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Oral Medicine

bstract

Allergies related

to

dentistry generally constitute

delayed

hypersensitive reactions

to

specific

dental

tnaterials-

Although true

allergic hypersensitivity

to dental

materials is

rare, certain products have

definite

allergenic properties.

Extensive

reports

in the

literature

substantiate that

certain

materials

catise allergies

in

patients, who exhibit ntueosal and skin symptoms.

Currently,

however neither

substantial data nor clinical

experienee unequivocally contraindícate

the

discontinuance

of any ofthe

tnaterials. which inchtde dental ainalgain

and nickel-

and

chromium containing

metals. The dentist fortns a

vital

link in the teatn

approach

to the

differential diagnosis

of

allergenic biomaterials

that

elicit

symptoms in a

patient

not only

Intraorally.

but

also

on unrelated parts ofthe

body

(Quintessence Int

¡996:27:513-520.

relevance

Pretoria, Faeiilty of Dentistry, Pretoria, South Africa

Ftead Eme ritus; Division of Dental M ateriais, University o fPreturia,

Faculty of Denti ïtrj , Pre toria, South Afriea,

Pretoria, Faculty of Dentistry, Pretoria, South Afriea,

circulating antibodies, because the causative agents

attain their allergenic properties y combining with the

mucosal tissues ofthe patient. The delayed hypersen-

sitive reaction is not manifested clinically until several

hours after exposure.

A contact allergy in dentistiy is the type of reaction

in which a lesion of the skin or mucosa occurs at a

localized site after repeated contact with the allergenic

material. The ability to cause contact sensitivity

appears to be related to the ability of the simple

chemical allergen to bind to proteins, especially those

ofthe epidermis,- and. in dentistry, specifically

the

oral

Contact dermatitis

Clinical features

As in all forms of eel I-mediated immunity, in con tact

dermatitis there is a minimum latent period of at least 5

days between the first contact with the allergen and the

ability to react at a distant site to further contact with a

nonirritant concentration of the allergen. Reactions

take between 24 and 48 hours to develop and , if severe,

may last for 7 to 10 days.-

Contact dermatitis is manifested by an itching or

burning sensation at the site of contact, followed a

short while later by the appearance of erythema and

then vesicles. Once the vesicles have ruptured, the

erosion may become more extensive, and secondary

infection may develop,

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Fig A suspected allergic reaction lo a self-cunng acrylic

resin provisional fixed partiai denture piaced in thG maxillary

anterior segment has developed at the corners of tine mouth

a few days toiiowing placement. The reaction is characte-

rized by itching vesicular formation and crusting. The

condition was alleviated when the permanent ceramometal

fixed partial denture was placed 9 days later

The oral man ¡testa

lions,

known as contact stomatitis

or stomatitis venenata, iticlude an inflamed and

edematous mucosa, accompatiied by a severe burning

sensation. Small, transiem vesicles may form; these

rupture to fonn areas ol erosion and ulcération.'

Erythema, papules, and edema are characteristic

ailergic manifestations and, in severe reactions, large

weeping blisters may appear, Stomatitis venenata

occurs iess frequently than do allergic skin lesions.

This can be ascribed to the diluting, digestive, and

washing effects of saliva,

Ahhough certain dental materials have been im-

plicated as causes of contact stomatitis, the reported

incidence is low. However, wheti an ofFending dental

material sensitizes an area oft he mucosa, no matter

how small the area, the individual may become

sensitized,^

Treattnent and prognosis

Several tnethods of treating allergies have been re-

ported, including íiymplomatic treatment, desensiti-

zation, and elimination of the allergen. Because the

mechanism of the allergic reaction is not yet ftilly

understood, the presently recommended method of

treatment may be elimination of the aileiên. ' Pres-

ently, the only effective trea tme nt for contact derm atitis

or stomatitis is the discontinuance of

all

contact with

the alleiênic m aterial, which usually results in prom pt

remission of

all

the lesions.

This article will review allergic hypersensitivity to

various modern dental materials.

