IABDM Certification Events

Event Date & Location

Biological Dentistry 101 course Thursday of our annual conference (usually held in October)

Written exam Successful examinations (80% correct or better) result in the applicant moving into the case presentation phase. Unsuccessful applicants may resubmit their application at a reduced fee ($600) and retest in 12 months.

Sunday of our annual conference OR online

Oral case presentations (2 cases, from examination through completion and follow-up: 1 amalgam removal case and 1 amalgam removal, root canal removal or cavitation case)

Sunday of our annual conference OR via Skype, by arrangement

Our certification program recognizes the differences in training and expertise of our member doctors. Credentialing confers a recognized level of achievement, based on a variety of criteria. The hierarchical achievement levels further recognize the efforts of our members who continue to add to their knowledge base and surgical skills. When a member is ready, credentialing is offered for Certified , Fellowship and Mastership levels.

Dentists and physicians who are members in good standing are eligible to sit for the written examination. Topics covered include homeopathy, meridians, mercury removal basics, fluoride and cavitations.

To maintain your certification, you must 1) stay current on your dues; 2) show proof of at least 12 hours of CE per year in biological dentistry or medicine; and 3) attend at least 1 IABDM conference every 2 years.

In addition to the following guide, you should study the current IABDM Standards of Practice: http://iabdm.org/about-iabdm/iabdm-standards-practice/.

International Academy of Biological Dentistry and M edicine Study Guide for Biological Dentist/Practitioner Cer tification

Founding Statement of the Academy PURPOSE The purpose of the IABDM is to promote biological dental medicine utilizing non-toxic diagnostic and therapeutic approaches in the field of clinical dentistry. OBJECTIVES We propose to accomplish this purpose by actively importing the technology and knowledge that our foreign and American colleagues now possess. Seminars on biological diagnosis and therapy with medical-dental therapy literature and instruments will be presented. We will also promote the transfer of worldwide biophysical knowledge to the field of clinical dentistry. We intend to bring the theory and practice of traditional Chinese acupuncture into better focus so as to act as a unifying concept to allow the biologically-oriented dentist to participate with the biologically-, ecologically- and environmentally-oriented physician in the resolution of common patient disease states. A network of physicians and dentists working conjointly to provide unified diagnosis and treatment procedures for their common patients will be established. Dentists will play a greater role in the treatment of the environmentally ill patient and those whose disease etiology is still identified as idiopathic or unknown. We intend to promote biocompatible corrections and restorative dental procedures based on our scientific knowledge of energy, electromagnetics, sound, light, acupuncture, homeopathy and nutrition, in addition to the myriad of traditional scientific disciplines that constitute clinical dentistry. ACKNOWLEDGMENTS The Academy acknowledges the great work Reinhold Voll, MD, initiated and developed, along with the tremendous contribution made by Dr. Med. Dent. Fritz Kramer in showing the energetic relationships of the teeth to the organs, glands, joints, muscles, nerves, vertebrae, dermatomes, sinuses, reflexes and fields of disturbance. These contributions will become an integral part of the foundation of 21st Century Medicine. Future 21st Century Medicine will be concerned with the depollution of the internal and external environments. It is time to correct our mistakes and become biologists of the mouth in addition to our technical expertise. Physicians and dentists must work together for the good of the whole person. The fragmentation caused by specialization must be rethought. An integrated and unified approach of mind, body and spirit in diagnosis and treatment must be instituted for all.

The ABCs of Biological Dentistry and Medicine: Biological Dentistry and Medicine Defined Dental and oral conditions can be understood only in relation to the whole body. Just as your foot bone’s connected to your ankle bone, your oral tissues are physically and energetically connected to every other part of you. Biological practitioners know that the body reflects what goes on in the mouth—and that the mouth reflects what goes on in the body. Dysfunction or disturbance in one area will eventually and invariably show up as illness in related areas of the body. A biological approach is holistic, a blend of clinical practice, sound scientific knowledge and the traditions of natural healing. It does not automatically equate symptoms with illness. For what we call “symptoms” often indicate important signs of healing. To suppress these symptoms and call it “cure” is both superficial and shortsighted. And by ignoring the actual causes of illness, this allopathic practice leaves the patient vulnerable to even more dysfunction and future disease. In contrast, biological practitioners try to find the systemic causes of illness. To remove the root cause is to take a major step towards healing. As a rule, they opt for the least invasive, least traumatic and least toxic means of diagnosis and treatment. True biological care supports the body’s natural abilities of self-healing and regeneration. Biological practice is socially, spiritually, ecologically and environmentally aware. Its practitioners honor the right to informed consent. They know the human body is more than a collection of parts that can be mechanically worked on in isolation. Seeing us as whole, unified beings, they respect each person’s individual uniqueness and dignity. They are committed to providing the patient with the knowledge, tools and power to take charge of his or her health. Biological practitioners know the profound impact they have on each other. They work together to help each patient heal and maintain his or her health and well-being. IABDM-trained, non-dental practitioners always look in each patient’s mouth for signs of toxicity or dysfunction in the teeth and jaws. If needed, they refer the patient to a biological dentist. In turn, biological dentists consider each patient’s whole health history. As needed, they refer the patient to allied practitioners to provide this holistic care. Health isn’t a condition. It’s a process. And it’s most sincerely engaged in when all involved consider and care for each person’s whole being. Success comes from cooperation—as, indeed, it must. For true healing and health involve the whole being: body, mind and spirit.

A Brief History of the Academy The Academy was founded in 1985 by two California dentists, Ed Arana and Gary Verigin. They had met the year before in a class featuring Reinhold Voll, MD. There, this German inventor of the diagnostic tool EAV (electroacupuncture according to Voll) spoke of a new field developing in Germany: biological dentistry. The practice was showing how illness can often be traced to oral-dental conditions, either as a cause or aggravating factor. It affirmed dentists as true medical specialists, not mere mechanics of teeth. German dentists were blending homeopathy, acupuncture and related remedies with standard clinical practice to help people support their bodies’ natural processes of self-healing. This hit home with Drs. Arana and Verigin. Each had long been dissatisfied with the “one tooth dentistry” practiced by most American dentists—an approach that sees the teeth and oral tissues as isolated from the rest of the body. They knew it just didn’t correspond with human physiology. Alone, each had sought something better. Both wanted a more informed dentistry. They saw biological dentistry as fully accounting for the systemic nature of health and illness, and the body’s self-regulating ability. They knew they were not alone. They often found each other’s company at seminars over the following months. One evening, after a class with German naturopath Andreas Marx, they talked about bringing more of the best German biological dentists to the US to teach them. Wanting to share this knowledge with the best American dentists, they dreamt of a global network of dentists committed to biological principles. They could share knowledge, technology and insight. They could establish standards of care. They could build a canon of legitimate scientific knowledge. And there would be strength in numbers. That evening, the American Academy of Biological Dentistry was born. [See Founding Statement of American Academy of Biological Dentistry] Dr. Arana soon traveled to Germany to meet some of the researchers at the fore of this emerging field. Most influential was Dr. Fritz Kramer. He was pleased to share his knowledge and moved by Arana’s passion. “Unfortunately,” said Kramer, “I cannot teach you everything in a single day!” So, in 1986, the Academy hosted its first seminar in Carmel, California. Dr. Kramer was joined by Dr. Jochen Gleditsch for sessions on oral acupuncture and mercury-related galvanism. At first, meetings were held twice a year in Carmel. [See A Timeline of Teaching] But as more practitioners turned to biological practice, participants increasingly came from around the world. Eventually, the Academy limited their meetings to one a year. Meetings were not held in 1991 and 1992, as board members had to focus on lawsuits that had been filed against individual dentists. The Academy also strove to bring the best European research into English language print. Many notable scientific studies were translated for Focus, the Academy’s quarterly journal. Books, videos, charts and other educational materials also were made available. At the 2005 meeting in Dallas, the Academy was renamed the International Academy of Biological Dentistry and Medicine, reflecting the group’s more global membership. The change also highlights the crucial role of collaboration in biological practice and the growing number of NDs, DCs, DOs, MDs and allied practitioners who understand the key role dental conditions play in systemic illness.

