Amalgam reconsidered

[Guest guest]

I thought that Vince would be particularly interested in this paper. I

am posting it here because I thought others might like to see the other

side of the issue. It is put out by a non-establishment organization.

Ira

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NCAHF Position Paper on Amalgam Fillings (2002)

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This statement was written in response to claims that the mercury content

of amalgam fillings causes toxic amounts of mercury to enter the body.

Advocates of this belief are seeking to ban amalgam use and to force

dentists and dental organizations to compensate all persons who claim

that amalgam has damaged their health. The National Council Against

Health Fraud believes that amalgam fillings are safe, that anti-amalgam

activities endanger public welfare, and that so-called " mercury-free

dentistry " is substandard practice.

NCAHF is a nonprofit consumer protection organization that promotes

rational health care. This page and the PDF version of this paper are

copyrighted but may be noncommercially reproduced with appropriate

credit.

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Background History

Dental amalgam has been widely used for over 150 years. It is made by

mixing approximately equal parts of elemental liquid mercury (43 to 54

percent) and an alloy powder (57 to 46 percent) composed of silver, tin,

copper, and sometimes smaller amounts of zinc, palladium, or indium [1].

Although some forms of mercury are hazardous, the mercury in amalgam is

chemically bound to the other metals to make it stable and therefore safe

for use in dental applications.

The difference between bound and unbound chemicals can be illustrated by

a simple comparison. Elemental hydrogen is an explosive gas. Elemental

oxygen is a gas that supports combustion. When combined, however, they

form water, which has neither of these effects. Saying that amalgam will

poison you is like saying that drinking water will make you explode and

burst into flames.

Amalgam is the most thoroughly studied and tested filling material now

used. Compared to other restorative materials, it is durable, easy to

use, and inexpensive. The American Dental Association, Consumers Union,

the U.S. Food and Drug Administration, the U.S. Public Health Service,

the World Health Organization, and many other prominent organizations

have concluded that amalgam is safe and effective for restoring teeth

[2-6]. It is safe to assume that if a better material is developed, the

dental profession will adopt and use it.

Amalgam Safety

The amount of mercury released from installed amalgam and absorbed by the

body is minuscule. Mercury is found in the earth's crust and is

ubiquitous in the environment. Thus, even without amalgam fillings,

everyone has small but measurable blood and urine levels. Amalgam

fillings may raise these levels slightly, but this has no practical or

clinical significance.

The legal limit of safe mercury exposure for industrial workers is 50

micrograms per cubic meter of air for 8 hours per day and 50 weeks per

year. Regular exposure at this level will produce urine mercury levels of

about 135 micrograms per liter. These levels are much higher than those

of the general public but produce no symptoms and are considered safe.

Most people with fillings have less than 5 micrograms per liter of urine.

Nearly all practicing dentists have levels below 10 micrograms per liter,

even though they are exposed to mercury vapor when placing or removing

amalgam filings and typically have amalgams in their own teeth. Thus,

even with that exposure, the maximum levels found in dentists are only

slightly higher than those of their patients and are far below the levels

known to affect health, even in a minor way [7-12].

No illness has ever been associated with amalgam use in patients, except

for rare instances of allergies. Moreover, there is insufficient evidence

to assure that components of other restorative materials have fewer

potential health effects than dental amalgam, including allergic

reactions.

Improper Claims

Despite the above facts, some dentists and other health professionals

advise people to avoid amalgam and to have their amalgam fillings

replaced with other materials. Dentists who oppose the use of amalgam may

refer to their approach as holistic dentistry, biological dentistry, or

mercury-free dentistry.

Offbeat practitioners often diagnose " amalgam toxicity " or " amalgam

illness " in patients who suffer from multiple common symptoms. One study

found that people with symptoms they related to amalgam fillings did not

have mercury blood and urine mercury levels that were significant or

higher than those of a control group [12]. Several studies have found

that many symptoms attributed to amalgam restorations are psychosomatic

in nature and have been exacerbated greatly by information from the media

or from a dentist [13-17]. False diagnoses of " mercury toxicity " are also

made by many of the physicians who offer chelation therapy, a series of

intravenous infusions that costs thousands of dollars.

The leading anti-amalgamist has been Hal Huggins, D.D.S., of Colorado

Springs, Colorado. Huggins claims that " sensitive " individuals can

develop emotional problems (depression, anxiety, irritability),

neurological disorders (facial twitches, muscle spasms, epilepsy,

multiple sclerosis), cardiovascular problems (unexplained rapid heart

rate, unidentified chest pains), collagen diseases (arthritis,

scleroderma, lupus erythematosus), allergies, digestive problems (ulcers,

regional ileitis), and immunologic disorders (which he claims include

leukemia, Hodgkin's disease, and mononucleosis). He recommends replacing

amalgam with other materials and taking vitamins and other supplements to

prevent trouble after amalgam removal [18]. There is no scientific

evidence that amalgam fillings cause or contribute to the development of

these diseases.

