While his attempts to broaden the scope of healthcare in the US, by making it, among other things, more affordable for everyone, continue to face mounting pro-test, he is nevertheless unwittingly in the vanguard of a movement that is expected to result in the restriction-and eventually the worldwide ban-of amalgam dental fillings.
Amalgam, or so-called 'silver', fillings contain mercury, the most toxic substance in the world and, as such, these tooth preparations have been associated with a range of chronic diseases-especially neurological and cognitive problems-from the time that they were first used more than 150 years ago.
These preparations are also suspected of being responsible for chronic degenerative diseases, such as Alzheimer's and multiple sclerosis. Mercury from amalgam vapours binds to tissues and has been detected in the brain years after a filling has been fitted.
Yet, despite these serious concerns-and the growing body of evidence that demonstrates the damage to our health in general that they cause-the British and American dental associations have persisted in blocking every move to ban the use of amalgam fillings while continuing to claim that they are safe.
Indeed, in the US, any dentist who recommends the removal of amalgam fillings for health reasons in general, or specifically for a given patient, can be barred from practising.
In addition, America's drugs watchdog and regulator, the Food and Drug Administration (FDA), has always supported the American Dental Association's strategy of blanket denial.
Yet, in an extraordinary volte face in 2009, the FDA stated that amalgam fillings were safe except in that 3 per cent of patients who have a mercury allergy.
On the other hand, it then went on to strengthen the position of amalgam manufacturers by allowing them to conceal from patients the fact that amalgam contains mercury.
Statements posted by FDA officials on its website just a year earlier had declared that amalgam fillings "may have neurotoxic effects on the nervous systems of developing children and fetuses". In addition, its own scientific advisory committee had recommended an immediate ban of the use of amalgam fillings in pregnant women and in children under the age of six.
Not surprisingly, anti-amalgam lobby groups smelled a rat. Indeed, the FDA's new commissioner, Dr Margaret Hamburg, who had joined just two months before the official decision was made, had been-just prior to her appointment-a member of the board of directors and a shareholder in Henry Schein Inc., America's major manufac-turer of amalgam fillings (see box, page 12).
However, there are powers at play even greater than the British and American dental associations -or even the FDA. President Obama has signed America up for the United Nation's Global Mercury Partnership, which seeks to ban the mining and stockpiling of mercury, which it describes as a "poisonous pollutant".
Although the Partnership's principal targets are its use in industrial processes, the UN cites amalgam fillings in its list of products that contain mercury-a list that also includes batteries, thermostats, lamps and thermometers-against which it is seeking a more cautious approach. The UN is also attempting to reduce environmental waste.
Around 55 per cent of all mercury in commercial use today is in the mouths of patients who have been given amalgam fillings. In total, around 1088 tonnes of mercury are in filled teeth in the US in 2004 alone, and 34 tonnes are added to that total each year through new fillings (Environmental Protection Agency International Mercury Market Study, cited in the Mercury Policy Project, Current Status of US Dental Mercury Reduction Initiatives, October 12, 2007).
Both the European Union and the US are expected to adopt the Partnership's final recommendations, as will every one of the other 150 participating nations.
The most conservative response will be to only ban the use of amalgam fillings in those who are mercury-allergic or pregnant, and in children under six years of age. However, the EU may go further and impose a total ban of its use, as has already happened in Sweden, Norway and Denmark.
As a result, the British Dental Association would be overruled, and all dentists in the UK and Ireland would have to stop using amalgam fillings in everyone.
In the US, six states have so far introduced 'informed consent' legislation, where the dentist must tell the patient that so-called 'silver' fillings contain mercury. Last October, the city council of Costa Mesa in California passed a resolution in which it "requests" that all dentists in the city voluntarily stop using amalgam fillings. The council has also called upon the other 33 cities in Orange County to issue a similar edict.
Are dentists from Mercury?
