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The Last Days of Mercury Fillings?

Posted Oct 13 2009 10:04pm

“Are Amalgam’s Days Numbered?” asks a recent opinion piece…er, article on DrBicuspid.com:

While the Bush administration long opposed any legally binding measures on mercury, the Obama administration is taking a very different tack. A global crackdown on its use – particularly in industrial applications – was unanimously agreed upon at the United Nations Environment Programme’s (UNEP) Governing Council Meeting in February in Nairobi, Kenya.

The governments of more than 140 countries, including the U.S., voted to begin developing an international treaty on the use and supply of mercury, according to a UNEP press release. They also agreed that the risks to human health and the environment are so significant that accelerated action under a voluntary Global Mercury Partnership is needed while the treaty is being finalized.

Being that DrBicuspid.com’s mission is “to deliver useful, trustworthy, and relevant news, features, columns, and more, that will help you [dentists] make your practice better, faster, smoother, and more profitable,” the next question in the article is, of course, how will this affect the industrial dentists?

The U.S. Environmental Protection Agency (EPA) – which estimates that dentists discharge approximately 3.7 tons of mercury each year to state and municipal wastewater treatment plants – says it is too soon to tell. But given that the U.S. Congress last year passed the Mercury Export Ban Act (introduced by then Sen. Barack Obama), which outlaws exports of elemental mercury beginning in 2013, the storage and transport of mercury could become more restricted in the U.S. as well.

It could also have implications for the regulation of dental amalgam wastewater, said Rod Mackert, D.M.D., Ph.D., a professor of dental materials at the Medical College of Georgia School of Dentistry and a specialist in dental mercury issues – although he doesn’t think it should.

Ah, Dr. Mackert again. And he’s baffled – just baffled!

“I don’t understand why there is such a focus on dental mercury or why dentistry is even considered in all this,” he said in an interview with DrBicuspid.com. “When you look at the amount of dental mercury it contributes to the environment, you could eliminate all of it today and it would have no detectable effect on what is going out into the environment. Other sources, such as the burning of coal for electric power, are so much bigger.”

So it’s okay to release a known neurotoxin into the environment so long as somebody else is releasing more of it than you are? Got it.

According to the article, “U.S. dental offices are the third largest users of mercury, consuming around 30 million tons of amalgam per year.” But Mackert, in his own inimitably charming way, tries to blow off the issue by noting how relatively little of this mercury is released into the air or water. While this may be the case, the claim ignores the glaring issue of where the bulk of the mercury does go: directly into human bodies via all those amalgam fillings.

The authors then note that several countries – including Sweden, Norway and Denmark – have already banned the use of mercury in dentistry.

Given the Obama administration’s position on mercury, will the U.S. follow suit?

Probably not.

And why not?

The ADA remains steadfast in its position that amalgam is “a valuable, viable, and safe choice for dental patients,” concluding in comments to the FDA last year that “the current evidence does not support a link between dental amalgam and systemic diseases or risks to children, pregnant women, or developing fetuses.”

* * *
Still, a report issued last June by J.P. Morgan concluded that “We do not believe that FDA will ban mercury fillings altogether, but it will likely restrict use in vulnerable populations. We do believe that the agency will ask for the label to indicate that mercury is an ingredient in the filling, and that special populations should be exempt from such fillings, such as nursing women, pregnant women, young children, and immunocompromised individuals.”

Again, we ask: if mercury fillings are so safe and if little or no mercury vapor is released from them, why should such restrictions be necessary? And while the ADA did tell the FDA that they acknowledge no evidence of risk, the FDA now acknowledges concern, at least for those “special populations.”

Finally, we get to the all-important matter of dentists’ bottom line:

A 2007 article on the economic impact of regulating amalgam restorations in the U.S. found that “If amalgam restorations are banned for the entire population, the average price of restorations before 2005 and after the ban would increase $52 from $278 to $330, and total expenditures for restorations would increase from $46.2 billion to $49.7 billion. As the price of restorations increases, there would be 15,444,021 fewer restorations inserted per year. The estimated first-year impact of banning dental amalgams in the entire population is an increase in expenditures of $8.2 billion” (Public Health Reports, September/October 2007, Vol. 122:5, pp. 657-63). An amalgam ban would have substantial short- and long-term impact on increasing expenditures for dental care, decreasing utilization, and increasing untreated disease, the authors concluded. ( Emphasis added )

Now, one of the reasons industrial dentists love amalgams is that they are less technique-sensitive and thus can be done more quickly. They can work on more patients in less time and therefore make more money even though the materials they’re using are quite cheap. Yet because those materials are cheap – and because insurance companies will foot the bill – some dentists will actually place more fillings than necessary, taking an aggressive approach where wait-and-see may be more appropriate. And this overkill may account for at least some of that decrease in restoration placement. It’s certainly hard to believe that a difference of $52 would be prohibitive and dissuade people from getting cavities filled. (If it is, a little talk about the cost of not filling them – the expense of root canal therapy or tooth loss requiring a more extensive restoration afterwards – should be sufficient persuasion, as should the pain from leaving caries untreated.)

So the objection seems to run something like this: We’ll make less money because people won’t want to pay more for composite fillings, and because people won’t want to pay, they won’t get treatment and they’ll suffer. Ergo, let us keep using mercury fillings.

Okay. But then we can’t make much sense of this final quote from Mackert:

“The white fillings are more aesthetic, which is why patients prefer them, even in the back teeth. I think this has been the main thing driving the preference [for composites], although likely the concern over mercury has had some effect as well.”

People won’t get them because they’re too expensive, but they prefer them and so they get them instead of amalgams.

