ASSOCIATION

REPORT

DENTAL AMALGAM:
UPDATE ON SAFETY CONCERNS
ADA COUNCIL ON SCIENTIFIC AFFAIRS

A B S T R A C T Dental amalgam is an alloy composed of a mixture of approxi-

mately equal parts of elemental liquid mercury and an alloy pow-
This report of the Council on
der.1 The first use of amalgam was recorded in the Chinese litera-
Scientific Affairs reviews and ture in the year 659,2 and for the last 150 years, amalgam has been
discusses recent studies the most popular and effective restorative material used in den-
tistry. The popularity of amalgam arises from its excellent long-
concerning the safety of dental
term performance, ease of use and low cost.1,3 Before the 1970s,
amalgam, with an emphasis on amalgam accounted for more than 75 percent of all restorations.4 In
studies that have been 1979, the total number of amalgam restorations placed by dentists
in the United States was estimated at 157 million.3,5 During the
published since the 1993 review
past 20 years, however, the use of amalgam in the United States
of dental amalgam by the U.S. has been declining, largely due to the decreasing incidence of dental
Public Health Service Committee caries, more frequent use of crowns and the availability of tooth-col-
ored alternative restorative materials for certain applications.3 In
to Coordinate Environmental
1991, the total number of amalgam restorations placed was esti-
Health and Related Programs. mated at approximately 96 million, which accounted for about 50
The Council concludes that, percent of all restorations.5
Despite the long history and popularity of dental amalgam as a
based on currently available
restorative material, there have been periodic concerns regarding
scientific information, amalgam the potential adverse health effects arising from exposure to mer-
continues to be a safe and cury in amalgam.6-10 As early as 1850, some U.S. dentists claimed
that removing amalgam fillings could bring miraculous cures in pa-
effective restorative material.
tients with chronic disease.11 Even today, some dentists remove
amalgam restorations from patients as a result of claims that amal-
gam restorations result in serious adverse health effects.12,13
Concerns in the public sector also were demonstrated in a 1991 sur-
vey conducted by the American Dental Association, which revealed
that nearly half of the 1,000 American adults surveyed believed
that health problems could develop as a result of dental amal-
gam.14,15
The safety of dental amalgam has been the subject of a number
of previous publications, expert panel meetings and national and
international conferences.3,16,17,18 During 1991 and 1992, the National
Institutes of Health and the U.S. Public Health Service, or PHS,
separately convened panels of experts to review the current state of
knowledge on amalgam safety. The expert panels were unable to

