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Invited Review

Is it the end of the road for dental amalgam? A

critical review
Arvind Shenoy
Department of Conservative Dentistry, Bapuji Dental College, Davangere, Karnataka, India

Abstract
The longevity of dental restorations is dependent on many factors, including those related to materials, the dentist, and the
patient. Dental amalgams have successfully served the profession for over a century. The main reasons for restoration failure
are secondary caries, fracture of the bulk of the restoration or of the tooth, and marginal deficiencies and wear. The importance
of direct-placement, aesthetic, tooth-colored restorative materials is still increasing. Amalgam restorations are being replaced
because of alleged adverse health effects and inferior aesthetic appearance. All alternative restorative materials and procedures,
however, have certain limitations. This article will attempt to critically analyse both amalgams and resin based composites,
through an evaluation of scientific literature.
Keywords: Composite resins; dental amalgam; failure; longevity.

INTRODUCTION There seems to be a curious reluctance to accept

composite resins as a viable alternative to amalgams,
According to the American Dental Association (ADA), and, more often than not, this reluctance can
more than 100 million silver-amalgam fillings are be attributed to anecdotal rather than evidence
placed in American mouths each year. A cursory search based data. This leads to a situation where most
through the Internet throws up a horde of articles, students who graduate are woefully inadequate,
speculative, informative, and even downright absurd. with little or no clinical skills in placing composite
The fact of the matter remains that silver amalgam is restorations. Posterior composite resin restorations are
still the most widely used restorative material in the an established feature of contemporary dental practice
developing world. In recent years, however, its usage and all new dental graduates should be competent in
has decreased dramatically and we are at that curious providing such treatment for their patients.
juncture, where people are beginning to ask, ‘Is it the
beginning of the end for silver amalgam?’ As an academician, I find that most dental institutions
passionately hold on to amalgam as the material of
I remember reading a news item regarding the ban choice for undergraduates. Surveys of educational
being imposed on dental amalgam in Norway. The curricula in this area, in the United Kingdom and
Norwegian Government (Ministry of Environment) Ireland, as well as North America, have demonstrated
passed this legislation on December 14, 2007. It aims variations both within and between dental schools.[1]
to prohibit the production, importation, exportation, At the British Association of Teachers of Conservative
sale, and use of substances that contain mercury. Dentistry Annual Conference held in Birmingham
in September 2005, a session was devoted to the
In India, the use of amalgam has been decreasing over development of guidelines for dental schools on
the years, not as much because of public perception teaching posterior composite resin restorations to
on mercury toxicity or regulatory issues but due to the dental undergraduates. The theme of the conference
increased demand for esthetic restoratives. concerned the teaching implications for changing from
amalgam to composite. Perhaps the time is ripe for
such a discussion in India as well.
Correspondence:
Dr. Arvind Shenoy, Department of Conservative Dentistry,
Bapuji Dental College, Siddarth Building, Davangere-577 004, DENTAL AMALGAM
Karnataka, India. E-mail: thedentist1@usa.net
Over its long clinical history, dental amalgam has
Date of submission: 31.01.2008 evolved, and current clinical restorations represent an
Review completed: 17.04.2008
Date of acceptance: 09.05.2008 effective low cost dental restorative treatment, with

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Shenoy: Is it the end of the road for dental amalgam?

potential clinical lifetimes in excess of several decades, longer than was previously thought [Figures 1-3]. The
under appropriate conditions. Modern amalgams older generation of low-copper amalgams (before 1963)
encompass a number of broad classes of materials, did have a limited life span, because they contained
with variations in phase content, making them the the gamma 2 phase that caused progressive weakening
most metallurgically complex biomaterials. of the amalgam through corrosion.[3] Several clinical
studies have demonstrated that high-copper amalgams
Amalgam restorations undergo a variety of solid-state can provide satisfactory performance for more than
and corrosion reactions after clinical placement. This 12 years [Figure 3].[4-8] This appears to be true even for
presents complications in the understanding of clinical large restorations that replace cusps.[9] In addition,
properties and biological characteristics. Dental high-copper amalgams do not appear to require
amalgam classes contain a number of common phases polishing after placement, to increase their longevity,
and undergo similar solid-state and corrosion reactions, as was recommended for low copper amalgams.[10]
some of which offer the potential for the release of
mercury (Hg). The major phases which release Hg as a Plasmans et al.[11] evaluated the long term survival of
result of these processes include the γ Ag-Hg matrix phase large multi-surface restorations and found that extension
and the γ2 phase, which occurs mainly in traditional low- of extensive amalgam restoration (i.e., the number of
copper amalgam formulations. Most of the Hg which is cusps involved in the restoration) had no influence on
released appears to react with residual alloy particles.[2] the survival rate, which is in accordance with the results
of a retrospective study by Robbins and Summitt, who
DURABILITY OF AMALGAM found a 50% survival rate of 11.5 years.[12]
RESTORATIONS
The reason for the satisfactory functioning of the
Recent research shows that amalgam restorations last extensive amalgam restorations over a long period of
time results from the prevention of the most important
traditional mechanical failure of amalgam restorations.
These include marginal fracture, bulk fracture and
tooth fracture.[13,14] With careful evaluation of cusp
strength and the reduction of weak cusps, these
types of clinical failures can generally be prevented.
The zinc and copper content of the alloy has been
found to have a strong impact on the survival rates of
amalgam restorations, since it influences the corrosion
resistance of the amalgam. High-copper amalgams have
higher survival rates than conventional amalgams.[13]

