Measures to reduce the use of Dental Amalgam in Europe
So far, the EU requirements as of July 1, 2017, have stipulated that dental amalgam is no longer allowed to be used for the treatment of deciduous teeth, of children under 15 years and of pregnant or breastfeeding women, except when deemed strictly necessary by the dental practitioner based on the specific medical needs of the patient.
In line with the European mercury regulation EU 2017/852, each member state had to submit a national action plan (by July 1, 2019) to further reduce the use of dental amalgam and preferrebly phase it out before 2030. Until today 24 of 27 national plans were published:
- Seven Member States adopted a phase-out plan: Italy, Croatia, Slovenia, Czech Republic, Finland, Ireland and Slovakia. Sweden, ended amalgam use a decade ago. Estonia, with amalgam use already under 5%, is assessing the feasibility of a full phaseout. Netherlands and Spain are 99% mercury-free in dental care.
- Lithuania and Netherlands ended the teaching of amalgam placement in its dental schools, effectively ending amalgam as the new generation of dentists take over.
- Croatia and Cyprus expanded for children by raising the minimum age for amalgam to 18, Slovenia to 25.
- Austria expanded protection by recommending not to use amalgam for those with kidney disease or certain neurological conditions.
- Spain will allow amalgam only with a showing of medical need and only in a hospital setting.
- Portugal, starting in 2021, requires written informed consent to amalgam.
- Finland, Ireland, Slovakia, Czech Republic, Croatia, Slovenia and Hungary will alter its insurance to favor mercury-free fillings in the coming years.
- 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%.
- Only the plans of Greece and Malta are still missing.
- Estonia, Lithuania, Latvia and Germany have submitted interim plans (assessing the actual use) and will present their long-term plan in the coming years.
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:
1. Sweden (current use of amalgam: 0%)
- 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 (the use of dental amalgam has decreased from 22% to 1,7% of the total amount of dental fillings in Denmark in the period 2007 to 2017)
- Since 1995 dental amalgam is only allowed to be used as fillingmaterial in permanent molars in the following exceptions:
1) lack of possibility of drying
2) difficult accessibility of the cavity
3) especially large cavity
4) large distance to neighbouring tooth
3. Italy (current use: <2,2%)
- 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 December 31, 2024.
4. Croatia (plan until 2025, current use >30%)
- Since February 24, 2020, alternative fillings 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 reduce the use of amalgam to a minimum.
5. Slovenia (use of amalgam: 71% in 2012)
- By Jan. 1, 2025 phase out the use of amalgam in adolescents and young adults aged 16 to 25.
- By Jan. 1, 2027 phase out the use of amalgam in premolars (molars Nr. 4+5) in the general population
- By Jan. 1, 2030 phase out the general use of amalgam. From 2030 onwards, amalgam fillings will be used only in specific, exceptional cases.
6. Slovakia (use of amalgam: 30%)
- 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 paid for by all health insurance companies for the entire population, has been identified and is indicated as a substitute material for filling therapy.
7. Czech Republic (use of amalgam: 92% in 2012)
- The NAP envisages that by 2030, the use of dental amalgam will represent only 1% of the total number of restorations.
- at the latest in 2025 (from 1 January) it should be possible to start 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.
8. Finland (current use of amalgam: < 1 %)
- 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.
- Since the use of amalgam is influenced by the public funding model, the model should be reviewed in the coming years and renewed from this perspective.
9. Ireland (current use of amalgam: 20%)
- 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.
10. Spain (current use: 1%)
- plan to reduce the use of dental amalgam to exceptional cases (both in the at-risk population and in the general population) by 2030
- plan to establish exclusive health centres authorised to place, remodel or extract dental amalgam fillings
11. Portugal (use of amalgam: 26% in 2012)
- 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.
12. Cyprus (use of amalgam: 30% in 2012)
- 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.
13. Hungary (current use: 4%)
- the objective is to reduce the use below 1% until 2030,
- to adopt the public reimbursement schemes and
- to make the mercury-free alternative the preferred choice for new fillings
14. Netherlands (current use: 0.55%)
- 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.
15. Austria (use of amalgam: 37% in 2012)
- 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.
16. Germany (interim plan, current use of amalgam: < 10%)
- 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 must declare the use of amalgam fillings in their invoicing with statutory health insurers.
17. Estonia (interim plan 2019-2023, use of amalgam: <5%)
- Estonia announced to examine legal steps for officially banning the use of amalgam by 2030 at the latest: “A formal process at national level that would be supported by the assessment of the feasibility of phasing-out dental amalgam commissioned by the European Commission and published in summer 2020“
18. Latvia (interim plan 2019-2020)
- Information on the use of amalgam in adult dentistry, is currently not available. Such data will 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.
- The Ministry of Health prepared an impact assessment of the plan and submit it to the Cabinet of Ministers by 1 July 2021.
- 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 longterm plan.
19. Lithuania (interim plan 2019-2023, use of amalgam: 57% in 2012)
- 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, based on several criteria. By the 1st of February each year the authorities and bodies implementing the action plan will submit a report on the implementation of the measures of the previous year to the National Centre of Public Health under the Ministry of Health.
- By the 1st of March each year the National Centre of Public Health will draw up a report on the implementation of the plan, to be submitted to the Coordinating Authority for the implementation of Regulation 2017/852.
- As of May 2021, dental amalgams may only be used for filling medium to deep dental cavities (at least 2 mm deep).
20. Romania (use of amalgam: 71% in 2012)
- will permit the use of dental amalgam only in a selected list of medical clinics
- Patients are obliged to complete an informed consent before using amalgam
21. Bulgaria (use of amalgam: 30% in 2012)
- 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.
22. France (use of amalgam: 5% – 25%)
- The NAP focuses primarily on oral health prevention and highlights the continued decrease in the use of dental amalgam.
- In 2014, the Dental Association updated its treatment recommendation for filling materials, encouraging professionals to use dental amalgam only for few limited and justified indications.”
23. Luxembourg (use of amalgam: 26% in 2012)
- 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.
24. Belgium (use of amalgam: 5% – 7%)
- The NAP focuses primarily on oral health prevention and highlights the continued decrease in the use of dental amalgam.
25. Poland (use of amalgam: 20%-26%)
- NAP focussing on training and caries prevention activities.
1. Norway (current use of amalgam: 0%)
- 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.
- Since 2008 Norway has had a general ban on mercury products. This included a ban on amalgam, with an exemption period –now expired –for special cases.
- Amalgam use has been eliminated since 2011.
2. New Caledonia (France)
- On 16th September 2019 the Haut-Commissariat de la République en Nouvelle-Calédonie decided to immediately stop the use of dental amalgam.
3. Republic of Moldova
- For the protectionof health and the environment, the production, placing on the market and use of Dental Amalgam is prohibited by 15.02.2020.
4. Switzerland (current use of amalgam: less than 1%)
- In Switzerland the 2005 Swiss Ordinance on Risk Reduction related to chemical products is prohibiting 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.