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Allergies to Dental Materials Oral Medicine Allergies to dental materials William A. Wiltshire*/Mat7na R. FeiTeira**/At J. Ligthelm*** Abstract 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.) Clinical relevance circulating antibodies, because the causative agents attain their allergenic properties by combining with the Although the dentist should be aware of the mucosal tissues ofthe patient. The delayed hypersen- sitive reaction is not manifested clinically until several allergenic materials used in practice, which include hours after exposure.' acrylic resin, amalgam, impression materials, euge- nol products, and metal products, particularly A contact allergy in dentistiy is the type of reaction nickel, currently neither substantial data nor clinical in which a lesion of the skin or mucosa occurs at a localized site after repeated contact with the allergenic experience unequivocally contraindicates the dis- material.' The ability to cause contact sensitivity continuance of any ofthe materials. 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 Introduction Allergic hypersensitivity related to dentistry is acquired Contact dermatitis by exposure to specific dental material allergens atid Clinical features the altered capacity of the patient to react when re-exposed to the allergen, Allei^ic reactions associ- As in all forms of eel I-mediated immunity, in contact ated with dental materials are generally delayed hyper- dermatitis there is a minimum latent period of at least 5 sensitive reactions that are usually not associated with 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 * Professor and Head, Departtnent of Orthodontics, University of take between 24 and 48 hours to develop and, if severe, Pretoria, Faeiilty of Dentistry, Pretoria, South Africa may last for 7 to 10 days.- *' Ftead Emeritus; Division of Dental Materiais, University ofPreturia, Contact dermatitis is manifested by an itching or Faculty of Dentiïtrj', Pretoria, South Afriea, burning sensation at the site of contact, followed a *** Professor and Head, Department of Orai Pathology, University of short while later by the appearance of erythema and Pretoria, Faculty of Dentistry, Pretoria, South Afriea, then vesicles. Once the vesicles have ruptured, the Reprint requests: Prof W A. Wiitshire. Department of Orthodontics, erosion may become more extensive, and secondary University of Pretoria, c/o PO Box 73752, Lynnwood Ridge, Pretoria 0040, South Africa, infection may develop,' Quintessence International Volume 27, Number 8/1996 513 Wiltshire et al 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 1 ), Normally, the patient is exposed to the free monomer in acrylic resin, which may causea toxic reaction, Hypersensitivily in denture wearers should not be confused, however, with physicai Fig 1 A suspected allergic reaction lo a self-cunng acrylic irritation of the oral mucosa caused by ill-fitting resin provisional fixed partiai denture piaced in thG maxillary dentures. Acrylic resin hypersensitivity may develop anterior segment has developed at the corners of tine mouth a few days toiiowing placement. The reaction is characte- shortly after insertion of the denture or may not rized by itching, vesicular formation, and crusting. The manifest for an extended period of time, even many condition was alleviated when the permanent ceramometal months' (Figs 2a and 2b), Clinical reactions may fixed partial denture was placed 9 days later occur at secondary sites (Figs 3a and 3b), Resit) composite Lind^ reported that resin composite materials could be The oral man ¡testa lions, known as contact stomatitis an etiologic factor in the development of lichenoid or stomatitis venenata, iticlude an inflamed and reactions in the oral mucosa. The pathogenic mech- edematous mucosa, accompatiied by a severe burning anism may be related to contact allergy to formalde- sensation. Small, transiem vesicles may form; these hyde formed in resin composite restorations. Formal- rupture to fonn areas ol" erosion and ulcération.' dehyde causes more than one third of all allergic Erythema, papules, and edema are characteristic reactions caused by dental materials, A report by ailergic manifestations and, in severe reactions, large 0ysaed et al^ indicated that formation of formaldehyde weeping blisters may appear," Stomatitis venenata was found in light , ultraviolet light-, and chemically occurs iess frequently than do allergic skin lesions. activated resin composites, This can be ascribed to the diluting, digestive, and washing effects of saliva, Itnpression materials Ahhough certain dental materials have been im- Polyether impression materials have been reported to plicated as causes of contact stomatitis, the reported cause allergic problems in the past, but have since incidence is low. However, wheti an ofFending dental changed their compositions. Care should be taken to material sensitizes an area ofthe mucosa, no matter mix the material thoroughly and to avoid contact ofthe how small the area, the individual may become aromatic sulfuric ester catalyst paste with the skin or sensitized,^ mucosa because it may elicit adverse tissue reactions, Treattnent and prognosis Ettgenol-containing products Several tnethods of treating allergies have been re- Oil of cloves, or eugenol in its unrefined form, is mixed ported, including íiymplomatic treatment, desensiti- with zinc oxide to form zinc oxide-eugenol (ZOE), zation, and elimination of the allergen. Because the which exhibits a combination of physical and thera- mechanism of the allergic reaction is not yet ftilly peutic properties making it useflil as a provisional understood, the presently recommended method of restorative materiai, base material, and root canal treatment may be elimination of the ailei^en."' Pres- filling material. Zinc oxide-eugenol impression pastes ently, the only effective treatment for contact dermatitis and ZOE periodontal packs are also available. Euge- or stomatitis is the discontinuance of all contact with nol is highly soluble and is continuously released from the allei^enic material, which usually results in prompt ZOE, which can lead to short-term saturation ofthe remission of all the lesions. oral environrnent with eugenol in a concentration 514 Quintessence International Volume 27, Number 8/1996 Wiltshire et al 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 An 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. sufficient to cause cytotoxicity. This is why eugenol context the cross reactivity between many allergenic periodontal packs, which are in contact with open substances, such as between eugenol and balsam of mucosal wounds, are no longer popular. Peru, should be borne in mind. Thus, when the causative Five ofthe periodontal dressing materials listed in agent in an allergic reaction to periodontai dressing Accepted Dental Therapeutic^ contain colophony materials has not been positively identified, a choice (resin), and four of them contain eugenol. The only among the materials, whether they are eugenol-frcc or one that is eugenol free (Coe-pak, Coe Laboratories) not, is impossible.^ contains, among other things, balsam of Peru.^ In this Quintessence International Volume 27, Number 8/1996 515 Wiltshire et al Fig 4 Suspected allergy to an amalgam alloy has caused Fig 5 Suspected allergic contact glossitis has developed erythema and vesicle formation. The symptoms disappear- adjacent to a gold crown The swelling and erythematous ed after a resin composite restorative material was placed. changes disappeared after the restoration was replaced with a porcelain orown. The inilatumatory response caused in mucosal Vernon et al "' reviewed 41 published cases of allergy tissue by eugenol should not, however, be confused to dental amalgam, which included 30 female
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