General Dentistry · Last reviewed May 2026
Safe Amalgam Removal: Full IAOMT Protocol
Add-On.
Every existing amalgam filling at Picasso is removed under a full IAOMT/SMART-style isolation protocol: rubber dam, high-volume suction immediately at the tooth, sectioning rather than pulverising, optional alternative air supply for the patient, all to minimise mercury vapour exposure during removal. The protocol is an add-on on top of standard composite filling pricing, and the cavity is replaced with bonded composite the same visit. Picasso does not place new amalgam fillings.
What is Safe Amalgam Removal?
Safe amalgam removal is a defined clinical protocol developed by the IAOMT (International Academy of Oral Medicine and Toxicology) and similar bodies, designed to minimise patient and operator exposure to mercury vapour during the removal of existing dental amalgam (silver) fillings. The published IAOMT protocol is called SMART, Safe Mercury Amalgam Removal Technique. Its key elements are rubber dam isolation around the treated tooth, high-volume air evacuation positioned immediately at the source, copious water cooling to suppress heat-driven vapour, sectioning of the filling into chunks rather than aggressive pulverising, an alternative air supply for the patient via nasal cannula, and where available room air filtration. The protocol does not eliminate exposure, but it materially reduces it during the part of an amalgam s lifetime when measurable vapour release is highest, the act of removal itself.
What's Included in the Picasso Protocol
Seven elements, applied in full to every amalgam removal at Picasso Dental, regardless of patient motivation. This is best practice for any amalgam removal.
1. Pre-Removal Briefing
Medical history review, photographs of the existing amalgam restorations, and a bite check. We brief you on the protocol, the tradeoffs, and the realistic outcome. Patient preferences around supplements are acknowledged, we do not prescribe pre-treatment regimens.
2. Patient Protection
Rubber dam isolation around the tooth being treated, protective body drape, eye protection, and on request an alternative air supply via nasal cannula so the patient breathes external air rather than air over the working field.
3. Operator Protection
Face shield, particle masks and gloves for the dentist and assistant. Operator protection matters because dental teams are exposed repeatedly across many removals.
4. Copious Water Cooling
Continuous water spray throughout the removal. Heat is one of the main drivers of mercury vapour release from amalgam; cooling suppresses it directly.
5. High-Volume Evacuation
Large-bore high-volume suction positioned immediately at the tooth, capturing vapour and particulate at the source rather than letting it disperse into the operatory air.
6. Sectioning, Not Pulverising
Where anatomy allows, the amalgam is sectioned into large chunks and lifted out cleanly, rather than ground into fine dust. Less grinding equals less vapour and less particulate.
7. Composite Replacement
After thorough rinsing and dam removal, the cavity is etched, bonded and restored with layered light-cured composite the same visit. Polished, occlusion checked, photographed.
Why Patients Request Safe Amalgam Removal
Patients come to us for several different, all valid, reasons. We do not gatekeep the protocol behind a particular motivation.
Personal Preference for Non-Metal
Some patients simply prefer non-metallic restorations for personal or aesthetic reasons. That is sufficient reason to request removal and replacement with composite.
Visible Silver in the Smile
Older amalgam fillings in upper premolars or front molars often show as dark patches when smiling. Cosmetic concern alone is a common and legitimate trigger for replacement.
Concern About Long-Term Exposure
Some patients are concerned about long-term mercury exposure from existing amalgams. Picasso does not make medical claims about systemic mercury impact, we provide the protocol, you make the decision.
Failed Amalgam Needing Replacement
Marginal leakage, recurrent decay around the filling, or fracture of the surrounding tooth structure all require replacement on clinical grounds. If the existing restoration is amalgam, the SMART protocol is the responsible way to remove it.
Pregnancy Planning
Some patients planning pregnancy choose to remove existing amalgams beforehand. The FDA 2020 guidance lists pregnant women among groups for whom alternatives to amalgam should be considered.
Mercury Allergy or Sensitivity
True mercury allergy is rare but documented. Patients who self-identify as sensitive are accepted without requirement to prove it; the protocol is the same either way.
What We Don't Claim
An honest evidence note. We are not a holistic clinic and we will not oversell this procedure to you.
The current scientific consensus, per the U.S. FDA (2020 update), the World Health Organization and the American Dental Association, is that dental amalgam is regarded as safe for most adults and children aged 6 and over. The FDA recommends caution and considering alternatives specifically for higher-risk groups: pregnant women and women planning pregnancy, nursing mothers, children under 6, people with neurological disease, impaired kidney function, or known mercury allergy.
