not Safety of Dental Amalgam and Alternative Dental
Restoration Materials for Patients and Users. 2007.
able, to avoid its use in pregnant women. fully established scientifically. In this con- 7. Jones DW. Has dental amalgam been torpedoed and
More recently, the Norwegian Government text, the proponent of an activity, rather sunk? J Dent Res 2008; 87:101–102.
8. Downer MC, Azli NA, Bedi R, Moles DR, Setchell
imposed a ban on dental amalgam from than the public, should bear the burden of DJ. How long do routine dental restorations last? A
1 January 2008 as part of legislation to pro- proof. The process of applying the precau- systematic review. Br Dent J 1999; 187:432–439.
hibit the production, exportation, sale and tionary principle must be open, informed 9. National Health Service Centre for Reviews and
Dissemination. The Longevity of Dental Restorations:
use of substances that contain mercury. and democratic and must include poten- a Systematic Review. CRD Report 19. University of
A Professor Emeritus of Biomaterials at tially affected parties. It must also involve an York; 2001.


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