The release of mercury from dental amalgam and potential neurotoxicological effects

Dental amalgam exposure can elevate urinary mercury concentrations in children

OBJECTIVES

Owing to its cost-effectiveness and operative convenience, dental amalgam remains in use as a restorative material for tooth caries in children in many countries. The aim of this study was to evaluate the relationship between dental amalgam exposure and urinary mercury (U-Hg) concentrations in children.

METHODS

In this longitudinal study, 463, 367 and 348 children, 8-11 years of age, were evaluated at baseline, and at the first and second follow-up visits, respectively. The interval between each survey was 6 months. For the oral examination and urine sample, the amalgam-filled tooth surface (TS), and U-Hg and creatinine concentrations of participants were determined, and the cumulative amalgam-filled TS and cumulative creatinine-adjusted U-Hg were calculated. To assess potential covariates, socio-demographic factors, oral health behaviour and dietary factors were surveyed by questionnaire. Data were analysed by the t-test, correlation analysis and mixed-model analysis. The statistical analyses were performed using SPSS 18.0.

RESULTS

Children with more than one amalgam-filled TS exhibited significantly higher creatinine-adjusted U-Hg concentrations than those without, in all three survey periods (P < 0.001). The results for the current and cumulative amalgam-filled TS significantly correlated with those for the current and cumulative creatinine-adjusted U-Hg concentration, respectively, in all surveys (P < 0.001). In the repeated-measures mixed model analysis, current and cumulative amalgam-filled TS was significantly related to current and cumulative creatinine-adjusted U-Hg concentration, respectively (P < 0.001).

CONCLUSIONS

Amalgam-filled TS was significantly correlated with U-Hg concentrations in children. Therefore, dental amalgam exposure can affect the systemic mercury concentration in children.

Correlation between long-term in vivo amalgam restorations and the presence of heavy elements in the dental pulp

PROJECT

To measure the levels of heavy metals (Hg, Sn) in the dental pulp and blood samples of patients with long-term amalgam restorations.

PROCEDURE

12 amalgam restored and 12 non-restored, sound teeth were chosen and access cavity preparation to the pulp chamber was made. The contents were transferred and dissolved in 5mL of concentrated nitric acid followed by placement in an oven at 180°C for tissue digestion. After cooling the tubes each digested sample was transferred to an atomic absorption system to measure the levels of heavy metals. The blood samples of five patients in each group were randomly analyzed to determine the levels of these heavy metals in the blood and if there were a correlation between these levels in blood and pulp. Data were analyzed by t-test at a P<0.05 level of significance.

RESULTS

No significant difference was seen between the levels of Hg and Sn in pulp tissues (P>0.05); however, the blood analysis showed higher level of Hg amalgam group (P=0.009). The analysis between the pulp and blood samples showed positive correlations for both Hg and Sn elements in dental pulp and the blood (P=1.000) (P=0.900).

CONCLUSIONS

The long-term presence of dental amalgam (at least 5 years) did not result in any remarkable changes in the levels of mercury and tin in the pulp tissue; however, there were increases in the level of mercury in the blood circulation even five years following the placement of the restoration.

Risk aspects of dental restoratives: From amalgam to tooth-colored materials

Dental materials’ choice of patients has considerably changed. Whereas cast gold and amalgam have been the predominant biomaterials for decades, today tooth-colored materials like resin-based composites and ceramics are more and more successful. However, are we going to replace a good but biologically questionable material (amalgam) with an equal material (resin composite) being more esthetic but also biologically questionable For amalgam, long-term clinical studies reported some significant hints that in single cases amalgam may be a health hazard for patients, finally Norway banned amalgam completely. The main advantage of a resin-based composite over amalgam is its tooth-like appearance and more or less absence of extensive preparation rules. For many years it was believed that resin-based composites may cause pulpal injury. However, pulpal injury associated with the use of resin-based composites is not correlated with their cytotoxic properties. Nevertheless, resin-based composites and other dental materials require rigorous safety evaluation and continuous monitoring to prevent adverse events similar like with amalgam. Because of non-biocompatible pulp responses to resin-based composites and amalgam, they should not be placed in direct contact with the dental pulp. The less dentin remaining in the floor of preparations between resin-based composites or other dental materials is more likely to cause pulpitis. Percentage of patients and dental practitioners who display allergic reactions is between 0.7% and 2%. The release of cytotoxic monomers from resin-based materials is highest after polymerization and much lower after 1 wk. Substances released from resin-based composites have been shown to be toxic in cytotoxicity tests. Nevertheless, in vitro cytotoxicity assays have shown that amalgam has greater toxic effects than resin-based composites, sometime 100-700-fold higher. Altogether, the risk of side-effects is low, but not zero, especially for dental personnel.

