New restrictions on use of dental amalgam
New environmental restrictions on dental amalgam use in specific patient groups came into effect in the UK and Republic of Ireland on 1 July 2018.
The use of dental amalgam for the treatment of patients under 15 years old, of pregnant or breastfeeding patients or of deciduous (primary) teeth in any patient is now only allowed when deemed strictly necessary by the dental practitioner, based on the patient’s dental or medical needs.
The restrictions, which are specified in EU regulations and applicable in UK and EU law, have been introduced to fulfil the requirements of the global Minamata Convention, to which the UK and Irish governments are signatories. This UN Convention aims to reduce use of mercury and mercury-containing products, including dental amalgam, on environmental grounds.
Why is there a need to phase down use of dental amalgam?
There is no evidence that mercury present in dental amalgam presents a direct health risk to individuals who have amalgam restorations or to dental staff. However, when released into the environment, the mercury within dental amalgam can be converted by aquatic microorganisms into a form that can accumulate to toxic levels in fish and other marine life and enter the human food chain. Therefore, by contaminating the environment, dental amalgam can contribute indirectly to the risk to human health from mercury. Phasing-down the production, use and disposal of dental amalgam will help to reduce this indirect risk.
What is the advice in Northern Ireland?
The four Chief Dental Officers of the UK requested that the Scottish Dental Clinical Effectiveness Programme (SDCEP) develop advice to support dental professionals in all four UK nations in interpreting and implementing the restrictions on dental amalgam use. The advice was developed following a rapid process that drew on elements on elements of SDCEP’s accredited guidance development methodology. A short-life working group that included experienced dental practitioners and experts in restorative and paediatric dentistry, drawn from across the UK, was convened to develop the advice. UK-wide consultation was conducted to allow stakeholders to comment on and contribute to the development of the advice.
What is the SDCEP advice in a nutshell?
Early prevention –Prevention is at the core of many national policies and it is estimated that every £1 spent on prevention leads to £3 saved on later restorative work. The guidance refers to current UK guidelines around the prevention of caries in children, which make recommendations including behaviour change, dietary and toothbrushing advice, and the use of fluoride varnish and sealants.
Use of alternative techniques and materials – The advice recommends the use of alternative techniques and materials in the treatment of dental caries and restoration. For children and deciduous teeth this includes the use of methods such as the Hall Technique, sealant or infiltration and preventive only interventions. The advice states that many of the same approaches and principles can be used for caries management in adults and permanent teeth. It discusses the use of alternative materials such as resin composites and glass-ionomers. The advice is clear that extraction should not be considered as an alternative to the use of dental amalgam.
Minimum intervention dentistry (MID) –MID is an approach that aims to prevent
and control oral disease and encompasses oral health promotion, prevention and minimally invasive operative interventions.
Northern Ireland: new SDR fees and codes
The Statement of Dental Remuneration (SDR) for Northern Ireland has been updated for the provision of non-amalgam fillings for children aged under-15 and in pregnant and breastfeeding women.
Five new codes and fees have been created in Section V (Conservative Treatment) of Determination I of the SDR. Five new parallel item codes with the same associated fees have also been inserted into Section XII (Occasional Treatment).
Four of the new SDR codes cover “Composite, glass ionomer or resin fillings in permanent or retained deciduous teeth in patients under 15 years.”
The fee structure for these is displayed in the table below:
|1406||Two or more surfaces where the occlusal surface is involved||£26.90|
|1407||Two or more surfaces: mesi-occlusal or disto-occlusal surfaces||£34.54|
|1408||Three or more surfaces: mesi-occlusal and disto-occlusal surfaces||£44.31|
For pregnant/nursing mothers the new SDR code is 1471: “Treatment of any surface of a permanent tooth using composite, glass ionomer, or resin material in pregnant or breastfeeding women”.
This will be paid £15.71 per filling and £23.29 maximum.
The Republic of Ireland
In the Republic, the HSE has stated that it is “committed to the full implementation of the Regulations under the Minamata Convention, including the phase down of dental amalgam”.
As part of this commitment it has outlined six key areas to support practitioners and patients, which have either been delivered or are in train. These are:
- Policy with a preventive ethos to minimise the need for restorative or surgical treatment
- Guidance Statement for clinicians on the future use of amalgam
- Public Information for those attending HSE Dental Clinics
- Training on the use of alternatives to amalgam
- Safe disposal of waste amalgam
- Measurement and monitoring of phase-down.
In addition, the Irish Dental Council has issued a Code of Practice document, which lays out practitioners’ legal and ethical obligations relating to the phase-down.
Amalgam: The new regulations
Regulation (EU) 2017/852 on Mercury contains the following provisions relating to dental amalgam:
Article 10(1): from 1 January 2019, dental amalgam shall only be used in pre-dosed encapsulated form.
Article 10(2): from 1 July 2018, dental amalgam shall not be used for dental treatment of deciduous teeth, of children under 15 years and of pregnant or breastfeeding women, except when deemed strictly necessary by the dental practitioner based on the specific medical needs of the patient.
Article 10(3): by 1 July 2019, each Member State shall set out a national plan concerning the measures it intends to implement to phase down the use of dental amalgam.
Article 10(4): from 1 January 2019, operators of dental facilities in which dental amalgam is used or dental amalgam fillings or teeth containing such fillings are removed, shall ensure that their facilities are equipped with amalgam separators for the retention and collection of amalgam particles, including those contained in wastewater.
10 October 2013: Minamata Convention on Mercury agreed
18 May 2017: EU Regulation on Mercury agreed
16 August 2017: Minamata Convention enters into force
1 January 2018: EU and UK mercury regulations come into force
1 July 2019: National plans for phase-down measures required