SMART Mercury Amalgam Removal

Why Mercury Amalgam Removal Requires a Protocol

Dental amalgam is approximately 50% elemental mercury by weight and releases small amounts of mercury vapor over time (FDA, Dental Amalgam Fillings). In its recommendations of September 24, 2020, the FDA stated that the majority of evidence suggests this exposure does not lead to harmful health effects for most people, that there may be some effects in people with certain health issues, and that certain higher-risk groups — including pregnant and nursing women, children, especially those under six, and people with neurological disease, impaired kidney function or a mercury allergy — should avoid new amalgam fillings whenever possible and appropriate.

What is not controversial is the physics of removal: when an amalgam filling is drilled out conventionally — with a high-speed bur generating heat and particulate — mercury vapor is released at concentrations many times higher than the resting emission level. The FDA makes the same point: removing intact amalgam fillings can cause a temporary increase in exposure to mercury vapor, which is one reason it recommends against removing fillings in good condition unless medically necessary.

The SMART protocol does not decide whether your amalgam fillings should come out — the FDA recommends against removing fillings in good condition unless it is medically necessary, for example a fractured filling, recurrent decay or a documented allergy to mercury or other amalgam components. SMART sets out how to remove them when they must come out, with measures designed to limit mercury vapor and particulate exposure during the procedure.

The IAOMT SMART Protocol: Component by Component

Before the Appointment

Some practitioners suggest supplements such as chlorella, activated charcoal or vitamin C before removal. This guide cites no clinical evidence that they reduce mercury uptake from a dental procedure, and they are not treatments for mercury exposure. Tell the clinic about your medications and any kidney or neurological condition, and discuss any supplement with your physician before starting it.

Protective Barriers for the Patient

Under SMART protocol, the patient receives:

• Full-body drape: A non-porous barrier over all clothing and exposed skin — amalgam particulate can contaminate clothing and cause secondary exposure.
• Nasal cannula delivering oxygen or filtered air: Prevents the patient from inhaling mercury vapor through the nose. Nasal oxygen is standard; some practitioners use positive-pressure air flow through a full nasal mask.
• Eye protection: Safety glasses or goggles protect the conjunctiva from amalgam particulate splatter.
• Oral evacuator dam or isolation dam: A rubber dam (or the IAOMT-recommended non-latex alternative) is placed around the tooth to create a physical barrier between the amalgam removal site and the oral cavity, reducing swallowed particulate.
• Chlorella or charcoal rinse: A pre-procedural rinse with a chlorella or charcoal suspension before rubber dam placement, intended to adsorb particulate; its effect on exposure has not been measured in any study cited here.

High-Volume Oral Aerosol Evacuation (HVOE)

SMART adds a high-volume oral aerosol evacuator — a larger-bore, high-flow device positioned close to the patient's mouth — to the standard high-volume suction, to capture mercury vapor and particulate close to where they are generated.

Sectioning Technique

The most important technical element of SMART is the sectioning method: rather than grinding the amalgam filling into fine particulate and dust (as conventional high-speed removal does), the SMART practitioner sections the amalgam into the largest possible chunks using a slow-speed handpiece with a carbide bur, cutting grooves into the filling and then leveraging the sections out intact with hand instruments. Larger chunks = less surface area = dramatically less mercury vapor generation per unit of amalgam removed.

Copious Water Irrigation

Constant water irrigation cools the amalgam during sectioning, reducing heat-driven mercury vaporization. The combination of cool water irrigation + slow-speed technique + large-chunk removal is the primary mechanism by which SMART achieves lower mercury vapor generation compared to conventional removal.

Immediate Replacement

Following SMART removal, the tooth is immediately restored with a biocompatible, mercury-free material — typically composite resin using the biomimetic bonding protocol, or a ceramic indirect restoration if the cavity is large. Leaving an unrestored tooth after amalgam removal is not acceptable practice.

After Removal

No detoxification step is part of restoring the tooth. Chelation drugs such as DMSA are prescription medicines for diagnosed heavy-metal poisoning; the FDA states that all FDA-approved chelation products require a prescription, that it has never approved any chelation product for over-the-counter use, and that there is no proof that detoxification with such products prevents or treats any condition. If you are concerned about mercury exposure, that is a question for your physician.

Staging the Removal: Why Not All at Once?

Where several fillings do need replacing, the work is often staged over more than one appointment. Ask the clinic to explain its reasoning: no source cited in this guide establishes an optimal number of fillings per visit or interval between visits.

Credentials to Verify

• IAOMT SMART
  IAOMT SMART Certification — the International Academy of Oral Medicine and Toxicology's formal training and certification program for safe mercury removal. Requires completion of the SMART course, written examination, and ongoing CE. Verify at iaomt.org.
• IABDM
  International Academy of Biological Dentistry and Medicine — a separate professional body for biological dental practitioners, with a focus on biocompatible replacement materials. IABDM membership is not SMART accreditation; verify each on the body's own register.

Frequently Asked Questions