SECTION
Dal.
EDITOR
E Saitb
Perceived Arne
side effects
Hensten-Pettersen,
of biomaterials
Dr.Odont,*
and Nils
Jacobsen,
in prosthetic
dentistry
Dr.Odont.**
NIOM. Scandinavian Institute of Dental Materials. Haqlum. Norway The present questionnaire survey of side eflects of biomaterials in prostbodontics had a response rate of 64%. There were occupational health problems associated with a variety of dental materials, especially acrylic resins, eugenol-containing materials, and elastomer impression materials. .Host reactions were mild to moderate dematoser of the Bngere or hands, but one prosthodontist had to cease practice due to a severe allergic reaction to acrylic resin materials. Of the respondents, 89~ had experienced reactions to latex gloves. Sondermatologic reactions seemed to be transient, ailecting the eyes, respiratory pathways, or occasionally causing generalized symptoms. These reactions were mainly attributed to vapors from acrylic resin monomers or cyanoacrylates. Adverse reactions in patients, tentatively estimated to be one out of 300, were observed by 40% of the prosthodontists. mostly as intraoral reactions. Acrylic resins, eugeaol-containing cements, base metal alloys, mercury, gold, polyetberlepimine based materials, and tissue conditioners were cited as causes. Skin contact with the dentists’ latex gloves elicited extraoral reactions in some patients. (J PROSTHET DEW 1991$36:13844.)
P
rosthodontic practice requires contact with restorative and auxiliary dental materials of widely different composition, such as metals, resin-based synthetic polymers, cements, and impression materials. Leakage and transfer of potentially allergenic components from such materials carry the risk of hypersensitive reactions among both patients and dental personnel. The hypersensitive reactions are explained as cau.sedby haptens from the biomaterials combining with mucosal or cuticular proteins to full antigens.’ The reactions are expressed as delayed hypersensitive reactions of a general or dermal type among dental patients, and often as contact dermatitis among dental personnel.* Apart from reactions to drugs, such reactions have been ascribed to metals such as mercury, chromium, cobalt, nickel, and copper; to monomers, degradation products, or additives in resin-ba.sed materials and composite resins; to catalysts in impression materials; and to components in temporary cementa and gingival dre.ssings.3 s The sensitizing process can be based on repeated contact with the allergenic components during dental treatment or by previous contact with such components as thtKe found in jewelry, perfume, or in performing housework.g In addition to the drug/biomaterials aspect, dental personnel are in close contact with chemically active elements
‘Senior Scientist. “Profe~nor. lOlll22769
I38
found in detergents, soaps, disinfectants, and radiograph developing fluids, which carry the risk of provoking irritant dermatoses, especially of the hands and fingers.‘O Lists of potentially allergenic substances in dentistry during the 1950s and 1960s were characterized by an emphasis on the chemical and drug aspects. The lists included items such as local anesthetics (procaine type), formalin- or formaldehyde-containing chemicals, tricresol. iodoform. eugenol or other essential oils, phenols, phosphoric acids, hydroquinone. and mercury, with methylmethacrylate monomer (MMA) as a “runner up”.“* l2 Later, several authors reported reactions to the para-amino type of surface anesthetic, to components or catalysts in elastomer impression materials, to temporary fixed partial denture materials, and to the metals chromium, cobalt, and nickel
2.3,
IR. I4
With an increasing amount of new synthetic resins in restorative dentistry, unwanted side effects may follow.‘5 On the other hand, manufacturers’ efforts and the increased use of protective equipment such as gloves may reduce these risks at least among dental personnel, not counting possible reactions to the protective equipment. It is reasonable to assume that unwanted side effects of this nature will depend on the repertoire of biomaterials used in each particular specialty of dentistry. The present investigation is aimed at clarifying the level and nature of adverse reactions relevant to dental biomaterials and treatments used by prosthodontista and prosthodontic patients. The investigation parallels similar reports in orthodontics and periodontics.‘6* I7
JANCARY
1991
VOLI’YE
85
NOMRPR
I
SIDE
EFFECTS
OF BIOMATERIALS
Age in years
n Fig.
