C O V ER

STORY
NATIONAL INSTITUTE
OF DENTAL RESEARCH

The benefits and risks

of dental amalgam:
C u rre n t fin dings re v ie w e d

V irtually every dentist, nearly all adult patients

In r e s p o n s e to re c e n t c o n c e rn and m ost school-aged children have an ongoing

an d r e s e a r c h fin d in g s ab o u t
and fam iliar relationship w ith dental am algam .
d en tal a m a lg am , th e U .S.
P ublic Health S e r v ic e c o n ­ The high prevalence of dental caries during m uch of the 20th
d u cte d a c o m p re h e n siv e
century necessitated th e availability of a safe, efficient, effective,
s c ie n tific re v ie w o f its b e n e fits
and risk s. T h is re v ie w w ou ld durable and inexpensive dental restorative m aterial.
s e r v e a s a b a s is fo r r e ­
D ental am algam has been widely viewed by h ealth professionals
exam in in g fe d e ra l p o licy on
th e u s e o f d en tal a m a lg am a s and the public alike as satisfying these criteria. However, claims
a re sto ra tiv e m aterial. T h is
about possible adverse h ealth effects of m ercury vapor from dental
a rtic le su m m a riz e s th e
p rincip al fin d in g s, c o n c lu s io n s am algam have surfaced periodically since the early 1900s—
and reco m m e n d a tio n s from
recently w ith nationw ide publicity.
th at rev iew .
C urrently, research has detected elevated levels of elem ental

m ercury vapor in the m ouths of individuals w ith dental am algam

fillings.14 Additional anim al research suggested th a t m ercury from

dental fillings could be deposited in tissues d ista n t from the site of

am algam placem ent.5-7 The television and p rin t m edia reported on

and in some cases sensationalized these findings, creating a specter

STEPHEN B. CORBIN, D.D.S.,
M.P.H.; WILLIAM G. KOHN, D.D.S. th a t dental am algam m ay be detrim ental to hum an health .811

JADA, Vol. 125, April 1994 381

■COVER STORY

effects? Are
Patient factors
some people
more sensitive
Personal oral Hygiene th an others—if
Prevention practices so, who?
Oral habits
Size of restorations
- Should
Cooperation at time dental
of placement am algam
continue to be
used?
■■ Should
existing
am algam s be
removed or
allowed to
rem ain in
Material factors people’s
Dentist factors m ouths?
Wear ■* W hat would
Clinical skill Strength
Size of preparation Durability
be the possible
Technique sensitive risks, benefits
and costs of
various policy
Figure 1. Factors influencing the success of a restoration.
changes
considered for
am algam ?
U.S. PUBLIC HEALTH
SERVICE RESPONDS benefits and a th ird used the *“ W hat scientific inform ation
risk and benefit analyses and do we not have th a t would be
In consideration of the recent other inform ation to develop a im portant in m aking sound
research reports, the bread th of risk m anagem ent strategy. public policy decisions?
exposure to dental am algam After a two-year review, a As these questions were
am ong the U.S. population, and diverse group of scientists— exam ined, it became clear to
the level of public and m edia epidemiologists, toxicologists the benefits subcom m ittee th a t
concern, th e U.S. Public H ealth and biom aterials experts from it was not possible to discuss
Service conducted a w ithin and outside th e federal the benefits of am algam
com prehensive scientific review governm ent—produced a report w ithout considering th e risks
of the benefits and risks of published in J a n u a ry 1993.12 and benefits of available
dental am algam . This review N early 500 scientific studies altern ativ e m aterials. Also,
served as a basis for were used as a basis for the because of declining disease
reexam ining federal policy on report. This article sum m arizes rate s and advances in
the use of dental am algam as a the report’s principal findings, restorative m aterials and
restorative m aterial. conclusions and techniques, the m anagem ent of
In 1991, th e U.S. A ssistant recom mendations. caries in th e U nited S tates is
Secretary for H ealth directed a changing.
SCIENTIFIC AND HEALTH
high-level USPHS interagency POLICY QUESTIONS
It’s becoming difficult to
group—th e Committee to separate the treatm ent from the
Coordinate E nvironm ental Com m ittee m em bers addressed prevention of dental caries.
H ealth and Related Program s— several im portant scientific and Therefore, the report also
to coordinate th e review. Three h ealth policy questions considered caries treatm ent as
independent subcom m ittees of including: an infectious disease process and
CCEHRP conducted the review. ■■ Is dental am algam toxic to the relative importance of dental
One exam ined th e risks of patients? Does it produce or can amalgam in treating this
dental am algam , a second the it produce adverse health disease.

