Treatment of health complaints attributed to amalgam.

The aim of the present study was to compare the reduction of subjective complaints by 3 treatment strategies in 90 "amalgam patients" whose complaints could not be explained by a medical or psychological disorder. The individuals were randomly assigned either to removal of dental amalgam only (removal group), or removal in combination with a "biological detoxification" therapy with high doses of vitamins and trace elements (removal-plus group), or participation in a health promotion program without removal of dental amalgam (no-removal group). Between baseline and month 12, the sum score of main complaints decreased by 3.5 (SD=2.2) points on average in the removal group as well as in the removal-plus group, and by 2.5 (SD=2.4) points in the no-removal group (p=0.152). Both removal groups showed a significant decrease in steady-state levels of inorganic mercury compared with the no-removal group. Thus, all 3 interventions were associated with clinically relevant improvements.

Blood and urine mercury levels in adult amalgam patients of a randomized controlled trial: interaction of Hg species in erythrocytes.

UNLABELLED: Parts of the population are permanently exposed to low levels of Hg degrees and Hg(II) from dental amalgam. It was the aim (1) to investigate the internal exposure to amalgam-related mercury from the kinetics of inorganic Hg in plasma and erythrocytes after amalgam removal, and (2) to estimate the amalgam-related absorbed dose. Dietary coexposure was monitored by determination of blood organic-Hg. Postremoval steady-state Hg concentrations were measured for 18 months. Eighty-two patients had been randomized into three groups: (A) removal of the fillings; (B) removal and non-specific detoxification, and (C) a health promotion program without removal. After amalgam removal, inorganic Hg dropped rapidly in plasma and red cells, stabilizing at 27% of preremoval levels after 60 days. Concentrations of organic Hg in plasma remained unchanged, indicating no change in dietary uptake of organic Hg. The concentration of organic Hg in red cells of group A was in the early postremoval phase lower and in the late postremoval phase higher than the preremoval control (p<0.01 for low-high difference). A protracted increase in organic Hg was also found in red cells of group B after 60 days. Thus, the effect of removal on organic Hg levels in the combined group A+B was compared with the values of group C in a linear mixed effects (LME) model which showed a significant increase with time in group A+B (p=0.028). In all groups, time profiles of urinary concentration and excretion of total-Hg were very similar to those of inorganic-Hg levels in plasma. From extrapolations of blood and urine data it was estimated that the amalgam-related inhalation and ingestion of Hg species were within the limits proposed by WHO, ATSDR and EPA. The integrated daily Hg dose absorbed from amalgam was estimated up to 3 microg for an average number of fillings and at 7.4 for a high amalgam load. CONCLUSIONS: This is the first study on adult amalgam patients which continuously monitored the postremoval decline of inorganic Hg and the coexposure from dietary organic Hg in a randomized-controlled-trial design. The integrated daily dose of 7.4 microg absorbed from a high amalgam load is well below the tolerable dose of 30 microg (WHO, 1990). The unexpected postremoval increase in erythrocyte organic Hg, which is associated with the depletion of cellular inorganic Hg, might result from binding of organic Hg to cellular sites previously occupied by inorganic Hg.

Steady-state transfer and depletion kinetics of mercury from amalgam fillings.

In 29 volunteers with a low amalgam load, the number of amalgam-covered tooth surfaces and the occlusal area of the fillings were determined. Before and at select times after removal of all amalgams, concentrations of total mercury were measured by cold-vapor atomic absorption in plasma and erythrocytes as well as in urine together with the excretion rate. Absorbed daily doses were estimated from intraoral Hg emission by two separate methods. The transfer of Hg from the fillings via the oral cavity and blood to urinary excretion was evaluated according to the most representative combination of parameters. This consisted of occlusal area (1), absorbed dose (2), Hg concentration in plasma (3) and urinary excretion (4). Pairwise correlation coefficients were 0.49 for parameters 1 vs. 2, and 0.75 each for parameters 2 vs. 3 and 3 vs. 4. Within 9 days after removal of the fillings, a transient increase in Hg levels was observed in plasma only; in the group without a rubber dam, concentrations increased significantly above pre-removal values at days 1 and 3, whereas they decreased significantly below pre-removal values at day 30 in the rubber-dam group and at day 100 in both groups. Excretion rates decreased significantly at day 100 in the protected group. Peak plasma-Hg was 0.6 ng/ml on average at day 1 and decreased with halftimes of 3 and 43 days in subjects protected by a rubber dam. The results indicated that concentrations of total mercury in plasma responded rapidly to changes in the amalgam status and reflected the actual absorption most reliably. Notably, plasma-Hg levels were sensitive enough to detect a transient attenuation of the additional exposure after using a rubber dam during the removal of only a few fillings. However, being small in magnitude and lasting 100 days at best, the rubber-dam effect had minor toxicological relevance.