Table
with 1.
q
complaints
Age distribution
without
complaints
of Scandinavian prosthodontists (n = 115).
I. Number and mean age of Scandinavian prosthodontists with or without occupation-related health complaints All
Men
With compl.sints Without complaints All
NO.
Mean age in years
NO.
Mean age in years
NO.
Mean age in years
12 10 22
43 44 43
36 57 93
49 49 49
48 67 115
47 48 48
MATERIAL, AND METHODS The questionnaire All members of the Scandinavian Society of Prosthetic Dentistry (SSPD) were mailed a questionnaire on occupation-related health problems supplemented with questions on age, sex, affiliation, percentage of prosthodontic practice, dental materials used, and adverse patient reactions. Occupation-related health problems were fit into a multiple choice list of time and locations describing dermal and other reactions. The questionnaire also contained an invitation to describe occupation-related reactions and patient reactions in the respondent’s own words and to provide information on possible medical diagnoses. Questions were asked about the materials used such as impression materials, polymer-based materials, metals for removable and fixed prostheses, and luting cements, and were supplemented by questions concerning the use of gloves and other disposable equipment. Questions about patient reactions were limited to the last 2 years, including information on the total number of patients seen in t.his period of time. The prosthodontists were asked to relate any adverse reactions to materials and the time periods of treatment procedures, if possible. They were asked to return completed forms in preaddressed envelopes. After 4 weeks a reminder was mailed, acknowledging the ones who had already responded.
THE
JOURNAL
OF
PROSTHETIC
DENTISTRY
Table II. Number and percentage of Scandinavian prosthodontists with occupation-related dermatoses and/or nondermatologic complaints: N = 115 No.
Dermatoses only Nondermatologic complaints only Dermatoses and nondermatologic complaints All with dermatoses All with nondermatologic complaints All with complaints
Percentage
30 9 9
26 8 8
39 18
34 16
48
42
Recording The occupational dermatoses were given “scores” according to severity by an arbitrary scoring system that has been described previously.16 Other occupational complaints and patient reactions were recorded without differentiating between degrees of reactions. All health data were arranged in double entry tables according to the location (or nature) of the ailment and its assumed cause, and were ranked in a descending order of frequency. The term “assumed cause” combined those diagnoses verified by qualified health personnel and those suggested by the prosthodontists.
139
HENSTEN-PETTERSEN
AND
JACOBSEN
Table III. Location and assumed cause of dermatoses among prosthodontists in Scandinavia (39 of 115): Data are arranged in descending order of frequency according to location (horizontally) and assumed cause (vertically) Location
Assumed cause
Back of hands
Seasonal, “work-
related,” unspecified Acrylic resin-related work or acrylic resin allery ’ Latex gloves Hand washing procedures Impression material components Eugenol-containing materials Epoxy allergy Fungus Facemask Gold ring No. of personswith dermatoseson specific location
Fingers, inside
Fingers, dorsal side
Hands, palms
Skin elsewhere
Nails
Nail borders
Wrists
3
3
1
2
2
3
2
2
12
3
5
5
5
5
3
3
5
10
7 1
3 1
1
2
1
1
1
1
2
1
9 4 4
1
1
1 1 1 16
16
14
14
Table IV. Severity of occupationally related dermatologic reactions among Scandinavian prosthodontists expressed as severity ratio according to its assumed cause Assumed cause
Acrylic resin-related work, acrylic resin allergy Eugenol-containing materials Impression material components Latex gloves Epoxy allergy Hand washing procedures Seasonal,“work-related,” or unspecified Fungi Facemask,gold ring
Severity ratio*
No. of persons
18
10
11.5 5.3 5 5 4.5 4.3 3 1
2 4 9 1 4 12 1 2
*Severity ratio = All dermatologic “scores” belonging to each particular cause divided by the relevant number of individuals.