494 JADA, Vol. 129, April 1998

 ASSOCIATION REPORT

identify, in the general popula- values ranging from 2 to 15 other hand, has adopted the
tion, any human health detri- µg/day.22,23 Estimates of inhaled lower limit of 25 µg/m3 as the
ments arising from the place- elemental mercury from air TLV for occupational mercury
ment of dental amalgam range from 40 to 120 exposure.28
restorations, and all concluded nanograms per day.16,20 In 1983, a study by Fawer
that amalgam was a safe and Controversy still exists as to and colleagues29 reported that
effective restorative material.3,19 whether mercury from amalgam industrial workers who had oc-
This article reviews more re- is a significant contributor to cupational mercury exposure at
cent studies on the safety of the total body mercury burden. a time-weighted average of 26
dental amalgams, with an em- The toxicological effects of µg/m3 in the workplace for an
phasis on those that have been various forms of mercury have average of 15.3 years showed a
published since the 1993 report been well-documented and in- significant increase in tremor
by the PHS Committee to Coor- vestigated, mainly in popula- when compared with a control
dinate Environmental Health tions with excessive occupation- group. Concerns about this
and Related Programs.3 For ref- al or environmental study have been expressed by
erence, a brief summary on mer- exposures.9,20,21,24,25 Besides aller- Mackert and Berglund,30 who
cury toxicity and current safety gic reactions, symptoms associ- re-evaluated the hand tremors
guidelines also is provided. ated with mercury toxicity in- in this group of 26 occupational-
clude tremor, ataxia, personality ly exposed industrial workers.
MERCURY TOXICITY AND
SAFETY GUIDELINES
Concerns with the study design
noted that the hand-tremor test
Controversy still
Chemically, mercury exists in apparently was not blinded, and
three major forms: elemental exists as to whether the medical and previous expo-
(valence 0), inorganic (valence mercury from amal- sure histories of the workers
+1 and +2) and organic (alkyl were not known. In addition,
gam is a significant
and aryl). These three forms are the researchers make no men-
different in their physical and contributor to the tion of any corrections for other
chemical properties, their rates total body mercury sources of mercury intake or
of absorption and excretion, and elimination. The sample pool
burden.
their distribution patterns in was small, and no dose-re-
tissues. The chemical form of sponse relation was found.
mercury, therefore, determines change, loss of memory, insom- Assuming that confounding fac-
its toxicological profile. nia, anxiety, fatigue, depression, tors were similar between the
Elemental mercury is the most headaches, irritability, slowed exposed and control groups, it
volatile of the three, and mer- nerve conduction, weight loss, can be estimated that the mer-
cury vapor in air is the predom- appetite loss, gastrointestinal cury level in the air for the con-
inant form of elemental mer- problems, psychological distress trol subjects was between 8 and
cury. Sources of mercury in and gingivitis.16,20 10 µg mercury/m3, which is ex-
drinking water and food are Consequently, various guide- ceptionally high.
generally inorganic and organic lines to prevent excessive occu- Furthermore, in a study by
mercury compounds, with or- pational exposure to mercury Nilsson and Nilsson,31 urinary
ganic compounds being particu- have been developed. Both the mercury concentrations found
larly associated with National Institute for Occu- in Swedish dentists, dental as-
seafood.16,20,21 Total daily expo- pational Safety and Health, or sistants and the rest of the staff
sure to methylmercury (a proto- NIOSH, and the Occupational were 2.5, 3.6 and 1.8 nanomole
type of organomercury), primar- Safety and Health Adminis- mercury/millimole creatinine, re-
ily stemming from the ingestion tration have adopted a thresh- spectively. These concentrations
of food (> 98 percent), is esti- old limit value, or TLV, of 50 µg were similar to those found in
mated at 5.8 micrograms by the mercury vapor per cubic meter the supposedly nonoccupation-
Environmental Protection of the breathing zone air for ally exposed control subjects in
Agency, or EPA,20 and 2.3 µg by eight hours per day, 40 hours the Fawer and colleagues29
Clarkson and colleagues.16 per week.26,27 The World Health study, who exhibited an average
Other studies have reported Organization, or WHO, on the of 3.4 nmol mercury/mmol crea-

