European Network for
Environmental Medicine

The European Network is a nonprofit organisation engaged in establishing Environmental Medicine in Europe. In light of the increasing environmental burdens and scientific evidence of correlations with chronic diseases, we are committed to reducing environmental exposures, promoting research into health links and treatments, better aligning medical care with these findings, and facilitating patient access to analysis.

Dental Amalgam

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28 August, 2022

Proud to present: Study on the Potential of HBM within the European exposure science strategy 2020–2030

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We are proud to present the work “Developing Human Biomonitoring as a 21st century toolbox within the European exposure science strategy 2020–2030” published in the Environment International.

It was outlined that findings from HBM can lead to improved health care when taken into account by physicians in medical treatments, which is a great achievement for Environmental Medicine:

[T]he knowledge about associations between exposure and health effects will help in identifying mitigation measures for people that are already exposed. Exposure to harmful substances, that are subject to the toxicologically relevant doseresponse principle or that have a primarily sensitising effect, can be tracked by the physician by means of evaluating the patients medical history, anamnesis, and specific laboratory tests (if relevant) (EC, 2018; Eva et al., 2022). Regular physical exams can provide additional information about the onset and diagnosis of the disease.

If restrictions on the use of medical data are followed, such data may also be used for scientific purposes. This approach of data collection from the disease point of view would complement the HBM approach (starting from the stressor) with cohorts covering the entire lifetime.

To improve human health data, it is suggested to establish a survey of the current number and standards of screenings of patients who test for environmental toxins. 

Read the full study here:

 

 

15 August, 2022

Public EU Consultation: 91% for Phasing out Dental Amalgam

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EU citizens, Dental Professionals, Manufacturers, Distributors, National Authorities/Health Care Organisation, Social Security Organizations and Private Health Insurance Companies almost unanimously (by 91 %) agree that Dental Amalgam should be banned. 95% of the general public would already choose a mercury free material and 74% say they would even pay more for non-mercury materials to be used. This is the outstanding result of an EU survey to assess three problem areas of mercury pollution including the continued use of dental amalgam, emissions of mercury from crematoria and the manufacture and trade of mercury-added products. The consultation was open from 8 February 2022 to 3 May 2022 to all interested stakeholders within the EU and internationally, however it was particularly focused on feedback from public authorities, companies and business associations, citizens, and civil society (academia/research institutions, Non-Governmental Organisations (NGOs), environmental organisations, consumer organisations, and trade unions). Participants could respond to the questionnaire on behalf of an organisation/institution or as individuals and were also invited to upload position papers. A total of 146 valid responses were submitted during the consultation period. The survey was conducted in the course of an impact assessment for the revision of the EU Mercury Regulation, which should, inter alia, evaluate an EU-wide phase-out of dental amalgam by 2030 or before. The EU Mercury Regulation became due for revision after the Commission concluded in a report in August 2020 that phasing out dental amalgam was both technically and economically feasible and announced to present a legislative proposal by the end of 2022. It is expected that the current impact assessment will be completed by September 2022. Here are our 👉 contribution and submitted position papers : 👉 Feedback on EU Inception Impact Assessment on the Revision of Regulation (EU) 2017/852 on mercury 👉 European Plans to Reduce and Eliminate Dental Amalgam Use Further Information: Official Summary Report 👉 Factual Summary Report on the Public Consultation for the Review of the Mercury Regulation https://ec.europa.eu/info/law/better-regulation/have-your-say/initiatives/12924-Mercury-review-of-EU-law/public-consultation_en
1 August, 2022

Report Released: European Plans to Reduce and Eliminate Dental Amalgam Use

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The EU and the United Nations Minamata Convention on Mercury are seeking to phase out the use of dental amalgam, as assessments have concluded that its use poses major environmental and health risks, and that a phase-out is both technically and economically feasible. To dispel final questions, an overview of countries that have already taken measures against the use of amalgam is particularly valuable. The European Centre for Environmental Medicine has compiled information from national regulations in Europe analyzing legislations, penalties, public insurance schemes or recommedations of more than 40 Countries. These Information are now published in the Report “European Plans to Reduce and Eliminate Dental Amalgam Use”. For Example Sweden, Norway and the Republic of Moldova have prohibited the use of dental Amalgam without any exception and several former Soviet States have officialy declared that dental amalgam is not used at all in their country. Denmark, Lithuania, Switzerland and Liechtenstein have banned the use with limited exceptions and in Estonia, Finnland, Luxembourg, the Netherlands and Spain the use is already below 1 %. Poland is withdrawing mercury fillings from the guaranteed benefits, effectively phasing out dental amalgam in 2022. Further EU Countries have set up national plans to phase out dental amalgam and some Non-EU Countries have followed the EU’s lead to phase out the use of dental amalgam for children, pregnant and breastfeeding women in a first step. Guidelines indicate that dental amalgam should not be used if there is evidence of allergy to any of the components, in patients with severe renal insufficiency or progressive degenerative diseases of the peripheral or central nervous system. It should not be used next to precious metal alloys, gold-plated brass anchors or other metal restorations or for patients with metallic denture frameworks, and there is a warning not to perform whitening on teeth filled with amalgam.  For proper use, a suitable pulp protection should be placed under the filling, the ingress of moisture during mixing and condensation should be avoided, since it can lead to increased expansion and corrosion of the filling (if the alloy contains more than 0.01% Zinc) and amalgam fillings should be polished, as this leads to a reduction of the surface and subsequently reduces corrosion. The polishing should be performed after 24 hours at the earliest, when the amalgam filling has hardened. Further Safety requirements are set up for the removal of dental amalgam and for the safety of the dental staff, which demonstrate how dangerous it is to work with this material. It is very difficult to say how much amalgam is still used in Europe today, as reliable data are not available. What is certain, however, is that the use of amalgam can and should be timely phased out. Download the full report:

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4 March, 2022

Pre-COP4.2 Side Event: World Alliance for Mercury-Free Dentistry

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As president of the World Alliance for Mercury-Free Dentistry, Charlie Brown was proud to lead a talented and united team from five continents at the second conference of the parties in Geneva in late November.

