Health Effects from
Dental Personnel Exposure to Mercury Vapor from Dental Amalgam B. Windham(Ed)
1. Dental offices are known to be
one of the largest users of inorganic mercury(71b,26,etc.). It is well documented that dentists and
dental personnel who work with amalgam are chronically exposed to mercury
vapor, which accumulates in their bodies to much higher levels than for
most non-occupationally exposed. Adverse
health effects of this exposure including neurological effects have also been
well documented that affect most dentists and dental assistants, with
measurable effects among those in the lowest levels of exposure. Mercury levels of dental personnel average at least 2
times that of controls for hair(397-401), urine (25d,57,64,69,99, 123,124,138,171,173,
222,249, 290,362,397-399), toenails(562), and for blood
(124,195,253,249,397,563). A Lebanese study(398b) found 25 % of dentists had hair mercury levels
over 5ppm and 8% had level over 10 ppm.
Sweden, which proposed to ban use of
mercury in fillings, is the country with the most exposure and health effects
studies regarding amalgam, and urine levels in dental professionals
from Swedish and European studies ranged from 0.8 to 30.1 ug/L with study
averages from 3.7 to 6.2 ug/L (124,172,253,64,68). The Swedish safety guideline for mercury in
urine is 5.6 nmol Hg/nmol(11.6 ug/L). Study averages for other countries ranged
from 3.2 to 15 microgram/liter(ug/L) (69,70,171,290,397). A large survey of dentists at the Norwegian
Dental Assoc. meeting(171) found that the mean mercury
level in 1986 was 7.8 ug/L with approx. 16% above 13.6ug/L, and for 1987 found
an average of 8.6 ug/L with approx. 15% above 15.8 ug/L, with women having
higher levels than men in general. A U.S. national sample of dentists provided
by the American Dental Association had an average of 5.2 ug/L
(290a). In that large sample of
dentists, 10% of dentists had urine mercury levels over 10.4 ug/L and 1% had
levels over 33.4ug/L(290,25c), indicating daily exposure
levels of over 100 ug/day. Another large U.S. study had an average mercury
level in urine of dentists of 3.2 ug/L(291a).
Researchers from the Univ. of
Washington School of Dentistry and Dept. of Chemistry tested a sample of
dentists at an annual ADA meeting(230). The study found that the dentists had a
significant body burden of mercury and the group with higher levels of mercury
had significantly more adverse health conditions than the group with lower
exposure. The increased effects in the
group with more mercury exposure included mood disturbances, memory deficits,
fatigue, confusion, anxiety, and delay in simple reaction time. A Norwegian
study compared the occurrence of neurological symptoms among dental assistants
likely to be exposed to mercury from work with dental filling material,
compared to similar health personnel with no such exposure (596). The dental
assistants reported significant higher occurrence of neurological symptoms;
psychosomatic symptoms, problems with memory, concentration, fatigue and sleep
disturbance. Another study of a group of 194 U.S. male
dentists with mean urine mercury level of 3.3 ug/L and 233 female dental
assistants with mean urine mercury level of 2.0 ug/L considered effects of
polymorphism in brain-derived neurotrophic factor(BDNF) or a polymorphyism in blood heme(CPOX4) as
well as mercury level(291). The study found significant effects of mercury
level on 9 measures of neurologicial deficits for the dentists and on 8
measures of neurological deficits for dental assistants(291),
as well as a significant difference relating to BDNF and to CPOX4.
Large studies of U.S. dentists and
dental assistants have found that mercury level in urine is significantly
associated with neurological dysfunction using several different measures, but
that among a population with low level mercury exposure those with a
polymorphism in blood heme (CPOX4) or to a polymorphism in neurofactor (BDNF)
or to a functional single nucleotide
polymorphism (Val158Met) in the gene encoding the
catecholamine catabolic enzyme catechol O-methyltransferase (COMT) were more
susceptible to neurological effects or deficits(291). An association in a
population with low level mercury exposure between such polymorphisms and mood
disorders was found only for female dental assistants. The associations between
a
polymorphism of the serotonin transporter gene
(5-HTTLPR), dental mercury exposure, and self-reported symptoms were evaluated
among 157 male dentists and 84 female dental assistants. The findings suggest that within this
restricted population of mercury exposed workers, increased symptoms of
depression, anxiety, and memory are associated with the 5-HTTLPR
polymorphism among both males and females(291d).
