The biological approach

Dr. Matthew Young’s West Hendersonville, N.C., practice is free of many things that can be commonly found in many dental offices. He practices without fluoride, without the use of any latex products and does not place any mercury amalgam fillings.

As a practitioner of “biological dentistry” Dr. Young regularly questions conventional dental wisdom and is always looking for new science to demonstrate whether or not the materials and techniques he employs are biocompatible with his patients and safe for both them and his dental team. As a member of the International Academy of Oral Medicine and Toxicology (IAOMT) he helps fund research into the toxicology of dental materials and works to promote high standards of both care and safety.

“We’re not dogmatic in that we insist everybody fall into that pigeon hole, but we try to be a little bit broad minded with our diagnosis and the way we treat patients,” he said.

Formed more than 25 years ago, IAOMT works to “bring scientific evidence into the issues facing dentistry,” said Dr. David Kennedy, fluoride information officer and past president of IAOMT. He believes dentists generally do not pay enough attention to recent scientific findings and stay too rooted in the way they were taught to do things in dental school. He said the industry would be very different if the latest science was more of a guide to the way people practice.

“It would fundamentally change the profession because they obviously would choose to use many different materials in their care and a totally different approach to treatment of gum disease and the prevention of tooth decay,” Dr. Kennedy said.

Amalgam ills

Due to the toxicity of elemental mercury, protecting the safety of both patients and clinicians by eliminating the use of mercury amalgam is at the heart of the biological dental movement, and one of the issues IAOMT advocates on with the most vigor. While some dentists and even the American Dental Association continue to proclaim that the mercury in dental amalgam is safe for patients and clinicians, Dr. Young cites a 1996 report by Health Canada among the many studies showing that the mercury content of amalgam does not stay confined to the restorations and poses a health risk for both patients and clinicians. Dr. Kennedy adds that according to the Environmental Protection Agency, there is no safe level of exposure to mercury.

Safety is at the heart of Dr. Young’s argument against amalgam, and he is quick to point out that OSHA’s Permissible Exposure Limits (PELs) on mercury are easily exceeded during common dental procedures such as autoclaving tools used in amalgam placement or removal. Noting that a horse liniment and mercury amalgam fillings are the only two medical-related products that still contain elemental mercury, he questions why dentists do not follow the same OSHA protocols as manufacturers of batteries or fluorescent light who use mercury in their businesses.

“They all have to follow the same PEL guidelines set by OSHA, but for some reason dentists and dental employees are exempt,” he said. “We’re trying to get into the 21st century as far as workplace safety goes, and to make the dental office a safe place to work.”

Safe handling

While his practice is among the many that no longer place amalgam fillings, Dr. Young still deals with patients who have had the fillings placed by previous dental providers. To keep his employees and patients as safe as possible, he monitors the air quality in his practice to make sure it is well below the mercury PEL. When removing amalgams from patients, he follows a set procedure that includes independent air for his patients to breath, and HAZMAT style masks for himself and his assistants.

“Our protective gear and our protective technique that we use helps to make it safer for everybody,” he said.

But while the ADA still promotes the safety of amalgam and Medicaid supports its use by basing reimbursement levels for dental fillings on the cost of amalgam, Dr. Young thinks the industry is ready to move away from the material, albeit slowly. While he wishes dentists were better educated on this issue, Dr. Kennedy said patient pressure is currently driving the move away from amalgam use. Dr. Young hopes that trend continues so he can practice in a world where amalgam becomes something from dentistry’s past rather than a standard of care.

“The patients are demanding a more natural looking and compatible material,” he added.

Material matching

The compatibility, or as he puts it “biocompatibility” of dental materials is another key to the way Dr. Young practices. With new products constantly on the market he and the IAOMT regularly test new materials to see if they emit harmful chemicals or pose any other risks. But beyond that, it often comes down to what material works best for an individual patient.

“We’re going to probably be looking at things a little differently,” Dr. Young said “Some patients are chemically sensitive to certain materials. We tend to go as metal free as possible, and we try to use materials that don’t give off any chemicals.”

Dr. Kennedy said IAOMT bases material recommendations on standard risk assessment models and published peer-reviewed research. The academy also hires specialists to evaluate the safety and biocompatibility of dental materials.

Sometimes it’s a patient-by-patient thing where different people react differently to different materials, and other times patients arrive in Dr. Young’s office seeking help because a restoration placed by another dentist seems to be causing issues, such as an allergy to nickel reacting badly to a PFM crown and irritating the gingiva.

While he is always trying to stay on top of new material options that might work better, Dr. Young said he has great success with 3M ESPE’s Filtek Supreme composite, likes to use Flexite for dentures because it is non-acrylic and doesn’t outgas monomers, and is a big proponent of the all-ceramic crowns he can produce with Sirona’s CEREC system.

“The patient gets it in one visit so there’s no temporary or impression material that you have to use,” he said of CEREC restorations.

Additional principles

In describing how the concept of biological dentistry fits into his practice, Dr. Young said there is more than just promoting patient and employee safety, eliminating amalgam and using biocompatible materials with his patients. Those are just some of the principles that guide how he provides care. Guided by the connection between oral and overall health, Dr. Young promotes good nutrition and hygiene for his patients. He is also a strong believer in patient education and informed consent.

Before treating a patient, Dr. Young tries to make sure the patient understands not just the end goals of what he is going to do, but everything involved in the process. He likes to explain the details of the materials he will be using and the possible impacts the procedure might have. It is a very patient-specific process and his recommended treatment is never based on a one-plan-for-all-situations model.

“We don’t necessarily say that everyone who walks into the office with amalgam has to have it out right away,” he said. “There’s a big spectrum of differences in the way a patient reacts to a non-compatible material.”

Goals for the profession

For now the biological dentistry movement remains a small part of the American dental landscape. One of just a handful of biological dentistry organizations, IAOMT has about 700 members. Still, Dr. Young remains optimistic that the way he practices will become more common in this country.

While he is aware that change comes slowly to the standards that govern how care is delivered, he is encouraged by the trend moving away from the use of amalgam. He would welcome more emphasis on OSHA regulations and workplace safety in dental schools, but for now would be satisfied to see dentists embrace a more environmentally friendly approach through expanded use of mercury separators in all offices.

“The main thing would be to educate the general dental community on how to think outside the box, how to improve their employee safety and their patient safety,” he said. “We’d like to use the environmental aspect as a way to improve the standard of care, and at least get everybody on board with safer handling of the materials that we already use.”

Noah Levine is a senior editor for DPR. Contact him at nlevine@advanstar.com.