The use of dental amalgam will be banned in the European Union from January 2025 – we take a look at the health risks associated with dental amalgam, why it’s being banned, and the impact this could have on the UK dental profession.

Amalgam ban: the key facts

In January of this year (2024), the European Parliament voted to ban dental amalgam. As a result, a total phase-out of the filling material will take place in the European Union (EU) from 1 January 2025.

The ban, which comes into effect five years earlier than anticipated, aims to protect both human health and the environment from the harmful effects of mercury.

In dentistry, the use and export of amalgam will be prohibited, with exceptions only ‘for specific medical needs and when deemed strictly necessary by a medical practitioner’.

However, countries that need more time to adapt their healthcare systems to the ban will receive an extension, allowing them to continue using and importing dental amalgam until 30 June 2026.

Amalgam use in UK dentistry

Amalgam has been used in dentistry as a filling material for over 175 years. The material is a mixture of metals – 50% liquid mercury and 50% powdered alloy composed of silver, tin and copper.

Its use was first introduced as a filling material in France and Britain in the early 1800s, with America following suit in the 1830s, though historians have potentially traced its use as far back as 659 AD. Following its introduction, it quickly became the most widely used filling material.

Controversy over the safety of dental amalgam has existed from the outset, however. When the American Society of Dental Surgeons formed in 1840, its members had to pledge to never use the filling material due to mercury toxicity.

Today, dental amalgam remains the most common material for NHS permanent fillings across the UK. But its use comes with firm regulations. Article 10 of the European Union Regulation 2017/852 states:

• Dental amalgam must only be used in pre-dosed encapsulated form. The use of mercury in bulk form by dental practitioners is prohibited
• Dental amalgam must not be used for the dental treatment of deciduous teeth of children under 15 years, or for pregnant or breastfeeding women. This is except when deemed strictly necessary by the dental practitioner based on the patient’s specific medical needs
• Dental practices must be equipped with an amalgam separator. All separators must retain at least 95% of amalgam particles.

Dental amalgam versus composite fillings

For over 100 years, dental amalgam has been the most popular filling material because of its strength, durability and low cost. Today, however, tooth-coloured restorative materials such as composite are rapidly gaining popularity due to their aesthetic appeal.

The British Dental Industry Association (BDIA) outlines the following advantages and disadvantages of the filling materials.

Handling dental amalgam in the dental practice

Previously, dental amalgam was made in practice by using a pestle and mortar to mix the metals together. This process has now been replaced by a dental amalgamator which uses vibrations to mix a pre-dosed capsule containing the mercury and powdered alloy.

Due to the high mercury content of dental amalgam, it is considered a hazardous waste. As a result, there are several regulations in place for the disposal of dental amalgam waste.

For staff handling dental amalgam in practice, small doses over a period of time can be harmful. As a result, any spillages must be immediately reported, and the manufacturer’s instructions must be closely followed.

Pete Gibbons, a decontamination specialist, says: ‘Dental amalgam is generally considered safe to the wider population, however it can create some irritations which WHO (the World Health Organization) and the FDI (World Dental Federation) recognise, so there are some precautions to consider.

‘For example, whenever removing amalgam, PPE (personal protective equipment) must be worn at all times. Always dispose of unused cartridges or amalgam waste in a lidded amalgam pot for safe removal. You should also always remove any amalgam from instruments before sterilisation as the particles can build up inside the steriliser.’

Practice regulations

NHS England outlines the following regulations for handling dental amalgam waste in Health Technical Memorandum 07-01: Safe and sustainable management of healthcare waste:

• Dental practitioners must ensure that all waste is treated appropriately, and that teeth containing amalgam are disposed of as dental amalgam waste. Specialised containers known as tooth pots, crown pots and bridge pots may be used to store extracted amalgam-contaminated teeth, crowns and bridges
• Due to its unique characteristics, dental amalgam should be treated as its own waste stream, with separate bins for infectious and non-infectious amalgam
• Amalgam waste may be packed in accordance with the SDS provided by the manufacturer, but the package should be marked with UN 2025
• Dental amalgam bins must be sealable and made from puncture-resistant rigid material and must contain a mercury suppressant. Bins must be clearly marked as dental amalgam and should feature the hazard symbols relevant to mercury (toxic, long-term health hazard and environmental hazard)
• If transporting dental amalgam waste, a container certified for transporting mercury may need to be used.

Impact of mercury on health

The World Health Organization (WHO) states that mercury is toxic to human health. In its liquid form, the metal has limited absorption through skin. But in vapour form, it becomes extremely toxic as absorption through lungs can damage the immune system. It is also particularly dangerous to foetuses.