RESULTS Response to the questionnaire Of 178 SSPD members who were actively practicing prosthodontics and could be reached by mail, 115 persons (64%) responded from Sweden, Norway, Denmark, and Iceland; 22 of these members were women. In addition, 15 respondents from Finland were not included in the follow-
140
Fingers, sides
No. of persons with dermatosis of specific cause
11
9
8
8
2
Table V. Severity of occupationally related dermatologic reactions among Scandinavian prosthodontists expressed as severity ratio according to its location Location
Severity
Fingers, dorsal sides Fingers, sides Fingers, insides Nail borders Hands, palms Hands, backs Wrists
ratio*
No. of persons
5.1
15
4.4 4.2 3.6 3.4 2.3
11 15 7 14 15 2
1.5
*Severity ratio: All dermatologic “scores” belonging to each particular location divided by relevant number of individuals.
ing tabulation because of the low response rate for the region (32%). About half of the responding SSPD members were occupied solely with prosthodontics or spent more than 75 % of their working hours practicing prosthodontics; about one quarter were so occupied for 50 % of the time; the remainder gave less than 30% of their time to practicing prosthodontics. About 60% of the Scandinavian prosthodontists were affiliated with one of the dental schools, either full or part time. The remainder were occupied in either private practice (20%) or in the public health service (20%).
JANUARY
1991
VOLUME
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NUMBER
1
SIDE EFFECTS
OF BI’DMATERIALS
Location and assumed cause of nondermatologic complaints among prosthodontists in Scandinavia (18 of 115): Data are arranged in descending order of frequency according to location (horizontally) and assumed cause (vertically) Table VI.
Eyes
Nose
Lungs
Acrylics resin, or other polymer materials, related work Seasonal, “work-related,” or unspecified
5
1
2
1
2
Cyanoacrylate Temporary crown/fixed partial denture material
1
Assumed cause
1
health
6
3
complaints
DENTISTRY
2
2
4 3 3
2
Of the respondents, 48 gave information on occupationrelated health complaints. Women prosthodontists were on the average 6 years younger than their male colleagues, and 55 % of them had health complaints compared with 38 % of the men (Table I). This difference is not statistically significant. Analyses of the individual answers did not reveal any differen.t pattern of reactions between men and women prosthodontists, and occupation-related health complaints were found in all age categories (Fig. 1). All information was therefore treated together. The complaints included dermatoses and nondermatologic reactions. Some persons had both (Table II). Dermatoses. The prevailing occupation-related complaints were dermatoses of the hands and fingers; descriptions ranged from transient or seasonal redness, irritation, or decreased tacttile sensitivity to seriously incapacitating blisters, desquamation, soreness, bleeding fissures, and pain. The dermatoses were evenly distributed to the dorsal sides and insides of hands and fingers (Table III). Sometimes nails and nail borders were affected and occasionally the skin on face, neck, or arms was affected. Frequent causes identified by the prosthodontists were acrylic resin-related work, or acrylic resin allergy, and latex gloves. Also mentioned as causes of the dermatoses were catalyst components of impression materials, eugenol-containing temporary cements, and hand washing procedures. Many dermatoses were not attributed to any specific cause, or were described as varying with temperature and air humidity (winter/summer), vacation periods, etc. (Table III). Attempts to assess the severity ratio specific for each assumed cause indicated that acrylic resin-related work or
OF PROSTBETIC
1
1 6
No. of persons with reactions of specific cause 6
2
1
No. of persons with reactions on specific locations
THE JOURNAL
Ears
2
Epoxy allergy Fungus
Occupation-related
Throat
Systemic symptoms
1 1
2
unspecific allergies and eugenol-containing materials were eliciting the most severe reactions (Table IV). Fingers, particularly the dorsal sides, seemed to be the most common location of severe dermatologic reactions (Table V). In one patient, severe dermatologic reactions to acrylic resin materials were responsible for retirement from dental practice. Nondermatologic health complaints. Nondermatologic complaints were less frequent than dermatoses (Table VI) and included eye reactions together with respiratory reactions attributed to acrylic resin related work, cyanoacrylate, and earlier a temporary crown/fixed partial denture material. Occasionally, headache and nausea were attributed to the use of cyanoacrylates.
