DENTAL AMALGAM

HISTORY TERMINOLOGIES ALLOY COMPOSITION MANUFACTURE OF ALLOY POWDER AMALGAMATION & RESULTING MICROSTRUCTURE

DIMENSIONAL STABILITY
STRENGTH CREEP CLINICAL PERFORMANCE OF AMALGAM RESTORATIONS FACTORS AFFECTING SUCCESS OF AMALGAM RESTORATIONS

MERCURY/ALLOY RATIO
MECHANICAL TRITURATION CONDENSATION CARVING & FINISHING CLINICAL SIGNIFICANCE OF DIMENSIONAL CHANGE

MARGINAL DETERIORATION
SIDE EFFECTS OF MERCURY SUMMARY CONCLUSION REFERENCES

HISTORICAL BACKGROUND
Silver Amalgam in Clinical Practice - I.D. Gainsford

 Used as a dental restorative material from the beginning of the 19th century. Amalgams were made by mixing mercury with the fillings from Spanish or Mexican silver coins (high silver content).

Failure causes:
1. 2. 3. 4.

Harsh mass which was difficult to mix Hardened very slowly Expanded enormously Stained the teeth black

YEAR

EVENTS

1819

First dental silver amalgam is supposed to have been introduced into England by Bell Bells Putty
Introduced to the North American continent by Cawcour brothers termed as Royal Mineral Succedaneum.
Resolution

1833

1843

passed by the American Society of Dental Surgeons (the first organised Dental Society in the U.S.A declaring the use of amalgam a Malpractice. Thus the Amalgam War began Amalgam Pledge was adopted by the society.

1845

YEAR 1850 1861

EVENTS Pledge was rescinded officially ending the amalgam war. First research programme was conducted by John Tomes ( Trans.Odontol.Soc. G.B.,Vol III) Who measured shrinkage of a number of amalgams

1871
1874

Charles Tomes measured shrinkage & expansions by specific gravity tests.

Thomas B.Hitchcock (Trans.N.Y.Odontol.Soc) did some important work in measuring more accurately by means of a micrometer changes of amalgam form

YEAR 1896
Classic

EVENTS work of G.V.Black that a more systematic study was made of the properties & manner of manipulation of silver amalgam and its relation to cavity preparation. Many of G.V.Blacks techniques for amalgam restorations are generally accepted today. New methods are often described as variations or modifications of those used by Black.

YEAR 1930
A.D.A

EVENTS research organisation conducted a survey and showed that only a few of the proprietary amalgam alloys on the market & tested by the National Bureau of Standards were reliable. A.D.A specification No. 1 for Alloy. A.D.A specification No. 6 for Mercury.

1934 & Revision of this specification 1960

HISTORY OVERVIEW

1833

Crawcour brothers introduce amalgam to U.S

powdered silver coins mixed with mercury

expanded on setting

1895

G.V. Black developed formula for modern amalgam alloy

67% silver, 27% tin, 5% copper, 1% zinc

overcame expansion problems

 1960s

conventional low-copper lathe-cut alloys

smaller

particles

first generation highcopper alloys

Dispersalloy

(Caulk)

Innes & Youdelis -1963 admixture of spherical AgCu eutectic particles with conventional lathe-cut eliminated gamma-2 phase
Mahler J Dent Res 1997

1970s

first single composition spherical

Tytin (Kerr) ternary system (silver/tin/copper)

1980s

alloys similar to Dispersalloy and Tytin

Mahler J Dent Res 1997

1990s

mercury-free alloys

TERMINOLOGIES & DEFINITIONS

AMALGAM DENTAL AMALGAM DENTAL AMALGAM ALLOY TRITURATION AMALGAMATION

Amalgam

Special type of alloy in that one of its constituents is mercury. Before these alloys combine with mercury they are known as dental amalgam alloys - ANUSAVICE (2003)

TERMINOLOGY

DEFINITION
Amalgam is an alloy which has mercury as one of its components Marzouk (1997) An alloy of mercury, silver, copper, tin, which may also contain palladium, zinc, and other elements to improve handling characteristics and clinical performance Anusavice (2003) An alloy of silver, copper, tin, and other elements that is formulated and processed in the form of powder particles or as a compressed pellet Anusavice (2003)

Amalgam

Dental Amalgam

Dental Amalgam Alloy / Alloy for Dental Amalgam

But to be more simple

AMALGAM = A + MASS OF GAM (GUM) (HAND TRITURATION) AMALGAM = AMALGAMATED GAM (GUM) (AMALGAMATOR)

FUTURE COULD BE

AMALGAM = AMALGAMATED MASS DELIVERED FROM GUN (COMPOSITE COMPULES)

TERMINOLOGY

DEFINITION

Amalgamation

The process of mixing liquid mercury with one or more metals or alloys to form an amalgam. Anusavice (2003)
The process of grinding powder, especially within a liquid. In dentistry, the term is used to describe the process of mixing the amalgam alloy particles with mercury in an amalgamator. Anusavice (2003)

Trituration

Why Amalgam?
Inexpensive Ease of use Proven track record

>150 years

Familiarity Resin-free

less allergies than composite

Constituents in Amalgam

Basic

Silver Tin Copper Mercury Zinc Indium Palladium

Other

1895

G.V. Black develops formula for modern amalgam alloy 67% silver, 27% tin, 5% copper, 1% zinc

Basic

Silver Tin Copper Mercury

Other

Amalgam Constituents

Zinc Indium Palladium

Basic Constituents

Silver (Ag)

increases strength increases expansion

Tin (Sn)

decreases expansion decreased strength increases setting time

Phillips Science of Dental Materials 2003

Basic Constituents

Copper (Cu)

ties up tin

reducing gamma-2 formation

increases strength reduces tarnish and corrosion reduces creep

reduces marginal deterioration

Phillips Science of Dental Materials 2003

Basic Constituents

Mercury (Hg)

activates reaction only pure metal that is liquid at room temperature spherical alloys

require less mercury

smaller surface area easier to wet 40 to 45% Hg

admixed alloys

require more mercury

Phillips Science of Dental Materials 2003

lathe-cut particles more difficult to wet 45 to 50% Hg

Other Constituents

Zinc (Zn)

used in manufacturing

decreases oxidation of other elements

sacrificial anode

provides better clinical performance

less marginal breakdown

Osborne JW Am J Dent 1992

causes delayed expansion with low Cu alloys

if contaminated with moisture during condensation

Phillips RW JADA 1954

H2O + Zn ZnO + H2
Phillips Science of Dental Materials 2003

Other Constituents

Indium (In)

decreases surface tension

reduces amount of mercury necessary reduces emitted mercury vapor

reduces creep and marginal breakdown increases strength must be used in admixed alloys example

Indisperse (Indisperse Distributing Company)

