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In light of the Minamata Convention on Mercury and efforts to phase down dental amalgam use, tracking dental amalgam proportions across US Food and Drug Administration (FDA)–identified at-risk populations is of interest to optimize material selection aligned with patient needs. A retrospective observational study of Epic's Cosmos electronic health records data set was conducted to calculate the rates of dental amalgam restorations from 2017 through 2023 and stratified using the social vulnerability index (quartile 4 indicates the highest social vulnerability and quartile 1 indicates the lowest) and payer type (Medicare, Medicaid, self-pay, miscellaneous or other). The authors included the following FDA-identified at-risk populations: pregnant people, children younger than 6 years, people with preexisting neurologic conditions, and people with impaired kidney function (n = 1,897,976). The overall rate of dental amalgam restoration placements in the general population declined from 21.8% in 2017 to 4.1% in 2023. Dental amalgam restoration trends, according to social vulnerability index quartile and payer type, decreased consistently across all 4 evaluated populations. Of all the social vulnerability index quartiles, quartile 4, representing the most socially vulnerable group, had the smallest decrease in dental amalgam placement rates among the FDA-identified populations examined. The study results showed a decreasing trend in dental amalgam restorations from 2017 through 2023 among FDA-identified populations, consistent with the Minamata Convention on Mercury directive for a phasedown in dental amalgam use. Notwithstanding improvements, lingering disparities persist among the most vulnerable population. Even within the groups identified as most vulnerable to harm, more targeted interventions and strategies are required to improve treatment among the most socially vulnerable. [ABSTRACT FROM AUTHOR]

Amalgam has been used for more than 150 years as a safe and reliable restorative material. The authors described the occurrence of amalgam and nonamalgam restorations in the United States in primary and permanent teeth across age groups and according to sociodemographic characteristics. The authors used clinical examination data from the National Health and Nutrition Examination Survey 2015-2018 for participants 2 years and older (n = 17,040). The authors estimated the prevalence and mean number of amalgam and nonamalgam restorations in primary and permanent teeth according to age groups (2-5 years, 6-11 years, 12-15 years, 16-19 years, 20-39 years, 40-59 years, 60-79 years, and ≥ 80 years), race and ethnicity, federal poverty guideline, education, and pregnancy status. The prevalence of amalgam restorations ranged from 4% through 69%. Overall, amalgam restorations were more prevalent in children and adolescents from racial and ethnic minority groups and families at lower poverty levels and with lower education. The mean number of teeth with nonamalgam restorations was higher than those with amalgam restorations in primary teeth of children aged 6 through 11 years, permanent teeth of those 12 through 15 years and 20 through 39 years, and women aged 20 through 49 years, regardless of pregnancy status. The mean number of amalgam restorations was higher than that for nonamalgam restorations in older age groups. Nonamalgam restorations were the most common in the primary teeth of children older than 5 years and in the permanent teeth of adults younger than 40 years. Amalgam restorations were more common in older adults. Amalgam and nonamalgam restorations were equally common in children younger than 5 years. The study findings suggest a shift from amalgam to alternative restorative materials in the United States. [ABSTRACT FROM AUTHOR]

In the context of evolving dental materials and techniques and a national agenda to phasedown use of dental amalgam, estimates of dental amalgam placement are necessary for monitoring purposes. Numbers of amalgam and composite posterior restorations from 2017 through 2019 were calculated using retrospective dental claims analysis of privately insured patients. Kruskal-Wallis and multilevel, multivariable negative binomial regression models were used to test for differences in rates of amalgam and composite restoration placement by age group, sex, urban or rural area, and percentage race and ethnicity area distribution. Statistical significance was set at 0.05, with Benjamini-Hochberg correction for false discovery rate. The rate of amalgam restorations declined over time from a mean of 6.29 per 100 patients in 2017 to 4.78 per 100 patients in 2019, whereas the composite restoration rate increased from 27.6 per 100 patients in 2017 to 28.8 per 100 in 2019. The mean number of amalgam restorations placed per person were lowest in females compared with males, in urban areas compared with rural areas, and in areas with more than 75% non-Hispanic White residents. Amalgam restoration placements in privately insured people in the United States declined from 2017 through 2019. Amalgam restoration placements may be unevenly distributed by location. Achieving further declines of dental amalgam use may require changes to insurance coverage, incentives, and provider training as well as augmented disease prevention and health promotion efforts. These efforts should focus particularly on groups with high caries risk or higher rates of amalgam placement. [ABSTRACT FROM AUTHOR]

