The Safe Mercury Amalgam Removal Technique (SMART)2018-09-19T16:52:23+00:00

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The IAOMT protocol recommendations for amalgam removal are known as the Safe Mercury Amalgam Removal Technique (SMART). Note that SMART is presented as a set of recommendations. Licensed practitioners must exercise their own judgment concerning the specific treatment options to utilize in their practices. The SMART protocol recommendations include the following measures, which are listed here with scientific research: 

The IAOMT safe amalgam removal protocol recommendations were most recently updated on December 6, 2016. Also, on July 1, 2016, the IAOMT protocol recommendations were officially renamed as the Safe Mercury Amalgam Removal Technique (SMART), and a training course for IAOMT dentists to become certified in SMART was initiated.

All dental amalgam restorations, also commonly referred to as silver fillings, contain approximately 50% mercury,1 and reports and research are consistent that these fillings emit mercury vapors.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19

Scientific research demonstrates that dental mercury amalgam exposes dental professionals, dental staff, dental patients, and fetuses to releases of mercury vapor, mercury-containing particulate, and/or other forms of mercury contamination.20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57

Furthermore, mercury vapor is known to be released from dental mercury amalgam fillings at higher rates during brushing, cleaning, clenching of teeth, chewing, etc.58,59,60,61,62,63,64,65,66,67,68,69,70,71 and mercury is also known to be released during the placement, replacement, and removal of dental mercury amalgam fillings.72,73,74,75,76,77,78,79,80 Essentially, an unsafe amalgam removal process releases mercury vapor and particles that can be harmful to the patient, the dentist, the dental staff, and the environment.81,82,83,84,85,86,87,88

Utilizing the most up-to-date science and research, the IAOMT has developed extensive safety recommendations for removal of existing dental mercury amalgam fillings, including detailed protective measures that are to be utilized for the procedure. The IAOMT’s innovative recommendations build upon traditional safe amalgam removal techniques such as the use of masks, water irrigation, and high volume suction by supplementing these conventional strategies with a number of additional protective measures, the need for which have only recently been identified in scientific research.

• An amalgam separator should be properly installed, utilized, and maintained to collect mercury amalgam waste so that it is not released into the effluent from the dental office.89,90,91,92,93,94,95,96,97,98,99,100

• Each room where mercury fillings are removed should have adequate filtration in place,101,102,103which requires a high-volume air filtration system (such as an at source oral aerosol vacuum) capable of removing mercury vapor and amalgam particles generated during the removal of one or more mercury fillings.104,105,106

• If possible, windows should be opened to reduce the mercury concentration in the air.107,108,109,110,111

• The patient should be given a slurry of charcoal, chlorella, or similar adsorbent to rinse and swallow before the procedure (unless the patient declines or there are other contraindications making this clinically inappropriate).112,113,114,115

• Protective gowns and covers for the dentist, dental personnel, and the patient should be in place.116All present in the room should be protected because substantial quantities of particles generated during the procedure will elude collection by suction devices.117It has been demonstrated that these particles can be spread from the patient’s mouth to the patient’s knee, and to the chest, shoulder, and neck of the dentist and dental assistant.118

• Non-latex nitrile gloves should be utilized by the dentist and all dental personnel in the room.119,120,121,122,123

• Face shields and hair/head coverings are to be utilized by the dentist and all dental personnel in the room.124,125

• Either a properly-sealed, respiratory grade mask rated to capture mercury or a positive pressure, properly-sealed mask providing air or oxygen should be worn by the dentist and all dental personnel in the room.126,127,128,129

• In order to protect the patient’s skin and clothing, a full body, impermeable barrier, as well as a full head/face/neck barrier under/around the dam, should be utilized.130,131

• External air or oxygen delivered via a nasal mask for the patient also should be utilized to assure the patient does not inhale any mercury vapor or amalgam particulate during the procedure.132,133,134A nasal cannula is an acceptable alternative for this purpose as long as the patient’s nose is completely covered with an impermeable barrier.

• A dental dam135,136,137,138,139that is made with non-latex nitrile material140,141,142should be placed and properly sealed in the patient’s mouth.