Manhart et al.[15] completed a review on the longevity

Figure 1: 15 year old amalgam restoration in 36 which shows
some evidence of corrosion and extrusion but continues to
function efficiently

Figure 3: Well polished amalgam restoration in perfect shape

after 10 years of service. No evidence of corrosion, marginal
Figure 2: 35 disto-occlusal restoration at 10 years discrepancy and secondary caries

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of restorations in stress-bearing posterior cavities COMPOSITE RESINS

and assessed the possible reasons for clinical failure.
Since 1990, dental literature was predominantly ‘Durability is a major problem with posterior composites.
reviewed for longitudinal, controlled clinical studies The typical life-span of posterior composites is from
and retrospective cross-sectional studies of posterior three to 10 years, with large fillings usually fewer than
restorations. The mean (SD) annual failure rate in five years. Polymerization shrinkage and inadequate
posterior stress-bearing cavities was 3.0% (1.9) for adhesion to cavity walls are remaining problems. Some
amalgam restorations. The main problems limiting the pulp irritation can occur if deep restorations are not
survival of amalgam restorations were reported to be placed over a protective film.’ Bowen.[18]
secondary caries, a high incidence of bulk and tooth
fracture, cervical overhang and marginal ditching. A lot has changed since Bowen made this statement in
1992. As a sign of the times, in 1999, around 86 million
Letzel[16] investigated survival and modes of failure composite restorations were placed in the United
of amalgam restorations retrospectively. The leading States, as against 71 million amalgam restorations. The
mode of failure was bulk fracture (4.6%), followed by reasons were improvements in composite materials
tooth fracture (1.9%), and marginal ridge fracture (1.3%). and techniques, and public demand for more esthetic,
For other reasons, 0.8% of the restorations failed. tooth-colored restorations.[17]

TOXICITY OF AMALGAMS Improvements in filler technology and the formulation

of composite materials have resulted in changes in the
The debate over the safety and efficacy of amalgam has reasons for restoration replacement, as well as the
raged since time immemorial. In recent times, it has increasing trend to insert composite restorations in
reached such a feverish pitch that it seems to drown stress-bearing areas of posterior teeth [Figures 4-6].
out all sounds of reason.
The issue with restorative composites is to increase their
Amalgam has served the dental profession for more
flexure strength and fracture toughness, and thereby
than 150 years. Incidents of true allergy to mercury
lengthen their service life in the oral cavity, while still
have been rare (only 41 cases have been reported
maintaining their esthetic value. However, longevity
since 1905), and attempts to link its usage with such
and survival studies in posterior teeth continue to show
diseases as multiple sclerosis and Alzheimer’s have
that amalgam has a better track record than composite,
not been scientifically proven, although there may be
further reinforcing the need to understand the failure
some association between amalgam restorations and
mechanisms of dental composites.[19,20]
oral lichenoid lesions.

Marshall,[2] in his review on Dental Amalgam, summed The recently developed resin composites are superior
it up appropriately: ‘If some reported values of Hg to the earlier versions, with regard to wear resistance
release are extrapolated to clinical lifetimes, the and color stability, but the main shortcoming of the
entire restoration could lose its Hg in a short time. composites, i.e. the polymerization, shrinkage of
For example, a 500-mg amalgam restoration contains the resin, still remains.[21-23] In posterior cavities,
approximately 200-250 mg of Hg, and the entire especially with the cervical margin situated in
quantity of Hg would be lost in 10,000 days if the Hg dentin, the mass to be polymerized is so large that
was released at the rate of 25 ug/day. This estimate of the shrinkage forces win out, producing marginal
release is of the order of magnitude reported in some defects and gaps, despite careful application.[24,25]
studies of vapor release.’ This facilitates microleakage, which can cause
secondary caries, pulpal irritation, postoperative
As recently as May 2005, the ADA endorsed amalgam sensitivity and marginal discoloration.[26,27]
as being safe for pregnant women. Still, the anti-
amalgamists persist in their efforts to discredit the LONGEVITY OF COMPOSITE
dental profession. A discussion on this issue is beyond RESTORATIONS
the scope of this article but a good starting point would
be Hyson’s[17] treatise on the history of amalgam, in Prospective clinical studies on posterior composite
which he has discussed the issue in detail. resin restorations show an annual failure rate of one

