Development of national public health policy requires consideration of both scientific research and experiential data. It is often influenced by the views of governmental and private health organizations with specialized knowledge about a particular subject. It is instructive, therefore, to examine the policy views that exist on dental amalgam. This is a useful process in the formulation of guidance to the Nation's dental care providers who look to the U.S. Public Health Service, among others, for expert advice on known and potential hazards and acceptable standards of practice. The policy views of others can also serve as guideposts for policy makers in the PHS who must decide on new program initiatives and the priority and funding levels that should be assigned to them.

Taken together, these policy statements reflect a general consensus that appears to be supportable by the latest scientific knowledge.

• "Current research on the use of silver dental amalgam suggests that amalgam continues to demonstrate clear advantages in many applications over other restorative materials. Significant evidence of patient risk associated with its use has not been demonstrated. Most therapeutic materials involve potential side effects or risks as well as benefits and dentists are trained to be on their guard for these reactions at all times."

Canadian Dental Association, 1986

• "At present, there are no scientific data indicating that exposure to mercury from dental amalgam causes symptoms of poisoning. The National Board of Health and Welfare's group of experts, however, underlined that amalgam is an unsuitable dental filling material from a toxicological point of view. The development should be stimulated of new dental filling materials which are technically and biologically toxicologically satisfactory. While waiting for such materials to become available as general replacement for amalgam, amalgam may therefore still be used as dental replacement material. On the other hand, the Board of Health and Welfare is of the opinion that treatment of pregnant women with amalgam should be avoided as far as possible. This judgment has been passed awaiting further research into disorders of the reproductive system related to exposure to mercury."

National Board of Health and Welfare of Sweden, June 1988

• "Assuming that a minute amount of mercury may be released from dental amalgams in humans, the question remains as to how much is released and absorbed and, more importantly, whether this amount of mercury has any bearing on human health. Until these questions are answered and we have reasonable evidence that dental amalgams actually can be handful to health, we cannot take action against these products, particularly in light of the value they provide in dental care."

Food and Drug Administration, October 1990

• "Throughout its use, there has been considerable scientific study of amalgam and no documented evidence to support the contention that amalgam, or the mercury contained in amalgam, has any deleterious effect on the health or physical well-being of the millions of patients served throughout the world. The research currently creating interest and controversy has been found by the scientific community to have considerable shortcomings in methodology and to be totally inconclusive as to any detrimental health ramifications for humans. Based on the research and epidemiological evidence available to date, the ADA continues to support dental amalgam as a safe and effective restorative material and sees no cause for public concern about either existing or future amalgam restorations."

American Dental Association, December 1990

• "Based on the available research, the NIDR concludes that dental amalgam poses no known health risk to individuals who are not hypersensitive to the materials. At this time, there is no reason for recommending either the discontinuation of dental amalgam as restorative materials or the removal of dental amalgam from patients who have no demonstrated hypersensitivity to mercury or other components of amalgam.

National Institute of Dental Research, March 1991

• "At present and until additional information under study dictates, there are no data that would compel a change in the current use of dental amalgam. When dentists are placing amalgam in teeth or removing amalgam, they should carefully adhere to guidelines developed for their use, and, to the extent possible, limit exposure to mercury."

U.S. Public Health Service, March 1991

• "Notwithstanding the mercury component of silver amalgam, extensive reviews of the scientific literature have not revealed any data published in refereed scientific journals to support claims that amalgam restorations have caused any adverse biological reactions other than extremely rare allergy to one of the amalgam components. Replacement of silver amalgam restorations is not justified except when the restoration has failed; where it has fractured; where there is recurrent dental caries at its margin; where access to the dental pulp is needed; or where there is a clearly-established case of mercury hypersensitivity associated with clear evidence of an adverse effect from an amalgam restoration."

Federal Dentaire Internationale, June 1991

• "According to the latest status of scientific knowledge, no reasonable suspicions that amalgam fillings are hazardous to one's health can be established from a medical point of view if one considers the already existent burden of mercury through a person's daily intake of mercury with food, water, and air. Nevertheless, the use of amalgams is to be decreased as much as possible in order to reduce the strain on the human body caused by general mercury intake. The Federal Public Health Office does not recommend to substitute already existing fillings by other filling materials, unless the individual medical situation, e.g. an allergic reaction, requires that. As already recommended in 1987 by the Federal Public Health Office, no major dental procedures involving amalgams should be done during pregnancy. Even though there are no reasons to believe that amalgams could be hazardous to the health of the unborn child, the Federal Health Office asks to observe this recommendation in the interest of preventive medicine."

Federal Public Health Office of Germany, 1992

• "Although minute amounts of mercury are released from amalgam restorations, these do not cause demonstrable adverse effects of significance to the general public. Published reports of systemic toxic effects documented to have been caused by mercury from dental amalgam, are not available in the scientific literature. Local allergic reactions are exceedingly rare, and when they occur, they can be eliminated by the substitution with another materiel. Available scientific evidence does not justify the discontinuation of the use of amalgam, nor does it endorse a clinical concept that recommends the removal and replacement of satisfactory amalgam fillings with other materials."

Swedish Medical Research Council, June 1992

During 1991-92, the U.S. Public Health Service Committee to Coordinate Environmental Health and Related Programs conducted a thorough assessment of the risks and benefits associated with dental amalgam, including a critical evaluation of the most current scientific information. Based upon those reviews, the PHS reaffirms its policy statement issued in March 1991 (as excerpted above). A full discussion of the rationale for this reaffirmation is discussed in Appendix VII of this report.