Meg Kaiser

Key Highlights

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The European Commission has published draft legislation to phase out dental amalgam in 2025. The revision of the EU Mercury Regulation has been expected since December 2022 and includes a ban on mercury-containing light bulbs and lamps.

Since there are viable mercury-free alternatives, dental amalgam shall no longer be used for dental treatments of any member of the population from January 1, 2025. The proposal also includes a ban on its manufacture and export, making an important contribution to reducing mercury emissions internationally.

The use of dental amalgam for children under the age of 15, as well as breastfeeding and pregnant women, has already been banned in the EU since 2018.

Amalgam consists of 50% mercury, one of the world’s most toxic substances. Despite all precautions taken in dentistry, mercury inevitably enters the environment, where it transforms into the even more toxic form methylmercury and contributes to mercury accumulation in the fish we eat.

Before the Commission’s proposal can take effect, it must be approved by the European Parliament and the Council. Given the delay, however, the Parliament will have to move fast to complete all the formalities before the 2024 parliamentary elections.

“This is a milestone. Finally, we get a regulation for dental amalgam, the largest remaining use of mercury in Europe and a serious threat to health and the environment,” says Florian Schulze, director of the European Network for Environmental Medicine, who has been pushing for the phase-out for years.

“Numerous countries, such as Sweden, Norway, Moldova, Lithuania, Switzerland, Bolivia, Ecuador, Indonesia, the Philippines, or Zambia, have already phased out the use of amalgam. Most recently, Poland had replaced amalgam with alternatives in the statutory health insurance,” explains Schulze.

FURTHER INFORMATION

Proposal for a REGULATION OF THE EUROPEAN PARLIAMENT AND OF THE COUNCIL amending Regulation (EU) 2017/852 of the European Parliament and of the Council of May 17, 2017, on mercury as regards dental amalgam and other mercury-added products subject to manufacturing, import, and export restrictions: https://ec.europa.eu/transparency/documents-register/detail?ref=SEC(2023)395&lang=en.

Global Overview of Countries Phasing Out Dental Amalgam: https://environmentalmedicine.eu/mercury-free-dentistry-for-planet-earth/.

FEATURED IMAGE CREDIT: Tobias Blad-Stahl/Shutterstock.com.

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Gordon J. Christensen, DDS, PhD, MSD

“I have been practicing for many years, and most of the indirect restorations I have placed in the past could be cemented with correct occlusion as they came from the laboratory. However, in recent years, I am seeing some crowns that are not even close to touching the opposing arch of teeth, and others are too high. These crowns come from my usual laboratory that has had near-optimal occlusion on the crowns in the past. Additionally, I still have some zirconia crowns coming off in service. What can I do about these challenges?”

Dr. Christensen: Both you and I are seeing the same problems, and I have several potential reasons and solutions to share.

Labs are making crowns out of contact with the opposing arch (figure 1). Some labs are making crowns up to 0.5 mm too low (500 microns or the thickness of at least 10 human hairs) as measured by Clinicians Report (CR) scientists. This reduction in crown height reduces the completed restoration occlusal thickness, potentially compromising crown strength and causing tooth extrusion of both the tooth being crowned and the opposing tooth, as well as stress on adjacent teeth.

Figure 1: Note the significant lack of occlusal contact on this zirconia crown example as sent from a large dental laboratory.

Why would technicians do this? Currently, the most popular crown types—zirconia and lithium disilicate—are very difficult to reduce in height and difficult to finish and polish smooth in the mouth, taking clinical time and frustrating the dentist and patient. The technician and the dentist would like to have the patient say the crown feels just right when closing the two arches together. Making the crown shorter with no occlusal contact avoids removal of ceramic on the occlusal/incisal surface when seating.

Most zirconia and lithium disilicate crowns are initially one color without significant translucence. Thus, most ceramic crowns have a layer of low-fusing ceramic fired over them to provide individual characterization of color and translucence on the crown. If the occlusal/incisal crown surface is adjusted, removing the superficial layer of low-fusing ceramic, the underlying zirconia or lithium disilicate is exposed and the restoration’s color and translucence are compromised.

In discussions with CR scientists and clinicians, they disagree with placement of superficial low-fusing ceramic. They have proven that the superficial glaze and stain wear off over time and wear the opposing teeth until worn off (personal communication, Rella Christensen, PhD).

