The death of amalgam is imminent ...

Silver amalgam has served the dental profession and its patients for many years. Although attacked and maligned by many individuals and groups, silver amalgam continues to be a simple, inexpensive, and relatively long-lasting restoration. However, in recent years, amalgam has become the subject of high controversy in both professional and lay groups. The allergenic and pathogenic potential of silver amalgam has been debated for many years without conclusive decisions.

Are you ready?

Gordon J. Christensen, DDS, MSD, PhD

Silver amalgam has served the dental profession and its patients for many years. Although attacked and maligned by many individuals and groups, silver amalgam continues to be a simple, inexpensive, and relatively long-lasting restoration. However, in recent years, amalgam has become the subject of high controversy in both professional and lay groups. The allergenic and pathogenic potential of silver amalgam has been debated for many years without conclusive decisions.

Amalgam`s death is not being caused by scientific inquiry. It is being caused by availability of materials that are tooth colored and appear to serve as well as amalgam. A recent Clinical Research Associates survey showed that approximately one-fifth of the intracoronal restorations placed in the United States were tooth colored. Although impressive, this data still means that four-fifths of the restorations were silver amalgam.

Is this true in other countries? It is well known that several countries are reducing or eliminating the use of amalgam, including Sweden, Germany, Japan, Switzerland, and others. The amalgam technique is not taught at dental schools in some of these locations. Amalgam will not continue to be used in these countries, since dental students will not be introduced to it. Will the same reduction in amalgam use be evident in the United States?

Amalgam use is decreasing every year, and it is likely that eventually amalgam in the United States will be reduced to very few restorations. I predict that this evolution will require many years.

Are tooth-colored intracoronal restorations ready to be accepted? Clinical Research Associates` long-term clinical research comparing silver amalgam with many brands of tooth-colored restorations has shown that composite resin has not only served as well, but (in some situations) better than amalgams placed by the same operators in comparative studies. It is evident that the smaller the restoration, the better the tooth-colored materials serve. However, this is true with silver amalgam as well.

I conclude that in small- to moderate-sized restorations, composite resin materials can serve well if placed properly. Can you place them properly? Numerous studies show placement of composite resin in Class II situations requires more time for novices than does placement of silver amalgam. Clinicians experienced with composite resin inform us that the time spent on these restorations decreases significantly upon continued use.

Eventually, it is easier and faster for them to place composite resin restorations than silver amalgam. When compared on an income-per-unit time basis, silver amalgam produces an inordinately low income for dentists. It has, therefore, been classified by third-party payment agencies and various dental administrators as being an inexpensive restoration.

It is my contention that silver amalgam is illegitimately inexpensive. The expertise required to place amalgam, as well as the time involved, should demand higher fees. Therefore, tooth-colored restorations should have higher fees than the current level of silver amalgam if they are to be acceptable as an income-producing part of the dental practice.

Overall, I contend that most restorative fees are too low when compared with the time spent in other areas of dentistry, including fixed prosthodontics and endodontics. For tooth-colored restorations to become the mainstay in restorative dentistry, fees must be raised, providing income for dentists to place these restorations properly, ensuring their long-term service.

If you have not mastered the Class II composite resin technique, I suggest that you find adequate courses or videotapes to do so. Your fees should be related to the time involved for placing tooth-colored restorations. Patients should be informed that some third-party payment agencies may not pay adequately for these restorations. However, the recent ADA acceptance of Class II composite restorations will reduce third parties` lack of acceptance of these restorations.

Further, I suggest you attempt to detect carious lesions when they are as small as possible. After accomplishing Class II resins for nearly 30 years and following the materials through their various physical changes, I find that these restorations currently are not only serviceable, but they are beautiful and provide a service that is desirable to patients and gratifying to dentists.

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