Use Of Amalgam Research Articles

Impact of bisphenol A and analogues eluted from resin-based dental materials on cellular and molecular processes: An insight on underlying toxicity mechanisms.

Dental resin systems, used for artificial replacement of teeth and their surrounding structures, have gained popularity due to the Food and Drug Administration's (FDA) recommendation to reduce dental amalgam use in high-risk populations and medical circumstances. Bisphenol A (BPA), an endocrine-disrupting chemical, is an essential monomer within dental resin in the form of various analogues and derivatives. Leaching of monomers from resins results in toxicity, affecting hormone metabolism and causing long-term health risks. Understanding cellular-level toxicity profiles of bisphenol derivatives is crucial for conducting toxicity studies in in vivo models. This review provides insights into the unique expression patterns of BPA and its analogues among different cell types and their underlying toxicity mechanisms. Lack of a consistent cell line for toxic effects necessitates exploring various cell lines. Among the individual monomers, BisGMA was found to be the most toxic; however, BisDMA and BADGE generates BPA endogenously and found to elicit severe adverse reactions. In correlating in vitro data with in vivo findings, further research is necessary to classify the elutes as human carcinogens or xenoestrogens. Though the basic mechanisms underlying toxicity were believed to be the production of intracellular reactive oxygen species and a corresponding decline in glutathione levels, several underlying mechanisms were identified to stimulate cellular responses at low concentrations. The review calls for further research to assess the synergistic interactions of co-monomers and other components in dental resins. The review emphasizes the clinical relevance of these findings, highlighting the necessity for safer dental materials and underscoring the potential health risks associated with current dental resin systems.

Mercurial risk from dental amalgam use in a population of Moroccan dentists: A latent class regression approach.

Dentists using dental amalgam are chronically exposed to low doses of elemental mercury. The complex toxico-kinetics of this systemic toxicant results in polymorphic and variable clinical phenotypes. In this context, adapted statistical methods are required to highlight potential adverse effects of occupational mercury exposure on dentists' health. The present study aims to analyze the distribution of self-reported subjective symptoms, commonly associated with chronic mercury poisoning, according to occupational mercury exposure in a population of Moroccan liberal dentists. In order to achieve the defined objectives, a three-step latent class regression was fitted. First a latent class analysis was performed to cluster the studied population according to their declared symptoms. Dentists were then classified in the defined latent classes based on their posterior probabilities. Finally, a logistic regression is fitted to identify predictors associated with latent classes' membership. The final obtained model showed acceptable calibration and discrimination. Its interpretation revealed that the increase of the frequency of amalgam use was associated with significant higher odds of belonging to the high risk latent class. The present study represents an initial step towards the development of diagnosis model that predict clinical profiles according to occupational mercury exposure.

Dental Amalgam from the Past to the Present: Utilization among Ministry of Health Dental Clinics in the Makkah Region of the Kingdom of Saudi Arabia

Background: Amalgam fillings were invented and introduced to dentistry in France and England during the 1800s. It has since become one of the most reliable dental filling materials to treat dental caries. Dental amalgam contains approximately 50% elemental mercury, a source of occupational exposure among dental personnel and non-occupational exposure among patients. Objective: This study describes the use of dental amalgam in Makkah region dental clinics as a direct restorative material compared to composite and glass ionomer cement. Methods: This longitudinal retrospective study included 335 dental clinics in Makkah and Jeddah, the two largest cities in the Makkah region, Kingdom of Saudi Arabia. Annual statistical data were obtained from the Directorate of Dentistry, Makkah and Jeddah Health Affairs, Ministry of Health. Data related to the restorative materials used (composite, glass ionomer cement (GIC), and amalgam) were counted for 11 years starting from 2009 to 2019 for Makkah city, and the restorative materials used (composite, GIC, and amalgam) from 2018 to the first quarter of 2021 for Jeddah city. Results: There was a slight increase in the number of amalgam restorations in Makkah from 2009 (37.15%) to 2011 (43.52%), followed by a gradual decrease until 2019 (1.39%). In Jeddah, there was a slight increase in amalgam restorations from 2018 (9.39%) to 2019 (11.03%). However, the use of amalgam restorations reduced sharply in 2020 (3.27%) and in the first quarter of 2021 (3.53%). Conclusion: There is a recognizable decreased trend in amalgam utilization in the Makkah region. Amalgam use is being phased down despite the lack of official regulation on its use.