5% indium

Powell J Dent Res 1989

Other Constituents

Palladium (Pd)

reduced corrosion greater luster example

Valiant PhD (Ivoclar Vivadent)

0.5% palladium

Mahler J Dent Res 1990

Classifications

Based on Based on Based on Based on copper Based on Based on Based on

number of alloys copper content particle shape method of adding manufacturing process powders particle size addition of Noble Metals

Copper Content

Low-copper alloys

4 to 6% Cu
thought that 6% Cu was maximum amount

High-copper alloys

due to fear of excessive corrosion and expansion at expense of Ag

Now contain 9 to 30% Cu

Phillips Science of Dental Materials 2003

COPPER CONTENT
Compos LOW ition COPPER
Particle shape Lathe- Cut / Spherical

HIGH COPPER
Admixed
Lathe-cut (2/3) Spherical (1/3)

Unicomposition
Spherical

Silver Tin

63-70% 26-23 %

40-70 % 26-30 %

40-65 % 0-30 %

40-60 % 22-30 %

Copper
Zinc

2-5 %
0-2 %

2-30 %
0-2 %

20-40 % 0%

13-30 %
0-4 %

Particle Shape

Lathe cut

Spherical

low Cu

low Cu

New True Dental alloy

ANA 2000

Cavex SF
Tytin, Valiant

high Cu

high Cu

Admixture

high Cu

Dispersalloy, Valiant PhD

Method of Adding Copper

Single

Composition Lathe-Cut (SCL) Single Composition Spherical (SCS) Admixture: Lathe-cut + Spherical Eutectic
(ALE)

Admixture:

Spherical (ALSCS)

Lathe-cut + Single Composition

Single Composition Lathe-Cut (SCL)

More Hg needed than spherical alloys High condensation force needed due to lathe cut 20% Cu Example

ANA 2000 (Nordiska Dental)

Single Composition Spherical (SCS)

Spherical particles wet easier with Hg

less Hg needed (42%)

Less condensation force, larger condenser Gamma particles as 20 micron spheres

with epsilon layer on surface

Tytin (Kerr) Valiant (Ivoclar Vivadent)

Examples

Composition

Admixture: Lathe-cut + Spherical Eutectic (ALE)

2/3 conventional lathe cut (3% Cu) 1/3 high Cu spherical eutectic (28% Cu) overall 12% Cu, 1% Zn no gamma 2 within two years

Initial reaction produces gamma 2

Example

Dispersalloy (Caulk)

Admixture: Lathe-cut + Single Composition Spherical (ALSCS)

High Cu in both lathe-cut and spherical components

19% Cu

Epsilon layer forms on both components 0.5% palladium added

reinforce grain boundaries on gamma 1 Valiant PhD (Ivoclar Vivadent)

Example

MANUFACTURE OF ALLOY POWDER

Classification Lathecut powder Homogenizing Anneal Particle Treatments Atomized powder Lathecut powder Vs Atomized Spherical powder

Manufacturing Process

Lathe-cut alloys

Ag & Sn melted together alloy cooled

phases solidify 100 C for 8 hours

heat treat

grind, then mill to 25 - 50 microns heat treat to release stresses of grinding

Phillips Science of Dental Materials 2003

Manufacturing Process
Spherical alloys

melt alloy atomize

spheres form as particles cool

sizes range from 5 - 40 microns

variety improves condensability

Phillips Science of Dental Materials 2003

ALLOY COMPOSITION

Metallurgical phases in dental amalgams

The Silver-Tin system The influence of Silver-Tin phase on amalgam properties

METTALURGICAL PHASES

PHASES

STOICHIOMETRIC FORMULA

NUMBER OF ATOMS

Ag3Sn Ag2Hg3

Sn8Hg

PHASES

STOICHIOMETRIC FORMULA

NUMBER OF ATOMS

Cu3Sn

Cu6Sn5

SilverCopper Eutectic

Ag-Cu

PHASE: Silver- Copper Eutectic

STOICHIOMETRIC FORMULA:

Ag-Cu
(5) - 1

(4) - 1

Cu

Ag

PHASE: Silver- Copper Eutectic

STOICHIOMETRIC FORMULA:

Ag-Cu

Basic Composition

A silver-mercury matrix containing filler particles of silver-tin Filler (bricks):

Ag3Sn called gamma

can be in various shapes

irregular (lathe-cut), spherical, or a combination

Matrix:

Ag2Hg3 called gamma 1

cement voids

Sn8Hg called gamma 2

Phillips Science of Dental Materials 2003

Basic Setting Reactions

Conventional low-copper alloys Admixed high-copper alloys Single composition high-copper alloys

Conventional Low-Copper Alloys

Dissolution and precipitation Hg dissolves Ag and Sn from alloy Intermetallic compounds formed

Ag-Sn Alloy Hg Sn Hg

Ag Ag Ag Sn Sn Ag-Sn Ag-Sn Alloy Alloy Mercury (Hg)

Ag3Sn + Hg Ag3Sn + Ag2Hg3 + Sn8Hg

Phillips Science of Dental Materials 2003

Conventional Low-Copper Alloys

Gamma () = Ag3Sn

unreacted alloy strongest phase and corrodes the least forms 30% of volume of set amalgam

Hg Ag-Sn Alloy Hg Hg Ag Ag-Sn Alloy Sn Sn Ag Sn Ag-Sn Alloy Ag

Mercury

Ag3Sn + Hg Ag3Sn + Ag2Hg3 + Sn8Hg

Phillips Science of Dental Materials 2003

Conventional Low-Copper Alloys

Gamma 1 (1) = Ag2Hg3

matrix for unreacted alloy and 2nd strongest phase 10 micron grains binding gamma () 60% of volume

Ag-Sn Alloy

1
Ag-Sn Alloy Ag-Sn Alloy

Ag3Sn + Hg Ag3Sn + Ag2Hg3 + Sn8Hg

Phillips Science of Dental Materials 2003

Conventional Low-Copper Alloys

Gamma 2 (2) = Sn8Hg

weakest and softest phase corrodes fast, voids form corrosion yields Hg which reacts with more gamma () 10% of volume volume decreases with time due to corrosion

Ag-Sn Alloy

Ag-Sn Alloy

Ag-Sn Alloy

Ag3Sn + Hg Ag3Sn + Ag2Hg3 + Sn8Hg

Phillips Science of Dental Materials 2003

Conventional Low-Copper Alloys

Ag3Sn + Hg Ag3Sn + Ag2Hg3 + Sn8Hg

(30%)
Ag-Sn Alloy Hg Sn Hg Ag-Sn Alloy

(60%)

(10%)
Ag-Sn Alloy

Ag Ag Ag Sn Sn Ag-Sn Ag-Sn Alloy Alloy Mercury (Hg)

