Journal of Dentistry (2004) 32, 359365

www.intl.elsevierhealth.com/journals/jden

Amalgam toxicityenvironmental and occupational hazards

rsted-Bindslev* Preben Ho
Department of Dental Pathology, Operative Dentistry and Endodontics, Faculty of Health Sciences, Royal Dental College, University of Aarhus, Vennelyst Boulevard, DK-8000 Aarhus C, Denmark
Received 2 December 2003; accepted 3 February 2004

KEYWORDS
Amalgam; Mercury; Environment; Waste; Body burden; Neuropathology; Reproduction

Summary Objectives. To discuss briey the recent developments in mercury production, consumption and waste handling especially in relation to the use of mercury in dentistry. Furthermore, to discuss the toxicological and reproductive aspects of the mercury body burden of dental personnel. Data, sources and study selection. The data discussed are primarily based on published scientic studies and on publications and reviews from governmental and other ofcial authorities which have been published within the last 10 years, References have been traced manually or by MEDLINEw. Conclusions. Global production and consumption of mercury is decreasing, as is the production of amalgam llings in some countries. By proper measures it is possible to further reduce the environmental burden of mercury from dental clinics. In general, the mercury body burden of the dental personnel can be kept below the normally accepted toxicological limits and reproductive effects have not been proven provided a proper mercury hygiene regimen is adopted. q 2004 Elsevier Ltd. All rights reserved.

The use of mercury for production of dental silver amalgam restorations and the later release of mercury from the restorations has been a matter for concern especially during the last 30 years.1 Passions have run high on the risk of health hazards from mercury in individuals with amalgam llings. The dentists, who are the persons, most highly exposed to mercury, have had a more relaxed attitude towards their own exposure and to some extent to the possibility of causing environmental problems. In recent years, the dental personnel have been aware of their environmental responsibility and for some years especially the female
*Tel.: 45-8942-4140; fax: 45-8620-2202. E-mail address: ph-b@odont.au.dk

personnel have been aware of the possible risk of reproductive disturbances caused by injudicious handling of mercury. The aim of this review article is to discuss briey the recent developments in the environmental and occupational aspects of dental treatment with amalgam.

Environment
Consumption
Mercury occurs naturally in areas of previous high volcanic activity and is also today produced from

0300-5712/$ - see front matter q 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.jdent.2004.02.002

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mining in areas, such as Algeria, Spain, Kyrgyzstan, China, Mexico and Peru. Mercury is released naturally to the environment by erosion of mineral deposits, volcanic eruptions and geysers. Mercury is moreover distributed in the environment by human activities such as metal smelting and coal production and as uncontrolled waste disposal. By natural means it has been estimated that between 2700 and 6000 t of elemental mercury is released to the biosphere through degassing from the earths crust and oceans. A further 2000 3000 t from industrial wastes and the combination of fossil fuels add up the environmental load.2 Mercury is known to be neurotoxic and nephrotoxic. Toxic effects on the respiratory, cardiovascular and gastrointestinal systems have been shown following acute exposure to elementary mercury.3 Fetuses and newborn babies are more sensitive to mercury than adults and there seems to be great differences in sensibility among individuals. Environmental mercury is accumulated in food chains, particularly in the aquatic milieu where a high degree of biomagnication occurs. The food chain seems to be the predominant route of human exposure to methyl mercury, which is the most toxic form of mercury.2 Because of the toxicity of mercury and the resulting environmental and occupational problems several countries have adopted regulations to reduce or ban the sale and use of mercury products. The global production from mining of mercury has decreased in the last 15 20 years from an estimate of about 6200 t per year in the period 1981 1985 to 1800 t in 2000.4 The use of mercury in the chloralkali production, which has been a prime consumer of mercury, is about to be phased out in several countries. Thus, in the USA consumption of mercury in this industry dropped from 247 t in 1990 to 136 t in 1996.4 However, a decrease in consumption of mercury in this industry does not automatically mean that less mercury come onto the market. Substitution and closing of a mercury based chloralkali plan renders a large inventory of mercury available for recycling. In dentistry, a comparable reduction of mercury consumption has occurred. In the USA the consumption dropped from 44 t in 1990 to 31 t in 1996.4 In Denmark, the consumption dropped from 3.1 t in 1982 1983 to 1.2 t in 2001.5 Similarly, the production of amalgam llings reported to the Danish National Health Service dropped from about 3.0 million items in 1982 to 1.1 million items in 2001 (Fig. 1). The tendency may reect the decrease in caries prevalence, but also a substitution of amalgam with alternative materials.

