18-19th Dec, 2012 Acknowledgement The East Africa Dental Project

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2. Case Studies Demonstrating Phase Down Approach, Desiree Narvaez, UNEP Chemicals. (on behalf of Michal Bender)

Brief Recap of the EADAP project:

The objective of the EADAP project is to explore essential conditions for a phase down in the use of dental amalgam.

The project has the following components:

  • Trade study and survey of dental amalgam waste practices

  • Selection of a national project coordinator and social preparation

  • Development of awareness raising material on disease prevention and available alternatives for dental restoration

  • Inception workshop

  • Demonstration activities.

Country level activities will be coordinated by the national project coordinator. The demonstration activities to be conducted after the inception workshop include:

Validation of the desk study results and revision of the national mercury inventories.

  • Stakeholders meeting to present the desk study and proposed demonstrations in the phase down approach.

  • Selection of 3 demonstration dental clinics with representation of government facility, private clinic and a teaching hospital.

  • Coordination with local waste management provider and external provider as relevant.

  • Capacity building of dental health sector in BMP in amalgam waste management

  • Demonstration of best practices in environmentally sound management of amalgam waste.

  • Raise awareness on oral health promotion and preventive care

  • Encourage the appropriate use of alternative restoration materials.

The Ministry of Environment will coordinate local waste management and will need to inform dental health practitioners on how to manage amalgam waste.

Results and Analysis of Survey Conducted in 10 countries that have demonstrated phase down of dental amalgam.

Case study by Mercury Policy Project seeks to contribute to EADAP by presenting cases from other countries demonstrating amalgam phase down approach.

Mercury Policy Project consulted with UNEP and WHO. The countries surveyed are those identified by WHO and others that have phased down amalgam use. Denmark, Switzerland, Norway and Sweden have already given responses. Surveys were also sent to Japan, Finland, Vietnam, Russia, Singapore and Mongolia.

All countries that responded used the substitution principle approach. Amalgam phase out was effected in Norway in 2008 and in Sweden in June 2009.

Denmark’s approach decrees that non-amalgam restoration is the first choice. Denmark has phased down to 5% with amalgam being used in large lesions, difficult cavities and where moisture control is difficult.

Switzerland has phased down to less than 10%.

Controlling mercury releases:

  • Best management practice of amalgam waste

  • Use of separators with maintenance of the separators in new and existing clinics.

  • Mercury controls in crematoria as they are a major mercury emitter.

  • Awareness raising and regulatory programs

  • Ban on import and export of mercury

  • Training in the use of alternative materials in dental schools.

Precautionary principle- amalgam use was drastically reduced in the surveyed countries and actually banned in Denmark.

Elements of a phase down approach:

  • Privatization

  • Substitution precautionary

  • Dental schools

  • Eliminate subsidies on amalgam

  • Raise awareness

  • Consultation with stakeholders

Obstacles to phase down:


Overall, the countries found no negative effects. Initial investment is in training and equipment. There is a net benefit in reducing mercury releases.

2.1 Question and Answer Session

  1. Q: Isn’t the reason that Denmark still uses amalgam the same reason to continue using amalgam in East Africa as patients present late for treatment and therefore the lesions are large.

A: There is emphasis that the reason that caries has been reduced globally is actually not through the health sector, which is set up because of the disease, but through population directed prevention which is more important. When prevention is introduced, then the lesions seen will be smaller, thus allowing use of alternative restoration material.

  1. Q: What was the response to reduction of amalgam use? What was the campaign used? What is the stand of USA on the issue of phase down?

A: Patients were happy as they liked the tooth colored materials. Dentists were less happy. In Norway, the ban on amalgam was introduced almost overnight so the Norwegian dentist had to quickly change care and there was frustration with use of alternative materials. Dentists in Denmark were happier as the change was slower.

Point to learn is that we must go for planned action.

In the USA, the trend of caries follows that of developed countries. Caries levels falling have decreased the use of dental amalgam. But there is no over-treatment as the population prefers the tooth coloured fillings leading to replacing of amalgams with the alternative materials.

  1. Q: Was the phase down brought about because of environmental concerns?

A: The phase down came as a response to less demand for amalgam fillings. The concern for the environment came later.

From the first application of composites, it was noted that there was allergic reaction to composites amongst dental personnel and this raised awareness amongst patients as well. In Norway, data is collected on all negative reactions experienced and this is because of increased awareness amongst dentists who are using only alternative materials.

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