Allergenic dental materials

Acrylic resin

Acrylic resin has been reported to occasionally induce

an allergic hypersensitivity when used as a denture

base, restorative material, or provisional fixed partial

denture resin (Fig

), Normally, the patient is exposed

to the free m onome r in acrylic resin, which

may

causea

toxic reaction, Hypersensitivily in denture wearers

should not be confused, however, with physicai

irritation of the oral mucosa caused by ill-fitting

dentures. Acrylic resin hypersensitivity may develop

shortly after insertion of the denture or may not

manifest for an extended period of time, even many

m on ths' (Figs 2a and 2 b), Clinical reactions may

occur at secondary sites (Figs 3a and 3b),

Resit composite

Lind^ repo rted that resin com posite m aterials could be

an etiologic factor in the development of lichenoid

reactions in the oral mucosa. The pathogenic mech-

anism may be related to contact allergy to formalde-

hyde formed in resin composite restorations. Formal-

dehyde causes more than one third of all allergic

reactions caused by dental materials, A report by

0y sae d et al indicated tha t formation of formaldehyde

was found in light , ultraviolet light-, and chemically

activated resin composites,

Itnpression materials

Polyether impression materials have been reported to

cause allergic problems in the past, but have since

changed their compositions. Care should be taken to

mix the material thoro ugh ly and to avoid contact ofthe

aromatic sulfuric ester catalyst paste with the skin or

mucosa because it may elicit adverse tissue reactions,

Ettgenol containing products

Oil of cloves, or eugenol in its unrefined form, is mixed

with zinc oxide to form zinc oxide-eugenol (ZOE),

which exhibits a combination of physical and thera-

peutic properties making it useflil as a provisional

restorative materiai, base material, and root canal

filling material. Zinc oxide-eugenol impression pastes

and ZOE periodontal packs are also available. Euge-

nol is highly soluble and is continuously released from

ZOE, which can lead to short-term saturation ofthe

oral environrnent with eugenol in a concentration

5 4

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Fig 2a The upper lip and eyelids

are severely swollen 5 days a¡ter

insertion of provisional acrylic resin

fixed parfial denture.

Fig 2b One week after removal of

Ihe provisional acrylic resin prosthe-

sis and after replacement with a

permanent ceramometal fixed par-

tial denture, the swelling is gone.

Fig 3a (/eW n allergic reaction may occur at a secondary

site in acrylic resin allergy After placement of a new

maxiiiary complete denture, a secondary allergic reaction

occurred on the inside ol this patient s upper legs.

Fig 3b below) The inside of the patienfs arm, and his

stomach and back, were also affected.

contain colophony

and four of them contain eugenol. The only

that is eugenol free Co e-pak, Coe Laborato ries)

ong o ther thing s, balsam of Peru.^ In this

context the cross reactivity between many allergenic

substances, such as between eugenol and balsam of

Peru, should be borne in mind. Thus, when the causative

agent in an allergic reaction to periodontai dressing

materials has not been positively identified, a choice

among the materials, whether they are eugenol-frcc or

not, is impossible.^

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Fig 4 Suspected allergy to an amalgam alloy has caused

erythema and vesicle formation. The symptoms disappear-

ed after a resin composite restorative material was placed.

Fig 5 Suspected allergic con tact glossitis has developed

adjacent to a gold crown The swelling and erythematous

changes disappeared after the restoration was replaced

with a porcelain orown.

The inilatumatory response caused in mucosal

tissue by eugenol should not, however, be confused

with allergic hypersensitivity. From a biologic point of

view. ZOE is in fact considered the least damaging

restorative material and possesses sedative or anodyne

propetiie s, which are very useful in den tistry. ^

Desp ite the advantageous prope rties of eugenol, how-

ever, sensitivity, tnanifested as positive inflammatory

responses to eugenol in certain root canal sealers has

been described,'-

Metals

Amalgam

Altho ughra re.allergyto mercury'-'as well as copper in

amalgam' * has been described. In addition, the release

of mercury from amalgam restorations has been the

cause of skin and mucosal disorders'^ (Fig 4) . There is

also growing evidence that amalgam restorations may

be etiologic factors in some of the mucosal changes

classified as oral lichen pianus.'^ Some of these

disorders may be considered a mucosal pattern of

response to several distinct pathogenic factors. Ailergy

to amalgam compounds may be one such pathogenic

me chanism . ln many cases, electrogalvanism may

enhance the allergic reaction as a transmitter of

reactive ions, justifying the term

electrog lv nic

white

lesion

used by Bánóczy et al.'^

Because erosive forms of oral lichen planus are

known to be susceptible to cancer deyelopment,

patients should be given effective causal treatment.'^

Vernon et al ' reviewed 41 published cases of allergy

to dental amalgam, which included 30 female and U

male patients. Twenty of the 41 patients recovered oa

removal of their amaigam restorations. The most

frequent symptoms were of the rem ote cutaneous type

(38 of 41 cases), while local symptoms, particularly

gingivitis and stom atitis, occ urred in 17 cases. The

authors suggested that the figures probabiy under-

estimate the true prevalence of the condition because

of underreporting of cases. Mercury was found to be

the most common sensitizing agent, but other metals,

particularly co pper, zinc, an d silver, could also be

implicated.