Mercury excretion levels were found to
have a positive correlation with the number of amalgams placed or replaced per
week, the number of amalgams polished each week, and with the number of
fillings in the dentist(171,172,173). In one study, each filling was found to
increase mercury in the urine approx. 3%, though the relationship was nonlinear
and increased more with larger number of fillings(124). Much higher accumulated body burden levels
in dental personnel were found based on challenge tests than for controls(303),
with excretion levels after a dose of a chelator as high as 10 times the
corresponding levels for controls (57,69,290a,303). Autopsy studies have found similar high body
accumulation in dental workers, with levels in pituitary gland and thyroid over
10 times controls and levels in renal cortex 7 times controls(99,363,38). Autopsies of former dental staff found
levels of mercury in the pituitary gland averaged as high as 4,040 ppb. They also found much higher levels in the
brain occipital cortex(as high as 300 ppb), renal cortex(as high as 2110 ppb) and
thyroid(as high as 28,000 ppb. In
general dental assistants and women dental workers showed higher levels of
mercury than male dentists (171,172,173,253,303,362).
Mercury levels in blood of dental professionals ranged from 0.6 to 57 ug/L, with study averages ranging from 1.34 to 9.8
ug/L (124,195,253,249,531). A review of
several studies of mercury level in hair or nails of dentists and dental
workers found median levels were 50 to 300% more than those of controls(38,
p287-288,& 10,16,178,531). Dentists have been found to have elevated
skeletal mercury levels, which has been found to be a factor in osteoporosis,
as well as mercury retention and kidney effects that tend to cause lower
measured levels of mercury in urine tests(258). A group of dental students taking a course
involving work with amalgam had their urine tested before and after the course
was over. The average urine level increased by 500% during the course(63). Allergy tests given to another group of dental
students found 44% of them were allergic to mercury(156). Studies have found that the longer time
exposed, the more likely to be allergic and the more effects(6b,154c,156,503a)
. One study found that over a 4 year
period of dental school, the sensitivity rate increased 5 fold to over 10%(154c). Another
group of dental students had similar results(362),
while another group of dental student showed compromised immune systems
compared to medical students. The total
lymphocyte count, total T cell numbers(CD3), T helper/
inducer(CD4+CD8-), and T suppressor/cytotoxic(CD4-CD8+) numbers were
significantly elevated in the dental students compared to the matched control
group(408). Similar results have been seen in other studies as well(408).
More
than 10,000 dental assistants were exposed to extremely high concentrations of
mercury fumes while working with amalgam in dental offices during the 60’s,
70’s, 80’s, and early 90’s(575). 25% of them report they often or very often
have neurological problems. They have
been compared with a group of nurses of the same age. Dental assistants scored much higher than
nurses on 4 health problems:
tremor/shaking;
heart and lung problems, depression, and lack of memory/memory
failure.
Urinary porphyrin profiles were found to be an excellent biomarker of
level of body mercury level and mercury damage neurological effects, with
coproporphyrin significantly higher in those with higher mercury exposure and urine
levels(70,260). Coproporphyrin levels
have a higher correlation with symptoms and body mercury levels as tested by
challenge test(69,303), but care should be taken
regarding challenge tests as the high levels of mercury released can cause
serious health effects in some, especially those who still have amalgam
fillings or high accumulations of mercury.
Screening test that are less burdensome and less expensive are now
available as first morning void urine samples have been found to be highly
correlations to 24 hour urine test for mercury level or porphyrins(73).
2. The average dental office
exposure affects the body mercury level at least as much as the workers on
fillings(57,64,69,123,138,171,173,303), with several studies finding levels
approximately the same as having 19 amalgam fillings(123,124,173). Many surveys have been made of office
exposure levels(1,6,7,10, etc.) The level of mercury
at breathing point in offices measured ranged form 0.7 to over 300 micrograms
per cubic meter(ug/M3) (120,172,253,249). The average levels in offices with reasonable
controls ranged from 1.5 to 3.6 ug/M3, but even in Sweden which has had more
office environmental controls than others spot levels of over 150 ug/M3 were
found in 8 offices(172). Another study found spot
readings as high as 200 ug/M3 in offices with few controls that only used
saliva extractor(120). OSHA surveys find 6-16% of U.S. dental
offices exceed the OSHA dental office standard of 50 ug/M3, and
residual levels in equipment sterilizers often exceed this level(454).