Successful cementing of zirconia crowns: Still a problem

Zirconia crowns in dentistry: Uses, clinical challenges, and solutions

Some labs are spacing the intaglio (internal) surfaces of crowns to reduce seating difficulty as measured by the CR science team (figure 2). You have probably noticed that many current zirconia crowns do not have a definitive seating location and tend to be mobile on the tooth until cemented. This unfortunate situation is directly related to internal spacing. So, how much internal spacing is necessary for optimum seating?

Figure 2: This crown came off in service and is from one of CR’s in vivo zirconia studies. It was placed only a short time before the photo was taken. Note the thickness of the resin cements as observed in the void area on the occlusal intaglio surface of the crown and the staining on the margins that occurred after a very short time.

You may remember when stone dies were the norm. A layer of lacquer was painted on the dies to allow space for the cement and reduce hydraulic resistance caused by the cement during seating. That layer was about 25 microns thick, which is probably enough even for the digital needs of today. However, if there are undercuts on the prep, those undercuts need to be filled with some material to avoid the digital directed milling device automatically overspacing the digital prep model. CR scientists have measured up to 500 microns (one-half mm) of internal spacing.

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How often do you solder? Have you ever asked yourself how important soldering is in the overall context of dental laboratory work – and which requirements are essential to achieve a successful soldering result? If you have, then you may find this background information insightful. Come with us on a journey through the past, present and future of the (dental) soldering technique!

Soldering: indispensable in the dental lab

“Soldering” as a joining technique is an essential aspect of everyday work in the dental lab. In dental technology, soldering has been used for over a hundred years – the method of soldering, however, has been known for much longer than that. Soldering was practised even in antiquity. The soldering methods of those days involved copper ore and helped goldsmith to design intricate pieces of jewellery.

Soldering is the most common method used to join metal materials and the principles on which this technique is based will not change in the future.

In spite of modern welding and bonding techniques, soldering has not lost its importance in dental technology due to its universal range of applications. In the dental lab, the daily number of soldering processes still clearly exceeds the number of other joining methods.

What is soldering?

Soldering is the process of joining pieces of metal using a molten filler metal, known as solder. The processing temperature of the filler metal is below the solidus point of the alloys to be joined. The solder wets these alloys but does not melt them during soldering.

During the soldering process, the liquid solder and solid-hot alloys undergo a process of mutual diffusion. The bond strength (= quality of diffusion structure) and resistance to corrosion are the decisive factors for the long-term success of the solder joint.

Solders: Resistance to the oral environment is essential!

Only hard solders are used in dental technology as resistance to the oral environment is essential. In addition to pre-solders (main solders), specially designed post-solders (secondary solders) having lower processing temperatures are available.

Solders are classified into high-fusing solders having a melting range between 950 and 1,200 °C and low-fusing solders with a melting range between approx. 700 and 900 °C. The different melting ranges accommodate different purposes. It is important that the solders and alloys are compatible with each other. A high degree of care is required to achieve a reliable solder joint. An understanding of the materials involved in the soldering process and knowledge of how to apply them correctly form part of a careful approach to soldering.

Below follow the most important requirements for successful dental soldering:

1) Compatibility of metals

The solders selected for the soldering process should have a processing temperature that is suitable for the alloys to be soldered. Dental solders must be resistant to the oral environment and their composition must be similar to the composition of the alloys being soldered. This means that (metallurgical) compatibility and similar coefficients of thermal expansion of solders and alloys are prerequisites for achieving a reliable solder joint.

2) Effective wettability

The solder’s capability of effectively wetting the alloy is another requirement for a successful soldering process. If the solder has ideal wetting properties, it spreads out evenly on the alloy, wets both surfaces and fills the soldering gap. If the solder has poor wettability, it forms droplets. In this case, the solder does not flow and diffusion does not occur; or in other words, the metal compounds contained in the alloy and the solder fail to intermix. An ideal diffusion structure forms if the difference between the processing temperature of the solder and the solidus point of the alloy is minimal.

3) Clean metallic surfaces

Clean soldering contact surfaces are a basic requirement for adequate wetting. The contact surfaces should be free of grease and oxide. Grinding and/or sandblasting can be used to prepare the soldering contact surfaces.