In the early days, Drs. Arana and Verigin spoke of Biological Dentistry as “dentistry for the 21st century.” We are now in the 21st century. Hopefully, through the continued growth of the IABDM and related organizations, their dream will be fully realized.

Thoughts on Biological Dentistry by the IABDM’s founding president, Edward Arana, DDS Founding President, American Academy of Biological Dentistry Biological Dentistry can be categorized as conscious dentistry. It is conscious of how treatments of the teeth and jaws affect the individual’s overall health. Will they be congruent and health-enhancing, or will they be health stressors? In the past, only lip service was paid to the biocompatibility of dental materials. It was judged on a general basis, not the required individual basis. The most tragic result of this is conventional dentistry’s continued advocacy of the use of a known poison—MERCURY—in amalgam filling. And their reason for doing so? Because it’s been done for more than 150 years. In maintaining this position, conventional dentistry has misled itself—and the public. Obscuring the truth that mercury does cause ill effects when implanted in the body, it denies that a filling inserted in a prepared tooth is even an implant! But the fact remains: mercury and other heavy metals from dental fillings contribute to all chronic disease states. So do multiple chemical-sensitizing exposures. Environmentally ill patients have provided clinical evidence that these conditions act synergistically to intoxicate and stress the patient, thus causing disease. In the late 1970s, Biological Dentistry emerged as a new field of Probiotic (life-supporting) dental medicine. Developed in Germany, it is now taught and practiced throughout the world. But what is Biological Dentistry exactly? Above all, Biological Dentistry is aesthetic, relatively nontoxic and individually biocompatible. Its practitioners use physiologic and electronic means to locate chronic areas of disease that are difficult to locate with conventional clinical methods. It incorporates the time-proven healing methods of homeopathy, acupuncture, nutrition, physical therapy and herbology, as well as the more modern sciences of neural therapy, hematology, immunology and electro-acupuncture. Such modalities complement the many scientific disciplines that encompass the field of clinical dentistry. The curative measures of Biological Dentistry are applied in accordance with each patient’s natural abilities of regulation, regeneration, adaptation and self-cure. Biological dental treatment removes the stress burdens that conventional treatment may induce. There are several dental situations that especially concern the Biological Dentist. The first is the toxicity of metals used in dental materials and their release from fillings and replacement appliances (metal partials and crowns containing nickel). Dissociating from their masses, these metal ions diffuse, migrate and are absorbed by the tissues, altering the electrochemical character of the immune system. At the same time, they change the ratios and populations of the blood cells (decreased white count), as well as those of the immune system. These migrating metal ions also stop or alter the function of the body’s enzymes. Another concern is the extent and character of the direct electrical currents generated by the mingling of dissimilar metals in electrolyte media (fluids and tissues of the human body). This is called oral galvanism. These currents carry disruptive metal ions to the opposite poles in what amount to oral galvanic batteries. How much oral galvanic power is necessary to change organic function and membrane permeability, to interfere with the power of thought of recall, or to initiate degenerative change? We still don’t know. But we do know that it changes the charge from electronegative to electropositive.

Is it possible that these metallic energy sinks act as blockades in the meridians, the bioenergetic circuits associated with the teeth? Indeed, it is. Can these blockades cause dysfunction in their respective organs, endocrine systems, vertebrae, muscles, nerves and nerve reflexes? Absolutely. Should we view current existing dental restorations as toxic scars? If mercury is involved, most definitely. With gold and other metals, or with composite cements? For a certain percentage of people, yes. With just about any restorative dental material, there will be blockades if the body’s immune system is still functional. This is because the tooth is an open and dynamic living organ. Biological Dentistry is concerned with treatment and therapies that cause the least disturbance to the immune system. A third area of concern is that of hidden or residual infection, including areas of necrosis (dead tissue) and chronic inflammation. Collectively, these areas are called Dental Interference Fields, or Foci. A focus is a diseased change in the soft connective tissue containing non-processable material that keeps the local and general defense reactions in a continuous state of active conflict. This can lead to abnormal distant effects far removed from the original source. It is most often chronic in nature. Ignoring this area as completely as it does, conventional dentistry misses out on the chance to make meaningful and effective therapeutic contributions in resolving chronic disease. In seeking the least toxic reparative and restorative materials for each patient’s dental work, Biological Dentists use materials reactivity testing. This individualizes biocompatibility. The patient’s blood serum is used for this qualitative antigen-antibody precipitin observation test. Developed by W.J. Clifford, MS, the test indicates which materials may be suitable for the individual patient. Parallel test methods include electrodermal testing as advocated by Reinhold Voll, MD, and Fritz Kramer, DDS, and Applied Kinesiology muscle testing as developed by George Goodheart, DC. Using all the knowledge and skills of Probiotic dental medicine, Biological Dentists strive to provide individual biocompatibility testing, and aesthetic, comfortable, functional and enduring dental replacements. Biological dental treatment has the possibility of stress reduction so great that the patient loses all or many of the distressing chronic disease symptoms, encompassing many pathological conditions. Biological Dentistry is the great contribution that Sir William Osler meant when he said, “The next great advancement in medicine will come from the dentists.” Biological Dentistry will, out of necessity, become the dental medicine of the 21st Century. This article originally appeared in modified form in the DAMS newsletter, Volume IV, Issue 2.

The Dental Physician by Felix Liao, DDS A dental physician is a health professional who promotes public awareness of whole- person health by focusing on the role of the mouth in systemic health and disease. A dental physician subscribes to the goals of relieving the body of burdens such as infections, toxic chemicals and metals, electromagnetic disturbances and radiation, food allergens and nutritional deficiencies, biomechanical imbalances, and psycho-emotional distress and dysfunction, in order to restore natural biological function, mind-body vitality, and the ability to self-regulate and maintain homeostasis. A dental physician is trained in the identification of existing and evolving dental co-factors in medical symptoms, as well as in the recognition and assessment of systemic co-factors in dental pain and disease. A dental physician applies his/her dental skills to safely and effectively remove dental co-factors clinically, and works with physicians and all complementary and alternative medicine practitioners in systemic disease prevention and reversal by rendering the oral cavity energetically neutral whenever possible.

A Position Paper of the International Academy of Bi ological Dentistry Medicine re: Mercury in Mercury/Silver Fillings used in Dentistr y

July 31, 2008

The IABDM congratulates Moms Against Mercury, attorney Charlie Brown of Consumers for Dental Choice, and all the plaintiffs for the progress made with the FDA in reclassifying mercury and its use in dentistry. We are concerned, however, that the FDA’s new position is inappropriately encouraging well-intended pregnant women and nursing mothers to seek dental care and “discuss options with their health practitioner.” Our formal recommendation is to STOP that plan righ t now. If the woman’s “health practitioner” is a physician, his source of information is most likely the physician’s conventional dentist, the AMA, or the American Dental Association. Neither of those people or groups has the same information or beliefs that the current directors of the FDA have appropriately chosen to consider. For those of us who have not placed a mercury filling in decades and who have been using patient-protecting, mercury removing protocols, it is rarely-to-never deemed appropriate to start a mercury/silver filling remov al program for this population . The damage to the fetus or newborn could be irreversible, especially when appropriate protection and detoxification protocols are not in place. We find scientific support for our conclusions in the research of Vimy and Lorscheider in the 1980s and 1990s, which startlingly documented the transfer of mercury in such fillings through the placenta to the fetus and through breast milk to the nursing infant. Such research has proven to some – and raised serious questions to many – that the use of mercury in dental restorations is foolhardy, given its clearly toxic effect on the human body. Our position is simply that every patient deserves to have a skilled and knowledgeable dental specialist and other experienced health practitioners who can properly evaluate their health situation and discuss the risks and benefits of removing their mercury/silver fillings. Indeed, on an individual basis, this might NOT be their next, best health move at a given time. Our position is simply that every patient deserves the benefit of current scientific knowledge: NO ONE should ever have another mercury/silver filling placed in their mouth. Is placement of mercury/silver fillings ever appropriate, especially in a pregnant or nursing woman? NO! It is simply beyond any further discussion! Further background details are available on the internet. You might want to start with these:

• http://iaomt.org • http://momsagainstmercury.com • http://www.toxicteeth.org • http://www.flcv.com/dams.html • http://www.mercurysafety.co.uk/hlthinfo.htm • http://en.wikipedia.org/wiki/Dental_amalgam_controversy

This form must be completed on every therapy, modal ity or equipment involved in the IABDM standards of care:

Name of Product/Equipment Received…………………………..Date Scientific Review……………….Date IABDM board review………..Date Reevaluation or revision ….Date

What does this do?

