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RestorativeDentistry

Rupert Austin

Shiyana Eliyas, FJ Trevor Burke, Phil Taylor, James Toner and Peter Briggs

British Society of Prosthodontics Debate

on the Implications of the Minamata
Convention on Mercury to Dental Amalgam
ÿ Should our Patients be Worried?

Abstract: In 2013, the Minamata Convention on Mercury called for a global phase-down of amalgam use, with a view to reducing
environmental mercury pollution. This will significantly impact UK dentistry, given the still extensive use of amalgam in UK general dental
practice. However, until now there has been little national discussion or debate. In Spring 2015, The British Society of Prosthodontics
dedicated a significant part of its Annual Conference to debating the implications of this issue. Clinical case examples were discussed with
audience interaction and voting facilitated using innovative Audience Response System Technology. A remarkable range of concerns and
opinions were given. The debate elicited specific concerns among clinicians regarding the suitability of mercury-free alternatives to amalgam;
particularly where cavities are large and extend beneath the gingival anatomy. There are also anecdotal reports of Dental Foundation (DF)
dentists not being adequately taught the use of dental amalgam in undergraduate dental schools.
CPD/Clinical Relevance: Many clinicians, especially those treating patients for whom moisture control is challenging, feel that amalgam should
remain available for clinicians to choose in certain clinical circumstances for the restoration of posterior teeth, even in the event of a complete
phase-down .
Dent Update 2016; 43:8–18

The phase-down of amalgam

Rupert Austin (RA), BDS(Hons), MClinDent, PhD, MPros RCS(Ed), MJD
The Minamata Convention on
FRCS(Eng), FAcadM(Ed), FHEA, Clinical Lecturer and Specialist in Prosthodontics,
Mercury, a United Nations treaty signed
King's College London Dental Institute, Shiyana Eliyas, BDS, MFDS RCS(Eng),
on the 10 October 2013 by 128 signatory
MRD RCS(Eng), FDS(RestDent) RCS(Eng), PGCertHE, Consultant in Restorative
nations, including the UK, was designed to
Dentistry, St George's Hospital NHS Foundation Trust, FJ Trevor Burke (TB), DDS,
protect human health and the environment
MSc, MDS, FDS MGDS RCS(Edin) FDS RCS, FADM, Professor of Primary Dental
from anthropogenic emissions and releases
Care, Birmingham School of Dentistry, Phil Taylor (PT), BDS(Ncle), MGDS RCS(Eng),
of mercury and mercury compounds.1
MSc(Lond), MRD RCS(Eng), FDS RCS(Edin), Senior Lecturer and Consultant in Restorative
Dentistry, Barts and the London School of Medicine and Dentistry, James Toner (JT), Minamata Bay in Japan was heavily
BA(Hons), FHEA, Senior Learning Technologist, King's Learning Institute and Center for polluted since the 1930s by wastewater,
Technology Enhanced Learning , King's College London and Peter Briggs (PB), mixed with mercury, dumped into Hyakken
BDS(Hons), MSc, MRD RCS(Eng), FDS RCS(Eng), Consultant in Restorative Dentistry, Harbor from the Chisso Corporation's
Barts and the London School of Medicine and Dentistry, London, UK. factory in Minamata, particularly by
methylmercury. The highly toxic compound
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bio-accumulated in fish and shellfish in the bay which, Offices in Norway may apply for exemptions to use also be carried out under rubber dam with high-