Figure 1 Number of amalgam llings (left) in relation to consumption of mercury in dentistry in Denmark (right).

Even though the use of mercury in dentistry has been reduced in countries where regulatory measures have been taken, the local governmental authorities may press for a further reduction. The use in dentistry may be strongly marked because the proportion used for amalgam makes up a greater percentage of the total amount of mercury when mercury used for other purposes as batteries and medical devices has been totally banned. Thus, even though consumption of mercury in dentistry in Denmark has dropped from 3.1 to 1.2 t the percentage of the total consumption doubled from 17 to 34% in the same period.5

Waste handling
As long as amalgam llings are produced in restorative dentistry and patients have amalgam llings in their teeth, the dental profession has an obligation to minimize or, preferably totally to eliminate release of mercury to the environment. The mercury cycle in dentistry is illustrated in Fig. 2. Surplus of triturated and carved amalgam should be collected and stored in tight boxes under cover of for example used X-ray xer for later recycling.6 Units must be equipped with lters and/ or separators, which catch particles occurring from removal of old amalgam llings. Installation of effective separators have shown to eliminate up to 91 99% of the mercury in the waste water from the dental clinic.7,8 It has further been shown that the mercury concentration in the sludge from waste water treatment plants declined 29 80% in areas where separators were installed in the dental ofces.9,10 If a signicant reduction is not obtained after installation of separators the reason may be sediments of mercury present in the sewerage. Thus, installation of lters is not a guarantee for low concentration of mercury in the wastewater.

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41,000 persons is emitted to the air. The Danish authorities have in line with most countries not decided in favour of combustion lters.

Occupational hazards
Body burden
The mercury body burden of dental personnel has often shown higher levels than the general population because dental personnel handle mercury in the clinic, remove or assist in removing amalgam llings and they may also have amalgam llings themselves. Urine mercury level is used for determining long time exposure to inorganic mercury. A concentration at 1 5 mg Hg/l urine is considered to be within normal range for non-occupational groups.12 15 The level at which symptoms of chronic intoxication are recognized vary greatly between individuals partly because of differences in individual sensibility. Subtle and non-specic symptoms of mercury intoxication have been discussed in the literature at concentrations above 25 50 mg Hg/l urine.3,16 19 Because of the diffuse nature of symptoms diagnosis of chronic mercury intoxication is always based on history of exposure. Weakness, fatigue, loss of appetite and gastrointestinal disturbances are described as symptoms occurring after long time exposure to low level exposure. Classical symptoms after high exposures are tremor and erethism.12 The urine mercury level of dental personnel has been determined for many years and examples are given in Table 1. In the USA measurements have been published in 1968 at 40 mg/l in 1987 at 12 mg/l and in 1995 at 5 mg/l showing a dramatic decline

Figure 2

Mercury cycle in dentistry.

The waste water pipes of old clinics may contain sediments of mercury, which is gradually released. Further, it is of utmost importance that the dental personnel act according to local regulations and are properly educated to handle and maintain lters and store scrap until later deposition. 11 Extracted teeth with amalgam llings should be handled as risk waste instead of being thrown in a waste basket which often happens in daily practice.11 In some countries, extracted teeth are donated to dental schools for teaching purposes. Mercury may slowly be released to the soil from buried persons with amalgam llings and to the air by cremation. However, analyses from soil and drain water samples from a Danish cemetery showed no detectable amounts of mercury.7 In Sweden, crematories performing more than 1000 cremations per year must be equipped with lters to catch emitted mercury from amalgam llings. In Denmark, the Danish Environmental Protection Agency5 has estimated that about 170 kg mercury from an annual cremation of about

