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View from the Chairside: Why I Love Amalgam…And You Should Too!

Once again, I welcomed Dr. Paul Belzycki, dental surgeon from Toronto, to continue our series of clinical mentorship presentations. Dr. Belzycki presents a few interesting cases to show why he likes to use amalgam and why you should too. His premise follows research findings on the biochemical stability and durability of dental resin composites and is based on a clinical career that spans over close to four decades. 

We hope that you enjoy the presentation and benefit from the clinical tips that he shares with you. Please share your thoughts, questions, and suggestions with us at oasisdiscussions@cda-adc.ca 

Until next time!

Chiraz Guessaier
CDA Oasis Manager

Dr. Belzycki’s Notes

All studies show that composite resin fillings last about half as long as amalgam restorations. My personal observations over a long career lead me to claim that this conclusion is false: composite resin fillings last much less than that. The statement could have been true “Back in the Day” that resin fillings may have lasted half as long. But only because we were not using them in clinical situations where we knew they would fail rapidly. This typically happens in molar teeth where a significant amount of tooth structure is needed to be restored or where a deep proximal box extends past the CEJ and the cavity preparation is no longer circumscribed by enamel.  
 
Every current textbook on dental materials and restorative dentistry claims composite resin is to be avoided where moisture control is problematic or where bruxism is an issue. So, why dear colleagues have many dentists, old and young, opted to “toss out” their amalgamators? In my opinion, there are three focal reasons. One is succumbing to market pressures. Two is not fully understanding or appreciating the difference between the various restorative materials we might use. And, sadly and unethically three, not having the patient’s best interest at heart. 
 
I hope you enjoy the presentation.
 
Full Presentation (43.23″)

 

 

37 comments

  1. This is a breath of fresh air and common sense! Thank you to Dr. Belzycki for setting out the case for continuing to use amalgam with it’s many fine clinical qualities. Certainly, in my own career, I found the same advantages for this material and gave similar advice to my own patients. Well done! (And beautiful clinical work as well!).

  2. Dear Brian,

    Man, for a while, I thought I was the only dentist on the continent still using amalgam. I have a patient that graduated dentistry and has been working for one year. I would love to have her as an associate but I do not play well with others and so must remain a solo-guy, also last of a dying breed. She sends me cases to treatment plan, because the group she works for has a Spa Clinic…you get the drift. The last case required amalgam restorations because many of the cavity preps would be subgingival due problems with root decay. She claims the office she works at does not have amalgam. My advice was go out and buy one for yourself. Treasure it, because one day it may no longer be manufactured. Hell, there are traveling dentists that come to offices equipped to sedation or implants, why not amalgam.

    I really do not care to change anyone’s mind on this…too busy in my own practice. I am not a political animal as “do not suffer fools gladly”. Anyone that does not have the capability to offer amalgam is making a foolish mistake. I fully expect to receive an avalanche of comments from that group claiming that using a new Super-Duper resin with the new XYZ matrixing toys will yield perfect restoration superior to amalgam in every way. The mindset of these folks is akin to deniers of Global Warming or Evolution. Don’t confuse me with the facts…my mind is made up. You just can not win against that kind of thinking and I feel no desire to champion a cause. To them I say, save your breath, I will not read your comments.

    Nice to know we are not alone and that we are, as a result of Dr. Finer’s findings, very much still relevant. Easy to argue with me…only have DDS after my name. Arguing with a guy that has an entire alphabet after his name is another story.

    Dr. Old School
    Dr. Paul Belzycki, DDS

  3. Very refreshing- honesty& practicality- true professional , looking after his patients’ interest 1st .

    • Dear Bill.

      In a few words, you have encapsulated my Philosophy of Treatment.
      Thank you for your kind words.

      I have never taken the path of least resistance where a patient dictates treatment. When I go to a healthcare provider, I would never imagine telling him/her how to treatment me. Particularly, if it is not my field of expertise. I consider it a grave insult to my decades of hard work and learning, when a patient presents me with a printout from Google. I take it from them, and rip it up and put it back in their hands. I then tell them, I will spend 20 minutes on the internet and then come to their place of work and tell how to their job. If they do not understand this point, they are free to go. I give a patient one choice: they can trust me or not. And I try very hard to earn their trust with honesty and commitment to excellence.

