What do patients think about Mercury in Dental Amalgam? Findings from Southeast part of Turkey- Juniper Publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF DENTISTRY & ORAL HEALTH
Abstract
Aim of the study:To research the perceptions of patients in the Diyarbakir region in respect of the toxicity of mercury in amalgam fillings.
Materials and methods:The study
included 500 patients with at least one amalgam filling who attended the
clinic for routine dental treatments. Data were gathered using a
single-page questionnaire The questions on the form related to age,
gender, marital status, level of education, economic status, types of
dental filling, whether or not the amalgam filling included mercury and
whether or not mercury was harmful to human health. Questions were also
asked to ascertain the patient’s level of knowledge in respect of
mercury, amalgam fillings and human health.
Results:A total of 500 patients were
included in the study, comprising 283 (56.6%) females and 217 (43.4%)
males. When economic status was questioned, 267 (53.4%) patients
reported monthly income of 0-1000TL and 233 (46.6%) patients reported
more than 1000TL. The level of education was primary school in 110 (22%)
patients, high school in 159 (31.8%), university or post-graduate in
190 (38%) and 41 (8.2%) were illiterate. The type of dental filling was
unknown by 64.4% of patients and 59.6% did not know that the amalgam
filling contained mercury. 52.6% of the patients did not know whether or
not mercury was harmful and 72% did not know whether or not mercury in
amalgam was harmful.
Conclusion:A low level of awareness was determined in the study participants in respect of the toxicity of mercury in amalgam fillings.
Keywords:Awareness; toxicity; Mercury; Dental AmalgamIntroduction
Amalgam is a restorative material that has been
widely used in dentistry applications for 160 years. Amalgam is a
composite of silver, copper, tin, palladium and mercury (Hg). The ratio
of mercury found in the structure of amalgam varies between 42% and 52%
depending on the weight [1]. It has been reported that there may be
potential toxic dangers of amalgam to patients through expression and
absorption of mercury. By gradual expression from the amalgam
restoration, mercury may accumulate in enamel, dentine, pulpal tissue
and gingival tissue [2]. Several materials have been have been developed
which can be used as an alternative to amalgam in the field of
restorative
dentistry, but there have been substantial criticisms of these materials
because of the mercury content of amalgam and the non-aesthetic
appearance. Therefore, amalgam remains a widely-used material in dental
clinics [3,4]. During the application or removal of amalgam, there could
be potential side-effects on the body of the expression of mercury,
creating a risk for both dentists and patients of chronic fatigue, loss
of strength, epilepsy, migraine, blindness and it has even been
suggested that it could lead to diseases such as multiple sclerosis and
Alzheimer’s [5].
The main reason for debate of amalgam restorations is
due to mercury. Very small amounts of elemental mercury vapour are
expressed from the amalgam filling when chewing [6]. Previous scientific
research has shown that after chewing, the amount of mercury in the
mouth and respiration of individuals with amalgam fillings is much
greater than in those without.7During the appication of amalgam,
polishing
and removal, an amount of mercury vapour is released into
the environment. Although patient plasma peak mercury
concentration values increase during removal, blood, plasma and
urine mercury levels fall significantly after a short period and it
has been repoted that if water cooling is applied during removal,
this short-term increase is less. With an intra-oral increase
in temperature from mechanical stimuli such as bruxism and
functional activities such as chewing, teeth brushing or chewing
gum, very small amounts of mercury vapour can be released into
the environment.
The extent of exposure to mercury in an individual is measured
in urine and blood levels. Rates of mercury in the blood and urine
of those with amalgam fillings has been observed to be increased
2-5 fold [7]. A previous study examining the relationship of
dentists and mercury exposure reported greater levels of
poor mental concentration, emotional lability and findings of
somatosensorial irritation in the group exposed to mercury
compared to the group with no exposure [8]. Amalgam fillings
are widely used in private clinics and public hospitals in Turkey.
However, the perceptions of patients and levels of knowledge
of the toxicity of mercury in amalgam fillings are unknown. The
aim of this study was to investigate the pereceptions of patients
in the Diyarbakir region of Turkey in respect of the toxicity of
mercury in amalgam fillings.
Materials and Methods
The study was planned and conducted in the Restorative
Dentistry Department of the Dental Faculty of Dicle University.
The study included 500 patients with at least one amalgam filling
who attended the clinic for routine dental treatments. Prior to
the study, approval was granted by the Non-Invasive Clinical
Research Ethics Committee of Dicle University Medical Faculty
(Ethics Committee No 304, Session No:08.07.2013).
