Policy Development Fosters Collaborative Practice

Policy Development Fosters Collaborative Practice

Dental Clinics of North America, 2016-10-01, Volume 60, Issue 4, Pages 921-942, Copyright © 2016 Elsevier Inc.

This article provides an example of interprofessional collaboration for policy development regarding environmental global health vis-à-vis the Minamata Convention on Mercury. It presents an overview of mercury and mercury-related environmental health issues; public policy processes and stakeholders; and specifics including organized dentistry’s efforts to create global policy to restrict environmental contamination by mercury. Dentistry must participate in interprofessional collaborations and build on such experiences to be optimally placed for ongoing interprofessional policy development. Current areas requiring dental engagement for interprofessional policy development include education, disaster response, HPV vaccination, pain management, research priorities, and antibiotic resistance.

Key points

  • The oral health community has responsibilities in interprofessional policy development that affect the general and oral health of the public.

  • Dentistry must assure involvement in science-based responses, with recognized expertise and advocacy, albeit without governmental standing.

  • Professional dental organizations can work to optimally respond, find common ground, and cooperate regarding complicated interprofessional health issues.

  • Establishing interprofessional partnerships enables collaboration on health issues and ensures that those outside of dentistry understand the importance of oral health.

  • The development of the Minamata Convention on Mercury showed the significance of the commitment by oral health stakeholders, sustained longevity of effort, science-based evidence, understanding of policy development ranging from local to global levels, and the dental profession working effectively in interprofessional collaborations.

Introduction

This article provides an example of interprofessional collaboration concerning policy development based on the impact of a global public health problem resulting from environmental accumulation of mercury. Contained are an overview of mercury and the environmental health issues related to mercury, a brief primer of policy and policy stakeholders, and a description of the collaborations including dentistry specifically concerning the Minamata Convention to create global policy to restrict environmental contamination with mercury.

Introduction to the mercury issues warranting global environmental policy development

Mercury in the Environment

Mercury is a chemical element known by the symbol Hg from its former name, hydrargyrum, or liquid silver. It is ubiquitous and found naturally in the environment throughout the world in 3 forms: elemental (or metallic), as part of an inorganic compound (eg, mercuric chloride), or as part of an organic compound (eg, methylmercury and ethylmercury). In its pure, elemental form, mercury is the only metal that is a liquid at room temperature. Mercury has been used to create alloys or amalgams with other metals, produce dental fillings, extract gold from its ores, and help extend the life of dry cell batteries. It can be released as the result of production or improper disposal of several mercury-containing products, including electrical applications (eg, switches and fluorescent lamps), paints, batteries, chlor-alkali, seed grain fungicides, scientific instruments (eg, thermometers and barometers), dental amalgam, topical antiseptics, antibacterial salves, and skin-lightening creams.

Global mercury assessment is intended as a basis for decision making, with an emphasis on anthropogenic emissions (mercury going into the atmosphere) and releases (mercury going into water and land); that is, those associated with human activities. An estimated 5500 to 8900 tonnes (1 tonne = 1000 kilograms) are emitted and reemitted to the atmosphere from 3 sources:

  • 1.

    Naturally (10%) from geological weathering and geothermal activity

  • 2.

    Anthropogenic (30%), mostly from artisanal and small-scale gold mining and coal burning

  • 3.

    Reemissions (60%) of previously released mercury that has built up over decades and centuries in surface soils and oceans without a determinable original source

A comparison of percentage of sector contributions to total anthropogenic emissions is shown in Table 1 , including cremation attributable to dental amalgams. North American emissions are notable at roughly 3% of total global emissions. Local and regional mercury depositions throughout the world have gradually increased contamination levels in the environment to the point that countermeasures have been enacted in recent decades to reduce anthropogenic mercury emissions. Because of long-range distribution and transport of mercury globally, nations with minimal mercury releases and other areas remote from industrial activity may be adversely affected. For example, increased mercury levels are observed in the Arctic, far from the sources of any significant releases.

Table 1
Global emission inventory, 2010, by-product/unintentional (B/U) and intentional (I) assessed sectors by percentage of total anthropogenic emissions
Adapted from UNEP. Global mercury assessment 2013: sources, emissions, releases and environmental transport. Geneva (Switzerland): UNEP DTIE Chemicals Branch; 2013. Available at: http://www.unep.org/PDF/PressReleases/GlobalMercuryAssessment2013.pdf ; with permission.
Sector Percentage
(I) Artisanal and small-scale gold mining 37
(B/U) Coal burning 24
(B/U) Primary production of nonferrous metals 10
(B/U) Cement production 9
(B/U) Large-scale gold production 5
(I) Consumer product waste 5
(B/U) Contaminated sites 4
(B/U) Primary production of ferrous metals 2
(I) Chlor-alkali industry 1
(B/U) Oil refining 1
(B/U) Mine production of mercury 1
(B/U) Oil and natural gas burning 1
(I) Cremation (dental amalgam) a <1

a Does not include preparation of dental amalgam fillings and disposal of removed fillings containing mercury.

Although natural emissions of mercury into the environment continue, human activities have exceeded natural emissions over the last 200 years and need to be controlled. Mercury can be repeatedly mobilized, deposited, and remobilized between air, water, and soil indefinitely. Although many countries have shown reductions of use and release of mercury, mercury can be transported by wind and ocean currents so it can only be controlled effectively by coordinated global programs.

Furthermore, mercury is very noxious to human health, particularly to fetal and childhood development. Each form has its own toxicologic profile, affecting the nervous, digestive, and immune systems, and specific organs such as lungs, kidneys, skin, and eyes. In adults, exposure to excessive levels of mercury has been linked to reduced fertility, brain and nerve damage, and heart disease. Hence, mercury is a global threat to human and environmental health, with organic mercury generally considered the most toxic, followed by elemental mercury, and then inorganic mercury.

Mercury Use in Dental Amalgam

Dental amalgam has been used widely as a restorative dental material since the early 1800s. The clinical properties of amalgam, including its ease of placement, high compressive strength, low cost, and long-term survival rates, remain largely unrivaled. During the past decades, a decrease in the use of dental amalgam and a corresponding increase in the use of tooth-colored restorative materials such as dental composites has occurred, primarily driven by esthetics.

Since the inception of dental amalgam, claims have been made about the possibility of detrimental health effects caused by the mercury in its mix. The health concerns and debates over the use of mercury in amalgam restorations are not new. For more than a hundred years, numerous assertions have implicated dental amalgam for causing or contributing to neurologic diseases, adverse health conditions, and toxic illnesses. No evidence for these assertions has been found by well-designed clinical studies. Two clinical trials sponsored by US National Institutes of Health National Institute of Dental and Craniofacial Research (NIH-NIDCR) involving more than 1000 children in Portugal and the US New England region, evaluating the potential effects of mercury from amalgam, provide sound data supporting the continued use of dental amalgam. These two children’s amalgam trials found no adverse effects in the 5 years following the placement of dental amalgam. Nonetheless, increasing concern over mercury in the environment has led to a worldwide movement against dental amalgam.

Dental Mercury in the Environment

Dental amalgam mercury release from cremated bodies is measurable at the global level (see Table 1 ). Although the amount emitted contributes to less than 1% of the global burden (as measured from cremation), the amount is estimated to be about 3.6 tonnes. Mercury may also be emitted during the preparation and disposal of fillings. In 2005, ENVIRON International Corporation, with funding from the American Dental Association (ADA), prepared a scientific assessment that calculated the amount of mercury attributable to amalgam wastewater that is discharged in effluent from US sewage treatment plants into surface water. This scientific assessment found that a total of approximately 0.4 tons of mercury enters surface water each year. The US Environmental Protection Agency (EPA) oversaw the validation of this approach and principally agreed with ENVIRON’s conclusions. Therefore, dental amalgam represents a small but quantifiable part of the overall mercury burden worldwide.

The EPA, among other efforts to limit human-related environmental contamination with mercury, seeks reduction of mercury release into the environment from dental offices. The Clean Water Act (CWA) was established in 1948 to give federal and state EPA, and even local municipal sewerage authorities, direct legal authority to protect waterways by limiting the discharge of mercury in all its forms, including the mercury in amalgam. The EPA sets broad minimum requirements in which states can elect to be more stringent. Typically, states regulate waste by granting permits to a municipal sewerage treatment plant, often referred to as the publicly owned treatment works (POTW). The permit limits the total amount of chemicals, such as mercury, the plant may discharge. POTW can either remove pollutants that enter the plant or limit their discharge into its sewerage system.

The EPA and the ADA are long-time collaborators on seeking means to reduce dental mercury environmental release. The ADA included amalgam separators as part of the ADA best management practices in October 2007. The EPA, the National Association of Clean Water Agencies, and the ADA have common commitments to reduce mercury levels in the environment through voluntary dental amalgam wastewater reduction measures. A key component of the ADA best management practices is recycling. Working with the EPA and recyclers, the ADA has been leading efforts to develop a national consensus standard for the use of amalgam separators to recycle waste amalgam in the dental office. The ADA has tested, according to ISO standards, amalgam separators that are available in the United States and have published peer-reviewed articles in its journal on the qualities of alternative brands and how dentists should choose a separator.

Estimates of mercury consumption include dental applications and are shown in Table 2 . Total consumption seems to be highest in the east/southeast Asia region, where it approaches twice that of the next highest region. The relative contributions to consumption via dental application is around one-third of total consumption for several regions. The North American region, although it has the third highest total, is has a low percentage from dental applications.

Table 2
Percentage of average selected dental applications (estimated from cremation and dental use) of total mercury consumption by world region, 2010, ordered by total mercury consumption
Adapted from AMAP/UNEP, 2013. Technical background report for the global mercury assessment. Geneva (Switzerland): Arctic Monitoring and Assessment Programme, Oslo, Norway/UNEP Chemicals Branch; 2013. p. vi. 263; with permission.
World Region Total Estimated as Dental Application (%)
East and southeast Asia 504 13.3
European Union (27 countries) 253 35.6
North America 213 16.0
South Asia 129 18.6
South America 100 33.0
CIS and other European countries 63 15.9
Middle-eastern states 53 30.2
Central America and the Caribbean 47 36.2
Sub-Saharan Africa 34 17.6
North Africa 20 25.0
Australia, New Zealand, and Oceania 17 23.5
Total 1433 21.4

Patient Care and Economic Considerations

Dental caries, although largely preventable, is the most common chronic disease, reaching across the human lifespan, not only in the United States but also worldwide. For restoration of dental caries, to date, tooth-colored materials are inferior to amalgam as fillings, especially for posterior teeth: they are far more technique sensitive, have lower clinical survival rates, are more expensive, and are far more difficult to adapt to proper tooth form under restricted clinical conditions such as in developing countries. In addition, economically, no adequate alternative for dental amalgam exists. Amalgam’s combination of durability and low cost is unmatched by any other dental restorative material. Chadwick and colleagues, found that, “When the initial cost and the longevity are considered together, resin composite turns out to be from 1.7 to 3.5 times more expensive than amalgam.” Multiple economic evaluations comparing the use of dental materials, including dental amalgam, have shown that dental amalgam is more cost-effective and cost-beneficial than tooth-colored alternatives, and it has a longer functional time and lower theoretic cost per year of function.