when eaten by the people living around the bay, gave amalgam on a case-by-case basis. speed suction, water spray and sectioning and
rise to Minamata disease (mercury poisoning) Therefore, dental professionals living in countries scooping of the fragments of the restoration.
affecting more than 10,000 people.2 Article 4 on that have ratified the Convention (of which the UK is
the Convention addresses the question of one) will need to amend their practice accordingly, The main alternatives to dental
mercury-added products and includes specific which is likely to affect the global dental profession amalgam for restoration of posterior teeth today are
requirements for signatory nations regarding the and public. This has resulted in a spectrum of resin composite and glass ionomer. The latter, in a
use of dental amalgam. The requirements are shown clinical opinion on the use of dental amalgam, review of the literature, has been shown to
in Figure 1. with views being expressed in the dental perform suboptimally under certain conditions,6
literature regarding the use of mercury-free direct
The aim is to reduce mercury restorative materials, which are perhaps not fully although results of a recent clinical
pollution over the next few decades with representative of the wider dental community, evaluation in Turkey indicate 100% survival of
targeted activities. The Convention prohibited a especially that of the general dental practitioner.3,4 reinforced glass ionomer restorations at four
number of mercury-containing products, including years.7 Recent work on the thermocuring
vaccines containing mercury, thermometers, a of glass ionomer restorations indicates that this
variety of light bulbs, blood pressure devices substantially improves the early physical properties
and dental fillings using mercury amalgam. By of these materials8 and appears to hold
Dental amalgam and its current
2020, their production and trade will be prohibited. promise for the future development of these materials
alternatives
in load-bearing situations. The use of resin composite
Amalgam is a cost-effective and restorations in posterior teeth has been the
However, dental amalgam is the clinically proven restorative material, the use of which subject of a number of extensive clinical
only mercury-added product that is subject to a has been popular in the UK for over a century. evaluations,9,10,11
phase-down, whereas all products will be banned Amalgam contains silver (40ÿ70%), tin (12ÿ30%),
or phased out. copper (12ÿ30%), zinc (1%) and 44ÿ48% mercury with positive findings, and two recently published
Countries such as Norway had previously by weight.5 systematic reviews, also publishing positive
undertaken significant national debate in the 1980s The process of mixing amalgam has changed findings, by Opdam and colleagues,12 and by
and 1990s and began phasing out dental amalgam significantly over the years, as has the handling and Astvaldsdottir et al,13
in 1991, mainly due to environmental concerns. disposal within a dental surgery. It is advocated that who concluded 'that the overall survival proportions
Since 2008 onwards, a ban on the import, export amalgam is placed under rubber dam with high of posterior resin composite restorations is high',
and use of most mercury-based products came into volume suction, within a room with good reporting that the overall failure incidence rate
place in Norway. However, dental ventilation. The removal of amalgam should for all reasons of failure was 1.55 restorations per 100