      Dr. Paul Belzycki, DDS

      • Which pin system do u use with amalgam?

        • Will let you know shortly. Away on vacation. I don’t personally order sundries. Best guess is TMS REGULAR self-shearing. I will confirm in a day or so.

          • Stabilok by Farfax Dental. The yellow coded .6mm diameter.
            I use this size all the time. One can bend it gently once without issue.
            If the pilot holes gets stripped, then I place the next size up. The orange-brown colour .76mm. This occurs very seldom. This size pin is almost too thick, and I use it as a last resort. Difficult of bend and my fear is transmitting too much stress to tooth structure.

            These pins also come in stainless steel. I have no clue why I use the titanium one over the steel.

            Dr. Paul Belzycki, DDS

  4. Too bad amalgam isn’t tooth colored…then we’d probably never have another discussion about a posterior restoration.

    I believe that amalgam still constitutes approximately 40% of restorations placed, as I recall the statistics I’ve seen. If correct, then there’s still a lot of dentists (and patients!) making the scientific, and logical, choice over the esthetic one…

    • Dear Eric

      I think a properly carved and polished metal restoration is aesthetic. But I was trained in the late seventies when your metal-work, what you produced with your own two hands, spoke for your clinical skills. I personally hate receiving dental treatment. The few times my teeth are cut into the better. I figure my patients share that sentiment.

      On statistics, a dentist that worked for an insurance company as a claims adjudicator confessed that the actuarial data proves how poorly resin composites last compared to amalgam. That is why early on, they refused to provide benefits. We all know that insurance companies are very good at tracking this sort of thing. But they too have succumbed to public pressures.

      And for those still trying to use amalgam toxicity as an argument, how come when buying a life insurance policy, we are never asked if we have amalgam fillings in our teeth? Surely insurance companies would be the first to discover any health risk. They ask for smoking, sky-diving, scuba-diving, motorcycle use…etc. Why not amalgam fillings?

      Common sense is often Uncommon.

      Thanks for taking the time and effort to reply. Greatly appreciated.

      • We have a local guy who’s a “metal free” guy…he commented to me, have you ever seen what’s under a really old amalgam…my response was that you’ll never see what’s under an old composite, because there aren’t any…

        It seems to me a lot of “modern” dentists have abandoned the science, and are always in search of the next whiz bang thing to dazzle their clients. When we do that, we are no longer professionals, and not far removed from the barber-dentists of the past.

        I use both materials in my practice, and in my experience once you educate and inform your patients as to the options, they usually select the most appropriate material; they don’t want their teeth repeatedly prepped either. Documented in my charts as “patient chooses……material”, and I sleep well knowing I have served my patients appropriately.

  5. A lot of dentists I speak to are no longer using amalgam. I shake my head when I wonder how they are properly restoring deep interproximal caries, or closing wide contacts, when a crown is not indicated.I would like to think I am proficient in isolation but there are certainly those cases where it is next to impossible to get a dry field required for a long lasting restoration. I use digital radiographs, very modern equipment, yet I will not throw out my amalgamator!!

    • Dear Dr. Kotansky

      I still shoot film. Too old fashion to spend 100K to get a radiograph. But more than that, when I ask trusted oral radiologists, they tell me old fashion film is still supreme. Yes, for Panoramic Views, digital is better because it seems to correct for less than stellar technique.

      The problems you have mentioned with resin restorations are similar to my experience. And when I replace a failed resin restoration that is deeply interproximal and see moisture seeping under the matrix band, no matter what I do to prevent it, I wonder…What went through the synapses of the dentist that placed it? Did they not see? Did they see, but not care? Do they not know any better?

      But then I surmise, if you don’t have an amalgamator, both you and the patient are behind the 8-ball before you have light-cured.

      For those younger colleagues that do not know reference of “behind the 8-ball”…Google it.

      Many thanks for your comment Dr. K

  6. I am sick and tired of dentists who promote their practices as “metal free” implying that they are better than those 3rd world dentists down the street that still use amalgam. My charts are full of countless other dentists’ composite restorations that have failed or are failing only because of the choice of restorative material – composite. I, too, have restorations that have secondary caries but the rate from composites is obscene. Worse still are composites placed on primary teeth.

