Amalgam Safety

Col Kraig S. Vandewalle
USAF Dental Evaluation & Consultation Service

Official Disclaimer
‡ The opinions expressed in this presentation are those of the author and do not necessarily reflect the official position of the US Air Force or the Department of Defense (DOD) ‡ Devices or materials appearing in this presentation are used as examples of currently available products/technologies and do not imply an endorsement by the author and/or the USAF/DOD

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

Amalgam ‡ An alloy of mercury with another metal. Click here for slide presentation on amalgam .

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

American Society of Dental Surgeons ± declared use of amalgam malpractice ‡ mercury is a poison ± threatened to expel users ‡ Amalgam use declined Mackert JADA 1991 .Crawcour brothers ± heavily marketed their amalgam of silver and mercury ‡ 1843 .Amalgam War I ‡ 1833 .

G.Amalgam War I ‡ 1895 . Black ± developed effective amalgam ‡ improved handling and performance ‡ similar to contemporary low-copper amalgam ‡ Popularity of amalgam increased ± failure of adverse health effects to materialize Black Dent Cosmos 1896 .V.

Alfred Stock ± German professor of chemistry ± became poisoned with mercury ‡ 25 years of laboratory research ± published papers on the dangers of mercury in dentistry ‡ Created considerable public concern Stock Med Klin 1296 .Amalgam War II ‡ 1924 .

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

1990 ± concern over occupational exposure of mercury vapor to dentists ± excess levels in 10% of dental offices ‡ > threshold limit of 50 ug/mm3 ± urinary mercury levels high ‡ mild functional effects found ± ADA institutes mercury hygiene campaign Mandel JADA 1991 .Amalgam War III ‡ 1970 .

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

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

Evidence-Based Care ‡ Critically evaluating research literature and clinical data ± lay population unfamiliar with peer-reviewed dental literature ± rely on media stories and internet ‡ Survey by ADA in 1991 ± 1000 adults ‡ nearly 50% believed health problems possible from dental amalgams ± click here for details Guyatt JAMA 1993 Dodes JADA 2001 .

Why Amalgam? ‡ Inexpensive ‡ Ease of use ‡ Proven track record ± >100 years ‡ Familiarity ‡ Resin-free ± less allergies than composite Ten Clinical and Legal Myths of Anti-Amalgam .

Amalgamation ‡ Alloy (Ag-Sn-Cu) mixed with approximately 50% mercury (Hg) ± within several hours. no free mercury remains ‡ stable intermetallic compounds Ag-SnAg-Sn-Cu + Hg   Ag-Sn-Cu + AgHg + Cu-Sn Ag-SnCualloy undissolved alloy matrix copper phase .

Liquid Mercury ‡ Hydrargyrum (Hg) ‡ Activates amalgamation reaction ‡ Only pure metal that is liquid at room temperature Click here for ADA Mercury Hygiene Recommendations .

Amalgam Restorations ‡ Half-billion restorations per year ± 75 tons of mercury ‡ Mercury vapor released ± chewing and brushing ‡ Berglund J Dent Res 1990 ± removal of amalgam ‡ reduced 90% with high-volume evacuation ± Pohl Acta Odontol Scand 1995 ± difficult to determine vapor levels accurately ‡ Olsson J Dent Res 1992 .

pre-clinical effects ‡ 30 ug per day ± considered dangerous ‡ 82 ug per day Olsson J Dent Res 1995 Mackert Crit Rev Oral Biol Med 1997 Berdouses J Dent Res 1995 .Mercury Dose from Amalgam ‡ Average daily dose from 8 ± 10 amalgam surfaces ± 1-2 ug per day ± well below threshold levels ‡ Threshold urine mercury levels ± subtle.

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

Sources of Mercury ‡ Ubiquitous in environment ± 30.000 tons/year released worldwide ‡ Natural ± volcanic emissions ± degassing of soil ± volatilization from oceans WHO 1989 .000 to 150.

