Review Article

The Dental Amalgam Toxicity Fear: A Myth or Actuality

Monika Rathore, Archana Singh1, Vandana A. Pant1

Departments of Pedodontics and 1Periodontics, BBD College of Dental Sciences, Lucknow, Uttar Pradesh, India

ABSTRACT
Amalgam has been used in dentistry since about 150 years and is still being used due to its low cost, ease of
application, strength, durability, and bacteriostatic effect. When aesthetics is not a concern it can be used in
individuals of all ages, in stress bearing areas, foundation for cast-metal and ceramic restorations and poor oral
hygiene conditions. Besides all, it has other advantages like if placed under ideal conditions, it is more durable
and long lasting and least technique sensitive of all restorative materials, but, concern has been raised that
amalgam causes mercury toxicity. Mercury is found in the earth’s crust and is ubiquitous in the environment, so
even without amalgam restorations everyone is exposed to small but measurable amount of mercury in blood and
urine. Dental amalgam restorations may raise these levels slightly, but this has no practical or clinical significance.
The main exposure to mercury from dental amalgam occurs during placement or removal of restoration in the
tooth. Once the reaction is complete less amount of mercury is released, and that is far below the current health
standard. Though amalgam is capable of producing delayed hypersensitivity reactions in some individuals, if the
recommended mercury hygiene procedures are followed the risks of adverse health effects could be minimized.
For this review the electronic databases and PubMed were used as data sources and have been evaluated to
produce the facts regarding amalgam’s safety and toxicity.

Key words: Amalgam, mercury, myth, restoration, safety, tooth, toxicity

INTRODUCTION natural tooth colour so patients and professionals preferred

tooth-coloured restorative material for cavity filling in
Amalgam, an alloy of mercury (Hg), is an excellent and carious teeth for better aesthetics. Researchers agree that
versatile dental restorative material. It has been used amalgam restorations leach mercury into the mouth, but
in dentistry since 150 years due to its low cost, ease consistent findings are not available to report whether it
of application, strength, durability, and bacteriostatic has any significant health risk.[3] In this review, an attempt
effects.[1] Popularity of amalgam as restorative material is has been made to summarize that there is no convincing
decreasing these days due to concerns about detrimental evidences pointed out to adverse health effects due to
health effects, environmental pollution, and aesthetics.[2] dental amalgam restorations and can be used as a preferred
The metallic colour of amalgam does not blend with the restorative material where aesthetics is not a concern.

Access this article online

Amalgam composition and historical
Quick Response Code:
Website: background
www.toxicologyinternational.com Amalgam consists of an alloy of silver, copper, tin, and
zinc combined with mercury. Unreacted alloy particles of
DOI: silver-tin are considered as gamma phase. These particles
10.4103/0971-6580.97191 combine with mercury and form a matrix consisting of
gamma-1(Ag2Hg3) and gamma-2 phases. (Sn7-8Hg). The

Address for correspondence: Dr. Vandana A. Pant, BBD College of Dental Sciences, 1, Akhilesh Das Nagar, Faizabad Road, Lucknow-227 105,
Uttar Pradesh, India. E-mail: drvandanapant@rediffmail.com

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 Rathore, et al.: Amalgam toxicity