    I propose that the fees for amalgams and composites be the same and then we will see how prevalent composite restorations will be when they should be contraindicated. We owe our patients better.

    • Dear Dr. Blischak

      Your last comment regarding fees is something I think about often.
      With amalgam, we are being financially penalized for providing a superior service because the folks that arrange our fee guide, (at least here in Ontario) are short sighted or driven by factors beyond my understanding. I posit that composite resins are placed more often because of the financial gain. There, I said it.

      Thanks for your reply.

      • Dr. Belzycki,
        Of course its for financial gain. You get more money for the filling because it takes longer. So cut corners on bulk and curing time. You get more money by lying to patients about amalgam and replacing good restorations with worse. You get to redo those fillings again and again until you, conveniently enough, place an implant. You go to courses in Vegas that blow smoke up your a** about how good you are because you bought their tuition. Then you charge those patients with excessive fees and false information and book them for 4 month cleanings because they aren’t flossing well enough. You advertise about how current and modern your clinic is because when you look into their mouths, you can’t see metal. You do composite restorations on baby teeth that you know do not bond to primary enamel or dentin. You can’t even place a silver stainless steel crown. You then do your own ortho in office because all your kids in your practice have space loss.
        Of course its for financial gain. There, I said it too.
        Fortunately, I have a young associate that feels the same as I do and I will have someone to restore my teeth.

        • Ah yes. Las Vegas, where in between gambling and martinis one can learn all about the ethics and mindset of providing excellence in dentistry…

  7. Prudent, practical time tested techniques and materials presented by a conscientious dentist. Thank you Dr. Belzycki

    • Dear Richard.

      You noticed!

      Thanks for the reply. My first few went unnoticed and I wondered if this was worth all the effort.
      I am touched.

  8. Congratulations on not bending on your philosophy regarding dental amalgam. You might want to incorporate heavy weight rubber dam even in the surgical situations and make your life easier. Given the success of well placed dispersed-phase amalgam and adding bonding to the cavity prep, the lifespan of these restorations approaches gold- the gold standard. The attention to biologic width and general periodontal principles are undoubtedly critical to your treatment outcomes. The amalgam Master of all time was the late Harold Shavell who wrote about and presented “Romancing the Silver Maiden” elevating amalgam restorations to an exquisite art form. I also agree in saying we should never accept “the patient made me do it” as an excuse. You are the doctor and they expect your best recommendation. In their eyes you are the expert. One of my favorite questions for my patient is “how long do you need this to last”? Once they realize the differences in material longevity, they always pick durability- as we would ourselves. Lastly, a dear dentist friend of mine who shared your views of both amalgam and perio treatment, used to refer to posterior composites as “tombstones for the teeth”.
    Keep up the good work! Nice clinical presentation.

    • Dear Brian.

      Typically I am too long-winded. Its my personality quirk.

      Let me just thank you for your comment.
      I had the great fortune of hearing Shavell.
      Every time I do an amalgam filling, I think of his results.
      There have been very few lecturers that have had that effect on me.
      Three for that matter, Ralph Youdelis (Washington) and Myron Nevins (Boston) and Blake MacAdam (Toronto) who gave me the appreciation of integrating perio, endo and restorative dentistry.

      Thanks from the Heart.

  9. Dr. Belzycki here…

    I left the following comment on Dr Rick Carvalho’s post regarding bond strength of adhesive materials. I recommend the reader to view that post if you have not.

    To Dr Carvalho

    “I graduated in 1979 at the start of the bonding revolution. I hated resin from the start for Aesthetic reasons and here I use Aesthetic in a philosophical context. With amalgam, I could condense a solid mass and then “sculpt” some semblance of natural dental anatomy with hand instruments, trying to mimic what Mother Nature had intended. This, I submit, is the Art part of dentistry. I could never do this effectively with resin. Forget for a moment the problems with shrinkage, wear, open contacts and recurrent decay. This handling characteristic was a turn-off for me. After packing, the restoration is high; one must use a high-speed air-rotor; and this invariably causes damage to surrounding cusps. The reasons being that it is difficult to control a high speed drill. Ironically, when the colour match is good, it is more difficult to know what is tooth or resin. It left me with an Ugly result not matter how I tried.

