AMALGAM WAR

Dona R.E.A.Ramanayake Dental Materials 1/16/2013

Amalgam war
Introduction
The current amalgam issue is not new. In the 1840s, there was even an amalgam war between the dentists who advocated the use of gold as a restorative material and those who used silver amalgam as a filling material. There were complaints of the ill effects of mercury in the amalgam as a health problem. The split on this issue threatened to divide dentistry into two camps: those who used amalgam and those who condemned it. The first national dental society in the United States, the American Society of Dental Surgeons, had to disband because of the controversy. However, amalgam has proven to be an excellent restorative material with few side effects amalgam saves teeth.

Amalgam
In dentistry, amalgam is an alloy of mercury with various metals used for dental fillings. It commonly consists of mercury (50%), silver (~22-32% ), tin(~14%), copper (~8%), and other trace metals. In the 1800s, amalgam became the dental restorative material of choice due to its low cost, ease of application, strength, and durability. Recently however, its popularity has diminished somewhat. Concern for aesthetics, environmental pollution, health, and the availability of improved, reliable, composite materials have all contributed. In particular, concerns about the toxicity of mercury have made its use increasingly controversial. Due to a worldwide plan to phase out the use of mercury, Norway and Denmark have deliberated in 2009 a ban of mercury dental amalgam. Sweden announced a similar ban and dentists in Sweden will no longer be allowed to use mercury in fillings after April 1, 2008. The Swedish amalgam ban is for both environmental and health issues, according to the Swedish authorities.

History of amalgam in dentistry

Dentistry in the U.S. did not develop as a separate profession until the period of 1780 to 1800. There were two types of "dentists" at this time. There were those who had medical training and practiced both professions. These were medical-dentists. Then there were "those who were merely craftsmen and engaged in some other trade, such as barbering, carving of wood, ivory and metals...among them were the itinerant tooth pullers". These were called craftsmen-dentists. There were no American national dental organisations and no dental schools in existence before 1840. Dentists were either self-taught by "trial and error on patients" or were apprenticed under a practicing medical-dentist. Also founded in 1840 was the first national dental organisation. It was called the American Society of Dental Surgeons. Its members were medical-dentists, not barbers, carpenters, or sculptors. The medical-dentists were vitally concerned with the medical, biological and mechanical aspects of dentistry. The craftsmen-dentists were concerned with the mechanical aspects and did not consider medical questions. Mercury-amalgam was first brought into the U.S. from Europe by the Crawcour brothers in 1833. They had a very strong, effective advertising campaign that promised to save decayed teeth by filling them without pain in minutes. The Crawcours were considered unethical charlatans by many medical-dentists. They removed gold fillings and replaced them with mercury-amalgams. They did not dry decayed teeth or even remove the decay before they packed the hole. There were even some reports of their packing amalgam between teeth when there were no cavities at all. This brings us to the amalgam war. "The amalgam war was the war between the craftsmen ideal of ease of manipulation and the medical ideal of avoidance of danger of systemic mercurial poisoning". Mercury was clearly known to be poisonous by the physicians in the 1830's.

The Amalgam War: 1841-1855

First Amalgam War

Figure :Crawcours advertisement

In 1833, two opportunists from England, the Crawcour brothers, brought amalgam fillings to America. The Crawcours were a family of five Polish dentists who acquired a superficial knowledge of dentistry in France before unleashing themselves on the English public in the 1780s. They advertised extensively, proclaiming their skill and claimed to be surgeon-dentists to the royal family and patronized by the courts of Austria, France, Russia, Prussia, and Belgium.In 1833, two of the Crawcour brothers invaded the United States with a cheap coin silver amalgam they called royal mineral succedaneum .The Crawcours set up lavish and elegant dental parlours in New York City and competed with the ethical dentists. With the grace and mannerisms of the French, they catered to the wealthy and influential residents of the city. The patients reclined on sumptuous easy chairs, and their dentistry was painless since they merely sloped and thumbed a soft plastic mix of their impure material into cavities without removing the decay. They were out-and-out moneygrabbing charlatans who exploited the public, charging exorbitant fees. As the Crawcours business boomed, the conscientious practitioners, who were still working with gold and tin, lost patients. Later, as the brothers fillings began to fall out, discolor the teeth, and cause tooth fracture because of the cheap amalgams expansion, the public realized they had been cheated. With that, the brothers beat a hasty retreat in 1834 back to Europe, leaving a long trail of victimized patients and exasperated dentists. However, the damage had been done amalgam now had a bad reputation, despite the fact that if used properly, it would later prove to be an excellent restorative material. In fact, in 1848, several dentists were suspended from the society in New York for malpractice because they were using amalgam. Thus ended the First Amalgam War.

