A Debate on Mercury in Fillings

SAN FRANCISCO —  Seated in dentist Robert Hepps’ chair with a cavity in need of attention, you are sure to hear about the beauties of porcelain, and will probably see a gruesome video of teeth deteriorating around black metal fillings.

Hepps believes porcelain fillings are healthier for teeth and--since traditional fillings are half mercury--possibly for the rest of the body. He believes patients have a right to know that, and the law is on his side.

But the mild-mannered Hepps tiptoes around the health issue, focusing on porcelain’s aesthetic advantages out of fear that total honesty could put his license at risk.

The problem is that despite California laws requiring full disclosure of the dangers of toxic substances, state dental regulators are committed to the use of mercury-based fillings. At a hearing last March, Board of Dental Examiners president Robert Christoffersen summarily dismissed mercury-free dentistry, saying it “does not fit the current practice of dentistry.”

Christoffersen’s statement kicked up a furor inside and outside the dental community. It unleashed the feisty Consumers for Dental Choice lobby group on California, where it has petitioned the Board of Dental Examiners to require dentists to warn patients about mercury’s health hazards, sued the board alleging that it illegally discriminated against another dentist at the March hearing, and asked the state attorney general to get involved in the issue.

All three actions are aimed at heightening public awareness of the state’s 1993 law requiring such warnings, and of the state Department of Consumer Affairs’ assertions that not telling patients violates the anti-toxins initiative approved by voters 13 years ago.

The debate over what patients should be told and when has even injected free-speech issues into what is typically among the least controversial branches of health care.

“We have been really quite stunned; at least among the conservative dental establishment, there is active hostility to informing consumers,” said James Wheaton, president of the Environmental Law Foundation in Oakland. Wheaton’s firm was a lead plaintiff in lawsuits related to Proposition 65, the 1986 initiative that requires workplace warnings for the presence of toxic substances, including mercury.

At one extreme in the debate are the dental regulators, who take their cue from the American Dental Assn. It considers traditional fillings--made from an amalgam of mercury and other metals--cheaper, easier to use and more durable than alternatives. In fact, the ADA bestows the dentists’ seal of approval, frequently seen on toothpaste, on dozens of amalgam products.

At the other extreme are dentists who believe the mercury in amalgam causes severe health problems ranging from Alzheimer’s disease to leukemia. They think the ADA is biased because it is paid for the endorsements.

Somewhere in the middle are dentists like Hepps, who turned to alternative fillings partly because they could not get a definite answer about mercury’s safety or their liability for problems traced to mercury.

“I relate it to cigarettes,” Hepps said. Against tobacco companies, he said, plaintiffs’ attorneys are “saying, ‘You knew there was a risk. Why didn’t you tell people?’ Shouldn’t we be saying there is a risk [with mercury] and this is your choice?”

Studies abound about mercury’s toxicity, second only to uranium as a human poison. But fillings are so small that many scientists consider them irrelevant.

No Consensus in Health Studies

The few studies that seriously evaluate fillings reach conflicting conclusions about exposure. Some say fish, water and perhaps air all transport far more mercury into the human body than fillings do. Others, including a 1997 report by the U.S. Environmental Protection Agency, say nothing deposits more inorganic mercury into the body than fillings.

Environmental toxicologist William Pease reviewed much of the literature on mercury fillings in connection with Proposition 65 litigation. He is unconvinced that they pose a significant health threat to patients--although he believes there is a threat to dental hygienists.

“It’s a totally unnecessary exposure, even if it’s not the worst health problem in the world,” he said. But dental regulators have “a certain circle-the-wagons mentality . . . and maybe they don’t want to think they’ve been poisoning their patients.”

Sweden, Denmark, Austria, Germany, England and Canada all have recommended that dentists seek alternatives to mercury fillings, especially for pregnant and breast-feeding women and in some cases children and those with kidney problems.

The American Public Health Assn. will vote next month on a proposed policy to urge dentists to eliminate “mercury-containing products where feasible alternatives are available.”

Statistics indicate that is already happening quietly in many dentists’ offices as the quality of alternative filling materials improves. The Academy of General Dentistry, a respected professional group, found that in 1998, 43% of its members reported using mercury fillings in more than half their patients’ cavities; this year, the number is 40%.

The cost of alternatives remains a barrier for some patients. Newer porcelain, ceramic and resin fillings cost anywhere from 20% to 100% more, and not all insurance plans will cover the difference.

In California and other states where regulators are hostile to the mercury-free movement, dentists recommend alternatives warily.

In Arizona earlier this year, a dentist was put on probation for preaching the benefits of being mercury-free. In 1996, a Maryland dentist faced state sanctions after publishing an article on filling removal and detoxification. In 1994, the California board revoked the license of an Apple Valley dentist who ran an ad in the local paper entitled “Mercury Emission from Silver Fillings Unsafe by Government Standards.”

