The effect of dental amalgam restorations on blood mercury levels

Mercury, silver and selenium in serum before and after removal of amalgam restorations: results from a prospective cohort study in Norway

OBJECTIVE

A prospective cohort study on changes of health complaints after removal of amalgam restorations was carried out at the request of the Norwegian Directorate of Health. The aim was to provide and evaluate experimental treatment to patients with health complaints attributed to dental amalgam fillings.

METHODS

Patients (n = 32) with medically unexplained physical symptoms (MUPS), which were attributed to dental amalgam restorations had all their amalgam restorations removed and replaced with other dental restorative materials. Samples of blood were collected before and 1 year after removal of the fillings, and concentration of inorganic mercury (I-Hg), methylmercury (MeHg), silver (Ag) and selenium (Se) in serum was determined by inductively coupled plasma-sector field mass spectrometry. The comparison groups (one with MUPS but without attribution to amalgam [n = 28] and one group of healthy individuals [n = 19]) received no treatment. The participants responded to questionnaires at baseline and at follow-up after 1 and 5 years.

RESULTS

Concentration of I-Hg and Ag in serum decreased significantly after removal of all amalgam restorations. Concentration of MeHg and Se in serum were not changed. Intensity of health complaints was significantly reduced after amalgam removal, but there were no statistically significant correlations between exposure indicators and health complaints.

CONCLUSIONS

Removal of all amalgam restorations is followed by a decrease of concentration of I-Hg and Ag in serum. The results support the hypothesis that exposure to amalgam fillings causes an increase of the daily dose of both I-Hg and Ag. Even though intensity of health complaints decreased after removal of all amalgam restorations there was no clear evidence of a direct relationship between exposure and health complaints. Trial registration: The project is registered at Clinicaltrials.gov (NCT01682278).

Children with Amalgam Dental Restorations Have Significantly Elevated Blood and Urine Mercury Levels

Human exposure to organic mercury (Hg) as methylmercury (MeHg) from seafood consumption is widely considered a health risk because pure methylmercury is extremely neurotoxic. In contrast, the clinical significance of Hg exposure from amalgam (AMG) dental restorations, the only other major nonoccupational source of Hg exposure, has long been debated. Here, we examined data from the two most recent National Health and Nutrition Examination Surveys (NHANES) on 14 181 subjects to assess the contributions of seafood consumption versus AMG to blood total mercury (THg), inorganic mercury (IHg), and methyl mercury (MeHg) and to urine creatinine corrected mercury (UTHg). All subjects were also classified as to their self-reported qualitative consumption of seafood (59% fish and 44% shellfish). Subjects with restorations were grouped into three groups (0) those without AMG (64.4%), (1) those with 1-5 dental AMG restorations (19.7%), (2) those with more than five AMG (16%). Seafood consumption increased total mercury in urine (UTHg) and total mercury (THg) and methyl mercury (MeHg) in blood, but unlike AMG, seafood did not increase blood inorganic mercury (IHg). Using stratified covariate (ANOVA) and multivariate (GLM) analyses revealed a strong correlation of blood (THg and IHg) and urine (UTHg) levels with the number of AMGs. In a subpopulation without fish consumption, having more than five AMG restorations raised blood THg (103%), IHg (221%), and urine UTHg (221%) over the group without AMG. The most striking difference was noted in classification by age: subjects under 6 years old with more than five AMG restorations had the highest blood IHg and urine UTHg among all age groups. Elevation of bivalent IHg on a large scale in children warrants urgent in-depth risk assessment with specific attention to genetic- and gender-associated vulnerabilities.

Total blood mercury and its determinants in New Zealand children and adults

BACKGROUND

Mercury is a widespread persistent environmental pollutant associated with adverse health effects.

OBJECTIVE

This first national biomonitoring survey of blood total mercury (tHg) conducted in New Zealand aimed to provide baseline data and identify exposure determinants.

METHODS

Blood was collected from 191 children (age 5-18 years) and 304 adults (20-65) in 2014-2016 and analysed for tHg using inductively coupled plasma mass spectrometry. Linear regression was used to assess associations with demographic and lifestyle factors.

RESULTS

Blood mercury was detected in 93% of children and 99% of adults, with geometric means (GMs) of 0.86 and 1.65 µg/L, respectively. The 60-65-year olds had the highest GM (2.34 µg/L). Regression indicated that tHg was 40% higher in boys compared to girls. Eating fish ≥ 3 times/week (compared to ≤once/week) was associated with 2.7 and 1.7 times higher tHg in children and adults, respectively. Shellfish consumption was also associated with higher tHg. High daily tap water consumption (≥2 L for children, ≥3 L for adults) was associated with lower tHg. In adults, smoking and milk consumption were associated with higher tHg.

SIGNIFICANCE

Fish and shellfish consumption is a strong determinant of New Zealanders blood tHg levels, with water and milk consumption possibly acting as modulating factors.

Removal of dental amalgam restorations in patients with health complaints attributed to amalgam: A prospective cohort study

BACKGROUND

The Norwegian Ministry of Health and Care Services initiated a project including experimental treatment for patients with health complaints attributed to amalgam restorations.

OBJECTIVE

The aim was to evaluate changes of general health complaints in patients who participated in the project and had all amalgam restorations removed.

METHODS

The project was designed as a prospective cohort study and organised by the Dental Biomaterials Adverse Reaction Unit in Bergen, Norway. The dental treatment was provided by the patient's local dentist. The main target group consisted of patients with medically unexplained physical symptoms, attributed to dental amalgam restorations (Amalgam cohort). The primary comparison group consisted of patients with medically unexplained physical symptoms without attribution to dental amalgam restorations (MUPS cohort). Primary outcome was self-reported general health complaints (GHC index) at follow-up 12-months after completed amalgam removal.

RESULTS

In the Amalgam cohort, a significant reduction of GHC index from 43.3 (SD 17.8) at baseline to 30.5 (SD 14.4) at follow-up (mean reduction 12.8, SD 15.9; n = 32; P < .001) was observed. The change scores for GHC index indicated that the reduction of complaints was significantly higher (P = .004) in the Amalgam cohort compared with the MUPS cohort (mean reduction 1.2, SD 12.3, n = 28). After adjustment for age, gender, education and baseline GHC index, the mean adjusted difference was -8.0 (95% confidence interval from -15.4 to -0.5; P = .036).

CONCLUSION

In a group of patients with medically unexplained physical symptoms, which they attributed to dental amalgam restorations, removal of amalgam restorations was followed by a significant reduction of health complaints.

Exposure to Dental Filling Materials and the Risk of Dementia: A Population-Based Nested Case Control Study in Taiwan

When studying the range of toxic substances triggering dementia, special attention should be paid to the materials used in dental practice, particularly to dental fillings containing amalgam. This necessitated conducting large-scale epidemiologic studies. The aim of our research was to determine the risk factors for developing dementia when filling materials containing amalgam are used in dental practice. In order to achieve the set goals, the following tasks were undertaken: (1) The social and demographic characteristics of the examined patients were studied; (2) the spectrum of concomitant somatic diseases was determined in patients of different gender and age; and (3) the relationship between dementia incidence and the volume of dental filling material containing amalgam was identified in patients with different somatic diseases. In general, the research conducted did not reveal any direct relationship between the development of dementia and the volume of filling material containing amalgam. However, among the people with dementia, there were persons for whom its progression was accelerated in cases where a large volume of dental filling material containing amalgam was present.