In Geneva, where over 100 governments gathered, our campaign to “Make Dental Amalgam History!” stirred intense interest. From our British chief dental officer to our Bangladeshi environmental colleagues to our Ethiopian international attorney, our team seized every opportunity by: 

Our key show-and-tell was the report of the world workshop we co-sponsored with the United Nations Environment Programme in Bangkok last May. This workshop brought together experts from 20 nations – many of them dentists – to discuss effective strategies for ending amalgam use in children in both developed and developing countries. Our report documents their strategies so that other countries and institutions can learn from them – and follow suit as a first step toward a total amalgam ban!

The world is ready to cross the finish line into a future free of dental mercury!

2 February, 2022

Germany: Declaration on phasing out Dental Amalgam by 2025

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As president of the World Alliance for Mercury-Free Dentistry, Charlie Brown was proud to lead a talented and united team from five continents at the second conference of the parties in Geneva in late November.

In Geneva, where over 100 governments gathered, our campaign to “Make Dental Amalgam History!” stirred intense interest. From our British chief dental officer to our Bangladeshi environmental colleagues to our Ethiopian international attorney, our team seized every opportunity by: 

Our key show-and-tell was the report of the world workshop we co-sponsored with the United Nations Environment Programme in Bangkok last May. This workshop brought together experts from 20 nations – many of them dentists – to discuss effective strategies for ending amalgam use in children in both developed and developing countries. Our report documents their strategies so that other countries and institutions can learn from them – and follow suit as a first step toward a total amalgam ban!

The world is ready to cross the finish line into a future free of dental mercury!

6 April, 2021

EU Commission starts legislative process for phasing out Dental Amalgam

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As president of the World Alliance for Mercury-Free Dentistry, Charlie Brown was proud to lead a talented and united team from five continents at the second conference of the parties in Geneva in late November.

In Geneva, where over 100 governments gathered, our campaign to “Make Dental Amalgam History!” stirred intense interest. From our British chief dental officer to our Bangladeshi environmental colleagues to our Ethiopian international attorney, our team seized every opportunity by: 

Our key show-and-tell was the report of the world workshop we co-sponsored with the United Nations Environment Programme in Bangkok last May. This workshop brought together experts from 20 nations – many of them dentists – to discuss effective strategies for ending amalgam use in children in both developed and developing countries. Our report documents their strategies so that other countries and institutions can learn from them – and follow suit as a first step toward a total amalgam ban!

The world is ready to cross the finish line into a future free of dental mercury!