A survey of amalgam use to guide dental education curriculums.

To identify behavioral, preferential, and professional factors influencing the use of amalgam in private practices; and to compare the incidence of the placement of amalgam versus composite resin restorations in the province of Ontario and its pedagogical implications on dental curricula. Participants responded anonymously to a 23-question online survey about their current use of dental amalgam and composite resins as well as their opinions regarding both dental materials. The explanatory variables were associated bivariately with the outcome variables, and the most significant predictors were identified using the multivariate analysis. Higher percentages of amalgam use were reported among clinicians who trained in Canada only (P=.009), who graduated before 1980 (p=<.001) and who work outside private practice (p=<.001). Familiarity with amalgam was higher among clinicians who are female (p=<.001), older (p= <.001), trained only in Canada (p=.017), who graduated prior to 2000 (p=<.001), and who work in locations with populations over 100,000 (p=.042). Familiarity with composite resin was higher among clinicians who graduated more recently (p= .002). A higher percentage of females (p=<.001), younger clinicians (p=<.001), recent graduates (p=<.001), and clinicians who work in private practice (p=.043) suggested that over 50% of dental student training time be allocated to amalgam. Decreased amalgam use was reported by later dental graduates and private practitioners; this may be impacted by familiarity with dental amalgam. As amalgam remains a safe and effective dental material, its removal may not be prudent. Dental educators play a crucial role in the future of amalgam opinion and use.

Posterior dental restoration material choices in privately insured people in the United States, 2017 through 2019

BackgroundIn 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. MethodsNumbers 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. ResultsThe 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. ConclusionsAmalgam restoration placements in privately insured people in the United States declined from 2017 through 2019. Amalgam restoration placements may be unevenly distributed by location. Practical ImplicationsAchieving 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.

Practices and Attitude of Dental Clinicians towards Dental Amalgam in Lahore

Background: Amalgam was the material of choice for dental restorations due to its excellent mechanical properties, but the World Health Organization recommended that it should be phased out due to its environmental concerns. Aim: To determine the dental clinicians’ attitude to amalgam use during routine clinical practice in Lahore. Methods: Cross-sectional study was conducted among private practicing dentists in Lahore.Using convenience sampling, 100 proformas were dispersed. The questionnaire included informed consent along with demographic data such as gender and years of practice, 17 questions related to perceptionand practices, and seven questions about knowledge of dental amalgam restorations.Chi-square test was used to determine statistical significance. P value of less than 0.05 was considered significant. Results: Seventy four questionnaires were returned filled by participants.Majority of the participants, 51 (68.9%), performed no amalgam restorations, but those with 10 years or more experience still used the material at their practices. Dentists based on clinical experience were: less than 5 years=14(18.9%), 5-10 years =31(41.9%), and more than 10 years = 29(39.2%). Significant association, p=0.02, was observed between clinical experience of clinicians and the number of amalgam restorations performed weekly in their clinics. Practical implication=Health organizations often debate about amalgam safety and the environmental issues of mercury. After the devastating floods in Sindh, environmental issues are recently raised in Pakistan. Conclusion: According to this research, dental amalgam use within private dental practitioners is definitely on a decline in Lahore. Some senior dental practitioners with 10 years or more of experienceregularly used amalgam as a restorative material. MeSH words: Dental amalgam, General Practice, Dental,

Decreased trends of using dental amalgam filling for decayed teeth in Taiwan from 1997 to 2013

