International Academy of Oral Medicine and
Protocol for Mercury/Silver Filling Removal
First in every concerned doctor's mind is the protection of the
patient from additional exposure to mercury. This is
especially true of
the mercury-toxic patient. The mercury-toxic patient may have been
exposed to varying amounts of mercury from diet, environment,
employment or from mercury/silver dental fillings. All forms
are cumulative and can contribute to the body burden. The goal of
this preferred procedure is to minimize any additional exposure of
the patient, ourselves, or staff to mercury.
During chewing the patient is exposed to intraoral levels which
several times the EPA allowable air concentration. During
the removal or placement of amalgam the patient can be exposed to
amounts which are a thousand times greater than the EPA allowable
concentration. Once the drill touches the filling,
temperature increases, immediately vaporizing the mercury component
of the alloy. There are 8 steps to greatly reducing everyone's
Step one Keep the fillings cool
1) All removal must be
done under cold water spray with copious
amounts of water. Once the removal has begun, the mercury
will be continuously released from the tooth.
2) Therefore, A high
volume evacuator tip should be kept near the
(1/2 inch) at all times to evacuate this vapour from the
of the patient. Polishing amalgam can create very
dangerous levels of mercury and should be avoided especially
mercury toxic patient.
3) All patients having
amalgam removed or placed should be provided with an alternative
air source and instructed to not breathe
through their mouth during treatment. A nasal hood such as
with the nitrous oxide analgesia equipment is excellent.
is best and oxygen is acceptable although not required. If
air is used it should be clean and free of mercury vapour
preferably from outside the dental office.
4) Particles of mercury
alloy should be washed and vacuumed away as soon as they are
generated. The filling should be sectioned and
removed in large pieces to reduce exposure.
present the International Academy of Oral Medicine and
Toxicology (IAOMT) has approved removal both with and without
use of a rubber dam. Some evidence exists to support both
since high levels of mercury and amalgam particles can
found under the dam. All members are agreed that whether or
rubber dam is used, the patient should be instructed to
breathe through their mouth or swallow the particles.
experts feel that it is better to remove the amalgam first
then apply the dam, if needed, for restorative procedures.
5) After the fillings
have been removed, take off the rubber dam
one was used and lavage the patients mouth for at least 30
seconds with cold water and vacuum. Remove your gloves and
replace them with a new pair. If a restorative procedure is
then reapply a new dam and proceed.
6) Immediately change
patients protective wear and clean their face.
7) Consider appropriate
nutritional support before, during and
8) Install room air
purifiers or ionizers and fans for everyone's
OSHA [4,5] requires
that employees be given written informed consent before the use of
any toxic chemicals, of which mercury is one. Elemental
mercury vapor is one of the most toxic forms of mercury and should
not breathed. Women of child bearing age should be exposed
to no more than 10% of the OSHA MAC . Women who are
pregnant should be exposed to no mercury. If you use
mercury or remove mercury in any form, the National Institute of
Occupational Safety and Health (NIOSH) has recommended that your
employees be medically monitored annually.
9) Any mercury exposure
requires that the employee wear an approved mercury filter
mask. An approved mask is appropriate for
wearing during all dental procedures which will expose you or
staff to mercury.
The manner in which dentists operate their equipment dramatically
affects the amount of mercury released. Never drill on mercury
It is hazardous to you, your staff, and your patient. Levels as
4000 mg/M3 have been measured 18" from the drill when using
high dry. Levels over 1000 mg/M3 are measurable upon opening an
amalgam mixing capsule.
One out of 7 Californian dental offices tested over the OSHA TWA
safety limit of
50 mg/M3. 100% of the vacuum cleaner exhaust tested over
100 mg/M3. Any office where mercury is used should be
tested regularly and staff should be monitored for exposure.
Testing services are available and a mercury sensor badge is
available for personnel monitoring. They should test inside
storage areas and along baseboards, where mercury might have
dropped. Office spills can go undetected for years and are
 IAOMT Standards of Care Preferred Procedure Approved 9/27/92
 EPA United States Environmental Protection Agency Office of
Assessment Mercury health effects update Final
EPA-600/8-84-019F 1971 EPA
 Cooley RL, Barkmeier WW: Mercury vapour emitted during
ultraspeed cutting of amalgam. J Indiana Dent Assoc
 OSHA Job Health Series: Mercury.(2234)8/1975
 Hazard Communication Program Federal Register/ Vol. 52. No. 163
Monday, August 24, 1987
 OSHA MAC is Threshold Limit Value of 100 micrograms/ cubic meter
100 PPM This is a
never to be exceeded standard.
