Journal of Nutritional & Environmental Medicine

ISSN: 1359-0847 (Print) 1364-6907 (Online) Journal homepage: http://www.tandfonline.com/loi/ijne20

Mercury from Dental Amalgam Fillings: Studies on

Oral Chelating Agents for Assessing and Reducing
Mercury Burdens in Humans

A. R. HIBBERD M. A. HOWARD A. G. HUNNISETT

To cite this article: A. R. HIBBERD M. A. HOWARD A. G. HUNNISETT (1998) Mercury from Dental
Amalgam Fillings: Studies on Oral Chelating Agents for Assessing and Reducing Mercury
Burdens in Humans, Journal of Nutritional & Environmental Medicine, 8:3, 219-231, DOI:
10.1080/13590849861998

To link to this article: http://dx.doi.org/10.1080/13590849861998

Published online: 13 Jul 2009.

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 Journal of Nutritional & Environmental M edicine (1998) 8, 219231

ORIGINAL RESEA RCH

Mercury from Dental Amalgam Fillings: Studies on Oral

Chelating Agents for Assessing and Reducing Mercury
Burdens in Humans
A. R. HIBBERD P H D DCC P H C FPS MRP H ARM .S, 1 M. A. HOW ARD 2
2
AN D A. G. HUNNISE TT M PHIL P H D
1
Bayswater Clinic, 25b Clanric arde Gardens, London W 2 4JL, UK*; 2 Biolab
M edical Unit, The Stoneh ouse, 9 W eymouth Street, London W 1N 3F F, UK
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Since the early nineteenth century, dentistry has relied mainly on amalgam (approximately
50% metallic mercury (Hg)) for lling teeth. Scienti c research has shown that Hg is
constantly released from amalgams, mainly as Hg vapour (Hg o),which is inhaled, absorbed,
metabolized to ionic Hg (Hg 2 1 ) and distributed throughout the body, mainly bound to
proteins. Dental amalgam is the major source of the body Hg burden. Toxicological research
on amalgam Hg has indicated deleterious effects on the immune, renal, reproductive and
central nervous systems, and oral and intestinal bacteria. Results do not indicate that
amalgam llings are safe. Oral DL -2,3-dimercapto-succinic acid, magnesium salt (DM SA);
2,3-dimercapto-1-propane-sulphonic acid, sodium salt (DM PS); N-acetyl-L -cysteine (NAC)
and potassium citrate B.P. (K Cit.) w ere studied for Hg chelating ability in patients w ho had,
or until recently had, amalgam llings. Based on the increase in urinary Hg concentrations
after single doses, compared with controls, the order of ef cacy was: DMPS plus K Cit., NAC
plus K Cit. and DMSA (each producing an increase of 163% ), then in descending order,
DM SA plus K Cit., DM PS, NAC and K Cit. Very signi cant (p , 0.01) correlations were
demonstrated between post-chelation urinary and post-chelation sweat Hg concentrations
with all agents. Both these parameters may be good indicators of total body Hg burden. The
advantages of employing combined chelating agents w ere examined and some clinically
useful and convenient methods of assessing and reducing Hg burdens suggested.

Keywords: dental amalgam, amalgam mercury, mercury vapour, urine and sweat mercury provocation
tests, oral chelating agents, DMSA, DMPS, NAC, K Cit., ED TA.

INTRODUCT ION
Backgroun d to Am algam Usage and Toxicity
Dental amalgam contains approximately 50% m ercury (Hg) with variable amounts of silver
(Ag), tin (Sn), copper (Cu) and sometimes zinc (Zn). It hardens rapidly, becom ing a solid
solution, not a chem ical com pound. Over m any years, it was erroneously taught in dental
schools throughout the world that am algam was a stable alloy which did not release Hg in
the m outh. However, in an average subject with eight occlusal amalgams, it has been
calculated that approxim ately 120 m g of Hg are released into the m outh per day owing to
mechanical wear, vaporization and dissolution [1, 2]. The amount of Hg absorbed into the
*Current address of A. G. Hunnisett: Park Surgery, Cirencester, Glos GL7 1US, UK.