This hypothesis-testing study evaluated the relationship between mercury (Hg)-based dental amalgams and arthritis diagnoses among adults in the United States (US). A total of 86 305 425 weighted-persons with ⩾1 dental amalgam filling surface (DAFS) (exposed group) and 32 201 088 weighted-persons with ⩾1 other dental filling surface (ODFS) (no DAFS, unexposed group) were examined in the 2015 to 2016 National Health and Nutritional Examination Survey (NHANES). All persons were 20 to 80 years-old with known demographic characteristics and arthritis status. Survey logistic regression and survey frequency modeling in SAS were employed with and without adjustment of covariates. The arthritis rate was significantly increased in the exposed group compared to the unexposed group in the unadjusted (7.68-fold) and adjusted (4.89-fold) models. Arthritis (per 10 000 weighted-person-years) was 6.0-fold significantly increased in the exposed group (6.2) compared to the unexposed group (1.06). A significant bimodal dose-dependent relationship between DAFS and arthritis rate was observed. The arthritis rate increased with increasing DAFS (peak among persons with 4-7 DAFS) and, subsequently, decreased among those with >6 DAFS. A significant decrease in arthritis rate among persons with >13 DAFS as compared to those persons with 4 to 7 DAFS was observed. A significant association between DAFS and arthritis risk and a dose-dependent DAFS associated immune-stimulation/immune-suppression with arthritis risk were observed. An estimated additional $96 835 814 US dollars (USD) are spent on annual medical costs and $184 797 680 USD are lost in annual wages from reported new onset arthritis attributably associated with DAFS (annual total cost = $281 633 494 USD). [ABSTRACT FROM AUTHOR]

Background: The use of artificial intelligence in the field of health sciences is becoming widespread. It is known that patients benefit from artificial intelligence applications on various health issues, especially after the pandemic period. One of the most important issues in this regard is the accuracy of the information provided by artificial intelligence applications., Objective: The purpose of this study was to the frequently asked questions about dental amalgam, as determined by the United States Food and Drug Administration (FDA), which is one of these information resources, to Chat Generative Pre-trained Transformer version 4 (ChatGPT-4) and to compare the content of the answers given by the application with the answers of the FDA., Methods: The questions were directed to ChatGPT-4 on May 8th and May 16th, 2023, and the responses were recorded and compared at the word and meaning levels using ChatGPT. The answers from the FDA webpage were also recorded. The responses were compared for content similarity in "Main Idea", "Quality Analysis", "Common Ideas", and "Inconsistent Ideas" between ChatGPT-4's responses and FDA's responses., Results: ChatGPT-4 provided similar responses at one-week intervals. In comparison with FDA guidance, it provided answers with similar information content to frequently asked questions. However, although there were some similarities in the general aspects of the recommendation regarding amalgam removal in the question, the two texts are not the same, and they offered different perspectives on the replacement of fillings., Conclusions: The findings of this study indicate that ChatGPT-4, an artificial intelligence based application, encompasses current and accurate information regarding dental amalgam and its removal, providing it to individuals seeking access to such information. Nevertheless, we believe that numerous studies are required to assess the validity and reliability of ChatGPT-4 across diverse subjects., (© 2024. The Author(s).)

Advancements in dental materials and changing parental preferences are modifying the frequency of use of restorative materials. This insurance claims analysis examined the trends in the use of amalgam and resin composite in the United States. Commercial dental insurance claims were analyzed to compare 505,994 restorations, corresponding with procedure codes for 1-, 2-, and 3-surface amalgam or resin restorations. Paid claims collected nationwide from January 2010 through March 2020 were analyzed. Data for children aged 3 through 12 years were used, resulting in 219,632 unique patient identification numbers. Generalized estimating equation models applied to logistic regression were used. All tests were conducted using a 2-sided 5% significance level. In general, girls were less likely to receive amalgam than boys. A $20,000 increase in median household income was associated with a 16% decrease in the odds of amalgam being placed. Pediatric dentists (performing 15.1% of all restorations) were not as likely as general dentists (18.4%) to use amalgam. Having more surfaces in a restoration was associated with higher probability of amalgam placement. The percentage of amalgam restorations was higher for 2010 (26.9%) than for 2011 through 2020, and this pattern recurred in several of the years analyzed. Generally, patient age at time of amalgam restoration increased over time. The use of amalgam is trending down; the sharpest decline was noted in 2014. Pediatric dentists were less likely to use amalgam than general dentists. Girls and patients with higher socioeconomic status were less likely to have amalgam. The findings of this study can inform and support clinical decisions and the formation of public policies. [ABSTRACT FROM AUTHOR]

