Cent4dent Blog

HR 2101 IH

110th CONGRESS

1st Session

H. R. 2101
To prohibit after 2008 the introduction into interstate commerce of mercury intended for use in a dental filling, and for other purposes.

IN THE HOUSE OF REPRESENTATIVES

May 1, 2007
Ms. WATSON (for herself and Mr. BURTON of Indiana) introduced the following bill; which was referred to the Committee on Energy and Commerce

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A BILL
To prohibit after 2008 the introduction into interstate commerce of mercury intended for use in a dental filling, and for other purposes.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,

SECTION 1. SHORT TITLE.

This Act may be cited as the `Mercury in Dental Fillings Disclosure and Prohibition Act’.

SEC. 2. FINDINGS.

(a) General Findings- The Congress finds as follows:

(1) Elemental mercury and mercury compounds are known to be toxic and hazardous to human health and to the environment.

(2) Mercury is number three on the 2003 CERCLA Priority List of Hazardous Substances, behind arsenic and lead.

(3) A dental amalgam, commonly referred to as a `silver filling’, consists of 42 to 58 percent mercury .

(4) Consumers may be deceived by the use of the term `silver’ to describe a dental amalgam, which contains substantially more mercury than silver.

(5) Dentists purchase 34 tons of mercury per year, the Nation’s third largest purchaser of mercury . Dentists place millions of amalgam fillings in children each year, even though interchangeable substitutes of non-toxic materials could also fill those cavities. Each amalgam filling contains 1/2 to 3/4 of a gram of mercury .

(6) The mercury contained in dental amalgam is continually emitted in the form of mercury vapor, and the total amount of mercury released depends upon the total number of fillings; their age, composition, and surface area; the intra-oral presence of other metals; dietary and lifestyle habits; and other chemical and metabolic conditions affecting the mouth.

(7) When mercury vapors are inhaled, most of the mercury (about 80 percent) enters the bloodstream directly through the lungs and then rapidly deposits preferentially in the brain and kidneys as well as other parts of the body.

(8) Mercury toxicity is a retention toxicity (total body burden) that builds up over years of exposure, and is therefore dependent on all sources of mercury to which an individual may be exposed.

(9) The National Institutes of Health has concluded that when inorganic mercury is located in brain tissue, researchers are unable to demonstrate an appreciable half-life, or decrease, of mercury over time (more than 120 days). The implications of this conclusion are that dental amalgam exposure will permanently increase mercury body burden.

(10) According to the World Health Organization, the estimated average daily intake and retention of mercury from dental amalgam ranges from 3 to 27 micrograms per day, and is greater than all other sources combined.

(11) The California Dental Association, by court order, requires postings of warnings about mercury fillings in California Dental Offices as of March 9, 2003. The warnings read `NOTICE TO PATIENTS: PROPOSITION 65 WARNING: Dental Amalgam, used in many dental fillings, causes exposure to mercury , a chemical known to the state of California to cause birth defects or other reproductive harm’.

(12) United States consumers and parents have a right to know, in advance, the risks of placing a product containing a substantial amount of mercury in their mouths or the mouths of their children.

(13) According to the Agency for Toxic Substances and Disease Registry, the mercury from amalgam passes through the placenta of pregnant women and through the breast milk of lactating women, increasing health risks to both unborn children and newborn babies.

(14) The National Academy of Sciences estimated that `over 600,000 children are born each year at risk for adverse neurodevelopmental effects due to in utero exposure to methyl mercury’ . This report urged the need to understand the relative amount of mercury attributable to dental amalgam and to thimerosal in vaccines.

(15) Studies show that a variety of commonly found human intestinal and oral bacteria can methylate mercury . In this way, the mercury vapor from fillings biotransforms into the highly neurotoxic and teratogenic methylmercury.

(16) The use of mercury in any product being put into the body is opposed by many health groups, such as the American Public Health Association, the California Medical Association, and Health Care Without Harm.

(17) Highly effective and durable alternatives to mercury -based dental fillings exist, but many publicly and privately financed health plans do not allow consumers to choose alternatives to dental amalgam.

(b) Environmental Findings- In addition to the findings of subsection (a), the Congress finds as follows:

(1) Mercury wastewater released from dental clinics has been shown to fail the Environmental Protection Agency’s toxicity characteristic leaching procedure and, therefore, is regulated as hazardous waste.

