J'A O A

REVIEW ARTICLES

M ercury has been used f o r a va rie ty o f m edicin al pu rposes f o r centuries. E xposure to m ercury
can occur fro m environm ental, d ieta ry, a n d o ccu pation al sources. Since the beginning o f the
early 180 0 s, in term itten t controversy has surrounded the use o f m ercury in d en ta l am algam
restorations. A t the center o f this controversy are questions concerning the am ounts a n d effects
o f m ercury exposure to d en ta l p a tien ts a n d personnel. This rep o rt review s recen t scien tific
literatu re on the safety a n d use o f mercury in den tistry.

The use of mercury in dentistry: a critical review

of the recent literature
Dan C. Langan, D D S
P. L. Fan, P h D
A lice A. H oos

M e rc u ry h as b een u sed f o r m o re History (Amalgam Wars) th e sa m e ” (G o ld w a te r, 1 9 7 2 ).11

th a n 2 ,0 0 0 y ears in p re p a r a tio n s
su ch as d iu re tic s , a n tib a c te ria l
a g e n ts , la x a tiv e s, sk in a n tis e p tic s , a n d
o t h e r o in tm e n ts . P re s e n tly , w o rk e rs in
m o r e th a n 60 in d u s trie s a re o c c u p a tio n ­
ally ex p o se d to m e rc u ry . T h e s e in d u s trie s
in c lu d e fa c to rie s p r o d u c i n g c h lo r in e ,
ca u stic so d a, insecticides, a n d fu n g icid e s,
as well as th o se involved in th e m a n u f a c ­
t u r e of n e o n lig h ts, p a p e r , p a in t, a n d
jew elry, a n d in th e p ra c tic e o f d e n tis try .1
S ince th e 1800s, m e rc u ry has b e e n an
im p o r t a n t c o m p o n e n t o f d e n ta l a m a l­
g a m s, b e in g u sed in v a rio u s fo rm s a n d
c o m p o sitio n s. In 1984, it w as e stim a te d
th a t 85% o f p o s te rio r re s to ra tio n s p lace d
in th e U n ite d States w ere a m a lg a m s.2 P re ­
vious re p o rts e stim a te d th a t 75% o f all
sin g le to o th re s to ra tio n s w e re a m a lg a m
re s to ra tio n s a n d th a t this p e rc e n ta g e h ad
re m a in e d stable fo r m an y y e a rs .3 In 1979,
a survey* c o n d u c te d by th e A m e ric an D e n ­
tal A sso ciatio n ’s B u re a u o f E co n o m ic a n d
B eh av io ra l R esearch e stim a te d th a t in th e
U n ite d S tates an n u a lly , n e a rly 57 m illion
o n e -s u rfa c e a n d 53 m illio n tw o -su rfa c e
a m a lg a m re s to ra tio n s a re p lace d .
Y et, th e safety o f d e n ta l a m a lg a m s fo r
b o th th e d e n ta l p a tie n t a n d th e d e n ta l p r o ­
fessio n al has b e e n q u e s tio n e d in te r m it­
ten tly since th e in c e p tio n o f th e use o f th is
m a te ria l. M any articles a n d re p o r ts h a v e
a p p e a re d in d e n ta l jo u r n a ls a n d th e lay
p re ss c o n c e rn in g th e p ro p e rtie s a n d safety
of d e n ta l am a lg a m s.5' 9
C o n tro v e rsy is n o t new fo r am alg am s. T h e
f o u n d a tio n s f o r th e e a r lie s t r e c o r d e d
“ A m a lg a m W a r” w e re laid a r o u n d 1833.
T h e C ra w c o u r b ro th e rs , th e n e x ile d fro m
F ra n c e fo r d e n ta l p ra c tic e irre g u la ritie s,
s ta rte d a th riv in g p ra c tic e in N ew Y ork
C ity u sin g a silver c o in -m e rc u ry m ix tu re
called “ro y al m in e ra l s u c c e d a n e u m .” B e­
c a u se th e ir tr e a tm e n t was in e x p e n siv e a n d
p ain less (th ey d id n o t b o th e r to rem o v e
d ecay ), p a tie n ts H ocked to th e C raw co u rs'
o ffice. M any d e n tists a b a n d o n e d th e tr a d i­
tio n a l g o ld foil te c h n iq u e o f th e d a y 10 in
fa v o r o f this m o re lu c ra tiv e te c h n iq u e .
A fte r a few y ears o f th e u n sc ru p u lo u s
a n d in e p t w o rk o f th e C ra w c o u rs a n d th e ir
fo llo w ers, d isa stro u s side effects sta rte d to
a p p e a r. In 1843, th e A m e ric a n Society o f
D en tal S u rg e o n s c o n d e m n e d th e use o f all
filling m ate ria ls o th e r th a n g o ld , th e re b y
ig n itin g th e first A m a lg a m W a r.10
T h e society w e n t f u r th e r a n d re q u e s te d
m e m b e rs to sign a p le d g e re fu s in g to use
am a lg a m s. M e m b e rs c o u ld stay in g o o d
g ra c e by sig n in g th e follo w in g : “ I h e re b y
certify it to be m y o p in io n a n d firm convic­
tio n th a t an y a m alg am w h a te v e r . . . is u n fit
fo r th e p lu g g in g o f te e th o r fan g s a n d I
p le d g e m yself n e v e r u n d e r a n y c irc u m ­
stan ces to m ak e use o f it in m y p ra c tic e as a
d e n ta l su rg e o n , a n d f u r th e r m o r e , as a
m e m b e r o f th e A m e ric a n A sso ciatio n o f
D e n ta l S u rg e o n s, 1 d o su b sc rib e a n d u n ite
w ith th e m in this p ro te s t a g a in s t th e use o f
T h e q u e stio n o f a m a lg a m c o m p o sitio n
was fin ally se ttle d in 1895 by D r. G. V.
B lack o f N o rth w e s te rn U n iv e rsity , w ho
a fte r y ears o f scien tific re s e a rc h o n a m a l­
g a m s, d e m o n s tra te d th e p r o p e r q u a n tita ­
tive a n d q u a lita tiv e m ix tu r e o f m e rc u ry in
a m a lg a m to m a k e a n effe c tiv e re s to ra tiv e
m a te ria l.
T h e w o rk o f B lack se rv e d as a basis fo r
m o d e r n c o n c e p ts a n d p ra c tic e s in th e use
o f a m a lg a m re s to ra tio n s a n d led to la te r
s ta n d a r d iz a tio n in th e m a n u f a c tu r e o f
a m a lg a m s. S p e c ific a tio n s f o r m e rc u ry to
be u se d in m a k in g d e n ta l a m a lg a m w ere
d ra w n u p a n d p ro m u lg a te d jo in tly by th e
A m e ric a n D en ta l A sso ciatio n a n d th e US
B u re a u o f S ta n d a rd s in 1 9 3 2 .11
T h e se c o n d A m a lg a m W a r was s ta rte d
by a G e rm a n c h e m ist, P ro fe sso r A. Stock,
in th e m id -1 9 2 0 s w h e n S to ck claim ed to
h a v e e v id e n c e sh o w in g th a t m e r c u ry c o u ld
be a b so rb e d fro m d e n ta l a m a lg a m s a n d
th a t this led to se rio u s h e a lth p ro b lem s.
S to c k a ls o e x p r e s s e d c o n c e r n f o r th e
h e a lth o f d e n tists, s ta tin g th a t n e a rly all
d e n tists h a d excess m e r c u ry in th e ir u rin e .
H e r e p o r te d th a t th e m e r c u ry levels in
u r in e o f sev en p a tie n ts w ith a m a lg a m s
ra n g e d fro m 0.1 to 4 .0 /xg/L, b u t failed to
re c o r d a n y u r in e m e r c u ry levels b e fo re
r e s to ra tio n s w e re p la c e d . S to c k ’s w o rk was
la te r q u e s tio n e d ; e v en S tock, in 1934, re ­
p u d ia te d his e a rlie r a n aly ses. R eg ard le ss,
th is m a rk s th e b e g in n in g o f a c o n tro v e rsy
th a t c o n tin u e s .11

JADA, Vol. 115, December 1987 ■ 867

 REVIEW ARTICLES
T h e c o n tr o v e rs y r e m a in e d d o r m a n t
u n til th e late 1970s w h en it was re ig n ite d
by p u b lish e d re p o r ts — e n tire ly u n s u b ­
sta n tia te d by scientific o r m ed ical ev id en c e
— th a t lin k e d m e rc u ry rele a se fro m a m a l­
g am s to sev ere a n d d eb ilita tin g c a rd io v as­
c u la r, p sy ch iatric, n eu ro lo g ic a l, a n d im ­
m u n o lo g ic d iseases.9,12 I t w as a d v o ca te d
th a t all am a lg a m s b e re m o v e d a n d th a t th e
b io ch em ical c o n d itio n o f th e b o d y b e d e ­
te rm in e d . E lectrical c u r r e n t fro m a m a l­
g am s w as to be m e a s u re d “to d e te rm in e
th e se q u e n c e o f n eg ativ e to positive elec­
trical c u r r e n ts .” T h is was essen tial, it was
claim ed , b ecau se th e rem o v a l o f th e a m a l­
g am s in th e w ro n g seq u e n c e a n d w ith o u t
c o n c o m ita n t biochem ical tr e a tm e n t w o u ld
w o rse n th e p a tie n t’s c o n d itio n . O n e p r o ­
p o n e n t o f this te c h n iq u e su g g e ste d th a t
n eg atively c h a rg e d a m alg am re s to ra tio n s
sh o u ld b e re m o v e d first fo r th e g re a te st
h e a lth b e n e fit, w h e re a s re m o v a l o f p o si­
tiv e ly c h a r g e d a m a lg a m r e s t o r a t i o n s
w o u ld n o t h a v e an im m e d ia te h e a lth e f ­
fe c t.13
T h e fo llo w in g d ra m a tic h e a lth h isto ry
also was r e p o r te d .12 A 1 7-year-old g irl,
w ith d ra w n , totally lack in g in e n e rg y , ev en
suicidal, s o u g h t tre a tm e n t. W h e n sh e b e ­
c a m e ill, sh e b e g a n to h y p e rv e n tila te , a n d
“s ta rte d w ith d ra w in g fro m life,” a n d e v e n ­
tu ally d r o p p e d o u t o f school. S h e w as sen t
to p s y c h i a t r i s t s , i n t e r n i s t s , a n d c a r ­
d io lo g is ts w ith o u t re s u lts , a n d b e c a m e
p ro g ressiv ely sicker. A d e ta ile d case h is­
to ry re c o rd e d by a d e n tis t d isclo sed th a t
h e r sy m p to m s h a d b e g u n 6 m o n th s e a r ­
lie r, a f te r th e p lacin g o f sev eral a m alg am
re s to ra tio n s. A m e rc u ry ev a lu a tio n a n d
b io ch em ical tests w ere d o n e . T h e a m a l­
g a m re s to ra tio n s w e re re m o v e d a n d
w ith in days all sy m p to m s c le a re d . T h e p a ­
tie n t h as b e e n r e p o r te d to h a v e re tu r n e d
to school a n d is now le a d in g a n o rm a l,
p ro d u c tiv e life. T h e s e re p o r ts m a d e th e ir
w ay in to th e p ro fe ssio n a l a n d lay p ress,
c a u sin g c o n c e rn a m o n g p a tie n ts a n d th e
d e n ta l p ro fe s s io n . A few d e n tis ts ev en
s ta rte d ad v o c a tin g th e rem o v a l o f d e n ta l
a m a lg a m re s to ra tio n s. I t se e m e d to so m e
th a t a th ird A m alg am W a r h a d sta rte d .
T h is r e p o r t p re s e n ts a critical review o f
th e li t e r a t u r e o n m e r c u r y a n d d e n ta l
a m alg am s, c o n c e n tra tin g o n m a te ria l a n d
re s e a rc h a fte r 1980 w h en a n ex c elle n t r e ­
view a p p e a r e d .5 M any fu n d a m e n ta l as­
p ects o f m e rc u ry m etab o lism a n d toxicity
h a v e b e e n well e stab lish ed a n d th is re p o r t
has re lie d o n c u r r e n t review s to c o m p le te
th e s e se c tio n s r a t h e r th a n o rig in a l r e ­
se a rc h articles, m o st o f w h ich w ere p u b ­
lish ed b e fo re 1980. S ubjects co v e re d in
th is p a p e r in c lu d e m e rc u ry e x p o s u re o f
868 ■ JADA, Vol. 115, December 1987
d e n ta l p e rs o n n e l d u r in g d e n ta l p ra ctice ;
m e rc u ry v a p o r release fro m am a lg a m s;
m e r c u ry m eta b o lism a n d its d is trib u tio n in
b o d y tissu es (su ch as h a ir, b lo o d , n e rv e
tissu e, a n d u rin e ); allerg y to m e rc u ry (in ­
c lu d in g p a tc h te stin g a n d th e m e c h a n ism
o f m e rc u ry allergy); a n d possible lin k ag es
b e tw e e n diseases a n d d e n ta l e x p o s u re to
m e rc u ry .
Chemical forms and sources of mercury
Chemical forms of mercury
M e rc u ry exists in th r e e m a jo r ch em ical
fo rm s, w hich d e te rm in e th e toxicity o f th e
m e tal. T h e s e fo rm s a re : e le m e n ta l m e r ­
c u ry (m e rc u ry v a p o r), in o rg a n ic m e rc u ry
o r salts o f m e rc u ry , a n d o rg a n ic m e rc u ry
(o rg a n o m e rc u ria ls).
E le m e n ta l m e rc u ry is th e m o st volatile
o f th e th r e e a n d e x p o s u re to it is usu ally
o c c u p a tio n a l. C h ro n ic e x p o s u re can re su lt
fro m m e rc u ry in th e a m b ie n t a ir a fte r ac­
c id e n ta l spills, im p ro p e r h a n d lin g o f m e r ­
c u ry , a n d p o o rly v e n tila te d w o rk ro o m s o r
la b o r a to r ie s . M e rc u ry v a p o r c a n h a v e
toxic e ffe cts a n d can b e an o c c u p a tio n a l
h a z a rd in d e n tis try .14 In o rg a n ic m e rc u ry
o r m e rc u ry salts can ex ist as m o n o v a le n t
m e r c u r o u s o r d iv a le n t m e r c u r ic sa lts.
M e rc u ry salts can b e irrita tin g a n d acu te ly
toxic. T h e o rg a n o m e rc u ria ls o r o rg a n ic
m e r c u ry c o m p o u n d s u sed to d ay c o n ta in
m e rc u ry w ith o n e c o v ale n t b o n d o n th e
c a r b o n a to m . T h is is a h e te r o g e n o u s
g ro u p o f c o m p o u n d s w ith th e ability to
p ro d u c e v a rio u s toxic effects. T h e alkyl-
m e r c u ry salts a r e th e m o st to x ic, w ith
m e th y lm e rc u ry b e in g th e m o st c o m m o n
fo rm o f th e se salts. O rg a n ic m e rc u ry c o m ­
p o u n d s a re n o t a h a z a rd in d e n tis try b u t
c a n b e a n e n v iro n m e n ta l h a z a rd .14
Mercury in the environment
and food chain
M e rc u ry is a n a tu ra lly o c c u rrin g e le m e n t
w ith 3 0 ,0 0 0 to 150,000 to n s b e in g re le a se d
in to th e a tm o s p h e re by th e d e g a ssin g o f
th e e a r t h ’s c ru s t a n d th e o ce a n s. A d d i­
tio n ally , 2 0 ,0 0 0 to n s o f m e rc u ry a re r e ­
le a se d in to th e e n v iro n m e n t th r o u g h th e
c o m b u s tio n o f fossil fu els a n d o th e r in d u s ­
trial activities. T e n to n s o f m e rc u ry a re
p ro d u c e d a n n u a lly fo r in d u s tria l u s e .15
U n f o r tu n a te ly , e n v ir o n m e n ta l p o llu ­
tio n h as in creasin g ly c o n ta m in a te d w ater,
a ir, a n d soil. T h is c o n ta m in a tio n resu lts
fro m th e u se o f m e rc u ry in a g ric u ltu ra l
fu n g ic id e s, in d u s tria l p o llu tio n , a n d a n in ­
c re a s e d b u rn in g o f fossil fuels c o n ta in in g
m e rc u ry . H o w e v e r, th e use o f m e rc u ry
c o n ta in in g fu n g ic id e s is now b a n n e d by
m a n y n atio n s.
M e rc u ry e n te rs th e fo o d c h a in by in ­
a d e q u a te a n d im p ro p e r d isp o sal o f w astes
in to o c e a n s, lakes, a n d stre a m s w h e re m i­
c ro o rg a n ism s m e th y la te in o rg a n ic m e r ­
c u ry to th e m o re toxic m e th y lm e rc u ry .
M e th y lm e rc u ry is th e n ra p id ly ta k e n u p by
p la n k to n alg ae a n d is c o n c e n tra te d in fish
via c o n su m p tio n o f th e se o rg a n ism s. P re ­
d a to ry a n d la rg e r fish c o n c e n tra te m o re
m e rc u ry th a n sm a lle r f e e d e r fish. F ro m
th e a q u a tic e n v iro n m e n t, m e th y lm e rc u ry
b eco m e s in c o r p o ra te d in th e te r re s tria l
e n v ir o n m e n t by species fe e d in g o n th e
a q u a tic o rg a n ism s. F acto rs in flu e n c in g th e
a m o u n t o f m e th y lm e rc u ry in fish a re :
m e rc u ry c o n te n t in w a te r a n d b o tto m s e d ­
im e n t; a c id ity a n d o x id a tio n - re d u c tio n
p o te n tia l o f th e w a te r; species, ag e, a n d
size o f fish.