1359-0847/98/030219-13 $9.50 1998 Carfax Publishing Ltd

 220 A . R . HIBBERD ET AL .

body in this situation is estimated to be 10 m g (range 317 m g) per day [3, 4]. All other
sources (food, water, air) total approximately 2.6 m g/day of absorbed Hg [4, 5]. It is
established that m ercury vapour (Hg o ) is continuously released from am algam llings [69].
The rate of release is enhanced by chewing [2, 6, 7, 9], tooth brushing [8], amalgam
polishing [10], and after hot drinks [11]. Intraoral Hg o levels correlate, before and after
chewing, with the num ber and type of am algam llings [2, 7], plasma Hg levels correlate
with the number and total surface area of amalgam s [12], and Hg levels in hum an milk [13,
14], faeces and urine [15] correlate with the num ber of amalgams.
The evidence suggests that dental amalgams constitute the m ajor source of Hg exposure
in the general population [4, 5, 16]. Human autopsy studies dem onstrate signi cantly higher
Hg levels in the brains and kidneys of subjects with dental am algams [17]. A speci c `no
observed effect level cannot be established for Hg o [4]. This is probably the m ost important
form determining hum an exposure to amalgam llings. The highly lipid soluble vapour
enters the blood from the lungs and oral m ucous m embranes, traverses cell membranes,
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including the bloodbrain barrier and placenta, rapidly partitions between plasma and red
blood cells and becomes widely distributed. Intracellular oxidation of Hg o by the catalase-
hydrogen peroxide complex forms the divalent ion, Hg 2 1 , the proximate reactive toxic
species, which com bines covalently with nearby sulphhydryl groups ( SH ), in, for
example, haemoglobin, reduced glutathione (GSH ), protein cysteine groups, etc. thus
causing enzym e and cellular dysfunction. Hg o dissolved in saliva may also be oxidized to
Hg 2 1 and be swallowed and partially absorbed in the gastrointestinal tract. The urine and
faeces are the major routes of excretion for the covalent com pounds of Hg 2 1 arising as
above [1822]. Additionally, sm all amounts of m ethyl-Hg (Hg 1 ) are produced in the mouth
from amalgam Hg o, possibly via Hg 2 1 [23], and can bind to SH groups.
Body tissues have various retention half-lives for Hg 2 1 and organic (m ethyl or ethyl) Hg,
(Hg 1 ), ranging from days to years. Half-lives may differ with chronic exposure as a result
of com prom ised cellular function (e.g. kidney Hg turnover decreases with age and duration
of exposure)[5, 21, 22]. Because blood and urine Hg levels remain relatively low during Hg
exposure from dental amalgam, they are poor diagnostic indicators of the very high Hg
levels which accumulate in some body tissues as a result of such exposure [21, 22].
Furthermore, there is poor correlation between the urinary excretion of Hg and the
occurrence of dem onstrable evidence of poisoning, and, in som e cases, failure to excrete Hg
is a factor in the development of poisoning [24, 25].
The choroid plexus, an important part of the bloodbrain barrier, acts as a sink for Hg
and other toxic m etals [26, 27]. Additionally, it has been shown that Hg is selectively
concentrated in hum an brain regions (medial basal nucleus, amygdala and hippocampus)
involved with m emory function, and it has been postulated that Hg m ay be im plicated in
the aetiology of Alzheimer s disease (AD) [28, 29]. Further work has suggested a
connection between exposure to inorganic Hg (Hg 2 1 ) and AD [30, 31, 32].
Also giving rise to concern is the nding that Hg released by dental amalgam can
enhance the prevalence of resistance to m ultiple antibiotics in the bacteria of the primate
normal ora [33].
Ongoing research on the pathophysiological effects of amalgam Hg has focused on the
im mune system, the renal system, oral and intestinal bacteria, the reproductive system and
the central nervous system. Research evidence does not support a belief in the safety of
amalgam [22].

Use of O ral Chelating Agents in Diagnosis and Treatm ent of Hg Overload

Therapeutic chelating agents are com pounds which can be administered to a patient for the
reduction of toxic m etals (or their compounds). They form metal complexes with these toxic
metal ions in vivo, which are readily excreted in the urine, faeces, etc. so reducing body
levels of the metals to a less dangerous range [34].
 ME RCURY FRO M DENTAL AMAL GAM FIL LINGS 221

A chelating agent, by de nition, form s a ring compound with a m etal [35]. All the
therapeutic compounds discussed below m ay not form ring compounds with the particular
Hg with which they are reacting; hence, the term com plexing agent may be a better term.
However, the term chelating agent will continue to be used here in the broad sense.
The chelating agents evaluated in this study are: DL -2,3-dimercapto-succinic acid,
magnesium salt (DMSA); 2,3-dimercapto-1-propane-sulphonic acid, sodium salt (DMPS ),
N-acetyl- L -cysteine (NAC), and potassium citrate B.P. (K Cit.).
DMSA, DMPS [3437] and NAC [34, 38] have all been em ployed in the in vivo
chelation of Hg. Because of the ease with which the Hg S linkage is formed with
SH containing com pounds, these three, but particularly DMSA and DMPS, can be used
with advantage for chelation of inorganic (Hg 2 1 ) and organic (Hg 1 ) Hg [34]. K Cit., a salt
of citric acid, can be used to alkalinize the urine to reduce kidney damage owing to
dim ercaprol chelated Hg [39], and citric acid can form complexes with traces of heavy
metals [40]. Additionally, the urinary excretion of the metal aluminium (Al) can be
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enhanced by citric acid [34].