Levels of Mercury in Fish-Eating Children, With and Without Amalgam Restoration

Background:

Mercury is a naturally occurring metal that exists in three forms: elemental (metallic), inorganic, and organic mercury. Amalgam, which is an alloy of inorganic mercury, is used as a restorative material in dentistry. Organic mercury gets ingested in the body mainly by the consumption of seafood. Mercury is also stated to cause various adverse health effects such as gastrointestinal disturbances, dermatitis, muscle weakness, and neurological disorders. In recent years, the use of amalgam has become a controversy stating the various adverse effects of mercury. Hence, the study was conducted to determine and compare the variation in levels of organic and inorganic mercury in fish-eating children before and after placement of amalgam restoration.

Materials and Methods:

Seventy-five subjects, 42 males (56%) and 35 females (44%) of age group ranging 7–13 years, living in South Canara district of Karnataka, India, were selected as a part of the study. Hair and urine samples were collected for estimation of organic and inorganic levels of mercury, respectively. Informed consent was collected from all the participating subjects.

Results:

On comparison between organic and inorganic mercury levels during the study period, the concentration of organic mercury in hair samples was greater irrespective of amalgam restorations present (1.172 and 0.085, respectively; P < 0.001).

Conclusion:

Thus inorganic levels of mercury do not seem to pose a threat as much as the organic levels observed in hair, which remain fairly constant for a longer period of time. Hence in a coastal region where this study was undertaken and fish being a staple food, the risk could probably be attributed to more of an organic toxicity than an inorganic one. Thus amalgam is relatively safe to be practiced and the controversy against it should be reevaluated.

Systematic review and meta-analysis links autism and toxic metals and highlights the impact of country development status: Higher blood and erythrocyte levels for mercury and lead, and higher hair antimony, cadmium, lead, and mercury

BACKGROUND

Autism spectrum disorder (ASD) is a heterogeneous neurodevelopmental disorder that affects cognitive and higher cognitive functions. Increasing prevalence of ASD and high rates of related comorbidities has caused serious health loss and placed an onerous burden on the supporting families, caregivers, and health care services. Heavy metals are among environmental factors that may contribute to ASD. However, due to inconsistencies across studies, it is still hard to explain the association between ASD and toxic metals. Therefore the objective of this study was to investigate the difference in heavy metal measures between patients with ASD and control subjects.

METHODS

We included observational studies that measured levels of toxic metals (antimony, arsenic, cadmium, lead, manganese, mercury, nickel, silver, and thallium) in different specimens (whole blood, plasma, serum, red cells, hair and urine) for patients with ASD and for controls. The main electronic medical database (PubMed and Scopus) were searched from inception through October 2016.

RESULTS

52 studies were eligible to be included in the present systematic review, of which 48 studies were included in the meta-analyses. The hair concentrations of antimony (standardized mean difference (SMD)=0.24; 95% confidence interval (CI): 0.03 to 0.45) and lead (SMD=0.60; 95% confidence interval (CI): 0.17 to 1.03) in ASD patients were significantly higher than those of control subjects. ASD patients had higher erythrocyte levels of lead (SMD=1.55, CI: 0.2 to 2.89) and mercury (SMD=1.56, CI: 0.42 to 2.70). There were significantly higher blood lead levels in ASD patients (SMD=0.43, CI: 0.02 to 0.85). Sensitivity analyses showed that ASD patients in developed but not in developing countries have lower hair concentrations of cadmium (SMD=-0.29, CI: -0.46 to -0.12). Also, such analyses indicated that ASD patients in developing but not in developed lands have higher hair concentrations of lead (SMD=1.58, CI: 0.80 to 2.36) and mercury (SMD=0.77, CI: 0.31 to 1.23). These findings were confirmed by meta-regression analyses indicating that development status of countries significantly influences the overall effect size of mean difference for hair arsenic, cadmium, lead, and mercury between patients with ASD and controls.

CONCLUSION

The findings help highlighting the role of toxic metals as environmental factors in the etiology of ASD, especially in developing lands. While there are environmental factors other than toxic metals that greatly contribute to the etiology of ASD in developed lands. It would be, thus, expected that classification of ASD includes etiological entities of ASD on the basis of implication of industrial pollutants (developed vs. developing ASD).

Severe dermatitis might be caused by a cross-reaction between nickel and palladium and dental amalgam resolved following removal of dental restorations

This report demonstrates a case of atopic dermatitis that was unresponsive to topical steroid therapy. This clinical report highlights the fact that metals used in dental treatment, such as mercury, as well as cross‐reactions between nickel and palladium, may cause systemic hypersensitivity or toxicity.

Long term changes in health complaints after removal of amalgam restorations

OBJECTIVE

Concerns over adverse effects of mercury released from dental amalgam sometimes lead patients to request removal of their amalgam restorations. Several studies report improvement of subjective health after removal of amalgam restorations, but the mechanisms are unclear. The aim of this paper is to present data on long term changes in intensity of health complaints after amalgam removal in a group of patients with health complaints self-attributed to dental amalgam. Data from the five years follow-up in a clinical trial are presented and related to potential determinants of change.

MATERIALS AND METHODS

Patients previously referred to a specialty unit for health complaints attributed to amalgam restorations were included in the study. The 20 participants who were allocated to the treatment group had all amalgam restorations removed and replaced with other dental restorative materials. Intensity of health complaints was calculated from questionnaire data and personality variables were measured by MMPI-2.

RESULTS

At the follow-up five years after the amalgam removal was completed, intensity of general health complaints was significantly reduced (p=.001), but the symptom load was still high. The reduction was significantly correlated with concentration of mercury in urine at pre-treatment. There were no significant correlations with personality variables.

CONCLUSIONS

Removal of amalgam restorations was followed by a long term reduction of general health complaints, which was associated with mercury concentration in urine before amalgam removal. Additional studies are needed to confirm the potential mechanisms for the observed reduction.

The Expression and Significance of Metallothioneins in Murine Organs and Tissues Following Mercury Vapour Exposure

The fate of inspired mercury vapour (Hg0) is critical in the central nervous system (CNS) where it can circumvent the blood—brain barrier (BBB) at the neuromuscular junction (NMJ) and accumulate indefinitely in motor neurons by retrograde transport. The detoxification of systemic Hg0 by lung and liver requires investigation. We exposed 129/Sv wild-type (Wt) and 129/Sv MT-I, II double knockout (KO) mice to 500 μg Hg0/m3 for 4 hours to investigate the expression of MT in the lung, liver, and spinal cord following Hg0 exposure using unexposed groups as controls. There were congestive changes in liver and lung of both Wt and MT-KO groups of Hg0-treated mice; these changes appeared more pronounced in the MT-KO group. Motor neurons in the spinal cord did not show any pathological changes. Based on expression of MT, liver appears to have a major role in trapping and stabilising mercury. In the spinal cord, MT was expressed in all white matter astrocytes and in some grey matter astrocytes. Notably, motor neurons did not express MT, and the presence of MT could not be demonstrated in the axons of the ventral root. The absence of MT expression in motor neurons and their axons suggests the dependence of the motor system on the detoxifying capacity of liver MTs.

