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AMALGAM:
Its History and Perils
J.M. Hyson, Jr., DDS, MS, MA
Abstract
The current amalgam issue is not new. In the 1840s, there was even an “amal-
gam war” between the dentists who advocated the use of gold as a restorative
material and those who used silver amalgam as a filling material. There were
A lthough dental amalgam
may be considered a relative-
ly new material, compared
to gold, in the dental arma-
mentarium, it appeared in the Chinese
materia medica of Su Kung back in
659 A.D. during the Tang Dynasty. In
Europe, Johannes Stockerus, a munici-
complaints of the ill effects of mercury in the amalgam as a health problem.
pal physician in Ulm, Germany, recom-
The split on this issue threatened to divide dentistry into two camps: those who mended amalgam as a filling material
in 1528.1
used amalgam and those who condemned it. The first national dental society Mercury, one of the key ingredi-
ents of dental amalgam, had first been
in the United States, the American Society of Dental Surgeons, had to disband described by Aristotle in 4th century
B.C. as “liquid silver.” Five centuries
because of the controversy. There was even a “New Departure” movement in later, Dioscorides, a Greek physician,
used it as an eye medicine, but warned
the 1880s to eliminate gold as a restorative material in badly broken down
it was dangerous if swallowed. In the
teeth, which could be more readily salvaged by the use of material that did 18th century, John Hill, an Englishman,
described mercury as, “It penetrates the
not require the force of condensation needed to pack a gold foil, then consid- substance of all metals, and dissolves,
and makes them brittle.” Workers in
ered the ultimate restorative material. However, amalgam has proven to be an the felt hat industry dipped furs into a
mercuric nitrate solution to make them
excellent restorative material with few side effects — amalgam saves teeth. pliable, and in the process inhaled the
mercury vapor. This process resulted
in “tremors, loss of teeth, difficulty on
walking, and mental disability.” The
mad hatter of Lewis Carroll’s Alice’s
Adventures in Wonderland (Figure 1) was
probably patterned after such a victim.2
In 1805, W.H. Pepys and Joseph
Fox of England first introduced “fusible
Figure 1. Mad Hatter from Alice’s Adventures in Wonderland by Lewis Figure 2. Crawcour’s advertisement (courtesy of the Samuel D. Harris
Carroll (courtesy of Bramhall House, Division of Clarkson N. Potter, Inc., N.Y.). National Museum of Dentistry).
metals” for filling cavities; however, the patronized by the courts of Austria, dentists.”1 However, the damage had
heat required to melt the material was France, Russia, Prussia, and Belgium.”4 been done — amalgam now had a bad
obviously objectionable. In 1818, Louis In 1833, two of the Crawcour brothers reputation, despite the fact that if used
Nicolas Regnart, a Parisian physician who invaded the United States with a cheap properly, it would later prove to be an
devoted himself to dentistry, overcame coin silver amalgam they called “royal excellent restorative material.5
this problem by the addition of one-tenth mineral succedaneum” (Figure 2). The
by weight of mercury; and, in this man- Crawcours set up lavish and elegant The Amalgam War: 1841-1855
ner, amalgam (an alloy of mercury with dental “parlours” in New York City The so-called “Amalgam War” raged
another metal or metals, from the French and competed with the ethical dentists. from 1840 to 1855, “broke up friend-
word amalgame, reportedly derived from With the “grace and mannerisms of the ships and, even threatened to disrupt
the Latin malagma, meaning a “soft French,” they catered to the wealthy the profession.”1 In 1841, the American
mass”) was invented. In 1826, Auguste and influential residents of the city. The Society of Dental Surgeons, which had
Taveau of Paris used a “silver paste” made patients reclined on sumptuous easy been founded the year before as the first
from filings of five French franc pieces chairs, and their dentistry was painless national dental society in the United
mixed with mercury. The silver coins also since they merely sloped and thumbed States (it gave the first honorary doctor
contained tin and a small amount of cop- a soft plastic mix of their impure mate- of dental surgery degree), appointed a
per, which gave the mixture more plastic- rial into cavities without removing the committee to study the amalgam prob-
ity and a quicker setting time. In 1837, decay. They were out-and-out money- lem. The committee, consisting of Drs.