DMPS has been shown to be capable of inducing Hg urinary excretion which
was directly proportional to the total body Hg burden in rats given mercuric chloride
(HgCl 2) or Hg o [44], and thus DMPS could prove to be a useful biological m onitoring or
diagnostic agent for total body burden of inorganic Hg [4143]. Additionally, after
treatment with DMPS, urinary excretion of Hg is signi cantly greater in hum an subjects
with am algams than in similarly treated subjects without amalgam s [42, 44]. At least
two-thirds of this excretable Hg in the urine of those with amalgams appears to be derived
from the amalgam and amounts of Hg excreted correlated with total am algam surface area
[44].
In animal experiments DMSA has been found to be m ore effective than DMPS for
removal of Hg from the body and brain [35], with the exception of the kidney, for which
DMPS was more effective [35, 41]. DMSA removed more organic Hg whereas DM PS
removed m ore inorganic Hg. A combination of DM SA and DMPS removed Hg from most
organs [35].

Safety of the Agents being Studied

DMSA and DMPS: these have been in use as effective chelating agents particularly for Hg,
lead (Pb) and arsenic (As) for many years in Russia (and the USSR), China, Japan,
Germany and the US. They are used orally and parenterally, DMPS more by the latter
route than DMSA [3437, 4144]. Therapeutically effective doses of the agents have
proved to be well tolerated, relatively non-toxic and with a wide therapeutic index. They
are readily excreted by the kidneys with no nephrotoxicity being reported [3537, 41, 45,
46]. They can increase the excretion of Cu, and that of Zn som ewhat, but other trace
elements do not appear to be signi cantly affected when therapeutically reasonable doses
are employed [35].
NAC: the following side effects have been reported after the use of NA as a m ucolytic,
by direct instillation or nubilization, of up to 20% solutions, through a face mask or
mouthpiece, from one to six hourly, in cases of cystic brosis of the pancreas and other
affections where mucolytic therapy is required: bronchospasm , nausea, vomiting, stom atitis
and rhinorrhoea. It should be used with caution in elderly patients with severe respiratory
insuf ciency or in asthmatic patients [47].
K Cit.: Potassium salts should be given cautiously to patients with renal or adrenal
insuf ciency, acute dehydration or heat cramp [48].
W ith all of the above background in mind, it was thought desirable to investigate possible
ways of assessing human body Hg load, and m ethods of removing it, with as little
inconvenience to the patient as reasonably possible.
 222 A . R . HIBBERD ET AL .

M uch m ore has been reported about the parenteral route for chelation of mercury than
the oral route. It was therefore decided, in the hum an situation,

(1) Com pare the abilities of oral DM SA , DMPS and NAC to increase the urinary
excretion of Hg, from whatever source (amalgam s, diet, environm ent amalgams
being the major source) [4, 5, 16].
(2) Determine at what time after oral dosing the Hg excretion rate is m axim al with the
above agents.
(3) Investigate the possible ability of oral K Cit. to increase urinary Hg excretion.
(4) Evaluate the effect of oral K Cit., given at the same time as each of the other agents,
on urinary Hg excretion.
(5) Decide from the data how best to apply a convenient oral test, in the clinical
situation, for the better diagnosis of those patients who may be in need of chelation
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treatment for an abnormal body Hg burden.

(6) Gain useful clinical information from the overall results which could lead to effective
oral chelation courses being employed to reduce abnormal body Hg burdens as
ef ciently as possible.

It was also decided to m easure sweat Hg concentrations, following the dosing with each
chelating agent, and the com binations with K Cit. It was considered worthwhile to
determine whether any relationship existed between post-chelation sweat Hg concentrations
and urinary Hg concentrations. Pre- and post-chelation sweat tests would have been
preferred but, owing to the cost (patients were paying for themselves) and the need for the
patients to be at the laboratory for an hour for each sweat test, only the post-chelation sweat
data were to be obtained in as m any cases as possible at this stage.
The correlations between the number of am algams with plasm a, breast milk, faeces and
urine Hg concentrations have been well recorded [l2, 13, 14, 15] and were not intended to
be re-examined in this study for urine or sweat. However, patients amalgam status has been
recorded.