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.

Mercury exposure levels in children with dental amalgam fillings

OBJECTIVES

Mercury combined with other metals to form solid amalgams has long been used in reconstructive dentistry but its use has been controversial since at least the middle of the 19th century. The exposure and body burden of mercury reviews have consistently stated that there is a deficiency of adequate epidemiological studies addressing this issue. Fish and dental amalgam are two major sources of human exposure to organic (MeHg) and inorganic Hg respectively.

MATERIALS AND METHODS

A total of 150 subjects aged between 9 and 14 years were divided into two groups of 75 subjects each depending on their diet, i.e. seafood or nonseafood consuming. Each category was subdivided into three groups based on number of restorations. Scalp hair and urine samples were collected at baseline and 3 months later to assess the organic and inorganic levels of mercury respectively by atomic absorption spectrophotometer (AAS).

RESULTS

The mean values of urinary mercury (inorganic mercury) in the group of children with restorations were 1.5915 μg/l as compared to 0.0130 μg/l in the groups with no amalgam restorations (p < 0.001) (Wilcoxon sign rank test and paired t-test). The hair mercury levels (organic mercury) varied signi-ficantly between the fsh-eating group and nonfsh-eating group, the average values being 1.03 μg/l and 0.84 μg/l respectively (p < 0.001) (Mann-Whitney U-test and paired t-test).

CONCLUSION AND SIGNIFICANCE

The notion about the mercury being released from the amalgam restorations as a sole exposure source needs to be put to a rest, as environmental factors collectively overpower the exposure levels from restorations alone. How to cite this article: Varkey IM, Shetty R, Hegde A. Mercury Exposure Levels in Children with Dental Amalgam Fillings. Int J Clin Pediatr Dent 2014;7(3):180-185.

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.

Neurodevelopmental outcomes at 5 years in children exposed prenatally to maternal dental amalgam: the Seychelles Child Development Nutrition Study

Limited human data are available to assess the association between prenatal mercury vapor (Hg⁰)) exposure from maternal dental amalgam restorations and neurodevelopment of children. We evaluated the association between maternal dental amalgam status during gestation and children's neurodevelopmental outcomes at 5 years in the Seychelles Child Development Nutrition Study (SCDNS). Maternal amalgam status was determined prospectively in a longitudinal cohort study examining the associations of prenatal exposure to nutrients and methylmercury (MeHg) with neurodevelopment. A total of 236 mother-child pairs initially enrolled in the SCDNS in 2001 were eligible to participate. Maternal amalgam status was measured as number of amalgam surfaces (the primary metric) and number of occlusal points. The neurodevelopmental assessment battery was comprised of age-appropriate tests of cognitive, language, and perceptual functions, and scholastic achievement. Linear regression analysis controlled for MeHg exposure, maternal fatty acid status, and other covariates relevant to child development. Maternal amalgam status evaluation yielded an average of 7.0 surfaces (range 0-28) and 11.0 occlusal points (range 0-40) during pregnancy. Neither the number of maternal amalgam surfaces nor occlusal points were associated with any outcome. Our findings do not provide evidence to support a relationship between prenatal exposure to Hg⁰ from maternal dental amalgam and neurodevelopmental outcomes in children at 5 years of age.

The association between amalgam dental surfaces and urinary mercury levels in a sample of Albertans, a prevalence study

OBJECTIVE

The objective of this study was to quantify the relationship between number of dental amalgam surfaces and urinary mercury levels.

METHODS

This study uses participant data from a large philanthropic chronic disease prevention program in Calgary, Alberta, Canada. Urine samples were analysed for mercury levels (measured in μg/g-creatinine). T-tests were used to determine if differences in urine mercury were statistically significant between persons with no dental amalgam surfaces and one or more dental amalgam surfaces. Linear regression was used to estimate the change in urinary mercury per amalgam surface.

RESULTS

Urinary mercury levels were statistically significantly higher in participants with amalgam surfaces, with an average difference of 0.55 μg/g-creatinine. Per amalgam surface, we estimated an expected increase of 0.04 μg/g-creatinine. Measured urinary mercury levels were also statistically significantly higher in participants with dental amalgam surfaces following the oral administration of 2,3-dimercaptopropane-l-sulfonate (DMPS) and meso-2,3-dimercaptosuccinic acid (DMSA) which are used to mobilize mercury from the blood and tissues.

DISCUSSION

Our estimates indicate that an individual with seven or more dental amalgam surfaces has 30% to 50% higher urinary mercury levels than an individual without amalgams. This is consistent with past literature that has identified seven amalgam surfaces as an unsafe level of exposure to mercury vapor. Our analysis suggests that continued use of silver amalgam dental fillings for restorative dentistry is a non-negligible, unnecessary source of mercury exposure considering the availability of composite resin alternatives.

Blood total mercury concentrations in the Canadian population: Canadian Health Measures Survey cycle 1, 2007-2009

OBJECTIVES

We present total mercury (THg) in blood of Canadians 6-79 years of age from the first to-date nationally-representative survey, the Canadian Health Measures Survey (CHMS). This analysis is particularly relevant in the context of recent changes to Health Canada's blood Hg guidance values.

METHODS

We used data from cycle 1 (2007-2009) of the CHMS, in particular focussing on 5,319 respondents aged 6-79 years for whom blood THg data were available. We calculated descriptive statistics of blood Hg levels and analyzed the associations between blood THg levels and relevant variables. We also compared blood THg levels to existing Health Canada blood Hg guidance values.

RESULTS

The geometric mean blood THg level of the Canadian population was 0.69 µg/L (95% CI 0.56-0.86 µg/L). The majority (97.8%) of Canadian women aged 16-49 years, including pregnant women, had blood Hg values below the provisional HC blood guidance value of 8 µg/L. Mean blood THg levels were significantly higher in the "other or mixed" (1.14 µg/L, p=0.0003) and Asian (1.41 µg/L, p=0.0476) groups compared to those who self-identified as solely Caucasian (0.62 µg/L). There was however no significant difference between participants self-identified as Aboriginal Canadians versus Caucasians (0.56 µg/L vs 0.62 µg/L, p=0.2902).Fish and shellfish consumption significantly influenced blood Hg levels, as did alcohol consumption and the presence of dental amalgams.

CONCLUSION

This paper presents the first description of blood THg levels in the general Canadian population. These findings will serve as a national baseline for monitoring future changes should they arise.