4) Oxide-dissolving flux

It is advisable to use a flux to prevent the formation of oxide. The flux dissolves the oxygen compounds on the surface of the alloy. During the dissolving process, the flux absorbs the oxides and prevents any further oxidation from occurring. The soldering process should be completed immediately after the application, as the solubility of the oxides captured in the flux is limited. This process is assisted by using the “reduced zone” of the flame.

5) Evenly pre-heated framework components

The framework components to be joined should be sufficiently preheated to ensure adequate flow and optimum wetting of the alloy. The temperature at the soldering site should be higher than the processing temperature of the solder but it must not exceed the solidus temperature of the alloy.

6) Soldering gap walls should be as parallel as possible 

Only if the walls of the framework components are parallel to one another is the solder pushed into the soldering gap by the pressure being released (capillary filing pressure). The walls should be aligned at an even gap from one another at a width of approx. 0.05 mm to no more than 0.2 mm.

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Many clearly recognize the importance of requiring dental laboratories to disclose to the dentist the point-of-origin and the material content of materials used in dental restorations as the accuracy of this information is essential to protect the patient safety. What many don’t recognize is that most states lack basic minimum standards for dental lab materials accountability and the risks that this creates for dentists and their patients.¹

The essential basic minimum standard for materials accountability requires that labs provide dentists a written materials disclosure for each restoration coupled with required dental laboratory registration.  In their absence, if a dentist catches that a rouge lab sold them cheaper gray/black market restorations or components, or misrepresented the point of origin and passed them off as what the dentist ordered, the risk to the offending lab is most likely only the loss of that one dentist as a customer.

Patient safety is compromised when a dentist, thinking they have receiving what they ordered, instead unknowingly places the adulterated or counterfeit components they actually received. Higher failure rates cost dentists lost chair time and adverse incidents expose the dentist to additional liability and possible reputational impact.

Imagine the nightmare of discovering that for the last year or two you have been unknowingly placing something other than what you prescribed. Would you be ethically required to notify your patients of the possibility? How would you determine whether potentially affected cases you placed were genuine or not without great discomfort to your patients, and great expense and professional embarrassment to yourself? Scary but cases like this actually happen.

Most dental laboratories are ethical and reliable. However, the economic pressure of the modern dental practice especially for debt laden younger practitioners, combined with the absence of basic minimum standards for accountability in most states, creates a fertile environment and an economic incentive for bad actors to profit from these practices.

In states where required material disclosure is coupled with a dental laboratory registration requirement, bad actors risk the loss of their registration and with it their ability to do dental laboratory work in the entire state. The result is increased accountability. Implementing these two basic minimum standards for materials accountability greatly reduces the likelihood that dentists and their patients will have to experience these unnecessary additional risks.

ADA policy has long supported written material content and point of origin disclosure and has more recently adopted an ADA policy specifically urging all state dental boards to register dental laboratories. Now is the time for those involved in restorative dentistry to actively demand that these important policies be implemented?

¹ Currently only FL, KY, MN, SC & TX have both disclosure and registration requirements for labs.

About the Author

Eric Thorn serves as in-house counsel for the National Association of Dental Laboratories (NADL). He is a leading voice for American dental laboratories on regulatory topics and works with state dental laboratory associations across the country helping to develop, present, and advance proposals and legislation relating to basic standards for the dental laboratory technology profession nationwide.

Eric Thorn formerly served as the General Counsel of the Florida House of Representatives. Prior to joining NADL, he spent over a decade in private practice with a prestigious Florida-based law firm representing businesses and associations in governmental relations and business development matters.

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We all know how busy the dentist and staff are in a successful practice.  As a matter of course, those practices work with successful and reputable dental laboratories.  The trend follows because of the need for expert technical assistance from the most experienced dental technician/technologist in the laboratory.  The dental technologist is in the position to serve the practice and as such makes him or herself immediately interruptible and available to the dentist and staff any time they call or visit the lab.  This is a great position to be in as a highly valued member of the dentist’s team.

This brings me to the meat of the subject – communication.

Too often a dental technologist will call or email the dentist or staff to ask for items that were not included on the work order and, too often the dentist and staff are too busy with a patient in the chair to respond.

Keep in mind that the dental technologist is acting for a patient who is expecting their new smile to be delivered on time, yet the response to the dental technologist may be given low priority.  The call back comes too late or is completely ignored leaving it up to the dental technologist to continually follow-up by phone or email.

