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Protocol for Amalgam-Mercury-Silver Filling Removal
International Academy of Oral Medicine and Toxicology (IAOMT)
PATIENT PROTECTION :
First in every concerned doctor's mind is the protection of
the patient from additional exposure tomercury.
This is especially true of the mercury toxic patient.
The mercury toxic patient may have been exposed to varying
amounts of mercury from diet, environment, employment or from
mercury/silver dental fillings. All forms are cumulative and can
contribute to the body burden. The goal of this preferred procedure
is to minimize any additional exposure of the patient, ourselves, or
staff to mercury.
During chewing the patient is exposed to intraoral levels which
are several times the EPA allowable air concentration.
2 During the removal or placement of amalgam the patient can be
exposed to amounts which are a thousand times greater than
the EPA allowable concentration.
3 Once the drill touches the filling temperature increases
immediately vaporizing the mercury component of the alloy.
There are 8 steps to greatly reducing everyone's exposure.
1. Keep the fillings cool.
All removal must be done under cold water spray with copious amounts
of water. Once the removal has begun, the mercury vapor will be
continuously released from the tooth.
2. Use a high volume evacuator.
Therefore, a high volume evacuator tip - such as the Cleanup
or similar apparatus - should be kept near
the tooth(1/2 inch) at all times to evacuate this vapor
from the area of the patient.
Polishing amalgam can create very dangerous levels
of mercury and should be avoided especially for
the mercury toxic patient.
3. Provide an alternative air source.
All patients having amalgam removed or placed should be provided
with an alternative air source and instructed to not breathe through
their mouth during treatment. A nasal hood such as is used
with the nitrous oxide analgesia equipment is excellent.
Air is best and oxygen is acceptable although not required.
If just air is used it should be clean and free of
mercury vapor preferably from outside the dental office.
4. Immediately dispose of the mercury alloy.
Particles of mercury alloy should be washed and vacuumed away
as soon as they are generated. The filling should be
sectioned and removed in large pieces to reduce exposure.
At present the International Academy of Oral Medicine and Toxicology
(IAOMT)has approved removal both with and without the use
of a rubber dam. Some evidence exist to support both views
since high levels of mercury and amalgam particles can be found
under the dam. All members are agreed that whether or
not a rubber dam is used the patient should be instructed
to not breathe through their mouth or swallow the particles.
Some experts feel that it is better to remove the
amalgam first and then apply the dam if needed
for restorative procedures.
5. Lavage, and change gloves.
After the fillings have been removed, take off the rubber
dam if one was used and lavage the patients mouth for
at least 30 seconds with cold water and vacuum.
Remove your gloves and replace them with a new pair.
If a restorative procedure is next then reapply
a new dam and proceed.
6. Immediately clean patient.
Immediately change patient's protective wear and
clean their face.
7. Consider nutritional support.
Consider appropriate nutritional support before,
during and after removal.
8. Keep room air pure.
Install room air purifiers or ionizers and fans
for everyone's well being.
STAFF PROTECTION :
OSHA4 5 requires that employees be given written informed consent
before the use of any toxic chemicals of which mercury is one.
Elemental mercury vapor is one of the most toxic forms of
mercury and should not breathed. Women of child bearing age should
be exposed to no more than 10% of the OSHA MAC6.
Women who are pregnant should be exposed to no mercury.7 If you use
mercury or remove mercury in any form the National Institute of
Occupational Safety and Health(NIOSH)has recommended that your
employees be medically monitored annually.
ANY MERCURY EXPOSURE REQUIRES THAT THE EMPLOYEE WEAR AN
APPROVED MERCURY FILTER MASK.
An approved mask is appropriate for wearing during all dental
procedures which will expose you or your staff to mercury.8
The manner in which dentists operate their equipment dramatically
affects the amount of mercury released. Never drill
on mercury high dry.
It is hazardous to you, your staff, and your patient. Levels
as high as 4000 m g/M3 have been measured 18" from the drill
when used high dry. Levels over 1000 m g/M3 are measurable
upon opening an amalgam mixing capsule.
One out of 7 California dental offices tested over the
OSHA TWA of 50 m g/M 3 . 100% of the vacuum cleaner exhaust
tested over 100 m g/M 3 .
Any office where mercury is used should be tested
regularly and staff should be monitored for exposure.
Testing services are available and a mercury
sensor badge is available for personnel monitoring.
They should test inside storage areas and along baseboards
where mercury might have dropped. Office spills can go
undetected for years and are extremely hazardous.