May 23-29, 2002
Photo By: Christina M. Felice
Dr. Andrea Brockman finally conceded there was a problem with the mercury bottles nestled in her cabinet when she realized nobody wanted to know they were there.
The silver-colored metal, in its liquid globular form, is as familiar a sight to scientists as the tiny orange skull and crossbones on each bottle that mark it as a hazardous toxin. So Brockman, a dentist, was all too eager to pass the bottles over to whichever environmental agency would take them off her hands.
She called the city. She called refineries, manufacturers and environmental agencies. Her inquiries were greeted with a surprising reply: The Environmental Protection Agency (EPA) and the city's Department of Public Health told her that they wouldn't retrieve such hazardous material from her workplace without a fee. Finally, in exasperation, she allowed her assistant to call the Public Health Department to ask what she should do if she found mercury in her apartment. Protocol kicked in: "OK, don't do anything. Don't touch it. We'll come and get it."
Photo By: Christina M. Felice
No health organization will dispute that mercury is a toxin: It arguably ranks as the second-most-poisonous compound on earth, after plutonium. What Brockman and her husband, Dr. Vincent DiLorenzo, discovered, in the years spent running a practice near Chestnut Hill, was that mercury inside a dental office is treated squarely as an industrial material; yet dentistry, they argue, is one of the few industries that has not sought to eliminate mercury from its day-to-day procedures. While Mercurochrome is no longer used in hospitals to disinfect cuts, nor are thermometers filled with the metal, the same mercury is habitually mixed with other metals and placed inside the mouths of patients, in one of the most common dental treatments: a "silver" filling.
There is no greater debate in modern dentistry than over continued use of this sort of filling, each of which contains roughly half a gram of mercury. On one hand, the American Dental Association (ADA), the premier governing body of dentistry, approves mercury amalgam fillings, finding no admissible science linking the roughly 50 million grams of mercury placed in mouths every year to possible exposure. ADA spokesperson Dr. Terry Donovan says,"Based on 150 years of effective use and a lot of scientific study, we believe amalgam is perfectly safe." On the other, small groups of consumers and concerned dentists have taken root, claiming that exposure through dental work has caused health problems ranging from skin irritation and memory loss to fertility and children's developmental disorders. Other research correlates symptoms of mercury poisoning with systemic illnesses, such as autoimmune disease and Alzheimer's.
Once trained as a nurse, Brockman recalls how hospital wards would be quarantined at the drop of a thermometer, for fear that mercury vapor, given off continuously by the metal, would poison those nearby. On starting dental school at Temple, however, she saw "how we were taking the same mercury that we weren't allowed to touch in the hospital and squeezing it in cheesecloths with our hands" as they prepared the amalgams. By the time she had completed dental school in 1979, an alarming range of health problems had convinced her that daily contact with the compound would pose a continual danger to her health. She had developed panic attacks, visiting the emergency room on several occasions, and later suffered a miscarriage. As the couple decided to begin practicing mercury-free in the late '70s, they both were aware that the ADA gave its seal of approval to the products that the EPA classified as hazardous; they could not yet know that, by 1986, proposing the removal of a patient's amalgam fillings purely out of concern about toxicity would contravene ADA regulations.
Now, 20 years on, DiLorenzo and Brockman stand by their decision to abolish use of the metal at their own level. Their efforts are now joined with those of other area residents -- both dentists and patients -- to do the impossible: to give consumers the chance to buck 150 years of traditional dentistry.
Their movement has not gone unnoticed. A bill currently sits before Congress demanding the abolition of mercury use in dentistry.
Mercury was first introduced as a filling component in the 1800s from France, and American dentists adopted it soon after. The new technique was greeted enthusiastically. Mixed with powdered metals, its liquid consistency at room temperature solidified to a malleable paste that could be set in a tooth cavity. Until the advent of this method, the only means of filling a tooth had been with molten metal.
Essentially, the technique for so-called "silver" fillings has remained the same to this day, and mercury continues to be the predominant ingredient. The Department of Health and Human Services stated, in its 1999 Toxicological Profile for Mercury, that an amalgam filling contains approximately 50 percent mercury, 35 percent silver and lesser amounts of tin, copper and zinc. To mix these together, DiLorenzo remembers adding "droppersful" of mercury to powdered alloy, before allowing a machine to shake them together. Once done, the mixture would be wrung out -- and, he explains ruefully, it was years after their training that gloves were commonly worn for such preparations. In 1998, the ADA ruled that dentists discontinue using bulk mercury to reduce the risk of exposure from handling, choosing capsulated mercury instead, though it maintains that the amalgam is largely inert once mixed. Other filling materials, including porcelain, composite and gold, are now available.