Second Amalgam War

For the next half century, the use of amalgams was abandoned in the United States. But then, near the turn of the twentieth century, experiments were again performed in an effort to improve these fillings. It was noticed that when different powdered metals were added to the silver filings (powder), the expansion rate was altered. When these new metal alloy mixtures were triturated

with mercury, the "silver" fillings no longer were cracking teeth. The metal element that was key in controlling the expansion rate was tin. As a result of this finding, dentists agreed that the perfection of dental amalgam had been obtained. Unfortunately most of these dentists were showing their true colors. They were indeed only micro-mechanics and not doctors. They were mainly interested in making more easy money with these quick, simply placed fillings and either ignored or forgot that mercury is a harmful, deadly poison. The anti-amalgamists lost the Second Amalgam War.

Third Amalgam war

It was not until 1981 that this mercury issue was reopened. Thus began the Third Amalgam War. This time, Sweden was at the forefront of the battle. A brilliant neurobiologist, Mats Hansen, at the Institute of Zoo physiology at the University in Lind, Sweden, sent a letter to the National Board of Health of Sweden demanding an unprejudiced evaluation of the hazards of dental amalgam.

Since the notion that dental mercury fillings are toxic is still very controversial in numerous circles, here are conclusive studies obtainted from peer-review medical and dental journals. The first was printed in 1979 in Lancet, the most prestigious peer-review medical journal in Great Britain. The title was "Chewing releases mercury from fillings" and it was written by Gay, Cox and Reinhardt. Then in 1984 in the American Journal of Dental Research, Abraham, Svare and Frank studied the effect of dental amalgam restorations on blood mercury levels. They found that the blood mercury concentrations were positively correlated with the number and surface area of amalgam restorations and were significantly lower in the group without dental fillings. It was not until 1986 that, in Lakartidningen, a Swedish medical journal, that Frieberg, Kullman, Lind and Nylander described a study relating mercury in the central nervous system to dental amalgams. Eighteen cadaver brain species were analyzed for organic and inorganic mercury. The brain specimen from the cadavers with amalgam fillings had about three times the mercury levels than the brain specimen from cadavers without amalgam fillings. The amount of mercury in the brain samples was directly related to the number of amalgam fillings in the individual.

The really impressive cadaver study was reported in 1987 in the Journal of the California Dental Association by Eggleston ,entitled "Correlation of dental amalgam with mercury in brain tissue." In this study, 77 cadavers were analyzed for total mercury content. Data from this project demonstrated a positive correlation between the number of occlusal surfaces of dental amalgam and mercury levels in the brain. Although the cause of the anti-amalgamists in America began slowly in the middle 1980s, it gained momentum in the 1990s. The political battle in America against dental amalgam began on 4 November 1986 when California voters passed their states Proposition 65, the California Safe Drinking Water and Toxic Enforcement Act of 1986. This act, now a part of the states health and

safety code, states: No person in the course of doing business shall knowingly and intentionally expose any individual to a chemical known to the state to cause cancer or reproductive toxicity without first giving clear and reasonable warning to such individual (California Health and Safety Code #25249.6). No person includes dental amalgam manufacturers, suppliers, and dentists. Penalties for violations accrue at a rate of $2,500/day, until the violations are corrected. How did the American Dental Association (A.D.A.), the professional organization of dentists in this country, respond to Proposition 65? On 1985, while Proposition 65 was being debated in the California state senate, J.M. Coady, D.D.S., the executive director of the A.D.A., issued a formal notification stating that as a voluntary professional organization, it [the A.D.A.] has no legal authority to regulate the use of any dental material. Further, in 1990 i n the Journal of the American Dental Association, the division of scientific affairs of the A.D.A. published an article entitled: When Your Patients Ask About Mercury in Amalgam (120:395-8). In this peer-reviewed journal sent to all members of the A.D.A., the A.D.A. leadership admitted that there is no scientific documentation establishing the safety of dental amalgam and that the defense of safety is based only on its having been used for over 150 years. In actuality, dental amalgams have been consistently used for only about 100 years. After Proposition 65s passing in 1986, the next noteworthy date in the Third Amalgam War occurred in October 1992. At that time, a civil lawsuit was filed in the Superior Court of the State of California, Santa Clara, as case no. 718288: W.H. Tolhurst v. Johnson & Johnson Consumer Products, Inc., Engelhard Corp., ABE Dental, Inc., American Dental Association. The plaintiff was a patient claiming his exposure to mercury from his dental amalgam fillings deteriorated his health. Then the A.D.A. was sued along with the dentist responsible for placing the mercury filling gave the dentist confidence that Big Brother would protect him. To his dismay, however, attorneys for the A.D.A. presented the following argument in court: [T]he A.D.A. owes no legal duty of care to protect the public from allegedly dangerous products used by dentists. The A.D.A. did not manufacture, design, supply or install the mercury-containing amalgams. The A.D.A. does not control those who do. The A.D.A.s only alleged involvement in the product was to provide information regarding its use. Dissemination of information relating to the practice of dentistry does not create a duty of care to protect the public from potential injury. The judge dismissed the A.D.A. as a defendant in the case, leaving the accused dentist to fend for himself.