Adverse
patient
reactions
Patient reactions are listed in Table VII, Only about one third of the prosthodontists had noticed patient reactions during a a-year period. Calculations based on the total number of patients seen by all prosthodontists indicated a frequency of about 0.3%) or on the average one patient per prosthodontist every second year. Adverse patient reactions were of varying severity, such as redness, swelling, and pain of the oral mucosa, gingiva, and lips, which is sometimes described as “burning mouth syndrome,” or as lichenoid reactions of the oral mucosa and gingiva. In some patients general symptoms such as depressed respiration, palpitation, sweating, or other diffuse general reactions were recorded. Adverse patient reactions were often attributed to acrylic resin-related work, or to contact with other polymer materials, or to eugenol-containing temporary cements. Allergic
141
HENSTEN-PETTERSEN
AND
JACOBSEN
Table VII. Patient reactions (N = 147) observed by 45 of 115 Scandinavian prosthodontists during a 2-year period: Data are arranged in descending order of frequency according to location/nature (horizontally) and assumed cause (vertically)
Assumed cause
Acrylic resin-related work/polymer materials Eugenol-containing temporary cement Co/Cr work or Cr allergy Scut.an/Impregum Metal/ceramic-related materials Tissue conditioners Amalgamor mercury allergy Treatment related, unspecified Latex (rubber dam, gloves) Impression materials Gold allergy Nickel allergy Chlorbexidine mouth rinse Flouride mouth rinse No. of patients with
Rubber, swelling, or pain of oral mucosa, gingiva, and lips
OraYgingival lichenoid reactions
Unspecified reactions
54
2
25
1
10 3 5
2 1
Systemic reactions
Strong taste
Dermal symptoms
No. of patients with reactions of specified cause
1
57 26
2 2
3
15 9 6
2
3
7 7
1
4
5
3
7
3 3 1
1
2 1 1 112
11
10
6
3
reactions of specific location/nature
reactions to metals of cobalt/chromium prosthetic castings and to ceramic metals were common, as were reactions to tissue conditioners. Overall, the data indicated that verified allergies to ingredients in prosthetic biomaterials (chromium, MMA, nickel, and eugenol) gave the most severe reactions. One prosthodontist, representing a referring institution for prosthetic patients, recorded 25 patients who were changed from MMA to a polycarbonatebased prostheses because of undesirable reactions to MMA.
DISCUSSION Questionnaire investigations dealing with adverse reactions carry intrinsic difficulties with respect tc the respondents’ abilities to observe, evaluate, and describe sometimes poorly understood reactions. Moreover, relevant information can be lost among the nonrespondents. With these reservations, information obtained with questionnaires is important in the total clinical evaluation of dental biomaterials, since only a few, severe reactions are published as case reports and most occupation-related reactions of this kind escape official recording. In the present investigation, the response rate (64 % ) was higher than in most previous questionnaire surveys, and 142
therefore the results were regarded as fairly representative of the Scandinavian prosthodontists in Sweden, Norway, and Denmark.
Dermatologic
reactions
As found in earlier reports, dermatoses were the most frequently related health problem. Dermatoses experienced by the prosthodontists were often of a mild type and were often connected with seasonal variations in air humidity and temperature or were unspecified. This finding is apparently a common trait found also among personnel in orthodontics, periodontics, in dental technicians, and in other clinical personnel in hospitals.16-20 In comparison with Scandinavian orthodontists and dental technicians, the frequency of dermatoses among prosthodontists was somewhat lower (36 % as opposed to 41% to 43 % ), but not as low ss that recorded for the periodontists. The causes of dermatoses among the prosthodontists reflected their occupational activity, and include acrylic resin-related work, hand washing procedures, components of impression materials, and temporary cements as important provoking factors. In addition, dermal reactions to latex gloves were not uncommon. Such reactions are found at an
JANUARY
1091
VOLUME
65
NUMBER
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SIDE EFFECTS
OF Bl OMATERIALS
increasing frequency among many categories of health personnel as a result of the increasing use of latex gloves.21s22 In contrast to earlier reports, reactions to local anesthetics and drugs were not reported. The factors that provoked the most severe :reactions relevant to dental biomaterials appeared to be acrylic resin-related work, eugenol-containing materials, and impression material compounds. All of these materials contain known allergenic factors capable of eliciting type IV immunoreactions of contact dermatitis. In summary, although dermatoses were frequent, most of them were bearable, and no “new,” particularly risky allergenic group of materials or material brands were revealed. On the other hand, the increased use of gloves, presumably preventing irritant dermatoses from disinfectants, detergents, and hand washing procedures, lead to irritative or hypersensitive reactions to the latex gloves. It should also be kept in mind that gloves are not impenetrable to allergenic components from synthetic resins.23True hypersensitive reactions may occur even with gloves.