Two-year clinical evaluation of direct and indirect composite restorations in posterior teeth.

STATEMENT OF PROBLEM: Few long-term clinical studies have reported data of modern posterior composites as direct and indirect restorations. PURPOSE: This prospective, long-term clinical trial (1) evaluated direct and indirect composite restorations for clinical acceptability as posterior restoratives in single or multisurface carious teeth and (2) provided a survey on the 2-year results. MATERIAL AND METHODS: Nine dental students placed 88 composite restorations (Tetric, blend-a-lux, Pertac-Hybrid Unifil), 43 direct composite restorations and 45 indirect inlays, under the supervision of an experienced dentist. The first clinical evaluation was performed 11 to 13 months after placement by 2 other experienced dentists, using modified USPHS criteria. A second follow-up of 60 restorations took place within 20 to 26 months after placement. RESULTS: A total of 93% of indirect and 90% of direct composite restorations were assessed to be clinically excellent or acceptable. Two restorations (1 indirect composite inlay and 1 margin of a direct composite restoration) failed during the second year because of fracture. Indirect inlays demonstrated a significantly better "anatomic form of the surface" than direct composite restorations. Premolars revealed a significantly better margin integrity and postoperative symptoms than molars. CONCLUSION: Posterior composite restorations provided a satisfactory clinical performance over a 2-year period when placed by relatively inexperienced but supervised students.

Effect of rubber dam on mercury exposure during amalgam removal.

It was the aim of this investigation to treat 20 volunteers with maximally 5 amalgam fillings by the same comprehensive protocol in which all removals with (n = 8) and without (n = 12) rubber dam had been performed within a few months. Nine amalgam-related parameters indicated a close matching of both groups before removal. In the group without rubber dam, mercury (Hg) levels in plasma increased significantly above preremoval values at days 1 and 3 after removal; they decreased significantly below preremoval values at day 30 in the rubber-dam group and at day 100 in both groups. Excretion rates did not increase significantly in either group, but decreased significantly at day 100 in the protected group. Peak plasma-Hg was 0.6 ng/mL on average at day one and decreased with halftimes of 3 and 43 d in subjects protected by rubber dam. The results indicated that concentrations of total mercury in plasma responded rapidly to changes in the amalgam status and reflected the actual absorption most reliably. Notably, plasma-Hg levels were sensitive enough to detect a transient attenuation of the additional exposure by using rubber dam during the removal of only a few fillings. However, being small in magnitude and lasting 100 d at best, the rubber-dam effect had minor toxicological relevance.

A multicenter survey of amalgam fillings and subjective complaints in non-selected patients in the dental practice.

The aims of this study were to examine whether there is a difference in symptoms between patients with amalgam fillings and patients without such restorations, to investigate the relationship between particular symptoms and the number of amalgam filled surfaces, and the differences in symptoms between patients with and without removal of amalgam fillings. Data from 6744 consecutive patients in 34 dental offices located throughout Germany were documented. Patients completed a questionnaire answering 48 items, and the current oral findings in the patients were registered. The analysis was restricted to 4,787 patients aged 21 to 60 yr because of special dental conditions in children and elderly persons. The study did not show any significant correlation between the intensity of complaints or particular groups of symptoms and the number of amalgam-filled surfaces. A higher number of symptoms as well as a higher intensity of symptoms were found in patients before amalgam removal compared to the remaining patients. The question remains open whether or not there may be a certain kind of relationship between the complaints and amalgam fillings in individual patients.

Systemic transfer of mercury from amalgam fillings before and after cessation of emission.