Banning the use of dental amalgam globally would have a strong economic impact from a dental perspective, particularly for practice in resource-poor locations. The impact would be most pronounced in low-income countries with limited access to dental materials, underfunded health care delivery systems, and/or inadequate numbers of practitioners trained to provide safe and effective alternatives. Studies have estimated the macroeconomic impact of regulating or banning the use of amalgam restorations in the United States. Beazoglou and colleagues estimated the direct costs of a ban on the use of amalgam restorations: a ban on their use in children and young people aged 0 to 19 years would increase dental expenditures by about $1.1 billion per year (totaling $13 billion from 2005 through 2020). Banning amalgam in the United States is estimated to increase dental expenditures by about $8.2 billion in the first year and lead to an increase of $98.1 billion from 2015 through 2020, based on an estimate of an average increase of $52 per restoration.

Introduction to policy development in oral health

The environmental laws that regulate the disposal of mercury from dental amalgam rely on a conservative approach to effluent limits because it is not known what happens to substances in the environment hundreds or thousands of years in the future. Experts do know a lot about the clinical safety of dental amalgam and mercury in patients because of the volume of peer-reviewed scientific studies that have been published over the past several decades. For providers who are not familiar with environmental laws, the use of environmental modeling assumptions of questionable scientific validity, uncertainty factors, safety factors, and the shifting burden of proof to the provider or alleged polluter can be bewildering and seem patently unfair. A review of policy and public policy is presented here before moving to the specifics of the Minamata Convention. It should be noted that the Minamata Convention applies at the global level, pending adoption at the country level, and having implications at local and professional levels.

Overarching Definition and Context of Policy Development for Oral Health

There is no universally agreed-on definition of the word policy. The term is used in different ways in different contexts. The Merriam-Webster dictionary ( http://www.merriam-webster.com/ ) provides several definitions of policy, including:

  • “A definite course or method of action selected from among alternatives and in light of given conditions to guide and determine present and future decisions”

  • “A high-level overall plan embracing the general goals and acceptable procedures especially of a governmental body”

Those related definitions capture some of the key attributes of policy making: it involves general agreement on goals and a broad roadmap on the actions that would help achieve those goals. In many ways, policy making can be thought of as a type of decision making. Governments, institutions, and organizations vary in the policy-making processes, but in general policy making comes down to a decision by a governing body. In most situations, policy development involves receiving input from key stakeholders, negotiation, and compromise. Policy making in oral health is no exception to that general rule. The diversity of opinion among stakeholders requires that various constituents within and outside of the oral health community come together to reach mutually agreed-on goals and chart the broad pathway to achieve them.

Public Policy Processes

Governments enact public policies in many domains that directly or indirectly affect population oral health, including but not limited to health care, education, food, water, licensure, and environment. Governmental policy is frequently reflected in legislative and regulatory action (ie, laws and regulations), and the actions supporting a set of agreed-on goals therefore enter the political realm. In the United States, policies that affect oral health are enacted at every level of government. For example, federal policy governs the mechanism of federal funding for dental research, national surveillance of oral diseases, safety of oral health workers, and mandated coverage of children’s dental services under Medicaid. State policies affect domains such licensure and scope of practice of oral health personnel and facilities, support for public universities and oral health training programs, and level and mechanism of reimbursement for Medicaid services. Both federal and state environmental policies affect factors such as the manufacture, use, and disposal of dental materials. Local government policy affects factors such as community water fluoridation, zoning for health care facilities, and school health programs. It is worth mentioning that there are influences on policies in North America from global ministries such as the World Health Organization (WHO) with the Pan American Health Organization as the regional component for the Americas, and the United Nations Environment Programme (UNEP). For oral health issues the organizations involved include the Oral Health Programme at WHO (Headquarters in Geneva, Switzerland; http://www.who.int/oral_health/en/ ) and the Environment Program at UNEP (Headquarters in Nairobi, Kenya; http://www.unep.org/About/ ). Both have regional offices as well, in the Americas, Africa, eastern Mediterranean, Europe, southeast Asia, and western Pacific.

The development of a global health treaty, and hence global public policy, requires a detailed process and involvement from the members of the United Nations (UN) and WHO. For example, in this article, the UNEP initiated the policy development because the issue is based on environmental contamination that caused public health concerns from the global production, transport, and release of mercury in the environment. Numerous reports were generated to collect the scientifically valid evidence and a process to develop a legally binding instrument (LBI) with an intergovernmental negotiating committee (INC) established to prepare it ( Fig. 1 ) . The meetings of the INC are numbered to help follow the process; for example, the first meeting is INC1. When the LBI is generated it is reviewed by the global governmental representatives. A convention is held for the signing of the LBI, which is named after the convention, by the representatives. On agreement the representatives take the convention to their countries (parties) for approval, called ratification. On reaching 50 ratifications, the convention becomes a treaty to be enacted by the ratifying parties. The process is enhanced by regional and other subgroup meetings outside of the INC meetings. The LBI can be further modified during the process of ratification. Research archives on treaties can be found at http://research.un.org/en/docs/law/treaties . Details on the process (eg, of the Convention on the Rights of Persons with Disabilities) can be seen in the Handbook for Parliamentarians on the Convention on the Rights of Persons with Disabilities at http://www.un.org/disabilities/default.asp?id=212 .

UNEP global mercury program (a twin-track approach). GC, governing council; OEWG, open-ended working group.
Fig. 1
UNEP global mercury program (a twin-track approach). GC, governing council; OEWG, open-ended working group.

Regardless of the level of government, policy development is often the result of advocacy, input, analysis, and negotiation. Examples in the United States of resources on policy making and the importance of information to congress include a 2009 review by Stine, and a focus in academic research is a 2015 thesis by Schneiderman. UNEP has developed the Toolkit for Identification and Quantification of Mercury Releases to assist countries in undertaking such work. The toolkit is available at the UNEP Web address ( www.chem.unep.ch/mercury/Toolkit/default.htm ).

Policy Among Several Nongovernmental Stakeholders

Many organizations and institutions enact their own specific policies that reflect their goals, often with a set of supporting recommendations or actions on how to achieve them. Most major dental and public health organizations have a formal policy-making mechanism. Overviews of the major policy-making oral health organizations in the United States involved with the Minamata Convention are presented here.

The American Association for Dental Research (AADR) is a nonprofit organization with more than 3700 members in the United States. AADR’s mission is to advance research and increase knowledge for the improvement of oral health, support and represent the oral health research community, and facilitate the communication and application of research findings ( http://aadr.org/i4a/pages/index.cfm?pageid=3452#.Vp2l-fkrJdg ). AADR currently has policy statements in effect and is heavily involved in advocacy at the federal level in support of its mission.

The ADA, the largest and oldest member organization representing dentists in the United States, with more than 158,000 members, enacts policy through the input of multiple levels of the organization. ADA’s 11 councils serve as policy-recommending bodies within their specific areas of expertise. The House of Delegates (the 480-member governing and legislative body of the ADA representing the constituent [state] dental societies, the federal dental services, and dental students) has sole authority to formally enact policy for the association (ADA Constitution and Bylaws 2015; https://www.ada.org/∼/media/ADA/Member%20Center/FIles/ADA_2015_Bylaws.ashx ). The ADA currently has several hundred policies in effect, reflecting the organization’s position on a wide range of topics relevant to oral health and safe practice of dentistry ( http://www.ada.org/en/member-center/leadership-governance/∼/media/1156718AF2E042D08AA6C3677A604C35.ashx ). The ADA also seeks to influence public policy through advocacy and lobbying.

The American Public Health Association (APHA) champions the health of all people and communities ( http://www.apha.org/about-apha ). Health policy is a major focus of this organization, which is more than 140 years old and brings together more than 25,000 members from all fields of public health. Through its policy statement proposal process, the various components within APHA work together to establish formal evidence-based position statements on public health issues, which helps guide the organization’s advocacy efforts and enables each community within the larger organization to leverage the capability and visibility of APHA to help achieve its goals. Policy statement proposals are voted on by the APHA Governing Council, the representative legislative body of the association. Successful policy statement proposals generally come about through collaboration and compromise because they must satisfy the goals and perspectives of the general public health community. APHA currently has approximately 1400 policy statements in effect ( http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database ). The APHA Oral Health Section, with nearly 500 members, is one of 31 member sections within APHA, and, as part of a large, diverse public health organization, has unique opportunities to ensure an oral health perspective, as well as challenges when the perspectives within and among various sections and interest groups are not completely aligned, thus making collaboration, negotiation, and compromise key to advancing a dental public health agenda.

All 3 of these US-based organizations are major components in their respective international networks. The AADR is the largest division of the International Association for Dental Research (IADR), whose primary mission is to advance research and increase knowledge for the improvement of oral health worldwide ( http://www.iadr.org/i4a/pages/index.cfm?pageid=3283#.Vp5QlvkrJdg ). The ADA is the US National Dental Association member of the World Dental Federation (FDI), which represents the global dental profession to international, intergovernmental, governmental, voluntary, and other organizations ( http://www.fdiworldental.org/about-fdi/mission/the-voice-of-dentistry.aspx#sthash.j8H5Igi7.dpuf ). The APHA is a member of the World Federation of Public Health Associations (WFPHA), whose mission is to promote and protect global public health. The WFPHA is accredited as a nongovernmental organization (NGO) in official relations with the WHO ( http://www.wfpha.org/about-wfpha ).

Governmental Policy Development Specific to the Minamata Convention on Mercury

In parallel with other activities concerning environmental mercury, in 1997, the WHO held a consultation meeting on the use of dental amalgam. The objective of this consultation was to provide more information to the member states. WHO Oral Health was requested to review again the WHO/FDI consensus statement and if necessary draft a relevant document on dental amalgam use, taking into account the benefits but also the risks for individual, occupational, and environmental health of restorative materials. The project was thoroughly scrutinized by the WHO Programmes on Environmental Health and Occupational Health. The consensus statement on restorative dental care also emphasized the need for further research on alternatives to dental amalgam. These actions show that global attention to amalgam predates the Minamata Convention process.

In 2001, UNEP agreed to conduct a global assessment of mercury and its compounds, including information on the health effects, sources, long-range transport, prevention strategies, and control technologies, hence starting the process that led to the Minamata Convention. In 2003, significant evidence was published of large-scale global harm from mercury and its compounds, warranting further international action to reduce the risks to human health and the environment.

In 2009, the UNEP Governing Council mandated the development of a global LBI on mercury because it was determined that voluntary actions to control mercury waste were insufficient and that there was a need for an LBI. An INC was established to prepare an LBI on mercury ( http://www.unep.org/chemicalsandwaste/Mercury/ReportsandPublications/GlobalMercuryAssessment/tabid/1060889/Default.aspx ).

Also in 2009, the WHO Global Oral Health Program organized a meeting in Geneva, Switzerland, in cooperation with UNEP. From this meeting, a report on dental restorative materials concluded that dental amalgam is an effective restorative material. Consequently, the report Future Use of Materials for Dental Restoration highlights the current scientific evidence on dental materials, including amalgam and nonamalgam restorative materials, and gathered information for future recommendations on the use of dental restorative materials, paying key attention to avoiding environmental pollution. The comprehensive review pointed out that existing alternative materials to dental amalgam are not ideal because of limitations in their durability, fracture resistance, and wear. The report also notes the widespread public health threat from any proposed or impending ban of dental amalgam. Long term, it was critically important for WHO, FDI, IADR, and national dental associations to increase global awareness about the importance of the relationship of oral health to general health and well-being by emphasizing the value of risk assessment, prevention, disease management, and minimal intervention care. Preventing and managing oral diseases diminishes the need to use amalgam and other restorative material alternatives.