Yet the ADA has long had to answer questions from concerned dentists such as Brockman, who eventually called the ADA to ask whether daily exposure to mercury might contribute to her health problems. "I was told there was nothing to worry about, that they'd get back to me with more information. But their stance didn't make sense to me." The response from her professors at Temple, who assured her that mercury was "locked into" amalgam, didn't make much sense to her either. Though a heavy metal, mercury is extremely volatile, releasing toxic vapor continuously while in its liquid state. This volatility is tempered when it bonds with other metals, but a recently developed method measuring intra-oral levels of mercury vapor has proven that emissions are given off after the amalgam is mixed and set.
An astonishingly simple chain of logic eventually led Brockman to the heart of the issue. Though she and DiLorenzo had turned away from placing mercury fillings in their patients, they were not yet free from the metal. During the late '70s and early '80s, they were still drilling out old fillings from patients' mouths. Knowing mercury behaved like other compounds, they surmised that the heat and pressure of a dental drill would accelerate the chemical reaction, increasing the chances that vapor would be released during these dental procedures. And yet, knowing what they did of the wear and tear that teeth withstand, particularly through chewing and contact with hot foods, they began to articulate a barely whispered question: What if mercury exposure did not stop with the dentist, but was continuously absorbed by the patient, once they were carrying mercury inside their mouths?
In 1991, nearly a decade later, the World Health Organization (WHO) estimated that the body absorbed roughly 3 micrograms to 17 micrograms of mercury per day from amalgams. Health and Human Services, summarizing data from recent studies in 1999, cited the report and estimated that a person's exposure to mercury from amalgams may account for 53 percent to 87 percent of their daily mercury exposure. By comparison, the second greatest source quoted was dietary content, specifically from fish and seafood, contributing only 2.31 micrograms per day. Airborne vapor concentrations, as assessed by the EPA in 1984, should not exceed 0.3 parts per million.
None of this history was known to Freya Koss when she slipped into the dentist's chair in March 1998. Arriving all the way from Wynnewood for her appointment with her Bronx-based dentist, she learned that the pain in her mouth was originating in one of her upper-left molars, which was in serious need of repair: Beneath an old amalgam filling, a cavity had continued to grow. She says that with peremptory speed the dentist drilled out the weathered portion, removed the decay and sealed up the tooth with new amalgam. At one point, Koss says, she asked him why he hadn't used a dental dam, which catches the metal shrapnel before it disappears into the patient's mouth. "He told me that, frankly, they were a pain to use. He hadn't fitted one in all the time he'd been practicing." Koss would not name the dentist.
To Koss, who, as an events planner, was used to noting details above all else, this seemed unusual. Other signs of sloppy procedure were there: Koss says she found out later that the dentist had mixed alloy with bulk mercury from a bottle, rather than using the neater -- and ADA-approved -- method of pre-measured capsules. Most of all, she laments, she "had no idea what questions to ask" her dentist -- and so had no idea what was going wrong.
Seven days later, she was returning to her car after an evening at the ballet when she was stung by an attack of dizziness. As the fog cleared, she found she could no longer see the oncoming cars clearly: They appeared in double vision, the headlights multiplied so many times that she could hardly see the road.
Apprehensive, she went to her optometrist for tests; on examining Koss' eyes, the specialist appeared concerned and told her that she shouldn't leave without first making an appointment with a neuro-ophthalmologist. The next day, she underwent tests at the Hospital of the University of Pennsylvania; within a week, she had the results back. Out of the blue, the doctor diagnosed her with either multiple sclerosis or lupus.
Absolute disbelief was her first reaction, which quickly hardened into determination: "I could not comprehend how I'd developed an autoimmune condition, such as MS, seemingly overnight," Koss recalls. So she initially refused the prescription of medication and steroids meted out by the doctors, and she set about doing her own research. Her touchstone, she says, was the Internet: She sat up for three days in a row, searching medical databases and newsgroups for some link between her stunning diagnosis and its manifestation -- now-drooping eyelids and worsening vision. She could barely see, but she donned an eye patch to minimize the blur and began to read, as she puts it, "with an open mind."
