Saturday, December 23, 2006

AMALGAM REMOVAL - Correct & Incorrect Protocols

International Academy of Oral Medicine and ToxicologyProtocol for Mercury/Silver Filling Removal[1]

International Academy of Oral Medicine and Toxicology

Protocol for Mercury/Silver Filling Removal[1]

Patient protection:

First in every concerned doctor's mind is the protection of the patient from additional exposure to mercury. This is especially true ofthe mercury-toxic patient. The mercury-toxic patient may have been exposed to varying amounts of mercury from diet, environment, employment or from mercury/silver dental fillings.

All forms are cumulative and can contribute to the body burden. The goal of this preferred procedure is to minimize any additional exposure of the patient, ourselves, or staff to mercury.

During chewing the patient is exposed to intraoral levels which areseveral times the EPA allowable air concentration.[2] During the removal or placement of amalgam the patient can be exposed to amounts which are a thousand times greater than the EPA allowable concentration.[3] Once the drill touches the filling, temperature increases, immediately vaporizing the mercury component of the alloy. There are 8 steps to greatly reducing everyone's exposure.

Step one Keep the fillings cool

1) All removal must be done under cold water spray with copious amounts of water. Once the removal has begun, the mercury vapour will be continuously released from the tooth.

2) Therefore, A high volume evacuator tip should be kept near the tooth (1/2 inch) at all times to evacuate this vapour from the area of the patient. Polishing amalgam can create very dangerous levels of mercury and should be avoided especially for the mercury toxic patient.

3) All patients having amalgam removed or placed should be provided with an alternative air source and instructed to not breathe through their mouth during treatment. A nasal hood such as is used with the nitrous oxide analgesia equipment is excellent.

Air is best and oxygen is acceptable although not required. If just air is used it should be clean and free of mercury vapour preferably from outside the dental office.

4) Particles of mercury alloy should be washed and vacuumed away as soon as they are generated. The filling should be sectioned and removed in large pieces to reduce exposure. At present the International Academy of Oral Medicine and Toxicology (IAOMT) has approved removal both with and without the use of a rubber dam.

Some evidence exists to support both views since high levels of mercury and amalgam particles can be found under the dam. All members are agreed that whether or not a rubber dam is used, the patient should be instructed to not breathe through their mouth or swallow the particles.

Some experts feel that it is better to remove the amalgam first and then apply the dam, if needed, for restorative procedures.

5) After the fillings have been removed, take off the rubber dam if one was used and lavage the patients mouth for at least 30 seconds with cold water and vacuum. Remove your gloves and replace them with a new pair. If a restorative procedure is next then reapply a new dam and proceed.

6) Immediately change patients protective wear and clean their face.

7) Consider appropriate nutritional support before, during and after removal.

8) Install room air purifiers or ionizers and fans for everyone's well being.

Staff protection OSHA [4,5] requires that employees be given written informed consent before the use of any toxic chemicals, of which mercury is one. Elemental mercury vapor is one of the most toxic forms of mercury and should not breathed. Women of child bearing age should be exposed to no more than 10% of the OSHA MAC [6]. Women who are pregnant should be exposed to no mercury.[7] If you use mercury or remove mercury in any form, the National Institute of Occupational Safety and Health (NIOSH) has recommended that your employees be medically monitored annually.

9) Any mercury exposure requires that the employee wear an approved mercury filter mask. An approved mask is appropriate for wearing during all dental procedures which will expose you or your staff to mercury.[8]

The manner in which dentists operate their equipment dramaticallyaffects the amount of mercury released. Never drill on mercury high dry.

It is hazardous to you, your staff, and your patient. Levels as high as4000 mg/M3 have been measured 18" from the drill when using high dry. Levels over 1000 mg/M3 are measurable upon opening an amalgam mixing capsule.

One out of 7 Californian dental offices tested over the OSHA TWA safety limit of 50 mg/M3. 100% of the vacuum cleaner exhaust tested over 100 mg/M3. Any office where mercury is used should be tested regularly and staff should be monitored for exposure. Testing services are available and a mercury sensor badge is available for personnel monitoring. They should test inside storage areas and along baseboards, where mercury might have dropped. Office spills can go undetected for years and are extremely hazardous.

REFERENCES[1] IAOMT Standards of Care Preferred Procedure Approved 9/27/92[2] EPA United States Environmental Protection Agency Office of Health and Environment Assessment Mercury health effects update Final Report EPA-600/8-84-019F 1971 EPA[3] Cooley RL, Barkmeier WW: Mercury vapour emitted during ultraspeed cutting of amalgam. J Indiana Dent Assoc 57:28-31, 1978[4] OSHA Job Health Series: Mercury.(2234)8/1975[5] Hazard Communication Program Federal Register/ Vol. 52. No. 163 / Monday, August 24, 1987[6] OSHA MAC is Threshold Limit Value of 100 micrograms/ cubic meter or 100 PPM This is a never to be exceeded standard.[7] Koos BJ and Lango LD , Mercury Toxicity in the pregnant woman, foetus, and newborn infant. A review Am J Obstetrics and Gynaecology, 126(3):390-409, 1976[8] Mine Safety Association high levels and 3M mercury dust mask lower levelsa) Patient Preparation for Amalgam Removal

AMALGAM REMOVAL PREPARATION WARNING: When the body is exposed to amalgam mercury it has an on-going need for detoxification and healing processes. If you have a medical condition, then hormones and enzymes the body needs to heal have likely been depleted by this on-going detoxification and healing process.

