Health Effects from Dental
Personnel Exposure to Mercury Vapor 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(290b). 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. 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(290b).
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(290b), as well as a significant difference relating to BDNF and to
CPOX4.
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,395,531,1b), 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). 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). 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).
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. 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).
8. 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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