Approval ……………………..Date Provisional Approval……. No Opinion………………….. No Approval ………………..

Explanation of IABDM position: Name of Scientific Review: Alternative name(s) of Scientific Review: This Scientific Revi ew is related to: This Scientific Review is a: Equipment or Procedure Purpose of the Scientific Review: Scientific Review History: A brief description of the Scientific Review: A specific description of the Scientific Review: Peer Review articles: Manufacturer (s): Distributors: Scientific Literature: Legal Aspects of this Scientific Review: Applicant Name: Office Phone: Mailing address:

Office Fax:

City:

Home Phone:

State/Province:

e-mail:

Postal Code or Zip:

Country:

Standard Operating Procedures

While it may be impossible to fabricate a complete list of protocols for the typical biological dental or medical office, we can make a list of protocols that are based on a common paradigm. The definition of biological means having to do with life; therefore any protocol followed we can safely assume has to have within it components that sustain life and or improves on the life of the persons in concern. The non-biological dental or medical practice may have as its focus the removal or lessening of symptoms, the improvement of aesthetics or the maintenance of life in a less than optimal state. We believe that there are many different types of biological dental and medical offices. They are as varied as the practitioners because each practitioner has studied different modalities and they possess different skills and interests. There is however a common thread that can be identified in each of these practices and that common thread is the desire of the practitioner to “first, do no harm.” The biological dental and medical office practice different modalities but all with the same intent to find the true cause of a patient’s ailment and not to simply treat symptoms. The biological dental office is one in which the dentist pays most attention to the way in which toxic materials are removed from the mouth and the way in which new restorative materials will affect the body. Many biological dental offices will also monitor and treat the patient as they undergo detoxification and recuperation. Sometimes that treatment is supervised by the dentist and sometimes by another practitioner. The following is a list of the different modalities that might be used in a biological dental office. While it is a long list, it is by no means an exhaustive one. ASSESSMENT OF THE PATIENTS’ PRESENT CONDITION

Nutrition Applied kinesiology Muscle yesting Autonomic response testing Bio-energetic response testing Neural therapy Acupuncture by Voll Transdermal assessment Scysis Ayurvedics Chinese pulse analysis Iridology

Microscopic analysis of saliva Live blood cell analysis Dried blood cell analysis Biological terrain assessment Colon hydrotherapy assessment of dtool Acupuncture Dental examination muscle Medical examination Chiropractic examination Cranial sacral assessment Physical therapy assessment Use of laser

DETERMINATION OF DENTAL MATERIALS This can be accomplished using various modalities: Blood compatibility testing (Scientific Health testing or the Clifford Test) Muscle testing Acupuncture by Voll Transdermal testing

Standard Operating Procedures for the Removal of Toxic Materials from the Mouth

Above all other techniques that may be used when removing dental materials the most important one is: PROTECTION OF THE PATIENT FROM FLYING DEBRIS ! Some dentists choose to accomplish this by the use of oral chelating substances prior to and during the removal. Some find that only the use of a rubber dam and high speed evacuation is acceptable. Some will use Hg collectors in the room. Some will use quartering technique. Patient and providers wear safety glasses. Copious amounts of water are used during amalgam removal. Some will use only high speed evacuation. Detoxification All patients will need some assistance with the detoxification phase of treatment, which may include the following: Oral supplementation IV chelation Sauna

Dry skin brushing Diet modification

Things to Study: Ceiling limit set by OSHA of mercu ry exposure

Occupational Safety and Health Guideline for Mercur y Vapor

DISCLAIMER:

These guidelines were developed under contract usin g generally accepted secondary sources. The protocol used by the contrac tor for surveying these data

sources was developed by the National Institute for Occupational Safety and Health (NIOSH), the Occupational Safety and Health Adminis tration (OSHA), and the

Department of Energy (DOE). The information contain ed in these guidelines is intended for reference purposes only. None of the a gencies have conducted a

comprehensive check of the information and data con tained in these sources. It provides a summary of information about chemicals t hat workers may be exposed to in their workplaces. The secondary sources used for supplements 111 and 1V were

published before 1992 and 1993, respectively, and f or the remainder of the guidelines the secondary sources used were publishe d before September 1996. This

information may be superseded by new developments i n the field of industrial hygiene. Therefore readers are advised to determine whether new information is

available.

Introduction | Recognition | Controls | References

Introduction

This guideline summarizes pertinent information about mercury vapor for workers and

employers as well as for physicians, industrial hygienists, and other occupational safety and health professionals who may need such information to conduct effective occupational safety and health programs. Recommendations may be superseded by new developments in these fields; readers are therefore advised to regard these recommendations as general guidelines

and to determine whether new information is available.

Recognition

SUBSTANCE IDENTIFICATION

* Formula Hg

* Structure

(For Structure, see paper copy)

* Synonyms None reported.

* Identifiers

1. CAS No.: 7439-97-6 2. RTECS No.: OV4550000 3. Specific DOT number: None 4. Specific DOT label: None

* Appearance and odor

Mercury vapor is the vapor generated from elemental liquid mercury or compounds of mercury. No information is available on the appearance or odor of mercury vapor.

CHEMICAL AND PHYSICAL PROPERTIES

* Physical data

1. Atomic weight: 200.59 2. Boiling point: Not applicable. 3. Specific gravity: Not applicable. 4. Vapor density: Data not available. 5. Melting/Freezing point: Not applicable. 6. Vapor pressure: Not applicable. 7. Solubility: Not applicable. 8. Evaporation rate: Not applicable.

* Reactivity

1. Conditions contributing to instability: None reported. 2. Incompatibilities: None reported. 3. Hazardous decomposition products: Not applicable. 4. Special precautions: None reported.

* Flammability

The National Fire Protection Association has not assigned a flammability rating to mercury vapor.

1. Flash point: Not applicable. 2. Autoignition temperature: Not applicable. 3. Flammable limits in air: Not applicable. 4. Extinguishant: Use an extinguishant that is suitable for the materials involved in the

surrounding fire.

Fires involving mercury vapor should be fought upwind from the maximum distance possible. Isolate the hazard area and deny access to unnecessary personnel. Firefighters should wear a

full set of protective clothing and self-contained breathing apparatus when fighting fires involving mercury vapor.

EXPOSURE LIMITS

* OSHA PEL

The current Occupational Safety and Health Administration (OSHA) permissible exposure limit

(PEL) for mercury vapor is 0.1 milligram per cubic meter (mg/m(3)) of air as a ceiling limit. A worker's exposure to mercury vapor shall at no time exceed this ceiling level.

* NIOSH REL

The National Institute for Occupational Safety and Health (NIOSH) has established a

recommended exposure limit (REL) for mercury vapor of 0.05 mg/m(3) as a TWA for up to a 10-hour workday and a 40-hour workweek. NIOSH also assigns a "Skin" notation, which indicates that the cutaneous route of exposure, including mucous membranes and eyes, contributes to

overall exposure [NIOSH 1992].