The German workplace mercury
standard of 1 ug/M3 is almost always exceeded(258).
The U.S. ATSDR mercury vapor exposure MRL for chronic exposure is much
lower, 0.2 ug/M3 (217) (giving approx. 4 ug/day exposure), similar to U.S. EPA
and Health Canada guidelines(2,209). Thus most office mercury levels were found to
far exceed the U.S. guidelines for chronic mercury exposure.
Use of high speed drill in removal or replacement has been found to
create high volume of mercury vapor and respirable particles, and dental masks
to only filter out about 40 % of such particles (219,247a). Amalgam dust generated by high speed drilling
is absorbed rapidly into the blood through the lungs and major organs such as
the heart receive a high dose within minutes(219a,395c,503c).
This produces high levels of exposure to patient and dental staff. Use of water
spray, high velocity evacuation and rubber dam reduce exposure to patient and
dental staff significantly, as seen in previous discussion. In addition to these measures researchers
also advise all dental staff should wear face masks and patients be supplied
with outside air (120,153). Some
studies note that carpeting and rugs in dental offices should be avoided as it
is a major repository of mercury (6,7,21d,71b,188,395c,503) For
office’s using an aspirator, at the dentist's breathing zone, mercury vapor
concentrations of ten times the current
occupational exposure limit of 25 microg/m3 were recorded after 20 minutes
of continuous aspirator operation(219).
A build up of amalgam contamination within the internal corrugated tubing of the aspirator was
found to be the main source of mercury vapor emissions followed by particulate
amalgam trapped within the vacuum motor. As the vacuum motor heated up with run time, mercury vapor emissions
increased. It was found that the bacterial air exhaust filter (designed to
clean the contaminated waste air entering the surgery) offered no protection to mercury vapor. Use of such measures along with a
Clean-UpTM aspirator tip was found to reduce exposure to patient and
staff approximately 90%(397).
3. Dentists
were found to score significantly worse than a comparable control group on
neurobehavioral tests of motor speed, visual scanning, and visuomotor
coordination (69,70,123,249,290ab,395d,531,1b), concentration , verbal memory,
visual memory (68,69,70,249,290ab,395,531,563,1b), and emotional/mood
tests(70,249,290a,395,563,1b). Test
performance was found to be proportional to exposure/body levels of mercury (68,70,249,290,395,1b). Significant adverse neurobehavioral
effects were found even for dental personnel receiving low exposure levels(less
than 4 ug/l Hg in urine)(70). This study was for
dental personnel having mercury excretion levels below the 10th percentile of
the overall dental population. Such levels are also common among the general
population of non- dental personnel with several fillings. This study used a
new methodology which used standard urine mercury levels as a measure of recent
exposure, and urine levels after chelation with a chemical, DMPS, to measure
body burden mercury levels. Thirty
percent of dentists with more than average exposure were found to have
neuropathies and visuographic dysfunction(395).
Mercury exposure has been found to often cause disability in dental workers(230b,395c,503,504a,etc.)
A large study at a Scottish
University found dentists had higher levels of mercury in their bodies,
compared with a sample group of academics(545).
Researchers obtained urine, hair and nail samples from 180 dentists in the west
of Scotland and 180 academics from the University of Glasgow. Levels of mercury were four times higher on
average among dentists compared with academics. The levels were found to be
strongly associated with the number of hours worked, the number of fillings
handled and the number of fillings they had themselves. There was evidence the
increased mercury exposure results in adverse effects. Dentists were 10 times
more likely to have sought medical treatment for kidney disorders and three
times more likely to have experienced fertility problems. There were also more
than twice as likely to have suffered from memory disturbances. These are all
problems known from other studies to be related to mercury exposure. (Some discussions of study findings such as
this make it clear that many critics of such study findings do not understand
the well documented fact that effects of mercury at not strictly dose related
and depend on susceptability as well as dose.