gamma-2 phase is responsible for early fracture and failure of mercury is released, that is far below the current health
of amalgam restorations. Hence, copper was introduced standard.[8] The exposure to mercury from restoration
to avoid gamma-2 phase, replacing the tin-mercury phase depends on the number and size of restoration, composition,
with a copper–tin phase (Cu5Sn5).[4] Louis Regnart, known chewing habits, food texture, grinding, brushing of teeth,
as the ‘Father of Amalgam’, improved on boiled mineral and many other physiological factors. As a vapour, metallic
cement by adding mercury, which greatly reduced the mercury could be inhaled and absorbed through the alveoli
high temperature originally needed to pour the cement on in the lungs at 80% efficiency. It is the main route of entry
to a tooth. In 1890s GV Black gave a formula for dental of mercury into the human body, whereas the absorption
amalgam that provided clinically acceptable performance of metallic mercury through skin or via the gastrointestinal
and remained unchanged virtually for 70 years. In 1959, tract is very poor.[8] The organic compounds of mercury such
Dr Wilmer Eames[5] promoted low mercury-to-alloy mixing as methyl mercury are readily absorbed by many organisms
ratio. The mercury-to-amalgam ratio, dropped from 8:5 and accumulate as it passes into food chain. Research on
to 1:1. The formula was again changed in 1963, when monkeys had shown that mercury released from amalgam
amalgam consisting of a high-copper dispersion alloy was restorations is absorbed and accumulated in various organs
introduced.[6] It was later discovered that the improved such as kidney, brain, lung, liver, gastro-intestinal tract,
strength of the amalgam was a result of the additional and the exocrine glands.[13] The organic form of mercury
copper forming a copper–tin phase that was less susceptible was also found to have crossed the placental barrier in
to corrosion than the tin–mercury phase in the earlier pregnant rats[14] and proven to cross the gastrointestinal
amalgam.[7] mucosa when amalgam particles are swallowed at the time
of amalgam insertion or during removal of old amalgam
Modern amalgams are produced from precapsulated fillings,[15] whereas the inorganic form of Mercury ions
(preproportioned) alloy consisting of 42% to 45% mercury (Hg+2) circulate into the blood stream but hardly cross the
by weight. These are convenient to use and provide some blood–brain barrier and placental barrier.
degree of assurance that the material has not been not
contaminated before use or spilled before mixing.[8] Mercury does not collect irreversibly in human tissues.
The average half life of mercury is 55 days for transport
Amalgam controversy and amalgam war through the body to the point of excretion. Thus mercury
In the year 1843, the American Society of Dental Surgeons that came into the body years ago may no longer be present
(ASDS), founded in New York City, declared use of in the body.[8]
amalgam to be malpractice because of the fear of mercury
poisoning in patients and dentists and forced all its members Diagnostic methods to detect levels of mercury
to sign a pledge to abstain from using it.[9] It was the in body
beginning of the amalgam war.[10] Because of its stance
Toxicity from mercury could occur through exposure
against amalgam, membership in the American Society of
to organic, inorganic, and elemental forms of mercury.
Dental Surgeons declined, and due to the loss of members,
According to decreasing toxicity of mercury it is classified
the organization was disbanded in 1856 thus resulting in
as organomercury (methyl and ethyl mercury), mercury
the end of the amalgam war. In 1859, the American Dental
vapour, and inorganic mercury. Various diagnostic methods
Association (ADA) was founded and it did not forbid
exist to detect the level of mercury in body, including tests
use of amalgam.[11] The ADA position on the safety of
for blood, urine, stool, saliva, hair analysis, and others.
amalgam has remained consistent since its foundation. In
These tests may determine if mercury is in the body and/or
1920s inferences were made that mercury was not tightly
if it is being excreted. A study[16] conducted by measuring
bound in amalgam so its use was discouraged. In 1991,
the intraoral vapour levels over a 24-h period in patients
National Institute of Health-National Institute for Dental
with at least nine amalgam restorations showed that the
Research (NIH-NIDR) and FDA concluded that there was
average daily dose of inhaled mercury vapour was 1.7 µg
no basis for claims that amalgam was a significant health
(range from 0.4 to 4.4 µg), which is approximately 1% of
hazard,[12] but claims of amalgam hazards continued to be
the threshold limit value of 300 to 500 µg/day established
published in non-scientific journals, and occasionally in
by WHO, based on a maximum allowable environmental
scientific journals.
level of 50 µg/day in the workplace. According to Berdouses
et al.[17] mercury exposure from amalgam can be greatly
Mercury exposure from amalgam restorations increased by personal habits such as, chewing and brushing.
Mercury is ubiquitous in environment and humans are
routinely exposed via air, water, and food.[8] Exposure to Berglund,[18] in 1993, determined the daily release of
mercury in human individuals with amalgam restoration mercury vapour from amalgam restorations made of alloys
occurs during the placement or removal of dental of the same types and batches as those used in the in vitro
restorations. Once the reaction is complete, less amount part of the study. He carried out a series of measurements