* ACGIH TLV

The American Conference of Governmental Industrial Hygienists (ACGIH) has assigned mercury vapor a threshold limit value (TLV) of 0.025 mg/m(3) as a TWA for a normal 8-hour

workday and a 40-hour workweek and considers mercury vapor an A4 substance (not classifiable as a human carcinogen). The ACGIH also assigns a "Skin" notation to mercury

vapor [ACGIH 1994, p. 25].

* Rationale for Limits

The NIOSH limit is based on the risk of central nervous system damage, eye, skin, and

respiratory tract irritation [NIOSH 1992]. The ACGIH has not published documentation for the current TLV for mercury vapor. The 1991 Documentation of Threshold Limit Values (6th edition) discusses the basis for the prior TLV of 0.05 mg/m(3), but does not discuss the current TLV for mercury vapor [ACGIH 1991, p. 881].

HEALTH HAZARD INFORMATION

* Routes of Exposure

Exposure to mercury vapor can occur through inhalation, and eye or skin contact.

* Summary of toxicology

1. Effects on Animals: Mercury vapor can damage the kidneys, liver, brain, heart, lungs and colon in experimental animals. It is also mutagenic and can affect the immune system. Rabbits exposed for a single 4 hour period to mercury vapor at a concentration of 28.8 mg/m(3) developed severe damage to the kidneys, liver, brain, heart, lungs, and colon [Clayton and Clayton 1981]. Rabbits exposed to 0.86 mg/m(3) for 6 weeks had significant brain and kidney damage, which resolved on cessation of exposure. Exposure to 6 mg/m(3) mercury vapor caused severe damage to the kidney, heart, lung, and brain of rabbits; however, dogs exposed to 0.1 mg/m(3) for 83 weeks had no microscopic indication of tissue damage [Clayton and Clayton 1981]. Mercury may injure the kidneys through an autoimmune mechanism [ACGIH 1991]. Mercury was mutagenic in eukaryotic cells [ACGIH 1991].

2. Effects on Humans: Mercury vapor can cause effects in the central and peripheral nervous systems, lungs, kidneys, skin and eyes in humans. It is also mutagenic and affects the immune system [Hathaway et al. 1991; Clayton and Clayton 1981; Rom 1992]. Acute exposure to high concentrations of mercury vapor causes severe respiratory damage, while chronic exposure to lower levels is primarily associated with central nervous system damage [Hathaway et al. 1991]. Chronic exposure to mercury is also associated with behavioral changes and alterations in peripheral nervous system [ACGIH 1991]. Pulmonary effects of mercury vapor inhalation include diffuse interstitial pneumonitis with profuse fibrinous exudation [Gosselin 1984]. Glomerular dysfunction and proteinuria have been observed mercury exposed workers [ACGIH 1991]. Chronic mercury exposure can cause discoloration of the cornea and lens, eyelid tremor and, rarely, disturbances of vision and extraocular muscles [Grant 1986]. Delayed hypersensitivity reactions have been reported in individuals exposed to mercury vapor [Clayton and Clayton 1981]. Mercury vapor is reported to be mutagenic in humans, causing aneuploidy in lymphocytes of exposed workers [Hathaway et al. 1991].

* Signs and symptoms of exposure

1. Acute exposure: Acute inhalation of mercury vapor may result in toxicity similar to metal fume fever including chills, nausea, general malaise, tightness in the chest, chest pains, dyspnea, cough, stomatitis, gingivitis, salivation, and diarrhea [ACGIH 1991; Hathaway et al. 1991].

2. Chronic exposure: Chronic exposure to mercury may result in weakness, fatigue, anorexia, weight loss, and disturbance of gastrointestinal function. A tremor may develop beginning with the fingers, eyelids, and lips which may progress to generalized trembling of the entire body and violent chronic spasms of the extremities. Parallel with

development of the tremors, behavioral and personality changes may develop including increased excitability, memory loss, insomnia, and depression. The skin may exhibit abnormal blushing, dermographia, excessive sweating and irregular macular rashes. Severe salivation and gingivitis is also characteristic of chronic toxicity [Hathaway et al. 1991; Gosselin 1984]. Another manifestation of chronic mercury exposure is characterized by apathy, anorexia, flush, fever, a nephrotic syndrome with albuminuria and generalized edema, diaphoresis, photophobia, insomnia and a pruritic and sometimes painful scaling or peeling of the skin of the hands and feet with bullous lesions [Gosselin 1984].

EMERGENCY MEDICAL PROCEDURES

* Emergency medical procedures: [NIOSH to supply]

Rescue: Remove an incapacitated worker from further exposure and implement appropriate emergency procedures (e.g., those listed on the Material Safety Data Sheet required by OSHA's

Hazard Communication Standard [29 CFR 1910.1200]). All workers should be familiar with emergency procedures, the location and proper use of emergency equipment, and methods of

protecting themselves during rescue operations.

EXPOSURE SOURCES AND CONTROL METHODS

The following operations may involve mercury and lead to worker exposures to the vapor of this substance:

� The mining, production, and transportation of mercury � The mining and refining operations for gold and silver ores � Use in thermometers, manometers, barometers, gauges, and valves � Use in amalgams for dentistry, preservatives, heat transfer technology, pigments,

catalysts, and in lubricating oils

Methods that are effective in controlling worker exposures to mercury vapor, depending on the feasibility of implementation, are as follows:

� Process enclosure � Local exhaust ventilation � General dilution ventilation � Personal protective equipment

Workers responding to a release or potential release of a hazardous substance must be protected as required by paragraph (q) of OSHA's Hazardous Waste Operations and

Emergency Response Standard [29 CFR 1910.120].

Good sources of information about control methods are as follows:

1. ACGIH [1992]. Industrial ventilation--a manual of recommended practice. 21st ed. Cincinnati, OH: American Conference of Governmental Industrial Hygienists.

2. Burton DJ [1986]. Industrial ventilation--a self study companion. Cincinnati, OH: American Conference of Governmental Industrial Hygienists.

3. Alden JL, Kane JM [1982]. Design of industrial ventilation systems. New York, NY: Industrial Press, Inc.

4. Wadden RA, Scheff PA [1987]. Engineering design for control of workplace hazards. New York, NY: McGraw-Hill.

5. Plog BA [1988]. Fundamentals of industrial hygiene. Chicago, IL: National Safety Council.

Controls

MEDICAL SURVEILLANCE

OSHA is currently developing requirements for medical surveillance. When these requirements are promulgated, readers should refer to them for additional information and to determine

whether employers whose employees are exposed to mercury vapor are required to implement medical surveillance procedures.

* Medical Screening

Workers who may be exposed to chemical hazards should be monitored in a systematic

program of medical surveillance that is intended to prevent occupational injury and disease. The program should include education of employers and workers about work-related hazards, early

detection of adverse health effects, and referral of workers for diagnosis and treatment. The occurrence of disease or other work-related adverse health effects should prompt immediate evaluation of primary preventive measures (e.g., industrial hygiene monitoring, engineering controls, and personal protective equipment). A medical surveillance program is intended to supplement, not replace, such measures. To detect and control work-related health effects,

medical evaluations should be performed (1) before job placement, (2) periodically during the term of employment, and (3) at the time of job transfer or termination.

* Pre-placement medical evaluation

Before a worker is placed in a job with a potential for exposure to mercury vapor, a licensed

health care professional should evaluate and document the worker's baseline health status with thorough medical, environmental, and occupational histories, a physical examination, and

physiologic and laboratory tests appropriate for the anticipated occupational risks. These should concentrate on the function and integrity of the eyes, skin, respiratory system, central and

peripheral nervous systems, and kidneys. Medical surveillance for respiratory disease should be conducted using the principles and methods recommended by the American Thoracic Society.