Ag-Sn Alloy

Ag-Sn Alloy

Ag-Sn Alloy

Ag-Sn Alloy

Admixed High-Copper Alloys

Ag enters Hg from Ag-Cu spherical eutectic particles

eutectic

Ag-Cu Alloy

an alloy in which the elements are completely soluble in liquid solution but separate into distinct areas upon solidification

Hg Ag Ag-Sn Alloy

Ag Ag Sn Sn

Hg Ag

Both Ag and Sn enter Hg from Ag3Sn particles

Ag-Sn Alloy

Mercury

Ag3Sn + Ag-Cu + Hg Ag3Sn + Ag-Cu + Ag2Hg3 + Cu6Sn5

Phillips Science of Dental Materials 2003

Admixed High-Copper Alloys

Sn diffuses to surface of Ag-Cu particles

Ag-Cu Alloy

reacts with Cu to form

(eta) Cu6Sn5 ()
around

unconsumed Ag-Cu particles

Ag-Sn Alloy

Ag-Sn Alloy

Ag3Sn + Ag-Cu + Hg Ag3Sn + Ag-Cu + Ag2Hg3 + Cu6Sn5

Phillips Science of Dental Materials 2003

Admixed High-Copper Alloys

Gamma 1 (1) (Ag2Hg3) surrounds () eta phase (Cu6Sn5) and gamma () alloy particles (Ag3Sn)

Ag-Cu Alloy

Ag-Sn Alloy

Ag-Sn Alloy

Ag3Sn + Ag-Cu + Hg Ag3Sn + Ag-Cu + Ag2Hg3 + Cu6Sn5

Phillips Science of Dental Materials 2003

Admixed High-Copper Alloys

Ag3Sn + Ag-Cu + Hg Ag3Sn + Ag-Cu + Ag2Hg3 + Cu6Sn5

Ag-Cu Alloy
Hg Ag Ag-Sn Alloy Sn Hg

Ag-Cu Alloy

Ag-Cu Alloy

Ag Ag Ag Sn

Mercury

Ag-Sn Alloy

Ag-Sn Alloy

Ag-Sn Alloy

AgSn Alloy

AgSn Alloy

Single Composition High-Copper Alloys

Gamma sphere () (Ag3Sn) with epsilon coating () (Cu3Sn) Ag and Sn dissolve in Hg

Ag-Sn Alloy Ag Sn Ag Sn

Ag-Sn Alloy
Ag-Sn Alloy

Mercury (Hg)

Ag3Sn + Cu3Sn + Hg Ag3Sn + Cu3Sn + Ag2Hg3 + Cu6Sn5

Phillips Science of Dental Materials 2003

Single Composition High-Copper Alloys

Gamma 1 (1) (Ag2Hg3) crystals grow binding together partiallydissolved gamma () alloy particles (Ag3Sn) Epsilon () (Cu3Sn) develops crystals on surface of gamma particle (Ag3Sn) in the form of eta () (Cu6Sn5)

Ag-Sn Alloy

Ag-Sn Alloy Ag-Sn Alloy

reduces creep prevents gamma-2 formation

Ag3Sn + Cu3Sn + Hg Ag3Sn + Cu3Sn + Ag2Hg3 + Cu6Sn5

Phillips Science of Dental Materials 2003

Material-Related Variables
Dimensional change Strength Corrosion Creep

DIMENSIONAL STABILITY
Delayed Expansion

The gradual expansion of a zinc-containing amalgam over weeks to months, which is associated with hydrogen gas development caused by contamination of the plastic mass with moisture during its manipulation in a cavity preparation Anusavice (2003)

DIMENSIONAL CHANGE THEORY OF DIMENSIONAL CHANGE EFFECT OF MOISTURE CONTAMINATION

DIMENSIONAL CHANGES
Dimensional changes on setting: CONTRACTION during alloy dissolution EXPANSION during impingement of reaction product crystals (EXPANSION if side reactions due to H2O contamination)
EXP (+)

ADA = 20 mm

TIME

CONT (--)

Dimensional changes depend on reaction variables: Particle size, Hg/alloy ratio, trituration time, condensation, ...

Dimensional Change
Most high-copper amalgams undergo a net contraction Contraction leaves marginal gap

initial leakage

post-operative sensitivity

reduced with corrosion over time

Phillips Science of Dental Materials 2003

Dimensional Change

Net contraction

type of alloy

spherical alloys have more contraction

less mercury

condensation technique

greater condensation = higher contraction overtrituration causes higher contraction

trituration time

Phillips Science of Dental Materials 2003

STRENGTH
Measurement of strength Effect of trituration Effect of mercury content Effect of condensation Effect of porosity Effect of amalgam hardening rate

Strength

Develops slowly

1 hr: 40 to 60% of maximum 24 hrs: 90% of maximum

Spherical alloys strengthen faster

require less mercury

Higher compressive vs. tensile strength Weak in thin sections

unsupported edges fracture

Phillips Science of Dental Materials 2003

Amalgam Properties
Compressive Strength (MPa) Amalgam Type Low Copper1 Admixture2 1 hr 145 137 7 days 343 431 2.0 0.4 60 48 % Creep Tensile Strength (24 hrs) (MPa)

Single Composition3
1Fine

262

510

0.13

64

Cut, Caulk Caulk 3Tytin, Kerr

2 Dispersalloy,

Phillips Science of Dental Materials 2003

CREEP
Creep

Marginal Breakdown

The time-dependent strain or deformation that is produced by a stress. The creep process can cause an amalgam restoration to extend out of the cavity preparation, thereby increasing its susceptibility to marginal breakdown. Anusavice (2003) The gradual fracture of the perimeter of margin of a dental amalgam restoration that leads to the formation of gaps or ditching at the external interfacial region between the amalgam and the tooth. Anusavice (2003)

Creep

Significance of creep on amalgam performance

Influence of microstructure on creep Effect on manipulative variable on creep

Creep

Slow deformation of amalgam placed under a constant load

load less than that necessary to produce fracture slow strain rates produces plastic deformation

Gamma 2 dramatically affects creep rate

allows gamma-1 grains to slide

Correlates with marginal breakdown

Phillips Science of Dental Materials 2003

Creep

High-copper amalgams have creep resistance

prevention of gamma-2 phase

requires >12% Cu total eta (Cu6Sn5) embedded in gamma-1 grains

single composition spherical

interlock

admixture

eta (Cu6Sn5) around Ag-Cu particles

improves bonding to gamma 1

Amalgam Type

% Creep

Low Copper1

2.0

Admixture2

0.4

Single Composition3

0.13

1Fine

Cut, Caulk Caulk

2 Dispersalloy, 3Tytin,

Phillips Science of Dental Materials 2003

Kerr

AMALGAM PROPERTIES
A. Introduction:

1. Specifications for Amalgam Properties a. ADA / ANSI and ISO

2. Clinical Performance a. Longevity = 20-25 yrs ideally, 8-12 yrs practically b. Modes of failure = caries, marginal fracture, bulk B. Properties: 1. 2. 3. 4. Physical Mechanical Chemical Biological
UNITED STATES ADA ANSI WORLD

FDI ISO

Physical Properties
1. 2. 3. 4. 5. Thermal conductivity = [High] Electrical conductivity = [High] Coefficient of thermal expansion = 25 ppm/C Radiopacity = [>2 mm Aluminum] Color = [Lustrous, shiny, white]

Mechanical Properties
TYTIN (Kerr Dental Mfg) = tie up the tin High-Copper, Spherical, 1 Particle, Zn-free 42% Hg mixed with alloy Fast-setting High early strength

Fracture Surface
Polished Surface

Mechanical properties
compressive strength is more for high cu amalgam Its much more for single composition,when compared to admixed alloys.