J.L. Murphy of London stated he had used grabbing charlatans who exploited the Eleazar Parmly, Elisha Baker, Solyman
amalgam for 12 years.3 public, charging exorbitant fees. As the Brown, Chapin A. Harris, and Jahiel
Crawcours’ business boomed, the con- Parmly, reported that all filling materi-
The Crawcour Brothers: Royal scientious practitioners, who were still als, in which mercury was an ingredi-
Mineral Succedaneum working with gold and tin, lost patients. ent, were “hurtful both to the teeth
The Crawcours were a family of Later, as the brothers’ fillings began to and every part of the mouth, and that
five Polish dentists who acquired a fall out, discolor the teeth, and cause there was no tooth in which caries
“superficial knowledge” of dentistry in tooth fracture because of the cheap in it could be arrested, and the organ
France before unleashing themselves amalgam’s expansion, the public real- rendered serviceable by being filled, in
on the English public in the 1780s. ized it had been cheated. With that, the which gold could not be employed.”6
They advertised extensively, proclaim- brothers beat a hasty retreat in 1834 Two years later, without even testing
ing their skill and claimed to be sur- back to Europe, leaving “a long trail silver amalgam, their derogatory report
geon-dentists to the “royal family and of victimized patients and exasperated resulted in the society’s blanket state-
cement in his teeth.” Before his death J. Foster Flagg: Amalgam Figure 4. Plastics and Plastic Fillings (1881)
later in 1847, his American physicians Advocate by J. Foster Flagg (courtesy of the Dr. Samuel D.
Harris National Museum of Dentistry).
disclaimed amalgam’s role (it had been In 1855, Dr. J. Foster Flagg (1828-
removed earlier) by stating that it had 1903), professor of dental pathology
“no agency in causing his disease.”13 and therapeutics at the Philadelphia 1950s for pediatric restorations, by the
Many dentists felt that the mercury College of Dental Surgery (Figure 3), 1970s, dentists were advised to avoid
in amalgam was a poison capable of began testing different amalgam for- heating it.23
“producing grave and lasting disturbanc- mulas for posterior restorations. Flagg
es of health.”14 On the other hand, Dr. modified the popular formula of 60 Amalgam in the 1860s: St. Louis
Elisha Townsend reported in 1855 that percent tin to 40 percent silver by Odontological Society
two amalgam fillings he had inserted in reversing it to 60 percent silver and 40 During the American Civil War, the
1834 were still “as good as when filled.” percent tin, and added combinations of debate on the merits of amalgam con-
Although he did not think it would other metals, e.g. copper, zinc, antimo- tinued. In 1861, Dr. John Tomes and
ever supersede gold, he felt that some ny, gold, cadmium, and platinum.11,21 his son, Charles, in England studied
cases it was in the best interest of the In 1861, he presented his findings to and conducted important experiments
patient to save the tooth using amal- the Pennsylvania Association of Dental testing the expansion and contraction
gam rather than gold, which required Surgeons. In 1881, he published his of the various amalgam products.24
“heavy pressure for consolidation.” book, Plastic and Plastic Fillings (Figure In April 1861, at the meeting of the
Townsend even gave his personal direc- 4), as amalgam fillings were then pop- Pennsylvania Association of Dental
tions for preparing the amalgam, known ularly referred to as “plastic fillings.” Surgeons, the subject of “amalgam”
as “Townsend’s Amalgam.”15 In a special The inevitable result of this affair was was the first topic on the agenda. It
meeting of the Pennsylvania Association that silver amalgam was proven to was argued that “the fault was not in
of Dental Surgeons held in October 1855, be “an excellent filling material” and the material but in the manipulation.”