• A saliva ejector should be placed under the dental dam to reduce mercury exposure to the patient.143,144,145

• During amalgam filling removal, the dentist should utilize an at source oral aerosol vacuum in close proximity to the operating field (i.e., two to four inches from the patient’s mouth) to mitigate mercury exposure.146,147

• High speed evacuation produces better capture when fitted with a Clean Up device, which is preferred.148,149

• Copious amounts of water to reduce heat150,151,152,153,154,155,156and a conventional high speed evacuation device to capture mercury discharges157,158,159,160,161,162,163should be used to reduce ambient mercury levels.164

• The amalgam should be sectioned into chunks and removed in as large of pieces as possible,165,166,167using a small diameter carbide drill.168,169

• Once the removal process is complete, the patient’s mouth should be thoroughly flushed with water170,171and then rinsed out with a slurry of charcoal, chlorella or similar
adsorbent.172

• Dentists must comply with federal, state, and local regulations addressing the proper handling, cleaning, and/or disposal of mercury-contaminated components, clothing, equipment, surfaces of the room, and flooring in the dental office.

• During the opening and maintenance of suction traps in operatories or on the main suction unit, dental staff should utilize the appropriate personal protection equipment described above.

It is important to note that as a safety precaution, the IAOMT does not recommend amalgam filling removal for women who are pregnant or breast-feeding and that the IAOMT does not recommend that dental personnel who are pregnant or breast-feeding conduct work that disrupts amalgam fillings (including their removal).

To learn more about SMART and to see videos of SMART being applied in practice, visit www.thesmartchoice.com

To Learn the facts about dental mercury from the IAOMT, visit:  https://iaomt.org/resources/dental-mercury-facts/

References

1. World Health Organization.  Mercury in Health Care: Policy Paper.  Geneva, Switzerland; August 2005: 1.  Available from: http://www.who.int/water_sanitation_health/medicalwaste/mercurypolpaper.pdf.  Accessed December 22, 2015.

2. Health Canada.  The Safety of Dental Amalgam.  Ottawa, Ontario; 1996: 4.  Available from: http://www.hc-sc.gc.ca/dhp-mps/alt_formats/hpfb-dgpsa/pdf/md-im/dent_amalgam-eng.pdf.  Accessed December 22, 2015.

3. State of Connecticut Department of Environmental Protection.  Fillings: The Choices You Have: Mercury Amalgam and Other Filling Materials. Hartford, CT: Brochure, Revised January
2011; 3. Available from: http://www.ct.gov/deep/lib/deep/mercury/gen_info/fillings_brochure.pdf. Accessed December 22, 2015.

4. Maine Bureau of Health.  Filling Materials Brochure.  2002.  Available from: http://www.vce.org/mercury/Maine_AmalBrochFinal2.pdf. Accessed December 22, 2105.

5. Advisory Committee on Mercury Pollution. Dental Amalgam Fillings: Environmental and Health Facts for Dental Patients.  Waterbury, Vermont.  Available from: http://www.mercvt.org/PDF/DentalAmalgamFactSheet.pdf. Accessed December 22, 2015.

6. Kennedy D.  Smoking Teeth = Poison Gas [online video]. Champion’s Gate, FL: IAOMT; Uploaded on January 30, 2007. Available from: http://www.youtube.com/watch?v=9ylnQ-T7oiA.  Accessed December 22, 2015.

7. Barregård L. Biological monitoring of exposure to mercury vapor. Scandinavian Journal of Work, Environment & Health. 1993:45-9. Available from: http://www.sjweh.fi/download.php?abstract_id=1532&%3Bfile_nro=1&origin=publication_detail.  Accessed December 18, 2015.

8. Gay DD, Cox RD, Reinhardt JW:  Chewing releases mercury from fillings. Lancet. 1979; 1(8123):985-6.

9. Hahn LJ, Kloiber R, Vimy MJ, Takahashi Y, Lorscheider FL. Dental” silver” tooth fillings: a source of mercury exposure revealed by whole-body image scan and tissue analysis. The FASEB Journal. 1989; 3(14):2641-6.  Available from: http://www.fasebj.org/content/3/14/2641.full.pdf.  Accessed December 18, 2015.