Figure 1. MINAMATA Convention on Mercury 2013 ÿ ANNEX A Part II: Products subject to Article 4, paragraph 3.

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restoration years. Major reasons for failure were this technology operated using clicker-based were then entered into the slides of the two main
secondary caries and restoration fracture. devices requiring dedicated battery- presenters representing the two sides of the debate
powered handsets distributed to the audience (PT spoke in favor of the continued use of
However, there are continuing and collected at the end amalgam and TB spoke in favor of the complete
concerns among dental professionals regarding of the session. However, this could only phase-down of amalgam). The two speakers had a
the management of large cavities in posterior teeth accommodate simple yes/no, true/false or multiple- two-week window prior to the event to provide
with direct restorations, which suggests that there is choice questions and therefore limited the uptake their responses to the questions. Therefore, once the
a need for wider debate among the UK dental of this technology. audience had been live-polled, the speakers' positions
profession as to whether an effective ban of Recently, the technology has become could be revealed and the chairman (PB) could
the use of amalgam may result. in poorer clinical sufficiently advanced allowing the use of challenge the speakers to defend their statements
outcomes for patients. This may be especially smartphones, tablets and laptops to respond to in light of the audience responses.
concerning for some patients (namely those patients text or image-based responses, as well as closed or
with special needs) for whom long clinical open-ended questions in real time via Powerpoint.15
appointments and increasingly complex alternative This expands the potential for interaction and Before the debate began the audience
treatments, such as posterior composite resin discussion with a potentially unlimited worldwide was asked to access, via their browsers, a
restorations or indirect restorations, are not audience via a web URL, as well as providing unique PollEv URL, which displayed a waiting screen
possible. beneficial qualitative information regarding until the first poll was displayed. During the live
the audience's responses in order to increase the debate, following the opening statements by the two
interaction between main speakers, the chairman ran the PowerPoint
Against this background, with the PollEv Add-In installed and the pre-selected
members of the British Society of speakers and their audience, whether they share the polls embedded within to enable a seamless
Prosthodontics expressed concern same physical location or not. experience.
regarding the phase-down of dental amalgam, To our knowledge, this is the first time
as it is still a clinically useful material without that a smartphone-based audience response As a result, the PowerPoint ran as normal and the
an ideal successor in system has been used during a live debate within polls were automatically opened and instantly
the event that it is no longer available. a dental educational 'pushed' to the audience's personal devices while
Therefore, the program of the 2015 British context. This article describes the debate also simultaneously displaying the polls using the
Society of Prosthodontics (BSSPD) and the resulting views of the audience; captured lecture theater projector in the normal way.
Annual Conference, which was held in London, using this novel information technology The respondents' answers were then displayed in
included a live interactive debate regarding the enhanced learning technique. real-time on the projected PowerPoint screen.
'Implications of the Minamata Convention on Mercury Participants were allowed to send in their answers
to Use of Dental Amalgam' entitled 'Should our Method: the debate as long as the chairman kept the poll open. The
patients be worried?'. The goal of the debate responses were tallied and displayed as a
A personal device-based ARS
was two-fold. First, to gauge the views of two horizontal bar chart, with a total count for the
(Polleverwhere, San Francisco, CA) was used
eminent speakers on the subject and, secondly, to multiple-choice questions and as a word cloud for
to live poll the audience at The British Society of
ask the large group of dentists (that consisted the free text responses. For the free text
Prosthodontics national debate on the global phase-
of specialists, generalists and foundation trainees) responses, two of the authors present (RA and JT)
down in the use of dental amalgam as a direct
who had listened to this debate, to input their acted as moderators to remove any inappropriate
restorative material in March 2015. The ARS
views on the management of several clinical examples. responses prior to display of the results of each poll.
was
operated via PowerPoint (Microsoft Office 2010)
using a free add-in (available from
www.polleverywhere.com/app) and the audience
The audience response system was asked to use their personal device internet
(ARS) browsers to navigate to the website (www.pollev.com/ The debate
This debate used novel bsspd ), in order to display and interact with the The chairman 'flipped' a coin and
Audience response system technology in order to question which was being simultaneously displayed TB chose to speak first in support of the phasing-
survey the audience regarding their opinions and via the projected PowerPoint slide. A series of image- down of amalgam. He began by summarizing the
feelings on the potential ramifications for based, closed- and open-ended questions were history of amalgam and citing the evidence
clinical practice, education and policy of phasing- displayed and the audience was invited to respond suggesting that amalgam restorations
down dental amalgam in the UK. There has via their personal devices. release small amounts of mercury, below
been increasing awareness of the use of the threshold levels considered dangerous for
technology-enhanced ARSs in order to occupational exposure for patients. The use of
enhance the quality and quantity of audience Two of the authors (PB and RA) amalgam has steadily decreased in the United
participation during higher education lectures developed the questions regarding amalgam for States and the United Kingdom, from 86% in 2002
and debates.14 Initially, this debate. Using the PollEv and PowerPoint to 59% in 2008.16 The
integration, the questions

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alternatives to amalgam were presented. Case 1: How would you manage the pulp in
Myths associated with composite this case?
restorations were challenged. It was stated that You have chosen to restore
polymerization shrinkage of the restoration with composite ÿ which would
would be reduced to 1% by the use of, for example, be your preferred cavity
Filtek Silorane (3M ESPE, Seefeld, Germany). Recently modification prior to applying
introduced bulk fill composites were recommended the dentine-bonding agent?
to reduce the technique sensitivity and the time
required to place and polish the restorations, with Which type of dentine-
most recent materials not requiring a conventional bonding agent would you use?
composite top layer. Supermat (Kerr-Hawe) matrix
bands and sectional matrices were advocated to What type of composite would
you use?