A su rv ey o f 34 c o u n trie s was c o n d u c te d
to estab lish th e levels o f m e rc u ry c o n ta m i­
n a tio n in fo o d a n d to d e te r m in e if th e se
levels p re s e n te d a h e a lth p ro b le m . T h e
re s u lts fro m each c o u n try w e re r e p o r te d
in th e fo rm o f m e d ia n a n d 9 0 th p e rc e n tile
levels. T h e h ig h e s t m e d ia n v alues w ere
r e p o r te d f o r s h a r k (1 ,8 0 0 /J-g/kg) a n d
sw o rd fish (1 ,5 0 0 /¿g/kg). F o r tu n a , th e
h ig h e s t m e d ia n level f o r an y c o u n try was
1,500 jug/kg, b u t th e m a jo rity o f sam p le
v alues was in th e ra n g e o f 100 to 500 /ug/
kg-
In 1972, th e J o in t F o o d a n d A g ric u ltu re
O rg a n iz a tio n /W o rld H e a lth O rg a n iz a tio n
(W H O ) E x p e rt C o m m itte e o n fo o d a d d i­
tives e sta b lish e d a p ro v isio n a l to le ra b le
w eekly in ta k e o f 0.3 m g o f to ta l H g p e r
p e rs o n w ith n o t m o re th a n 0.2 m g b e in g
m e th y lm e rc u ry .16
T h e e a rliest in d ic a tio n th a t m e th y lm e r­
c u ry was an e n v iro n m e n ta l h a z a rd cam e
fro m tw o ep iso d e s in M in am a ta Bay a n d
N iig a ta , J a p a n , fro m 1953 to 1960. In
M in a m a ta , 121 p e o p le w e re p o iso n e d w ith
m e th y lm e r c u r y , 4 6 o f w h o m d ie d . In
N iig ata, 4 7 cases w e re id e n tifie d w ith six
d e a th s . A d u lts a n d c h ild re n c o n su m in g
th e c o n ta m in a t e d fis h s u f f e r e d a d e ­
g e n e r a t i v e n e u r o l o g ic a l d is e a s e w ith
p a re s th e s ia , a ta x ia , h e a r in g a n d v isual
c h a n g e s, a n d d y sa rth ria . A fte r th e c o n ­
ta m in a tio n , 6% o f b irth s re s u lte d in c e re ­
b ra l p alsy . I n b o th th e M in a m a ta a n d
N iig ata ep id e m ic s, th e r e was a re la tio n ­
sh ip b e tw e en th e n a tu r e o f th e disease a n d
fish in ta k e . In b o th e p iso d e s, th e fish w ere
c o n ta m in a te d by m e rc u ry fro m d isc h a rg e s
fro m fa c to rie s u sin g m e rc u ric c h lo rid e
c a ta ly s ts in th e m a n u f a c t u r e o f v in y l
c h lo rid e a n d a c e ta ld e h y d e .17
M ajo r in c id e n ts o f h u m a n p o is o n in g

also o c c u rre d fro m th e in a d v e r te n t c o n ­
su m p tio n of m e r c u ry -tre a te d se e d g ra in in
I r a q , P a k istan , G h a n a , a n d G u a te m a la .
T h e m o st c a ta stro p h ic o u tb re a k o c c u rre d
in Ira q in 1972. Ir a q , h a v in g im p o rte d
la r g e q u a n ti ti e s o f s e e d t r e a t e d w ith
m e th y lm e rc u ry f u n g ic id e , d is trib u te d th e
g ra in fo r p la n tin g . D esp ite of ficial w a rn ­
ings, th e g ra in was g r o u n d in to flo u r a n d
m a d e in to b re a d . As a resu lt, 6 ,5 3 0 victim s
w e re h o sp italized a n d 500 d ie d .18,19
Mercury exposure from other sources
M e rcu ry e x p o s u re can re s u lt fro m m an y
c o m m e rc ia l p ro d u c ts. M e rc u ro u s c h lo rid e
o r calo m el, th e b est-k n o w n m e rc u ry co m -
he potential hazards of mercury exposure in the dental
environment are preventable by using proper mercury hygiene
practices.
p o u n d , is still u sed in so m e face c re a m s as
an an tise p tic . M e rc u ry e x p o s u r e also can
re s u lt fro m e x p o s u r e to a n tise p tic a g e n ts
su ch as m e rb ro m in , tin c tu re o f m e rc re sin ,
a n d m e r th io la te . E x p o s u re m a y o c c u r
fro m th e use o f m e rc u ry -c o n ta in in g m e d i­
c a m e n ts, such as d iu re tic s a n d o in tm e n ts .1’
C ases o f ra sh a n d skin re a c tio n s have b e e n
r e p o r te d 20 fro m m e rc u ric c o n ta c t a f te r
b re a k in g clinical th e rm o m e te rs .
R ecen tly , n e u ro p s y c h ia trie s y m p to m s
w e re r e p o r te d in a s p h y g m o m a n o m e te r
re p a irm a n w ho u sed p o o r m e rc u ry
h y g ie n e .21 A lso, tw o cases of a c ro d y n ia —
fo llo w in g th e a c c id e n ta l h o m e sp ill of
m e rc u ry fro m th e re p a ir of a m a n o m e te r
a n d b a ro m e te r — h av e b e e n r e p o r te d in
y o u n g c h ild re n .22,23
Occupational exposure to mercury
Mercury vapor levels in dental offices
E x p o s u re to m e rc u ry a n d m e rc u ry v a p o r
h as b een re c o g n iz e d as a p o te n tia l h e a lth
h a z a r d to d e n ta l p e r s o n n e l f o r m a n y
years. E x p o su re can o c c u r e ith e r th r o u g h
d i r e c t s k in c o n ta c t w ith m e r c u r y o r
m e rc u ry -c o n ta in in g c o m p o u n d s , o r
th r o u g h th e in h a la tio n o f m e rc u ry v a p o r,
in h a la tio n of m e rc u ry v a p o r is th e p r i­
m ary ro u te o f e x p o s u re ; a p p ro x im a te ly
8 0 % o f i n h a l e d m e r c u r y is a b s o r b e d
th r o u g h th e lu n g s.24 A t 25 C , th e e q u ilib ­
riu m v a p o r c o n c e n tra tio n of m e rc u ry is
c a lc u la te d to be 20 m g /m 3.24,25 T h e v a p o r
p re s s u re of m e rc u ry in crea se s ra p id ly w ith
in crea se s in te m p e ra tu re . T h e th re s h o ld
lim it v alu e (T L V ) fo r m e rc u ry v a p o r re c ­
o m m e n d e d by th e N a tio n a l In s titu te fo r
O c c u p a tio n a l S afety a n d H e a lth (N IO S H )
is 5 0 /u.g/m3, b ased o n a tim e -w e ig h te d av ­
e ra g e d u rin g an 8 -h o u r d a y .26,27 T h e T L V
is c o n s id e re d to be th e c o n c e n tra tio n of
m e rc u ry v a p o r to w hich n e a rly all w o rk ers
m ay b e re p e a te d ly e x p o se d w ith o u t a d ­
verse effe c ts.28
M any re c e n t su rv e y s24, 27-32 h av e b e e n
u n d e rta k e n to d e te r m in e th e ca u se a n d
e x te n t of m e rc u ry v a p o r c o n ta m in a tio n in
d e n ta l offices. C o m p a riso n s b e tw ee n s u r­
veys a re d iffic u lt b e c au se o f th e v ariety of
sites te s te d a n d sa m p lin g te c h n iq u e s u sed .
A re c e n t stu d y o f 528 d e n ta l o ffices in
N o rth C a ro lin a — in w hich a m b ie n t a ir
m e r c u ry v a p o r c o n c e n tra tio n s w ere re ­
c o rd e d in 1,064 ro o m s — fo u n d th a t 108
ro o m s (10.2% ) h a d m e rc u ry v a p o r c o n ­
c e n tra tio n s g re a te r th a n 50 |Ug/nr!, a n d 44
ro o m s (4.1% ) h a d levels r e p o r te d as eq u a l
to 50 jug/m 3.28 C a n a d ia n stu d ie s in M an ­
ito b a 29 a n d th e A tla n tic re g io n s 24 fo u n d
m e rc u ry v a p o r c o n c e n tra tio n s in th e a m ­
b ie n t a ir above th e T L V in 11.4% a n d
3.2% o f offices respectively. H o w e v e r, in
th e la tte r stu d y so m e a re a s , su ch as th e
a re a u sed fo r tr itu ra tio n , 15.7% h a d m e r­
c u ry v a p o r c o n c e n tra tio n s eq u a l to o r ex­
c e e d i n g 5 0 /¿ g /m 3. S im ila r s tu d ie s in
T e x a s 27 a n d N ew Y o rk 30 fo u n d th a t 10%
a n d a p p ro x im a te ly 6% , resp ectiv ely , h ad
a m b ie n t a ir m e rc u ry v a p o r levels e x c e e d ­
in g th e T L V , w h e re a s an Io w a stu d y 31
n o te d th a t 16% of th e o ffices su rv e y e d h ad
m e rc u ry v a p o r m e a s u re m e n ts ab o v e th e
T L V in o n e o r m o re locatio n s. In g e n e ra l,
r e c e n t s tu d ie s s u p p o r t e a r lie r r e p o r ts ,
c o n c lu d in g th a t at least 10% o f d e n ta l o f­
fices h av e m e rc u ry v a p o r c o n c e n tra tio n s
h ig h e r th e n th e 50 /xg/m 3 level re c o m ­
m e n d e d by N IO S H .25
Sources of mercury exposure
S o u rc e s o f m e rc u ry c o n ta m in a tio n in th e
d e n t a l e n v i r o n m e n t in c lu d e m e r c u r y
spills, e x p re s sio n o f excess m e rc u ry from
a m a lg a m , leak a g e fro m d is p e n se rs , im ­
p r o p e r sto ra g e o f sc ra p a m a lg a m , leak ag e
fro m a m a lg a m c a p su le s d u r i n g tr it u r a ­
tio n , m e rc u ry v a p o riz a tio n f ro m c o n ta m ­
Langan-Fan-H oos: USE OF M ERCURY IN DEN TISTRY ■ 869
REVIEW ARTICLES
in a te d in s tru m e n ts p la c e d in sterilizers,
g rin d in g of a m a lg a m d u r i n g re m o v a l of
re s to ra tio n s , a n d a m a lg a m c o n d e n s a tio n
w ith u ltra so n ic c o n d e n s e rs .
M e rc u ry spills a n d th e s u b s e q u e n t ac­
c u m u la tio n o f m e rc u ry in c a rp e tin g o r
c rack s in th e flo o rin g m a te ria l a re a m a jo r
so u rc e o f m e rc u ry c o n ta m in a tio n . S tu d ies
h a v e fo u n d little o r n o d if fe re n c e in a m ­
b ie n t a ir c o n c e n tra tio n s o f m e rc u ry v a p o r
b e tw e e n of fices w ith c a rp e tin g a n d th o se
w ith h a r d f lo o r c o v e rin g s .24,28,30 E ach
k in d o f flo o rin g p o ses u n iq u e p ro b le m s
w ith re g a r d to sp illed m e rc u ry . M e rc u ry
sp illed o n h a r d su rfa c e s te n d s to be d is­
p e r s e d m o r e w id e ly a n d d iv id e d in to
sm a lle r d ro p le ts , w h e re a s m e rc u ry spilled
o n c a rp e ts is c o n ta in e d to a sm a lle r are a .
C le a n u p o f m e rc u ry o n se am less vinyl o r
lin o le u m flo o rs is re la tiv e ly easy to ac­
c o m p lish , b u t c o m p le te d e c o n ta m in a tio n
o f c a rp e ts is d iffic u lt e x c e p t fo r re m o v a l o f
th e c a rp e t.24,26,28
M u ch a tte n tio n h a s b e e n fo c u s e d o n
m e rc u ry v a p o r le a k a g e fro m d isp o sa b le
a n d re u s a b le a m a lg a m c a p su le s.33' 37 B oth
ty p es o f c a p su les a re p o ssib le so u rces o f
m e r c u ry v a p o r d u r i n g tr itu r a tio n w ith
n e i t h e r h a v in g a p r o v e d s u p e r i o r i t y .
H o w e v e r, r e s e a r c h e r s h a v e c o n c lu d e d
th a t d isp o sa b le c a p su les a re p re f e ra b le b e ­
c a u se th e ir u sa g e g re a tly re d u c e s th e risk
o f a c c id e n ta l m e rc u ry spills.35 C o n ta m i­
n a te d c a p su le s o f e ith e r ty p e sh o u ld be
re a s s e m b le d a f t e r u se , if p o ssib le , a n d
s to re d o r d is p o se d of p ro p e r ly in a n a ir ­
tig h t c o n ta in e r o r plastic b a g to p re v e n t
m e rc u ry v a p o riz a tio n .34
O th e r possibly c o n ta m in a te d d e n ta l o f­
fice e q u ip m e n t a n d fu r n is h in g s o f c o n ­
c e rn as in d ire c t so u rc e s o f m e rc u ry in ­
c lu d e c o n ta m in a te d a m a lg a m a to rs ,
ste riliz e rs, c a b in e ts a n d c o u n te r to p s , c u s­
p id o rs, d ra in s , filte rs in h e a tin g o r co o lin g
sy stem s, w aste c o n ta in e rs , c a p su le s to ra g e
a re a s , a n d d r a p e s .24,38'40
Mercury hygiene procedures
The p o te n tia l h a z a rd s o f m e r c u ry e x p o ­
s u re in th e d e n ta l e n v ir o n m e n t a re p r e ­
v e n ta b le by u sin g p r o p e r m e rc u ry h y g ie n e
p ractices. R e c o g n iz in g th e im p o rta n c e o f
m e r c u ry h y g ie n e , th e A D A C o u n c il o n
D e n ta l M a te r ia ls , I n s t r u m e n t s , a n d
E q u ip m e n t h a s p e rio d ic a lly p u b lis h e d
r e c o m m e n d a t i o n s in d e n t a l m e r c u r y
h y g ie n e .26 In a d d itio n , se v e ra l a u th o r s
h a v e in v e stig a te d th e ef fectiv e n e ss o f v a ri­
o u s h y g ie n e p ro c e d u r e s a n d co m m ercially
av ailab le p ro d u c ts fo r p re v e n tio n a n d d e ­
c o n ta m in a tio n .
Ef fective te c h n iq u e s f o r c le a n u p o f any
 REVIEW ARTICLES
sp ille d m e r c u ry in c lu d e u s in g a w ash-
b o ttle tr a p c o n n e c te d to su ctio n system s
f o r re m o v in g visible d ro p le ts of m e rc u ry .
O th e r devices fo r re c o v e rin g m e rc u ry in ­
c lu d e h a n d h e ld p u m p s , a s p ira to r b ulbs, o r
p lastic sy rin g es. S p o n g e s a re g e n e ra lly
m u c h le s s e f f e c t i v e f o r m e r c u r y
c le a n u p .41'42 A d h esiv e ta p e , tin foil, o r a
fresh m ix o f d e n ta l a m a lg a m can rem o v e
d ro p le ts o f m e rc u ry a n d have b een
su g g e s te d .26'43 P o w d e re d s u lfu r a n d o th e r
chem ical p ro d u c ts th a t re a c t w ith th e s u r ­
face o f m e rc u ry d ro p le ts will su p p re ss va­
p o riz a tio n only w h en th e m e rc u ry is u n ­
d is tu rb e d . R e a g e n ts th a t c o m b in e w ith
m e rc u ry m ay facilitate c le a n u p . C o m m e r­
cially available spill c le a n u p kits th a t c o n ­
tain a c o m b in a tio n o f th e se devices a n d
m aterials have p ro v e d u s e fu l.2“’41,42
A “n o -to u c h ” te c h n iq u e sh o u ld be u sed
fo r h a n d lin g a m a lg a m .26 U sin g p re c a p su -
la te d allo y s e lim in a te s m a n y p o te n tia l
so u rces o f m e rc u ry v a p o r a n d m inim izes
th e possibility o f ac c id e n ta l spillage. O f­
fices u sin g p re c a p s u la te d alloys hav e low er
m e rc u ry v a p o r levels. 2 -1.2 7 , 3 0 , 3 1 , 3 5 jrXp ress.
in g excess m e rc u ry fro m a m a lg a m sh o u ld
be a v o id e d .26,30 A m a lg a m a to r a rm s a n d
capsules sh o u ld be c o v e re d d u r in g tr itu r a ­
tio n .24,26,30
R e s e a r c h e r s r e c o m m e n d th a t s c r a p
a m alg am be sto re d in sea le d c o n ta in e rs
u n d e r s u lfu r-c o n ta in in g so lu tio n s su ch as
u sed X -ray fix e r so lu tio n , o r a co m m ercial
m e rc u ry v a p o r s u p p re s s o r w hich h as b een
p r o v e d e f f e c ti v e .26,44,45 M e r c u r y a n d
am alg am sh o u ld b e sto re d aw ay fro m h e a t
so u rc e s. C o n ta m in a te d in s tru m e n ts
sh o u ld b e th o ro u g h ly c le a n e d b e fo re s te r­
ilizatio n .46 D isposable item s c o n ta m in a te d
w ith m e r c u r y s h o u ld be d is c a r d e d in
p ro p e rly sealed c o n ta in e rs .34
D u rin g rem o v al o f a m a lg a m r e s to ra ­
tions, th e use o f a w a te r sp ra y a n d hig h -
v o lu m e ev acu atio n g reatly re d u c e s m e r ­
c u ry v a p o r lev els.47,48 G o o d v e n tila tio n
w ith ra p id fre sh a ir e x c h a n g e s a n d a n o u t­
side e x h a u s t is e x tre m e ly im p o r ta n t to
p re v e n t in h a la tio n o f m e rc u ry v a p o r in
h ig h c o n c e n tra tio n by d e n ta l p e rs o n n e l.26
A lth o u g h n o t a s u b s titu te fo r g o o d m e r ­
cu ry h y g ien e, a ir filters w ith ch em ical ab-
so rb a n ts (usually io d ized ch arco al) can r e ­
d u c e m e rc u ry v a p o r levels.42'49,50
In v e stig a to rs hav e te s te d sev eral devices
fo r m o n ito rin g m e rc u ry v a p o r a n d c o n ­
c lu d e d th a t so m e o f th e s e d evices m ay be
valuable a d ju n c ts fo r assessin g th e e ffec ­
ti v e n e s s o f m e r c u r y h y g i e n e p r o c e ­
d u re s .26,42 B iologic m o n ito rin g th r o u g h
p e rio d ic u rin e analysis fo r m e rc u ry is a
re c o m m e n d e d m e th o d fo r assessing th e
e x p o s u r e o f d e n ta l o ffic e p e r s o n n e l.26
870 ■ JADA, Vol. 115, December 1987
A lso, th e se p e rio d ic c h e c k u p s a re ex cel­
le n t fo r in d ire c t e v a lu a tio n o f th e e ffe c ­
tiveness o f th e m e rc u ry h y g ie n e in a n o f­
fice.