Responding to the lawsuit, California State Sen. Diane Watson authored, and Gov. Gray Davis signed, Senate Bill #934 in 1992. That bill required that a mercury amalgam fact sheet be given by the dentist to the patient, and that the patient read it before any mercury fillings are placed. Also responding to the lawsuit, the Environmental Law Foundation, a California nonprofit watch-dog group, in 1993 issued a directive to amalgam manufacturers to provide health warnings concerning their products. In an unrelated move, in May 1994, the U.S. Department of Health and Human Services updated their Toxicological Profile for Mercury, a compendium issued every three or four years b y their Agency for Toxic Substances and Disease Registry. Page 5 of their 366-page book reads: How might I be exposed to Mercury?

A most likely form of exposure is by absorbing mercury vapors released from dental fillings. Most silver-colored dental fillings are about 50% metallic mercury. Two years later, on 5 August 1996, Californias Ninth Circuit Court of Appeals mandated the posting of a specific sign in all dental offices using amalgam. The wording of this warning conforms with the requirements of Proposition 65 and is as follows: WARNING! This office uses amalgam filling materials which contain and expose you to mercury, a chemical known to the State of California to cause birth defects and other reproductive harm. Please consult your dentist for more information. By 2001, dentists in California were not the only ones required to post warnings about amalgam fillings. Arizona, Maine and Colorado also had passed laws requiring that similar warnings be posted at dental offices using amalgam. What about the rest of the world? During the last decade, Germany, Austria and Canada joined Sweden in prohibiting placing mercury fillings in pregnant women.

The debate continues 1990-2002

Haikel and his group at the Pasteur University in their study of the patients exposure to mercury vapors in 1990 found that mercury vapor was released during insertion, condensation, carving, and removal of amalgam. The mercury was measured in the intraoral air using atomic absorption spectrometry.The same year, Clarkson reported that acrodynia or mercury poisoning in young children was not caused by chewing on amalgam fillings. In 1991, the FDA dental devices panel concluded that none of the data presented show a direct hazard to humans from dental amalgams.The same year, Dr. L. Jackson Brown, acting director of Epidemiology and Disease Prevention Program, National Institute of Dental Research, National Institute of Health, Bethesda, Md., called the amalgam question an issue serious enough to merit additional research.Moreover, in 1991, Mortensen brought up the question of the safety of the composite restorations that are replacing amalgam. Do composite materials remain unchanged in the hostile oral environment of physical and chemical attacks; and are the dental professionals who inhale the solvent-laden vapors on a daily basis safe? Has our experience with composites been long enough to presume safety?Eley and Cox also brought up the long-term biocompatibility of composites and their shorter clinical life, adding to both the cost and progressive tooth destruction.In 1996, at a symposium held by the International Association for Dental Research (Continental European and Scandinavian Divisions) in Berlin, Germany, Ekstrand et al. concludedthat exposure to amalgam fillings does not cause serious health risks to large numbers of individuals in the general population and, consequently, removal of intact amalgam fillings is not indicated. Despite this statement, the Swedish government in 1995 banned the use of amalgam in all public health clinics for children, and recommended that it not be used in adults after 1997.The same year, Sandborgh-Englund et al. in Sweden investigated kidney function in 10 subjects after exposure to mercury during dental treatment and found no signs of renal toxicity in conjunction to and after mercury exposure from \the removal of amalgam fillings.On May 13, 1997, the NBC network aired a segment on Dateline, which provided a very accurate and well-balanced review of the dental amalgam issue.The same year, Eley reviewed the dental literature and noted that a pacifying layer of corrosive products is formed on amalgam fillings, which is disturbed by tooth brushing and chewing. The mercury released is in the form of vapor, which passes into the intraoral air or as mercury ions, which passes into the saliva and gastrointestinal tract (between 1 to 2 g per day).The ADA Council on Scientific Affairs adopted new recommendations for mercury hygiene in October 1998 to update the 1991 guidelines published by the former ADA Council on Dental Materials, Instruments and Equipment. Basically they were the same as the previous ones, but recommended recycling scrap amalgam according to state and federal laws, disposing of mercurycontaminated items in sealed bags, and removing professional clothing before leaving the workplace. As a sign of the times, in 1999, some 86 million composite restorations were placed in the United States as contrasted to 71 million amalgam restorations. The reasons were the improvements in composite materials and techniques, and the public demand for more esthetic, toothcolored restorations.In 2002, the Food and Drug Administration proposed to upgrade dental mercury from a Class I (low risk to patients) to a Class II medical device, which would require amalgam manufactures to list the special controls and regulations of manufacture of the product ingredients on their labels.Gottwald and associates, in their 2002 publication Psychotherapy and Psychosomaticsfound no significant correlation between psychic distress and mercury burden. They concluded that the theory that amalgamrelated complaints are often an expression of underlying psychic problems seems to be more

