restorative materials after minamata: what will be left? (gottfried schmalz)

Science Committee Forum / World Oral Health Forum

Are you ready for amalgam phase-down?

How the Minamata Convention impacts your Dental Practice

G. Schmalz

Department of Operative Dentistry and PeriodontologyUniversity of Regensburg, Germany

School of Dental Medicine (ZMK Bern) University of Bern, Switzerland

Restorative materials after Minamata: What will be left?

Rest. Mat. after Minamata

• What does phase down mean?– Amalgam still available– Certain provisions

• “Alternatives”• Existing alternatives


• What are alternatives?– Different materials– But also– Different approaches

Phase down by diversification?


• Selection: Extent of cavitation

Intens. prevention/Monitoring

infiltration/fissure sealant

fillings/Inlays (?)

fillings (partial) crowns

(partial) crowns

fillings crowns

Preventive measures

ICDAS 1/2 ICDAS 3/4 decidous

ICDAS 3 permanent

ICDAS 4 permanent

ICDAS 4 permanent

Non- Invasive Invasive


• Selection: Extent and site

Intens. prevention/Monitoring

infiltration/fissure sealant

fillings/Inlays (?)

fillings (partial) crowns

(partial) crowns

fillings crowns

Preventive measures

ICDAS 1/2 ICDAS 3/4 decidous

ICDAS 3 permanent

ICDAS 4 permanent

ICDAS 4 permanent

Non- Invasive Invasive

Class I and II


• Selection: BiologyAmalgam Resin based material

Glass iono-mer cements

Release/Ex posure

+ + + (F-, Al3+)

Resorption + + ?

Biologic reaction

Systemic - (claimed) - (BPA ?) -**

Local + (seldom) + + (p cap)

Allergic + (seldom) + - (very seld)

CMR - - ? -

Excretion + + +

Environ-ment + (handled) ? -

No general rankingCase by case


• Selection: EU Report 2015– The safety of dental amalgam and alternative

dental restoration materials for patients and users

– Summary • current evidence does not preclude the use of either

amalgam or alternative materials. • Existing Alternatives

– The alternative materials also have clinical limitations and toxicological hazards.

– Cytotoxic, mutagenic, allergies – Informations on the tox profile of alternative

materials and clinical data on possible adverseeffects of alternatives are very limited.

SCENIHR 2015


• Selection: EU Report 2015– The safety of dental amalgam and alternative

dental restoration materials for patients and users

– Summary • current evidence does not preclude the use of either

amalgam or alternative materials. • The choice of material should be based on• patient characteristics

– Pregnancy– Allergies– Impaired renal clearance

SCENIHR 2015


• Selection: EU Report 2015– Primary or permanent teeth

– CasaPia Study* (USA/Portugal) NewEngland Study** (USA) amalgam vs composite in primary teeth

– No difference neurological markers– Amalgam better longevity

– EU-Report 2015– Longevity in primary teeth may be of less concern than in

permanent teeth

To reduce the use of mercury-added products in line with the intentions of the Minamata Convention (reduction of mercury in the environment) it can be recommended that for primary teeth alternative materials to amalgam should be the first choice.

*DeRouen et al. JAMA April 2006**Bellinger et al.,. JAMA April 2006

but stays available …


• Selection: Longevity– Group 1: Studies 1990 to 2003; primary teeth

• Annual failure rates: all studies• Only GIC ss different, the rest in same homogeneous

subset

Hickel et al., Am J Dent 2005

0

2

4

6

8

10

12

14

Frencken, J. et al. 2014

≠


• Selection: Longevity– Group 2: external evaluation of longevity studies

from a non-dentist group • Data from 1996 to 2006, Median survival time

(Antony et al. GMS Health Technology Assessment 2008 Open Access)

50 100 150 years

Composite

Amalgamclinicpractice

clinicpractice

11.4 to 150

7.1 to 44.7

8.0 to 44.4

16


• Selection: Longevity– Group 3: recent RCT trials (Casa Pia)

Bernardo, M et al. (DeRouen), JADA 2007


• Selection: Longevity– Group 3: recent RCT trials (Netherlands)

• 1949 large class II restorations (1202 amalgam/747 composite).

• After 12 years• 293 amalgams and 114 composites failed. • Composites: higher survival in the combined population

and in the low caries risk group. • Amalgam: higher survival rate for three-surface

restorations in high caries risk patients

Opdam et al., 12 year survival of composite vs amalgam restorations, J Dent Res 2010


• Selection: Longevity– Within alternative materials?

• Composites* (RMGI)• GIC (only single surface)**

*Schwendicke 2016**Frencken et al., 2012


• Selection: Economics– Sweden Social health care system

• Initial costs: – 1 Amalgam– 1.25 Composite– O.6 Glass ionomer

• Costs per year of function– 1 Amalgam– 2.5 Composite– 1.8 Glass ionomer

Sjögren & Halling, 2002


• Selection: Economics– UK Wales– Composite was between

• 1.7 and 3.5 more expensive than amalgam• To generate one tooth year

Chadwick et al., Qual Health Care, 1999


• Selection: Economics– Norway

2012


• Selection: Economics– Summary

Amalgam Composite Glass Ionomer

Indirect CAD/CAM

Indirect classical

+ ++ +? +++ ++++


• Selection: Summary• ISDAS 0 – 2: non invasive• Pregnants emergency treatment

Glass ionomer• Allergies not in allergic patients• Red. renal clearance no amalgam• Deciduous teeth amalgam not 1st choice• Economics amalgam 1st choice• General Alternatives not without

toxicological hazards

Rest. Mat. after Minamata• Conclusions

– Is possible in a number of cases– (very) expensive, open tox questions– Existing alternatives are no replacement– Research needed: existing and new materials


Rest. Mat. after Minamata• Conclusions

– Is possible in a number of cases– (very) expensive, open tox questions – Existing alternatives are no replacement– Research needed: existing and new materials


Thank you

restorative materials after minamata: what will be left? (gottfried schmalz)

Healthcare