10. Haley BE. Mercury toxicity: genetic susceptibility and synergistic effects. Medical Veritas. 2005; 2(2): 535-542.

11. Hanson M, Pleva J. The dental amalgam issue. A review. Experientia. 1991; 47(1):9-22. Available from: https://www.researchgate.net/profile/Jaro_Pleva/publication/21157262_The_dental_amalgam_issue._A_review/links/00b7d513fabdda29fa000000.pdf.  Accessed December 18, 2015.

12 Leistevuo J, Leistevuo T, Helenius H, Pyy L, Osterblad M, Huovinen P, Tenovuo J. Dental amalgam fillings and the amount of organic mercury in human saliva. Caries Res. 2001; 35(3):163-6. Abstract available from: http://www.karger.com/Article/Abstract/47450.  Accessed December 22, 2015.

13. Mahler DB, Adey JD, Fleming MA. Hg emission from dental amalgam as related to the amount of Sn in the Ag-Hg Phase. J Dent Res. 1994; 73(10):1663-8. Abstract available from: http://jdr.sagepub.com/content/73/10/1663.short.  Accessed December 22, 2105.

14. Nylander M, Friberg L, Lind B. Mercury concentrations in the human brain and kidneys in relation to exposure from dental amalgam fillings. Swed Dent J. 1987; 11(5): 179-187.  Abstract available from: http://europepmc.org/abstract/med/3481133.  Accessed December 22, 2015.

15. Richardson GM, Brecher RW, Scobie H, Hamblen J, Samuelian J, Smith C. Mercury vapour (Hg(0)): Continuing toxicological uncertainties, and establishing a Canadian reference exposure level. Regul Toxicol Pharmicol. 2009; 53(1):32-38. Abstract available from: http://www.sciencedirect.com/science/article/pii/S0273230008002304.  Accessed December 17, 2015.

16. Stock A. [Zeitschrift fuer angewandte Chemie, 29. Jahrgang, 15. April 1926, Nr. 15, S. 461-466, Die Gefaehrlichkeit des Quecksilberdampfes, von Alfred Stock (1926).]  The Dangerousness of Mercury Vapor. Translated by Birgit Calhoun.  Available from: http://www.stanford.edu/~bcalhoun/AStock.htm. Accessed December 22, 2015.

17. Vimy MJ, Lorscheider FL.  Intra-oral air mercury released from dental amalgam.  J Den Res. 1985; 64(8):1069-71.

18. Vimy MJ, Lorscheider FL:  Serial measurements of intra-oral air mercury; Estimation of daily dose from dental amalgam.  J Dent Res. 1985; 64(8):1072-5. Abstract available from: http://jdr.sagepub.com/content/64/8/1072.short.  Accessed December 22, 2015.

19. Vimy MJ, Luft AJ, Lorscheider FL. Estimation of mercury body burden from dental amalgam computer simulation of a metabolic compartment model. J. Dent. Res. 1986; 65(12):1415-1419.  Abstract available from: http://jdr.sagepub.com/content/65/12/1415.short.  Accessed December 22, 2015.

20. Al-Saleh I, Al-Sedairi A. Mercury (Hg) burden in children: The impact of dental amalgam. Sci Total Environ. 2011; 409(16):3003-3015.  Abstract available from: http://www.sciencedirect.com/science/article/pii/S0048969711004359.  Accessed December 22, 2015.

21. Ask K, Akesson A, Berglund M, Vahter M. Inorganic mercury and methylmercury in placentas of Swedish women. Environ Health Perspect. 2002; 110(5):523-6. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1240842/pdf/ehp0110-000523.pdf. Accessed December 22, 2015.

22. Barregård L. Biological monitoring of exposure to mercury vapor. Scandinavian Journal of Work, Environment & Health. 1993:45-9. Available from: http://www.sjweh.fi/download.php?abstract_id=1532&%3Bfile_nro=1&origin=publication_detail.  Accessed December 18, 2015.

23. de Oliveira MT, Pereira JR, Ghizoni JS, Bittencourt ST, Molina GO. Effects from exposure to dental amalgam on systemic mercury levels in patients and dental school students. Photomed Laser Surg.  2010; 28(S2): S-111. Abstract available from: https://www.researchgate.net/profile/Jefferson_Pereira/publication/47369541.pdf.  Accessed December 22, 2015.