So before your amalgam restorations are removed, blood testing should be performed to determine what hormones and enzymes are deficient. Based on the blood test results a medical doctor can evaluate what nutritional and hormonal supplements are needed to prepare the body. After amalgams are removed, the healing usually accelerates, so there will be an even greater demand for the hormones and enzymes that were depleted. So a patient with a medical condition should take nutritional and hormonal supplements before, during and after amalgam removal.

b) Dental Procedures for Patient Protection During Amalgam Removal
IAOMT Standards of Care, Preferred Procedure, "Reducing Mercury Vapor Exposure for the Patient During Amalgam Removal." (September 1992)
The IAOMT has currently established the following amalgam removal protocols. If these protocols are followed, the amount of mercury released into the body during amalgam removal is reduced.

Place a rubber dam around the tooth to isolate it from the body.
Provide an alternative source of air to the patient.
Place a saliva ejector under the dam to remove mercury vapour that penetrates the latex.
Use high volume evacuation with isolate attachment.
Section amalgams and remove in as large pieces as possible.
Remove and properly dispose of rubber dam and mercury after amalgam removal.
Other amalgam removal precautions in addition to the protocols listed above include:
Remove no more than two amalgams per appointment.
Time amalgam removal appointments at least one month apart.
Administer intravenous Vitamin C before removal (Hg has a greater affinity to Vitamin C that is present in the blood than it does for body tissue).
Do not remove amalgams from a pregnant woman.

Further information pertaining to proper amalgam removal can be found on the web page:

c) Amalgam Removal without Patient Protection

This study measures the mercury level when amalgams are removed not following the protocols presented above.
Molin, M., Bergman B., Marklund, S.L., Schutz, A., Skerfving, S., "Mercury, Selenium, and Glutathione Peroxidase Before and After Amalgam Removal in Man" Acta Odontal Scandinavia; 48:189-202. Oslo. ISSN 0001-6357 (1990).

ABSTRACT: In 10 healthy persons all amalgam fillings were replaced with gold inlays. Blood and urinary levels were measured on 10 occasions during a 4-month period before and a 12-month period after amalgam removal. These variables were also measured three times in 10 healthy controls. A strong statistically significant relation was found between plasma mercury values and both the total number of amalgam surfaces (r=0.71, p=0.0006) and the total surface area of the fillings (r=0.73, p=0.004). In the immediate post removal phase plasma mercury rose by three- to four-fold, whereas the urinary and erythrocyte mercury rose about 50%. These peak values declined to the pre-removal level at about 1 month after removal.

Twelve months after the removal plasma and urinary mercury levels were reduced to 50% and 25%, respectively, of the initial values for the experimental group. Apart from the significantly lower plasma selenium values 5 and 10 days after removal no significant differences were found with regard to plasma selenium or erythrocyte glutathione peroxidase either within or between the experimental and the control groups. A large number of supplementary biochemical analyses did not show any influence on organ functions or any differences between the groups before or after the amalgam removal. Amalgam fillings considerably contributed to the plasma and urinary mercury levels.

d) Amalgam Removal with Patient Protection
This study measures the mercury level when amalgams are removed when not following the IAOMT protocols presented above.
Molin, M., Berglund, J.R., Mackert, J.R., "Kinetics of Mercury in Blood and Urine after Amalgam Removal." J. Dental Research, 74:420,IADR abstract 159, (1995).

ABSTRACT: Even through a number of studies have not been able to reveal any correlation between subjective symptoms and amalgam load, there are still speculations as to whether patients with subjective symptoms related by the patients themselves to their amalgam fillings could have a changed pattern of elimination of mercury. The aim of the present investigation was to study the elimination half-time of mercury in plasma, erythrocytes and urine over an extended period of time after amalgam removal in a group of 10 patients with subjective symptoms by the patients themselves referred to their amalgam fillings and a group of 8 healthy subjects. The average number of occlusal and total amalgam surfaces in the patient group were 13.0 (range 4-20) and 44.4 (range 24-68), respectively. Corresponding figures in the control group were 12.9 (range 10-16) and 40.9 (range 24-63).

The amalgam removal using rubber dam, water spray cutting and high volume vacuum evacuator, was carried out at one and the same time. Blood and urine samples were collected at two occasions before the amalgam removal, then blood was collected at thirty two occasions and urine at forty three occasions during the following year. The mercury content was analyzed by CVAAS technique.
The measured P-, Ery- and U-Hg concentrations before amalgam removal were slightly higher in the control group (6.43.3 nmol/L, 19.46.6 nmol/L, and 2.71.3 nmol/nmol) creatinine respectively than in the symptom group (5.61.8 nmol/L, 14.88.8 nmol/L, and 1.60.9 nmol/nmol) creatinine respectively.