Chemical Properties
(b)

CHEMICAL CORROSION:

(b)

AgS
(a)
(a)

Sn-O-Cl Sn-O
Clean Surface, CleanSurface, High O Potential High O22Potential (CATHODIC) (CATHODIC) Plaque Buildup, PlaquePotential Low O2 Buildup, (ANODIC) Low O2 Potential Plaque Buildup

Plaque Buildup

(ANODIC)
(a) (b)

(a)

(b)

ELECTROCHEMICAL CORROSION:

Galvanic corrosion Local galvanic corrosion (structure selective) Crevice corrosion (concentration cell) Stress corrosion

Biological Properties
Mercury Toxicity: OSHA maximum TLV = 50 mg/m3 (vapor) per 40 hr work week Transient intraoral release (<35 mg/m3)

Mercury Hypersensitivity: Low level allergic reaction Estimated to be < 1 / 100,000,000 Amalgam Tatoo: Can occur during amalgam removal if no rubber dam Embedded amalgam particles corrode and locally discolor gum No known adverse reactions

Clinical Performance
Reasons for Failure: Secondary caries -- principally with low-copper amalgam Marginal fracture -- prevalent with low-copper amalgam Bulk fracture -- most common with high-copper amalgam Jorgensen theory of mercuroscopic expansion

Corrosion at margins Internal corrosion

Sn-O-Cl and Sn-O

PENETRATING versus SUPERFICIAL CORROSION

Clinical Evaluation
Hi-Cu Mahler scale: Low-Cu

???

CLINICAL PERFORMANCE OF AMALGAM RESTORATIONS

Tarnish & Corrosion

Compositional effects on the survival of amalgam restorations

Corrosion
Reduces strength Seals margins TYPES

Dry corrosion/chemical corrosion Wet corrosion/electrochemical corrosion Galvanic corrosion Hetrogenous Stress corrosion Concentration cell corrosion [crevice corrosion]
Sutow J Dent Res 1991

Manufacturer controlled variables

The composition of the alloy The heat treatment of the alloy The size, shape, & method of production of the alloy particles The surface treatment of the particles The form in which the alloy is supplied

Dentist-Controlled Variables

Alloy Selection Manipulation

Mercury/Alloy ratio trituration Condensation technique Marginal integrity Anatomic characteristics burnishing polishing

Alloy Selection
Handling characteristics Mechanical and physical properties Clinical performance

Handling Characteristics

Spherical

advantages

easier to condense
around pins

hardens rapidly smoother polish difficult to achieve tight contacts higher tendency for overhangs

disadvantages

Phillips Science of Dental Materials 2003

Handling Characteristics

Admixed

advantages

easy to achieve tight contacts good polish hardens slowly

lower early strength

disadvantages

Overview of Manipulation
TIME Placement and Condensation Onset of WORKING Carving Burnishing Polishing

Onset of MIXING

Onset of SETTING

End of SETTING

24 hours

Selection / Proportioning / Amalgamation / Manipulation / Polishing

ALLOY MANIPULATION
Manual Trituration Procedures: Alloy + Hg mortar + pestle
manual mixing

Mechanical Trituration Procedures: Powdered alloy + Hg capsule + pestle Pelleted alloy + Hg capsule + pestle

amalgamator amalgamator

Powdered alloy + Hg

pre-capsulated

amalgamator

Amalgamators

SPEED TIME

ENERGY = Speed x Time

Trituration

Mixing time

refer to manufacturer recommendations

Overtrituration

hot mix

sticks to capsule

decreases working / setting time slight increase in setting contraction grainy, crumbly mix

Undertrituration

Phillips Science of Dental Materials 2003

Condensation

Forces

lathe-cut alloys

small condensers high force

spherical alloys

large condensers less sensitive to amount of force vertical / lateral with vibratory motion intermediate handling between lathe-cut and spherical

admixture alloys

Burnishing

Pre-carve

removes excess mercury improves margin adaptation improves smoothness

less leakage

Post-carve

Combined

Ben-Amar Dent Mater 1987

Early Finishing

After initial set

prophy cup with pumice provides initial smoothness to restorations recommended for spherical amalgams

Polishing
Increased smoothness Decreased plaque retention Decreased corrosion Clinically effective?

no improvement in marginal integrity

Mayhew Oper Dent 1986 Collins J Dent 1992

ALTERNATIVES TO AMALGAM

1. Mercury-free direct filling alloy:

ADA-NIST (National Institute on Standards and Technology) Patented this alloy Silver coated Silver-Tin particles that can be selfwelded by compaction (hand-consolidated) Redesigning amalgam to have much less initial mercury Alloy particles pack together well Reduce mercury for mixing to the 15%-25% range

2. Transitional Approaches:

PRIMM - Poly Rigid Inorganic Matrix Material - Porous Ceramic fibers. Condensable, curable, carvable, polishable. "White amalgam" Restorations with >0.3% Zn and >12% Cu have minimal corrosion and the longest longevity. Zn and Cu act synergistically. (J. Dent Res, Nov 1997)

3. Gallium Alloys:

Mercury controversy limits the use of Silver Amalgam Toxic effects coupled with mercury hygiene led the researchers think of mercury free alloys Suggested by PuttKammer -1928 PROPERTIES:

Wettability Sets in reasonable time and possesses strength Diametrical stability & corrosion resistance equal to or greater than silver amalgam

COMPOSITION:
LIQUID

ALLOY

Silver (Ag) 60%

Tin (Sn) -25%

Gallium (Ga) - 62%

Iridium (Ir) - 25%

Copper (Cu) -13%

Palladium ( Pd) - 20%

Tin (Sn) -25%

ALLOY

CREEP %

COMPRESSIVE STRENGTH (AFTER 6 HOURS) 370 MPa

Silver 1.04_0.06 + Alloy (High Copper) Gallium 0.09_0.03 Alloy

+

SETTING (CONTRACTI ON/EXPANSI ON %) -0.05

350 MPa

+0.39

BONDED AMALGAM RESTORATIONS:

