What happens during SMART amalgam removal?

A step-by-step guide to the treatment journey

The short answer: SMART amalgam removal involves assessing the tooth, planning how it will be restored, making you comfortable, putting additional protective measures in place, carefully removing the amalgam and restoring the tooth appropriately afterwards.

If you have never experienced SMART amalgam removal, the setup can sound more complicated than an ordinary filling appointment.

Understanding why each stage is there can make the process much easier to picture.

Here is what you can generally expect at Evolve Dentistry.

Step 1 – We start with assessment, not removal

Your first appointment is not about immediately taking amalgam fillings out.

Carol or Maggie will first understand why you are considering treatment.

Perhaps:

• another dentist has told you a restoration needs replacing
• a filling has fractured or changed
• you are concerned about an old restoration
• you dislike seeing a silver-coloured filling
• you have several restorations and want to understand their condition
• you have heard about SMART and want reliable information

We then examine the restoration and surrounding tooth.

Where clinically appropriate, dental X-rays may form part of the assessment.

Step 2 – We decide whether treatment is appropriate

An amalgam filling does not automatically need removing.

If the restoration appears serviceable, monitoring it may be an option.

If treatment is recommended, we will explain why.

If your reason for considering replacement is cosmetic, we will discuss the implications of removing a functioning restoration before you decide.

This stage matters because SMART describes amalgam is removed.

It does not tell us whether it should be removed.

Step 3 – We plan what will replace the amalgam

Before removing a filling, we need to consider what the tooth will require afterwards.

For some teeth, a direct tooth-coloured composite restoration may be appropriate.

For others, particularly where a substantial amount of tooth structure has already been lost, a different restoration may be recommended.

Possible options can include:

• composite
• an inlay
• an onlay
• a crown
• another restoration appropriate to the tooth

We will explain the expected approach before treatment begins.

Step 4 – The tooth is made comfortable

Local anaesthetic can be used to numb the tooth and surrounding area.

The aim is to make treatment comfortable.

You may still be aware of sensations such as:

• pressure
• vibration
• water
• suction
• sound

If you are nervous, tell us before treatment begins.

We can explain what is happening and agree a signal you can use if you want us to pause.

Step 5 – SMART precautions are put into place

SMART stands for Safe Mercury Amalgam Removal Technique.

The protocol incorporates additional measures intended to reduce exposure to amalgam particles and mercury vapour during removal.

The precise clinical setup depends on the individual treatment, but precautions relate to areas including:

• isolation
• suction
• water cooling
• protective barriers
• air management
• removal technique

The setup can therefore look more involved than you might expect for an ordinary restorative appointment.

Step 6 – The tooth is isolated

Rubber dam isolation can be used around the tooth being treated.

A rubber dam is a flexible sheet that separates the treatment area from the rest of your mouth.

It helps control debris and provides a more isolated working environment.

You remain able to breathe through your nose.

If you have never experienced a rubber dam before, we can explain how it works before it is placed.

Step 7 – Suction and other precautions are positioned

High-volume suction is placed close to the treatment area.

Additional protective and air-management measures associated with the SMART protocol are also used as appropriate.

Step 8 – The amalgam is removed

The existing restoration is carefully removed.

Where clinically appropriate, it can be divided into sections so that pieces can be removed rather than unnecessarily grinding away the entire restoration.

Water cooling and suction are used during this process.

Step 9 – We can properly assess the tooth underneath

There is an important point patients sometimes overlook:

we cannot always know exactly what lies underneath a large old restoration until it has been removed.

Assessment and X-rays help us plan, but they cannot reveal every detail.

Once the amalgam has been removed, Carol or Maggie can examine the remaining tooth more directly.

Often this confirms what was expected.

Occasionally we may discover:

• more loss of tooth structure than anticipated
• decay
• cracks
• areas requiring additional treatment

If that happens, we will explain what we have found and what it means for the restoration.

Step 10 – The tooth is restored

Once the old filling has been removed and the tooth prepared appropriately, the replacement restoration can be provided according to the treatment plan.

The objective is not simply to make the tooth “white”.

The new restoration needs to function appropriately for that particular tooth.

