Dentists Still Divided over Silver Filling Safety

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Cost of root canal therapyIs there a more divisive issue in dentistry than amalgam? Merely by asking the question, we are accused of bias on both sides. Overall, dentists are still split right down the middle. Is amalgam poisonous? Are silver fillings safe? Does *anyone* really know?

Read our editorial article about dentists’ passions and the amalgam safety issue

We asked, “Does your dental practice place amalgam fillings?” Two years ago, 48% of dentists said they placed amalgams, and 52% did not. The numbers have changed very little since 2007. Today, 47% place amalgams and 53% do not.

Top reasons dentists like amalgam:

  • Been around for over a century
  • Better than composite in some cases
  • Composite and resins may not be safe
  • Last longer and have less redecay
  • Affordable and paid for by insurance

Top reasons dentists avoid amalgam:

  • Mercury is bad for patients, dentists and the environment
  • An old dental technology
  • Today’s composites are superior
  • Silver fillings are ugly
  • Amalgam can crack teeth


More materials mean more options

  • “If you stop and listen to the people that are arguing about this point, you will get two skewed views. If you present the science in an unbiased way to your patients many will choose amalgam and many will choose composite. You need to be honest about all the treatment you present.” (Colorado dentist)
  • "I think amalgam is safer than composite, and more durable. Composite looks better and has the advantage of being at full strength immediately. I use both materials and hope both materials remain available to use. If Amalgam is taken away from us it won't be long before composite is taken away for other reasons." (Colorado dentist)
  • “Until we have a much better chairside tooth colored restoration, amalgam still has a lot to offer. The push to eliminate this material I feel is an ego effort for different people, and some for profit.” (Pennsylvania dentist)
  • “There are situations where, all things considered, amalgam is a better choice and there are situations where composite is a better choice.” (Oregon dentist)
  • “Yes That the issue is being politicized and that the real answer is both composite and amalgam have a place. I do both and plan to continue doing so. I do more composites than amalgam, but there are a number of situations that amalgam is the superior material.” (Pennsylvania dentist)
  • “Overblown, unsubstantiated fear-based reaction which some dentists are taking advantage of. I feel both amalgam and composite are foreign materials which are proven safe and effective. Each has its advantages and disadvantages. Both are good materials.” (California dentist)

What controversy? Amalgam is safe

  • “There is no controversy — it is a safe material with the longest history of use. We don't know what we don't know with composites – although they are indicated in many situations. We should have amalgam as a tool in our armamentarium.” (Vermont dentist)
  • “What controversy? In terms of risk/benefit, the benefit of an inexpensive, durable, easy to place restoration far outweighs the risk (so far unproven) of bound mercury in amalgam alloy. How will more expensive, harder to place, too new to be proven safe, but more esthetic restorations help with access to care issues.” (Oklahoma dentist)
  • “What controversy? Oh, the controversy that has been going on since 1840 or thereabouts? Give it a rest. The "controversy" has made a lot of unscrupulous people wealthy, and continues to give the entire profession a bad name.” (California dentist)
  • “It's as serious as the Swine Flu problem (not).” (California dentist)
  • “It is a fake 'controversy,' purely media driven. Except for gold, all materials have small potential safety issues. Our patients are given the choice, and most choose composites for esthetic reasons.” (Florida dentist)

What controversy? Amalgam is unsafe

  • “No There is no real controversy in the scientific arena. Mercury release from amalgam is the primary contributor of human body burden and causes pathophysiology. It should be banned.” (Virginia dentist)
  • “No There should be no controversy..It's bad for kids to play with toys whose paint is .08% lead, but ok to chew on 50% mercury? It should not be used any longer. Would you want it in your child's teeth?” (North Carolina dentist)
  • “It's difficult to get a true picture; there's a great deal of money on the pro-amalgam side that has a potential to bias the data. Many composite restorations still functioning 15-20 years later, which is longer than most people keep their automobiles, houses, or spouses. Why would we want to make ugly black teeth by using Ag? Why do we want to deliberately want to inflict psychological trauma on to people by making their teeth ugly? What is the desire to create a galvanically active mouth by using an electrolytically active metal like Ag? Why would we want to use a thermally conductive material such as Ag and deliberately create thermal sensitivity for our patients?” (California dental machinist & engineer) 