achieve a good contact point, a problem noted when

using resin composites in Class II cavities prior
to the introduction of dedicated composite matrices.
Proximal box elevation using resin modified glass
ionomer cements were endorsed for
Case 2: Which matrix band system would
deep proximal boxes with limited or no enamel for you use to restore the proximal
bonding, with the caveat that the patient must be cavity?
warned that this is a compromised situation. It was
suggested that new graduates in some schools have
received more training and experience in the
placement of composite restorations than in placing
amalgam restorations. At five years the annual
failure rate of posterior composite restorations has
been cited at 1.8% and that at 10 years as 2.4%.11
Other studies have suggested the overall failure of
posterior composite restorations to be 2% per
annum.10.12

The second speaker (PT)

spoke against the phasing-down of amalgam, Case 3: What would be your
citing evidence that there was no significant risk to preferred material choice for restoring
neuropsychological function from amalgam these teeth?
restorations in children. Numerous governments
(United States, Canada, Australia and a number of
countries in Europe) had issued statements to the
effect of maintaining amalgam as a dental restorative
material as the current evidence suggests that it is a
safe and effective material. The Norwegian Board Case 4: What would be your
of Health stressed that its decision to phase out preferred material choice for restoring
amalgam was not related to safety of dental amalgam this tooth?
but due to long-term goals in reducing the release of What would be your tooth-colored
mercury into the environment. Both Norway and restoration of choice for this
Sweden have stated that they will issue exemptions to tooth?
the ban on amalgam on a case-by-case basis. Potential If using amalgam restoration, what
health risks associated with composite monomers design would you choose?
were discussed.17

Table 1. Clinical case photographs and questions posed to the audience regarding the clinical
Composite restorations were said to have a
management of the tooth.
significantly higher risk of failure than

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amalgam (RR 1.89, 95% CI 1.52ÿ2.35), with of composite restorations was said to produce was shown to be significantly weaker than the
an increased risk of secondary caries under significantly greater increases in cavity volume bond to axial walls, with in vivo
composite restorations.18 compared to the removal of amalgam.20 bond strengths significantly weaker than in vitro
Composite restorations were said to lead to 1.9 The micro-tensile bond strength of adhesive/resin- conditions.21 The degradation of the resin-dentine
times more need for endodontic intervention bonds and destruction
based composite bonded to the gingival wall
than amalgam.19 Removal of the composite itself with time was
highlighted.22 The economic impact for banning
dental amalgam was considered to lead to a
significant short- and long-term increase in
1. Assuming that there will phase-down of dental amalgam use, should we be fighting for continued use of expenditure on dental care, leading to a decrease
dental amalgam in selected clinical situations? in the utilization of dental treatment and an increase in

2. If amalgam is no longer allowed to be used, do you think that more indirect restorations will be
untreated disease in the United States23 and a
prescribed for broken down posterior teeth?
significant potential increase in cost to the National
3. Those who said yes ÿ please state clinical situations for which amalgam should continue to be used Health Service in the UK.
The Interactive Clinical Case
Discussion included four cases and a series
4. For those who answered no ÿ state clinical situations when you consider composite resin contra-indicated
in posterior teeth of open- and closed-ended questions.
Table 1 shows the clinical case photographs and the
5. Having listened to the debate, do you believe that the clinical performance of amalgam and
questions posed to the audience regarding the
composite are equal for approximate posterior restorations?
clinical management of the tooth. Table 2 shows
the open-ended and closed-ended questions put to
6. Do you believe that amalgam should still be taught in UK dental schools?
the audience regarding the potential ramifications to
7. Do London DFs feel that they were adequately trained to use amalgam at dental school? the phase-down of dental amalgam.

The main screen allowed the

8. Having worked for 6 months as a DF trainee, do you think composite is the solution for all clinical situations
audience to view, in real time, the results of 'yes'/'no'
when restoring posterior teeth?
and free text votes. The technology allowed comparison
9. Those who have said no ÿ state examples of clinical situations for which composite has not been the solution of the views of the two specialist speakers and the
audience. It was possible to ask specific questions of
the Dental Foundation trainees enrolled with
10. Do you believe that the view of the UK GDP is being appropriately heard in this debate?