During this 2009 WHO meeting, consideration was given to the importance of strengthening oral health promotion and disease prevention as the strategy to reduce the use of restorative dental materials. In the case of tooth decay, the best care possible should be provided to meet patients’ needs. The meeting recognized the variation in dental practice among countries and the challenges faced by middle-income and low-income countries providing dental care, hence likely resulting in different approaches to dental caries management in different countries that need to be considered in oral health policy, training personnel, and development and planning of specific public health programs. It was noted that only a few countries, of high income, had initiatives to phase out the use of amalgam.

Among countries using amalgam, additional costs, especially if not part of their current systems, would be added by requiring systems for waste management to prevent environmental release of mercury to the environment. Following a review of existing evidence and much deliberation, the meeting recognized the huge challenges faced in dental restoration, disease prevention, and oral health promotion globally. As a result, the meeting considered that all currently existing methods and materials to manage dental caries need to remain available to dental professions in the short and medium terms.

Furthermore, the meeting noted that although alternative dental restorative materials may be desirable from an environmental health perspective, a progressive move away from dental amalgam would depend on adequate quality of these materials. Existing alternative dental materials are not ideal because of limitations in durability, fracture resistance, and wear resistance. Therefore, the meeting recognized the need for strengthening of research into the long-term performance, possible adverse effects, and viability of such materials.

Consideration of phasing down instead of targeting to phasing out dental amalgam arose at this 2009 WHO meeting. A multipronged approach with short-term, medium-term, and long-term strategies should be considered. Alternatives to dental amalgam exist but the quality of such materials needs to be further improved for use in public health care. The meeting suggested important strategies that can be put in place while waiting for new materials to be developed. The roles of WHO, UNEP, and NGOs such as the IADR and the FDI, user groups, and industry were seen as critical and it was decided that further meetings must be convened to discuss the way forward and to develop strategies to address issues in both developed and developing countries.

The Minamata Convention on Mercury

In January 2013, at the conclusion of INC5, the INC agreed on the text of what is now The Minamata Convention on Mercury. More than 750 participants attended that session, representing 137 governments, as well as 57 nongovernmental and 14 intergovernmental organizations. Hence, wording was agreed on by 147 nations. Following a round of regional group meetings, delegates to the convention addressed several complex policy and technical issues, including mercury air emissions and releases to water and land, health aspects, and the phase-out (ban) and phase-down (limits and control) dates for specified products and processes.

The Minamata Convention text was formally adopted in Japan on the 10 October 2013 and was made available to countries for signature. The main objective of the Minamata Convention was to protect human health and the environment from anthropogenic emissions and releases of mercury and mercury compounds ( www.mercuryconvention.org ). The convention establishes a range of measures to control the supply and trade of mercury. It sets limitations on mercury sources, such as primary mining, small-scale gold mining, manufacturing processes, and mercury-added products.

The convention title of Minamata has historic and health significance. Minamata disease was first seen in Japan in 1956 at Minamata. The illness is a form of severe methylmercury poisoning. Between 1932 and 1968, an industrial acetaldehyde plant released massive amounts of effluents containing methylmercury compounds into Minamata Bay and subsequently, into the Minamata River and the Shiranui Sea. The methylmercury bioaccumulated in the fish, shellfish, and the large marine life, which constituted much of the local diet. The mass exposure led to severe, chronic poisoning to more than 200,000 residents of the coastal areas. Since the Minamata disaster, there has been a growing international awareness and need to control the anthropogenic sources of mercury.

Some of the key elements of the Minamata Convention were to control mercury by banning new mercury mines, phasing out of existing mines, controlling measures on air emissions and surface water releases, regulating artisanal and small-scale gold mining, and banning, phasing out, or limiting (phasing down) specified mercury-added products. At the end of 2015 there were 128 nation signatures and 20 ratifications, and as this article goes to press at the end of March 2016 there are 25 ratifications ( http://www.mercuryconvention.org/Countries/tabid/3428/Default.aspx ). The convention shall enter on the ninetieth day after the date of deposit of the fiftieth instrument of ratification, acceptance, approval, or accession (article 31, item 1), which means that the convention will come into force as a treaty, once it has been ratified by 50 signatory countries. It becomes law in the ratifying countries only.

Coverage of Dental Amalgam in the Minamata Convention Process

Because dental amalgam contains mercury, its environmental impact was considered, debated, and addressed in the convention/treaty negotiations. In the initial draft, dental amalgam was included in the list of industrial mercury-added products to be phased out or banned. WHO Oral Health took the lead to create text to phase down the use of dental amalgam. With this input and collaborative efforts, it was agreed that dental amalgam use would be included as a phase-down, without a specific time frame. The statement is shown in Box 1 .

Box 1
Provisions from the Minamata Convention on Mercury for dental amalgam
From Minamata Convention on Mercury: texts and annexes. 2013. Available at: http://www.mercuryconvention.org/Portals/11/documents/Booklets/Minamata%20Convention%20on%20Mercury_booklet_English.pdf . Accessed April 7, 2016; with permission.

Measures to be taken by a party to phase down the use of dental amalgam shall take into account the party’s domestic circumstances and relevant international guidance and shall include 2 or more of the measures from the following list:

  • 1.

    Setting national objectives for dental caries prevention and health promotion, thereby minimizing the need for dental restoration

  • 2.

    Setting national objectives for minimizing its use

  • 3.

    Promoting the use of cost-effective and clinically effective mercury-free alternatives for dental restoration

  • 4.

    Promoting research and development of quality, mercury-free materials for dental restoration

  • 5.

    Encouraging representative professional organizations and dental schools to educate and train dental professionals and students on the use of mercury-free dental restoration alternatives and on promoting best management practices

  • 6.

    Discouraging insurance policies and programs that favor dental amalgam use rather than mercury-free dental restoration

  • 7.

    Encouraging insurance policies and programs that favor the use of quality alternatives to dental amalgam for dental restoration

  • 8.

    Restricting the use of dental amalgam to its encapsulated form

  • 9.

    Promoting the use of best environmental practices in dental facilities to reduce releases of mercury and mercury compounds to water and land

Coordinated efforts by parties described later led to the separation of dental amalgam for phase-down considerations rather than the general phase-out. Although there are 9 provisions in the Minamata Convention for phasing down dental amalgam, to be compliant with the convention wording, governments do not need to adopt all of the provisions but must implement at least 2 of these provisions. The wording was designed to allow significant flexibility to account for local circumstances. This flexibility means that each country has options to comply with it as a treaty in its own unique way.

Throughout the process the FDI/ADA and IADR representatives conducted multiple meetings with the US and other national delegations. FDI and IADR representatives presented formal, scientifically based interventions throughout the negotiations. The verbal and written statements were designed to protect the environment and to safeguard oral health care, eliminating the risk that an amalgam ban would slip through the treaty negotiations without a thorough vetting. WHO emphasized the importance of strengthening dental caries prevention, which would contribute to reducing the need for any restorative dental care. The WHO Oral Health, FDI/ADA, IADR, International Dental Manufacturers (IDM), and other respected health care organizations were aligned in principle on supporting prevention efforts and advocating for research to develop safe and effective alternative treatment options. Dentistry collectively argued against a ban and in favor of a public health (prevention) approach to the issue. A concerted effort to focus on preventing dental disease, combined with responsible handling of amalgam waste and funding for research for alternative materials would reduce the use of amalgam (and limit its environmental impact) and promote public health.

American Dental Association Involvement with Expertise and Advocacy

The ADA actively participated in the UNEP INC process since its launch in 2009. Although the ADA did not have a formalized, NGO relationship with UNEP, the ADA was involved in providing its scientific acumen as representative members of the FDI and the IADR delegations. In addition, the ADA worked closely with the US State Department, the EPA, and the US Food and Drug Administration (FDA) to inform those who did not fully understand the negative public health impact that would result from banning a safe and cost-effective dental restorative material. The ADA helped to inform the US delegation during those meetings about the positions that were advocated for by the WHO, ADA, FDI, IADR, organized dentistry, and its stakeholders.

From the beginning of the UNEP INC process, the ADA responded to the possibility that the INC political process would interfere with the doctor-patient relationship. Issues were immediately raised by national dental associations throughout the world about government representatives who did not understand the oral health consequences that would result from banning or limiting the use of safe and effective dental restorative materials. In response to those concerns, the ADA worked with the FDI and IADR to advocate on behalf of the public and the profession about the potentially negative public health impact that could result from a ban on dental amalgam, both in the United States and throughout the world. ADA representatives to the FDI and the IADR delegations provided professional expertise and regulatory guidance to work in tandem with the WHO to help make clear to government delegations participating in the INC meetings that dental amalgam should not be equated or confused with elemental mercury, inorganic mercury, or organic mercury compounds.

The ADA provided extensive scientific evidence on its Web site, ADA.org , from well-designed laboratory and clinical studies from numerous health care organizations, including the US Centers for Disease Control and Prevention, FDA, WHO, and FDI. The professional organizations were in agreement that dental amalgam is a safe and effective cavity-filling material. Other science-based professional organizations, such as the Alzheimer’s Association, American Academy of Pediatrics, Autism Society of America, and National Multiple Sclerosis Society, also made clear that dental amalgam does not create adverse health conditions or cause identifiable diseases ( http://www.ada.org/en/press-room/press-kits/dental-fillings-press-kit/dental-amalgam-what-others-say ). As clearly stated by the FDA, although high levels of exposure to elemental mercury have been associated with adverse health effects, the levels released by dental amalgam fillings are not high enough to cause harm in patients ( http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DentalProducts/DentalAmalgam/ucm171094.htm ). Consistent with the EPA’s position, the Scientific Committee of the European Commission also addressed safety concerns for patients, professionals, and the use of alternative restorative materials. The committee independently concluded that dental amalgams are effective and safe, both for patients and dental personnel, and also noted that alternative materials have clinical limitations and toxicologic hazards ( http://ec.europa.eu/health/scientific_committees/consultations/public_consultations/scenihr_consultation_24_en.htm ).

The ADA followed through with letters to the US State Department, reiterating its evidence-based scientific rationale to promote health and address environmental concerns. In addition to the ADA, several US professional organizations sent letters to the State Department expressing their respective evidence-based views on dental amalgam in support of protecting the public’s health. The Academy of General Dentistry, American Academy of Pediatric Dentistry, American Academy of Periodontology, American Association of Oral and Maxillofacial Surgeons, American Association of Orthodontists, and the Hispanic Dental Association all expressed their concerns. The US Association of State and Territorial Dental Directors also supported the unique opportunity to implement an oral health care model, based on disease prevention, health promotion, and materials science research. These congruent measures have helped to ensure optimal oral health, particularly for the most disadvantaged patients in need of dental care in the United States and throughout the world.

International Association for Dental Research Involvement as Facilitator and Science Advocate

In addition to partnering with the FDI, ADA, IDM, and the WHO Oral Health Programme, IADR made substantive contributions to the 2009 WHO and UNEP meeting on Future Use of Materials for Dental Restoration . In 2010, the IADR was accepted into the UNEP Global Mercury Partnership. IADR shared the overall goal of the UNEP partnership, which was “to protect human health and the global environment from the release of mercury and its compounds by minimizing and, where feasible, ultimately eliminating global, anthropogenic mercury releases to air, water and land. ”

IADR hosted and published the proceedings of the Dental Materials Innovation Workshop (DMIW), which took place December 10 to 11, 2012, at King’s College London. The meeting was sponsored by IADR, WHO, UNEP, FDI, and King’s College London Dental Institute. The proceedings are published in the November 2013 issue of the IADR/AADR Advances in Dental Research , an E-supplement to the Journal of Dental Research . The DMIW was timed as part of IADR’s commitment to the UNEP Global Mercury Partnership and as an NGO participant in the UNEP negotiations to develop the Minamata Convention on Mercury.

