After careful evaluation of all the selected full-text, only six RCT were included in this review. The I2 test describing the heterogeneity-linked percentage of total variation across studies was considered as measure of heterogeneity, following the subsequent scheme:(i)0–40%: might not be important(ii)30–60%: may represent moderate heterogeneity(iii)50–90%: may represent substantial heterogeneity(iv)75–100%: considerable heterogeneity [21]. in 1997 reported that some antibiotic resistant bacteria could also be mercury-resistant [40]; it has been, moreover, considered that genes linked with antibiotic resistance are susceptible to be transferred [41]. The only study included in the review that dealt about an adult population was written by Halbach et al. mercury. Mercury is a highly toxic heavy metal and the mental, physical and emotional effects of mercury on the body have been well documented and known for centuries. Forest plot of comparison for urinary mercury concentration after 5 years of exposure to dental amalgam or composite resin in children. The authors designed a detailed protocol following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement [19]. Two authors (FG and AC) dealt with the screening of the studies independently and in duplicate. Amalgam tattoo (AT),”, V. C. Galletta, G. Artico, A. M. C. Dal Vechio, C. A. Lemos Jr., and D. A. Migliari, “Tatuagem extensa por amálgama em mucosa gêngivo-alveolar,”, H. Amano, A. Tamura, M. Yasuda et al., “Amalgam tattoo of the oral mucosa mimics malignant melanoma,”, K. S. Staines and D. Wray, “Amalgam-tattoo-associated oral lichenoid lesion,”, V. Aggarwal, A. Jain, and D. Kabi, “Oral lichenoid reaction associated with tin component of amalgam restorations: a case report,”, B. Kabi, M. Pemberton, E. D. Theaker, J. Such checklist was administered to a parent at baseline prior to dental treatment and 5 years later, at the completion of the trial. A wide variety of symptoms is attributed to toxicity resulting from mercury amalgam. 1986 Jan-Dec;6(1-4):297-309. doi: 10.1515/reveh.1986.6.1-4.297. The authors decided to conduct the systematic review by including only RCTs since they are considered as having high strength of evidence. To ensure safe and sustainable outcomes in any dental procedure, it is a good idea to select a dentist who offers mercury safe dental treatments in Anderson SC. The study lasted approximately 18 months during which in each of the groups analysed, it was noted a decline of the total mercury levels in erythrocytes and then an early in the composite resin group or late increase in the dental amalgam group. eCollection 2020. For this reason, the design of longer RCTs for assessing various types of adverse effects linked to the use of dental amalgam is strongly suggested. Rojas M, Guevara H, Rincón R, Rodríguez M, Olivet C. Rev Environ Health. 2 . Literally amalgam means “mixed with mercury,” and in dental terms, this is true because the composition of the ones used in fillings is formed by 50% Mercury (Hg) and other metals as silver, copper, zinc and tin, that when mixed it hardens in a few minutes at room temperature. Its indisputable advantages in the treatment of very young patients and in those suffering from systemic syndromes that compromise their collaboration make it a material that can still have a fair use in dental clinical practice. Results. Methods. Moreover, it has to be reported that some authors published cases of burning mouth syndrome and orofacial granulomatosis arisen in patients previously treated with dental amalgam [63, 64]. Colorado dentist Hal Huggins has devoted his life to trying to share this information about mercury toxicity. Mercury is a type of toxic metal that comes in different forms within the environment. MERCURY HAZARDS AND TOXICITY Under the guidance of : Dept of conservative dentistry and endodontics NORTH BENGAL DENTAL COLLEGE AND HOSPITAL. Agreement level between reviewers was evaluated through Cohen’s kappa coefficient (k). Study characteristics are reported in Table 2. So all data of the single trials were entered into the TSA software; the alpha error was set at 0.05 and the beta error at 20%. Despite these very conflicting opinions, in July 2018, the European Union (EU) started a global expiring one year policy for reducing the use of amalgam for dental treatment of children under 15 years and of pregnant or breastfeeding women unless deemed strictly necessary by the dental practitioner on the ground of specific medical needs