The long-term oral health consequences of an amalgam phase-out.

Understanding the long-term oral health implications of an amalgam phase-out is complex. However, amalgam is a simpler, cheaper, quicker, more predictable and effective material to place and replace than composite, which is the main alternative. It also has fewer postoperative complications in United Kingdom (UK) primary care and has been shown to be more cost-effective over a lifetime. Existing economic evaluations are limited, however, with rudimentary models which fail to consider clinicians and patients, and likely significantly underestimate the broader costs of placing composite compared to amalgam. Amalgam alternatives require improvement and their environmental impacts require characterisation. Composite restorations can be successful in extensive cavities, but they require much technical skill and expensive and time-consuming specialised equipment, which are not being commonly used in UK primary care, especially by National Health Service (NHS) dentists. Postgraduate composite education is not generally making UK clinicians confident when faced with difficult cavities and requires improvement. Expert consensus on the use of techniques to restore varying cavity presentations with composite would help to guide this, while also considering how its dissemination could be improved. NHS clinician fees are significantly lower than in Europe. The NHS system therefore essentially incentives the use of amalgam and disincentivises the use of expensive and time-consuming recommended equipment for composite restorations. This has likely contributed to a failure of clinicians to upskill and be confident in providing posterior composite restorations safely. These issues, alongside a loss of trust, have led to dentists leaving the NHS, which has created access issues for patients, disproportionately affecting the most at need in society. An amalgam phase-out would almost certainly exacerbate this issue, widening existing health inequalities while not providing restoration characteristics which the most affected patients most value. Failure to urgently address these issues risks an oral health crisis in the UK if amalgam is imminently phased out.