Dr.

Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


1
MERCURY TOXICITY
INTRODUCTION
Silver amalgam has been in use as a restorative material since the beginning
of the nineteenth century. Unlike any other plastic dental filling material, it has
been in continuous clinical use for more than 160 years. Yet the safety of dental
amalgam for both the dental patient and the dental personnel has been questioned
intermittently since the inception of the use of this material. The controversy
relates to the important component of the dental amalgam, that is, mercury.
The seemingly constant pronouncements about the toxic effects of mercury
and the suggested links between dental amalgam and disease have confused and
frightened the general public. While there is no scientific evidence whatsoever to
support such claims, they continue to fuel the anti-amalgam fire. Jones has arqued
that the media is not the place to present preliminary research results, especially
when they involve an emotionally charged subject such as mercury poisoning.
HISTORY [Amalgam Wars]
Controversy is not new for amalgam. The foundation for the earliest
recorded amalgam war were laid around 1833. The Crawcour brothers, then
exiled from France for dental practice irregularities started a thriving practice in
New York city using a silver coin-mercury mixture called Royal Mineral
succedaneum. However, there was no attention to the proper mercury alloy ratios
or to the type of alloy being used. For the most part, the alloy mixed with the
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


2
mercury was prepared by filling silver coins whose composition was considerably
variable. After a few years of the unscrupulous and inept work of the Crawcours
and their followers, disastrous side effects started to appear. In many cases, the
inconsistency in materials and techniques led to slow setting amalgams that
released mercury from the unset mass into unprotected dentinal tubules. Although
there were no reported cases of patient deaths, there were several cases of pulp
death.
In 1843, the American Society of Dental Surgeons condemned the use of
all filling materials other than gold, thereby igniting the first amalgam war.
The question of amalgam composition was finally settled in 1895 by Dr.
G.V. Black, who after years of scientific research on amalgams, demonstrated the
proper quantitative and qualitative mixture of mercury in amalgam to make an
effective restorative material.
The second amalgam war was started by a German chemist, professor
Alfred Stock in the mid 1920s when. Stock claimed to have evidence showing
that mercury could be absorbed from dental amalgams and that this led to serious
health problems. Stock reported that nearly all dentists had excess mercury in their
urine. He reported that mercury levels in urine of 7 patients with amalgam ranged
from 0.1 to 40 g/L but failed to record any mercury urine levels before
restorations were placed. Stocks work was later questioned: even Stock, in 1934,
repudiated his earlier analyses.
Following these controversies, a dramatic health history was reported. A
17-year-old girl, withdrawn, totally lacking in energy, even suicidal sought
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


3
treatment. When she became ill, she began to hyperventilate and started
withdrawing from life and eventually dropped out of school. She was sent to
psychiatrists, internists and cardiologists without results and became progressively
sicker. A detailed case history recorded by a dentist disclosed that her symptoms
had begin 6 months earlier, after the placement of several dental amalgam
restorations. A mercury evaluation and biochemical tests were done. The amalgam
restorations were removed and within days all symptoms cleared.
Interestingly, one of the arguements is that if mercury was the cause of the
patients problem, she would feel much worse rather than much better
immediately following the removal of her amalgam restorations.
The current controversy, sometimes termed the Third Amalgam War
began primarily through the seminars, writings and videotapes of H.A. Huggins, a
dentist from Colorado Springs. He was convinced that mercury released from
dental amalgam was responsible for a plethora of human diseases affecting the
cardiovascular and nervous systems. Patient claimed recoveries from multiple
sclerosis, Alzheimers disease and other afflictions as a result of removing their
amalgam fillings.
In 1991, the General American public was widely exposed to the
controversy when it was reported by a major television program (60 minutes). In
response to numerous public questions, although the experts agreed dental
amalgam research was needed and should continue, they concluded that there was
no basis for claims that dental amalgam was a significant health hazard.

Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


4
Amalgam controversy in Western countries
The use of dental amalgam has been strongly debated in Sweden, Germany,
the United States and Canada.
The Public Health Department in Berlin has initiated the withdrawal of r-2
containing amalgam from the German market. The German authorities have
further recommended that amalgam restorations be avoided in patients with kidney
complaints and in children under 6 years of age who, they claim, are generally
believed to have a higher mercury sensitivity.
Historically, despite Swedens recent decision to ban the use of mercury in
industry, the major cause of mercury contamination in the food chain was the use
of methyl mercury coated seed. Eggs, fish and other Swedish foodstuffs were
found to have higher mercury levels than identical products produced in other
European countries. It is worth noting that Sweden, to date, is the only European
country that plans to prohibit the use of dental amalgam. Swedens motives for
examining the possible discontinuation of dental amalgam are based entirely on
environmental concerns, and not on the potential health hazard to dental patients.
After intensive studies and discussion a scientific panel appointed by
Swedish Medical Research Council concluded that
- Mercury released from dental amalgam does not, according to the available
data, contribute to systemic disease.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


5
- No significant effects on the immune system has been demonstrated with the
amounts of mercury which may be released from amalgam fillings.
- Allergic reactions to mercury from amalgam fillings have been demonstrated,
but are extremely rare.
- In a very small number of individuals, local reactions, such as lichernoid
reactions of the mucosa, may occur adjacent to amalgam restorations as well as
adjacent to dental restorations made of other materials.
- There are no data to support the belief that mercury released from dental
amalgam gives rise to teratological effects.
- The possible environmental consequence resulting from handling dental
amalgam can be controlled by proper waste management.
- Available data do not justify discontinuing the use of mercury containing
dental amalgam fillings or recommending their replacement.
The story from the National Health Service in the United Kingdom is the
same. In response to a question raised in Parliament, Mr. Hayhoe, the secretary of
state for social services, stated: In our opinion, the use of dental amalgam is free
from risk of systemic toxicity and only a few cases of hypersensitivity occur.
Mercury in the environment and food chain
Mercury is a naturally occurring element with 30,000 to 150,000 tons being
released into the atmosphere by the degassing of the earths crust and the oceans.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


6
Mercury has been used in preparations such as diuretics, antibacterial agents,
laxatives, skin antiseptics and other ointments. Presently, workers in more than 60
industries are occupationally exposed to mercury. These industries include
factories producing chlorine, caustic soda, insecticides and fungicides as well as
those involved in the manufacture of neon lights, paper and paint.
Mercury enters the food chain by inadequate and improper disposal of
wastes into oceans, lakes and stream where microorganisms methylate inorganic
mercury to the more toxic methyl mercury. Methyl mercury is then rapidly taken
up by plankton algae and is concentrated in fish via consumption by these
organisms. From the aquatic environment, methylmercury becomes incorporated
in the terrestrial environment by species feeding on the aquatic organisms.
The earliest indication that methyl mercury was an environmental hazard
came from two episodes in Minamata Bay and Nigata, Japan from 1953 to 1960.
In both episodes, the fish were contaminated by mercury from factories using
mercuric chloride catalyst in the manufacture of vinyl chloride and actaldehyde.
Several deaths were reported in these episodes.
Major incidents of human poisoning also occurred from the inadvertent
consumption of mercury treated seed grain in Iraq, Pakistan, Ghana and
Guatemala. The most catastrophic outbreak occurred in Iraq in 1972. Iraq having
imported large quantities of seed treated with methyl mercury fungicide
distributed the grain for planting. Despite official warnings, the grain was ground
into flour and made into bread. As a result, 6,350 victims were hospitalized and
500 died.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


7
Chemical forms of mercury
Mercury exists in three major chemical forms
These forms are.
1. Elemental mercury (mercury vapor)
2. Inorganic mercury or salts of mercury.
3. Organic mercury (organomercurials)
Elemental mercury is the most volatile of the three and exposure to it is
usually occupational. Chronic exposure can result from mercury in the ambient air
after accidental spills and poorly ventilated workrooms or laboratories. Mercury
vapors can have toxic effects and can be an occupational hazard in dentistry.
Inorganic mercury or mercury salts can exist as monovalent mercurous or
divalent mercuric salts. Mercury salts can be irritating and acutely toxic.
Organic mercury is highly absorbed from the gut. The alkylmercury salts
are the most toxic, with methylmercury being the most common form of these
salts. Organic mercury components are not a hazard in dentistry but can be an
environmental hazard.
Absorption bio-transformation, distribution and elimination of mercury
The metabolism of mercury is dependent on the chemical form of mercury
and the route of exposure.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