A pre-placement medical evaluation is recommended to assess medical conditions that may be

aggravated or may result in increased risk when a worker is exposed to mercury vapor at or below the prescribed exposure limit. The health care professional should consider the probable

frequency, intensity, and duration of exposure as well as the nature and degree of any applicable medical condition. Such conditions (which should not be regarded as absolute

contraindications to job placement) include a history and other findings consistent with diseases of the eyes, skin, respiratory system, central and peripheral nervous systems, or kidneys.

* Periodic medical evaluations

Occupational health interviews and physical examinations should be performed at regular

intervals during the employment period, as mandated by any applicable Federal, State, or local standard. Where no standard exists and the hazard is minimal, evaluations should be

conducted every 3 to 5 years or as frequently as recommended by an experienced occupational health physician. Additional examinations may be necessary if a worker develops symptoms attributable to mercury vapor exposure. The interviews, examinations, and medical screening

tests should focus on identifying the adverse effects of mercury vapor on the eyes, skin, respiratory system, central and peripheral nervous systems, or kidneys. Current health status should be compared with the baseline health status of the individual worker or with expected

values for a suitable reference population.

* Termination medical evaluations

The medical, environmental, and occupational history interviews, the physical examination, and selected physiologic or laboratory tests that were conducted at the time of placement should be

repeated at the time of job transfer or termination to determine the worker's medical status at the end of his or her employment. Any changes in the worker's health status should be

compared with those expected for a suitable reference population.

* Biological monitoring

Biological monitoring involves sampling and analyzing body tissues or fluids to provide an index of exposure to a toxic substance or metabolite. No biological monitoring test acceptable for

routine use has yet been developed for mercury vapor. However, total inorganic mercury can be measured in the urine by preshift sampling. A mercury level of 35 micrograms per gram of

creatinine should be used as the biological exposure index. In addition, total inorganic mercury can also be measured in the blood by sampling at the end of shift at the end of the workweek. A

mercury level of 15 micrograms per liter of blood should be used as the biological exposure index.

WORKPLACE MONITORING AND MEASUREMENT

Determination of a worker's exposure to airborne mercury vapor is made using a Hydrar or

Hopcalite tube (200 mg section), SKC brand with a prefilter/cassette. Samples are collected at a maximum flow rate of 0.2 liter/minute (TWA) until a minimum collection volume of 3 liters (or a

maximum collection volume of 96 liters) is reached. Analysis is conducted by atomic absorption spectroscopy/ cold vapor (AAS/cold vapor). This method (OSHA ID-140) is described in the OSHA Computerized Information System [OSHA 1994] and is fully validated. This method is

also described in NIOSH Method No. 6009 of the NIOSH Manual of Analytical Methods [NIOSH 1994b].

SPECIAL REQUIREMENTS

U.S. Environmental Protection Agency (EPA) requirements for emergency planning, reportable quantities of hazardous releases, community right-to-know, and hazardous waste management

may change over time. Users are therefore advised to determine periodically whether new information is available. The following section uses information pertaining to elemental mercury

because mercury vapor itself is not listed.

* Emergency planning requirements

Mercury is not subject to EPA emergency planning requirements under the Superfund

Amendments and Reauthorization Act (SARA) (Title III) in 42 USC 11022.

* Reportable quantity requirements for hazardous releases

A hazardous substance release is defined by EPA as any spilling, leaking, pumping, pouring, emitting, emptying, discharging, injecting, escaping, leaching, dumping, or disposing into the

environment (including the abandonment or discarding of contaminated containers) of hazardous substances. In the event of a release that is above the reportable quantity for that chemical, employers are required to notify the proper Federal, State, and local authorities [40

CFR 355.40]. The reportable quantity of mercury is 1 pound. If an amount equal to or greater than this

quantity is released within a 24-hour period in a manner that will expose persons outside the facility, employers are required to do the following:

- Notify the National Response Center immediately at (800) 424-8802 (800) 424-

8802 or at (202) 426-2675 (202) 426-2675 in Washington, D.C. [40 CFR 302.6].

* Community right-to-know requirements

Employers who own or operate facilities in SIC codes 20 to 39 that employ 10 or more workers and that manufacture 25,000 pounds or more of mercury per calendar year or otherwise use

10,000 pounds or more of mercury per calendar year are required by EPA [40 CFR Part 372.30] to submit a Toxic Chemical Release Inventory form (Form R) to EPA reporting the amount of

mercury emitted or released from their facility annually.

* Hazardous waste management requirements

EPA considers a waste to be hazardous if it exhibits any of the following characteristics: ignitability, corrosivity, reactivity, or toxicity as defined in 40 CFR 261.21-261.24. Under the

Resource Conservation and Recovery Act (RCRA) [40 USC 6901 et seq.], EPA has specifically listed many chemical wastes as hazardous. Mercury is listed as a hazardous waste under RCRA and has been assigned EPA Hazardous Waste No. U151. This substance has been

banned from land disposal until treated by retorting or roasting. Providing detailed information about the removal and disposal of specific chemicals is beyond the scope of this guideline. The U.S. Department of Transportation, EPA, and State and local

regulations should be followed to ensure that removal, transport, and disposal of this substance are conducted in accordance with existing regulations. To be certain that chemical waste

disposal meets EPA regulatory requirements, employers should address any questions to the RCRA hotline at (703) 412-9810 (703) 412-9810 (in the Washington, D.C. area) or toll-free at (800) 424-9346 (800) 424-9346 (outside Washington, D.C.). In addition, relevant State and local authorities should be contacted for information on any requirements

they may have for the waste removal and disposal of this substance.

RESPIRATORY PROTECTION

* Conditions for respirator use

Good industrial hygiene practice requires that engineering controls be used where feasible to reduce workplace concentrations of hazardous materials to the prescribed exposure limit.

However, some situations may require the use of respirators to control exposure. Respirators must be worn if the ambient concentration of mercury vapor exceeds prescribed exposure limits.

Respirators may be used (1) before engineering controls have been installed, (2) during work operations such as maintenance or repair activities that involve unknown exposures, (3) during operations that require entry into tanks or closed vessels, and (4) during emergencies. Workers should only use respirators that have been approved by NIOSH and the Mine Safety and Health

Administration (MSHA).

* Respiratory protection program

Employers should institute a complete respiratory protection program that, at a minimum, complies with the requirements of OSHA's Respiratory Protection Standard [29 CFR 1910.134].

Such a program must include respirator selection, an evaluation of the worker's ability to perform the work while wearing a respirator, the regular training of personnel, respirator fit testing, periodic workplace monitoring, and regular respirator maintenance, inspection, and

cleaning. The implementation of an adequate respiratory protection program (including selection of the correct respirator) requires that a knowledgeable person be in charge of the program and that the program be evaluated regularly. For additional information on the selection and use of respirators and on the medical screening of respirator users, consult the latest edition of the

NIOSH Respirator Decision Logic [NIOSH 1987b] and the NIOSH Guide to Industrial Respiratory Protection [NIOSH 1987a].

PERSONAL PROTECTIVE EQUIPMENT

Workers should use appropriate personal protective clothing and equipment that must be

carefully selected, used, and maintained to be effective in preventing skin contact with mercury vapor. The selection of the appropriate personal protective equipment (PPE) (e.g., gloves,

sleeves, encapsulating suits) should be based on the extent of the worker's potential exposure to mercury vapor. There are no published reports on the resistance of various materials to

permeation by mercury vapor. To evaluate the use of PPE materials with mercury vapor, users should consult the best

available performance data and manufacturers' recommendations. Significant differences have been demonstrated in the chemical resistance of generically similar PPE materials (e.g., butyl) produced by different manufacturers. In addition, the chemical resistance of a mixture may be

significantly different from that of any of its neat components.

Any chemical-resistant clothing that is used should be periodically evaluated to determine its effectiveness in preventing dermal contact. Safety showers and eye wash stations should be

located close to operations that involve mercury vapor. Splash-proof chemical safety goggles or face shields (20 to 30 cm long, minimum) should be

worn during any operation in which a solvent, caustic, or other toxic substance may be splashed into the eyes.