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8 March, 2022

Plans to phase out Dental Amalgam in Europe

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Due to the European Mercury Regulation (EU 2017/852), as of 1 July 2018, amalgam may no longer be used in the EU for the treatment of deciduous teeth, children under 15 years of age and pregnant or breastfeeding women, unless the dentist considers it absolutely necessary due to the specific medical needs of the patient. Each member state was further required to submit a National Action Plan (by 1 July 2019) to further reduce the use of dental amalgam and preferably phase it out by 2030. Until today 26 of 27 national plans were published:
  • Eleven Member States went for a general phase-out: Italy, Croatia, Slovenia, Slovakia, Czech Republic, Finland,  the Netherlands, Ireland, Spain, Greece and Poland. Sweden, ended amalgam use a decade ago. Estonia, with amalgam use already at 1 % is assessing the feasibility of a full phaseout.
  • Having long ago banned amalgam in the primary teeth, Denmark prohibited its use in permanent teeth except under four limited exceptions – so now amalgam use is under 2%. Lithuania is following the Danish example and restricts the use to exceptional cases.
  • Poland withdraws mercury fillings from the guaranteed benefits, effectively phasing out dental amalgam in 2022.
  • In Finland, a composite restoration costs the patient the same as an amalgam restoration.
  • Ireland, Slovakia, Czech Republic, Croatia, Slovenia and Hungary will alter its insurance to favor mercury-free fillings in the coming years.
  • Croatia and Cyprus stepwise expand the phase out of the use for children by raising the minimum age for amalgam to 18, Slovenia to 25.
  • Romania and Spain will permit the use of dental amalgam only in a selected list of medical clinics.
  • Cyprus, Czech Republic, the Netherlands, Portugal and Spain, will allow amalgam only with a showing of medical need.
  • Portugal, Romania and the Czech Republic will require informed consent to amalgam.
  • Lithuania, Latvia and the Netherlands ended the teaching of amalgam placement in its dental schools, effectively ending amalgam as the new generation of dentists take over.
  • Austria, Italy and Germany expanded protection by recommending not to use amalgam for those with kidney disease, Austria additionally for those with certain neurological conditions. Lithuania by prohibiting the use for patients with metallic denture frameworks that could interact with amalgam. France and Italy by recommending to avoid the placement of amalgam in direct or indirect contact with precious metal alloys, gold-plated brass anchors or other metallic restorations and strongly discouraging to perform whitening on teeth filled with amalgam.
  • Estonia, Lithuania, Latvia, Greece, Cyprus and Germany have submitted interim plans (first assessing the actual use) and will present their long-term plan in the coming years.
Non-EU members in the transition to mercury-free dentistry:
  • Norway (in 2008), New Caledonia (France, in 2019) and the Republic of Moldova (in 2020) have generally phased out dental amalgam without any exceptions.
  • Russia, Kazakhstan, Armenia, Azerbaijan and Georgia have declared not to use mercury fillings at all.
  • As dental amalgam was not allowed for children in the Soviet Union since 1982 and hardly used at all, its use never gained significance in Ukraine, Belarus, Kyrgyzstan, Uzbekistan and Turkmenistan.
  • Switzerland is prohibiting the use of dental amalgam in cases where mercury-free alternative can be preferred. The use declined to less than 1 %.
  • Iceland, Albania and the UK joined the phasing out of the use for children under the age of 15, pregnant and breastfeeding women.
A recently published WHO survey has revealed that two-thirds of European countries will have phased out the use of dental amalgam by 2025. (👉 Report of the Informal Global WHO consultation with policymakers in dental public health, 2021.Monitoring country progress in phasing down the use of dental amalgam. Geneva: World Health Organization; 2021.) The European Center for Environmental Medicine published an extensive report about 👉 European Plans to Reduce and Eliminate Dental Amalgam Use in August 2022. For any extra amalgam filling which is created, mercury is released to the environment. This is undesirable and will prolong the significant environmental burden. Here are the regulations in a nutshell country by country:
European Union
The use of dental amalgam is indicated compared to alternative filling materials with reference to:  BIO Intelligence Service (2012), 👉 Study on the potential for reducing mercury pollution from dental amalgam and batteries, Final report prepared for the European Commission – DG ENV and Deloitte et al., 👉 Assessment of the feasibility of phasing-out dental amalgam, report prepared under contract to the Directorate-General Environment of the European Commission, 17 June 2020. 1. Sweden 🇸🇪 current use of amalgam: 0% 👉 Swedish National Plan to Phase Out Dental Amalgam, March 2019
  • Sweden stopped to subsidize dental amalgam in 1999
  • In 2009 dental Amalgam was banned with following exceptions: 1) Technical difficulties in the placement of alternative materials 2) Adverse reactions to alternative materials 3) In restorations done under general anaesthesiain Specific medical condition
  • Sweden ceased the exemptions in 2018 as they were only applied to very few individual cases
2. Denmark 🇩🇰 use of amalgam: 5% in 2010 / 1% in 2018 👉 Danish legislation and actions in connection with the phasing out of dental amalgam, 29 January 2019
  • By 1 January 1995 Denmark prohibited the import, sale and export of dental amalgam, except for fillings in permanent molars, where the filling is worn.
  • The exception was specified by the Public Health Authority in 2006 and allowed the use of dental amalgam only in the following cases: 1) lack of possibility of drying 2) difficult accessibility of the cavity 3) especially large cavity 4) large distance to neighboring tooth
3. Italy 🇮🇹 use of amalgam: 1% in 2010 / 2,2% in 2018 👉 Piano nazionale per l’eliminazione dell’utilizzo dell’amalgama dentale, 23 February 2021
  • Italy has presented a National Plan which describes the actions necessary to achieve the gradual phasing down of the use of dental amalgam in dentistry, with the ultimate goal of achieving complete elimination of its use (phase out), through non-mandatory measures, by 31 December 2024.
👉 Decreto n°.261 Ministero della Salute,  10 October 2001 Following information should be included in the instructions for use of amalgams placed on the market in Italy:
  • store amalgam capsules in a cool, ventilated environment;
  • work in ventilated rooms with decontaminable non-textile coverings;
  • always carry out under cooling, suction and isolation of the operating field, milling and polishing of amalgam;
  • do not place dental amalgam in the vicinity of other metal restorations in order to avoid corrosion risks;
  • in case of supervening local reactions, especially lichenoid lesions in the vicinity of an amalgam, or in cases, definitely established, of allergy to such material, removal of the filling is indicated.
4. Poland 🇵🇱 use of amalgam: 57% in 2010 / 20% – 26% in 2018 👉 Draft amendment of the regulation on guaranteed benefits in the field of dental treatment, 17 February 2022
