As reported by The International earlier this month, a looming EU-wide ban on amalgam fillings has brought financial negotiations between the Austrian Insurance Fund (ÖGK) and the country’s Dental Chamber to a standstill. This could mean that, in future, patients in Austria may have to cover the cost of all fillings themselves.

by Alexei Korolyov

For now, those who visit insurance-contracted dentists can still receive certain fillings, including amalgam, free of charge, as the ÖGK covers the costs for both dentists and patients. But what will happen after the amalgam ban comes into force on 1 January 2025 is anyone’s guess. What’s more, it appears that only one company, Ivoclar, will supply the material intended to replace amalgam. For Miona Jovanovic, a dentist practising privately in Vienna, the situation is baffling. “The industry has been well aware of the coming ban on amalgam for years, so why are these negotiations only happening now?”

What is amalgam?

The origins of the issue date back to 2018, when the EU banned the use of amalgam for children, pregnant women and breastfeeding mothers.

Amalgam is the most common type of filling, known for turning black over time due to oxidation. It’s made from a mix of metals, including mercury – a substance toxic to humans. The European Commission has called it a “global and major threat to human health.” Yet toxicity is not the only problem with amalgam: placing an amalgam filling requires the removal of more of the tooth around the cavity than is necessary with other materials – up to two-thirds, in fact. Even so, amalgam’s low cost and long lifespan have, for decades, outweighed these concerns, making it an indispensable part of state-funded healthcare across Europe.

In April, the European Parliament finally voted to extend the ban on amalgam fillings to all groups of people, with the prohibition set to take effect on 1 January 2025. This will also outlaw the manufacture and import of amalgam from outside the EU, although a few member states will be allowed to continue its use until June 2026. Austria, however, is not among them.

Supposed Monopoly

“The state representatives, in our case the ÖGK and the Dental Chamber, need to be aware of the realities of the market,” Jovanovic, the Vienna-based dentist, tells The International. “The ÖGK does not understand the problems that dentists are facing, and the Chamber is too impotent to really fight for us.” Although Jovanovic is not contracted by the ÖGK and therefore not directly impacted by the negotiations, she remains an interested party in the debate. For several years, she collaborated on research projects with Ivoclar, the company holding the alleged monopoly on the mercury-free replacement material for amalgam.

The material is called alcasite (marketed by Ivoclar under the brand name Cention Forte), and it has been officially chosen by the ÖGK as the successor to amalgam. Ivoclar is based in Liechtenstein but runs production facilities in Austria, Italy, Sweden, the US and the Philippines. Cention Forte is patented by the company and costs between one-and-a-half and two times more than amalgam.

This creates problems for contracted dentists, as the ÖGK has refused to cover the extra costs they will face in buying alcasite. At the same time, it has promised to keep alcasite fillings free for patients.

Future Uncertain

When contacted by The International, the Dental Chamber would not confirm or deny Ivoclar’s future influence in Austrian dentistry. Instead, in an email response, it explained that it had approached the ÖGK shortly after the European Parliament’s April vote extending the amalgam ban. However, “the first official meeting regarding a follow-up regulation for dental amalgam took place at the beginning of October.” Negotiations subsequently broke down when the Chamber disagreed with the level of compensation for alcasite fillings proposed by the ÖGK. “However, if the ÖGK presents another offer that reflects the realities of today’s dental practice, the Austrian Dental Chamber is willing to engage in constructive talks.”

Whatever happens with the negotiations, Jovanovic, who completed her doctoral thesis on alcasite, is keen to defend Ivoclar despite no longer working with it. “Any company could have developed a replacement [for amalgam], so it wasn’t specifically given to Ivoclar. My question is, should we now cry monopoly because no one else bothered to step in?” The International has not been able to verify whether other companies tried to develop alternatives. Another option is glass ionomer cement, which is covered by the ÖGK but seen as a provisional material that is unsuitable for back teeth. Composite fillings – the white ones – are not covered by the fund unless used for front teeth.

Meanwhile, the ÖGK remains firm in its assurances to the public. In a statement on its website, Moritz Mitterer, Chair of the General Assembly of the ÖGK, said: “The fund will continue to protect insured individuals from excessive costs for dental fillings even without amalgam, and patients need not worry if they experience issues with their dental fillings.”