Prenatal exposure to dental amalgam in the Seychelles Child Development Nutrition Study: associations with neurodevelopmental outcomes at 9 and 30 months

BACKGROUND

Dental amalgam is approximately 50% metallic mercury and releases mercury vapor into the oral cavity, where it is inhaled and absorbed. Maternal amalgams expose the developing fetus to mercury vapor. Mercury vapor can be toxic, but uncertainty remains whether prenatal amalgam exposure is associated with neurodevelopmental consequences in offspring.

OBJECTIVE

To determine if prenatal mercury vapor exposure from maternal dental amalgam is associated with adverse effects to cognition and development in children.

METHODS

We prospectively determined dental amalgam status in a cohort of 300 pregnant women recruited in 2001 in the Republic of Seychelles to study the risks and benefits of fish consumption. The primary exposure measure was maternal amalgam surfaces present during gestation. Maternal occlusal points were a secondary measure. Outcomes were the child's mental (MDI) and psychomotor (PDI) developmental indices of the Bayley Scales of Infant Development-II (BSID-II) administered at 9 and 30 months. Complete exposure, outcome, and covariate data were available on a subset of 242 mother-child pairs.

RESULTS

The number of amalgam surfaces was not significantly (p>0.05) associated with either PDI or MDI scores. Similarly, secondary analysis with occlusal points showed no effect on the PDI or MDI scores for boys and girls combined. However, secondary analysis of the 9-month MDI was suggestive of an adverse association present only in girls.

CONCLUSION

We found no evidence of an association between our primary exposure metric, amalgam surfaces, and neurodevelopmental endpoints. Secondary analyses using occlusal points supported these findings, but suggested the possibility of an adverse association with the MDI for girls at 9 months. Given the continued widespread use of dental amalgam, we believe additional prospective studies to clarify this issue are a priority.

The relation between human exposure to mercury and thyroid hormone status

The aim of this study was to investigate total mercury (THg) and methylmercury (MeHg) exposure of 75 mother-child pairs in relation to their thyroid hormone status (thyroid-stimulating hormone (TSH), triiodothyronine (T3), free triiodothyronine (fT3), thyroxine (T4), and free thyroxine (fT4)). THg and MeHg in blood samples were measured by atomic absorption spectrometry and gas chromatography-inductively coupled plasma-mass spectrometry, respectively. The median THg and MeHg levels in maternal blood, cord blood, and blood of 6-month-old children were 0.50, 0.53, and 0.32 and 0.22, 0.32, and 0.08 μg/L, respectively. There were significant correlations between paired maternal-cord blood levels for THg and MeHg, with a greater transplacental transport of MeHg compared with THg (mean cord/maternal blood ratio, 1.80 vs. 1.24). The maternal blood THg was found to be a better predictor of TSH levels in children than their current THg exposure. There was a positive correlation between maternal THg and children's TSH. T3 and fT3 levels in children were negatively related to cord blood THg in the majority (Caucasian) subgroup, whereas these associations were positive in the Roma subgroup. Mothers with dental amalgam fillings had significantly lower T4 and fT4 levels. Moreover, fT4 in the mothers of boys negatively correlated with maternal THg levels. MeHg exposure lowered T3 levels in the mothers of girls. Our results suggest that low-level exposure to Hg can affect thyroid hormone status during prenatal and early postnatal exposure depending on the form of Hg, gender, ethnicity, lifestyle, or socioeconomic status (dental amalgam fillings).

Mercury exposure and risks from dental amalgam in the US population, post-2000

Dental amalgam is 50% metallic mercury (Hg) by weight and Hg vapour continuously evolves from in-place dental amalgam, causing increased Hg content with increasing amalgam load in urine, faeces, exhaled breath, saliva, blood, and various organs and tissues including the kidney, pituitary gland, liver, and brain. The Hg content also increases with maternal amalgam load in amniotic fluid, placenta, cord blood, meconium, various foetal tissues including liver, kidney and brain, in colostrum and breast milk. Based on 2001 to 2004 population statistics, 181.1 million Americans carry a grand total of 1.46 billion restored teeth. Children as young as 26 months were recorded as having restored teeth. Past dental practice and recently available data indicate that the majority of these restorations are composed of dental amalgam. Employing recent US population-based statistics on body weight and the frequency of dentally restored tooth surfaces, and recent research on the incremental increase in urinary Hg concentration per amalgam-filled tooth surface, estimates of Hg exposure from amalgam fillings were determined for 5 age groups of the US population. Three specific exposure scenarios were considered, each scenario incrementally reducing the number of tooth surfaces assumed to be restored with amalgam. Based on the least conservative of the scenarios evaluated, it was estimated that some 67.2 million Americans would exceed the Hg dose associated with the reference exposure level (REL) of 0.3 μg/m(3) established by the US Environmental Protection Agency; and 122.3 million Americans would exceed the dose associated with the REL of 0.03 μg/m(3) established by the California Environmental Protection Agency. Exposure estimates are consistent with previous estimates presented by Health Canada in 1995, and amount to 0.2 to 0.4 μg/day per amalgam-filled tooth surface, or 0.5 to 1 μg/day/amalgam-filled tooth, depending on age and other factors.

A significant relationship between mercury exposure from dental amalgams and urinary porphyrins: a further assessment of the Casa Pia children's dental amalgam trial

Previous studies noted specific changes in urinary porphyrin excretion patterns associated with exposure to mercury (Hg) in animals and humans. In our study, urinary porphyrin concentrations were examined in normal children 8-18 years-old from a reanalysis of data provided from a randomized, prospective clinical trial that was designed to evaluate the potential health consequences of prolonged exposure to Hg from dental amalgam fillings (the parent study). Our analysis examined dose-dependent correlations between increasing Hg exposure from dental amalgams and urinary porphyrins utilizing statistical models with adjustments for the baseline level (i.e. study year 1) of the following variables: urinary Hg, each urinary porphyrin measure, gender, race, and the level of lead (Pb) in each subject's blood. Significant dose-dependent correlations between cumulative exposure to Hg from dental amalgams and urinary porphyrins associated with Hg body-burden (pentacarboxyporphyrin, precoproporphyrin, and coproporphyrin) were observed. Overall, 5-10% increases in Hg-associated porphyrins for subjects receiving an average number of dental amalgam fillings in comparison to subjects receiving only composite fillings were observed over the 8-year course of the study. In contrast, no significant correlations were observed between cumulative exposure to Hg from dental amalgams and urinary porphyrins not associated with Hg body-burden (uroporphyrin, heptacarboxyporphyrin, and hexacarboxyporphyrin). In conclusion, our study, in contrast to the no-effect results published from the parent study, further establishes the sensitivity and specificity of specific urinary porphyrins as a biomarker for low-level Hg body-burden, and also reveals that dental amalgams are a significant chronic contributor to Hg body-burden.

The Release of Mercury from Amalgam Restorations and Its Health Effects: A Review

Amalgam remains an important restorative material in dentistry. Because of continuing controversy concerning the material's safety and environmental friendliness, dentists should remain current in their knowledge of the effect of mercury and its release from amalgam. This will enable dentists to provide accurate, evidence-based information to their patients.

