The Clinical and Legal Mythology of Anti-Amalgam
Michael J. Wahl, D.D.S.
Myth 10: Amalgam has been banned in Germany and Sweden
and therefore should be banned in the United States.
Fact 10: Dental amalgam has not been banned
in any country in the European Union.
Many anti-amalgamists state that amalgam has been banned in foreign countries  notably Sweden [2,3] and Germany . Even a respected research newsletter has stated that amalgam “is or will be banned in Germany and Sweden.” Actually, the use of amalgam fillings is not banned in Germany or Sweden  or any other country in the European Union . In countries in the European Union, including both Sweden and Germany, dental amalgam filling material is governed by the Medical Devices Directive 93/42/EEC . An Ad Hoc Working Group of experts from the countries of the European Union issued a report on dental amalgam in 1998. After an extensive review of the available literature, the group concluded that there was no scientific evidence of systemic health problems (other than rare cases of allergy) or toxic effects from dental amalgam and it did not recommend any special reservations on its use . Sweden and Germany not only implemented these recommendations but also participated in their development .
There are no recommendations or restrictions for health reasons on the use of dental amalgam in Belgium, Denmark, France, Greece, Iceland, Ireland, Italy, Luxembourg, the Netherlands, Portugal, Spain, or the United Kingdom . There are general recommendations advising restriction in certain situations (eg, in children and/or pregnant women) for use and removal of dental amalgam in Austria, Germany, and Sweden. In each of these countries, the recommendations are slightly different. In Norway, Sweden, and to a certain extent Finland, adverse effects that can be related to any dental materials are to be reported to the appropriate government agency.
Health restrictions should be distinguished from environmental regulations. The Swedish Parliament, in a legally nonbinding resolution, recommended against the use of dental amalgam for environmental reasons after January 1, 1997. Denmark, Finland, and Belgium have also made environmental recommendations restricting the use of dental amalgam .
In 1997, the German Ministry of Health published a consensus report of various German dental and medical associations . This report stated that the choice of restorative material should be made by individual dentists and their patients. Although the report recommended against the use of amalgam in certain situations, it also stated, “Alternatives to amalgam should only be recommended if sufficient knowledge concerning the safety of the alternatives for the individual is available.The dentist is responsible for the individual ‘right choice’ of the material.” The Swedish Medical Research Council issued a similar statement in 1992, stating that there was no evidence of systemic health risks from amalgam fillings and there was no justification to discontinue the use of dental amalgam fillings or recommend their replacement in Sweden . The Swedish National Board of Health and Welfare’s expert committee declared amalgam safe and effective in 1994 .
If amalgam were ever banned in a foreign country, that would not necessarily be sufficient reason to ban it in the United States. The sale, import, and manufacture of chewing gum are banned in Singapore . Private health insurance is banned in Canada . Most American films are effectively banned on television in France to protect the French film industry . It would be senseless to institute these bans in the United States simply because they have been instituted in a foreign country. Laws such as these are often passed more for political than for scientific reasons.
It is time for the resurrection and redemption of dental amalgam. The facts of amalgam should be distinguished from the folklore of anti-amalgam opinion. The clinical performance of amalgam restorations is remarkable. Teeth with amalgam restorations have a low incidence of cusp fracture and recurrent decay. Amalgam restorations have been shown to last longer than composite restorations and can now be bonded to teeth. In addition, amalgam restorations can often be repaired. Amalgam bonding and other advances should be considered when studies on the clinical longevity of amalgam restorations are reviewed.
By most measures of clinical performance, other than appearance, amalgam is unsurpassed by resin composite for the restoration of posterior teeth. As scientific and clinical advances are made, it is possible this will change and other materials will become available. In the meantime, dentists can be confident in recommending amalgam restorations as an excellent choice in many clinical situations.
- Dickerson WG. The great white hype, or the no silver image? Round #5. Dent Econ 1999;89(5):18.
- Swedish government announces total ban of amalgam dental fillings. Bio-Probe Newsletter, March 1994;10(2):1-3.
- Larose P. Mercury toxicity: outdated facts! J Can Dent Assoc 1994;60:579.
- Eley BM. Have Germany and Sweden banned the use of amalgam? Dent Update 1996;23:313-4,28.
- Silver amalgam, update 1995. CRA Newsletter 1995;19(8):1-2.
- National regulations and policies. In: Dental Amalgam: A report with reference to the Medical Devices Directive 93/42/EEC from an Ad Hoc Working group mandated by DGIII of the European Commission. 1998:13-8.
- Mandate. In: Dental Amalgam: A report with reference to the Medical Devices Directive 93/42/EEC from an Ad Hoc Working group mandated by DGIII of the European Commission. 1998:12.
- Conclusions. In: Dental Amalgam: A report with reference to the Medical Devices Directive 93/42/EEC from an Ad Hoc Working group mandated by DGIII of the European Commission. 1998:103-5.
- Consensus statement of the German Ministry of Health, the German Institute for Drugs and Medical Devices (BfArM), the Federal Dental Chamber, Kassenzahnärztliche Bundesvereinigung, the German Scientific Dental Association, the German Association for Operative Dentistry and the German Association of dentists practising naturopathy. Restorative materials in dentistry. 1997.
- Swedish Medical Research Council. Potential biological consequences of mercury released from dental amalgam. In: U.S. Public Health Service, Committee to Coordinate Environmental Health and Related Programs. Dental amalgam: A scientific review and recommended public health service strategy for research, education and regulation. Final report of the Subcommittee on Risk Management. Washington, D.C.: U.S. Governement Printing Office, 1993; PHS publication no. 342-322/60025, pp. VIII-1 to VIII-11.
- Swedish National Board of Health and Welfare’s expert committee in 1994. Swedish National Board of Health and Welfare. Blir man sjuk av amalgam? SOS-rapport 1994:21. As cited in: Li Y, Siew C, Shearer BG, ADA Council on Scientific Affairs. Dental amalgam: update on safety concerns. JADA 1998;129:494-503.
- Corrections. New York Times, Aug. 15, 1999. Arts & Leisure, p. 2.
- Goodman JC, Musgrave GL. National health insurance in other countries. In: Goodman JC, Musgrave GL. Patient Power. Washington, DC:Cato Institute 1992:477-550.
- Riding A. French fume at one another over US films’ popularity. New York Times, Dec. 14, 1999:E1-2.
Dr. Wahl practices dentistry in Wilmington, Delaware. This article was originally published in Quintessence International 32:525-535, 2001 and is reproduced here with the kind permission of Quintessence Publishing Co. The author also thanks Drs. J. Rodway Mackert, Ivar A. Mjör, and Fred Eichmiller for reading the manuscript and offering several helpful suggestions.
This page was posted on November 1, 2002.