In 29 volunteers with a low amalgam load, the number of amalgam-covered tooth surfaces and the occlusal area of the fillings were determined. Concentrations of total mercury were measured in plasma and erythrocytes as well as in urine together with the excretion rate. Absorbed daily doses were estimated from intraoral Hg emission by two separate methods. The transfer of Hg from the fillings via the oral cavity and blood to urinary excretion was evaluated according to the most representative combination of parameters. This consisted of urinary excretion (1), Hg concentration in plasma (2), absorbed dose (3), and occlusal area (4). Pairwise correlation coefficients were 0.75 for parameters 1 vs 2 and 2 vs 3 and 0.49 for parameters 3 vs 4. Within 9 days after removal of the fillings, a transient increase was observed in plasma Hg levels only. This was reduced in those volunteers to whom a rubber dam had been applied during removal. Peak plasma Hg was 0.6 ng/ml on average and decreased with halftimes between 5 and 13 days. A significant decrease in Hg excretion was noted not before 100 days after removal. Being relatively insensitive to dietary mercury, the determination of total mercury in plasma and of its urinary excretion rate appears, under practical aspects, most suitable for the investigation of Hg uptake from amalgam.

3D volume-ablation rate and thermal side effects with the Er:YAG and Nd:YAG laser.

OBJECTIVES: The aim of this investigation was to determine the influence of a variety of parameters on the effectiveness of hard substance ablation and the thermal side effects when using Er:YAG laser (Key I and II, KaVo) and Nd:YAG laser (SunLase 800, Sunrise Technologies/Orbis). METHODS: For this study, ablation and temperature measurements were carried out on 170 dentin slices and 170 extracted teeth via computer-controlled cavity preparation. The Er:YAG laser settings varied from 250-400 mJ/pulse, 3-15 pps and 20-180 s processing time, and in the case of the Nd:YAG laser from 83-100 mJ/pulse, 10-20 pps, and 20-260 s processing time. The ablation rate was measured volumetrically via a 3D sensor. Temperatures were measured for each setting both on the dentin slice and in the pulp of the extracted teeth. The results were analyzed using a t-test for independent samples and a one-way ANOVA (Bonferroni). Also a liner regression analysis was done using Pearson's coefficient. RESULTS: The results show that with the Er:YAG laser, in combination with water-spray cooling, an effective 3D ablation rate (up to 0.017 mm3/pulse = 50 microns linear) can be achieved without raising the temperature of the surrounding tissue. In the case of the Nd:YAG laser, no measurable ablation rate was evident without conditioning of the dentin surface and, in the case of conditioning with black ink, a low ablation rate (0.00004 mm3/pulse = linear 0.2 micron/pulse) was found. SIGNIFICANCE: In contrast to the Er:YAG laser, it is apparent, that with the Nd:YAG laser from a total energy of 80 J onwards, the rise in temperature in the pulp is above 8 degrees C. For that reason, the use of the Nd:YAG laser at higher total energies is not recommended. The temperature rise with the Nd:YAG laser is dependent on the direction of the dentin tubuli. Dentin tubuli running parallel to the surface prevent significant heat penetration, whereas those running in a transverse direction to the surface (= parallel to the laser beam) support the penetration of heat. This finding supports the light-propagating theory for spreading effects of laser beams in dentin.

One-year clinical evaluation of composite fillings and inlays in posterior teeth.

In the course of a prospectively designed long-term clinical trial, composite fillings and inlays were evaluated for clinical acceptability as restorative materials in one, two or more surface cavities of posterior teeth over a 1-year period. In 45 patients, 88 restorations were placed by nine student operators, under the supervision of an experienced dentist, to compare the two half sides using the composite resins Tetric (Vivadent), blend-a-lux (Blend-a-med), and Pertac-Hybrid Unifil (Espe). The first clinical follow-up check took place within a time period of 11-13 months after placement of the restorations using modified USPHS criteria. The interpretation of the clinical criteria showed satisfactory results over this time period: more than 85% of the inlays and direct fillings were rated "alpha" or "bravo", using the parameters of assessment defined in this study. Only three restorations (two fillings, one inlay), all in molars, were rated "delta", i.e., unacceptable. The reasons for their replacement were marginal opening, secondary caries, and loss of sensitivity. For the criteria "surface texture", "anatomical form of the surface", and "occlusion", composite inlays were significantly better than composite fillings. These results indicate that posterior composite restorations provide acceptable and excellent clinical service, even if they are placed by relatively inexperienced student operators.

Compartmental transfer of mercury released from amalgam.

