NeuroToxicology 30 (2009) 1202–1206

Contents lists available at ScienceDirect

NeuroToxicology

Occurrence of cognitive symptoms in dental assistants with previous

occupational exposure to metallic mercury
B. Hilt a,b,*, K. Svendsen c, T. Syversen d, O. Aas a, T. Qvenild a, H. Sletvold e, I. Melø f
a
Department of Occupational Medicine, St. Olav’s University Hospital, Trondheim, Norway
b
Department of Cancer Research and Molecular Medicine, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
c
Department of Industrial Economics and Technology Management, Norwegian University of Science and Technology, Trondheim, Norway
d
Department of Neuroscience, Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
e
Trondheim, Norway
f
County Public Dental Services, County of Sør-Trøndelag, Trondheim, Norway

A R T I C L E I N F O A B S T R A C T

Article history: Previous investigations have presented evidence for an increased prevalence of late cognitive effects in
Received 25 November 2008 dental personnel exposed to metallic mercury. We wanted to examine if there was a correlation between
Accepted 29 April 2009 mercury exposure and cognitive effects in a Norwegian population of dental workers, and if so, to
Available online 7 May 2009
quantify the occurrence.
The study group consisted of 608 female dental assistants from central Norway and 425 female
Keywords: controls from the general population, all under the age of 70. They had responded to a standardized
Cognitive function
postal questionnaire (Euroquest) inquiring about seven symptoms in regard to neurology, psychoso-
Dental work
Occupation
matics, memory, concentration, mood, sleep disturbances, and fatigue. A score was calculated for each
Metallic mercury symptom based on 4–15 single questions graded on a scale from 1 (seldom or never) to 4 (very often).
Euroquest Dental assistants and controls had a participation rate of 56.4% and 42.9% respectively. Dental
assistants reported more cognitive symptoms than the controls, but on average they reported having
each of the symptoms ‘‘now and then’’ or less frequently. There were 4.4% of the dental assistants and
2.8% of the controls who reported having three or more of the seven symptoms ‘‘often’’ or more
frequently. The corresponding figures for five or more of the seven symptoms were 1.0% and 0.5%
respectively.
The occurrence of cognitive malfunction may be moderately increased in dental assistants. For dental
assistants there was a relative risk of 1.6 of having three or more symptoms ‘‘often’’ or more frequently,
and a relative risk of 2.0 of having five or more symptoms as frequently. It can be assumed from our
results that the prevalence of possibly work-related cognitive malfunction in dental assistants is
between 0.4% and 2.8%, dependent on the applied severity.
ß 2009 Elsevier Inc. All rights reserved.

1. Introduction mercury and alloy to beyond 200 8C with an increased risk of

Dental personnel have been exposed to metallic mercury when
handling amalgam for teeth restoration for a long period of time.
The degree of exposure has varied with the extent of the use, work
performance, and the properties of the physical environment. In
some countries, including Norway, a special kind of copper
amalgam containing 70% mercury was used from the 1950s to
as late as the 80s for restoring deciduous teeth in particular. The
work with copper amalgam entailed the heating of solid tablets of
* Corresponding author at: Department of Occupational Medicine, St. Olav’s
University Hospital, Olav Kyrres gt, N-7006 Trondheim, Norway.
Tel.: +47 72571407/90069490; fax: +47 72571347.
E-mail address: bjorn.hilt@stolav.no (B. Hilt).
inhaling mercury vapour. It was also customary for many years for
the assistants to handle amalgam in their bare hands in order to
keep the amalgam soft while it was used.
From 1955 to 2000 the National Institute of Occupational
Health offered a voluntary monitoring of mercury levels in urine
for dental personnel in Norway with a total of 4030 samples
analysed from 2028 persons. The mean values for dental assistants
showed a steady decrease from 216 (range = 7.5–3100) nmol/l in
the 50s to 27 (range = 5–133) nmol/l in the 90s. From all the
measurements, 135 (3.3%) samples from 50 (2.5% of all) subjects
showed values above 300 nmol/l. These were all before 1985
(Lenvik et al., 2006).
Two recent reviews, including meta-analyses of several studies
of exposure to metallic mercury in mostly industrial settings, have
concluded that long term exposure to metallic mercury vapour

