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Dental Materials

Amalgam
War
Assignment

VISHESH JAIN
1/21/2013
ROLL NO. 110301066
SERIAL NO. 25
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Acknowledgement

I take this opportunity to express my profound gratitude and deep regards to my


guide Mr. Nagrajan Upadhaya for his exemplary guidance, monitoring and
constant encouragement throughout the course of this thesis. The blessing, help
and guidance given by him time to time shall carry me a long way in the journey
of life on which I am about to embark. I also take this opportunity to express a
deep sense of gratitude to Mr. Kishore Ginjupalli for his cordial support, valuable
information and guidance, which helped me in completing this task through
various stages. I would like to acknowledge and extend my heartfelt gratitude to
Mr. Abhishek Bhagat for the help and inspiration he extended. Lastly, I thank
almighty, my parents and friends for their constant encouragement without which
this assignment would not be possible.

Vishesh Jain

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Index

Introduction 3

Dental Amalgam 4

Amalgam War 6

Alternative Materials 13

Conclusion 14

Bibliography 15

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Introduction

Dental amalgam is an alloy composed of a mixture of approximately equal parts


of elemental liquid mercury and an alloy powder. The first use of amalgam was
recorded in the Chinese literature in the year 659, and for the last 150 years,
amalgam has been the most popular and effective restorative material used in
dentistry. The popularity of amalgam arises from its excellent long term
performance, ease of use and low cost. Before the 1970s, amalgam accounted for
more than 75 percent of all restorations. In 1979, the total number of amalgam
restorations placed by dentists in the United States was estimated at 157 million.
During the past 20 years, however, the use of amalgam in the United States has
been declining, largely due to the decreasing incidence of dental caries, more
frequent use of crowns and the availability of tooth-colored alternative restorative
materials for certain applications. In 1991, the total number of amalgam
restorations placed was estimated at approximately 96 million, which accounted
for about 50 percent of all restorations. Despite the long history and popularity of
dental amalgam as a restorative material, there have been periodic concerns
regarding the potential adverse health effects arising from exposure to mercury in
amalgam. As early as 1850, some U.S. dentists claimed that removing amalgam
fillings could bring miraculous cures in patients with chronic disease. Even
today, some dentists remove amalgam restorations from patients as a result of
claims that amalgam restorations result in serious adverse health effects.

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Dental Amalgam

Composition

Amalgammation
Alloy (Ag-Sn-Cu) mixed with approximately 50% mercury (Hg), within
several hours, no free mercury remains
stable intermetallic compounds
Ag-Sn-Cu + Hg Ag-Sn-Cu + AgHg + Cu-Sn

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Why Amalgam?

Inexpensive
Ease of use
Proven track record
>100 years
Familiarity
Resin-free
less allergies than composite

Mercury Dose from Amalgam


Average daily dose from 8 10 amalgam surfaces is about 1-2ug per day (well
below threshold levels). Estimates are that 450-530 amalgam surfaces would be
necessary to achieve considerable biological effects. Even if all 32 teeth were
restored on all surfaces with amalgam, the total number of surfaces would be
only 192. Other studies have measured renal function in with whom all
amalgams were removed simultaneously (worst case). Despite markedly elevated
blood, plasma, and urine levels of mercury, no renal impairment has been noted.
Mercury is persistent, bio-accumulative, and toxic and is responsible for
significant environmental degradation around the world.
Although its use in most product applications does not present a risk, the
subsequent disposal of any product containing mercury does.
Amalgam is no different.

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Amalgam War

Dental amalgam has been controversial ever since it was introduced, early in the
nineteenth century, because of its mercury content. People of the Napoleonic era
knew full well that mercury was poisonous, and the best that anyone has ever
claimed about amalgam is that the mercury exposure may be too small to hurt
anyone. Over time, though, a great body of evidence has accumulated showing
that mercury is released from amalgam in significant quantities, that it spreads
around the body, including from mother to fetus, and that the exposure causes
physiological harm.