PA TIENTS AND METHODS

A total of 191 polysymptomatic patients with am algam llings (74.6% ) and some who had,
until recently, had am algam llings (25.4% ) were admitted to this study. The latter group
had not had chelation following am algam removal to reduce the residual heavy m etal load.
Haematology/serum biochem istry screens via the Biolab M edical Unit and the London
Clinic, London W 1 were obtained for all patients considered for the study. Patients with
medical histories of cardiac, renal, hepatic or psychiatric disease, those taking medically
prescribed xenobiotic treatm ent, or those with clearly abnorm al haematology or serum
biochemistry results were excluded from the study.
Of the patients, 12 (6.3%) failed to com plete the required procedures, leaving 179 who
completed the requirements. Ages ranged from 18 to 82 years, with an average of 43.4
years. The group com prised 106 women (59.2% ), average age 42.9 years, and 73 m en
(40.8% ), average age 44.2 years.
NAC as 500 mg powder in gelatin capsules, and DMSA as 500 mg powder in gelatin
capsules, were obtained from Biocare Ltd, Lakeside, 180 Lifford Lane, Kings Norton,
Birmingham B30 3NT, UK. DM PS as a 5% (w/v) sterile solution in 5-ml ampoules
(Unithiol) were manufactured by the Chemical Pharmaceutical Department, M inistry of
Industrial Medicine, St Petersburgh, Russia, and kindly supplied by Professor Dr Med.
Dent. Gerd S. Hausmann, Munich, Germany. K Cit. was obtained from Thornton & Ross,
Hudders eld, UK.
 ME RCURY FRO M DENTAL AMAL GAM FIL LINGS 223

22
20
18
16 N -Acetyl-L-cysteine (30 mg kg 1)
1)

Potassium citrate (5 g single dose)

14
Urine Hg (m g l

DMSA (30 mg kg 1)
12 DMPS (10 mg kg 1)
10
8
6
4
2
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0
0 1 2 3 4 5
Time (h)

FIG. 1. Single dose studies to determine tim es of peak urinary Hg excretion.

Determination of Tim e of M axim al Urinary Hg Concentration ( m g l 2 1

)
Six patients (three male and three female), randomly selected from a group of 18, were used
for each chelating agent. The average age was 43.2 years with a range of 25 to 64 years.
They were not taking any medication or other compounds which could have affected
urinary Hg excretion and had no diagnosed medical conditions. W hen the same patients
were used for m ore than one chelating agent, a period of at least seven days separated the
tests.
Early morning control urines were collected in 50-ml sterile Universal containers. The
patients were instructed to empty their bladders completely after the sample collection.
Each group of six then im mediately received either DMSA (30 mg kg 2 1 in capsules),
DMPS (10 mg kg 2 1 in solution from am poules diluted with sterile water to 100 ml), NAC
(30 mg kg 2 1 in capsules) or K Cit. (5 g dissolved in 200 m l of sterile water) orally, and
test urine samples were collected, as above, at hourly intervals for up to ve hours.
Imm ediately after collection all samples were labelled, refrigerated and analyzed within 24
h of collection. The tim e of maximum urinary Hg concentration was observed from the
means of the results of Hg concentration vs. time (Fig. 1).

Evaluation of the Individual Ch elating Agents, and with K Cit., as Shown by Urinary
and Sw eat H g Excretion
Having determined the tim e of m axim al urinary Hg excretion following oral dosage with
each chelating agent, patients, im mediately after collection of an early morning control
urine, were given, orally, either DMSA (30 m g kg 2 1 ); DM PS (l0 mg kg 2 1); NAC (30 mg
kg 2 1); and/or K Cit. (5 g). These were given on a random basis. Som e results, however,
had been collected during preliminary work using DM SA , prior to the use of the other
agents in the study. This m ade the DM SA group larger than the other groups. Test urines
were collected at the laboratory, 3 h after dosing with DMSA, NAC, K Cit., and when the
rst two agents were given with K Cit., and at 2 h after DMPS alone and with K Cit. All
urine samples were refrigerated im mediately after collection and analysed within 24 h.
Sweat patches were applied when the patient reported at the laboratory, imm ediately
following the collection of the test urine samples. Patches were removed after 1 h and
im mediately analyzed for mercury.
 224 A . R . HIBBERD ET AL .