The IADR participated in the UNEP negotiations along with the FDI, the ADA, and the IDM. Working as a team, the dental NGOs advocated that a phase-down of dental amalgam was only possible with enhancement of dental prevention, further research on suitable alternatives, and the use of best management practices for dental amalgam waste. Those provisions are largely intact in the signed convention.

World Federation of Public Health Associations/American Public Health Association

As an accredited NGO in official relations with the WHO, the WFPHA collaborates with the WHO to advance public health through the promotion of prohealth policies, strategies, and best practices around the world. The federation also holds consultation status with the UN Economic and Social Council ( http://www.wfpha.org/about-wfpha ). In April 2012, the WFPHA general assembly and council approved the establishment of the WFPHA Oral Health Working Group (OHWG; http://www.wfpha.org/oral-health-wg#the-working-group ). Around this same time, the OHWG and the Oral Health (OH) Section of APHA became aware of a WFPHA letter signed by the Environmental Workgroup calling for the deliberate phase-out and ban of dental amalgam. The letter was aligned with the release of a June 2012 report authored by nondental professionals involving the Chair of the WFPHA Environmental Workgroup and member of the Occupational Health and Safety (OHS) Section of APHA. The WFPHA letter and report supported language in early drafts of the Minamata Convention for dental amalgam to be included on the list of industrial mercury-added products to be phased out or banned.

The OH Section of APHA immediately mobilized and strategically prepared a policy proposal statement for the preservation and phase-down of dental amalgam, which was submitted as a late-breaker policy statement at the APHA annual meeting in October, 2012. Dental Amalgam—Preserving a Proven Dental Material was thus passed, but with challenges from members of the OHS Section and the Environment (ENV) Section. The writers of the OH Section policy reached out to the Policy Committee Chairs of both the OHS Section and ENV Section in an effort to address their concerns and find common ground. When the language of the Minamata Convention was accepted (January 2013), including language for the phase-down of amalgam, further discussions occurred, including a face-to-face meeting at the 2013 APHA annual session that led to an agreement to work together. In January 2014, via conference call, it was decided that because all sections were in agreement with the language of the Minamata Convention, that the sections would accept that language. Subsequently, the OH Section of APHA arranged for there to be an OHS speaker at an April 2014 dental public health conference, where there was also a roundtable presentation on the Minamata Convention and its meaning to dentistry. In addition, an interprofessional invited speaker panel session, The Minamata Convention on Mercury: Implications for the Environment, Occupational Health and Dental Public Health, was held at the November 2014 APHA annual meeting.

Subsequent dental activities

Government authorities and dental stakeholders will need to continue to work together to address the complexity of barriers that must be overcome to develop a new cost-effective material that replaces dental amalgam. Researchers and clinicians need to work in harmony to sort through the complexities of regulatory approval, intellectual property rights, distribution challenges, educational models, creating state-of-the-art information, and transferring skills to the workforce. Inconsistent national and international regulatory systems often create seemingly insurmountable demands on dental manufacturers. Translating novel research products into clinical practice creates educational challenges for dental students, providers, and the dental workforce, which are ongoing concerns.

In April 2015, a European review by the Scientific Committee on Health and Environmental Risks of the environmental impact of dental amalgam confirmed that, when suitable precautions are provided, dental amalgam does not pose a significant risk. Precautions include using amalgam separators and appropriate waste disposal.

The ADA and national dental associations working through the FDI have passed resolutions and policies, affirming that the signing of a globally binding treaty on the use of mercury is a sensible outcome that recognizes the practicalities of improving oral health globally. For many years, numerous recognized health care organizations have stressed the importance of avoiding a complete phase-out of the use of mercury in dentistry, particularly in a short time frame, without an adequate substitute for dental amalgam. The FDI’s General Assembly approved policies to ensure that flexible approaches are available to take into account each country’s domestic circumstances. The FDI encourages national policies by member associations to phase down dental amalgam, as well as devoting more resources to promote prevention; appropriately funded health care systems; materials science research; and the production of accurate, peer-reviewed information on the efficacy of all dental materials. The ADA, FDI, and IADR continue to seek a balance between being good stewards to sustain a safe environment and the use of amalgam or advanced non–mercury-based materials to promote oral health and well-being.

World Dental Federation: Implementation Plan

The FDI, with the support of the IADR, IDM, national dental associations, and dental stakeholders, created a series of education and advocacy initiatives to protect and maintain public health gains, improve oral health worldwide, and strengthen environmental stewardship through sound lifecycle management approaches. National dental associations, including the ADA and the AADR, took roles in providing critical expertise to inform governments on the opportunities to improve health and protect the environment, consistent with objectives of the Minamata Convention, without compromising the professional roles of providers being able to deliver safe, effective, and affordable oral health care.

Publications and guidance for understanding and achieving the goals of the Minamata Convention from the FDI are listed in Box 2 . The FDI documents are intended to supply information to national dental associations, providers, patients, government officials, and media on the provisions, responsibilities, and commitments of the Minamata Convention on Mercury.

Box 2
Publications and guidance for understanding and achieving the goals of the Minamata Convention available from the FDI

Role of Dentists and Dental Teams Regarding Implementation

In support of the Minamata Convention, providers are reminded to integrate the following into their clinical practices. As members of the dental and medical professions, there are shared responsibilities to meet the objectives of the convention in order to protect human health and the environment from anthropogenic emissions and releases of mercury. These issues are not new to dental practitioners, with Hiltz’s discussion in 2007 providing an example. The impact of the convention is not limited to amalgam, but includes other health care equipment, such as thermometers and sphygmomanometers, that are to be phased out. WHO has provided guidance on national strategies for compliance.

Given that amalgam may sometimes be the best choice, or the only option, for effectively restoring carious posterior teeth, the WHO, FDI, IADR, IDM, ADA, APHA, and EPA fully support the proper handling of dental amalgam, amalgam separation technologies, and the recycling of mercury waste. It is anticipated that coordinated implementation of the obligations of the convention will lead to an overall reduction in mercury levels in the environment over time.

Dentists should discuss all dental restorative options with their patients. There is no universal alternative or one-size-fits-all restorative material that matches amalgam’s characteristics. The chemical, biological, and environmental effects of any restorative material need to be considered by both dentists and patients. Dentists and patients must also consider involvement in support of dental research for optimal dental materials and disease prevention. Although this current focus is on the fate of amalgam waste, it is likely that the impact of waste from all dental materials will be evaluated in more detail in the future. Amalgam separators significantly reduce particulate mercury in wastewater effluent. However, separators are unlikely to capture nanoparticles or chemicals, such as bisphenol A, from resin composites or other dental materials. There is only limited information available on the ultimate fate and environmental impact of these particles and chemicals. The identified waste products from dental amalgam need to be kept in the proper context in consideration of the unknown and potentially adverse consequences from other dental restorative materials.

Dental caries remains a global burden that extends far beyond the destruction of hard tooth structure. The Minamata Convention clearly highlights the important role of disease management within any oral health care strategy, but it was not designed to reverse the progression of past dental diseases. There will always be a public health need for dental materials to restore dentitions and maintain public health. Dental caries causes pain, suffering, and compromised health, and results in economic burdens to individuals, governments, and third parties. The costs for providing definitive treatment far exceed the resources to prevent disease.

Recent global trends have generally shown a decline in caries in many developed countries, whereas, in the same time frame, there has been a dramatic increase in some developing countries. These trends largely reflect changes in dietary patterns, including increased and more frequent consumption of sugar. Dental teams have an important role to help their patients and communities understand that adopting healthier behaviors leads to improved health and well-being. Each member of the dental team has an opportunity to participate in programs designed to increase oral health literacy in their communities. Public health education programs for the community should be tailored in consideration of individual risk factors and needs.

Summary

The Minamata Convention is the first major international treaty-level effort to identify dentistry and its global public health leadership role advocating for preventive programs, clinical care, and dental research, albeit from the context of environmental mercury release. Crucial roles were played by the dental stakeholders during the negotiations to balance the need to protect the environment and best management practices, together with the responsibility to support quality oral health care. The convention includes a full range of forward-thinking provisions to advance oral health care as well as to help protect the environment. These provisions include oral health promotion through risk assessment and disease prevention, dental materials research, and guidelines for best management practices to limit amalgam waste. The profession of dentistry has responsibilities and roles that could not be represented by others in the process of this policy development designed for overall health.

Protecting the environment while reducing the need for dental restorations will lead to improved access to care and, ultimately, significant improvements in health and well-being for all populations. As new dental restorative materials are developed, it will be necessary for policy makers to realize that no restorative material is entirely free of risk. Meeting the challenges to develop a cost-effective alternative to replace dental amalgam provides the dental profession with a unique opportunity to work collaboratively to drive global innovation for the development of advanced research, preventive techniques, and advanced restorative materials.

The Minamata Convention is an example of the requisite levels of expertise, communications, collaboration, cooperation, and commitment that are necessary to develop relevant and meaningful interprofessional policies that can have a significant impact on dentistry. It is hoped that the Minamata Convention helps to show that, although such issues may seem to arise rapidly and without warning, dentistry must be poised as an informed, understanding, knowledgeable, organized, and effective advocate to ensure that expert oral health professionals are able to provide an optimal, positive impact from the onset.

The dental profession must be prepared to fully participate in interprofessional collaborations with all stakeholders and build on such experiences to effectively address current and future public health demands and needs. Examples of several other existing areas undergoing policy development and implementation policy are discussed in this issue and include at the institutional and accreditation levels for interprofessional education ; emergency response ; genetics ; and affordable, appropriate, and accessible health care, including oral health care. Appropriate use of antibiotics, although not included in this issue, is another important topic warranting interprofessional collaboration on policy.

The oral health community has responsibilities in interprofessional policy development that affect the general and oral health of the public. Dentistry must ensure that it is involved in scientifically based responses, with recognized expertise and advocacy, albeit without governmental standing. Professional dental organizations can work to optimally respond, find common ground, and cooperate regarding complicated interprofessional health issues. Establishing interprofessional partnerships enables collaboration on health issues and helps ensure that those outside of dentistry understand the importance of oral health. The development of the Minamata Convention on Mercury showed the significance of the commitment by oral health stakeholders, sustained longevity of effort, science-based evidence, understanding of policy development ranging from local to global levels, and the dental profession working effectively in interprofessional collaborations.

Acknowledgments

The authors with to thank the AADR, ADA, APHA, FDI, IADR, WFPHA, and their constituencies for the work they do towards optimal oral and general health for all.

