1. Dizziness 2. Speech problems 3. Visual disturbances 4. Tingling, numbness 5. Weakness 6. Hearing loss 7. Confusion, memory loss 8. Renal failure 9. Fetal effects ‘Mad Hatter

Amalgam Safety Flashcards by sophie rosen

What is amalgam?
(3)

 “a mixture or blend”
 “an alloy of mercury with another metal, especially one used
for dental fillings.”
 Silver, tin, copper, and mercury

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Dental amalgam used for >– years

150

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Dental amalgam used for >150 years
 1800-1950’s: Hg to alloy ratio =
 — technique, 1959

8:5
Eames

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Eames technique, 1959
 Hg:alloy ratio =

1:1

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 How much Hg in current dental amalgam alloys?
 Spherical: ~–% Hg
 Admixed: ~–% Hg

42
47-50

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Mercury (Hg)
 Naturally occurring —
 Mercury forms:
 Organic:
 Elemental:
 Inorganic Hg salts: (2)

element
methyl Hg
Hg0
Hg+1, Hg+2

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Most toxic form

Organic Mercury -
Methyl Hg

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Organic Mercury -
Methyl Hg
 (3)
 When taken up by fish, — up
the food web.
 –% GI absorption
 — soluble, uniform distribution
throughout body tissues
 Toxicity: — damage
 Most large scale —, organic Hg

Fungicides, fish, water
bioaccumulates
95
Lipid
neurological
poisonings

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Hg Forms: Elemental Hg0
 — metal
 Vaporizes easily, passes through (3)
 Little or no oral or —
 — absorb vapor
 Can have toxic — effects with breathing lots
of vapor
 Occurs through — in occupational
setting or mercury spills in poorly ventilated
area
 Used in —

Liquid
membranes,
skin, and blood brain barrier
GI absorption
Lungs
CNS
inhalation
dentistry

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Hg Forms: Inorganic mercury
Mercurous Hg+1, Mercuric Hg+2 salts
 Compounds used extensively in —
 (4)
 — toxic form
3. GI absorption —
4. Mercuric ions concentrate in kidneys, —
5. — soluble, environmental water pollution

industry
Mercuric chloride, bromide, sulfate, nitrate
Least
poor
acute toxicity renal necrosis
Water

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ELEMENTAL Hg VAPOR
Acute
(3)

Chills, cough
Metallic taste
Weak, dizzy

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ELEMENTAL Hg VAPOR
Chronic
(4)

Tachycardia
Tremor, confusion
Depression
Excess salivation

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ORGANIC Hg
(9)

Dizziness
Speech problems
Visual disturbances
Tingling, numbness
Weakness
Hearing loss
Confusion, memory
loss
Renal failure
Fetal effects
‘Mad Hatter

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Sources of Mercury
1. Food, inorganic and methyl Hg

 Non-fish, inorganic Hg
 Seafood, methyl Hg (organic)
 EPA recommendations → remember dose is important
 Not eat shark, swordfish
 12 oz (2 meals)/wk of lower Hg fish
 Shrimp, light tuna, salmon, pollock, catfish
 Albacore tuna, higher Hg than light tuna, 6 oz/wk2. Water, inorganic Hg
 Electronics manufacturing plants
 Air emissions recycle into water
 Dental office waste water. (small amount)

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Water, inorganic Hg
(3)

 Electronics manufacturing plants
 Air emissions recycle into water
 Dental office waste water. (small amount)

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Sources of Mercury
3. Air, Hg vapor, elemental
(3)

 Power plant emissions,
 Municipal combustors,
 Medical waste incinerators
 Dental amalgams, HG vapor

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 Dental amalgams, HG vapor =

Elemental Mercur

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Daily mercury exposure
1. Food: – g
2. Air: – g
3. Water: – g
4. Amalgam vapor: – g (~1% of max allowable in
industry workers)
(8-10 amalgam restorations) → DENTAL WORKERS ARE MOST
SUSEPTABLE. DENTAL WORKERS DO NOT HAVE A HIGHER
INCIDENCE OF “MERCURY RELATED ILLNESSES”
5. Maximum allowable: – g
a. Workers in Hg industry, 40-hr wk