Keep in mind that the dental technologist is acting for a patient who is expecting their new smile to be delivered on time, yet the response to the dental technologist may be given low priority.  The call back comes too late or is completely ignored leaving it up to the dental technologist to continually follow-up by phone or email.

In my lab of 75 core dentist clients this is the rule rather than the exception.  I think the solution is to view the dental technologist more as an advocate for the most important patients in the practice and not as an interrupter who can be ignored.

Some time ago I wrote a pictorial article explaining my suggestion that all dentists should, at some time in their career, pour casts from their impressions and trim their own master dies.  In my experience, all dentists who have followed this practice have improved their impression techniques immensely.  Following that practice all dentists begin to look at their own impressions much more critically and their impressions improve as a matter of course. The resulting restorations fit far better and the dentist’s appreciation for their own personal skill raises to one of fulfillment.

At the end of the day, both the dentist, dental staff and dental technologist want to provide the best experience and restoration for the patient.  Clear and timely communication and great impressions will help go a long way in ensuring a positive outcome.

Steve Killian studied dental technology at Southern California College of Medical and Dental Careers, graduating in 1973, number one in his class. Soon after he joined with Jim Glidewell Laboratories and became senior ceramist and general manager for two of his laboratories, El Toro Dental Ceramics and later Cal-West Dental Ceramics. In 1980 Stephen became a National Board Certified Dental Technician in Ceramics. With his growing interest and attention to premium esthetics and quality, he opened his own laboratory in 1983. Steve began to partner

with his brother Greg in 1985 allowing Steve to focus on the technical side while Greg focus’ on the administrative side of Killian Dental Ceramics, Inc, CDL a 30-person lab in Irvine. Steve has served on NADL in various capacities since 2011 and now serves on the board for The Foundation for Dental Laboratory Technology, promoting education and awareness in the profession, while raising money for scholarships, grants and on-line learning programs.

Notable Positions

• The National Association of Dental Laboratories, The Foundation for Dental Laboratory Technology – January 2017 Fundraising Committee Chair, three-year term
• The National Association of Dental Laboratories, The Foundation for Dental Laboratory Technology – August 2013 Elected to Board of Trustees, three-year term
• The National Association of Dental Laboratories, Board of Directors – January 2012 Dental Laboratory Representative at Large, two-year term
• The National Association of Dental Laboratories, Board of Directors – January 2010 Dental Laboratory Representative at Large, two-year term

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LMT asked dentist-participants in our 2018 Dentist Survey to rank the challenges they assume laboratory owners face. Interestingly, they were correct in choosing the top two, saying a lab’s biggest struggles are hiring competent staff (which lab owners ranked as their #2 problem) and making do with inadequate work by clients (which labs ranked as their #1 challenge.)

With regard to the challenge of hiring qualified technicians, some dentists expressed concern about the future of our community, citing declining educational programs and the aging technician base. “Let’s concentrate on actually supporting the dental technology industry with training programs, rather than pushing everything onto a computer,” says a dentist from Florida. “There is so much we cannot do digitally and we will need to have people who still understand this.”

Some dentists also commented on the difficulty laboratories have in dealing with subpar work from their clients, urging laboratories to hold them accountable.

“Feedback is crucial; don’t be afraid to tell us you need a better impression or more information. Any dentist who is too proud to receive feedback is not serving his/her patients and will not improve clinically,” says a dentist-participant from Tennessee. “Don’t be afraid to hold your dentists to the same standards as they hold you.”

Labs Weigh in

Similarly, laboratory-respondents to LMT’s 2018 Relationship Survey were asked: what do you think are dentists’ biggest challenges when running their practices? They were right on the money, not only choosing the same two problems the dentists did—dealing with insurance companies and hiring competent staff—but also in the correct order.

It’s possible laboratories were so easily able to identify a dentist’s number-one struggle because it has an effect on them. “Insurance reimbursement is the biggest issue; we have great clients who are constantly battling this problem,” says Kelly Pickworth, CDT, Owner, Ohio Dental Lab, Mason, OH. “The impact of this on our lab is huge: they are constantly requesting lower fees to deal with reimbursement problems.”

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In LMT’s joint survey with Dental Economics, 46% of dentists say they’ve switched their primary laboratory—meaning the one they use most often—in the last five years. Here’s what leads them to end laboratory relationships and what they look for next time around.