It didn't take her too long to find a kindred spirit by spreading her net of research internationally. A woman in the U.K. was the first to match Koss' symptoms and MS diagnosis against her own experience with heavy metal toxicity. Anecdote after anecdote provided Koss with a window on other sufferers whose symptoms had been exacerbated after visiting a dentist.
What she hadn't realized was how far the U.S. dental establishment differed from health organizations and agencies abroad in its support of mercury-based fillings: Sweden, Germany and Canada,
for example, no longer allow application of amalgam, while other nations, such as Norway and Australia, have adopted warnings against its use in children and pregnant women. By contrast, roughly 96 million amalgam fillings were placed in the U.S. in 1990, according to a 1993 Health and Human Services study, and it is currently the treatment afforded by most basic insurance policies. Furthermore, it seemed to Koss no coincidence that research from other countries, notably from Canada and Sweden, was making bolder statements on the transmission of mercury from amalgams throughout the body. A 1989
University of Calgary study planted amalgam fillings in sheep's mouths to study the effects of chewing on vapor release. The mercury, tagged radioactively, could be followed through the animals' systems over a 29-day period -- rapidly accumulating in the liver and kidneys, as well as lung and jawbone tissue. A further Calgary study found similar buildup in pregnant ewes, while their fetuses had high mercury levels in the liver and the developing brain's pituitary gland.
Pinning down symptoms for mercury poisoning is almost impossible: Since it can accumulate in different tissues, its effects can be unpredictable, and very localized. In Koss' case, the shifting diagnoses from her doctors only made her more inquisitive. "As I learned more about mercury, I kept thinking back to that day at the dentist, so soon before my vision deteriorated." While a succession of doctors refused her offers to show them dental journal studies regarding mercury toxicity in relation to amalgam, she was told eventually that, in spite of her initial test results, she was unlikely to have MS; instead, a condition known as myasthenia gravis, another autoimmune disease which controls muscle function, particularly near the eye, was more probable.
The illness hit Koss hard. While she spent months trying to work out what caused her loss of vision, she let slip her career planning events, for the National Museum of American Jewish History and, later, through her own business, for clients such as the Annenberg Center. As she started to come to terms with what had happened to her -- aided by the eventual diagnosis by an environmental physician of a high mercury body burden, based on tests that drew out the metal from her tissues -- she found herself drawn to the idea of spreading the word. For, in the process of gathering background on what she calls a "deliberate cover-up" of the content of mercury fillings, she stumbled across a national organization, the Dental Amalgam Mercury Syndrome (DAMS), that offered support and information for victims of poisoning. It seemed almost preordained that she would get involved: The vice president of the organization, Carol Ward, turned out also to live in Wynnewood, only a few miles from Koss' house.
Ward received a call at 10:30 one night. It was Koss, having just been misdiagnosed with MS, distraught at what she was learning about the potential risk of amalgams. It only took a few moments for Ward to recognize what she was hearing. "In all the people who call me, I've started to notice a few patterns," she says. She was prepared to suggest to Koss that, yes, she might have mercury poisoning: "We're not doctors or dentists here at DAMS, so we always qualify it that way, but we can say, What worked for me....'"
What worked for Ward had been, in the end, complete removal of her mercury amalgam fillings, some of which she had had since she was 7, others which had been put in at age 47. She had been prone to infections throughout her teens and, after having dental work done in her 20s, she noticed she was unable to sleep and was losing her hair. By 1985, her hectic life, working as the branch administrator at the Cobbs Creek Free Library, or hiking, playing the piano and jogging in her free time, was starting to take a downward slide. She noticed she was having equilibrium problems, which she knew might signal the start of MS. Again, her trips to various doctors yielded no answers, and it was only a consultation with a nutritionist that first threw up the putative diagnosis of adverse reaction to amalgam. Having found herself exhausted, housebound and virtually incapable of moving about, Ward undertook a regimen of vitamins and supplements aimed at strengthening her system and helping to detox. Then, referred to a mercury-free dentist in Bala Cynwyd, she was able to have her amalgams removed. It took time, since the necessary drilling-out is considered to be a flashpoint for vapor exposure, so a mouthful such as Ward's 16 fillings were removed by quadrant (a quarter-mouth at a time). The results were undeniably remarkable: Within a couple of visits, her continuous vision impairment receded, allowing her to take up reading again. Even more extraordinary, she reports experiencing her vision field return to normal in the car on the way home from the last appointment, allowing her to see the horizon properly. A practical person, not seemingly given to exaggeration, she puts it quite simply: "Getting rid of a substance that is known to be toxic allowed me to heal."
