The Minamata Convention on mercury
A treaty determining the future of dental amalgam was agreed by the United Nations Environmental Programme’s Intergovernmental Negotiating Committee in Geneva on 20 January 2013. The global, legally-binding treaty aims to reduce environmental pollution from mercury, to which amalgam makes a contribution.
The BDA has welcomed the final version of the treaty, which achieves a reasonable balance between environmental considerations and the public health benefits of dental amalgam. Nations will be allowed to phase down amalgam use over an appropriate time period, an approach advocated by the World Health Organisation (WHO). It had been feared that a rapid ban on dental amalgam would be ordered, with a phase-out date possibly set within five years and with no provision for essential improvements in caries prevention and insufficient time allowed for the development of effective and safe alternative restorative materials. Drs Stuart Johnston and Susie Sanderson of the BDA’s Principal Executive Committee (PEC), working through the FDI World Dental Federation and Council of European Dentists, led international lobbying efforts to avert a complete phase-out within a very short timescale and ensure that the treaty would recognise the need for improving oral health. PEC Chair Dr Martin Fallowfield also wrote to UK Environment and Health Departments urging them to press for the WHO’s approach to be adopted.
In summary, the treaty sets out the future of dental amalgam as follows:
- Progress must be made in reducing the use of mercury in dentistry; this should be kept under frequent review. The WHO’s phase-down approach has been acknowledged, by implication, as being appropriate.
- National governments may pace the phase-down according to domestic needs.
- Public health and prevention programmes designed to reduce the incidence of dental disease should be a focus.
- The use of appropriate non-mercury based materials should be encouraged.
- Research into improved non-mercury based alternative restorative materials should be encouraged.
- Best practice measures should be employed in reducing the environmental load arising from waste dental amalgam products.
- An earlier reference to non-evidence based “high risk” groups (children and pregnant women) has been removed.
In practice, the pace of amalgam phase-down in the UK will be determined at European level. The BDA will continue to work hard through the Council of European Dentists (CED) to ensure that an achievable and evidence-based legislative framework is developed.
The EU’s independent Scientific Committees on Emerging and Newly Identified Health Risks (SCENIHR) and on Health and Environmental Risks (SCHER) are in the process of updating their 2008 opinions on the environmental impact and safety of both dental amalgam and alternative restorative materials. The BDA submitted evidence in October 2012, in response to their calls for information. The 2008 reports concluded that dental health can be adequately ensured by both types of material and that they are safe to use. Since dental amalgam is the second greatest use of mercury in the EU (although its contribution to mercury pollution on a global scale is much smaller), it has been subject to particular scrutiny.
The CED, of which the BDA is a member, has taken the position that the phasing out of amalgam will be appropriate only when viable replacement restorative materials are available. It believes that due to its ease of use, durability and cost-effectiveness, dental amalgam continues to be the most appropriate filling material for many restorations, and that restrictions on the use of amalgam would damage the financial stability of health systems as well as impact on individual patients’ ability to afford dental care. It has called on European Governments to encourage the effective prevention of caries through health promotion programmes - which would result in the reduction in the use of all current restorative materials, including amalgam.
The FDI World Dental Federation has adopted a similar position, noting that the currently available alternative restorative materials are not economically viable in many circumstances, particularly for developing countries. Introducing general restrictions on the use of amalgam could lead to significant global public health problems.
The WHO has advocated a phasing down, rather than a phasing out, of the use of dental amalgam and called for a multi-pronged strategy with short-, medium- and long-term elements. It also contends that the quality of alternatives to amalgam must be further improved for use in public dental care, arguing that a progressive move away from amalgam would be dependent on that quality improvement being achieved.
The BDA will continue to ensure that national and international organisations understand the benefits of amalgam and the implications for public health of restricting its use before suitable alternatives are available and improvements in dental health are established. We will keep members up to date with further developments as they occur.