16.0 146% increase

163% increase 163% increase
(p < 0.01) 163% increase (p < 0.01)
(p < 0.01)
14.0 (p < 0.01)
135% increase
(p < 0.01)
12.0 131% increase
1)

83% increase (p < 0.01)

Urine Hg (m g l

(p < 0.01)
10.0
8.0
6.0
4.0
2.0
0.0
Potassium DMPS DMPS + N -Acetyl-L - N -Acetyl-L - DMSA DMSA +
citrate (n = 20) Potassium cysteine cysteine (n = 65) Potassium
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(n = 18) citrate (n = 22) + Potassium citrate

(n = 16) citrate (n = 22)
(n = 16)

2
FIG. 2. Mean urinary Hg concentrations ( m l ), pre- and post-chelating agent. Chelation period was 3 h except
1

for DMPS and DMPS plus K Cit. when it was 2 h ( h control; 7 post-chelation).

DETER MINATION OF MERCU RY IN URINE AND SWEAT SAMPL ES

The procedure for the collection of sweat samples for trace element analysis was as
previously described [49].
The technique for the m easurement of total Hg in all samples was atomic absorption
spectrophotometry with cold vapour hydride generation [50]. The initial m easurements were
carried out on a Pye Unicam PU 9000 atomic absorption spectrophotometer (ATI Unicam
Ltd, York Street, Cambridge CB1 2PX, UK), and later measurements on a Hitachi Z-8200
Polarized Zeeman atomic absorption spectrophotom eter (Hitachi Scienti c Instruments,
Hogwood Industrial Estate, Finchampstead, W okingham, Berkshire RG11 4QQ, UK). Both
were attached to a Pye Unicam PU9060 continuous ow vapour system. Analyzer settings
were as suggested in the manufacturer s recom mendations and analytical reference book.
All reagents were of analytical grade (M erk (UK) Ltd, Hunter Boulevard, M agna Park,
Lutterworth, Leicestershire LE17 4XN). Inter- and intra-batch precision, measured using
Nycom ed QC material (Nycomed (UK) Ltd, Nycomed House, 2111 Coventry Road,
Sheldon, Birmingham B26 3EA) was , 10% in both cases.

Statistical M ethods Em ployed

The M ann W hitney U-Test was used to analyze differences between the pre- and
post-chelation urinary Hg concentration data for each of the agents employed. Correlation
coef cients were obtained using M icrosoft Excel for W indows 95 (M icrosoft Ltd, Microsoft
Place, W innersh, W okingham, Berkshire RG11 5TP, UK).

RE SU LTS
The single dose studies showed that peak urinary Hg excretion times were as follows:
DMPS and K Cit., at 2 h; DMSA and NAC, at 3 h (see Fig. 1).
The details of the groups given the various agents are as follows (see Fig. 2 and Table
1).
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1 1
TABLE 1. Control and post-chelation Hg levels in sweat ( m g kg 2 ) and urine ( m g l 2 ) with different chelating agents

r(p)
Sweat Hg Urine Hg
Sweat vs. Sweat vs.
Pre-chelation Post-chelation Pre-chelation Post-chelation Pre-chelation Post-chelation
n Mean (SD) Mean (SD) n Mean (SD) Mean (SD) p Value urine Hg urine Hg
a b d
Potassium citrate 12 4.58 (1.4) 18 5.25 (1.6) 9.56 (3.1) , 0.01 0.62 ( , 0.03) 0.62 (, 0.01)
c e
DMPS 12 5.50 (1.7) 20 5.05 (1.7) 11.88 (6.7) , 0.01 0.70 ( , 0.02) 0.62 (, 0.01)
c e
DMPS 1 Potassium citrate 13 6.31 (3.2) 16 5.25 (2.0) 13.8.(6.3) , 0.01 2 0.02 ( . 0.62) 0.81 (, 0.01)
N-Acetyl- L -cysteine 14 5.00 (1.7) b 22 4.52 (2.1) 10.43 (4.6) d , 0.01 0.12 ( . 0.33) 0.70 (, 0.01)
N-Acetyl- L -cysteine 1
b d
potassium citrate 14 5.50 (2.8) 16 5.13 (2.7) 13.50 (9.6) , 0.01 0.29 ( . 0.31) 0.86 ( , 0.01)
DMSA 42 6.52 (4.2) b 65 4.98 (3.5) 13.11 (9.0) d , 0.01 0.29 ( . 0.05) 0.56 ( , 0.01)
b d
DMSA 1 Potassium citrate 18 5.78 (1.9) 22 5.68 (1.6) 13.95 (5.4) , 0.01 0.19 ( . 0.45) 0.77 ( , 0.01)
a
5 No data, bTest started at 3 h after oral chelating dose. c Test started at 2 h after oral chelating dose. d Results at 3 h after oral chelating dose. e Results at 2 h after oral
ME RCURY FRO M DENTAL AMAL GAM FIL LINGS

chelating dose.
r 5 correlation coef cient.
225
 226 A . R . HIBBERD ET AL .