After detox, she found her hands could reach the intervals in a piano concerto once again.
Koss was initially drawn to DAMS as an outlet for her zeal. She subscribed to its mailing list, produced every three to four months, and used its database of mercury-free practitioners to find someone who could remove her amalgams safely. Yet her efforts were taken in a different direction, after a chance suggestion that she get in touch with Anita Tibau, based in California and working as West Coast representative of the anti-amalgam movement's lobbying arm, Consumers for Dental Choice.
They met; shortly thereafter, Koss began working for the nonprofit as director of development, organizing fundraising and outreach as Tibau's East Coast counterpart.
Charles G. Brown, former attorney general of West Virginia and now a D.C.-based lawyer, has represented Consumers for Dental Choice since 1996. Its national counsel for legislation, he remembers how the organization got started. "We wanted to create a level playing field for mercury-free dentists. We knew the ADA was harassing those dentists, and so the situation was in defensive mode." Brown points to what he terms the "gag rule" as evidence of the ADA's suppression of mercury-free practice. In its Code of Ethics and Professional Conduct, the organization ruled in 1986 that to recommend the removal of amalgam restorations "for the alleged purpose of removing toxic substances from the body... is improper and unethical." According to Brown, the ADA amended this clause in May this year -- it now applies not only to amalgam but to all materials. The actual bestowing of licenses to practice dentistry is handled at the state level, by the dental boards. Yet the national ADA, in an "outrageous partnership" with the state boards, Brown says, can pursue a dentist to the point of revoking his or her license, if, unsolicited, the dentist so much as nudges a patient in the direction of a contents list, for amalgam or any other material. The ADA's Donovan confirms that certain dentists have had their permits revoked, after recommending "unwarranted" amalgam removal.
Consumers for Dental Choice argues that until dentists can discuss filling materials openly with the patient, consumers are expected to make treatment decisions without necessary information.
The Pennsylvania Dental Board refers to its code of professional conduct on this issue, wherein it states, "The Board has neither the resources nor the mandate to make or endorse scientific findings on this issue." It recommends that dentists follow certain guidelines, including explaining the current state of research to a patient and referring a patient to a physician for recommendations on treatment before proceeding with removal. Brown cites its stance as one he respects: "They, unlike some other dental boards, do not seek to rule what the dentist can say on the issue."
Photo By: Christina M. Felice
There are signs that cooperation between other state boards and the ADA is starting to crumble. In March, the ACLU won an Oregon lawsuit that forced the dental board to rescind its rule that discussion of amalgam replacement constituted "fraud" because it violated dentists' First Amendment rights.
However, Brown sees other instances of the ADA using its established reputation to preserve the status quo: In its code of ethics, "unsubstantiated representations" regarding the dentist's "capacity to cure or alleviate diseases" refers to any statements not supported by "accepted scientific evidence" -- which, in Brown's eyes, has been any research the ADA wishes to discredit. "[It's] an amazing position for a group that claims to have an interest in science. They do not have an interest in science; their interest is economics." The ADA held patent on two amalgam products until 1994 and 1995 respectively.
Lawsuits filed in other states, such as California and Maryland, challenge the ADA on scientific and economic grounds. The suits allege that the ADA engaged in "deceptive" business practices by referring to the fillings as "silver" rather than "mercury." Furthermore, in some cases, the suits claim, exposure from mercury coming partly from amalgams contributed to cases of childhood autism. The ADA claims the suits are without basis.
Besides autism, Alzheimer's has been the focus of research for its connection to mercury toxicity. Boyd Haley, chair of the University of Kentucky's department of chemistry and one of the movement's scientific big hitters, has pioneered research into the biomarkers for this neurological condition -- chemical changes in the body that might give some clue as to the cause of the disease. These biomarkers -- two proteins, tubulin and creatine kinase -- were found to be suppressed in sufferers of Alzheimer's: The lower the tubulin uptake, the more likely the formation of "tangles" of protein in the brain, a classic indicator of the disease. "We found there was only one heavy metal which repeatedly was causing those proteins to be suppressed," explains Haley. "It was mercury."
Government reaction to the anti-amalgam movement has been slow. A five-year study begun in 1997 and funded by the National Institutes of Health is measuring the behavioral, renal and neurological effects of amalgams -- on two groups of children, one in Boston and Maine, one in Lisbon, Portugal. Opponents of the study point to its relatively short time-span, which may not yield results of long-term exposure. Meanwhile, the House Committee on Government Reform held hearings in 2001 examining increased rates of autism in the U.S. Haley addressed the hearings, as did the ADA president, Dr. Robert Anderton. Haley later wrote a letter of rebuttal to the ADA, challenging his statements. As he puts it, "This was toxicology research being presented by a dentist, not a toxicologist."
