Lessons learned from countries phasing out dental amalgam in public programs

Experiences from European countries demonstrate successful pathways for the transition to mercury-free oral health care. As effective and affordable alternatives are available, the primary challenge remains, to establish financial arrangements with dentists to provide aesthetic fillings in public programs. It should be borne in mind that dental amalgam is far more expensive than most, if not all, alternative materials when the high environmental costs are taken into account.

Since the development of resin composites in the 1960s and glass ionomers in the 1970s, dental amalgam has step by step become the mercury-releasing, more invasive, unaesthetic, second class, filling material, which is nowadays almost exclusively used for basic treatments in public programs while aesthetic fillings are standard for people who can afford additional costs in private dentistry.

The primary political challenge in replacing dental amalgam in public programs is therefore to find a financially viable agreement with dentists. Even though there is no longer any significant difference in the material cost or placing time of modern alternatives, low reimbursement fees could bring difficulties with the dental profession, which is used to established market prices in private dentistry.

Negotiations might be especially challenging in countries where the majority of the population receives substantial or full coverage of dental fillings and has broad access to a contracted dentist. In countries where fillings are only covered for children and other groups, or in countries with a voucher system, the transition might be easier. For countries where the public health care systems don’t cover dental fillings, the transition shouldn’t pose a problem.

When the European Union banned the use of dental amalgam by January 2025 (except when deemed strictly necessary by the dental practitioner based on the specific medical needs of the patient), negotiations between public insurances and dental associations resulted in divergent outcomes.

Looking at the agreements, it is notable that public health insurances in several countries, such as Poland, Germany, Denmark, the Netherlands, Lithuania, Latvia, Slovenia, and Slovakia, differentiate between reimbursable mercury-free filling materials (negotiations on the materials are still ongoing in Austria and Croatia).

Poland, for example is reimbursing glass ionomers with the indication for temporary and permanent fillings, Germany is reimbursing all self-adhesive materials and other countries reimburse single layer composites (which include compomers, alkasites and bulk-fill composites).

This differentiation between basic care materials has the advantage that fees for public reimbursements can be adapted to a reasonable extent while dentists can continue to offer more elaborated materials in private dentistry. Also where reimbursed filling materials are not specified, it can be assumed that dentists differentiate and primarily rely on glass ionomers and single-layer composites in public healthcare schemes.

There are just a few countries, such as the Netherlands, Slovakia, Sweden or Estonia, where no significant difference could be found between the cost of a composite filling in private dentistry and the rates for mercury-free fillings set by public health insurances.

To conclude: Dental amalgam can successfully be replaced in public healthcare by adapting the reimbursement fees to a very reasonable extent, especially when differentiating between filling materials. The cost-effectiveness of Glass-Ionomer Cement and other self-curing materials is constantly increasing.

Public Programs can and should cover exclusively mercury-free filling materials, especially when extending the public access to restorations in line with new ambitions for Universal Oral Health Coverage.