Background/purposeMercury within dental amalgam has been criticized for the potential toxicity and environmental hazard. Phasing down the use of dental amalgam is the transition for amalgam free dentistry. However, little is known about dental amalgam filling (AMF) in Taiwan. In this study, time trends of AMF were measured by using National Health Insurance Research Database (NHIRD). Materials and methodsA retrospective study was conducted to analyze the AMF data in registered database compiled by Taiwanese NHIRD from 1997 to 2013. The AMF data were further analyzed according to sex, age, and geographic location, respectively. Time trends of dental visits for AMF and medical expenses for AMF were also evaluated. ResultsThe average annual AMF ratio was 8.965% of nationwide population in Taiwan. The prevalence of AMF was significantly decreased both in male and female from 1997 to 2013 (P for trend <0.0001). The decreased pattern of AMF was found by the age stratification (P for trend <0.0001). The significant fall of AMF was also displayed in six districts (P for trend <0.0001). The number of dental visits were ranged from 821,749 in 1997 to 1,313,734 in 2013. However, time trends of dental visits for AMF were significantly decreased (P for trend <0.0001). The medical expenses for AMF were simultaneous significantly decreased from 1997 to 2013 (P for trend <0.0001). ConclusionForm the results of this nationwide population-based database, a significant decrease of AMF in Taiwan was observed during past 17 years.

Developments in resin-based composites

With the phasing down of dental amalgam use in response to the Minamata Convention, it is likely that resin-based composite restoratives will be the dental material of choice for the direct restoration of compromised dentition in the UK, at least for the foreseeable future. The current materials have a finite lifespan, with failures predominately due to either secondary caries or fracture. Consequently, there is considerable in vitro research reported each year with the intention of producing improved materials. This review describes the recent research in materials designed to have low polymerisation shrinkage and increased mechanical properties. Also described is research into materials that are either antimicrobial or are designed to release ions into the surrounding oral environment, with the aim of stimulating remineralisation of the surrounding dental tissues. It is hoped that by describing this recent research, clinicians will be able to gain some understanding of the current research that will potentially lead to new products that they can use to improve patient treatment in the future.

Attitudes and Knowledge of dentists in Pakistan regarding the use of Dental Amalgam as a restorative material

Aim: To assess the attitudes of Pakistani dentists regarding the safe use of amalgam as a restorative material. Study design and setting: This cross-sectional, was conducted at Women medical and dental College, Pakistan. Methods: This cross- sectional study was conducted amongst the dentist of Pakistan. Survey utilized for this study was adopted and modified from the study conducted by Alkhudhairy F. Descriptive statistics were checked by means of percentages and frequency for all variables. In order to check significant difference among the responses given Chi-square test was applied. Results: From a total of 212 participants, there were 97 (45.8%) males and 115 (54.2%) females. There were 167 participants working in private sector while 45 worked in public sector. Amalgam was most commonly preferred for preparation of small cavities, agreed mutually by both males (45.4%) and females (27%). Majority of the male participants (51.5%) stated being unsure regarding the safety of amalgam, while majority of females (49.5%) reported amalgam unsafe for both dentist and the patients. Composite was the frequently used alternative restorative material by both males (39.2%) and females (51.3%). Conclusions: Though amalgam was the utmost frequently used material used for restoration of posterior teeth. Many study participants had awareness regarding the mercury toxicity but still it was used. However additional sessions can be conducted for reinforcing the safety element regarding the use of amalgam. Keywords: Dentists’ opinion, material, mercury, restorative materials, esthetics

Amalgam phase-out, an environmental safety concern: a crosssectional study among general dental practitioners in Pakistan

Amalgam has been the gold standard for restorations in posterior teeth. Mercury, a major component of dental amalgam, is considered an environmental pollutant. The Minamata Convention on mercury recomends a reduction in the use of mercury-containing products. Since Pakistan is a signatory to the Convention, the same amalgam phase-out limitations are implemented in Pakistan. To identify and assess the use of amalgam and its waste management by dentists in Pakistan post-Minamata Convention guidelines. A cross-sectional study was conducted in Lahore among 520 general dental practitioners in 2019. The sample size for the study was calculated as 500; the questionnaire was distributed among 550 dentists. Dental amalgam was used by only 41.6% of the dentists in their practice; 55.0% perceived it to be a health risk. Most of the dentists (76.3%) were unaware of the proper disposal protocols for dental amalgam and 76.5% were unaware of any guidelines regarding amalgam use and disposal. Although there is a gap in knowledge among the dentists regarding amalgam disposal, dentists in Pakistan are reducing their use of dental amalgam in accordance with the guidelines of the Minamata Convention.