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Policy Development Fosters Collaborative Practice Daniel M. Meyer DDS , Linda M. Kaste DDS, MS, PhD , Kathy M. Lituri RDH, MPH , Scott Tomar DMD, MPH, DrPH , Christopher H. Fox DMD, DMSc and Poul Erik Petersen DDS, Dr Odont, MSc (Sociology) Dental Clinics of North America, 2016-10-01, Volume 60, Issue 4, Pages 921-942, Copyright © 2016 Elsevier Inc. This article provides an example of interprofessional collaboration for policy development regarding environmental global health vis-à-vis the Minamata Convention on Mercury. It presents an overview of mercury and mercury-related environmental health issues; public policy processes and stakeholders; and specifics including organized dentistry's efforts to create global policy to restrict environmental contamination by mercury. Dentistry must participate in interprofessional collaborations and build on such experiences to be optimally placed for ongoing interprofessional policy development. Current areas requiring dental engagement for interprofessional policy development include education, disaster response, HPV vaccination, pain management, research priorities, and antibiotic resistance. Key points The oral health community has responsibilities in interprofessional policy development that affect the general and oral health of the public. Dentistry must assure involvement in science-based responses, with recognized expertise and advocacy, albeit without governmental standing. Professional dental organizations can work to optimally respond, find common ground, and cooperate regarding complicated interprofessional health issues. Establishing interprofessional partnerships enables collaboration on health issues and ensures that those outside of dentistry understand the importance of oral health. The development of the Minamata Convention on Mercury showed the significance of the commitment by oral health stakeholders, sustained longevity of effort, science-based evidence, understanding of policy development ranging from local to global levels, and the dental profession working effectively in interprofessional collaborations. Introduction This article provides an example of interprofessional collaboration concerning policy development based on the impact of a global public health problem resulting from environmental accumulation of mercury. Contained are an overview of mercury and the environmental health issues related to mercury, a brief primer of policy and policy stakeholders, and a description of the collaborations including dentistry specifically concerning the Minamata Convention to create global policy to restrict environmental contamination with mercury. Introduction to the mercury issues warranting global environmental policy development Mercury in the Environment Mercury is a chemical element known by the symbol Hg from its former name, hydrargyrum, or liquid silver. It is ubiquitous and found naturally in the environment throughout the world in 3 forms: elemental (or metallic), as part of an inorganic compound (eg, mercuric chloride), or as part of an organic compound (eg, methylmercury and ethylmercury). In its pure, elemental form, mercury is the only metal that is a liquid at room temperature. Mercury has been used to create alloys or amalgams with other metals, produce dental fillings, extract gold from its ores, and help extend the life of dry cell batteries. It can be released as the result of production or improper disposal of several mercury-containing products, including electrical applications (eg, switches and fluorescent lamps), paints, batteries, chlor-alkali, seed grain fungicides, scientific instruments (eg, thermometers and barometers), dental amalgam, topical antiseptics, antibacterial salves, and skin-lightening creams. Global mercury assessment is intended as a basis for decision making, with an emphasis on anthropogenic emissions (mercury going into the atmosphere) and releases (mercury going into water and land); that is, those associated with human activities. An estimated 5500 to 8900 tonnes (1 tonne = 1000 kilograms) are emitted and reemitted to the atmosphere from 3 sources: 1. Naturally (10%) from geological weathering and geothermal activity 2. Anthropogenic (30%), mostly from artisanal and small-scale gold mining and coal burning 3. Reemissions (60%) of previously released mercury that has built up over decades and centuries in surface soils and oceans without a determinable original source A comparison of percentage of sector contributions to total anthropogenic emissions is shown in Table 1 , including cremation attributable to dental amalgams. North American emissions are notable at roughly 3% of total global emissions. Local and regional mercury depositions throughout the world have gradually increased contamination levels in the environment to the point that countermeasures have been enacted in recent decades to reduce anthropogenic mercury emissions. Because of long-range distribution and transport of mercury globally, nations with minimal mercury releases and other areas remote from industrial activity may be adversely affected. For example, increased mercury levels are observed in the Arctic, far from the sources of any significant releases. Table 1 Global emission inventory, 2010, by-product/unintentional (B/U) and intentional (I) assessed sectors by percentage of total anthropogenic emissions Adapted from UNEP. Global mercury assessment 2013: sources, emissions, releases and environmental transport. Geneva (Switzerland): UNEP DTIE Chemicals Branch; 2013. Available at: http://www.unep.org/PDF/PressReleases/GlobalMercuryAssessment2013.pdf ; with permission. Sector Percentage (I) Artisanal and small-scale gold mining 37 (B/U) Coal burning 24 (B/U) Primary production of nonferrous metals 10 (B/U) Cement production 9 (B/U) Large-scale gold production 5 (I) Consumer product waste 5 (B/U) Contaminated sites 4 (B/U) Primary production of ferrous metals 2 (I) Chlor-alkali industry 1 (B/U) Oil refining 1 (B/U) Mine production of mercury 1 (B/U) Oil and natural gas burning 1 (I) Cremation (dental amalgam) a <1 a Does not include preparation of dental amalgam fillings and disposal of removed fillings containing mercury. Although natural emissions of mercury into the environment continue, human activities have exceeded natural emissions over the last 200 years and need to be controlled. Mercury can be repeatedly mobilized, deposited, and remobilized between air, water, and soil indefinitely. Although many countries have shown reductions of use and release of mercury, mercury can be transported by wind and ocean currents so it can only be controlled effectively by coordinated global programs. Furthermore, mercury is very noxious to human health, particularly to fetal and childhood development. Each form has its own toxicologic profile, affecting the nervous, digestive, and immune systems, and specific organs such as lungs, kidneys, skin, and eyes. In adults, exposure to excessive levels of mercury has been linked to reduced fertility, brain and nerve damage, and heart disease. Hence, mercury is a global threat to human and environmental health, with organic mercury generally considered the most toxic, followed by elemental mercury, and then inorganic mercury. Mercury Use in Dental Amalgam Dental amalgam has been used widely as a restorative dental material since the early 1800s. The clinical properties of amalgam, including its ease of placement, high compressive strength, low cost, and long-term survival rates, remain largely unrivaled. During the past decades, a decrease in the use of dental amalgam and a corresponding increase in the use of tooth-colored restorative materials such as dental composites has occurred, primarily driven by esthetics. Since the inception of dental amalgam, claims have been made about the possibility of detrimental health effects caused by the mercury in its mix. The health concerns and debates over the use of mercury in amalgam restorations are not new. For more than a hundred years, numerous assertions have implicated dental amalgam for causing or contributing to neurologic diseases, adverse health conditions, and toxic illnesses. No evidence for these assertions has been found by well-designed clinical studies. Two clinical trials sponsored by US National Institutes of Health National Institute of Dental and Craniofacial Research (NIH-NIDCR) involving more than 1000 children in Portugal and the US New England region, evaluating the potential effects of mercury from amalgam, provide sound data supporting the continued use of dental amalgam. These two children’s amalgam trials found no adverse effects in the 5 years following the placement of dental amalgam. Nonetheless, increasing concern over mercury in the environment has led to a worldwide movement against dental amalgam. Dental Mercury in the Environment Dental amalgam mercury release from cremated bodies is measurable at the global level (see Table 1 ). Although the amount emitted contributes to less than 1% of the global burden (as measured from cremation), the amount is estimated to be about 3.6 tonnes. Mercury may also be emitted during the preparation and disposal of fillings. In 2005, ENVIRON International Corporation, with funding from the American Dental Association (ADA), prepared a scientific assessment that calculated the amount of mercury attributable to amalgam wastewater that is discharged in effluent from US sewage treatment plants into surface water. This scientific assessment found that a total of approximately 0.4 tons of mercury enters surface water each year. The US Environmental Protection Agency (EPA) oversaw the validation of this approach and principally agreed with ENVIRON’s conclusions. Therefore, dental amalgam represents a small but quantifiable part of the overall mercury burden worldwide. The EPA, among other efforts to limit human-related environmental contamination with mercury, seeks reduction of mercury release into the environment from dental offices. The Clean Water Act (CWA) was established in 1948 to give federal and state EPA, and even local municipal sewerage authorities, direct legal authority to protect waterways by limiting the discharge of mercury in all its forms, including the mercury in amalgam. The EPA sets broad minimum requirements in which states can elect to be more stringent. Typically, states regulate waste by granting permits to a municipal sewerage treatment plant, often referred to as the publicly owned treatment works (POTW). The permit limits the total amount of chemicals, such as mercury, the plant may discharge. POTW can either remove pollutants that enter the plant or limit their discharge into its sewerage system. The EPA and the ADA are long-time collaborators on seeking means to reduce dental mercury environmental release. The ADA included amalgam separators as part of the ADA best management practices in October 2007. The EPA, the National Association of Clean Water Agencies, and the ADA have common commitments to reduce mercury levels in the environment through voluntary dental amalgam wastewater reduction measures. A key component of the ADA best management practices is recycling. Working with the EPA and recyclers, the ADA has been leading efforts to develop a national consensus standard for the use of amalgam separators to recycle waste amalgam in the dental office. The ADA has tested, according to ISO standards, amalgam separators that are available in the United States and have published peer-reviewed articles in its journal on the qualities of alternative brands and how dentists should choose a separator. Estimates of mercury consumption include dental applications and are shown in Table 2 . Total consumption seems to be highest in the east/southeast Asia region, where it approaches twice that of the next highest region. The relative contributions to consumption via dental application is around one-third of total consumption for several regions. The North American region, although it has the third highest total, is has a low percentage from dental applications. Table 2 Percentage of average selected dental applications (estimated from cremation and dental use) of total mercury consumption by world region, 2010, ordered by total mercury consumption Adapted from AMAP/UNEP, 2013. Technical background report for the global mercury assessment. Geneva (Switzerland): Arctic Monitoring and Assessment Programme, Oslo, Norway/UNEP Chemicals Branch; 2013. p. vi. 263; with permission. World Region Total Estimated as Dental Application (%) East and southeast Asia 504 13.3 European Union (27 countries) 253 35.6 North America 213 16.0 South Asia 129 18.6 South America 100 33.0 CIS and other European countries 63 15.9 Middle-eastern states 53 30.2 Central America and the Caribbean 47 36.2 Sub-Saharan Africa 34 17.6 North Africa 20 25.0 Australia, New Zealand, and Oceania 17 23.5 Total 1433 21.4 Patient Care and Economic Considerations Dental caries, although largely preventable, is the most common chronic disease, reaching across the human lifespan, not only in the United States but also worldwide. For restoration of dental caries, to date, tooth-colored materials are inferior to amalgam as fillings, especially for posterior teeth: they are far more technique sensitive, have lower clinical survival rates, are more expensive, and are far more difficult to adapt to proper tooth form under restricted clinical conditions such as in developing countries. In addition, economically, no adequate alternative for dental amalgam exists. Amalgam’s combination of durability and low cost is unmatched by any other dental restorative material. Chadwick and colleagues, found that, “When the initial cost and the longevity are considered together, resin composite turns out to be from 1.7 to 3.5 times more expensive than amalgam.” Multiple economic evaluations comparing the use of dental materials, including dental amalgam, have shown that dental amalgam is more cost-effective and cost-beneficial than tooth-colored alternatives, and it has a longer functional time and lower theoretic cost per year of function. Banning the use of dental amalgam globally would have a strong economic impact from a dental perspective, particularly for practice in resource-poor locations. The impact would be most pronounced in low-income countries with limited access to dental materials, underfunded health care delivery systems, and/or inadequate numbers of practitioners trained to provide safe and effective alternatives. Studies have estimated the macroeconomic impact of regulating or banning the use of amalgam restorations in the United States. Beazoglou and colleagues estimated the direct costs of a ban on the use of amalgam restorations: a ban on their use in children and young people aged 0 to 19 years would increase dental expenditures by about $1.1 billion per year (totaling $13 billion from 2005 through 2020). Banning amalgam in the United States is estimated to increase dental expenditures by about $8.2 billion in the first year and lead to an increase of $98.1 billion from 2015 through 2020, based on an estimate of an average increase