On the other hand…
It’s fair to say that the issue of the phase-down of dental amalgam is not without controversy. The advice published by SDCEP in June 2018 is welcome and has been greeted positively. However, it is important to recognise that there are some outstanding issues, the solution to some of which is not in the remit of SDCEP, or any similar group or organisation that produces guidelines, writes Sarah Allen.
There has been significant concern among dental professionals that some of the alternative materials are not durable enough for use in certain circumstances in posterior teeth, and to allow equitable access to those materials which have optimal and durable properties would require significantly increased financial remuneration. In addition, it is widely accepted that alternative materials such as composite take approximately double the time to place than amalgam. Coupled with the increased material costs of composite (and relevant etch-bond systems required for their use) over amalgam, dental professionals working under NHS regulations in Scotland may be faced with the prospect of potentially having to do more for less. Although changes have been made to the SDR, there is wide-spread concern among practitioners that the increase to existing fees, and the ones newly introduced, are inadequate to allow for the use of composites that can be a realistic, ethical and durable alternative to amalgam.
Prevention rightly plays a key part in the phase-down and, though the profession is in agreement that prevention must be at the core of national policies around oral health, it is a long-term strategy which does not really support practitioners dealing with the reduction of amalgam use in the short and medium term. Many dental professionals would like to see more practical and financial support from both within the profession and government, to facilitate appropriate implementation of the changes required by amalgam phase-down. Additionally, though the advice is clear that exceptions can be made when there are real medical or dental reasons, many would still like more clarity around how this applies when treating certain groups such as young teenagers with high caries risk or those under 15 with learning disabilities or autism.
Bearing in mind that the phase-down of dental amalgam is purely environmental, another question lingers around the environmental impact of alternative materials. Concerns have been raised about the environmental effect of resin composites, but, as little is known about the longer term environmental effect of these materials, there is a need for further research in this area.
This is, of course, the first of several stages of the phase-down of amalgam, and there is hope that some of these outstanding issues can be addressed more fully in future guidance. This will, of course, require support from both the UK and Scottish governments as many of the questions that remain cannot be fully addressed as part a guidance development process, or be solved by the guidance itself. Ideally, all stakeholders must work together nationally and internationally to co-ordinate implementation of and appropriately support the phase-down during the different stages required by Minimata, however far it is implemented.
It is imperative that the wider issues around funding and support for this very significant change to UK dentistry, which have been brought into focus by these developments, are more effectively and efficiently addressed.
Words: Sarah Allen