The incidence of maternal dental treatment during pregnancy

A questionnaire was given to women who had delivered a live baby to assess their knowledge and uptake of dental treatment during their recent pregnancy of the 496 women surveyed, 95% knew that dental treatment was free on the National Health Service for 1 year after that pregnancy. Despite a high level of knowledge in this area, 64% underwent a dental check-up during pregnancy and of those women who had a check-up 27% had dental restorations placed in their teeth during that pregnancy. Only 26% of women were advised to see a dentist by a health professional. The exact incidence of dental treatment during pregnancy is not known, however, if our area is typical of the United Kingdom, large numbers of women are undergoing dental treatment during pregnancy and the contribution that this makes to maternal and fetal health should be studied.

The effects of amalgam restorations on plasma mercury levels and total antioxidant activity

OBJECTIVE

This study evaluated the effects of amalgam restorations on plasma mercury levels and total antioxidant activities (TAA).

DESIGN

The study was comprised of 48 subjects ranging in age from 20 to 32 years. Of these, 33 had dental amalgam restorations and 15 had no dental amalgam restorations. In those patients with amalgams, the total number of amalgam restorations and surfaces were counted, and the total and occlusal areas (mm(2)) of restorations were measured using a Counting Measurement Machine. Blood samples were collected from all participants. Plasma mercury levels were measured using an Atomic Absorption Spectrometer and Hydride System, and plasma TAA levels were measured using an Antioxidant Assay Kit. Statistical analysis was performed using the SPSS 10.01 software program. Data was evaluated by t test and correlation analysis.

RESULTS

Plasma mercury (P-Hg) levels were found to be significantly higher in subjects with amalgam restorations when compared to subjects without amalgams (p<0.01); the differences in P-TAA levels between subjects with and without amalgams were not found to be statistically significant (p>0.05). No significant correlations were found between P-Hg concentrations and P-TAA levels (p>0.05). Significant positive correlations were found between P-Hg concentrations and the number of amalgam restorations (p<0.01), number of amalgam surfaces (p<0.05), total amalgam surface area (p<0.05) and amalgam occlusal surface area (p<0.01). However, no significant correlations were found between these parameters and P-TAA (p>0.05).

CONCLUSIONS

The results of our study showed that dental amalgams are a major source of plasma mercury; however, amalgam restorations were not found to have a significant effect on plasma-total antioxidant activities.

Dental amalgam and multiple sclerosis: a systematic review and meta-analysis

OBJECTIVES

Amalgam restorations have long been controversial due to their mercury content. Allegations that the mercury may be linked to nervous disorders such as Alzheimer's, chronic fatigue syndrome, and multiple sclerosis (MS) have fueled the calls for the removal of amalgam restorations from dentists' armamentarium. To explore and quantify the association between amalgam restorations and MS we have conducted a systematic review and meta-analysis of the literature.

METHODS

A systematic search in Medline (from 1966 to April 2006), EMBASE (2006, Week 16), and the Cochrane library (Issue 2, 2006) for English-language articles meeting specific definitions of MS and amalgam exposure was conducted. Studies were also identified using the references of retrieved articles. Studies were independently reviewed by two authors and disagreements were resolved by consensus. Studies were selected based on an a priori of defined criteria. Odds ratios (ORs) or relative risks were pooled using the random effects model. Heterogeneity was assessed using Q statistics.

RESULTS

The pooled OR for the risk of MS among amalgam users was consistent, with a slight, nonstatistically significant increase between amalgam use and risk of MS.

CONCLUSION

Future studies that take into consideration the amalgam restoration size and surface area along with the duration of exposure are needed in order to definitively rule out any link between amalgam and MS.

Mercury exposure and public health

Mercury is a metal that is a liquid at room temperature. Mercury has a long and interesting history deriving from its use in medicine and industry, with the resultant toxicity produced. In high enough doses, all forms of mercury can produce toxicity. The most devastating tragedies related to mercury toxicity in recent history include Minamata Bay and Niagata, Japan in the 1950s, and Iraq in the 1970s. More recent mercury toxicity issues include the extreme toxicity of the dimethylmercury compound noted in 1998, the possible toxicity related to dental amalgams, and the disproved relationship between vaccines and autism related to the presence of the mercury-containing preservative, thimerosal.

The experimental toxicology of metallic mercury on the murine peripheral motor system: a novel method of assessing axon calibre spectra using the phrenic nerve

The toxicology of metallic mercury on motor neurons and their processes requires further work to resolve controversial implications in the aetiology of human motor neuron disease (MND). The assessment of experimental neurotoxicity in the peripheral motor system is, however, technically problematic and difficult to interpret. The mean number of axons in a nerve can vary considerably due to a high degree of biological variation. Atrophy of large axons can appear as loss when, in fact, their numbers appear in smaller diameter axonal categories. We addressed these quantitative problems using the murine phrenic nerve (MPN), a mono-fascicular, predominantly motor nerve as a model system. One micrometer transverse sections of gluteraldehyde/osmium tetroxide fixed MPNs were stained for myelin using a silver technique. Axon areas were measured from digital images of the nerve in cross-section (ImagePro Plus software) and transformed to circular diameter equivalents, then displayed as frequency distributions. We found a high biological variation in the mean axon number between paired nerves within experimental groups. Therefore, axon diameter data within individuals group was pooled. Theoretical simulation of axonal degeneration, atrophy and hypertrophy of larger myelinated axons (also affected in MND) were modelled by manipulating the original data set. With this model, by comparing normal distributions, it is possible to distinguish axonal atrophy, degenerative loss, and hypertrophy as distinct pathological processes in the large calibre axon subgroup that are selectively vulnerable to metallic toxins such as mercury.

Behavioral changes in metallothionein-null mice after the cessation of long-term, low-level exposure to mercury vapor

The neurobehavioral changes in wild-type and metallothionein (MT)-null mice after the cessation of long-term, low-level exposure to Hg0 were investigated. MT-null and wild-type females were continuously (24 h/day) exposed to mercury vapor (Hg0) at 0.055 mg/m3 (range: 0.043-0.073 mg/m3), which was similar to the current threshold limit value (TLV), for 29 weeks. The effects on behavior, such as locomotor activity in the open field (OPF), learning ability in the passive avoidance response (PA) and spatial learning ability in the Morris water maze (MM) were examined immediately and 12 weeks after the cessation of exposure. Immediately after the exposure had ceased, total locomotor activity in OPF was decreased in the both strain of mice, although the MT-null mice appeared to show more distinct effect. In the PA test, the exposed animals of both strains showed learning impairment as compared to un-exposed mice. Twelve weeks after the cessation of exposure, the locomotor activity in OPF was elevated in the exposed mice of both strains, while the learning ability in the PA test appeared normal in both strains. Spatial learning ability was not affected at all. Immediately after the exposure had ceased, the brain mercury concentration of the exposed wild-type mice was 1.75 microg/g, twofold of that in the MT-null mice. In 12 weeks, brain mercury levels decreased to approximately 1/20 of those in immediately after the exposure in both of the strains. These results for the first time indicated that long-term, low-level exposure to Hg0 could exert neurobehavioral effects, which were not reversible even after a long exposure-free period. Whereas the effects on learning ability were presumably transient, the effects on spontaneous behavior as evaluated in OPF were persistent. Finally, the MT-null mice seemed more susceptible to Hg0-induced neurotoxicity than the wild-type mice, confirming our previous results.