The first Amalgam War

The English brothers Crowcour opened in New York in 1833 a dental practice
where they used the "new" amalgam of silver and mercurial, the so called "silver
fillings". The fillings where supposed to compensate gold and also be much
cheaper. After a few years amalgam was declared to be an extremely bad tooth
filling material witch also caused sickly changes in the mouth, and all sorts of
terrible side effects.
Many American Dental Associations excommunicated unanimously the use of
amalgam and in 1848 eleven dentists where excluded from the Dental
Association in New York because they had neglected their patients by using
amalgam. . As the use of amalgam grew, the American Society of Dental
Surgeons fell apart, and in 1859, the proamalgam faction formed the American
Dental Association, the same organization that leads the dental profession in the
USA to this day, and remains steadfast in its defense of amalgam.

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The Second Amalgam War

In the rear 1926 a German chemist Alfred Stock called out with his own
warnings about using mercurial Amalgam. Stock mentioned his own experiences
about mercurial poisoning. Stock was himself ill from a slowly insidious
mercurial poisoning. This is a summary of all the symptoms he had:
First stage: Mental disturbances, tiredness, reduced capacity to work, irritation,
swelling in the mucous membrane in the upper area of the nose cavity.
Second stage: Very high tiredness, reduced concentration, bad memory for
numbers and names, irritation, capricious, the feeling of being "stupid", stopped
nose with dryness, nose secretion viscous and at times bloody, singing in ears,
headache (often in forehead), bleeding gums when brushing teeth, Irregular heart
activity, periodical diarrhea, had to go often to the toilet, slight trembling.
Third stage: Headache (very troublesome), dizziness, giddiness, inability to act,
depression, backaches, urinating often, intestine catarrh, diarrhea , Doge catarrh,
bleeding gums, the sense of sullen galle, paradentosis, dental caries, decreased
saliva excrete, laryngitis.
Gradually after moving to "Hg-free" laboratory facilities and also removing his
mercurial fillings to friendlier materials, Stock was able to recover from his
severe mercurial poisoning and also contribute with new important findings to
research.
Unfortunately now came the second world war over Europe and under the rug
where swept all trivial discussions about "capricious" people, mentally abberated
politicians and statesmen, changing from fury to deep depression all probably
caused by mercurial poisoning and all while" the second amalgam war" fell in
forgetfulness.

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The Third Amalgam War

We are currently in the advanced stages of the third amalgam war. The argument
was reopened in the late 1970s, as modern methods of detecting the presence of
trace amounts of mercury were introduced, including mass spectrophotometry
and the Jerome mercury vapor detector. Famed Swedish neurobiologist Mats
Hansen, reviewing a series of studies of the early and mid-twentieth century, sent
a letter to the Swedish National Board of Health demanding an unprejudiced
evaluation of the hazards of dental mercury amalgam. Due to Hansen and others
efforts, Sweden banned the use of amalgams in pregnant women in 1987.
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 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.
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. On 1985, while Proposition 65 was being debated in the California
state senate, 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 in 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. 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.