Abstract: Dental amalgam is 50% metallic mercury (Hg) by weight and Hg vapour continuously evolves from in-place dental amalgam, causing increased Hg content with increasing amalgam load in urine, faeces, exhaled breath, saliva, blood, and various organs and tissues including the kidney, pituitary gland, liver, and brain. The Hg content also increases with maternal amalgam load in amniotic fluid, placenta, cord blood, meconium, various foetal tissues including liver, kidney and brain, in colostrum and breast milk. Based on 2001 to 2004 population statistics, 181.1 million Americans carry a grand total of 1.46 billion restored teeth. Children as young as 26months were recorded as having restored teeth. Past dental practice and recently available data indicate that the majority of these restorations are composed of dental amalgam. Employing recent US population-based statistics on body weight and the frequency of dentally restored tooth surfaces, and recent research on the incremental increase in urinary Hg concentration per amalgam-filled tooth surface, estimates of Hg exposure from amalgam fillings were determined for 5 age groups of the US population. Three specific exposure scenarios were considered, each scenario incrementally reducing the number of tooth surfaces assumed to be restored with amalgam. Based on the least conservative of the scenarios evaluated, it was estimated that some 67.2 million Americans would exceed the Hg dose associated with the reference exposure level (REL) of 0.3μg/m3 established by the US Environmental Protection Agency; and 122.3 million Americans would exceed the dose associated with the REL of 0.03μg/m3 established by the California Environmental Protection Agency. Exposure estimates are consistent with previous estimates presented by Health Canada in 1995, and amount to 0.2 to 0.4μg/day per amalgam-filled tooth surface, or 0.5 to 1μg/day/amalgam-filled tooth, depending on age and other factors. [Copyright &y& Elsevier]

The article focuses on the study that examines the materials used by dentists in The Dental Practice-Based Research Network (DPBRN) in putting the first restoration on permanent posterior tooth surfaces. A cross-sectional study was conducted by DPBRN practitioner-investigators and informed consent was sought to patients. The study indicates that amalgam was more often used by practitioner-investigators than direct resin-based composite (RBC) for posterior carious lesions.

BACKGROUND: Mercury is nephrotoxic and dental amalgam is a source of mercury exposure. METHODS: Children 6-10 years of age (n = 534) with two or more posterior teeth with caries but no prior amalgam restorations, were randomized to one of two treatments—amalgam or resin composite (white fillings)—used for caries treatment during 5 years of follow-up. The primary outcome was change in IQ, but important secondary outcomes were effects on markers of glomerular and tubular kidney function: urinary excretion of albumin, alpha-1-microglobulin (A1M), γ-glutamyl transpeptidase (γ-GT), and N-acetyl-β-D-glucosaminidase (NAG). These markers were measured on several occasions during the trial, together with urinary mercury and covariates. We evaluated the results using repeated-measures analyses. RESULTS: There were no significant differences between treatment groups in average levels of renal biomarkers, nor significant effects of number of dental amalgams on these markers. There was, however, a significantly increased prevalence of microalbuminuria (MA) among children in the amalgam group in years 3-5 (adjusted odds ratio 1.8; 95% confidence interval, 1.1-2.9). Most of these cases are likely to be temporary MA, but 10 children in the amalgam group had MA in both years 3 and 5, versus 2 children in the composite group (p = 0.04). There were no differences in the occurrence of high levels of renal tubular markers (A1M, γ-GT, or NAG). CONCLUSIONS: The increase in MA may be a random finding, but should be tested further. The results did not support recent findings in an observational study of an effect of low-level mercury on tubular biomarkers in children. [ABSTRACT FROM AUTHOR]

BACKGROUND: Urinary mercury (U-Hg) excretion is a commonly used biomarker for mercury exposure from dental amalgam restorations. OBJECTIVES: Our goal was to determine the most efficient measure of dental amalgam exposure for use in analyses concerning U-Hg in children. METHODS: We analyzed time-sensitive longitudinal amalgam exposure data in children randomized to amalgam restorations (n = 267) during the 5-year New England Children's Amalgam Trial. We calculated 8 measures of amalgam, evaluating current versus cumulative exposure, teeth versus surfaces, and total versus posterior occlusal amalgams. Urine samples collected during follow-up years 3-5 were analyzed for mercury excretion. Multivariate models for current and cumulative U-Hg excretion estimated associations between exposures and U-Hg. RESULTS: At the end of follow-up, the average (± SD) cumulative exposure was 10.3 ± 6.1 surfaces and 5.7 ± 2.9 teeth ever filled with amalgam, corresponding to 30 ± 21 surface-years. Amalgam measures and U-Hg were moderately correlated. Of amalgam exposure measures, the current total of amalgam surfaces was the most robust predictor of current U-Hg, whereas posterior occlusal surface-years was best for cumulative U-Hg. In multivariate models, each additional amalgam surface present was associated with a 9% increase in current U-Hg, and each additional posterior occlusal surface-year was associated with a 3% increase in cumulative U-Hg excretion (p < 0.001). CONCLUSIONS: One single measure of amalgam exposure is insufficient. Studies of cumulative effects of mercury from amalgam exposure in children are likely to have improved validity and precision if time-sensitive amalgam exposure measures are used. In contrast, simple counts of current amalgam fillings are adequate to capture amalgam-related current U-Hg. [ABSTRACT FROM AUTHOR]

