One of the most important questions for dentistry over the next decade in the UK and across the globe is the future reduction in amalgam usage. In mid-July over 50 senior oral health leaders met at King’s College London’s Dental Institute to agree consensus on pathways for reduction of amalgam usage that are common for the UK and in developing countries, along with a set of priorities and challenges differentiated at the national (UK) level.
The intensive, multi-day conference was led by Professor Dianne Rekow, executive dean of the Dental Institute, and Julian Fisher, resource person for the UN Environmental Programme Global Mercury Partnership Area on Waste Management. The event was co-hosted by University of Leeds School of Dentistry and Newcastle University School of Dental Sciences, and endorsed by the UK Dental Schools Council. It brought together UN agencies, dental policy makers, national chief dental officers, representatives from NGOs, and members of the clinical and academic communities, who worked together to plan a clear pathway for the phase down of dental amalgam.
“The expertise of the symposium participants created a rare opportunity to address the breadth of challenges intrinsic in creating the pathways. We brought our own expertise and learned a great deal from others about the realities of changing materials and how we deliver dentistry,” explains Professor Rekow of King’s College London’s Dental Institute.
Managing the replacement of amalgam as a frontline material will become a very high priority on many fronts, driven in large measure by national legislation and international agreements. Dental amalgam is a mixture of mercury, silver, tin and copper. Mercury, which makes up about 50 percent of the compound, is used to bind the metals together and to provide a strong, hard, durable filling. Whilst in the past dental amalgam has often been the material of choice, there is a worldwide move away from the substance for environmental and health reasons.
However, the phasing down of the use of amalgam is not straightforward. It is not just a matter of ‘putting down the amalgam’ and picking up a new material. When materials change, a host of factors are affected; including costs, benefits and decisions about prevention versus restoration, diagnosis of decay and associated risks, restoration design to accommodate the material, both tooth and restoration longevity, and many others.
“The complexity of something seemingly as simple as changing a material is remarkable. Indeed, this ‘simple’ change has ripple effects that change the philosophy and practice of dentistry, as well as the economies of health care. Furthermore, the ripples inform future research and have a significant impact on the future workforce and how we educate them. One of the most impressive features of the symposium was the willingness of the participants to explore the implications and interdependencies of the ‘ripples’ and assertively work toward finding ways to improve both the environment and health,” says Professor Rekow.
There is also a wider question related to how to facilitate an important change in behaviour across the profession to make sure we do not end up with a different material that causes new and perhaps bigger educational and clinical problems. There are economic questions related to the best way of investing scarce resources. There are commercial opportunities in terms of further improvements in existing materials and development of new materials from which we can benefit as a nation. The symposium started generating answers to these questions.
“I was very impressed by the committment of the major dental community stakeholder to a measureable, equitable and sustainable phase down of dental amalgam use, as well as the recognition that ‘dentistry can’t do this alone’. This will need the engagement of other actors such as other health professions, industry/manufacturers and importantly, civil society. The meeting built on past discussions and focused on health systems thinking, as well as highlighting the need for a global set of indicators for the phase down of dental amalgam use from WHO and UNEP”, explains Julian Fisher.
Over the course of the symposium, participants exchanged knowledge and research, examined case studies and shared best practices, particularly from the UNEP WHO East Africa Project which is catalysing action in the African region and providing leadership and valuable lessons learnt to inform phase down actions in other regions. Several presentations highighted minimal invasive dentistry and how UK dental schools are focusing teaching on preventive approaches and preparing their students to be change agents.
The meeting proactively engaged a wide range of stakeholders to build and strengthen a valuable network of contacts and forge pathways for the phase down of the use of dental amalgam worldwide.
“For me there was one stand out take away message; the dental profession has a unique and critical opportunity through the the phase down of dental amalgam to implement and deliver prevention orientated oral healthcare within integrated people centred services” concludes Fisher.