SMART: Safe Mercury Amalgam Removal Technique, Explained

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Dental amalgam has been used to repair decayed teeth for generations. Commonly called a “silver filling,” amalgam is a mixture of metals that contains approximately 50% elemental mercury by weight.

Many patients who have older amalgam restorations want to understand whether those fillings should be replaced and how removal can be performed with greater attention to mercury vapor, particles, and environmental waste.

The Safe Mercury Amalgam Removal Technique, commonly known as SMART, is a set of recommendations developed by the International Academy of Oral Medicine and Toxicology. The protocol adds protective measures to conventional dental isolation, irrigation, suction, ventilation, and personal protective equipment.

At Tetrahealth Dentistry, SMART safe mercury amalgam removal is performed by trained clinicians using a structured protocol intended to reduce exposure for the patient, dental team, and treatment environment.

What Is Dental Amalgam?

Dental amalgam is a material made by combining elemental mercury with an alloy containing metals such as silver, copper, and tin.

Mercury helps bind the other components into a workable material that hardens after being placed in a prepared tooth.

Amalgam became widely used because it is:

• Strong under chewing forces
• Relatively resistant to moisture during placement
• Durable in many posterior teeth
• Generally less expensive than certain alternatives

However, amalgam does not match the natural color of teeth, does not bond directly to tooth structure as modern adhesive restorations do, and requires special handling because it contains mercury.

The U.S. Food and Drug Administration’s dental amalgam guidance explains that amalgam fillings release small amounts of mercury vapor and that exposure can temporarily increase during placement or removal.

What Does SMART Stand For?

SMART stands for Safe Mercury Amalgam Removal Technique.

The protocol was created by the International Academy of Oral Medicine and Toxicology and was formally named SMART in 2016.

Rather than being a single device or procedure, SMART is a collection of recommendations designed to limit contact with:

• Mercury vapor
• Amalgam particles
• Aerosols produced during drilling
• Contaminated water and debris
• Mercury-containing waste entering the environment

Why Are Special Precautions Used During Amalgam Removal?

Removing an amalgam filling requires a dental handpiece to cut through or around the restoration.

This process can generate:

• Heat
• Fine amalgam particles
• Larger pieces of filling material
• Water spray
• Aerosols
• Mercury vapor

The purpose of a mercury-conscious removal protocol is to capture as much of this material as reasonably possible while reducing the amount that reaches the patient, dental team, operatory air, or wastewater.

Routine dental precautions, such as water irrigation and high-volume suction, already help control heat and debris. SMART expands these measures with additional isolation, respiratory protection, air filtration, and waste-management procedures.

The goal is to reduce avoidable exposure during a procedure that can temporarily release additional mercury vapor and particulate material.

What Happens During the SMART Mercury Removal Protocol?

Exact procedures may vary by clinician and patient. A SMART appointment commonly incorporates the following measures.

1. Examination and Treatment Planning

The dentist first evaluates the filling and the tooth supporting it.

Large amalgam restorations sometimes function like wedges within weakened teeth. Once the filling is removed, the dentist may discover fractures or insufficient tooth structure for a simple filling.

Patients should understand the potential restorative outcomes before treatment begins.

2. Preparing the Treatment Environment

The operatory is prepared to control airborne particles and vapor.

The IAOMT SMART recommendations call for adequate room filtration and a high-volume air-filtration system positioned close to the treatment source.

Depending on the office, environmental controls may include:

• High-volume air filtration
• Source-capture aerosol evacuation
• Room ventilation
• Mercury-rated filtration equipment
• Careful cleaning after the procedure
• Restricted access to the treatment room

These systems supplement—not replace—intraoral suction and isolation.

3. Protective Equipment for the Dental Team

The dentist and assisting team use personal protective equipment appropriate for the procedure.

SMART recommendations include:

• Protective gowns
• Nitrile gloves
• Head or hair coverings
• Face shields
• Respiratory protection designed for the anticipated exposure

Standard surgical masks are primarily designed for droplets and splashes. SMART protocols may call for additional respiratory protection or a properly sealed positive-pressure air system.

The equipment used should fit properly and be selected according to occupational-safety requirements.

4. Protecting the Patient

The patient is covered to reduce contact with particles generated during removal.

Protective measures may include:

• A waterproof or impermeable body covering
• Head, neck, and face protection
• Protective eyewear
• A rubber dam
• Barriers surrounding the treatment area
• High-volume suction
• A separate source of air or oxygen delivered through the nose

The goal is to isolate the tooth while helping prevent debris from contacting the patient’s skin, clothing, eyes, or unprotected oral tissues.

5. Rubber Dam Isolation

A rubber dam is a thin sheet placed around the tooth or teeth being treated.

It helps:

• Separate the treatment area from the rest of the mouth
• Reduce the chance of swallowing filling particles
• Keep saliva away from the tooth
• Improve visibility
• Protect oral tissues
• Support adhesive placement of the new restoration

A rubber dam alone does not control all mercury vapor or aerosols. It is used as one part of a layered protocol that also includes water and suction.

6. Nasal Air or Oxygen

A nasal hood or cannula may provide the patient with an alternative source of air during removal.

The system is intended to reduce the amount of operatory air the patient breathes while the filling is being sectioned.

The patient should tell the dental team about:

• Chronic nasal congestion
• Respiratory disease
• Claustrophobia
• Oxygen sensitivity concerns
• Previous difficulty with nasal cannulas
• Any condition affecting breathing

Supplemental oxygen should be delivered and monitored according to appropriate clinical standards.

7. High-Volume Suction

High-volume evacuation is positioned close to the tooth being treated.

The suction system helps collect:

• Water spray
• Filling fragments
• Fine particles
• Aerosols
• Vapor near the treatment source

Some offices use more than one suction device, with one inside or near the mouth and another positioned outside the oral cavity for additional source capture.

