August 11, 2010

Dr. John E. Thompson

Division Director
Bureau of Oceans, Environment and Science
U.S. Department of State
2201 C Street, N.W.
Washington, D.C. 20520

Dear Dr. Thompson:

The American Dental Association (ADA), the nations largest dental professional association
comprised of more than 157,000 member dentists, is committed to improving public health in
our country and the oral health of our patients. To prevent and to treat oral disease, dentists
need access to all proven safe and effective restorative materials. Dentists, as health
professionals, are uniquely qualified to advise the Department of State on the value and
overall importance of these dental materials, including dental amalgam. Dental amalgam is
a compound of silver, copper, tin and zinc combined with mercury that has been used for
more than a hundred years to safely and cost effectively restore teeth damaged by dental
disease.
The ADA has provided resources for the Department of State ("State") and the
Environmental Protection Agency ("EPA") periodically during the development of the
Working Group recommendations on global mercury. Now that formal mercury treaty
negotiations are underway, the ADA is submitting a number of recommendations to the
United States (U.S.) negotiators concerning dental amalgam, one product that contains
mercury and is used worldwide to treat dental disease.
Please feel free to circulate this to others within the U.S. mercury treaty negotiating team.
RECOMMENDATIONS
First, any treaty requirement related to amalgam must consider the dental health
benefits of amalgam.
No decision regarding the use of dental amalgam should ignore the health benefits to
patients from the availability and use of dental amalgam. Dental amalgam remains a very
important treatment option for repairing teeth damaged by dental caries (the infectious
disease that causes cavities) because it is easy to use, cost effective, safe based on
decades of use and research, and reliable. Dental amalgam is one of the most durable and
affordable cavity filling materials, and is an important treatment option in certain
circumstances. For instance, dental amalgam is especially well-suited to treat large cavities
in rear teeth where chewing forces are the greatest or to treat cavities below the gum line

August 11, 2010

Page 2

where moisture levels make it difficult to maintain the dry field needed for the use of other
materials. Dental amalgam can be placed more rapidly than other materials; thus treatment
can be completed far sooner, potentially avoiding the need for sedation or anesthesia. This
is often an important consideration for special needs patients. And dental amalgam is more
durable than many alternatives.
Second, any treaty requirement related to amalgam must be consistent with existing
policy.
EPA's long-standing policy is that:
"the choice of dental treatment rests solely with dental professionals and their patients and
[EPA] does not intend to second-guess these treatment decisions" (2003)1 and the choice of
dental treatment rests with dental professionals and their patients, so you should talk with
your dentist about dental treatment options that are available. (2010).2
The ADA believes that the U.S. position in these treaty negotiations must be consistent with
this view.
Third, the other consequences of any proposed ban or limit on the use of amalgam
should be taken into account, including, but not limited to the costs of alternatives.
Some context is needed to assess the true environmental impact of restrictions on the use
of dental amalgam. Given existing controls, the environmental impact from dental amalgam
is small.
In 2003, the EPA determined that [d]ental amalgam contributes a small proportion of all
mercury released to the environment from human activities.3 The ADA has since shared
with EPA scientific information on potential releases of mercury from amalgam-related
sources into the environment.4 The attached letter includes a summary of the releases
assuming that amalgam separators (an amalgam wastewater removal technology) are
required and if they are not. The conclusions in this letter are consistent with the EPAs
2003 determination.
In addition, any environmental impact will just get smaller over time, as the use of amalgam
is falling on its own. As noted above, the use of amalgam in the United States has
1
2

Letter from Tracey Mehan, Assistant Administrator for Water (2003).

EPA's mercury web site available at http://www.epa.gov/mercury/consumer.htm#den).

Statement of Geoffrey Grubbs, Director of the Office of Science and Technology, EPA, before the
Subcommittee on Human Rights and Wellness, Committee on Government Reform at 1 (October 8,
2003).

See Letter from the ADA to EPA (April 2, 2010), a copy of which accompanies this letter.

August 11, 2010

Page 3

decreased dramatically in recent years, primarily due to improvements in alternatives and