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Figure 4: Disto occlusal composite restoration in 15 Figure 5: 15 and 16 restorations at 3 years in perfect function,
showing minimal discoluration

coarse particle hybrid composite). The failure rate of

the composite restorations was approximately two to
three times that of the control high copper amalgam
restorations (5.8%). The main modes of failure of the
composites were bulk fracture and secondary caries at
the margin; these comprised 72% of the known modes
of failures.

Raskin[30] found actual 10-year failure rate to have

been between 40 and 50%. Cumulative approximal and
related occlusal wear, with the resultant loss of contact
Figure 6: Multiple large composite restorations at 7 years. 16
MOD showing signs of marginal discolouration , wear and areas, was found to be an important cause of failure,
secondary caries.17 multi surface restoration still in good 10 years after placement.
shape
However, any practical application of longevity data is
to four percent, depending on the type of study and somewhat offset by the fact that composite products
the materials selected.[15] are being modified or superseded almost constantly.
The impact of advances in composite research and
A 17-year study of ultraviolet-cured posterior technology on the longevity of posterior restorations
composites by Wilder and others demonstrated an is evident in the retrospective study conducted by
excellent success rate of 76%. Color matching (94% Baratieri and Ritter on the clinical performance of
Alpha), marginal discoloration (100% Alpha), marginal Class I and Class II composite restorations after
integrity (100% Alpha), secondary caries (92% Alpha), four years. Although 2.5% of the restorations had
surface texture (72% Alpha), anatomic form (22% Alpha) clinically detectable marginal fracture, none required
and a mean occlusal wear of 264 µm were recorded replacement.[31] Hickel et al., in a meta-analysis, found
after 17 years. the failure rate to be less than 9 %.[32]

The improved reliability of composite resin as a The fact of the matter is that these materials are
restorative material in posterior teeth largely depends constantly improving to a point when new data is
on the combination with an adhesive technique, which available; there is newer, stronger and improved
results in reduced microleakage and strengthening of material available.
weakened tooth structures.[28]
The present ADA guidelines require an 18-month
Hodge[29] found that the overall failure rate of the period of clinical service for acceptance of a new all-
composite restorations in posterior teeth at eight years purpose composite resin. It might be better to have an
was 13.7% (16.4% for the microfilled composite; 15.4% evaluation period of at least five years before coming
for a fine particle hybrid composite; 9.3% for a relatively to any conclusions.

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Interestingly, Opdam and colleagues, in a longitudinal established by either a direct or an indirect method.
study of over 700 posterior composite restorations The clinical reports of heat-treated inlays do not
placed by dental students, reported a 5-year survival confirm the suggested superior mechanical strength. It
rate of 87%, with an annual failure rate of 2.8%. They has been shown that the improvements of some of the
concluded that dental students are able to place resin properties were only short-time and these decreased
composite restorations in posterior teeth, with an due to weakening of the polymer by water uptake in the
acceptable mean annual failure rate.[33] same way as for light-cured-only resin composites.[38]