of $52 per restoration. Introduction to policy development in oral health The environmental laws that regulate the disposal of mercury from dental amalgam rely on a conservative approach to effluent limits because it is not known what happens to substances in the environment hundreds or thousands of years in the future. Experts do know a lot about the clinical safety of dental amalgam and mercury in patients because of the volume of peer-reviewed scientific studies that have been published over the past several decades. For providers who are not familiar with environmental laws, the use of environmental modeling assumptions of questionable scientific validity, uncertainty factors, safety factors, and the shifting burden of proof to the provider or alleged polluter can be bewildering and seem patently unfair. A review of policy and public policy is presented here before moving to the specifics of the Minamata Convention. It should be noted that the Minamata Convention applies at the global level, pending adoption at the country level, and having implications at local and professional levels. Overarching Definition and Context of Policy Development for Oral Health There is no universally agreed-on definition of the word policy. The term is used in different ways in different contexts. The Merriam-Webster dictionary ( http://www.merriam-webster.com/ ) provides several definitions of policy, including: “A definite course or method of action selected from among alternatives and in light of given conditions to guide and determine present and future decisions” “A high-level overall plan embracing the general goals and acceptable procedures especially of a governmental body” Those related definitions capture some of the key attributes of policy making: it involves general agreement on goals and a broad roadmap on the actions that would help achieve those goals. In many ways, policy making can be thought of as a type of decision making. Governments, institutions, and organizations vary in the policy-making processes, but in general policy making comes down to a decision by a governing body. In most situations, policy development involves receiving input from key stakeholders, negotiation, and compromise. Policy making in oral health is no exception to that general rule. The diversity of opinion among stakeholders requires that various constituents within and outside of the oral health community come together to reach mutually agreed-on goals and chart the broad pathway to achieve them. Public Policy Processes Governments enact public policies in many domains that directly or indirectly affect population oral health, including but not limited to health care, education, food, water, licensure, and environment. Governmental policy is frequently reflected in legislative and regulatory action (ie, laws and regulations), and the actions supporting a set of agreed-on goals therefore enter the political realm. In the United States, policies that affect oral health are enacted at every level of government. For example, federal policy governs the mechanism of federal funding for dental research, national surveillance of oral diseases, safety of oral health workers, and mandated coverage of children’s dental services under Medicaid. State policies affect domains such licensure and scope of practice of oral health personnel and facilities, support for public universities and oral health training programs, and level and mechanism of reimbursement for Medicaid services. Both federal and state environmental policies affect factors such as the manufacture, use, and disposal of dental materials. Local government policy affects factors such as community water fluoridation, zoning for health care facilities, and school health programs. It is worth mentioning that there are influences on policies in North America from global ministries such as the World Health Organization (WHO) with the Pan American Health Organization as the regional component for the Americas, and the United Nations Environment Programme (UNEP). For oral health issues the organizations involved include the Oral Health Programme at WHO (Headquarters in Geneva, Switzerland; http://www.who.int/oral_health/en/ ) and the Environment Program at UNEP (Headquarters in Nairobi, Kenya; http://www.unep.org/About/ ). Both have regional offices as well, in the Americas, Africa, eastern Mediterranean, Europe, southeast Asia, and western Pacific. The development of a global health treaty, and hence global public policy, requires a detailed process and involvement from the members of the United Nations (UN) and WHO. For example, in this article, the UNEP initiated the policy development because the issue is based on environmental contamination that caused public health concerns from the global production, transport, and release of mercury in the environment. Numerous reports were generated to collect the scientifically valid evidence and a process to develop a legally binding instrument (LBI) with an intergovernmental negotiating committee (INC) established to prepare it ( Fig. 1 ) . The meetings of the INC are numbered to help follow the process; for example, the first meeting is INC1. When the LBI is generated it is reviewed by the global governmental representatives. A convention is held for the signing of the LBI, which is named after the convention, by the representatives. On agreement the representatives take the convention to their countries (parties) for approval, called ratification. On reaching 50 ratifications, the convention becomes a treaty to be enacted by the ratifying parties. The process is enhanced by regional and other subgroup meetings outside of the INC meetings. The LBI can be further modified during the process of ratification. Research archives on treaties can be found at http://research.un.org/en/docs/law/treaties . Details on the process (eg, of the Convention on the Rights of Persons with Disabilities) can be seen in the Handbook for Parliamentarians on the Convention on the Rights of Persons with Disabilities at http://www.un.org/disabilities/default.asp?id=212 . Fig. 1 UNEP global mercury program (a twin-track approach). GC, governing council; OEWG, open-ended working group. Regardless of the level of government, policy development is often the result of advocacy, input, analysis, and negotiation. Examples in the United States of resources on policy making and the importance of information to congress include a 2009 review by Stine, and a focus in academic research is a 2015 thesis by Schneiderman. UNEP has developed the Toolkit for Identification and Quantification of Mercury Releases to assist countries in undertaking such work. The toolkit is available at the UNEP Web address ( www.chem.unep.ch/mercury/Toolkit/default.htm ). Policy Among Several Nongovernmental Stakeholders Many organizations and institutions enact their own specific policies that reflect their goals, often with a set of supporting recommendations or actions on how to achieve them. Most major dental and public health organizations have a formal policy-making mechanism. Overviews of the major policy-making oral health organizations in the United States involved with the Minamata Convention are presented here. The American Association for Dental Research (AADR) is a nonprofit organization with more than 3700 members in the United States. AADR’s mission is to advance research and increase knowledge for the improvement of oral health, support and represent the oral health research community, and facilitate the communication and application of research findings ( http://aadr.org/i4a/pages/index.cfm?pageid=3452#.Vp2l-fkrJdg ). AADR currently has policy statements in effect and is heavily involved in advocacy at the federal level in support of its mission. The ADA, the largest and oldest member organization representing dentists in the United States, with more than 158,000 members, enacts policy through the input of multiple levels of the organization. ADA’s 11 councils serve as policy-recommending bodies within their specific areas of expertise. The House of Delegates (the 480-member governing and legislative body of the ADA representing the constituent [state] dental societies, the federal dental services, and dental students) has sole authority to formally enact policy for the association (ADA Constitution and Bylaws 2015; https://www.ada.org/∼/media/ADA/Member%20Center/FIles/ADA_2015_Bylaws.ashx ). The ADA currently has several hundred policies in effect, reflecting the organization’s position on a wide range of topics relevant to oral health and safe practice of dentistry ( http://www.ada.org/en/member-center/leadership-governance/∼/media/1156718AF2E042D08AA6C3677A604C35.ashx ). The ADA also seeks to influence public policy through advocacy and lobbying. The American Public Health Association (APHA) champions the health of all people and communities ( http://www.apha.org/about-apha ). Health policy is a major focus of this organization, which is more than 140 years old and brings together more than 25,000 members from all fields of public health. Through its policy statement proposal process, the various components within APHA work together to establish formal evidence-based position statements on public health issues, which helps guide the organization’s advocacy efforts and enables each community within the larger organization to leverage the capability and visibility of APHA to help achieve its goals. Policy statement proposals are voted on by the APHA Governing Council, the representative legislative body of the association. Successful policy statement proposals generally come about through collaboration and compromise because they must satisfy the goals and perspectives of the general public health community. APHA currently has approximately 1400 policy statements in effect ( http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database ). The APHA Oral Health Section, with nearly 500 members, is one of 31 member sections within APHA, and, as part of a large, diverse public health organization, has unique opportunities to ensure an oral health perspective, as well as challenges when the perspectives within and among various sections and interest groups are not completely aligned, thus making collaboration, negotiation, and compromise key to advancing a dental public health agenda. All 3 of these US-based organizations are major components in their respective international networks. The AADR is the largest division of the International Association for Dental Research (IADR), whose primary mission is to advance research and increase knowledge for the improvement of oral health worldwide ( http://www.iadr.org/i4a/pages/index.cfm?pageid=3283#.Vp5QlvkrJdg ). The ADA is the US National Dental Association member of the World Dental Federation (FDI), which represents the global dental profession to international, intergovernmental, governmental, voluntary, and other organizations ( http://www.fdiworldental.org/about-fdi/mission/the-voice-of-dentistry.aspx#sthash.j8H5Igi7.dpuf ). The APHA is a member of the World Federation of Public Health Associations (WFPHA), whose mission is to promote and protect global public health. The WFPHA is accredited as a nongovernmental organization (NGO) in official relations with the WHO ( http://www.wfpha.org/about-wfpha ). Governmental Policy Development Specific to the Minamata Convention on Mercury In parallel with other activities concerning environmental mercury, in 1997, the WHO held a consultation meeting on the use of dental amalgam. The objective of this consultation was to provide more information to the member states. WHO Oral Health was requested to review again the WHO/FDI consensus statement and if necessary draft a relevant document on dental amalgam use, taking into account the benefits but also the risks for individual, occupational, and environmental health of restorative materials. The project was thoroughly scrutinized by the WHO Programmes on Environmental Health and Occupational Health. The consensus statement on restorative dental care also emphasized the need for further research on alternatives to dental amalgam. These actions show that global attention to amalgam predates the Minamata Convention process. In 2001, UNEP agreed to conduct a global assessment of mercury and its compounds, including information on the health effects, sources, long-range transport, prevention strategies, and control technologies, hence starting the process that led to the Minamata Convention. In 2003, significant evidence was published of large-scale global harm from mercury and its compounds, warranting further international action to reduce the risks to human health and the environment. In 2009, the UNEP Governing Council mandated the development of a global LBI on mercury because it was determined that voluntary actions to control mercury waste were insufficient and that there was a need for an LBI. An INC was established to prepare an LBI on mercury ( http://www.unep.org/chemicalsandwaste/Mercury/ReportsandPublications/GlobalMercuryAssessment/tabid/1060889/Default.aspx ). Also in 2009, the WHO Global Oral Health Program organized a meeting in Geneva, Switzerland, in cooperation with UNEP. From this meeting, a report on dental restorative materials concluded that dental amalgam is an effective restorative material. Consequently, the report Future Use of Materials for Dental Restoration highlights the current scientific evidence on dental materials, including amalgam and nonamalgam restorative materials, and gathered information for future recommendations on the use of dental restorative materials, paying key attention to avoiding environmental pollution. The comprehensive review pointed out that existing alternative materials to dental amalgam are not ideal because of limitations in their durability, fracture resistance, and wear. The report also notes the widespread public health threat from any proposed or impending ban of dental amalgam. Long term, it was critically important for WHO, FDI, IADR, and national dental associations to increase global awareness about the importance of the relationship of oral health to general health and well-being by emphasizing the value of risk assessment, prevention, disease management, and minimal intervention care. Preventing and managing oral diseases diminishes the need to use amalgam and other restorative material alternatives. During this 2009 WHO meeting, consideration was given to the importance of strengthening oral health promotion and disease prevention as the strategy to reduce the use of restorative dental materials. In the case of tooth decay, the best care possible should be provided to meet patients’ needs. The meeting recognized the variation in dental practice among countries and the challenges faced by middle-income and low-income countries providing dental care, hence likely resulting in different approaches to dental caries management in different countries that need to be considered in oral health policy, training personnel, and development and planning of specific public health programs. It was noted that only a few countries, of high income, had initiatives