RDH EXCLUSIVE! What if amalgam is the enemy?

Aug. 31, 2001
As a dental hygienist for the past 25 years, I have spent a considerable amount of time telling patients that the bacteria in plaque is the enemy, and teaching them how to wage a successful battle against it.

What if amalgam is the enemy?

Dear RDH:

As a dental hygienist for the past 25 years, I have spent a considerable amount of time telling patients that the bacteria in plaque is "the enemy," and teaching them how to wage a successful battle against it. But during the past three years, I have learned the hard way that some enemies masquerade as something meant to be helpful. Until all nine of my teeth with amalgam restorations had been affected, it never occurred to me or anyone who was treating me that the restorative material that has been used in dentistry for the past 150 years could be the cause of so much pain and destruction.

For 15 years, I had what is referred to as "migraine equivalent" episodes. These occurred sporadically and for no apparent reason that could be discerned, even after consultation with a neurologist. This condition never involved pain, only the classic visual disturbances and numbness on one side of my face. In February 1998, I developed what appeared to be a sinus and ear infection on both sides that didn�t respond to any of the treatments prescribed over the two-month period of time that it lasted. During that time, my head, sinuses, ears, and face throbbed with intense pain and pressure.

Once this condition seemed to subside, I was left with frequent, persistent headaches, and the awareness that I just never seemed to feel good anymore. In addition, I started having what the neurologist referred to as "atypical migraines." These were excruciatingly painful, as if my head and face were being crushed inside a giant fist, and made me sick and unable to function normally for many hours at a time. I was eventually given a prescription for the beta blocker Inderal (propranolol), which is one of the drugs commonly used to prevent migraines from occurring.

I was given prescriptions for Claritin (an antihistamine) and Nasonex (a steroid spray used to treat allergies) for what was diagnosed as a chronic allergy-related sinus condition. I was also referred to an ear, nose, and throat specialist (ENT) for examination, and I had X-rays of my sinuses and a CAT scan of my sinuses and maxillary area. The ENT stated that while there were signs of previous sinus problems, there was nothing present that he felt justified surgery or any type of treatment that he could provide.

The first indication of a dental problem occurred when I had an amalgam restoration placed in tooth #15 in July 1998. It was the only restoration I ever had where the tooth became painful immediately and just really never got better. Within one week, I also was experiencing pain in #12, a relatively small DO amalgam that had been placed approximately 15 years before.

Over the following year and a half, tooth after tooth became painful for no apparent reason, until all nine of my teeth with amalgam restorations had been affected (#15, #19, #12, #31, #3, #14, #13, #18, #2). Many of these teeth did not respond as might be expected when testing the nerve with the customary hot, cold, and percussion tests. That "glue-you-to-the-ceiling" response generally looked for during the evaluation,only occurred , in may instances, after I had endured pain from the affected tooth for many months. During the day, I would notice pain provoked by hot, cold, and chewing. But most of the time, intense pain occurred with nothing provoking it. This was a gradually intensifying pain that lasted for long periods of time, sometimes hours, and it reminded me of a bee�s nest being stirred up. By far, the worst pain occurred at night, and I was frequently awakened by it in the early morning hours and then was unable to fall asleep again because of it.

After endodontic treatment of #12, I was still having pain in the root area that I could literally put my finger on. I also had similar pain above #3, which at that point had had its small occlusal amalgam removed and a sedative filling material placed. These two teeth had been at each end of some partial orthodontic treatment I had done in 1994. It was suspected that these two teeth might have a dehiscence of the root (separation from the bone). After consulting with the neurologist to rule out neuralgia, two exploratory surgeries revealed dehiscences of the apical 1/3 of the root on both #12 and #3, and of the apical 2/3 of the root on #14 (although that tooth had not become symptomatic at that point). Guided tissue regeneration (a type of bone graft) was used to treat those areas.

What was puzzling, however, was the fact that dehiscences are not usually painful. They are usually discovered and treated during the course of surgery for something else. I suspect that maybe the reason I felt these areas so acutely may have been due to inflammation and swelling in the root area, since noticeable and painful swelling did occur under each of the mandibular molars once they became symptomatic.

What further complicated all of this was the fact that I have very long, curved roots which make them difficult to treat endodontically. The first five root canals were performed by a general dentist. Two of those teeth (#15 and #3) had nickel-titanium endodontic instruments stuck inside the roots when treatment was completed, and this caused me considerable pain. Number 15 developed a lesion at the apex and was extracted because I was told that its position did not allow access for an apicoectomy. Number 3 required three more procedures done by an endodontist to remove two instruments stuck in one of the roots. Number 31 also continued to cause sporadic, but very intense, pain after endodontic treatment. When it was eventually extracted, there was evidence of perforation between the roots.