Townsend, the association’s president, expanded dentistry’s “ability to save Flagg stated that “the mission of the
reiterated his views on amalgam that “a teeth.”2 true dentist is not merely to be able
plastic material” was invaluable. He stat- Meanwhile, in 1859, M. Gershrine to put in a solid gold filling, regard-
ed, “I am not a prodigy, and I do often developed a new copper amalgam, less of consequences, but to operate in
see teeth my patient will thank me for which was rendered soft by heating such a manner as would best subserve
saving, even if for a few months, which to about 675 degrees, then triturating the interest of the patient.” He did
I have not the skill to fill with gold.”16 in an iron mortar, and heated to 225 not use amalgam in anterior teeth as
Townsend said that he had seen hun- degrees until it became soft.22 Although he believed “the preservation of their
dreds of amalgam fillings and had never copper amalgam was used up until the beauty” was as essential as preserving
mel (mercurous chloride) by his physi- lips.” The next day, the fillings were it could pose a health hazard to the
cian for “trench mouth” after a severe removed and the problem resolved.76 In dental staff.83 Griffith in 1963 reviewed
cold.69 In 1951, a case of true allergy to 1983, the ADA reiterated its stance that the literature and concluded that the
mercury was reported in the Journal of the there was “no reason to remove amalgam amount of mercury exposure to dental
American Dental Association. A 4-year-old restorations from a patient or prohibit personnel was “not expected to cause
girl developed allergic symptoms on two the use of dental amalgam in restorative any detectable harm at any time during
occasions following insertion of amalgam dentistry except in those cases of proved life.”84 Joselow et al. in their 1968 study
fillings. A patch test was positive for mer- sensitivity of the patient to mercury.”77 of dental offices showed 14 percent had
cury alone, but not amalgam.70 Johnson However, true allergy is rare and may mercury concentrations in excess of what
et al. reported the case of a 32-year-old spring from the “unfounded fear that the was considered “good hygienic practice.”
veteran treated at the Dermatological amalgam may be poisonous.”78 Absorption of mercury was evidenced
Service, Crile VA Hospital, for sensitiv- by higher than normal urinary mercury
ity to his amalgam fillings. A patch Amalgam in the 1960-70s: levels.85 However, the 1960s ended with
test confirmed the diagnosis, and the Mercury Vapor the death of a 42-year-old dental assistant
six teeth with amalgam fillings were As early as 1935, McGeorge, in his with a 20-year history of exposure to
extracted.71 In 1962, the British Dental article on mercurial stomatitis, men- mercury in England. She had developed a
Journal reported a case of mercury allergy tioned that mercury may be inhaled “rapidly fatal nephritic syndrome,” from
in a 33-year-old woman mulling amalgam in the
in Stockholm.72 In 1963, Giese warned dentists in 1948 that mercury vapor was palm of her hand.86
Engelman reported a case The concern about mer-
of a 27-year-old woman toxic and that famous scientists, such as Michael Faraday and cury vapor extended into
who had been allergic to the 1970s when squeeze
mercury since the age of 2. Blaise Pascal, were victims of “chronic mercury poisoning.” cloths were still being used
Two amalgam restora- to express the excess mer-
tions were placed and the patient devel- “in the form of mercury vapor.”79 Giese cury. Then, too, the 1970 Occupational
oped a “generalized, weeping vesicular warned dentists in 1948 that mercury Safety and Health Act created a legal
eruption, accompanied by an itching vapor was toxic and that famous scien- responsibility for the employer-dentist to
sensation,” which was relieved by an tists, such as Michael Faraday and Blaise protect their employees.87
antihistaminic. A patch test confirmed Pascal, were victims of “chronic mercury In 1970, Gronka and his associates
the mercury allergy.65 In 1969, Frykholm poisoning.”80 Grossman and Dannenberg found mercury contamination in one in
et al. first reported a link between amal- in 1949 published their study on mercury seven dental offices.88 In 1973, Lenihan,
gam and lichen planus. A 45-year-old vapor in dental offices and laboratories, Smith, and Harvey surveyed 62 den-