The Hg-concentrations did not significantly increase in the two groups after amalgam removal. Six days after the removal the plasma mean concentration was significantly decreased at P level and ten days after the decrease was at a permanent P level. The mean Ery-Hg level was significantly decreased after eleven days (p), a level that remained stable for the rest of the year. The mean U-Hg level was significantly decreased to one month after the removal and after six months the mean level was reduced with 80 % compared to the initial level in both groups.

The conclusion to be drawn for the present study is that the symptom group did not have a changed pattern of elimination of mercury compared to the healthy group.
Begerow, J., Zander, D., Freier, I., Dunemann, L. "Long-Term Mercury Excretion in Urine After Removal of Amalgam Fillings" International Arch. Occupation Environmental Health 66:209-212 (1994).

ABSTRACT: The long-term urinary mercury excretion was determined in seventeen 28- to 55-year old persons before and at varying times (up to 14 months) after removal of all (4-24) dental amalgam fillings. Before removal the urinary mercury excretion correlated with the number of amalgam fillings. In the immediate post-removal phase (up to 6 days after removal) a mean increase of 30 percent was observed. Within 12 months the geometric mean of the mercury excretion was reduced by a factor of five from 1.44ug/g (range: 0.57 to 4.38ug/g) to 0.35 ug/g (range: 0.13 to 0.88 ug/g).

The exposure from amalgam fillings thus exceeds the exposure from food, air and beverages. Within 12 months after removal of all amalgam fillings the participants showed substantially lower urinary mercury levels which were comparable to those found in subjects who have never had dental amalgam fillings. A relationship between the urinary mercury excretion and adverse effects was not found. Differences in the frequency of effects between the pre- and post-removal phase were not observed.

DISCUSSION: The initial urinary mercury concentrations (before amalgam removal) were similar to those found in previous studies in people with amalgam fillings while the final values (12 months after amalgam removal) were comparable to those for people who have never had amalgam fillings.Our results are in excellent agreement with those of Molin et. al., who found a 75 percent reduction in urinary mercury levels within 12 months after amalgam removal. In accordance with the findings in this study, Molin also found a 50 percent increase in the urinary mercury excretion in the immediate post-removal phase.

Elligsen et. al. and Roels et. al. monitored the urinary mercury excretion after cessation of occupational exposure in a chloralkali plant. The biological half-life was calculated to be 91 days and 90 days, respectively. Both groups of authors concluded that the elimination rate after cessation of mercury exposure seems to be monophasic. This is in agreement with the results of this study based on dental exposure levels.The present study indicates that in persons with amalgam fillings on an average about 80 percent of the urinary mercury excretion is caused by the release from dental amalgam. Thus the inorganic mercury exposure form this source far exceeds the exposure from all other enviornmental sources (food, water, beverages, air).

e) Pregnancy Precaution

The formation of a foetus is very much at risk to mercury in its mother's blood, so the continuous release of mercury from amalgam restorations may be responsible for a portion of the birth defects seen in our society today. When an amalgam filling is removed or an amalgam-filled tooth is extracted, a surge of mercury may be released into the bloodstream. Women should have their amalgam fillings removed at least one year in advance of when they intend to become pregnant and discuss the risk with an informed medical doctor or dentist. Women should never have amalgam fillings removed during a pregnancy.

f) Patient Reports

Siblerud, R.L. "Health Effects After Dental Amalgam Removal" Journal of Orthomolecular Medicine. Vol. 5, No. 2, (1990).

SUMMARY: A Utah dentist provided the names and addresses of approximately 300 people who had their amalgams removed. A health questionnaire was sent to these people; 86 subjects responded. Eighty (80) % of the subjects reported that they felt better following amalgam removal. Nearly all of the subjects (91%) said they were glad their amalgams had been removed and 88% said they would do it again. An increase in happiness and peace of mind was experienced by 58% of the subjects. This evidence suggests that the well being of these subjects improved immensely after amalgam removal.

Mary Davis editor "Solving the Puzzle of Mystery Syndromes" Hot Off the Press Printing Co. 2000

SUMMARY: This book presents patient-reported case histories, where they associate their health problems with dental amalgam mercury. Case histories include: Chronic Fatigue Syndrome, Seizures, Memory Loss, Migraines, Multiple Allergies, Multiple sclerosis, Depression, Lupus, Maldigestion, Chemical Sensitivities, Insomnia, Miscarriages, Paralysis, Sinus Problems, Emotional & Mental Disorders, Infertility, Endometriosis, Crohn's Disease, Rashes, Anxiety, Tremors & Spasms, Amyotrophic Lateral Sclerosis, Universal Reactor and many others.......

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