Huggins's dental license was revoked in 1996. During the revocation

proceedings, the administrative law judge concluded:

Huggins had diagnosed " mercury toxicity " in all patients who consulted

him in his office, even some without mercury fillings.

He had also recommended extraction of all teeth that had had root canal

therapy.

Huggins's treatments were " a sham, illusory and without scientific

basis. " [19]

A practitioner who does not wish to use amalgam can still practice

ethically by giving appropriate advice and and referring patients

elsewhere when amalgam is the best choice. But advertising a practice as

" mercury-free " is unethical because it falsely implies that amalgam

fillings are dangerous and that " mercury-free " methods are superior.

Dubious Tests

The advice from anti-amalgam practitioners is typically accompanied by

one or more tests that are either misinterpreted or completely bogus.

Breath Testing. Breath testing involves probing the mouth with a vacuum

device after the patient chews gum vigorously for several minutes. The

procedure causes tiny amounts of mercury to be released from amalgam

fillings and deposited on a gold foil within the device. Because people

only chew during a small part of the day, the resultant readings are much

higher than the average amounts released per 24 hours. In addition, the

amounts deposited the foil are artificially high because most mercury

vapor is exhaled rather than absorbed by the body and the device

remeasures the same air several times, which inflates the reading. The

readouts of the device are also raised by the presence of traces of

foods, bacterial gases, and other substances commonly found within the

mouth.

Urine Testing. Because mercury is ubiquitous, the body reaches a steady

state in which tiny amounts are absorbed and excreted. Thus, mercury is

commonly found in people's urine. Mercury can also be found in the blood,

because this is the major medium for transporting materials around the

body. Large-scale studies have shown that the general population has

urine-mercury levels below 10 micrograms/liter. Industrial workers, and

dentists, who have regular exposure to mercury vapor also have low

values. Urine testing, which is a fairly reliable indicator of chronic

exposure, is best performed on a 24-hour urine specimen. Urine mercury

levels can be temporarily raised by administering a chelating agent such

as DMSA or DMPS, which collects the small amounts of mercury from the

body, concentrates them, and then forces them to be excreted. In other

words, mercury that normally recirculates within the body is now bound

and excreted. The urine level under such circumstances is artificially

raised above the steady-state level. The use of a chelating agent before

testing should be considered fraudulent.

Blood Testing. Mercury is excreted by the kidneys, which filter the

blood. The mercury levels of blood are lower than those of urine and

therefore more difficult to detect. Even at high levels of mercury

exposure, industrial workers show blood concentrations in the

parts-per-billion range, typically less than 5 parts per billion. In this

range, the amounts are too small to identify the type of mercury or its

source. Urine mercury testing gives a more meaningful picture of exposure

and is also more accurate because the mercury is more concentrated.

Skin Testing. Some anti-amalgamists administer a " patch test " with a

dilute solution of corrosive mercury salts that cause the skin to redden

and possibly swell [20]. The reaction is misinterpreted as a sign of

mercury allergy or toxicity.

Stool Testing. Fecal mercury levels are not an accurate indicator of

mercury exposure. The amount found in stool reflects the amount eaten and

not absorbed plus anything excreted in the stool. At best, a stool test

might indicate that mercury entered the gastrointestinal tract, but it

could not provide an accurate measurement of either exposure or what was

absorbed into the body.

Hair Analysis. Hair analysis is performed by sending a sample of hair to

a commercial hair analysis laboratory, which issues a computerized report

indicating the number of micrograms found and whether that amount should

be considered harmful. This procedure is not valid. Hair contains trace

amounts of mercury from food, water, and air, regardless of whether the

person has amalgam fillings. Because hair can absorb mercury from

external sources, amount of mercury it contains does not necessarily

reflect the amount within the body. In addition, hair mercury testing

cannot be standardized because hair thickness, density, shape, surface

area, and growth rate vary from person to person. The laboratory used

most for hair analysis is Doctor's Data of Chicago, which reports " toxic

mineral " levels as " high " when the amounts are near the top of their

" reference range. " [21] This merely means that the specimen contained

more than most other hair specimens handled by the lab. It does not mean

that the level is abnormal or that the level within the patient's body is

dangerous. Thus even if hair analysis were valid, the reporting process

is not.