aesthetic concerns. While amalgam once accounted for the vast majority of restorations in
the United States, its use has declined to 31.6% as of 2005 and has decreased at a 3.7%
annual rate over the prior 12 years.5
The health benefits from the use of amalgam, the minimal relative contribution of mercury to
the environment from amalgam, and the decreasing use of amalgam require that the
practical considerations of a ban on the use of amalgam be taken into account. A peerreviewed study demonstrated the huge costs, both in human health and in resources, that
would result from a ban on dental amalgam. It concluded that [i]f amalgam restorations are
banned,
there would be 15,444,021 fewer restorations inserted per year and in the first-year
the incremental cost is estimated to be $8.2 billion.An amalgam ban would have a
substantial short- and long-term impact on increasing expenditures for dental care,
decreasing utilization, and increasing untreated disease. (Emphasis added.)6
A United Nations Report likewise noted the challenges created by the higher costs of
amalgam alternatives:
Mercury-free alternatives to dental amalgam include composite and glass
ionomer materials.The alternatives cost more, take longer to place, and often have
lower resistance to fracture and wear.Despite the fact that transition success has been
demonstrated in some countries, the higher cost of the alternatives is a challenge that is
preventing the further transition away from dental amalgam." (Emphasis added.)7
These impacts would be significant in the United States but would be even more severe in
developing nations. The ADA believes that the treaty negotiators must consider these
effects on public health and resources when contemplating possible restrictions on the use
of amalgam restorations.
Fourth, the treaty must allow individual countries to select mandatory or voluntary
programs consistent with national programs.
It would be a serious error for any treaty to force every country into identical environmental
controls. Circumstances and history simply differ too much among potential signatory
5

ADA, Economic Impact of Regulating Amalgam, Public Health Reports. SeptemberOctober 2007
/Volume 122. at 657, 659
http://www.dentalpbrn.org/studyClub/litWatch/Economic_Impact_Banning_Amalgam_PHR.pdf.
6

Id. at 659-660.

United Nations Environment Program (UNEP), Report On the Major Mercury-Containing Products
and Processes, Their Substitutes and Experience In Switching to Mercury-Free Products and
Processes at 7 (October 2008)
()http://www.chem.unep.ch/mercury/OEWG2/documents/g7)/English/OEWG_%202_7.pdf).

August 11, 2010

Page 4

nations. The United States, for example, is using voluntary amalgam wastewater reduction
programs to reduce the impact on the environment (including an EPA, ADA, National
Association of Clean Water Agencies memorandum of understanding). Even the United
Nations Technical Guidelines specifies the use of the ADA best management practices
(which includes amalgam separators) for dental amalgam waste.8
Fifth, if amalgam is improperly diverted to illegal uses (e.g., small local gold mining
operations) in some countries, the solution should be focused on providing a
disincentive to such misuses, not banning all uses of amalgam.
Some have argued that amalgam should be banned because artesian gold miners allegedly
divert dental amalgam for use in their gold mining operations. It is not the presence of
dental amalgam that causes an illegal use of mercury for gold mining; it is the economic
conditions of the people and the absence of an amalgam collection system.
Lastly, the UNEP report on the impact of mercury containing products should be
accurate and consistent with the existing scientific peer reviewed literature.
The draft of the new UNEP report indicates that the air releases from dental amalgam is 27
tons per year, which is approximately 1% of the world total of 1,921 tons per year. 9
The ADA believes that EPA or other authoritative sources have gathered much of the
information that might be appropriate to include in the UNEP report. The ADA provided
citations and other information on releases and discharges due to amalgam wastewater
(see attached letter to EPA, above). As noted in this submission and prior communications
with EPA, there are significant uncertainties associated with the current estimates of air
releases from crematoria in the United States and many of these uncertainties are likely to
apply to the estimates in the draft of the new UNEP report. No report which relies on such
speculative data should be permitted to shape the terms of a treaty.
CONCLUSION
The ADA is more than willing to assist you and work in conjunction with the international
dental group (the FDI World Dental Federation)10 in order to provide you additional
information on mercury releases associated with amalgam wastewater or provide other
assistance that may be relevant to the mercury treaty negotiations.
8

UNEP, Technical Guidelines for Environmentally Sound Management of Wastes Consisting of,
Containing or Contaminated with Mercury, 5th draft at 42 (March 2010, available at
http://www.basel.int/techmatters/mercury/guidelines/240707.pdf).
9

Table 1, p. 10 of the zero draft, available at

http://www.chem.unep.ch/mercury/Paragraph29/Zero%20Draft%20Report%20March%208.pdf.
10
See FDI Statement on Amalgam Wastewater at
http://www.fdiworldental.org/sites/default/files/statements/English/Amalgam-waste-management2009.pdf.

August 11, 2010

Page 5

Clearly, the ADA would like to be informed and provide you with additional input if broad
mercury product bans that might impact dentistry are discussed, particularly if they are being
seriously considered for inclusion in any final treaty.
The ADA representatives look forward to attending future State Department meetings.
Please feel free to direct any questions or comments to Jerry Bowman, the ADAs Public
Affairs Counsel (312-440-2877 or bowmanj@ada.org).
Sincerely,

Ronald L. Tankersley
President
Enclosure
RLT:JKB
cc: Susan C. Gardner, State Department
David O. Buchholz, State Department
Jacob E. Palley, State Department
Marianne Bailey, Environmental Protection Agency
Dianne L. Poster Council on Environmental Quality
Jerome Bowman, public affairs counsel, American Dental Association