The more things change, the more they remain the same: while dentistry has undergone unprecedented changes over the last 25 years, the number-one reason dentists switch laboratories has steadfastly remained the same: inconsistent quality.

Dentists first told us this in 1994 and have emphasized it in all of our dentist surveys since, including the most recent one conducted with Dental Economics (click here for survey demographics), where 71% said inconsistent work was the impetus to end their relationship with their last laboratory. The unpredictability of what they might receive from the lab hits dentists where it hurts the most, costing them chairtime and damaging their relationships with patients.

“Too many adjustments. Too many returns. Too much chairtime,” says a dentist-participant from Vermont. “That was the situation last time I switched laboratories. I hate adjusting porcelain; the micro fractures lead to breakage and then I have to explain to the patient why the crown needs to be replaced.”

As in the past, some dentists say the quality of work they receive from laboratories routinely starts to decline as time goes on. “What labs do is tough and good work should be applauded. But I just hate when I use a lab for awhile, then start getting back junk. I literally have used the same burs, the same impression trays, the same material, etc. but am told it’s my fault when cases start coming back incorrect,” says one. “Then I switch labs and magically everything is perfect again for a while. That gets old.”

Although laboratories have long lamented price-shopping dentists, price is a distant second to inconsistency, with only a third of dentists saying it was a factor last time they switched labs (see chart). In fact, the majority of dentists say they expect labs to increase prices once a year or every two years.

While this seems at odds with what we hear from laboratory owners, it likely comes down to a misperception: what laboratory owners may perceive as shopping for price, dentists view as shopping for value. In other words, the prices they’re willing to pay are in direct correlation to their estimation of the quality of service they receive.

For example, one dentist switched from his last lab because a fee increase and reduction in staff coincided with a perceptible decline in quality; he suspected the lab started outsourcing without acknowledging the change. Another dentist says he knows he pays higher-than-average lab fees but feels the ease of the relationship and excellent work are worth it.

A dentist from Illinois shares this story: he was paying $155 for a hard/soft nightguard at his long-time laboratory and came across a similar one at a larger lab for just less than half that price. “I called my technician and then sent him a sample of the other lab’s nightguard; he agreed it was similar in quality to what he was offering but acknowledged he didn’t have the thermoforming equipment to enable him to produce it for that price,” he says. “We had an honest and upfront conversation; I would never end our relationship just because of price, but if there’s something that doesn’t sit right, I’ll talk about it with him.”

There’s a tie for the third most common reason dentists change laboratories: delayed turnaround/late cases and prescriptions not being thoroughly followed. “When a technician doesn’t read and follow an Rx, the lab needs to be replaced. The problem—especially when you work with a lab for awhile—is the technicians assume they know what you want and then stop reading the instructions thoroughly, causing delays and frustration,” says one dentist. “Read the Rx and follow it! If you disagree, call to discuss your concerns.”

When dentists are ready to make a move, the top features they look for in a new laboratory are high-quality work, good communication and reasonable prices, in that order (see chart).

To find that new lab, they value their colleagues’ advice more than anything else; in fact, 44% of dentists say a referral from another dentist is how they found their last laboratory. They also respond to in-person sales calls and seeing samples of the lab’s work.   

When Loyalty Lasts

In all this talk about switching, let’s not overlook the fact that many dentists are relatively loyal to their laboratories: in the past five years, half of them have NOT switched their primary laboratory.

Our dentist-participants also acknowledge the positive connection they have with their technicians: nearly all say their relationships with their current laboratories are good or even excellent, and many noted it takes effort on both sides to make quality work and effective communication happen. “I’m not one of those dentists who call and scream at the lab when something goes wrong with a case,” says a dentist from Missouri. “It’s just as easy for me to screw up too. I work hard to give my lab quality work and I appreciate the quality I get back.”

Repeatedly, dentist-participants say a commitment to consistent quality, effective communication and the assurance they can rely on their labs is the key to a long relationship. “My technician and I have been working together for 30 years; he has great skills, helps me out when I get stuck, suggests clever ways to find solutions and is my friend,” says Dr. John Leitner, Grand Haven, MI. “It’s pretty simple, really.”  (Read profile of Dr. Leitner and Laboratory Owner Rick Knecht here)

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