Part of the problem in California is that pinning down the state’s policy is like playing tag. The Board of Dental Examiners’ official position is that it looks to the dental profession to set standards, according to Chief of Enforcement Jeff Wall. The California Dental Assn., the state’s largest professional organization for dentists, in turn reports that it relies on the ADA.

The ADA notes that mercury has been used for 160 years--since blacksmiths and barbers won out over medical professionals, who preferred to pull teeth or fill them with gold. Alternatives are still too fragile, the ADA says, even though many dentists who use them report that is no longer the case.

Informing Patients of the Issues

Where the ADA, and the state, draw a clear line is with dentists who remove healthy fillings, declaring them toxic, or who suggest removal will cure chronic diseases. They are “unethical” and subject to loss of their state licenses, according to the ADA.

That is why even moderate dentists like Hepps worry.

After hearing him out in his clinic near San Francisco State University, “most people . . . would rather do [porcelains] . . . than have metal in their mouths,” Hepps said.

Although he emphasizes aesthetic issues, patients who ask about mercury do get an explanation of Hepps’ 1996 decision to quit tamping it into people’s cavities.

“On the [traditional filling] instruction sheet it has a skull and crossbones; it says, ‘Danger: poison,’ and that refers to mercury,” he said. “I thought, ‘I don’t want to put that in my kids’ mouths or my mouth.’ ”

Hepps stopped using mercury after learning the ADA had filed testimony in a lawsuit related to a patient who had a bad reaction to fillings, arguing that it “owes no legal responsibility to protect the public from allegedly dangerous products used by dentists.” Although the organization later explained it was simply citing standard legal principle for third-party negligence, its response meant something different to Hepps.

“A lot of my colleagues were concerned about it,” he said. “Who do we turn to if we have a problem? Are they sidestepping the issue? Are they going to back us on this?”

Hepps strives to distance himself from more messianic dentists such as Andy Landerman, the subject of last March’s hearing before the state board. Landerman, who has lost his license, has sued the board for reinstatement in Sonoma County Superior Court.

He practices what is sometimes described as holistic dentistry, linking an array of diseases to “dental toxicity” related not only to mercury fillings but also to root canals and wisdom tooth extraction.

Radical Dentist Seen as Menace, Martyr

He advocates drilling out all mercury fillings, pooh-poohing scientific findings that doing so releases dormant mercury into the body. “Is it better to have exposure of one big magnitude over a two-hour period, or to be exposed all your life?” he asks.

Landerman practiced in Northern California for 20 years before his license was suspended in 1987, after former patients alleged he removed healthy teeth and sound fillings. As a condition of reinstatement, the state required Landerman to take some courses in traditional dentistry. He regained his license in 1990, then lost it again two years later for returning to his old ways.

When Landerman reapplied this year, the board turned him down, saying he had not kept up with changes in dentistry.

Landerman is a martyr to people like Bob Jones of Denver, who counts himself a victim of traditional fillings. Jones, a former airline pilot, formed the nationwide coalition of patients and dentists called Consumers for Dental Choice after experiencing what he considered a miracle.

Jones said he suffered fatigue so severe he could barely drag himself out of bed. He found a local dentist willing to remove all his old fillings and crowns, a process he said amounted to an instant cure. His dentist has since lost his license for allegedly misleading patients with scientifically unsupported claims.

Though Consumers for Dental Choice defends dentists like Landerman, the demands in the group’s petition against the California board are far from radical: Advise dentists to better inform patients, hygienists and other employees of the potential hazards of mercury and notify them that they open themselves up to liability if they do not disclose those hazards.

Whether any of that will make a difference in dentists’--or patients’--lives remains to be seen. And the petition could be preempted by the anticipated settlement of a suit that Wheaton, the environmental lawyer, filed years ago against 36 makers of mercury filling material under Proposition 65.

One firm has already agreed to require dentists who use its products to post mercury warnings, provided its larger competitors also comply. An agreement with the bigger firms is near, Wheaton said.

What’s more, six years ago a law required the board to develop and distribute to all California dentists a fact sheet on the pros and cons of various types of fillings. The document was supposed to urge dentists to discuss all alternatives with patients.

The board dragged its feet, and when the fact sheet was produced the next year, the Department of Consumer Affairs--the Board of Dental Examiners’ own parent agency--criticized it for minimizing the mercury controversy.

The sheet stated that “the preponderance of scientific evidence” showed mercury fillings posed no health risk except to a few sensitive patients. The consumer department countered that, because of the lack of conclusiveness in existing research, “the lack of evidence of a health risk is not necessarily evidence that [mercury fillings] are safe.”

That fact sheet was never revised and has never been widely distributed, being sent out only “if someone requested it,” said Wall, the dental board’s enforcement chief.

How can dentists and consumers know to request it?

“That’s a good question,” Wall said. “I don’t know.”