Dental Tribune United Kingdom Edition

April 23-29, 201210 Interview United Kingdom Edition N K: A recent WHO re- port recommended the phase down of the use of amalgam in dentistry. What impact will this have on the profession? SS: I know quite a lot about this, because I chair the work- ing group of Council of Euro- pean Dentists. This issue has been going on for a very, very long time, but started for the Council of European Dentists with the European mercury strategy, back in 2006. The mercury strategy doesn’t just cover dentistry, it covers the whole use of mer- cury in Europe and the aims were to reduce environmen- tal impact, reduce use where it could be substituted with something else, replaced with alternative materials, right across the board. So for example the chlor-alkali industry and batteries, gold mining, etc. We did a huge amount of work to review the literature and evidence on the health issues of dental amalgam. At that point the health risks were not seen to be significant and, as things currently stand, as a result the Commission has virtually parked health anxi- eties about dental amalgam. But it did find, through the work of its Scientific Commit- tees, there was very little evi- dence about the environmen- tal impact and how it would be mitigated if there was a difficulty. So that was around 2006 and they said they would review the mercury strategy about now, and that’s exactly what they are doing. Bio Intelligence Services is carrying out a big piece of work on behalf of the Com- mission at the moment look- ing at the life cycle of dental amalgam. All the way through the interim five years we’ve discussed with the Commis- sion that really the only way you can look at dental amal- gam is through the life cycle of how you track where it is, who’s using it, what they’re doing with it, how they’re dis- posing of it. At the same time we’ve monitored European den- tists’ approach to dealing with the environmental load, and we’ve watched the improve- ment of the implementa- tion of the Hazardous Waste Regulations, not only by the governments in Europe, but also the dentists. It’s got bet- ter and better and better, and we’ve done year on year sur- veys to see how, for example, amalgam seperators are being installed, used, checked and monitored. Dentists are large- ly seen in Europe as being hugely responsible about their use of dental amalgam. They also understand the Council of European Dentists’ stance that dental amalgam should remain as part of a dentist’s ‘armoury’ in combatting oral disease and that the choice of materials to be used should be a clinical decision in discus- sion with the patient and con- sented by the patient after a proper evaluation of the risks and advantages. So the ideal is that it remains as an avail- able material for as long as it’s needed, because there is no equivalent substitute. Dental amalgam has quali- ties which none of the other materials that we currently have at our disposal satisfy in the same way. None of them are as cheap, long lasting, durable, safe and malleable, and most importantly, usable in circumstances that are less than ideal. In the meantime the Unit- ed Nations Environment Pro- gramme also decided it need- ed to look at mercury globally (and it is mercury globally, not just dentistry again). Dentist- ry is high profile once more because, like compliance in any other area, we’re really easy to circumscribe and pick off in terms of enforcement of change. For a regulatory author- ity, it’s really easy to control mercury in dentistry – you just say, don’t use it any more. Now if you say to the chlor- alkali industry or the Chinese power station industry, stop using anything that’s got mer- cury in it, they’ll go ‘we can’t, the whole industry would fall apart – we can’t do it’. So then dentistry is a very easy target. However the World Health Organisation document has been published. It is a re- port of a consensus seminar day with all the world’s ex- perts present and it proposes that a “phase down” would be the best way forward. We acknowledge that actually it would be useful if we could get to a situation where we weren’t contributing to the global mercury environmental load, but until there is some- thing that we can use as ef- fectively, in the circumstances I have just described, it has to be a phase down. A phase down is over, say 20-25 years might give an opportunity for research to produce a substi- tute material. Until we have that, we can’t lose amalgam. NK: I think that’s something which, for a number of other reasons with the use of mer- cury, I’ve felt for a long time that it might be inevitable. SS: Yes, but preferably not next week. NK: In private practice it might be able to be accom- modated. SS: So we’re talking about the cost of it and who pays for the increased time that will be needed to provide good qual- ity restorations without the availability of amalgam. We’ve described the risk in our lob- bying in Europe and at world level as potentially destabilis- ing state health economies, and that’s what it would do. If in, say, three years the Department of the Environ- ment told the Department of Health to stop allowing den- tal amalgam, there will have to be serious consideration of the increased costs of NHS dentistry and the potential im- pact on workforce planning. It will, of course be totally unreasonable for the DH to at- tempt to insist that the same volume of care is provided within the same contract val- ues. It is widely acknowledged that composite fillings take longer to place than amalgam and that fact must be taken into account if a ban is intro- duced. At the moment, where the patient pays the full cost of their care through private contract, dentists can offer a genuine choice of materials. NK: That’s the difficulty, isn’t it? SS: Absolutely. So we’re talk- ing about the destabilising of health services. What we’re fighting for is a new contract which will give dentists the time to do what’s right. So, ‘phase down’. The ter- minology is really important. A ‘phase out’ we could prob- ably entertain if it was 30 or 50 years, because by that time we might have a proper substi- tute material. A ‘phase down’ over the next 20-25-30 years is probably acceptable. The Department of Health will say that the use of dental amal- gam is dropping significantly and that in 20 years we prob- ably won’t be using that much of it anyway. But during that ‘phase down’ time, the invest- ment governments have to in- vest properly in implementing genuine prevention. So all in all there’s a mas- sive piece of diplomatic and scientific work going on. It’s like a swan paddling like any- thing underneath while we’re trying not to create panic. Apart from anything else, the minute you start talking about amalgam in public all the an- ti-amalgamists emerge and create smoke screens about the real issues. So we keep it low key in public, but it takes huge resources here, in this building, to be dealing with it. NK: Now that you’re in your final six months as chair of the BDA, what do you consider are your proudest achievements and what do you see as priorities for den- tistry in the future? In the fourth and final part of this interview, Neel Kothari talks to Susie Sanderson about the amalgam issue and her thoughts on the future of dentistry Looking towards the future Amalgam has been widely used in dentistry ‘Dental amalgm has qualities which none of the other materials that we currently have at our disposal satisfy in the same way’