Against this stormy backdrop, the introduction of a federal bill aimed at abolishing the use of mercury in dentistry by 2006, and immediately issuing warnings on the product against using the material for children and pregnant or nursing women, appears timely. Remarkably, the bill has bipartisan support: Democratic Rep. Diane Watson and Republican Rep. Dan Burton worked together to introduce it to the House. While Watson has been actively working toward disclosure legislation regarding mercury amalgam since her days in the California legislature, Burton became aware of the issue through its relation to the controversy over thimerosal (a mercury compound) used in vaccines. Both sides of the issue, it seems, are ready for a fight: While Watson says that the dental establishment "wrongly" calls amalgam "silver," the ADA counters by stating that "Watson's attempt to ban dental amalgam would effectively deprive patients of an essential treatment that is clinically and scientifically substantiated to be safe."
For his part, Brown says that common sense disputes this assertion: "What pregnant woman, who won't even have a glass of wine, would want a known neurotoxin in her system?"
The Watson-Burton bill has been referred to the Committee for Energy and Commerce; in the meantime, while Koss and Tibau have spent time lobbying for its support on Capitol Hill, Consumers for Dental Choice is also focusing on state bills, such as the one Watson brought in California in 1992. Three more have been passed, in Arizona, Maine and, most recently, New Hampshire; Brown says states like New York and Pennsylvania are natural contenders to follow the "trendsetter state" of California because of their educated consumer base and active environmental movements.
Until the current climate relaxes, however, practitioners such as Dr. Blanche Grube know that mercury-free dentistry must tread softly. In 1984, she moved from New York with her husband, a chiropractor, down to Scranton, "a secluded community." In 1992, her 20 years of practicing conventional dentistry was brought to an abrupt halt. Grube and her husband came across a patient of his, with a mouthful of fillings, whose toxicity was affecting her muscles. Once she had familiarized herself with the prevailing research, Grube stopped practicing altogether for a time. "I was devastated to think that, while I had been hoping to help my patients, I might have put them at risk." When she returned to work, after traveling to classes and seminars to educate herself further, she realized the benefits of her location. "Scranton has always been very separate from the rest of the world. It's a good place for a holistic dentist to hide."
She, like Brockman and DiLorenzo, learned about mercury exposure up close. She recalls bouts of hives on her arms while working as a dental assistant in Queens, N.Y., that corresponded to dermal contact with liquid mercury; carpets would soak up mercury spills, and waste amalgam was flushed down the drain or thrown in the trash. Now, she says, there's increased concern regarding pollution from dental offices entering the environment. Though she says that the EPA continues to leave its guidelines at the door of dental practices -- "mercury is classed as hazardous before it's placed, and hazardous waste once it's removed" -- a voluntary statewide cooperation was launched in May 2000 by the Pennsylvania Department of Environmental Protection and the Pennsylvania Dental Association to cut down on pollutant dental waste.
Grube's long-term view of the need for holistic dentists who follow extremely stringent standards in removing amalgams is reflected in her work environment: No carpets -- and oxygen tanks and gas masks sit ready for use when drilling into mercury. She categorically states that it is not safe for the public to demand amalgam removal by a conventional dentist. Careless removal, as Koss' story illustrates, can result in acute exposure. Her advice is simply for patients to be aware -- and to avoid amalgam placement where possible. (For fear of reprisals for her mercury-free policy, Grube takes most of her patients on referral from physicians, to work out whether they are suffering mercury toxicity.) In allying herself with holistic dental organizations, she also acknowledges the educational void surrounding issues of toxicity in dental care. "As long as the ADA accredits dental schools, I don't believe the revolution can start there." For that reason, she, together with Brockman and DiLorenzo, sits on the board of the newly initiated Institute for Natural Dentistry, an Academy of General Dentistry-accredited organization wherein dentists can learn to reconcile their concerns about toxicity with the available research and practical applications of holistic treatment.
She sees the movement gaining pace, at its grassroots as much as at its federal figurehead: for better or worse, not everyone can spend 10 years educating themselves now, as she did. "The fear," says Grube, "is that when the public finds out that there's a neurotoxin in a dental filling, there'll be a panic. Who'll be there to extract them safely, if we don't learn now?"