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  • What are the patients’ opinions on the health effects of mercury in amalgam?
  • More assessment4 presentation - 2nd final

    1. 1. By Marise Butler, 2010
    2. 2.  As an oral health student I want patients’ to be aware of the properties of the restorative materials used.  Attention has been placed on the health effects of amalgam.  Patient should have the right information regarding restorative materials.  To understand why patients have formed the opinion that amalgam is unsafe – is there a health link?  To decrease negative views of amalgam.
    3. 3.  What are the patients’ opinions on the health effects of mercury in amalgam? Aims:  To explore dental patients views on mercury in amalgam.  To see if there is a link between mercury in dental amalgam and the health effects.
    4. 4.  As this study is seeking the patients’ opinions regarding the health effects of mercury in amalgam, the methodology is qualitative.  This is because focus groups will be used as they are the most effective way for gaining opinions as it allows for discussion about mercury with all group members.  Choosing focus groups over individual interviews allows everyone’s opinions to be heard and shares knowledge on the topic.  If this research was done using a quantitative approach, opinions would be limited as surveys do not allow the participant to explain their thoughts clearly due to short answer questions (Davidson, 2005).  Participants will feel safe in groups and will feel better valued as there opinion is listened to.
    5. 5.  This research study does not use random selection methods (which is a quantitative method), as it needs specific participants.  Specific data collection called purposive sampling which is a form of non- probability sampling, samples individuals that are selected due to a characteristic, in this case the need for restorative restorations with the option of using amalgam or composite/GIC.  To gain specific participants through the purposive sampling method, dental professionals (dentists & health care centres) who have prospective patients with restorative work required will be provided with information regarding the study.  This information will state that the targeted participants must be familiar with amalgam and visit their dental professional regularly (Syque, 2010).
    6. 6.  Focus groups will be used to seek patient’s opinions regarding amalgam and composite/GIC, which is a qualitative approach.  Limited numbers of participants in each group, so that each member feels they have a chance to self-report which is an effective method which allows the participants to say their opinions on the discussion and be acknowledged (Polit, 2008).  A researcher will be used as an instrument, to keep the groups on track, facilitating the discussion on the health effects of mercury in amalgam.  Data saturation will occur when the focus groups have discussed all the participants’ views and opinions about the mercury in amalgam and no new information is being discussed.  Qualitative research data is analyzed throughout the study while it is taking place.
    7. 7. The Researcher:  Have an amalgam background to understand the conversation.  The researcher will not contribute to the thoughts or ideas of the participants, ensuring quality.  Will abide by the three principles of theTreaty of Waitangi.  Will utilise the time the group has allocated.  Open-ended questions allowing the participants to be able to respond with reasoning. For example: ‘What are your personal views on the mercury content of amalgam?’  The researcher will record the discussions from the focus group sessions, but due to confidentiality, the researcher will not mention or identify any individual involved in the discussion.
    8. 8.  Rigour is essential in a research study as it provides accuracy.  Reflexivity is used to maintain accuracy, as it requires the researcher to be aware of contributions they may make or that they themselves might influence in the focus group sessions which could affect the accuracy of the study results (Davidson, 2005).  As interpreters will be used, if required, there will be no discrimination and this will allow participants to feel involved and appreciated. Venue:  Auckland University ofTechnology (AUT) as it is a neutral environment.  Food and beverages will be provided to encourage participants to attend and keep them focused, allowing them to feel able to socialise with each other (Moon, 2008).
    9. 9.  The results of the individual opinions and group decisions will be documented well, noting the patterns and/or meaning of the data obtained from the focus groups.  The responses will be coded which will allow these themes to emerge.  Thematic analysis is a qualitative data analysis method. Once the data has been analysed, the researcher will go over the analysis to gain confirmation and validation of the results which will improve rigour (Babbie, 2008).
