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Filling a Need

Dentistry: Patients with cavities have more choices, with varying durability and aesthetic appeal.


Cavity treatment used to be simple. A dentist drilled away the decayed part of the tooth and packed the resulting hole with silver-colored mercury amalgam. It wasn't pretty, but it did the job--at least until the amalgam started to crack or come out.

But as dental science has become more technologically sophisticated, so too have the options for replacing the enamel, dentin and pulp ravaged by bacteria and plaque. Decayed areas of teeth can now be restored with mixtures of plastics, glass, ceramic and quartz, each with varying degrees of aesthetic appeal and durability.

The variety has been driven, in large part, by cosmetic concerns. Given the choice between a molar full of grayish metal or a synthetic compound tinted to resemble tooth enamel, patients generally opt for the latter.

"Very few people today want anything placed in their mouth that doesn't match," said Rella Christiansen of Clinical Research Associates, a Provo, Utah-based nonprofit organization that evaluates dental materials and techniques.

But, with adults today keeping their teeth longer than in generations past, dentists have also been searching for cavity fillers that can last for decades.

Meanwhile, vocal consumer advocates have been fighting to rid dentists' offices of mercury amalgam, which has been used since the 1850s. Mercury has already been taken out of childhood vaccines because of potential damage to developing brains, and health authorities often warn about the danger of eating mercury-contaminated fish.

Charles Brown, a Washington, D.C., lawyer who as founder of Consumers for Dental Choice has led the anti-mercury charge, is now working to garner support for a bill sponsored by U.S. Rep. Diane Watson (D-Calif.) that would abolish mercury amalgam nationwide. Said Brown: "There is no science in support of mercury fillings."

The majority of U.S. dentists, following American Dental Assn. guidance, counter that no one has proved that mercury amalgam fillings diminish health, although a small number of people develop allergic reactions to the substance. Although they acknowledge that mercury can be released from fillings when you chew and can be detected in breath vapor and in the bloodstream, they point to reassurances from the ADA and a handful of federal agencies that mercury released by fillings falls well within safe levels.

Some dentists are playing it safe just the same. Figures from the American Dental Assn. show mercury amalgam fillings losing ground to higher-tech materials. In 1990, amalgam accounted for 99.5 million new fillings, including 23 million fillings placed in the mouths of U.S. youngsters ages 2 to 17. By 1999, amalgams accounted for just under 71 million new fillings, including 21.5 million fillings for children.

At the same time, more dentists have stopped using mercury, according to surveys of dental preferences. Last December, Clinical Research Associates found that 27% of randomly sampled subscribers to its newsletter weren't using mercury amalgam, up from 3% in 1985 and 9% in 1995.

Dental insurance, however, hasn't caught up with all the developments. Many plans, including Medi-Cal, will pay only for the standard amalgam (except where a front tooth is involved). Consumers who want something else must make up the difference, often 30% or more above the cost of mercury.

"We're moving toward better access because everybody is paying attention" to how the newer materials are working, said Dr. Van P. Thompson, who heads the dental materials department at New York University College of Dentistry.

Since last year, Californians sitting in the dentist's chair who need fillings, crowns, bridges or other restorations have been handed a fact sheet that acknowledges controversy about the safety of mercury amalgams and details the pros and cons of alternatives.

Carol Cromer of Marina del Rey, who in February was told that her 6-year-old daughter, Caitlin, needed a handful of fillings, said she carefully reviewed all the listed options with her child's dentist. Although she considered using amalgam, she eventually decided on composites. "I did have less doubts about it," she said.

Some experts say dental consumers may be trading one set of health concerns for others as more is known about the long-term effects of newer filling materials, not to mention the cements sometimes needed to make them stick. For example, composite fillings can leach a substance called bisphenol-A, a material found in plastic food can linings that appears to mimic the female hormone estrogen, although the California fact sheet says concerns about it aren't supported by research studies.

"Like everything in life, there's a pro and a con," said Dr. Mark Goldenberg, a Beverly Hills dentist who helped draft the California dental fact sheet.

Here are your options when getting a tooth filled:

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