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What`s your Favourite Filling?
Well mine is chocolate fondant, what`s yours?
A very significant event occurred this month which is going to affect our choice of filling from now on. A thousand delegates from about 140 nations adopted a treaty last Thursday regulating the use and trade of mercury at an international conference organized by the U.N. Environment Program. The landmark Minamata Convention on Mercury is named after the Japanese city where industrial emissions of the toxic substance caused a poisoning disease affecting thousands of people. The pact maps out measures to curb health and environmental damage caused by mercury. Each party country will not allow, by taking appropriate measures, the manufacture, import or export of mercury-added products after the phaseout date of 2020. The treaty also says “each party shall not allow the export of mercury except for uses specified under the convention”. The treaty will ban mining of fresh mercury and only allow “primary mercury mining that was being conducted within its (party’s) territory at the date of entry into force of the Convention for it, for a period of up to 15 years after that date.”
Various organisations, including the BDA, wanted to lessen the effect that a straight ban on amalgam by 2020 would cause and significantly dental fillings are exempt from the 2020 ban. The BDA warned that more time is needed both for preventive oral health initiatives to be implemented and show results, and for suitable alternative filling materials to be developed. British Dental Association representatives Drs Stuart Johnston and Susie Sanderson, both members of the organisation’s Principal Executive Committee, led international lobbying on behalf of dental associations around the world.
However, countries agree to a phasedown of mercury in fillings by promoting alternatives, creating dental programs to minimize the need for fillings or taking other steps.
In summary, the treaty sets out the future of dental amalgam as follows:
- Progress must be made in reducing the use of mercury in dentistry; this should be kept under frequent review. The WHO’s phase-down approach has been acknowledged, by implication, as being appropriate.
- National governments may pace the phase-down according to domestic needs.
- Public health and prevention programmes designed to reduce the incidence of dental disease should be a focus.
- The use of appropriate non-mercury based materials should be encouraged.
- Research into improved non-mercury based alternative restorative materials should be encouraged.
- Best practice measures should be employed in reducing the environmental load arising from waste dental amalgam products.
- An earlier reference to non-evidence based “high risk” groups (children and pregnant women) has been removed.
This means the Department of Health should now be adopting a defined stance, not just on the use of amalgam but the promotion of good oral health as well. There is now an international treaty which commits them to Public Health centred prevention programmes designed to reduce the incidence of dental disease.
In practice, we should now be `encouraging the use of appropriate non-mercury based materials`. In my opinion, this means amalgam is no longer an equal and appropriate choice. There will be fewer and fewer occasions when amalgam is a treatment choice that should be placed in front of patients. There are real evidence-led arguments that support this argument too. Not least of which is that cavity design for amalgam placement is more destructive than adhesive materials. Remember, this is not about any health-related danger to patients. There is no increased evidence pointing at direct dangers of mercury in amalgam. The drive behind the treaty is in the danger of mercury in industrial processes and in the dangers from the retention of mercury in waste, both clinical and industrial. However, we still have a duty to encourage the alternatives. Research into improved non-mercury based alternative restorative materials is providing more choices almost on a daily basis. Fibre reinforced composites, composites that can be cured in deeper layers and all varieties of compomer in between. In the future, I see adhesive restorations replacing crowns and veneers as well as amalgam fillings.
As individual practitioners, we have more of a responsibility to come up with ideas for Practice based prevention programmes, designed to reduce caries in our local groups of patients. This treaty will drive more than just the decrease in dental use of mercury, as we have to also decrease the need for procedures in the first place. The logical projection of this is that we will need to improve our communication skills and the marketing of the preventative message. Personally, I`m really excited that there is new impetus to this.
There is a mode of practice that supports all these requirements. Minimal Intervention Dentistry (MID) aims to prevent caries in the first place. Where caries develops, MID aims to encourage re-calcification or minimal restoration with adhesive materials. The tenets of MID only promote amalgam as a provisional restoration in larger lesions (before probable laboratory manufactured restorations). I`m willing to bet we can now replace this need with one of the new generation of reinforced composite. MID may take a little while to become more `mainstream`, but the principles will become more fitting to modern practice. I feel it is a way of life we should be embracing.
The British Dental Association (BDA) believes that the signing of a globally binding treaty on the use of mercury is a sensible outcome that recognises the practicalities of improving oral health. It`s statement also says - 'Importantly, it also acknowledges the crucial role that preventive oral health programmes can make to reducing need and demand for fillings.'
Dr John Shapter - QCS Expert Dental Contributor