JADA, Vol. 129, April 1998 495

ASSOCIATION REPORT

tinine. It, therefore, can be in- ries; even in poorly ventilated organomercury compounds by
ferred that the Fawer and col- operatories, mercury vapor con- microorganisms in the mouth
leagues study is unsuitable for centrations returned to levels and gastrointestinal tract. To
determining an occupational ex- below NIOSH’s TLV within 20 examine the potential of such a
posure level at which preclinical to 30 min. The study concluded risk, Chang and co-workers41
symptoms can be established. that mercury remained in vapor conducted a study in both den-
Nevertheless, using Fawer form for only limited periods, tists and nondentists. Although
and colleagues’ data as the low- presumably because of its den- the investigation found that
est observed adverse effect level sity and affinity for surfaces, blood inorganic mercury levels
and a safety factor of 100, the and that a single accidental were higher among dentists
Agency for Toxic Substances mercury spill probably would with poor mercury hygiene
and Disease Registry set the not be a significant source of practices, blood organomercury
minimal risk level, or MRL, at mercury in a dental operatory. levels were statistically in-
0.3 µg/m3 for long-term human Exposure to mercury vapor significant between the two
exposure to mercury in ambient during the placement of amal- groups. Thus, researchers con-
air.24 (The MRL is defined as gam restorations also was found cluded that biotransformation
the level of mercury vapor to be minimal when appropriate of inorganic mercury to organo-
below which a person can con- hygiene procedures were fol- mercury did not occur in vivo.
tinuously be exposed with no lowed.37,38 Although significant One human study42 found
harmful health effects.) The concentrations of mercury may that female dental assistants
EPA also uses 0.3 µg/m3 as the be generated during restorative with high occupational exposure
inhalation reference concentra- procedures, approximately 90 to mercury were less fertile
tion for elemental mercury in percent can be eliminated by than unexposed control sub-
air.3,32 using high-volume evacuation.39 jects. Interestingly, however,
A recently published study by subjects with low mercury expo-
DENTAL PROFESSIONALS
AND EXPOSURE TO
Langworth and colleagues40 sure were more fertile than un-
MERCURY FROM found that the levels in the den- exposed control subjects. In a
AMALGAM
tal clinics averaged approxi- 1994 study, Sundby and Dahl43
It has long been recognized in mately 2 µg mercury/m3, and no found no differences in fertility
dentistry that chronic exposure adverse health effects on the and pregnancy outcome be-
to mercury vapor owing to inap- personnel could be seen. In ad- tween female teachers and fe-
propriate handling of dental dition, another study conducted male dentists. This study offers
amalgam can be a potential in Sweden38 showed the impor- a useful comparison, as den-
health hazard in the tance of practicing proper mer- tists’ mercury exposure general-
workplace.3,33 Recent studies, cury hygiene measures. ly exceeds mercury exposure in
however, show that mercury ex- Mercury vapor in the breathing non–occupationally exposed
posure levels among dental pro- zone of the dentist was minimal people with amalgam restora-
fessionals have been steadily (1 to 2 µg/m3) when the high- tions. Recently, Warfvinge44 re-
decreasing,34 probably as a re- volume evacuator was used; ported a case of a pregnant den-
sult of improved mercury hy- without high-volume evacua- tist with chronic occupational
giene techniques. Average uri- tion, however, mercury vapor exposure to mercury vapor and
nary mercury levels among levels were two to 15 times elevated urinary levels. Ultra-
dentists were 19.5 µg/liter in higher than the TLV as defined sound examination of the fetus
1980 and 6.7 µg/L in 1986, as by WHO. According to these in- at 20 weeks of gestation showed
compared with 4.9 µg/L in vestigators, however, the level a mild bilateral hydronephrosis,
1991.35 Ferracane and co-work- of mercury fluctuated signifi- which resolved at 32 weeks of
ers,36 investigating exposure to cantly, with peaks lasting for gestation. The dentist gave
elemental mercury vapor from periods of only a couple of sec- birth to a normal baby who was
mercury spills in the dental of- onds during the removal proce- clinically healthy at a two-year
fice, reported that elevated mer- dure. follow-up study. The clinical
cury vapor concentrations per- There have been concerns cause of the hydronephrosis is
sisted only 10 to 20 minutes in that mercury vapor may be con- unknown.
well-ventilated dental operato- verted into highly toxic Although mercury exposure