The number of amalgam-covered surfaces and the occlusal area of the fillings, the concentrations of total mercury in plasma, erythrocytes and urine, the urinary excretion rate, and the absorbed daily doses estimated by two separate methods from intra-oral Hg emission were determined in 29 volunteers with a low amalgam load. The transfer of Hg from the fillings via the oral cavity and blood to urinary excretion was evaluated by multiple correlations between these variables. In addition, the combination of variables most representative of the entire compartmental transfer of amalgam Hg was determined. Urinary excretion (1), Hg concentration in plasma (2) and absorbed dose (3) were most closely correlated to each other, followed by correlations with the variables of the fillings (4). Correlation coefficients were 0.75 for variables 1 vs 2 and 2 vs 3, and 0.49 for variables 3 vs 4. It was concluded that variables 1-3 best reflected the transfer of mercury from amalgam fillings throughout the organism and that they were relatively insensitive to dietary mercury. The determination of total mercury in plasma and of its urinary excretion rate appears, under practical aspects, most suitable for the investigation of Hg uptake from amalgam.

CAD/CAM--fillings of the future?

The development of computer aided technology in restorative dentistry has created a range of techniques for the modern dentist. The types of systems now available and the literature published thus far on long term clinical results of restorations created by such techniques are reviewed.

Microleakage of gold casting repairs with different materials as quantified by a helium gas system.

Inadequate adaptation of a filling material to a gold crown can promote the passage of bacteria; thus, recontamination of sound dentin and/or the pulp canal space is feasible. The aim of this study was to determine the marginal microleakage between two different amalgams (Tytin and Valiant PHD-XT), three different composites (Tetric, Charisma, and Polofil Molar), and one glass-ionomer cement (Ketac Silver) and gold cast crowns using a helium gas microleakage method. In order to standardize the research parameters, gold washers with standardized dimensions were used as study models together with a helium leakage testing device. Standardized cavities were filled according to the manufacturers' recommendations with the different materials. The amount of helium passing the marginal interface between the fillings and cavities was measured with a mass spectrometer 48 hours after the fillings were placed and 100, 1000, and 2000 thermocycles (5 degrees C-55 degrees C). The results showed that amalgam allowed the least microleakage. Ketac Silver showed the greatest microleakage. Statistically significant differences were found between the composites and both amalgams and Ketac Silver between the 48-hour and 100-thermocycling groups. Yet, Ketac Silver showed a significant ascending tendency when compared to the composites and amalgams after 100, 1000, and 2000 thermocycles.

Comparison by means of a computer-supported device of the enlarging characteristics of two different instruments.

Numerous studies report different results when testing endodontic instruments with similar and/or different research protocols. However, objective studies that could eliminate the factors inherent to the operator have not yet been developed. Simulated root canals in clear casting resin were used as models. The Canal Master U and Flexogate were tested by using a double exposure photographic technique. A computer-aided device capable of reproducing three-dimensional enlarging movements and irrigation of the simulated canals was developed. The enlarging movements were programmed according to the step-back and step-down techniques. The enlarging of simulated root canals with this device proved to be constant and reproducible. Standard deviations were kept low and were dependent on the degree of canal curvature. The enlarged simulated root canals showed that both instruments could be kept centered in the path of the root canal. Results showed only a few significant differences between the effective material removed and a theoretical ideal amount of removed material.

[Enamel damage depending on the method of bracket removal]. / Uber die Schmelzchädigung in Abhängigkeit von der Methode der Bracketentfernung.

Two different methods of removing brackets, on the one side by torsion and on the other by bending, were compared for the purpose of analyzing the respective enamel lesions. Each test group consisted of 19 extracted human molars with metal brackets attached to the molars by means of the "concise etching technique". Bracket removal was standardized through the use of a Wolpert "Universalprüfmaschine TZZ 707" with modified torsion and bending mechanism. A scanning electron microscope was used to analyze the enamel surface. When using the torsion method, the mean extension of the enamel lesions was 48.3% of the adhesive free enamel surface. These lesions often reached into the deeper enamel layers and were mainly to be found on the broad side of the bonded area. On the other hand, when using the bending method, the enamel lesions were less frequent. They were mainly superficial and were confined almost exclusively to the pressure zones. The stress required to remove the brackets and the stress distribution were calculated on mechanical models and these results corresponded well with the enamel lesions observed on the molars. It can thus be concluded that the method of removing brackets is clinically relevant in relation to enamel lesions.