Scandinavian woman had developed the using a portable General Electric mer- tal practices for mercury hazards. They
disease on her oral mucosa and tongue. cury-vapor detector of the instantaneous studied the mercury levels in head and
Allergy to the copper in her amalgam fill- type. They studied 50 dental offices and body hair, fingernails and toenails from
ings was demonstrated by positive skin concluded that the concentrations of 183 dentists, dental assistants, and office
tests. The replacement of her fillings with mercury were not toxic to dental person- managers. They concluded that although
copper-free materials resulted in a cure.73 nel; however, they were directly propor- there was “no evidence that the amount
Silver was even blamed for an allergic tional to the “amount of mercury used of mercury absorbed is harmful to the
reaction in a 52-year old female patient.74 by the individual dentist.”81 patient, there should be “monitoring
Wright, in 1971, reported a case of a In 1960, air analyses were conducted programmes to assess individual con-
positive mercury allergy in a 9-year-old in the Helsinki dental school to evaluate tamination by mercury” for the den-
girl. She had been sensitized to mercury the mercury vapor content during the tal staff.89 The American Conference of
at the age of 13 months by an ointment mixing of amalgam. The mercury values Governmental Industrial Hygienists rec-
applied to her lower lip.75 The British were considered below what is a safe mar- ommended a mercury threshold limit of
Dental Journal reported a case in 1982 of gin for dental personnel. The investigators 50 µg/m for a 40-hour workweek.90
a Greek Cypriot who had a positive reac- recommended adequate size rooms and Finally, in 1973, the ADA House of
tion to amalgam powder when tested. proper ventilation.82 In 1962, Krykholm Delegates adopted a resolution on the
Twenty years earlier, after the insertion and, in 1963, Knapp warned that when biological levels of mercury for the dental
of amalgam fillings, he had immediately the concentration of mercury in the air in team. The guidelines were published in
developed “swollen itching fingers and the dental office exceeded 1:100,000,000, February 1974.91 Atmospheric mercury is
mask.105 However, Roydhouse, professor detailed than the earlier recommenda- panies using phenylmercuric acetate
of restorative dentistry at the University tions. They recommended a well-ventilat- as a preservative to prolong the shelf
of British Colombia, still felt that “most ed operating room; monitoring for mer- life of interior latex paint. She tested
mercury contamination is needless and a cury vapor once a year or after a mercury 74 exposed people in recently painted
sign of poor occupational hygiene.”106 spill; following the National Institute for homes and 28 control people in homes
Carpeting also came under criticism Occupational Safety and Health’s thresh- not painted, and found that “potential-
again in 1981; however, Kantor and old limit for mercury of 50 µg/m, based ly hazardous exposure to mercury” had
Woodcock’s survey of 1,064 rooms in 528 on a eight-hour workday; periodic urinal- occurred among those in the painted
North Carolina dental offices showed yses for all dental staff; using single-use, homes at approximately 21⁄2 times the
“no difference in ambient breathing zone precapsulated alloy; using water spray and Environmental Protection Agency’s rec-
concentrations of mercury vapor between high-volume evacuation when remov- ommended limits.114
offices with hard floors and offices with ing old amalgam; wearing a face mask to
carpets.” They recommended that the avoid breathing amalgam dust; storing The Anti-Amalgamists: 1980-90s
exposure limit for mercury vapor for den- amalgam scrap covered by a sulfide solu- The anti-amalgamists became active
tal personnel be reduced again in the 1980s, despite
from 0.05 mg/cu m to 0.02 the lack of evidence. The
mg/cu m.107 Yamanaka and
The ADA estimated that each year, more than 100 National Institute of Dental
his associates at the Tokyo
Dental College in their
million amalgam fillings were inserted in the United Research issued a statement
in 1984 that “health haz-
1981 survey of Japanese States, and that fewer than 50 cases of allergic reactions to ards of blood mercury lev-
dental workers showed that els associated with dental
dentists had “statistically mercury had been reported since 1905. amalgams have not been