496 JADA, Vol. 129, April 1998

 ASSOCIATION REPORT

levels among dental profession- simulate the mouth found that the α phase could be described by
als have been steadily decreas- dry polishing of amalgam a half-life of 1.8 days and the β
ing during recent years, occupa- restorations resulted in the re- phase by a half-life of 24 days. A
tional exposure remains a lease of 44 µg of mercury vapor very similar decline pattern
safety concern. The risk is per restoration. Removal of also was observed in fecal mer-
mainly associated with improp- amalgam in vivo initiated the cury levels. These data demon-
er handling, repeated accidental release of 15 to 20 µg of mer- strate the transitional nature
spilling and skin contact with cury vapor per restoration. The of mercury derived from amal-
mercury. Subclinical adverse short duration of these expo- gam removal.49
health effects, primarily in sures, however, is considered Sällsten and colleagues50 re-
manual dexterity profiles, were inadequate to cause any ad- cently looked at the influence of
reported in a group of 19 prac- verse health effects, and the long-term, frequent nicotine
ticing dentists whose urinary placement and removal of amal- gum chewing on mercury levels
mercury concentrations aver- gam restorations does not ap- in plasma and urine. Mercury
aged 36 µg/liter.45 Improper pear to constitute a significant levels were significantly higher
handling of amalgams, includ- health concern to patients.3,16 In in the gumchewers than in the
ing the use of squeeze cloths to addition, studies have demon- control group and were found to
extract mercury from triturated strated that up to 90 percent of be four times higher than was
amalgam, was found to be the the mercury vapor generated the median reported for
primary source of mercury ex- during restorative procedures Swedish dental personnel.31 In
posure in these dentists. fact, in three out of the 18 gum-
Another study34 examined per- With the development chewers examined, urinary
sonal, professional and office mercury levels in excess of 10
of highly sensitive
characteristics of dentists to de- nmol/mmol creatinine were ob-
termine factors that contribute techniques, measure- served; such levels are normally
to mercury exposure. The find- ment of mercury seen only among chloralkali
ings showed that dental profes- workers (those in heavy indus-
release from amalgam
sionals can minimize unneces- try who deal with strong acid).
sary exposure to elemental restorations has However, urinary mercury lev-
mercury simply by following become possible. els were still well below levels
recommended mercury hygiene at which adverse health effects
procedures such as those recom- might be expected. This study
mended by the American can be effectively eliminated by also demonstrates the need for
Dental Association.46,47 using a high-volume evacua- careful selection of a control
tor.38,39 group when setting baseline
DENTAL PATIENTS AND
EXPOSURE TO MERCURY
In 1997, Bjorkman and col- mercury exposure levels in clin-
FROM AMALGAM leagues49 demonstrated that the ical studies.
RESTORATIONS
removal of dental amalgam re- Much recent research has fo-
It is known that both the place- sulted in a considerable in- cused on mercury released from
ment and removal of amalgam crease in soluble mercury con- amalgam restorations after in-
restorations can result in signif- centrations in a group of 10 sertion and, thus, chronic mer-
icant levels of intraoral mercury patients. The average median cury exposure experienced by
vapor.39,48 An early study using concentration in saliva was 130 patients. Dental amalgam
copper amalgam and proce- nmol mercury/kg; in feces, the restorations used to be consid-
dures that are no longer con- median was 280 µmol/kg dry ered inert, and it was thought
ventionally used in today’s den- weight two days after amalgam that little mercury release
tal practices reported that removal. Mercury in saliva was would occur after the material
intraoral mercury vapor can found to decline exponentially had set. Additionally, as mer-
reach up to 388 µg/m3 of air over a two-week period. Using cury exists widely in our envi-
during the insertion of an amal- the median value from each day ronment, including in various
gam restoration,48 while an in and assuming a two-compart- foods, air, paint and certain
vitro study by Engle and col- ment model and common half- medications,51 mercury from
leagues39 using a small box to life for all people in this group, dental amalgam was considered