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 Rathore, et al.: Amalgam toxicity

on each of eight subjects before and after amalgam therapy Removing these restorations do not eliminate exposure to
and found that none of the subjects were occupationally mercury. Maternal amalgam restoration results in in utero
exposed to mercury. The amalgam therapy, that is, from 3 exposure to low levels of elemental mercury. There is no
to 6 occlusal amalgam surfaces and from 3 to 10 surfaces evidence that exposure to mercury has been associated
in total-had very little influence on the intraoral release with any adverse pregnancy outcomes or health effects in
of mercury vapour, regardless of amalgam type used, the newborn and infants. In a prospective study consisting
effects was not found on mercury levels in urine and of 72 pregnant women, it was found that the number and
saliva. Rapid and reliable detection of mercury in blood surface areas of amalgam restorations positively influenced
and urine resulting from environmental and occupational the concentration of mercury in amniotic fluid. The levels
exposure may be carried out by using atomic fluorescence of mercury detected in amniotic fluid were low and no
spectrophotometry.[19] Measurements of total mercury in adverse outcomes were observed during the pregnancy or
the urine tend to reflect inorganic mercury exposure and in the newborns.[21] Blood samples obtained from umbilical
total mercury levels in whole blood are more indicative cord had no significant mercury levels considered to be
of methyl mercury exposure. Commonly two types of hazardous for neurodevelopmental effects in children using
urine tests have been used in which one is the unprovoked the EPA reference dose (5.8 μg/L in cord blood).[22] To
mercury test that does not use a pharmaceutical mercury find co-relation between mercury exposure from amalgam
chelator and only reflects the amount of mercury the restorations placed during pregnancy and low-birth weight
body naturally removes via the urine. The other is the 1,117 women with low birth weight infants were compared
urine mercury challenge (provoked) test, which uses a with random sample of 4,468 women who gave birth to
pharmaceutical chelator to remove the mercury captured infants with normal birth weight. Women (4.9%) had at
via the kidneys/urine pathway. Both methylmercury and least one amalgam restoration placed during pregnancy.
inorganic mercury can also be measured in breast milk. These women were not at greater risk for a low birth weight
The relative proportions of these species depend on the infant and neither were women who had 4 to 11 amalgam
frequency of fish consumption, dental amalgam status, restorations placed.[23] In a study conducted by Daniels[24]
and occupational exposures. In a study for comparison of 90% of the women received dental care during pregnancy.
hair, nails, and urine for biological monitoring of low level Having more restorations placed at time of conception did
inorganic mercury exposure in dental workers, the data not negatively affect pregnancy or birth outcome. Mean
suggested that urine mercury remains the most practical umbilical cord mercury concentration was slightly higher
and sensitive means of monitoring low level occupational in women who had dental care. However, cord mercury
exposure to inorganic mercury.[20] concentrations did not differ significantly among mothers
in relation to amalgam restoration during pregnancy or
Various related studies by the number of amalgams in place prior to pregnancy.
In this review electronic databases and PubMed have been Overall, amalgam restorations were not associated with
used for data sources and articles from peer reviewed negative birth outcomes or delayed language development.
journals and various organizations including WHO (1991), They stated that amalgam restorations in girls and women
the Agency for Toxic Substances and Disease Registry of reproductive age should be used with caution to avoid
(ATSDR) (1999), US Environmental Protection Agency prenatal mercury exposure, although there were no adverse
(EPA,1997), the National Research Council (NRC) effects seen.
(2000), the Institute of Medicine (2001; 2004) and
Life Science Research Office (LSRO) (2004) have been Health effects of amalgam in children
evaluated to investigate the biochemical, behavioural, and/ The Children’s Amalgam Trial is a randomized trial,
or toxicological effects resulting from exposure to amalgam, to address potential impact of mercury from amalgam
mercury vapour (HgO), inorganic mercury (Hg2+), or restorations on neuropsychological and renal function in
organic mercury (methyl and ethyl mercury). The LSRO
children. Bellinger et al.[25] conducted a study on 534 New
search was limited to in vivo studies on humans relevant to
England children, aged 6–10 years for 5 years. All subjects
amalgam and biochemical, behavioural and/or toxicological
were in need of at least two posterior occlusal restorations.
effects as health effects in laboratory animals do not reliably
Participants were randomized to receive either amalgam or
predict health effects in humans.
composite restoration at baseline and at subsequent visits.
The primary endpoint was to assess the 5-year change in
Effects of prenatal mercury exposure IQ scores. Secondary endpoints included measures of other
Nonionized mercury is capable of crossing through lipid neuropsychological assessments and renal functioning. In
layers at membrane barriers of the brain and placenta, is the 5-year follow-up period the investigators conducted
oxidised within these tissues and is slowly removed. This multiple assessments of IQ score, memory index, and
fact has become the basis for claims of neuromuscular urinary albumin. No statistically significant differences were
problems in patients with amalgam restorations. [8] reported in neuropsychological or renal effects observed in