Health Education London (London Dental Education

11. Those who have said no ÿ how can it be heard better?
and Training) as many would have had limited
undergraduate experience with dental amalgam.
Table 2. Pre-selected open-ended and closed-ended questions regarding the potential ramifications to
the phase-down of the use of dental amalgam in which participants were asked to provide their opinions.

Poll results
The total sample size was 323 and
the audience was composed of 134 Dental
Foundation Trainees (Postgraduate Dentists who
qualified less than 12 months prior) and 189 dentists
who had a special interest in Prosthodontics. An
average response rate of 48% was received.

Case 1
The majority of respondents (34%)
would indirectly pulp cap using a dentine-bonding
agent. TB stated that he would use a dentine-
bonding agent to seal the dentinal tubules and an
incremental
composite. PT would use direct amalgam and avoid
a dentine-bonding agent as bonding agents can
Figure 2. Audience response results to the question 'Why would you choose to restore Case 1 with
hydrolyse leaving a space between the restoration
amalgam?' (n = 93).
and the

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RestorativeDentistry

Case 4
tooth. Fifty six percent of respondents would core restoration with a view to placing a cuspal
use a total etch technique using 37% Forty percent of respondents would coverage indirect restoration.
restore this tooth with an indirect
orthophosphoric acid prior to the bonding agent, Having listened to the debate, 66.7%
as would both speakers. metal restoration, 18% stated that they would of the participating audience stated that amalgam
Seventy percent of respondents preferred a two- restore with amalgam, 15% would restore with and composite were not equal in their clinical
bottle or two-stage 'total etch' or 'total rinse' indirect composite. Twelve percent would restore performance as approximate posterior
system. TB stated that he would use a new Universal the tooth with ceramic and 12% with direct restorations and that amalgam performs better than
Bonding System and PT stated that he would use composite. composite.
a three-step system every time. The majority TB stated that he would use direct resin When asked if we should be
(30%) of respondents stated that they would use composite and PT stated that he would use fighting for the continued use of dental amalgams
a microhybrid composite and 20% would restore amalgam. If using a tooth-colored restoration, in selected clinical situations, 89.5% of the
this cavity with amalgam. The main reason given 27% percent (the majority) of respondents stated participating audience stated that we should (Figure
for restoring with amalgam was longevity (Figure 2). that they would restore this tooth with an indirect 3). The free text responses stated moisture
resin composite onlay. TB stated that he would use control as the main reason for not using composite
direct composite and PT an amalgam core and a and for using amalgam in posterior teeth (Figure 4
milled partial coverage crown. If using amalgam, and Figure 5). The two questions, which effectively
Case 2 50% would place an amalgam asked the same open-ended
Forty nine percent of
respondents would use a sectional matrix with ring
retainer for restoring the proximal cavity, as would
TB. PT stated that he would use a Siqveland
(Dentsply, Addlestone, UK) or Automatrix (Dentsply,
Addlestone, UK), which were the second and third
choices of respondents.

Case 3
The majority of respondents would
restore these teeth with direct
composite (61%), as would TB. Twenty one percent,
and PT, stated that they would restore using
amalgam.

Figure 4. Audience response results to the question 'State clinical situations for which you consider
composite resin contra-indicated for posterior teeth?' (n = 63).

Figure 3. Audience response results to the

question 'Assuming that there will be a phase-
down of dental amalgam use, should we be
fighting for continued use of dental amalgam in Figure 5. Audience response results to the question 'State clinical situations for which amalgam should continue
selected clinical situations?' (n = 153). to be used?' (n = 106).