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Concerns identified by Lorscheider and colleagues include possible detrimental
effects of mercury on the immune, renal, reproductive and central nervous
systems, as well as on oral and intestinal bacteria. Other reviews of the literature,
however, result in very different conclusions. Halbach found that the combined
mercury intake from food and amalgam did not exceed the acceptable daily
intake and that blood and urinary mercury levels in patients with dental
amalgams were below one tenth of the critical concentrations usually associated
with the onset of subclinical health effects attributable to mercury toxicity.
Furthermore, a study by Langworth and colleagues examined the immune
systems of chloralkali workers, dental personnel, subjects allergic to mercury,
subjects with alleged amalgam disease and control subjects. Nearly all values fell
within the reference interval. No significant difference in the immune parameters
was found, and no significant correlation between mercury exposure parameters
and the immune parameters was noted. Hultman and colleagues, studying the
effects of amalgam on the immune system, reported that chronic
hyperimmunoglobulinemia, among other immune irregularities, developed in a
time- and dose-dependent manner after implantation of amalgam or silver alloy
in genetically sensitive mice. These effects, however, could not be attributed
directly to mercury from amalgam, as similar immune irregularities were
observed in mice that received silver alloy without mercury.
Indeed, another study using human subjects failed to detect any immune
irregularities attributable to mercury from amalgam. This study found that, while
there was a direct correlation between the number of dental amalgams and
plasma mercury concentrations, neither the number of amalgams nor the plasma
mercury concentration had any significant influence on a wide range of immune
factors, including B and T lymphocytes; T4 and T8 monocytes; neutrophilic,
eosinophilic and basophilic granulocytes; large unstained cells; and a range of
humoral factors.
The renal and central nervous systems also are considered susceptible to the
effects of mercury toxicity. A study by Herrstrom and colleagues investigated the
association between the number of amalgam restorations, urinary mercury and
proteinuria in 48 male students. The presence of certain proteins (albumin, alpha-
1-microglobulin, or N-acetyl-D glucosaminidase) in two urine samples was
considered to be indicative of a tubular or glomerular lesion that might be related
to mercury toxicity. The study found no significant relationship between
proteinuria and amalgam or urinary mercury, and therefore did not suggest that
mercury from amalgam results in kidney dysfunction in humans.

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The ADA maintains that dental amalgam is safe and inert. On its website, it
states, Dental amalgam contains elemental mercury combined with other metals
such as silver, copper, tin and zinc to form a safe, stable alloy. Dental amalgam
has been used for generations to fill decayed teeth that might otherwise have
been lost to decay. While the ADA is providing dentists with brochures to calm
patients concerns about the safety of amalgam, the amalgam manufacturers place
inserts with their product that warn dentists of health risks from amalgam. In
1997, DENTSPLY, a leading amalgam manufacturer, disclosed that amalgam is a
neurotoxin (toxic to the brain and central nervous system), a nephrotoxin (toxic
to the kidneys) and a lung and skin sensitizer.
The ADAs position on the safety of amalgam has been made even more
untenable by the fact that the Environmental Protection Agency (EPA) has
declared amalgam to be a hazardous material and issues specific instructions for
its handling and disposal.
ADA institutes mercury hygiene campaign
1970 - 1990
urinary mercury levels lowered 50 %
a shift in concerns
from occupational risk to dentists to patient risk
ability to measure mercury release from amalgam restorations in
expired air
early tests grossly overestimated

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For more than 150 years, dental amalgam has provided excellent clinical service
with few documented adverse effects in either dental patients or dental
professionals. While occupational exposure may be of a concern, recent data
have suggested that if recommended mercury hygiene procedures are followed,
the risks of any adverse health effects arising from mercury exposure in the
dental office are minimal. However, controversy persists concerning potential
adverse health effects that patients may experience as a result of chronic
exposure to mercury released from amalgam restorations. While the
overwhelming body of scientific evidence demonstrates amalgam to be a safe
restorative material, debate continues regarding not only the degree of mercury
exposure, but alsoand more importantly whether this exposure results in any
ill effects on health.

There is little doubt that minute levels of mercury are released from amalgam,
but the extent to which this release contributes to the total daily exposure has yet
to be ascertained. It is crucial to remember that mere exposure is not synonymous
with adverse health effects. As stated in the 16th century by Paracelsus, an
eminent Swiss alchemist and physician, All substances are poisons; there is
none which is not a poison. The right dose differentiates a poison and remedy.
On this basis, therefore, the question of degree of exposure only becomes
important when it is directly related to adverse health effects. Thus, two major
factors support the continuing controversy over the safety of amalgam: first, the
lack of a consensus as to how daily exposure to mercury from amalgam can be
reliably estimated; and second, the fact that most toxic signs and symptoms
suggested as being attributable to mercury from amalgam are nonspecific,
difficult to define and often reported by subjects themselves without
documentation of any physical or mental characteristics that can be directly
measured or observed. So far, few large scales human studies have been
conducted that have the statistical power to investigate any direct correlation
between amalgam and ill effects to health.