Amalgam is not the future

  • .”The ADA is behind the times.” (Utah dentist)
  • “Amalgam is old technology.” (Texas dentist)
  • “Amalgam is outdated treatment with what we know and the materials available.” (Arizona dentist)
  • “Get over it… Today's composites are superior.” (Illinois dentist)
  • “I feel we have better materials available today.” (Pennsylvania dentist)
  • “I think amalgam is archaic, and should no longer be used.” (Washington dentist)
  • “I think it should be banned in US and Canada.” (Canada dentist)
  • "In with the new and out with the old! Let third world countries use amalgam!" (Florida dentist)
  • “I think that doctors should have stopped this a long time ago. Funny how we find out that meds cause certain side effects and we are made to state them but knowing what amalgam could do, we have to say nothing.” (Texas dentist)
  • “No I think eventually it will be no longer used. It doesn't make since that you can't through captured amalgam in the trash and have to use amalgam separators but it's ok to put in into someone's mouth.” (Texas dentist)
  • “Why risk it? Discontinue amalgam since other suitable materials are now available.” (Maine dentist)
  • “This is something that worked; it did the physical mechanical job. But like most things from that era, no one looked into the components' effect on the biology. You can't make a deadly poison into a health food!” (New York dentist)

Amalgam is tried and true

  • “Amalgam is a good restoration and it has proven itself over the years.” (California dentist)
  • “Hey, if they want amalgam – it worked for 180 years. They can pay me to put it in.” (California dentist)
  • “I don't agree that amalgam is unsafe. It's been used in dentistry for over 150 years.” (Arizona dentist)
  • “No illness from amalgam in 150 years.” (New York dentist)
  • “It's a long lasting durable restoration. Not pretty, but you can't beat the proven track record.” (Oklahoma dentist)
  • “I think it's totally sad – and driven by 'cosmetic elitists.' If it's a small prep, and me, or my family that I know I can monitor, I may select Composite. I love doing them, with full triangular, and supplemental anatomy. HOWEVER, the State requires Amalgams, and I have no problem placing something, in someone that I may not be able to monitor, will probably last much longer, is bacteriostatic at its margins, I can place a great shine on, and costs a lot less. It's still one of the best materials dentistry has ever developed, and has been around as long as Dr. Pepper – yet no one is telling us to drop it!, (which probably causes far more damage than Amalgam!).” (Arkansas dentist)

Silver fillings are ugly

  • “I have not placed an amalgam in over 13 years. I think both materials are safe and affective, and hold up fine long term if placed properly. I and my patients like the look of composite much better.” (New York dentist)

Is composite safe? BPA fears

  • "Yes amalgam lasts longer and is easier to place. The bisphenol toxicity may make it more toxic than amalgam. they leak in people with poor hygiene. are more susceptible to pupal problems." (dentist)
  • “Yes It was started by our accountants..LOL The dumb thing is that composites (Bis-GMA) contain Bisphenol which is potentially more dangerous then any evidence based dangers from Hg.” (California dentist)
  • "Amalgam is most likely not the threat public perceives it as. Resins may have estrogens in them that in the long run may cause controversy also. We do still occasionally place amalgam when the situation calls for it.” (Illinois dentist)
  • “In terms of healthcare, there is no reason not to place amalgam fillings. Who knows what effect all the substances in bonding for example have? Nevertheless, they look horrible, and for that reason I would never go for amalgam.” (London, UK dentist)