0161-813X/$ – see front matter ß 2009 Elsevier Inc. All rights reserved.
doi:10.1016/j.neuro.2009.04.012
 B. Hilt et al. / NeuroToxicology 30 (2009) 1202–1206
with urine levels above 500 nmol/l can lead to chronic cognitive
effects, while there is more doubt as to whether exposures below
this level can lead to similar long term effects (Meyer-Baron et al.,
2004; Rohling and Demakis, 2006). During the last 25 years, several
studies have given indications which raised concern, by showing
that both dentists and other dental personnel have had an
increased prevalence of symptoms of cognitive malfunction, and/
or have shown cognitive impairments in neuropsychological
investigations (Shapiro et al., 1982; Uzzell and Oler, 1986; Nilsson
et al., 1990; Ngim et al., 1992; Ibarra Fernandez de la Vega et al.,
1992; Echeverria et al., 1995; Langworth et al., 1997; Ritchie et al.,
2002; Aydin et al., 2003; Moen et al., 2008).
The toxic mechanism in the nervous tissue after metallic
mercury exposure has not been completely worked out. When
metallic mercury vapour is inhaled and absorbed in the form of Hg0
it is transported in the blood stream and deposited throughout the
body. Hg0 is oxidised to form mercuric mercury, Hg2+ in different
organs, and there is a dynamic equilibrium between Hg0 and Hg2+
in blood. It is believed that mercury deposited in the brain after Hg0
exposure is taken up as the metallic form and not as the oxidised
form Hg2+. Once mercury has passed the blood–brain barrier as
Hg0, some of it will be intracellularly oxidised to Hg2+, most
probably in the astrocytes. It has repeatedly been suggested that
exposure to metallic mercury may result in both short term and
long term psychological and cognitive effects. The milder form of
these effects, characterized by weakness, fatigue, psychological
disturbances, and asthenia, is termed micromercurialism, while
the more severe form of intoxication, which entails psychotic
symptoms, is termed erethism (Clarkson and Magos, 2006; Berlin
et al., 2007).
In Norway, the preliminary publication of the results from a
small study of cognitive problems in 41 dental assistants (Moen
et al., 2008), and a television programme broadcasted in 2005
raised considerable public concern by indicating that chronic
metallic mercury intoxication and cognitive injuries were common
in dental personnel. After that, the Ministry responsible for labour
protection initiated research on the topic.
The aim of this study was to see whether dental assistants have
an increased prevalence of symptoms consistent with cognitive
malfunction, and, if so, to quantify the occurrence of such
complaints.
2. Subjects and methods
We asked the public dental health care system and some dentists
in private practice in three counties in Central Norway for lists of all
employees who had ever worked as dental assistants. In this way we
identified 1224 females who had probably worked as dental
assistants and thus were candidates to be included in the study.
All the identified women were invited to participate in the
study by filling out a posted primary questionnaire and to answer a
second questionnaire relating to their work career and working
conditions while working in the dental health care system. We
asked them to submit both questionnaires in a prepaid envelope.
More details on our inquiry about working conditions in
Norwegian dental health care and the results thereof are described
at more length in another publication (Svendsen et al., submitted
for publication). In addition, all the identified dental assistants
were asked for written permission to access any results on urine
mercury levels held at the National Institute of Occupational
Health. Norwegian dental personnel had throughout the years
been invited to submit urinary samples to this central institute