According to WHO, the health impacts of mercury include kidney problems, nervous system damage and skin problems. In addition, the inhalation, ingestion or dermal exposure of mercury can result in neurological and behavioural disorders.

Symptoms of this can include:

• Tremors
• Insomnia
• Memory loss
• Neuromuscular effects
• Headaches
• Cognitive dysfunction
• Motor dysfunction.

Patients are most likely to be impacted by mercury during the placement or removal of dental amalgam. As a result, unless the filling is damaged or defective, it is safer to leave the fillings in place than remove them.

According to the European Commission, when in close contact with skin and mucous membranes, mercury can cause allergic skin inflammation. Therefore, dental amalgam fillings can sometimes result in inflammation of the gums and painful ulcers in the mouth. In some cases, the inflammation can occur in other parts of the body, such as the face.

If a patient is experiencing these symptoms, removal of the amalgam filling will usually resolve the problem.

Impact of mercury on the environment

Steven Mulligan is a dentist and clinical teacher in the School of Clinical Dentistry at the University of Sheffield. He has published a number of works on the environmental impacts of dental materials and integrating sustainability into oral healthcare.

Here, Steven discusses how dental amalgam impacts the environment…

The main environmental impacts attributed to amalgam stem from the release of mercury into wastewater from its use in dental surgeries and from mercury vapour into the atmosphere from crematoria. Amalgam separators remove approximately 95% of amalgam particles from clinical wastewater, and filters are present in crematoria flues to mitigate released pollutants.

We should recognise that amalgam separators have only been used in some countries for the last thirty years; it became federal law in the USA as late as 2013, and in many lower- and middle-income countries, separators are not used at all. To that end, the environmental and biological impact of the mercury from dental amalgam remains a persistent worldwide problem.

As such, under the auspices of the Minimata Convention, a global treaty effective since 2017 which requires signatory nations to reduce mercury release, amalgam is scheduled to be phased-down until it is ultimately phased-out.

It should also be recognised that aside from the direct pollution potential of dental amalgam, the carbon footprint of amalgam manufacturing is greater than alternative materials such as resin-based composite and glass ionomers. In addition, resin-based composite materials are durable long-term restorative options, further bolstering calls for amalgam’s demise.

However, it should also be noted that alternative materials have carbon impacts from production, distribution, use and disposal. The truth is that all dental materials and their use have environmental impacts.

Sustainable oral healthcare provision must recognise this through the prevention of disease and provision of high-quality restorative care that is durable and requires fewer replacements. This is just one aspect of providing more environmentally sustainable dentistry.

The UK profession’s reaction to the dental amalgam ban

Following news of the EU ban, members of the UK dental profession shared their views on the ruling.

Dentist James Goolnik said: ‘Finally the European Parliament is banning the use of amalgam fillings. It has been used as a filling material since 1826 – a mixture of mercury, silver, copper, tin and zinc.

‘Amalgam is a cheap and easy to use filling material, but it is terrible for the body and the environment. This is wonderful news for patients and clinicians.’

He added: ‘I am sorry for NHS dentistry, but it is time to put the patient first by practicing preventive dentistry starting with diet and nutrition and using more biocompatible materials that do not harm the clinical team and the environment.’

Similarly, dental therapist Linzy Baker highlighted the flaws of dental amalgam as a filling material. She said: ‘In my daily practice I see a lot of amalgam restorations that are now, after many years, starting to deteriorate. On removal, many have fracture lines within the tooth structure, requiring further destruction to remove. If these are too large, it can change the plan of refilling into something lab-made.’

On the impact of the NHS, she said: ‘There are concerns around how the NHS will continue should this material be removed from UK NHS practices, as it is the most commonly used posterior filling material due to cost and longevity.

‘The advancements in adhesive materials, to me, negate the longevity argument as, done well, they have also been proven to stand for just as long of which I see the evidence in my daily practice.I, for one, welcome the change and think the benefits outweigh the risks moving forward.’

How will the ban impact UK dentistry?

Currently, dental amalgam is the most common material for NHS permanent fillings in the UK.

According to the British Dental Association (BDA), fillings account for around a quarter of all NHS treatment delivered in England, with amalgam being used in one third of these procedures.

As a result, concerns have been raised on the impact of the ban on the trade and supply of dental amalgam in the UK. This comes at a time when an independent investigation into the state of NHS dentistry has found it to be ‘in a critical condition’.

In response to the ban announcement, the BDA stated that while it supports a phase-down of dental amalgam, the rapid phase-out is neither ‘feasible nor justifiable’.