A significant portion of the population are more immune reactive or have
less system ability to detoxify and excrete mercury than others. The fact that
some aren’t significantly affected by levels that disable others has been used
inappropritately as an argument against accepting consistent significant
findings.)
Chelators like DMPS have
been found after a fast to release mercury from cells in tissue to be
available for excretion. This method was
found to give enhanced precision and power to the results of the tests and
correlations. Even at the low levels of
exposure of the subjects of this study, there were clear demonstrated
differences in test scores involving memory, mood, and motor skills related to
the level of exposure pre and post chelation(290). Those with higher levels of mercury had deficits
in both memory, mood, and motor function compared to
those with lower exposure levels. And
the plotted test results gave no indication of there existing a threshold below
effects were not measurable. Mood scores
including anger were found to correlate more strongly with pre chelation urine
mercury levels; while toxicity symptoms, concentration, memory(vocabulary,word),
and motor function correlated more strongly with post-chelation mercury
levels. Another study using DMPS
challenge test found over 20 times higher mercury excretion in dentists than in
controls, indicating high body burden of mercury compared to controls(491).
Many dentists have been documented
to suffer from mercury poisoning (6f,71,72,74,193,246,247,248,369,531) other
than the documented neurological effects, such as chronic fatigue, muscle
pains, stomach problems, tremors, motor effects, immune reactivity, contact
dermatitis etc. One of the common
effects of chronic mercury exposure is chronic fatigue due to immune system
overload and activation. Many studies
have found this occurs frequently in dentists and dental staff along with other
related symptoms- lack of ability to concentrate, chronic muscular pain,
burnout, etc.(249,369,377,378,490,531,1b). In a group
of dentists and dental workers suffering from extreme fatigue and tested by the
immune test MELISA, 50% had autoimmune reaction to inorganic mercury and immune
reactions to other metals used in dentistry were also common(369). Tests of controls did not find such immune
reactions common. In another study
nearly 50 % of dental staff in a group tested had positive autoimmune ANA
titers compared to less than 1 % of the general population(35).
One dentist with severe symptoms similar to ALS improved after treatment
for mercury poisoning(246), and another with
Parkinson’s disease recovered after reduction of exposure and chelation(248).
Similar cases among those with other occupational exposure have been seen. A survey of over 60,000 U.S. dentists and
dental assistants with chronic exposure to mercury vapor and anesthetics found
increased health problems compared to controls, including significantly
higher liver, kidney, and neurological diseases(99,193). A recent study in
Scotland found similar results(531). Other studies reviewed found increased rates
of brain cancer and allergies(99,193) and lupus(113,234a). Swedish male dentists were found to have an
elevated standardized mortality ratio compared to other male academic groups(284). Dental workers and other workers exposed to
mercury vapor were found to have a shortening of visual evoked potential
latency and a decrease in amplitude, with magnitudes correlated with urine
excretion levels(190).
Dentists were also found to have a high incidence of radicular muscular
neuralgia and peripheral sensory degradation(190,395,490). In one study of dentists and dental
assistants, 50% reported significant irritability, 46% arthritic pains, and 45%
headaches(490a), while another study found selective atrophy of muscle fibre in women dental workers(490b)
and in a third study
significant between-group differences were found in current
health symptom experience and reproductive health, especially early
hysterectomy experience. Reporting of Occupational Overuse Syndrome was
strongly positively correlated with years of work(490c).
In a study in Brazil(492), 62% of dental
workers had urine mercury levels over 10 mg/L, and indications of mild to
moderate mercury poisoning in 62% of workers.
The most common problems were related to the central nervous
system. Recent studies in Turkey(492b) found the dental staff group had higher whole
blood (B-Hg) and urine (U-Hg) Hg levels than the control group. The mean B-Hg
value was 2.18 nmol/l and U-Hg was 1.17 nmol/mmol
creatinine. U-Hg had an inverse relationship with logical memory (in WMS-R
test) and total retention score (in VTMP test), and a positive relationship
with increased scores of Anxiety and Psychoticism (in SCL-90-R). Dentists mercury levels in urine were 3 times
higher than controls(492c).