8
Absorption efficiencies for different forms of mercury.
Mercury Skin Lungs GIT
Elemental -- 80% 0.01%
Inorganic -- 80% 7%
Organic -- -- 95 98%
There is evidence that elemental mercury can penetrate skin, but
quantitative data are lacking Ingested elemental mercury vapor readily crosses cell
membranes because of its high diffusibility and lipid solubility. About 80% of
inhaled mercury is absorbed across alveolar membranes into blood stream and
then transported to other tissues. Accumulation occurs in spleen, muscle, glands
such as thyroid gland, salivary gland and tests. The accumulation of mercury, after
exposure is dependent on the close, frequency and duration of exposure as well as
a number of metabolic factors related to the exposed individual. The retention time
of mercury in organs varies considerably, with biologic half-life ranging from a
few days to months. On an average biologic half-life of inorganic mercury is 50-
60 days.
The organs with the longest retention times are the brain, kidneys and
testicles. The kidney especially renal cortex is the main organ of accumulation. In
cases of chronic low level exposure, the critical organ is the brain.
Mercury ions (H
+2
) circulate readily in the blood but pass the membrane
barriers of the brain and placenta only with difficulty. In contrast, honionized
mercury (Hg) is capable of crossing through lipid layers at these barriers and, if
subsequently oxidized within these tissues, is only slowly removed.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


9
The elimination of mercury from the body occurs primarily by the
excretion of Hg
++
via the 1) Urine and 2) feces. 3) Exhalation of mercury vapor
accounts for only a small portion of 7%. 4) Perspiration may also have a role
under certain conditions.
All forms of mercury cross the placenta to varying degrees.
Olsonn and Bergman model
Total absorption dose
Hg absorbed in GI tract Hg absorbed in lung
Ingestion absorption Inhalation absorption
Hg
2+
in saliva

Hg in oral air
Amalgam fillings
Richardson model
Hg in urine
Distribution, metabolism, excretion
Total absorption dose
Amalgam fillings
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


10
Mercury exposure from various sources
The sources are
- Food
- Fish
- Other (egg etc.)
- Water
- Soil
- Air
- Amalgam
- Drug
Eg: Calomel used in face creams.
Antiseptic agent eg. Merbromin
Diuretics.

Sources of mercury in dental office.
These include
- mercury spills
- expression of excess mercury from amalgam
- leakage from dispensers
- leakage from amalgam capsules during trituration
- mercury vaporization from contaminated instruments placed in
sterilizers.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


11
- grinding of amalgam during removal of restorations
- amalgam condensation with ultrasonic condensers
- contaminated furnishings of the office
- contaminated amalgamators, cabinets, drains, drapes
- waste containers
Mercury vapor from amalgam
The levels of mercury vapor in the expired air of patients, reported in
different studies varied greatly, as did the methods of measurement. It is observed
that chewing or brushing increases the level of mercury vapor released from dental
amalgam.
It has also been found that certain types of food on the surface of fillings
can influence the rate of mercury release and can either increase of decrease it
Effect Food & drink
No effect
Decrease
Increase
Hot and cold drinks, bread roll, apple.
Mixed lunch, eggs.
Brittle biscuits.
Average stimulation Factors
Gum chewing
Mixed food chewing
Tooth brushing
X 5.3
X 3.7
X 1.9
The mercury levels released as a result of various dental procedures are as
follows.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


12
Trituration
Placement of amalgam restoration
Dry polishing
Wet polishing
Removal of amalgam under water spray and high volume section
Additional evacuation for 1 minute to remove residual amalgam
dust
1 2 g
6 8 g
44 g
2 4 g
15 20 g
1.5 2.0 g
Corrosion of amalgam
The
2
phase (mercury tin phase) found in low copper alloys renders an
amalgam alloy much more susceptible to corrosion and significantly lowers the
strength of the alloy. Work by Jorgensen suggested that mercury released from the
breakdown of mercury tin phase ( 2 phase) is absorbed by the unreacted
particles in the matrix i.e. phase, resulting in the expansion and protrusion of the
cavo-surface margins. Increased marginal breakdown was associated with the
phenomenon of expansion. Research by Sarkar and Greener clearly established
that the - 2 phase of amalgams was the most electrochemically active phase, and
would undergo selective attack in a stimulated clinical environment.
High copper amalgams contain no 2 phase and thus more resistant to
corrosion than silver tin amalgams. In the corrosion of the high copper amalgams
the most corrosion prone phase is the phase (Cu
6
Sn
5
) and during this process
tin oxide and tin oxychloride corrosion products are formed. The preferential
corrosion of this phase does not therefore release mercury.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