Composite is better

  • “Science is continuing to uncover new things, and since for the most part, today's composites are equal to or superior to amalgam, the question as to whether or not to end amalgam usage is pretty much already made.” (Washington dentist)
  • “I believe that composite is a superior product. I'm not so worried about amalgam safety as I am about it's lack of bonding and cosmetics. Most amalgam fillings are replaced much too late. They leak and teeth crack around them. Most people still using amalgam tend to place restorations much larger than is intended for the type of material. There is always gingival inflammation around amalgam, usually from poorly placed/finished materials. Cast (or milled restorations as I use) are stronger, cleaner, and more esthetic. Amalgam is a non-issue in my practice. It's either composite or porcelain.” (California dentist)
  • “My concerns do not include the mercury. Properly done, composite in my hands is a better restoration.(Over 15 years).” (Michigan dentist)
  • “While I consider amalgam safe, I choose composite because it has superior qualities as a more natural restorative.” (Massachusetts dentist)
  • “Amalgam was a wonderful material, in its day. Except for bonded amalgams, I feel comfortable saying that 98% of those I remove, minimally harbor evidence of leakage. Most have large areas of stain that may include soft carious regions. I do not believe that the previous doctor left those there. I think that there is no controversy. Bonded restorations are superior, in that properly bonded restorations strengthen teeth and minimize recurrent caries.” (Pennsylvania dentist)
  • "I place amalgam, but not much. Composite is now better overall.” (California dentist)

Sometimes amalgam works better than composite

  • “There are certain places where composites just won't work.” (Ohio dentist)
  • "If you want to restore a furcation, I guarantee you can't get isolation for a composite.” (Virginia prosthodontist)
  • “A bunch of bull. Amalgam can be used in situations that composite will fail in. Amalgam is safe, if not esthetic. Often extremely difficult to be sure you are removing all of an old composite without inadvertently removing solid tooth structure.” (Illinois dentist)
  • “I actually think that amalgam is a better restoration than composite.” (Tennessee pediatric dentist who does not place amalgam)
  • “I avoid it when I can, although there are still times when it can be the better option.” (California dentist)
  • “Too much emotion and not enough science on either side of the argument. There are times when you just can't stop the moisture so there are times when you are better off using Amalgam, but we probably have this situation 3-4 times a year.” (New York dentist)

Science suggests amalgam is unsafe

  • “There is overwhelming evidence in the Basic science, Toxicology, and Neurological literature to show that Mercury-releasing Amalgams are a serious threat to health and the environment.” (Arkansas dentist)

Science suggests amalgam is safe

  • “Mostly Hype. Scientific evidence does not support the level of fear that the general population has about amalgam.” (California dentist)
  • “It's still a low cost restorative material with no scientific evidence of harm.” (Washington dentist)
  • “Pure bullshit. Since the 1960's there has been no gamma 3 phase in any pre-measured amalgam capsules, due to mercury scavenger technology.” (California dentist)
  • “It's a shame to throw out a good solution to lots of situations when there is no good scientific proof that the risks outweigh the benefits.” (Texas dentist)
  • “I see no evidence in science that concerns me to date.” (Mississippi dentist)
  • “A waste of time until proven scientifically.” (Massachusetts dentist)

Follow the money

  • “The controversy is fueled by greed. Posterior amalgams are easier to place and last longer than composite.” (General dentist)
  • “The demand for posterior composites come from dentistry and the higher fee that it establishes. Evidenced based, it does not hold up as long as amalgams. Composites do have a place.” (New York dentist)
  • “I think that the controversy has been promoted mostly to make work for dentists that have a busy-ness problem. The detractors have no good science to back up their claims. They are taking advantage of the mostly less educated, gullible dental patients to sell mostly unnecessary dental work to line their own pockets.” (Illinois dentist)

Who knows?

  • “Who knows. ADA protects the tradition; extreme research creates the pandemic.” (Canada dentist)
  • “Not sure, keep receiving conflicting news from different sources, not sure if resin is the answer.” (New York dentist)
  • “I see dishonest arguments and exaggeration on both sides. No matter what our feeble science shows, mercury is a poison and it cannot be good for us. So what is the argument? Are we saying that because we can't see the damage there is no damage?” (Washington dentist)
  • “I place amalgam fillings, but I feel there is something to it. There is none in my mouth or my kids. If safe, why does OSHA say we have to take such precautions to protect our staff from scraps left over?” (California dentist)