Measurement of patient satisfaction with two different restorative materials in non-aesthetic zone area by using OHIP5: Prospective study.

Many dental restorative materials are used in dental clinics, while in a new practice, many countries are trying to ban dental amalgam for many reasons. Dental mercury is the main issue for suspending the use of dental amalgam. Another restoration method, the composite restoration for posterior and anterior teeth for esthetic porous, became the alternative to amalgam. To measure patient satisfaction with two different materials based on multiple criteria using an oral health impact profile (OHIP) form. This is a prospective study on two groups. The patients visiting the clinic with a vital posterior tooth indicated for restoration were requested to participate in the study. The first group received composite restoration of the posterior teeth. Contrarily, the second group underwent an amalgam restoration application. Patient satisfaction was assessed using the OHIP5 to assess different aspects of patient satisfaction. The patients were asked to fill out a form before starting the procedure, and after 4 weeks, the procedure was reported. The operators were requested to fill out their forms based on the procedure done to determine the participant eligibility criteria. Overall 64 subjects were involved in the study among them 35 participants who received composite restoration, 48.5% were female, whereas 51.5% were male. Under other conditions, the patients who underwent amalgam application were 29, and 41.4% were female. Based on the study results, the participants underwent before and after assessment and showed no demands for different aspects with the two different materials. No significant differences using amalgam or composite restoration regarding appearance, functional, and psychological factors in the posterior teeth were noted.

Dental Amalgam- Anthropogenic Aspects

Mercury is released in the environment by various natural and anthropogenic activities. As mercury is toxic, presence of high levels of mercury in the environment is a major concern. One source of mercury in humans is dental amalgam fillings. Dental amalgam has been used for ages in dental clinics and dental hospitals for restoring defective and decayed teeth. This raises concern regarding the use of dental amalgam and its disposal. The purpose of this article is to sensitize people about the hazards of mercury, make them cognizant with guidelines regarding the use of mercury in dental clinics and enforce the use of alternatives to mercury when possible.

The use of dental amalgam and amalgam waste management in Kosova: An environmental policy approach.

Dental amalgam from dental clinics in Kosova is an uncontrolled source of mercury. The environmental legislative framework related to its use does not fully provide measures that reduce amalgam use and the release of its waste into the environment. This paper highlights issues related to environmental policy covering mercury amalgam waste management. Existing national regulations on hazardous waste management in Kosova consider the waste from dental health care as hazardous. Currently, however, no regulations restrict the use of dental amalgam or specifically oblige the generators of amalgam to treat or dispose of waste properly, thus leading to inconsistent legislation. New regulations, revised hazardous waste management standards, and new infrastructure for waste treatment and disposal, in compliance with EU regulations, should be developed to create a holistic approach that prevents the adverse effects of amalgam waste. Integr Environ Assess Manag 2021;17:1037-1044. © 2021 SETAC.

Awareness About Dental Amalgam Among Turkish Dentists and Patients: A Questionnaire and Search Engine Based Cross-Sectional Study

ObjectivesThere has been considerable controversy concerning the health risks and benefits of using mercury-containing amalgam. This study aimed to evaluate the Turkish dentists’ and patients’ preference and opinion about amalgam and to assess Internet search trends about amalgam. MethodsThe study consists of three stages. The first two stages of the study are cross-sectional studies to verify both the patients’ perception with amalgam restorations and dentists’ attitudes regarding the use of dental amalgam. The third stage of the study evaluated the Internet search trends of Turkish people about mercury and amalgam related concerns between 2004 and 2018. ResultsA total of 320 patients (180 female, 140 male) and 1,211 dentists (533 female, 678 male) participated in this study. Majority of the patients have no idea about the type of dental restorations and effect of dental materials on their health. 188 (58.8%) participants stated that they would not prefer amalgam restoration in their teeth as amalgam is unaesthetic. A total of 24% (291) of the dentists used amalgam routinely; 9.5% (156) of them used amalgam rarely, and 63.1% (764) did not use amalgam at all. The reason for not using amalgam included the patients’ desire and unaesthetic properties. According to the Internet search trends, Turkish people do not know as much about amalgam as people in the rest of the world. ConclusionAwareness about dental amalgam is low among patients studied. Although dentists do not use dental amalgam frequently, they disagree on banning dental amalgam.