to phase out the use of amalgam. Among countries using amalgam, additional costs, especially if not part of their current systems, would be added by requiring systems for waste management to prevent environmental release of mercury to the environment. Following a review of existing evidence and much deliberation, the meeting recognized the huge challenges faced in dental restoration, disease prevention, and oral health promotion globally. As a result, the meeting considered that all currently existing methods and materials to manage dental caries need to remain available to dental professions in the short and medium terms. Furthermore, the meeting noted that although alternative dental restorative materials may be desirable from an environmental health perspective, a progressive move away from dental amalgam would depend on adequate quality of these materials. Existing alternative dental materials are not ideal because of limitations in durability, fracture resistance, and wear resistance. Therefore, the meeting recognized the need for strengthening of research into the long-term performance, possible adverse effects, and viability of such materials. Consideration of phasing down instead of targeting to phasing out dental amalgam arose at this 2009 WHO meeting. A multipronged approach with short-term, medium-term, and long-term strategies should be considered. Alternatives to dental amalgam exist but the quality of such materials needs to be further improved for use in public health care. The meeting suggested important strategies that can be put in place while waiting for new materials to be developed. The roles of WHO, UNEP, and NGOs such as the IADR and the FDI, user groups, and industry were seen as critical and it was decided that further meetings must be convened to discuss the way forward and to develop strategies to address issues in both developed and developing countries. The Minamata Convention on Mercury In January 2013, at the conclusion of INC5, the INC agreed on the text of what is now The Minamata Convention on Mercury. More than 750 participants attended that session, representing 137 governments, as well as 57 nongovernmental and 14 intergovernmental organizations. Hence, wording was agreed on by 147 nations. Following a round of regional group meetings, delegates to the convention addressed several complex policy and technical issues, including mercury air emissions and releases to water and land, health aspects, and the phase-out (ban) and phase-down (limits and control) dates for specified products and processes. The Minamata Convention text was formally adopted in Japan on the 10 October 2013 and was made available to countries for signature. The main objective of the Minamata Convention was to protect human health and the environment from anthropogenic emissions and releases of mercury and mercury compounds ( www.mercuryconvention.org ). The convention establishes a range of measures to control the supply and trade of mercury. It sets limitations on mercury sources, such as primary mining, small-scale gold mining, manufacturing processes, and mercury-added products. The convention title of Minamata has historic and health significance. Minamata disease was first seen in Japan in 1956 at Minamata. The illness is a form of severe methylmercury poisoning. Between 1932 and 1968, an industrial acetaldehyde plant released massive amounts of effluents containing methylmercury compounds into Minamata Bay and subsequently, into the Minamata River and the Shiranui Sea. The methylmercury bioaccumulated in the fish, shellfish, and the large marine life, which constituted much of the local diet. The mass exposure led to severe, chronic poisoning to more than 200,000 residents of the coastal areas. Since the Minamata disaster, there has been a growing international awareness and need to control the anthropogenic sources of mercury. Some of the key elements of the Minamata Convention were to control mercury by banning new mercury mines, phasing out of existing mines, controlling measures on air emissions and surface water releases, regulating artisanal and small-scale gold mining, and banning, phasing out, or limiting (phasing down) specified mercury-added products. At the end of 2015 there were 128 nation signatures and 20 ratifications, and as this article goes to press at the end of March 2016 there are 25 ratifications ( http://www.mercuryconvention.org/Countries/tabid/3428/Default.aspx ). The convention shall enter on the ninetieth day after the date of deposit of the fiftieth instrument of ratification, acceptance, approval, or accession (article 31, item 1), which means that the convention will come into force as a treaty, once it has been ratified by 50 signatory countries. It becomes law in the ratifying countries only. Coverage of Dental Amalgam in the Minamata Convention Process Because dental amalgam contains mercury, its environmental impact was considered, debated, and addressed in the convention/treaty negotiations. In the initial draft, dental amalgam was included in the list of industrial mercury-added products to be phased out or banned. WHO Oral Health took the lead to create text to phase down the use of dental amalgam. With this input and collaborative efforts, it was agreed that dental amalgam use would be included as a phase-down, without a specific time frame. The statement is shown in Box 1 . Box 1 Provisions from the Minamata Convention on Mercury for dental amalgam From Minamata Convention on Mercury: texts and annexes. 2013. Available at: http://www.mercuryconvention.org/Portals/11/documents/Booklets/Minamata%20Convention%20on%20Mercury_booklet_English.pdf . Accessed April 7, 2016; with permission. Measures to be taken by a party to phase down the use of dental amalgam shall take into account the party’s domestic circumstances and relevant international guidance and shall include 2 or more of the measures from the following list: 1. Setting national objectives for dental caries prevention and health promotion, thereby minimizing the need for dental restoration 2. Setting national objectives for minimizing its use 3. Promoting the use of cost-effective and clinically effective mercury-free alternatives for dental restoration 4. Promoting research and development of quality, mercury-free materials for dental restoration 5. Encouraging representative professional organizations and dental schools to educate and train dental professionals and students on the use of mercury-free dental restoration alternatives and on promoting best management practices 6. Discouraging insurance policies and programs that favor dental amalgam use rather than mercury-free dental restoration 7. Encouraging insurance policies and programs that favor the use of quality alternatives to dental amalgam for dental restoration 8. Restricting the use of dental amalgam to its encapsulated form 9. Promoting the use of best environmental practices in dental facilities to reduce releases of mercury and mercury compounds to water and land Coordinated efforts by parties described later led to the separation of dental amalgam for phase-down considerations rather than the general phase-out. Although there are 9 provisions in the Minamata Convention for phasing down dental amalgam, to be compliant with the convention wording, governments do not need to adopt all of the provisions but must implement at least 2 of these provisions. The wording was designed to allow significant flexibility to account for local circumstances. This flexibility means that each country has options to comply with it as a treaty in its own unique way. Throughout the process the FDI/ADA and IADR representatives conducted multiple meetings with the US and other national delegations. FDI and IADR representatives presented formal, scientifically based interventions throughout the negotiations. The verbal and written statements were designed to protect the environment and to safeguard oral health care, eliminating the risk that an amalgam ban would slip through the treaty negotiations without a thorough vetting. WHO emphasized the importance of strengthening dental caries prevention, which would contribute to reducing the need for any restorative dental care. The WHO Oral Health, FDI/ADA, IADR, International Dental Manufacturers (IDM), and other respected health care organizations were aligned in principle on supporting prevention efforts and advocating for research to develop safe and effective alternative treatment options. Dentistry collectively argued against a ban and in favor of a public health (prevention) approach to the issue. A concerted effort to focus on preventing dental disease, combined with responsible handling of amalgam waste and funding for research for alternative materials would reduce the use of amalgam (and limit its environmental impact) and promote public health. American Dental Association Involvement with Expertise and Advocacy The ADA actively participated in the UNEP INC process since its launch in 2009. Although the ADA did not have a formalized, NGO relationship with UNEP, the ADA was involved in providing its scientific acumen as representative members of the FDI and the IADR delegations. In addition, the ADA worked closely with the US State Department, the EPA, and the US Food and Drug Administration (FDA) to inform those who did not fully understand the negative public health impact that would result from banning a safe and cost-effective dental restorative material. The ADA helped to inform the US delegation during those meetings about the positions that were advocated for by the WHO, ADA, FDI, IADR, organized dentistry, and its stakeholders. From the beginning of the UNEP INC process, the ADA responded to the possibility that the INC political process would interfere with the doctor-patient relationship. Issues were immediately raised by national dental associations throughout the world about government representatives who did not understand the oral health consequences that would result from banning or limiting the use of safe and effective dental restorative materials. In response to those concerns, the ADA worked with the FDI and IADR to advocate on behalf of the public and the profession about the potentially negative public health impact that could result from a ban on dental amalgam, both in the United States and throughout the world. ADA representatives to the FDI and the IADR delegations provided professional expertise and regulatory guidance to work in tandem with the WHO to help make clear to government delegations participating in the INC meetings that dental amalgam should not be equated or confused with elemental mercury, inorganic mercury, or organic mercury compounds. The ADA provided extensive scientific evidence on its Web site, ADA.org , from well-designed laboratory and clinical studies from numerous health care organizations, including the US Centers for Disease Control and Prevention, FDA, WHO, and FDI. The professional organizations were in agreement that dental amalgam is a safe and effective cavity-filling material. Other science-based professional organizations, such as the Alzheimer’s Association, American Academy of Pediatrics, Autism Society of America, and National Multiple Sclerosis Society, also made clear that dental amalgam does not create adverse health conditions or cause identifiable diseases ( http://www.ada.org/en/press-room/press-kits/dental-fillings-press-kit/dental-amalgam-what-others-say ). As clearly stated by the FDA, although high levels of exposure to elemental mercury have been associated with adverse health effects, the levels released by dental amalgam fillings are not high enough to cause harm in patients ( http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DentalProducts/DentalAmalgam/ucm171094.htm ). Consistent with the EPA’s position, the Scientific Committee of the European Commission also addressed safety concerns for patients, professionals, and the use of alternative restorative materials. The committee independently concluded that dental amalgams are effective and safe, both for patients and dental personnel, and also noted that alternative materials have clinical limitations and toxicologic hazards ( http://ec.europa.eu/health/scientific_committees/consultations/public_consultations/scenihr_consultation_24_en.htm ). The ADA followed through with letters to the US State Department, reiterating its evidence-based scientific rationale to promote health and address environmental concerns. In addition to the ADA, several US professional organizations sent letters to the State Department expressing their respective evidence-based views on dental amalgam in support of protecting the public’s health. The Academy of General Dentistry, American Academy of Pediatric Dentistry, American Academy of Periodontology, American Association of Oral and Maxillofacial Surgeons, American Association of Orthodontists, and the Hispanic Dental Association all expressed their concerns. The US Association of State and Territorial Dental Directors also supported the unique opportunity to implement an oral health care model, based on disease prevention, health promotion, and materials science research. These congruent measures have helped to ensure optimal oral health, particularly for the most disadvantaged patients in need of dental care in the United States and throughout the world. International Association for Dental Research Involvement as Facilitator and Science Advocate In addition to partnering with the FDI, ADA, IDM, and the WHO Oral Health Programme, IADR made substantive contributions to the 2009 WHO and UNEP meeting on Future Use of Materials for Dental Restoration . In 2010, the IADR was accepted into the UNEP Global Mercury Partnership. IADR shared the overall goal of the UNEP partnership, which was “to protect human health and the global environment from the release of mercury and its compounds by minimizing and, where feasible, ultimately eliminating global, anthropogenic mercury releases to air, water and land. ” IADR hosted and published the proceedings of the Dental Materials Innovation Workshop (DMIW), which took place December 10 to 11, 2012, at King’s College London. The meeting was sponsored by IADR, WHO, UNEP, FDI, and King’s College London Dental Institute. The proceedings are published in the November 2013 issue of the IADR/AADR Advances in Dental Research , an E-supplement to the Journal of Dental Research . The DMIW was timed as part of IADR’s commitment to the UNEP Global Mercury Partnership and as an NGO participant in the UNEP negotiations to develop the Minamata Convention on Mercury. The IADR participated in the UNEP negotiations along with the FDI, the ADA, and the IDM. Working as a team, the dental NGOs advocated that a phase-down of dental amalgam was only possible with enhancement of dental prevention, further research on suitable alternatives, and the use of best management practices for dental amalgam waste. Those provisions are largely intact in the signed convention. World Federation of Public Health Associations/American Public Health Association As an accredited NGO in official relations with the