Dr. O'Rielly's White Paper on Amalgam Fillings

Controversy:
Amalgam or 'silver' fillings have been the mainstay of modern dentistry ever since the mid 1800's. They are inexpensive, easy to place and last a long time. However, even when they were first introduced there was controversy as to whether or not they should be used. The problem with amalgam fillings according to many is that they contain up to a half gram or 50% mercury per filling. They are not a true alloy but an amalgamation of metals that can release small amounts of mercury during chewing and when eating warm or hot foods.

For a long time the American Dental Association maintained that mercury was not released from silver fillings. Now it is generally known that a filling does release mercury, up to 10-15 micrograms per day. Now the ADA position highlights the fact that amalgam fillings have 150 years of successful use in the profession and all during that time there has been little peer review research showing that the mercury released from these fillings causes any sort of disease state or builds up to a toxic level in the body. In fact the ADA maintains that there is little to no risk inherent in placing and keeping these fillings except in cases of allergy, which is extremely rare. Additionally the ADA stance is that it is professionally questionable to replace them at all, because the aggressive nature of dental treatment necessary to replace them risks tooth damage and root canals.

The Environmental Protection Agency has maintained that mercury in small amounts is a very toxic substance and an environmental hazard. The State of California regulates the use of toxic substances in the workplace and has mercury on its list of substances that cause birth defects. The World Health Organization has stated that there are no safe levels of mercury when it comes to the human body. The quote that follows came from a 2005 report, "Recent studies suggest that mercury may have no threshold below which some adverse effects do not occur." At the same time, however, the W.H.O. sets the toxic threshold for mercury toxicity at a high enough level as to all but eliminate amalgam fillings as a source of mercury poisoning.

The Food and Drug Administration until recently has maintained the safety of amalgams and refused to classify them. Now, due to a settlement resulting from a lawsuit, they have changed their wording on their website when it comes to 'mercury' or amalgam fillings. According to Charlie Brown, the lawyer who sued the FDA, the agency had to retract its claims of amalgam's safety from its website. To quote from the FDA's website, "Dental amalgams contain mercury, which may have neurotoxic effects on the nervous systems of developing children and fetuses. When amalgam fillings are placed in teeth or removed from teeth, they release mercury vapor. Mercury vapor is also released during chewing."

According to an article on Dr. Mercola's website, "A single dental amalgam filling releases as much as 15 micrograms of mercury per day. The average individual has eight amalgam fillings and could absorb up to 120 micrograms of mercury per day. In contrast, eating mercury-tainted seafood will expose you to about 2.3 micrograms per day -- and that is enough for scientists to call for a world-wide warning."

Dr. Mercola goes on to say, "Mercury vapor from the amalgams passes readily through cell membranes, across the blood brain barrier, and into the central nervous system, where it causes psychological, neurological, and immunological problems. Mercury can persist in your body for years unless it is actively removed."

Norway and Denmark banned mercury from fillings earlier this year while Finland and Japan have severe restrictions. The use of mercury amalgams has been banned and is on a scheduled phase-out in Germany, Austria, and Denmark. In Sweden, the use of amalgam has been reduced by 90 per cent since 1997, as its use is severely restricted and a total ban exists when it comes to children and youth. Also, the Canadian government has instructed its dentists not to place amalgams in the teeth of pregnant women and children.

In defense of continued amalgam usage is the position of the ADA as summarized above. Also, in 1992 a review by the U.S. Public Health Service concluded that it was inappropriate to recommend restricting the use of dental amalgam, because current scientific evidence does not show that exposure to mercury from amalgam restorations poses a serious health risk in humans [13]. This is basically the same position as the ADA. They go on to say, "Sweden, Denmark, and Germany have proposed restrictions on dental amalgam use. They have done so in an effort to diminish both human exposure to and environmental release of mercury and not because of any documented health effects associated with exposure to dental amalgam." This statement seems to contradict itself and even erode the validity of their claim that amalgams are safe.

Two recent studies by the University of Washington show that mercury in amalgam fillings does not cause health problems, even in young children. The research is referenced in the footnotes. In reply to this research Herbert Needleman M.D., who according to a Newsweek article is the scientist who did more than any other to document the toxicity of lead to developing brains, filed an editorial in JAMA, the Journal of the American Medical Association, in 2006. He argued, "Given limitations in design in the studies by Bellinger et al1 and DeRouen et al it was unscientific to assume a no-effect conclusion. The limitations were statistical power too low to find a relatively small harmful effect, follow-up too brief, and nondifferential errors in exposure measurement that would lead to a null bias. Neither Dr Ismail nor Dr Fung and colleagues addressed these criticisms."