Silver does not adhere properly to cavity walls Adhesive systems designed to bond amalgam to enamel & dentin Improve adhesion, strengthen remaining tooth structure, decreases the need for removal of health tooth structure Pioneers were Sun Medical (Superbond), Kurrary (Panavia) Superbond was based on 4-META/MMA resins Panavia was based on Bis GMAphosphonated ester

Later dentin bonding agents have also been a subject of bonding amalgam to dentin Various Agents are

Amalgam Bond with HPA ( Parkell) All Bond 2 (Bisco) Optibond 2 (Kerr) Panavia 21(Kuraray) Clearfil Linear Bond 2 (Kuraray) Scothbond MP (3M)

a) etching the dental surface with acid, b) applying a treatment composition comprising an aromatic sulfinate salt to the etched dental surface, c) applying a priming solution containing a film-former to the treated dental surface, d) applying a chemically curable dental adhesive to the primed dental surface, and e) applying amalgam to the adhesive-coated dental surface. The chemically curable adhesive comprises an oxidizing agent and a reducing agent. The oxidizing agent is present in an amount sufficient to interact with said aromatic sulfinate salt to achieve higher adhesion to the dental surface than a like method not comprising an aromatic sulfinate salt in the treatment composition. - U.S Patent Issued on January 21, 1997

INDICATIONS:

Auxillary retention Extensively carious posterior teeth Teeth with low Gingival-Occlusal height Temporary restorations Amalgam Sealants More conservative Reinforces tooth structure Eliminates the use of pins Decreases the incidence of marginal fracture Provides a bond at the tooth restoration interface Biologic sealing of the pulpo-dentinal complex Appointment time Cost effective

ADVANTAGE:

DISADVANTAGE:

Technique sensitive Time to adapt to the new technique Clinical performance are not documented No sustained effects of amalgam bonding when subjected to thermocycling Hydrolytic stability of the bond is questionable

"...amalgam bonding is an adjunct to and not a substitute for mechanical retentive form. The main advantage of conventional amalgam adhesives seems to be their ability to seal the tooth restorative interface, preventing microleakage into the dental tubules and pulp and reducing post-operative sensitivity. - Cobb, et al, Am J Dent, Oct 1999 "Continuous microgaps were observed between amalgam and dentin in the specimens using no lining material and Copal varnish compared to specimens using adhesive bonding system." -Estafan, Gen Dent, March-April 2000

Criteria when considering amalgam substitutes:

service life, radiopacity, wear properties, marginal adaptation, setting expansion/contraction, technique sensitivity, potential secondary caries risk. What materials are better than amalgam in these areas? (Lutz and Krejc-2000)

CONCLUSION

SUMMARY
Dental alloys are manufactured for us. Amalgams we make for ourselves and the strength and the stability of the hardened amalgam and the merit of the filling are only as good as the cause and the skill the dentist puts into it. - William E. Harper; J.Am.Dent.Assoc.13,119-125,1926. The tongue represents the best and the worst amongst things; amalgam restorations might be the most noble restorations but also the worst ignoble fillings. - Aesop

REFERENCES
Phillips Science of Dental Materials10th,11th Edition: Kenneth Anusavice Art & Science of Operative Dentistry-4th Edition: Sturdevant. Restorative Dental Materials-11th Edition: Robert G.Craig.

Jones DW: Putting dental mercury pollution into perspective. BDJ 2004;197:175-177. Eichmiller FC: Research into Non-Mercury Containing Metallic Alternatives. Op Dent 2001;6:111-118. Ronald K Harris: Dental Amalgam: Success Or Failure?. Op Dent 1992;17:243-252. Dunne SM et al: Current materials and Techniques for direct restorations in posterior teeth. IDJ 1997;47:123-136.

MERCURY TOXICITY

Mercury the Metal

Hg Facts & Uses

Quicksilver 13.6 times the weight of water Evaporates at room temperature Bacteria change to Methylmercury Amalgam Many Industrial uses
(thermometers, chemical reactions, gold mining)

Sources of Mercury

Dental Schools Dental clinics Colleges & universities Hospitals, medical clinics & laboratories Home owners/communities Plumbers/electricians Junkyards/auto crushers & recyclers MSW incinerators Federal & other government facilities Farms

Mercury-Added Products
Fever & lab thermometers Blood pressure devices Barometers, manometers, gauges Auto switches Elemental mercury from dental offices & schools Appliances Fluorescent & other lamps

Mercury Collection Programs from Schools, Dental Offices & Households

Hg Liquid and Vapor

Gas Hg = odorless, colorless gas Hg = penetrating liquid
BEFORE REACTION AFTER REACTION
Alloy Reaction Products

Alloy Mercury

Vapor Toxicity Calculations: Liquid Vapor Limits (TLV) = 0.05 mg/m3 = 50 mg/m3 = 5 ppb Sensitivity Calculations: ADA 1 / 100,000,000 UNC 1 / 180,000,000


1.

2.

3.

Current Controversy on Mercury (Types): Elemental - Least toxic. Very small contribution to total body burden of Hg. Is the form found in dentistry. Lipid soluble, absorbed in lungs. Very short-lived due to rapid oxidation. Inorganic - Moderate toxicity. Formed by oxidation of elemental. Limited lipid solubility. Becomes sequestered in kidney, excreted slowly in urine. Half life ~ 60 days. Organic - Most toxic. High lipid solubility. Only from non-dental sources. 90% absorbed in gut. Accumulates in red blood cells, sequestered in CNS and liver. Not found in urine. Excreted in feces.

Elemental Mercury: Hg 0 InorganicMercury : Hg +1 or Hg +2 Organic Mercury; Compounds such as: Methyl mercury - HgCH3+ Dimethyl mercury - Hg(CH3)2

PHYSIOLOGICAL Hg CYCLE
Hg FORM ABSORPTION ROUTE TRANSPORTION and LOCALIZATION EXCRETION of Hg

Elemental Hg

SKIN

All other sites BLOOD Brain BLOOD

URINE FECES

Inorganic Hg

LUNGS

Organic Hg

GI TRACT

Hair, Nails

EXFOLIATION of Skin, Hair, Nails

Average Half-Life in Human Body = 55 Days

Hg Release from Amalgams

Mercury Release (mg/m3) 50
Many

TLV (40 hrs/wk)

40 30 20
Few
F M

10
F F M No Chewing Chewing

30 Time (minutes)

60

Pronounced symptoms.

1000 500

Mild-to-moderate symptoms. Subtle changes on some tests. No known health effects.

100
50 10 5

Hg Swallowed from Amalgams

Af Geijersstam E, Sandborgh-Englund G, Jonsson F, Ekstrand J. Mercury uptake and kinetics after ingestion of dental amalgam. J Dent Res 2001;80:1793-1796.

