Dentists do still use amalgam fillings, but barely. In the United States, the share of dental restorations placed with amalgam dropped from about 22% in 2017 to just 4% in 2023, a collapse that cuts across every income level and insurance type.1PubMed. Declining US dental amalgam restorations in US Food and Drug Administration-identified populations: 2017-2023 The material that dominated dentistry for over 150 years is now a niche choice, kept alive by specific clinical situations and economic pressures rather than any widespread preference.
How Fast Amalgam Use Has Fallen
The speed of the decline is striking even by modern standards. The drop in the U.S. from roughly one in five restorations to one in twenty-five happened in just six years.1PubMed. Declining US dental amalgam restorations in US Food and Drug Administration-identified populations: 2017-2023 That trend held regardless of whether patients paid out of pocket or through insurance, and it held across communities with different levels of social vulnerability, though the most socially vulnerable communities saw a somewhat slower decline than less vulnerable ones.1PubMed. Declining US dental amalgam restorations in US Food and Drug Administration-identified populations: 2017-2023
This is not an American quirk. In Taiwan, amalgam use for decayed teeth fell significantly across all age groups, all regions, and both sexes between 1997 and 2013, even as the total number of dental visits rose substantially.2Journal of Dental Sciences. Decreased trends of using dental amalgam filling for decayed teeth in Taiwan from 1997 to 2013 European countries have moved even faster. Norway, Sweden, and Denmark effectively ended amalgam use years ago, and the European Union phased out amalgam for children and pregnant women starting in 2018, with a broader ban taking effect in 2025. The global direction is clear even if the timeline varies by country.
Why Amalgam Dominated for So Long
To understand why amalgam is still around at all, you have to appreciate what made it the default for so long. Dental amalgam is a mix of a metal alloy, primarily silver, tin, and copper, combined with liquid mercury. When the powder and mercury are mixed, a chemical reaction hardens the material into a durable restoration. The process is not a simple mixing; it involves the dissolution of metals into the mercury and then precipitation of new crystalline phases, making the final product structurally different from any of the starting ingredients.3PubMed. Setting reactions in dental amalgam. Part 2. The kinetics of amalgamation
The result is a filling that holds up remarkably well under the punishment of chewing. A systematic review comparing amalgam and composite resin in back teeth found that amalgam restorations had a median survival time exceeding 16 years, compared with about 11 years for composites.4PubMed Central. Longevity of Amalgam Versus Composite Resin Restorations in Permanent Posterior Teeth: A Systematic Review When amalgam fillings eventually fail, they tend to crack or fracture. Composites, on the other hand, most often fail because new decay forms around their edges.4PubMed Central. Longevity of Amalgam Versus Composite Resin Restorations in Permanent Posterior Teeth: A Systematic Review That five-year gap in average lifespan matters a lot when you are placing a filling in a molar that has to survive decades of daily grinding.
Amalgam also has a practical advantage that rarely gets mentioned outside clinical circles: it is far more forgiving to place. Composite resins require a dry field, meaning the tooth must be kept completely free of saliva during placement, which can be difficult in the back of the mouth or in patients who struggle to keep still, like young children. Amalgam tolerates moisture much better and is less sensitive to small errors in technique.5PubMed Central. The dental amalgam toxicity fear: a myth or actuality In high-volume public health clinics where a dentist might be treating dozens of patients a day, that difference in fussiness is not trivial.
The Mercury Safety Question
Mercury is the reason amalgam has been controversial since it was first introduced in the 1800s. The concern is straightforward: amalgam fillings contain about 50% mercury by weight, and that mercury does not just sit inert in your tooth forever. People with amalgam fillings have measurably higher levels of mercury vapor in their mouths than people without them, and those levels spike after chewing.6PubMed. Intra-oral air mercury released from dental amalgam Early measurements found that chewing could raise intra-oral mercury vapor to levels many times above baseline.
That sounds alarming until you look at the actual amounts involved. Laboratory simulations measuring the steady-state mercury dose from a single amalgam filling found it to be roughly 0.03 micrograms per day, which is far below the threshold considered hazardous for occupational exposure in the United States.7PubMed. Mercury release from dental amalgams: an in vitro study under controlled chewing and brushing in an artificial mouth The vapor is real, but the dose is very small for patients with a typical number of fillings.