Mercury-containing products release mercury (Hg) throughout their lifecycles, frequently in ways that are difficult to measure directly. Therefore, there are considerable uncertainties about the magnitude of mercury releases associated with products, about which products and which release pathways contribute the most to mercury releases, and about the likely impact on mercury releases of various possible interventions in the mercury content of products or in the management of mercury-containing wastes. This article presents an effort to use substance flow analysis to develop improved estimates of the environmental releases caused by mercury-containing products and to provide policy-makers with a better understanding of opportunities for reducing releases of mercury caused by products. [ABSTRACT FROM AUTHOR]

An assessment was conducted of the discharge from dental facilities of mercury in the form of amalgam to surface waters in the United States. Two pathways were examined – effluent from publicly owned treatment works (POTWs) and air emissions from sewage sludge incinerators (SSIs). The annual use of mercury in the form of amalgam in the U.S. is approximately 35.2 tons (31.9 metric tons). It was estimated that 29.7 tons (26.9 metric tons) of mercury in the form of amalgam are annually discharged to the internal wastewater systems of dental facilities during amalgam placements and removals. Based on the partial capture of this amalgam in conventional chair-side traps and vacuum filters, the discharge of mercury in the form of amalgam from dental facilities to POTWs was estimated to be 6.5 tons (5.9 metric tons). The discharge of mercury to surface water via POTW effluents and SSI emissions was estimated to total approximately 0.4 tons (0.4 metric tons). A cost-effectiveness analysis determined that the annual cost to the dental industry to reduce mercury discharges through the use of amalgam separators would range from 380 millionto 1.14 billion per ton. [ABSTRACT FROM AUTHOR]

Background: Clinicians often encounter defective restorations and are faced with the difficult decision of whether to repair the existing restoration or replace it., Methods: An electronic survey on repairing or replacing defective restorations was developed to assess how clinicians are making these decisions and the technical aspects considered when making a repair. E-mails containing the survey link were sent to the American Dental Association Clinical Evaluators (ACE) Panel on August 14, 2019, and the survey remained open for 2 weeks. Nonrespondents were sent reminders 1 week after deployment., Results: Approximately 4 of every 5 respondents repair defective restorations. The top 3 conditions for making these repairs were noncarious marginal defects (87%), partial loss or fracture of the restoration (79%), and crown margin repair due to carious lesions (73%). Among respondents who repair defective restorations, almost all repair direct resin composite (98%), whereas approximately one-third do not repair the other restorative materials (that is, amalgam, glass ionomer, and fractured indirect all-ceramic crowns). Resin composite is used most often to repair resin direct composite restorations, and likewise, glass ionomer is used most often to repair glass ionomer restorations. Only 54% of respondents use amalgam to repair amalgam restorations. Surface treatments varied among the 3 available restorations types., Conclusions: Many dentists are actively making restoration repairs, but choosing clinical scenarios to make these repairs is material dependent., Practical Implications: The repair of defective restorations is an acceptable and more conservative alternative than restoration replacement, and its success depends on proper case selection, material, and technique., (Copyright © 2021 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to evaluate the performance of a commercially available chairside amalgam separator (CAS) in a clinical setting in which a relatively high number of amalgam restorations are placed. Performance parameters investigated included service life, amalgam collected, mercury concentrations in effluent, and solids retention efficiency., Methods and Materials: CASs were tested per International Organization of Standardization (ISO) 11143:2008 prior to installation in a military dental treatment facility and after removal from service (n=4) in order to confirm compliance with the recently enacted United States Environmental Protection Agency (EPA) Effluent Limitations Guidelines and Standards for the Dental Category. During the units' time in service, biweekly effluent grab samples were collected from the high-volume evacuation system of each chair (n=6) and analyzed for total mercury concentration by inductively coupled plasma mass spectrometry (ICP-MS). The mean total accumulated solids at the end of service life (n=6) was determined for potential design optimization. The service life expectancy in a military dental treatment facility was determined in terms of calendar and workdays. Procedural data were collected to determine the daily mean number of amalgam surfaces placed during the service life of each chairside amalgam separator (n=9)., Results: The CAS evaluated met minimum EPA compliance requirements when used in a military dental treatment facility. The solids removal efficiency at the end of service life was 99.82% ± 0.14% (n=4). The mean service life (n=8) was 131.6 ± 45.1 calendar days (67.1±37.6 workdays). Effluent mercury concentrations ranged from 0.05 to 11.93 mg/L. Total solids accumulated in each CAS (n=6) at the end of service life was 195.4 ± 63.4 g. The mean number of amalgam surfaces placed per workday during the service life span of each CAS was 8.4 ± 1.4.