Hg Concentraion in Plasma (nmol / L = 0.2 ppb)

10.0

Controlled for baseline levels in volunteers. Pulverized fresh dental amalgam. 1.0 gm amalgam powder placed in gelatin capsules. Drew blood samples at 5, 24, 30 hrs and 2, 7, 14, 21,
28, 56, 90 days.

1.0

Hg rapidly detected from GI track but at very low levels. No difference between 0 and 90 days. Hg half-life about 37 days.
0.1 20 40 60 TIME (days) 80

Body-Burden Calculations
Elemental AIR WATER FOOD Amalgams 0.5 mg/day .. .. 20 mg/day Inorganic .. 10 mg/day .. .. Organic .. .. 100 mg/day .. = TOTAL = 0.5 mg/day = 10 mg/day = 100 mg/day = 20 mg/day

TOTAL

= 130.5 mg/day

18 occlusal amalgams = all Hg release absorbed Actual body burden due to amalgam estimated as <0.5% of total

Environmental Impact of Hg
Humans are continually exposed to a variety of sources of Hg
from the environment ----- Hg is omnipresent.
AIR supply WATER supply FOOD supply DENTAL and MEDICAL = natural sources, human pollution, = natural sources, human pollution, = natural sources, human pollution, = amalgams, OTC ointments, ...

AIR

Hg mine....300 mg/m3 Industrial emission3 Urban air...0.05 Pure air..0.002

FOOD Tunafish..1000 mg/kg Cattle..160 Humans25

MERCURY TOXICITY
Historical Problems: Tanners Thermometer technicians HgS mine workers Recent Incidents: Almaden, Spain (Hg mine) Minamata Bay, Kyushu, Japan (fish problem) Iraq (grain problem) Alamogordo, NM (grain problem) Sweden (environmental load problem) Michigan (redistillation problem)

Historical Awareness

ALMADEN, SPAIN
SPAIN Almaden Mercury Mine 2400 Years of Continuous Productions

>300 mg/m3

KYUSHU, JAPAN
1953, Minamata Bay, Chisso Corporation Factory
Methyl mercury waste dumped into bay.

CHISSO CORPORATION
Produced fertilizers, chemcial, plastics

Minamata Bay Contamination Hg(CH3)2 laden fish Chronic Hg toxicity 202 People Poisened 52 Deaths

SYMPTOMS of chronic Hg poisoning:

Ataxic gait. Convulsions. Numbness in mouth and limbs. Constriction of visual field. Difficulty in speaking.

BANNED IN EUROPE ???

Swedish National Board of Health and Welfare (April 20th, 1992 --Report to the Government) 1. No amalgam restorations in deciduous teeth after July 1, 1993. 2. No amalgam restorations in permanent teeth up to age 10 after July 1, 1995. 3. Evaluate in 1996 the possibility of discontinuing all amalgam use after 1997.

Sweden

Minamata Bay, Japan

1953 startup of acetaldehyde production at a coastal factory using mercuric oxide as a catalyst Stray cats 1953- outbreak of polio-like disease among coastal fishing villages went crazy after eating fish 1968-mercury diagnosed as cause of 2000 disease victims

Discharge in Minamata Bay

Polluting with HG

Minamata disease-infants
Mental retardation in infants Abnormal reflexes, ataxia, involuntary movements Cerebral palsy Developmental delayssome didnt walk until age 7

in Minamata disease adults

Paresthesia-numbness pins and needles Cerebellar ataxia, tremors, convulsions Constriction of visual fields, loss of smell Loss of hearing, dizziness, insomnia Dysarthria -speech disorder. Speech was slow, weak, imprecise or uncoordinated. Cognitive impairments, such as inattention, excitement, hallucinosis, loss of intelligence

Life Long Effects of Methyl Hg

Biotransformation of Mercury
Inorganic Mercury Discharge Ambient Water Sediments Bioaccumulation Edible Fish

Biomethylation
MethylMercury

Methyl-Mercury In Humans

Exposure

Out Breaks of MeHg Poisoning

Place
Minamata

Year
1953-60

Cases
1000

Negate Guatemala
Ghana Pakistan Iraq Iraq Iraq On-going

1964-65 1963-65
1967 1969 1956 1960 1971 2001

646 45
144 100 100 1,002 40,000 ???

Seed Grain Outbreaks

Mercury compounds applied as antifungal agent to seed grains Iraqmade bread directly from treated seed grain

Planting Seed with Mercury

Iraq Mothers with Bread

Iraq Infant - Effects of Mercury

Neurobehavioral Effects
Blindness - Deafness Cerebral Palsy - Seizures Abnormal reflexes & muscle tone Retarded motor development Visual and Auditory Deficits Delayed motor development

Effects On The Brain

Decrease in Brain Size Cell loss Disorganization of cells Cell migration failures

Fetal Toxicity
Birth defects may be due to a brief exposure during critical periods of fetal development Affected fetuses may spontaneously abort Relationship between exposure and outcome is difficult to establish

Environmental Sources of Mercury

Natural Degassing of the earth Combustion of fossil fuel Industrial Discharges and Wastes Incineration & Crematories Dental amalgams

Hg0

Hg2+

CH3Hg+

Mercury Release

50-75% mercury released in the environment related to human activities, but there is lots of mercury in the soil from millions of years ago

The Mercury Cycle

Mercury A Global Issue

Mercury distribution and exposure is a global problem

Hg and Heart Attacks

2002 case-control study showing higher mercury in men who had heart attacks vs. controls Hoping to start series of studies in Population Health Sciences on Hg and cardiovascular disease

Can Vaccines Containing Thimerosal (ethyl

mercury) Cause Autism?

Parents say yes Science studies say no Hviid A, et al. Association between thimerosal-containing vaccine and autism. (Denmark registry) JAMA October 1, 2003;290:1763-6 totally negative

Inst. of Medicine: Immunization Safety Review: Vaccines and Autism Report: No Association, May 2004

Mercury in Dental Amalgams

Dose is high in mouth, but low to the body Adult brain is developed Subtle changes in brain or kidney function due to such a low dose? Alzheimers disease?

In one study, dentists with abnormally high concentrations of urinary mercury, attributable to their occupational exposure, showed no evidence of kidney impairment on several key measurements of renal function Another study examined claims that dental amalgam interferes with immune function. The researchers found that subjects with dental fillings had the same number of disease fighting white blood cells as people who were amalgam-free. A Swedish researcher found no differences between amalgam and non-amalgam groups in measures used to assess immune system health, liver and kidney function, and skeletal muscle status. A Swedish study of 1024 women looked at the prevalence of 30 symptoms often claimed to reflect toxic effects of amalgam, including fatigue, dizziness, irritability, and back pain. Women with more than 20 amalgam fillings were no more likely to complain of these symptoms than women with few or no amalgams.