Nondermatologic
reactions
Acute, toxic, nondermatologic reactions were experienced by some prosthodontists occasionally following activities such as working with MMA or other synthetic resin materials or with cyanoacrylate liners. The reactions were expressed as eye, respiratory, or general symptoms in connection with exposure to volatile liquids and grinding dust. Such reactions were of a transient nature. Permanent sequelae were not reported and are not known except in the case of MMA exposure among dental technicians.24,25
Patient
IMPLICATIONS
Side effects on dental personnel in contact with biomaterials should be carefully recorded in the same manner as one records adverse reactions in patients. Information of
THE
JOURNAL
SUMMARY
AND CONCLUSIONS
A questionnaire survey of Scandinavian prosthodontists revealed a fairly high frequency of dermatologic ailments located on the hands and fingers. Most dermatoses were bearable and were attributed to seasonal variations in air humidity and temperature, giving irritant reactions in combination with hand hygiene. More severe hand dermatoses were connected with biomaterial-related treatment procedures, including contact with acrylic resins, eugenolcontaining materials, impression materials, latex gloves, or epoxy. One prosthodontist was reported to have retired because of severe reactions to MMA. Nondermatologic reactions occurred in the eyes, respiratory pathways, or occasionally as general symptoms (nausea, headache). Such reactions were of a transient nature and were attributed to vapors from MMA or cyanoacrylate. Patient reactions, assessed to take place in approximately 1 of 300 persons, had been observed by some, but not all prosthodontists, mostly as intraoral reactions to acrylic resins; eugenol-containing temporary cements; cobalt, chromium, nickel, mercury, or gold allergies; and reactions to tissue conditioners or latex gloves.
reactions
The frequency of patient reactions in prosthetic dentistry was low, and most of these were intraoral/gingival reactions related to synthetic resins, eugenol or cobalt/ chromium materials-all materials that are compatible with hypersensitive responses to known allergens. The exact number of reactions was difficult to assess,since the total number of patients reported was obviously an approximation, and since many prosthodontists had not observed any reactions. Tlne uneven observation of patient reactions among the prosthodontists may therefore reflect a real variation of such reactions among dental patients, or may be underestimated for lack of clinical acuity or difficulties in relating treatment procedures and oral reactions. Nonoral reactions among patients (dermal, systemic) were infrequent and were attributed to metal allergy or to allergies to components in impression materials. In some cases,patients also reacted to latex gloves, as was reported in periodontal patients.17
CLINICAL
this kind is important in the general evaluation of side effects of materials. It may also be of clinical significance when dental personnel need treatment of their own dentition. The uneven distribution of observed side effects of dental biomaterials among prosthodontic patients indicates that some reactions may be overlooked or forgotten.