382 JADA, Vol. 125, April 1994

 COVER STORY

A lthough the
report
reaffirm s the
USPHS
position tak en
in 1991 th a t
“th ere are no
d a ta to compel
a change in the
c u rren t use of
dental
am algam ,” the
rep o rt urges
continued
research “to fill
in as m any
gaps as
possible in the
c u rren t
knowledge
about the
potential
biological
effects of dental
am algam and
alternative
restorative
m aterials.”
F u rth e r, the AGE OF INDIVIDUAL
report
reaffirm s the
Figure 2. Lifetime tooth cost model. Relative cumulative costs of restoring a carious
USPHS posterior tooth in 60 years, using various restorative materials. Each step on plot lines
com m itm ent to represents average years to replacement based on published studies. Initial cost of
th e prevention amalgam equals 1.0.
of disease and
prom otion of
h e a lth by em phasizing tooth-
conserving tre a tm e n ts and the
proper use of currently
ESTIMATED DIRECT COSTS FOR REPLACEMENT OF
available preventive therapies.
In effect, th is would m inim ize DENIAL AMALGAMS IN TRE U.S.
th e use of all restorative
One-time replacem ent o f all existin g
m aterials.
am algam s in perm anent posterior te e th .
C onsistent w ith this
$ 2 4 8 b i ll io n
approach, the report em pha­
sizes th a t the purpose of
Increased cost in 1990 i f alternative
disease prevention and
restorative m aterials had been
tre a tm e n t efforts m u st be the
substituted for the 96 m illion am algam s
optim ization of oral health
placed.$12 .4 b illio n
outcomes for patien ts over a
lifetim e, not ju s t tre a tm e n t of
tooth surfaces over an Figure 3. Estimated direct costs for replacement of dental amalgam in
appointm ent. United States (fromthe USPHS Dental Amalgam Report, 1993).

JADA, Vol. 125, April 1994 383

COVER STORY

TABLE 1

ESTIMATES OF MEAN DAILY ELEMENTAL MERCURY UPTAKE FROM

DENTAL AMALGAM RtS UHA UNS.
Principal author No. of surfaces Mercury (ug/day)

[Patterson (1985)* N ot recorded 27.0

Langworth (1988) 8-54 3.0

Berglund (1990) 13-48 1.7

Vimy (1985) 1-16 19.8

Clarkson (1988)t
Svare (1981) Not. recorded 17.5
Vimy (1985) 1-16 2.9
Abraham (1984) N ot recorded 4.4
Patterson (1985) N ot recorded 2.5

Mackert (1987)t
Vimy (1985) 1-16 1.24

* Based on upper one-tenth percentile of subjects,

t Recalculation of previously published values.

SUMMARY FINDINGS
FROM THE BENEFITS replacem ent. It has been m aterials is less costly th a n
REVIEW estim ated th a t betw een 60 to 70 dental am algam . Models can
percent of restorations are predict patient outcomes and
The principal findings from the replacing previous restorations. costs using various clinical
research evidence related to Some research h as indicated scenarios and incorporating
am algam benefits are: th a t not only are dentists more different clinical life expect­
■■ D ental am algam is an likely to replace restorations ancies for restorations. One
effective restorative m aterial placed by another dentist, b ut such model from th e USPH S
th a t offers m any advantages also in a significant percentage report is presented in Figure 2.
over other restorative m aterials of cases, the replacem ent On a tooth lifetime basis, all
including: wide potential restoration was judged, by alternatives are more expensive
applications, ease of m anipu­ independent observation, th an am algam —in some cases
lation, reasonable clinical inferior to th e one removed. The m any tim es more expensive.
serviceability and relatively low longevity and clinical » There is no single restorative
cost. effectiveness of any restoration m aterial yet available th a t can
■■ The oral h ealth benefits of is ultim ately the resu lt of an reasonably substitute for dental
dental am algam m ay be interaction betw een patient, am algam in all situations. Each
underestim ated. Research dentist and m aterials factors has particular advantages and
suggests th a t m any am algam s (Figure 1). disadvantages. M any patien ts
are replaced more often th an *■ Several alternative m aterials like the enhanced esthetics of
necessary from a strictly can replace dental am algam in alternative restorative
disease standpoint. G reater m any traditional situations, m aterials. There are trade-offs
attention should be paid to the particularly in low stress- in clinical effectiveness,
rep air of restorations ra th e r bearing areas. On a one-time however, which m ay place the
th a n complete rem oval and use basis, none of these health of teeth a t g rea ter risk.

