Dental amalgam – still with us for now
Susie Sanderson provides an update on the latest guidelines surrounding the use of dental amalgam.
No one will have missed the introduction of The Control of Mercury (Enforcement) Regulations 2017 that came into force on 1 January 2018.
Restrictions on the use of dental amalgam are in place in all four countries of the UK. They apply to all dental practice, regardless of whether services are provided privately or under NHS contract.
Very helpful guidance is available from the Scottish Dental Clinical Effectiveness Programme (SDCEP). It is accompanied by material to assist in communicating with patients.
The current regulations have largely been quietly embedded into dental practice. Practically, it is Article 10(2), that affects our treatment of patients: ‘From 1 July 2018, dental amalgam shall not be used for dental treatment of deciduous teeth, of children under 15 years and of pregnant or breastfeeding women, except when deemed strictly necessary by the dental practitioner based on the specific medical needs of the patient.’
The regulations originated from the European Union (EU). They are the EU’s strategy for ratifying the Minamata Convention on Mercury and were translated into UK law.
The convention is a global treaty, ratified by 127 countries and governs the mining, use and trade in mercury. It seeks to protect the environment, and consequently human health, from the adverse effects of mercury.
Dental amalgam is the only mercury-added material that is subject to phase down as opposed to phase out. Consequently, it attracts heated debate.
The EU Commission received an ‘Assessment of the feasibility of phasing out dental amalgam’ in 2020. Also, a phase out legislative proposal will be made in 2022.
At the same time, international professional bodies – such as the FDI World Dental Federation, Council of European Dentists, International Association of Dental Research and the American Dental Association – support and are lobbying for a continued and measured phase down of the use and availability of dental amalgam that allows countries to make progress in the light of domestic circumstances.
The World Health Organisation has said ‘…a phase out of dental amalgam approach is not a one-size-fits all solution for all countries…’
The EU regulations required the UK countries to develop an action plan to reduce the use of dental amalgam. As health is a devolved issue, each has published its own. These focus on improving oral health, changes in emphasis of service delivery and the training in and use of treatment techniques such as minimally invasive dentistry.
Concerns are expressed regarding the absence yet of ideal replacement materials. Also, the not properly understood environmental impacts of alternative materials. The general conclusion is that dental professionals should continue to have the option to use dental amalgam.
The current post-Brexit understanding is that the UK will not be bound by new EU legislation. It is, however, a signatory of the Minamata treaty, so any changes made by the Conference of Parties (COP) of the treaty will impact on the UK in some form.
The acceleration of the phase down of dental amalgam will feature heavily on the agenda when the COP meets next in November 2021.
Is this relevant to us?
So, how does this affect us in the UK? What should we be aware of to mitigate any risks arising from the current discussions?
The balance of the use of different materials has changed significantly over the last 15 years or more. Patients are routinely offered more aesthetically pleasing restorative solutions. The benefits of bonding dental materials to teeth can be exploited in appropriate clinical circumstances.
Nevertheless, it appears that dental amalgam will continue for now to be legislatively approved in the UK excepting the groups to which restrictions apply.
As discussions gain pace at both EU and global level, the public’s interest may be engaged via media attention.
The 2017 regulations introduced potential tensions between professional and ethical duties to act in the patient’s best interests alleviated by the flexibility provided by the exceptions in Article 10(2).
In particular, questions have been raised about the offer of private composite restorations to NHS patients in the restricted groups.
The requirement for dental amalgam not to be used for these patients (except when deemed strictly necessary by the dental practitioner based on the specific medical needs of the patient), implies that, within an NHS course of treatment, restorations carried out with appropriate alternative materials must be available on the NHS.
A patient or parent/guardian can, of course, choose to opt for private treatment under the NHS mixing regulations. For consent to be valid, the regulatory situation must be explained to them and they should be made aware of the treatment and qualities of materials available to them on the NHS.
This is no different from the consent processes that should be followed for. For example, treatment offered for most restorative issues and periodontal conditions.
Patients must not be misled about treatment that is available on the NHS.
Avoid stressful and time-consuming complaints. It is useful to make sure that the entire team is familiar with a compliant practice policy and can communicate it to patients.
Time is precious in dental practice and taking account of the principles that emerged from the Montgomery case may prevent frustrating, longwinded and expensive challenges. Remembering that consent should include shared decision-making is good risk management.
What does this particular patient need to know and to what might they attach significance? The process of deciding on the restorative material for a specific tooth is no different from any treatment planning situation.
The patient (or patient/guardian) must be given the opportunity and time to ask questions about the options and information you have presented to them.
Would you prefer this in white?
Patients need to know more about restorative choices than simply being informed about the cosmetic benefits of composite restorations and the related costs.
Be prepared to explain why you consider the proposed treatment to be in the patient’s best interests. Compare and contrast the properties of the materials and the risks and benefits as they apply to the patient.
If you practise amalgam-free dentistry, you still need to inform the patient of the availability of all materials. You must clearly state their pros and cons. Make sure the patient knows they may choose to seek treatment elsewhere if they wish.
The expectations of patients who request the replacement of multiple amalgam restorations with alternative restorative materials must be carefully managed. Especially if the patient believes that replacement will improve their general health.
It goes without saying that careful history-taking and thorough record-keeping is essential. This is so that anyone reviewing the patient’s notes in the future can see clearly evidence of the consent process. This includes entries that confirm the information provided was evidence-based and accurate.
Finally, it is generally accepted that posterior composite restorations are technique sensitive. They are often more time consuming for the operator and cost more for the patient.
The trend to phase down dental amalgam, whether it is driven by legislation or patient preferences, means that practitioners need to be able to ‘do it once and do it well’ whenever possible.
The current COVID-19 pandemic has resulted in the postponement of hands-on courses. However, there are a number of virtual courses that practitioners can access to update their knowledge on current thinking and clinical techniques relating to the placement of composite restorations as well as the related dentolegal requirements.
In the light of the possible outcomes of Minamata, these might prove to be a worthwhile investment for the future for those seeking to update their knowledge on the subject.