JADA, Vol. 129, April 1998 497

ASSOCIATION REPORT

to contribute a relatively small these findings may seem signifi- mates of mercury exposure from
portion of a person’s total daily cant, the study design and meth- dental amalgam. As an exam-
mercury exposure.22,52,53 With the ods of data analyses are ques- ple, previous studies reported
development of highly sensitive tionable. Study subjects reported that chewing significantly in-
techniques, however, measure- no occupational mercury expo- creased mercury release from
ment of mercury release from sure or frequent consumption of amalgam restorations.
amalgam restorations has be- seafood, yet the interview did Consequently, many studies cal-
come possible. Early estimates of not provide reliable information culated daily mercury exposure
average daily dose, in people on the influence of other envi- by estimating the total chewing
without occupational exposure, ronmental and other dietary fac- and nonchewing time in a 24-
range from 1.24 to 27 µg/day,54-60 tors that may significantly influ- hour period. However, more re-
although more recent studies re- ence the degree of mercury cent studies indicate that the ef-
port a lower daily mercury dose exposure in humans.51 fect of meals and snacks on
from amalgam.61-67 Using an im- Furthermore, information im- mercury release from amalgams
proved technique, Halbach66 portant in assessing potential is not consistent; some meals
showed that mercury release mercury exposure from amal- have been shown to actually re-
was linearly correlated to time gam restorations—such as the duce intraoral mercury vapor.71,73
and the surface area of restora- age, location and surface area of The daily mercury exposure
tions; in a study group of 20 peo- the restorations—was not avail- from amalgam, therefore, would
ple with between 1 and 46 amal- able. Also puzzling is that the in- be overestimated if all chewing
gam surfaces, mercury dose vestigators grouped mothers time is considered to cause in-
ranged from 0.3 to 13.9 µg/day, with zero and up to two amal- creases in mercury vapor levels.
with an average daily mercury gam restorations together, re- Overestimation also may occur
dose of 4.5 µg /day in the study sulting in no true control for the when baseline intraoral mer-
group. The same investigator re- study. Well-designed studies are cury is measured after eating
ported essentially the same find- needed, not only to assess the and toothbrushing.63
ings in another group of sub- extent to which amalgams are In short, there is consider-
jects, in which the daily mercury responsible for exposing the able controversy as to the ex-
dose from amalgam averaged 4.8 human fetus to mercury, but tent to which mercury from
µg.67 Another recently published also to determine the clinical sig- amalgam contributes to our
study, using an artificial mouth nificance of this exposure, if any, total daily exposure to mercury.
system, found an even lower av- with respect to ill health effects. Further refinement of measure-
erage mercury dose—0.03 To approach this question, infor- ment techniques, appropriate
µg/day—from amalgam.68 mation on the daily dose of mer- experimental design and judi-
The potential effects of mer- cury absorbed into the blood and cious data analyses all will aid
cury release from amalgam on the subsequent transfer of mer- in reaching a consensus on this
the fetuses of pregnant women cury through the body compart- issue. It is doubtful, however,
and on newborns also has been ments70 is of prime importance. whether this is the vital ques-
investigated.69 Mercury content There are substantial differ- tion when considering the safe-
was determined in samples of ences in the methods and as- ty of dental amalgam. Rather,
liver, kidney cortex and cerebral sumptions used for estimating the more significant question is
cortex from deceased infants, the average daily mercury dose whether mercury released from
and in liver and kidney cortex from amalgam restorations.54- dental amalgam results in sig-
from fetuses. Mothers were in- 57,60,62-65,71,72
Many factors—includ- nificant adverse health effects,
terviewed to assess possible oc- ing the number and age of as mere exposure is not synony-
cupational, domestic and medi- restorations, type of amalgam mous with ill effects to health.
cal mercury exposures, and material, surface area and qual-
DENTAL AMALGAMS,
their dental status was record- ity of the restoration, methods MERCURY AND THE
ed. The results showed that of measuring mercury, individu- HEALTH RISK DEBATE
mercury content in the tissues al variability in subjects and ap-
correlated significantly with the proaches for data analysis— Although the overwhelming
number of amalgam restora- may all be responsible for the body of scientific evidence
tions in the mothers. While reported differences in esti- demonstrates amalgam to be a