higher mercury levels in documented … and there
hair and urine” than the control group. tion in tightly closed containers; avoiding appears to be little correlation between
Occupational handling of mercury and direct handling of mercury or amalgam; (mercury) levels in urine, blood or hair,
eating fish was thought to be the causal and checking clothing for mercury before and toxic effects.” The same year, the
factor. The dental assistant’s hair mercury leaving the office.111 In 1985, the ADA U.S. Public Health service stated that
was not elevated, but their urinary mer- reported that the urinary mercury levels patients “should not seek replacement
cury was higher than the control group. for 4,272 dentists who participated in of amalgam fillings … based on a fear
They recommended regular monitoring their health assessment program (1975- of harm.” The ADA estimated that each
of hair and urine mercury.108 1983) had a mean level of 14.2 µgm/l.112 year, more than 100 million amalgam
Another method recommended U.S. Air Force investigators even fillings were inserted in the United States,
was the use of commercial monitors. found that amalgam-contaminated and that fewer than 50 cases of allergic
Basically, there were two types: the pal- instruments placed in a chemical vapor reactions to mercury had been report-
ladium chloride film detector and the sterilizer contaminated the sterilizer. ed since 1905. The National Multiple
gold film detector.109 Paper sterilization bags were effective in Sclerosis Society issued a strongly worded
Despite the popularity of composites, containing mercury vapor and reduced statement that amalgam had no cause
it was estimated that 85 percent of pos- it to zero, but once a sterilizer became or effect on the disease. Groups car-
terior restorations inserted in the United contaminated; it could not be effec- rying the torch against amalgam were
States in 1984 were amalgams. Langan tively decontaminated. Still, from 1989 identified as Dental Amalgam Mercury
et al. found “no evidence in the scien- to November 1990, eight episodes of Syndrome, and the Foundation for Toxic
tific literature that the minute amounts mercury exposure in private homes or Free Dentistry.115
of mercury vapor that may be released schools were reported to the Agency for However, the main protagonist against
from amalgam restoration can cause mer- Toxic Substances and Disease Registry. amalgam seems to have been Dr. Hal A.
cury poisoning.” However, they admitted In one case, an individual was smelting Huggins, a Colorado dentist. In 1982, he
the association between amalgam restora- dental amalgam in a casting furnace published a paper, “Mercury: A Factor in
tions and oral lichen planus “requires fur- in his basement to recover the silver Mental Disease.” He blamed the “mercury
ther investigation.”110 In 1984, the ADA from the amalgam. Apparently, mer- leaching out” of dental amalgam fillings
Council on Dental Materials, Instruments, cury fumes had entered the air ducts for affecting the “peripheral nervous sys-
and Equipment issued new guidelines for and circulated throughout the house.113 tem, immune system, and cardiovascular
mercury hygiene, which were much more Agocs studied the effects of paint com- system.”116 All these charges were made
that acrodynia or mercury poisoning that “exposure to amalgam fillings does amalgam as a source of pollution in
in young children was not caused by not cause serious health risks to large the United States, in 1992, batteries
chewing on amalgam fillings.124 One numbers of individuals in the general “accounted for 86 percent of discarded
British wit even brought up the sub- population and, consequently, removal mercury and dental amalgam a mere
ject of the effect which “cremation of of intact amalgam fillings is not indicat- 0.56 percent.”136
deceased people with amalgam restora- ed.” Despite this statement, the Swedish As a sign of the times, in 1999, some
tions has on the ambient atmosphere government in 1995 banned the use 86 million composite restorations were
near a crematorium.”125 of amalgam in all public health clinics placed in the United States as contrasted
The “mercury scare” was highlighted for children, and recommended that it to 71 million amalgam restorations. The
by television network CBS in their 1990 not be used in adults after 1997.131 The reasons were the improvements in com-