Mercury exposure from amalgam
Mercury vapor from amalgam
M e a su ra b le a m o u n ts o f m e rc u ry v a p o r
hav e b ee n r e p o r te d in th e e x p ire d a ir o f
p a tie n ts w ith o r w ith o u t a m alg am re s to ra ­
tio n s.51 56 In p e rs o n s w ith am alg a m re s to ­
ra tio n s, in crease s in th e a m o u n t o f m e r­
c u ry v a p o r w e re o b s e rv e d a f t e r c h e w ­
in g 51'55 a n d b ru s h in g ; th e d e g re e to w hich
this v a p o r is in h a le d is n o t k n o w n .56 N e g ­
ligible c h a n g e s w e re o b se rv ed in subjects
w ith o u t am alg a m s. T h e levels o f m e rc u ry
v a p o r r e p o r te d in d if fe re n t stu d ies v aried
g rea tly , as d id th e m e th o d s o f m e a s u re ­
m e n t. T h e ch e w in g b e fo re m e a s u re m e n t
also v aried a n d ra n g e d fro m 3 m in u te s at
120 cycles/m in to 10 m in u te s w ith o u t a
d e fin e d fre q u e n c y . I n te rp re ta tio n a n d e x ­
tra p o la tio n o f th e d a ta a re also n o t u n i­
f o r m , m a k i n g c o m p a r is o n s b e tw e e n
stu d ies d iffic u lt.
In a stu d y r e p o r te d in 1979,51 seven p a ­
tie n ts w e re in s tru c te d to e x h a le ten tim es
in to a c o llecto r tu b e filled w ith silver wool.
T h e silver w ool was th e n h e a te d to release
m e rc u ry v a p o r, w hich was m e a s u re d by
u ltra v io le t a b so rp tio n . A fte r ch ew in g , th e
a m o u n t o f m e rc u ry co llected ra n g e d fro m
64 to 244 n g p e r te n ex h a la tio n s.
In a s tu d y o f e ig h t su b je c ts w ith o u t
a m a lg a m s (am alg am less g ro u p ), a n d 40
sub jects w ith am a lg a m s, th e m e rc u ry c o n ­
c e n tra tio n s o f e x p ire d a ir sam p les w ere
m e a s u re d by co llectin g 2.7 L o f e x p ire d a ir
in a plastic b a g a n d p assin g it th r o u g h a
g o ld foil m e rc u ry v a p o r a n a ly z e r. T h e
m e a n a v e ra g e m e rc u ry c o n c e n tra tio n s b e­
fo re c h e w in g w e re 0 .2 6 ¿ig /m 3 fo r th e
a m alg am less g r o u p a n d 0.88 /¿g/m 3 fo r th e
a m a lg a m g ro u p . A fte r v ig o ro u s ch ew in g
fo r 10 m in u te s , th e m e a n m e rc u ry c o n c e n ­
tra tio n s w e re 0.13 fJ-g/m3 fo r th e a m a lg a m ­
less g ro u p a n d 13.74 f i g /m 3 fo r th e a m a l­
g am g r o u p .52 A sim ilar a p p ro a c h was u sed
in a n o th e r stu d y o f 15 subjects w ith o u t
am a lg a m s, a n d 54 subjects w ith am alg am s.
B e fo re ch ew in g, th e m e a n m e rc u ry c o n ­
c e n tra tio n s w ere 0.05 /¿g/m 3 fo r th e a m a l­
gam less g ro u p a n d 0 .2 9 /¿g/m 3 fo r th e
a m a lg a m g ro u p . A fte r ch ew in g , th e m e r­
c u ry levels w e re 0.05 /ag/m 3 fo r th e a m a l­
g am less subjects a n d 1.35 /¿g/m 3 fo r th e
a m a lg a m g r o u p .53
As e x p ire d a ir is a m ix tu re o f a ir fro m
th e m o u th a n d th e e n tire re s p ira to ry tra ct,
a la te r s tu d y f lu s h e d a ir th r o u g h th e
m o u th f o r 15 seco n d s in an a tte m p t to
m e a s u re m e rc u ry c o n c e n tra tio n s in th e
m o u th o n ly . T h e ra te o f a ir flu sh was r e ­
p o r te d to h a v e little in f lu e n c e o n th e
a m o u n t o f m e rc u ry v a p o r m e a s u re d . A
1 5-second a ir flu sh was an aly zed w ith a
g o ld foil m e r c u ry v a p o r a n a ly z e r in a
g ro u p o f 14 am a lg a m le ss subjects, a n d 47
subjects w ith am alg a m s. B efo re chew ing,
th e m e rc u ry levels w e re 1.13 ng/15 sec fo r
th e a m a lg a m less g ro u p a n d 2.24 n g /1 5 sec
fo r th e a m a lg a m g ro u p . A fte r chew ing,
th e m e rc u ry levels w e re 1.06 n g /15 sec fo r
am a lg a m le ss sub jects a n d 18.97 n g /1 5 sec
fo r th e a m a lg a m su b jects.54
In a n o th e r stu d y 55 u sin g a go ld foil m e r ­
cu ry v a p o r an aly z e r, th e co llection tu b e
w as m o v e d r a p id ly a n d c o n tin u o u s ly
a ro u n d th e o p e n m o u th fo r 10 o r 20 sec­
o n d s a t a flow ra te o f 0.75 IVmin. B e fo re
ch ew in g , th e m e a n m e rc u ry c o n c e n tra ­
tio n s w e re 0 .5 4 /¿g/m 3 f o r th e am algam less
g ro u p a n d 4.91 /¿g/m 3 fo r th e am alg am
g ro u p . A fte r ch ew in g , th e m e rc u ry c o n ­
c e n tra tio n s w e re 0.72 /¿g/m 3 fo r a m a lg a m ­
less sub jects a n d 2 9 .1 0 /ig /m 3 fo r subjects
w ith am a lg a m s. T h e m e rc u ry level d e ­
c re a s e d as a fu n c tio n o f tim e a fte r cessa­
tio n o f ch e w in g . F ro m th e re s u lts , a t ­
te m p ts w e re m a d e to estim ate th e daily
d o se o f m e r c u ry a c c o rd in g a s u b je c t’s
n u m b e r o f o c c lu sa l a m a lg a m s u rfa c e s.
T h e e stim a te d d aily d o se fo r all subjects
(o n e to 16 occlusal su rfaces) was 19.85 /¿g.
f o r th e su b g ro u p s o f subjects w ith less
th a n fo u r, o r g re a te r th a n 12 occlusal s u r­
faces, th e e s tim a te s w e re 8 .1 0 /¿g a n d
2 9 .2 4 /¿g , resp ectiv ely . A n a tte m p t to esti­
m a te th e b o d y b u rd e n o f m e rc u ry u sin g a
c o m p u te r m o d e l w as r e p o r te d in 1986.57
T h e in v e s tig a tio n s c o n c lu d e d t h a t th e
c o m p u te r sim u la tio n re m a in s to be c o n ­
firm e d by in vivo e x p e rim e n ta l d a ta .
T h e e ffe c t o f b ru s h in g o n th e level o f
m e rc u ry in e x p ire d a ir has also b e e n as­
sessed. M e a s u re m e n ts w e re m a d e by col­
lectin g b re a th sam ples e x h a le d fro m th e
m o u th a t a p p ro x im a te ly 22 L /m in in to a
tu b e filled w ith g o ld trim m in g s. T h e m e r ­
c u ry was th e n m e a s u re d u sin g a p h o to ­
aco u stic m e rc u ry d e te c to r.56 A m e a n value
o f 8 .2 n g /L w a s fo u n d a fte r b ru s h in g co m ­
p a re d to 3.1 n g /L b e fo re b ru s h in g fo r 172
sub jects w ith a m a lg a m re sto ra tio n s. T h e
m ea n m e rc u ry level in th e e x p ire d a ir o f
five subjects w ith o u t am a lg a m re s to ra tio n s
was 0 .0 6 n g /L . T h e s e re su lts a re sh o w n in
T a b le 1.
T h e v a lid ity o f m e a s u r in g m e r c u r y
v a p o r c o n c e n tra tio n s in a sm all v o lu m e
sa m p le a n d e x tra p o la tin g th e resu lts to
m u c h la rg e r v o lu m es is q u e stio n a b le. T h e
a m o u n t o f m e rc u ry v a p o r available fo r r e ­

lease fro m a fin ite so u rc e — su ch as th e
su rfa c e o f a n a m a lg a m re s to ra tio n — m ay
lim it th e c o n c e n t r a ti o n w h ic h c a n be
re a c h e d in a v o lu m e as la rg e as th e total
v o lu m e o f a ir in h a le d by a n in d iv id u a l
o v e r a n u m b e r o f years. F u rth e rm o r e , th e
a ss u m p tio n th a t th e s e e x tr a p o la te d v alues
a re c o m p a ra b le to situ a tio n s in th e in d u s ­
tria l w o rk e n v ir o n m e n t in v o lv in g co n sis­
te n t e x p o s u re to ele v a te d m e rc u ry v a p o r
c o n c e n tra tio n s is also q u e stio n a b le .
It h as b e e n show n th a t sm all b u t m e a ­
su ra b le e le v a tio n s exist (lastin g a b o u t 10
m in u te s) in th e level o f m e rc u ry in th e
e x p ir e d a ir o f p a tie n ts as th e re su lt o f
a m a lg a m re m o v a l.58 T h is k in d o f e x p o ­
su re to m e rc u ry can b e re d u c e d w ith th e
use o f c e rta in te c h n iq u e s, su ch as w et c u t­
tin g , h ig h v a c u u m e v a c u a tio n , a n d a r u b ­
b e r d a m . A n in v itro sim u latio n o f a m a l­
g am rem o v al d e m o n s tra te d th a t w ith th e
u se o f w a te r sp ra y , e x p o s u r e to m e rc u ry
v a p o r a n d p a rtic u la te a m a lg a m seem s n e g ­
ligible. In a stu d y sim u la tin g o p e ra to ry
p ro c e d u re s , th e m e a s u re d m e rc u ry v a p o r
in th e b re a th in g zo n e a n d in th e e x h a le d
a ir o f d e n tists re m o v in g a m a lg a m s was
sim ilarly re d u c e d w h e n w a te r sp ra y a n d
v ac u u m e v a c u a tio n w e re u s e d .48
Corrosion of amalgam
T h e re a c tio n o f a m a lg a m w ith ch em ical
sp ecies in th e s u r r o u n d in g liq u id p r o ­
d u c e s s o lu b le a n d in s o lu b le c o rr o s io n
p ro d u c ts. S im u latio n s o f m e rc u ry d isso lu ­
tio n fro m am a lg a m s h av e b e e n re p o r te d
fo r in v itro stu d ie s59' 62 u sin g d istilled w a­
te r, iso to n ic saline so lu tio n , a n d saliva as
liq u id m e d ia . T h e m e r c u ry d is so lu tio n
fro m d e n ta l a m a lg a m in to m ix e d saliva in
v itro w as r e p o r te d to hav e a m e a n v alu e o f
0.853 ± 0.423 p p m .59 O n e stu d y 63 sh o w ed
th a t th e c u m u la tiv e d isso lu tio n o f m e rc u ry
a f t e r 6 m o n th s ra n g e d fro m 0.001 to 0.003
/¿g /m L in w a te r, a n d 0.003 to 0 .0 8 8 /¿g/m L
in 0.5% so d iu m c h lo rid e . T h e d is so lu tio n
o f m e rc u ry fro m th r e e ty p e s o f a m a lg a m
a f te r 7 days in 0.9% s o d iu m c h lo rid e so lu ­
tio n ra n g e d fro m 0 .5 0 to 2.21 /¿g/cm 2.62
T h e effe c ts o f o rg a n ic acids, c h lo rid e s,
su lfites, a n d a m m o n ia o n th e c o rro sio n
a n d d isso lu tio n o f a m alg am have also been
r e p o r te d . A fte r im m e rsio n in ch em ical so­
lu tio n s fo r 6 m o n th s , th e a m o u n ts o f m e r­
c u ry d is so lv e d fro m a m a lg a m sa m p le s
w ere 0.05 to 0 .0 9 /¿g /m L fo r acetic acid,
0.01 to 0 .1 0 /¿g/m L f o r fo rm ic acid , 1.30 to
2.6 4 /¿g/m L f o r lactic acid, a n d 0 .0 2 to 0.04
/¿g/m L fo r succin n ic a c id .64 T h e c o rr e ­
s p o n d i n g v a lu e s f o r s o d iu m c h lo r id e ,
so d iu m su lfid e , a n d a m m o n ia so lu tio n s
w e re 0 .0 4 to 0.17 /¿g/m L , 0.23 to 2 1 .1 9
Table 1 ■ Summary of reports of mercury vapor released from dental amalgam
restorations.
C hew ing
Investigator or b ru sh in g
A braham an d others (1984) Before
After
Svare a n d others (1981) Before
After
Vimy an d L orscheider (1985) Before
After
P atterson an d others (1985) Before
After
O tt an d others (1984) Before
After
/¿g/m L , a n d 6.2 4 to 7 .3 9 /¿g/m L , resp e c ­
tively.65
T h e in v itro test re su lts o f m e rc u ry d is­
so lu tio n fro m a m a lg a m in sim u la te d oral
e n v iro n m e n ts h a v e b e en re v ie w e d .66 F o r
th e first 2 4 h o u rs , m e rc u ry d isso lu tio n in
m o st cases ra n g e d fro m 0.5 to 5 /¿g/cm 2,
w ith o n e stu d y re p o r tin g h ig h e r v alu es.67
T h e d isso lu tio n ra te s d e c re a s e d sh arp ly
w ith tim e .68,69 L o n g -te rm d isso lu tio n rates
a fte r 10 o r m o re d ay s r a n g e d fro m 0.01 to
0.5 /¿g/cm 2 p e r d a y . It was c o n c lu d e d th a t
o v e r th e lo n g te rm , d is so lu tio n o f m e rc u ry
fro m a m a lg a m in to saliva is in s u ffic ie n t to
c a u se c o n c e rn .66
T h e in v itro c o rro sio n ra te o f d e n ta l
a m a lg a m w as in c re a se d if th e am alg a m
su rfa c e w as su b je c te d to a b ra s io n .70 T h e
o b se rv e d in c re a se w as a ttrib u te d to th e
d is ru p tio n o f th e p ro te c tiv e passive s u r­
face la y e r, a n d rep a ssiv a tio n is relatively
slow. T h e re le a se o f m e r c u ry fro m an
a m a lg a m d u r i n g cyclic lo a d in g to sim u late
c h e w in g a n d u n d e r static c o n d itio n s has
also b e e n s tu d ie d in v itro .71 A m a lg a m p a r ­
ticles a c c o u n te d fo r m o st o f th e m e rc u ry
loss o f a b o u t 10 /¿g/cm 2 d u r i n g a cyclic
lo a d in g o f 2 0 -m in u te d u r a tio n . T h e
a m o u n t o f io n ic m e rc u ry re le a se d was es­
tim a te d to be 3 /¿g/cm 2 o r a b o u t 18 /¿g daily
fo r a p e rs o n w ith 2 0 am a lg a m su rfaces,
w h ich is less th a n h a lf o f th e p ro v isio n al
to le ra b le in ta k e (43 /¿g/day o r 3 0 0 /¿g/
w eek) e sta b lish e d by W H O .16
T h e e le m e n ta l c o n te n ts o f a 6 -y ear-o ld
c o p p e r a d m ix a m a lg a m re s to ra tio n , a fte r
6 y ears o f clinical service, h av e b e e n co m ­
p a re d w ith th e c a lc u la te d v alues b ased on
p h a s e c o m p o s itio n .72 T h e p e rc e n t o f m e r­
c u ry in th e g a m m a o n e p h a se o f th e re s to ­
Langan-Fan-H oos: USE OF M ERCURY IN DEN TISTRY ■ 871
REVIEW ARTICLES
M ercury v a p o r levels
W ith o u t
am alg am A m algam U nits
1.13 2.24 n g /1 5 sec
1.06 18.97
0.26 0.88 M g/m3
0.13 13.74
0.54 4.91 M g/m3
0.72 29.10
0.06 3.1 n g /L
8.2
0.05 0.29 jug/m 3
0.05 1.35
ra tio n was 72.8 ± 2.3 c o m p a r e d w ith a
c a lc u la te d v alu e o f 7 3 .6 . T h e m ic ro s tru c ­
tu re s o f a m a lg a m s c o rr o d e d in v itro a n d in
vivo w e re also c o m p a r e d , a n d it w as c o n ­
c lu d e d th a t th e c h a n g e s in m ic ro s tru c tu re
w e re sim ilar. T h e m ic ro s tru c tu re c h a n g e s
a p p e a r to be c o n siste n t w ith th e a m o u n t of
c o rro sio n p ro d u c ts re le a se d in to sa lin e so ­
lu tio n s in v itro .