  • Poland announced on 25 February 2022 to withdraw mercury fillings from the guaranteed benefits without any transition period (effectively phasing out dental amalgam). In place of the dental amalgam, the following dental restorative materials will be used for the entire population of beneficiaries:
    • Glass ionomer cements,
    • high density glass ionomer cements and
    • resin-reinforced glass ionomer cements.
  • Patients will also be reimbursed for the removal of amalgam fillings as a guaranteed benefit.
  • Only dental clinics where amalgam is removed, must be equipped with amalgam separators.
5. Croatia 🇭🇷 interim plan until 2025 / use of amalgam: 20% – 70% in 2018 👉 Nacionalni Plan Mjera Ukidanja Dentalnog Amalgama 2020-2025, September 2020
  • Since 24 February 2020, alternative fillings (glass ionomer cements with an indication for permanent fillings (glass-hybrid) and composite) have become the standard material for children up to the age of 18 as well as pregnant and nursing women in compulsory health insurance.
  • The right to full reimbursements of alternative fillings will be further extended to all insured persons by 31 December 2025, which will effectively phase out dental amalgam.
6. Slovenia 🇸🇮 use of amalgam: 71% in 2010 / 20% – 70% in 2018 👉 Nacionalni Načrt o Ukrepih za Postopno Opustitev Uporabe Amalgama v Zobozdravstvu do Leta 2030, 30 June 2021
  • By 1 January 2025 phase out of the use of amalgam in adolescents and young adults aged 16 to 25.
  • By 1 January 2027 phase out of the use of amalgam in premolars (molars Nr. 4+5) in the general population
  • By 1 January 2030 phase out of the general use of amalgamFrom 2030 onwards, amalgam fillings will be used only in specific, exceptional cases.
The Slovenian public health services will reimburse alternative fillings (composites) instead of amalgam with a limitation for patients not having visited a dentist in the last two years. The Compulsory Health Insurance Rules will be amended in the coming years.
7. Slovakia 🇸🇰 use of amalgam: 71% in 2010 / 20% 26% in 2018 👉 Národný plán opatrení Ministerstva zdravotníctva Slovenskej republiky v súvislosti s postupným ukončovaním používania zubného amalgámu, 27 June 2019
  • Slovakia anchored a total ban on amalgam from 1 January 2031 in the national legislation Act no. 578/2004 Coll. The competent regional authority may grant dentists a fine of up to EUR 3,919.
  • An adjustment of the subsidy for alternative fillings is planned in the next few years.
  • Glass-ionomer cement, fully covered by all health insurance companies for the entire population, has been identified as a substitute for filling dental cavities.
8. Czech Republic 🇨🇿 use of amalgam: 92% in 2010 / 20% – 26% in 2018 👉 Národní plán týkající se opatření, která Česká republika hodlá provést za účelem postupného omezování používání zubního amalgámu, 10 July 2019
  • The NAP envisages that by 2030, the use of dental amalgam will represent only 1% of the total number of restorations.
  • At the latest by 1 January 2025 it should be possible to have uniform payments for dental fillings regardless of the material by the public health insurances.
  • From 2030 onwards, amalgam fillings will only be reimbursed in exceptional indications where no alternatives are available and the patient wishes to have an amalgam filling.
9. Finland 🇫🇮 use of amalgam: 3% in 2010 / 1% in 2018 👉 Plan for the abolition of dental amalgam by 2030, 30 July 2019
  • The long-term objective is to phase out the use of amalgam completely by 2030.
  • Short-term goals: Reduce amalgam consumption by at least 25% by 2022 from 2019; 50% by 2025 and 75% by 2028.
  • In 2021, according to a survey conducted by the Ministry of Social Affairs and Health, 86 % of dental practices did not use amalgam at all. Most dental practices that still used amalgam used it very rarely.
  • In Finland, there are no policies or programs that would favor dental amalgam use over mercury-free dental restoration, a composite restoration costs the patient the same as an amalgam restoration.
10. Ireland 🇮🇪 use of amalgam: 35% in 2010 / 15% – 19% in 2018 👉 Ireland’s National Plan for Phase-down to Phase-out of Amalgam towards 2030, 1 July 2019
  • Ireland supports a phase down towards phase out/ban of amalgam across all age groups by 2030.
  • The use of amalgam will be allowed only in exceptional clinical circumstances. The ongoing need for clinical exemptions will be reviewed periodically.
  • The public payment system will be revised to support mercury-free alternatives for eligible persons across all age groups.
11. Spain 🇪🇸 use of amalgam: 26% in 2010 / 1% in 2018 👉 Plan Nacional para la Reduccíon del Uso de Amalgamas Dentales, 28 February 2020
  • Spain plans to reduce the use of dental amalgam to exceptional cases (both in the at-risk population and in the general population) by 2030.
  • Exclusive health centers authorized to place, remodel or extract dental amalgam fillings will be established.
12. Portugal 🇵🇹 use of amalgam: 26% in 2010 / 1% – 8% in 2018 👉 Plano Nacional para Eliminação Gradual da Utilização do Amálgama Dentário, June 2020
  • The Government of Portugal is committed to progressively reducing the use of dental amalgam by replacing it with other mercury-free materials. It is proposed to reduce the possibility of dental restorations using amalgam in NHS health units (within the scope of primary health care and hospital health care), and only in duly justified situations.
  • From 2021, whenever the need for an amalgamated restoration is justified, the patient must accept this procedure through the declaration of informed consent.
13. Cyprus 🇨🇾 interim plan 2019-2024 / use of amalgam: 30% in 2010 / 10% in 2018 👉 Εθνικό Σχέδιο Δράσης της Κυπριακής Δημοκρατίας για τη Σταδιακή Μείωση (phase down) της χρήσης οδοντιατρικών αμαλγαμάτων, 18 July 2019
  • From 1 January 2025 the use of dental amalgam is prohibited in persons under the age of 18 unless the dentist considers it strictly necessary because of the patient’s specific medical needs.
  • Until 1 January 2025 Cyprus assess the possibility of prohibiting the use of dental amalgams throughout the population unless the dentist deems it absolutely necessary due to patient’s specific medical needs.
14. Hungary 🇭🇺 use of amalgam: 16% in 2010 / 2% – 4% in 2018 👉 Nemzeti terv a fogászati amalgám használatának fokozatos csökkentését szolgáló intézkedésekről, 24 August 2020
  • The objective of Hungarian NAP is to reduce the use below 1% until 2030,
  • The public reimbursement schemes will be adopted and Mercury-free alternative become the preferred choice for new fillings.
15. Netherlands 🇳🇱 use of amalgam: 10% in 2010 / 0,5% in 2018 👉 Beleidsplan voor terugdringing gebruik amalgaam in de tandheelkunde, 27 June 2019
  • As soon as the use of amalgam will increase above 1%, the Netherlands will evaluate actions how to further reduce the use.
  • The Dutch dentistry faculties have stopped teaching students to use dental amalgam since 1997.
  • The Royal Dutch Dental Association (KNMT) announced to produce an overview of the situations in which the use of amalgam is considered medically necessary.
16. Lithuania 🇱🇹 use of amalgam: 57% in 2010 / 20% – 26% in 2018 👉 Įsakymas Dėl Dantų amalgamų naudojimo tvarkos aprašą patvirtinimo, 25 January 2021
  • As of May 2021, dental amalgams may only be used for few limited and justified indications such as
    • for the restoration of defects in the masticatory surfaces of molars (Class I, II),
    • medium to large dental cavities (at least 2 mm deep),
    • when it is not possible to restore the tooth with an alternative filling due to difficulties in controlling the moisture or the accessibility of the cavity