Examination of urinary mercury levels in dentists in Turkey

Mercury (Hg) is a naturally occurring element and its toxicity, especially in certain forms, has been known for many years. Exposure to Hg can occur in occupational and environmental settings. The toxicity of Hg compounds in dentistry has been an issue of increasing concern. Dental personnel are occupationally exposed to Hg vapor in their working environment and this exposure constitutes a potential risk to people in the dental surgery, mainly from the inhalation of Hg vapor and fine particles of amalgam. In this study, the urinary Hg excretion levels of 20 dentists and nine control subjects, matched for age, were determined by cold-vapor atomic absorption spectrometer (CV-AAS). The levels of Hg in the urine samples of the dentists was about three times higher than the control subjects (6.2 +/- 3.5 and 1.97 +/- 0.9 microg/L, respectively) (P <0.001). Some 90% of dentists wore both gloves and masks. Standards of hygiene (use of mask, glove and gown) may contribute to the degree of exposure. Attention to important hygiene measures, such as the avoidance of spills of Hg, cleaning of floors after such spills, ventilation and the installation of ventilation, depending on technology, should be taken into consideration. Age and smoking habits did not influence the urinary Hg excretion. Our results showed that dentists had significant exposure to Hg vapor compared to control subjects and therefore might be subject to possible adverse effects due to Hg toxicity.

Mercury exposure in children: a review

Exposure to toxic mercury (Hg) is a growing health hazard throughout the world today. Recent studies show that mercury exposure may occur in the environment, and increasingly in occupational and domestic settings. Children are particularly vulnerable to Hg intoxication, which may lead to impairment of the developing central nervous system, as well as pulmonary and nephrotic damage. Several sources of toxic Hg exposure in children have been reported in biomedical literature: (1) methylmercury, the most widespread source of Hg exposure, is most commonly the result of consumption of contaminated foods, primarily fish; (2) ethylmercury, which has been the subject of recent scientific inquiry in relation to the controversial pediatric vaccine preservative thimerosal; (3) elemental Hg vapor exposure through accidents and occupational and ritualistic practices; (4) inorganic Hg through the use of topical Hg-based skin creams and in infant teething powders; (5) metallic Hg in dental amalgams, which release Hg vapors, and Hg2+ in tissues. This review examines recent epidemiological studies of methylmercury exposure in children. Reports of elemental Hg vapor exposure in children through accidents and occupational practices, and the more recent observations of the increasing use of elemental Hg for magico-religious purposes in urban communities are also discussed. Studies of inorganic Hg exposure from the widespread use of topical beauty creams and teething powders, and fetal/neonatal Hg exposure from maternal dental amalgam fillings are reviewed. Considerable attention was given in this review to pediatric methylmercury exposure and neurodevelopment because it is the most thoroughly investigated Hg species. Each source of Hg exposure is reviewed in relation to specific pediatric health effects, particularly subtle neurodevelopmental disorders.

Childhood urine mercury excretion: dental amalgam and fish consumption as exposure factors

The authors investigated the effect of amalgam fillings and fish consumption on urine mercury level (UHg), in children aged 4-8 years old inclusive. Using a sample of 60 children, we found that children with amalgam fillings had significantly higher UHg levels than children without amalgams (geometric mean=1.412microg Hg/g versus 0.436 microg Hg/g, respectively, P = 0.0001). Subjects with reported higher fish consumption also had significantly higher UHgs (P = 0.004). Univariate analyses provide evidence of an association between elevated UHg level and young age (P = 0.009), short height (P = 0.024), and low weight (P = 0.049) in children with amalgam chewing surfaces. We also found a negative correlation between urine mercury and age (-0.378), height (-0.418), and weight (-0.391). A multiple logistic regression model shows that the presence of amalgam fillings leads to increased odds of high UHg in children (OR=47.18), even after adjusting for high fish consumption (OR=8.66) and height (OR=11.36).

Surface analysis of dental amalgams by X-ray photoelectron spectroscopy and X-ray diffraction

OBJECTIVES

It is important to characterize the surface of dental amalgam in order to understand the process of mercury release from amalgam restorations in the oral cavity. The mercury evaporation occurs not only from the newly made restoration but also from the set material.

METHODS

The surfaces of four different types of amalgams, which had been well set, were analyzed with X-ray photoelectron spectroscopy (XPS) and X-ray diffraction (XRD) and the relationship between surface compositions and mercury release was studied. Fresh amalgam surfaces as well as aged surfaces, which were stored for 30 days in air, were investigated using XPS and the chemical states of amalgam components and oxygen were studied. The aged surfaces were also characterized with XRD and grazing angle XRD.

RESULTS

With increased oxidation, the surface contents of tin and oxygen were increased in all amalgams. In contrast, the surface contents of copper and mercury were decreased. An increase of zinc or indium content were observed in zinc or indium containing amalgams, respectively. A surface layer enriched with indium and oxygen was clearly detected by XPS but not with grazing angle XRD.

SIGNIFICANCE

The thickness of the enriched surface layer is estimated to be in the order of few nanometer, which is approximately equal to the analysis depth of XPS. In addition, the presence of metallic elements, like tin and zinc, that readily form a stable oxide layer at the surface suppress the release of mercury.

The relationship between amalgam restorations and mercury levels in male dentists and nondental health professionals

OBJECTIVES

The objectives of this study were: (1) to compare the mercury levels in general dentists with the mercury levels in other health professionals using toenail clippings as a biomarker, (2) to identify risk factors associated with high mercury levels, and (3) to compare practice characteristics of dentists with high and low mercury levels.

METHODS

A sample of 579 men was randomly selected from the 33,737 men participating in the Health Professionals Follow-up Study who had provided toenail samples in 1987. A questionnaire was sent to these male subjects in 1991 to obtain information on fish consumption, toothbrushing frequency, number of teeth, number of amalgam restorations, general practice or specialty status, number of amalgam restorations placed and removed per week, mercury storage and handling procedures, and mercury spillage incidents. A measure of long-term mercury exposure was obtained from toenail samples using neutron activation analysis for the 410 respondents (71% response rate). The 90th percentile mercury level in toenails (0.88 ppm) was selected as the threshold for elevated toenail mercury level.

RESULTS

No relationship was found between the number of dental amalgams and toenail mercury levels among general dentists, dental specialists, and nondental health professionals. General dentists were found to have more than twice the level of mercury in toenails than nondental health professionals (mean level = 0.94 vs 0.45) and 60 percent higher than dental specialists (mean = 0.59). The combined use of disposable capsules and water storage of scrap amalgam appeared to reduce the risk of elevated mercury levels. Regardless of professional status, consumption of tuna and saltwater fish were the primary exposure factors that were positively associated with toenail mercury levels.