Biocompatibility of dental amalgams

Objective. The purpose of this review paper is to review the literature regarding the toxicology of mercury from dental amalgam and evaluate current statements on dental amalgam. Materials and Methods. Two key-words “dental amalgam” and “toxicity” were used to search publications on dental amalgam biocompatibility published in peer-reviewed journals written in English. Manual search was also conducted. The most recent declarations and statements were evaluated using information available on the internet. Case reports were excluded from the study. Results. The literature show that mercury released from dental amalgam restorations does not contribute to systemic disease or systemic toxicological effects. No significant effects on the immune system have been demonstrated with the amounts of mercury released from dental amalgam restorations. Only very rarely have there been reported allergic reactions to mercury from amalgam restorations. No evidence supports a relationship between mercury released from dental amalgam and neurological diseases. Almost all of the declarations accessed by the internet stated by official organizations concluded that current data are not sufficient to relate various complaints and mercury release from dental amalgam. Conclusions. Available scientific data do not justify the discontinuation of amalgam use from dental practice or replacement with alternative restorative dental materials.

To Evaluate Cytotoxicity of Resin-based Restorative Materials on Human Lymphocytes by Trypan Blue Exclusion Test: An in vitro Study

The cytotoxicity of a resin-based material can be evaluated on isolated human lymphocyte. Since resin-based dental materials have been used with increasing frequency in anterior and posterior teeth restorations, the uncured resin monomers are leached out from the restorations and diffuses into the dentine and ultimately hampers the odontoblastic layers of pulp as well as gingiva. It is also reaches into the saliva and circulatory blood. The study evaluates and compares the relative cytotoxicity of resin-based dental materials at different time interval, i.e. 24, 48, and 72 hours on human lymphocyte by Trypan blue exclusion method. All resins were found to be cytotoxic to human lymphocyte. Resin samples cytotoxicity was the highest in first 24 hours followed by 48 and 72 hours.

Mercury exposure assessment in Iranian women's hair of a port town with respect to fish consumption and amalgam fillings

In this study we aimed to estimate the level of mercury in women's hair and its association with fish consumption and amalgam fillings in an Iranian southern port town (named Mahshahr). A total number of 195 hair samples were collected randomly from women aged 25-45 years free from occupational exposures to mercury. Additional information about these women's age, weight, height, number of pregnancies, level of education, number of amalgam fillings and fish consumption were also gathered. The determination of Hg level in hair samples was carried out by the LECO, AMA 254, Advanced Mercury Analyzer, according to ASTM standard No. D-6722. The average mercury level in these women's hair was 2.95+/-2.33microg/g (ranged from 0.07 to 24.46microg/g). In the next stage, the study participants were divided into four groups with respect to their fish consumption and number of amalgam fillings; A) <3 amalgam fillings, <3 times fish consumption per month, B) <3 amalgam fillings, >7 times fish consumption per month, C) >6 amalgam fillings, <3 times fish consumption per month, and D) >6 amalgam fillings, >7 times fish consumption per month. Statistical analysis showed that the Hg level was significantly different in these four groups (P<0.001). Mercury levels in this sample exceeded the USEPA-recommended 1microg/g in 76.4% of the studied population. Finally, the multiple linear regression results revealed that frequency of fish consumption and amalgam restorations are the most important routes of Hg exposure. However, the main determinant of Hg exposure was the intake of Hg through fish consumption.

Twenty-First Century Challenges for In Vitro Neurotoxicity

During the last 40 years, studies incorporating in vitro methodologies have greatly advanced our understanding of human nerve cell biology. Attempts have been made to apply these to investigations of neurotoxicity. Due to the complexity of the nervous system, underpinned by an array of integrated interactions between a host of cell types, it is concluded that, at present, alternative neural models are most successful in determining the underlying mechanisms which can cause perturbation of normal functioning of the nervous system, both in adults and during the embryonic period. The use of tiered batteries of test models has been proposed in screening programmes for neurotoxicity, with the generation of much encouraging data in laboratories across the globe. This review aims to discuss the development of neural alternatives, considers the various model systems available, and highlights specific neuronal endpoints which can be tested, in addition to the cytotoxic evaluation of neuronal viability. Developments in molecular and stem cell biology, which are appropriate to neural tissue, and which offer the prospect of exciting advances for the next decade, are cited.

Effect of placement of calcium sulphate when used for the repair of furcation perforations on the seal produced by a resin-based material

AIM

To evaluate the sealing ability of calcium sulphate when used under composite resin for the repair of furcation perforations having different diameters.

METHODOLOGY

Perforations of different diameter were created in the floors of pulp chambers in 60 extracted human molar teeth with either a number 3 (1 mm diameter) or 5 (1.5 mm diameter) round bur. The specimens of each group were divided into four sub-groups which were repaired with composite resin either alone or in combination with calcium sulphate that created an artificial floor (15 teeth group(-1)). Eight teeth without furcation perforations served as negative controls. In the leakage detection device, 1 mol L(-1) glucose solution was forced under a pressure of 1.5 KPa from the crown towards the pulp chamber floor. The concentration of leaked glucose was measured at 1, 2, 4, 7, 10, 15 and 20 days using a glucose oxidase method and the data evaluated using the rank sum test.

