Amalgam (dentistry)

Dental amalgam is a liquid mercury and metal alloy mixture used in dentistry to fill cavities caused by tooth decay. Low-copper amalgam commonly consists of mercury (50%), silver (~22–32%), tin (~14%), copper (~8%) and other trace metals. Dental amalgams were first documented in a Tang Dynasty medical text written by Su Gong (苏恭) in 659, and appeared in Germany in 1528. In the 1800s, amalgam became the dental restorative material of choice due to its low cost, ease of application, strength, and durability. In July 2018 the EU prohibited amalgam for dental treatment of children under 15 years and of pregnant or breastfeeding women. There are, according to Geir Bjørklund, indications that dental amalgam was used in the first part of the Tang Dynasty in China (AD 618–907), and in Germany by Strockerus in about 1528. Evidence of a dental amalgam first appears in the Tang Dynasty medical text Xinxiu bencao《新修本草》 written by Su Gong (苏恭) in 659, manufactured from tin and silver. Historical records hint that the use of amalgams may date to even earlier in the Tang Dynasty. It was during the Ming Dynasty that the composition of an early dental amalgam was first published, and a text written by Liu Wentai in 1505 states that it consists of '100 shares of mercury, 45 shares of silver and 900 shares of tin.' Ever since its introduction in the Western world in the 1830s, amalgam has been the subject of recurrent controversies because of its mercury content. Early amalgam was made by mixing mercury with the filings of silver coins. In 1833 Englishmen, Edward Crawcour and his nephew Moses Crawcour (incorrectly referred to as 'the Crawcour brothers'), brought amalgam to the United States, and in 1844 it was reported that fifty percent of all dental restorations placed in upstate New York consisted of amalgam. However, at that point the use of dental amalgam was declared to be malpractice, and the American Society of Dental Surgeons (ASDS), the only US dental association at the time, forced all of its members to sign a pledge to abstain from using the mercury fillings. This was the beginning of what is known as the first dental amalgam war. The dispute ended in 1856 with the disbanding of the old association. The American Dental Association (ADA) was founded in its place in 1859, which has since then strongly defended dental amalgam from allegations of being too risky from the health standpoint. Amalgam has been used for many years for restorations, commonly known as fillings. Prior to 1900 many compositions were tried but few were successful when placed in the oral environment. Around 1900, small amounts of copper and occasionally zinc were added. Zinc acts as a scavenger because it prevents oxidation of the other metals in the alloy during the manufacturing process. Zinc accomplishes this by combining readily with oxygen to form zinc oxide. Amalgam restorations made from this balanced formula were reasonably successful and its longevity increased. However, one disadvantage that remained was fracture at the tooth-amalgam interface commonly called marginal fracture. Sn8Hg (γ2 phase) was considered to be responsible for this problem. This phase has been shown to be the weakest phase in the set amalgam and is subject to corrosion, particularly at the tooth-amalgam interface. In 1962 a new amalgam alloy, called Dispersalloy, was introduced with the addition of a spherical silver-copper eutectic particle to the traditional lathe-cut Ag3Sn particle in a ratio of 1:2. The mixture of these two types of particles is known as admix alloy. The benefits of this alloy was to strengthen the set amalgam and reduce the γ2 phase (Sn8Hg). The increased copper in the silver-copper eutectic reacted preferentially with tin so that Sn8Hg could not form. Early results from the clinical use of this new amalgam showed an improvement in marginal integrity. About 10 years later, another alloy, called Tytin, was introduced by adding significant amount of Cu3Sn together with Ag3Sn, in the form of a unicompositional spherical particle to eliminate the γ2 phase. Both of these relatively new alloys raised the copper content from 5%, present in the older balanced composition alloy, to about 13% for the newer alloys. Dental amalgam is produced by mixing liquid mercury with an alloy made of silver, tin, and copper solid particles. Small quantities of zinc, mercury and other metals may be present in some alloys. This combination of solid particles is known as amalgam alloy. The composition of the alloy particles are controlled by the ISO Standard (ISO 1559) for dental amalgam alloy in order to control properties of set amalgam such as corrosion and setting expansion. It is important to differentiate between dental amalgam and the amalgam alloy that is commercially produced and marketed as small filings, spheroid particles, or a combination of these, suitable for mixing with liquid mercury to produce the dental amalgam. Amalgam is used most commonly for direct, permanent, posterior restorations and for large foundation restorations, or cores, which are precursors to placing crowns. The reaction between mercury and alloy when mixed together is termed an amalgamation reaction. It will result in the formation of a silver-grey workable mass which can be condensed into cavities. After condensing, the dental amalgam is carved to generate the required anatomical features and then hardens with time. In the pre-1986, the standard composition of alloy is referred to as conventional amalgam alloy. More recently (post-1986), there have been a change in the compositional standard of the alloy due to better understanding of structure-property relationships for the materials. Conventional amalgam alloy commonly consists of silver (~65% ), tin (~29%), copper (~8%) and other trace metals; current amalgam alloy consists of silver (40%), tin (32%), copper (30%) and other metals.