T h e c o rro sio n o f a n a m a lg a m m ay be
a ffe c te d w h e n th e a m a lg a m is in c o n ta c t
w ith a d issim ila r m eta l fo r m in g a g alv an ic
cell. T h e re le a se o f m e r c u ry fro m a m a l­
g a m was s tu d ie d in v itro w ith a m a lg a m in
c o n ta c t w ith g o ld ,73 g o ld a n d b ase-m etal
c a stin g allo y s,74 a n d a m a lg a m s o f d iff e r e n t
c o m p o s itio n .75 T h e to ta l a m o u n t o f m e r ­
c u ry re le a se d in to so lu tio n ra n g e d fro m 62
to 1,650 /¿g/cm 2 a f te r a 3 5 -w eek p e rio d .
W h e n a m a lg a m w as in c o n ta c t w ith g o ld ,
th e a m o u n t o f m e r c u r y r e l e a s e d w as
g r e a te r in th e e a rly p e rio d s o f th e stu d y ,
b u t th e v alu es fo r a m a lg a m s w ith o r w ith ­
o u t c o n ta c t w ith g o ld w e re s im ila r fo r
lo n g e r p e rio d s. W h e n d if f e r e n t a m a lg a m s
w e re in c o n ta c t, th e a c c u m u la te d m e rc u ry
re le a s e d d u r i n g th e 3 5 w eeks r a n g e d fro m
122 to 176 /¿g. T h e d iffe re n c e s in values
w e re d e p e n d e n t o n th e sa m p le c o n fig u ra ­
tio n s as well as th e ty p e s o f a m a lg a m .
Particulate exposure from amalgam
A m a lg a m p a rticle s e m b e d d e d in o ra l tis­
su es m ay m a n ife st clinically as p ig m e n te d
m a c u le s th a t a r e r e f e r r e d to as “a m a lg a m
ta tto o s .” The lo calized tissu e re a c tio n s to
im p la n te d a m a lg a m h a v e b e e n r e ­
v ie w e d .76,77 A m a lg a m p a rtic le s a re p r e s ­
e n t in th e tissu e in tw o fo rm s: very fin e,
REVIEW ARTICLES
d is c r e te , r o u n d , b la c k , o r d a r k b ro w n
g ra n u le s o f 1.0 yxm o r less in size, o r as
ir re g u la r, d a rk , solid fra g m e n ts o f v a rio u s
la r g e r sizes. T h e e m b e d d e d p artic le s u s u ­
ally elicit n o re a c tio n , a lth o u g h in som e
cases a m ild to m o d e r a te c h ro n ic in fla m ­
m a to ry re s p o n s e o c c u rs. T h is re s p o n se
m ay re s u lt in th e fo rm a tio n o f a fo re ig n -
b o d y g ra n u lo m a w ith m a c ro p h a g e s a n d
m u ltin u c le a te d g ia n t cells.
T h e p ig m e n te d a re a s m ay possibly in ­
cre a se in size a n d in te n sity o f c o lo r fro m
th e c o n tin u o u s d is in te g ra tio n o f th e a m a l­
g am p a rtic le s a n d m ig ra tio n o f th e b re a k ­
d o w n p r o d u c ts . In a d d itio n to th e lo ­
calized tissu e re a c tio n s , th e release, d is tri­
b u tio n , a n d e x c re tio n o f m e rc u ry fro m
im p la n te d a m a lg a m h av e b e en stu d ie d in
g u in e a pigs.™ '81 It h as b e e n o b se rv e d th a t
la r g e r a m a lg a m p a rticles b e c o m e en clo sed
in fib ro u s tissu e a n d th a t th e r e is lim ited
b re a k d o w n a n d c o rro s io n o n th e p a rtic le
s u r fa c e s . F in e ly p o w d e r e d a m a lg a m is
p h a g o c y tiz e d by m a c ro p h a g e s a n d g ia n t
cells. F u r th e r in v e stig a tio n disclosed d isso ­
lu tio n a n d re d is trib u tio n o f m e rc u ry fro m
th e g a m m a o n e a n d g a m m a tw o ph ases o f
a m a lg a m in to b o d y tissu es. E lev ated m e r­
c u ry c o n c e n tra tio n s w e re d e te c te d in sev­
e ra l tissu es— in c lu d in g b lo o d , k id n ey , a n d
liver— w ith th e h ig h e s t c o n c e n tra tio n in
th e re n a l c o rte x . M icro an aly sis a n d im ­
p la n ta tio n o f in d iv id u a l c o n s titu e n t
p h a se s of d e n ta l a m a lg a m h av e d e m o n ­
s tr a te d t h a t m e r c u ry a n d tin a re c o m ­
p letely re m o v e d fro m e x p e rim e n ta l a m a l­
g am ta tto o s. T a tto o s alw ays re su lt fro m
th e p e rs iste n c e o f m in u te p a rtic le s o f silver
a n d s u lf u r asso ciate d w ith basal lam in a
a n d c o n n e c tiv e tissu e .79
T h e in g e stio n o f a m a lg a m p artic les a n d
su b s e q u e n t d isso lu tio n in th e g a stro in te s­
tin al e n v ir o n m e n t h a v e b e e n stu d ie d in
rats. P articles o f 7 -d ay -o ld a m a lg a m w ere
a d m in is te re d g a s tro in te stin a lly , a n d th e
a n im a l tissu es w e re a n a ly z e d 20 h o u rs la­
te r. T h e h ig h e s t levels o f m e rc u ry w ere
f o u n d in th e k id n ey s (a b o u t 0.01 to 0.1
/u.g/g w et tissue) a n d in b lo o d (a b o u t 6 .0 0 5
to 6.1 /Xg/g). T h e v alues v a rie d a m o n g th e
v a rio u s k in d s o f a m a lg a m s tu d ie d .82
Absorption, biotransformation,
distribution, and elimination of mercury
T h e m e tab o lism o f m e rc u ry is d e p e n d e n t
on th e ch em ical fo rm o f m e rc u ry a n d th e
ro u te o f e x p o s u re . O n ly th o se fo rm s o f
m e r c u ry e n c o u n te r e d by d e n ta l p e rs o n n e l
o r d e n ta l p a tie n ts will b e c o n s id e re d in this
r e p o r t.
M etal io n s in c lu d in g th e m e rc u ric ion
(H g ++) m ay b e re le a se d fro m am a lg a m
872 ■ JADA, Vol. 115, December 1987
r e s to ra tio n s b e c a u se o f c o rr o s io n . T h e
q u a n titie s o f su ch io n s re le a se d a re e x ­
tre m e ly m in u te . E x p o s u re to th e H g ++ ion
in th e fo rm o f m e rc u ric salts resu lts in
g a stro in te stin a l a b s o rp tio n o f 10% o r less
o f th e in g e s te d m e r c u ric io n s .14' 15 F o r
th e s e re a s o n s, it is u n lik e ly th a t e x p o s u re
to ionic m e rc u ry h as a n y sig n ific a n t ro le in
e x p o s u r e o f d e n ta l p a tie n ts to m e rc u ry .
O n e possible e x c e p tio n is th a t m e rc u ric
ions, as well as o th e r fo rm s o f m e rc u ry ,
m ay act as a lle rg e n s le a d in g to allerg ic
rea c tio n s.
T h e r e is n o d ire c t e x p o s u r e o f p e rs o n ­
n el o r o f p a tie n ts to o rg a n ic m e rc u ry in
7 he accumulation of mercury, after exposure to mercury
vapor, is dependent on the dose, frequency, and duration of
exposure, as well as metabolic factors related to the
individual.
d e n tistry . O n th e basis o f in v itro stu d ie s,
so m e in v e stig a to rs h a v e sp e c u la te d th a t
m e rc u ry re le a se d fro m a m a lg a m in p a r ­
tic u la te o r ionic fo rm m ay u n d e rg o b io lo g ­
ical m e th y la tio n by b a c te ria p re s e n t in
e ith e r th e m o u th o r th e in te s tin e .83 A r e ­
c e n t in v itr o s t u d y 84 h a s s h o w n t h a t
m e th y lm e rc u ry can be fo rm e d by c o m ­
m o n o ra l strep to c o c c i in a n u tr ie n t b ro th
c o n t a i n i n g m e r c u r y f r o m p u lv e r iz e d
a m a lg a m . H o w e v e r , t h e s t u d y in v e s ­
tig a to rs ca u tio n a g a in s t e x tra p o la tio n o f
th e se re su lts to in vivo situ a tio n s w ith o u t
f u r th e r in v e stig atio n .
A stu d y th a t c o m p a re d o n e g ro u p o f
d e n tists w h o a re o cc u p a tio n a lly e x p o se d to
in o rg a n ic m e rc u ry w ith a n o th e r c o n tro l
g r o u p n o t o c c u p a tio n a lly e x p o se d to in o r­
g a n ic m e rc u ry f o u n d th a t th e d e n tis ts ’
b lo o d levels o f in o rg a n ic m e rc u ry w ere
sig n ifican tly h ig h e r. 1lo w e v e r, n o sig n ifi­
c a n t d if fe re n c e e x isted in th e b lo o d c o n ­
c e n tra tio n s o f o rg a n ic m e rc u ry betw een
th e tw o g ro u p s .85 T h e s e fin d in g s su g g e st
th a t in vivo b io tra n s f o rm a tio n o f in o r­
g an ic m e rc u ry to m e th y lm e rc u ry p ro b a b ly
d o es n o t o c c u r to a n y sig n ifica n t d e g re e .
T h e r e is e v id e n c e 25 th a t e le m e n ta l m e r­
c u ry can p e n e tr a te th e sk in , b u t q u a n tita ­
tive d a ta a re lacking. In g e s te d e le m e n ta l
m e rc u ry is v ery p o o rly a b so rb e d fro m th e
g a stro in te stin a l tr a c t a n d n o t c o n sid e re d
p a rtic u la rly to x ic .14 25 In c o n tra st, e le m e n ­
tal m e r c u r y v a p o r re a d ily c ro s se s cell
m e m b ra n e s b e c a u se o f its h ig h d if fusibil­
ity a n d lip id so lu b ility .15,25 A b o u t 75% to
80% o f in h a le d m e rc u ry v a p o r is a b so rb e d
ac ro ss a lv e o la r m e m b ra n e s in to th e b lo o d ­
s tre a m .83 M e rc u ry v a p o r d issolved in th e
b lo o d is tr a n s p o r te d to o th e r tissues a n d
a b so rb e d by th o s e tissues, in c lu d in g th e
b r a in .15,25 H o w e v e r, m e rc u ry v a p o r h as a
lim ite d lifetim e in th e b o d y as it is ra p id ly
o x id iz e d to d iv a le n t m e rc u ric ion (H g°—
H g +2) by th e a ctio n o f ca ta lase in e r y th r o ­
cytes a n d in cells o f o th e r tissues.
T h e m e rc u ric io n d o e s n o t easily cross
cell m e m b ra n e s , e ith e r fro m blood to tis­
su e o r fro m t issue to b lo o d .25 R ed u c tio n o f
H g ++ also o c c u rs, b u t th e e x te n t o f this
re a c tio n is u n c le a r. T h e m e rc u ric ion is
b eliev ed to be larg ely b o u n d to su lfh y d ry l
g ro u p s o n p ro te in s a n d h as lim ited m o b il­
ity in th e b o d y .15
T h e a c c u m u la tio n o f m e rc u ry , a f te r e x ­
p o s u re to m e r c u ry v a p o r, is d e p e n d e n t on
th e d o se , fre q u e n c y , a n d d u ra tio n o f e x ­
p o su re , as well as a n u m b e r o f m etabolic
fa c to rs re la te d to th e e x p o se d in d iv id u a l.83
T h e re te n tio n tim e o f m e rc u ry in o rg a n s
v a rie s c o n s id e ra b ly , w ith b io logic h alf-
t i m e s r a n g i n g f r o m a fe w d a y s to
m o n th s .15,25 T h e o rg a n s w ith th e lo n g est
r e te n tio n tim es a re th e b ra in , k id n ey s, a n d
te stic les.15 T h e k id n ey s a re th e m ain o rg a n
o f a c c u m u la tio n .86 In cases o f c h ro n ic low
level e x p o s u re , th e critical o rg a n is th e
b r a in .83
T h e e lim in a tio n o f m e rc u ry fro m th e
b o d y o c c u rs p rim a rily by th e e x c re tio n o f
H g ++ via th e u rin e a n d fec e s.14,25 E x h a la ­
tio n o f m e rc u ry v a p o r h as b e e n d e m o n ­
s tra te d in h u m a n s a fte r in h a la tio n e x p o ­
su re b u t is th o u g h t to a c c o u n t fo r only a
sm all p o rtio n (7% ) o f to ta l m e rc u ry elim i­
n a tio n .15,83 P e rs p ira tio n m ay also h av e a
ro le in th e e x c re tio n o f m e rc u ry u n d e r
c e rta in c o n d itio n s .88 O v e ra ll, b a se d o n th e
lim ite d d a ta av ailab le, it is b elieved th a t th e
m ajo rity o f in o rg a n ic m e rc u ry a c c u m u ­
la te d in th e b o d y has a b iologic h alf-life o f
a b o u t 5 0 to 6 0 d a y s.15,25,86
All fo rm s o f m e rc u ry cro ss th e p la c e n ta
to v a ry in g d e g re e s . T h e re su lts o f an im a l
e x p e rim e n ts in d ic a te th a t e le m e n ta l a n d
o rg a n ic m e rc u ry c ro ss th e p la c e n ta to a
g r e a te r e x te n t th a n in o rg a n ic m e rc u ry .87
S ev eral s tu d ie s88 h a v e r e p o r te d th a t th e
m e a n to tal m e rc u ry c o n c e n tra tio n o f fetal

Table 2 ■ Mercury concentrations associated with time-weighted-average air con­
centrations of mercury that cause the earliest effects in the most sensitive adults with
long-term exposure to mercury vapor.*
Blood U rin e
(itg/100 mg) (* g /L )
3.5 150
7-14 300-600
* Adapted from G oyer, 1986.87
c o rd b lo o d is 13% to 24% h ig h e r th a n in
m a te rn a l b lo o d . O f th e se stu d ie s, o n e th a t
a n aly z ed o rg a n ic a n d in o rg a n ic m e rc u ry
in fetal co rd b lo o d a n d m a te rn a l b lo o d
in d ic a te d th a t h ig h e r m e th y lm e rc u ry c o n ­
c e n tra tio n s in fe ta l c o rd b lo o d a re p r im a r ­
ily re s p o n sib le fo r th e d if fe re n c e . T h e
m e a n v alues o f to ta l m e rc u ry in fe ta l c o rd
b lo o d a n d m a te rn a l b lo o d , re sp e ctiv e ly ,
ra n g e fro m 1.2 p a rts p e r billio n (p p b ) a n d
1.0 p p b (fro m a stu d y in r u r a l Iow a) to
2 0 .0 p p b a n d 16.8 p p b (fro m a stu d y in
J a p a n ) .89 B ased o n th e s e fin d in g s , r e ­
s e a rc h e rs have su g g ested th a t d ie t is an
im p o rta n t fa c to r in e x p la in in g th e v a ria ­
bility o f th e m e rc u ry c o n c e n tra tio n s r e ­
p o r te d .89 T h e re la tio n sh ip o f o c c u p a tio n a l
e x p o s u r e to m e r c u ry in d e n tis tr y a n d
p re g n a n c y o u tc o m e w as e x a m in e d in a
stu d y o f 3 0 ,2 7 2 fe m a le d e n ta l a ssistan ts
a n d th e wives o f 2 9 ,5 1 4 d e n tists. T h e s u b ­
je c ts w ere d iv id e d in to low e x p o s u re a n d
h ig h e x p o s u r e g ro u p s b a se d u p o n th e
n u m b e r o f a m a lg a m p ro c e d u re s th e y o r
t h e i r s p o u s e s p e r f o r m e d . T h e s tu d y
fo u n d th a t th e r e w as n o d if fe re n c e in th e
ra te o f s p o n ta n e o u s a b o rtio n s o r c o n g e n i­
ta l a b n o r m a l i t i e s b e t w e e n t h e lo w -
e x p o s u r e g r o u p a n d th e h ig h -e x p o s u re
g r o u p in e ith e r th e d e n ta l a ssistan ts o r th e
wives o f d e n tis ts .90
Biologic monitoring for mercury exposure
Methods and relationship to exposure
B iologic m o n ito rin g o f m e rc u ry c o n c e n ­
tra tio n s in b lo o d , u rin e , a n d h a ir h a s failed
to p ro d u c e an e x a c t re la tio n sh ip b e tw e e n
th e s e p a ra m e te rs , o rg a n c o n c e n tra tio n s ,
a n d toxicity.83 It is n ecessary to e x e rc ise
c a u tio n w h e n re v ie w in g r e p o r ts o f th e
c o n c e n tra tio n o f m e rc u ry in b iologic sa m ­
ples since m e th o d o lo g ie s v ary a n d so m e
p a st s tu d ie s h av e lacked a d e q u a te c o n ­
tro ls. O n a g ro u p basis, a lin e a r c o rre la tio n
se e m s to e x is t b e tw e e n a v e r a g e tim e -
w e ig h te d a tm o sp h e ric a ir c o n c e n tra tio n s
o f m e rc u ry v a p o r a n d a v e ra g e u rin a ry
m e r c u r y c o n c e n t r a ti o n s .86 B e c a u s e o f
Air
(jig /m 3) E arliest effects
50 N onspecific sym ptom s
100-200 T rem o r
h ig h in d iv id u a l v a ria tio n s a n d d a ily fluc­
t u a t i o n s , s e r ia l m o n i to r in g is r e c o m ­
m e n d e d to in c re a se th e reliab ility o f b lo o d
a n d u rin a ry c o n c e n tra tio n s as a m e a s u re
o f e x p o s u r e f o r in d iv id u a ls .83,86 B lood
levels re fle c t very re c e n t e x p o s u r e since
m e rc u ry in b lo o d has a s h o rt h alf-life , es­
ti m a t e d to b e a b o u t 3 d a y s . U r in a r y
m o n ito r in g is re c o m m e n d e d f o r assessing
lo n g -te rm stead y -state e x p o s u r e .86 A c o r­
re la tio n has b e e n sh o w n b e tw e e n levels o f
m e rc u ry in u rin e a n d b lo o d ; h o w ev e r, this
c o rre la tio n c a n n o t b e a ssu m e d to b e lin e a r
o v e r a w ide ra n g e o f c o n c e n tra tio n s , a n d
an e x a c t q u o tie n t b e tw e en m e rc u ry c o n ­
c e n tra tio n in u rin e a n d b lo o d c a n n o t be
g iv e n .'5
T h e ra n g e of c o n c e n tra tio n s o f m e rc u ry
in u rin e a n d b lo o d in th e g e n e ra l p o p u la ­
tio n (n o t excessively o r o c c u p a tio n a lly ex ­
p o se d to m e rc u ry ) is 0 to 20 /ug/L91 92 a n d 0
to 1.0 /xg/100 m L ,83,93 resp ectiv ely . O n a
g r o u p basis, b lo o d a n d u rin a ry m e rc u ry
c o n c e n tra tio n s o f 3.5 /xg/100 m L a n d 150
¿ig/L, resp ectiv ely , a re asso cia te d w ith an
a v e ra g e a ir m e rc u ry level o f 0 .0 5 m g /m 3.83
T h e s e c o n c e n tr a tio n s , 3 .5 ju.g H g /1 0 0
m L 83 fo r b lo o d a n d 150 /xg/L87 fo r u rin e ,
also a re e stim a te d to b e th e m in im a l co n ­
c e n tra tio n s asso ciate d w ith clinical effects
(T a b le 2). H o w e v e r, g r o u p o c c u p a tio n a l
e x p o s u r e d a ta h av e in d ic a te d th a t d e te c t­
ab le h e a lth effec ts— m e a s u re d as a n in ­
c re a se in tr e m o r f re q u e n c y o f th e fo re a rm
w h e n lo a d e d w ith a 15-lb w e ig h t — may
rise sig n ifican tly w h en u rin a ry m e rc u ry
c o n c e n t r a t i o n s e x c e e d 5 0 |U g /L .15 As
sta te d , b ecau se o f th e n u m b e r o f v ariab les
af fe c tin g toxicity, clinical sy m p to m s o r d e ­
g re e o f e ffe c t c a n n o t b e p re d ic te d p re ­
cisely by biologic m o n ito rin g . H o w ev er,
b e c au se u rin e sam p les re fle c t e x p o s u re
(w hich in tu r n lead s to th e a c c u m u la tio n o f
m e r c u r y in th e C N S , a n d as a c o n s e ­
q u e n c e , a d v e rse h e a lth effects), th e se p a ­
ra m e te r s d o p ro v id e u sefu l in fo rm a tio n
f o r th e p r e v e n t io n o f to x ic ity .15 T h e
m o n ito rin g o f u rin a ry m e rc u ry is th e c u r ­
re n t m e th o d fo r e v a lu a tin g e x p o s u r e o n a
g ro u p basis in in d u s try .88
L angan-Fan-H oos: USE OF MERCURY IN DEN TISTRY ■ 873
REVIEW ARTICLES
A n a ly s is o f s e q u e n t i a l s e g m e n ts o f
h u m a n h e a d h a ir h as b e e n a d v o c a te d fo r
th e d e te r m in a tio n o f lo n g itu d in a l e x p o ­
s u re to m e th y lm e rc u ry . H a ir re fle c ts th e
b lo o d c o n c e n tra tio n s o f m e th y lm e rc u ry at
th e tim e o f f o r m a tio n .86,94' 98 B ecau se o f
th e d if fe re n c e s in m eta b o lism o f th e d if ­
fe r e n t ch e m ic al fo rm s o f m e rc u ry , lo n g ­
te rm e x p o s u r e to m e th y lm e rc u ry can be
a ss e sse d by a n a ly s is o f h a i r , a lth o u g h
lo n g -te rm e x p o s u r e to m e r c u ry v a p o r is
b e tte r assessed by u r in e an aly sis.86 H a ir
an aly sis fo r m e r c u ry v a p o r e x p o s u r e is n o t
c o n s id e re d valid b e c a u se m e rc u ry v a p o r
m ay d ire c tly c o n ta m in a te th e h a ir a n d not
re fle c t m e rc u ry m e ta b o liz e d in to th e h a ir.