(2) Research from the Naval Dental Research Institute indicates that, when discharged to the environment, conditions may be right for waste dental mercury to methylate, become bioavailable, and subsequently biomagnify in fish as methyl mercury , the most toxic form of mercury .

(3) Forty-eight States, the District of Columbia, and the United States Territory of American Samoa have issued 2,362 fish consumption advisories to their residents due to mercury contamination.

(4) The Food and Drug Administration has issued fish consumption advisories due to levels of mercury in commercially-caught fish and, in January 2001, warned pregnant woman and young children not to eat certain marine fish.

(5) According to the Environmental Protection Agency, United States dentists use approximately 34 tons of mercury per year.

(6) A report issued on June 5, 2002, by the Mercury Policy Project, the Sierra Club, Health Care Without Harm, Clean Water Action, and the Toxics Action Center stated that, because of mercury fillings, dental offices are now the leading source of mercury in the Nation’s wastewater.

(7) Mercury from dental amalgam can enter the environment during any point of the product’s life-cycle. This includes placement or removal of fillings; through bodily excretions; when sewage sludge is incinerated, spread on crops, or dumped in land fills; when vapor is released or land filled; when vapor is released directly from the filling (which increases with brushing, chewing, and consuming hot foods or salt); and during cremation. Currently there are no requirements for mercury capture before or during cremation.

(8) The Association of Metropolitan Sewerage Agencies reported human wastes from individuals with dental amalgam fillings to be the most significant source of domestic mercury entering publicly owned treatment works, greater than 80 percent of the total contributing factors.

(9) According to the Association of Metropolitan Sewerage Agencies, removal of mercury from publicly owned treatment works has been shown to cost $10,000,000 to $100,000,000 for every pound removed.

(10) Mercury use by the dental industry increased from 2 percent in 1980 to 22 percent of the total use of mercury in the United States in 2001, because of drastic declines in mercury use by other industries over that period.

(11) Amalgam restorations were estimated to be 55 percent of the total mercury product reservoir in 2004 by the Environmental Protection Agency, and will therefore be a source of environmental contamination into the future.

(12) According to a joint study by the Environmental Protection Agency and the Cremation Association of North America, approximately 238 pounds of mercury , mostly from dental amalgam fillings, were released from crematoria nationally in 1999.

(13) Cremation is chosen in approximately 30 percent of all deaths, and this percentage is expected to increase every year.

(14) According to industrial hygiene surveys, 6 to 16 percent of dental offices exceed the exposure levels for air mercury permitted by Occupational Safety and Health Administration standards.

SEC. 3. PROHIBITION ON INTRODUCTION OF DENTAL AMALGAM INTO INTERSTATE COMMERCE.

(a) Prohibition- Section 501 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 351) is amended by adding at the end the following:

`(j) Effective January 1, 2009, if it contains mercury intended for use in a dental filling.’.

(b) Transitional Provision- For purposes of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 301 et seq.), effective December 31, 2007, and subject to the amendment made by subsection (a), a device that contains mercury intended for use in a dental filling shall be considered to be misbranded, unless it bears a label that provides as follows: `Dental amalgam contains approximately 50 percent mercury , a highly toxic element. Such product should not be administered to children less than 18 years of age, pregnant women, or lactating women. Such product should not be administered to any consumer without a warning that the product contains mercury , which is a highly toxic element, and therefore poses health risks.’.

For more information visit the mercury links page at www.cent4dent.com

The American Dental Association has created some uproar in our community by trying to handcuff dentists in their ability to offer oral conscious sedation. Already, in the state of New Jersey, the state board has mandated that all OCS dentists receive an extra 40 hours of training, which all the dentists at “The Centre” completed in ‘06.

Sedation dentists have organized, and are working assiduously to prevent this incursion into our ability to treat you. To read what the surgeon general had written, click here. http://www.agd.org/pdf/surgeon_general2m.pdf

I have been invited to address City Council on the issue of mercury separators. These are used to remove mercury from the wastewater lines of dental offices before they hit the sewer lines. As a steward of the environment and a child of the 60’s, I installed a separator on our building in 1997. These are just starting to become mandatory in some areas of the country. This is the text of the speech I will be presenting:

My name is Dr. Steve Markus, a general dentist from South Jersey. About 15 years ago my belief system was turned upside down by something we in dentistry refer to as “The Sheep Study”. Up until that point in time, I believed what the ADA fed all dentists, and that was that mercury became inert when combined with the other ingredients in dental amalgam. I believed that any dentist who spoke out against our vaunted mercury fillings was unbalanced. That study proved otherwise. Mercury from dental fillings is dispersed via evaporation to all organ systems of the body. Silver dental fillings, you see, are 50% mercury by weight. Mercury is the most toxic naturally occurring substance on earth.

