Vermont Agency of Natural Resources
Advisory Committee on Mercury Pollution

Advisory Committee on Mercury Pollution

Meeting #52: Thursday, May 13, 2004
Time: 10:00 am to 12:00 noon
Location: Large Conference Room - 5 Burlington Square
Burlington, Vermont

MINUTES

Members Present:
Michael Bender, Abenaki Self-Help Association, Inc.
Bill Bress, Vermont Department of Health
Mary Canales, Department of Nursing, University of Vermont
Neil Kamman, Agency of Natural Resources, Water Quality Division
Ruma Kohli, chemical Management Program Manager, IBM, Burlington
Rich Phillips, Vermont Agency of Natural Resources, Environmental Assistance

Guests Present:
Liljan Smith Aandahl, Norwegian Directorate for Health and Social Welfare (via telephone)
Peter Taylor, Vermont State Dental Society
Gary Gulka, Vermont Agency of Natural Resources, Environmental Assistance
Karen Knaebel, Vermont Agency of Natural Resources, Environmental Assistance
Greg Lutchko, Vermont Agency of Natural Resources, Environmental Assistance

The Committee members and interested parties gathered in the Large Conference Room in Community Public Health at the Vermont Department of Health. Rich Phillips called the meeting to order.

Agenda Item 1-
Overview of Norwegian Federal Health Agency guidelines on amalgam - presented by: Liljan Smith Aandahl, Senior Advisor, Norwegian Directorate for Health and Social Welfare.

Liljan Smith Aandahl introduced herself and advised the Committee that she has held her current position for one year. She has a master's degree in dental public health.

Ms. Aandah began by presenting to the Committee an overview of the process involved in creating the Norwegian "National Clinical Guideline for the Use of Dental Filling Materials"

The process began in 1998 and was the result of two reports, which were sent to Karen Knaebel, state mercury education and reduction coordinator, for distribution to the Committee. Until recently, the document was only in Norwegian, but there is now an English translation available at the Norwegian Directorate for Health and Social Welfare's website at: http://www.shdir.no/index.db2?id=11566. The previous document released to the Committee was a summary, which was an unofficial translation.

Development of the final guidelines took several years to complete and involved a number of steps. The Norwegian Federal Health Agency issued its first report in 1998, entitled "Use of Dental Filling Materials in Norway. The 1998 report was 25 chapters including toxicology, environment, patients' aspects and the report was more or less summarized in what was sent to Karen this morning. The conclusion was that Health Authorities should develop recommendations that would result in less amalgam use.

The guideline set procedure and after reviewing research came to two conclusions, which were in direct, conflict with each other.

1. When a dental filling is placed, the technique should involve the least amount of tissue removal as possible.
2. Although amalgam is the longest lasting, least expensive, and most durable, it requires the removal of more tissue.

The lifetime perspective is to save as much tooth tissue as possible and that amalgam is not the most desirable in the long run.

The Norwegian guidelines will be presented at the International Conference on Mercury as a Global Pollutant in Slovenia in late June.

The Norwegian legal system has two important principals: the public health perspective and the environmental perspective. They are also required by the Norwegian Control Act to observe the Principal of Substitution, which would promote the least amount of health affects or environmental damage. The Director of Environmental Affairs stated that this principal applied to amalgam because of the high concentrations of mercury.

It was determined that:

• Tissue conserving techniques are more important than longer lasting mercury.
• Use as little mercury as possible as they fear there might be health affects although they cannot be proven.
• Use precautionary principal.

The guidelines address both of these area by first reducing the use and subsequent environmental release of dental mercury and second, by reducing mercury exposure in patients.

One of the more problematic issues is the total exposure to mercury contributed to sensitive populations. For a long time, it was thought that not much mercury is released from amalgam. However, over the last decade it was noted that releases of mercury into the body, due to amalgam fillings, are much higher than previously believed. Primary studies have indicated that mercury was detected in the mother's milk and in the fetus.

Therefore, it is important to have this population's exposure to mercury at the lowest possible levels. It was decided that there must be a discontinuation of the use of amalgam as much as possible. There were also some undesirable effects of the new replacement restoration materials but there was not much documentation to substantiate the findings.

Summary - Short version of guideline:

• Preventative treatment priority
• Tissue conserving technique also to be chosen in dental restorations
• Amalgam should not be the first choice for any restoration
• Use of mercury should be limited as much as possible in consideration of environmental and possible health affects
• Avoid during pregnancy
• Contact with amalgam and other metals must be avoided
• Allergy to dental filling materials
• Reduce exposure of patients and dental health professionals to mercury during placement and removing of amalgams
• Contact with materials before hardened should be avoided
• Water cooling infractions used when removing

Questions by Committee:

• Health Canada also recommends that pregnant women avoid amalgam. Is she aware of other countries that have used the precautionary principal.
  • Great Britain sent a letter regarding pregnancy and amalgam therapy. In Norway ALL filling materials are to be avoided during pregnancy and this is purely precautionary.
• Danish officials estimate of placement of amalgam fillings is less than 10%. Are there any current figures on amalgam use?
  • Report sent to Karen includes the statistics in reduction of use of amalgam over time
  • In 1978, 99% of all fillings in 5 year olds were amalgam
  • 18 years later that number (5 year olds) had fallen to 7% - as a result of this recommendations came in 1991 regarding the effect of all discussions and focus in media which, did not focus on children.
  • Copper amalgam was banned in 1984.
  • Guidelines in July 2003 and in November 2002 -decided to make a baseline for amalgam use for total dental health. Sent questionnaire to 10% of all dentists - total 10% of fillings are now amalgam

Ms. Aandahl stated that the initial review process actually began much before the 1998 recommendation with the prior recommendation in 1991 for pregnant women to avoid amalgam placement. There was also considerable comment from members of the public saying they were becoming ill from amalgam fillings. In the late 1980s there was a also lot of discussions.