In a d d itio n , o th e r e x o g e n o u s so u rc e s o f
m e r c u ry su c h as h a n d s , g lo v es, e q u ip ­
m e n t, a n d so m e h a ir tr e a tm e n ts c o n ta in ­
in g m e rc u ry m ay also d ire c tly c o n ta m in a te
th e h a ir.
T h e le g itim a te u se o f h a ir a n aly sis by
q u a lifie d re s e a rc h e rs sh o u ld n o t b e c o n ­
fu s e d w ith th e m isu se o f h a ir analysis to
assess n u tr itio n a l sta tu s o r d ia g n o s e to x i­
city to v a rio u s tra c e e le m e n ts . T h is m isu se
a n d m is in te rp r e ta tio n o f h a ir an alyses has
b e e n th e su b je c t o f sev e ral re c e n t a r t i­
cles.97"101 A re c e n t s tu d y ,98 in w hich h a ir
sa m p le s fro m tw o h e a lth y te e n a g e rs w ere
s u b m itte d to 13 c o m m e rc ia l la b o ra to rie s
p e r f o r m in g h a ir analysis, fo u n d th a t th e
r e p o r te d levels o f tra c e e le m e n ts v a rie d
c o n s id e ra b ly b e tw e e n id e n tic a l sa m p le s
s e n t to th e sam e la b o ra to ry a n d f ro m la b o ­
ra to ry to la b o ra to ry . In th e w o rd s of th e
stu d y in v e stig a to r: “ . . . m o s t re p o r ts c o n ­
ta in e d c o m p u te riz e d in te rp re ta tio n s th a t
w e re v o lu m in o u s, b iz a rre , a n d p o te n tia lly
f r i g h t e n i n g to p a t i e n t s . ” 97 O t h e r r e ­
s e a rc h e rs 98 h a v e n o te d th a t su ch re p o r ts
o f te n s u g g e s t “ n u tr it io n a l im b a la n c e s ”
a n d “ to x ic levels” o f c e rta in e le m e n ts a n d
th e n p ro c e e d to m a r k e t d ie ta ry s u p p le ­
m e n ts, v itam in s, a n d c h e la tin g a g e n ts to
c o n s u m e rs .98
Monitoring to assess occupational
mercury exposure
M o n ito rin g of a ir f o r m e r c u ry v a p o r levels
in d e n ta l of fices is im p o r ta n t fo r m a in ta in ­
in g a safe w o rk in g e n v ir o n m e n t, b u t b e ­
c a u se e x p o s u r e a n d a b s o r p tio n a re a f ­
fe c te d by a n u m b e r o f in d iv id u a l specific
v a riab le s, th e a b s o rb e d m e rc u ry level can
b e d e te r m in e d o n ly by biolo g ical m o n ito r­
in g o f b o d y flu id s a n d tissu es.25 S everal
re c e n t stu d ie s h a v e r e p o r te d th e m e rc u ry
c o n c e n tra tio n s o f u r in e ,29 102 b lo o d , 85-93’
io3,io4 anc[ h a ir s a m p le s 29,95,96 co llected
fro m d e n ta l p e rs o n n e l. In a 9 -y ear stu d y
d u r i n g w h ich u rin e sp e c im e n s w e re col­
 REVIEW ARTICLES
lected fro m 4,2 72 d e n tists, it was fo u n d
th a t 19% o f th e d e n tists h a d u rin a ry m e r­
c u ry c o n c e n tra tio n s g re a te r th a n 20 /¿g/L,
w hich is c o n sid e re d th e u p p e r lim it o f th e
n o rm a l ra n g e . T h e m ean u rin a ry m e rc u ry
c o n c e n tra tio n w as 14.2 /xg/L w ith a ra n g e
o f 0 to 5 56 /*g/L. A m o n g th e fa cto rs sig n if­
icantly re la te d to u rin a ry m e rc u ry c o n c e n ­
tra tio n s w ere th e type o f p ra ctice , h o u rs
p ra c tic e d p e r w eek, type o f a m a lg a m c a p ­
sules u se d , a n d th e n u m b e r o f am a lg a m s
p lace d p e r w e e k .102
In a stu d y o f 205 d e n tists, th e m ea n
w hole b lo o d c o n c e n tra tio n o f m e rc u ry was
fo u n d to be 0.61 /xg/100 m L as o p p o se d to
0 .40 /xg/100 m L fo r a g r o u p o f 24 c o n tro l
su b je c ts n o t o c c u p a tio n a lly e x p o s e d to
m e r c u ry .85 In a n o th e r stu d y o f 23 d e n tists,
w ho h a d b een in active p ra c tic e fo r a t least
2 0 years, a se ru m m e rc u ry c o n c e n tra tio n
of 1.13 /xg/100 m L was fo u n d c o m p a re d to
a se ru m c o n c e n tra tio n o f 0 .7 2 /xg/100 m L
in a g r o u p o f c o n tro l su b je c ts.93 In a K o­
re a n stu d y o f 35 d en tists, th e m ea n b lo o d
m e rc u ry c o n c e n tra tio n was r e p o r te d to b e
21.62 /ig /1 0 0 m L .103 T h e K o re a n stu d y
d id n o t m e a s u re b lo o d c o n c e n tra tio n s in a
c o n tro l g ro u p , b u t cited a n o th e r K o rean
stu d y th a t fo u n d a m ean b lo o d c o n c e n tra ­
tio n o f 25.3 /xg/100 m L in a g r o u p o f p e r ­
sons n o t o ccu p atio n ally e x p o se d to m e r ­
c u r y . T h e s e d a ta s u g g e s t t h a t o t h e r
s o u r c e s o f m e r c u r y , s u c h as d ie t a r y
so u rces, m ay have a m u c h g re a te r e ffec t
o n b lo o d m e rc u ry c o n c e n tra tio n th a n o c­
c u p a tio n a l e x p o su re .
A lth o u g h rec o g n iz in g th e lim ita tio n s o f
h a ir analysis, sev eral stu d ie s h av e re p o r te d
th e h a ir m e rc u ry values fro m d e n ta l p e r ­
so n n e l, a n d o n e su ch stu d y is n o te d h e re to
in d ic a te th e m a g n itu d e o f th e levels r e ­
p o rte d . In a B ritish stu d y 96 o f 150 d en tists,
43 d e n ta l su rg e ry assistants, a n d 28 c o n ­
tro l subjects, th e ra n g e o f h a ir m e rc u ry
levels was 0.5 to 64 p p m fo r th e d e n ta l
p e rs o n n e l a n d 0.35 to 2.7 p p m in th e c o n ­
tro l subjects. F o u rte e n p e rc e n t o f th e d e n ­
ta l p e r s o n n e l h a d h a ir m e r c u r y levels
g r e a te r th a n 10 p p m . It was also r e p o r te d
th a t o n e d e n tist w ith a h a ir m e rc u ry c o n ­
c e n tra tio n o f 40 p p m h a d b e e n fo rc e d to
give u p his d e n ta l p ractice b e c au se o f th e
g ra d u a l d e v e lo p m e n t o f a ta x ia a n d a c e re ­
b e lla r sp e e c h d e fe c t. T h e in v e s tig a to rs
n o te d th a t th o se d e n tists w ith th e h ig h e st
h a ir m e rc u ry levels e x p re s s e d th e least
c o n c e rn in o b ta in in g th e re su lts o f th e
analysis. Sim ilarly, C a n a d ia n re s e a rc h e rs,
w ho su rv e y e d m e rc u ry v a p o r levels, n o te d
th a t only 10% of th e d e n ta l p e rs o n n e l h a d
b e e n te ste d fo r m e rc u ry levels in th e body
a n d su g g e ste d th a t f u r th e r e m p h a sis be
p lace d on th is su b ject in th e e d u c a tio n o f
874 ■ JADA, Vol. 115, December 1987
d e n tists, h y g ien ists, a n d a ssista n ts.24
In a d d itio n to m o n ito rin g o f b o d y flu id s
a n d h a ir, a n a tte m p t h as b e e n m a d e to
m e a s u re th e m e rc u ry c o n te n t o f tissues o f
d e n tists in situ u sin g a n X -ray flu o re sc e n c e
te c h n iq u e . E v alu a tio n o f th e te c h n iq u e in
v itro w ith sam p les ir ra d ia te d fo r 20 m in ­
u tes p ro d u c e d resu lts th a t c o m p a re d well
w ith a ch em ical assay; h o w ev er, th e in situ
tissu e m e a s u re m e n ts w ere m a d e w ith an
X -ray e x p o s u re tim e o f o n ly 1 m in u te .
F u rth e rm o r e , th e te c h n iq u e is lim ite d to
m e a s u r in g m e r c u ry in th e s u p e r fic ia l
layers o f tissues only. T h e m e rc u ry c o n ­
te n t o f th e su p erficia l layers o f th e h e a d
a n d w rist w as d e te rm in e d in situ f o r 298
d e n tists u sin g this te c h n iq u e . O f th e 298
sub jects stu d ie d , 84 h a d d e te c ta b le m e r­
c u ry levels (d e fin e d as g re a te r th a n 20
/xg/g) in th e su p erficia l tissu es o f th e h e a d
a n d 32 subjects h a d d e te c ta b le levels in th e
w ris t.105 T o e q u a te th e se m e a s u re m e n ts
w ith m e rc u ry b o d y b u rd e n w o u ld a p p e a r
u n w a rra n te d as th e re s e a rc h e rs n o te th a t
th e m e rc u ry c o n te n t o f tissues su c h as th e
k id n e y a n d liver c o u ld n o t be m e a s u re d
w ith th is te c h n iq u e b ec a u se o f th e th ick ­
n ess o f th e o v e rly in g tissue. T h e im p lic a­
tio n th a t “h e a d ” m e rc u ry levels a re in d ic a ­
tive o f b ra in m e rc u ry c o n c e n tra tio n s has
n o t b e e n p ro v e d . In a fo llo w -u p o f th e
stu d y , 23 d e n tists w h o se m e rc u ry levels
ra n k e d w ith in th e to p 20% o f th e stu d y
p o p u la tio n , a n d 22 c o n tro l d e n tists w hose
levels w ere d e sig n a te d u n d e te c ta b le , w ere
a ss e sse d by n e u ro p h y s io lo g ic a l a n d
n e u r o p s y c h o l o g i c a l t e s t s . P o ly -
n e u ro p a th ie s , d e fin e d as re d u c e d m o to r
o r se n so ry c o n d u c tio n velocities o r r e ­
sp o n se a m p litu d e s in tw o o r m o re n erv es,
w e re fo u n d in seven d e n tists, all in th e
e le v a te d m e rc u ry g r o u p . T h e e le v a te d
m e rc u ry g ro u p was also r e p o r te d to have
m o re v isu o g ra p h ic a lte ra tio n s as d e te c te d
by th e n e u ro p sy c h o lo g ic a l tests a n d h ig h e r
d istre ss levels m e a s u re d fro m se lf re p o rts
o f sy m p to m s o n a ch e ck list.106
A n e c ro p s y r e p o r t o f se v e n cases—
th r e e o f w h o m w ere d e n tists a n d fo u r c o n ­
tro l subjects w ith n o k n o w n o c c u p a tio n a l
e x p o s u re to m e rc u ry — m e a s u re d th e m e r­
c u ry c o n te n t o f tissues fro m th e occipital
c o rte x a n d p itu ita ry g lan d s. T h e occipital
c o rte x levels ra n g e d fro m 5 to 14 n g /g w et
w eig h t fo r th e d e n tists a n d fro m 5 to 21
n g /g w et w eig h t fo r th e c o n tro l subjects. In
c o n tra st, th e p itu ita ry g la n d levels fo r th e
d e n tists ra n g e d fro m 135 to 3 4 9 n g /g w et
w e ig h t, w h e re as th ese levels fo r th e c o n ­
tro ls ra n g e d fro m 5 to 97 n g /g w et w eight.
T h e c o n tr o l s u b je c t w ith th e h ig h e s t
p itu ita ry g la n d level h a d sev eral am a lg a m
re s to ra tio n s re m o v e d d u r in g th e last y e ar
o f life. T h e resu lts o f th is c o n tro l su b ject
a n d th o s e fro m th e th r e e d e n tists su g g est
th a t in h a la tio n o f m e rc u ry v a p o r m ay lead
to h ig h m e r c u ry c o n c e n tra tio n s in th e
p itu ita ry g la n d .107
Monitoring to assess mercury
exposure from amalgam
A lth o u g h n u m e ro u s re p o r ts o n th e c o n ­
c e n tra tio n s o f m e rc u ry in th e u rin e o f su b ­
je c ts w ith o c c u p a tio n a l e x p o s u r e to m e r ­
c u ry exist, sim ilar inf o rm a tio n o n subjects
w ith o u t su c h e x p o s u r e is lim ite d . O n e
s tu d y 108 o f su ch n o n e x p o s e d subjects r e ­
p o rte d th a t th e m e a n u r in e m e rc u ry val­
u es w ere 1.66 /xg/L fo r 25 subjects w ith
a m a lg a m re s to ra tio n s, a n d 1.54 /xg/L fo r
19 su b jects w ith o u t a m a lg a m re s to ra tio n s.