60 Minutes show, which presented a “gag- same year, Sandborgh-Englund et al. in posite materials and techniques, and the
gle of less-than-credible patients … to Sweden investigated kidney function in public demand for more esthetic, tooth-
testify to their miraculous recovery from 10 subjects after exposure to mercury colored restorations.137 In 2002, the Food
a variety of specific or amorphous mala- during dental treatment and found “no and Drug Administration proposed to
dies.” By contrast, the message Consumer signs of renal toxicity in conjunction upgrade dental mercury from a Class I
Reports had conveyed to its readers back to and after mercury exposure from (low risk to patients) to a Class II medical
in 1986 was that “if a dentist wants the removal of amalgam fillings.”132 device, which would require amalgam
to remove your fillings manufactures to list the
because they contain mer- As a sign of the times, in 1999, some 86 million special controls and regu-
cury, watch your wallet.”126 lations of manufacture of
In 1991, the FDA dental composite restorations were placed in the United States the product ingredients on
devices panel concluded their labels.138
that “none of the data pre- as contrasted to 71 million amalgam restorations. Gottwald and associ-
sented show a direct hazard ates, in their 2002 publi-
to humans from dental amalgams.”127 On May 13, 1997, the NBC network cation Psychotherapy and Psychosomatics
The same year, Dr. L. Jackson Brown, act- aired a segment on Dateline, which found “no significant correlation
ing director of Epidemiology and Disease provided a “very accurate and well-bal- between psychic distress and mercury
Prevention Program, National Institute anced review of the dental amalgam burden.” They concluded that “the the-
of Dental Research, National Institute of issue.”133 The same year, Eley reviewed ory that amalgam-related complaints
Health, Bethesda, Md., called the amal- the dental literature and noted that a are often an expression of underlying
gam question “an issue serious enough to pacifying layer of corrosive products psychic problems seems to be more
merit additional research.”128 Moreover, is formed on amalgam fillings, which reasonable than the theory of mercury
in 1991, Mortensen brought up the ques- is disturbed by tooth brushing and intoxication or the theory of an amal-
tion of the safety of the composite resto- chewing. The mercury released is in gam allergy.”139
rations that are replacing amalgam. Do the form of vapor, which passes into In December 2003, Dr. Frederick
composite materials remain “unchanged the intraoral air or as mercury ions, Eichmiller, director of the ADA
in the hostile oral environment of physi- which passes into the saliva and gastro- Foundation’s Paffenbarger Research
cal and chemical attacks”; and are the intestinal tract (between 1 to 2 µg per Center, testified, “The overriding body
dental professionals who inhale the “sol- day).134 The ADA Council on Scientific of scientifically valid and peer-reviewed
vent-laden vapors” on a daily basis safe? Affairs adopted new recommendations research supports only one conclusion:
Has our experience with composites been for mercury hygiene in October 1998 to that amalgam is a safe, affordable, and
long enough to “presume safety?”129 Eley update the 1991 guidelines published durable material.” He added that the
and Cox also brought up the “long-term by the former ADA Council on Dental major U.S. and international scientific
biocompatibility” of composites and their Materials, Instruments and Equipment. and health organizations, including
shorter clinical life, adding to both the cost Basically they were the same as the the national Institutes of Health, U.S.
and “progressive tooth destruction.”130 previous ones, but recommended recy- Public Health Service, Food and Drug
In 1996, at a symposium held by cling scrap amalgam according to state Administration, Centers for Disease
the International Association for Dental and federal laws, disposing of mercury- Control and Prevention and World
Research (Continental European and contaminated items in sealed bags, and Health Organization have all stated that
Scandinavian Divisions) in Berlin, removing professional clothing before “dental amalgam is a safe restorative
Germany, Ekstrand et al. concluded leaving the workplace.135 As far as scrap material.”140
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