15
1
0.4
1-4
350-500

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Mercury Allergy
(2)

a. True hypersensitivity?
rare ( 1% population)
b. Documented by physician, patch
testing

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skipped
Amalgam Mercury Toxicity?
 Hal Huggins, DDS

 Leading anti-amalgamist
 Diagnosed “mercury toxicity” in all pts, even
some without amalgam restorations
 Recommended extraction of any teeth with
root canal therapy
 Lost dental license
 “Mercury Toxicity” Scam: How anti-
amalgamists swindle people
http://www.quackwatch.org Dentalwatch.org
 Anti-amalgam claims
 Numerous emotional and physical disorders

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skipped
Anti-amalgam,
mercury toxicity claims?
(5)

 Hg migrates through tooth roots into bone and
gingiva
 I.Q. and brain Hg level proportional to number of
fillings
 Amalgams cause 50% reduction in kidney function
 Hg causes immune disorders such as arthritis, lupus,
lichen planus, Crohn’s diease, Alzheimer’s disease,
amyotrophic lateral sclerosis, multiple sclerosis
 Amalgam Related Syndrome (ARS) has no one typical
presentation. “Micromercurialism”: vague diffuse
symptoms.

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No — Hg in dental amalgam

methyl

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Elemental Hg0 versus chemically bound Hg
(3)

Study These Flashcards

 In final restoration, Hg chemically bound to Ag (1)
 Elemental H and O versus H2O
 Elemental Na and Cl versus NaCl (table salt)

Mercury Vapor (elemental Hg)
(2)

Study These Flashcards

 Mixing, insertion, polishing, and removal
 Mastication (minute amounts)

Facts about amalgam restorations  Over 150 years. Affordable, durable, safe. 80% last 15+ years.  Composite: (2)

 Increased cost, Longevity (posterior): 5-10 yrs  Bisphenol A release?

Hg not enter (3)

pulp, bone, or gingiva

Hg vapor release (2)

 Mixing, insertion  Polishing & removal, heat 

Small amounts Hg vapor absorbed by lungs, concentrated in kidney, excreted in urine → mercury levels are best measured through ---.

urine

Composite, Sealant Safety  Bisphenol A release (5)

 BPA estrogenicity (Endocr J 2004)  Association diabetes and cardiovascular disease (JAMA 2008)  Editorial, MU Columbia researcher (JAMA 2008)  Concerns composites and sealants, Pediatrics 2010 (Bb)  How much BPA released?

O2 inhibited layer, unreacted monomer  Composites: ---  Sealants: ---

shape/polish pumice

Dental Amalgam Biocompatibility Mercury levels 1. Blood (2)

a. Patients with amalgam restorations: 0.6-0.7 g/L b. Patients with no amalgam: 0.3-0.8 g/L

Dental Amalgam Biocompatibility Mercury levels 2. Urine a. Better indicator b. Patients with amalgam restorations: c. Dental personnel: d. One seafood meal:

5 g/L 10 g/L 5-20 g/L

Dental Amalgam Biocompatibility Mercury levels 3. All these levels well within normal (2)

a. Blood: 0-10 g/L (0-3 g/L) b. Urine: 0-25 g/L (Neurologic changes: 500 g/L)

US Public Health Service: Review of 500 Dental Amalgam Studies, 1993  Dental amalgams, minute amounts of ---  decrease with --- of amalgam  No demonstrable clinical effects with exposure  Removing amalgam, no improvement of ---  Hg vapor highest at ---

elemental Hg vapor (mastication) age symptoms or illnesses. insertion or removal

 Amalgam Exposure and Neurological Function, NeuroToxicology 2005 (1)

 1663 adults, no neurological effects from amalgams

 Neuropsychological and renal effects of dental amalgam in children, JADA 2007 (2)

 5-year study, 534 children, 6-10 yo at baseline  Amalgam or composite, no difference

 Neurobehavioral effects of dental amalgam in children, JADA 2008  7-yr study, 507 children, 8-10 yo at baseline  Amalgam or composite, no difference  Interesting fact: at 5 yrs, --% more retxt in composite group

skipped Amalgam Safety Reports  European Commission Health and Consumer Protection, 2008 (3)

a. Safety of amalgam and alternative (composite) dental restoration materials b. Amalgam safe, effective restorative 1) Material of choice in some situations c. Despite possible hazards of composites, also deemed safe

2. FDA 2009 a. Reclassified as Class ---: same classification as dental composites and other dental alloys b. Hg vapor not a risk for patients ... c. Limited to no information on fetus or children under...