K Cit.; Urinary tests; 18 patients, 10 m en and eight wom en; age, range 2065, average
(av.) 45.6 years; av. number (no.) of amalgams 5 6.8. Of these patients, 12, ve men and
seven women, also had post-chelation sweat tests at the same time as the test urine sample;
age, range 2765, av. 41.3 years, av. no. of am algams 5 7.0.

DM PS; Urinary tests; 20 patients, nine men and 11 women; age, range 2776, av. 44.7
years; av. no. of amalgams 5 9.6. Of these patients, 12, four men and eight wom en, also had
post-chelation sweat tests, as above; age, range 2776, av. 42 years; av. no. of am al-
gams 5 9.8.

DM PS plus K Cit; Urinary tests; 16 patients, nine m en and seven women; age, range
2562, av. 43.1 years; av. no. of amalgams 5 8.8. Of these patients, 13, six men and seven
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wom en, also had post-chelation sweat tests, as above; age, range 2562, av. 44.3 years; av.
no. of amalgams 5 9.6.

NA C; Urinary tests; 22 patients, seven m en and 15 wom en; age, range 2475, av. 43.2
years; av. no. of amalgams 5 7.0. Of these patients, 14, four men and 10 women, also had
sweat tests, as above; age, range 2475, av. 43.6 years; av. no. of am algam s 5 6.9.

NA C plus K Cit.; Urinary tests; 16 patients, six m en and 10 women; age, range 2660,
av. 41.2 years; av. no. of amalgams 5 9.4. Of these patients, 14, ve men and nine women,
also had post-chelation sweat tests, as above; age range 2660, av. 41.7 years; av. no. of
amalgam s 5 9.7.

DM SA; Urinary tests; 65 patients, 24 m en and 41 women; age, range 1882, av. 42.7
years; av. no. of am algams 5 8.0. Of these patients, 42, 17 m en and 25 wom en, also had
post-chelation sweat tests, as above; age, range, 1870, av. 41.2 years; av. no. of
amalgam s 5 8.5.

DM SA plus K Cit.; Urinary tests; 22 patients, eight men and 14 women; age, range 2366,
av. 44.9 years; av. no. of am algams 5 8.0. Of these patients, 18, eight m en and 10 women,
also had post-chelation sweat tests, as above; age, range, 2366, av. 45.3 years; av. no. of
amalgam s 5 8.2.

M ean urinary and sweat test Hg concentrations, as well as statistical data, are set out in
Fig. 2 (urinary data) and Table 1 (urinary and sweat data).
Fig. 2 shows that the m ean pre (control) and post (test) chelation urinary Hg concentra-
tions ( m g l 2 1), for each agent and combination studied, at the previously determined peak
tim es (Hg concentration using K Cit. was determined at 3 h), exhibited highly signi cant
differences (p , 0.01). Each agent and combination showed a positive ability to increase
mean urinary Hg concentration. DM PS plus K Cit. (sets of results, n 5 16), NAC plus K
Cit. (n 5 16), and DMSA (n 5 65) were the m ost effective, showing a m ean increase in
urinary Hg concentration of 163% in each case; in descending order of increase these were
DMSA plus K Cit. (n 5 22), 146%; DMPS (n 5 20), 135% ; NAC (n 5 22), 131% , and K
Cit. (n 5 18), 83% .
Table 1 shows that, in the case of each chelating agent and com bination, the mean
post-chelation urinary Hg concentration was seen to be highly signi cantly (p , 0.01)
increased compared with its control value.
W ith control urinary Hg concentration ( m g l 2 1 ) vs. post-chelation sweat Hg concentration
(ppb) (the sweat test having been started at the same time as the subsequent test
 ME RCURY FRO M DENTAL AMAL GAM FIL LINGS 227

(post-chelation) urine sample was taken), results show that there were signi cant correla-
tions between the above parameters, only with K Cit. (p , 0.03) and DM PS (p , 0.02).
Post-chelation test urinary Hg concentrations ( m g l 2 1) vs. post-chelation sweat Hg
concentrations (ppb) showed highly signi cant correlations (p , 0.01) with all the agents
and combinations employed.

