I'm getting ready to go down to our clinic in Guatemala and some of my questions for our team were about amalgam. Do we have it there, what kind is it? How are we handling the separation and disposal of the excess?
I have only a very general idea about the patients I will see and their dental needs, so I have this image of lots of decay and less than ideal home care. In some of those situations my choice of operative repair material in the posterior would be amalgam.
Turns out we DO have it available for use and we have a suction system that will filter and separate the amalgam scrap for proper disposal. One of the team members, a much younger member, asked why I would ever want to use amalgam, isn't it poison?
I would be less than truthful if I said I didn't respond to the public in my treatment modalities. I have done porcelain on a lot of second molars that probably would have been more predictable with gold – because it was what the patient wanted.
If people have been made to believe that amalgam is poison that's probably a good reason to remove it from my practice. The facts cannot be allowed to get in the way of the right business decision when there are alternatives – so amlagam is not in my practice. Today I can mill a beautiful composite, porcelain, or lithium disilicate restoration that will outperform amalgam and look really good doing it.
In the appropriate tooth I can place a direct composite that will perform equally against the amalgam and once again, beat it in the looks department with little or no effort. SO, why would anybody WANT to have amalgam, and why would I want it in Guatemala?
In my experience, particularly with patients who have rampant decay and heavy plaque, amalgam restorations can provide a bridge to health and stability that is not as easily built with composite. A friend of mine once said, “A very average amalgam can last for years, a very average composite cannot.”
Now I hope my amalgams (and composites) are not “average,” but there may be clinical situations in which amalgam might be the best treatment option for my patient. If my view of the patients I will see is wrong, the question may be moot.
I do not believe that having an amalgam filling in a tooth hurts people. I absolutely agree that there are serious disposal issues around amalgam scrap, and the danger that anything containing free mercury presents is uncontestable (the unmixed amlagam capsules). In my opinion, these reasons alone could, should, and have driven the switch to alternatives.
The problem I see in a clinic and locale like our clinic in Guatemala is that in cases where extensive tooth loss has occurred from decay, and the follow-up of a more “definitive” restoration may not be in the cards for the patient, could amalgam, handled appropriately, better serve their needs?