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the children who had amalgam restorations compared to physical coordination, and velocity of nerve conduction, the
those with composite restorations. scientists did not detect a pattern of decline in the test scores
of individual children who received amalgam restorations.
In another study, authors have concluded that there was They found a trend of higher treatment need in children
no difference in the neuropsychological function of the receiving composite, thus suggesting that amalgam should
children who received amalgam restorations compared remain a viable dental restorative option for children.
to the children with composite restorations.[26] A dose- The investigators performed annual clinical neurological
effect analysis of children’s exposure to amalgam and examinations to assess neurobehavioral and neurological
neuropsychological function was also evaluated in the effects. The authors concluded that amalgam exposure had
children’s amalgam trial. The authors examined a sample no adverse neurological outcomes.[31]
of children with substantial unmet dental needs using a
dose–effect analysis. There was no significant association The 7 years of longitudinal data provide extensive evidence
between neuropsychological outcomes and mercury about relative safety of amalgam in dental treatment.
exposure. The authors concluded that there appeared to Substantial amalgam exposure did lead to creatinine
be no detectable adverse neuropsychological outcomes in adjusted urinary mercury levels that were higher in the
children attributable to the use of amalgam restorations.[27] amalgam group. Children with amalgam restorations had
The relation between amalgam and the psychosocial status slightly elevated levels of mercury in their urine, measuring
of children was also assessed as a part of the New England on average 1.5 µg/L of urine for the first two years and
Children’s Amalgam Trial (NECAT). The two groups of levelling off to 1.0 µg/L or less thereafter. However, these
children were examined for psychosocial outcomes. It was values fall within the background level of 0–4 µg/L, which
carried out using both a parent-completed “Child Behaviour is usual for an average person not exposed to industrial or
Checklist” and children’s self-reports and concluded that other known sources of mercury.[32] Thus, the longitudinal
there was no evidence associated with adverse psychosocial studies on the use of amalgam in children did not suggest
outcomes in the 5-year period following amalgam any negative effects on neuropsychological function or renal
placement.[28] function within the 5-year follow-up period. It was reported
that urinary mercury concentrations were highly correlated
Kingman et al.[29] studied correlation between exposure with both the number of amalgam restorations and the time
to amalgam and neurological functions. No significant since placement in children. The finding suggested that
associations between amalgam exposure and clinical there may be sex-related differences in mercury excretion.
neurological signs of abnormal tremor, coordination, gait, They found that females have significant increase in the
strength, sensation or muscle stretch reflexes or for any level rate of mercury excreted in urine than males. Thus, this
of peripheral neuropathy in the subjects have been observed. association might confer a lower mercury toxicity risks in
A significant association was detected between amalgam females.[33] Dunn et al.[34] evaluated scalp, hair, and urine
exposure and the continuous vibro-tactile sensation mercury content of children collected over the 5-year
response. The study reported that this association was a period, mean hair mercury level was 0.3–0.4 μg/g and mean
subclinical finding that was not associated with symptoms, urinary mercury level was 0.7–0.9 μg/g creatinine. The
clinically evident signs of neuropathy or any functional authors reported that use of chewing gum in the presence
impairment. of amalgam restoration was a predictor of higher urinary
mercury levels. Data suggested that amalgam-associated
In the Children’s Amalgam Trial, one of the secondary mercury exposure might be reduced by avoidance of gum-
endpoints included renal functioning. The investigators chewing in the presence of amalgam restorations.
assessed changes on markers of glomerular and tubular
kidney function and urinary mercury levels. They found no Sixty children were studied to assess urinary mercury
significant differences between the treatment groups and no excretion and its relation to amalgam restoration and fish
significant effects related to the number of dental amalgam consumption. Children with amalgam restorations had
restorations on the markers. Children in both treatment significantly higher urinary mercury levels compared to
groups experienced micro albuminuria, but the prevalence children with non-amalgam restorations. The urinary
was higher in amalgam group. The authors concluded that mercury levels in the amalgam group were well below levels
the increase in micro albuminuria may be random, but that are known to cause adverse health effects.[35]
should be further evaluated.[30] The other safety trial was
conducted in Lisbon, Portugal[27] in which a randomized
controlled clinical trial carried out in 507 children 8- to Health effects related to mercury exposure in
10-years old at baseline. They were evaluated for several adults
years thereafter to determine if any health changes occurred An investigation on 20,000 people in the New Zealand
following restorations with amalgam or composites. On Defence Force between years 1977–1997 was done to find
carrying out annual standardized tests of memory, attention, out association between amalgam restorations and disorders