In 1949, the American Graves Registration Service Pacific Zone proposed the identification of 27 sets of remains (skulls/crania/mandibles) based on comparisons with written dental records. All were denied, and the remains were buried as unknowns. In 2003 and 2015, the remains were exhumed by the DPAA. Currently, 26 individuals previously recommended for identification have been positively identified. The DPAA Science Director's opinion corresponded with 24 of their recommendations, while DNA excluded three. Caution should be taken by the forensic scientist when building assemblages through skeletal and dental articulation. The forensic odontologist must always consider variations in restorative care/extraction patterns and the possibility of documentation errors when reviewing/interpreting historical and current day dental records used for AM/PM comparisons. The odontologist should base their opinion on the strength of the antemortem/postmortem comparison, number and type of concordances, and distinct dental care and extraction patterns., (Published 2019. This article is a U.S. Government work and is in the public domain in the USA.)

Background: The Minamata treaty (2013) enacted a globally binding agreement to phase down amalgam use, which may significantly affect dental care for underserved populations. To comply with the Minamata treaty, strategic approaches need to be implemented to reduce amalgam use while imposing minimal risk on the dental care of the underserved., Objectives: To establish strategic approaches to reduce amalgam use, the aim of this study is to use a marketing research analysis to determine which patient-related factors influence pediatric dentists' choice of amalgam., Methods: A survey containing questions regarding amalgam use, perception about the environmental impact of amalgam waste, and hypothetical clinical scenarios of a child with dental caries with varying levels of caries risk and types of dental insurance was developed and pretested. Emails linked to an electronic survey were sent via Qualtrics to all active American Academy of Pediatric Dentistry members ( n = 5,101), followed by 3 reminders. Descriptive analysis and choice-based conjoint analysis were performed to investigate trade-offs between selected factors, using SAS version 9.3., Results: Of 892 (17.6%) replies, 850 responses were eligible for analysis. Only 385 (45%) respondents indicated using amalgam, and their responses were analyzed in the conjoint model. Respondents' selection of amalgam varied between 8% and 28% across all the clinical scenarios, with most respondents choosing composite or stainless steel crowns. Conjoint analysis revealed that, while both caries risk and type of insurance affected respondents' decision about amalgam use, caries risk was the driving factor in decision-making for using amalgam., Conclusion: These results underscore the importance of prevention and management of risk factors to successfully phase down amalgam use., Knowledge Transfer Statement: Our study applied the marketing research tool, choice-based conjoint analysis, to investigate the relative importance of different factors on dentists' decision-making regarding amalgam use. This study should be of great interest to policy makers when developing strategic approaches to comply with the 2013 United Nations Environment Programme (a.k.a. Minamata treaty) policy recommendations for phase-down of dental amalgam.

Increased concerns about the safety of amalgam restorations in children have resulted in many dental schools emphasizing the teaching of alternative dental materials. This study investigated the current teaching of different dental materials for use in posterior teeth in the United States predoctoral pediatric dentistry programs. In 2011, the authors invited the chairs of the predoctoral pediatric dentistry departments in all accredited dental schools at that time ( N  = 57) to participate in an internet-based survey. Descriptive statistics were calculated to describe the frequency of using different restorative materials. Regression models were developed to explore the factors related to the use of dental restorations in predoctoral pediatric clinics. Among the 44 dental schools that responded (77% response rate), 74% used amalgam, and 93% used composite in primary posterior teeth. Glass ionomer was used by 61% of the schools in primary posterior teeth. Placing amalgam in primary posterior teeth was associated with programs that treated more 3-5-year-old patients (β = .302, p  < .043), whereas the use of glass ionomer was associated with having students serving at off-site satellite dental clinics (β = .015, p  < .012). In general, having departments with chairs who had positive attitudes towards Minimal Invasive Dentistry (MID) used composite (β = .091, p  < .0001) and glass ionomer (β = 103, p  < .0001) more frequently and were less likely to use amalgam (β = -.077, p  < .005) in primary posterior teeth. Although teaching MID concepts in predoctoral pediatric clinics in dental schools is increasing, the use of amalgam in posterior primary and permanent teeth is still widely practiced., Competing Interests: The authors declare no conflict of interest.