reasonable than the theory of mercury intoxication or the theory of an amalgam allergy.In December 2003, Dr. Frederick Eichmiller, director of the ADA Foundations Paffenbarger Research Center, testified, The overriding body of scientifically valid and peer-reviewed research supports only one conclusion: that amalgam is a safe, affordable, and durable material. He added that the major U.S. and international scientific and health organizations, including the national Institutes of Health, U.S. Public Health Service, Food and Drug Administration, Centers for Disease Control and Prevention and World Health Organization have all stated that dental amalgam is a safe restorative material.

Further Experimental studies

Dentists have the highest suicide rate. One symptom of mercury poisoning is depression. Maybe the high suicide relate is correlated to a higher than average amount of mercury accumulation in the brain of dentists using mercury fillings. In fact, in 1986, one year before the Eggleston, Nylander et al., publication, Lancet had published a research study by Nulander of Sweden. Nylander had analyzed seven cadavers. Three of them had been dentists. He found very large amounts of mercury in their pituitary glands. The non-dentist cadavers had much less in their pituitary glands and brains. It was surmised that the mercury from the vapor of dental amalgams being placed in teeth may have been absorbed by the nasal mucosa and directly transported to the cranial cavity and the pituitary gland.

Although many organs have also been shown to accumulate mercury to a greater extent in someone with more fillings, the brain studies are most crucial and important. These studies culminated with the work of Murray Vimy, D.D.S., in 1990. Vimy conducted his research at the University of Calgary in Alberta, Canada, and had his double-blind study published in one of the most revered medical peer-review journals in the world, the American Journal of Physiology. Vimy drilled and filled the molars of half of the ewes in his sampling with silver amalgam fillings containing radioactively tagged mercury. The other half of the ewes in his study had no fillings of any kind placed in their teeth. When the fetuses of these ewes with fillings were analyzed, he discovered that they had the same radioactively tagged mercury in their brain cells as was present in the parent ewe's fillings. The control group of fetuses had no mercury in their brain cells at all! What may be concluded from this brilliant experiment? #1 Mercury is released from silver-mercury fillings. #2 Mercury passes through the placental barrier. #3 Mercury in our blood passes the blood-brain barrier to enter our brain cells.

This impressive, well-planned study ruled out the possible influence of environmental sources of mercury by using radioactively tagged mercury. Many of the previous experiments indicated the release of mercury from amalgams and its accumulation in the brain, kidney, pituitary and other organs, and the conduction of mercury through the circulatory system and placental barrier. However, this was the first experiment to incorporate all of these factors in one.

Conclusion

Amalgam has served the dental profession for more than 150 years. Incidents of true allergy to mercury have been rare (only 41 cases have been reported since 1905), and attempts to link its usage with such diseases as multiple sclerosis and Alzheimers have not been scientifically proven, although there may be some association between amalgam restorations and oral lichenoid lesions.As recently as May 2005, the ADA endorsed amalgam as being safe for pregnant women.Still, the anti-amalgamists persist in their efforts to discredit the dental profession and the ADA for supporting amalgam as an economical, long-lasting, tooth-saving, and effective restorative material. On the positive side, perhaps because of their efforts, more emphasis has been placed on mercury hygiene in the dental office. Where the story of amalgam will end remains for the future.

References :
Dentistry: Stepping Out of the 1830's ,By James E Hardy, D.M.D. The Third Amalgam War, Part 1 ,October 29, 2005 by Stephen R. Goldberg, DDS, CCN AMALGAM: Its History and Perils ,J.M. Hyson, Jr., DDS, MS, MA