498 JADA, Vol. 129, April 1998

 ASSOCIATION REPORT

safe and effective restorative veloped in a time- and dose-de- croglobulin, κ and λ light chains
material, recent publications pendent manner after implan- or N-acetyl-—D glu-
continue to debate not only the tation of amalgam or silver cosaminidase) in two urine sam-
degree of mercury release, but alloy in genetically sensitive ples was considered to be in-
also the clinical significance mice. These effects, however, dicative of a tubular or
such release may have on the could not be attributed directly glomerular lesion that might be
health of patients.57,73-83 to mercury from amalgam, as related to mercury toxicity. The
Literature reviews by Pleva78 similar immune irregularities study found no significant rela-
and Lorscheider and col- were observed in mice that re- tionship between proteinuria
leagues82,83 both expressed con- ceived silver alloy without mer- and amalgam or urinary mer-
cerns relating to the safety of cury. Indeed, another study cury, and therefore did not sug-
amalgam. Concerns identified using human subjects failed to gest that mercury from amal-
by Lorscheider and col- detect any immune irregulari- gam results in kidney
leagues82,83 include possible ties attributable to mercury dysfunction in humans. Other
detrimental effects of mercury studies have confirmed this
on the immune, renal, reproduc- finding.93
tive and central nervous sys- A recent study of In investigating the possible
tems, as well as on oral and in- Swedish twins re- toxicological effects of mercury
testinal bacteria. Other reviews vealed no negative from amalgam on the CNS,
of the literature, however, re- Tulinius94 studied the potential
sult in very different conclu- effects from dental relationship between amalgam
sions. Halbach67 found that the amalgam on physical and intellectual abilities in
combined mercury intake from or mental health or schoolchildren. Mercury concen-
food and amalgam did not ex- tration in the hair of study sub-
ceed the acceptable daily intake memory functions. jects was recorded and com-
and that blood and urinary mer- pared with the subjects’ scores
cury levels in patients with den- from amalgam.86 This study in selected school subjects.
tal amalgams were below one- found that, while there was a Although a weak trend (no sig-
tenth of the critical concen- direct correlation between the nificant correlation) was detect-
trations usually associated with number of dental amalgams ed between the number of amal-
the onset of subclinical health and plasma mercury concentra- gam fillings and mercury
effects attributable to mercury tions, neither the number of content in hair, no correlation
toxicity. Furthermore, a study amalgams nor the plasma mer- between hair mercury content
by Langworth and colleagues84 cury concentration had any sig- and school performance was
examined the immune systems nificant influence on a wide noted. The significance of this
of chloralkali workers, dental range of immune factors, in- finding, however, is doubtful;
personnel, subjects allergic to cluding B and T lymphocytes; mercury concentrations in hair
mercury, subjects with alleged T4 and T8 monocytes; neu- are generally not considered a
amalgam disease and control trophilic, eosinophilic and ba- reliable parameter for deter-
subjects. Nearly all values fell sophilic granulocytes; large un- mining exposure to mercury
within the reference interval. stained cells; and a range of vapor,16,25 and estimating intel-
No significant difference in the humoral factors. lectual abilities by merely mea-
immune parameters was found, The renal and central ner- suring school performance is
and no significant correlation vous systems also are consid- likely an inadequate measure.
between mercury exposure pa- ered susceptible to the effects of Another investigation exam-
rameters and the immune pa- mercury toxicity.45,87-91 A study ined the effect of amalgam on
rameters was noted. by Herrstrom and colleagues92 the cognitive function of Roman
Hultman and colleagues,85 investigated the association be- Catholic nuns.95 The number
studying the effects of amalgam tween the number of amalgam and surface area of occlusal
on the immune system, report- restorations, urinary mercury amalgams were measured, and
ed that chronic hyperim- and proteinuria in 48 male stu- cognitive function was evaluat-
munoglobulinemia, among dents. The presence of certain ed using a battery of eight es-
other immune irregularities, de- proteins (albumin, α-1-mi- tablished tests. The results