of the patient [17]. Mercury in dental amalgams is released in the form of vapor and can be inhaled and absorbed by the lungs. COVID-19 is an emerging, rapidly evolving situation. Keywords: According to the ongoing controversy over the safety of dental amalgam, the authors conducted a systematic review with meta-analysis and trial sequential analysis to investigate the effect of the exposure to Hg in adults and children with and without dental amalgam fillings measuring the Hg concentration in various biological fluids (urine, hair, blood, and saliva) in order to assess their reliability as biomarkers of Hg exposure from dental amalgam fillings. One of the most investigated topics was antibiotic resistance. A comprehensive systematic literature search was performed in four databases (Ovid via PubMed, Web of Science, Scopus, and CENTRAL) by two calibrated examiners (FG and AC). For children belonging to the CPSST, the urinary mercury analyses were performed with continuous cold-flow, cold-vapour atomic spectrofluorometry and a PSA Merlin mercury analysis (Questron Corp, Mercerville, NJ) [32, 34]. However, if you have symptoms which may be mercury-related, then you should get your fillings changed by a dentist specialising in mercury-free dentistry. In case of a not-negligible heterogeneity (>50%) among studies, a random-effects model was used. Adult population considered in the present review was the one presented by the RCT of Halbach et al. Where can I find a dentist trained in these techniques? An author supervisor (RP) was consulted in case of disagreement. Even if the result of the meta-analysis was found not to be significant, the adjunctive TSA revealed that such nonsignificance was not due to a hypothetical equivalency between the two interventions but rather to a lack of statistical power. Also neurological and social-behavioural effects were evaluated as secondary outcomes. From the initial 2555 results, only 6 publications were included in the review: five were considered as having high risk of bias, whereas one as having moderate risk. The WISC-III was administered 3 times: at baseline prior to caries restoration and 3 and 5 years after baseline. In NECAT also the social-behavioural outcomes contained into the Child Behaviour Checklist (CBCL) were analysed [39]. Many evidences, however, report that restorations made with composite resins do not have the same duration over time as those made in amalgam and they have a higher incidence of failures and relapses and higher costs and that the treatment’s success is greatly influenced by the operator’s experience [3–5]. Anyway, starting from the first year of experimentation, mercury urinary levels were found to be significantly higher in the amalgam group ( < 0.001). The primary outcome was the Hg concentration in biological fluids (urine, hair, blood, and saliva) with the aim of assessing their reliability as biomarkers of Hg exposure. (1)Case report, case series, any type of observational studies, letters, and narrative or systematic reviews(2)Studies published before January 1995(3)Grey literature(4)In vitro studies(5)Animal studies(6)Studies conducted on nonhealthy subjects in the enrolment phase(7)Studies with less than 1 year of follow-up. Anyway, all the scores of the amalgam group increased more than the ones of the resin composite group. Read More . HHS 2020 Oct 8;18(2):1655-1669. doi: 10.1007/s40201-020-00558-w. eCollection 2020 Dec. Attiya N, Fattahi R, El-Haidani A, Lahrach N, Amarouch MY, Filali-Zegzouti Y. Pan Afr Med J. Nevertheless, the results of such investigations gave controversial results [15, 42]. Sign up here as a reviewer to help fast-track new submissions. All dental examinations and procedures took place only in university dental clinics [32–34] or also in community-based ones [24, 35, 36]. Such evaluation was conducted using the Cochrane collaboration tool for assessing the risk of bias. The increase of mercury concentrations in breast milk, umbilical cord, and amniotic fluid was found to be statistically significant in the majority of publication reports about this topic [45–49], whereas controversial results have been published regarding the hypothetical influence of dental amalgam on the onset of mental disorders (mainly Parkinson and Alzheimer disease) [50–52] and of lichen planus and associated lesions [53–55]. Because of the different appearance of the materials to be evaluated in the trials, participants could not be blinded; for this reason, the reviewers decided to exclude participants’ blindness from the judgment regarding the performance bias. NLM Methodological quality of trials was also analysed for the purposes of the TSA, and one study was considered as at low risk of bias [24], while the other one included in the analysis was considered as at high risk [32]. An adjunctive analysis was performed independently by two reviewers (FG and AC) regarding the overall quality of evidence at the outcome level using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. 