In th e sam e stu d y , th e m e a n values fo r
sub jects w ith o c c u p a tio n a l m e rc u ry e x p o ­
su re w e re 3.99 /xg/L fo r 43 su bjects w ith
a m a lg a m re s to ra tio n s, a n d 2.4 /xg/L fo r 15
su b je c ts w ith o u t a m a lg a m re s to ra tio n s .
T h e c o n c e n tra tio n s o f m e r c u r y in th e
u rin e o f subjects b e fo re a n d a fte r am a l­
g a m p l a c e m e n t s h a v e a ls o b e e n r e ­
p o r te d .60 T h e c o n c e n tra tio n s o f m e rc u ry
in u r in e w e re o b se rv e d to rise f o r 24 h o u rs
a fte r a m a lg a m p la c e m e n t, b u t r e tu r n e d to
p r e tr e a tm e n t levels a fte r 7 days.
In a g ro u p o f 73 N o rw e g ia n schoolchil­
d r e n , w ith a m e a n a g e o f 12, th e m ean
c re a tin in e -a d ju s te d c o n c e n tra tio n o f m e r­
c u ry in u r in e was 0.58 n m o l H g /m m o l
c re a tin in e . A sig n ifican t p o sitiv e c o rre la ­
tio n (R = .5 5 ) w as fo u n d b e tw e e n th e c o n ­
c e n tra tio n s o f m e rc u ry in u rin e a n d th e
e x te n t o f a m a lg a m re s to ra tio n s as assessed
o n a p o in t scale th a t to o k in to a c c o u n t th e
n u m b e r a n d size o f re s to ra tio n s in each
ch ild . H o w ev e r, n o c o rre la tio n w as fo u n d
b e tw e e n th e e x te n t o f a m a lg a m re s to ra ­
tio n s a n d illness o r a llerg y . T h e a u th o rs
c o n c lu d e d th a t th e very sm all a m o u n ts o f
m e rc u ry fo u n d d id n o t w a rra n t ré é v a lu a ­
tio n o f th e u se o f a m a lg a m as a d e n ta l
re s to ra tiv e m a te ria l.109
T h e c o n c e n tra tio n s o f m e rc u ry in blood
h a v e b e e n c o m p a r e d b e tw e e n s u b je c t
g ro u p s w ith o r w ith o u t a m a lg a m re s to ra ­
tions. In o n e c o m p a riso n th e m e a n value
o f m e rc u ry in b lo o d fo r 4 7 su bjects w ith
a m a lg a m re s to ra tio n s was 0 .0 7 /xg/100 m L
w ith a r a n g e o f 0 to .3 3 /x g /1 0 0 m L ,
w h e re a s th e m e a n v a lu e f o r 14 subjects
w ith o u t a m a lg a m r e s to r a tio n s w as .03
/xg/1 0 0 m L , w ith a ra n g e o f 0 to 0.1 /¿g/100
m L .54 A n o th e r stu d y 53 sh o w e d th e m e a n
v alu e fo r 54 subjects w ith a m a lg a m re s to ­
ra tio n s was 0.06 /xg/100 m L w ith a ra n g e o f
0 .0 1 2 to 0 .1 8 /A g/i00 m L , w hile th e m e a n
v alu e fo r 15 subjects w ith o u t am a lg a m was

Table 3 ■ Mercury concentrations of subjects with and without amalgam resto­
rations.
Investigator
U rin e levels (Mg/L)
A m algam
Kroncke and others (1981) 1.66
K roncke an d others (1981) 3.99
Blood levels (/ug/100 mL)
A m algam
Kroncke and others (1981) 0.18
0.21
A braham an d others (1984)
0.07
O tt and others (1984) 0.06
0.0 8 /xg/100 m L w ith a ra n g e o f 0 .0 1 6 to
0 .3 3 /xg/100 m L .53 Y et a n o th e r s tu d y 108
r e p o r te d th a t fo r subjects w ith o u t o c c u p a ­
tio n al c o n ta c t w ith m e rc u ry , th e m e a n val­
u es fo r 23 subjects w ith a m a lg a m r e s to ra ­
tio n s w e re 0.18 /xg/100 m L w hile th e m e a n
v alu e fo r 16 subjects w ith o u t a m a lg a m re s­
to ra tio n s w as 0 .1 9 /xg/100 m L . T h e m e a n
values fo r subjects w ith o c c u p a tio n a l m e r­
c u ry e x p o s u re w e re 0.21 /xg/100 m L fo r 41
su b jects w ith a m alg am re s to ra tio n s a n d
0 .2 4 /xg/100 m l. fo r 14 sub jects w ith o u t
a m a lg a m re s to ra tio n s. T h e re s u lts o f th e
f o r e g o in g s t u d ie s a r e s u m m a r iz e d in
T a b le 3.
T h e c o n c e n tra tio n s o f m e rc u ry in saliva
h a v e b een re p o r te d in several stu d ie s. O n e
su ch s tu d y 60 fo u n d g e o m e tric m e a n v alues
o f 1.91 p p b fo r 141 subjects in c e n tra l
T o k y o a n d 1.01 p p b fo r 57 su b jects in a
s u b u rb a n lo catio n . T h e sam e stu d y also
r e p o r te d th a t th e m e a n c o n c e n tra tio n s o f
m e rc u ry in saliva w ere 2.11 p p b f o r 133
su b jects w ith a m a lg a m re s to ra tio n s a n d
0 .8 8 ppl> fo r 65 subjects w ith o u t am alg am
re s to ra tio n s. T h e stu d y e stim a te d th a t th e
daily in g e stio n o f m e rc u ry in saliva w o u ld
be 1.5 /x g a n d w ould be in crea se d by 2.1 /xg
by th e p re s e n c e of a m a lg a m re s to ra tio n s.
T h e s e e stim a te s c o rr e s p o n d to 1/30 o f th e
to ta l m e rc u ry in ta k e fro m fo o d fo r a p e r ­
so n w ith o u t a m alg am re s to ra tio n s a n d 1/13
o f th e in ta k e o f a p e rs o n w ith a m a lg a m
re s to ra tio n s.
In a n o th e r in v e stig atio n o f th e m e rc u ry
c o n c e n tra tio n in saliva, n o sig n ific a n t d if ­
fe re n c e s w ere d e m o n s tra te d b etw een su b ­
je c ts w ith o c c u p a tio n a l e x p o s u re (d e n ta l
o ffice p e rs o n n e l) a n d su b jects w ith a m a l­
g a m r e s to r a tio n s w ith o u t o c c u p a tio n a l
e x p o s u r e .61 O th e r in v e stig a to rs c o m p a r­
in g th e m e rc u ry levels in saliva r e p o r te d a
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n g /g . T h e m e a n level in c e re b e lla r c o rte x
w as 1 1.2 n g /g w ith a ra n g e o f 3.0 to 33.8
n g /g ; a n d th e m e a n level in th e s e m ilu n a r
g a n g lio n was 5 .0 n g /g w ith a ra n g e o f 1.5 to
14,,8 ng /g . T h e in v e stig a to rs also r e p o r te d
a Statistically s ig n ific a n t c o rr e la tio n b e ­
Sam ple O ccupational exposure tw ee n th e to ta l m e rc u ry level in th e o c cip i­
tal c o rte x a n d th e n u m b e r o f d e n ta l a m a l­
g a m re s to ra tio n s. In c o n tra s t to th e s e v al­
W ith o u t am algam u e s, a c o m p u te r sim u la tio n m o d e l o f m e r ­
1.54 No c u ry e x p o s u r e fr o m a m a lg a m th a t a s­
2.4 Yes
s u m e d lo n g -te rm p re f e re n tia l a c c u m u la ­
tio n o f m e rc u ry in th e b ra in p ro je c te d a
c o n c e n tra tio n o f m e rc u ry in th e b ra in o f
W ith o u t am algam 4 .0 /xg/g w et tissu e .57
0.19 No D ata o n th e b ra in level o f m e rc u ry th a t
0.24 Yes
No
cau ses toxicity a re scarce. I t has b e e n r e ­
0.03
0.08 No p o r t e d 15 th a t in tw o c o n firm e d cases o f
m e r c u ry to xicity fro m lo n g -te rm m e rc u ry
v a p o r e x p o s u re , th e b ra in m e rc u ry c o n ­
c e n tra tio n s r a n g e d fr o m 6 to 9 \ i g /g, b u t in
m e a n level o f 30.8 p p b fo r sub jects w ith o n e o th e r case o f c h ro n ic c alo m el in ta k e
f o u r o r m o re a m a lg a m re s to ra tio n s w hich th e c o n c e n tra tio n s r a n g e d b e tw e e n 4 to 5
w as 16 tim es th e m e a n v alu e o f 1.9 p p b fo r /xg/g. T h e s e th r e e cases re p r e s e n t th e low ­
su b jects w ith o u t a m a lg a m re s to ra tio n s .110 est levels r e p o r te d . O th e r a u to p s y stu d ie s
A s tu d y 53 th a t assessed t lie ef f e ct o f ch ew ­ h a v e r e p o r te d h ig h e r levels o f m e r c u ry in
in g r e p o r te d th a t th e m e a n m e rc u ry levels th e b ra in .
in saliva f o r subjects w ith a m a lg a m re s to ­
ra tio n s w as 4.9 0 /xg/L (ra n g e 0 .6 0 to 143.0) Mercury toxicity
b e fo r e c h e w in g a n d 12.95 /xg/L (ra n g e
0 .3 0 to 193.8) a fte r ch ew in g . T h e c o rr e ­ T h e toxic effe c ts o f e le m e n ta l m e r c u ry a re
s p o n d i n g v a lu e s f o r s u b je c ts w ith o u t p ro d u c e d a f te r it h a s b e e n o x id iz e d to
a m a lg a m r e s to r a tio n s w e re 0 .3 0 /xg/L m e rc u ric io n , w hich h as a s tro n g affin ity
(r a n g e 0 .1 0 to 2.70) a n d 0.4 /xg/L (ra n g e fo r th e su lfh y d ry l g ro u p s o f p r o te in s .114
0.1 to 0.5), respectively. A n e v a lu tio n o f 12 T h e m e rc u ric io n also co m b in e s w ith o th e r
su b jects fo r v a rio u s m etal io n s in saliva lig a n d s, su c h as th e p h o s p h o ry l, c arb o x y l,
sh o w ed th a t only o n e h a d a m e rc u ry c o n ­ a m id e , a n d a m in e g r o u p s .14 W ith in cells,
c e n tra tio n above th e d e te c tio n lim it o f 2.0 m e rc u ric io n s a c t as p o te n t n o n sp e c ific e n ­
p p b . T h e stu d y c o n c lu d e d th a t th e r e is no zym e in h ib ito rs a n d d é n a tu r a n ts o f p r o ­
s u p p o r t fo r th e th e o ry th a t in c re a se d o ral t e i n , t h u s i n t e r f e r i n g w ith c e l l u l a r
g alv an ic actio n in flu e n c e s th e saliva c o n ­ m e ta b o lism a n d fu n c tio n .14,114 T h e m e r ­
c e n tra tio n o f m e rc u ry o r ions o f o th e r c u ric io n h a s also b e e n sh o w n to a lte r
e le m e n ts c o n ta in e d in a m a lg a m s .111 m e m b ra n e fu n c tio n a n d tr a n s p o r t, in c lu d ­
T h e m e rc u ry c o n te n t o f n e rv e tissue in g th e r e le a s e a n d u p ta k e o f n e u r o ­
fro m th e h e a d a n d p e rip h e ra l n e rv e s was tra n s m itte rs in th e b r a in .15,83 A lth o u g h lit­
d e te r m in e d in an a u to p sy stu d y o f two tle is k n o w n a b o u t th e e x ac t d is trib u tio n of
m e n w hose d e n ta l sta tu s was re c o rd e d . m e rc u ry in th e b ra in , it d o e s a p p e a r to be
T h e m e rc u ry levels ra n g e d fro m 0 .0 3 to n o n u n if o rm , w ith p re f e re n tia l a c c u m u la ­
130 /xg/g d ry w eight. In th e sa m e re p o r t, tio n in c e rta in cells.15,114
an e x p e rim e n t was c o n d u c te d o n d o g s to C h ro n ic e x p o s u r e to m e r c u r y v a p o r
assess th e ef fect o f a m a lg a m re s to ra tio n s p ro d u c e s a fo rm o f tox icity th a t is d o m i­
o n th e m e rc u ry levels o f n e rv e tissues. T h e n a te d b y n e u r o lo g ic a l e f f e c t s .14 E a rly
m e rc u ry c o n te n t o f n e rv e tissues in b o th n o n s p e c ific sig n s o f m e r c u ry e x p o s u r e
h u m a n s a n d d o g s d if fe re d w idely fro m h a v e b e e n te r m e d th e asth e n ic -v e g a tiv e
o n e n e rv e to a n o th e r w ith n o a p p a r e n t s y n d ro m e o r m ic ro m e rc u ria lism a n d in ­
re la tio n s h ip to th e n u m b e r , ty p e , o r lo ca­ c lu d e su c h sy m p to m s as w eak n ess, fa tig u e ,
tio n of am a lg a m re s to ra tio n s .112 A n o th e r a n o re x ia , w eig h t loss, a n d g a stro in te stin a l
s tu d y 113 th a t a tte m p te d to re la te m e rc u ry d is tu rb a n c e s . W ith in c re a sin g e x p o s u r e ,
in th e c e n tra l n e rv o u s system to d e n ta l th e c h a ra c te ris tic m e r c u ria l tr e m o r a p ­
a m a lg a m re s to ra tio n s r e p o r te d th a t, fo r p e a rs as fin e tre m b lin g o f m u scles in te r ­
15 h u m a n su b jects, th e m e a n m e r c u ry r u p te d by c o a rse s h a k in g m o v e m e n ts .15
level (w et w eight) in th e occip ital c o rte x T h e tr e m o r b e g in s w ith in te n tio n tr e m o rs
w as 12.4 n g /g w ith a ra n g e o f 4 .8 to 2 8 .7 o f m u s c l e s i n v o l v e d in f i n e m o t o r
Langan-Fan-H oos: USE OF M ERCURY IN DENTISTRY ■ 875
 REVIEW ARTICLES
fu n ctio n » — su ch as th o s e in th e fin g e rs,
ey elid s, a n d lips— a n d p ro g re sse s to a g e n ­
e ra liz e d tr e m o r in v o lv in g th e e n tire b o d y
a n d v io le n t c h r o n ic s p a s m s o f th e e x ­
tr e m itie s .15,87 C o n c u r r e n t w ith th e d e ­
v e lo p m e n t o f tr e m o rs , p sy ch o lo g ical a n d
b e h a v io ra l c h a n g e s o c c u r .15 S y m p to m s
m ay in c lu d e in c re a se d ex citab ility , loss o f
m e m o ry , in so m n ia , sev ere d e p re s s io n , ir­
ritab ility , excessive sh y n e ss, a n d c o n fu ­
sion. O th e r r e p o r te d sy m p to m s83 in c lu d e
a ta x ia , sp e e c h d is o rd e rs , re fle x a b n o r ­
m alities, visual d is tu rb a n c e s , a n d im p a ire d
n e rv e c o n d u c tio n . O ra l sy m p to m s o f m e r ­
c u ry in to x ic a tio n in c lu d e ging iv itis, e x ces­
sive saliv atio n , m etallic ta ste, a n d lo o se n ­
in g o f te e th .15,87 T h e tria d c o n sistin g o f
in c re a se d excitability, tr e m o rs , a n d g in ­
givitis has b een re c o g n iz e d as th e m a jo r
m a n ife s ta tio n o f m e rc u ry p o is o n in g fro m
in h a la tio n o f m e rc u ry v a p o r.87
In a ll c a s e s o f s u s p e c t e d m e r c u r y
p o is o n in g , t r e a t m e n t b e g in s w ith im ­
m e d ia te te rm in a tio n of e x p o s u re . In so m e
cases, th e sy m p to m s of m e rc u ry e x p o su re
a r e re v e rsib le w h e n e x p o s u r e is e lim i­
n a te d . B lood a n d 2 4 -h o u r c o n c e n tra tio n s
o f m e rc u ry in u rin e a re g e n e ra lly m e a ­
s u re d as so o n as possible a n d a re u se d to
m o n ito r th e effectiv en ess o f tr e a tm e n t.91
T h e af finity o f m e rc u ry fo r th io ls p ro v id e s
th e b asis f o r tr e a tm e n t w ith c h e la tin g
a g e n ts .14 D im e rc a p ro l, p e n ic illa m in e , a n d
N - a c e ty l - D ,I .- p e n i c il la m i n e a r e m o s t
c o m m o n ly re c o m m e n d e d f o r the. tr e a t­
m e n t o f c h ro n ic m e r c u r y v a p o r e x p o ­
s u r e .14,91,1 15 A re c e n t r e p o r t h as su g g e ste d
th a t 2 ,3 -d im e rc a p to -p r o p a n e -l- s u lf o n a te
m ay also b e a safe a n d effe ctiv e a g e n t.116
Mercury allergy
Mechanisms of mercury allergy
R ecen t stu d ie s r e p o r tin g m e rc u ry re le a se
fro m a m a lg a m , e ith e r as m e rc u ry v a p o r o r
m e r c u ry io n s in saliva, h av e fo cu sed in ­
c re a s e d a tte n tio n o n th e in c id e n c e a n d e f ­
fects o f m e rc u ry h y p ersen sitiv ity . T h e lit­
e r a t u r e 83,117,118 in d ic a te s t h a t c o n s id e r­
able c o n fu s io n exists a b o u t th e m isuse o f
th e te rm h y p e rsen sitiv ity as it a p p lie s to
m e rc u ry in d e n ta l a m a lg a m . M erc u ry h y ­
p e r s e n s it iv i ty is a n a ll e r g i c r e s p o n s e
m e d ia te d by th e im m u n e system . It is a
ty p e IV o r ce ll-m e d ia te d re s p o n se th a t is
u sually d e la y e d b ecau se o f th e tim e r e ­
q u ir e d fo r e ffe c to r cells to a c c u m u la te a n d
p ro d u c e sy m p to m s a t th e site o f th e re a c ­
tio n . T h e re a c tio n is th e re s u lt o f th e r e ­
le a s e o f ly m p h o k in e s f r o m s e n s itiz e d
T -cells s tim u la te d by c o n ta c t w ith th e a n ti­
g e n . T h e rele a se o f ly m p h o k in e s re s u lts in
876 ■ JADA, Vol. 115, December 1987
a n in fla m m a to ry re s p o n s e a n d localized
tissu e d a m a g e . M e rc u ry , like m o s t s u b ­
stan ces th a t in d u c e c o n ta c t a llerg ie s, is an
in c o m p le te a n tig e n o r h a p te n . It m u s t
c o m b in e w ith p ro te in s in th e sk in o r m u ­
c o u s m e m b ra n e s to fo rm a h a p te n - p ro te in
c o n ju g a te th a t is th e c o m p le te a n tig e n .119
A s in o th e r alle rg ic re a c tio n s, p r io r e x p o ­
s u re to th e a n tig e n , th a t is, se n sitiz atio n , is
n e c e ssa ry b e fo r e a se c o n d a ry re s p o n s e
th a t resu lts in sy m p to m s can o c c u r. A l­
th o u g h th e re a s o n s a r e n o t c le a r, it is
k n o w n th a t th e re is a m u c h lo w er ra te o f
se n s itiz a tio n to m o s t c o m p o u n d s w h en
e x p o s u r e is th r o u g h m u c o u s m e m b ra n e s
th a n w h e n it is th r o u g h th e sk in , a n d th is
a p p e a rs to be tr u e fo r m e r c u ry .120
T h e m e th o d fo r c o n firm in g allerg y to
m e rc u ry involves th e p r o p e r use a n d in ­
te r p re ta tio n of a p a tc h te s t.121 M an y d if­
he method for confirming allergy to mercury involves the
proper use and interpretation of a patch test.