Table 1 Mercury concentration in urine from dental personnel. Mean USA USA Sweden Control USA Norway USA Sweden Control Venezuela Mexico Holland 196820 198521 198622 198723 199024 199525 199726 200127 200228 200315 40 mg/l 15 mg/l 4 mg/l 3 mg/l 12 mg/l 8 mg/l 5 mg/l 5 mg/l 4 mg/l 22 mg/l 3 mg/l 11 mg/l Range

5% . 50 mg/l

13% . 20 mg/l 055 mg/l 2% . 20 mg/l 227 mg/l 023 mg/l 0.212 mg/l 522 mg/l

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during the period (Table 1). The decrease may mainly reect better operatory mercury hygiene, but the 1995 level may also reect a decrease in caries prevalence and to some extent use of alternative materials. In Sweden, the gures from 1986 to 1997 are almost similar and not different from a control group reecting a high operatory standard (Table 1). Still in some countries the mean and range HgU level is rather high and approaches concentration where subtle symptoms have been observed in sensitive individuals. The high concentration in some dentists may indicate that a change in operatory hygiene is required (Table 1). Thus, in the latest study from the USA more than 20% of the dentists still used squeeze cloths.25 Mercury hygiene measures comprise proper layout of the surgery, removal of amalgam restorations, methods of trituration and condensation, cleaning and sterilization of instruments and storage of amalgam waste.6,29 Also spillage must be considered although it should be possible to avoid this by use of modern trituration methods such as disposable capsules. If proper mercury hygiene is adopted it is possible to conne the mercury body burden of the dental personnel to concentrations which do not differ signicantly from non-occupational groups.

Neurobehavioral studies
A method to evaluate occupational exposure is to measure the air mercury level at the workplace. WHO has decided an exposure limit of 50 mg Hg/m3 air (TWA: Time weighted average) corresponding to an estimated urine concentration of about 80 mg Hg/l30 which with todays knowledge of mercury toxicology seems to be too high. Some countries have therefore adopted a lower concentration of 25 or 30 mg Hg/m3 as the upper limit. In recent years, focus has been directed against neurobehavioral diagnosis of subtle symptoms caused by long time occupational exposure of low dose inorganic mercury. As discussed in the previous paragraph the mercury body burden of dental personnel may be slightly higher than non-exposed controls, but most often below the normally accepted toxicological concentrations and unless acute symptoms occur after spillage the personnel in general do not exhibit the classical symptoms of mercury intoxications. In order to disclose subtle differences from nonexposed groups which may not be visible in the daily practice, various neurobehavioural and other tests

have been used. Some examples of the test batteries are given in the following. Finger tapping requires the subject to tap a lever as many times as possible with the index nger in 10 s.31 Intentional hand steadiness test requires the subject to insert and hold a metal stylus in a series of six increasingly smaller holes for 15 s intervals.31 Also reaction time, hand tremor, electro neurography, simple reaction time, word recognition, word recall and various other memory tests together with questionnaires on previous maladies and mood state personality have been used.26,31 33 How do dental personnel perform compared to other groups occupationally exposed to inorganic mercury? Electrophysiological and neurological examinations were performed at a group of dentists chlor-alkali workers and miners from the Czech Republic exposed to a level of Hg concentration in the air of the workplace of 20, 36 and 77 mg Hg/ m3, respectively.32 The mean HgU/l concentration was 13, 129 and 840 mg, respectively, and 1 mg in a control group. Electroneurography did not show reduced velocity on motor bres in peripheral nerves in the dental and chlor-alkali groups, but a tendency to subtle changes in latency was observed with a visual evoked potential examination in these groups. Most of the miners showed classical signs of mercury intoxication.32 A few studies have found that dentists perform worse in some neurobehavioral tests compared to unexposed controls.34 35 The mean HgU/l of the dentists in one of the studies was 36 mg Hg/l35 and signicantly higher than in a study from Sweden where the mean TWA was 3.0 mg pr. m3 corresponding to a mean HgU of 5 mg Hg/l and no neuropathological problems were recorded.26 A study from Scotland33 with a similar low HgU concentration of 4 mg among the dentists, but a rather high TWA from the area of the mixing device of 30 mg Hg/m3 did show some changes in psychomotor response compared to controls, but without signicant association between changes and mercury concentration in urine. Neither did self-reported kidney disturbances and memory disorders, which were more pronounced among the dentists compared to controls, have any relation to the mercury concentration in urine. Also there was no association between number of amalgam surfaces in the dentists and controls and their scores in any of the psychomotor tests. A recent meta analysis for neurobehavioural results due to occupational mercury exposure concluded that a signicant performance effect