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

gov/mercury/exposure.epa.Fate and Transport of Mercury ‡ Continuously mobilized.htm . deposited and remobilized ± atmosphere ‡ global circulation ± transferred to surface » wet or dry deposition ± terrestrial ‡ soil deposition ± aquatic ‡ may enter food chain ± concentrates in fish » greatest source of human exposure www.

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

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

Mercury Vapor ‡ Accounts for most occupational and home exposures ± mercury spills ‡ thermometers ‡ fluorescent light bulbs ‡ Significant toxicity when inhaled ± 80% absorbed by lungs ‡ Acute toxicity is rare Hursh Arch Environ Health 1976 .

Inorganic Mercury ‡ Highly toxic as inorganic salts ‡ Hg2+ mercuric ion ± mercuric oxide ‡ swallowed batteries by children ± mercuric sulfide ‡ red tattoos ‡ Hg1+ mercurous ion ± mercurous chloride ‡ laxatives ‡ teething powder Wands Am J Med 1974 Litovitz Pediatrics 1992 .

most toxic form ‡ 95% absorbed in gut ‡ responsible for several mass poisonings ± Minamata Bay.1950 » inorganic mercury dumped in bay » methylated by aquatic organisms » concentrates up food chain ± ethyl ± preservative ‡ Thimerosal ± anti-microbial in pharmaceuticals ‡ Aryl ± highly toxic ± antifungal on seeds Renzoni Environ Res 1998 . Japan .Organic Mercury ‡ Alkyl ± methyl .

Mercury Monitoring ‡ Exhalation ± difficult to perform reliably ‡ Urine ± best method for chronic exposure ‡ symptoms ± 300 ug/L ‡ normal < 25 ug/L Goldfrank¶s Toxicologic Emergencies 1990 .

Mercury Monitoring ‡ Blood ± normal < 6 ug/L ± reflects recent exposure ‡ 3-day half-life ± reliable measurement of methylmercury exposure ‡ Hair ± not a reliable method WHO Environmental Health Criteria .

Biologic Activity of Mercury ‡ Binds to protein sulfhydryl groups ± loses structure and function ‡ No carcinogenicity ‡ Teratogenicity .

Symptoms of Toxicity ‡ Acute high-level exposure ± ± ± ± ± ± ± hypersalivation cough dyspnea bronchitis Pneumonia vomiting gastroenteritis ‡ Chronic low-level exposure ± ± ± ± ± ± ± depression irritability weakness tremor insomnia renal failure memory loss .

Concerns with Amalgam ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Dental occupational exposure Amalgam waste Hypersensitivity Mercury accumulation Multiple sclerosis Alzheimer¶s disease Renal toxicity Reduced immunocompetence Amalgam illness Ten Medical Myths of Anti-Amalgam .

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

Dental Occupational Exposure ‡ Poor mercury hygiene ± in-office dispensing ‡ mercury and alloy powder ± mercury spills ± use of squeeze cloths ± inadequate suction and water spray during amalgam removal .

Minimizing Office Exposure ‡ Pre-capsulated amalgam ‡ Store scrap amalgam in tightly-closed unbreakable container ± recap capsules ‡ Water spray and high-volume evacuation when polishing or removing amalgam ‡ Close cover on triturator when in use ‡ Use care when handling amalgam ± avoid skin contact Click here for slide presentation on Mercury Hygiene Click here for ADA Mercury Hygiene Recommendations .

Dental Occupational Exposure ‡ No negative reproductive effects ± Ericson Int Arch Occup Environ Health 1989 ± Brodsky JADA 1985 ± Sundby J Women¶s Health 1994 ± Dahl Scand J Work Environ Health 1999 ± Heidam J Epidemiol Community Health 1984 ± Warfvinge Br Dent J 1995 .

