At Gartside Street Dental Lounge in Manchester city centre, our clinicians share practical guidance to help you make confident treatment decisions.
A steady stream of patients arrive at our practice asking us to remove all of their amalgam fillings, often because they have read something online or seen a friend do the same. It is a sensible question and we never dismiss it. The honest answer, however, is more nuanced than either "all amalgams are dangerous" or "all amalgams are fine." This post lays out what amalgam actually is, what the regulatory and scientific consensus says about its safety, when replacement is genuinely indicated, and how the SMART protocol works if you do decide to have one or more amalgams removed.
Dental amalgam is a metal alloy made of silver, tin, copper, zinc, and elemental mercury. Mercury makes up about 50 per cent of the alloy by weight, which is what surprises most people. It has been used in dentistry for around 150 years, and for most of that time it was the only filling material capable of withstanding the chewing forces in molars while being affordable, durable, and tolerant of imperfect dry-field conditions during placement. A well-placed amalgam filling routinely lasts fifteen to twenty-five years, sometimes considerably longer.
Composite resin — the white filling material — has only become genuinely comparable in durability and bond strength over the last twenty to thirty years. Earlier generations of composite shrank as they cured, leaked at the margins, and failed faster than amalgam in load-bearing situations. Modern composites and ceramics have largely closed that gap, but the historical reason amalgam dominated for so long was practical, not ideological.
The reason mercury matters is that, in elemental and methyl forms, it is a known neurotoxin. The clinical question that has been studied for decades is whether the small amounts of mercury vapour released by a set amalgam filling, during chewing or grinding, are biologically meaningful for human health. Major reviews by the FDA, the EU Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR), the World Health Organization, the NHS, and the British Dental Association have consistently concluded that set amalgam releases mercury at very low levels and that placed fillings are not harmful to most adults.
The strongest safety signal in the literature is for specific groups: pregnant and breastfeeding women, children under fifteen, and patients with severe kidney disease. For these groups, the EU phased out amalgam placement in 2018 as a precaution, and from 2025 amalgam has been banned for all new placements across the EU, with the UK following similar timelines. This is largely an environmental decision — mercury released through cremation, sewage, and waste disposal is a legitimate ecological concern — rather than a sudden change in the safety assessment for individual patients.
The most important point for anyone with existing amalgam fillings is that the regulatory phase-down does not mean your existing fillings need to come out. The risk-benefit calculation for an existing, sound amalgam is different from the calculation for a new filling. Removing a sound, well-sealing amalgam exposes you to a brief peak of mercury vapour during drilling, replaces it with a composite that may not last as long, and can require more tooth structure to be removed in the process. Unless there is a clinical reason for replacement, the safer course in most cases is to monitor and leave well alone.
When is replacement genuinely indicated? Visible cracks or fractures in the filling or in the surrounding tooth. Recurrent decay underneath the filling, usually first spotted on a bitewing X-ray. The filling is leaking or breaking down, with rough or stained margins. The tooth is symptomatic — sensitive in a pattern that suggests bacterial ingress or pulpal involvement. A diagnosed allergy or lichenoid reaction in the gum or cheek adjacent to the filling, which is rare but real. Aesthetic concerns about visible silver showing when you smile, particularly on premolars. Each of these is a clinical reason, and replacement in these cases is straightforwardly justified.
When is replacement not clinically needed? Your amalgam is intact, well-sealed at the margins, no decay underneath on imaging, and the tooth is asymptomatic. In this case watchful monitoring at routine check-ups is the safest path. We will track the filling year by year and act if and when something changes.
If you do decide to replace one or more amalgams, what goes in their place? The two main options are composite resin and ceramic. Composite is the most common: a tooth-coloured resin bonded directly into the prepared cavity in a single visit, looking natural and lasting in the order of five to fifteen years for moderate-sized restorations. Ceramic inlays and onlays are lab-made restorations bonded into the tooth over two visits, are stronger and longer-lasting than composite for larger cavities, and cost more. Both avoid metal entirely.
The SMART protocol — Safe Mercury Amalgam Removal Technique, developed by the International Academy of Oral Medicine and Toxicology — exists specifically to minimise mercury exposure during the removal process, which is when the bulk of vapour is generated. Its key elements are straightforward: rubber dam isolation around the tooth so that fragments and vapour do not enter the rest of the mouth, high-volume suction held close to the tooth throughout drilling, copious water cooling to suppress vapour, dedicated air filtration in the surgery, and in some protocols a separate nasal oxygen mask so the patient breathes filtered air. We follow these protocols as a matter of routine when removing amalgams, regardless of the reason for removal.
The protocol matters less for the dentist than it does for the patient. The dentist and nurse are protected throughout their working day by the same high-volume suction, masks, and ventilation; the patient is exposed only during the brief minutes of drilling. The single biggest risk factor for mercury exposure during amalgam removal is poor isolation and inadequate suction, which a well-organised UK private practice avoids as standard.
It is worth saying something about the more aggressive end of the 'biological dentistry' spectrum. Some clinics market full-mouth amalgam removal as a route to general health improvement, sometimes alongside chelation or unproven detox protocols. The peer-reviewed evidence for these claims is weak, and the recommendation to remove all amalgams without any clinical indication is, in our view, not in the patient’s interest. Replacement should be driven by a specific reason for each tooth, not a blanket protocol.
Allergy and lichenoid reactions deserve a quick mention. A small minority of patients develop a localised tissue reaction adjacent to an amalgam filling, usually a white, lacy patch on the inside of the cheek or on the tongue next to the filling. In these cases removal is appropriate and the reaction usually resolves over a few weeks. True systemic allergy to amalgam is extremely rare.
Cost realism is also important. Composite restorations cost more per filling than amalgam ever did, and ceramic inlays significantly more again. Replacing every amalgam in a heavily restored mouth is often a multi-thousand-pound decision. We would rather you spent that money on a smaller number of replacements where there is a genuine clinical reason, and put the rest towards hygiene visits, an electric toothbrush, and any other restorative work that is more pressing.
If you have amalgam fillings and would like a calm, evidence-based opinion on which (if any) genuinely need replacing, we are happy to assess them as part of a new-patient examination. We will give you an honest view tooth by tooth, explain the composite and ceramic options, and follow SMART removal protocols if and when replacement is indicated. Book an assessment and we can talk it through. 