    Then, there was a lecturer, whose name I can’t recall, and he presented amalgam restorations that glistened like the finest silver jewelry. Polished with exacting technique. The shear artistry blew me away. And to do this, he booked a separate appointment, 24 hours later, to allow the material enough time to fully harden. There was a sequence of ever finer polishing materials, whose names I also have forgotten. I cheat and use prophy paste in a rubber cup some 10 minutes after placement. Works well enough, but nowhere near the shine of Dr. Wine. They were truly aesthetic in terms of form, function and longevity.

    My own mentor was Dr. Blake MacAdam (back then we did not call them mentors, nor did we let them know, we secretly respected their work and hoped to equal their results). He too produced cast gold, gold foil and amalgam restorations that were more jewelry than restorations. Those clinicians took pride in craftsmanship that will not be matched by CAD/CAM.

    Hearing the term Cosmetic or Aesthetic dentistry nowadays makes me nauseous. So, it is tooth-coloured … big deal. Today, it has become fashionable to stain one’s skin…tattooing…and pierce one’s face, lips and tongues with metal. So, for those patients that argue with me regarding amalgam restorations, I merely inform them that I am ahead of the fashion curve and now “Piercing Teeth” not merely filling teeth.”

    To us like-minded dentists. At the end of his presentation, Dr Carvalho claimed he too was a product of the Amalgam Era (my term) and still uses it. He said so almost apologetically. Perhaps I read too much into his body language and hope he corrects me, if I am wrong. Philosophically, this visceral response is a product of self-perception as being out-of-step with a new Worldview, in this case, the every increasing use of composite resin in dentistry.

    Here is what blows me away. Everyone stresses the value of the importance of practicing Evidence-Based Dentistry. (I personally have a pet peeve with all the different suffixes we give Dentistry). Many lectures and articles abound trying to pin down exactly what this is. So far, over the 4 decades that I have been a dentist, every scientifically peer-reviewed article I come across, including dispatches from our governing bodies, claim amalgam lasts longer than composite resin. So, again I ask…why is amalgam use on the decline?

    Seems everyone talks a Big Ball Game about Evidence-Based Dentistry, but fewer of us practice what we preach, including perhaps the younger professors who have been trained in the Composite Era Worldview.

    I am proud as punch to do beautiful metal work.

    Stay Cool Doing It Old School. And by the way…it is the only school!

    Dr. Paul Belzycki, DDS

  10. Dear Dr. Paul,

    I graduated in 2014 and I love amalgam too! And FMC with at least 50% Au. Unfortunately I have not the 30+ year span to observe my restorations but I am confident that all my metal hardware will be there for decades.

    My biggest peeve for posterior resins is post-op sensitivity. I find myself having to redo them for free, to add dycal and vitrebond, to reduce sensitivity, even when restorations are shallow. As a young dentist, doesn’t help that I look young too, patients lose confidence in me because of that sensitivity. Drives me insane. If I could, I would only place amalgams in molars and subgingival class Vs. I absolutely hate having to spend much of my treatment planning time explaining why amalgams are better. Also a disservice that some Scandinavian countries have banned Amalgam altogether!

    Having spent 2 years in Thunder Bay and currently in the Bruce Peninsula, I have seen copious geriatric patients and patients with poor oral hygiene. I’ve replaced a filling 3x on a Native kid who refuses to pick up a brush, and NIHB doesn’t pay for it… thus learned my lesson, do the damn amalgam! I’ve done 13 and 23 MIDBL amalgam on a Native lady so her RPDs would still fit, because NIHB won’t cover a new denture unless an upper clearance was done. Your lecture forgot to mention how much more durable amalgam is in poor hygiene situations, as plaque that is found on composite are live and on amalgam are dead. (From a study, can’t remember.)

    Thanks so much for reconfirming my beliefs, I hope it continues to turn the tide against the anti-amalgam movement and calls to ban the material. Gold foil is too expensive as an alternative!

    • Dear Anne,

      Keep doing what you are doing.
      Your patients deserve the best you can give.