384 JADA, Vol. 125, April 1994

 COVER STORY

TABLE 2

ESTIMATED DAILY ABSORPTION OF MERCURY FROM SOURCES OTHER TRAN AMALGAM.

Hg Hg" M eH g Daily
ng/day ng/day ng/day

Clarkson et al. (1988)

Air 32
Food 60 2160
"Water 5
T o ta l 32 65 2160 2 .3 ^ g / d a y

EPA (1984)
Air 96 30 27
Food (fish) 94 3572
(non-fish) 2000
Water 5
T o ta l 96 2124 3599 5 .8 n g / d a y

Other authors (1976-1983) 2-15 n g / d a y

MeHG = methylmercury.
Adapted from: USEPA. 1984, Mercury health effects update. United States Environmental Protection Agency, Washington, D.C.: Report No.
EPA - 600/8-84-019F.

Although there have been restorations poses potential Declining caries rates in
im portant improvements in risks to the oral and general children, generally sm aller
polymeric restorative m aterials h ealth of individuals. Removing lesion sizes, increasing
(for example, composites), they dental restorations will have attention to conservative cavity
cannot be “routinely” substi­ significant cost im plications for form and increasing use of
tuted for dental am algam and individuals and public alternative m aterials (including
achieve the sam e clinical program s (Figure 3). crowns, composites, glass
results. In the posterior denti­ If all th e am algam s placed in ionomers and ceramics) are
tion, in situations where 1990 (about 96 million) had reducing the reliance on dental
occlusal stresses are concen­ been restored w ith a suitable am algam . N evertheless, there
trated, the current composites alternative m aterial, more th a n are millions of existing
or glass ionomer restorative 12 billion additional dollars am algam s th a t will need to be
m aterials are inappropriate would have been spent im ­ replaced in future years, likely
choices. Additionally, success­ m ediately, w ith higher costs in w ith am algam .
fully placing posterior composite late r years. To completely ■■ The best restoration is one
m aterials, especially in Class II replace all existing posterior th a t never has to be placed. The
situations, can be more am algam s in perm anent teeth attem p t should be m ade to
challenging th an successfully w ith appropriate alternatives prevent initial lesions through
placing an amalgam. (including cast restorations) effective oral hygiene, use of
» The rem oval of any dental would cost an estim ated $248 sealants, fluorides and
restoration should be based on billion. chlorhexidine where
sound scientific criteria. The ■■ Reliance on dental am algam appropriate, dietary
extensive removal of dental has been declining for years. modification—perhaps xylitol