Once all nine of my teeth with amalgam had been affected, and I suspected that the problem must be something to do with the amalgam itself, I tried to make arrangements to be tested for metal allergies. In preparation for allergy testing, I was required to stop taking both the Claritin and Inderal. Several weeks of tapering off were necessary to accomplish this safely, and subsequently the severe migraines and constant headaches returned. At the allergy-testing appointment, which was my second appointment in that office after initially being seen for consultation, I was informed that to be tested for metal allergies, I would have to go to the Hospital of the University of Pennsylvania (HUP). So after testing for molds, pollens, dust, and the like on that day, I tried to get an appointment at HUP for consultation. The four-month wait for the consultation appointment made the time frame from the point at which I realized that I was probably reacting to something in the amalgam, until I was actually able to have the patch testing for metal allergies done, stretch to six months.

Patch testing that was done at HUP in June 2000 revealed two definite positive delayed hypersensitivity reactions to gold in both the dental materials tested and the metals tested. This was followed a few months later by a toxicological evaluation, also done at HUP. While I did not fit the profile for metal poisoning � and actually tested low for those metals tested � the toxicologist believed we already had our answer with the two positive reactions to gold with the patch testing.

Or, as he so quaintly put it, "What are we looking for?" Even though gold is not generally used in amalgam, true allergies to gold are actually rare. He said that the fact that all of my teeth with amalgam were affected � and only those teeth � and also the fact that inflammation was present with no infection detected in each of the affected teeth, suggests an immunologic (allergic) reaction to something in the amalgam. Inflammation would be the expected allergic response. He said the soft tissues of the mouth represent one of the areas of the body that have the type of cells responsible for an allergic reaction.

The dermatologist who did the patch testing stated that the patch test itself is really a very crude test, and it will really only show if you are likely to have a skin or a mucous membrane reaction to the substance being tested. He also stated that just because you don�t get a reaction to something with a patch test doesn�t mean you don�t have a problem with it; it just means that a patch test isn�t going to prove it. I believe this is true in my case since with some pieces of jewelry, some clothing fasteners, and especially with some pierced earrings, I develop redness, itching, swelling, and sometimes pain, even when it looks like there is no gold at all in that item.

On Page 94 of the December 2000 issue of Allure magazine, there was a short article written by Dianne Partie Lange about metal-allergy testing done by dermatologists in Sheffield, England, on more than 1,000 people. They found that 62 percent of those who had reactions to jewelry tested negative for allergies on the standard series of metal-allergy tests. Even an extended series of metal-allergy tests � which included gold and palladium (frequently used in amalgam) � wasn�t foolproof. Thirty-nine percent of those who reacted to jewelry did not test positive.

According to the American Dental Association, less than 100 cases of adverse reactions to dental amalgam have been reported, most of these being allergic reactions. Going to the ADA Web site (www.ada.org) and searching for "allergic to amalgam" revealed the following: "Only a very small number of people are allergic to amalgam fillings. Fewer than 100 cases have ever been reported. In these rare instances, mercury may trigger an allergic response. Symptoms of amalgam allergy are very similar to a typical skin allergy. Often, patients who are truly allergic to amalgam have a medical or family history of allergies to metals."

When she was in her 20s, my mother had an allergic reaction to some rings she wore every day. The reaction spread up both of her arms, and was treated with radiation. Since that happened, she has routinely removed all of her jewelry as soon as she comes home because she is afraid she might have another reaction like that. As far as her dentist in Florida could discern for us at her recent checkup, she has no amalgam restorations or metal of any type in her mouth. All of her crowns are all porcelain. She says that about 25 years ago, she was being treated by a dentist in California "who didn�t like amalgam."

Perhaps a question concerning a personal or family history of allergies to metals should be included on health questionnaires that we have our patients fill out. Subsequently, this information should be considered when choosing restorative materials for that patient.

According to the Food Allergy and Anaphalaxis Network, my 11-year-old son is among the 1.1 percent (or close to three million) Americans who have learned to live with a life-threatening peanut and tree nut allergy. He has fortunately never needed any dental restorations, but he will grow up knowing that amalgam fillings may not be the safest choice of restorative materials for him, just as foods that might contain nuts are not.

My 18-year-old son already has seven amalgam restorations. Over the past few years he had experienced several migraine equivalent episodes similar to what I had before the more serious symptoms began. We are planning to have his amalgam restorations gradually replaced with what I hope are safer options for him. I considered having patch testing done for him also, but even if he were to test negative for all metals at this point, how would we know if he might develop this problem later? Within one year of realizing that I had some type of severe, undiagnosed dental problem, I had nine root canals, two extractions, two exploratory surgeries, and numerous other procedures just to try to get out of pain. Like a row of falling dominos, it was too late to stop what was happening to me.