Modeling Subjective Symptoms Related to Micro-Hydrargyrism in a Population of Moroccan Dentists.

The ability of mercury to deposit throughout the body and alter a wide range of molecular and cellular pathways results in a polymorphic and complex clinical phenotype with over 250 possible symptoms. However, some of them are recurrently cited as evoking chronic mercury poisoning. In this light, dentists users of dental amalgams are chronically exposed to mercury so that in-depth epidemiological investigations and adapted statistical methods are required to highlight adverse effects of this exposure. In order to study the health impact of the occupational mercury exposure in a population of liberal dentists practicing in two Moroccan regions, a list of eighteen subjective symptoms commonly associated with micro-hydrargyrism was drawn up. Then, seven statisctical models adapted to count data were fitted. Finally, three methods were used to compare their relative performance in order to choose the most appropriate one. The adopted logical path, from the response variable selection till models' comparison, led us to lean towards quasi-Poisson regression as the best way to predict the number of symptoms declared by dentists according to mercury exposure. Interpretation of the selected model allowed us to conclude that the reduction of dental amalgam use allows the reduction of subjective symptoms related to mercury exposure.

Dentists’ restorative treatment decisions: A south african study

Aim: To focus on clinical decision-making by dentists for defective restorations in the context of an overburdened healthcare system and a high caries rate. Materials and Methods: A cross-sectional study was conducted using mixed-methods. An online survey was administered to all members of the South African Dental Association followed by in-depth interviews of 15 purposefully selected dentists in the Western Cape. The online data included demographic data, education level, knowledge, attitudes, and practises related to dental amalgam use. The interviews consisted of two patient cases where dentist were asked to explain their treatment decisions. Quantitative data was analysed using statistical software SAS (SAS Institute Inc., Cary, NC, USA) and a Chi-square test and Spearman’s correlation was used with P < 0.05. The interviews were coded, transcribed, and analysed using the Atlas.ti ® software. Responses were analysed using the framework method. Results: A significant relationship was found between dentists with more than 21 years of experience and the repair of defective restorations (P = 0.0027*). Remaining tooth structure and the presence of pain were the most important clinical factors influencing treatment decisions. Non-clinical factors such as fear, ethical conscience, cost to patient and dental school had an influence on their decisions. Conclusion: Clinical factors and non-clinical factors influence dentists’ treatment decisions. There was a lack of translation of evidence-based information to everyday general practice dentistry in South Africa. These results have implications in changing current continuing professional education activities and motivating policy makers to incentivize preventive and minimally invasive dentistry.

Mercury in Dental Amalgam, Online Retail, and the Minamata Convention on Mercury.

The Minamata Convention on Mercury (ref. 1) is a global treaty to protect human and environmental health from adverse effects of the toxic element mercury and its compounds. During the Third Conference of Parties (COP-3) in November 2019, elimination of the use of dental amalgam in oral health care was discussed. Dental amalgam is one of the most commonly used restorative materials in oral health care due to its strength and longevity (ref. 2). However, the use of mercury in an amalgam adds to global environmental mercury pollution and can contribute to adverse health effects on humans and other organisms. The outcomes of the COP-3 meeting included a call for information on the availability at a national scale, the economic and technical feasibility of alternatives, and the associated risks or benefits. In this feature, we discuss the risks and benefits of dental amalgam, the global tracking of availability and procurement, and the implications and realities for global phase out. We suggest a better accounting of mercury use in dental amalgam is needed with sales being made only to registered practitioners via a Know Your Customer approach.

Clinical Effects of Mercury in Conservative Dentistry: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Controlled Trials.