Gold

Gold is generally regarded as an inert and safe

material,-' but the belief that gold is nonsensitizing is

not substantiated by reported data. Comaish'^ re-

ported allergic dermatitis to a gold wedding ring,

Elgart and Higdan'** described stomatitis caused by a

gold dental restora tion and conc om itant dermatitis at

sites in contact with gold jewelry worn by the patient.

The num ber of confirmed cases of gold sensitivity is

extremely low^ (Fig 5),

Nickel

In general, nickel, ranJted third among the five most

comm on causes of allergic contact derm atitis- and

first in most industrialized countries, is the most

common contact allergen in dentistry affecting females

in Europe and the United States.'' Nickel hypersen-

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Fig 6a

left)

Nickel dermatitis of the earlobe is common in

niokef-sensilive individuals who vîear nickel-containing

jewelry.

Fig 6b below) Swelling and erythema of the earlobe are

evident after removal of the earring.

n.-* Aboul 10% of females are sensitive to

ry,-- although one re pot indicates that up to 20%

males are sensitive to n icke l.-- N ickel derm atitis of

b). Only

1%

to

2%

of males are found to

The signs and symptoms of nickel sensitivity

ry, suchas watches (Fig 7) and bracelets, is worn.

l have been reported to cause contact dermatitis,-^

, swollen and fissu red lips, and chronic eczema

Fig 7 Contact dermatitis has developed after ej Dosure to

nickel in a watchband.

However, such spreads to secondary sites may be

caused by contaminated, perspiring fingers of the

patient during the initial eruptive

stage.

In orthodontics, allergic reactions to nickel in

cervical headgear-' as well as allergic reactions to

orthodontic wires-^ and nickel-titanium orthodontic

wires,

have been reported. However, a recent study did

not find that nickel-sensitive person s are at greater risk

of developing discomfort in the oral cavity when

wearing an intraoral orthodontic appliance.-'

Despite the reported allergenicity of nickel, few

cases of adverse reactions to nickel-containing dental

prostheses have been reported. The evidence that

nickel absorption intraorally exacerbates existing der-

matitis is also minimal. Furthermore, there is little

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evidence available to implicate nickel as playing any

part in the rejection of nickel-containing prostheses,

dental or orthopedic,-^ and it must be concluded that

nickel materials are generally safe to use in dentistry.

Chromate

Chrom ium differs from nickel in that it is not antigenic

in metal form, but usually only in the hexavaletit salt

form as chromate. M inute quantities of chromium salts

can, however, sensitize. Chromium compounds, on

the other ha nd, can induce cotitact de rmatitis and even

cause severe corrosive irritation o fthe skin. Exposure

normally occurs due to industrial exposure or through

handling or use of detetBents, bleaches, shaving

creams, lotions, matches, and chromated catgut,-*

However, it has been found that neither chromium-

containing alloys nor chromium-plated objects, such

as jewelry, produce allergic contact dertnatitis in

chromium-sensitive individuals. Although alleiîc

reactions resulting from contact with chromium-type

alloys do occur, such allergies are usually due to some

other metal in the alloy, normally nickel.-'

Although base tnetal alloys contain between 11

and 35% chromium,-* chromium allergy is rarely seen.

It is a less common problem than is nickel allergy. The

chances of an adverse reaction to chromium found in

dental materials, therefore, appears to be remote,--'-^

but clinicians should nevertheless always be on the

alert.

Platinum

Documented cases of platinum hypersensitivity are

even more rare than is chromium allergy, Platinosis is

not caused by metallic platinum but by contact with

complex platinum salts and mainly affects platinum

refiners. Manifestations include pruritis, erythema,

eczema, and urticaria, usually limited to the exposed

parts ^^

Cobalt

Cobalt-chromium alloys, forming the framework of

metal partial dentures, and base metal alloys contain

about 60% to 65% cobalt. They are regarded as

biocompatible because of the absence of nickel and

beryllium in their comp osition. C obalt is nevertheless

listed as a sensitizing metal. Allergic reactions to

cobalt used in dentistry are very rare, however. In

patients with no known allergy, preventive screening is

unnecessary, • '