Mercury does not belong in anyone’s body. Yet the FDA has failed to reclassify it as a class III medical device. One can only wonder what the possible agenda could be, of the lobby which has supported the implantation of this potent neurotoxin into the heads of Americans, and Mercury does not belong in anyone’s body. Yet the FDA has failed to reclassify it as a class 3 medical device. One can only wonder what the possible agenda could be, of the lobby which has supported the implantation of this potent neurotoxin into the heads of Americans.

I applaud City Council for considering this bill which requires “informed consent” for all dental patients, but I also recommend that they consider a ban on using mercury fillings in the city’s children and pregnant women. You see, mercury crosses the placenta. It has been shown that the mercury level in a woman who has had a recent mercury filling is twice as high in placental blood.
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I anticipate that those who will testify before you today in favor of mercury will have many of the same things on their agenda as those who spoke before the FDA. Following two days of public testimony, this learned panel voted 13-7 against the adoption of their own white paper.

Those who supported mercury spoke about the costs on the health care system if mercury fillings were to be banned. They spoke about the technique sensitivity required for the composite resin alternatives.

The speech I gave at that time, before the FDA is included after the end of the printout of this speech on the documents you have been or will be provided with. In it, you will see my refutation of the claims about the costs on dental system may be more than offset by the savings in the healthcare system because many cases of mercury toxicity masquerade as symptoms parallel those of chronic fatigue, MS, Alzheimer’s, and many others. Very expensive medical treatment could be avoided. Mercury has been implicated as a possible cause of autism. How much would public education expenditures be decreased if the population of autistic students could be decreased?

There is no denying the technique sensitivity demanded in the placement of composite resin. However, dental students are in school to learn technique and dexterity. To state that they cannot be trained is subterfuge. In reality, it might be that the dinosaurs teaching in the dental schools might be the ones who cannot be re-tooled. If, as the ADA would contend, dental fillings are safe, why would LD Caulk, the manufacturer of Dispersalloy, one of the most widely used dental amalgams have in its material safety data sheets for that product the following: These fillings should not be used in patients with severe renal deficiency. In children 6 and under.
In expectant mothers.

Removal of clinically acceptable amalgam restorations should be avoided to minimize mercury exposure, especially in expectant mothers.

Furthermore, their cautionary statement states that dentists should store amalgam scrap in well sealed containers. Regulations for disposal must be observed

Many of the answers to questions that might arise may be found on the mercury links page of my website which was published about 12 years ago for the express purpose of educating the public about the pitfalls of the managed care system, and the toxic nature of mercury.

I would like to spend the balance of my time explaining to you why your proposal to mandate mercury separators on all dental offices, clinics and dental schools is a very forward thinking idea. Many states mandate separators. A partial list of them includes New York, Maine, Connecticut, New Hampshire, Areas surrounding the Great Lakes, Puget Sound, and my state, New Jersey.

I have provided for the Council, a 34 page copy of the NJ DEP’s rationale behind mandating separators. They do not rely on voluntary compliance. My understanding of members of my profession would be to advise you to put some teeth in your bill with respect to documentation, inspection, and penalties for failure to comply. Most dentists you speak with don’t feel our profession is the cause. Let me tell you a little about what’s contained in that report.

“Exposure to mercury contamination can cause permanent brain damage to the fetus, infants and young children. Mercury exposure has been shown to affect the ability of children to pay attention, remember, talk draw, run, see and play.”

“Mercury enters the aquatic environment through a variety of sources that release mercury to the land, air and water”.

”New Jersey’s wastewater treatment plants (POTW’s) , receive substantial amounts of mercury. While there is significant amount of incidental removal of mercury at the POTW, this removal is not complete. As a result, POTW’s discharge mercury directly in to the surface waters of the state. Much of that ercury is concentrated in the POTW’s sludge. Approximately 27% of sewage sludge generated in NJ is incinerated, resulting in the atmospheric release of mercury, and ultimately deposition to surface waters”.