Amalgam Waste ‡ Mercury is a naturally occurring metal ‡ Half of environmental mercury comes from human activity ± < 1% dentistry 13% <1% Fuel Combustion Waste Combustion Manufacturers Dentistry 34% 52% .

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

Amalgam Waste ‡ Non-contact amalgam ± store in sealed container ‡ Contact amalgam ± disinfect and dry ‡ non-chlorine disinfectant ± combine with non-contact amalgam ‡ Used amalgam capsules ± recap. if possible ± store in sealed container Click here for USAF Best Management Practices for Amalgam Waste Click here for slide presentation on Mercury Hygiene .

Amalgam Waste ‡ Extracted teeth ± disinfect and dry ‡ non-chlorine disinfectant ± store in sealed container ‡ Chairside traps ± disinfect and dry ± store with used amalgam capsules .

Sweden Rowland Occup Environ Med 1994 . Denmark.Amalgam Restrictions ‡ Typically to reduce the amount and sources of mercury by various countries ± in the environment ± exposure to children and pregnant women ‡ Examples ± Belgium. Finland.

Hypersensitivity ‡ Type IV or cell-mediated immune response ‡ Contact dermatitis ‡ Lichenoid lesions adjacent to amalgam ‡ Most reactions subside ± amalgam removal usually not necessary ‡ True allergy is rare ± < 1% Anneroth Acta Odontol Scand 1992 Duxbury Br Dent J 1982 McGiven Br Dent J 2000 .

Hypersensitivity ‡ Double-blind study ± 660 subjects ± tested with 1% ammoniated mercury ± 3% positive skin response ‡ only 20% of these had true allergy (0.6%) Storrs J Am Acad Dermatol 1989 .

Mercury Accumulation ‡ Studies found higher mercury levels in various organs ± in sheep and monkeys with amalgam placement ± Hahn FASEB 1989. 1990 ‡ critical review of studies ± Eley Br Dent J 1997 » probable result of swallowed scrap amalgam » no controls ± in dental staff ‡ Nylander Swed Dent J 1989 .

Multiple Sclerosis ‡ Studies found no relationship between amalgam restorations and MS ± McGrother Br Dent J 1999 ± Bangsi Int J Epidemiol 1998 ‡ Study found no difference in mercury levels between autopsied brains in patients with and without MS ± Clausen Acta Neurol Scand 1993 .

Multiple Sclerosis ‡ Overnight cure claimed after amalgam removal ± highlighted on ³60 Minutes´ and by Hal Huggins ‡ Huggins Dent Assist 1985 ± not logical ‡ mercury burden increases after mercury removal ‡ strong placebo effect .

including brain ± Eggleston J Prosthet Dent 1987 ± Nylander Lancet 1986 ‡ Studies evaluating mercury levels in autopsied brains of Alzheimer¶s patients ± higher ‡ Wenstrup Brain Res 1990 ± no correlation ‡ Saxe JADA 1999 .Alzheimer¶s Disease ‡ Mercury from dental amalgam can accumulate in many body tissues.

Alzheimer¶s Disease ‡ Controlled human studies fail to find link between amalgam or mercury levels and Alzheimer¶s ± Saxe JADA 1995 ‡ 129 nuns ‡ existing amalgams not associated with low performance on neuropsychological tests ± Fung Gen Dent 1996 ‡ found no significantly higher levels of mercury in urine. blood or brain tissue of Alzheimer¶s patients Q&A About Dental Fillings and Alzheimer's Disease .

Renal Toxicity ‡ Study evaluating kidney function ± Boyd AM J Physiol 1991 ‡ 6 sheep with 12 amalgams ‡ 2 sheep with glass ionomers (control) ‡ reported 60% loss of renal function compared to control ± study reviewed by renal physiologists ‡ Malvin Am J Physiol 1992 ± poor model ± data support improved renal function .

