Inside Dentistry
January 2014
Volume 10, Issue 1

Global Amalgam Governance: The Need for Clinician Leadership

Grassroots education and action from dentists are needed next steps

John T. Contreras, DDS | Tim K. Mackey, MAS, PhD | Bryan A. Liang, MD, PhD, JD

Dental amalgam’s fate seems unlikely to be decided anytime soon. Initially, the US delegation sent in October 2013 to the Diplomatic Conference for the Minamata Convention on Mercury in Japan returned home without signing a new international treaty that recommends the eventual phasedown of mercury use in dental amalgam. The International POPs Elimination Network’s (IPEN’s) Senior Science and Technical Advisor Joseph DiGangi, PhD, stated that the U.S. Department of State and Environmental Protection Agency officials were recalled because of the recent federal government shutdown,1 although historically the United States has avoided entering into internationally binding agreements. Despite this brief setback, in support of the convention’s international agreed-upon principles to address mercury exposure and its environmental impact, the United States simultaneously signed and ratified the treaty on November 6.2

For certain anti–dental amalgam activists and environmentalist groups, celebration of America’s support for the treaty as a means of settling the amalgam controversy could be premature. These groups oppose continued use of dental amalgam based on concerns for human health and adverse environmental impact from mercury. Although the United States is now a party to the convention, the treaty has permissive language that only requires parties to take a minimum of two of nine measures to address mercury amalgam use and disposal. Because of the nonbinding nature of the convention’s language, a new phase in the dental amalgam controversy could be evolving. Key stakeholders in dentistry will likely be split over the three possible positions regarding amalgam—continued use, phasedown, or phaseout—which will spark new debate.

Other nations and non-governmental organizations generally agree that a phasedown of mercury dental amalgam should occur.3 This concern is voiced in the Review of the Community Strategy Concerning Mercury, which reported that the largest source of mercury exposure for most people in developed countries is inhalation of mercury vapor from dental amalgam,4 a position also reported by authors who write that amalgam fillings are the chief source of exposure to mercury vapor in the general population.5 Stakeholders are also cognizant of potentially hazardous occupational exposure to elemental mercury from dental amalgam use in the dental workplace.6 Globally, everyone is affected by the environmental contamination of mercury from dental amalgam waste when it is not managed or disposed of properly. Despite this general consensus, a key question remains: Who will make important decisions on properly phasing down and phasing out mercury dental amalgam use once the treaty comes into effect?

Other commentators who have written about the treaty have called for “top-down leadership” in addressing this process.7 However, little is discussed about active engagement of the clinical dentist as a primary actor in this decision-making process. The authors of this article believe the practicing dentist is a critical player in making rational decisions about phasing down and phasing out dental amalgam use in America. The dental professional must lead the policy and advocacy process that has been agreed upon by the international community. Specifically, the dental professional who sees the spectrum of issues associated with amalgam use and directly interacts with the patient is a key, informed stakeholder. This reality is especially relevant now that the United States has become the first nation to deposit its “instrument of acceptance” at the United Nations’ headquarters.2,8 Indeed, the United States’ quick ratification of the treaty reflects the belief that the country can implement treaty-bound obligations under existing legislative and regulatory authority.2,8

As an expert, the dentist is professionally duty bound to learn through review and study of scientific literature which materials are suitable and proper to recommend to patients receiving treatment. The dentist then invests resources in these materials, learns the requisite techniques to handle them, and masters the clinical skill to effectively use them. In addition, as a practice leader, the dentist is responsible for setting the professional tone of patient-centered leadership by virtue of ethical and legal obligations to office staff, patients, and the public. Hence, efforts at reducing exposure to avoidable occupational mercury health hazards while offering patients the safest available quality dental materials and treatment options can be achieved by discussing and responding to patients’ requests for alternatives to amalgam. Further, as a trusted local community leader, the dental practitioner can serve as an environmental steward by reducing dentistry’s anthropogenic contribution of environmental mercury contamination. Coincidentally, many dental teams have independently already eliminated amalgam from their practices at the same time as its popularity among patients has been waning.9

Leadership in amalgam policy by the dental clinician also comes at an opportune time given increasing research interests in improved materials. The National Institutes of Health recently announced an award of $2.8 million for six research projects (5 years each) to pursue longer-lasting dental composite.10 This national research investment in alternatives to dental amalgam points to expanding demand for an esthetically pleasing and mercury-free dental restorative material. As composites improve in strength and cost, benefits can inure to both patients and providers while simultaneously aligning with international consensus on the need for amalgam phasedown for important human health and environmental considerations.

The global dental amalgam controversy is likely to continue despite the recent opening for signature of the Minamata Convention. More than ever, dental clinicians are critical global health leaders in determining a pathway forward for the safe and responsible use of dental restorative materials and should be active in this process. In fact, the very future of global oral health and protection of the environment likely depends on their leadership.

To learn more about the conference, visit www.mercuryconvention.org.


1. US misses mercury vote due to government shutdown. Environmental Health News website. www.environmentalhealthnews.org/ehs/news/2013/us-absent. Accessed November 2, 2013.

2. Global treaty on mercury pollution gets boost from United States: UNEP’s Achim Steiner welcomes first ratification of the Minamata Convention on Mercury. Minamata Convention on Mercury website. www.mercuryconvention.org/News/GlobalTreatyonMercuryPollutionGetsBoostfrom/tabid/3524/Default.aspx. Accessed November 11, 2013.

3. Mudgal S, Van Long L, Mitsios A, et al. Study on the potential for reducing mercury pollution from dental amalgam and batteries. http://ec.europa.eu/environment/chemicals/mercury/pdf/final_report_110712.pdf. Accessed November 2, 2013.

4. Mudgal S, Van Long L, Pahal S, et al. European Commission (DG ENV): Review of the community strategy concerning mercury. http://ec.europa.eu/environment/chemicals/mercury/pdf/review_mercury_strategy2010.pdf. Accessed November 2, 2013.

5. Clarkson TW, Magos L, Myers GJ. The toxicology of mercury—current exposures and clinical manifestations . N Engl J Med. 2003;349(18):1731-1737.

6. Mutter J. Is dental amalgam safe for humans? The opinion of the scientific committee of the European Commission . J Occup Med Toxicol. 2011;6(1):2.

7. Lynch CD, Wilson NH. Managing the phase-down of amalgam: part II. Implications for practicing arrangements and lessons from Norway . Br Dent J. 2013;215(4):159-162.

8. United States joins Minamata Convention on Mercury. U.S. Department of State website. www.state.gov/r/pa/prs/ps/2013/11/217295.htm. Accessed November 11, 2013.

9. Thewealthydentist.com. Dentists split over mercury amalgam. www.thewealthydentist.com/survey/surveyresults/16_MercuryAmalgam_Results.htm. Accessed November 2, 2013.

10. NIH funds six grants to build next generation composite [press release]. The National Institutes of Health website. www.nih.gov/news/health/sep2013/nidcr-05.htm. Accessed November 2, 2013.

About the Authors

John T. Contreras, DDS
Graduate Student
Master of Advanced Studies in Health Policy and Law Program
University of California, San Diego and California Western School of Law
San Diego, California

Tim K. Mackey, MAS, PhD
Assistant Professor
Department of Anesthesiology
University of California, San Diego School of Medicine
San Diego, California

San Diego Center for Patient Safety
University of California, San Diego School of Medicine
San Diego, California

Bryan A. Liang, MD, PhD, JD
Department of Anesthesiology
University of California, San Diego School of Medicine
San Diego, California

San Diego Center for Patient Safety
University of California, San Diego School of Medicine
San Diego, California

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