In addition to the possible need for wearing protective outer apparel (e.g., aprons, encapsulating

suits), workers should wear work uniforms, coveralls, or similar full-body coverings that are laundered each day. Employers should provide lockers or other closed areas to store work and street clothing separately. Employers should collect work clothing at the end of each work shift

and provide for its laundering. Laundry personnel should be informed about the potential hazards of handling contaminated clothing and instructed about measures to minimize their

health risk.

Protective clothing should be kept free of oil and grease and should be inspected and maintained regularly to preserve its effectiveness.

Protective clothing may interfere with the body's heat dissipation, especially during hot weather

or during work in hot or poorly ventilated work environments.

References ACGIH [1991]. Documentation of the threshold limit values and biological exposure indices. 6th ed. Cincinnati, OH: American Conference of Governmental Industrial Hygienists. ACGIH [1994]. 1994-1995 Threshold limit values for chemical substances and physical agents and biological exposure indices. Cincinnati, OH: American Conference of Governmental Industrial Hygienists. ATS [1987]. Standardization of spirometry -- 1987 update. American Thoracic Society. Am Rev Respir Dis 136:1285-1296. CFR. Code of Federal regulations. Washington, DC: U.S. Government Printing Office, Office of the Federal Register. Clayton G, Clayton F [1981-1982]. Patty's industrial hygiene and toxicology. 3rd rev. ed. New York, NY: John Wiley & Sons. Gosselin RE, Smith RP, Hodge HC [1984]. Clinical toxicology of commercial products. 5th ed. Baltimore, MD: Williams & Wilkins. Grant WM [1986]. Toxicology of the eye. 3rd ed. Springfield, IL: Charles C Thomas. Hathaway GJ, Proctor NH, Hughes JP, and Fischman ML [1991]. Proctor and Hughes' chemical hazards of the workplace. 3rd ed. New York, NY: Van Nostrand Reinhold. Mickelsen RL, Hall RC [1987]. A breakthrough time comparison of nitrile and neoprene glove materials produced by different glove manufacturers. Am Ind Hyg Assoc J 48(11): 941-947. Mickelsen RL, Hall RC, Chern RT, Myers JR [1991]. Evaluation of a simple weight-loss method for determining the permeation of organic liquids through rubber films. Am Ind Hyg Assoc J 52(10): 445-447. NIOSH [1987a]. NIOSH guide to industrial respiratory protection. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 87-116. NIOSH [1987b]. NIOSH respirator decision logic. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 87-108. NIOSH [1992]. Recommendations for occupational safety and health: Compendium of policy documents and statements. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 92-100.

NIOSH [1994a]. NIOSH pocket guide to chemical hazards. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 94-116. NIOSH [1994b]. NIOSH manual of analytical methods. 4th ed. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 94-113. NIOSH [1995]. Registry of toxic effects of chemical substances: Mercury. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Institute for Occupational Safety and Health, Division of Standards Development and Technology Transfer, Technical Information Branch. NLM [1995]. Hazardous substances data bank: Mercury. Bethesda, MD: National Library of Medicine. OSHA [1994]. Computerized information system. Washington, DC: U.S. Department of Labor, Occupational Safety and Health Administration. Rom WN [1992]. Environmental and occupational medicine. 2nd ed. Boston, MA: Little, Brown and Company. USC. United States code. Washington. DC: U.S. Government Printing Office. Windholz M, ed. [1983]. Merck Index 10th ed. Rahway, NJ: Merck & Company.

Things to Study: How a rubber dam can be helpful Use a rubber dam. A rubber dam isolates the tooth or teeth being worked on. Some mercury free dentists don’t believe this is absolutely necessary, but it’s our opinion that it can reduce the amount of mercury vapor inhaled through the mouth. Even though mercury vapor can pass through the rubber dam, we believe that a rubber dam makes it easier to evacuate the filling material and prevent amalgam particles from being swallowed. As long as the patient breathes through the nose, little if any mercury vapor will pass through the rubber dam. Finally, it offers an isolated and dry field for placing the composite filling. It does take a little extra time to place and remove the rubber dam, and some patients don’t welcome this. But anyone who is concerned about minimizing mercury exposure should insist on its use. In any case, the patient should be instructed not to swallow while the fillings are being drilled. As in everything, there are exceptions. With some teeth, particularly 3rd molars, or so-called wisdom teeth, it may not be possible to place a rubber dam. As long as the dental team uses all the other protocols, this is acceptable.

Things to Study: Toxicity of mercury compared to ot her heavy metals

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Toxic Metals

Introduction

Toxic metals, including "heavy metals," are individual metals and metal compounds that negatively affect people's health. Some toxic, semi-metallic elements, including arsenic and

selenium, are discussed in this page. In very small amounts, many of these metals are necessary to support life. However, in larger amounts, they become toxic. They may build up in biological

systems and become a significant health hazard. This page provides a starting point for technical and regulatory information about toxic metals.

Arsenic Common sources of exposure to higher-than-average levels of arsenic include near or in hazardous waste sites and areas with high levels naturally occurring in soil, rocks, and

water. Exposure to high levels of arsenic can cause death.

Beryllium Elemental beryllium has a wide variety of applications. Occupational exposure most often occurs in mining, extraction, and in the processing of alloy metals containing beryllium. Beryllium can cause sensitization, lung and skin disease in a significant

percentage of exposed workers.

Cadmium Cadmium is an extremely toxic metal commonly found in industrial workplaces,

particularly where any ore is being processed or smelted. Several deaths from acute exposure have occurred among welders who have unsuspectingly welded on cadmium-

containing alloys or with silver solders.

Hexavalent Chromium Calcium chromate, chromium trioxide, lead chromate, strontium chromate, and zinc

chromate are known human carcinogens. An increase in the incidence of lung cancer

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� Keeping Workers Safe During Clean Up and Recovery OperationsOSHA. Includes links to OSHA fact sheets & QuickCards, related Safety and Health Topics Pages, training programs, and other resources.

has been observed among workers in industries that produce chromate and manufacture pigments containing chromate.

Lead Occupational exposure to lead is one of the most prevalent overexposures. Industries

with high potential exposures include construction work, most smelter operations, radiator repair shops, and firing ranges.

Mercury Common sources of mercury exposure include mining, production, and transportation of mercury, as well as mining and refining of gold and silver ores. High mercury exposure

results in permanent nervous system and kidney damage.

Providing more than simply lab reports

Are You Ready for the USP <231> Heavy Metals Transition?

By Francine Walker

Last fall the United States Pharmacopeia (USP) published a stimuli article in the Pharmacopeial Forum proposing a new USP General Chapter for the control of inorganic impurities in drugs and dietary supplements. The intent of this article was to initiate a dialogue between the USP, FDA and industry experts, resulting in a scientifically valid and practical method to replace the current USP <231> Heavy Metals method. This stimuli article included a table identifying 21 individual metals and their associated Permissible Daily Exposure (PDE) limits, which are to be used in the newly proposed method.

As expected, the sweeping changes addressed in the article have created quite a stir in the pharmaceutical and dietary supplement industries. Through USP meetings, trade association committees, and online research, we have been following the progress of the proposed changes to USP <231>, and will maintain doing so as they continue to unfold. Here are some of the key points of the proposed new method as they currently stand.

Reason for the Revision: The current USP <231> Heavy Metals method is over 100 years old and lacks the ability to identify and quantitate individual elements to the new limits of detection deemed necessary by recent toxicologically-based health safety data. Rigorous investigation of the current method indicates that it often fails to detect volatile elements (especially mercury) and may greatly underestimate the amount of other heavy metals in common matrices.

Current PDE values are identified in the stimuli article as amounts as low as 0.02 ug/day for parenteral administration of certain elements (methyl mercury). Several current technology options can now detect such elements with high amounts of accuracy and precision. Some of these technologies were included a few years ago in USP General Chapter

<730> titled Plasma Spectroscopy. This chapter, however, did not replace <231> and did not contain the detailed quality control criteria currently proposed for inclusion in the new method.

