SDCEP implementation advice
On 1 July 2018, restrictions on the use of dental amalgam came into effect throughout the UK. In this article we look at what these restrictions are, how they came about, advice for adhering to them and what is likely to happen next
Dr Michele West, SDCEP
What are the new restrictions on dental amalgam use?
New environmental restrictions on dental amalgam use in specific patient groups came into effect in the UK on 1 July 2018. The use of dental amalgam for the treatment of patients under 15 years old, of pregnant or breastfeeding patients or of deciduous (primary) teeth in any patient is now only allowed when deemed strictly necessary by the dental practitioner based on the patient’s dental or medical needs.
The restrictions, which are specified in EU regulations and applicable in UK law, have been introduced to fulfil the requirements of the global Minamata Convention, to which the UK government is a signatory. This United Nations Convention aims to reduce the use of mercury and mercury containing products, including dental amalgam, on environmental grounds.
Why is there a need to phase-down the use of dental amalgam?
There is no evidence that mercury present in dental amalgam presents a direct health risk to individuals who have amalgam restorations or to dental staff. However, when released into the environment, the mercury within dental amalgam can be converted by aquatic microorganisms into a form that can accumulate to toxic levels in fish and other marine life and enter the human food chain. Therefore, by contaminating the environment, dental amalgam can contribute indirectly to the risk to human health from mercury. Phasing-down the production, use and disposal of dental amalgam will help to reduce this indirect risk.
What support is there for dental practitioners?
Advice published in June 2018 by the Scottish Dental Clinical Effectiveness Programme (SDCEP) aims to support dental professionals across the UK in interpreting and implementing the restrictions on dental amalgam use specified in Article 10(2) of the EU regulations. The advice emphasises the importance of caries prevention and provides information about alternative caries management approaches and restorative materials to inform practitioners’ clinical decision-making.
Examples of situations where dental amalgam may be the only feasible treatment option are presented, and these include when there is an allergy or local adverse reaction to alternative materials, or when moisture control or patient co-operation is insufficient to allow the use of an alternative to dental amalgam for the treatment required. It is advisable to document the reasons why amalgam was used in individual circumstances for these patients in the patient’s record.
It is recognised that, in light of the new regulations, patients may have concerns about existing or planned dental amalgam restorations. Consequently, information leaflets for the patient groups to which the restrictions apply are provided by SDCEP to help practitioners explain the new regulation, support discussions with patients and parents or carers and provide reassurance about their care.
The Scottish Government has issued a memorandum to NHS Boards and Practitioner Services advising of new arrangements relating to the phasing down of dental amalgam, including a new amendment to the Statement of Dental Remuneration (SDR).
How was the SDCEP Implementation Advice developed?
The advice was requested by the UK Chief Dental Officers and has been developed following a rapid process that draws on elements of SDCEP’s accredited guidance development methodology. A short-life working group that included experienced dental practitioners and experts in restorative and paediatric dentistry, drawn from across the UK, was convened to develop the advice. UK-wide consultation was conducted to allow stakeholders to comment on and contribute to the development of the advice. The Dental Faculties of the Royal College of Surgeons of Edinburgh, the Royal College of Physicians and Surgeons of Glasgow and the Faculty of General Dental Practitioners (UK) have endorsed the implementation advice.
While this has been standard practice in Scotland for several years, the banning of bulk form dental amalgam and the requirement for amalgam separators both come into effect on 1 January 2019 to help reduce amalgam waste and improve use, storage and waste management. The next key milestone designated by the EU regulations is the requirement for a national plan by 1 July 2019 on measures to phase-down the use of dental amalgam.
In the longer term, the direction of travel may be towards a more substantial phase-down and ultimately phase-out of dental amalgam, as has been implemented in countries such as Norway and Sweden, although at this point this is speculation. A feasibility study by the European Commission on the potential phase-out of the use of dental amalgam, preferably by 2030, is due to report by 2020.
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Words: Sarah Allen