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

change was consistent with normal diurnal variation in cell counts and measuring error ± Mackert JADA 1991 .Reduced Immunocompetence ‡ Study showing drop in lymphocyte level with amalgam placement ± Eggleston J Prosthet Dent 1983 ‡ baseline CBC on 2 patients ± placed amalgams and new CBC ± removed amalgams and new CBC ‡ However.

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

Amalgam Illness ‡ Multitude of conditions reportedly caused by the presence of amalgam ± symptoms may be due to mental disorders ‡ Studies found reduction of symptoms after amalgam removal ± 70% of patients reported reduction ‡ Siblerud J Orthomol Med 1990 ± patients reported 88% reduction ‡ Lichtenberg J Orthomol Med 1993 ‡ Critics site lack of control groups. poor study design. and placebo effect ‡ Wahl Quintessence Int 2001 .

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

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

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

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

Risk vs. Benefit Relationship
‡ Benefits and detriments to the use of any material ‡ Unbalanced risk assessments may lead to the waste of limited health resources
± deny public access to beneficial therapies

ADA Council on Scientific Affairs JADA 1998 Corbin JADA 1994

Survey of Practice Types
Civilian General Dentists

32%

Amalgam Free

Amalgam Users

68%

Haj-Ali Gen Dent 2005

Frequency of Posterior Materials
by Practice Type
3% 7% 39%

Amalgam Users
51%

Am g m

r

ompo i

Indir

ompo i

Oh r

12% 8%

3%

Amalgam Free

Haj-Ali Gen Dent 2005

77%

Profile of Amalgam Users Civilian Practitioners Do you use amalgam in your practice? 22% Do you place fewer amalgams than 5 years ago? 12% No Yes No Yes 78% 88% DPR 2005 .

Review of Clinical Studies (Failure Rates in Posterior Permanent Teeth) % Annual Failure 8 6 4 2 0 Amalgam Direct Comp Comp Inlays Ceramic CAD/CAM Inlays Inlays Gold Inlays & Onlays GI Longitudinal Cross-Sectional Hickel J Adhes Dent 2001 .

Review of Clinical Studies (Failure Rates in Posterior Permanent Teeth) % Annual Failure 15 Standard Deviation 10 Longitudinal and Cross-Sectional Data 5 0 GI Am al ga Di m re ct Co Co mp m po m Co er m p Ce In la ra ys m ic In la CA ys D/ CA M Ca st G ol d Tu nn el Manhart Oper Dent 2004 Click here for abstract AR T .

Summary ‡ Dental amalgam ± releases minute amounts of elemental mercury ‡ no evidence of systemic health problems ± limited cases of allergy ‡ Mercury absorbed from many sources ± no demonstration of clinical effects from additional burden from amalgam Click here for Talking Paper on Amalgam Safety (PDF) .

Summary ‡ No cure or health benefit from amalgam removal ‡ Dentists must inform patients ± risks and benefits of restorative materials ‡ Research needed on specific health effects of low-level mercury exposure ± determine effects of amalgam-derived mercury ‡ need large-scale human studies Click here for Talking Paper on Amalgam Safety (PDF) .

Summary ‡ Materials research ± alternatives to amalgam ± reduce mercury emission from amalgams ‡ Amalgam will eventually be replaced by composite and other materials ± esthetics ± environment .

S. Centers for Disease Control Resource Library Fact Sheet. Accessed Nov 2005 ‡ California Dental Materials Fact Sheet Accessed Nov 2005 Online Video ‡ FDA Confirms Safety of Amalgam Accessed Nov 2005 .Online Fact Sheets ‡ Dental Amalgam Use and Benefits U. December 2001.

129:494-501. Accessed Nov 2005 American Academy of Pediatrics Web site Accessed Nov 2005 Dental Amalgam: Update on Safety Concerns JADA 1998. Accessed Nov 2005 Dental Watch Website Accessed Nov 2005 . Education and Regulation US Public Health Service 1993.Online References Dental Amalgam: A Scientific Review and Recommended Public Health Strategy for Research.

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

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