Updated: Lessons learned from countries replacing dental amalgam in public programs

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

Since the development of composite resins in the 1960s and glass ionomers in the 1970s, dental amalgam has gradually become a second-class filling material due to its mercury content, more invasive application, and unaesthetic appearance. Today, it is used almost exclusively for basic treatments in public programmes, while aesthetic fillings have become the standard for patients who can afford the additional costs of private dental care. But can alternative filling materials also replace dental amalgam in public programmes?

The primary political challenge in replacing dental amalgam in public programmes is to reach a financially viable agreement with dentists. Although there is no longer any significant difference in the material costs or placement time of modern alternatives, low reimbursement fees may create difficulties with the dental profession, which is accustomed to established market prices in private dentistry.

Negotiations may be particularly challenging in countries where the majority of the population receives substantial or full coverage for dental fillings and has broad access to contracted dentists. In countries where fillings are covered only for children and other specific groups, or where voucher systems are used, the transition may be easier. In countries where public healthcare systems do not cover dental fillings, the transition should not pose a significant challenge.

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.

A review of the resulting agreements and the financial impacts (country by country below) shows that public health insurers in Poland, Germany, Denmark, the Netherlands, Lithuania, Latvia, Czechia, Slovenia, Slovakia and Croatia, differentiate between reimbursable mercury-free filling materials (negotiations on the materials are still ongoing in Austria).

Poland, for example, limits reimbursement to glass ionomers for both temporary and permanent fillings. Germany reimburses only self-adhesive materials, while several other countries define single-layer composites—including compomers, alkasites, and bulk-fill composites—as the reimbursable category.

This differentiation among basic-care materials has the advantage of allowing public reimbursement fees to be adjusted to a reasonable level while enabling dentists to continue offering more advanced materials in private practice. Even where reimbursed filling materials are not explicitly specified, it can be assumed that dentists differentiate among available options and primarily rely on glass ionomers and single-layer composites within public healthcare schemes.

There are only a few countries, such as the Netherlands, Slovakia, Sweden, and Estonia, where no significant difference can be observed between the cost of a composite filling in private dentistry and the reimbursement rates for mercury-free fillings provided by public health insurers.

In conclusion, dental amalgam can be successfully replaced in public healthcare systems by adjusting reimbursement fees to a reasonable extent, particularly when reimbursement schemes differentiate between filling materials. The cost-effectiveness of glass-ionomer cement and other self-curing materials continues to improve.

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. Glass Ionomer Cement and Composite Resin are on WHO’s list of Essential Medicines, Dental Amalgam is not.