This is my personal guess, but most dentists in the United States don’t place amalgam. What Is Dental Amalgam? Dental amalgam, sometimes called a “silver-filling” due to its appearance, is a mixture of mercury, silver, copper, tin and zinc used to fill cavities in teeth. Dental amalgam is approximately half (50%) mercury, by weight. While there probably still are plenty out there that do, I placed amalgams in dental school because it was a requirement. We were told it was cost-effective, strong, durable, and would corrode – filling in any microgaps. The public health benefit from the material made it imperative to still be placed in modern dentistry and I accepted that modality of treatment for many patients who needed a cheaper alternative. While the evidence-based decisions behind amalgam haven’t changed much since I was in dental school, I have changed my treatment philosophy towards it as my career has evolved.
“Does that make sense?”
I had a patient, we’ll call her Jane Doe, who had broken a piece of amalgam from her second molar. She swallowed the amalgam and was asking if there were any health concerns with the mercury in the amalgam. I informed the patient the same information most organizations like the American Dental Association, Food and Drug Administration, European Commission say – the main concern with amalgams are elemental mercury, the main concern with elemental mercury is inhalation in the lungs, and that very little mercury is absorbed into the bloodstream through the digestive tract, etc. I told her that current evidence says she should be okay and toxicology is often in the dose and the dose is presumed to be low. She reported back, “Why is any dose okay?! You doctors say something is safe and then 20 years later take it back. No insult to you, but I don’t want this even as a possibility. Does that make sense?”
Medical/Dental Reversal or Advancements?
I’m not going to sound like Chicken Little. The sky’s not falling. Dentists don’t need to be removing amalgams for every patient. But could there be a health detriment that we haven’t been able to measure yet? It’s really not that crazy of a question. Medicine and dentistry are constantly evolving and the history of medicine is filled with moments where healthcare had to eat our own words. Medical reversals are part of the process of medicinal science and most likely will be even more evident with the advancement of precision medicine. On the topic of amalgam, in 2020, the Food and Drug Administration stated that high-risk individuals (women who are or planning to be pregnant, nursing mothers, children under the age of 6, people with a sensitivity to mercury or other component of amalgams, people with neurological impairment or kidney dysfunction) should “avoid dental amalgam if possible and appropriate.” It says “little information is known” meaning it wasn’t an evidence based decision, but a philosophical one. If that’s the case, why wasn’t this philosophical distinction made before?
Public Health vs What’s Best for the Individual
Especially after the Covid-19 pandemic, public trust of the healthcare system has gone down. We often speak in absolutes to the patient rather than saying risk level and cost-benefit. Evidence-based decision making is by far the best protocol medicine and dentistry has in order to make informative and healthy decisions. But a little humility is at times needed and a little common sense would be appropriate to help alleviate the patient’s concerns. Every individual does a cost-benefit analysis and if the patient is informed and doesn’t want a material that contains mercury in their mouth, they’re not crazy, they’re skeptical of the current evidence. Telling the patient the most up to date information combined with the patient’s philosophies and common sense for the patient should be the goal for all doctor-patient relationship. Since there are plenty of dental material alternatives, mercury doesn’t provide a systemic benefit and is known to be toxic, and controlled removal is possible – rubber dam, high speed suction, high-powered extra-oral vacuum – providing that service has become part of my service to my patients. It may not be the current evidence-based decision, but it “does make sense”.