Making educated choices

  • “Dentists should make up their own decisions regarding the services they feel comfortable with. It is not a controversy, it is a choice.” (California dentist)
  • “Educate your patient and let them chose, They are intelligent and will make the correct decision for them.” (New York dentist)
  • “Every dentist must make his own decision about what materials they want to offer their patients.” (Alabama dentist)
  • “I always discuss all treatment options (including advantages, disadvantages, possible problems, average longevity, etc) with my patients. That includes amalgam, composite, and other restorative filling materials. If, after fully informing the patient, the patient chooses amalgam, I have no problem providing that service to him/her. It is, by the way, a good restorative material and also costs less for the patient (very important to many financially strapped patients).” (Ohio prosthodontist)

Silver fillings crack

  • “I am not worried so much about the mercury toxicity as the setting expansion of amalgam, which cracks teeth.” (Colorado dentist)
  • “It is blown out of proportion, but I don't want them in my mouth. I have seen too many cracked teeth with their use – including mine.” (Kentucky dentist)
  • “l would not place amalgam. It is ugly, corrosive and causes teeth to fracture in addition to the mercury content which is unhealthy. If you have to put amalgam scrap in a special container and treat it as hazardous waste, then I would not put it into someone's mouth.” (California dentist)
  • “Silver Amalgam causes excessive tooth reduction for retention and stresses enamel with initial and secondary set expansion of material causing fractures.” (North Dakota dentist)
  • “Though I place them, I don't like Amalgams due to their ability to create cracks in teeth. I'm not concerned about the Mercury issue as much as others. Obviously an esthetic problem. They still do work well for many individuals but I'd rather place (or have done to me) composites.” (Michigan dentist)

There's still a place for amalgam

  • “It is a fine restoration and has its place in society.” (Washington dentist who does not place amalgam)
  • "I think it is a good material." (California dentist who does not place amalgam)
  • “It needs to be continually looked at, but I feel that amalgam is an acceptable material in a lot of cases. It is nice to have choices.” (Ohio dentist)

Amalgam costs less

  • “Several of our large insurers pay well for amalgam, but not for composites. FDA should regulate it out of use, or ADA should remove it from acceptable restorations. Otherwise, I'll continue to give patients a choice. 75% in my practice choose composite now and pay the difference.” (Georgia pediatric dentist)
  • “We place amalgam fillings if the patient asks for them. Most people don't want them anymore, but some people just want what insurance covers or what they can afford. I would rather help the patient by taking care of the cavity and staying within their budget than allowing a cavity to spread. Personally, I think the controversy is unfortunate, as amalgam is a valid restorative material.” (Oregon dentist)
  • “I work at a public health clinic and many of the patients receive insurance from public assistance. Until the insurance companies begin to
    reimburse for composite fillings then we are forced to do amalgams.” (Pennsylvania dentist)

Mercury is not eco-friendly

  • “Amalgam works as a restorative material, but its use is unquestionably bad for the environment and does adversely effect the heath of some patients.” (Illinois dentist)
  • “No I think that any amount of mercury is bad. We now know that it is released during chewing, that it is contaminating water supplies when it is released in the sewer system.” (Missouri dentist)

Amalgams can last for decades

  • “I think amalgam is a great long lasting restoration.” (Missouri dentist)
  • “Yes I do not believe MOST 'plastic fillings' will last 1/2 as long as many of the 60-70 year old restorations I still check that my grandfather placed. I do NOT believe mercury fillings or Bis-phenol A-like composite fillings materials to be a danger.” (Maryland dentist)
  • “I still have amalgam in my own mouth that is still wearing well.” (California dentist)
  • “Yes I think it's been blown way out of proportion. I see amalgam restorations every day that have been in my patients mouths for 20 years or longer. I have a dozen or more in my own mouth that have been there over 30 years. I use them for restorations in my children. I think the controversy has been used by some practitioners to scare their patients into using composite or cast restorations to enhance their practices bottom line.” (Florida dentist)
  • “I can find no hard scientific reasons to reject amalgam fillings. I see such a higher proportion of failing and flawed resin fillings than amalgam
    fillings that there is no reason to reject silver amalgam. I see 30 to 40 year old or older amalgam fillings that are still in pretty good shape. Resin often does well to hit 10 years. In my opinion, most dentists that reject silver fillings do it to improve their financial status and not for scientific considerations. I do lots of both types of fillings, but I always inform patients about the advantages and disadvantages of both types of fillings. I sleep better that way.” (New Mexico dentist)

