Dental Amalgams

September 24, 2009

Dental Amalgams in the News (Again)

FDA Ruling Does Not Change Our Opinion

Enlow & Vance Dental Partners, P.A.

www.yourdentalfitness.com

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Years ago we made the decision in our Tampa dental practice not to place amalgam (silver/mercury) fillings.  There were a number of reasons for this decision and the recent ruling from the Food and Drug Administration (FDA) has not changed our opinion.

On July 28, 2009 the FDA issued what is termed a “final” ruling regarding the safety of these controversial fillings.  A short interpretation of their rule is, although mercury is a toxic substance known to cause adverse health effects, the restorative and economic benefit outweigh the risks.

(For a complete reprint see Medical Devices Appendix 1:  Summary of Changes to the Classification of Dental Amalgam and Mercury at http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DentalProducts/DentalAmalgam/ucm171120.htm.)

When we look at their decision in its entirety it is our professional opinion that their conclusions are not logical or consistent with the facts on health, well being and the environment.  We certainly do not believe that their “final” ruling will be final.

To review the FDA ruling in its entirety, take a deep breath, plan to stay awhile, and visit:

www.fda.gov/downloads/MedicalDevices/ProductsandMedicalProcedures/DentalProducts/DentalAmalgam/UCM174024.pdf

At Enlow & Vance Dental Partners we dispute the “final” ruling of the FDA and the American Dental Association (ADA) support of these findings regarding dental amalgam and mercury for a number of reasons.

In the FDA ruling the established toxicity of mercury is not disputed.  The FDA clearly admits that mercury is toxic to the patient.  They admit that mercury is released continually from the amalgam/mercury fillings and inhaled.  They acknowledge that certain events such as chewing gum or food, bruxism, and consuming hot beverages or food will increase the amount of vapor released.  That approximately 80% of the inhaled vapor is absorbed by the blood in the lungs.  It is accepted as fact that mercury may cause damage to the brain/nervous system, lungs, liver, immune system and kidneys causing a myriad of illness and disease causing tremors, paralysis, loss of sight and hearing, insomnia, emotional disturbances, dementia, developmental defects and deficits, attention deficit, Alzheimer’s, Parkinson’s, and the list could and should possibly go on.

So, why is amalgam use still advocated?  Money!

Because it is a lower cost restorative material – or is it?

According to the ADA News article Amalgam Economics Ban Would Spike Dental Costs:  Study, by Jennifer Garvin (August 20, 2007, Vol. 38, No. 15), “Amalgam isn’t just a clinical preference or something that draws fire from passionate environmentalists, banning the restoration could have devastating ramifications for access to care and dental costs.”

There is no dispute that composite fillings cost more than amalgam fillings (approximately 18% more) but the economic figures cited by the amalgam advocates are flawed. We would suggest that the true potential long-term costs of mercury toxicity far outweigh the shortsighted immediate cost difference.  A study referenced by the ADA News article mentioned above as fact is The Economic Impact of Regulating the Use of Amalgam Restorations.  This study draws conclusions based on one regional dental insurer’s claim and enrollment data and a very limited ADA Survey of Dental Fees and Dental Services Rendered.  The sampling size may be adequate to make generalizations but hardly accurate enough to make the authoritative conclusions that they derive.

Also, proponents of dental amalgam who conducted this study produced biased conclusions reported to the public as scare tactics.

The insurers claim information was skewed in that the insurer (Delta Dental) applies economic pressure on dentists to place amalgam instead of composite by downgrading benefits to the cheapest possible reimbursement level.  This does, therefore, put economic pressure on the patient to request and accept only the amalgam alternative.  This simply means that regardless of the dentist’s restorative preference the insurance company will only pay for the cheapest product and any alteration from their desire may result in delayed payment for the completed procedure.  Lets face it.  Insurance companies are for-profit entities whose narrow fiduciary responsibility is to their stockholders – not the patient, the purchaser of the policy, or the doctor providing the service.  Consider all insurance corporate profits, dividends, and executive bonuses as part of the high cost of health care.  Hardly, the ones we want gathering data for an impartial decision.