JADA, Vol. 125, April 1994 385

COKED STORY

chewing gum —and possibly in m ost people experience any ■■ Available d a ta are not
the not too d ista n t future, the clinical effects from this sm all sufficient to indicate th a t health
use of calcium phosphate- additional body burden of hazards can be identified in
releasing chewing gum. W here m ercury from am algam s. non-occupationally exposed
th ere are incipient lesions, ■■ If there are adverse health persons. The possibility of
consider clinical reversal effects from m ercury in dental h ealth hazards, however,
strategies—fluorides, enhanced am algam , they m ay be so subtle cannot be dismissed.
oral hygiene and dietary and non-specific th a t they ■■ Because of the variability of
modification. would be difficult to detect. exposures to m ercury from all
W here th e lesions are Slight neurological or sources in the population, the
established, the best behavioral change is one m argin of safety for some
preparations are conservative example. individuals m ay be lower th a n
w here little more th an the « True allergies to dental desirable when th e m ercury
diseased tissue is removed, am algam rarely have been from dental am algam s is added.
such as th e preventive resin reported (50 cases since the ■■ There is not persuasive evidence
restoration. Given the caries tu rn of the century). Even local that the mercury doses produced by
p a tte rn s generally encountered reactions (for example, amalgam fillings can cause the
today, th e new er bonding lichenoid reactions) appear wide variety of non-specific
agents, and improved infrequently and usually can be symptoms that have been
restorative m aterials and m anaged through substitution attributed to fillings, nor that cure
techniques, traditional cavity of m aterials. or health improvement can be
preparation (G.V. Black’s " E stim ates of h u m an uptake achieved after their removal.
extension for prevention and of m ercury vapor from dental Because minimal directly
retention) is overly aggressive am algam s have ranged betw een applicable data exist for deter­
and usually inappropriate. 1.24 and 27 m icrons/day (Table mining potential health effects of
Em phasize tooth conservation. l).1319 a factor of more th an low level mercury exposure from
twentyfold. However, the widely dental amalgams, additional
SU M M ARY FINDINGS
FROM THE RISK REVIEW
varying experim ental conditions scientific research needs to be
and assum ptions in calculations pursued.
The principal findings from the undoubtedly contribute to the The report contains m any
research evidence related to the wide range of results. Non- recom m endations in th e areas
dental am algam safety are: physiologic based models of professional and public
■■ D ental am algam can release resulted in several of the education, research and
m inute am ounts of elem ental estim ates likely being several regulation.
m ercury, a heavy m etal whose tim es too high. Recalculations E d u c a tio n . The public and
toxicity a t high exposure levels correcting for these factors the h ealth care comm unity
is well-established. produce estim ates of less th a n 5 m ust be properly informed
Occupational studies indicate microns per day. Studies have about the risks and benefits of
th a t subclinical effects m ay dem onstrated higher blood and dental am algam . D entists,
occur a t exposure levels tenfold urine levels of m ercury in physicians and other health
higher th a n those of the general individuals w ith am algam s. professionals need accurate
population. Severity of response However, estim ates of m ean inform ation about the risks and
generally follows a dose daily m ercury exposure from all benefits of all dental restorative
response p attern . sources vary (Table 2). m aterials to provide patients
™ The existence of specific ™ There is evidence th a t w ith the inform ation necessary
responses, let alone a dose m ercury levels in body fluids to m ake informed and
effect, h as not been spike during placem ent or intelligent choices in regard to
dem onstrated a t levels of rem oval of am algam s and then dental restorative m aterials
exposure associated w ith dental decline over several days and selection or removal.
am algam s. M ercury is absorbed weeks. B ut no controlled T hird-party payers should be
from m any sources, including clinical studies of h ealth educated on relevant topics of
food and the air we breathe. It consequences have been tooth conservation techniques
has not been dem onstrated th a t conducted. and m aterials, such as sealants