Around a third of all dentists in the US already offer alternatives to amalgam, and a similar pro-portion probably does so in the UK, too. However, far fewer claim to be totally 'mercury-free'-or, if they are, they are keeping a very low profile about it. The UK's Society for Mercury-Free Dentistry lists only 52 dentists in the UK and Ireland combined who do not use amalgam, which is an extremely tiny proportion of the 24,000 dentists registered in the UK as a whole.
While many dental professionals may not want to work with mercury fumes every day, few are prepared to speak out against amalgam fillings and, in effect, their dental associations, which have maintained a fearsome defence of amalgam fillings for more than a century.
In fact, the American Dental Association (ADA) came into being only because the country's first organization for the dental profession-the American Society of Dental Surgeons, founded in 1840-refused to allow its members to work with mercury, so concerned was the Society about the health hazards of the metal.
Since then, the ADA and its UK counterpart, the British Dental Association, have maintained that the mercury found in fillings is rendered harmless, as it is combined with the silver, tin and copper that are also included in amalgam. Liquid mercury is then used to bind these metals, and it's this form of mercury that makes up around half of the filling's actual contents.
Vapours are released from the elemental mercury (Hg) used in the fillings whenever we chew food or brush our teeth. And no one is disputing that high levels of mercury vapour are dangerous, and can affect the brain and kidneys in particular, although the dental and health associations maintain that fillings emit very low amounts that are harmless.
If dental associations are evidently cavalier about the impact of these fillings on patients' health, they might at least be more concerned over the wellbeing of its own membership, as there's plenty of evidence to suggest that they should be.
One study of 106 dentists discovered that all of them had very high levels of mercury in their urine compared with 94 general practitioners, who are not exposed to such vapours on a daily basis. The dental surgeries themselves were also found to have abnormally high levels of mercury vapours in their immediate environment. The researchers, from Shiraz University in Iran, noted that neuropsychological, respiratory, cardiovascular, skin and muscle problems were more frequent in dentists than in the general population (Ind Health, 2010; December 16; e-pub ahead of publication).
In addition, in Norway, a small study of dental assistants who had been working in surgeries from before the country banned amalgam fillings in 2008 found them to have "significantly higher" levels of neurological problems, such as memory loss, inability to concentrate, fatigue and sleep disturbances, compared with hospital nurses (J Occup Med Toxicol, 2008; 3: 10).
Indeed, dental nurses-who are usually the ones who have to handle the liquid mercury to make the amalgam-are clearly at the sharp end, as another study has discovered. Their levels of mercury were far higher than those of the dentists, despite the fact that they were often sharing the same surgery. Nevertheless, both the dentists and their assistants had levels higher than those found in the general population. What's more, the study also found that the mercury was having a negative effect on thymus gland function, the researchers noted (Toxicol Ind Health, 2009; 25: 159-67).
Moreover, dentists had four times the levels of mercury in their urine compared with the general population, according to one study of 180 dentists and a similar number of controls. In that study, the researchers also noted that dentists were "significantly more likely" than the controls to suffer from disorders of the kidney and from memory lapses (Occup Environ Med, 2002; 59: 287-93).
Women and children first
According to the world's dental associations, mercury fillings pose no risk to human health. Yet, at the same time, they accept that dentists should exercise caution in their use of these preparations in those who have mercury sensitivity, in women who are pregnant and in children under the age of six. Although it has yet to introduce a total outright ban, Germany has already barred the use of amalgam fillings in the latter two groups.
Mercury vapours from amalgam fillings can pass through the blood-brain barrier and affect the developing fetus, a study of 99 mothers has discovered. The amount of mercury found in both the maternal and cord blood correlated with the number of amalgam fillings the mother had, researchers from the Slovak Medical University in Bratislava discovered (J Expo Sci Environ Epidemiol, 2008; 18: 326-31).