The study questionnaire was based on the based on standard,
validated questions assembled from previous publications [6].
Data were gathered using a single-page questionnaire which had
been developed in the standard manner. After the identification
of patients with a dental amalgam filling, the study was conducted
by dental assistants. Informed consent was obtained from the
patients and the questionnaires were immediately completed in the clinic. Participation in the study was completely voluntary.
The questions on the form related to age, gender, marital status,
level of education, economic status, types of dental filling,
whether or not the amalgam filling included mercury and
whether or not mercury was harmful to human health. Questions
were also asked to ascertain the patient’s level of knowledge in
respect of mercury, amalgam fillings and human health and were
analysed with a Likert scale:
- Despite the mercury content, I would have an amalgam filling
- When there is no alternative, I would have an amalgam filling.
The responses to these statements were in the form of I
completely agree-5, I agree-4, I don’t know - 3, I don’t agree - 2,
I completely disagree -1. The results were input to an SPSS 16.0
program and evaluated.
Determination of the Level of Agreement with the Use of Amalgam
The total weight value (TWV) of agreement was calculated
as follows: TWV=Ʃn.w (n means the number of respondents for
each rating and w is the weight assigned to the rating). The levels
of agreement (Z) were arrived at by dividing the TWV by the total
number of respondents (n=500).
Results
The study included 500 patients, comprising 283 (56.6%)
females and 217 (43.4%) males. The age range of the patients
was 15-24 years in 176 cases, 25-34 in 151 cases, 35-44 in 102
cases, 45-54 years in 44 cases and 55 years + in 27 cases. Marital
status was reported as married by 264 and single by 236 patients.
Economic status was reported as 0-1000TL monthly income by
267 (53.4%) and over 1000TL by 233 (46.6%) patients. The
level of education of the patient group was reported as primary
school in 100 (22%), high school in 159 (31.8%), university or
postgraduate in 190 (38%) and 41 (8.2%) patients were illiterate.
Of the total patients, 64.4% did not know the type of filling and
59.6% did not know that the amalgam filling contained mercury.
52.6% of patients did not know whether or not mercury was
harmful and 72% did not know whether or not the mercury in
the amalgam filling was harmful (Table 1).
The responses to the statement, ‘Despite the mercury
content, I would have an amalgam filling’ are presented in Table
2 and the responses to ‘When there is no alternative, I would
have an amalgam filling’, are given in Table 3. When patients
were questioned where they had learned that the amalgam
filling was harmful or harmless, the responses were from the
dentist or doctor in 24% of patients, from mass media in 21.4%
and from their social environment in 5% of patients. When the
numbers of fillings in the teeth of the patients were examined, 90
patients had 1 filling, 88 had 2 and 322 patients had 3 or more
fillings. The number of amalgam fillings were determined as 1
in 174 patients, 2 in 119 patients and 3 or more in 207 patients.
Discussion
Amalgam fillings have been in widespread use for many
years. However, recent studies demonstrated that due to
esthetic demands and potential health concerns have led to
loss of popularity of amalgam among dental patients. In Turkey,
amalgam is not seen as a significant problem of debate between
dental practitioners and state policies. According to the results
of Zogby International Poll 76% Americans don’t know mercury
is the primary component of amalgam fillings. Another study in
Nigeria, it was stated that only 35% of the participant know that
amalgam fillings contain mercury [6]. In our study, around 40%
of participants reported that they knew amalgam fillings
contained mercury which is close to Nigerian data [6]. In a
study by Faraj M et al, awareness of mercury toxicity was found to
be low. That result was associated with discussions of amalgam
in the North of Iraq. In addition, it was reported that the level
of acceptance of amalgam fillings was related to the economic
status, oral and dental education and aesthetic expectations [9].
Similarly, in the current study, the awareness of participants of
the toxicity of mercury in amalgam fillings was found to be low.
The observation that the approximately half of the (47.4%)
of particiapants in the current study agree that mercury was
harmful to human health is in considerably higher than with
the results of a previous surveys conducted among Nigerian
and North Iraq population. This level of knowledge is thought
to be related to the level of education. Of the total participants,
38% had a university or postgraduate level of education. Of the
participants with postgraduate education in the current study,
84.4% knew that mercury was harmful to health. In the group
of participants who were illiterate, 7.3% knew that mercury was
harmful to health. These findings demonstrate the importance of
education and are consistent with the results of previous studies
[10-12]. In respect of economic status, 75.9% of the participants
in the current study with a monthly income of over 2000TL and
75.6% of those with a monthly income of over 3000TL knew that
mercury was harmful to health.