Methods A systematic literature search was conducted in four electronic databases (Ovid via PubMed, Web of Science, Scopus, and CENTRAL) including all available randomised controlled trials published in the last 15 years comparing the use of dental amalgam with composite resins in humans with a follow-up period of at least one year. The primary outcome was the Hg concentration in biological fluids (urine, hair, blood, and saliva) with the aim of assessing their reliability as biomarkers of Hg exposure. The risk of bias was assessed through the Cochrane Collaboration tool and the overall quality of evidence through the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) system. The results of the meta-analysis were expressed using a random-effects model, and their power was assessed through the trial sequential analysis (TSA). Results From the initial 2555 results, only 6 publications were included in the review: five were considered as having high risk of bias, whereas one as having moderate risk. Only two articles were eligible for quantitative analysis. The meta-analysis gathered data from 859 patients but was nevertheless not significant (p = 0.12). The TSA confirmed this evidence revealing that it was due to a lack of statistical power since the required information size (RIS) threshold is not reached. Conclusions The existing evidence revealed that there are not enough data to support the hypothesis that restorations with dental amalgam can cause nephrotoxicity when compared with composite resins restorations.

Knowledge and Attitude of Dentists and Patients Toward Use and Health Safety of Dental Amalgam in Saudi Arabia.

Objective The aim of this study was to assess: (1) the perceptions of dentists in Saudi Arabia concerning the amalgam controversy, (2) their attitude toward the ethical responsibility of patient information, and (3) patients’ knowledge and attitude toward the use of dental amalgam. Materials and Methods A total of 1,139 dentists were sampled on convenience by electronic survey. The questionnaire contained questions about the safety of dental amalgam, use of amalgam, case selection, alternate materials, and informing their patients about risks of amalgam. Also, 425 patients were sampled on convenience and information collected on their knowledge about amalgam and its acceptance in their oral cavities. Results A total of 201 dentists and 425 patients participated in the study. A total of 60% of dentists and specialists declared it safe. A total of 32.4% (31) of general dental practitioners and 41% (43) specialists considered it a moral obligation to inform patients about the potential health risks associated with amalgam. Mercury toxicity was identified as the most common health hazard. About 57.3% dentists and 36.2% specialists opted for superior longevity as the principle advantage. Majority of patients (52.2%) in Saudi Arabia had no knowledge about dental amalgam. While 23.1% (98) had concern about poor color, 8.7% (30) knew it contained silver while only 7.8% (27) patients were aware of its mercury content. Conclusion Majority of dentists in Saudi Arabia found it safe to use amalgam while the patients had little knowledge about the possible issues with amalgam. It is recommended to improve public awareness about impact of mercury containing products on the environment.

Knowledge, attitude and practice of dental students, interns and practitioners to the use of amalgam in a dental institution of Kathmandu, Nepal

Background: Dental practitioners of Nepal have been using amalgam for years for restoration, but the concern for mercury related health issues and inventions in metallurgy science have recently led to its decreased use. &#x0D; Objectives: To assess the knowledge, attitude and practice of students, interns and dentists to the use of dental amalgam in a dental institution of Kathmandu, Nepal.&#x0D; Methodology: A cross-sectional study was conducted in a dental institution of Kathmandu among 192 Dental students, interns, dental officers and dental specialists selected by census sampling method. Self-administered questionnaire consisting of 16 questions related to amalgam war, its use and safety was used. Data collected were analyzed using Statistical Package for Social Sciences version 20. Frequency and percentage were calculated for each response according to different professional levels. &#x0D; Results: Most of the respondents including all the dental officers did not use amalgam frequently for restoration (141, 73.44%). Mercury toxicity was their major concern that restricted amalgam use (60, 31.25%). Most of them, (135, 70.31%) agreed on stopping the use of amalgam. They were comfortable to use composite resin as an alternative to amalgam (185, 96.35%). Majority (123, 64.06%) considered amalgam to be an unsafe material and were bothered about the environmental issues of mercury in the dental office (152, 79.16%).&#x0D; Conclusion: This study concludes that amalgam was less frequently used for restoration due to the increasing concerns of mercury toxicity. Further studies on safety of other materials that can replace amalgam with long term follow up are necessary before they are considered as a definitive alternative for amalgam.