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was shown for mean urinary concentrations between 18 and 34 mg Hg/g creatinin.36 Based on the rather heterogeneous picture of results from neurological studies it seems justied to conclude that with our present knowledge a risk of subtle neurotoxic changes may occur in dental personnel showing a urine concentration of mercury below what can be shown when operating within the accepted threshold limit. However, it must be stressed that other factors such as the daily exposure to high frequency vibrations37 and stress may be equally important for the subtle behavioural changes. Also it should be stressed that none of the studies referred to has shown the dental personnel to suffer the classical signs of mercury intoxication.

working in ofces with poor hygiene and many amalgams. It was also found that women with low exposure were more fertile than unexposed controls.29 In a recent major study from Norway no difference in fertility was found between high school teachers and dental surgeons of whom 1/3 placed more than 50 llings a week.43 The Norwegian study showed that it is possible to make a considerable number of amalgams without fertility problems whereas the USA study suggests that establishing a proper hygiene regimen is of prime importance.

Conclusions
Reproductive hazards
Although the placenta acts as a barrier to prevent toxic substances to the fetus it has been shown that a substantial fraction of maternal blood containing inorganic mercury can reach the fetus.38 However, major studies from the USA, Sweden and Denmark have not found differences in spontaneous abortions, infant survival, birth weight and congenital abnormalities between dental personnel and control groups39 41 and Schuurs42 concluded in a review paper that negative reproductive effects from exposure to mercury in the dental ofce are unproven. In a study from the USA, mercury hygiene factors were evaluated and augmented with the number of amalgams prepared each week, determination of mercury concentration in operatory air was not made. It was shown that dental assistants with a high occupational exposure to mercury were less fertile than unexposed controls.29 The authors conclude that the fecundability of women who prepared more than 30 amalgams per week and who had ve or more poor mercury hygiene factors was only 63% of that for unexposed women (Table 2). The authors emphasize that reduced fertility could reect other exposures found among women Amalgam is about to be replaced by alternative restorative materials. The risk of environmental problems from disposal of mercury containing waste from dental clinics will therefore decrease over time. All forms of mercury have adverse effects on health at high doses. However, the evidence that exposure to very low doses of mercury has adverse effects is open to wide interpretation.1 Based on our present knowledge on risk of environmental and occupational hazards from use of mercury in dentistry the following conclusions can be drawn:

Table 2 The hygiene factors which have been related to risk of reduced fertility of female dental assistants in a study by Rowland et al.29 Use of mortar/pestle/cheese cloth No capsules No cover on amalgamator No gloves Presence of carpet Eating in operatory History of spills Disposal in zink or dry storage

Use of mercury in dentistry has decreased substantially, especially during the last decade. Amalgam separators and proper collection, handling and storage of waste have shown to signicantly reduce mercury discharge from the dental clinics. Given a proper mercury hygiene the mercury body burden of dental personnel may not differ from the general population. A subtle neurobehavioural effect from long time work in dentistry cannot be ruled out. Such effect may be caused by a variety of factors such as various chemicals, high-frequency vibrations and stress. Provided a good mercury hygiene is established there is no proven negative reproductive effect from exposure to mercury among dental personnel.

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