In addition, the association between the number of amalgam fillings and levels of mercury in the body continues well into child-hood. In one study of 507 children, aged between eight and 10 years, who had amalgam fillings in their mouths for up to seven years, the researchers discovered "a strong, positive" association between levels of mercury in the urine, and the number of amalgam fillings and the duration of time they had been in the teeth. It was also found that girls had much higher mercury levels than boys, even though the number of fillings was around the same in both genders (Environ Health Perspect. 2007; 115: 1527-31).
Researchers from the Institute of Chronic Illnesses Inc. in Silver Spring, MD, made a similar discovery when they re-analyzed data from a study that had examined the impact of amalgam fillings on mercury levels in adults. While the earlier study had found no association in the adults, the link between the fillings and mercury levels in these adults' children was marked. Overall, having an "average" number of amalgam fillings-which was not defined in the report-could increase mercury levels in children by up to 10 per cent.
"Dental amalgams are a significant chronic contributor to the mercury body burden", the researchers concluded (Biometals, 2010; November 5; e-published ahead of publication).
Conversely, researchers in Germany discovered that the overall level of mercury has been declining since its nationwide ban of the use of amalgam fillings in children. In 2000, levels had dropped by around two-thirds compared with mercury levels taken in 1992, say researchers (Gesundheitswesen, 2003; 65: 327-35).
So, how does mercury affect the health of children once it's present in their bodies? One study of 534 children, aged between six and 10 years, discovered that the metal affects IQ levels and kidney function.
Also, mercury was detected in some of the children as long as five years after they first had an amalgam filling, said researchers from the Sahlgrenska University Hospital in Sweden (Environ Health Perspect, 2008; 116: 394-9).
How much is safe?
Individuals with amalgam fillings are absorbing up to 17 mcg/day of mercury, as estimated by the World Health Organization (WHO) in its 1991 report Environmental Health Criteria 118. A more recent estimate puts the intake at slightly lower at 12 mcg/day from amalgam fillings (Arch Environ Health, 1994; 49: 384-94), although those with a mouthful of fillings could be absorbing up to 100 mcg/day (FASEB J, 1995; 9: 504-8).
Our immune systems can handle up to 2.4 mcg/day of mercury before we begin to feel any ill effects, says the US Agency for Toxic Substances and Disease Registry, based in Atlanta, GA. However, the US Environmental Protection Agency (EPA) considers the tolerance level to be slightly higher-at 3.84 mcg/day (U.S. Environmental Protection Agency. Health Effects Assessment Summary Tables. FY 1997 Update. Office of Research and Development, Office of Emergency and Remedial Response, Washington, DC; EPA/540/R-97-036, 1997).
Canada's health authority, Health Canada, is more conservative, and puts the tolerable level at around only 1 mcg/day (Health Canada, Assessment of Mercury Exposure and Risks from Dental Amalgam, 1995).
In fact, the effect is cumulative. Although mercury vapours stay in the blood for only three days, they bind to cell structures in organs and especially in the brain, where traces of mercury have been found for up to 18 years after the fitting of an amalgam filling (Neurotoxicology, 2001; 22: 577-92).
Why take the risk?
Mercury is the most toxic metal known to man. We have all probably already absorbed more mercury from our fillings than is safe. Even though some critics argue that our teeth are releasing levels of mercury that are far too low to affect our health, the truth is that there is no safe level when it comes to mercury.
This view is supported by the WHO, which maintains that there is no such thing as a 'safe level' for mercury, or a no-observed-effect level (NOEL), according to its Environmental Health Criteria 118 (see www.inchem.org/documents/ ehc/ehc/ehc118.htm).
And the UK's Health and Safety Executive agrees. In its own statement, mercury vapour is described as "highly toxic" at any level, and it urges dentists to use "less hazardous substitutes . . . when-ever possible".
Although amalgam fillings have been in use for more than 150 years, no health agency has ever assessed their safety. Indeed, America's FDA approved its use as part of its so-called 'grandfather' procedure, which grants automatic approval to drugs and devices that have been in continuous use since before 1976.