Who is affected: The areas intended to be covered by the proposed General Chapter include Drug Articles (drug substances and products including those from natural sources and rDNA), Dietary Supplements, and Ingredients/Excipients for these materials. The article explicitly excludes Foods and Food Ingredients from the initial intended coverage.

Which elements are included: The article, as it currently stands, lists 21 individual elements as shown in Table 1: USP Proposed Heavy Metal Toxicity Limits. This table includes the oral PDEs for the elements, which are based on a certain amount of each element (ug amounts) consumed daily by a person of average weight (50 kg). Since the PDE is based on a daily consumption amount, the detection limits required for testing each element will vary based upon the serving size of the individual product being tested. A product with a serving size of 1 gram would require that the detection limit (expressed in ppm) be equal to the PDE. A product with a 10 gram serving size would require that the detection limit (expressed in ppm) be 1/10 of the PDE.

Table 1: USP Proposed Heavy Metal Toxicity Limits

While it is not certain what the next draft of this method will contain, it is clear that there is substantial consensus that an abbreviated list of proposed elements is desired by many experts who have been providing loud feedback to the USP technical committee. Based on the feedback it is expected that the “Big Four” (As, Cd, Hg, Pb) will be included for general testing of most, if not all substances and it is likely that chromium would be the next metal to be added to the ‘hit list’. Other metals may also be included in the order of their toxicological importance and likelihood of being found in commonly covered substances.

Also worth noting is the fact that several elements (As, Cr, Hg) have different PDE limits based upon the various valence states in which they are found. For these particular elements, the toxicology varies greatly based upon the available form of the element. In the proposed method, the ‘speciation’ of these elements is likely to be encouraged only after an initial testing is completed to find the total amount of each element in a given product. If the total amount of arsenic, for instance, is found to be below the PDE for inorganic arsenic, no additional testing would be needed to further identify the source of the arsenic.

As you can see, there are many issues that are likely to be changing with regard to heavy metals testing on dietary products. We at Chemical Solutions are currently testing the full list of elements included in the proposed method and will continue to provide the services necessary to meet the ongoing changes that will almost certainly occur in the method. Our ICP-MS instrumentation includes the most up-to-date features to assure the lowest detection limits with the highest accuracy available. Our Dynamic Reaction Cell technology included in our ICP-MS instrument allows us to eliminate interferences common to other technologies. Please give us a call to see how we can assist you to prepare for and comply with the new USP methods or cGMPs.

General Chapter on Inorganic Impurities: Heavy Metals. Pharmacopeial Forum Vol. 34(5) [Sept.-Oct. 2008], p. 1348.

Things to Study: o Equipment that might be helpful in Hg removal o Symptoms of chronic Hg exposure o What tests are used to evaluate Hg levels in a patient o How Hg gets passed to a fetus o Galvanism o Weston Price’s theory of dental foci o Etiology of cavitations (osteonecrosis) o Basics of homeopathy o Basics of homotoxicology o Steiman’s Loma Linda study of tubule flow o MELISA testing o Porhyrin levels in urine as they relate to Hg levels o Mercury vapor exposure verses other Hg exposures o Toxicity of fluoride o G.V. Black o Diagnostic blocks o Pathophysiology of ischemic bone disease o NICO, FOMD, Osteomyelitis o Bacteria in biofilms o Labs (Hg A1c, Pt, Ptt, INR, CRP)

Reading Materials Helpful for Certification :

• Whole Body Dentistry by Mark Breiner • Uninformed Consent by Hal Huggins • The Poison In Your Teeth by Tom McGuire • Paul Connett’s http://www.fluoridealert.org/fluoride-statement.htm • Healthy Mouth Healthy Body by Victor Zeines • Let the Tooth Be Known by Dawn Ewing • Homotoxicology http://www.iah-online.com/cms/docs/doc26605.pdf • Radical Medicine by Louisa Williams – chapters 2, 4 and 6 • Oral & Maxillofacial Pathology by Neville, Damm, Allen, Bouquot – pp. 631-632 (“Neuralgia

Inducing Cavitational Osteonecrosis [NICO]”) • Illustrated Guide to Diagnostic Tests – pp. 53-54, 52-64

Prothrombin Time (Source: WebMD Medical Reference) Prothrombin time (PT) is a blood test that measures how long it takes blood to clot. A prothrombin time test can be used to check for bleeding problems. PT is also used to check whether medicine to prevent blood clots is working.

A PT test may also be called an INR test. INR (international normalized ratio) stands for a way of standardizing the results of prothrombin time tests, no matter the testing method. So your doctor can understand results in the same way even when they come from different labs and different test methods. Using the INR system, treatment with blood-thinning medicine (anticoagulant therapy) will be the same. In some labs, only the INR is reported and the PT is not reported.

About 12 blood clotting factors are needed for blood to clot (coagulation). Prothrombin, or factor II, is one of the clotting factors made by the liver. Vitamin K is needed to make prothrombin and other clotting factors. Prothrombin time is an important test because it checks to see if five different blood clotting factors (factors I, II, V, VII, and X) are present. The prothrombin time is made longer by:

• Blood-thinning medicine, such as heparin. Another test, the activated partial thromboplastin time (APTT) test, is a better test to find out if the right dose of heparin is being used.

• Low levels of blood clotting factors. • A change in the activity of any of the clotting factors. • The absence of any of the clotting factors. • Other substances, called inhibitors, that affect the clotting factors. • An increase in the use of the clotting factors.

An abnormal prothrombin time is often caused by liver disease or injury or by treatment with blood thinners.

Another blood clotting test, called partial thromboplastin time (PTT), measures other clotting factors. Partial thromboplastin time and prothrombin time are often done at the same time to check for bleeding problems or the chance for too much bleeding in surgery.

Why It Is Done Prothrombin time (PT) is measured to:

• Find a cause for abnormal bleeding or bruising. • Check to see if blood-thinning medicine, such as warfarin (Coumadin), is working. If the

test is done for this purpose, a PT may be done every day at first. When the correct dose of medicine is found, you will not need so many tests.

• Check for low levels of blood clotting factors. The lack of some clotting factors can cause bleeding disorders such as hemophilia, which is passed in families (inherited).

• Check for a low level of vitamin K. Vitamin K is needed to make prothrombin and other clotting factors.

• Check how well the liver is working. Prothrombin levels are checked along with other liver tests, such as aspartate aminotransferase and alanine aminotransferase.

• Check to see if the body is using up its clotting factors so quickly that the blood cannot clot and bleeding does not stop. This may mean the person has disseminated intravascular coagulation (DIC).

Results Prothrombin time (PT) is a blood test that measures how long it takes blood to clot.

Normal Normal values may vary from lab to lab.

A method of standardizing prothrombin time results, called the international normalized ratio (INR) system, has been developed so the results among labs using different test methods can be understood in the same way. Using the INR system, treatment with blood-thinning medicine (anticoagulant therapy) will be the same. In some labs, only the INR is reported and the PT is not reported.

Prothrombin time (PT)

Normal: 10-13 seconds

International normalized ratio (INR): 1.0-1.4

The warfarin (Coumadin) dose is changed so that the prothrombin time is longer than normal (by about 1.5 to 2.5 times the normal value or INR values 2 to 3). Prothrombin times are also kept at longer times for people with artificial heart valves, because these valves have a high chance of causing clots to form.

Abnormal values

• A longer-than-normal PT can mean a lack of or low level of one or more blood clotting factors (factors I, II, V, VII, or X). It can also mean a lack of vitamin K; liver disease, such as cirrhosis; or that a liver injury has occurred. A longer-than-normal PT can also mean that you have disseminated intravascular coagulation (DIC), a life-threatening condition in which your body uses up its clotting factors so quickly that the blood cannot clot and bleeding does not stop.