2020, Article ID 8857238, 12 pages, 2020. https://doi.org/10.1155/2020/8857238, 1Department of Head, Neck and Sense Organs, School of Dentistry, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, 00168 Rome, Italy, 2Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples “Federico II”, 80125 Napoli, Italy, 3Institute of Dentistry, I. M. Sechenov First Moscow State Medical University, Moscow 119146, Russia. Dental amalgam is a liquid mercury and metal alloy mixture mainly used in dentistry to fill cavities produced by the treatment of dental caries. Studies indicate that chronic exposure to mercury, even at low levels, can cause the following: Cardiovascular conditions. Following the PICO format, a focused question was also developed: “Can the use of dental amalgam in restorative dentistry in children or adults cause neurotoxicity, nephrotoxicity, or an increase in mercury percentage in blood when compared with composite resin?”. The mercury contained in the amalgam leaches out as a vapour into your body for the lifetime of the filling. This site needs JavaScript to work properly. Chronic low-level mercury exposure, BDNF polymorphism, and associations with self-reported symptoms and mood. reported data belonging to the two areas [24]. Even though the mercury is still doing systemic, physiological damage, the patient may not be showing signs or symptoms. Nine studies were excluded after full-text evaluation; their references are listed in the excluded studies table along with rationale for exclusion (Table 1). Children were evaluated comparing data at baseline and 5 years later. The meta-analysis was conducted with a fixed-effects model comparing mean differences and standard deviations in case of continuous data. Call (864) 224-7812 Number of studies according to meta-analysis, P. H. Keyes, “Recent advances in dental research: bacteriology,”, B. H. Clarkson, “Introduction to cariology,”, V. Moraschini, C. K. Fai, R. M. Alto, and G. O. dos Santos, “Amalgam and resin composite longevity of posterior restorations: a systematic review and meta-analysis,”, D. Hurst, “Amalgam or composite fillings—which material lasts longer?”. RCT = randomized controlled trial; M = male; F = female; Hg = mercury; IQ = intelligence quotient; NA = not available; CBCL = Child Behaviour Checklist; BASC = behaviour assessment system for children; NHS = neurological hard sign; NSS = neurological soft sign; WBC = white blood count. Biological Periodontal Therapy; Safe Removal of Mercury Amalgam Fillings; ... Mercury Toxicity. Instead it’s simply being “phased out” of use in dentistry by legislators in most Westernised countries! Another limitation of the present review has to be pointed out: even if generally RCTs are considered “gold standard” for clinical research, they may not be long enough to assess the long-term effect of an intervention such as detection of long-term adverse effects after chronic exposure. Such intervention can be considered a step forward to line up with the previous “Minamata Convention on Mercury,” an international treaty that aimed at protecting human health environment from emissions and releases of mercury and its compounds [18]. Mercury poisoning symptoms can arise from dental amalgam mercury fillings, also called silver fillings, as they continuously release mercury vapor. Our Nashville practice offers mercury-free fillings at the Centre for Holistic and Biological Dentistry. A manual search was conducted on European Journal of Oral Sciences, Journal of Oral Pathology and Medicine, British Dental Journal, Clinical Oral Investigations, Gerodontology, Journal of Dental Research, and Dental Materials analysing all available RCTs published between January 1995 and March 2020. in 2008 [36]. In the article by Shenker et al., reporting analysis of data gathered from a subgroup of children enrolled in the NECAT, immunological parameters were evaluated: white blood cell enumeration, assessment of T- and B-cell responsiveness, and analysis of neutrophil and monocyte responsiveness. Even if the meta-analysis has drawn conclusions from RCT that should be considered as the best evidence in scientific literature, data regarding the level of urinary mercury in children after 5 years of restoring dental caries with dental amalgam or composite resin were considered to have only moderate strength of evidence because of the high heterogeneity among studies and the presence of one study assessed as having high risk of bias.  |  (7) L.Kantor et al,"Mercury vapor in the dental office-does carpeting make a difference? Peadiatric participants were enrolled if they needed a conservative caries treatment; they were divided in two treatment arms: dental amalgam arm if the lesion was restored with amalgam and composite resin arm if restoration was carried out with composite resin material. Since only values regarding the urinary levels of mercury were homogenously reported in publications showing data from NECAT and CPSST, the authors decided to carry out a quantitative analysis only regarding that data. Indeed, most of the evidence supporting the thesis of a link between oral mucosal reactions and dental amalgam are based on case reports [56–62]. The articles reported data about the Hg concentration in urine, hair, and blood [32, 33], and some reported neurological and social-behavioural effects of amalgam restorations [34, 35], whereas Bellinger et al. Print this Checklist to take with you to your next dental appointment. What health problems are related to the exposure of toxins such as those in Mercury fillings? Find a mercury-free dentist in your area here. Qualitative analysis was carried out about the other data. The Beneficial and Debilitating Effects of Environmental and Microbial Toxins, Drugs, Organic Solvents and Heavy Metals on the Onset and Progression of Multiple Sclerosis. Calculations, using a conservative approach, demonstrate that vaccinations of infants exposed them to concentrations of thimerosal that could biologically injure them, especially if they were exceptionally susceptible to mercury toxicity due to genetic predisposition, other concurrent toxic exposures (e.g. Results about functionality of T-cells and monocytes revealed a decline at 5–7 days after treatment if compared with the composite group, even if not significant. For this reason, a quantitative analysis was possible only for the data reported homogenously in at least two studies. Conclusions. Dental amalgams were first documented in a Tang Dynasty medical text written by Su Gong (苏恭) in 659, and appeared in Germany in 1528. Urinary mercury was measured also in children belonging to the NECAT with the help of an immunochemical nephelometric method from Beckman Coulter (Fullerton, Calif). In the 18th and 19th centuries, hatters would use mercury compounds in order to manufacture felt. Copyright © 2020 Romeo Patini et al. To prevent additional mercury exposure, patients should inquire about the amalgam removal protocols: IAOMT Protocols for Mercury Filling Removal. in 2006 presented data regarding mercury levels in urine and hair and about three neuropsychological outcomes (WISC-III full-scale IQ, general memory index, and visuomotor composite) in 534 children [24]. Composite resins are a material, which guarantee a much better aesthetic result than dental amalgam. INTRODUCTION • Mercury is a known toxic , bio accumulative substance and it often finds its way into body through dental amalgams, which is used to restore cavitated tooth. Randomization of patients was performed stratifying them according to the total number of tooth surfaces filled with amalgam (1–12, 13–18, and 19–25 surfaces) within each group. Unfortunately, Mercury toxicity can cause significant problems in any tissue that gets in its way. Dr Lorscheider's view was that if you are relatively well, then just go ahead and get the fillings replaced by your usual dentist. Special designed data extraction forms were used for this purpose. All available randomized controlled trials (RCT) published from January 1995 to March 2020 conducted on humans were selected. The statistical analyses carried out in the present systematic review demonstrate the absence of sufficient evidence to ban the use of dental amalgam for caries conservative treatments both in adults and in children. Hg exposure from dental work may also induce various chronic conditions such as elevation of amyloid protein expression, deterioration of microtubules and increase or inhibition