Step 11 – Your bite is checked

Once the restoration is in place, we check how it feels when your teeth meet.

A restoration that sits slightly too high can feel uncomfortable once the anaesthetic wears off, so adjustments can be made where required.

Step 12 – We explain your aftercare

Before you leave, we will explain what you may notice once the local anaesthetic wears off.

Some temporary sensitivity or awareness can occur after restorative treatment.

You will also know when to contact us if something does not feel right.

What will I feel during the procedure?

The local anaesthetic is intended to prevent painful sensation from the tooth during treatment.

You may nevertheless notice:

• vibration
• pressure
• water
• suction
• the rubber dam
• noise from dental equipment

Some patients find the SMART setup reassuring because the treatment area feels more separated from the rest of the mouth.

Others simply need a little time to become accustomed to it.

How long does the appointment take?

There is no single SMART appointment length.

Treatment time depends on:

• which tooth is being treated
• filling size
• complexity
• number of restorations
• the replacement required
• whether several teeth are treated together

Following assessment, we can give you a much more useful idea of the time required for your own treatment.

What happens immediately afterwards?

Your mouth may remain numb for a period after the appointment.

Take care when eating until normal sensation has returned so that you do not accidentally bite your cheek, lip or tongue.

The tooth may initially feel different.

This can happen simply because the shape and material of the restoration have changed.

If your bite feels wrong, symptoms persist or you are concerned about anything, contact us.

Myth vs reality

Myth: SMART removal is a completely different dental treatment

Reality: The tooth still undergoes restorative dental treatment. SMART adds specific precautions to the amalgam-removal stage.

Myth: The dentist knows exactly what is beneath every old filling before removal

Reality: Examination and X-rays provide valuable information, but sometimes the full condition of the tooth only becomes clear once the existing restoration has been removed.

Myth: Once the amalgam is out, treatment is finished

Reality: The tooth then needs to be restored appropriately.

Myth: SMART guarantees that nothing can go wrong

Reality: No dental procedure is entirely without risk. SMART adds precautions during removal but does not remove the normal considerations associated with restorative treatment.

Frequently asked questions

Do I need local anaesthetic?

Local anaesthetic can be used to make the tooth comfortable during treatment. Carol or Maggie will discuss your individual appointment with you.

Can I breathe normally with a rubber dam?

Yes. The dam isolates the treatment area in the mouth, but you continue breathing through your nose.

Can I stop the dentist if I need a break?

Yes. We can agree a signal before treatment so you remain able to communicate if you need us to pause.

Will I leave with a new restoration?

This depends on your individual treatment plan and the type of restoration required. We will explain the expected sequence before treatment.

Will my tooth be sensitive?

Some temporary sensitivity can occur after restorative treatment. We will explain what to expect and when we would like you to contact us.

Key takeaways

• Assessment comes before amalgam removal.
• SMART is used once the decision to treat has been made.
• The replacement restoration should be planned before removal.
• Local anaesthetic can be used for comfort.
• Additional SMART precautions are put in place before the amalgam is removed.
• The filling may be sectioned into pieces during removal.
• The underlying tooth is assessed once the old restoration is out.
• The tooth is then restored appropriately.
• Aftercare and any expected sensitivity are explained before you leave.

Continue exploring

For more detail, read:

What is SMART amalgam removal?

Is it safe to remove amalgam fillings?

What can replace an amalgam filling?

Does amalgam removal hurt?

How long does amalgam removal take?

Or return to the complete:

Amalgam removal using the SMART protocol

Download the complete guide

Your guide to SMART amalgam removal explains the full journey from deciding whether treatment is appropriate through to replacement and aftercare.

Download the free guide

Every patient’s circumstances are different, and your clinician will explain the procedure, precautions and treatment options before proceeding. You can find out more about ⁠SMART amalgam removal at Evolve Dentistry and how we approach treatment at our Portishead practice.

Thinking about treatment?

Carol or Maggie can assess your existing restorations and explain what your individual treatment would involve.

An assessment does not commit you to having anything removed.

Arrange an amalgam consultation

Authoritative external resource

Read more about the SMART protocol from the IAOMT

Read our CQC report