JADA, Vol. 129, April 1998 499

ASSOCIATION REPORT

from this relatively homoge- mented adverse effects in either ably estimated; and second, the
neous population found no cor- dental patients or dental profes- fact that most toxic signs and
relation between amalgam sionals. While occupational ex- symptoms suggested as being
restorations and lower cognitive posure may be of a concern, re- attributable to mercury from
ability. A recent study of cent data have suggested that if amalgam are nonspecific, diffi-
Swedish twins came to the recommended mercury hygiene cult to define and often reported
same conclusion, revealing no procedures are followed, the by subjects themselves without
negative effects from dental risks of any adverse health ef- documentation of any physical
amalgam on physical or mental fects arising from mercury ex- or mental characteristics that
health or memory functions, posure in the dental office are can be directly measured or ob-
even after the researchers con- minimal. However, controversy served.73,99-105 So far, few large-
trolled for age, sex, education persists concerning potential scale human studies have been
and number of remaining adverse health effects that pa- conducted that have the statisti-
teeth.96 tients may experience as a re- cal power to investigate any di-
The placement of amalgams sult of chronic exposure to mer- rect correlation between amal-
also has been suggested to re- cury released from amalgam gam and ill effects to health.
sult in a host of nonspecific restorations. While the over- One study conducted in Sweden
symptoms, such as personality whelming body of scientific evi- involving 1,462 women102-104 pro-
change, insomnia, anxiety, fa- dence demonstrates amalgam to vided no evidence of a correla-
tigue, depression, headaches, ir- be a safe restorative material, tion between dental amalgam
ritability, weight loss and psy- debate continues regarding not and cardiovascular disease, dia-
chological distress.16,20 Berglund only the degree of mercury ex- betes, cancer, death rate or vari-
and Molin,73 in studying such posure, but also—and more im- ous subjective symptoms such
reports, found that patients re- portantly—whether this expo- as irritability, depression, fa-
porting nonspecific symptoms sure results in any ill effects on tigue and readiness to cry.
had neither a higher estimated health. Various biochemical parameters
daily uptake of inhaled mercury There is little doubt that of blood and urine also were not
vapor or a higher blood or uri- minute levels of mercury are re- affected by the presence of more
nary mercury concentration leased from amalgam, but the than 20 amalgam surfaces.
than patients reporting no such extent to which this release con- Interestingly, among the group
symptoms. tributes to the total daily expo- of 50-year-old women, subjects
To date, there is no evidence sure has yet to be ascertained. with 20 or more amalgam
to suggest that mercury re- It is crucial to remember that restorations reported fewer sub-
leased from dental amalgams mere exposure is not synony- jective symptoms (such as irri-
results in any adverse effects to mous with adverse health ef- tability, depression, fatigue and
health in the general popula- fects. As stated in the 16th cen- readiness to cry) than those
tion. However, several recent tury by Paracelsus, an eminent with four or fewer restorations.
studies97-99 support earlier work Swiss alchemist and physician, Unfortunately, these data are
suggesting that a very small “[A]ll substances are poisons; not able to provide any defini-
percentage of people—less than there is none which is not a poi- tive conclusions, particularly re-
1 percent—may have allergic son. The right dose differenti- garding potential neurological
reactions to mercury, as well as ates a poison and remedy.”101 On and psychological effects of
other metals, from amalgam. this basis, therefore, the ques- amalgam, as these subjective
Research would indicate that tion of degree of exposure only symptoms also are common in
these allergic reactions to met- becomes important when it is women experiencing meno-
als in amalgam may be linked directly related to adverse pausal stress.
to certain major histocompati- health effects. So is amalgam safe? The
bility complex genotypes.100 Thus, two major factors sup- FDA, in defining safety, re-
port the continuing controversy quires that an ingredient or a
DISCUSSION
over the safety of amalgam: material have a low incidence of
For more than 150 years, dental first, the lack of a consensus as adverse reactions or significant
amalgam has provided excellent to how daily exposure to mer- side effects when used accord-
clinical service with few docu- cury from amalgam can be reli- ing to adequate warnings and

500 JADA, Vol. 129, April 1998

 ASSOCIATION REPORT

directions. Inherent in this defi- cury released from amalgam 1982;10(6):47-61.

8. Gay DD, Cox RD, Reinhardt JW.
nition are considerations of the restorations have been demon- Chewing releases mercury from fillings.
risk-vs.-benefit relationship of strated. Given the available sci- Lancet 1979;1:985-6.
9. Langan DC, Fan PL, Hoos AA. The use of
the material.106,107 In relation to entific information and consider- mercury in dentistry: a critical review of the
mercury exposure from dental ing the demonstrated benefits of recent literature. JADA 1987;115:867-80.
10. McHugh WD. Statement: effects and
amalgam, available data have dental amalgams, unless new side-effects of dental restorative materials.
not identified any significant scientific research dictates oth- Adv Dent Res 1992;6:139-44.
11. Koppang R, Stromme-Koppang A.
side effect(s), other than the erwise, there currently appears Dentale amalgamer igar og idag. Nor
rare allergic reaction, after to be no justification for discon- Tannlaegeforen Tid 1985;95:205-9.
12. Huggins HA. Mercury: a factor in men-
more than 150 years of use. tinuing the use of dental amal- tal disease? Can mercury-silver amalgams
Based on this overwhelming gam. Carefully designed, com- cause psychiatric symptoms? Oral Health
1983;73(12):42-5.
body of scientific data support- prehensive research is 13. Huggins HA. Amalgam in motion. Dent
ing the safety and efficacy of encouraged to investigate poten- Assist 1985;54(3):10-3.
14. McCann D. What does the public think
dental amalgam, and the ab- tial biological effects resulting of amalgam? ADA News 1991;April 8:3.
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