of transmitter release at motor nerve terminal endings. Two reviewers (AC and FG) independently and in duplicate screened 2308 articles as results of the elimination of 247 duplicates. This was a 7-year trial starting in January 1997, which enrolled children aged 8–10 years during the recruitment phase. Eighty-three patients were lost before the assessment of the neuropsychological outcomes and additional 42 patients before the mercury urinary check-up (39 and 20 for the amalgam group and 44 and 22 for the composite group, respectively). Subsequent research showed that the exposure time of these factors also plays a crucial role [2]. All children belonged to the New England Children’s Amalgam Trial (NECAT) and to the Casa Pia School System Trial (CPSST). in 2008 investigated some neurological parameters in the population that made up the sample of the CPSST [34]. Your Dental Amalgams and Mercury Toxicity Symptoms. to lead, elemental mercury, cadmium, etc.) The meta-analysis of the two included trials (one assessed as having high risk of bias and the other one as having moderate risk) analysed data of 859 patients and did not find evidence to determine that dental amalgam restorations in children increased the urinary mercury levels after 5 years of observation (mean difference: 0.77 μg/g; 95% CI: −0.21 to 1.75 ( value: 0.12), heterogeneity: Chi2 = 15.47, df = 1 ( value: < 0.0001); I2: 94%) (Figure 4). Unfortunately, the fact that all the enrolled studies took place before the growing containment measures against the use of amalgam demonstrates on the one hand that such measures were probably taken without correctly assessing the strength of evidence of scientific publications and on the other hand that it will be very difficult to achieve statistically significant sample numbers in the future. 2020 Jun 19;36:110. doi: 10.11604/pamj.2020.36.110.19623. With the aim of highlighting any relationship between dental amalgam and neurotoxicity and nephrotoxicity, the authors defined as primary outcome the Hg concentration in various biological fluids (urine, hair, blood, and saliva). In 2006, DeRouen et al. Biological Dentistry. Apr 07 2016 . Table showing references of excluded studies after full-text evaluation with rationale for exclusion. 2. CPSST’s children were also evaluated about the presence of neurological hard signs (NHSs) and soft signs (NSSs). In the 1800s, amalgam became the dental restorative material of choice due to its low cost, ease of application, strength, and durability. The risk of bias was assessed through the Cochrane Collaboration tool and the overall quality of evidence through the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. Inclusion criteria were absence of any prosthetic rehabilitation or unsuccessful endodontic treatment and general health status. The publications investigated eventual nephrotoxicity or neurotoxicity of dental amalgam restorations in children. Toxicol Sci. In fact, Wireman et al. Analyses were carried out at baseline (patients enrolment), 7 days, and 6, 12, and 60 months after the enrolment [36]. The authors declared a significant dropout rate since 55 patients did not complete the study through the first 5 years, and additional 96 were lost in the last two years. The search strategy reported above was designed for MEDLINE PubMed and then adapted to the other three databases. Title and abstract analysis led to the elimination of 2293 articles, so 15 results were selected for full-text analysis. Romeo Patini, Gianrico Spagnuolo, Federica Guglielmi, Edoardo Staderini, Michele Simeone, Andrea Camodeca, Patrizia Gallenzi, "Clinical Effects of Mercury in Conservative Dentistry: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials", International Journal of Dentistry, vol. Mercury toxicity is a concern in dentistry because mercury and its chemical compounds are toxic to the kidneys and the central nervous system. Mercury forms various compounds, well known for their toxicity … While on the one hand, in fact, composite resins can provide a better aesthetic result; on the other hand, they need an absolutely dry and bloodless environment to guarantee a correct marginal seal. Urine mercury levels and associated symptoms in dental personnel. GRADE summary of findings for meta-analysis on urinary mercury concentration after 5 years of exposure to dental amalgam or composite resin in children. Low-copper amalgam commonly consists of mercury (50%), silver (~22–32%), tin (~14%), zinc (~8%) and other trace metals.. Mercury Poisoning Symptoms and Dental Amalgam Fillings. He found that when he removed the fillings of people who were very ill, many of them recovered from a variety of medical conditions, including rheumatoid arthritis and neurological impairments like Parkinson’s disease and amyotrophic lateral sclerosis (ALS). in 1992, mercury could interfere with heme synthesis, thus causing the presence of urinary coproporphyrin [43]. Dental caries is a progressive disease affecting the hard tissues of the tooth that originates from its surface and that could proceed until involving the dental pulp with an inflammatory process. A. Bergdahl, L.