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Treaty imposes no curbs on amalgam use

The Association commended the prevention focus of the international mercury treaty approved in Geneva Jan. 19.

"Caries, the disease that causes tooth decay, afflicts 90 percent of the world's population, making this a global public health issue," said Dr. Robert A. Faiella, president of the American Dental Association. "The ADA is gratified that the treaty conditions pertaining to dental amalgam protect this important treatment option without restrictions for our patients while balancing the need to protect the environment. It is vital for people throughout the world to continue to have access to a safe, durable, affordable treatment for tooth decay."

Governments approved treaty "exceptions" to restrictions or bans for medical devices "where currently there are no mercury-free alternatives," according to the United Nations Environment Program, which convened the Geneva negotiations among more than 140 nations including the United States:

•    "vaccines where mercury is used as a preservative have been excluded from the treaty as have products used in religious or traditional activities;

•    "delegates agreed to a phase-down of the use of dental fillings using mercury amalgam."

Dental amalgam is not subject to any restrictions on use. Instead, the treaty calls for phasing down the need for amalgam through increased prevention and other activity. Language in ANNEX C Part II: Products subject to Article 6, paragraph 2 said, "Measures to be taken by a Party to phase down the use of dental amalgam shall take into account the Party's domestic circumstances and relevant international guidance, and shall include two or more of the measures from the following list:

•    "setting national objectives aiming at dental caries prevention and health promotion thereby minimizing the need for dental restoration;

•    "setting national objectives aiming at minimizing its use;

•    "promoting the use of cost-effective and clinically effective mercury-free alternatives for dental restoration;

•    "promoting research and development of quality mercury-free materials for dental restoration;

•    "encouraging representative professional organizations and dental schools to educate and train dental professionals and students on the use of mercury-free dental restoration alternatives and promoting best management practices;

•    "discouraging insurance policies and programs that favor dental amalgam use over mercury-free dental restoration;

•    "encouraging insurance policies and programs that favor the use of quality alternatives to dental amalgam for dental restoration;

•    "restricting the use of dental amalgam to its encapsulated form;

•    "promoting the use of best environmental practices in dental facilities to reduce releases of mercury and mercury compounds to water and land."

"By phasing up global preventive strategies, we can tremendously improve oral health outcomes and by extension overall health outcomes," said Dr. Faiella, the ADA president. "Countries must make concerted efforts to raise awareness and empower healthier behaviors."

The FDI World Dental Federation and its constituency of 200 plus national dental organizations including the ADA and dental specialties and International Association for Dental Research have long supported a phase down approach to the use of dental amalgam accompanied by a "phase up" focus on preventive strategies to reduce caries, the disease that causes tooth decay. The dental organizations also support other treaty measures calling for increased research, development of alternatives to dental amalgam and best management practices that involve capturing and recycling amalgam waste.

The ADA is particularly pleased that the treaty calls for setting national objectives aimed at dental caries prevention and health promotion, Dr. Faiella said. "Long term it is critically important to raise global awareness of the importance of oral health to overall health, including how to prevent dental diseases. Doing so decreases the need for all cavity-filling and other restorative materials including dental amalgam."

The United States took part in the treaty negotiations that concluded with a fifth and final session Jan. 13-19 in Geneva. ADA observers attended the Geneva conference and other sessions convened over a four-year period to prepare a legally binding treaty to reduce mercury emissions and releases to air, water and land. The treaty text will be open for signature at an October 2013 diplomatic conference in Japan. The UNEP expects the treaty to come into force in three to five years. Initial funding "to fast track action" has been pledged by Japan, Norway and Switzerland.

"The ADA appreciates the willingness of the U.S. delegation from the State Department, Food and Drug Administration and Environmental Protection Agency to consider and be guided by the best available scientific information pertaining to dental amalgam," the Association president, Dr. Faiella, said in a statement.

The Association and a coalition of American dental organizations in a June 2012 letter to the State Department urged the U.S. negotiating team "to use the ongoing negotiations…as an opportunity to promote public health here and throughout the world."

The largest non-natural source of mercury in the environment comes from the burning of coal. The treaty also considered other sources such as small-scale gold mining and the Chlor-alkali sector. The negotiations included discussion of mercury-containing products. Based on usage, dental amalgam was last on a list of products that included batteries, measuring devices, electric switches and relays and mercury-containing lamps, meaning light bulbs.

The International Association for Dental Research participated in and contributed to the treaty negotiations, along with the FDI World Dental Federation and the International Dental Manufacturers, "and has advocated for a reduction in the use of dental amalgam (versus a ban) through increased attention to dental prevention and health promotion, increased research and development on alternatives and best management techniques for amalgam waste," said an IADR news release.

In advance of the Geneva negotiations and the treaty's ANNEX C call for "promoting research" on alternatives to dental amalgam, a December 2012 Dental Materials Innovation Workshop identified potential research priorities, according to an IADR workshop summary. The workshop was sponsored by the IADR, King's College London and FDI World Dental Federation and co-sponsored by the World Health Organization and U.N. Environment Program. Proceedings will be covered in greater detail in a scientific peer-reviewed journal, the IADR said.