”Dental facilities (such as private dental practices, as well as hospitals and dental schools where placing or removing dental fillings occurs contribute more than any other sector to the mercury entering POTW’s. A study by Vandeven estimated that about half of the estimated total mercury load at POTW’s come from dental faciilites”.

This is because dental fillings are 50% mercury.

”Dental facilities generate mercury waste when they create or remove fillings. Examples of those wastes include scrap, which is the excess filling material not used in the filling, extracted teeth with mercury fillings in them, carving scrap collected at chairside traps filters or screens; empty amalgam capsules in which these toxic fillings are mixed”.

”Everything that is not collected in these traps end up in the waste water, and then into the POTW’s. Mercury not removed by the POTW’s treatment process is discharged into the surface waters of the state. Mercury that is removed is concentrated in sludge which is then incinerated and re-enter the environment through the atmosphere. ”

”For these reasons, mercury containing wastes from a dental facility are difficult to control once it leaves the facility. Conversely, those wastes can be controlled most effectively before they leave the facility. ”

”Based on ADA data, NJ dental facilities discharge about 2580 pounds of mercury each year. It is estimated that traps or filters capture about 78% of this material from the wastewater, with recycling not currently required. ”

”Any separator you recommend must meet 99% removal efficiency established under the International Standards Organization (ISO) 11143 protocol”.

”It was estimated that removal and recycling would cost between 54 and 81 cents per NJ dental patient per year.”

”The proposal requires dental facilities to implement BMP’s (best management practices) within 12 months, and install separators no later than 24 months after the effective date. New facilities that begin operating after the effective date must have separators in place when they commence operation.”

Here’s something you’ve probably never considered: In Brooklyn, the Williamsburg Savings Bank building was home to many dental offices for the better part of the last century. It was sold and converted by Magic Johnson into luxury apartments. I correctly predicted that this facility was going to be a mess to clean-up. I would think that all offices in buildings in this city that house dental practices should be inspected for mercury vapor from the sludge laying at the connection to the city sewers which can come back up into any office in the building through drain lines.

”The separator must serve every dental chair in the facility, and must be sized adequately for the maximum expected flow rate. The proposed rule also requires the owner of a dental facility to register and certify with the DEP that they are in compliance. The DEP will make an effort to incorporate the reporting provisions within the annual registration submitted by all dental facilities under the Regulated Medical Waste Generator Registration Program. ”

”The Toronto Sewer District found that after requiring installation of spearators by dental facilities, the average monthly mass of mercury in the combined sludge of its four treatment plants had been reduced by 58%. There was only 73% compliance. Toronto estimated that full compliance would result in an 80% reduction in the monthly mass of mercury in sewage sludge.”

”The DEP estimates that costs for recycling amalgam waste associated with BMP’s (not including separators) would be approximately $300 per facility per year, or about 20 cents per patient per year.”

In 1988 my profession underwent a major paradigm shift, when suddenly we were required to wear gloves and sterilize our equipment (a mandate without teeth, and therefore skirted by many cost-conscious dentists) because of HIV. Just as we must treat all patients as if they might have the virus, dentists of the future must accept the mandate to protect the environment, and to do no harm to our patients.

Text of my FDA speech:

My name is Steve Markus, and I have been practicing dentistry for 31 years, in Haddon Heights, NJ. I have also been a member of the ADA for those 31 years. Hopefully, this conference will mark the fulfillment of a more than 15 year quest. That quest is to be proven prudent in erring on the side of caution.
We have heard the expression, erring on the side of caution several times yesterday from Canadian and Swedish speakers. Let me tell you about my quest.
While at the University of Pennsylvania, my mother got into the habit of sending me articles from the Sunday Times. Once a month, I got a fat envelope. Then, there arrived one envelope changed my professional life.
In it was an article about the Vimy study in Calgary. When I read the words of Alton Lacey, president of the ADA as you recall hearing yesterday, that this was not a human study, I wondered what the ADA’s agenda was? I stopped placing mercury fillings that day, and have not done so since.
I began thinking about the storage of mercury amalgam scrap. The ADA told us to store it in a sealed glass jar, under antifreeze or high specific gravity fluid. But the ADA told dentists, out of the other side of their mouth, that mercury became inert once placed. So why did it eat a hole in the top of the storage jar? What was it doing to my patients?
I thought about the environmental impact of all the mercury that was going through my suction, and out into the sewer system. I installed a separator on my building, and now, every year we proudly recycle 3-5 pounds of mercury that otherwise would have become an ecological bio-burden.
At the beginning, it took a lot of time to explain the whole issue to my patients; the Vimy study, the story about amalgam scrap and that I preferred to err on the side of caution. When properly educated, who in their right mind would choose mercury?
About 20 years ago, the profession underwent a major paradigm shift. We had to treat everyone as if they were an AIDS threat. Now, another shift is in order. We must treat everyone as if they are one of the susceptible, to mercury toxicity. We have heard, repeatedly about the myriad symptoms that are part of the diagnostic equation. The A-Z. Alzheimer’s to Zygote abortion and everything in between.
A member of the panel asked a very salient question of Dr. Phillipson yesterday. What did he expect the epidemiologic impact of eliminating the placement of dental amalgam to be, in Sweden?
Many pro-mercury dentists argued about the cost of eliminating mercury from their armamentaria. But nobody asked what the financial burden is on the medical system for symptoms resulting from the use of mercury implanted in people’s skulls. Hopefully, if this body deems it correct to take the appropriate stance, we may see serious decreases in much of the chronic illness physicians might attribute to factors other than people’s fillings.
Pro-mercury dentists argued yesterday, that composite fillings are less durable, that dental schools can’t teach it. This is all ludicrous. Dental schools teach dexterity and technique. They also insist on the use of the rubber dam. It’s not the training of the students, it’s the retraining of some of the dinosaurs that may still be teaching that is the obstacle.
The image of the fighting, screaming welfare child is the exception and not the rule. It is certainly not the reason for you to approve the use of mercury in children’s heads, a substance that has no known half-life, and as we have heard, can cause symptoms 35 years later, not 5-7 years, as the limitations of the study presented indicated.
What needs to be done is parents need to be educated that what they allow their children to put into their mouths is going to affect their spending money. The schools need to reform the foods they offer. Soda machines need to be banned. Warnings need to be placed on bottles of Mountain Dew. Not to get off topic, but have you ever seen Dew Mouth? It’s very similar to Meth mouth, and it’s disgusting what these chemicals do to the hardest substance in the body.
How do you give informed consent that says – here is a list of 105 symptoms you might develop as a result of this filling I’m placing? Keep it in your wallet, it may be 30 years until they develop, but if they do, they’re tremendously debilitating.
How many of you have ever heard of an MD asking about fillings in someone’s mouth? Medical education begins at the tonsils.
On the basis of the information provided, how many of you are willing to take the risk to have a large mercury filling placed in your mouth? In your child’s mouth. In the mouth of the woman who is about to deliver your grandchild? How, therefore, can you allow it in the mouth of any American? I encourage you to consider taking a cautious and courageous approach. The ADA won’t do it, the State Boards of Dentistry won’t do it, the dental profession won’t do it voluntarily. The act of placing mercury in the head of anyone, not just a pregnant woman, or a young child must be banned. How do you, the FDA, listen to all of this information and apologize to future mercury cripples? How do you ignore the science? Mercury has no known half-life when it resides in human tissue.
What I read in the paper over the weekend is that the FDA’s mind was already made up, that mercury was safe. I hope we have altered some of that thinking. Be a hero of the documentary, be my hero. Be a representative of the people, by the people, and for the people.

I will be on Fox News Tonight at 5 to discuss this issue. Here are the notes I’ve prepared for the broadcast:

Decay Story:

• Tooth decay in primary teeth of children aged 2 to 5 years increased from 24 to 28% – a 16% increase from the 88-94 period vs the 99-04 period
• Significant disparities along racial, ethnic and economic lines – Hispanics 6-11 showed 31% fill rate in permanent teeth vs 29 % non-Hispanic/white kids
• Three times as many children living below the poverty line ages 6-11 had unfilled cavities compared with those with incomes above the poverty line.
• Adults 20-64 showed a 4% decrease in dental visits at least once a year when comparing the same 88-94 vs 99-04 date parameters – tie into oral/systemic link