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To date, there is no evidence to suggest that mercury released from dental
amalgams results in any adverse effects to health in the general population.
However, several recent studies support earlier work suggesting that a very small
percentage of peopleless than 1 percentmay have allergic reactions to
mercury, as well as other metals, from amalgam. Research would indicate that
these allergic reactions to metals in amalgam may be linked to certain major
histocompatibility complex genotypes.

However a reference on absorbed mercury from amalgam fillings comes from the
World Health Organization proceeding of 1991. This was the report of a meeting
of toxicologists and environmental health specialists with few dentists and no
industry lobbyists invited.
The conclusion was that the average person in the industrial world with an
average number of amalgam fillings and no occupational exposure to mercury
would absorb between 3 17 micrograms per day, with an average of 10
micrograms, from the fillings; 2.3 micrograms from all dietary sources; and 0.3
micrograms from all other environmental sources. This totals, on average, 12.6
micrograms per day. The current allowable of safe intake of mercury has recently
been reduced to 0.1 micrograms/ day per kilogram of body weight, set by the US
Public Health Service. Say, at 170 lbs., the maximum allowable dosage would be
about 7.5 micrograms per day. Many scientists think even this reduced allowable
dosage is much too high.

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Alternative Materials

Typically higher cost and/or greater technique sensitivity


composite resin
glass ionomer
ceramic
metal alloys

Amalgam Composite Glass Ionomers


Systemic Toxicity
- acute None None None
- chronic
Not verified Not verified Not verified
Allergic Reactions Rare Rare, but many Extremely rare
components have
allergic potential
Anaphylaxis None so far Isolated cases None so far
Cytotoxicity Low Slight to high Slight to high
Mutagenicity or None Certain components Slight mutagenicity
Carcinogenicity mutagenic in vitro

Lichenoid reactions Yes Yes None

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Conclusion

No cure or health benefit from amalgam removal


Dentists must inform patients
risks and benefits of restorative materials
Research needed on specific health effects of low-level mercury exposure
determine effects of amalgam-derived mercury
need large-scale human studies
Materials research
alternatives to amalgam
reduce mercury emission from amalgams

Millions of people have amalgam restorations in their mouths, and millions more
will receive amalgam for restoring their carious teeth. Over the years, amalgam
has been used for dental restorations without evidence of major health problems.
Newly developed techniques have demonstrated that minute levels of mercury
are released from amalgam restorations; but no health consequences from
exposure to such low levels of mercury released from amalgam restorations have
been demonstrated. Given the available scientific information and considering
the demonstrated benefits of dental amalgams, unless new scientific research
dictates otherwise, there currently appears to be no justification for discontinuing
the use of dental amalgam. Carefully designed, comprehensive research is
encouraged to investigate potential biological effects resulting from low-level
mercury exposure from amalgam restorations. The ADAs Council on Scientific
Affairs will continue to review and evaluate scientific data on the safety of
amalgam and make recommendations to the dental profession that are grounded
in sound science.

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Bibliography

http://www.tinnitusformula.com/library/silver-fillings-mercury-risks-for-health-
hearing-and-tinnitus/

http://www.wholebodymed.com/historypolit.php

http://www.not-
na.org/Conditions/Treatments/PDF_Files/Scientific_Case_Against_Amalgam.pdf

http://www.netikka.net/carina/amaleng.php

DENTAL AMALGAM: UPDATE ON SAFETY CONCERNS


ADA COUNCIL ON SCIENTIFIC AFFAIRS

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