24. Fredin B. Mercury release from dental amalgam fillings.  Int J Risk Saf Med.  1994; 4(3): 197-208.

25. Gay DD, Cox RD, Reinhardt JW:  Chewing releases mercury from fillings. Lancet. 1979; 1(8123):985-6.

26. Goldschmidt PR, Cogan RB, Taubman SB. Effects of amalgam corrosion products on human cells.  J Period Res. 1976; 11(2):108-15.  Abstract available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0765.1976.tb00058.x/abstract.  Accessed December 22, 2015.

27. Hahn LJ, Kloiber R, Vimy MJ, Takahashi Y, Lorscheider FL. Dental” silver” tooth fillings: a source of mercury exposure revealed by whole-body image scan and tissue analysis. The FASEB Journal. 1989; 3(14):2641-6.  Available from: http://www.fasebj.org/content/3/14/2641.full.pdf.  Accessed December 18, 2015.

28. Haley BE. Mercury toxicity: genetic susceptibility and synergistic effects. Medical Veritas. 2005; 2(2): 535-542.

29. Hanson M, Pleva J. The dental amalgam issue. A review. Experientia. 1991; 47(1):9-22. Available from: https://www.researchgate.net/profile/Jaro_Pleva/publication/21157262.pdf.  Accessed December 18, 2015.

30. Herber RF, de Gee AJ, Wibowo AA. Exposure of dentists and assistants to mercury: mercury levels in urine and hair related to conditions of practice. Community Dent Oral Epidemiol. 1988; 16(3): 153-158. Abstract available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0528.1988.tb00564.x/abstract;jsessionid=0129EC1737083382DF5BA2DE8995F4FD.f03t04.  Accessed December 22, 2015.

31. Karahalil B, Rahravi H, Ertas N. Examination of urinary mercury levels in dentists in Turkey.  Hum Exp Toxicol.  2005; 24(8): 383-388. Abstract available from: http://het.sagepub.com/content/24/8/383.short.  Accessed December 22, 2015.

32. Krausß P, Deyhle M, Maier KH, Roller E, Weiß HD, Clédon P. Field study on the mercury content of saliva. Toxicological & Environmental Chemistry.  1997; 63(1-4):29-46.  Abstract available from: http://www.tandfonline.com/doi/abs/10.1080/02772249709358515.  Accessed December 22, 2015.

33. Leistevuo J, Leistevuo T, Helenius H, Pyy L, Osterblad M, Huovinen P, Tenovuo J. Dental amalgam fillings and the amount of organic mercury in human saliva. Caries Res. 2001; 35(3):163-6. Abstract available from: http://www.karger.com/Article/Abstract/47450.  Accessed December 22, 2015.

34. Lönnroth EC, Shahnavaz H. Amalgam in dentistry. A survey of methods used at dental clinics in Norrbotten to decrease exposure to mercury vapour. Swed Dent J.  1995; 19(1-2): 55.  Abstract available from: http://europepmc.org/abstract/med/7597632.  Accessed December 22, 2015.

35. Mahler DB, Adey JD, Fleming MA. Hg emission from dental amalgam as related to the amount of Sn in the Ag-Hg Phase. J Dent Res. 1994; 73(10):1663-8. Abstract available from: http://jdr.sagepub.com/content/73/10/1663.short.  Accessed December 22, 2105.

36. Martin MD, Naleway C, Chou HN. Factors contributing to mercury exposure in dentists. J Am Dent Assoc.  1995; 126(11): 1502-1511. Abstract available from: http://www.sciencedirect.com/science/article/pii/S0002817715607851.  Accessed December 22, 2015.

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38. Mortada WL, Sobh MA, El-Defrawi, MM, Farahat SE. Mercury in dental restoration: is there a risk of nephrotoxity? J Nephrol. 2002; 15(2): 171-176. Abstract available from: http://europepmc.org/abstract/med/12018634.  Accessed December 22, 2015.

39. Mutter J.  Is dental amalgam safe for humans? The opinion of the scientific committee of the European Commission.  Journal of Occupational Medicine and Toxicology. 2011; 6:2. Available from: http://download.springer.com/static/pdf.  Accessed December 22, 2015.