386 JADA, Vol. 125, April 1994

 COVER STORY

and preventive resins, and device. The k it is proposed for

appropriateness of restoration Class II.
rep air in specific cases to assure
REFLECTIONS
reim bursem ent.
Any credible education An effective risk m anagem ent
program on dental restorative strategy is the u ltim ate purpose
Dr. Kohn is special Dr. Corbin is
m aterials m u st be fran k about assistant, Science associate director, for a h ealth risk assessm ent. It
th e uncertainties involved. A Transfer, Office of External Relations, m ust consider th e range of
Division of Oral
program developed w ith th e the Director; and
Health, National
reasonable options, and the
deputy director, Oral
involvem ent of consum ers, Medicine Program,
Center for benefits and risk s (including
Prevention Services,
m anufacturers and dental Clinical costs) of p articu lar options.
Investigations and U.S. Centers for
professionals would likely have Patient Care Branch, Disease Control and Obviously, if a risk is clearly too
balance as well as credibility, National Institute of Prevention, 5600 high on face value (for example,
Dental Research, Fishers Lane,
and could more easily be Parklawn Bldg.,
exposure to benzene), fu rth er
National Institutes of :
accepted by all comm unities. Health. Room 5A 20, consideration of benefits
Rockville, Md.
D ental restorative practices 20857. Address
becomes moot. For m ost
should m aximize preservation scientific reprint requests to assessm ents, however, the
of sound tooth stru ctu re and questions Dr. Corbin. choice is not so obvious.
stress appropriate use of raised in the Although the issue of
am algam and alternative report. Still, targ eted research potential h e a lth risks from
m aterials. is needed in several critical dental am algam initially drove
R e s e a rc h . R esearch is areas. The N ational In stitu te of the scientific review forward,
needed on the specific health D ental Research is pursuing the benefits of dental am algam
effects of low-level m ercury several such research projects and th e benefits and risks of
exposure; on the absorption, and supporting the alternative restorative
distribution, m etabolism and investigation of new m aterials m aterials also assum ed a
elim ination of this m aterial; on and techniques to help preserve prom inent position. I t is not
potential biological m arkers for sound tooth stru ctu re and enough to answ er w hether
exposure and effect; on the address biocom patibility m ercury from d en tal am algam
medical significance of such concerns. causes any adverse h ealth
m arkers; and, on the R e g u la tio n . The FDA effects. B roader questions
significance of various blood, should require restorative should be asked: “How should
urine or tissue levels of m aterials m anufacturers to the disease of dental caries be
m ercury; w hether low-level identify product ingredients. m anaged, as it occurs in various
m ercury effects are prevalent in This could assist dentists in parts of th e U.S. population?”
the general population, and identifying th e causes of And, “How im p o rtan t is
w hether these can be a ttrib u ted sensitivity reactions and am algam to the continued oral
to am algam ; which special facilitate selection of alternative health of the nation?”
population groups, if any, m ight m aterials. D ental am algam along w ith
be especially sensitive to The FDA should develop an fluoride has transform ed the
m ercury effects; how hum an educational program for dental U.S. oral h ealth picture. Indeed,
studies could be designed to providers regarding adverse hundreds of m illions of teeth
assess th e potential effects of action reporting th a t would be have been retain ed th a t
dental am algam ; how m ercury “u ser friendly” and, thus, be otherwise would have been
in am algam m ight be used by dentists. sacrificed because restorative
“stabilized” to m inim ize release Elem ental m ercury and alternatives would have been
into the body; and how safe and dental alloy should be regulated too expensive for m any people.
effective are th e altern ativ es to as a kit, ra th e r th a n as separate For some people, dental
dental am algam . constituents, since th is is the am algam placed a t one tim e
In 1991 alone, USPH S way in which they come into “tem porized” th e tooth for
conducted nearly 70 research contact w ith tissues. Currently, years, u ntil th e ir clinical
projects to taling several million dental m ercury is a Class I situation called for a more
dollars th a t relate to the device, and alloy, a Class II perm anent altern ativ e and

JADA, Vol. 125, April 1994 387

COVER STORY

th e ir personal resources be able to quantify its precise 6. Vimy MJ, Takahashi Y, Lorscheider FL.
Maternal-fetal distribution of mercury (203-
p erm itted th e choice. degree. B ut w here there is a Hg) released from dental amalgam fillings.
A t th e sam e tim e, the basic large know n benefit (such as Am J Physiol 1990;258:R939-45.
7. Boyd ND, Benediktsson H, Vimy MJ,
science and toxicity aspects of vaccines to prevent childhood Hooper DE, Lorscheider FL. Mercury from
am algam have not been fully diseases), th en individuals and dental “silver” tooth fillings impairs sheep
kidney function. Am J Physiol
explored. And as new m aterials society m ust acknowledge and 1991;261:R1010-14.
have em erged, knowledge of determ ine an acceptable level of 8. “60 Minutes.” CBS; Dec. 16,1990.
9. Jones D. Giving science a bad name. J
th e ir basic science and toxicity risk as the necessary side effect Can Dent Assoc 1991;57(4):291-3.
h a s not been fully revealed. In of a highly technological society, 10. Paulson T. Danger in fillings indicated.
Seattle Post-Intelligence 1992; Feb. 25.
th e past, the burden of oral one th a t we all benefit from 11. Lowey M. Scientists bolster mercury
diseases in this country has every hour of the day. ■ findings. Calgary Herald 1992; Feb 26.
12. USDHHS, PHS. Dental amalgam: a
been so g rea t an d our A limited number of copies of the report scientific review and recommended Public
technology insufficient to obtain “Dental Amalgam: A Scientific Review and Health Service strategy for research,
Recommended Public Health Service Strategy education, and regulation. Washington, D.C.:
complete answ ers to some of for Research, Education and Regulation” are DHHS, PHS. January 1993.
these questions. We can now available. Individual copy requests should be 13. Berglund A. Estimation by a 24-hour
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Policy m aking m ust be done This paper was presented at the Scientific Nylander M. The prediction of intake of
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The opinions expressed or implied are those 15. Langworth S, Svare CW, Frank CW. The
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tre a tm e n t m ay pose some
potential risk—and we m ay not

388 JADA, Vol. 125, April 1994