We do not claim that removing existing amalgam fillings produces a measurable systemic health benefit in the general population. The published evidence does not support that claim, and we will not make it.
What we do claim is narrower and defensible: if you are going to remove an amalgam filling, for any reason, the IAOMT/SMART protocol is the best-practice way to do it, because the act of removal is the part of an amalgam s lifetime when measurable vapour release is highest. We apply the protocol because it is good practice, not because we are selling a health outcome. Picasso does not place new amalgam fillings at all, every new restoration we provide is composite, ceramic or porcelain.
Patient choice is respected. We will not pressure you to remove amalgams that are clinically sound, and we will not pressure you to keep them either.
Pricing
Per-tooth pricing. The IAOMT protocol is a flat add-on on top of the underlying composite filling fee. Pricing is identical across all six Picasso branches.
| Service | Price |
|---|---|
| Composite filling, small (replacement) | |
| Composite filling, moderate (replacement) | |
| Composite filling, large (replacement) | |
| Safe amalgam removal protocol (IAOMT) add-on | |
| Total per tooth, typical range | 1,200,000 – 1,500,000 |
| Inlay / onlay if cavity too large for direct fill (Emax) | |
| Crown if tooth structure compromised (Emax) |
For larger restorations see dental fillings, porcelain crowns or veneers.
How the Procedure Works
Seven steps per tooth. Most single-tooth removals complete in 60 minutes. Multiple-tooth cases are usually spread over two or more visits, one quadrant at a time.
1. Rubber Dam
A latex or non-latex rubber dam is placed around the tooth being treated, isolating it from the rest of the mouth and forming a barrier against debris and water spray.
2. Suction Positioned
High-volume evacuation is positioned immediately adjacent to the tooth. An optional nasal cannula provides clean external air to the patient.
3. Sectioning
The amalgam is cut into large segments under copious water spray and lifted out, rather than ground into dust. This is the part where the protocol differs most visibly from conventional removal.
4. Composite Layered
The cavity is cleaned, etched and bonded. Composite is built up in increments, shaping the contour and contact point.
5. Light Cured
Each composite increment is light-cured to full hardness before the next. This is what allows large fillings to be placed reliably in a single visit.
6. Polished
Once the dam is removed, the filling is shaped, polished and the bite is checked with articulating paper. Adjustments are made until the bite feels even.
7. One-Week Review
Optional review at one week to confirm no sensitivity, polish refinement if needed, and a final bite check once the new filling has settled into your bite cycle.
Who Is, and Isn't, a Good Candidate?
The IAOMT protocol itself is appropriate for any amalgam removal. The question of when to remove is more nuanced, and case-by-case.
You're a Strong Candidate If
You have visible silver fillings in your smile and want them replaced for cosmetic reasons.
An existing amalgam shows marginal failure, recurrent decay or fracture and requires replacement on clinical grounds.
You have a personal preference for non-metallic restorations and have made an informed choice.
You are planning pregnancy and want existing amalgams replaced beforehand.
You have a documented or self-identified mercury sensitivity and are willing to proceed.
Waiting May Be Appropriate If
You are pregnant in the first or third trimester. Per FDA 2020 guidance, defer non-urgent removal or schedule in the second trimester.
The amalgam is clinically sound, well-sealed, asymptomatic and not visible in your smile, leaving it in place is a reasonable option.
The tooth is severely compromised and will need a crown or inlay regardless. In that case the discussion is about the final restoration, not just the filling.
You have several large amalgams. Removing them all in one visit is rarely the right plan; we will sequence over two or more appointments by quadrant.
Aftercare
Same-day recovery. There is no special detox protocol.
A brief metallic taste in the first 24 hours is normal as residual particles are flushed by saliva. Mild sensitivity to cold or pressure can persist for 48 hours, occasionally a few days, especially after large fillings. Eat normally once the local anaesthetic wears off, avoid very hot or very cold drinks for the first few hours, brush and floss as usual.
We do not prescribe charcoal, chlorella, glutathione or chelation regimens. There is no established evidence base for these in routine post-removal care, and your money is better spent on the protocol itself, which is the part that actually controls exposure during the procedure.
Risks & Honest Tradeoffs
The protocol minimises risk; it does not eliminate it. Here is what to know.
Transient Vapour Exposure
The IAOMT protocol minimises but does not eliminate mercury vapour release during removal. The brief exposure during a controlled removal is small; the literature does not establish a defined safe threshold, which is part of why the protocol exists.
Post-Op Sensitivity
48 hours of sensitivity to cold or pressure is common after any moderate-to-large filling, amalgam or composite. It usually resolves on its own. Persistent sensitivity beyond a week warrants a review.