4. Both dental hygienists and
patients get high doses of mercury vapor when dental hygienists polish or use
ultrasonic scalers on amalgam surfaces (240,400,503c). Use of hydrogen peroxide or other bleaching
agents for teeth whitening in dental office or home bleaching products also results
in significant increases in release of mercury by amalgams(505). Pregnant women or pregnant hygienist
especially should avoid these practices during pregnancy or while nursing since
maternal mercury exposure has been shown to affect the fetus and to be related
to birth defects, SIDS, etc.(10,23,31c,37,38,110,142,146,401,19,31,50). Amalgam has been shown to be the main source
of mercury in most infants and breast milk, which often contain higher mercury levels than in the
mother’s blood (20,61,112,186,287). Because of high documented exposure levels
when amalgam fillings are brushed(182,222,348) dental
hygienist are advised not to polish dental amalgams when cleaning teeth. Face masks worn by dental workers filter out
only about 40% of small dislodged amalgam particles from drilling or polishing,
and very little mercury vapor(247a). Dental staff have
been found to have significantly higher prevalence of eye problems,
conjunctivitis, atopic dermatitis, and contact urticaria(247,156,74).
Finnish dental staff have the highest occupational risk of contact dermatitis
with 71% affected over time(247b) with plastics,
rubber, and mercury the most common causes of sensitization.
Korean dental technicians have a high
incidence of contact dermatitis, with dental metals the most common
sensitizers. Over 25% had contact dermatitis with over 10% sensitive to 5
metals, cromium, mercury, nickel, cobalt, and palladium(247c).
Another study found a high prevalence of extrapyramidal signs and symptoms
(tremor) in a group of male dental technicians working in a state technical
high school in Rome(247d).
An epidemiological survey conducted in Lithuania on women working in
dental offices(where Hg concentrations were < 80 ug/M3)
had increased incidence of spontaneous abortions and breast pathologies that
were directly related to the length of time on the job(277a). A large U.S. survey also found higher
spontaneous abortion rate among dental assistants and wives of dentists(193), and two other studies found an increased risk
of spontaneous abortions and other pregnancy complications among women working
in dental surgeries(277bc). A study of dentist and dental assistants in the
Netherlands found 50% higher rates of spontaneous abortions, stillbirths, and
congenital defects than for the control group(394),
with unusually high occurrence of spina bifida.
A study in Poland also found a
significant positive association between mercury levels and occurrence of
reproductive failures and menstrual cycle disorders, and concluded dental work
to be an occupational hazard with respect to reproductive processes(401).
5. Body burden increases with time
and older dentists have median mercury urine levels about 4 times those of
controls, as well as higher brain and body burdens(1,34, 68-74,99), and poor
performance on memory tests(68, 69,70,249,290a) Some older dentists have mercury levels in
some parts of the brain as much as 80 times higher than normal
levels(14,34,99). Dentists and dental personnel
experience significantly higher levels of neurological, memory,
musculoskeletal, visiomotor, mood, and behavioral problems, which increase with
years of exposure (1,34,68-73,88,123,188,246,247,248,249,290a,395). Even dental personnel with relatively low exposure(urine Hg<4 ug/l) were found to have significant
neurological effects(70) and was found to be correlated with body burden of
mercury. Most studies find dentists have
increased levels of irritability and tension(1,490,504b),
high rates of drug dependancy and disability due to psychological
problems(15,1b), and higher suicide rates than the general white population
(284,493,1b), but one study found rates in same range as doctors.
6. Female dental technicians who
work with amalgam tend to have increased menstrual disturbances
(275,401,10,38), significantly reduced fertility and lowered probability of
conception (10,24,38,121), increased spontaneous abortions (10,31,38,277,433),
and their children have significantly lower average IQ compared to the general
population (1,279,541,38,110).
Populations with only slightly increased levels of mercury in hair had
decreases in academic ability(3). Effects are directly related to length of
time on the job(277).
