What Is the SMART Dental Technique for Amalgam Removal?

The Safe Mercury Amalgam Removal Technique (SMART) is a specialized protocol for removing dental amalgam fillings. Its primary function is to implement safety measures that reduce mercury exposure for both patients and the dental team during the procedure. Developed by the International Academy of Oral Medicine and Toxicology (IAOMT), SMART provides a standardized method that goes beyond traditional techniques by specifying steps and equipment designed to capture mercury particles and vapor.

Understanding Amalgam and Mercury Concerns

Dental amalgam is a filling material used for over 150 years to treat cavities. It is created by mixing liquid elemental mercury with a powdered alloy of silver, tin, and copper. An amalgam filling consists of about 50% mercury by weight, which acts as a binding agent for the metal alloy particles, resulting in a durable and long-lasting restorative material.

The primary concern with these fillings is the mercury content and its capacity to be released as vapor. While a stable filling releases small amounts, activities like tooth grinding and chewing can increase these emissions. The most significant release of mercury vapor and fine particles occurs during dental procedures, especially the removal of a filling. The heat and friction from a dental drill can aerosolize the mercury, creating a plume that can be inhaled.

Traditional amalgam removal methods often involve drilling out the filling without extensive protective measures, heightening the risk of mercury exposure. The process of grinding the amalgam generates a substantial amount of fine particulate matter that can be easily dispersed into the air. This increased exposure risk during removal procedures prompted the development of more controlled techniques.

Key Elements of the SMART Protocol

A primary element of the SMART protocol is the isolation of the tooth being worked on. Dentists place a non-latex nitrile dental dam in the patient’s mouth, which is a flexible sheet that fits around the tooth. This barrier prevents amalgam particles from being swallowed or inhaled during the procedure.

To control the spread of mercury vapor, the protocol requires powerful ventilation and suction. A high-volume evacuation (HVE) device is used continuously with the tip placed close to the filling. This is often supplemented by an at-source oral aerosol vacuum to capture aerosols that escape the immediate area. The treatment room is also equipped with a high-volume air filtration system to purify the ambient air.

Instead of grinding the entire filling into a fine powder, the dentist uses a small-diameter drill to cut the amalgam into larger chunks. This method minimizes the generation of fine particles and vapor. Throughout this process, a large amount of water is sprayed onto the filling to keep it cool, as heat from drilling increases the release of mercury vapor.

Extensive personal protective equipment is required for both the dental team and the patient. The dentist and assistant wear protective gowns, non-latex gloves, face shields, and sealed respiratory-grade masks. The patient is covered with a full-body, impermeable barrier and receives a separate supply of air through a nasal mask to avoid breathing air from the procedure site.

After the removal is complete, the patient’s mouth is thoroughly flushed with water. It is often rinsed with an adsorbent slurry, such as charcoal or chlorella, to bind any remaining mercury particles.

Preparing for a SMART Procedure

The decision to remove amalgam fillings may be for personal health reasons, a metal allergy, or part of a holistic health approach. Before committing to the procedure, patients should have a thorough discussion with a qualified dentist. This conversation should cover the dentist’s specific training and certification in the SMART protocol, as well as their experience performing these removals.

The IAOMT maintains a directory of its SMART certified members, which patients can use to locate qualified practitioners. During the consultation, patients should also inquire about the restorative materials that will be used to replace the amalgam filling. Common options include composite resin or porcelain, and it is important to understand the choices available.

Some dentists may suggest a preparatory regimen, such as dietary supplements, though this varies by practitioner. After the procedure, patients can expect some temporary tooth sensitivity, which is common after any filling replacement. The dentist will provide specific aftercare instructions for the new restoration to ensure its longevity and proper function.