The most rigorous safety data comes from two large randomized trials in children, which are the gold standard for settling questions like this. In one trial, 507 children aged eight to twelve were assigned to receive either amalgam or composite fillings, then followed for seven years with annual neurological examinations. There were no significant differences between the two groups on any neurological measure, including tremor and other neurological signs.8PubMed. Neurological outcomes in children with and without amalgam-related mercury exposure: seven years of longitudinal observations in a randomized trial A second trial, the New England Children’s Amalgam Trial, randomized 534 children and tracked kidney function markers over the study period. It found no significant differences in kidney biomarkers between the amalgam and composite groups, though there was a small uptick in temporary microalbuminuria (a marker of mild kidney stress) in the amalgam group that the researchers said could be a chance finding and warranted further investigation.9PubMed Central. Renal effects of dental amalgam in children: the New England children’s amalgam trial
The evidence does not show that existing amalgam fillings pose a measurable health risk to the general population. But “not measurably harmful” is a hard sell when a mercury-free alternative exists. Most regulatory bodies have landed on a cautious middle position: amalgam is considered safe for most adults, but there is a growing consensus that reducing its use is prudent, particularly in children and pregnant women, where the precautionary principle weighs more heavily.
Environmental Pressure and International Policy
If patient safety concerns alone did not kill amalgam, environmental concerns pushed the timeline forward considerably. The problem is not the fillings sitting in people’s mouths; it is the mercury that enters wastewater when amalgam is placed, removed, or when dental waste is improperly handled. Dental offices equipped with amalgam separators are supposed to catch mercury particles before they reach the sewer system, but real-world performance often falls short of lab-certified efficiency. Commercial separators that claimed 99% efficiency in standardized tests were found in actual clinical use to capture only about 79 to 91% of mercury, leaving meaningful amounts in outgoing wastewater.10PubMed. Mercury recovery in situ of four different dental amalgam separators Some studies of dental clinics found high mercury emissions despite the presence of separators, and concluded that improved discharge system design, careful maintenance, and ultimately banning mercury in dentistry were the only reliable long-term solutions.11PubMed. High mercury emissions from dental clinics despite amalgam separators
The 2013 Minamata Convention on Mercury, signed by over 140 countries, addressed dental amalgam specifically, calling for a voluntary phase-down of its use. Critics have pointed out that the convention stopped short of binding, measurable targets, essentially asking countries to try rather than requiring them to succeed.12Science of the Total Environment. The Minamata Convention on Mercury: Attempting to address the global controversy of dental amalgam use and mercury waste disposal Still, the phase-out date for most mercury-added products under the convention falls between 2020 and 2025, with dental amalgam, as one of the few products given a phase-down rather than phase-out, facing a softer target of 2030.13Hindawi / International Journal of Dentistry. Dental Amalgam Phase-Down-Status, Alternatives, Strategies and Preparedness for Implementation: A Review In practice, the combination of international policy, EU regulation, and shifting market preferences has made amalgam increasingly difficult to justify on a routine basis.
What Has Replaced Amalgam
The primary replacement is composite resin, the tooth-colored material most people picture when they think of a modern filling. Composites have improved substantially over the past two decades. Manufacturers have developed new types of filler particles, bonding agents, and resin chemistries aimed at closing the durability gap with amalgam.14PubMed Central. Wear of contemporary dental composite resin restorations: a literature review Modern composites wear better and bond more tightly to tooth structure than earlier generations, though as noted, they still do not match amalgam’s longevity in back teeth on average.
Glass ionomer cements occupy a different niche. These materials release fluoride over time, which helps protect the tooth against further decay, a genuinely useful property in high-risk patients.15PubMed Central. An In Vitro Study to Compare the Release of Fluoride from Glass Ionomer Cement (Fuji IX) and Zirconomer Traditional glass ionomers are weaker than either amalgam or composite and wear down more quickly, so they are most often used in baby teeth, small fillings, or areas that do not bear heavy chewing force. Newer formulations like resin-modified glass ionomers and products marketed as “zirconomers” are trying to improve strength while keeping the fluoride benefit. The amount of fluoride released varies widely between products, with conventional glass ionomers releasing substantially more than hybrid materials.16PubMed Central. Fluoride Release by Glass Ionomer Cements, Compomer and Giomer
For larger restorations where neither composite nor glass ionomer is ideal, dentists may turn to porcelain or gold. Porcelain inlays and onlays are strong and esthetically excellent but require lab fabrication and cost considerably more. Gold has always been an outstanding restorative material with superb longevity, but its cost and appearance limit its appeal to most patients. None of these alternatives hits the exact combination of cheap, durable, and easy to place that made amalgam so widespread.
The Cost and Equity Problem
Here is where the story gets uncomfortable. Amalgam is cheaper than any alternative. It requires less chair time, less equipment, and less technique sensitivity. When you remove it from the menu, the cost of filling a cavity goes up, and the patients who feel that price increase most acutely are those who can least afford it.