  • The use of dental amalgams is prohibited if patients have dentures made of other metals that could cause galvanizes by interacting with the dental amalgam alloy.
  • Dentistry students in Lithuanian universities are only introduced to the history of tooth filling, listing the materials used, including amalgams, but they have not been trained in dental amalgams since 2008.
  • The implemented measures to phase out dental amalgam will be evaluated every calendar year.
17. Austria 🇦🇹 use of amalgam: 37% in 2010 / 5% – 7% in 2018 👉 Nationaler Maßnahmenplan (ÖNAP-Dentalamalgam 2019) zur schrittweisen Verringerung der Verwendung von Dentalamalgam gem. EU-VO 2017/852, 21 June 2019
  • Since 1995, amalgam is not indicated in patients with impaired renal function or progressive degenerative diseases of the peripheral or central nervous system.
  • Dental amalgam is not allowed to be used • for retrograde root fillings; • as material for stump abutments under crowns or bridges; • as sealing material for cast crowns.
18. Germany 🇩🇪 interim plan / use of amalgam: 10% in 2010 / 5% – 7% in 2018 👉 The German Government’s National Action Plan for the Phase-down of Dental Amalgam, 10 July 2019
  • The Federal Government has set itself the goal of working towards further reducing the use of amalgam in dental treatment and limiting it to indispensable special cases.
  • The first National Plan is focusing on further strengthening the prevention of caries and collecting data about the actual use of dental amalgam. It will be periodically updated in subsequent years.
  • As of January 01, 2021, dentists are obliged to declare the use of dental amalgam in the invoicing with statutory health insurers.
  • Public health insurences fully reimburse composite fillings for children under the age of 15 and pregnant and breastfeeding women, patients allergic to any component of dental amalgam, and patients with severe kidney disease.
19. France 🇫🇷 use of amalgam: 50% in 2010 / 5% – 25% in 2018 👉 Plan national de suppression d’utilisation des amalgames dentaires au mercure en France, 19 April 2021
  • The NAP focuses primarily on oral health prevention and highlights the continued decrease in the use of dental amalgam. No measures to further reduce the use are foreseen.
  • In 2014, the Agence nationale de sécurité du médicament et des produits de santé (French Agency for the Safety of Health Products) updated its 👉 recommendations for the use of dental amalgam, encouraging professionals to use dental amalgam only for few limited and justified indications.
    • The patient must be fully informed about the different filling materials available before any amalgam-based restoration is performed.
    • Dental amalgam should only be used in posterior permanent teeth (molars and premolars) in the case of multiple and extensive lesions.
    • Dental amalgam should not be used in patients with impaired kidney function and in patients with a known allergy to mercury.
    • The placement of amalgam in direct or indirect contact with precious metal alloys, gold-plated brass anchors (screw-post type) or other metallic restorations should be avoided.
    • It is strongly discouraged to perform whitening on teeth filled with amalgam.
    • The presence of localized lichenoid lesions in direct contact with amalgam fillings may warrant removal of otherwise satisfactory fillings.
20. Estonia 🇪🇪 interim plan 2019-2023 / use of amalgam: 5% in 2010 / 1% in 2018 👉 Euroopa Parlamendi ja Nõukogu määrus (EL) 2017/852 elavhõbeda kohta amalgaamiplaan, 25 June 2020
  • Dental amalgam is practically no longer used in Estonia. The measure of the national plan to reduce the use of dental amalgam is to find a solution at the legal level to officially ban the use of amalgam.
21. Latvia 🇱🇻 interim plan 2019-2020 / use of amalgam: 32% in 2010 / 20% – 26% in 2018 👉 The Plan for the Gradual Reduction of the Use of Dental Amalgam in 2019-2020 year, 2 July 2019
  • Information on the use of amalgam in adult dentistry, is currently not available. Such data should be available in perspective with the introduction of an information system developed by dentists for the period 2020-2021.
  • “Procedures for the Organisation and Payment of Health Care Services” (28 August 2018) ensures access to state-funded dental services (including use of alternatives) for children under 18 years of age.
  • In November 2021 the Ministry of Health published a 👉 report about the interim measures with findings about the current use. These should serve now for the development of a long-term plan.
  • Compared to 2018, there has been a 50.3% reduction in the use of dental amalgam in 2019 and 67.7% in 2020.
  • There is no training on the use of Hg amalgam in training programs.
22. Greece 🇬🇷 interim plan / use of amalgam: 57% in 2010 / 10% in 2018 👉 Action Plan for the phasing out of the use of dental amalgams “ANTIPAS”, 15 August 2021
  • The interim National Plan calls for first collecting data on the actual use of dental amalgam.
  • The prevention of caries diseases will be promoted.
  • A campaign to inform dentists and the public about the health effects of mercury and the contribution that reducing the use of dental amalgam makes to limiting mercury releases is to be launched.
22. Romania 🇷🇴 use of amalgam: 71% in 2010 / 20% – 70% in 2018 👉 Plan naţional de măsuri pentru eliminarea treptată a utilizării amalgamului dentar, 19 December 2019
  • Romania will permit the use of dental amalgam only in a selected list of medical clinics.
  • Patients will be obliged to complete an informed consent before using amalgam.
👉 Consiliul naţional al Colegiului Medicilor Stomatologi din România, Moțiune privind reducerea utilizării amalgamului dentar, 14 June 2019
  • The Romanian Dental Association (Colegiului Medicilor Stomatologi România) had called on the Ministry to immediately extend the ban on the use of dental amalgam to children up to 18 years of age when drafting the national plan for dental amalgam and to completely ban the use of dental amalgam by 1 July 2025.
23. Bulgaria 🇧🇬 use of amalgam: 30% in 2010 / 20% – 70% in 2018 👉 Национален план за мерките за постепенно прекратяване на употребата на дентална амалгама в Република България, 23 October 2019
  • The NAP emphasises the need for data collection, providing information to dentist students as well the need for increased prevention on oral health and provide more information on risks of dental amalgam to the population.
  • No further measures to reduce the use are foreseen.
25. Luxembourg 🇱🇺 use of amalgam: 26% in 2010 / 0,5% in 2018 👉 Plan national pour la réduction progressive de l’utilisation de l’amalgame dentaire, 3 October 2019
  • The Health Directorate has drawn up a national plan which has as its objectives the prevention of dental caries throughout life, easy access to treatment with mercury-free materials, objective communication on risks and alternatives to reduce the use of dental amalgam and professional management of amalgam waste to avoid environmental contamination.
  • No further measures to reduce the use are foreseen.
26. Belgium 🇧🇪 use of amalgam: 32% in 2010 / 5% – 7% in 2018 👉 Plan National Belge d’Elimination Progressive des Amalgames Dentaires,  20 Decembre 2019
  • The NAP focuses primarily on oral health prevention and highlights the ongoing decrease in the use of dental amalgam.
  • No further measures to reduce the use are foreseen.
27. Malta 🇲🇹 use of amalgam: 57% in 2010 / 10% in 2018
  • Malta has not presented a National Plan to reduce the use of amalgam.