In addition, are we the only ones that find it appalling that because the cost of treatment is approximately 18% higher you can only have the TOXIC OPTION?!!  Patients should have choice.  When given the facts on the dental materials they will choose the healthy, aesthetic, and better restorative – composite.  It is simply a non-issue in our practice.

The article also states “a ban on amalgam would increase the use of crowns and composite resins.”  Duh.  Of course the use of composite would increase – it is the alternative.  As for the increased use of crowns, there is no restorative logic that would dictate more crowns would be needed with composite use over amalgam use.  If there is inadequate tooth structure to restore a tooth with a filling then a crown is indicated independent of the material that would have been used for the filling that can’t be done.  If amalgam is so great why do dental materials manufacturers make all build-up materials that serve as foundation for a crown out of composite?  It seems as though they don’t want to work with the amalgam materials and we don’t blame them for that.

As for the true economics of amalgam use there were systemic health conditions and environmental factors that were conveniently left out of the discussion.  Limited research has been done on the dental amalgam–systemic link.  The very limited research conducted to date was looking for immediate and short-term acute hard and soft signs of mercury toxicity.  As we know, most disease processes take years of exposure to develop.  A person’s ability to adapt to insult allows disease to progress unperceived and gradual until systemic failure.  At this point healthcare is unaware of the causes of many illness.  Therefore, it treats the symptoms of disease and not the root cause.  This is why healthcare is so expensive.  Instead of understanding what causes disease and changing personal habits and health choices to prevent disease we supervise disease and illness by neglect.  Then when physical breakdown occurs we treat their symptoms with a myriad of expensive treatments and pharmaceuticals.  Citing the World Health Organization’s (WHO) policy paper on Mercury in Health Care “recent studies suggests that mercury may have no threshold below which some adverse effects do not occur.”

Human physiology and biochemistry is a staggeringly complex interrelationship of metabolic processes.  For anyone to claim complete understanding of the impact of mercury exposure on the intricate nexus of inter- and intra-cellular metabolism and declare that it is absolutely safe is arrogant and irresponsible.  If it is so safe why has the FDA written a “special controls guidance document” and lengthy precautionary informed consent statement (included in the Appendix I Summary noted above) stating that mercury is “in the device and the possibility of harm if vapors are inhaled.”  Reminds us of the tobacco industry.  In 1991, WHO confirmed mercury vapor from amalgam fillings was the greatest source of exposure in non-industrialized settings, significantly exceeding those set for food and air.  (Source:  http://www.who.int/ipcs/publications/cicad/en/cicad50.pdf.)

If you think mercury is bad for a person’s health what effect do you suppose amalgam has on the environment?  Not good.  Environmental mercury contamination from human activities accounts for 33-67% of all mercury found in the soil, air and water.  The remainder is naturally occurring as a result of normal breakdown of rock and soil.  The organization Environment Canada claims that 1/3 of the mercury found in Canadian waste water is of dental origin.  The Environmental Protection Agency (EPA) has identified 714 of the 1,467 hazardous waste sites in the United States to be mercury polluted.  Not all sites have been tested which means this number will certainly rise.  In the United Kingdom, 53% of all mercury emissions were found to come from dental amalgam and other health related devices.

It is important to remember the occupational health hazards associated with amalgam’s manufacturing, distribution and handling by the dental team treating the patients.  If it is bad for the patient it is certainly bad for the dental professional.  These risks and their associated costs and cleanup were not even mentioned by the amalgam proponents.  Now that is irresponsible.  An 18% increase in the cost of restoration now seems to be a great alternative to the environmental clean-up costs and medical health care expense to treat the results of mercury associated disease.

In our opinion, the only way to completely control the risks associated with mercury is to avoid placing the amalgam fillings altogether.

If you have amalgams we recommend that they be removed.  But, mercury exposure risk is at its greatest during the removal process.  For these reasons we have established a specific safety protocol to protect the patient as well as the doctor and the assistants involved in the procedure.  Most dental offices don’t recognize the dangers of mercury fillings so it is vitally important to seek out a dentist who not only acknowledges the danger but who takes great caution in the removal of these fillings. This is Serious!

For more information regarding our Tampa Dental practice and our opinion on amalgam fillings and Your Dental Fitness visit our website at www.yourdentalfitness.com.

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