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Oh no, readers say, more of Burke's incomprehensible rubbish, just when they thought that they had been given an Editorial Director who could write sense!
In that regard, even the most erudite readers of the UK's best-selling subscription journal, Dental Update, may not appreciate the thread running between the items in the title! On the other hand, older readers may (or probably may not!) recall, in 2004, the year in which the Hong Kong tram system, which runs from one end of the city to the other and celebrated its 100th anniversary in that year, that the trams were the subject of an editorial comparing their longevity to that of dental amalgam, with the 100th anniversary tram being featured on the cover of Dental Update (Figure 1). The trams remain, to the present time, a useful and functional form of transport as opposed to being a relic of the past. Indeed, as trams in UK cities such as Manchester and Glasgow were retired and replaced by petrol-powered buses, the trams were added to the Hong Kong fleet.
Not many things survive for 120 years or more, other than perhaps well-maintained buildings, cathedrals and the like. However, in dentistry, dental amalgam has survived for even longer than the Hong Kong trams, but today its days are numbered, first because of environmental concerns related to its mercury content and, most recently, as uncertainties regarding its availability have surfaced, following the recent ban on its manufacture and sale in the EC. Why has one survived and not the other? While amalgam is considered simple to use, the trams also seem simple to drive, given that the driver doesn't have a steering wheel (obviously not needed because it travels along tracks), only a stop/start handle. The Hong Kong trams are a cheap form of transport, but amalgam is also a cheap dental material, given that it can be placed relatively quickly, and clinician time (=money) is low. However, other comparisons are not so flattering for amalgam. The trams, being electric, are environmentally favourable – they do not emit exhaust fumes and heat, let alone noise, like their petrol driven replacements, while, on the other hand, it is environmental concerns that are driving the demise of amalgam. The trams have, to some degree, adapted to the times: they may be slow, but this has facilitated their reincarnation as an advertising medium (Figure 2), given that the public on the streets through which the trams trundle can read the advertisements on the trams.(Daresay, this is why we don't see advertising on trains and planes!) They have also diversified – there are now four ‘party trams’ and a couple dedicated to city tours. They have modernized, with digital displays and sat-nav stop announcements having been installed in the past 10 years. On the other hand, the formulation of dental amalgam has not lent itself much to modernization, diversification and change. But, both the trams and dental amalgam have been proven to be reliable and effective for 120 years, and longer in the case of amalgam, which was introduced in the mid-19th century, but only became widely used after the work of GV Black.
What now for dental amalgam? The Minimata Convention agreed that amalgam would be phased out by 2030, but the EC pulled a fast one and announced its sales and manufacturing ban from 2025, as explained in the Dental Update editorials of January and February of this year,1,2 with a European Union draft document to phase out all amalgam use by 1 January 2025 setting out rules:
While these changes will have implications for dentists who use amalgam extensively, they have been felt most acutely in Northern Ireland, given that there, they have to abide by (some) post-Brexit EU regulations and amalgam is more widely used there than in other parts of the UK. It would mean that it would not simply be illegal to import dental amalgam, but to use it at all (except in exceptional circumstances), in Northern Ireland. Shortly after the initial announcement, there was further clarification when the European Union swiftly ratified the draft document, thereby banning dental amalgam from use and export, with an implementation date of January 2025, ‘except when the use of dental amalgam is deemed strictly necessary by the dental practitioner to address specific medical needs of the patient’. Of course, the UK is no longer in the EU, but when the ban comes into force, it will affect UK dentists because it will disrupt supply chains, thereby making dentistry more expensive, with the BDA adding that the NHS dentistry service is ‘unstable’ and the conditions have not been met to see a move away from amalgam from 1st January 2025.
However, while the Council of the EU maintained the Commission's proposed date for the total phase-out in the EU, it introduced a 2-year derogation for those member states where low-income individuals would otherwise be socio-economically disproportionally affected by a phase-out in January 2025. It was considered that those member states would have to justify their use of the derogation and notify the Commission of the measures they intend to implement to achieve the phase-out by 1st January 2027.
However, help for dentists in Northern Ireland is at hand, following extensive lobbying from the Secretary of State, the British Dental Association (BDA) and others.
On 19 July 2024, The European Commission granted a derogation to Northern Ireland from the EU's new mercury regulations, which allows Northern Irish dentists to continue using dental amalgam until 31st December 2034, until the date agreed for amalgam's withdrawal by the Minamata Convention (to which the UK is a signatory), whichever is earlier. The derogation is subject to a number of conditions, including reporting and showing progress in reducing the use of amalgam. The BDA in Northern Ireland welcomed the derogation, arguing that a ban would have had a negative impact on NHS dentistry, with 92% of dentists in Northern Ireland being concerned that a ban would have reduced NHS activity and increased costs. In that regard, the BDA stated: ‘Securing a bespoke arrangement for Northern Ireland on dental amalgam involved a massive effort on the part of the profession and its representatives, working to inform and influence decision-makers, who in turn must be credited with finding a workable way forward’. Quite correctly adding: ‘Now, we urge authorities to commit to followingthrough on prevention initiatives, reforming dental services, and giving a greater focus to new treatment materials and techniques’, and, ‘After years of delay and neglect, let's grasp the nettle on reforming our dental services and improving oral health outcomes’. Ciara Gallagher, chair of the BDA's Northern Ireland dental practice committee, said: ‘A ban on dental amalgam in 2025 could have spelled the end for NHS dentistry in Northern Ireland. We sounded the alarm and fought tooth and nail for a workable solution. This delay is a glimmer of hope for a service that's on its knees and could not have shouldered any further financial pressure. We have some breathing space, but Stormont and Westminster cannot take their feet off the pedal to affect a seamless transition to amalgamfree dentistry’.
Finally, I should remind readers that this political controversy is nothing new for dental amalgam, with the so-called ‘Amalgam Wars’ in which American dentists who used amalgam were threatened with malpractice actions by dentists who did not use it, and that the American Society of Dental Surgeons was disbanded because of the Amalgam War, with, in 1859, the American Dental Association (ADA), a group who supported the use of amalgam, becoming the nation's new dental society. Amalgam has also been debated in the US Congress, with two members of the US Congress moving a bill to abandon amalgam, and Congresswoman Diane Watson promoting the ‘Mercury in Dental Filling Disclosure and Prohibition Act’ as recently as 2002, stating ‘we have abandoned all other forms of pre-Civil War medicine’! But, who would have thought that banning of amalgam in Europe would have led to such political outcry, while the trams in Hong Kong, which continue to amble through the crowded streets, are not being phased out any time soon.
Thanks to Professor Damien Walmsley
Damien has been a stalwart, and very active, member of the Editorial Board of Dental Update for circa 20 years. Throughout that time, he has been a willing reviewer of articles in his specialist field of prosthodontics, but more recently, his knowledge has proved invaluable as the number of manuscripts submitted on artificial intelligence has increased exponentially. This was something that Damien was aware of, well before the rest of us! In that regard, older readers will remember his innovative (dare I say geeky!!) long running series called ‘Walmsley's Web Watch’. Add to this that Damien has been a model Board member, by way of proposing article titles in collaboration with a wide variety of colleagues, titles which he always followed through to completion, much to the benefit of readers.
Damien wrote, when stating his intention to retire from the Editorial Board, ‘I have now come off the Register and want to have time to follow lots of interests outside dentistry.’