Restorations

Recently, Suzuki^^ ¡ ¿

^-ray fluorescence spec-

troscope to detect the allergenic metals in intraoral

metal restorations and personal and household itetns

of metal-allergic patients, Ofthe 275 subjects who had

positive reactions to M-9 series patch tests, the 10

most common elements detected for restorations were

silver, copper, zinc, gold, palladium, tin, mercury,

indium, nickel, and chronnium. A llergens were de-

tected in 161 patients, and the five elements wilh

higher allergetiicity were mercury, nickel, tin, chro-

mium, and cobalt. In personal and household items,

the top five elements with higher allergenicity were

copper, nickel, chromium, zinc, and molybdenutn,

Su zuk i'- co ncluded that metal allet^y should be

taken into consideration whenever dental treatments

with alloys are planned. For patients with metal

allergies, as well as for those without, it is prudent to

avoid the use of mercury, nickel, and other elemetits

with a high sensitization rate, if possible, Eveti

precious metals, such as gold or p latinum, may cause

allergies, especially for individua ls with a history of

direct contact with intradermal tissues. It is recom-

mended that similar types of alloys be used in a single

oral environment, where possible, to prevent corro-

sion and dissolution by intraoral electric current.'^

Hilde brand et al ^ repor ted on 139 published cases

of allergy to dental restorations. The most frequent

symptom s were local gingivitis and stom atitis (99 of

139} while general and remo te symptoms occurred in

33 patients. Ninety-two female and 47 male patients

were involved. In another review, the same authors^''

reported that allergic reactions to nickel, cobalt, and

chrotnium in dental prostheses and restorations tnay

appear either locally as stomatitis or distantly in the

form of general or local contact dermatitis.

Allergy testing

Allergy testing of dental materials consists of epicuta-

neous patch testing, in which readings of skin reac-

tions are made on removal of patches after 48. 72, or

96 hours. The presence of erythema, combined with

edem atous infiltration with or without papules or

vesicles, is used as the criterion for a positive result,^^

There is no need to perfonn an epimucous test to

detect contact allergy in the oral mucosa, because the

epicutaneous test gives the applicable information.'^

Ax ell et a l designed a hst for patch test screening

of dental materials in cooperation with The Nordic

518

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s (dental sc reening) consists of 2 chemicals. The

ances used in the list were chosen from re ports in

y, Axell et

al-'

described a new method

plates carrying test pieces contaitting 66 nickel

iorrs. Biopsy specimens from con trol sites showed

not allergy testing pe r se, the Fleigl test, a

a

1 alcoholic solution

glyoxime and a few d rops of ammonia water

a

metallic object, on skin, or

in

a solution, produces

s In the literature indicate that certain

indicates the discontinuance of any ofthe materials,

including mercury-, nickel-, chromium-, or eugenol-

containing dental materials,^'^^ Nevertheless, it is

advisable to ask patients questions concerning past

hypersensitivity to dental materials or following dental

procedures. As pari of the medical history, each

patient should also be specifically asked whether a rash

or eczema had ever developed following the wearing of

earrings or jewelry.

In most patients, there is no indication for patch

testing. Routine use of such a test for all patients

should be avoided, because the test procedure tnay in

some cases provoke sensitization ofthe patient.-'^ The

main indication for an ep i cutaneous test is the

presence of local symptoms in the mouth close to a

dental restoration or prosthetic or orthodontic ap-

pliance.

When skin symptoms are present, the patient should

be referred to a dermatologist for consultation. The

epicutaneous test should be undertaken by a dermatol-

ogist.^^ Once a positive test has been confirmed by the

dermatologist, the offending material should be with-

drav/n. Rapid remission ofthe symptoms will confirm

the positive allergy test, and the patient should be

made aware of his or he r aüergie status and be advised

to repo rt it to future dental practitioners, A repeat test

may be necessary for true confirmation of allergy, but

because of ethical co nsiderations, may not be clinicaUy

possible.

The dentist forms an important link In the differen-

tial diagnosis of allergy. Ail possible allergenic dental

materials should be considered when allergic patients

with symptoms, whether intraoral or on unrelated

parts ofthe body, are tested.

cknowledgments

The authors are grateful to Mrs Yvonne Skinner, Deparlment of

Ortho dontic s, for typjni; Lht manuscript, n welt as Kobtis van derM erw e.

Henriette Rothmann, and Lydia Faber for llie photographic work.

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