Eddie Crouch, BDA chair, said: ‘When we are set to lose a key weapon in the treatment of tooth decay all four UK governments appear asleep at the wheel.

‘When alternative materials can’t compete, this will add new costs and new uncertainties to practices already on the brink. Without decisive action this could be the straw that breaks the back of NHS dentistry.’

‘Vital restorative material’

Crouch wrote to the UK’s chief dental officers following news of the ban, saying: ‘I am writing once again to seek your commitment to address international developments concerning the future of dental amalgam, which are likely to significantly affect the delivery of dentistry and population oral health in the UK.’

He continued: ‘We are extremely concerned about the impact this EU phase-out will have on services across the UK, both directly under post-Brexit arrangements and indirectly as a result of supply chain collapse in Europe. NHS dentistry is already in precarious situation across the UK, with the Nuffield Trust recently warning that the service has most likely “gone for good”.

‘The loss of a vital restorative material and its replacement with more expensive and time-consuming alternatives is only a further blow to the financial viability of NHS dentistry. It is a particular loss in the context of high needs patients for whom amalgam remains the best treatment option.’

When asked how the ban might impact UK dentistry, a Department of Health and Social Care (DHSC) spokesperson told Dentistry: ‘We do not expect the ban on dental amalgam to affect patients being able to get dental treatment when they need it.

‘Prevention is better than cure, and this government is committed to ensuring good oral health in our future generations.’

Northern Ireland exemption

When the EU ban was first announced, concerns were especially raised about the ‘adverse impact’ on Northern Ireland, as the UK nation with the highest proportion of filled teeth.

Under post Brexit arrangements, Northern Ireland was expected to phase out dental amalgam on the same basis as EU member states.

However, six months later, the European Commission approved an exemption for Northern Ireland from the amalgam ban. This came as a great relief to dental leaders, after a survey found that 92% of dentists in Northern Ireland were on track to reduce the amount of NHS activity at their practice in the event of a ban.

In addition, 92% said it would increase costs for NHS activity at their practice, and 91% reported it would impact on higher needs patients seen at their practice. A further 88% said it would lead their practice to reduce or end its NHS commitment.

The exemption means that Northern Ireland dentists can continue to use dental amalgam until 31 December 2034 – unless an earlier date is agreed on by the global Minamata Convention.

Ban ‘could have spelled the end for NHS dentistry’

Ciara Gallagher is chair of the BDA’s Northern Ireland dental practice committee. She said: ‘A ban on dental amalgam in 2025 could have spelled the end for NHS dentistry in Northern Ireland.

‘We sounded the alarm and fought tooth and nail for a workable solution. This delay is a glimmer of hope for a service that’s on its knees and could not have shouldered any further financial pressure.’

She continued: ‘We have some breathing space, but Stormont and Westminster cannot take their feet off the pedal to affect a seamless transition to amalgam-free dentistry.

‘Any progress will require reform, investment, and concerted action on deep oral health inequalities.

‘When the plug is finally pulled on amalgam, Northern Ireland will need to have a healthier population and a more sustainable service. Otherwise, this 10-year derogation is a mere stay of execution for NHS dentistry.’

The DHSC stated: ‘As a result of constructive work between the UK Government and the EU, the EU published a notice that recognises the unique circumstances of Northern Ireland and the representations made by the UK Government.

‘It sets out a specific set of arrangements for Northern Ireland, providing an additional ten years to still use amalgam fillings, or until any earlier time is agreed by the Minamata Convention, to which the UK is a party.’

It added: ‘The ban on EU dental amalgam in Northern Ireland should not affect NHS patients in Northern Ireland being able to get dental treatment when they need it.’

How will the EU amalgam ban impact UK trade?

While the EU amalgam ban does not affect the UK, the BDA warns that the nation faces disruption and higher costs due to the impact on supply chains.

Both Dentsply Sirona and Kerr ceased production of dental amalgam following the FDA’s (US Food and Drug Administration) warning in 2020 that certain groups may be at greater risk of health effects from the mercury vapor released from dental amalgam.

The FDA said: ‘Our reviews and discussions have generally arrived at the same conclusion: while the majority of evidence suggests exposure to mercury vapor from dental amalgam fillings doesn’t lead to harmful health effects for most people, there may be some effects in people with certain health issues such as those who are hypersensitive to mercury.

‘Uncertainties remain about: the effects that long-term exposure to dental amalgam may have on the specific high-risk groups we’ve listed above, the potential for mercury in dental amalgam to convert to other mercury compounds in the body, and whether the accumulation of mercury in some body fluids and tissues results in other unintended health outcomes.’