POLYMERISATION STRESSES Dijken,[39] in a 11-year evaluation of direct inlays and

onlays, found good durability for the direct resin
Shrinkage stresses have often been the bane of composite inlay/onlay technique. Excellent marginal
composite resin restorations. These stresses, which adaptation and low frequency of secondary caries in
develop during polymerisation, lead to a host of issues patients with high caries risk were shown. No apparent
including tooth flexure, post operative sensitivity and improvement of mechanical properties was obtained
craze lines in marginal areas. Many factors affect the by the secondary heat treatment of the inlays. Also, the
development of contraction stress in dental composites. difference in failure rate between the resin composite
These can be separated into material formulation direct technique and the inlay technique was not large;
factors (filler content, monomer chemistry, monomer indicating that the more time-consuming and expensive
structure, filler/matrix interactions, additives etc.) inlay technique may not be justified. The direct inlay/
and material polymerization factors (polymerization onlay technique is recommended to be used in Class
rate, i.e. catalyst and inhibitor concentration, external II cavities of high caries risk patients, with cervical
constraint conditions, cavity geometry, curing marginal placed in dentin. A review of inlay studies
method, placement technique etc.). Ferracane et showed a low secondary caries rate in most of the
al.,[34] in a systematic review, discussed the issue of evaluations.[40-41]
polymerisation stresses in detail. They concluded that
volumetric shrinkage should not be the only parameter THE SANDWICH TECHNIQUE
to be considered for predicting composite behaviour
regarding stress development. Materials with relatively In the years when reliable dentin adhesive systems were
low shrinkage, due to high inorganic filler content, not available, application of a glass-ionomer cement
also present high elastic modulus, which may result lining was the standard procedure to obtain bonding
in increased stress. of the composite resin to dentin. Two variations of
that type of restorations exist: the open and closed
Reduced polymerization rate, due to the use of sandwich. In a closed sandwich, the dentin is covered
alternative photo activation methods, does not with resin-modified glass-ionomer (RMGI) lining
necessarily lead to significant reductions in contraction cement. In an open sandwich, RMGI is used to replace
stress. Also, a particular curing routine may not be the dentin and also to fill the cervical part of the box,
efficient with composites from different manufacturers. which results in a substantial part of the glass-ionomer
Stress reduction cannot be achieved at the expense of cement being exposed to the oral environment.[42]
adequate degree of conversion.[35]
A lining with a low modulus of elasticity, such as a
Several new restorative techniques have been glass ionomer cement, is expected to act as a stress-
introduced during the last years, to minimize the absorbing layer and to compensate for polymerization
development of stresses, such as multiple increment shrinkage stress.[43]
techniques, replacement of the dentin with glass
ionomer cement in the sandwich technique. Opdam, [42] in a retrospective study with a five-
year observation period, made some interesting
INDIRECT INLAYS observations. Total-etch restorations placed with a
highly filled hybrid composite resin showed a higher
A promising method introduced to reduce the clinical survival than closed-sandwich restorations
shrinkage problem was the resin composite inlay/ using a lining of RMGIC, due to a lower fracture rate.
onlay technique.[36,37] The form of the inlay can be Fracture and secondary caries, the most important

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reasons for failure, mostly occurred after a period of Cavity size also exerts a significant effect in the
more than three years. survival of composite restorations. When compared
to a one-surface restoration, the relative risk of failure
It is often suggested that glass-ionomer cement should is approximately 2.3 times greater for two-surface
lead to a prevention of secondary caries. A lining of restorations and 3.3 times greater for multi-surface
RMGIC is considered to act as an elastic layer, which restorations. Reduction in cavity size will protect the
should improve adaptation of the restoration and restoration of the chewing forces.[15] Generally, multi-
compensate for polymerization stress. Both these surface restorations will involve the marginal ridges
assumptions were disproved in this study, which (Class II), which are areas of increased loading. In a
questioned the alleged advantages of the elastic layer clinical trial of amalgam restorations, deterioration
underneath a composite resin restoration. was greater in molars and large-sized restorations.
[50]
Another long-term (15 years) longitudinal study of
Randall[44] found no data to support the cariostatic amalgam restorations corroborates this study, showing
effects of GIC bases under restorations. that the replacement risk for MOD restorations was
significantly higher than for MO/OD restorations.[51]
It would then be prudent to assume that the use of the
RMGI liner should not be based on these criteria. The Additionally, Brunthaler et al., [52] in a survey of
consensus, however, seems to suggest that increasing prospective studies showed that filling extension
the compliance of the cavity walls by applying an influenced failure rates. (Class II fillings had higher
intermediate low-modulus layer may lead to significant failure rates.)
stress relief, depending on its thickness and elastic
Van Nieuwenhuysen et al., [53] in a prospective
modulus. The alternative to RMGIC would be a flowable
longitudinal study, evaluated extensive amalgam and
composite which would bond to dentine and provide
composite restorations as substitutes for crowns. At
a good seal.
the closure of the study, 48% of the restorations were
Flowable composites may offer significant advantages well functioning, 24% were lost to lack of follow-up,
and 28% had failed. The most frequent reasons for
when used as intermediate layers, according to the
failure were fracture of restoration (8%), secondary
concept of radiopaque filled adhesives. They can also
caries (6%) and fracture of cusp (5%). Failures were more
be used to improve adaptation to the cavity surface
often found in premolar teeth (34%) than in molars
in areas that are difficult to access, especially when
(27%) and occurred in 28% of the amalgam restorations,
high-viscosity posterior composite materials are used
30% of the resin restorations and 24% of the crowns.
subsequently.[45-46]
Molar restorations were more frequently repaired
than replaced, in contrast to premolar restorations.
POST OPERATIVE SENSITIVITY The highest percentage of extractions was related
to complex amalgam restorations in premolars. The
Postoperative sensitivity is often mentioned in
Kaplan-Meier median survival times were 12.8 years for
relation to posterior composite resin restorations.
amalgam restorations, 7.8 years for resin restorations,
The introduction of self-etching primers, which do not
and more than 14.6 years for crowns, considering all
remove the smear layer, has virtually eliminated the
retreatment as failures.
problem of postoperative sensitivity.[47] Two clinical
studies that examined whether self etching adhesives Rodolpho et al.[54] found that clinical performance
result in less postoperative sensitivity than total-etch of posterior resin composite restorations evaluated
adhesives were not able to demonstrate a difference was acceptable after 17-year evaluation. These were
between the two methodologies.[48,49] Both studies restorations placed in a private practice and reflected
found virtually no postoperative sensitivity with either clinical reliability of composites. They also found
technique. Present day adhesives, when used with care, that the probability of failure of resin composite
following the manufacturer’s instructions, produce restorations in molars, Class II, and large restorations
little or no post operative sensitivity. Consistent post was higher. The materials used in the study, namely P
operative sensitivity could be attributed to faulty 50 (3M) and Herculite XR (Kerr), have been surpassed
technique rather than a deficiency in the material. by far superior materials.