Cavity Larger Than Expected
Once an old amalgam is removed, the underlying tooth is sometimes more compromised than the X-ray suggested. A direct composite may not be the right restoration; an inlay, onlay or crown may be needed instead. We will tell you the same visit and quote in writing before proceeding.
No Promised Systemic Benefit
We are not promising you will feel different. The published evidence does not support a general claim of systemic improvement after amalgam removal in healthy adults. We are promising the removal itself will be done responsibly.
Your Treating Team
Safe amalgam removal at Picasso is performed by our general dentistry team under clinical standards set by the founding clinical director. Branch assignment is confirmed at booking.
Dr. Thao Tran
General Dentist. Routine restorative care including composite fillings and amalgam removal under the IAOMT protocol.
Dr. Nhung Duong
General Dentist. Restorative dentistry, composite fillings, and rubber dam isolated procedures including SMART-protocol amalgam removal.
Dr. Emily Nguyen
Founding Clinical Director. Sets clinical standards for case selection, surgical protocols and prosthetic delivery group-wide, including the protocol followed for amalgam removal.
Common Questions
What is the IAOMT SMART protocol?
SMART stands for Safe Mercury Amalgam Removal Technique, published by the International Academy of Oral Medicine and Toxicology (IAOMT). It is a defined removal protocol designed to minimise patient and operator exposure to mercury vapour during removal of dental amalgam restorations. Key elements: rubber dam isolation, high-volume air evacuation at the tooth, copious water cooling, sectioning rather than aggressive grinding, alternative air supply, and where available room air filtration.
Is dental amalgam dangerous?
The current scientific consensus, per the U.S. FDA (2020 update), the World Health Organization and the American Dental Association, is that dental amalgam is safe for most adults and children aged 6 and over. The FDA recommends considering alternatives for higher-risk groups: pregnant or planning-pregnancy women, nursing mothers, children under 6, people with neurological disease, impaired kidney function, or known mercury allergy. Picasso does not place new amalgam fillings, and respects patient choice on removing existing ones.
Do I need supplements or detox before or after?
No. Picasso does not prescribe pre-removal supplements, post-removal chelation, charcoal, chlorella or other detox regimens. The evidence base for these is not established. We acknowledge that some patients use them on their own initiative. We focus our protocol on minimising exposure during the removal itself, the part within our control.
Can I remove all my amalgams in one visit?
It depends on the number, size and your tolerance. Many patients prefer to space removals over two or more visits, one quadrant at a time. This is also the IAOMT-recommended pattern, it limits the total exposure of any single appointment. We plan the sequence at consultation.
Can I have safe amalgam removal during pregnancy?
The U.S. FDA 2020 guidance recommends caution for pregnant women and considering alternatives where amalgam removal is not urgent. Where removal is needed during pregnancy, the second trimester is generally regarded as the safer window. We will defer non-urgent removal until after pregnancy where you prefer, and follow the full IAOMT protocol if removal proceeds.
Why does this cost more than a normal filling?
The protocol takes longer and uses more disposable material: full rubber dam setup per tooth, additional suction, body drape, optional nasal cannula air supply, and slower sectioning technique. The add-on covers the additional time and consumables on top of the standard composite filling fee.
Will I feel different afterwards?
Honestly, we cannot promise a systemic health change. The published evidence does not support a general claim that healthy adults feel different after amalgam removal. What you will reliably get: no more visible silver in your smile, a properly bonded composite that seals the tooth, and the knowledge that the removal was done under a defined exposure-minimising protocol.
Do you accept patients with multiple chemical sensitivities?
Yes. We do not require patients to justify their preference for safe amalgam removal. The IAOMT protocol is best practice for any amalgam removal, regardless of the patient s reason for requesting it.
What about charcoal, chlorella and binders during the visit?
If you wish to take your own supplements at home before or after the appointment, we do not object. We do not administer or recommend them as part of the clinical protocol because the supporting evidence is not established.
Will my insurance cover it?
Most international dental insurance covers the underlying composite filling cost when there is a clinical indication (failed amalgam, decay, fracture). The IAOMT protocol add-on is generally treated as an elective upgrade and may not be reimbursed. We provide itemised invoices in English so you can submit to your insurer.
Start Here
Replace Your Amalgams
Under a Real Protocol.
Book a free consultation. We will photograph your existing fillings, plan a removal sequence, quote you in writing, and walk you through every element of the IAOMT protocol before you commit. No pressure, no upselling, no detox theatre.