where the samples were analysed as they came in by cold vapour
flameless atomic absorption spectrophotometry and the results
were given in nmol/l (Gundersen and Mowé, 1977; Lenvik et al.,
2006).
1203
To form a control group, the Norwegian Central Bureau of
Statistics randomly chose 1062 women from the same counties
with a categorical matching for age within 5-year groups. To be
included in the study, the control subjects had not to have been
engaged in dental health care, and had to have worked outside
their homes for more than 5 years after 1960. The control group
was invited and asked to fill out and submit the primary
questionnaire in the same way as the dental assistants.
In addition to inquiring about some general information such as
age, education, some life style issues, and a few health questions,
the first questionnaire comprised a Norwegian version of the
standardized European questionnaire called ‘‘Euroquest’’ which
has been designed to monitor cognitive symptoms in subjects
exposed to neurotoxic substances (Carter et al., 2002). We used the
parts of that questionnaire inquiring about mood, memory, ability
to concentrate, sleep disturbances, neurological symptoms,
psychosomatic symptoms, and fatigue. For each of these symp-
toms there are 5–15 different questions. Each of these can be
answered with the alternatives ‘‘seldom or never’’, ‘‘now and then’’,
‘‘often’’ or ‘‘very often’’ with designated values from 1 to 4
respectively. In order to have a valid answer for each symptom, it
was required that two thirds of the questions included in that
particular symptom had been answered. A score was calculated for
each symptom as the mean of the values for the questions
included.
By comparing the occurrence of cognitive symptoms with
increasing levels of severity between the group of dental assistants
and the control group, we were able to calculate a range of
corresponding etiological fractions that could be used to assess the
share of dental assistants with different levels of cognitive
symptoms that could possibly be attributed to their occupational
exposure to mercury.
2.1. Statistical analysis
Data were registered and analysed with the data program
Statistical Package for Social Science version 14.0 (SPSS) (SPSS Inc.,
Chicago, IL, USA). The differences between the dental assistants
and the controls in scores for each symptom group was analysed by
general linear modelling controlling for age and educational level.
A 5% level was chosen for statistical significance, and all p-values
were calculated as two-sided.
2.2. Ethical considerations
The study was approved by the ethical committee for medical
research in Central Norway, and had a licence for personal
registrations from the Norwegian Social Science Data Services. The
authors declare that there are no conflicts of interest.
3. Results
Out of the 1224 presumed dental assistants who were asked to
participate, 690 (56.4%) responded and 655 of them confirmed that
they had worked as a dental assistant. Of these, 47 were excluded
because they were over the age of 69, leaving us with 608 dental
assistants for the analysis. From the 1062 women who had been
selected for the control group, 456 (42.9%) participated. Of the
controls, 31 were excluded because they had not been occupa-
tionally active for at least 5 years, had worked in the dental health
care themselves, and/or were older than 69 years of age. Table 1
shows background variables and some information on life style
issues for the participating dental assistants and the control group.
The groups were rather similar in regard to most variables, apart
from the control group having a somewhat higher level of formal
education than the dental assistants.
1204 B. Hilt et al. / NeuroToxicology 30 (2009) 1202–1206