Dentists who don't do amalgams

  • "I have never used amalgam restorations in my practice – I have been practicing for 23 years and have never felt it was a safe procedure.” (Georgia dentist)
  • “No have not done it in over 25 years."
  • “Since I placed my last amalgam somewhere around 1987, there really isn't much controversy to me.” (Illinois dentist)
  • “We retired amalgam back in 1993. We just preferred a more biocompatible and esthetically pleasing restoration."

Mostly composite, but sometimes amalgam

  • “I primarily place composite posterior restorations primarily because that is the option my patients have opted. I like the composites because of the esthetics and the bonding. However, for heavy bruxers, particularly in the second and third molar teeth and also for deep subgingival and bloody
    restorations, I prefer amalgam. I do not see the scientific evidence contraindicated my usage of amalgam. This could change tomorrow.” (Virginia dentist)
  • “There are times when you simply must place one. I would say that the "controversy" is a good news item more than good science. Yet I admit to placing composite 95%+ of the time. I tired of giving the pros and cons of both and then having the patients choose the composite 99% of the time in spite of what I thought was a very fair presentation of the facts."

Much ado about nothing

  • “I think it's a bunch of hoopla over nothing. There are far more dangerous ingredients in the burger we are feeding our kids from the fast food joint down the street.” (Illinois dentist)
  • “Research does not justify concern about the mercury in amalgam restorations.” (Michigan dentist)
  • "Much ado about very little. Well placed amalgams hold up for a very long time in very healthy mouths and individuals. I still place amalgam on occasion (<1%), but patient demand is for composite, which is far more technique-sensitive to place properly.” (Michigan dentist)
  • "Much ado about nothing, but newer composites are just as strong and look better when used properly.” (Georgia dentist)

Dentists risk exposure

  • “No I worry about mercury vapor in the dental office mort than the safety in the mouth. Have not used it since 1993.” (Illinois dentist)
  • "I don't think amalgam is esthetic at all, and the people most harmed with amalgams are dentists, so why should I use them?” (Costa Rica dentist)

Raw mercury is poison

  • “No if a drop of mercury is dropped in a school the school is closed and completely cleansed yet we tell our patients we shake up mercury and silver and cram it in your tooth but it's ok. They don't buy it.” (Florida dentist)
  • “Amalgam has to be treated as a toxic material, so why is it 'safe' to put in a patient's mouth?” (California dentist)
  • “If I can't suction the amalgam and let it go down the drain, why am I putting it in people's mouth?” (California dentist)
  • "It is absurd that the only safe place for amalgam is in peoples mouths. It is a hazard before it goes in and after it comes out. Please always use a precautions when removing them, like a rubber dam.” (Texas dentist)
  • “Mercury a neurotoxin, so why use it?” (California dentist)
  • “Mercury is a potent neurotoxin and has no place in medicine. Once amalgam is removed from a patient's mouth, it is considered toxic waste and must be disposed of as such; what was it while in a person's mouth?.” (Washington dentist)
  • “Mercury is a toxin no matter what form.” (Missouri dentist)
  • “Mercury is the most toxic non-radioactive element on earth. It is more toxic than arsenic. It emits vapor constantly, which is absorbed. It should not be used in the restoration of human teeth.” (Georgia dentist)
  • “Mercury is a poison and should not be used. Odd how it is shipped as a biohazard, safe once mixed and put in someone's mouth and then becomes a biohazard once again upon removal.” (dentist)
  • “The doctor who places amalgams is essentially saying, 'Sure the filling has poisonous mercury in it, but you'll only get a little bit.'” (Texas dentist)
  • “We can't throw the stuff into a landfill because a few parts per million in the water table would be dangerous, but the 500,000 parts per million that we place, it is absolutely safe? I don't think so.” (Texas dentist)
  • “Why would anyone want to put mercury in someone's body? It's illegal in most other countries.” (General dentist)
  • “No The information that mercury is toxic is very convincing.” (Kentucky dentist)