ficu ltie s a re a sso c ia te d w ith th e u se o f
p a tc h tests, in c lu d in g th e fac t th a t m an y o f
th e c o m p o u n d s u se d fo r te s tin g a re irri­
ta n ts o r have b e en u se d in excessive c o n ­
c e n tra tio n s, p ro d u c in g false-p o sitiv e r e ­
su lts.120 It sh o u ld also be n o te d th a t allerg y
to c e rta in m e rc u ry -c o n ta in in g c o m p o u n d s
d o e s n o t n ecessarily in d ic a te a tr u e allerg y
to m e rc u ry , a n d a p a tie n t w ith allerg y to
o n e fo rm o f m e rc u ry m ay o r m ay n o t
cro ss-re a c t to o th e r fo rm s o f m e r c u ry .120
A p a tc h test is ju d g e d p o sitiv e o n th e basis
o f th e e v a lu a tio n o f c u ta n e o u s sign s su ch
as e ry th e m a , e d e m a , vesicles, a n d p a p u le s,
a n d n o t o n system ic c h a n g e s, su ch as p ulse
ra te a n d blo od p re s s u re , as s u g g e s te d by
so m e o p p o n e n ts of a m a lg a m u s a g e .117,118
T h e N o rth A m e ric a n C o n ta c t D e rm a titis
G r o u p h as re c o m m e n d e d th a t 1% am -
m o n ia te d m e rc u ry in p e tr o la tu m be u sed
in th e p a tc h test fo r m e rc u ry a lle rg y .122
S o m e E u ro p e a n in v e s tig a to rs 118,123 use
0 .5 % m e ta llic m e r c u r y in p e tr o la tu m .
P atch te s tin g w ith m e rc u ric c h lo rid e is
c o n sid e re d e x tre m e ly u n re lia b le b e c a u se
of th e h ig h n u m b e r o f ir r ita n t re a c tio n s
th a t o c c u r.118
Occupational contact dermatitis
O c c u p a tio n a l e x p o s u r e to m e r c u r y is
k n o w n to c au se c o n ta c t d e rm a titis; h o w ­
e v e r, c a se r e p o r ts o f m e r c u r y a lle rg y
a m o n g d e n ta l p e rs o n n e l a re e x tre m e ly
r a r e .25,124 In a re c e n t case r e p o r t 124 o n a
4 4 -y e a r-o ld m ale w h o h ad b e en a d e n tis t
fo r 2 y ears, th e sy m p to m s w e re e ry th e m a ,
vesicles, a n d itc h in g o f th e fin g e rs s p r e a d ­
in g to th e p a lm s a n d b ack o f th e h a n d s.
T h e p a tie n t also sh o w ed positive p a tc h
tests to 1% a m m o n ia te d m e rc u ry in p e t­
ro la tu m a n d 0.5% m etallic m e rc u ry in p e t­
ro la tu m . T h e sy m p to m s c le a re d w ithin I
w eek a fte r u sin g to p ical ste ro id s a n d sto p ­
p in g w o rk . T h is w o u ld a p p e a r to be a ty p i­
cal case o f o c c u p a tio n a l c o n ta c t d e rm a titis.
C o n t a c t w ith m e r c u r y o r m e r c u r y -
c o n ta in in g c o m p o u n d s is easily av o id e d in
d e n ta l p ra c tic e w ith th e u se o f gloves a n d
“ n o -to u c h ” te c h n iq u e s fo r a m a lg a m p r e p ­
a ra tio n .
T h e in c i d e n c e o f m e r c u r y a lle r g y
a m o n g d e n ta l p e r s o n n e l h a s b e e n r e ­
p o r te d m o st re ce n tly in a s tu d y 125 th a t
te ste d d e n ta l s tu d e n ts at th e U n iv ersity o f
T e x a s . T h e stu d y sh o w e d th a t positive
p a tc h test re a c tio n s to a 0.1% m e rc u ric
c h lo rid e so lu tio n in c re a se d fro m 2.0% in
p re f re s h m e n (s tu d e n ts te s te d b e fo r e e n try
in to d e n ta l school) to 10.8% in s e n io r d e n ­
tal stu d e n ts . T h e s tu d e n ts w e re also tested
f o r positive re a c tio n s to a p a tc h test o f a 5%
m ix tu r e o f p o w d e r e d a m a lg a m a n d
a n h y d ro u s lan o lin . T h e re su lts o f th e lat­
te r test sh o w ed th a t o n ly five of th e 396
s tu d e n ts te s te d (1.3% ) e x h ib ite d a positive
re a c tio n a n d th a t th e r e w as n o in c re a se in
th e in c id e n ce o f se n sitiza tio n fro m p r e ­
fre sh m e n (o n e case) to se n io rs (0 cases).
C o n s id e rin g th e c o n c e n tra tio n a n d th e
u n reliab ility of m e rc u ric c h lo rid e in p atch
te stin g , th e re su lts o f th e p o w d e re d a m a l­
g am p a tc h test m ay b e m o re in d icativ e o f
t h e a c tu a l in c i d e n c e o f s e n s iti z a ti o n
a m o n g d e n ta l p e rs o n n e l.
Allergic reactions to amalgam
restorations
In a c o m p re h e n siv e review , F re n c h r e ­
s e a r c h e rs 119 cite 41 p u b lish e d clinical cases
o f alle rg y to d e n ta l a m a lg a m re s to ra tio n s
fro m 1905 to 1986. T h e a u th o r s ack n o w l­
e d g e th a t in f o u r o f th e 41 cases, it was

d if ficu lt to be c e rta in th a t a n a llerg ic re a c ­
tio n to a m a lg a m w as th e p rin c ip a l cau se o f
th e sy m p to m s r e p o r te d . T h e y also re c o g ­
n ized th a t six a d d itio n a l cases h av e b een
m e n tio n e d in th e lite r a tu re b u t w e re n o t
in c lu d e d in th e ir review b eca u se th e r e was
in su ffic ie n t in fo rm a tio n available. Since
1980, th e r e have b e e n five cases re p o r te d ;
all b u t tw o w ere co v e re d in th e F re n c h
rev iew .20-12<i' 128
A stu d y o f th e 41 cases disclo sed som e o f
th e c h a ra c te ristic m a n ife sta tio n s o f a lle r­
gic re a c tio n s to a m alg am re s to ra tio n s. In
37 o f th e 41 cases, allerg y to m e rc u ry o r
m e rc u ry a n d a n o th e r m etal w as p re s e n t.
In th e o th e r fo u r cases, tw o w ere c o n sid ­
e re d to b e ca u se d by allerg y to silver a n d
tw o by allerg y to c o p p e r.
W o m en seem to be af f e c te d m o re of te n
th a n m e n , as 30 o f th e cases in v o lv ed
fem ales. C u ta n e o u s signs a n d sy m p to m s
w e re p re d o m in a n t, o c c u rrin g in 38 o f th e
41 cases. T h e m o st c o m m o n sy m p to m s
w e re d e rm a titis , eczem a, u rtic a ria , e ry ­
th e m a , e d e m a , a n d itc h in g , o c c u r r in g
p rim arily o n th e face, n eck , lim bs, a n d
u p p e r to rso . T h e sy m p to m s usu ally a p ­
p e a r 24 to 48 h o u rs a fte r th e p la c e m e n t o f
a n a m a lg a m re s to ra tio n . O ra l m a n ife sta ­
tio n s w ere seen in 17 o f th e 41 cases a n d
w e re d e sc rib e d as g in g iv o sto m atitis. O th e r
o ra l sy m p to m s in c lu d e d b u rn in g se n sa ­
tio n s, h y p e rsa liv a tio n , d ry m o u th , a lte ra ­
tio n s o f taste, a n d erosive lesions. Less f r e ­
q u e n tly r e p o r te d (six o f 41) w ere g e n e ra l
sy m p to m s, u sually m alaise o r fev e r. In 20
of th e cases, th e sy m p to m s reso lv ed a fte r
rem o v al o f th e a m a lg a m re s to ra tio n s, u s u ­
ally w ith in a few d ay s to 2 w eeks, w h ere a s
in e ig h t cases, th e sy m p to m s re s o lv e d
s p o n ta n e o u s ly w ith o u t a m a lg a m r e ­
m o v al.119
T w o o f th e re c e n t re p o rts o f allerg ic
re a c tio n s to m e rc u ry d e se rv e clo se r sc ru ­
tin y b ecau se o f th e s p re a d o f sy m p to m s
o v e r larg e a re a s o f th e body. A J a p a n e s e
stu d y 20 r e p o r te d 15 cases o f p a tie n ts w ith a
g e n e ra liz e d ra sh th a t th ey te rm e d “m e r ­
c u ry e x a n th e m ” a n d d e sc rib e d as d iffu se
sy m m etrical e ry th e m a p re d o m in a n tly o n
m a jo r fle x u ra l a re a s o f th e b o d y . O th e r
c o m m o n sy m p to m s in c lu d e d V -sh a p e d
e ry th e m a to u s a re a s o n b o th u p p e r a n -
te ro m e d ia l th ig h s, p y re x ia , m alaise, m ild
itc h in g , a n d , in so m e cases, b u rn in g se n sa ­
tions. S ev ere cases e x h ib ite d m iliary p u s ­
tu le s a n d /o r p u r p u r a o n e ry th e m a to u s
skin. A lm o st all of th e cases o c c u rre d 1 to 2
d ay s a fte r e x p o s u re to m e rc u ry fro m a
b ro k e n clinical th e r m o m e te r. O n e case
w as th o u g h t to b e d e fin ite ly re la te d to d e n ­
tal tr e a tm e n t, a n d o n e o th e r case h a d a
h isto ry o f b o th th e p la c e m e n t o f a d e n ta l
re s to ra tio n a n d th e b re a k in g o f a th e r ­
m o m e te r. In b o th th e se la tte r cases, th e
p a tie n ts sh o w e d p o sitiv e p a tc h tests to
p h e n y l m e r c u r i c n i t r a t e , a m m o n ia t e d
m e rc u ry , a n d m e rc u ric c h lo rid e . P rev io u s
sen sitizatio n was th o u g h t to hav e o c c u rre d
fro m p r io r e x p o s u re to m e rc u ro c h ro m e .
It w as p o in te d o u t th a t th e r e is p ro b a b ly a
h ig h e r f re q u e n c y o f sen sitizatio n to m e r­
c u rials in th e J a p a n e s e p o p u la tio n as a r e ­
su lt o f ex te n siv e u se of m e rc u ro c h ro m e . A
sim ilar case was r e p o r te d 127 in G re a t B rit­
ain in v o lv in g a 3 6 -y ear-o ld m a n w ho e x p e ­
rie n c e d w id e sp re a d e ry th e m a to u s e r u p ­
tio n s w ith a sim ilar fle x u ra l d is trib u tio n
fo llo w ed by a n e c z e m ato u s p ro cess. T h e
re a c tio n o c c u rre d a fte r re ce iv in g d e n ta l
tre a tm e n ts . P atch te stin g sh o w ed a p o si­
tiv e re a c tio n to a m m o n ia te d m e r c u ry .
T h e s e cases seem to d e m o n s tra te th a t sys­
tem ic a b so rp tio n o f m e rc u ry can p re c ip i­
ta te a w id e sp re a d o r system ic c o n ta c t d e r ­
m atitis. A n o th e r ty p e o f re a c tio n th a t has
b e e n r e p o r te d to be th e re s u lt o f m e rc u ry
allerg y a re lesions th a t w e re d ia g n o s e d as
o ra l lich en p lan u s.
Oral lichen planus and allergy to amalgam
restorations
O ra l lic h e n p la n u s o c c u rs in re tic u la r,
p a p u la r , p la q u e lik e, b u llo u s, erosiv e, a n d
a tr o p h ic fo rm s, c h a ra c te riz e d by w h ite
stria e (W ick h am ’s striae) in n etlik e o r lacy
p a tte rn s o r ra d ia tin g o u tw a rd fro m th e
e d g e o f th e lesion. H istologically th e le­
sio n s show “sa w -to o th e d ,” re te rid g e s, a
b a n d lik e su b e p ith e lia l in filtra tio n o f ly m ­
p h o c y te s, d e g e n e ra tio n o f th e basal cell
lay er, a n d h y p e rp a ra k e ra to s is. A lth o u g h
th e ca u se o f o ra l lich en p la n u s is u n k n o w n ,
so m e re c e n t re p o rts h a v e su g g e ste d th a t
so m e cases m ay be ca u se d o r a g g ra v a te d
b y a n a lle rg y to m e r c u ry fro m d e n ta l
a m a lg a m s .129"131 A n o th e r possibility is th a t
m e rc u ry allerg y m ay d e v e lo p se co n d arily
in p a tie n ts w'ith o ra l lich en p la n u s b e cau se
o f th e g re a te r p e n e tra tio n o f m e rc u ry ions
in to su b e p ith e lia l layers w h en th e in te g rity
o f th e o ra l m u co sa is c o m p ro m ise d . T h e
in c id e n c e o f m e rc u ry allergy associated
w ith o ra l lich en p la n u s varies g rea tly in th e
lite r a tu re rev iew ed . In a stu d y o f 67 p a ­
tie n ts w ith o ra l lich en p la n u s , 64 of w h o m
h a d a m a lg a m re s to ra tio n s , 11 p a tie n ts
(1 6 % ) w e r e p o s i ti v e to a t le a s t o n e
m e rc u ry -c o n ta in in g c o m p o u n d in a p a tc h
test series o f fo u r m e rc u ry c o m p o u n d s . In
c o n tra st, fo u r o f 50 p a tie n ts (8% ) in a r e ­
fe re n c e g ro u p , w h o w e re te ste d b e c a u se o f
s u sp e c te d c o n ta c t d e rm a titis b u t d id n o t
h a v e o ra l lich en p la n u s , sh o w ed a positive
p a tc h test re a c tio n to m e rc u ry .129 A n o th e r
Langan-Fan-Hoos: USE OF M ERCU RY IN D EN T IST R Y ■ 877
REVIEW ARTICLES
s tu d y 132 r e p o r te d th a t 18 o f 29 p a tie n ts
(62% ) w ith o ra l lich en p la n u s sh o w ed a
p o sitiv e p a tc h te st to 0.5% m etallic m e r ­
c u ry in p e tr o la tu m v ersu s 3.2% positive in
a g r o u p o f c o n tro l p a tie n ts w ith o u t lichen
p la n u s.
In a th ir d g r o u p o f 52 p a tie n ts w ith e r o ­
sive lich en p la n u s to p o g ra p h ic a lly re la te d
to a m a lg a m r e s to r a t io n s , 18 p a ti e n ts
(34% ) w ere r e p o r te d to h a v e a n allerg y to
m e rc u ry as in d ic a te d by p a tc h te s tin g .133
A lth o u g h th e s e stu d ie s co n v in cin g ly d e m ­
o n s tra te a n associatio n b e tw e e n positive
p a tc h tests fo r m e rc u ry allerg y a n d som e
cases o f o ra l lich en p la n u s , th e fre q u e n c y
o f th is o c c u rre n c e is still u n c e rta in .