• Question: Do they have any data for fillings as to how to much mercury is absorbed into the body per filling?
  • Swedish studies show a considerable variation among individuals based on the amount of mercury released and the amount shown in the blood and urine samples.
  • Studies show that chewing gum, especially that used to quit smoking, created higher mercury levels in body fluids at an amount that could cause adverse health affects.

It was determined that the recommendation would be extended regarding all filling therapy for pregnant women. Because alternative-filling material contains Bisphenel "A", (hormone mimicking) it has adverse affects on cell cultures similar to estrogen. It is unknown how much is released and how long it is release and it was felt that this could possible cause adverse affects on the fetus.

Question:

• What has been the opinion of Norway dentists to directorate?
  • At first emotions were high in discussions
  • Confrontations with scientific communities
  • Now they have accepted use of principals adopted by health and Norwegian authorities
  • Cannot wait for proof when you see the handwriting on the wall - sometimes the scientific community wants proof before they abide- they felt that it was better to prove harmless considering the serious problem with mercury.
  • Health Authorities and Pollution Control Authorities felt it was strange to put a known pollutant into the mouth.
  • Believe that with this ruling that this will prompt more research to produce better alternatives.
• Will you be translating more of what you're doing into English, as it would benefit many? She will mail copies to Karen who will provide a mailing address to her.
• What is the standard practice in Vermont for dentist's use of amalgam? Dentists were surveyed in the past and another survey could be done later - 50% of the dentists in Vermont are 50 years are older, as they retire newer graduates are using newer materials and many of the dentists have already made the change from amalgam.
• Nationally in a 2001 study, it was determined that only 20% to 27% of dentists were not placing amalgams- what does that translate to in terms of use of mercury in the dental sector now that the USGS is no longer tracking this?

Agenda Item 2-
Updates on current progress of Amalgam Separator Project.

Greg Lutchko and Gary Gulka gave the Committee an overview of the Amalgam Separator Project as follows:

In November 2002 the Committee looked at dental as a release source of mercury through wastewater. A sub-committee was formed to determine what types of units were on the market, their performance, and what recommendations should the Committee make. Field testing was already available for amalgam separator units and there was no requirement for installation in Vermont. Several states and municipal districts now require separators but there is no first hand testing on how these units perform over a period of time or if there are any maintenance issues. This project began in May 2003. There are approximately ten commercial units on the market. The idea was that the vendors would donate the units for the pilot and DEC would arrange for installation of the units by licensed plumbers that were mostly paid for by the vendors. Six different types of units were installed at 17 installation sites. DEC visited the dental offices about four times through March of 2004 asking dentists about such things as any loss of suction in the vacuum system, observations about accumulation in the separator units, etc. Each of these units is ISO certified for a 95% or greater removal rate for particulate mercury. One important issue was the maintenance of these units including cleaning the lines at the end of each day. DEC tried to match separators with types of offices. There were wet and dry vacuum system variations and space issues. The Committee was given a draft overview of the separators used and findings.

Handouts were provided to the Committee that were excerpts of the draft report and included: (1) a chart of separators in the pilot describing unit specifications, costs, maintenance, etc.; (2) diagrams of separator installations and field observations on each type of separator in the pilot, and (3) recommendations on choosing an amalgam separator.

Comments from committee:

• Suggestion to make specific recommendations for dentists on septic systems.
• Important to understand capture of particulates and units that also collect dissolved particulates.
• ACMP and vendors to review draft prior to release. (Draft phase in June) - Hope to provide draft to Committee at next meeting.
• Suggestion to have display at Dental Society meeting in September.
• Strongly suggest that report simply state facts.

Agenda Item 3-
Discussion of dental office brochures.

This discussion moved to next meeting due to time constraints.

Agenda Item 4-
Accept minutes of the March meeting and possible changes to today's agenda.

March minutes were accepted with no changes.

Agenda Item 5-
Set date and agenda for next meeting.

The next meeting is scheduled for Friday, June 4, 2004 to be held from 9:00 to 11:30 in the Environmental Assistance Office (EAO) Conference Room at the Waterbury State Complex, Waterbury, Vermont. The agenda will be a discussion of dental brochures, and updates on: 1) outreach to sensitive populations, 2) lamp outreach efforts, 3) mercury legislation, 4) NESCAM meeting and 5) New England Fish Forum. If the amalgam separator draft report is available, the Committee will be given a copy at the next meeting for review.