This level of awareness shows a relationship with economic
status. The level of awareness of mercury was seen to be in parallel
with the level of education. Contrarily, in a study by Bamise, Oginni
[6] in Nigeria demonstrated that only 26% participants believed
that mercury can cause health problem on human body even
though 92% of the them were either undergraduate or graduate
level. Similarly in a study by Faraj, Mohammad9 observed that
24.32% of the participants claimed to have heard about adverse
reactions to dental amalgams. Bamise CT et al. [6] stated that
50% of participants in a study knew the type of fillings they had.
In the same study, the importance of the use of informed consent
and amalgam alternatives was reported. Various materials have been developed as an alternative to amalgam. However, none
of these have been able to meet conditions as an economical
alternative to amalgam [10]. In the current study, the vast
majority of participants did not know what type of fillings they
had, with only 35.6% able to state the type of dental filling. In
Turkey, amalgam is used routinely in public hospitals and private
clinics and is economical and easy to apply compared to other
restorative materials. These features could be the reasons for
preference.
In the currrent study, although the health risks of amalgam
were known, it was seen to be popular among the participants.
According to the results of the Likert scale analysis, while
58.52% of participants responded positively to the statement,
‘Despite the mercury content, I would have an amalgam filling’,
67.76% responded positively to the statement, ‘When there is
no alternative, I would have an amalgam filling’. These results
showed that patients were familiar with amalgam and that it was
a popular filling material. The results of the current study were
consistent with those of the study by Bamise et al. [6] In another
study by Udoye and Aguwa in Nigeria, amalgam was reported
to be an acceptable material by both dentists and patients [10].
Contrary to all these data, Zogby International Poll demonstrated
that the majority (77 percent) of Americans would choose higher
cost fillings that do not contain mercury if given the choice.
Amalgam fillings and mercury have been debated in the written
and visual media of most countries. When the level of awareness
increases, there is seen to be an increase in these discussions.
However, even if the results of this study are to be examined,
discusssion of amalgam is not a priority in the Diyarbakir region.
A 2007 declaration by the World Health Organisation related
to mercury recommended that exposure be reduced, that it is not
used wherever possible and that support is given to alternatives.
After the publication in 2008 of ‘Protective Regulations’ by most
Health Ministers in Europe to prevent the use of mercury-based
materials in children below the age of 6 years, firstly Norway,
then Sweden and Denmark took the important step in the same
year of formalising this as legislation. Following this process,
Germany, Austria and Russia banned or restricted the use of
mercury. Japan is known to have introduced this ban previously.
When the involvement of the WHO and the EU is taken into
consideration, the use of amalgam can be considered to have
gone through the process of prohibition. It is also noticeable
that in countries where it has not been banned, the majority of
dentists have started to abandon this type of filling [13].
The mass media, in the form of the radio and television,
are an effective way to persuade target audiences to adopt new
behaviors, or to remind them of critical information. Besides
informing the public about new diseases and where to seek
help, they can also keep the public updated about environmental
issues. The mass media can enlighten rural populations to
increase their knowledge about potential toxic effect of mercury.
In our study only 21% of participants report that where they had learned that the amalgam filling was harmful or harmless
from mass media. This finding sugges that in Turkey mass media
should take more responsibility and action to inform population
on health and enviromental issues. The effects of amalgam
fillings on human tissue and reported that even though there are
many studies showing the effects on tissue of mercury vapour
released from amalgam, there is a need for studies which would
examine the relationship between neurodegenerative diseases
and mercury released from amalgam, which would investigate
the role of amalgam on Alzheimer’s disease and multiple
sclerosis and which would evaluate the neurobiological and
neurodevelopmental effects of mercury in children exposed to
mercury expressed from amalgam fillings of the mother during
pregnancy [14].
Conclusion
The results of this study showed that the level of awareness
of the toxicity of mercury was low in the study participants. Until
the development of a restorative material which is as economical
as amalgam, has proven long-term success and is biocompatible,
then amalgam can be said to be a safe and reliable restorative
material for our patients. From the results of this study in the
Diyarbakir region, it can be seen that amalgam fillings were
popular among the participants. When the socio-economic and
educational levels of the region increase, it can be assumed that
there will be an increase in perceptions and awareness.
For more articles in Open Access Journal of
Dentistry & Oral Health please click on:
Comments
Post a Comment