OF PROSTHETIC
DENTISTRY
REFERENCES Andersen KE, Benezra C, Burrows J, et al. Contact dermatitis. A review. Contact Dermatitis 1987;34:55-78. 2. Forck G, Wingert F. Kontakterkrankungen des Zahnarztes und seiner Helfer. ZWR 1977;7:352-60. 3. Franz G. The frequency of allergy to dental materials. J Dent Assoc S Afr 1982;37:805-10. 4. Ruyter IE, @ysaedH. Analysis and characterization of dental polymers. CRC Crit Rev Biocompatibility 19884247-79. 5. Malmgren 0, Medin L. Overkiinslighetsreaktioner vid anviindning av bonding material inom ortodontivard. Tandllkartidn 1981;73:544-6. 6. Altuna G, Lewis D, Rourke M, Woodside D. Tissue reactions to orthodontic materials. A survey of Canada’s orthodontists [Abstract]. J Dent Res 1986;65:795. Van Groeningen G, Natar JP. Reactions to dental impression materials. Contact Dermatitis 1975;1:373-6. Haugen E, Hensten-Pettersen A. The sensitizing potential of periodontal dressings. J Dent Res 1978;57:950-8. Hensten-Pettersen A, Gjerdet NR, Kvam E, Lyberg T. Nikkelallergi og kjeveortopedisk behandling. Nerd Tannlegeforgen Tid 1984;567-72. 10. Samits MH, Shmunes E. Occupational dermatoses in dentists and allied personnel. Cutis 1969;5:180-4. 11. Calnan CD, Stevenson CJ. Studies in contact dermatitis. XV. Dental materials. St John’s Hosp Dermatol Sot Trans 1963;49:9-26. 12. Djerassi E, Berowa V. Kontakt allergic in der Stomatologie als Berufsproblem. Berufsdermatosen 1966$4:225-80. 13. Wulf S. Das Berufsekzemes der Zahnarztes und seine Problematik. Thesis. Medisinischen Hochschule Hannover, 1975% pp. 14. Irmer J. Kontaktekzeme bai Zahniirzten. Thesis. Westphalischen Wilhelm+ Universitlt zu Miinster 1978:69 pp. 1.
143
15. Kanerva L, Estlander T, Jolanki R. Allergic contact dermatitis from dental composite resins due to aromatic epoxy acrylates and aliphatic acrylates. Contact Dermatitis 1989;20:201-11. 16. Jacobsen N, Hensten-Pettersen A. Occupational health problems and adverse patient reactions in orthodontics. Eur J Orthod 1989;ll: 254-64. 17. Jacobsen N, Hensten-Pettersen A. Occupational health problems and adverse patient reactions in periodontics. J Clin Periodontol 1989; 16428-33. 18. Jacobsen N, Hensten-Pettersen A. Yrkesrelaterte helseplager hos tannteknikere. Tenner I focus 1988;48:18-27. 19. Kavli G, Angel1 E, Moseng D. Hospital employees and skin problems. Contact Dermatitis 1987;17:156-8. 20. Lammintausta K. Hand dermatitis in different hospital workers who perform wet work. Dermatosen 1983;31:14-8. 21. Carillo T, Cuevas M, Munoz T, Hinojosa M, Manes I. Contact urticaria and rhinitis from latex surgical gloves. Contact Dermatitis 1986;15:6972. 22. Wrangsjii K, Wahlberg JE, Axelsson JGK. IgE-mediated allergy to nat-
Bound volumes
available
ural rubber in 30 patients with contact urticaria. Contact Dermatitis 1988;19:264-71. 23. Reitschel RL, Higgins R, Levy N, Pruitt PM. In viva and in vitro testing of gloves for protection against UV-curable acrylate resin systems. Contact Dermatitis 1984;11:279-82. 24. Christiansen ML, Adelhardt M, Kjaergaard Stensen N, Gynthelberg F. Methylmetakrylat-en Lsag til toksisk hjerneskade. Tannlaegebladet 1986;90:759-64. 25. Rajaniemi R. Clinical evaluation of occupational toxicity of methylmethacrylate monomer to dental technicians. J Sot Occup Med 1986:36:56-g. Reprint requests to: DR. ARNE HENSTEN-PE?TERSEN NIOM, SCANDINAVIAN INSTITUTE OF DENTAL MATERIALS POB 70, N-1344 HASLUM NORWAY
to subscribers
Bound volumes of the JOURNAL OF PROSTHETIC DENTISTRY are available to subscribers (only) for the 1990 issues from the publisher at a cost of $44.00 ($56.00 international) for Vol. 63 (January-June) and Vol. 64 (July-December). Shipping charges are included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stamped in gold on the spine. Volumes 61 and 62 are also available. Payment must accompany all orders. Contact Mosby-Year Book, Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, MO 63146-3318, USA; phone (800) 325-4177, ext. 4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.
144
JANUARY
1091
VOLUME
65
NUMBER
1
Dal.
