Many dentists wonder if patients would leave their practices should they stop doing amalgams. First of all, dentists must do what they feel is right. If a dentist believes that amalgam is the best restoration, then that should be the restoration of choice. I couldn't in good conscience put in the mouths of my patients what I wouldn't put in the mouths of my family. But the decision is ultimately the choice of the treating dentist. It is up to you to determine the evidence and decide how you want to practice.
Evidence against amalgams:
- The cusps of amalgam-restored teeth are only 30 percent as strong as healthy teeth or teeth restored with bonded restorations.
- Amalgam expands as it ages, causing significant tooth fracturing.
- Mercury concerns. The great controversy about the health concerns associated with amalgams containing mercury continues. Superior restorations are available. Use them - and bypass the debate.
- Aesthetic concerns. Most patients prefer teeth that look like teeth.
Those who agree that amalgam is not the restoration of choice, but use it anyway due to the dictates of the insurance industry are practicing questionable dentistry. Failure to give your honest and professional opinion about the efficacy of any product amounts to neglect. Dentists have a duty to recommend to their patients what they would - or would not - use in their own mouths.
Many dentists fear that if they don't do amalgams, or if they try to convince their patients that a more expensive restoration is best, they will lose patients. Yet, I have never heard of a dentist losing income after deciding not to do amalgams. In fact, most say it's the most painless thing they have ever done. Most people don't want "silver/mercury fillings." Amalgam has survived all these years only because dentists have given this service away. If it were not the cheapest material available and forced on our profession by the insurance industry as a means to hold down their costs, these restorations would have been eliminated a long time ago.
What are the alternatives?
Herein lies the problem. Amalgams are easy to place. Aesthetic restorations, on the other hand, are more technique-sensitive. Composite or porcelain restorations require great attention to detail to prevent sensitivity. These restorations are not hard -but they do have to be done right. Since most dentists have not learned how to properly complete these restorations in dental school, it is imperative that they get hands-on training elsewhere. Improper techniques, resulting in post-operative sensitivity, will cause patients to leave the practice.
If dentists take the steps necessary to properly prepare and seat these restorations, they can become practice builders, rather than practice destroyers. Restoring teeth to their natural form and function will create enthusiasm and excitement in your patients. They often become missionaries for your practice. The "strong" feeling of these bonded restorations will be something that the patients will talk about compared to the weakened cusps of an unbonded restoration. The positive reactions from their patients convince most dentists that the decision to eliminate amalgams from their practices was the correct one.
But what do we replace amalgams with? Composite restorations come in two forms, direct and indirect. The advantage of indirect composites is that the physical properties are improved by the processing technique. Shrinkage is eliminated - except for the thin layer of luting cement - since the shrinkage occurs in the lab and not in the mouth. Examples of indirect composite material are BelleGlass (Kerr) and Targis (Ivoclar). These materials can be reinforced with strong, pressed-fiber material called Vectris (Ivoclar) that will dramatically improve the physical properties, allowing them to be used in situations not normally associated with composite material (bridges, onlays, etc.).
Porcelain restorations can be in the form of feldspathic or pressed ceramic. Probably the most popular porcelain material for this purpose is Empress (Ivoclar). Although Empress II was introduced as a crown and bridge material, some early problems have prevented it from widespread use. Some alterations of Empress have allowed it to be used for bridges when reinforced with Vectris (the LVI bridge). In many practices, metal-free restorations are a reality. Advances in these types of aesthetic materials will continue to evolve. Metal-free practices will be the norm, not the exception.
Regardless of your choice of material, there are many options that will allow the practicing dentist to confidently eliminate amalgam fillings from their practices. It can be done with confidence and the knowledge that the material chosen is a viable and even superior replacement to the standards dictated by the insurance industry. As the Nike commercial states, "Just Do It!" You and your patients will be glad you did.