Another Swedish study examined mercury serum levels in a population of 1462 women in order to correlate the serum mercury level (from all sources including diet) to the vague symptoms often claimed to be due to mercury intoxication from amalgam. The study correlated serum mercury levels with the incidence of Dizziness, Eye complaints. Hearing defects, Headache, General fatigue, Sleep disturbances and 25 other symptoms over a period of 25 years. This study found NO correlation between serum levels of mercury and the 31 symptoms studied. (Note: In Sweden, serum mercury levels tend to be much higher than those found in North America or other nonScandinavian parts of Europe because Scandinavians are more likely to eat large amounts of ocean caught fish which increases serum mercury levels much more than mercury from amalgam fillings.)

A study of 30,000 female dental assistants and the wives of 29,000 dentists, divided into high and low mercury exposure groups found no difference between the two groups in the incidence of miscarriage or of birth defects in their offspring.
Standards set by the Occupational Safety and Health Administration (OSHA) estimate the mercury-vapor concentration to which even the most sensitive workers can be chronically exposed without suffering adverse effects. Under OSHA guidelines, the maximum safe occupational dose approximates roughly 300 to 500 micrograms of mercury vapor per day. Current estimates predict that people with a moderate to large number of fillings are exposed to 1 to 4 micrograms of mercury per day, barely 1% of the dose considered safe.

INHALED MERCURY: The results of one study in which patients with amalgam restorations were monitored with mercury vapor detectors over a 24-hour period showed that the amount of vapor inhaled was 1.7 g/day. Three other studies have confirmed that the magnitude of vapor exposure for a patient with 8 to 10 amalgam restorations is in the range of 1.1 to 4.4 g/day. The threshold value for workers in the mercury industry is 350 to 500 g/day, depending on activity level, and is based on an exposure of 40 hours per week.

Blood Levels: Mercury blood levels that were measured in one study indicated that the average level in patients with amalgam was 0.7 ng/mL compared with a value of 0.3 ng/mL for subjects with no amalgam. This difference was found to be statistically significant (P 0.01). However, one should be aware of a study in Sweden that demonstrated that one saltwater seafood meal per week raised average blood levels of mercury from 2.3 to 5.1 ng/mL, a sevenfold increase (2.8 ng/mL) compared with that (0.4 ng/mL) associated with amalgam restorations. The normal daily intake of mercury is 15 g from food, 1 g from air, and 0.4 g from water.

Total mercury vapor release was consistently found to be greater for admixed as compared to spherical amalgam. Amalgam restorations prepared by an inexperienced operator demonstrated statistically less mercury vapor than a novice or experienced clinician for both spherical and admixed morphologies. A statistically significant difference in mercury vapor using different condensation and carving techniques was found for the spherical amalgam but not for the admixed material. Restoration design demonstrated significant differences in total mercury vapor dependent on volume and exposed surface area of the amalgam restoration.

ADA Hg HYGIENE
Recommendations
Dental mercury hygiene recommendations: Sources of dental mercury in the office. General mercury hygiene recommendations. Office emergencies. Hygiene recommendations during preparation and placement of dental amalgam. Management of mercury spills. Management of small mercury spills. Management of large mercury spills.

Recommendations are changing stay current. Understand recycling documentation. Look for similar recommendations for other office materials.

Residual Hg in Capsules
OBJECTIVE: Measure (1) residual Hg in capsules and (2) potential for leaching in landfill. METHODS: Residual Hg (USEPA Method 7471); Leaching Hg (USEPA Method 1311). Capsule: Residual Hg (mg / capsule) Leached Hg P/F (mg / L / capsule)

Dispersalloy Regular Set Valliant PhD Optaloy Megalloy Valliant Snap Set Tytin Regular Set Tytin FC Contour Self-Activating Sybraloy Regular Set Tytin Regular Set

1.255 0.793 0.770 0.330 0.650 0.644 0.590 0.504 0.534 0.398 0.266 0.184 0.223 0.120 0.181 0.121 0.142 0.163 0.125 0.063

0.0477 (P) 0.0261 (P) 0.0340 (P) 0.0399 (P) 0.0425 (P) 0.0104 (P) 0.1640 (P) 0.4120 (F) 0.2530 (F) 0.0110 (P)

Stone ME, Pederson ED, Cohen ME, Ragain JC, Karaway RS, Auxer RA, Saluta AR. Residual mercury content and leaching of mercury and silver from used amalgam capsules. Dent Mater 2002;18:289-294.

Non-Contact Amalgam
Pass-through jar lid

Rubber dam with slit

Hg Vapor

Spent fixer, glycerine, or water

Unused amalgam and mercury collection

Hg Spill Kits

Spills = small; medium; large Spills = accidents; daily micro-spills

HG HYGIENE Amalgam Mixing

PLUMBING Sink Traps and Plumbing Suction / Mini-Trap

Capsules Non-Contact Hg

SEWER

Amalgam Storage Hg-Spill Kit

Chairside Filter

60% 30% 10%

Large Particles Small Particles Very Small Particles, Liquid, and Vapor

>100 mm 10-100 mm <10 mm

Separator Vacuum Pump Filter or Trap Vacuum Pump

SEWER SEWER

Amalgam/Hg Separators
OBJECTIVE: Remove amalgam and/or mercury from air/water stream in HVAC system. METHODS: ISO 11143 for Amalgam Separators. Amalgam Separator: EMPTY
(% Efficiency)

FULL
(% Efficiency)

Total Effluent Hg
(ppb, range)

A1000 Amalgam Collector Asdex BullfroHg Durr 7800/7801 ECO II HgS Hg10 MRU MSS 2000 Rasch 890-4000 RME 2000

96.09 0.39 99.89 0.06 99.10 0.09 98.88 0.64 98.06 1.08 98.17 0.43 99.36 0.15 99.99 0.06 99.96 0.03 99.66 0.30 99.93 0.03 99.67 0.13

96.24 0.46 99.96 0.03 99.36 0.14 99.38 0.48 97.66 0.35 97.51 0.74 99.28 0.10 (not tested) 99.95 0.04 98.94 0.06 99.90 0.03 99.66 0.24

30,200 - 34,899 1,180 - 3,350 9,930 - 15,750 5,850 - 16,270 970 4,070 16,310 - 26,340 6,430 - 9,600 20 100 200 570 730 - 4,040 600 - 1,250 1,530 - 3,430

Fan PL, Batchu H, Chou HN, Gasparac W, Sandrik J, Meyer DM. Laboratory evaluation of amalgam separators. J Am Dent Assoc 2002; 133: 577-589.