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related with nervous system and kidney. No significant to dermatitis or type IV delayed hypersensitivity reactions
correlation between amalgam restorations and chronic most often affecting the skin as a rash.[43]
fatigue syndrome or kidney disease was observed. A slightly
elevated risk for multiple sclerosis was reported, but may Mercury exposure in dental professionals
have been due to confounding variables.[36] In another study,
Dentists and dental nurses are at risk of potential exposure
where few patients believed that their amalgam restoration
to inorganic mercury through their handling of amalgam,
made them ill, medical examination including physical
although now days their exposure has reduced due to low
examination, electrocardiogram, abdominal sonography,
mercury to alloy ratio and through mercury management.
and blood chemistry was done. The study concluded that
One hundred and eighty dentists were evaluated in West
symptoms of the patients were due to psychological factors.
Scotland for mercury exposure and its effects on their health
There was no connection between the mercury levels in the
and cognitive function. Dentists were found to have, on
patient’s blood, urine, and saliva and their symptoms.[37]
an average, over four times the level of urinary mercury
The association between amalgam and multiple sclerosis
compared to age and education-matched control subjects.
was assessed via a systematic review and meta-analysis. The authors reported that based on their questionnaire,
Three case control studies and one cohort study met their dentists were more likely to report having a disorder of the
inclusion criteria. The meta-analysis revealed a slight kidney, although the effect was not significantly associated
nonstatistically significant increase between the presence with their urinary mercury level. An age effect was found
of amalgam restorations and multiple sclerosis. The study for memory disturbances in dentists but not in the control
does not provide evidence for or against an association.[38] subjects. There was no significant association between
urinary mercury concentrations and self-reported memory
Halbach et al. [39] evaluated the internal exposure to disturbance.[44] A study on 43 dental nurses, with an average
amalgam-related mercury and estimated the amalgam- age of 52, were exposed to copper amalgam with a 30-year
related absorbed dose of mercury. The integrated mercury follow-up; were compared with 32 matched controls. It
absorbed from amalgam restorations was estimated at was concluded that the dental nurses did not appear to
up to 3 μg per day for an average number of restorations be neurobehavioraly compromised. Seven symptoms of
and 7.4 μg per day for a high amalgam load. The authors mercury poisoning that were reported at a higher rate by
concluded that these estimates are below the tolerable dose exposed group than by the control group (arthritis, bloating,
of 30 μg per day established by WHO. dry skin, headache, metallic taste, sleep disturbances, and
unsteadiness). It did not appear that the investigators
Hypersensitivity reactions by amalgam performed post-hoc testing to compensate for multiple
restorations comparisons.[45] The possible health risk of occupational
Amalgam is capable of producing delayed hypersensitivity exposure to mercury vapour in the dental office was assessed
reactions in some individuals. These reactions usually by evaluating the cytogenetic examination of leukocytes
present with dermatological or oral symptoms. The and blood mercury levels of dentists.[46] Genotoxicity of
constant exposure to mercury in amalgam restorations may occupational exposure to mercury vapour in ten dentists
sensitize some individuals, making them more susceptible to was evaluated. The authors concluded that mercury vapour
oral lichenoid lesions. These oral lesions are rarely noticed concentration in blood was below 0.1 mg/m3 and did not
by the affected individuals and cause no discomfort. There exhibit cytogenetic damage to leukocytes.
is evidence that a certain percentage of lichenoid lesions are
caused by amalgam restorations,[40] but other restorative Mercury management in dental operatory
materials can also cause lichenoid lesions. It was also noted In 1999, the ADA Council on Scientific Affairs adopted
that the restorations associated with lichenoid lesions are mercury hygiene recommendations to provide guidance
poorly contoured, corroded and old. Hence corrosion to dentists and their staff members for safe handling of
of amalgam restoration or perhaps the biofilm present mercury and minimizing the release of mercury into the
on such restorations may contribute to the development dental office environment. These were updated in 2003
of hypersensitive reaction rather than material itself.[41] and are as follows: work in well-ventilated areas, remove
Symptoms of an amalgam allergy include skin rashes in professional clothing before leaving the workplace,
the oral, head and neck area, itching, swollen lips, localized periodically check the dental operatory atmosphere for
eczema-like lesions in the oral cavity. These clinical signs mercury vapour, (use dosimeter badges or use of mercury
usually require no treatment and will disappear on their own vapour analysers for rapid assessment after any mercury
within a few days of exposure. However, in some instances, spill or clean-up procedure). The current Occupational
an amalgam restoration will have to be removed and replaced Safety and Health Administration (OSHA), standard for
with alternate restorative material. The replacements have mercury is 0.1 mg per cubic meter of air averaged over 8-h
led to significant improvements. [42] Although mercury work shift. The National Institute for Occupational Safety
allergy is rare but sometimes hypersensitivity to it may lead and Health has recommended the permissible exposure