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The most recent development in resin chemistry is based on the survival of the restorations. No significant effect
on using ring opening polymerization of the silorane of operator, material as well as combination of material
molecules, instead of free radical polymerization and operator, was found.
of dimethacrylate monomers. Silorane resin reveals
lower polymerization shrinkage, as compared to the One thing that is clear from these and other studies is
dimethacrylates. The ring opening polymerisation that both amalgam and composite resins have excellent
of the silorane molecule is a cationic polymerization longevity, in excess of seven years. Interestingly, a
reaction, where no oxygen inhibition layer exists on unique and somewhat controversial study by Fairhurst
the surface of the composite after polymerization in et al.[58] provided some interesting insights. This 10-
air.[55,56] Having had the opportunity to use this material, year study evaluated bonded and sealed composite
it holds promise for the future in eliminating the issue restorations placed directly over frank cavitated
of shrinkage [Figures 7 and 8]. lesions extending into dentin vs. sealed conservative
amalgam restorations and conventional unsealed
COMPARATIVE EVALUATION OF amalgam restorations. The results indicated that both
LONGEVITY types of sealed restorations exhibited superior clinical
performance and longevity, when compared with
Two recent studies with relatively long term follow ups unsealed amalgam restorations. Also, the bonded and
provide partly contradictory results. sealed composite restorations placed over the frank
cavitated lesions arrested the clinical progress of these
Bernardo et al.[20] evaluated a total of 1,748 restorations lesions for 10 years.
at baseline, which the authors followed for up to seven
years. Overall, 10.1 percent of the baseline restorations CONCLUSIONS
failed. The survival rate of the amalgam restorations
was 94.4 percent; that of composite restorations was A random search of MEDLINE, limited to dental
85.5 percent. Annual failure rates ranged from 0.16 to journals in the past five years, threw up some rather
2.83 percent for amalgam restorations and from 0.94 interesting results. Keywords such as ‘dental amalgam’
to 9.43 percent for composite restorations. Secondary and ‘amalgam’ yielded 515 and 499 results respectively.
caries was the main reason for failure in both materials. The same search with the keyword ‘composite resin’
Risk of secondary caries was 3.5 times greater in the threw up 3271 results. A search on scholar.google.com
composite group. yielded 28600 results for ‘dental amalgam’ and 361000
results for ‘composite resins’. This clearly reveals the
Opdam et al,[57] found a survival rate of 91.7% for shift away from amalgams towards composite resins.
composite resin, at five years, and 82.2% at 10 years. This shift has been brought about due to concerns
For amalgam, the survival rate was 89.6% at five years about mercury toxicity as well as the general trend
and 79.2% at 10 years. Cox-regression analysis resulted towards esthetic tooth coloured restorations. In
in a significant effect of the amount of restored surfaces clinical practice, most patients demand tooth coloured

Figure 7: 46 glass ionomer disto-occlusal restoration showing Figure 8: Fractured restoration replaced with Silorane based
bulk fracture composite (P 90,3MESPE)

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failures, and causes of failure. Dent Mater 1989;5:115-21.
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replacement. Chicago: Quintessence Publishing Co Inc; 1989.
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15. Manhart J, Chen H, Hamm G, Hickel R. Buonocore memorial
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