 Koos BJ and Lango LD , Mercury Toxicity in the pregnant woman,
foetus, and newborn
infant. A review Am J Obstetrics and Gynaecology, 126(3):390-409, 1976
 Mine Safety Association high levels and 3M mercury dust mask
a) Patient Preparation for Amalgam Removal
AMALGAM REMOVAL PREPARATION WARNING:
When the body is exposed to amalgam mercury it has an on-going
need for detoxification and healing processes. If you have a
medical condition, then hormones and enzymes the body needs to
heal have likely been depleted by this on-going detoxification and
healing process. So before your amalgam restorations are removed,
blood testing should be performed to determine what hormones and
enzymes are deficient. Based on the blood test results a medical
doctor can evaluate what nutritional and hormonal supplements are
needed to prepare the body. After amalgams are removed, the
healing usually accelerates, so there will be an even greater
demand for the hormones and enzymes that were depleted. So a
patient with a medical condition should take nutritional and
hormonal supplements before, during and after amalgam removal.
b) Dental Procedures for Patient Protection
During Amalgam Removal
IAOMT Standards of Care, Preferred Procedure,
"Reducing Mercury Vapor Exposure for the Patient During
Amalgam Removal." (September 1992)
The IAOMT has currently established the following
amalgam removal protocols. If these protocols are followed, the
amount of mercury released into the body during amalgam removal is
Place a rubber dam around the tooth to isolate
it from the body.
Provide an alternative source of air to the
Place a saliva ejector under the dam to remove
mercury vapour that penetrates the latex.
Use high volume evacuation with isolate
Section amalgams and remove in as large pieces
Remove and properly dispose of rubber dam and
mercury after amalgam removal.
Other amalgam removal precautions in addition to
the protocols listed above include:
Remove no more than two amalgams per
Time amalgam removal appointments at least one
Administer intravenous Vitamin C before
removal (Hg has a greater affinity to Vitamin C that is
present in the blood than it does for body tissue).
Do not remove amalgams from a pregnant woman.
Further information pertaining to proper amalgam
removal can be found on the web page:
c) Amalgam Removal without Patient Protection
This study measures the mercury level when
amalgams are removed not following the protocols presented above.
Molin, M., Bergman B., Marklund, S.L.,
Schutz, A., Skerfving, S., "Mercury, Selenium, and
Glutathione Peroxidase Before and After Amalgam Removal in
Man" Acta Odontal Scandinavia; 48:189-202. Oslo. ISSN
ABSTRACT: In 10 healthy persons all
amalgam fillings were replaced with gold inlays. Blood and urinary
levels were measured on 10 occasions during a 4-month period
before and a 12-month period after amalgam removal. These
variables were also measured three times in 10 healthy controls. A
strong statistically significant relation was found between plasma
mercury values and both the total number of amalgam surfaces
(r=0.71, p=0.0006) and the total surface area of the fillings
(r=0.73, p=0.004). In the immediate post removal phase plasma
mercury rose by three- to four-fold, whereas the urinary and
erythrocyte mercury rose about 50%. These peak values declined to
the pre-removal level at about 1 month after removal. Twelve
months after the removal plasma and urinary mercury levels were
reduced to 50% and 25%, respectively, of the initial values for
the experimental group. Apart from the significantly lower plasma
selenium values 5 and 10 days after removal no significant
differences were found with regard to plasma selenium or
erythrocyte glutathione peroxidase either within or between the
experimental and the control groups. A large number of
supplementary biochemical analyses did not show any influence on
organ functions or any differences between the groups before or
after the amalgam removal. Amalgam fillings considerably
contributed to the plasma and urinary mercury levels.
d) Amalgam Removal with Patient Protection
This study measures the mercury level when
amalgams are removed when not following the IAOMT protocols presented
Molin, M., Berglund, J.R., Mackert, J.R., "Kinetics
of Mercury in Blood and Urine after Amalgam Removal."
J. Dental Research, 74:420,IADR abstract 159, (1995).
Even through a number of
studies have not been able to reveal any correlation between
subjective symptoms and amalgam load, there are still speculations
as to whether patients with subjective symptoms related by the patients
themselves to their amalgam fillings could have a changed pattern
of elimination of mercury. The aim of the present investigation
was to study the elimination half-time of mercury in plasma,
erythrocytes and urine over an extended period of time after
amalgam removal in a group of 10 patients with subjective symptoms
by the patients themselves referred to their amalgam fillings and
a group of 8 healthy subjects. The average number of occlusal and
total amalgam surfaces in the patient group were 13.0 (range 4-20)
and 44.4 (range 24-68), respectively. Corresponding figures in the
control group were 12.9 (range 10-16) and 40.9 (range 24-63).
The amalgam removal using rubber dam, water spray
cutting and high volume vacuum evacuator, was carried out at one
and the same time. Blood and urine samples were collected at two
occasions before the amalgam removal, then blood was collected at
thirty two occasions and urine at forty three occasions during the
following year. The mercury content was analyzed by CVAAS
The measured P-, Ery- and U-Hg concentrations
before amalgam removal were slightly higher in the control group
(6.43.3 nmol/L, 19.46.6 nmol/L, and 2.71.3 nmol/nmol) creatinine
respectively than in the symptom group (5.61.8 nmol/L, 14.88.8
nmol/L, and 1.60.9 nmol/nmol) creatinine respectively.