EDITOR
E Saitb
Perceived Arne
side effects
Hensten-Pettersen,
of biomaterials
Dr.Odont,*
and Nils
Jacobsen,
in prosthetic
dentistry
Dr.Odont.**
NIOM. Scandinavian Institute of Dental Materials. Haqlum. Norway The present questionnaire survey of side eflects of biomaterials in prostbodontics had a response rate of 64%. There were occupational health problems associated with a variety of dental materials, especially acrylic resins, eugenol-containing materials, and elastomer impression materials. .Host reactions were mild to moderate dematoser of the Bngere or hands, but one prosthodontist had to cease practice due to a severe allergic reaction to acrylic resin materials. Of the respondents, 89~ had experienced reactions to latex gloves. Sondermatologic reactions seemed to be transient, ailecting the eyes, respiratory pathways, or occasionally causing generalized symptoms. These reactions were mainly attributed to vapors from acrylic resin monomers or cyanoacrylates. Adverse reactions in patients, tentatively estimated to be one out of 300, were observed by 40% of the prosthodontists. mostly as intraoral reactions. Acrylic resins, eugeaol-containing cements, base metal alloys, mercury, gold, polyetberlepimine based materials, and tissue conditioners were cited as causes. Skin contact with the dentists’ latex gloves elicited extraoral reactions in some patients. (J PROSTHET DEW 1991$36:13844.)
P
rosthodontic practice requires contact with restorative and auxiliary dental materials of widely different composition, such as metals, resin-based synthetic polymers, cements, and impression materials. Leakage and transfer of potentially allergenic components from such materials carry the risk of hypersensitive reactions among both patients and dental personnel. The hypersensitive reactions are explained as cau.sedby haptens from the biomaterials combining with mucosal or cuticular proteins to full antigens.’ The reactions are expressed as delayed hypersensitive reactions of a general or dermal type among dental patients, and often as contact dermatitis among dental personnel.* Apart from reactions to drugs, such reactions have been ascribed to metals such as mercury, chromium, cobalt, nickel, and copper; to monomers, degradation products, or additives in resin-ba.sed materials and composite resins; to catalysts in impression materials; and to components in temporary cementa and gingival dre.ssings.3 s The sensitizing process can be based on repeated contact with the allergenic components during dental treatment or by previous contact with such components as thtKe found in jewelry, perfume, or in performing housework.g In addition to the drug/biomaterials aspect, dental personnel are in close contact with chemically active elements
‘Senior Scientist. “Profe~nor. lOlll22769
I38
found in detergents, soaps, disinfectants, and radiograph developing fluids, which carry the risk of provoking irritant dermatoses, especially of the hands and fingers.‘O Lists of potentially allergenic substances in dentistry during the 1950s and 1960s were characterized by an emphasis on the chemical and drug aspects. The lists included items such as local anesthetics (procaine type), formalin- or formaldehyde-containing chemicals, tricresol. iodoform. eugenol or other essential oils, phenols, phosphoric acids, hydroquinone. and mercury, with methylmethacrylate monomer (MMA) as a “runner up”.“* l2 Later, several authors reported reactions to the para-amino type of surface anesthetic, to components or catalysts in elastomer impression materials, to temporary fixed partial denture materials, and to the metals chromium, cobalt, and nickel
2.3,
IR. I4
With an increasing amount of new synthetic resins in restorative dentistry, unwanted side effects may follow.‘5 On the other hand, manufacturers’ efforts and the increased use of protective equipment such as gloves may reduce these risks at least among dental personnel, not counting possible reactions to the protective equipment. It is reasonable to assume that unwanted side effects of this nature will depend on the repertoire of biomaterials used in each particular specialty of dentistry. The present investigation is aimed at clarifying the level and nature of adverse reactions relevant to dental biomaterials and treatments used by prosthodontista and prosthodontic patients. The investigation parallels similar reports in orthodontics and periodontics.‘6* I7
JANCARY
1991
VOLI’YE
85
NOMRPR
I
SIDE
EFFECTS
OF BIOMATERIALS
Age in years
n Fig.
Table
with 1.
q
complaints
Age distribution
without
complaints
of Scandinavian prosthodontists (n = 115).
I. Number and mean age of Scandinavian prosthodontists with or without occupation-related health complaints All
Men
With compl.sints Without complaints All
NO.
Mean age in years
NO.
Mean age in years
NO.