Patients prefer pretty restorations

  • “I think patients are not educated enough about it, but when I try to talk to them they still insist on 'white filling material' – that is why I became a CEREC dentist!” (North Dakota dentist)
  • “Most people want Composite for esthetics. Composite's dirty little secret is, of course, redecay. After 20 years amalgam will cause fractures. After 5-10 years, composite will have redecay.” (Florida dentist)

Is anything safe?

  • “I abandoned Amalgam in 1983 after becoming ill form mercury poisoning. Mercury Amalgam fillings should be banned. Every dentist should know how to protect themselves and their patients from mercury exposure when amalgam is removed; just look at the IAOMT website. Bisphenol-based composites are harmful. here are many problems with other materials as well. Our patients present with a broad spectrum of sensitivities to what we place in their mouths.” (New York holistic dentist)

Removing old silver fillings?

  • “I replace amalgams as they become worn down or get recurrent caries around the margins, but I do not indiscriminately take them out unless at the request of my patient.” (Kentucky dentist)
  • “I have yet to see any clinical evidence of the benefits of removal of amalgam fillings. I believe that in order for people to adequately assess their exposure to toxic mercury they need to have proper heavy metal testing to make that determination. there is no way to determine just by replacing or not using amalgam that you have toxicity or increased levels. Besides the people exposed to the elemental mercury is the dental professional and there is no evidence that dentist have any increased levels of mercury exposure in the body. So although I believe in using composite restorations, I am not so sure that there is any grave health risk from amalgam fillings. There is exposure to mercury from fish that we eat. environmental mercury and the new light bulbs also contain mercury and require special disposal which i don't even think the average person is aware of. there is a lot that needs to be done before just making a blanket inference to health risk and diseases as it relates to the use of amalgam” (Pennsylvania dentist)

Don’t you dare say "mercury amalgam"

  • “The term ‘mercury amalgam’ is a misnomer. Since the word ‘amalgam’ by definition, means a mixture containing mercury, why would you say ‘mercury amalgam?’ That's like saying ‘amalgam amalgam’ or ‘mercury mercury.’ It's redundant, and merely shows the ignorance of the speaker.” (California dentist)

Cosmetic elitism

  • “I think it's totally sad – and driven by ‘cosmetic elitists.’ If it's a small prep, and me, or my family that I know I can monitor, I may select Composite. I love doing them, with full triangular, and supplemental anatomy. HOWEVER, the State requires Amalgams, and I have no problem
    placing something, in someone that I may not be able to monitor, will probably last much longer, is bacteriostatic at its margins, I can place a great shine
    on, and costs a lot less. It's still one of the best materials dentistry has ever developed, and has been around as long as Dr. Pepper – yet no one is
    telling us to drop it!, (which probably causes far more damage than Amalgam!).” (Arkansas dentist)

Life is full of risk

  • “I work at a public health clinic and many of the patients receive insurance from public assistance. Until the insurance companies begin to reimburse for composite fillings then we are forced to do amalgams. I have yet to see any clinical evidence of the benefits of removal of amalgam fillings. I believe that in order for people to adequately assess their exposure to toxic mercury they need to have proper heavy metal testing to make that determination. There is no way to determine just by replacing or not using amalgam that you have toxicity or increased levels. Besides the people exposed to the elemental mercury is the dental professional and there is no evidence that dentist have any increased levels of mercury exposure in the body. So although I believe in using composite restorations, I am not so sure that there is any grave health risk from amalgam fillings. There is exposure to mercury from fish that we eat. Environmental mercury and the new light bulbs also contain mercury and require special disposal which I don't even think the average person is aware of. There is a lot that needs to be done before just making a blanket inference to health risk and diseases as it relates to the use of amalgam.” (Pennsylvania dentist)

 

Note: Survey sample included 320 respondents.

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