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Europe
1. Norway 🇳🇴 use of amalgam: 0% 👉 Review of Norwegian experiences with the phase-out of dental amalgam use, 10 May 2012
  • In 1991, Norway issued guidelines that the use of amalgam should be limited due to environmental impacts. Stronger guidelines were issued in 2003, requiring materials other than amalgam to be considered as the first choice in tooth fillings.
  • In 2008 Norway general bans mercury containing products. This included a ban on amalgam, with an exemption period –now expired –for special cases.
  • Amalgam use has been eliminated since 2011.
2. Republic of Moldova 🇲🇩 use of amalgam: 0% 👉 Lege Nr. 277 din 29.11.2018 privind substanțele chimice
  • For the protection of health and the environment, the production, placing on the market and use of Dental Amalgam is prohibited by 15.02.2020.
3. New Caledonia 🇳🇨 (France) use of amalgam: 0% 👉 Arrete de l’Haut-Commissariat de la République en Nouvelle-Calédonie, 16 September 2019
  • On 16 September 2019 the Haut-Commissariat de la République en Nouvelle-Calédonie decided to immediately stop the use of dental amalgam and referred to the National Medical Devices Regulation.
4. Russia 🇷🇺 use of amalgam: 0% 👉 Report of the Informal Global WHO consultation with policymakers in dental public health, 2021.Monitoring country progress in phasing down the use of dental amalgam. Geneva: World Health Organization; 2021
  • The Russian Federation consistently reported to have phased out use of dental amalgam
5. Mongolia 🇲🇳 👉 First full national report of the Minamata Convention on Mercury due by 31 December 2021
  • Purchase and usage of mercury-added dental amalgam were banned by the joint order 07/27 of 2011 by the Minister and Health and the Chief of National Emergency Management Authority.
6. Kazakhstan 🇰🇿 use of amalgam: 0% 👉 Report on second level mercury inventory in the Republic of Kazakhstan, 2019
  • Dental amalgam is not used in the Republic of Kazakhstan
7. Armenia 🇦🇲 use of amalgam: 0% 👉 Minamata Convention Initial Assessment Report, Armenia, 2019
  • Dental fillings containing mercury, are not used in dental clinics of Armenia for a long
    time already
8. Azerbaijan 🇦🇿 use of amalgam: 0% 👉 Minamata Convention Initial Assessment Report, Azerbaijan, 2018
  • There is no use of dental amalgams in Azerbaijan
9. Georgia 🇬🇪 use of amalgam: 0% 👉 Minamata Convention Initial Assessment Report, Georgia, 2017
  • Dental amalgam is no more in use by dental clinics and not imported in the country.
10. Switzerland 🇨🇭 current use of amalgam: less than 1%* 👉 Chemikalien-Risikoreduktions-Verordnung, ChemRRV of 18 May 2005 (as of 1 December 2020)
  • In September 2015 Switzerland amended the Swiss Ordinance on Risk Reduction (ChemRRV) related to chemical products to prohibit the use of dental amalgam in cases where mercury-free alternative can be preferred for medical reasons.
  • In any case, the patient’s consent to the treatment procedure is absolutely necessary.
  • In July 2018 Switzerland amended the ChemRRV to end the export of mercury for use in dental amalgam capsules by 31 December 2027.
* Statement of the Swiss Dental Association (SSO), 👉 Neue Züricher Zeitung, 14.03.2017 11. Liechtenstein 🇱🇮  👉 First full national report of the Minamata Convention on Mercury 2021
  • Dental amalgam is regulated in the Swiss ORRChem ordinance (Annex 1.7 ORRChem). This ordinance applies in Liechtenstein based on the Customs Union Treaty.
  • According to ORRChem the use of dental amalgam is prohibited. An exemption from the general prohibition is granted if priority cannot be given to a different filling material for medical reasons.
12. Iceland 🇮🇸 👉 Lög um breytingu á efnalögum, nr. 61/2013, með síðari breytingum, 11 June 2019
  • From 1 July 2019 the use of dental amalgams for the dental treatment of deciduous teeth, children under the age of 15 and pregnant and breastfeeding women is prohibited.
  • The Minister of Health, in consultation with the Minister in charge of public health and prevention, announced to issue an action plan for measures that need to be taken in order to reduce the use of dental amalgam. The action plan shall be made public.
13. Albania 🇦🇱 👉 Vendim Nr. 442 Për miratimin e rregullave të ndalimit të eksportit të merkurit metalik, komponimeve dhe përzierjeve të caktuara të merkurit, ruajtjes së sigurt të merkurit metalik dhe të kriteret specifike të ruajtjes së merkurit metalik të konsideruar si mbetje, 26. June 2019
  • From 1 July 2021 the use of dental amalgams for the dental treatment of deciduous teeth, children under the age of 15 and pregnant and breastfeeding women is prohibited.
  • By 1 July 2021 the Ministry of Health should prepare a national plan with measures to be taken for phasing out the use of dental amalgam.
14. United Kingdom 🇬🇧 use of amalgam: 71% in 2010 / 15% – 19% in 2018 👉 The Control of Mercury (Amendment) (EU Exit) Regulations 2018, 25 January 2019
  • The European mercury regulation from 2017 has passed into national law post-Brexit, prohibiting the use of dental Amalgam for dental treatments of deciduous teeth, children under the age of 15 and pregnant and breastfeeding women in  England, Scotland, Wales and Northern Ireland.
2 March, 2022

