Safe Removal Guidelines for Removing Mercury Amalgam/Silver Fillings
1. Keep the fillings cool during removal
Drilling out an amalgam filling generates a tremendous amount of heat, which causes a significant increase in the release of mercury, both as a vapor and in amalgam particles, during the entire removal process. Cooling the filling with water and air while drilling substantially reduces the amount of mercury vapor the filling releases.
2. Cutting the Amalgam into Chunks
Most mercury-safe dentists use a removal process that’s commonly referred to as chunking. This involves less drilling, because the dentist only drills enough to cut the filling into chunks, which can then be easily removed by a hand instrument or suction. Both chunking and keeping the filling cool during removal are very important and I believe all mercury safe dentists should follow this procedure.
3. Use a high-volume evacuator
Most mercury safe dentists use a more powerful suction system than the type used by most pro-amalgam dentists. I feel this is one of the most important tools in minimizing the patient’s exposure to mercury vapor and amalgam particles. The evacuator tip should be kept to within 1⁄2 inch of the filling during the entire time the filling is being removed. This helps capture more of the mercury vapor and particles. All mercury safe dentists should follow this procedure.
4. Provide the patient with an alternative source of air
Not every mercury safe dentist agrees with the need for this as long as steps 1 & 2 are being done and a high-volume evacuator is being used. But I personally believe the patient should be provided with an alternative air source while their amalgam fillings are being removed. Even if steps 1 - 3 were not being done you'd still be protected if you had an alternative source of air to breathe. If your mercury safe dentist doesn't provide an alternative source of air you should ask him or her why they aren't and what else they are dong to compensate for not using it.
An alternative source of air isn’t necessary when the tooth is being prepared for the new filling or while the new filling is placed. But during the actual removal, the patient should be provided with a nasal hood through which he or she can breathe either compressed air from a tank, air from a source outside the office, or oxygen from a tank. The patient should be instructed to concentrate on breathing through the nose and avoid breathing through the mouth while mercury amalgam silver fillings are being removed.
The consensus is to not remove mercury amalgam fillings during a pregnancy or during nursing. I discuss this topic in Chapter 6 of my Poison in Your Teeth book. But if for whatever reason that procedure is done, I personally believe that an alternative source of air should be provided when removing amalgam fillings from the teeth of pregnant and nursing mothers, patients who have multiple allergies and sensitivities, immune system problems, or any other health issues that could berelated to chronic mercury poisoning.
A rubber dam isolates the tooth or teeth being worked on. It was believed that the rubber dam would protect the patient from breathing mercury vapor in through the mouth. We now know that mercury vapor can readily pass through a rubber dam made out of latex, the most commonly used rubber dam material. Many patients have heard that the rubber dam offers a great deal of protection and should absolutely be included as part of the safe removal protocol. Some people will even insist on its use to protect them from mercury vapor.
My personal opinion is that, because the rubber dam does not protect you from inhaling mercury vapor during the removal process, it does not absolutely have to be used when removing amalgam fillings. Incorporating the first 4 steps listed above will provide the greatest source of protection from mercury vapor for the patient. But while the rubber dam offers little protection against mercury vapor I believe that it does make it easier to evacuate the filling material and prevent amalgam particles from being swallowed. (Even though swallowed amalgam particles contain mercury it is not believed to be released during its journey through the intestine, it is sound procedure to prevent as much of it as possible from being swallowed. So the particles are not a threat to your health.)
If a composite filling is used to replace a mercury amalgam filling, the rubber dam offers an isolated and dry field for placing the composite filling. The dentist will decide when it is or isn't necessary. It does take some time to place and remove the rubber dam, it can be a little uncomfortable, and some patients simply cannot tolerate its use. There are other exceptions to its use because the position or location of some teeth, particularly 3rd molars, or so-called wisdom teeth, may make it impossible to place a rubber dam.
There are more and more isolation systems being used in dentistry that are more effective than the rubber dam and your dentist may be using them.
A Note to the Patient
Whether your dentist uses a rubber dam (or other isolation systems) or not you should always focus on breathing through your nose during the entire time the amalgam fillings are being removed. This is especially important if an alternative source of air is not available.
6. Remove gloves and clean the patient’s mouth
Once the filling(s) have been removed and replaced, the dentist and the assistant should remove and dispose of their gloves and the rubber dam, and thoroughly rinse and vacuum the patient’s entire mouth for at least 15 seconds. This will help remove amalgam particles and residual mercury vapor from the mouth. The patient should make every effort not to swallow during the rinsing procedure. I also suggest that after the rinsing procedure, the patient use a small amount of water and gargle as far back into his throat as possible. The patient should not swallow this watery residue! Instead, he or she should spit it into a sink or cup.All mercury free dentists should follow this procedure but it won't hurt to remind him or her.
After the fillings have been removed and replaced, the dentist or dental assistant should immediately remove and dispose of the patient’s protective covering and thoroughly clean his face and neck.All mercury safe dentists should routinely do this but remind the assistant if she forgets, after all you don't want to take any mercury home with you.
8. Use additional air purification
Some mercury safe dentists use an additional air filtering system that’s placed as close to the patient’s mouth as is practical. The more popular ones resemble an elephant’s trunk and have openings about 4 inches in diameter. This can be helpful, but I agree with those mercury safe dentists who believe that the patient can be adequately protected without such a system. More and more mercury safe dentists are using this type of purification system and while it’s a nice addition to the removal protocol, it is more important for the dentist and assistant than the patient.
9. Filtering air in the operatory
There are a number of effective ways to purify the air in the dental office. I’m not making specific recommendations. But many mercury safe dental offices filter the office air, as they work in it all day and it’s to their benefit to do so. This is more important for the dentist and staff than for the patient. Although mercury safe offices don’t place amalgam fillings, they certainly are required to remove them. Keep in mind that you will only be at the office for a short period of time but the dentist and his or her staff will be removing these fillings many times throughout the day. I believe all mercury safe dentists would want to take the necessary precautions to protect themselves and their entire staff from excessive exposure to mercury.
There’s some evidence that activated charcoal taken 10-15 minutes before amalgam removal can bind smaller particles of swallowed mercury, allowing them to be harmlessly passed out of the intestine via the feces. I consider this to be optional, as very little elemental or inorganic mercury is absorbed through the intestine, but it can’t hurt to add it, especially if you are in the high risk category.
Comments from Dr. Tom
As you can see, the amalgam removal procedure done in a mercury safe office is vastly different from what you have experienced at a pro-amalgam dental office. The above are only presented as guidelines for the safe removal of mercury amalgam fillings and there are similar protocols that are equally effective.
It should be noted that all of the above procedures are not weighted equally in regard to how much protection from mercury vapor and particles they will provide. Some are more important than others but I believe it is absolutely necessary for Steps 1, 2 and 3 to be taken. For example, it is much more important to the patient to breathe an alternative source of air than to take activated charcoal so you wouldn't want to trade taking charcoal for an alternative source of air.
It is also more beneficial to the patient if the dentist keeps the fillings cool, uses a high speed evacuator and a rubber dam (or equivalent), than filtering the dental office air. Again, not all the above procedures are absolutely necessary to safely remove amalgam fillings but the more of them your mercury dentist uses the better. Always ask the dentist if you are unsure about any procedure he or she is using.