"Ismail states that neurobehavioral deficits in dental professionals have nothing to do with dental fillings and dismisses my mention of the possible effects of amalgam in the aging brain. The findings of neurological deficits in dental professionals were offered in evidence of the neurotoxicity of amalgam, whatever the source. Both trials1-2 followed up patients for a relatively short period. The potential effects of fetal toxicant exposure on neural function later in life is a subject gathering considerable attention."

It is clear from the above that there is strong disagreement between the American Dental Association and both Consumer groups and certain physicians, with each side arguing that the research bears out their position. This being said much of the research I have seen seems to question the use of amalgam fillings rather than support it.

Many say that the ADA is biased because they are trying to protect the profession from possible legal liability. A more balanced view is that dentists for the most part are a pretty altruistic group when it comes to watching out for the patient's best interest. A big consideration for the ADA has always been cost and the availability of other treatment choices. There were simply not as many choices 10-20 years ago as there are today.

Despite this, there remains a huge disagreement and controversy when it comes to amalgams that is likely to continue for quite some time. So what is a patient to do? Unfortunately, after hearing all the facts and discussing your individual situation with your health care providers, you are going to have to rely on your own good sense and decide for yourself.

Advantages of using Amalgams:

1. Cheaper than most other fillings
2. Relatively easy to place
3. Can be placed in presence of moisture
4. Lasts a long time
5. Resists new decay probably because it is hard and contains mercury

Disadvantages of using Amalgams:

1. Not very cosmetic looking
2. Tarnishes and corrodes over time
3. Releases mercury in small amounts
4. Weakens the tooth over time because of cracking
5. Causes galvanic (stress) reaction with other metals
6. Often stains underlying tooth black

Dr. O'Rielly's position on mercury toxicity:
In my generation and my parent's generation, we grew up in a less toxic world. Today the situation is different. During the last 50 years because of the advent of the chemical revolution, industrialization and increase in consumption, there has been a significant increase in environmental toxicity in this country. Therefore, the total burden we are exposed to and our bodies have to deal with and attempt to eliminate has increased as well. Because of the greater body burden of toxicity, the stress it puts on our organs of elimination, and the lower quality of the foods we consume, the relative effects of our exposure to an environmental and biological toxin like mercury can be magnified. In other words what may affect us today may not have affected us the same way 50 or even 25 years ago.

While on the surface the ADA's position makes some sense, as a dentist and healthcare provider, I believe that their position is outdated. This is because amalgams can result in exposure to mercury over time, and what does this constant exposure do to us later in life, when it is probably too late to do anything about it? I am concerned that over time this exposure can affect our immune system, our organs of elimination and our nervous system in ways we can't anticipate. This is especially true of people with weakened immune systems and weakened organs of elimination. As Dr. Needleman states, one of his concerns is the, "Possible effects of amalgam on the aging brain."

There is no longer a disagreement when it comes to mercury being released from your silver fillings and ending up in your body. So as with any plan to maintain or regain health, dentistry- including replacing amalgam fillings- should be considered. How high of a priority the removal will be depends on the age of the fillings that are in place. The other issue is whether you will be receiving any detoxification treatment requiring their removal. According to most of the physicians that I have worked with over the years, DMPS and usually DMSA treatments that target systemic mercury require removal of amalgam fillings before treatment begins.

From the dental point of view many of the patients that come to see us have amalgam fillings that have been in place for quite some time. I have noticed over the years that amalgam fillings tend to crack the tooth structure underneath them. These cracks tend to become bigger over time due to the stress of chewing and are accelerated when there is any clenching or grinding occurring especially at night. This can lead to tooth fracture which typically requires caps / crowns and sometimes root canals.

As with anything else it is usually better to be proactive and address the problem before it breaks down and gets worse. The best example of course is the advice that many of us get from our car mechanic; that it is cheaper to take care of things and maintain our cars as we go rather than wait till it breaks down and something major happens. The same is true when it comes to our dental care and dental health in general.

Risks involved:
On a simple level it comes down to the following question, "Is the risk of leaving my amalgam fillings in greater than the risk of taking them out?" After hearing all the facts this is something that each patient needs to decide for themselves. With this in mind let's look at some of the issues involved.

From a dental point of view, leaving old amalgam fillings in place too long risks damaging tooth structure, due to cracks and eventually fractures. This can lead to crowns and root canals in some cases. Taking them out can also lead to tooth loss and root canals due to the trauma of additional dental drilling on teeth. This can be somewhat of a dilemma for people with good reason. However, bonding helps in this area because it often requires that you remove less tooth structure. This puts less stress on the nerve and thus results in fewer root canals than crowns do.