Manufacturers leaving the business of dental amalgam in Europe

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Since the new Medical Devices Regulation (MDR 2017/745) enterd into force on May 26, 2021, the legal safety requirements for dental amalgam capsules have increased significantly, why manufacturers start leaving the business. Of the 23 European dental amalgam manufacturers listed in the EU’s 2020 Assessment, only 4 minor manufacturers remain that have not yet declared their exit from the business. Among others Kerr and DMG have recently left the business; IvoclarDMP, Ardent and UnoDent (which is no longer an EU Producer) have confirmed that they will leave in the near future. Nordiska has moved its production to the US and the amalgam branch of Safina, has been taken over by Silmet in Israel. Only CavexMadespa, World Work Srl, and Global Dental Trade (which was not listed in the EU’s 2020 report) have not yet declared their exit, but their certifications according to 93/42/EEC are expiring. For certifications under the MDR, manufacturers have to proof that the release of mercury and other components of amalgam (in mass/unit time) do not exceed the safety thresholds under all possible conditions like, teeth grinding, chewing, age corrosion or oral galvanism. These are requirements that amalgam fillings didn’t have to fulfill before. How can the EU hold on to amalgam fillings when there are strong indications that they may no longer be available on the European market by 2025? The transition period during which certificates under the former Medical Devices Directive (MDD 93/42/EEC) are still valid will end on May 26, 2024 at the latest and certifications according to MDR 2017/745 have not been issued so far. The major international producer Dentsply Sirona has stopped its production of dental amalgam in 2020 and only stocks from the dental depots can continue to be sold until 2024 in Europe. Here is a list of manufacturers offering Dental Amalgam in Europe (including manufacturer from outside the EU) with the expiration dates of their certificates and decisions  to generally leave the business. After the end of the certificates, amalgam capsules may only be sold in Europe until their expiry date of approximately 3 years.
  • Merz Dental (Germany, Exit by Dec 2019)
  • Dentsply Sirona (US, CE 93/42/EEC valid until 26/05/2024, Exit by Dec 2020)
  • DMG (Germany/US, CE 93/42/EEC valid until 26/05/2024, Exit by 2021)
  • Envista Holdings (Kerr, US/Italy, Exit by Jan 2022)
  • Uno Dent (UK, Exit by June 2022)
  • Prima Dent (UK, Subsidiary: SSWhite, Exit before July 2022)
  • AB Ardent (Sweden, 👉 CE 93/42/EEC valid until 01/09/2022 – exit by June 2022)
  • Ivoclar Vivadent (Lichtenstein, CE 93/42/EEC valid until 26/05/2024 – announced exit by Dec 2022)
  • DMP (Greece, CE 93/42/EEC valid until 26/05/2024 – announced exit by 2024)
  • Cavex Holland BV (Netherlands, 👉 CE 93/42/EEC valid until 04/08/2022 – Exit in Germany by Jan 2022)
  • World Work Srl (Italy, 👉 CE 93/42/EEC valid until 20/9/2022)
  • Wykle Research (US, Amalgam segment of Nordiska Dental (Sweden),  👉 CE 93/42/EEC valid until 30/09/2022)
  Further Players in the Non-EU market are coming especially from China, India, Mexico, Turkey and the US.
5 October, 2021

EU Mercury Regulation: Penalties for dentists misusing dental amalgam

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For the effective implementation of regulations, it is necessary to establish penalties in case of non-compliance. Penalties for misuse of mercury in dentistry may be found in various regulations such as Health Care Provider Acts, Public Health Regulations, Chemical Laws, or Environmental Protection Acts. In the case of EU member states, there may also be specific penalties for violations of the provisions of Regulation (EU) 2017/852 on mercury. According to Article 16 of the EU Mercury Regulation, Member States shall lay down the rules on penalties applicable to infringements of the Regulation and shall take all measures necessary to ensure that they are implemented. The penalties provided for shall be effective, proportionate and dissuasive. Member States shall, by the respective dates of application of the relevant provisions of this Regulation, notify the Commission of those rules and of those measures and shall notify it, without delay, of any subsequent amendment affecting them. Since the EU Mercury Regulation entered into force 15 Member States notified the EU about their rules on penalties (as of 19 August 2021 *) which include penalties related to the obligations to use (or remove) amalgam only in practices where an amalgam separator is available and the exclusive use of amalgam in children up to 15 years of age, pregnant and lactating women for whom amalgam is absolutely necessary for medical reasons. *Ask The EU: 👉 https://www.asktheeu.org/en/request/article_16_of_regulation_eu_2017? Here is an overview: In Sweden, Finland and Denmark dentist risk a fine or an imprisonment for up to two years.
In Germany and Bulgaria, the fines are up to 50.000 €, in Austria up to 40.000 € (in case of repetition) in the Czech Republic up to 7.800 €, Slovakia up to 3.319 €, Romania up to 1.600 €, Latvia up to 1.400 € and Lithuania up to 600 €.
In Italy, the penalties specifically for the use of dental amalgam were published by the Ministry of Health on 27 October 2021. Italy imposes a fine of 10,000 to 100,000 euros on dentists who use dental amalgam in violation of the regulation.
  Here is a list with quotes and references:

1. Sweden 🇸🇪

A fine or imprisonment for a term not exceeding two years shall be imposed for an offence against the environment if, intentionally or through negligence 👉Environmental Code (1998 :808), Chapter 29 Article 1 and Article 3 the first paragraph

2. Finland 🇫🇮

A fine or imprisonment for a term not exceeding two years. 👉Chemicals Act, Waste Management Act, Penal Code 1 § (24.8.2018/761) Deterioration of the environment

3. Denmark 🇩🇰

Unless a higher penalty is prescribed by other law, a fine shall be imposed. The penalty may be increased to imprisonment for up to 2 years if the offence is committed intentionally or with gross negligence and if, in committing the offence 1) caused damage to human or domestic animal life or health or created a danger thereof, 2) damage or danger to the environment 👉§59(1)(1) and (2) of the Chemicals Act, as laid down in Legislative Decree No 115 of 26 January 2017

