Northern Ireland: Dental amalgam update

While this wasn’t the final stage in the process, it has generated considerable concern, not least in Northern Ireland where the default position appears to be that an amended EU Mercury Regulation would have direct application under post-Brexit arrangements, namely the Northern Ireland Protocol. All this at a time when Health Service dentistry is already at breaking point.

This has also coincided with the return of the Stormont institutions, including new democratic scrutiny structures provided for by the Windsor Framework - an NI Assembly Windsor Framework Democratic Scrutiny Committee that can hold an Inquiry where application of an EU act is determined to pose a significant impact to everyday life/communities in Northern Ireland that is liable to persist, and the ‘Stormont Brake’ mechanism which can potentially be applied by 30 MLAs to trigger an objection by the NI Assembly to new or replacement EU acts.

This is completely unchartered constitutional territory, with more unknowns than knowns at this stage. We find ourselves at the centre of a process which could have massive implications for the dental profession and the future of dental services in Northern Ireland.

But our focus is clear. To quote the UK Chief Dental Officers (CDOs), “it is extremely important that dental amalgam remains within our treatment armamentarium for the foreseeable future”.

Therefore, maintaining a phase-down approach to dental amalgam use is considered essential.

EU developments

Following the EP vote, on 8 February, the European Council and EP have reached provisional agreement on a proposal to revise the 2017 Mercury Regulation. While this is pending formal adoption by both institutions, the agreement reached is as follows:

• A ban on use of dental amalgam in the EU from 1 January 2025, except where deemed strictly necessary by the dental practitioner to address specific medical needs of the patient
• Provision for an 18-month derogation for member states where low-income individuals would otherwise be socio-economically disproportionately affected
• A ban on export of dental amalgam from the EU from 1 January 2025, and a ban on manufacturing and import of dental amalgam in the EU from 30 June 2026, with provision for a derogation to allow import and manufacturing of amalgam for patients with specific medical needs
• A review of exemptions for use of dental amalgam to be performed by the European Commission by 31 December 2029 taking into account availability of mercury-free alternatives.

Crucially, the accelerated timescale for phase-out of amalgam (1 January 25) has been agreed between the EU institutions.

An amalgam phase-down trajectory

The UK government has for many years maintained their commitment to work with the dental profession to phase down the use of dental amalgam. They are signatories to the Minamata Convention on Mercury which sets out measures to phase down the use of dental amalgam.

National plans, including the Northern Ireland Plan to phase down the use of Dental Amalgam, were published in all four UK nations. The NI plan (2019) seeks to ensure a gradual reduction in the use of dental amalgam through three key pillars:

1. Improving oral health by prevention
2. Promoting R&D of alternative restorative materials and new techniques
3. Bringing forward changes to service delivery, including a new General Dental Services Contract, and further development of Community Dental Services (CDS) to meet rising population needs.

BDA position on dental amalgam

In our dental amalgam position paper, we have emphasised the importance of maintaining a phase-down approach across the UK, including NI, and the continued validity of the key pillars set out in our national plans that will take us to our goal. Quite simply, the core preparatory steps around prevention, service delivery/contract reform and alternative materials and techniques set out in 2019 have not materialised.

Northern Ireland is nowhere near being ready to move to a phase-out position, least of all to a date arbitrarily set as 1 January 2025.

What we’ve been doing

• We’ve shared a UK-wide BDA position paper on dental amalgam with the Department of Health (DoH), which reaffirms the basis for maintaining a phase-down approach to dental amalgam in all four nations, a position that continues to be affirmed by all four CDOs
• We have written to NI Health Minister Robin Swann, urging him and his department to provide clarity that DoH will continue to adopt a phase-down policy position to dental amalgam, and as such commit to working to highlight in full the risks associated with phase-out in informing the work of the Assembly Windsor Framework Democratic Scrutiny Committee
• We will be engaging directly with the NI Assembly Windsor Framework Democratic Scrutiny Committee. We have already written to the committee to highlight this issue, and hope to present evidence in pressing for a committee Inquiry in the coming days
• We will utilise feedback received from our NI committees and from our GDP survey on the risks posed from an amalgam ban to inform our messages to Stormont
• We will continue to highlight the many concerns from right across dental services -GDS, CDS and the Hospital Dental Service in continued engagements with policymakers, politicians, and the media.

Looking forward

The threat of amalgam phase-down has come at a time when we thought things couldn’t get any worse for dental services in Northern Ireland.
We are clear that the strongest possible case must be put forward to Stormont for phase-down, and against this replacement EU act from having direct application. We have urged Minister Robin Swann and his officials to join us in that approach.

Our committee representatives are working tirelessly on your behalf and have appealed to the Department to step up to the plate to take whatever steps are necessary to mitigate the significant risks to practitioners, and to the future provision of dental services associated with an amalgam ban.

This issue merely highlights why governments need to get on with making much more rapid progress on key areas like prevention and investing properly in modern dental services.

There is no way to predict where we will land on the dental amalgam issue. But we will commit to highlighting loud and clear the concerns of the profession on this issue, and the potential impact on dental services over the coming weeks.

We must strive for the outcome that best reflects the needs and oral health profile of the local population, and which will make dental services sustainable in the future.