While I am grateful to all the providers who did what they could to try to help me get out of pain without the benefit of a clear diagnosis, it was na� of me not to realize that an absence of kindness and compassion can be just as evident in all areas of health care as it is in all areas of life. I was unprepared for the humiliation I endured from providers who weren�t patient enough to listen to what I was saying, who didn�t want to be bothered trying to help me, who made it clear that they didn�t believe what I was telling them, or who obviously felt it necessary to put me in my place. Such callous, cruel, judgmental, and blatantly egotistical statements as: "If you�re in as much pain as you say you are ...," "I don�t think you�re as swollen as you think you are. We�ll adjust your bite again and you�ll be fine," "Nobody has this many problems at one time," "Maybe you should get a pill to help you deal with this better," "I don�t know what your problem is, but you don�t have a dental problem. I�ve been doing this for years, and if you have a dental problem, I would know it;" "You do not feel that file stuck in there," and "I�ll handle this. She�s one of those nuts who make a career out of their symptoms."

These statements have very effectively destroyed the confidence I once had that a patient in pain who seeks help can expect to receive the compassionate care that every patient deserves. There is no appropriate context or acceptable excuse for saying any of those things to a patient. Why does something we don�t understand immediately become a psychiatric illness? I can�t help but wonder if things might have gone quite differently if instead of being a female dental hygienist in her forties, the patient had been a male of any age, or a physician or dentist.

Through all of this, I have received a very clear demonstration of completely financial factors. The type of health insurance you have is the determining factor in when, how, where, and if a patient receives help. It was devastatingly clear that my pain wasn�t being taken seriously each time I heard that this was "just your sinuses," or "just your teeth," or "just a headache," or that I wasn�t "really sick."

I was constantly being asked if I was still working, to which I always replied, "Of course,. I have to pay for all of this somehow." The conclusion was always that if I was still working, then whatever was wrong with me must not be very bad. So much for any credit for carrying on in the face of adversity! I also noticed that there seemed to be a pervasive attitude of separateness between the medical and dental professions, with each claiming to know nothing about the other. And yet, I was constantly being advised to go back and see the specialist that I had already seen, with the direct implication being that this doctor hadn�t done his or her job properly. Upon questioning this at one point, I was told that these "games" are played all the time.

On several occasions, it was suggested that I should see a specialist in long-term pain control for patients whose pain can�t be adequately treated. In the absence of a diagnosis, this seemed totally ludicrous to me. I wasn�t going to just give up � and I preferred to spend my time, energy, and dwindling money on finding out what was wrong and doing something about it! The neurologist, for much of the time, classified my problem as atypical facial pain. I found out later that this is a category reserved for patients who nobody knows what�s wrong with them.

For several months, I was on the drug Neurontin, which in addition to being a medication for treating epilepsy, also is used for long-term pain control. But the very slight amount of relief that it provided did not justify the pronounced dizziness and the sense of being off-balance that I felt while taking it.

One alternative medication that I found to be very helpful was the herbal supplement milk thistle, which I inadvertently discovered helped in controlling my migraines during one of the periods that I was required to be off of the Inderal. Milk thistle is used to protect the liver, which is the main detoxifying organ of the body. While no one was sure why it helped me, the toxicologist suggested that it may have been because many plant substances have a relaxing effect on the blood vessels of the brain. This also is one of the beneficial effects that Inderal provides for migraine sufferers.

I am in the process of having pressed ceramic crowns made for seven treated teeth that I was able to keep. One restorative problem that doesn�t seem to have a suitable answer is that I no longer have any molars in the lower right quadrant since #30 was extracted when I was a young teenager and #32 was removed due to impaction. I haven�t come across any implant options that wouldn�t require the use of metal.

Although several daily doses of Inderal and the constant use of allergy medications still is necessary, I am very aware each day of how nice it is to be pain-free. But I remain stunned that something like this could happen and no one would know or even suspect what was causing it.

Once I realized myself that this must be something in the amalgam, total skepticism was the most prevalent response. I was told over and over again that "An allergic reaction like you�re suggesting isn�t possible." And that, "An allergic reaction to any of the base metals isn�t possible." And that, "This problem isn�t well documented." Even after the positive patch-test results, I was being told that "No one is allergic to gold." And, "I just don�t believe that amalgam could do this to you. It must be something else."

If what has happened to me is to be used as an example, then nobody knows that this type of reaction is possible, nobody knows what the symptoms are, nobody knows what the best way to treat it would be, and nobody is reporting the cases that do occur. As far as I know to date, nobody has reported my case or suggested that it should be. Even if someone wanted to report it, who would they report it to? Then what, if anything, would be done with that information that might actually help anyone?

As rare as it may be, and as difficult as it is to definitively proven, amalgam is "the enemy" in some cases. Could what happened to me happen to you or to someone you care about? Amalgam has been used for 150 years, so why don�t we know?

Elizabeth Markley, RDH

Norristown, Pennsylvania