CONCLUSIONS

As shown by the associations with dental profession and fish consumption, the mercury content of toenails is a stable biomarker of cumulative long-term mercury exposure. The lack of association between nail mercury levels and number of amalgam restorations suggests that avoidance of mercury amalgam restorative materials cannot be justified by the presence of mercury released from dental amalgams.

Evaluation of the long-term corrosion behavior of dental amalgams: influence of palladium addition and particle morphology

OBJECTIVES

The purpose of this investigation was to evaluate the long-term corrosion behavior of experimental amalgams as a function of particle morphology and palladium content.

METHODS

Samples of four experimental high copper amalgams were prepared according to ADA specifications. Two of them had the same chemical composition but one had lathe cut particles (LCP) and the other had spherical particles (SP). The two others had spherical powders with an addition of 0.5 wt% of palladium (SP 0.5) and 1 wt% of palladium(SP 1) for the other. Corrosion resistance was evaluated by electrochemical techniques in Ringer's solution in a thermostated cell at 37 degrees C for samples aged 5, 8, 12, 16 months and 10 years. Potentiokinetic curves were drawn and the potential and the current density corresponding to the first anodic peak were registered.

RESULTS

For all the amalgam samples the corrosion behavior improves over the 10-year period. SP samples exhibit a better behavior than LCP. Palladium addition improves corrosion behavior as compared to samples without palladium. No real difference is found regarding the amount of palladium between 0.5 and 1%. The potentials progress from a range between 0 and 20 mV/SCE to a range of 60-80 after 10 years. The stabilization of the potential begins after only 16 months. Except for the LCP, all the values converge to the same level of 80 mV/SCE.

SIGNIFICANCE

The addition of no more than 0.5 wt% Palladium in a high copper amalgam powder improves the corrosion behavior of the amalgam up to a period of 10 years. The potential of the first anodic peak increases for each amalgam, probably in relation to the evolution of the structure of the material. Clinically, it is of interest to consider the good electrochemical behavior of older restorations when contemplating the repair or replacement of such fillings. At the same time, galvanic current can occur when a new amalgam restoration is placed in contact with an old one even if the same amalgam is used. In this situation, the new filling will be anodic and its degradation will be accelerated. The evaluation of the corrosion behavior of dental amalgams has to take into account the age of the samples.

Placental transfer of mercury in pregnant rats which received dental amalgam restorations

Mercury vapor released from one, two and four amalgam restorations in pregnant rats and mercury concentrations in maternal and fetal organs were studied. Dental treatment was given on day 2 of pregnancy. Mercury concentration in air samples drawn from each metabolism chamber with a rat were measured serially for 24 h on days 2, 8 and 15 of pregnancy. On each day of pregnancy, the amount of mercury in 24 h air samples was in proportion to the amalgam surface areas. Linear regression analysis showed relatively high correlation coefficients between the mercury content and amalgam surface areas, and the coefficients were statistically significant. A highly significant correlation was also found between the number of amalgam fillings and their surface areas. Mercury concentrations in major maternal organs with one, two and four amalgam fillings tended to increase with the increasing amalgam surface areas. Spearman's rank correlation test revealed significant correlations in the brain, liver, kidneys and placenta but not in the lung. Furthermore, significant correlations were also found between the mercury concentrations in all maternal organs and the amount of mercury in 24 h air samples on day 15 of pregnancy. Mercury concentrations in fetal brain, liver and kidneys were much lower than those of the dams but liver and kidneys showed positive correlations between the mercury content and maternal amalgam surface areas. Similar correlations were observed between the mercury concentrations in fetal organs and the amount of mercury in 24 h air samples on day 15 of pregnancy. In fetal brain, no significant correlations were found between either maternal amalgam surface areas or the amount of mercury in 24 h samples on day 15 of pregnancy but significant uptake of mercury was found in the samples from the dams given four amalgam fillings. The results of the present study demonstrated that mercury vapor released from the amalgam fillings in pregnant rats was distributed to maternal and fetal organs in dose-dependent amounts of the amalgam fillings.

Effects of gallium and mercury ions on transport systems

Mercury was previously shown to exert toxic effects by influencing ion channels and transporters in the kidney and brain. Gallium alloys were suggested as less toxic restorative materials. To compare the toxicity of gallium ions with those of mercury ions, we applied gallium nitrate Ga(NO3)3 (0.1-100 microM and mercuric chloride (HgCl2) (0.001-10 microM) to Xenopus oocytes expressing mammalian ion channels and transport proteins. Mercury (10 microM) inhibited the K+-channels ROMK and HERG, the phosphate transporter NaPi-3, the amino acid transporter rBAT, the cation transporter OCT-2, and the osmolyte transporter BGT. It activated the I(Ks)-channel but did not affect the Na+-channel ENaC, the anion channel NaPi-1, and the glucose transporter SGLT-1. Gallium was without significant effect on the channels and on SGLT1, NaPi-3, and rBAT, but inhibited BGT and OCT-2. In conclusion, both Hg2+ and Ga3+ may exert toxic effects on transport systems, which may partially explain their cytotoxic effects.

Use of inductively coupled plasma-emission spectroscopy and mercury vapor analyses to evaluate elemental release from a high-copper dental amalgam: a pilot study

STATEMENT OF PROBLEM

The use of dental amalgam as a direct restorative material has been a subject of controversy for many years. The potential safety of amalgam has been questioned because of leakage of elements such as mercury, copper, tin, and silver.

PURPOSE

This study evaluated the elemental leaching from Tytin dental amalgam placed in deionized water for 2 months. Both mercury vapor and elemental (silver, copper, tin, and mercury) analyses were performed.

MATERIAL AND METHODS

Two capsules of Tytin amalgam were triturated (one for the precipitate and liquid analysis, and the other for the mercury vapor analysis) and stored in a polypropylene tube with 10 mL deionized water for 60 days at room temperature. The amalgam pellet then was removed and rinsed with deionized water. The resulting liquid was separated from a precipitate, and 2 separate analyses were run: one on the liquid without any precipitate and another on the precipitate. Elemental analyses for copper (Cu), tin (Sn), mercury (Hg), and silver (Ag) were determined by inductively coupled plasma-emission spectroscopy with a Perkin-Elmer P2000 spectrometer. Mercury vapor analyses were performed daily for 60 days with a Jerome 431-X vapor analyzer.

RESULTS

The maximum amount of copper (80 microg), silver (2.6 microg), mercury (15 microg), and tin (550 microg) was found in the precipitate. The maximum amount of mercury vapor released was 67 microg/m(3)/d.

CONCLUSION

Under the conditions of this in vitro study, there was a significant amount of elemental leaching and mercury vapor release from the Tytin amalgam over a 60-day period.