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 Rathore, et al.: Amalgam toxicity

limit to be changed to 0.05 mg/m3 averaged over 8-h “Christensen[50] quoted Amalgam restorations are and will
work shift over a 40-h workweek.[47] During preparation continue to be the mainstay of posterior tooth restorations
and placement of amalgam only precapsulated amalgam for many years to come.” Though use of amalgam has
alloys should be used. If possible, recap single-use capsules decreased during the past few years, more studies on safety
after use, store them in a closed container and recycle of composites or other aesthetic materials with long-term
them. Avoid skin contact with mercury or freshly mixed follow-up of are necessary before they can be considered a
amalgam. Use high-volume evacuation systems when definitive alternative for amalgam.
finishing or removing amalgam. Floor coverings should be
non absorbent, seamless and easy to clean. Use of carpet in
operatory is not recommended where an accidental mercury CONCLUSION
spill might occur. Chemical decontamination of carpeting
may not be effective, as mercury droplets can seep through The current use of amalgam has not posed a health risk
the carpet and remain inaccessible to the decontaminant. apart from allergic reactions in few patients. Clinical
In case of accidental mercury spill a vacuum cleaner should justifications have not been available for removing clinically
never be used to clean up the mercury. Small spills (less satisfactory amalgam restorations, except in patients allergic
than 10 g of mercury present) can be cleaned safely using to amalgam constituents. Mercury hypersensitivity is an
commercially available mercury cleanup kits. immune response to very low levels of mercury. There is
no evidence that mercury released from amalgams results
in adverse health effects in the general population. If the
Amalgam substitutes recommended mercury hygiene procedures are followed,
In the recent year’s composites, glass ionomer cements the risks of adverse health effects in the dental office could
and a variety of hybrid structures have been used due to be minimized. Amalgam is safe and effective restorative
increased demand for aesthetic restorations. Composite material and its replacement by nonamalgam restorations is
serves better than amalgam when conservative preparation not indicated. Also a recent review by the American Dental
is recommended like small occlusal restorations, in which Association Council on Scientific Affairs states that: “Studies
amalgam require removal of more sound tooth structure. [48] continue to support the position that dental amalgam is a
Composites have different setting reaction mechanisms safe restorative option for both children and adults. When
and it interacts with the patient’s tissues in different ways. responding to safety concerns it is important to make the
The small organic molecules (monomers) react to form distinction between known and hypothetical risks.”
polymers. Some of the monomers may not have reacted
during placement and therefore low levels remain in the
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 Rathore, et al.: Amalgam toxicity

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2000;131:1186-7. Source of Support: Nil. Conflict of Interest: None declared.

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