Causes of increased decay

• Access to care issues, and the fact that so few dentists participate in Medicaid system, which is frought with problems:
o Payment is very small
o Patients don’t keep appointments
o Limited numbers of procedures – eg Hg vs composite
 Talk about California and Maine, and soon, other parts of the US
• Entitlement mentality
o If I don’t have dental insurance I don’t go to the dentist
o Boss is responsible for whether my family and I keep my teeth – this is a quality of life decision, not a quality of job decision
• The managed care system
o Babies don’t come with owner’s manuals – baby bottle syndrome used to be a precautionary lesson, I think today it’s glossed over
o Baby teeth are not expendable.
o Parental and grandparental coping mechanisms are not in place, priorities are misplaced, many mothers out in the workplace and therefore cannot control the diet children are getting during the day.
• A nation of over-indulged children and adults – check out love and logic.com
• Misplaced dollars – toys (child and adult), consumer debt, pampering (nails grow back, teeth don’t).
• Study faulted bottled water – this IMHO is not the case. Fluoridation has not been shown to be effective. In many areas water is not fluoridated. Osteosarcoma in adolescent males. Fluoride needs to be applied topically, not taken systemically.
• Baby teeth decay very rapidly
• Spaces between baby teeth are there so that there’s room for the larger permanent teeth. Sticky candies, like jelly beans get stuck between, and start the decay process. Also get stuck in grooves of teeth. This is something that is seldom taught to parents – How to brush your child’s teeth.

Effects of increased decay
• Invasive treatment on infants is scary both for the child and the dentist.
• Creates dental anxieties that can take decades, even a lifetime to overcome
• Budgetary changes which can lead to a lack of care, or undercare.
• Lack of access to care led to the death of a 12 year old in Maryland, so this simply isn’t only about teeth, it is a life and death issue.
• Many children’s decay is so severe that the children need to be treated under sedation or general anesthesia. This poses a substantially added risk to a situation that could have been avoided, had the proper nutritional and preventative information been given the parents.

What can parents do?

• The causes of decay in children must be understood. The cause of rampant decay like we see here in this child was baby bottle syndrome – there should be nothing but water in a bottle in the child’s mouth when it goes to sleep or for a nap. Sugar is present in juices, formula. It lays on the teeth and if not removed, starts the decay process. Once the decay starts, it gets deeper in the enamel and then it hits the underlying layer, the dentin which is 60 times softer than the enamel. From there it spreads like wildfire to the nerve of the tooth.
• Too many sweets that are sticky lock into the grooves in the top of teeth, and between spaces in the teeth, and again, spread like wildfire.
• Soda and fruit juices with sugar are major culprits – children should be encouraged to rinse and spit after ingesting these foods.
• Jellybeans and other sticky candies should never be used as rewards without an immediate toothbrushing by the parent.
• Children should not be entrusted to their own toothbrushing until around age 8 or 9.
• Parents should sit cross-legged on the floor so that they have visual access to all tooth surfaces and brush them. This position also trains the child for their first dental visit which will be in a dental chair, with them lying down.
• As soon as the teeth begin to erupt into the mouth, parents should start at least wiping the erupting teeth down with a gauze square.
• Children’s first dental visit should be around age 1 or 2.
• Dietary information and a whole lot of other information about this is available on our website at: http://www.cent4dent.com/html/treatment/kids_teeth.html
• If there is an older sibling who is a good dental patient, bring the younger sibling in, to observe the procedures and gain trust, take a ride in the dental chair.
• Sealants on permanent molars as soon as they erupt into the mouth.

When I first started practice, in 1976 I set up next door to a pediatrician so I saw a lot of child patients. The parents of these patients were well educated by the pediatrician, and it was backed up by the preventative procedures we used on them. I thought that we’d make life really easy for these kids, by providing them with regular, preventative services. Many of those children are now bringing their children into the practices, and understand what it takes to keep their teeth.

However, parents whose parents didn’t place these priorities on them while growing up are now facing large dental and financial problems because the knowledge was not passed forward. Hoping that the access to care for patients below the poverty line is going to get better is not going to eliminate this problem. Many dentists simply will choose, as we have, not to participate in a program where they are not being reimbursed and patients do not respect our time. Many of us get involved in various charity programs to assuage our guilt of not participating in government programs. In our office, we often will provide treatment for our patients of record who have fallen on hard times and cannot afford the treatment their children need. We do not do this for people outside the practice, because I get at least 3 emails a week from people searching for a dentist to treat them for free.