13
The corrosion of an amalgam may be affected when the amalgam is in
contact with a dissimilar metal forming a galvanic cell.
Corrosion is limited by three factors,
1. The formation of a pacifying layer of corrosive products on its surface.
2. The formation of additional
1
and
2
phases from the action of the
released mercury on the residual phase (Ag
3
Sn).
3. The preferential corrosion of the (Cu
6
Sn
5
) phase of high copper
amalgams.
Particulate exposure from amalgam
Amalgam particles embedded in oral tissues may manifest clinically as
pigmented molecules that are referred to as amalgam tattoos. Amalgam particles
are present in the tissues in two forms: Very fine, discrete, round black or dark
brown granules of 1.0 m or less in size or as irregular, dark, solid fragments of
various larger sizes. The embedded particles usually elicit no reactions, although
in some cases a mild to moderate chronic inflammatory response occurs.
Monitoring Mercury Levels:
Biologic monitoring for mercury exposure
Because of high individual variations and daily fluctuations, serial
monitoring is recommended to increase the reliability of blood and urinary
concentrations as a measure of exposure to individuals. Blood levels reflect very
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


14
recent exposure since mercury in blood has a short half-life, (destruction by
erythrocytes) estimated to be about 3 days. Urinary monitoring is recommended
for assessing long-term steady state exposure. Analysis of sequential segments of
hair has been advocated for determination of longitudinal exposure to methyl
mercury as hair reflects the blood concentrations of methyl mercury at the time of
formation. But this procedure is not considered valid because mercury vapor may
directly contaminate the hair and not reflect mercury metabolized into the hair.
The range of concentrations of mercury in urine and blood in general
population, (not excessively or occupationally exposed to mercury) is 0 to 20 g/L
and 0 to 1.0g / 100ml respectively. Several surveys have shown mercury levels in
dentists and dental assistants are often at higher levels compared to general public.
Also levels were highest in eaters of fish and farmers using fungicides indicating
that mercury burden is from a non dental source.
100g/m
3
Clinical mercurism threshold (LOAEL)
50g/m
3
Nephrotoxicity threshold (LOAEL)
25g/m
3
WHO industrial threshold (NOAEL)
5g/m
3
General public threshold (NOAEL)
1g/m
3
Children, pregnant, sick threshold (NOAEL)
Monitoring the mercury vapor levels in dental offices
Monitoring the mercury vapor in the office has to be done periodically.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


15
The Threshold Limit Value (TLV) is the concentration of mercury vapor to
which nearly all workers may be repeatedly exposed without adverse effects. The
TLV recommended by OSHA is 50g/m
3
, based on a time-weighted average
during an 8 hours work shift over a 40 hours workweek.
LOAEL Lowest Observed Adverse Effect Level is the lowest level at which
an adverse effect has been observed.
NOAEL No Observed Adverse Effect Level is the level at which adverse
effects have never been observed.
Air Mercury Exposure Hazards
Mercury toxicity
Mechanism of action:
- The elemental mercury gets oxidized into mercuric ion, which has a strong
affinity for the sulfydryl groups of proteins.
- The mercuric ion also combines with other ligands, such as the phosphoryl,
carboxyl, amide and amine groups.
- Within cells mercuric ions act as potent nonspecific enzyme inhibitors and
denaturants of proteins, thus interfering with cellular metabolism and function.
- The mercuric ion has also been shown to alter membrane function and
transport, including the release and uptake of neurotransmitters in the brain.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


16
Chronic exposure to mercury vapor produces a form of toxicity that is
dominated by neurological effects. The characteristic mercurial tremor appears
as fine trembling of muscles interrupted by coarse shaking movements.
- Psychological and behavioral changes occur. Symptoms may include increased
excitability, loss of memory, insomnia, severe depression, irritability,
excessive shyness and confusion. Other reported symptoms include ataxia,
speech disorders, reflex abnormalities, kidney dysfunction, visual disturbances
and impaired nerve conduction.
- Oral symptoms include gingivitis, excessive salivation, metallic taste, and
loosening of teeth. The triad consisting of increased excitability, tremors and
gingivitis has been recognized as the major manifestation of mercury poisoning
from inhalation of mercury vapor.
- The possible harmful effects from amalgam could be
- neurotoxicity
- kidney dysfunction
- reduced immunocompetence
- birth defects
- general health
But several studies have demonstrated no relationship between the presence
of amalgam fillings and the above mentioned harmful effects.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