-E. Bratteby et al., “Mercury and selenium in whole blood and serum in relation to fish consumption and amalgam fillings in adolescents,”, D. C. Bellinger, D. Daniel, F. Trachtenberg, M. Tavares, and S. McKinlay, “Dental amalgam restorations and children’s neuropsychological function: the New England Children’s Amalgam Trial,”, D. C. McKinlay, F. Trachtenberg, L. Barregard et al., “Neuropsychological and renal effects of dental amalgam in children,”, A. McKinlay and M. Molin, “Mercury levels in plasma and urine after removal of all amalgam restorations: the effect of using rubber dams,”, J. Molin, T. Haraldson, B. Meding, E. Yontchev, S.-C. Öhman, and J. Ottosson, “Potential side effects of dental amalgam restorations,”, P. Herrström, B. Högstedt, S. Aronson, A. Holmén, and L. Rastam, “Acute glomerulonephritis, Henoch-Schönlein purpura and dental amalgam in Swedish children: a case-control study,”, J. Råstam, T. Leistevuo, H. Helenius et al., “Dental amalgam fillings and the amount of organic mercury in human saliva,”, M. Levy, S. Schwartz, M. Dijak, J.-P. Weber, R. Tardif, and F. Rouah, “Childhood urine mercury excretion: dental amalgam and fish consumption as exposure factors,”, A. Rouah, M. Wilhelm, U. Rostek et al., “Mercury concentrations in urine, scalp hair, and saliva in children from Germany,”, J. S. Woods, M. D. Martin, B. G. Leroux et al., “The contribution of dental amalgam to urinary mercury excretion in children,”, T. A. DeRouen, M. D. Martin, and B. G. Leroux, “Neurobehavioral effects of dental amalgam in children,”, S. Halbach, S. Vogt, W. Köhler et al., “Blood and urine mercury levels in adult amalgam patients of a randomized controlled trial: interaction of Hg species in erythrocytes,”, M. Lauterbach, I. P. Martins, A. Castro-Caldas et al., “Neurological outcomes in children with and without amalgam-related mercury exposure,”, D. C. Bellinger, F. Trachtenberg, A. Zhang, M. Tavares, D. Daniel, and S. McKinlay, “Dental amalgam and psychosocial status: the New England Children’s Amalgam Trial,”, B. J. McKinlay, N. N. Maserejian, A. Zhang, and S. McKinlay, “Immune function effects of dental amalgam in children,”, J. E. Peters, J. S. Romine, and R. A. Dykman, “A special neurological examination of children with learning disabilities,”, J. Wireman, C. A. Liebert, T. Smith, and A. O. Summers, “Association of mercury resistance with antibiotic resistance in the gram-negative fecal bacteria of primates,”, M. C. Roberts, “Antibiotic resistance in oral/respiratory bacteria,”, R. Pike, V. Lucas, A. Petrie et al., “Effect of restoration of children’s teeth with mercury amalgam on the prevalence of mercury- and antibiotic-resistant oral bacteria,”, M. A. Bowers, L. D. Aicher, H. A. Davis, and J. S. Woods, “Quantitative determination of porphyrins in rat and human urine and evaluation of urinary urinaryporphyrin profiles during mercury and lead exposures,”, D. A. Geier, T. Carmody, J. K. Kern, P. G. King, and M. R. Geier, “A significant relationship between mercury exposure from dental amalgams and urinary porphyrins: a further assessment of the Casa Pia children’s dental amalgam trial,”, M. Barghi, R. D. Behrooz, A. Esmaili-Sari, and S. M. Ghasempouri, “Mercury exposure assessment in Iranian pregnant women’s hair with respect to diet, amalgam filling, and lactation,”, L. Palkovicova, M. Ursinyova, V. Masanova, Z. Yu, and I. Hertz-Picciotto, “Maternal amalgam dental fillings as the source of mercury exposure in developing fetus and newborn,”, P. F. Luglie, G. Campus, G. Chessa et al., “Effect of amalgam fillings on the mercury concentration in human amniotic fluid,”, S. L. d. Costa, O. Malm, and J. G. Dórea, “Breast-milk mercury concentrations and amalgam surface in mothers from Brasília, Brazil,”, G. Drasch, S. Aigner, G. Roider, E. Staiger, and G. Lipowsky, “Mercury in human colostrum and early breast milk.