WHO, the WFPHA collaborates with the WHO to advance public health through the promotion of prohealth policies, strategies, and best practices around the world. The federation also holds consultation status with the UN Economic and Social Council ( http://www.wfpha.org/about-wfpha ). In April 2012, the WFPHA general assembly and council approved the establishment of the WFPHA Oral Health Working Group (OHWG; http://www.wfpha.org/oral-health-wg#the-working-group ). Around this same time, the OHWG and the Oral Health (OH) Section of APHA became aware of a WFPHA letter signed by the Environmental Workgroup calling for the deliberate phase-out and ban of dental amalgam. The letter was aligned with the release of a June 2012 report authored by nondental professionals involving the Chair of the WFPHA Environmental Workgroup and member of the Occupational Health and Safety (OHS) Section of APHA. The WFPHA letter and report supported language in early drafts of the Minamata Convention for dental amalgam to be included on the list of industrial mercury-added products to be phased out or banned. The OH Section of APHA immediately mobilized and strategically prepared a policy proposal statement for the preservation and phase-down of dental amalgam, which was submitted as a late-breaker policy statement at the APHA annual meeting in October, 2012. Dental Amalgam—Preserving a Proven Dental Material was thus passed, but with challenges from members of the OHS Section and the Environment (ENV) Section. The writers of the OH Section policy reached out to the Policy Committee Chairs of both the OHS Section and ENV Section in an effort to address their concerns and find common ground. When the language of the Minamata Convention was accepted (January 2013), including language for the phase-down of amalgam, further discussions occurred, including a face-to-face meeting at the 2013 APHA annual session that led to an agreement to work together. In January 2014, via conference call, it was decided that because all sections were in agreement with the language of the Minamata Convention, that the sections would accept that language. Subsequently, the OH Section of APHA arranged for there to be an OHS speaker at an April 2014 dental public health conference, where there was also a roundtable presentation on the Minamata Convention and its meaning to dentistry. In addition, an interprofessional invited speaker panel session, The Minamata Convention on Mercury: Implications for the Environment, Occupational Health and Dental Public Health, was held at the November 2014 APHA annual meeting. Subsequent dental activities Government authorities and dental stakeholders will need to continue to work together to address the complexity of barriers that must be overcome to develop a new cost-effective material that replaces dental amalgam. Researchers and clinicians need to work in harmony to sort through the complexities of regulatory approval, intellectual property rights, distribution challenges, educational models, creating state-of-the-art information, and transferring skills to the workforce. Inconsistent national and international regulatory systems often create seemingly insurmountable demands on dental manufacturers. Translating novel research products into clinical practice creates educational challenges for dental students, providers, and the dental workforce, which are ongoing concerns. In April 2015, a European review by the Scientific Committee on Health and Environmental Risks of the environmental impact of dental amalgam confirmed that, when suitable precautions are provided, dental amalgam does not pose a significant risk. Precautions include using amalgam separators and appropriate waste disposal. The ADA and national dental associations working through the FDI have passed resolutions and policies, affirming that the signing of a globally binding treaty on the use of mercury is a sensible outcome that recognizes the practicalities of improving oral health globally. For many years, numerous recognized health care organizations have stressed the importance of avoiding a complete phase-out of the use of mercury in dentistry, particularly in a short time frame, without an adequate substitute for dental amalgam. The FDI’s General Assembly approved policies to ensure that flexible approaches are available to take into account each country’s domestic circumstances. The FDI encourages national policies by member associations to phase down dental amalgam, as well as devoting more resources to promote prevention; appropriately funded health care systems; materials science research; and the production of accurate, peer-reviewed information on the efficacy of all dental materials. The ADA, FDI, and IADR continue to seek a balance between being good stewards to sustain a safe environment and the use of amalgam or advanced non–mercury-based materials to promote oral health and well-being. World Dental Federation: Implementation Plan The FDI, with the support of the IADR, IDM, national dental associations, and dental stakeholders, created a series of education and advocacy initiatives to protect and maintain public health gains, improve oral health worldwide, and strengthen environmental stewardship through sound lifecycle management approaches. National dental associations, including the ADA and the AADR, took roles in providing critical expertise to inform governments on the opportunities to improve health and protect the environment, consistent with objectives of the Minamata Convention, without compromising the professional roles of providers being able to deliver safe, effective, and affordable oral health care. Publications and guidance for understanding and achieving the goals of the Minamata Convention from the FDI are listed in Box 2 . The FDI documents are intended to supply information to national dental associations, providers, patients, government officials, and media on the provisions, responsibilities, and commitments of the Minamata Convention on Mercury. Box 2 Publications and guidance for understanding and achieving the goals of the Minamata Convention available from the FDI FDI policy statement: dental amalgam and the Minamata Convention on Mercury : http://www.fdiworldental.org/media/55201/6-fdi_ps-dental_amalgam_and_minamata_adopted_gab_2014.pdf Use and future use of materials for dental restoration – FDI advocacy toolkit : http://www.fdiworldental.org/media/9450/use_of_materials_english.pdf Dental restorative materials and the Minamata Convention on Mercury – guidelines for successful implementation : http://www.fdiworldental.org/media/54670/minamata-convention_fdi-guidelines-for-successful-implementation.pdf Understanding the Minamata Convention and its effect upon oral health care – practical advice for dentists : http://www.fdiworldental.org/media/67938/minamata-convention_practical-advice-for-dentists.pdf FDI vision 2020 – shaping the future of oral health : http://www.fdiworldental.org/media/12308/idj_vision_2020_editorial.pdf and http://www.fdiworldental.org/media/12303/idj_vision_2020_final.pdf Role of Dentists and Dental Teams Regarding Implementation In support of the Minamata Convention, providers are reminded to integrate the following into their clinical practices. As members of the dental and medical professions, there are shared responsibilities to meet the objectives of the convention in order to protect human health and the environment from anthropogenic emissions and releases of mercury. These issues are not new to dental practitioners, with Hiltz’s discussion in 2007 providing an example. The impact of the convention is not limited to amalgam, but includes other health care equipment, such as thermometers and sphygmomanometers, that are to be phased out. WHO has provided guidance on national strategies for compliance. Given that amalgam may sometimes be the best choice, or the only option, for effectively restoring carious posterior teeth, the WHO, FDI, IADR, IDM, ADA, APHA, and EPA fully support the proper handling of dental amalgam, amalgam separation technologies, and the recycling of mercury waste. It is anticipated that coordinated implementation of the obligations of the convention will lead to an overall reduction in mercury levels in the environment over time. Dentists should discuss all dental restorative options with their patients. There is no universal alternative or one-size-fits-all restorative material that matches amalgam’s characteristics. The chemical, biological, and environmental effects of any restorative material need to be considered by both dentists and patients. Dentists and patients must also consider involvement in support of dental research for optimal dental materials and disease prevention. Although this current focus is on the fate of amalgam waste, it is likely that the impact of waste from all dental materials will be evaluated in more detail in the future. Amalgam separators significantly reduce particulate mercury in wastewater effluent. However, separators are unlikely to capture nanoparticles or chemicals, such as bisphenol A, from resin composites or other dental materials. There is only limited information available on the ultimate fate and environmental impact of these particles and chemicals. The identified waste products from dental amalgam need to be kept in the proper context in consideration of the unknown and potentially adverse consequences from other dental restorative materials. Dental caries remains a global burden that extends far beyond the destruction of hard tooth structure. The Minamata Convention clearly highlights the important role of disease management within any oral health care strategy, but it was not designed to reverse the progression of past dental diseases. There will always be a public health need for dental materials to restore dentitions and maintain public health. Dental caries causes pain, suffering, and compromised health, and results in economic burdens to individuals, governments, and third parties. The costs for providing definitive treatment far exceed the resources to prevent disease. Recent global trends have generally shown a decline in caries in many developed countries, whereas, in the same time frame, there has been a dramatic increase in some developing countries. These trends largely reflect changes in dietary patterns, including increased and more frequent consumption of sugar. Dental teams have an important role to help their patients and communities understand that adopting healthier behaviors leads to improved health and well-being. Each member of the dental team has an opportunity to participate in programs designed to increase oral health literacy in their communities. Public health education programs for the community should be tailored in consideration of individual risk factors and needs. Summary The Minamata Convention is the first major international treaty-level effort to identify dentistry and its global public health leadership role advocating for preventive programs, clinical care, and dental research, albeit from the context of environmental mercury release. Crucial roles were played by the dental stakeholders during the negotiations to balance the need to protect the environment and best management practices, together with the responsibility to support quality oral health care. The convention includes a full range of forward-thinking provisions to advance oral health care as well as to help protect the environment. These provisions include oral health promotion through risk assessment and disease prevention, dental materials research, and guidelines for best management practices to limit amalgam waste. The profession of dentistry has responsibilities and roles that could not be represented by others in the process of this policy development designed for overall health. Protecting the environment while reducing the need for dental restorations will lead to improved access to care and, ultimately, significant improvements in health and well-being for all populations. As new dental restorative materials are developed, it will be necessary for policy makers to realize that no restorative material is entirely free of risk. Meeting the challenges to develop a cost-effective alternative to replace dental amalgam provides the dental profession with a unique opportunity to work collaboratively to drive global innovation for the development of advanced research, preventive techniques, and advanced restorative materials. The Minamata Convention is an example of the requisite levels of expertise, communications, collaboration, cooperation, and commitment that are necessary to develop relevant and meaningful interprofessional policies that can have a significant impact on dentistry. It is hoped that the Minamata Convention helps to show that, although such issues may seem to arise rapidly and without warning, dentistry must be poised as an informed, understanding, knowledgeable, organized, and effective advocate to ensure that expert oral health professionals are able to provide an optimal, positive impact from the onset. The dental profession must be prepared to fully participate in interprofessional collaborations with all stakeholders and build on such experiences to effectively address current and future public health demands and needs. Examples of several other existing areas undergoing policy development and implementation policy are discussed in this issue and include at the institutional and accreditation levels for interprofessional education ; emergency response ; genetics ; and affordable, appropriate, and accessible health care, including oral health care. Appropriate use of antibiotics, although not included in this issue, is another important topic warranting interprofessional collaboration on policy. The oral health community has responsibilities in interprofessional policy development that affect the general and oral health of the public. Dentistry must ensure that it is involved in scientifically based responses, with recognized expertise and advocacy, albeit without governmental standing. Professional dental organizations can work to optimally respond, find common ground, and cooperate regarding complicated interprofessional health issues. Establishing interprofessional partnerships enables collaboration on health issues and helps ensure that those outside of dentistry understand the importance of oral health. The development of the Minamata Convention on Mercury showed the significance of the commitment by oral health stakeholders, sustained longevity of effort, science-based evidence, understanding of policy development ranging from local to global levels, and the dental profession working effectively in interprofessional collaborations. Acknowledgments The authors with to thank the AADR, ADA, APHA, FDI, IADR, WFPHA, and their constituencies for the work they do towards optimal oral and general health for all. References 1. Petersen P.E.: The World Health Report 2003: Continuous improvement of oral health in the 21st century – the approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2003; 31: pp. 3-24. 2. 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