17
Mercury allergy / hypersensitivity
Although poorly understood, mercury hypersensitivity has also at times
been claimed as a potential hazard. This is an immune system response to very
low levels of mercury. It is a type IV or cell mediated delayed hypersensitivity
reaction. However, the number of individuals identified as potentially
hypersensitive is extremely low, and the sensitivity reaction is very mild. Also, it
is not life threatening.
Treatment for mercury poisoning
- In all cases of suspected mercury poisoning, treatment begins with immediate
termination of exposure. Usually symptoms are reversible.
- Blood and urine analysis is done as soon as possible and are used to monitor
the effectiveness of treatment.
- The affinity of mercury for thiols provides the basis for treatment with
chelating agents. Dimercaprol, penicillamine, and N-acetyl D,L penicillamine
are most commonly recommended for treatment of chronic mercury vapor
exposure.
Dental mercury hygiene recommendations
1. Ventilation: Provide proper ventilation in the work place by having fresh air
exchanges and periodic replacement of filters, which may act as traps for
mercury.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


18
2. Monitor office: Monitor the mercury vapor level in the office periodically.
This may be done by using dosimeter badges.
3. Monitor personnel: Monitor office personnel by periodic analysis. (The
average mercury level in urine is 6.1 g/litre for dental office personnel).
4. Office design: Use proper work area design to facilitate spill containment and
cleanup.
5. Pre-capsulated alloys: Use pre-capsulated alloys to eliminate the possibility
of a bulk mercury spill. Otherwise store bulk mercury properly in unbreakable
containers on stable surfaces.
6. Amalgamator cover: Use an amalgamator fitted with a cover.
7. Handling care: Use care in handling amalgam. Avoid skin contact with
mercury or freshly mixed amalgam. Avoid dry polishing.
8. Evacuation systems: Use high volume evacuation when finishing or removing
amalgam. Evacuation system have traps or filters. Check, clean or replace traps
and filters periodically.
9. Masks: Change mask as necessary when removing amalgam restorations.
10. Recycling: Store amalgam scrap under radiographic fixer solution in a covered
container. Recycle amalgam scraps through refiners.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


19
11. Contaminated items: Dispose of mercury contaminated items in sealed bags
according to applicable regulations.
12. Spills: Clean up spilled mercury properly by using bottles, tapes or fresh mixes
of amalgam to pick-up droplets: or use commercial clean up kits. Do not use
household vacuum cleaner.
13. Clothing: Wear professional clothing only in dental operatory.
14. Do not use ultrasonic condensers.
15. Select an appropriate alloy: mercury ratio to avoid the need to remove excess
mercury before packing.
16. Do not eat drink or smoke while working.
Possible alternative materials to dental amalgam
Metal alloys
1. Gold: The only real alternative to amalgam as a material in moderate to large
cavities in cast gold. For small cavities gold foil can be used.
Advantages:
- superior qualities compared to amalgam
Disadvantages:
- Demands high levels of clinical and laboratory skills in fabrication.
- Expensive.
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


20
2. Gallium alloys
Gallium is a metal with similar atomic structure and characteristics to
mercury and has a melting point of 29C. This property has been used to produce
gallium based alloys which can be used in a similar way to mercury based
amalgam. They consist of about 65% gallium and in the commercial products, the
material is supplied in a powder / liquid form. The liquid is an alloy of silver, tin,
indium and gallium.
When set these alloys consist of a number of inter metallic compounds
similar to that seen in mercury based amalgams. These are indium / tin, gallium /
copper and gallium / palladium compounds.
Disadvantages:
- 16 times more expensive compared to amalgams.
- Sticky when mixed, therefore more difficult to pack and special Teflon
instruments are necessary to overcome this problem.
- High level of corrosion
- High level of expansion
- Tooth fracture due to high expansion.
- Toxicology of gallium is unknown.



Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


21
Tooth colored alternatives
These are:
- Glass ionomer cement
- Composite resins
- Resin modified GIC
- Polyacid modified composites
- Ceramics
Dr.Alok Misra
M.D.S.
Conservative- Dentistry and Endodontics


22
Conclusion
It has been said that we know only what we can measure. We can measure
the mercury given off from amalgam restorations, and we can measure the amount
of mercury present in the environment. And while we have not yet measured any
casual relationship between dental amalgam and disease, we can measure the
superior clinical performance of dental amalgam compared to other restorative
materials. It is possible to clean up our environment without banning the use of
dental amalgam. In the words of the Swedish MRC panel With proper mercury
hygiene measures, mercury emerging from dental amalgam does not per se
represent an environmental hygiene problem. And as Marie Curie once said
Nothing in life is to be feared, it is only to be understood. Let us hope that we
can understand the enigma of amalgam in dentistry and that common sense
prevails.