Scenario 4 Your morning patient,Mrs.

Maha Hafez,comes to you distressed because of an article she read on the internet about the dangers of mercury in her amalgam restorations.She is worried that her seven amalgam fillings are poisoning her.She is very concerned not only for her own health but her two young daughters who also have amalgam restorations.Maha doesnt want to replace her fillings if it isnt necessary but needs proof that she and her children are going to be healthy.In order to reassure your patient,you give her advoce based on your clinical experience and judgement;however,she still seems very upset and troubled.You inform her that you will investigate the latest information and get back to her with your findings.She seems more relaxed with thos thought and leaves eager to hear from you soon.

GROUP 2a(d)
1.Khuzaimah bt Khasnulhadi 2.May Thandar Nwe 3.Mazreen bt Mohd Kamal 4.Mohamad Afiq Farhan bin Roslan 5.Mohamad Baihaqi bin Mohd Ramli @ Anuar

PICO Components
P

- Patients with amalgam restoration I - Mercury amalgam filling C - (no comparison) O Adverse effect

Pico and focused clinical question

PICO

question: For patients with mercury amalgam filling, what is the risk to get the adverse effect? Focused Clinical Question: Are there adverse effects of amalgam restoration?

Evidence search PUBMED

Search terms: Dental amalgam toxicity Articles found: 389 Search limit: Random Clinical Trial Articles found: 3 Highest level of evidence:1 Search limits: Meta-analysis Articles found: 3 Highest level of evidence: NA Search limits: Randomized Controlled Trial Articles found: 20 Highest level of evidence: 1b

ADA

EBD Database

Search terms:amalgam Articles found:23 Highest level of evidence:1

Number of articles selected: 2 General criteria for selection: side effects of dental amalgam

Evidence found
Article

1 Complete Reference:Lauterbach M, Martins IP, Castro-Caldas A, Bernardo M, Luis H, Amaral H, et al.J Am Dent Assoc 2008;139(2):138-45. Retrieved from: http://www.ncbi.nlm.nih.gov/pubmed/2023096 1 Why did you select this articles?:

It is a randomized clinical trial addressing the possible relationship between amalgam and the adversely affect on neurological development in children.

Critical appraisal of article: Study subjects were randomly assigned to receive dental treatment with either amalgam or resin-based composite for posterior restorations (and composite for all anterior restorations);which is the same cohort of children used in a previous study.So the randomisation process worked the groups are similar(from baseline characteristic).Apart from the intervention the patients in different group treated equally. Over the 7-year duration of the study, there were slight differences in the percentages of subjects exhibiting any NHSs (including tremor, which was reported separately) between the 2 treatment groups, but the directions of the differences were not consistent from year to year, and the differences were not statistically significant in any year. No statistically significant difference in NSSs--either percentage of subjects exhibiting NSSs or NSS severity scores--was observed between the 2 groups in any year. Summary of evidence related to PICO: exposure to mercury from dental amalgam does not adversely cause neurological development in children.(note:no RR and AR from the abstract)
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Evidence Found
Article 2 Complete reference: Bruce J.Shenker,PHD,Nancy N.Maserejian,ScD,Annie Zhang,Msand,Sonja McKinlay,PhD.2008 139 no. 11 14961505.Retrieved from: http://jada.ada.org/content/139/11/1496.abstr act?sid=4eb5446d-e9c0-4605-bb74e16efc408958 Why did you select this article? : It is a systematic review looking specifically

Critical appraisal of article: The subjects requiring dental restorative treatment were randomly assigned to receive either amalgam for posterior restorations or resin-based composite restorations.There is no baseline characteristics to comparing the randomized groups on a number of variables that could affect the outcome . Because of the small number of participants, the authors acknowledge that the study is exploratory in nature and has limited statistical power.The blinding of the outcome assesor is critical ; subjective. They assessed 66 children, aged 6 to 10 years, for total white blood cell counts, specific lymphocyte (T-cell and B-cell) counts and lymphocyte, neutrophil and monocyte responsiveness across a five-year period. The mean number of tooth surfaces restored during the five-year period was 7.8 for the amalgam group and 10.1 for the composite group. In the amalgam group, there was a slight, but not statistically significant, decline in responsiveness of T cells and monocytes at five to seven days after treatment; the authors consistently observed no differences at six, 12 or 60 months.

Summary evidence related to PICO: Minimal and transient immunotoxic effects of amalgam restoration.(note:no RR and AR from the abstract)
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evidence found

Article 3
Complete Reference: Jennifer Ann Soncini, Nancy Nairi Maserejian, Felicia Trachtenberg, Mary Tavares,and Catherine Hayes.JADA June 2007 138(6): 763-772 Why did you select this articles?

It is a randomized clinical trial researching specifically on the longevity of amalgam restoration.

Level of evidence:1 Critical appraisal of article: Careful assessment of highest levels of evidence in the literature.

Summary of evidence related to PICO: Although the overall difference in longevity was not statistically significant, compomer was replaced significantly more frequently owing to recurrent caries, and composite restorations required seven times as many repairs as did amalgam

Summary of critical appraisal of evidence

Based

on the studies, it is not statistically significant that the use amalgam is toxic and gives adverse effects to the human body. On the contrary, amalgam restorations last longer than other types of fillings.

Clinical applicability

Based on our findings, it is clinically significant to continue using dental amalgam as exposure to mercury from dental amalgam does not cause toxicity to the human body. Therefore, dental practitioners considering this treatment plan for their patients need not be gravely concerned of its toxicity.

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