What logic!


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Can

“Are Amalgam’s Days Numbered?” asks a recent opinion piece…er, article on DrBicuspid.com:

While the Bush administration long opposed any legally binding measures on mercury, the Obama administration is taking a very different tack. A global crackdown on its use – particularly in industrial applications – was unanimously agreed upon at the United Nations Environment Programme’s (UNEP) Governing Council Meeting in February in Nairobi, Kenya.

The governments of more than 140 countries, including the U.S., voted to begin developing an international treaty on the use and supply of mercury, according to a UNEP press release. They also agreed that the risks to human health and the environment are so significant that accelerated action under a voluntary Global Mercury Partnership is needed while the treaty is being finalized.

Being that DrBicuspid.com’s mission is “to deliver useful, trustworthy, and relevant news, features, columns, and more, that will help you [dentists] make your practice better, faster, smoother, and more profitable,” the next question in the article is, of course, how will this affect the industrial dentists?

The U.S. Environmental Protection Agency (EPA) – which estimates that dentists discharge approximately 3.7 tons of mercury each year to state and municipal wastewater treatment plants – says it is too soon to tell. But given that the U.S. Congress last year passed the Mercury Export Ban Act (introduced by then Sen. Barack Obama), which outlaws exports of elemental mercury beginning in 2013, the storage and transport of mercury could become more restricted in the U.S. as well.

It could also have implications for the regulation of dental amalgam wastewater, said Rod Mackert, D.M.D., Ph.D., a professor of dental materials at the Medical College of Georgia School of Dentistry and a specialist in dental mercury issues – although he doesn’t think it should.

Ah, Dr. Mackert again. And he’s baffled – just baffled!

“I don’t understand why there is such a focus on dental mercury or why dentistry is even considered in all this,” he said in an interview with DrBicuspid.com. “When you look at the amount of dental mercury it contributes to the environment, you could eliminate all of it today and it would have no detectable effect on what is going out into the environment. Other sources, such as the burning of coal for electric power, are so much bigger.”

So it’s okay to release a known neurotoxin into the environment so long as somebody else is releasing more of it than you are? Got it.

According to the article, “U.S. dental offices are the third largest users of mercury, consuming around 30 million tons of amalgam per year.” But Mackert, in his own inimitably charming way, tries to blow off the issue by noting how relatively little of this mercury is released into the air or water. While this may be the case, the claim ignores the glaring issue of where the bulk of the mercury does go: directly into human bodies via all those amalgam fillings.

The authors then note that several countries – including Sweden, Norway and Denmark – have already banned the use of mercury in dentistry.

Given the Obama administration’s position on mercury, will the U.S. follow suit?

Probably not.

And why not?

The ADA remains steadfast in its position that amalgam is “a valuable, viable, and safe choice for dental patients,” concluding in comments to the FDA last year that “the current evidence does not support a link between dental amalgam and systemic diseases or risks to children, pregnant women, or developing fetuses.”

* * *
Still, a report issued last June by J.P. Morgan concluded that “We do not believe that FDA will ban mercury fillings altogether, but it will likely restrict use in vulnerable populations. We do believe that the agency will ask for the label to indicate that mercury is an ingredient in the filling, and that special populations should be exempt from such fillings, such as nursing women, pregnant women, young children, and immunocompromised individuals.”

Again, we ask: if mercury fillings are so safe and if little or no mercury vapor is released from them, why should such restrictions be necessary? And while the ADA did tell the FDA that they acknowledge no evidence of risk, the FDA now acknowledges concern, at least for those “special populations.”

Finally, we get to the all-important matter of dentists’ bottom line:

A 2007 article on the economic impact of regulating amalgam restorations in the U.S. found that “If amalgam restorations are banned for the entire population, the average price of restorations before 2005 and after the ban would increase $52 from $278 to $330, and total expenditures for restorations would increase from $46.2 billion to $49.7 billion. As the price of restorations increases, there would be 15,444,021 fewer restorations inserted per year. The estimated first-year impact of banning dental amalgams in the entire population is an increase in expenditures of $8.2 billion” (Public Health Reports, September/October 2007, Vol. 122:5, pp. 657-63). An amalgam ban would have substantial short- and long-term impact on increasing expenditures for dental care, decreasing utilization, and increasing untreated disease, the authors concluded. ( Emphasis added )

Now, one of the reasons industrial dentists love amalgams is that they are less technique-sensitive and thus can be done more quickly. They can work on more patients in less time and therefore make more money even though the materials they’re using are quite cheap. Yet because those materials are cheap – and because insurance companies will foot the bill – some dentists will actually place more fillings than necessary, taking an aggressive approach where wait-and-see may be more appropriate. And this overkill may account for at least some of that decrease in restoration placement. It’s certainly hard to believe that a difference of $52 would be prohibitive and dissuade people from getting cavities filled. (If it is, a little talk about the cost of not filling them – the expense of root canal therapy or tooth loss requiring a more extensive restoration afterwards – should be sufficient persuasion, as should the pain from leaving caries untreated.)

So the objection seems to run something like this: We’ll make less money because people won’t want to pay more for composite fillings, and because people won’t want to pay, they won’t get treatment and they’ll suffer. Ergo, let us keep using mercury fillings.

Okay. But then we can’t make much sense of this final quote from Mackert:

“The white fillings are more aesthetic, which is why patients prefer them, even in the back teeth. I think this has been the main thing driving the preference [for composites], although likely the concern over mercury has had some effect as well.”

People won’t get them because they’re too expensive, but they prefer them and so they get them instead of amalgams.

What logic!


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