The level of mercury excreted in urine is significantly higher for
female dental assistants than dentists due to biological factors
(171,172,173,247,124a). Several dental
assistants have been diagnosed with mercury toxicity and some have died of related
health effects(32,245,246,247,248). From the medical register of births since
1967 in Norway, it can be seen that dental nurse/assistants have a clearly
increased risk of having a deformed child or spontaneous abortion(433). Female dentists have increased rates of
spontaneous abortion and perinatal mortality (193,38,10,433)),compared to
controls. A study in Poland found a much higher incidence of birth defects
among female dentist and dental assistants than normal(10). A chronically ill dental nurse diagnosed
with mercury sensitivity recovered after replacement of fillings and changing jobs(60), and a female dentist recovered from Parkinson’s
after mercury detox(248). Some studies
have found increased risk of lung, kidney, brain, skin melanoma, and CNS system
cancers among dental workers(14,34,99,143,283).
7.Studies
have reported that inorganic mercury induces immunosuppression by decreasing
the production of thymus gland hormone (thymulin) and causes other systemic immune effects (495,etc.) A recent
study(495a) found that dentists and dental nurses have
increased mercury exposure compared to controls and reduced thymus function.
8. Many homes of dentists have been
found to have high levels of mercury contamination used by dentists bringing
mercury home on shoes and clothes (188).
9. Nationwide the dental
industry is the third largest user of mercury, using over 45 tons of mercury
per year(26), and most of this mercury eventually ends
up in the environment. Amalgam from
dental offices is by far the largest contributor of mercury into sewers and
sewer plants(84,13b,19,26), with mercury from replaced
amalgam fillings and crown bases the largest source. As much as 10% of prepared
new amalgam becomes waste. This mercury also accumulates in building sewer
pipes and septic tanks or drain fields where used, creating toxic
liabilities. Unlike most European
countries and Canada
which have much more stringent regulation of mercury that
requires amalgam separators in dental offices(26,28,42), the U.S. does not and
most dental offices do not have them.
The discharge into sewers at a dental office per dentist using amalgam
without amalgam separators is between 270 and 570 milligrams per day(84,26). For the U.S. with approximately 170,000
dentists working with amalgam(26), this
would be approximately 16,000 kg/yr (or slightly over 16 tons/year of mercury
into sewers and thus into streams, lakes, bays, and sewer sludge. In Canada the annual amount discharged is
about 2 tons per year(28), with portions ending up in waters/fish, some in
landfills and cropland, and in air emissions. The recently enacted regulations
on dental office waste are expected to reduce emissions by at least 63% by
2005, compared to 2000(28).
A study in Michigan estimated that dental
mercury is responsible for approximately 14 % of mercury discharged to
streams(85). An EPA study(13) found that dental office waste were responsible
for similar levels of mercury in lakes, bays, and streams in other areas
throughout the U.S. A Canadian study
found similar levels of mercury contribution from dental offices into lakes and
streams, and surveys of dental office disposal practices found the majority
violated disposal regulations, and dangerous levels of mercury are accumulating
in pipes and septic tanks from many offices(19,41,26).
The total discharge into sewers from
dental amalgam at individual homes and businesses is almost as large as that
from dental offices, since the average person with amalgam fillings excretes in
body waste approx. 100 micrograms per
day of mercury(86,87,89,520). This has
also been confirmed by medical labs(13c), such as Doctors Data Lab in Chicago
and Biospectron in Sweden, which do thousands of stool tests per year and is
consistent with studies measuring levels in residental sewers by
municipalities(13b). In the U.S. this
would amount to approximately 7300 kilograms per year into sewers or over 8
tons per year. Thus the amount of
mercury being excreted from dental amalgam is more than enough to cause
dangerous levels of mercury in fish in most U.S. streams into which sewers
empty. Studies by Oak Ridge National
Laboratory(U.S. Dept. of Energy) and other studies have confirmed high levels
of mercury in sewers and sewer sludge(42,43).
According to an EPA study the majority of U.S. sewerage plants cannot
meet the new EPA guideline for mercury discharge into waterways that was
designed to prevent bioaccumulation in fish and wildlife due to household sewer
mercury levels(15,13). Over 3 tons of mercury flows into the Chesapeake Bay
annually from sewer plants, with numerous resulting fish consumption advisories
for that area and similar for other areas(17).
The EPA discharge rule had been reduced due to a National Academy of
Sciences report of July 2000 that found that even small levels of mercury in
fish result in unacceptable risks of birth defects and developmental effects in
infants(18).
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