Mercury (Hg) has been identified as one of the most toxic nonradioactive materials known to man. Although mercury is a naturally occurring element, anthropogenic mercury is now a major worldwide concern and is an international priority toxic pollutant. It also comprises one of the primary constituents of dental amalgam fillings. Even though dental mercury amalgams have been used for almost two centuries, its safety has never been tested or proven in the United States by any regulatory agency. There has been an ongoing debate regarding the safety of its use since 1845, and many studies conclude that its use exposes patients to troublesome toxicity. In this review, we present in an objective way the danger of dental amalgam to human health based on current knowledge. This dilemma is addressed in terms of an integrated toxicological approach by focusing on four mayor issues to show how these interrelate to create the whole picture: (1) the irrefutable constant release of mercury vapor from dental amalgams which is responsible for individual chronic exposure, (2) the evidence of organic mercury formation from dental amalgam in the oral cavity, (3) the effect of mercury exposure on gene regulation in human cells which supports the intrinsic genetic susceptibility to toxicant and, finally, (4) the availability of recent epidemiological data supporting the link of dental amalgams to diseases such as Alzheimer's and Parkinson.

Purpose: The purpose of this study is to evaluate the extent of change in the professional practice environment for dental hygienists in the 50 states and District of Columbia by comparing the state supervision requirements for dental hygienists during 2001 to 2011 to the previous 7 year period, 1993 to 2000., Methods: A retrospective comparison evaluation was conducted using the 2 tables entitled "Tasks Permitted and Mandated Supervision of Dental Hygienists by State, 1993, 1998 and 2000" and "Dental Hygiene Practice Act Overview: Permitted Functions and Supervision Levels by State." To score the net change in supervision, a numerical score was assigned to each level of alteration in supervision with a +1 or -1 for each level of change., Results: With a 95% confidence level, the mean change in dental hygiene supervision from 2001 to 2011 was 6.57 with a standard deviation of 5.70 (p-value=0.002). The mean change of supervision from 1993 to 2000 was 2.61 with a standard deviation of 4.36 (p-value=0.0002). The difference in the mean scores for the periods 1993 to 2000 and 2001 to 2011 was 3.96 (p-value=0.06)., Conclusion: This study shows that the majority of the states are moving toward a decrease in dental hygiene supervision. Study results suggest that the movement appears to be accelerating with more states adopting fewer supervision regulations at a faster rate. Therefore, direction is moving toward more access to dental health care for underserved populations.

The authors conducted a review to evaluate the current literature addressing root surface caries treatment in the vulnerable elderly, to identify any gaps in the literature that will need to be addressed in the future. The authors conducted a literature search of the electronic databases using MEDLINE, PubMed, to identify original clinical research articles regarding treatment of root caries lesions, with emphasis on research focused on the vulnerable elderly. Five articles were clinical studies of root caries restorations. Only one was conducted on a vulnerable elderly population. The results of the literature review show that there is a need for further studies addressing the restorative needs of the vulnerable elderly. With the aging of the American population, more research is needed to provide adequate care to this population. At this time, glass ionomers are a good treatment option., (©2012 Special Care Dentistry Association and Wiley Periodicals, Inc.)

Purpose: The purpose of this study was to investigate the extent of clinical training on atraumatic restorative treatment (ART) among pediatric dentistry residency programs and assess program directors' attitudes toward ART., Methods: All U.S. Pediatric Dentistry residency programs' directors were asked to complete a web-based survey. Sixty-one of the 76 directors (80 percent) completed the survey, with no significant response bias., Results: Eighty-nine percent of the responding programs provided clinical instruction on ART. Of these, 30 percent provided ART training often/very often. ART was used mostly in single-surface cavities (43 percent) and as an interim treatment in primary teeth (57 percent). Factors associated with ART clinical training included not placing amalgams in primary teeth (P<.03) and having directors with positive attitudes toward ART (P<.001). Factors associated with directors' positive attitudes included believing that child's caries risk (P<.006), professional guidelines (P<.003), and patient insurance status (P<.04) were all important in selecting restorative treatment., Conclusions: Atraumatic restorative therapy appears to be underused in pediatric dentistry residency programs in the United States. Residency directors' attitudes were highly predictive of the amount of clinical training provided, suggesting that directors need to be better informed about the use of ART.