Mercury exposure from dental amalgam fillings: absorbed dose and the potential for adverse health effects

This review examines the question of whether adverse health effects are attributable to amalgam-derived mercury. The issue of absorbed dose of mercury from amalgam is addressed first. The use of intra-oral Hg vapor measurements to estimate daily uptake must take into account the differences between the collection volume and flow rate of the measuring instrument and the inspiratory volume and flow rate of air through the mouth during inhalation of a single breath. Failure to account for these differences will result in substantial overestimation of the absorbed dose. Other factors that must be considered when making estimates of Hg uptake from amalgam include the accurate measurement of baseline (unstimulated) mercury release rates and the greater stimulation of Hg release afforded by chewing gum relative to ordinary food. The measured levels of amalgam-derived mercury in brain, blood, and urine are shown to be consistent with low absorbed doses (1-3 micrograms/day). Published relationships between the number of amalgam surfaces and urine levels are used to estimate the number of amalgam surfaces that would be required to produce the 30 micrograms/g creatinine urine mercury level stated by WHO to be associated with the most subtle, pre-clinical effects in the most sensitive individuals. From 450 to 530 amalgam surfaces would be required to produce the 30 micrograms/g creatinine urine mercury level for people without any excessive gum-chewing habits. The potential for adverse health effects and for improvement in health following amalgam removal is also addressed. Finally, the issue of whether any material can ever be completely exonerated of claims of producing adverse health effects is considered.

The amalgam controversy. An evidence-based analysis

BACKGROUND

There are a number of patients and health care professionals who believe dental amalgam restorations are a factor in a host of diseases and conditions. They have been influenced by anecdotal case reports in the medical and dental literature, research published in the refereed literature and media stories concerning the alleged dangers of amalgam restorations.

METHODS

The author uses an evidence-based approach in analyzing the data both supporting and condemning the continued use of amalgam restorations. He reviewed the articles from both peer-reviewed and non-peer-reviewed sources and evaluated their relevance, research design and statistical analysis, as well as whether the conclusions follow from the data.

CONCLUSIONS

There are numerous logical and methodological errors in the anti-amalgam literature. The author concludes that the evidence supporting the safety of amalgam restorations is compelling.

CLINICAL IMPLICATIONS

Amalgam restorations remain safe and effective. Dentists should educate patients and other health care professionals who may be mistakenly concerned about amalgam safety.

Metal exposure from amalgam alters the distribution of trace elements in blood cells and plasma

Twenty-seven consecutive patients with health problems associated with dental amalgam were recruited. In spite of thorough medical examinations, there were no diagnoses available. The patient group was dominated by women. A healthy age- and sex-matched control group with dental amalgams without symptoms was also recruited. Metal level monitoring in plasma and nuclear microscopy of isolated individual blood cells were carried out. Significant increases of copper, iron, zinc and strontium were found in patient plasma. There was no significant difference in plasma selenium between the groups. Mercury was significantly increased in patient plasma, although there was overlap between the groups. In erythrocytes a significant increase in calcium and a significant decrease in magnesium, copper, manganese and zinc were found. Calcium, magnesium, manganese and copper increased in patient neutrophil granulocytes. A significant decrease was found for zinc. A conspicuous finding was the presence of measurable mercury in a few of the cells from the patient but not in the control group. Thus, nuclear microscopy of isolated individual blood cells might provide a better diagnostic tool for metal exposure than blood plasma measurements.

Steady-state transfer and depletion kinetics of mercury from amalgam fillings

In 29 volunteers with a low amalgam load, the number of amalgam-covered tooth surfaces and the occlusal area of the fillings were determined. Before and at select times after removal of all amalgams, concentrations of total mercury were measured by cold-vapor atomic absorption in plasma and erythrocytes as well as in urine together with the excretion rate. Absorbed daily doses were estimated from intraoral Hg emission by two separate methods. The transfer of Hg from the fillings via the oral cavity and blood to urinary excretion was evaluated according to the most representative combination of parameters. This consisted of occlusal area (1), absorbed dose (2), Hg concentration in plasma (3) and urinary excretion (4). Pairwise correlation coefficients were 0.49 for parameters 1 vs. 2, and 0.75 each for parameters 2 vs. 3 and 3 vs. 4. Within 9 days after removal of the fillings, a transient increase in Hg levels was observed in plasma only; in the group without a rubber dam, concentrations increased significantly above pre-removal values at days 1 and 3, whereas they decreased significantly below pre-removal values at day 30 in the rubber-dam group and at day 100 in both groups. Excretion rates decreased significantly at day 100 in the protected group. Peak plasma-Hg was 0.6 ng/ml on average at day 1 and decreased with halftimes of 3 and 43 days in subjects protected by a rubber dam. The results indicated that concentrations of total mercury in plasma responded rapidly to changes in the amalgam status and reflected the actual absorption most reliably. Notably, plasma-Hg levels were sensitive enough to detect a transient attenuation of the additional exposure after using a rubber dam during the removal of only a few fillings. However, being small in magnitude and lasting 100 days at best, the rubber-dam effect had minor toxicological relevance.

Multiple sclerosis, dental caries and fillings: a case-control study

OBJECTIVES

To investigate the association between multiple sclerosis, dental caries, amalgam fillings, body mercury and lead.

DESIGN

Matched case-control study.

SETTING

Leicestershire in the years 1989-1990.

SUBJECTS

Thirty-nine females with multiple sclerosis (of recent onset) were matched with 62 controls for age, sex and general practitioner.

METHODS

Home interview of cases and controls within which there was an assessment of the DMFT index and blood and urine mercury and lead levels.

RESULTS

The odds of being a MS case increased multiplicatively by 1.09 (95% CI 1.00, 1.18) for every additional unit of DMFT index of dental caries. This represents an odds ratio of 1.213 or a 21% increase in risk of MS in relation to dental caries in this population. There was no difference between cases and controls in the number of amalgam fillings or in body mercury or lead levels. There was a significant correlation between body mercury levels and the number of teeth filled with amalgam (controls: r = +0.430, P = 0.006, cases: r = +0.596, P = 0.001).

CONCLUSION

There was evidence of excess dental caries among MS cases compared with the controls. This finding supports the strong geographical correlation between the two diseases. A further study of this association is recommended.

The usefulness of a piezo-micromanipulator in intracytoplasmic sperm injection in humans

Intracytoplasmic sperm injection (ICSI) has wide clinical application. In order to achieve good results with this method, it is important to restrict the possibility of oocyte injury as much as possible, and securely inject spermatozoa into the ooplasm. For this purpose, we clinically applied piezo-ICSI, which employs a micromanipulator with piezoelectric elements, to humans, and compared the results with those obtained by conventional ICSI. Conventional ICSI and piezo-ICSI were used in 279 cycles and 335 cycles respectively. Piezo-ICSI showed significantly more favourable results, with a survival rate of 88.1% (conventional ICSI: 81.4, P < 0.001), a fertilization rate of 79.4% (conventional ICSI: 66.4%, P < 0.001), and a pregnancy rate of 23.1% (conventional ICSI: 14.9%, P < 0.05). In piezo-ICSI, the needle used is not sharpened and has a flat tip. However, deformation of the oocyte during insertion of the needle is restrained by vibration of the piezo, and the oolemma is punctured readily and securely by the piezo pulse, at the site where the spermatozoon is injected. Piezo-ICSI is a promising new technique for human ICSI that should improve the survival, fertilization and pregnancy rates after ICSI.