4. Italy 🇮🇹

An administrative fine of 10,000 to 100,000 euros for dentists who use dental amalgam in violation of the regulation and the fine of 4,000 to 20,000 euros for those who do not ensure that the management and collection of their amalgam waste and the same penalty, as well as the temporary closure of the activity, for those who use dental amalgam or remove fillings containing dental amalgam in violation of the rules, until the installation of appropriate amalgam separators. Atto del Governo 249. Disciplina sanzionatoria per la violazione delle disposizioni divcui al regolamento (UE) 2017/852 sul mercurio

5. Germany 🇩🇪

Any person who intentionally or negligently contravenes a directly applicable provision in legal acts of the European Communities or of the European Union may be punished by a fine of up to 50.000 €. 👉Law on Protection against Hazardous Substances (Chemicals Act – ChemG), 26 Regulations on Fines No. 11. (2)

6. Bulgaria 🇧🇬

Fines from 10 000 to 100 000 BGN; (ca. 5000 to 50000 €) In case of a repeated violation, the fine, respectively the proprietary sanction shall be imposed in a double amount. Act on Protection from the harmful impact of chemical substances and mixtures. Chapter eight: Administrative punitive provisions, Section I; Compulsory administrative measures, Article 44-48

7. Austria 🇦🇹

To be fined from a minimum of €500 up to €20180, in case of repetition up to €40375. The attempt is punishable. 👉Art. 71 of the Federal Chemicals Act 1996

8. Czech Republic 🇨🇿

Who uses dental amalgam in the provision of health services in contravention of directly applicable European Union legislation on mercury should be punishable with a fine up to CZK 200 000 (ca. 7.800 €) 👉Health Services Act, Zákon č. 372/2011 Sb

9. Slovakia 🇸🇰

Fines up to EUR 3 319 👉Act No. 578/2014 Coll. on health care providers, healthcare workers, health care organizations and amendments to certain laws (Art.82(10); 79(1)(bd)

10. Romania 🇷🇴

Fines from 3.000 lei to 5.000 lei (ca. 600-1.000 €) for natural persons and a fine from 5.000 lei to 8.000 lei (ca. 1.000-1.600 €) for legal persons. 👉Government Decision No 857/2011 on the establishment and sanctioning of contraventions of public health rules, Art 18. and 53.

11. Latvia 🇱🇻

A fine shall be imposed on natural persons from 30 to 430 €, and on legal persons – from 350 to 1.400 €. 👉Law of the Republic of Latvia “Latvian Administrative Violations Code” Article 88, 88.4, 166.9, 166,10

12. Lithuania 🇱🇹

Fines of between 400 and 600 € 👉Article 3. Addition of Article 1091 to the Law, Add Article 1091 to the Act: “Article 1091. Liability of legal persons for non-compliance with the requirements laid down in Regulation (EU) 2017/852” Law on Environmental Protection No XIII-1109

13. Spain 🇪🇸

Laws on Contraband, penalties provided for REACH, Prevention and Control of Pollution, Waste and Contaminated Soils, Air Quality and Atmospheric Protection, General Health, Consumer and User Protection Regulations and other complementary laws. 👉https://environmentalmedicine.eu/wp-content/uploads/Penalties-SPAIN.pdf

14. Belgium 🇧🇪

Law on product standards aimed at promoting sustainable production and consumption and protecting the environment, health and workers and Royal Decree on medical devices 👉https://environmentalmedicine.eu/wp-content/uploads/Penalties-BELGIUM.pdf

15. Luxembourg 🇱🇺

Act of February 23, 2010 concerning certain implementing rules and the sanctioning of Regulation (EC) No 1102/2008 of the European Parliament and of the Council of October 22, 2008 on the banning of exports of metallic mercury and certain mercury compounds and mixtures and the safe storage of and the safe storage of metallic mercury. 👉https://environmentalmedicine.eu/wp-content/uploads/LU-penalties-Art-16-Hg-Reg.pdf

16. France 🇫🇷

Code de l’environnement for installations classified for the environment and Code de l’environnement regarding waste management 👉https://environmentalmedicine.eu/wp-content/uploads/Penalties-FRANCE.pdf  

German Chapter 🇩🇪

See all
22 October, 2022

EU-Kommission gibt der Chemieindustrie nach und verschiebt REACH Revison

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Die EU Kommission hat ihr Arbeitsprogramm für das Jahr 2023 vorgestellt. Wichtige geplante legislative Initiativen wurden von der EU Kommission auf unbestimmte Zeit verschoben. Deutsche NGOs, darunter das European Center for Environmental Medicine, forderten die EU-Kommission auf, den Legislativvorschlag für die REACH Revision wie geplant Ende des Jahres vorzulegen. Die Revision ist nun aber erst für das letzte Quartal in 2023 vorgesehen. Dies bedeutet, dass das Vorhaben wahrscheinlich nicht mehr in dieser Legislaturperiode der EU-Kommission abgeschlossen werden kann und damit in den Händen einer neuer Kommisison liegen würde, die vielleicht andere Ziele verfolgen wird. Mit dieser Entscheidung hat die EU-Kommission die Interessen der vornehmlich deutschen Chemieindustrie vor den Schutz von Umwelt und Gesundheit gestellt. In ihrere Pressemitteilung reagieren das European Center for Environmental Medicine, HEJSupport, BUND, CHEM Trust, DNR, Forum Umwelt und Entwicklung, Verbraucherzentrale Nordrhein-Westfalen und WECF auf das Arbeitsprogramm der EU Kommission. Die Nichtregierungsorganisationen haben sich auch im Vorfeld der Entscheidung mit einem Brief an EU Kommissionspräsidentin Ursula von der Leyen gewendet.

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The health impact of chemicals in the environment is constantly increasing. There is a significant associated rise in neurological, autoimmune and cancer diseases. Male fertility decreases dramatically. However, when patients go to the doctor, hardly any examinations are carried out for possible chemical exposures.

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