Table 1
Background variables for the participating dental assistants and controls.

Variables Dental assistants Controls

Number of participants 608 425

Age in years, mean (SD) 51.7 (9.7) 49.4 (10.8)
Married/cohabiting (% of the participants) 82.7 78.0

Formal education (% on each level)

Elementary 20.2 18.5
College/vocational training 66.8 32.4
University 12.9 39.1

Smoking habits (% of the participants)

Yes, daily 18.4 21.2
Yes, now and then 9.3 8.0
Ex-smoker 33.2 26.9
Never smoker 39.0 43.9 Fig. 1. The decade when starting to work in dental health care for the 591 dental
assistants who submitted this information.
Use of alcohol last year (% of the participants)
Yes, every week 25.6 23.3
Yes, more seldom 63.5 61.8
No use 10.9 14.9 between 1962 and 1992 with a median year in 1980. We used the
Used to use more in earlier life 7.5 13.1 highest value ever for each person in an analysis by general linear
Amalgam in own teeth (% of the participants)
modelling, controlling for level of education and age. The mean
Yes 92.1 89.1 urine value was 91.2 nmol/l (range = 12–1075, SD = 114.5). There
Number of surfaces, mean (SD) 8.2 (4.3) 9.0 (4.7) was a statistically significant relationship between the maximum
Had major removal of amalgam fillings 23.5 26.2 urine value and the sum of the symptom scores (B = 0.55,
Current diseases (% of the participants) p < 0.001), but the statistical significance disappeared when age
Diabetes mellitus 2.0 3.5 was also included in the model.
Arterial hypertension 13.3 13.4 Information on how long they had worked in the dental health
service was available for 577 of the dental assistants with a mean
number of years of 18.1 (range = <1–49, SD = 11.7). There was a
In Table 2 the mean scores for each symptom group are statistically significant relationship between the number of years
presented for the dental assistants and the controls. Most scores worked and the sum of the symptom scores (B = 0.48, p < 0.001),
are below or around the value 2 (‘‘now and then’’) for all the but, here too, the statistical significance disappeared when age was
symptom scores in both groups. The difference between scores in also included in the model.
the dental assistants and the controls are, though, statistically As the mean scores for each symptom turned out to be low, we
significant for all the single symptoms except for ‘‘mood’’. The also made a categorisation by looking at the prevalence of subjects
mean sums of the symptom scores were 12.3 (SD = 3.5, with three, four, or five of the seven symptoms occurring ‘‘often’’
range = 7.0–23.6) and 11.3 (SD = 3.1, range = 6.3–22.3) for the (value 3) or more frequently. This was done on the assumption that
dental assistants and the controls respectively (p = 0.001 adjusted subjects who had three or more of the seven symptoms often or
for age and level of education). more frequently could be those who, to some extent, suffered from
Fig. 1 shows which decade the participating dental assistants or were disabled by their symptoms. Table 3 shows the number
had started to work in the dental health care system. Of the 559 and the share of subjects in each group who reported having three,
who had answered that particular question, 233 (41.7%), con- four, or five of the symptoms ‘‘often’’ or more frequently. The rate
firmed that they had used copper amalgam in their work, most of ratios between the groups vary between 1.6 and 2.8, but none of
them before 1990, but 6 also later than that. Out of 469 who had the differences reached statistical significance.
answered, 44 (4.3%) reported having experienced serious spills of The dental assistants did not report more of other health
mercury in their working environment at least once during their complaints such as migraine, respiratory symptoms, musculoske-
career. For the 490 participants who started to work as a dental letal complaints, or kidney diseases than the controls.
assistant before 1990, the sum of symptom scores was 12.6
(SD = 2.7) while it was 10.9 (SD = 3.5) for the 101 who started after 4. Discussion
1990 (p = 0.024 adjusted for age).
For 115 of the dental assistants, we had urine values from the The aim of this study is to elucidate whether Norwegian dental
previous voluntary measurements. These had all been taken assistants with previous occupational exposure to metallic

Table 2
Mean scores for seven symptom groups from the Euroquest questionnaire reported by 608 dental assistants and 425 controls.

Symptom Dental assistants Controls

Number of valid answers Mean symptom score (SD) Number of valid answers Mean symptom score (SD)

Mood 605 1.71 (0.56) 421 1.62 (0.54)