• A longer-than-normal PT can be caused by treatment with blood-thinning medicines, such as warfarin (Coumadin) or, in rare cases, hep

Periodontal Therapy May Help Diabetic Patients Impr ove Sugar Control (Source: American Academy of Periodontology, archived: https://web.archive.org/web/20100813215120/http://www.perio.org/consumer/diabetes06.htm) Studies have demonstrated an association between pe riodontal therapy and improved metabolic control in diabetic patients.

CHICAGO – April 11, 2006 – Results of a new study support the hypothesis that periodontal therapy may improve metabolic control (lower HbA1c) in diabetic patients. This study appears in April’s issue of the Journal of Periodontology. Study Abstract *

The results suggest that periodontal therapy may reduce a diabetic patient’s HbA1c count by as much as 20 percent at three and six months following treatment. According to the American

Diabetes Association, HbA1c provides patients with a picture of their average blood sugar changes in the past two to three months and gives them a good idea of how well their diabetes treatment plan is working. A healthy HbA1c count is between the ranges of 4.0 to 6.0.

“We found that conventional treatment for chronic moderate generalized periodontitis, which included a simple, non-surgical procedure called Scaling and Root Planing (SRP) lowered the study group’s HbA1c count from 7.2 to 5.7,” said study authors Prof. Antonio Bascones and Dr. Ricardo Faria-Almeida from Department of Medicine and Buccofacial Surgery of the Complutense University in Madrid Spain. “This could significantly put diabetic patients who are just above the normal HbA1c range into the healthy range and reduce their risk of serious complications from diabetes.”

Bascones cautioned that these findings should not be considered definitive or universally generalizable because of the study sample size. In addition, this study compared the response to conventional periodontal treatment between type 2 diabetic and non-diabetic patients with chronic moderate generalized periodontitis and did not include a group of diabetics that was not undergoing periodontal treatment. The absence of this information is a limitation because it is not known how diabetic patients who were not undergoing periodontal treatment would have progressed.

“For a long time we’ve know that diabetic patients have a higher risk of developing periodontal disease compared to non-diabetics,” said Kenneth A. Krebs, DMD and AAP president. “The results of this study provide additional evidence about the other side of the equation: that periodontal treatment may affect metabolic control in diabetic patients who have periodontal disease. While we can’t say periodontal treatment will definitively help, to date no reports indicate a harmful effect of periodontal treatment on a diabetic patient’s metabolic control.”

Relationship between periodontal disease and C-reac tive protein among adults in the Atherosclerosis Risk in Communities study (Source: Arch Intern Med. 2003 May 26;163(10):1172-9.)

Slade GD, Ghezzi EM, Heiss G, Beck JD, Riche E, Offenbacher S.

Center for Oral and Systemic Disease, Department of Dental Ecology, University of North

Carolina at Chapel Hill, Chapel Hill, NC 27599-7450, USA.

Abstract

BACKGROUND: Moderately elevated serum C-reactive protein (CRP) concentration is a

systemic marker of inflammation and a documented risk factor for cardiovascular disease in

otherwise healthy persons. Unrecognized infections, such as periodontal disease, may induce

an acute-phase response, elevating CRP levels. We evaluated the association between

periodontal disease and CRP levels in adults in the Atherosclerosis Risk in Communities study.

METHODS: Oral examinations were conducted between January 1, 1996, and December 31,

1998, on 5552 ARIC participants (aged 52-74 years) from 4 US communities. Periodontal

disease was quantified as the percentage of periodontal sites with pocket depth of 4 mm or

more. Serum CRP concentration was quantified in milligrams per liter using an enzyme-linked

immunosorbent assay. RESULTS: Mean (SE) CRP level was 7.6 (0.6) mg/L among people with

extensive periodontal pockets (>30% of sites with pocket depth > or =4 mm), approximately

one-third greater than that for people with less extensive periodontal pockets (5.7 [0.1] mg/L). In

a multivariable linear regression model that controlled for age, sex, diabetes mellitus, cigarette

use, and nonsteroidal anti-inflammatory drug use, the association of extensive periodontal

pockets with CRP concentration was modified by body mass index (BMI; calculated as weight in

kilograms divided by the square of height in meters). For people with a BMI of 20, the model

predicted a 2-fold difference in mean CRP concentration between periodontal pocket groups

(7.5 vs 3.6 mg/L), but the difference decreased with increasing BMI and was negligible when

BMI equaled 35. CONCLUSIONS: Extensive periodontal disease and BMI are jointly associated

with increased CRP levels in otherwise healthy, middle-aged adults, suggesting the need for

medical and dental diagnoses when evaluating sources of acute-phase response in some

patients.

PMID: 12767953 [PubMed - indexed for MEDLINE]

Homeopathy

What is Homeopathy? Homeopathy is the system of medicine which works on the principle of 'like cures like' (Similia Similibus curanter). This system of holistic healing was founded by Dr.Samuel Hahnemann, a German physician. Hahnemann, who was translating the a book on the medicinal properties of drugs, was reading the properties of the medicine Cinchona, when he read that Cinchona cures malaria, because of its bitter taste. Hahnemann was surprised by this statement and when he read on, he found a footnote which said that cinchona poisoning leads to malaria-like symptoms. This set him thinking and he decided to test the medicine of himself. He experienced the symptoms of malaria, by repeatedly taking the Cinchona medicine and after continuing his experiments found that those medicines which cause disease-like symptoms in healthy individuals are capable of curing the diseased individuals. So, homeopathy relies on the Materia Medica - a book containing the properties of medicines, properties which have been proved on healthy individuals. Homeopathic doctors rely on the materia medica as the authority for it contains not empty theories, but details of symptoms which were experienced

by hundreds of provers. It is thus a system based on sound principles and as a result of solid experiments.

How does Homeopathy work ? The theory behind the working of homeopathy is that the body of every human being contains a vital force within the body which regulates the functioning of the body. Due to reasons such as heredity, environmental conditions, stress etc, this vital force weaken causing disease. So, disease is nothing but a complex of certain symptoms observed in the human body. The homeopathic physician make a study of not only the symptoms the patient is complaining of, but of the entire patient himself. This leads to a picture of the patient. The physician then prescribes homeopathic medicine, which matches this picture. Now, the medicine so prescribed would have caused the same symptoms in healthy person during 'drug provings'. This medicine is given in a highly diluted dose, so as to prevent side effects. This minute dose, creates a similar disorder in the vital force and provokes the vital force to react to the symptoms and overcome. (The same system is used in vaccines, where vaccination against small-pox is done by injecting the small-pox disease-causing organism, so that the body can build up its natural immunity

Principle of Potentisation Homeopathic medicines are diluted in alcohol or milk-sugar(lactose) to make them more palatable and also to reduce the harmful effects. It has been found that the more the medicine is diluted, the more effective and powerful it becomes. So, the process of the dilution is called as potentisation and the medicines are referred to as potencies . The crude homeopathic medicine(eg : Cinchona/Lachesis) is triturated in alcohol to yield the mother tincture. The mother tincture is denoted by the symbol ø.

Potency : 1x potency of the medicine signifies 1 part of mother tincture diluted with 9 parts of alcohol / milk sugar. 2x potency is 1x of medicine diluted with 9 parts of sugar milk / alcohol. 1C potency is mother tincture diluted with 99 parts. 1M potency is mother tincture diluted with 999 parts. Low potency : 1x, 3x , 6x (3c), 12x (6c) Medium potency : 12x, 30x, 30c High potency : 200c, 1M, 20 M , CM, LM, etc.

Law of Direction The law of direction of cure proposed by Dr.Constantine Hering states that - "As a patient recovers from a disease, the symptoms move from within outwards, from above downwards, from center to circumference and disappear in the reverse order of their appearance" A patient suffering from a skin disease may use various medicines which suppress this disorder and send it into the body and it may manifest as asthma. So, when this patient takes homeopathic medicine, the asthma is replaced with the skin infection and then finally the skin infection leaves to yield a cure.