    10. 10.  Dental patients’ opinions on the health effects of mercury in amalgam will be explored.  These opinions will help to identify if there is any link between mercury in dental amalgam and the health effects.  The gap as to why patients are moving away from a safe restorative material will be identified  Patients will use the most appropriate restorative materials
    11. 11.  The ethics committee that needs to approve research study is Auckland University ofTechnology Ethics Committee (AUTEC).This ensures study respects the three principles of theTreaty of Waitangi, as it protects the participants’ rights and ensures nothing has been left out of the research proposal at the negligence of the organisation or researcher involved (Auckland University ofTechnology, 2010; Australian Evaluation Society, 2000; Moon, 2008).  Participating in the research study is voluntary.They are allowed to withdraw their consent and opt out of the research at any time. Informed consent must declare any risk of harm, such as emotional, psychological or physical that the participants may be subjected to. It also will declare what the intention of the research study is, its benefits and factors such as time and cost the participant may experience. Informed consent will also disclose the contact details of the research organisation.  Confidentiality and anonymity must be maintained throughout the research study.This means information gained from the participants for the purposes of the research study is not disclosed, assuring their privacy is maintained at all times (Auckland University ofTechnology, 2010).
    12. 12.  All ethnicities are eligible to participate in the study.  New Zealand studies must comply with the three principles of theTreaty of Waitangi (Moon, 2008).  Partnership is represented by the researcher and the participants working together to achieve a positive educational outcome regarding health. It is about mutual respect, making sure all participants are treated equally, spoken to with respect and understood for any cultural beliefs they have. For example, an important cultural belief is that the head is tapu (sacred) which may be a reason Maori are not having amalgam fillings. Informed consent is of the highest importance to maintaining partnership (Moon, 2008).  Participation is about acknowledging the barriers participants may face. Maori may have limited English which would prevent them from understanding and discussing the amalgam topic therefore an interpreter will be arranged for these participants. Another barrier is transportation, as some participants may not be able to attend due to being of low socio-economic status therefore car-pooling can be arranged for these participants (Moon, 2008).  Protection is about making sure the participant’s time is not wasted. Therefore the focus groups will be arranged with the participants at a convenient time and will be allocated a period of time such as one hour.The participants confidentially will be maintained throughout the study (Moon, 2008).
    13. 13.  Dental amalgam, consists of 50% mercury (Ferracane, 2009).  Alternatives such as, composite or Glass Ionomer Cement (GIC) have been developed for cosmetic reasons and they do not contain mercury (Larkin, 2002).  Amalgam is cost effective, strong, durable, easy to use and can withstand heavy chewing.  In 1990, approximately 200 million amalgam restorations were placed, proving the material is widely used and safe (Green, 2004).  Millions of patients have been treated with no adverse health effects reported, although there were a few rare cases of patients who have a mercury allergy (Colgate, 2010).  The New Zealand Ministry of Health (MOH), Medsafe, British Dental Association, United State Public Health Service, Federation Dentaire Internationale (FDI) World Dental Federation and World Health Organisations (WHO) all agree and state that amalgam is safe to use (Colgate, 2010; MOH, 2008).
    14. 14.  Individuals with amalgam restorations absorbs minuscule amounts of mercury vapour, far below the level that exerts any adverse health effect. - Participants did not have significant mercury levels as they had neither, a higher estimated daily uptake of inhaled mercury vapour, and did not have a higher mercury concentration in their blood or urine in comparison (Quackwatch, 2006).  There is no significant link between mercury levels in the blood and the amount of amalgam restorations in patients with reported symptoms (Bailer et al, 2001).  Some studies relate problems patients attribute to amalgam restorations being psycohosomatic in nature and patients have worsened their beliefs by receiving incorrect information from the media (Quackwatch, 2006).
    15. 15.  A study found an increase in blood mercury levels (Abraham, Svare, & Frank, 1984).  Another study (Damian, Michael, Derek, & Boyd, 2006) found that patients that removed their amalgam restorations experienced reduced symptoms such as memory loss, depression and fatigue, which they claimed were associated with the mercury content.  The FDA is using scientific literature to investigate claims that amalgam adversely affects the health of pregnant women and of younger children (MOH, 2008).  While New Zealand supports the use of amalgam, countries like Austria, Canada, Germany and Sweden have restrictions on the use of amalgam due to wider environmental effects of mercury and low mercury uptake (Medsafe, 1999).