Memory 605 1.99 (0.72)** 424 1.79 (0.63)
Ability to concentrate 603 1.76 (0.63)** 423 1.58 (0.52)
Sleep disturbances 604 1.81 (0.63)* 423 1.66 (0.60)
Neurological symptoms 608 1.49 (0.49)** 422 1.35 (0.40)
Psychosomatic symptoms 604 1.59 (0.56)* 421 1.50 (0.41)
Fatigue 605 2.06 (0.5)** 422 1.87 (0.69)
*
p < 0.05 by general linear modelling adjusted for age and level of education.
**
p < 0.01 by general linear modelling adjusted for age and level of education.
 B. Hilt et al. / NeuroToxicology 30 (2009) 1202–1206
Table 3
Percent of the dental assistants and the controls who had answered that they had
three, four or five of the seven symptoms often (value 3) or more frequently.
Dental assistants Controls
n = 608 n = 425
Three or more symptoms 4.4 2.8
Four or more symptoms 2.5 0.9
Five or more symptoms 1.0 0.5
mercury have an increased prevalence of symptoms consistent
with cognitive malfunction. When compared to a control group
from the general population, we found that some dental assistants
may suffer from long term cognitive effects, mainly reflected by
problems with their memory, ability to concentrate, neurological
symptoms, and fatigue.
Both for dental assistants and the control group, the results may
be hampered by a low participation rate. This could entail bias in
both directions because it might be that the non-responders from
both groups, as often is the case, were less healthy than the
responders, and, thus, the real occurrence of symptoms in both
groups has been underscored. The present study was carried out
about a year after a television programme which brought the issue
of mercury exposure in dental offices and possible injuries from
that into the public agenda. This may influence both the quantity
and quality of the response to our questionnaire. A possible bias
might be that dental assistants who believe that their health
problems are related to previous exposure will be more likely to
respond—and that they are inclined to report symptoms in a more
aggressive manner. This would, in both cases, have biased the
results in the direction of enhanced differences between the
groups. One feature which is an argument against a serious bias in
our material, is that the dental assistants did not report more of the
other health complaints that had also been mentioned in the media
as possible effects of mercury exposure. Moreover, our results were
in line with the other Norwegian study (Moen et al., 2008) which
was conducted before the media attention about the health of
dental assistants emerged. Thus, neither selection, nor recall bias
can be ruled out, but we do not think that the possible effects
thereof have been decisive in the results in regard to cognitive
symptoms.
Uncontrolled confounding may also have had impact on the
results of the present study. The group of dental assistants and the
controls were fairly similar in regard to smoking habits, alcohol
consumption, and amalgam fillings in their own teeth, while we
lacked information on other potential confounders such as drug
abuse, mental illness, cardiovascular diseases, and previous head
injuries. At least age turned out to play a role when we used general
linear modelling to look at possible impacts of urine mercury
values and length of employment as a dental assistant.
Previous studies of cognitive problems in dental personnel have
addressed performance by the use of neuropsychological tests
(Shapiro et al., 1982; Uzzell and Oler, 1986; Ngim et al., 1992), the
occurrence of symptoms (Nilsson et al., 1990; Langworth et al.,
1997; Moen et al., 2008), or both (Ibarra Fernandez de la Vega et al.,
1992; Echeverria et al., 1995; Ritchie et al., 2002; Aydin et al.,
2003). However, only one study made use of the same
standardized Euroquest questionnaire (Moen et al., 2008) that
we used in this study. It is therefore difficult to relate our results to
the results of others, except to the recently published Norwegian
study that also made use of Euroquest and which reported similar
symptom scores in dental assistants as in our study (Moen et al.,
2008). The use of Euroquest has also the limitation that there are
no reference values available yet, and thus, we can only compare
the occurrence of symptoms in the dental assistants who
participated in our study with our control group of women from
1205
the general population, where we find small, but yet, some
statistically significant differences.
As the symptoms scores reported were low, and mostly in the
Relative range from ‘‘never/seldom’’ to ‘‘now and then’’ for both dental
risk
assistants and controls, this did not say much about a possible
1.6 health injury. We therefore tried to refine the results by elucidating
2.8 how many of the participants who had a certain amount of the
2.0
seven symptom groups ‘‘often’’ or more frequently, and thus could
be disabled by their symptoms to some extent. In the dental
assistants we found three, four or five of the symptom groups to be
present ‘‘often’’ or more frequently in 4.4%, 2.5% and 1%
respectively. When comparing with the control group, the rate
ratios were 1.6, 2.8, and 2 respectively. Thus, depending on what
degree of symptom severity we chose, we found the prevalence of
cognitive complaints in dental assistants to be probably some-
where below 5%, with an etiological fraction between 38% and 64%.
In this analysis we did not attempt to relate the occurrence of
symptoms to exposure. This might be difficult anyway in this kind
of low dose, long term toxicological effect where many factors,
including a probable individual susceptibility may play a role in
determining the effects (Echeverria et al., 2006). We do, however,
find it worth mentioning, and which is also to some degree relief,
that in dental assistants who had started to work after 1990 when
amalgam was gradually phased out of Norwegian dental health
care, our results showed the same symptom scores as in the
controls.
In conclusion, some of the dental assistants who were exposed
to mercury from dental amalgam during earlier years may suffer
from long term cognitive effects. We must, however, in light of the
methodological difficulties and limitation that we faced, be
cautious to interpret this as causality. Even so, when applying
our criteria for the graveness of symptoms and an etiological
fraction between 38% and 64%, it can be assessed from our material
that the prevalence of possibly work-related cognitive malfunction
in dental assistants is between 0.4% and 2.8%, dependent on the
severity.
Conflicts of interest
The authors declare that there are no conflicts of interest.
Acknowledgement
Cordial thanks to Prof. Bente Moen at the University of Bergen
for providing us with a correctly translated Norwegian version of
the Euroquest questionnaire, to Patricia Flor for linguistic help, to
the Norwegian Ministry of Labour and Inclusion for initiating and
financing the study, and not least to all the participants for their
great patience when answering a lengthy questionnaire.
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