by Bulela Vava, President of the Public Oral Health Forum, and Rico Euripidou, environmental epidemiologist

The global commitment to phase out dental amalgam has been an ongoing journey for countries that have recognised the environmental and health risks posed by mercury. South Africa, as a signatory to the Minamata Convention on Mercury, pledged in 2019 to gradually reduce the use of dental amalgam in line with global strategies.

Yet, it seems that we have taken a wrong turn. 

The recent issuance of a government contract by the National Treasury to Sikelela Medical and Dental Supplies (Pty) Ltd, which includes the procurement of dental amalgam, is an alarming indicator that the country is not only stalling in its efforts but may be regressing.

This decision flies in the face of South Africa’s commitment to reduce mercury in the environment. Dental amalgam, which contains about 50% metallic mercury (Hg⁰) by weight, remains a source of environmental pollution, especially when waste from dental practices is improperly managed. 

Global Commitments

The Minamata Convention, to which South Africa is a signatory, urges countries to take measures to phase out dental amalgam by focusing on preventive care, promoting mercury-free alternatives, and encouraging best practices in oral health care. 

The World Health Organisation (WHO) recently launched a new course for dental professionals aimed at facilitating the global phase-out of amalgam. The course offers insights into mercury-associated risks and the implementation of safe and effective mercury-free alternatives, highlighting the urgency for countries like ours to transition fully to sustainable dental practices. 

The alternatives are tooth-friendly, unlike amalgam, and similarly priced. Dental amalgam, with its high mercury pollution cost, including poisoning fish, is penny-wise and pound-foolish for our government. 

The recent Children’s Amendment to the Minamata Convention on Mercury protects children, pregnant women, and breastfeeding mothers from mercury exposure in dentistry. The amendment prohibits the use of dental amalgam for children under 15, pregnant women, and breastfeeding women, except when deemed necessary by a dental practitioner. Children are more vulnerable to mercury exposure because their nervous systems and organs are still developing. Mercury, particularly in the form of methylmercury (a more toxic form), can interfere with brain development, leading to cognitive deficits, learning disabilities, and behavioural problems. Exposure to mercury during pregnancy has been linked to developmental delays and other neurological impairments in children. Mercury can also accumulate in a breastfeeding mother’s body and be passed to the infant through breast milk. 

Considering these efforts, it is perplexing that our National Treasury would approve a contract that seems to perpetuate the use of dental amalgam. This signals a disturbing disconnect between the policy commitments we’ve made on the international stage and the reality on the ground.

Slow Pace of Change

South Africa lags far behind SADC nations: Mauritius ended amalgam for children in 2014, and Zambia stopped amalgam use in 2022 by agreement with the dental association. Tanzania has gone further with a 2020 law that phases out all amalgam use on a deadline. Meanwhile, the ban on amalgam use in the European Union begins in a few weeks, on 1 January 2025.

Even more concerning is the slow pace of change within our dental training institutions. Many South African dental schools continue to teach amalgam restorations as part of the standard curriculum, producing new generations of dentists who are still trained to use this outdated material. 

While some steps have been made toward teaching the placement of composite and other mercury-free restoratives, the shift is happening at a snail’s pace. This is particularly troubling given that dental professionals are the key players in this transition. How can we expect change when the core training of new dentists still includes amalgam as a viable option?

The delay in eradicating dental amalgam from both the market and the education system is not just an issue of convenience; it is an issue of public health and environmental justice. 

Communities living near landfills, waste incineration facilities, and waterways are disproportionately affected by mercury pollution, further entrenching existing health inequalities in South Africa. The government’s continued support for contracts like the one awarded to Sikelela Medical and Dental Supplies perpetuates the use of a harmful substance that we have committed to phasing out.

The Minamata Convention and subsequent resolutions passed by the South African government have consistently reiterated the need to adopt mercury-free alternatives and to protect vulnerable populations from the adverse effects of mercury exposure. Yet, with the issuance of new contracts and the slow reforms in our dental schools, it is clear that there is a significant gap between what we have promised and what we are doing. As a country, we must not lose sight of the global consensus and the moral imperative to protect our environment and people.

Way Forward

The path forward is clear. The government must not only retract its support for amalgam-containing contracts but also actively work with the dental industry to promote mercury-free alternatives. At the same time, dental schools should expedite their transition away from dental amalgam restorative therapies. 

South Africa’s role in the global environmental health movement cannot simply be symbolic; it must be practical and firmly rooted in action. Several countries have begun making resolutions to phase out dental amalgam, many of these amalgam-producing countries. 

If we do not correct course soon, we will find ourselves falling behind in an era where sustainability and environmental protection should be the cornerstones of modern healthcare. 

Beyond falling behind: with amalgam producers out of the market, without a carefully considered plan for a post-amalgam oral healthcare environment, practitioners will be forced into a hard transition with unfavourable outcomes for practitioners and patients alike. It is time for the government, dental professionals, and educators to align their efforts, phase out dental amalgam, and honour the commitments we have made to the world. 

_____________________________________________________________________________________

Bulela Vava is a Tekano (Atlantic Fellows for Health Equity in South Africa) Lifelong Fellow and President of the Public Oral Health Forum, a network of oral health professionals committed to improving oral health outcomes in South Africa through strategic advocacy, education, research, and collaboration. 

Rico Euripidou is an environmental epidemiologist with groundwork, Friends of the Earth, South Africa, with over 20 years of experience working on issues of chemical safety.

The views and opinions expressed in this opinion piece are those of the authors, who are not employed by Health-e News. Health-e News is committed to presenting diverse perspectives to enrich public discourse on health-related issues.