RESULTS

The specimens with larger perforations repaired with composite resin alone had significantly more leakage (P < 0.05). Using calcium sulphate as an artificial floor significantly decreased leakage of smaller perforations (P < 0.05). In groups repaired with calcium sulphate under composite resin, leakage in smaller perforations was markedly lower than that in larger ones (P < 0.05). No significant difference was found between the specimens with 1 or 1.5 mm perforations repaired with resin alone (P > 0.05).

CONCLUSIONS

Calcium sulphate significantly improved the sealing ability of 1 mm perforations repaired with composite resin but not for 1.5 mm perforations.

A 7-year prospective quasi-experimental study of the effects of removing dental amalgam in 76 self-referred patients compared with 146 controls

BACKGROUND

Dental amalgam has been suggested to cause long-term physical and mental problems. Claims that removal of the amalgam may lead to dramatic improvements in health have not been tested empirically in controlled studies with a long follow-up period.

PURPOSE

To investigate the long-term effects of removal of dental amalgam on physical and mental symptoms in self-referred patients who complained of multiple somatic and mental symptoms attributed to dental amalgam fillings.

METHODS

In a quasi experimental study, changes in the mental and physical symptoms in 76 patients who had their dental amalgam removed 7 years ago were compared with changes in symptoms among patients with known chronic medical disorders seen in alternative (n=51) and ordinary (n=51) medical family practices and noncomplaining patients with similar amounts of dental amalgam fillings (n=44) seen in an ordinary dental practice. The assessments included written self-reports, a 131-item somatic symptom checklist, Eysenck Personality Questionnaire (EPQ), the General Health Questionnaire (GHQ) and Toronto Alexithymia Scale (TAS).

RESULTS

Subjects who removed their dental amalgam reported reduced physical and mental symptom load compared to status prior to removal, but only to a level comparable with that reported by the other groups with chronic medical disorders. The dental control group consistently reported lower symptom load during the whole period. In a hierarchical three-step regression model, pretreatment physical symptom load (P<.01), age (P<.10) and removal of dental amalgam (ns) predicted 26% of the variance in posttreatment physical symptom load.

CONCLUSION

In a self-referred group of subjects with health complaints attributed to dental amalgam who remove their dental amalgam, the symptom load at follow-up corresponds to the level seen in chronic medical disorders despite the strong implicit placebo effect of the present quasi-experimental design. The finding does not support the hypothesis that removal of dental amalgam will reduce health complaints to normal levels and seriously questions the hypothesis that dental amalgam is an important cause of distress and health complaints.

Cytotoxicity of composite resins polymerized with different curing methods

AIM

To compare the relative cytotoxicity of resin-based composite materials polymerized with three different curing methods on L 929 cells over a period of 1 week.

METHODOLOGY

Ten discs of each material (Flowline, P 60 and Z 250) were cured from one side with either standard cure (Optilux 401), soft-start cure (Elipar Free Light) or fast cure (Hilux Ultra Plus). Then the samples were aged for 1, 2, 3, 5 and 7 days in Dulbecco's Modified Eagle Medium/Ham's F12 (DMEM/F12). After each ageing interval, cytotoxicity of the extracts to cultured fibroblasts (L 929) was measured by MTT assay. The degree of cytotoxicity for each sample was determined according to the reference value represented by the cells with a pure culture medium. Statistical significance was determined by one-way analysis of variance (anova), followed by the Student's Newman-Keuls test.

RESULTS

Exposure of L 929 cells to the test materials resulted in a high survival fraction at 1 and 7 days. Flowline specimens, either cured with Optilux 401 or Elipar Free Light, had no toxic effect on the cells, whereas the other groups were moderately toxic on the 2-day interval. All experimental groups presented lower cell viability than the control at the 3- and 5-day intervals.

CONCLUSIONS

The composite resins used in this study were cytotoxic after 48 h pre-incubation, but this toxicity disappeared after pre-incubation in a biological medium for 7 days. Curing did not have a significant effect on the cytotoxicity of the composite materials tested.

The Children's Amalgam Trial: design and methods

The safety of silver amalgam as a dental restorative material has been controversial since its introduction 150 years ago, but until recently it has been assumed that the exposure to mercury from dental amalgam is limited to the acute placement phase. However, some recent studies have raised safety concerns by demonstrating chronic release of mercury vapor from amalgam fillings during chewing and brushing. The Children's Amalgam Trial is a two-arm randomized trial of safety, comparing amalgam with a mercury-free restorative material. A single masking procedure is used to ensure that all investigators and staff measuring outcomes are unaware of assigned trial arm. The study follows 534 New England children, aged 6-10 years at enrollment, for 5 years. The children were recruited from two northeastern U.S. communities, one in rural Maine and one in urban Massachusetts. No trial subjects received prior amalgam restorations, and all were in need of at least two posterior occlusal fillings. Participants were randomized to receive either amalgam or composite material for all posterior restorations at baseline and at subsequent visits. The primary endpoint will be 5-year change in IQ scores. Secondary endpoints will include measures of other neuropsychological assessments and renal functioning. This paper describes the design of the Children's Amalgam Trial and includes data on baseline characteristics of the subjects.