40. Nimmo A, Werley MS, Martin JS, Tansy MF. Particulate inhalation during the removal of amalgam restorations. J Prosth Dent. 1990; 63(2):228-33. Abstract available from: http://www.sciencedirect.com/science/article/pii/002239139090110X.  Accessed December 22, 2015.

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42. Nylander M, Friberg L, Lind B. Mercury concentrations in the human brain and kidneys in relation to exposure from dental amalgam fillings. Swed Dent J. 1987; 11(5): 179-187.  Abstract available from: http://europepmc.org/abstract/med/3481133.  Accessed December 22, 2015.

43. Parsell DE, Karns L, Buchanan WT, Johnson RB. Mercury release during autoclave sterilization of amalgam. J Dent Educ.  1996; 60(5): 453-458. Abstract available from: http://www.jdentaled.org/content/60/5/453.short.  Accessed December 22, 2015.

44. Redhe O, Pleva J.  Recovery of amyotrophic lateral sclerosis and from allergy after removal of dental amalgam fillings. Int J Risk & Safety in Med. 1994; 4(3): 229-236.  Available from: https://www.researchgate.net/profile/Jaro_Pleva/publication/235899060.pdf.  Accessed December 22, 2015.

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46. Richardson GM, Brecher RW, Scobie H, Hamblen J, Samuelian J, Smith C. Mercury vapour (Hg(0)): Continuing toxicological uncertainties, and establishing a Canadian reference exposure level. Regul Toxicol Pharmicol. 2009; 53(1):32-38. Abstract available from: http://www.sciencedirect.com/science/article/pii/S0273230008002304.  Accessed December 17, 2015.

47. Richardson GM.  Inhalation of mercury-contaminated particulate matter by dentists: an overlooked occupational risk. Human and Ecological Risk Assessment. 2003; 9(6): 1519-1531. Abstract available from: http://www.tandfonline.com/doi/abs/10.1080/10807030390251010.  Accessed December 22, 2015.

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51. Vimy MJ, Lorscheider FL.  Intra-oral air mercury released from dental amalgam.  J Den Res. 1985; 64(8):1069-71.

52. Vimy MJ, Lorscheider FL:  Serial measurements of intra-oral air mercury; Estimation of daily dose from dental amalgam.  J Dent Res. 1985; 64(8):1072-5. Abstract available from: http://jdr.sagepub.com/content/64/8/1072.short.  Accessed December 22, 2015.

53. Vimy MJ, Luft AJ, Lorscheider FL. Estimation of mercury body burden from dental amalgam computer simulation of a metabolic compartment model. J. Dent. Res. 1986; 65(12):1415-1419.  Abstract available from: http://jdr.sagepub.com/content/65/12/1415.short.  Accessed December 22, 2015.

54. Votaw AL, Zey J. Vacuuming a mercury-contaminated dental office may be hazardous to your health. Dent Assist.  1991; 60(1): 27.  Abstract available from: http://europepmc.org/abstract/med/1860523.  Accessed December 22, 2015.

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56. Weiner JA, Nylander M, Berglund F. Does mercury from amalgam restorations constitute a health hazard?  Sci Total Environ. 1990; 99(1-2):1-22.  Abstract available from: http://www.sciencedirect.com/science/article/pii/004896979090206A.  Accessed December 22, 2015.

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58. State of Connecticut Department of Environmental Protection. Fillings: The Choices You Have. Hartford, CT; Revised May 2011. Available from: http://www.ct.gov/deep/lib/deep/mercury/gen_info/fillings_brochure.pdf. Accessed December 22, 2015.

59. Maine Bureau of Health.  Filling Materials Brochure.  2002.  Available from: http://www.vce.org/mercury/Maine_AmalBrochFinal2.pdf. Accessed December 22, 2015.

60. Advisory Committee on Mercury Pollution.  Dental Amalgam Fillings: Environmental and Health Facts for Dental Patients.  Waterbury, VT, October 27, 2010; 1.  Abstract available from: http://www.mercvt.org/PDF/DentalAmalgamFactSheet.pdf. Accessed December 22, 2015.

61. Abraham JE, Svare CW, Frank CW. The effect of dental amalgam restorations on blood mercury levels. J Dent Res. 1984; 63(1):71-3. Abstract available from: http://jdr.sagepub.com/content/63/1/71.short.  Accessed December 22, 2015.