Objective: The authors conducted a study to identify and quantify the reasons used by dentists in The Dental Practice-Based Research Network (DPBRN) for placing restorations on unrestored permanent tooth surfaces and the dental materials they used in doing so., Methods: A total of 229 DPBRN practitioner-investigators provided data from their practices regarding 9,890 consecutive restorations in 5,810 patients. Information the practitioner-investigators provided included their reasons for restoring the teeth, the specific teeth and surfaces they restored and the restorative materials they used., Results: Primary caries (85 percent of teeth, 8,351 of 9,890) and noncarious defects (15 percent, 1,479 of 9,890) were the main reasons participants gave for placing restorations. Participants placed restorations necessitated by caries most frequently on occlusal surfaces (49 percent, 4,091 of 8,351). They used amalgam for 47 percent of the molar restorations and 45 percent of the premolar restorations. They used directly placed resin-based composite (RBC) for 48 percent of the molar restorations, 50 percent of the premolar restorations and 93 percent of the anterior restorations., Conclusion: DPBRN practitioner-investigators cited dental caries on occlusal and proximal surfaces of molar teeth as the main reasons for placing restorations on previously unrestored tooth surfaces. RBC was the material they used most commonly for occlusal and anterior restorations. Amalgam remains the material of choice to restore posterior teeth with proximal caries, although the authors noted significant differences in the use of amalgam and RBC by dentists in various regions of the DPBRN.

Dental amalgam has been extensively used as a tooth filling material for many decades and has beyond doubt saved millions of teeth that otherwise would have needed to be extracted. The release of amalgam particles into dental office wastewater is a matter of particular concern as amalgam particles could then be discharged into the environment. Amalgam waste discharges contribute to mercury in the environment through direct wastewater discharge, incineration, land-filling and sewage sludge incineration, although the discharge from dentistry is probably responsible for less than 1% of the total mercury discharged annually into the environment as a result of human activities. Nevertheless, dentists, by being producers of amalgam waste, have a responsibility and a duty of care for the proper management of this waste within their practices. Appropriate measures should be taken to minimise the amount of waste where possible or take action to ensure that all generated waste is disposed of in accordance with environmental legislation.

In this article, methods are proposed for design and analysis of clinical trials that gather longitudinal data on multiple outcome variables. A valid test of the null hypothesis of no treatment group differences can be obtained for any choice of a working alternative hypothesis and a working covariance matrix for the outcome variables. Increased power can be achieved by accurate modeling of the true treatment effect and covariance structure. Implementation of the procedure is simple using existing software for generalized estimating equations. The procedure is an extension of the 'derived variable' technique (univariate analysis applied to a linear combination of the outcome variables) and also of O'Brien's generalized least squares test. The procedure is extended to allow sequential testing using an arbitrary division of the total type I error rate among repeated hypothesis tests. The methods are illustrated by the design of a study on the safety of dental amalgam fillings, which served as the motivation for the research.

Background: Most reports of oral lesion prevalence are based on studies of atypical populations. There are no published studies on oral mucosal lesion prevalence in U.S. adults that are based on a national probability sample., Methods: The Third National Health and Nutrition Examination Survey, or NHANES III, employed a complex, multistage sample of 33,994 civilian, noninstitutionalized people from 19,528 households. Dentist examiners were trained to recognize, classify and record in a standardized manner the clinical characteristics of each of the 48 conditions of interest to include diagnosis, size, location, surface morphology, color consistency, pain, duration and history using procedures based on the World Health Organization's Guide to Epidemiology and Diagnosis of Oral Mucosal Diseases., Results: Examinations were performed on 17,235 people aged 17 years and older, of whom 4,801 (27.9 percent) had a total of 6,003 lesions. Denture-related lesions (stomatitis, hyperplasia, ulcers, inflammation and angular cheilitis) composed 8.4 percent and tobacco-related lesions (smokeless tobacco-related and nicotinic stomatitis) composed 4.7 percent of all lesions. Discounting denture-related lesions, amalgam tattoos were the most prevalent lesions (3.30 percent), followed closely by cheek/lip bites (3.05 percent) and frictional white lesions (2.67 percent). Smokeless-tobacco users (odds ratio, or OR, = 3.90) and removable denture wearers (OR = 3.57) had the highest odds of having a lesion., Conclusion: Lesion prevalences differed significantly by age, sex, race/ethnicity, denture wearing and tobacco use. When lesion-specific prevalences are cited in the literature, they should be stratified by covariates known to be associated with them.