      Paul

    • Hello Anne,

      I too had that problem years ago. I found the local water was contaminated. I changed to distilled water with disinfected water lines and the sensitivity issues IMMEDIATELY went away. I realized the sensitivity was a bacterial issue and added using Gluma (G5) under every restoration. I now NEVER have sensitivity issues with comp, or amalg., or crowns as long as I use the G5 and wait the proper time for my multi-step adhesive (do not use single step. It is the lazy way). Very carefully dry or keep moist where you have to and remember that the mesial of each banded resto has poor access and this is where there is a pooling of water or primer or bond. Details, Details, Details. I also think amalgam has a huge benefit in certain situations.

      All the best,
      Dr. Oly Eichstadt

      • Dr. Sheryl P. Lipton

        I used chlorhexidene (peridex) before placing any restoration and rarely get sensitivity. But I do wash it away when using a comp as I am worried about the bonding with a pool of chlorhexidene. So far, so good.

  11. At a dental materials lecture I attended some time ago, the speaker stated that the amalgam formula in today’s amalgam has changed and they aren’t as effective as before because of that.
    What amalgam do you use?

    • Dispersalloy (Densply are you listening?) my entire career. I did try Tytin some 20 years ago for a short time, but returned to this product for reasons I fail to recall. Dispersalloy, fast set, seems to work best for me. As mentioned in the post, I will often do the periodontal surgery first, then prepare the crown margins, and lastly, place the amalgam build-up. The set-time seems to match my pace. And I am slow.
      If no periosurgery is required, an impression can be taken after 10 minutes or so. This takes another 10 minutes say. So, 20 minutes after placement, the core build-up is hard enough that one can do provisionals with no problems.

      Hope this helps.

      Dr. Paul Belzycki, DDS

  12. Hi Paul,

    Looks like you touched upon a subject that dentists really care about.
    I cannot believe the number of patients who come into my practice who are stunned when I recommend amalgam because their last dentist advised them to remove all of their amalgams. There was a nice article in Ontario Dentist in the past year or so where the author drew an analogy between resin vs amalgam and drug A vs drug B. If drug B had to be replaced more often, was more expensive and resulted in greater side effects (Post op sensitivity) then it would never be covered by the drug company or the provincial health plan. Despite this, resin is used more commonly than amalgam.
    In any case, you know I think your work is beautiful and I commend you for taking a stance about this. I am only out of school 6 years and almost exclusively place posterior amalgam.

    • Dear Erin

      You have restored my confidence in our “new generation” of dentists.
      As I mentioned on a previous post, most of my career I have flown under the radar.
      I am not one to take up causes or lead.
      Thought I would sell my practice and ride off into the sunset, with only my patients and staff knowing how hard I have tried to provide the best I could.
      Hope you do the same. There is honour and dignity in a hard days work done right.

      Good luck.

      Paul

  13. Dear Dr Belzycki,
    This was yet another first class presentation. The dental profession needs to hear this material. My hope is that you will be asked to lecture at Provincial and national meetings to spread the word. Again, a beautifully illustrated presentation that speaks for itself. We are indeed fortunate to have you have the courage to speak the truth, even when it goes against the grain. The work speaks for itself, as in your previous presentation.
    Thank you

    • These posts are akin to providing good dentistry. It has taken much effort over the past few posts to refine style and presentation theme. It is not without great effort. Wondered if it was all worth that effort. My first post went viral…it got a bug and died quickly. I have gotten more comfortable talking to a computer in my back-office and trying to guess the response of a virtual audience.

      Thanks for making the audience feel real with your comment.
      And many thanks to all the other dentists that have responded in kind.

      Paul

  14. Dr. Sheryl P. Lipton

    Paul, you are not alone. My classmates and I still use amalgam. I love it. Sure, we all do more composites than we used to, but there are many situations which amalgam is really the only option that has any chance of success. The problem is trying to convince some patients who think that “white” is the only way to go. It’s like dealing with anti-vaxers. But I think that everyone here who is answering if our “vintage”.

    Regards from a fellow Mackenzie-ite and U of T’er!