Research from the UK has found that the public, particularly low-income groups, actually valued amalgam more than composite as a restorative option, and that an imminent phase-out raised concerns about the survival of restored teeth, funding, patient safety, and access to care, with the risk of worsening existing health inequalities.17Newcastle University eTheses. Amalgam phase-out: what next for dentistry? Costs and benefits of the alternative direct restorations A separate cost analysis reached a similar conclusion: the price difference between amalgam and composite may primarily affect people of low socioeconomic status, potentially resulting in more teeth being extracted rather than filled in that group.18British Dental Journal. Amalgam versus composite restorations: a cost-consequence analysis
In the U.S., researchers analyzing insurance data noted that further reducing amalgam use would likely require changes to insurance coverage, provider incentives, and training, with particular attention to groups at high risk for tooth decay or with higher rates of amalgam placement.19PubMed. Posterior dental restoration material choices in privately insured people in the United States, 2017 through 2019 Simply banning amalgam without addressing cost barriers could mean that some patients end up losing teeth that could have been saved with a cheaper filling material. The ethical calculus is not simple.
What Dental Schools Teach Now
If you want to know where a profession is heading, look at what it teaches its students. Many dental schools have been steadily reducing amalgam training for years. Some have eliminated it entirely. One European dental school stopped teaching amalgam placement in 2001, after a decade-long transition during which composite resins gradually became the first-choice material for primary cavity treatment.20PubMed. The amalgam-free dental school
In the U.S., the picture is more mixed. A survey of predoctoral pediatric dentistry programs found that schools where department leaders held positive attitudes toward minimally invasive dentistry used composite and glass ionomer more frequently and placed less amalgam. But the use of amalgam in both primary and permanent back teeth was still widely practiced across U.S. dental schools at the time of the survey.21PubMed Central. The transition from amalgam to other restorative materials in the U.S. predoctoral pediatric dentistry clinics Students still need to learn how to handle existing amalgam, whether or not they ever plan to place new ones, because millions of amalgam fillings are still in people’s mouths and will eventually need to be replaced.
Should You Have Old Amalgam Fillings Removed
This is one of the most common questions patients ask, and the evidence-based answer is usually no, not for health reasons alone. Removing an intact amalgam filling that is doing its job exposes you to more mercury during the removal process than the filling would release over years of normal use. Drilling through amalgam generates particulate matter and mercury vapor, and protecting both the patient and the dental team from that burst of exposure requires specific precautions: rubber dam isolation, high-volume suction, and sometimes respiratory protection for the operator.22PubMed Central. Mercury vapor volatilization from particulate generated from dental amalgam removal with a high-speed dental drill – a significant source of exposure Protocols exist for safe amalgam removal, including patient preparation and post-treatment steps to help clear any absorbed mercury.23PubMed Central. A safe protocol for amalgam removal
Some patients do report feeling better after having amalgam fillings removed, but the reasons for that are hard to untangle. The placebo effect is powerful, and patients who are anxious about their fillings experience real stress that can cause real symptoms. A Norwegian study tracking patients over years after amalgam removal noted that concerns over potential adverse effects of mercury sometimes motivate patients to seek removal.24PubMed. Long term changes in health complaints after removal of amalgam restorations But major dental organizations generally advise against removing amalgam solely because of mercury fears if the filling is intact and not causing problems. When an amalgam filling cracks, develops decay underneath, or needs replacement for any clinical reason, replacing it with composite or another modern material is perfectly reasonable and routine.
Where Amalgam Still Makes Sense
Despite all the pressure against it, there are specific clinical situations where amalgam remains a defensible choice. Large cavities in back teeth with deep margins below the gumline, where keeping the area dry enough for a proper composite bond is nearly impossible, are the classic example. Patients with extremely high decay rates who need multiple teeth filled quickly and affordably, and who may not return reliably for follow-up care, represent another. Field dentistry in low-resource settings, where the infrastructure for composite placement (curing lights, bonding agents, careful moisture control) may be unreliable, is a third.
The controversy over amalgam stretches back remarkably far. When amalgam was first introduced to American dentistry in the 1830s, it was so divisive that the first national dental society in the United States, the American Society of Dental Surgeons, collapsed partly over the fight.25PubMed. Amalgam: Its history and perils Nearly two centuries later, amalgam inspires less dramatic institutional warfare but remains a material caught between its undeniable track record and a world that has decided the mercury trade-off is no longer worth making. For the handful of situations where nothing else works as well, you can still get an amalgam filling. For everything else, the silver filling has already become a historical artifact in most dental offices.