Electrodermal Testing. Some practitioners use quack diagnostic devices

that are said to detect " electromagnetic imbalances. " One wire from the

device goes to a brass cylinder that the patient holds in one hand. A

second wire is connected to a probe, which the operator touches to

various points inside the mouth. This completes a low-voltage circuit,

and the device registers the flow of current, which the operator

misinterprets as abnormal.

Physical Harm

Inappropriate removal of amalgam fillings is usually followed by

replacement with a more costly material. But removing good fillings is

not merely a waste of money. In some cases, it results in significant

damage or loss of the tooth. To remove an intact filling, it is necessary

to drill into the tooth around the outer edges of the amalgam. If the

filling is large or deep, the tooth can be significantly weakened and the

heat from the drilling process can injure the relatively delicate tissues

of the pulp beneath the filling. To this risks must be added the general

risks of anesthesia and other types of mechanical injury that are

uncommon but are inexcusable when a procedure is unnecessary.

In 1985, a $100,000 settlement was awarded to a 55-year-old California

woman whose dentist removed her amalgam fillings. Based on testing with a

phony electrodiagnostic device, the dentist had claimed that six of her

fillings were a " liability " to her large intestine [22]. In removing the

fillings, the dentist caused severe nerve damage necessitating root canal

therapy for two teeth and extraction of two others.

Regulatory Action

The American Dental Association Council on Ethics, Bylaws, and Judicial

Affairs has concluded that " removal of amalgam restorations from the

non-allergic patient for the alleged purpose of removing toxic substances

from the body, when such treatment is performed at the recommendation or

suggestion of the dentist, is improper and unethical. " [23] The policy,

initiated in 1986, was triggered in part by the case of an Iowa dentist

who had extracted all 28 teeth of a patient with multiple sclerosis. The

dentist received a 9-month license suspension followed by 51 months of

probation.

Dentists who attempt to " diagnose " or " treat " " heavy metal toxicity " , or

who test patients for heavy metals by any means are not practicing

dentistry. These activities fall outside the scope of dental licensure.

Any dentist who believes a patient requires diagnosis or treatment for

any medical condition outside of the scope of dentistry is obliged to

make a referral to a physician or other health professional as

appropriate. Failure to make such a referral should be considered

negligence.

Selection of a material should be based only on its known clinical

properties and performance for the particular placement situation,

coupled with the needs of a patient. A dentist who excludes any material

from possible selection for a given restoration on the sole basis of

personal opinion or unsupported conjecture cannot be providing optimal

services for all of his/her patients. Such a dentist may be denying a

patient the benefits of a material that is most suitable for that

patient's needs. Such denial should be considered unprofessional conduct.

No dentist is required to use amalgam. However, dentists who make false

claims about amalgam safety create unnecessary patient anxiety, and

undermine confidence in the profession. Such behavior should be

considered unprofessional conduct. Consumers Union (CU) has concluded:

Dentists who purport to treat health problems by ripping out fillings are

putting their own economic interests ahead of their patients' welfare.

The false diagnosis of mercury-amalgam toxicity has such harmful

potential and shows such poor judgment on the part of the practitioner

that CU believes dentists who engage in this practice should have their

license revoked [24].

Legal and Political Action

Class-action suits have been filed in land and California claiming

that patients have been harmed by amalgam fillings and that the American

Dental Association (ADA) and state dental associations have engaged in

unfair and deceptive trade practices as well as fraud and conspiracy to

defraud by not informing patients that amalgam fillings contain mercury .

The ADA has countered that the suits are part of a " coordinated attempt

by some to have judges decide matters of scientific debate, and stifles

discussion within the scientific community, most of whose members simply

do not agree with their views. " [25] In a news report, an ADA official

referred to a California suit as " " an egregious abuse of the legal

system. " [26] NCAHF concurs with this assessment.

U.S. Representative Diane (D-CA) has introduced a bill to prohibit

interstate commerce of mercury intended for use in dental fillings by

2007. She does not appear to understand that the properties of chemical

combinations can differ greatly from those of the individual ingredients

that form them. Calling " scientifically unsophisticated, " Time

magazine science writer Leon Jaroff has urged to get over her

" amalgam hang-up " and " learn not to be taken in by quacks. " [27] NCAHF

hopes that she will do so.

Recommendations

To Consumers

There is no logical reason to worry about the safety of amalgam fillings.

Anyone told that a urine mercury level produced after taking DMPS

represents a toxic state is being misled.