Background: Growing environmental concern over the accumulation of mercury in some fish has led some state and local environmental agencies to pursue stricter regulation of mercury in wastewater. Dental offices are an identifiable source of mercury in the form of dental amalgam. Although mercury in dental amalgam is not immediately bioavailable (that is, it has not been shown to contribute significantly to the problem of mercury in fish tissue), environmental agencies in some locales are asking dental offices to install amalgam separators in an effort to reduce amalgam discharges beyond those already achieved through chairside traps and vacuum filters. Field experience indicates that the configuration and operation of the dental office infrastructure can significantly affect the choice of separator, as well as the operation and maintenance of the installed equipment., Overview: The authors review factors related to office infrastructure and operation that dentists should consider when investing in an amalgam separator. They also provide a cost-analysis worksheet and checklist that may be useful to dentists who are considering purchasing a separator., Conclusions and Clinical Implications: Before purchasing or installing an amalgam separator, dentists should consider factors specific to the available models, including size and maintenance requirements. In addition, office-specific actors should be considered (such as the plumbing configuration, available space for installation and subsequent access to that space for equipment replacement and maintenance). Dentists also should research whether any local or state regulations exist that might influence product selection or installation. Dentists should consider the effect an amalgam separator could have on existing suction equipment. Finally, dentists will want to consider the short- and long-term costs (including maintenance and parts replacement) of the available options.

Background: Amalgam in dental wastewater is receiving increasing scrutiny from regulators because of national, state and local initiatives to reduce or virtually eliminate the discharge of mercury and mercury-containing items into the environment. Amalgam separators are considered to be one means of reducing the amount of amalgam that dental offices discharge into sewers. The purpose of this study was to evaluate the amalgam removal efficiency of commercially available amalgam separators and the total mercury concentration in the effluent from laboratory testing., Methods: The authors evaluated the amalgam removal efficiency of 12 amalgam separators according to International Organization for Standardization, or ISO, Standard 11143 for Amalgam Separators. Total mercury concentration in the effluent was calculated using the mass of amalgam particles larger than 1.2 micrometers and the volume of effluent, together with U.S. Environmental Protection Agency, or EPA, Method 245.1 for amalgam particles smaller than 1.2 microm. Total dissolved mercury also was determined., Results: The results show that all 12 amalgam separators exceeded the ISO 11143 requirement of 95 percent amalgam removal efficiency. Statistical differences were found in the efficiencies of the separators. Both the total mercury concentration and total dissolved mercury concentration in the effluent demonstrated large variations., Conclusions and Clinical Implications: This laboratory evaluation shows that amalgam separators removed at least 96.09 percent of the amalgam in samples with particle-size distribution as specified in ISO 11143. Total mercury concentration and total dissolved mercury concentration in the effluent varied widely for each amalgam separator. Additional research is needed to develop test methods to evaluate the efficiency of amalgam separators in removing small amalgam particles, colloidal amalgam particles and ionic mercury in solution.

Purpose: The purpose of this study was to obtain an overview of materials and restoratives techniques taught for Class I and Class II restorations in primary molars in different pediatric dentistry departments in North America., Methods: A form with response alternatives was mailed to 63 dental schools in the United States and Canada. The forms were addressed to the chairman/undergraduate program director of the department of pediatric dentistry. Questions regarding the restorative materials taught, indications and contraindications for the use of tooth-colored materials and the type of cavity preparation indicated for those materials were among the topics assessed., Results: Eighty-six percent of the dental schools responded to the survey. Amalgam continues to be the material of choice for Class I and II restorations in primary molars, although hybrid composites and compomers are gaining some popularity. When tooth-colored materials were indicated, the slot-type of cavity preparation was the preferred one., Conclusions: The diversity in teaching may reflect uncertainty related to requirements for optimal restorations of primary teeth. Data from dental schools of other countries may be important to obtain to establish universally accepted criteria and standards for restorative techniques of primary teeth.

A review of U.S. dental amalgam waste management activities finds a wide variety of approaches, processes and results, within which the authors have observed an inconsistency of definitions, measurements, standards and even of clearly applied goals. As a result, outcomes have varied greatly from community to community. This manuscript attempts to deliver logical options, which might prevail even within an atmosphere of differing perspectives. The authors believe that successful outcomes are achievable within a collaborative environment of shared learning and cooperative planning. By example, the authors attempt to demonstrate how the joint acceptance of certain definitions and goals has served as a pathway to success in one community's dental waste management project. The goal of this paper is to share tools that may contain some measure of applicability to other similar collaborations.

In reviewing U.S. dental amalgam waste management activities, one finds a wide variety of approaches, processes, and results, within which the authors have observed an inconsistency of definitions, measurements, standards, and even of clearly applied goals. As a result, outcomes have varied greatly from community to community. This manuscript attempts to deliver logical options which might prevail even within an atmosphere of differing perspectives. The authors share the belief that successful outcomes are achievable within a collaborative environment of shared learning and cooperative planning. By example, the authors attempt to demonstrate how the joint acceptance of certain definitions and goals has served as a pathway to success in one community's dental waste management project. The goal of this paper is to share tools that may contain some measure of applicability to other similar collaborations.