II (moderate risk) 6 and over 6

3. ADA 2009 statement (2)

 Safe, affordable, durable material  Cite European Commission, FDA 2009

National Council Against Health Fraud Position Paper on Amalgam Fillings (Bb) 1. Amalgam most thoroughly tested restorative material 2. Conclusions of testing: a. Rare true allergy 3. Durable, inexpensive material 4. “Mercury-free dentistry” considered substandard practice 5. Cannot suggest amalgam removal for health reasons a. Lose dental license

AMALGAM IS SAFE

Future of Amalgam Restorations  No anti-amalgam/patient safety legislative bills have passed in US (2)

 No evidence to support  Norway and Sweden ban for environmental reasons

 --% of restorations currently placed are amalgam  Increased use of --- and other materials  MO amalgam-free practices: --% rural; --% urban (2008)  More appropriate material in certain application

30 composites 30, 60

 Economic impact of banning amalgam1 (2)

 Increased cost of alternative restorations  Increased untreated disease, under- and uninsured

 More important issue for future of amalgam:  Not mercury release from restorations

 Mercury/Amalgam waste management (EPA regulations)

Mercury Management 1. Dental personnel at greater risk for mercury exposure. We are the canary. 2. Appropriate techniques reduce mercury vapor in dental office a. -- g/m3 of air: maximum safe exposure level

Mercury Hygiene Recommendations 1. Avoid direct contact with Hg alloy 2. Clean up spills immediately a. Mercury spill kit, Nitrile gloves 3. Well-ventilated office 4. No ultrasonic amalgamators 5. Use amalgamator lid 6. High-volume evacuation and water spray 7. Monitor Hg levels in office 8. Avoid carpeted operatories 9. Don’t heat, incinerate, or sterilize amalgam, Why????? 10. Scrap amalgam, store in air-tight container and then recycle

creates vapor

Mercury Hygiene Recommendations 6. High-volume evacuation and water spray  ---fold decreased Hg vapor  --- heat from cutting  ---, decreased pt exposure

6 Decreased Rubber dam

Overall Environmental Mercury Release  --% fuel combustion  --% waste combustion  --% manufacturers and consumers  <--% from dentistry  To control dental Hg release, amalgam waste must be handled correctly.

53 34 13 1

Amalgam Waste  Amalgam capture device: (3)

 Chair side trap  Vacuum pump filter  Amalgam separator

Amalgam Waste (5)

 Amalgam capture device:  Contact amalgam, has contacted pt  Non-contact amalgam, leftover mix  Amalgam sludge  Empty amalgam capsules

 Contact amalgam, has contacted pt (1)

 Carving scrap, extracted teeth, amalgam in traps, filters, or screens

Evacuation System Amalgam waste collection  ---, collects amalgam particles from evacuation line  ---, upstream from central vacuum pump, to remove amalgam from suctioned water  Amalgam separator

Chairside Trap Vacuum Filter

Amalgam separator  Collects amalgam prior to ---  Sedimentation/filtration/ion exchange  Without separator, up to --% is captured at the office and up to the remaining --% at the waste water treatment plants.  ISO 11143 certification: ≥---% Hg removal  EPA mandated 2017. Compliance by 7/14/2020.  Chairside or central system, # operatories  Cost

central vacuum pump 80, 20 95

Amalgam Separators  Chairside (2)

 Need multiple.  Filters/collection needs sent off annually.

Amalgam Separators  Central  Problem:  Advantage:  Cost:

prophy paste cause system clogs only one filter to replace $1000 + 300 year

Amalgam Safety Flashcards

(57 cards)