Hg Release from Amalgam

Chemical and Electrochemical Corrosion NO Hg RELEASED a. Low-copper dental amalgam: [Sn-Hg] [Sn] + saliva [Sn-O-Cl] [Sn] + saliva [Sn-O] [Hg] + [Sg-Sn] [Sg-Hg] + [Sn+Hg] b. High-copper dental amalgam: [Cu-Sn] [Sn] + saliva [Sn-O-Cl] [Sn] + saliva [Sn-O] [Cu] + saliva [Cu-Cl] (soluble) (insoluble) (more rx) (soluble) (insoluble) (soluble)

Current Separator Technologies

Company: Location: Telephone Number

SOLMETEX DRNA Max. Separ. Systems AB Dental Trends Rebec Air Techniques Inc.

(Northburough, MA) (Hackensack,NJ) (Sanichton, BC) (Lynden, WA) (Edmonds, WA) (Hicksville, NY)

978-262-9690 800-360-1001 800-799-7147 360-354-4722 800-569-1088 800-Air-Tech

http://www.ncddental.org

P.O. Box 1069 Hackensack, NJ 07601 1-800-360-1001 (TEL) 1-201-489-4740 (FAX)

SEWER

99+ %

SOLMETEX
SolmeteX 29 Cook Street Billerica, MA 01821 TEL = 978-262-9690 FAX = 978-262-9889
Air-Water Separator Filter and Hg Absorber

$695 for installation $150 per cartridge exchange

99.5% recovery is typical

DETECTION OF Hg
HOME ENVIRONMENT
Work Place Monitoring: Air sampling -- 3M badges Air sampling -- Jerome Hg analyzer

DENTAL OFFICE

Dental Personnel Monitoring: Air sampling -- 3M badges Blood tests Urine tests Hair tests

Patient Monitoring: Intraoral air measurements Patch testing (by dermatologist or allergist) Immune system tests

Hg ROAD MAP
Safety, Efficacy
Patients Personnel

BMPs
Purchase Storage Usage Non-Contact Filters Training, Spills

Hg

Leach Field Stream Dumping

CITY / EPA

FDA

OSHA / ADA
TRASH

Burning Land Spreading

WASTEWATER TREATMENT PLANT

Incinerator (audits) Sanitary Landfill (audits)

OFFICE PLUMBING
[Chairside Filter] [Vacuum System and Trap] Separators Flushing Plumbing Lines

RECYCLING PLANT (audits)

EPA / NCDENR

200

Total Amalgams
150

PROCEDURES / 100 pts

100

PRESENT
New Amalgams

50

1960

1970

1980

1990

2000

2010

DATE (year)

The US Food and drug administration has this to say about international acceptance of dental amalgam: "The safety of dental amalgams has been reviewed extensively over the past ten years, both nationally and internationally. In 1994, an international conference of health officials concluded there is no scientific evidence that dental amalgam presents a significant health hazard to the general population, although a small number of patients had mild, temporary allergic reactions. The World Health Organization (WHO), in its Consensus Statement on Dental Amalgam reached a similar conclusion. They wrote: "Amalgam restorations are safe and cost-effective. Components in dental restorative materials, including amalgam, may, in rare instances, result in local side-effects or allergic reactions. The risk of adverse side-effects is very low for all types of restorative materials, including amalgam and all resin-based materials. Similar conclusions were reached by the United States Public Health Service, the European Commission, the National Board of Health and Welfare in Sweden, the New Zealand Ministry of Health, Health Canada and the province of Quebec." Dental amalgam is NOT banned in any state in the US or in any Western country. However, legislation to ban it exists all over the map. The legislation is not the work of scientists. It is the work of anti-amalgamists pushing a political, not a scientific agenda, and the fact that it is not passed into law is because there is no scientific evidence that it is harmful to the general public and lots of evidence that

Making a amalgam restoration might be considered to be a chain process. The strength of a chain depends upon its weakest link. Misjudgment of its properties or the smallest neglect as to its manipulation might have unfavorable effects with regard to the restoration & even result in its total failure.

A.D.A & F.D.A state that use of amalgam is safe scientifically

Mercury and the American Dental Association

The American Dental Association (ADA) continues to remain in denial about the toxicity of mercury. A news release by the American Dental Association (ADA) on June 13, 2001 contains a significantly erroneous statement. The American Dental Association (ADA) President Dr. Robert M. Anderton is reported as saying, "There is no sound scientific evidence supporting a link between amalgam fillings and systemic diseases or chronic illness''.

However, it is a well known fact in the published, peerreviewed dental journals that mercury leaks directly from amalgam into adjacent oral tissues causing periodontal disease (gum disease).

Dr. Murray Vimey is one of the top mercury researchers in the world and he has provided a detailed chronology documenting how mercury has been clearly established as a contributing factor for periodontal disease. Dr. Vimy is one of the leading mercury researchers and his rebuttal to the ADA press release is most informative: Fact #1: In 1957, Zander (JADA, 55:11-15) reported "materials used in restorative dentistry may be a contributing factor in gingival disease. "Fact #2: In 1961, App (J Prosth Dent 11:522-532) suggested that there was greater chronic inflammation around amalgam sites than non-amalgam areas .Fact #3: In 1964, Trott and Sherkat (J CDA, 30:766-770) showed that the presence of mercury amalgam correlates with gingival disease. Such disease was not present at contralateral amalgamfree sites. Fact #4: In 1969, Sanches Sotres et al (J. Periodo. l40: 543-546) confirmed Trott and Sherkat findings .Fact #5: In 1972, Turgeon et al. (J CDA 37:255-256) reported the presence of very significant erythema around amalgam restorations which was not present at control non-amalgam sites.

Fact #6: In 1973, Trivedi and Talim (J. Prosth. Dentistry, 29:7381) demonstrated that 62% of amalgam sites have inflammatory periodontal tissue reaction. Thus, as early as 1973, a case can be made that the presence of dental mercury-amalgam results in chronic inflammation and bleeding in the gingival tissue adjacent to it; in other words, 'in situ' amalgam produced chronic Gingivitis. Fact #7: In 1974, Freden et al. (Odontol. Revy, 25: 207-210) showed that gingival biopsy material from sites not adjacent to amalgam had 1-10 g mercury/gram of tissue (mean=3); whereas, gingival biopsy sites near amalgams contained 19-380 g mercury/gram of tissue (mean=147). Fact #8: In 1976, Goldschmidt et al (J. Perio. Res., 11:108-115) demonstrated that amalgam corrosion products were cytotoxic to gingival cells at concentrations of 10-6; that is, micrograms/gram of tissue. Fact #9: In 1984, the year of the NIDR/ADA Workshop, Fisher et al (J Oral Rehab, 11:399-405) reported that at amalgam sites alveolar bone loss was very pronounced and statistically significant as compared to control non-amalgam sites. In other

Therefore, for the American Dental Association (ADA) to conclude "There is no sound scientific evidence supporting a link between amalgam fillings and systemic diseases or chronic illness'' is not correct.

THANK YOU