R e se a rc h e rs h av e in v e stig a te d th e effect
o f a m a lg a m re m o v a l o n th e clinical c o u rs e
o f o ra l lich e n p la n u s. In th e stu d y th a t
fo u n d a 62% fre q u e n c y o f m e rc u ry al­
le r g y , a m a lg a m r e s to r a t io n s w e re r e ­
m o v ed fro m fo u r p a tie n ts a n d re p la c e d
w ith g o ld o r c o m p o site m ate rials. In th r e e
o f th e s e cases, th e lesio n s h e a le d c o m ­
p letely w ith in a n o b se rv a tio n p e rio d o f 1
y ear, a n d c o n sid e ra b le im p ro v e m e n t was
r e p o r te d in th e f o u r th c a s e .132 I n th e
g r o u p o f 52 p a tie n ts p re v io u s ly m e n ­
tio n e d (34% a lle rg ic to m e r c u ry ), th e
a m a lg a m re s to ra tio n s o f 18 p a tie n ts w ere
re p la c e d by o th e r m a te rials su ch as g o ld ,
p o rc e la in , o r c o m p o site resin . In 16 o f
th e se 18 p a tie n ts , c o m p le te rem issio n o f
th e lesions was o b se rv e d w ith in 1 to 12
m o n th s a fte r re p la c e m e n t o f th e a m a lg a m
re s to ra tio n s. O f th e tw o re m a in in g cases,
p a rtia l re m issio n was seen in o n e case a fte r
4 m o n th s, a n d in th e o th e r case, n o clinical
c h a n g e o c c u rre d a fte r 2 years. O f 23 cases
in w h ich n o re p la c e m e n t of a m a lg a m s was
p e rf o rm e d , tw o sh o w ed s p o n ta n e o u s r e ­
m issio n , a n d 21 sh o w ed o n ly m in o r flu c­
t u a t i o n s in c l i n i c a l c o u r s e a n d
s y m p to m s.133 I t sh o u ld b e n o te d th a t six o f
th e cases in w h ich c o m p le te re m issio n o f
lic h e n p la n u s o c c u rre d a fte r re m o v a l o f
a m a lg a m re s to ra tio n s d id n o t te st positive
fo r m e rc u ry allerg y .
In a n o th e r re p o r t, 31 o f 4 8 p a tie n ts w ith
h istologically v e rifie d o ra l lich en p la n u s
w e re p a tc h te s te d fo r allerg ic re a c tio n s to a
b a tt e r y o f 3 0 s u b s ta n c e s t h a t th e r e ­
s e a rc h e rs sele c te d to in d ic a te alle rg ies to
d e n ta l m a te ria ls. T w elv e p a tie n ts (39% )
te s te d p o sitiv e fo r allerg y to o n e o r m o re
o f th e su b stan c es. E ig h t o f th e p a tie n ts
(26% ) te s te d positive to m e rc u ry in th e
f o r m o f 0 .1 % m e r c u r o u s b i c h l o r i d e
(H g C k ) o r 0.1% m e rth io la te . T h e d e n ta l
re s to ra tio n s a n d /o r p ro sth e se s o f e ig h t o f
th e p a tie n ts w e re re p la c e d w ith a lte rn a tiv e
re s to ra tiv e m a te ria ls to e lim in a te th e al­
le rg e n s d isc o v e re d . T h e a lle rg e n re p la c e d
 REVIEW ARTICLES
was m e rc u ry in six of th e cases, c o p p e r in
o n e case, a n d h v d ro q u in o n e in o n e o th e r
case. In six o f th ese e ig h t p a tie n ts, th e o ral
lichen p la n u s lesions sh o w ed reg re ssio n
a n d in th e o th e r tw o p a tie n ts th e lesions
d is a p p e a re d c o m p le te ly .134 T h e s e resu lts
su g g est th a t allergic re a c tio n s to a variety
o f su b stan ces m av be o f sig n ifican ce in
cases o f o ra l lichen p lan u s.
T h e s e cases o f rem issio n a fte r re p la c e ­
m e n t o f am a lg a m re s to ra tio n s w ith a lte r­
native re sto ra tiv e m a te ria ls s u p p o r t th e
th e o ry th a t m e r c u ry a lle rg y m ay b e a
causative o r a g g ra v a tin g fa c to r in c e rta in
cases o f o ra l lichen p la n u s. A s it is u n lik elv
th a t a single a g e n t is re sp o n sib le fo r all
lesions c u rre n tly classified as o ra l lichen
p la n u s th e te rm “o ra l lic h e n o id re a c tio n "
p ro p o s e d by L in d a n d o th e r s 133 is p ro b a ­
bly m o re a p p ro p r ia te fo r d e sc rib in g th ese
lesions.
Discussion
E x p o s u re to m e r c u r y c o m p o u n d s can
o c c u r fro m m a n u f a c tu r e d m e rc u ria ls a n d
a w ide variety o f o th e r so u rc e s in c lu d in g
e n v iro n m e n ta l, d ie ta ry , a n d o c c u p atio n al.
T h e r e a re m an y w e ll-d o c u m e n te d cases o f
m e rc u ry toxicitv fro m th e s e so u rces. M e r­
c u ry toxicity is d e p e n d e n t o n th e ch em ical
fo rm a n d d o se of m e rc u ry to w hich an
in d iv id u al is ex p o se d . In d e n tistry , e le ­
m en tal m e rc u ry v a p o r is th e o n ly chem ical
fo rm o f m e rc u rv e n c o u n te re d in suf ficient
q u a n titie s to be o f possible c o n c e rn w ith
re g a r d to toxicity.
O cc u p a tio n a l e x p o s u re h as b een well
d o c u m e n te d a m o n g d e n tists a n d d e n ta l
a s s is ta n ts . R e c e n t in v e s tig a tio n s h a v e
show n th a t a signif ican t p o rtio n o f d e n ta l
p e rs o n n e l a re b e in g e x p o se d to m e rc u ry
v a p o r levels in excess of re c o m m e n d e d
safety lim its. B iologic m o n ito rin g h as c o n ­
firm e d th a t som e d e n ta l p e rs o n n e l have
m e rc u ry c o n c e n tra tio n s in b lo o d , u rin e ,
a n d tissues above th e n o rm a l ra n g e o f th e
g e n e ra l p o p u la tio n . H o w e v e r, e v e n at
th ese h ig h e r levels of e x p o s u re , sy m p to m s
o f toxicity a re ra re . M any so u rc e s o f m e r­
cu ry e x p o su re in th e d e n ta l office have
been id e n tifie d a n d c o rre la te d w ith b lo o d
a n d u rin e m e rc u ry c o n c e n tra tio n s. Excess
e x p o su re to m e rc u rv v a p o r is com p letely
p re v e n ta b le th r o u g h th e im p le m e n ta tio n
of p r o p e r m e rc u ry h y g ie n e p ractices th a t
have been w idely d is se m in a te d to th e p ro ­
fession.
T h e p o te n tia l toxicity of m e rc u ry a n d
a d v a n c e s in te c h n o lo g y f o r m e a s u rin g
m e r c u ry v a p o r h a v e re v iv e d th e c o n ­
tro v ersy o v e r th e safety o f d e n ta l am a l­
g am . Several stu d ies hav e sh o w n th a t m e a ­
878 ■ JADA, Vol. 115, December 1987
su ra b le a m o u n ts o f m e rc u ry v a p o r a re re ­
leased fro m am alg a m re s to ra tio n s, p a r ­
ticu larly w h e n th e su rfa c e o f th e am alg am
is su b ject to m e c h a n ic a l fo rces su ch as
c h ew in g o r b ru s h in g . T h e critical issues
th a t n e e d to be c o n sid e re d a re th e a m o u n t
of m e rc u ry re le a se d , th e a m o u n t of m e r­
c u ry a b so rb e d , a n d th e e ffe ct o f th is e x p o ­
su re o n th e p a tie n t's h e a lth .
A w ide ra n g e o f e x p e rim e n ta l values
have b e e n r e p o r te d fo r th e a m o u n t o f
m e rc u rv v a p o r re le a se d fro m a m alg am
follow ing m e ch a n ical stim u latio n (T ab le
1). T h e m e a s u re m e n ts o f m e r c u ry r e ­
leased fro m am a lg a m a re in flu e n c e d by
e x p e rim e n ta l d esig n a n d su b ject to a v a ri­
ety o f in te rp re ta tio n s a n d e x tra p o la tio n s.
As an e x a m p le , a series o f 13 m e rc u ry
v a p o r m e a s u re m e n ts o f 10- o r 20 -seco n d
d u ra tio n , m a d e a t 5 -m in u te in terv als, has
b e e n e x tra p o la te d to calc u late c u m u lativ e
e x p o s u re fo r 10 years. T h e a b so lu te dose,
fre q u e n c y , a n d d u ra tio n o f e x p o s u re re ­
m ain a m a tte r o f sp e c u la tio n , as d o th e
effects o f c o n fo u n d in g v ariab les such as
th e a g e a n d co m p o sitio n o f th e d e n ta l
a m alg am .
B ecau se e x p o su re p a ra m e te rs c a n n o t be
p recisely d e fin e d , th e a m o u n t o f m e rc u ry
a b so rb e d a n d its c o n c e n tra tio n in b o d y tis­
sues a n d flu id s m ay be b e tte r in d ica to rs
fo r assessing p o te n tia l toxicity. E x p o su re
p re v e n tio n p ro g ra m s in in d u s try a n d clin­
ical m a n a g e m e n t o f cases o f m e rc u ry to x i­
city h av e lo n g re lie d o n biologic m o n ito r­
in g . A lth o u g h e a c h o f th e m e th o d s o f
biologic m o n ito rin g has re c o g n ize d lim ita­
tions as p re c ise in d ic a to rs o f m e rc u ry to x i­
city, th e se m e th o d s p ro v id e a g o o d in d i­
c a to r o f th e a b so rb e d d o se a n d can be u sed
to c o m p a re th e rela tiv e m a g n itu d e of e x ­
p o su re fro m v ario u s so u rc e s of m e rc u ry .
T h e b lo o d a n d u rin e m e rc u ry c o n c e n tra ­
tio n s o f subjects w ith d e n ta l am a lg a m s in ­
d ica te th a t th e m a g n itu d e o f th e a b so rb ed
d o se o f m e rc u ry fro m th is so u rce is su b ­
stantially less th a n th e low est m e rc u ry c o n ­
c e n tr a tio n s r e p o r te d to c a u se a d v e rs e
h ea lth effects (T ab le 2). In a d d itio n , an
a u to p s y stu d y th a t m e a s u re d m e rc u ry
c o n c e n tra tio n s in th e b ra in tissues o f p a ­
tie n ts w ith am alg am s fo u n d m e a n levels of
12.4 n g /g , 11.2 n g /g , a n d 5.0 n g /g in th e
o ccip ital c o rte x , c e re b e lla r c o rte x , a n d
s e m ilu n a r g a n g lio n , re s p e c tiv e ly . T h e
m a x im u m b ra in tissue level fo u n d in any
su b ject was 33.8 ng/g. T h is a m o u n t is 100
tim es less th a n th e 4 .0 /xg/g (4,000 ng/g)
p re d ic te d by so m e in v e stig a to rs o n th e
basis o f in tra o ra l m e a s u re m e n ts o f m e r­
cu ry v ap o r. T h e c o n c e n tra tio n s o f m e r­
cu ry m e a s u re d in u rin e , b lo o d , a n d n erv e
tissues e m p h a siz e th e n e e d to ex ercise ca u ­
tio n in e x tr a p o la tin g m e rc u ry e x p o su re ,
o n th e b asis o f b r ie f m e a s u re m e n ts of
m e rc u ry v a p o r in th e m o u th , follow ing
stim u la tio n by ch e w in g o r b ru s h in g .
T h e fin a l issue th a t n e e d s to be a d ­
d re s s e d is th e q u e stio n o f sy m p to m s o f
m e rc u ry toxicity r e p o r te d in p a tien ts w ith
d e n ta l a m alg am s. T o d a te , n o stu d ies o r
case re p o r ts h av e a p p e a re d in re fe re e d
scientif ic jo u r n a ls to s u p p o r t th e assertio n
th a t d e n ta l am a lg a m s a re th e c a u se o f re c ­
o g n iz e d sy m p to m s o f m e rc u ry toxicity.
O p p o n e n ts o f a m a lg a m u sa g e hav e relied
u p o n th e ir ow n a n e c d o ta l re p o rts th a t cite
sy m p to m s su ch as b a c k a c h e a n d h e a rt p a l­
p ita tio n s to s u p p o r t th e ir con clusions.
In c o n tra st, m e rc u ry allerg y m a n ife ste d
as an allerg ic re a c tio n to am a lg a m re s to ra ­
tio n s h a s b e e n d o c u m e n t e d . A c o m ­
p re h e n s iv e review o f a llerg ic re actio n s to
d e n ta l a m a lg a m s p u b lish e d in 1986 fo u n d
41 cases a n d n o te d th e possibility o f six
a d d itio n a l cases. R e c e n t re p o r ts w ould
a d d tw o m o re cases fo r a to tal o f 49 cases,
e x c lu d in g p ossible cases th a t a p p e a r as
o ra l lic h e n p la n u s . C o n s id e r in g th a t a
1979 su rv ey e stim a te d th a t 110,000,000
o n e - a n d tw o -su rfa c e am alg am s a re placed
in 1 y e a r in th e U n ite d S tates alo n e, it is
o b v io u s th a t allerg ic re a ctio n s to am alg am
r e s t o r a t i o n s a r e a n e x c e e d in g ly r a r e
phenom enon.
W h e n allerg ic re a c tio n s to am alg am d o
o cc u r, th e sy m p to m s a re c o n sisten t w ith a
ty p e IV alle rg ic re s p o n se m e d ia te d by th e
im m u n e system . S y m p to m s a re usually lo­
calized a n d m o st fre q u e n tly in clu d e d e r ­
m a titis , e c z e m a , u r t i c a r i a , e r y t h e m a ,
e d e m a , a n d itch in g . T h e m o st com m o n ly
r e p o r t e d o r a l s y m p to m s a r e g in g iv o ­
sto m atitis, b u rn in g sen satio n s, alte ra tio n s
o f taste o r salivary flow, a n d ero sive lesions
a d ja c e n t to th e a m a lg a m re s to ra tio n . S us­
p ec te d cases sh o u ld be c o n firm e d by a p ­
p r o p r i a t e te s ts p e r f o r m e d by p r o f e s ­
sionals tr a in e d in th e a d m in is tra tio n a n d
in te rp re ta tio n o f th ese tests, su ch as a lle r­
gists o r d e rm a to lo g ists.
R ec e n t re p o rts have in d ic a te d th a t c e r­
tain cases o f o ra l lich en p la n u s m ay be
c a u se d o r a g g ra v a te d by m e rc u ry allergy.
T h e possibility th a t m e rc u ry allergy m ay
d e v e lo p se c o n d a rily to o ral lichen p la n u s
h as also b e e n su g g e sted . In th e stu d ies o f
o ra l lichen p la n u s rev iew ed, a total of 61
cases w e re cited th a t d e m o n s tra te d m e r­
c u ry allerg y , as e v id e n c ed by a positive
p a tc h te s t to m e r c u ry -c o n ta in in g c o m ­
p o u n d s , o r rem issio n o f th e o ra l lichen
p la n u s fo llo w in g am alg am rem o v al. O th e r
a lle rg e n s, su ch as c o p p e r, w'ere also n o te d
in a few cases o f rem issio n .
T h e s e s tu d ie s p ro v id e s u ffic ie n t evi­

d e n c e to w a rra n t f u r th e r in v e stig atio n o f
th e possible re la tio n sh ip b etw e en m e rc u ry
allerg y a n d o ra l lich en p la n u s. H o w e v er,
e v e n w h e n th e se cases a re c o m b in e d w ith
th e o th e r cases o f a llerg ic re a c tio n s to
a m a lg a m re s to ra tio n s , th e in c id e n c e o f
a d v e rs e effects fro m a m alg a m s is m in u s­
cu le , c o n sid e rin g th e n u m b e r o f p a tie n ts
w h o h a v e su ch resto ra tio n s.
Conclusions
O c c u p a tio n a l e x p o s u re to m e rc u ry is a p o ­
te n tia l h a z a rd fo r d e n ta l p e rs o n n e l, b u t is
c o m p le te ly p r e v e n t a b l e w ith t h e im ­
p le m e n ta tio n o f p r o p e r m e rc u ry h y g ie n e
p ractices. T h e r e is n o ev id en c e in th e sci­
e n tific lite r a tu re th a t th e m in u te a m o u n ts
o f m e rc u ry v a p o r th a t m ay b e re le a se d
fro m a m a lg a m re s to ra tio n s ca u se m e rc u ry
p o iso n in g . A llergic re a ctio n s to m e rc u ry
a n d o th e r c o n stitu e n ts o f a m a lg a m h av e
b e e n d o c u m e n te d , b u t a re e x c e e d in g ly
ra r e . T h e asso ciatio n b e tw e e n alle rg ie s
a n d o ra l lich en p la n u s re q u ire s f u r th e r
in v e s tig a tio n . F in ally , d e n ta l a m a lg a m ,
w h ich h as b e e n u se d exten siv ely f o r m o re
th a n 100 y ears, has an e x e m p la ry re c o rd
o f safety a n d b e n e fit to th e d e n ta l p a tie n t.
------------------------ j m ) A ------------------------
T h e a u th o rs th a n k D r. E nid A. N eidle, assistant
executive d ire c to r, Scientific A ffairs, a n d D r. A. Carl
V erru sio, secretary, C ouncil o n D ental R esearch, fo r
th e ir c om m ents, suggestions, a n d g u id an ce d u rin g the
p re p a ra tio n o f th e m an u scrip t a n d Ms. M arsh a Riley
fo r secretarial assistance.
D r. L angan is assistant secretary, Council on D ental
T h e ra p e u tic s; D r. Fan is associate secretary, C ouncil
o n D ental M aterials, In stru m e n ts, a n d E q u ip m en t;
a n d Ms. H oos is technical in fo rm a tio n assistant, C o u n ­
cil o n D ental T h e ra p e u tic s, A m erican D ental Associa­
tion, C hicago. A ddress req u ests fo r re p rin ts to Dr.
L angan.
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