The groups the FDA found to be at a greater risk include:

• Pregnant women and their developing foetuses
• Women who are planning to become pregnant
• Nursing women and their newborns and infants
• Children, especially those younger than six years of age
• People with pre-existing neurological disease such as multiple sclerosis, Alzheimer’s disease or Parkinson’s disease
• People with impaired kidney function
• People with known heightened sensitivity (allergy) to mercury or other components of dental amalgam.

SDI to cease dental amalgam manufacture

Southern Dental Industries Limited (SDI) is currently one of the world’s leading manufacturers of dental amalgam. This year, the company told investors that it plans to cease production of dental amalgam by around 2028. This begs the question of how many other manufacturers will follow suit, and the impact this could have on UK dentistry.

Samantha Cheetham is SDI CEO and managing director. When asked the company’s plans to cease its dental amalgam production, she told Dentistry: ‘SDI is committed to pioneering dental science and driving innovation in oral health. A new production site is currently being built and we have made the strategic decision discontinue our amalgam manufacturing when we move in 2028.

‘However, we are very dedicated to ensuring UK dentists will not have any disruption to supply of amalgam. While the use of dental amalgam is declining, there are some populations and dental situations where amalgam is the only possible treatment. The priority for every stakeholder must first be oral health for everyone.

‘We fully support the EU’s recent decision to ban dental amalgam for most situations. While amalgam has historically played a vital role in restorative dentistry due to its strength and ease of use – something our founder, Jeff Cheetham, championed – modern dentistry is evolving beyond these materials. The EU ban is not for every country and every situation, and amalgam will be used when a dentist sees there is no alternative.

‘The amount of mercury used in amalgams is extremely low compared to other sources. The greatest atmospheric mercury pollution comes from coal-fired power plants, while the largest pollution sources to waterways are from mining operations.

‘The introduction of Stela, our innovative amalgam replacement, is a testament to 50 years of expertise. Stela mirrors amalgam’s strength and simplicity but aligns with the values of minimal intervention dentistry, offering a more sustainable and patient-friendly option.  

‘We recognise that although the EU ban does not apply to the UK, it may nevertheless impact the demand from dentists as they look for alternatives. We will also provide Stela, a superior alternative to support this transition.’

Dental amalgam ‘should no longer be used’

Florian Schulze is administrative vice-president of the World Alliance for Mercury-free Dentistry and managing director of the European Network for Environmental Medicine, campaigning for an international phase-out of dental amalgam.

Following SDI’s announcement, he said: ‘There are only a few manufacturers left that produce amalgam and the number is constantly shrinking. More than 60 countries have already phased out its use and the UK could follow soon.

‘When manufacturers stop making a product to protect the public, it should no longer be used by public health services for treatments. In the EU, the use of dental amalgam will be banned from 1 January 2025 and public reimbursement systems started to replace it with alternatives that are available, effective and affordable.

He continues: ‘In order to not be left behind, the UK should phase out amalgam use as well. Dental amalgam is the largest remaining use of mercury and mainly responsible for mercury emissions to wastewater. The government will not achieve its legally binding targets for water health, which requires water bodies to achieve good ecological status by 22 December 2027, without ending the use of dental amalgam.

‘Factoring in the environmental costs, dental amalgam is more expensive than most, if not all, other filling materials.’

Find out more about all the current manufacturers of amalgam here.

Is the UK following suit?

As the EU moves towards a full ban on dental amalgam, the UK’s position remains one of a ‘phase down’ of the filling material.

Whether the UK follows suit will depend on the outcome of the sixth meeting of the Conference of the Parties (COP 6) to the Minamata Convention on Mercury, an international treaty focused on reducing mercury pollution globally.

The Minamata Convention, signed by over 150 countries, encourages the reduction of mercury use due to its harmful impact to health and the environment.

The UK’s ‘phase down’ approach has been in place since 2017 when the Minamata Convention first entered into force.

The BDA states: ‘The UK dental profession has a longstanding commitment to environmental responsibility and the BDA agrees with the UK position and the measures set out by the Minamata Convention.

‘We believe that the phase down of dental amalgam, at a rate appropriate for each signatory country, to be the best option for public health, particularly considering the strain on healthcare systems especially in light of the profound impact of the COVID-19 pandemic and the risk of further exacerbating inequalities.’

Due to take place in Geneva, Switzerland from 3 to 7 November 2025, COP 6 will see member countries, including the UK, discuss updates to policies on mercury.

Decisions made at this meeting could influence the UK’s future regulations on dental amalgam, potentially paving the way for a complete ban. For now, however, the UK maintains its current ‘phase-down’ approach, with no immediate plans to implement an outright ban on amalgam use.

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