Avoid health professionals who advise you that amalgam fillings cause

disease or should be removed as a " preventive measure. "

Report any such advice to the practitioner's state licensing board.

To Dental Organizations

Issue clear and forceful guidelines indicating that unnecessary amalgam

removal is unethical and unprofessional and that the diagnosis of mercury

toxicity is outside the proper scope of dentistry.

Issue a position statement about dubious mercury testing

To Dental Licensing Boards

Practice standards should be based solely on scientifically gathered

objective evidence.

Classify as unprofessional conduct any advice that amalgam fillings are

dangerous and therefore should be avoided or removed.

Ban the use of hair analysis and chelating agents by dentists.

Ban any advertising of " mercury-free dentistry " which falsely implies

that amalgam fillings are dangerous and should therefore be avoided or

removed.

To Legislators

Do not be misled by false claims that amalgam is dangerous.

Do not support special laws that would restrict or discourage amalgam

use.

References

Dental amalgam use and benefits. U.S. Centers for Disease Control

Resource Library Fact Sheet, December 2001.

ADA Council on Scientific Affairs. Dental amalgam: Update on safety

concerns. JADA 1998;129:494-501.

The mercury in your mouth. Consumer Reports 1991;56:316-319.

Benson JS and others. Dental Amalgam: A Scientific Review and Recommended

Public Health Strategy for Research, Education and Regulation.

Washington, D, US Public Health Service, 1993.

Consumer Update: Dental amalgams. FDA Center for Devices and Radiological

Health, Feb 11, 2002.

World Health Organization. Consensus Statement on Dental Amalgam. Mjor

IA, Pakhomov GN. Dental Amalgam and Alternative Direct Restorative

Materials. Geneva: World Health Organization, 1999.

Mackert JR. Dental amalgam and mercury. JADA 1991;122:54-61.

Olsson S, Bergman M. Daily dose calculations from measurements of

intra-oral mercury vapor. J Dent Res 1992;71:414-423.

Mackert JR. Factors affecting estimation of dental amalgam exposure from

measurements of mercury vapor in levels in intraoral and expired air. J

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Mackert JR Jr, Berglund A. Mercury exposure from dental amalgam fillings:

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Berglund A. Molin M. Mercury vapor release from dental amalgam in

patients with symptoms allegedly caused by amalgam fillings. Eur J Oral

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Dodes J. The amalgam controversy: An evidence-based analysis. JADA

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Herrstrom P, Hogstedt B. Clinical study of oral galvanism: No evidence of

toxic mercury exposure but anxiety disorder an important background

factor. Scand J Dent Res 1993;101:232-237.

Lindberg NE, Lindberg E, Larsson G. Psychological factors in the etiology

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associated with mercury release from dental restorations: Psychiatric

aspects. Acta Psychiatr Scandinavia 1997;96:475-482.

Malt UF, Nerdrum P, Oppedal B, et al. Physical and mental problems

attributed to dental amalgam fillings: a descriptive study of 99

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Bailer J, Rist F, Rudolf A, at el. Adverse health effects related to

mercury exposure from dental amalgam fillings: toxicological or

psychological causes? Psychol Med 2001;31:255-263.

Huggins HE, Huggins SA. It's All in Your Head. Self-published, Colorado

Springs, Colorado,1985.

Connick N. Before the State Board of Dental Examiners, State Board of

Colorado. Case No. 95-04. In the matter of the disciplinary proceedings

regarding the license to practice dentistry in the State of Colorado of

Hal A. Huggins, D.D.S., License No. 3057. Feb 29, 1996.

Fisher AA. The misuse of the patch test to determine " hypersensitivity "

to mercury amalgam dental fillings. Cutis 1985;35:109, 112, 117.

Druyan ME and others. Determination of reference ranges for elements in

human scalp hair. Trace Elem Res 1998;62:183-197.

Sherry v Doe. California Sonoma County Superior Court, No. 134740, March

1, 1985.

Dental amalgam and other restorative materials. Advisory opinion 5.A.1,

American Dental Association Principles of Ethics and Code of Professional

Conduct, revised April 2002.

Barrett S and the editors of Consumer Reports. Health Schemes, Scams, and

Frauds. New York: Consumer Reports Books, 1990.

Berry J. ADA pledges vigorous defense' against land amalgam suit. ADA

News March 4, 2002.

Another amalgam suit filed in California. ADA news release, March 21,

2002.

Jaroff, L. There's nothing dangerous about 'silver' fillings: But some in

Congress continue to insist there is. http://www.time.com. May 8, 2002.

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This article was posted on October 7, 2002.

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IRA L. JACOBSON

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