    • Dear Sheryl,

      Mackenzie (our high school) was more than a lifetime ago. For that matter, so was U of T.
      Some folks who have replied are new dentists.
      I gave this presentation to students at their first National Convention.
      You would be surprised as to how many students came up to me after, claiming they had little clue there could be such a difference. It is my opinion that when presented with solid facts and case histories, they too will choose wisely. At least the ones possessing integrity.

      It is also amazing to CDA Oasis as to how many of us amalgam users have come “out of the closet” as a result of this post. For me, it is heartwarming.

      Dr. Paul Belzycki, DDS

  15. Dr Elizabeth Newman

    Hi Paul
    Bravo on such a fabulous presentation. I enjoyed every minute of it —and you even made me laugh when you made mention of patients who come in all pierced up in a grotesque fashion sometime and yet take exception to a little “silver metal” showing in their mouths. How very true!

    I have used amalgam for almost 47 years (yes, I am an old time dentist who graduated in 1971) and I absolutely love it and still use it and I still use pins also. Amalgam has always been the material of choice that I recommend to patients for posterior restorations. It is the material that I and my husband and my children and my granddaughter have in their posterior teeth. That is how comfortable I am with the safety and longevity and excellence of amalgam as a restorative material.

    I fully agree with Dr Blischak’s earlier suggestion that the fee for amalgams and composite restorations be the same.

    Thank you for such a superb and informative presentation. I truly hope that the younger dentists who do not do amalgam restorations and those dentists who have thrown out their amalgamators will return to amalgam. (For the record, I have 3 amalgamators in the office in case one or two of them breaks down—-just to ensure that I will always be able to place an amalgam.)

    My sincere compliments to you on the excellent work that you provide to your patients.

    Liz

    • Dearest Elizabeth,

      During our study club lunches, I would often say ” You have no idea as to what goes on at my office.”
      So, now you know.
      I may play the part of the joker, but the work is all serious business.
      Regrettably, I had more amalgamators than you, but traded Andrew Moncarz (superb endodontist) my first amalgamator from 1980 for an ultrasonic unit. This way he can do the odd amalgam filling and I can do the odd root-end procedure. An even trade.

      Dr. Paul Belzycki, DDS

  16. On behalf of Dr. Gerry Chu

    Totally agree.

    There are places and situations where amalgam is much better than composites. If patients are given the facts plus what we 40 plus years of experience and being continuing education junkies have seen and what have served our patients well over the long run there is still a place for it. As well Gold is still one of the best materials. Both metals have proven themselves and look like the day we placed them over 30-40 plus years. Although the majority of patients prefer our great tooth coloured materials when given choices with pros and cons they’ll choose the metals.

    We had Harold Heyman from UNC doing a lecture at our Thompson Okanagan Dental Society Meeting on Kelowna about 12 years ago. We we’re having breakfast before his lecture and he’d expressed despite how they’d taught their students properly at North Carolina he’d see them advertising that they were non-metal practices. He said he considered them non-brain practices.

    I guess there are still a few of us old farts around that although we are still keeping up and excited about the new advancements, we don’t throw out the old because we have seen them stand up and have served our patients very well.

    • Dear Gerry,

      Thankfully Dr. Heyman said it first. I too have uttered the same words. And when you point out to this group that many of the materials they use contain metals, they just stare back in bewilderment. For they are truly either brain-dead, (periodic table of elements is lost on them) or they do understand, but promotional gimmickry and financial concerns override what is best for patient.

      I do not care to debate these folks, as the employment of rationality is useless against the irrational. Akin to debating Evolution with the fundamentally religious. “Don’t confuse me with the facts…my mind is made up.” These words were spoken by Richard Dawkins on a TED talk. He claimed that other theories of science do not need to be reaffirmed with every conversation, for example theories of the Atom or Relativity…only Evolution…and currently Climate Change. I feel this way about amalgam. Always having to re-educate and argue the superior characteristic of the material over composite resin, or as another Old Timer commented to previous post I made, “com-poo-site”.

      I know, you know and apparently, so do many other dentists.
      Perhaps the general public, the patient, needs to be made aware of these facts.
      But, that is not my department, nor to do I care to make it so, beyond my patients.

      Nice to hear from the folks in Kelowna.
      Dr. Paul Belzycki, DDS

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