However, there are other compelling reasons for dental associations to deny that there are any health risks with the use of amalgam.
o Convenience. Amalgam is relatively inexpensive, it is durable and it is very easy to work with. Alternatives, such as composites and porcelain inlays, hit the pocket of the dentist harder, and they will last for only half the life of an amalgam filling, which can remain in the tooth for around 10 years. Using non-amalgam fillings will double the effort and expenses for the dentist.
o Capacity. Declaring amalgam fillings as unsafe would trigger the greatest health panic of all time, overwhelming dentistry everywhere around the world. Virtually everyone would want their amalgam fillings removed, and dentists would be unable to cope. According to the ADA, in 2009, more than 100 million Americans had amalgam fillings in their teeth.
o Lawsuits. It is imperative for dental associations to maintain their party line claiming the safety of amalgam fillings, as any admission that they are harmful would spark an investigation into the time they have 'sat' on the discovery, and could herald a spate of lawsuits, especially from people suffering from cognitive and neurological problems. Despite insisting that amalgam fillings are safe, the ADA has also declared that it "owes no legal duty of care to protect the public from allegedly dangerous products used by dentists".
In an interview with the present author on 6 January, 2011, consumer lobbyist Charlie Brown, of Consumers for Dental Choice (CDC), summed the situation up more prosaically. "Dentists just want to make quick and easy profits, and get out on the golf course."
However, the CDC points out that the position of the ADA, as well as those of other dental associations, is confusing. While its public statements have been insistent that amalgam is safe, the ADA has admitted, in various comments and documents over the years, that the fillings can affect health.
The CDC has collated these comments, which show that, in summary, the ADA has stated that amalgam fillings can cause:
o depression and fatigue
o inability to concentrate
o loss of memory
o birth defects
o nephritis and kidney disease
o swollen glands
o mouth ulcers.
For the consumer, the decision is clear: as there are alternatives that are safe and available, why take the risk with amalgam?
Are amalgam fillings affecting you?
If you are suffering from a chronic condition and you can't work out the cause, your amalgam fillings could be to blame. In a round-up of four studies, involving 1569 individuals, here are the main health hazards seen with amalgam fillings, and the extent to which they can be improved after their removal.
Condition (% affected) Improvement (%)
Fatigue (45) 86
Headaches (34) 87
Vision problems (29) 63
Depression (22) 91
Dizziness (22) 88
Skin problems (20) 81
Memory loss (17) 73
Metallic taste in mouth (17) 95
Loss of concentration (17) 80
Gastrointestinal problems (15) 83
Allergy (14) 89
Mouth ulcers (12) 86
Insomnia (12) 78
Irregular heart rhythm (10) 87
Nervousness (10) 83
Source: Holistic Dental Centre, Farnham, Surrey
'Scheiny' silver fillings
The world was watching when, in 2009, the Food and Drug Administration (FDA), America's health watchdog agency, declared that amalgam fillings were safe. The decision astonished almost everyone except perhaps the American Dental Association (ADA).
Even the FDA's own scientific advisory committee had, just a year earlier, recommended that the mercury-sensitive, pregnant women and children under six years of age should not be fitted with amalgam fillings. The FDA quickly included the recommendations on its website as if this was the new official policy.
Yet, the decision a year later not only denied that there were any health hazards with amalgam fillings, but it also strengthened the position of amalgam manufacturers, who are allowed, under the new FDA ruling, to conceal from the public the fact that amalgam contains mercury. Indeed, amalgam manufacturers and dentists can continue to use the misleading description of 'silver' fillings.
So what changed? According to the lobby group Consumers for Dental Choice (CDC), the FDA's commissioner changed. In May 2009, it appointed Dr Margaret Hamburg to the post. One of her part-time positions until then-and since 2003-had been as a member of the board of directors and a shareholder in Henry Schein Inc., the US' major manufacturer of dental amalgam.
It's a moot point as to exactly when she relinquished her position and her company holdings. According to the FDA, she did so immediately before she became Commissioner, but the CDC maintains that she did so only on July 27, just one day before the FDA announced its unexpected decision on amalgam.