    16. 16.  Every time restorations are re-done the size of the cavity is increased and more sound tooth structure, which is free from decay, is destroyed (Larkin, 2002). Therefore, the MOH does not recommend amalgam removal or replacement, without clinical indication as it can’t be justified on present clinic and scientific evidence. The exception is the patient who has an allergy or hypersensitivity reaction to amalgam (Medsafe, 1999).  Research reveals that mercury levels have been shown to be minuscule. Therefore, if there has been almost no adverse health effects related to the mercury in amalgam (aside from mercury allergy) and it is classed as safe to use, then why are patients choosing to use alternative restorative materials such as composite/GIC?  Therefore it is worth enquiring the patients’ opinions on the health effects of mercury in amalgam to address this gap.
    17. 17.  Abraham, J. E., Svare, C.W., & Frank, C.W. (1984).The effect of dental amalgam restorations on blood mercury levels. Journal of Dental Research, 63(1), 71-73. doi:10.1177/00220345840630011801  Auckland University ofTechnology (2010). Ethics knowledge base. Retrieved on September 30, 2010 from ethics/ethics?sq_content_src=%2BdXJsPWh0dHAlM0ElMkYlMkZ pbnRvdWNoLmF1dC5hYy5ueiUyRmludG91Y2glMkZFdGhpY3Ml MkZrbm93bGVkZ2VfYmFzZSUyRmtiX2hvbWUucGhwJmFsbD0x  Australian Evaluation Society (2000). Code of Ethics. Retrieved on September 30, 2010 from %20ongoing/code_of_ethics.pdf
    18. 18.  Babbie, E. (2008). The basics of social research. Thomson/Wadsworth, Belmont, CA.  Bailer, J., Rist, F., Rudolf, H., Staehle, H. J., Eickholz, P.,Triebig, G., . . . Pfeifer, U. (2001). Adverse health effects related to mercury exposure from dental amalgam fillings: toxicological or psychological causes?. Psychological Medicine, 31(2), 255-263. doi:10.1017/S0033291701003233  Colgate, (2010). Fillings. Retrieved on August 22, 2010, from,280,
    19. 19.  Damian, P.W., Michael, E. G., Derek, C., & Boyd, E. H. (2006). Mercury toxicity presenting as chronic fatigue, memory impairment and depression: Diagnosis, treatment, susceptibility, and outcomes in a New Zealand general practice setting (1994– 2006). Neuroendocrinology Letters, 27(4), 415-423. Retrieved from MercuryToxicityPresentingAsChronicFatigue..pdf  Davidson, E. J. (2005). Evaluation Methodogy Basics:The nuts and bolts of sound evaluation: Sage Publications.  Dingwall, R. (2008). Qualitative health research. Sage Publications.
    20. 20.  Ferracane, J. L. (2001). Materials in dentistry, principles & applications, (2nd ed.). Lippincott,Williams &Wilkins: Philadelphia, USA.  Green, S. A. (2004). Dental amalgam overview. Retrieved on August 22, 2010, from 4.html  Larkin, M. (2002). Don't remove amalgam fillings, urges American Dental Association. The Lancet, 360(9930), 393. doi: 10.1016/S0140-6736(02)09626-5
    21. 21.  Medsafe. (1999). Archived medical devices. Retrieved on August 22, 2010, from issuesarchived.asp#Amalgam  Moon, P. (2008). Health in the context of Aotearoa. TheTreaty of Waitangi. Oxford University Press: NewYork.  New Zealand Ministry of Health (2008). Ministry of Health statement on amalgam and other dental filling materials. Retrieved on August 22, 2010, from of-amalgam-for-dental-fillings-not-changed
    22. 22.  Polit, D. F. (2008). Designing and implementing a data collection plan. Lippincott, Williams &Wilkins: Philadelphia.  Quackwatch, (2006). The “MercuryToxicity” scam: How anti- amalgamists swindle people. Retrieved on August 22, 2010, from ury.html  Syque. (2010). Non-Probability Sampling. Retrieved August 22, 2010, from probability_sampling.htm