The Hg-concentrations did not significantly
increase in the two groups after amalgam removal. Six days after
the removal the plasma mean concentration was significantly
decreased at P level and ten days after the decrease was at a
permanent P level. The mean Ery-Hg level was significantly
decreased after eleven days (p), a level that remained stable for
the rest of the year. The mean U-Hg level was significantly
decreased to one month after the removal and after six months the
mean level was reduced with 80 % compared to the initial level in
The conclusion to be drawn for the present study
is that the symptom group did not have a changed pattern of
elimination of mercury compared to the healthy group.
Begerow, J., Zander, D., Freier, I.,
Dunemann, L. "Long-Term Mercury Excretion in Urine After
Removal of Amalgam Fillings" International Arch.
Occupation Environmental Health 66:209-212 (1994).
ABSTRACT: The long-term urinary
mercury excretion was determined in seventeen 28- to 55-year old
persons before and at varying times (up to 14 months) after
removal of all (4-24) dental amalgam fillings. Before removal the
urinary mercury excretion correlated with the number of amalgam
fillings. In the immediate post-removal phase (up to 6 days after
removal) a mean increase of 30 percent was observed. Within 12
months the geometric mean of the mercury excretion was reduced by
a factor of five from 1.44ug/g (range: 0.57 to 4.38ug/g) to 0.35
ug/g (range: 0.13 to 0.88 ug/g).
The exposure from amalgam
fillings thus exceeds the exposure from food, air and beverages.
Within 12 months after removal of all amalgam fillings the
participants showed substantially lower urinary mercury levels
which were comparable to those found in subjects who have never
had dental amalgam fillings. A relationship between the urinary
mercury excretion and adverse effects was not found. Differences
in the frequency of effects between the pre- and post-removal
phase were not observed.
DISCUSSION: The initial urinary
mercury concentrations (before amalgam removal) were similar to
those found in previous studies in people with amalgam fillings
while the final values (12 months after amalgam removal) were
comparable to those for people who have never had amalgam
Our results are in excellent agreement with those of Molin et.
al., who found a 75 percent reduction in urinary mercury levels
within 12 months after amalgam removal. In accordance with the
findings in this study, Molin also found a 50 percent increase in
the urinary mercury excretion in the immediate post-removal phase.
Elligsen et. al. and Roels et. al. monitored the urinary mercury
excretion after cessation of occupational exposure in a
chloralkali plant. The biological half-life was calculated to be
91 days and 90 days, respectively. Both groups of authors
concluded that the elimination rate after cessation of mercury
exposure seems to be monophasic. This is in agreement with the
results of this study based on dental exposure levels.
The present study indicates that in persons with amalgam fillings
on an average about 80 percent of the urinary mercury excretion is
caused by the release from dental amalgam. Thus the inorganic
mercury exposure form this source far exceeds the exposure from
all other enviornmental sources (food, water, beverages, air).
e) Pregnancy Precaution
The formation of a foetus is very much at risk to
mercury in its mother's blood, so the continuous release of
mercury from amalgam restorations may be responsible for a portion
of the birth defects seen in our society today. When an amalgam
filling is removed or an amalgam-filled tooth is extracted, a
surge of mercury may be released into the bloodstream. Women
should have their amalgam fillings removed at least one year in
advance of when they intend to become pregnant and discuss the
risk with an informed medical doctor or dentist. Women should
never have amalgam fillings removed during a pregnancy.
f) Patient Reports
Siblerud, R.L. "Health Effects After
Dental Amalgam Removal" Journal of Orthomolecular
Medicine. Vol. 5, No. 2, (1990).
SUMMARY: A Utah dentist provided the
names and addresses of approximately 300 people who had their
amalgams removed. A health questionnaire was sent to these people;
86 subjects responded. Eighty (80) % of the subjects reported that
they felt better following amalgam removal. Nearly all of the
subjects (91%) said they were glad their amalgams had been removed
and 88% said they would do it again. An increase in happiness and
peace of mind was experienced by 58% of the subjects. This
evidence suggests that the well being of these subjects improved
immensely after amalgam removal.
Mary Davis editor "Solving the Puzzle
of Mystery Syndromes" Hot Off the Press Printing Co.
SUMMARY: This book presents
patient-reported case histories, where they associate their health
problems with dental amalgam mercury. Case histories include:
Chronic Fatigue Syndrome, Seizures, Memory Loss, Migraines,
Multiple Allergies, Multiple Sclerosis, Depression, Lupus, Maldigestion, Chemical Sensitivities, Insomnia, Miscarriages,
Paralysis, Sinus Problems, Emotional & Mental Disorders,
Infertility, Endometriosis, Crohn's Disease, Rashes, Anxiety,
Tremors & Spasms, Amyotrophic Lateral Sclerosis, Universal
Reactor and many others.......