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question in two different ways, resulted in two word When the Dental Foundation trainees dentists whose main occupation is the restoration
clouds with very similar appearances, providing were asked if they felt that they were adequately of teeth. As indicated by the responses to Cases 1,
internal validity to this question. trained to use amalgam at dental school, 34.7% stated 2 and 3, a majority of the respondents were content
that they were not adequately trained. Having worked to use resin composite as the restorative material,
If amalgam were no longer as a DF trainee for 6 months, 93.9% stated that they these cases being cavities of moderate proportions,
available, 80.5% of the participating audience did not think that composite was the solution for all although the interproximal box in Case 3 was
thought that more indirect restorations would clinical situations when restoring posterior teeth; the wide. It is also of interest
be prescribed for broken-down posterior teeth. main reason given being 'time', followed by 'NHS' and
Fifty-three percent said that they believed more teeth to note a respondent's preference for a two-stage
'subgingival' (Figure 7).
would be extracted if amalgam was unavailable etch and rinse system in Case 1.
and 93.8% said that they believed that amalgam It is also interesting to note the popularity of the

should still be taught in dental schools in the UK. relatively recently introduced bulk fill composites,

When asked if the voice of the general dental which were chosen by 22% of the respondents.
Discussion Twenty per cent of respondents decided that they
practitioner is being appropriately heard in this
debate, only a third felt that it was being heard The results of this poll make would restore the cavity with amalgam, the main

(Figure 6). interesting reading and, while not a reason for this (Figure 2) being longevity

representative sample of all UK dentists, may be (although, as stated by TB, the literature no longer

considered to give a snapshot of supports amalgam being of greater longevity,9

despite respondents' opinions not appearing to
support this) along with ease-of-use and cost,
which favor amalgam in comparison to resin
composite, with clinical time costs being the main
factor in any restoration. It was for more challenging
clinical situations, such as in Case 4, that the
respondents would generally not choose resin
composite, in this case an indirect restoration being
favoured. This is reflected by the response which
indicated that 89% of respondents considered that
amalgam should continue to be used in selected
clinical situations. This is further

reflected by the response to the statement that 'if

Figure 6. Audience response results to the question 'How can the voice of the GDP be heard in the
amalgam were no longer available', more indirect
amalgam debate?' (n = 99). restorations would be

prescribed for broken down posterior teeth and an

increased number of teeth would be extracted.

Perhaps the respondents perceived a concept

similar to the situation in Norway, where amalgam is
effectively banned,24 but in which dentists may
apply to use amalgam for certain clinical
situations.

This is the first publication to present

results from the use of smartphone-and tablet-based
audience response system (ARS) technology to live-
survey the views of a large dental audience. This
technology provided an ideal method for collecting
quantitative and qualitative information regarding a
sensitive and impassioned topic such as the
continued use of dental amalgam.

Figure 7. Audience response results to the question 'State examples of clinical situations for which
The use of audience response systems
composite has not been the solution?' (n = 70)
operating using personal devices

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can be an inexpensive and environmentally friendly Indeed all the respondents of this BSSPD survey, increasingly trends towards the complete phase-
alternative to clicker-based ARS and has keenly await the development of this material. down of dental amalgam use.
the added advantage that the communication Furthermore, given industry awareness of the
medium is familiar to nearly all audience vast global demand for a mercury-free alternative to Conclusions
members, thus allowing live surveying of a dental amalgam, all major dental materials
This debate has confirmed that dental
potentially unlimited audience size. Although manufacturers are investing significant resources and
amalgam is still considered a useful and important
those without an internet-enabled device or with revenue to develop exactly such a solution.
material for the restoration of posterior teeth. Over
90% of those who voted wanted to see the choice
difficulty using their device are not able to participate, Currently, however, over 90% of
of dental
in this present study only one audience member respondents stated that they believed the use of
amalgam continue into the future within the UK for
reported that they felt excluded by the process as dental amalgam should continue to be taught in
certain indications. The majority of conference
they did not have a smartphone. As the market UK dental schools, with only 62% of the younger
attendees participating in the amalgam debate
presence of smartphones, tablets and laptops widens dentists in the audience saying that they felt
also felt that more posterior teeth will be extracted
to almost universal adoption, such issues will become adequately trained to use amalgam at undergraduate
if amalgam is no longer available.
ever rarer due to increasing familiarity with their dental school. On the other hand, it may be salutary
features and usages. to note that, when the phase-down of amalgam
takes effect, many senior practitioners may not
The results of this survey appear necessarily have the skills to provide posterior
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