Children of Color and LowIncome Kids Still Receive Unsafe

Rueben C. Warren and Mark Mitchell

Originally published June 22, 2022 in Health Affairs Forefront

It has been more than a year since the Food and Drug Administration (FDA) asked dentists to stop using amalgam—the familiar silver-colored material used to fill cavities—in children and other “high risk” groups. That’s because amalgam contains 50 percent mercury, a well-known neurotoxicant.

The risks are alarming. We know that mercury from amalgam is absorbed into the body, where it can be detected in blood and tissue samples. The more amalgam fillings a person has, the higher their blood levels of mercury. Mercury exposure is associated with irreversible cognitive and neurological impairment, as well as other long-term health impacts. Children, whose brains are still developing, are at greatest risk from exposure to neurotoxicants such as mercury.

While the science on amalgam and health continues to evolve, the data are strong enough to prompt a global shift away from mercury-based fillings. The World Health Organization recently declared mercury a major public health and environmental concern, recommending composite and glass ionomer fillings as healthful, cost-effective alternatives to amalgam. The European Union bans amalgam in children younger than age 15, pregnant women, and breastfeeding mothers. Many other countries have banned or limited amalgam use. And the Minamata Convention on Mercury, which the US signed in 2013, has called for a phase-out of amalgam use in those same vulnerable groups.

The data on the extent of amalgam use in the US are sparse and out of date, but in our experience as dental and medical professionals, we’ve seen that Black, Latino, Native American, and low-income kids are much more likely to get mercury-based amalgam fillings than their more affluent non-Hispanic White counterparts. Anecdotally, just recently, one of us (Dr. Mitchell) was talking with a dental colleague and, when asked how often he uses amalgam in his private practice, the colleague responded, “only three or four times per year.” However, he noted that his wife—a pediatric dentist—uses amalgam “all the time” in her Medicaid patients, who are mostly children of color.

Indeed, low-income kids of color are more likely to get dental care through Medicaid and other governmental programs that still use amalgam than from any other insurance source. In three states (Georgia, Kentucky, and West Virginia) Medicaid will only pay for amalgam, and not the slightly more expensive alternatives. The Indian Health Service is gradually phasing out amalgam but continues to use mercury-based fillings, even in small children. Also, many low-income kids get their fillings at dental school clinics, where amalgam is still part of the curriculum and clinical requirements.

In the US, the decision to use amalgam is left to the discretion of dental providers, allowing racial bias to put a thumb on the scale. We know that bias can play a role in whether Black patients receive pain medication and also contributes to racial disparities in health outcomes. Perhaps, some dentists weigh health risks differently when they are deciding how to fill the cavities of Black and Brown children.

No matter the reason that dentists still use them, mercury-based fillings add to an already heavy burden of toxics for children of color from all income levels. Black children, who are more likely to live near toxic waste sites, coal-fired power plants, and other polluting facilities, already have higher levels of mercury in their bodies than non-Hispanic White kids. They don’t need more mercury from amalgam.

Amalgam fillings also poison the environment, which affects us all. Dental amalgam accounts for much of the mercury in use in the United States. Mercury from amalgam leaches into the environment through cremation and burial, dental clinic water and air emissions, and human waste. Our health and that of the environment are intimately connected.

The ethical, practical solution to this problem is to ban amalgam use in the US, particularly in children and other at-risk groups. While the full

Section V: Climate and Health Equity Fellowship (CHEF) scope of the problem is unclear without better data, we know that many government programs, including Medicaid and the Indian Health Service, continue to place mercury fillings in children’s mouths—in defiance of the FDA’s warnings. And we know that safer alternatives, such as composite and glass ionomer, are available at a reasonable cost. It is time for the US Secretary of Health, Xavier Becerra, to halt the use of amalgam in dental care provided or subsidized for by the federal government.

As longtime champions of environmental health and social justice, we envision a world where all people have equal access to health and to the health care they need to thrive. As long as Black, Latino, Native American, and low-income children receive amalgam fillings while their affluent non-Hispanic White counterparts get the safer alternative, that vision remains elusive.