62. Björkman L, Lind B. Factors influencing mercury evaporation rate from dental amalgam fillings. Scand J Dent Res. 1992; 100(6):354–60. Abstract available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0722.1992.tb01086.x/abstract.  Accessed December 22, 2015.

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65. Gay DD, Cox RD, Reinhardt JW.  Chewing releases mercury from fillings.  Lancet.  1979; 313(8123):985-6.

66. Isacsson G, Barregård L, Seldén A, Bodin L. Impact of nocturnal bruxism on mercury uptake from dental amalgams. European Journal of Oral Sciences. 1997; 105(3):251-7.  Abstract available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0722.1997.tb00208.x/abstract.  Accessed December 17, 2015.

67. Krausß P, Deyhle M, Maier KH, Roller E, Weiß HD, Clédon P. Field study on the mercury content of saliva. Toxicological & Environmental Chemistry.  1997; 63(1-4):29-46.  Abstract available from: http://www.tandfonline.com/doi/abs/10.1080/02772249709358515#.VnnujPkrIgs.  Accessed December 22, 2015.

68. Sällsten G, Thoren J, Barregård L, Schütz A, Skarping G. Long-term use of nicotine chewing gum and mercury exposure from dental amalgam fillings. Journal of Dental Research. 1996; 75(1):594-8.  Abstract available from: http://jdr.sagepub.com/content/75/1/594.short.  Accessed December 17, 2015.

69. Svare CW, Peterson LC, Reinhardt JW, Boyer DB, Frank CW, Gay DD, et al. The effect of dental amalgams on mercury levels in expired air. J Dent Res. 1981; 60:1668–71.  Abstract available from: http://jdr.sagepub.com/content/60/9/1668.short.  Accessed December 22, 2015.

70. Vimy MJ, Lorscheider FL. Clinical Science Intra-oral Air Mercury Released from Dental Amalgam. Journal of Dental Research. 1985; 64(8):1069-71.  Abstract available from: http://jdr.sagepub.com/content/64/8/1069.short.  Accessed December 17, 2015.

71. Vimy MJ, Lorscheider FL. Serial measurements of intra-oral air mercury: estimation of daily dose from dental amalgam. Journal of Dental Research. 1985; 64(8):1072-5.  Abstract available from: http://jdr.sagepub.com/content/64/8/1072.short.  Accessed December 17, 2015.

72. Health Canada.  The Safety of Dental Amalgam. 1996: 4.  Available from Health Canada Web site: http://www.hc-sc.gc.ca/dhp-mps/alt_formats/hpfb-dgpsa/pdf/md-im/dent_amalgam-eng.pdf.  Accessed December 15, 2015.  

73. Karahalil B, Rahravi H, Ertas N. Examination of urinary mercury levels in dentists in Turkey. Hum Exp Toxicol. 2005; 24(8):383-388.  Abstract available from: http://het.sagepub.com/content/24/8/383.short.  Accessed December 16, 2015.

74. Lönnroth EC, Shahnavaz H. Dental clinics–a burden to environment?  Swed Dent J. 1996; 20(5):173.  Abstract available from: http://europepmc.org/abstract/med/9000326.  Accessed December 16, 2015.

75. Martin MD, Naleway C, Chou HN. Factors contributing to mercury exposure in dentists. J Am Dent Assoc. 1995; 126(11):1502-1511.  Abstract available from: http://www.sciencedirect.com/science/article/pii/S0002817715607851.  Accessed December 16, 2015.

76. Nimmo A, Werley MS, Martin JS, Tansy MF. Particulate inhalation during the removal of amalgam restorations. J Prosth Dent. 1990; 63(2):228-33.  Abstract available from: http://www.sciencedirect.com/science/article/pii/002239139090110X.  Accessed December 16, 2015.

77. Oliveira MT, Constantino HV, Molina GO, Milioli E, Ghizoni JS, Pereira JR. Evaluation of mercury contamination in patients and water during amalgam removal. The Journal of Contemporary Dental Practice. 2014; 15(2):165. Abstract available from: http://search.proquest.com/openview/c9e4c284ca7b3fd3779621692411875c/1?pq-origsite=gscholar.  Accessed December 18, 2015.

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