She said she recused herself-disqualified herself because of professional involvement-and did not participate in either the mercury debate or the decision.
In any case, it was certainly a decision that benefited Henry Schein stockholders. Wall Street analysts were expecting a dip in the share price as everyone was anticipating a ban on the use of amalgam in children and pregnant women. Yet, the share price immediately rose $2 after the 'good' news. Schein's CEO Henry Bergman told analysts after the FDA decision that he offered his "sincere thanks to Dr Margaret Hamburg . . . for the insight she shared with the Henry Schein board throughout the years".
Fish and the red herring
Defenders of amalgam fillings sometimes accuse critics of bad science. They point out that mercury from fish is different from the mercury from amalgam fillings, while also claiming that it's more toxic and dangerous.
Mercury comes in three forms:
o methyl, from fish, especially oily fish such as tuna and salmon;
o phenyl, from amalgam fillings and the linings of nappies (diapers); and
o alkyl, from fungicides used for wheat and other agricultural produce.
As such, eating fish and having a mouthful of amalgam fillings doesn't necessarily add to your mercury 'load'-but they are wrong to underplay the importance of amalgam. It is, by far, the most common source of mercury overload in the body, and phenylmercury-from amalgam-is the most neurotoxic of the three forms of the metal. Other useful facts include the following.
o Our body absorbs more mercury from our amalgam fillings than from any other source, including fish. Around two-thirds of the mercury in the human body comes from our fillings (FASEB J, 1992; 6: 2472-6).
o Around 80 per cent of the phenylmercury we inhale from amalgam vapours gets into the bloodstream and, from there, into the body's tissues, including the brain (Acta Pharmacol Toxicol, 1965; 23: 250-62).
o Phenylmercury from amalgam stays in the body far longer than does the methylmercury from fish. One study involving pregnant women who ate fish seven times a month could find no traces of methylmercury in hair and blood samples, but did find high levels of phenylmercury-and the levels increased with the number of amalgam fillings (Environ Health Perspect, 2003; 111; 637-41).
Other studies have come to similar conclusions: those with amalgam fillings have up to five times higher concentrations of mercury in blood and urine samples, and up to 12 times higher mercury levels in organ tissues (J Dent Res, 1998; 77: 461-71).
o Methylmercury from fish is far less toxic than phenylmercury, which may be up to 20 times more dangerous (Science, 2003; 301: 1203).
One out, all out?
If you are suffering from a chronic health problem (see box, Are amalgam fillings affecting you?, page 11), your amalgam fillings could be the culprit. However, only a dentist who fully understands the dangers of amalgam, and who follows strict protocols to protect you, should remove them.
High levels of toxic mercury vapour are released during amalgam extraction. For this reason, the International Academy of Oral Medicine & Toxicology (IAOMT) has prepared eight 'best practice' steps that every dentist should follow when attempting such a procedure.
1. Keep the fillings cool. Throughout the procedure, copious amounts of water should be used to prevent the fillings from heating up.
2. A high-volume evacuator. This should be placed near the tooth at all times during extraction of the filling to help 'vacuum up' the vapours released from amalgam.
3. An alternative air source, such as a nasal hood, throughout the procedure. The patient should be breathing through the nose, not the mouth.
4. Dispose of the mercury alloy immediately. Particles of mercury alloy should be washed and vacuumed away as soon as they are removed.
5. Lavage. When removal is complete, the patient's mouth should be washed and vacuumed for at least 30 seconds.
6. Clean the face. The patient's face should be washed, and any protective wear should be changed.
7. Nutrition. Nutritional support should be provided before, during and after removal of the fillings. Patient aftercare is especially important, and nutrients and supplements can help to 'mop up' any phenylmercury still
in the body.
8. Keep the air in the room pure. The surgery should have air purifiers or ionizers.
WDDTY VOL. 21 NO. 11