The health risk of leaving amalgam fillings in place is something that I cannot comment on because I am not a physician. However, if you are interested in being tested or treated for heavy metal like mercury, I would strongly support seeing a qualified health care provider who specializes in heavy metal toxicity and its treatment. If you live in San Diego we can provide you with referrals to help you in this area. Suffice it to say that I strongly believe that heavy metals should be considered in any health plan.

"So I have looked at treatment risks with my dentist and health issues with my healthcare provider, and I have decided to remove my old amalgams, now what?" In my opinion if you are going to do something make sure you do it right the first time. I often hear people choosing cheaper treatment options so that they can 'get their mercury fillings out' without thinking of long term consequences. You are actually better off waiting till you have the money to do the procedure with proper precautions than to shortchange yourself and risk bigger problems with your teeth down the road.

How to avoid jumping from the frying pan into the fire:
It is important how amalgams are removed. Can you imagine the amount of mercury that is released when amalgams are drilled out by burs that produce heat? To put this in perspective, the EPA. has stated - and I quote from their website, "It is important to note that only a gram of mercury can pollute an entire body of water." So the next time you go to your dentist and have a couple of those old amalgams removed, think about the effect of this on the environment and possibly your body. With the above quote in mind imagine drilling out amalgams and mercury being released into your mouth where some of it might be swallowed. I'm amazed that rubber dams are not used routinely when removing old amalgams.

A rubber dam is a simple procedure that all dentists have been trained to use in dental school. So if you have an amalgam removed by your dentist make sure that s/he does at least this much to protect you from more exposure to metal and mercury during the removal process. If they refuse I would recommend that you go to another recommended dentist that will do this for you.

The second thing you can do for yourself is protect yourself from exposure when you breathe by having a nose piece in place. This is because most of the mercury released into the air and that you breathe in will cross into your blood stream due to the high efficiency of your lungs.

Also, after the metal fillings have been removed it is important that they are replaced with the right materials. Basically, the problem comes down to using composites to replace large amalgams on back chewing teeth. This results in breakdown and failure of these composites sometimes on the order of 3-5 years. Due to chewing forces the composites are just not strong enough and lose their bond strength and re-decay. Once this process of breakdown starts it can quickly result in spreading decay and create a higher risk of root canal infection. So beware out there.

Another area of concern is placing composite crowns on teeth to try to maximize the biocompatibility of the material used for sensitive people. In my experience this is contra indicated in almost every case. Again, this results in decay sneaking in around the edges in a relatively short time frame.

Dr. O'Rielly's advice for removing amalgams:

1. Get fully informed before proceeding
2. See a dentist that uses a protocol for amalgam removal (see below)
3. Use a biocompatible material that will stand up to the test of time
4. Use bonding when possible to save tooth structure
5. Don't do a composite when an inlay or onlay is called for
6. If you can't afford it, save your money until you can

The right way to remove amalgams:

1. Use a rubber dam
2. Use a nose piece for clean air
3. Wear glasses for eye protection
4. Have high speed intra-oral suction where the work is being done
5. Have a high speed suction and filtration unit in place for the room
6. Have supplemental air filters for the room where the work is done
7. Try to find an office that has access to fresh air and windows that open
8. The office should also have a filtration unit in place that removes all the mercury from the water lines before it leaves the office.

This additional mercury filter prevents mercury from escaping the dental office and getting into the environment. This is in addition to the traps and particle filters that are usually in place, and I only know of a few offices that have this in San Diego.

This is important for the environment because dental offices account for at least 6 tons of mercury being dumped in this country every year according to the ADA By some accounts it is as much as 20 tons. This is a lot of mercury and it is yearly. In 2004 there were over 2,400 advisories posted by the EPA. for mercury pollution in our waterways. According to the EPA's website, "Seventy-six percent of all advisories have been issued, at least in part, because of mercury." Also, according to their website this is three times more than the next highest pollutant PCB. Keep in mind there are approximately 70 million amalgams placed every year in the US alone.

My Philosophy:

1. First do no harm
2. Provide a supportive environment
3. Listen carefully to what patients are asking for
4. Achieve the best result possible for each patient
5. Maximize longevity, biocompatibility and cosmetic results

I also believe that if you help one person, you are helping your community. If you help hundreds of people, you are helping the planet.

I look forward to serving you, your friends, and your loved ones.

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