Amalgam dental fillings: action plan

This plan sets out action we are taking in Scotland to reduce dental amalgam use. It is part of a UK-wide response to an EU directive which places restrictions on the use of amalgam.

Background

The United Kingdom has a duty under European Union (EU) Regulation 2017/852 on Mercury (Article 10 (3)) to develop a national plan to phase down remaining use of amalgam in dentistry.  This plan covers Scotland only, as the four nations of the UK maintain separate health jurisdictions.

The phase-down of amalgam filling use in Scotland is planned to be delivered through the general improvement of oral health across the population, supported within an increasingly preventive model of care. 

Scottish action

Scotland has already taken action to reduce the levels of amalgam being used in treatment, with the introduction of new restrictions on 1 July 2018. 

Clinical best practice guidelines highlighting alternatives to amalgam are supported by the Scottish Dental Clinical Effectiveness Programme (SDCEP). This guidance has been made available to all dental teams in Scotland and covers expectant/new mothers and those under 15 years of age.  Any use of amalgam in Scotland must be clinically justified and clearly stated reason in patient notes.

There are no current plans to extend restrictions across other sections of the population because of a large base with existing amalgam fillings that will require future replacement and extension.

At present there is not a suitable replacement material for amalgam in terms of strength, durability, and technique sensitivity.  

In order to ensure public confidence, improve environmental outcomes and maintain care standards any replacement for amalgam should represent a more sustainable and as clinically effective proposition. 

There are potential environmental concerns with existing resin-based replacement materials which require further research.

See, for example, Mulligan, S. et al in the British Dental Journal (2018): The environmental impact of dental amalgam and resin-based composite materials. 

National child oral health improvement programme

The national oral health improvement programme for children, Childsmile remains in place and over the last decade has delivered significant improvements.

Childsmile is delivered via nursery schools, primary schools, and dental practices, and includes free, daily, supervised toothbrushing, the application of fluoride varnish, and dietary and oral hygiene advice. The increasing focus on prevention, rather than restorative treatment has resulted in significant improvements in children’s oral health. 

Child oral health improvement to date

According to figures from NHS Scotland (Primary 1 report), the proportion of Primary 1 children with ‘no obvious decay experience’ has increased to 71% in 2018, compared with 58% in 2008. The Primary 7 report shows that in Primary 7 children, 75% of children in 2017 had ‘no obvious decay experience’ with the equivalent figure in 2007 at 59%. 

Oral health inequalities in children living in the most and least deprived communities remains an key priority for government.  In order to improve the oral health outcomes children living in the most deprived areas are able to receive four fluoride varnish applications, compared with two applications for all other children.

Fig 1:  % of P1 children with ‘no obvious decay experience’

Reducing oral health inequalities

Our Fairer Scotland Action Plan (2016) includes a commitment to extend the current nursery and primary school elements of Childsmile to deliver increased activities across areas of multiple deprivation. As part of this, all Primary 1 and 2 age children living in the 20% most deprived areas across Scotland receive fluoride varnish.

The publication of our Oral Health Improvement Plan (2018)  provided for the introduction of a Community Challenge Fund.  The Fund will enable the third sector to work alongside families living in deprived areas to improve their oral health and over time to link to other local community health initiatives.

Adult oral health improvement

We are clear that through the repositioning of adult primary dental care services to focus on prevention is a key measure to reduce the prevalence of restorative dentistry, including dental amalgam.

Over the next few years adult dental care in Scotland will be centred around an oral health risk assessment, which will ensure that each patient receives oral health care based on a range of risk factors.

The assessment will include a comprehensive clinical examination and a discussion  between clinician and patient about risks to oral health such as diet, smoking and alcohol, with the outcome being a personalised care plan to minimise risk of future dental disease.

Conclusion

We are committed to an approach that is both good for the environment and ensures that patients and practitioners are able to access the best care.

Through the measures outlined in moving to a preventive model of care the government believes that oral health outcomes will improve and a phase-down of amalgam usage will be a key outcomes, as disease prevention and alternative materials improve. 

Tom Ferris
Chief Dental Officer (Interim)