DISCU SSION
Although it had been established that the peak urinary Hg excretion for K Cit. was at 2 h
(Fig. 1), it was decided to give it at the same time as each of the other three agents being
studied. This allowed evaluation of the joint combinations together, over the same times,
which was considered desirable for proper evaluation of possible true synergism. The
results (Fig. 2) show K Cit. to be a useful agent in increasing urinary Hg excretion and that
it im proves urinary Hg excretion produced by DMPS and NAC. The contribution of K Cit.
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to the latter two agents, however, was not synergistic (i.e. results were not seen to be m ore
than the sum of the effects of the agents used separately), or even fully additive with that
of DM PS (determined at 2 h) or NAC, and indeed appeared to reduce the ef cacy of DMSA
(the latter two determined at 3 h).
It appears from these results that the use of K Cit. separately, rather than with DMSA,
may be more effective in the prom otion of urinary Hg excretion, and, in the cases of DM PS
and NAC, K Cit. may be bene cially used with the latter two agents.
DMPS has been shown to be m ore effective than DM SA in increasing the excretion of
kidney Hg [35, 41] and K Cit. is known to facilitate the safer passage of chelated Hg
through the kidney [39], and has been employed as a urinary alkalinizing agent and m ild
diuretic for decades [51]. Thus the fact that K Cit. increased the urinary Hg excretion when
combined with DMPS was not surprising, and the im proved result when K Cit. was
combined with NAC m ay indicate that the latter agent is also effective in removing
kidney-bound Hg. DMSA has been shown to be m ore effective than DMPS in the removal
of Hg from the body (with the exception of the kidney) and brain [35]. The reduced Hg
excretion seen after 3 hours with DMSA plus K Cit., as compared with DM SA alone, is
som ething which will be further investigated.
As shown in Table 1, the highly signi cant (p , 0.01) bene cial increases in urinary Hg
concentrations, com pared with control results, for each agent and combination used
demonstrate a range of useful oral m ethods for reducing body Hg levels. However, DMSA
and K Cit. appear to be better employed separately.
Signi cant correlations between control urine and post-chelation sweat Hg concentrations
occurred only with K Cit. (p , 0.03) and DM PS (p , 0.02). The latter chelating agent is
reported to exert its m ajor effect on kidney Hg [35, 41], which could also apply to K Cit.,
in light of its properties [39, 40, 51]. Both agents, separately, m ay have less effect on sweat
Hg excretion than DM SA , NAC or the com bined agents employed, and this may account
for the results obtained. Further work with these agents, including pre- and post-chelation
sweat Hg excretion, will be needed before rm conclusions can be drawn.
The highly signi cant (p , 0.01) correlations for all agents, and combinations, between
post-chelation urine and post-chelation sweat Hg concentrations is a very interesting
nding. This indicates that both these concentrations appear to be relevant and useful
parameters for the evaluation of the ef cacy of the oral agents em ployed to reduce
body Hg load. Further, it is suggested, by analogy with the parenteral use of DM PS
[41, 42, 43], that these results may be directly proportional to the total body Hg load.
Additionally, results from Fig. 2 and Table 1 indicate that the oral use of DM PS (10 mg
kg 2 1), with or without K Cit. (5 g) 2 h before test urine collection, or DM SA (30 m g kg 2 1 )
alone, or NAC (30 m g kg 2 1), with or without K Cit. (5 g) 3 h before test
urine collection, respectively, would provide `useful diagnostic urinary Hg provocation
tests for assessment of body Hg burden when compared with control urine Hg concentra-
 228 A . R . HIBBERD ET AL .

tions. A sweat test for Hg, started at the same tim e as the test urine collection, would also
provide additional useful data on the total body Hg burden. Thus `urine plus sweat m ercury
provocation tests could provide useful diagnostic information on body Hg load which
arises mainly from amalgam llings [4, 5, 16].
Adverse side effects arising from the single dose procedures described above were
monitored and reported in a small percentage (approximately 5% ) of patients and included
mild gastrointestinal discomfort, mild fatigue, mild mental `fuzziness , m ild headache and
mild diuresis. These side effects usually cleared within 6 h of the dose and were, in most
cases, likely to have been due to heavy m etal m obilization. No case of hypersensitivity to
any of the agents used was seen.