The effectiveness of suction depends on its flow, placement, maintenance, and proximity to the procedure.

8. Continuous Water Irrigation

The dentist uses water while cutting the amalgam.

Water helps cool the filling and tooth. Limiting heat is important because heating an amalgam can increase mercury vapor release.

Irrigation also helps carry particles away from the tooth.

9. Sectioning the Filling Into Larger Pieces

Rather than pulverizing the entire restoration, the dentist typically makes strategic cuts through the filling.

The amalgam can then be lifted or removed in larger sections when the tooth’s condition allows.

This approach may:

• Reduce drilling time
• Reduce heat generation
• Produce fewer fine particles
• Preserve more healthy tooth structure
• Make debris easier to capture

The exact method depends on the shape, depth, and retention of the restoration.

10. Cleaning and Inspecting the Tooth

After the amalgam has been removed, the dentist cleans and examines the remaining tooth.

This stage may reveal:

• Hidden decay
• Cracks
• Staining
• Unsupported enamel
• Previous liners or bases
• Pulpal exposure
• Inadequate tooth structure
• A need to revise the original restorative plan

Discolored dentin is not necessarily infected dentin. A minimally invasive clinician distinguishes between staining, affected tissue, active decay, and structurally compromised areas.

Tetrahealth may incorporate principles of biomimetic dentistry to preserve healthy tooth structure and restore the tooth in a way that manages chewing stress.

11. Placing the Replacement Restoration

Once the tooth has been prepared, it is restored with a material selected for the clinical situation.

Possible options include:

• Direct composite resin
• Ceramic inlay
• Ceramic onlay
• Porcelain or ceramic crown
• Glass-ionomer or resin-modified material in selected situations
• A temporary restoration when additional treatment is required

The best material depends on:

• The size and location of the defect
• Remaining enamel and dentin
• Bite forces
• Moisture control
• Aesthetic goals
• Material sensitivity
• Cost
• The need for a laboratory-made restoration

For patients with a history of allergies, autoimmune conditions, or chemical sensitivities, dental biocompatibility testing may be discussed.

Testing cannot guarantee that a material will never cause a reaction or that a restoration will succeed. It should be interpreted together with the patient’s history and the material’s clinical suitability.

What Is Used to Replace Mercury Amalgam?

The replacement must be strong enough for the tooth, compatible with the patient, and suitable for the size of the defect.

Composite Resin

Composite is a tooth-colored material bonded directly to the tooth.

It can be appropriate for small and moderate restorations when the dentist can maintain good moisture control and preserve adequate supporting structure.

Ceramic Inlays and Onlays

Ceramic inlays and onlays are laboratory-made or digitally fabricated restorations bonded to the tooth.

An onlay can protect weakened cusps while preserving more natural structure than a full crown in selected cases.

Ceramic Crowns

A crown may be necessary when the tooth has extensive structural loss, multiple cracks, or insufficient support for a filling or onlay.

A crown requires additional tooth preparation, so it should be recommended based on structural need rather than automatically after every amalgam removal.

Temporary Restorations

If the tooth requires further evaluation or the final restoration cannot be completed immediately, a temporary material may be placed.

The patient should understand how long the temporary restoration is expected to remain and what symptoms require follow-up.

How Should You Prepare for a SMART Appointment?

Follow the instructions provided by the treating dentist.

Preparation may include:

• Updating the practice about medical conditions
• Providing a complete medication and supplement list
• Discussing allergies and material sensitivities
• Eating according to the office’s instructions
• Arranging transportation if sedation will be used
• Asking how long the appointment will last
• Understanding the proposed replacement restoration
• Reviewing possible changes to the treatment plan
• Planning for temporary numbness afterward

Do not begin chelation therapy, stop prescribed medication, or take large doses of supplements without guidance from an appropriately qualified healthcare professional.

What Is Recovery Like?

Recovery depends more on the size and depth of the restoration than on SMART precautions themselves.

Patients may experience:

• Temporary numbness
• Gum tenderness from the rubber dam or clamps
• Mild jaw fatigue
• Brief temperature sensitivity
• Awareness of the new bite
• Sensitivity while the tooth adapts to the new restoration

Contact the dentist if you experience:

• Increasing or spontaneous pain
• Pain that wakes you at night
• Significant swelling
• Fever
• A restoration that feels too high
• Pain when biting
• A broken temporary or permanent restoration
• Sensitivity that worsens rather than improves
• Difficulty breathing or another urgent symptom

Some sensitivity can be normal, but persistent or severe pain may indicate pulpal inflammation, a crack, or a bite problem.

SMART Mercury Removal at Tetrahealth Dentistry

Tetrahealth approaches amalgam replacement through a combination of biological, restorative, and patient-safety principles.

The practice’s safe mercury amalgam removal protocol includes:

• IAOMT SMART-trained providers
• Patient and clinical team barriers
• Rubber dam isolation
• Nasal air or oxygen
• Continuous water cooling
• High-volume intraoral evacuation
• Additional source-capture filtration
• Sectioning of amalgam restorations
• Mercury-conscious waste management
• Selection of non-amalgam replacement materials
• Restorative planning focused on preserving the tooth

Care is led in part by Dr. Michele Volchonok, a SMART-certified biologic restorative and cosmetic dentist.

Patients can also explore Tetrahealth’s educational presentation on why safe amalgam removal matters in biologic dentistry.

SMART mercury removal is available at Tetrahealth’s Manhattan biological dentistry office and Greenwich biological dentistry office.

Schedule a SMART mercury removal consultation to have your existing fillings evaluated and discuss whether monitoring, repair, or replacement is appropriate.