SU GGEST ED METHODS FO R RE DUCT ION OF BODY Hg LOAD

Various oral m ethods, using the agents studied above, have been employed with good
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results, as measured by reduction of Hg levels in follow-up laboratory testing and clinical

im provement in patients Hg-related sym ptoms [52]. Broadly, dosage, length and frequency
of courses, as well as duration of treatment, are dictated by the medical condition of the
patient, including the severity of Hg-related symptoms, size of the body Hg load, and results
of regular haematology, serum biochem istry and appropriate Hg provocation tests, as
described above. The following, therefore, will act as a general guide only:
(1) Oral DMSA (from 2 to 30 mg kg 2 1 daily, divided into three doses) for 2 to 7 days.
Repeat twice with breaks of 3 weeks, then reassess and repeat as considered
necessary to deal with the Hg load. High uid intake (2.5 to 3 l/day) is advisable
while on DMSA . K Cit., 1.5 to 3 g (adult dose) in a glass of water three times a day
after food, for 2 to 7 days between the DMSA courses m ay be advisable to aid the
clearance of heavy metal chelates through the kidney [39], particularly where the
renal history has not been normal. Dosage, length and num ber of courses, of each
agent, must be decided on the basis of laboratory tests, the patient s clinical
condition, and tolerance of the sym ptoms produced because of the m ercury mobiliza-
tion. If hypersensitivity is suspected (e.g. skin rash, etc.) the DM SA should be
stopped.
The periodic laboratory tests should also include data on the patient s trace
elements status (e.g. Zn, Cu, Fe, Chromium (Cr), etc.).
(2) Oral DMPS (2 to 10 mg kg 2 1 daily, as one dose in water) for 2 to 7 days. Then, as
above, including monitoring, except K Cit. (dosage as above) can be used during the
DM PS courses, and will be bene cial in increasing Hg excretion.
(3) Oral NAC (2 to 30 m g kg 2 1 daily, divided into three doses) for 2 to 7 days. Then,
as above, including m onitoring. K Cit., as in (2), will be bene cial in increasing Hg
excretion.
(4) K Cit. (dosage as before) may also be used in courses of up to 7 days, between
courses of DM PS or NAC, to improve Hg clearance. Serum potassium levels should
be m onitored with repeated K Cit. courses. In some cases other citrate salts, such as
sodium citrate, m ay be judged to be m ore appropriate clinically.
It must be appreciated that the successful removal of body Hg burden requires sustained
treatment along the above lines, often for several m onths. Hg binds very tenaciously to
many tissue nucleophilic sites and it requires the persistent spaced application of external
competing Hg binding ligands to displace the endogenously bound heavy metal. A
satisfactory result is achieved when urinary Hg concentration is not more than 1 to 2 m g l 2 1,
and does not rise to more than about 3 to 4 m g l 2 1 after at least two urinary Hg provocation
tests, using oral DMSA (30 mg kg 2 1), at intervals of 2 to 3 weeks.
Retesting after the load appears to have been suf ciently reduced is advisable after 3
months. If Hg seepage is seen, from the results of urinary provocation tests, introduce 0.5
 ME RCURY FRO M DENTAL AMAL GAM FIL LINGS 229

to 1 g DM SA , orally daily, on two to three consecutive days a m onth for three months, then
reassess. Repeat this treatm ent if necessary, and continue with laboratory tests every 3
months for at least two tests until the results are satisfactory. Chelation can then be stopped.
Following this it is advisable to carry out laboratory m onitoring at 6-month intervals, as
further seeping of Hg may occur, and m ust be dealt with for best results to ensue.
Any increase in body heavy metal load (particularly Pb and Hg) owing to environmental
and/or dietary sources will also be controlled by the above procedure.

CONCL USIONS
The chelating agents studied were clinically effective orally for increasing the urinary
excretion of Hg. W hen K Cit. was given with DMPS or NAC the urinary Hg concentrations
were further increased. Results showed that DMSA and K Cit. are better em ployed
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separately to reduce body Hg. Both the post-chelation urinary and sweat Hg concentrations
appear to be useful parameters in the clinical assessment of body Hg burdens in patients
who have been exposed to Hg from dental amalgam , and other sources. All the agents
studied can be employed orally, as discussed above, for the clinical assessment and
reduction of raised body mercury burdens in a way that is convenient to the patient.
This study has indicated that further work to investigate pre and post oral chelation sweat
Hg concentrations, and to correlate these, in each patient, with pre and post oral chelation
urine Hg concentrations, should be done.

ACKNOW LEDGEMENTS
The authors wish to thank Professor Dr Med. Dent. Gerd S. Hausmann, Munich, Germany
for donating an initial supply of Unithiol (DM PS), and, the Biolab Research and Benevolent
Fund (London, UK) for carrying out some of the urine Hg analyses free of charge. W e also
wish to thank Dr Dam ien Downing, senior editor, and Dr Stephen Davies, consulting editor,
Journal of Nutritional & Environmental M edicine, for helpful discussions concerning the
paper.

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