Mean age in years
12 10 22
43 44 43
36 57 93
49 49 49
48 67 115
47 48 48
MATERIAL, AND METHODS The questionnaire All members of the Scandinavian Society of Prosthetic Dentistry (SSPD) were mailed a questionnaire on occupation-related health problems supplemented with questions on age, sex, affiliation, percentage of prosthodontic practice, dental materials used, and adverse patient reactions. Occupation-related health problems were fit into a multiple choice list of time and locations describing dermal and other reactions. The questionnaire also contained an invitation to describe occupation-related reactions and patient reactions in the respondent’s own words and to provide information on possible medical diagnoses. Questions were asked about the materials used such as impression materials, polymer-based materials, metals for removable and fixed prostheses, and luting cements, and were supplemented by questions concerning the use of gloves and other disposable equipment. Questions about patient reactions were limited to the last 2 years, including information on the total number of patients seen in t.his period of time. The prosthodontists were asked to relate any adverse reactions to materials and the time periods of treatment procedures, if possible. They were asked to return completed forms in preaddressed envelopes. After 4 weeks a reminder was mailed, acknowledging the ones who had already responded.
THE
JOURNAL
OF
PROSTHETIC
DENTISTRY
Table II. Number and percentage of Scandinavian prosthodontists with occupation-related dermatoses and/or nondermatologic complaints: N = 115 No.
Dermatoses only Nondermatologic complaints only Dermatoses and nondermatologic complaints All with dermatoses All with nondermatologic complaints All with complaints
Percentage
30 9 9
26 8 8
39 18
34 16
48
42
Recording The occupational dermatoses were given “scores” according to severity by an arbitrary scoring system that has been described previously.16 Other occupational complaints and patient reactions were recorded without differentiating between degrees of reactions. All health data were arranged in double entry tables according to the location (or nature) of the ailment and its assumed cause, and were ranked in a descending order of frequency. The term “assumed cause” combined those diagnoses verified by qualified health personnel and those suggested by the prosthodontists.
139
HENSTEN-PETTERSEN
AND
JACOBSEN
Table III. Location and assumed cause of dermatoses among prosthodontists in Scandinavia (39 of 115): Data are arranged in descending order of frequency according to location (horizontally) and assumed cause (vertically) Location
Assumed cause
Back of hands
Seasonal, “work-
related,” unspecified Acrylic resin-related work or acrylic resin allery ’ Latex gloves Hand washing procedures Impression material components Eugenol-containing materials Epoxy allergy Fungus Facemask Gold ring No. of personswith dermatoseson specific location
Fingers, inside
Fingers, dorsal side
Hands, palms
Skin elsewhere
Nails
Nail borders
Wrists
3
3
1
2
2
3
2
2
12
3
5
5
5
5
3
3
5
10
7 1
3 1
1
2
1
1
1
1
2
1
9 4 4
1
1
1 1 1 16
16
14
14
Table IV. Severity of occupationally related dermatologic reactions among Scandinavian prosthodontists expressed as severity ratio according to its assumed cause Assumed cause
Acrylic resin-related work, acrylic resin allergy Eugenol-containing materials Impression material components Latex gloves Epoxy allergy Hand washing procedures Seasonal,“work-related,” or unspecified Fungi Facemask,gold ring
Severity ratio*
No. of persons
18
10
11.5 5.3 5 5 4.5 4.3 3 1
2 4 9 1 4 12 1 2
*Severity ratio = All dermatologic “scores” belonging to each particular cause divided by the relevant number of individuals.
RESULTS Response to the questionnaire Of 178 SSPD members who were actively practicing prosthodontics and could be reached by mail, 115 persons (64%) responded from Sweden, Norway, Denmark, and Iceland; 22 of these members were women. In addition, 15 respondents from Finland were not included in the follow-
140
Fingers, sides
No. of persons with dermatosis of specific cause
11
9
8
8
2
Table V. Severity of occupationally related dermatologic reactions among Scandinavian prosthodontists expressed as severity ratio according to its location Location
Severity
Fingers, dorsal sides Fingers, sides Fingers, insides Nail borders Hands, palms Hands, backs Wrists
ratio*
No. of persons
5.1
15
4.4 4.2 3.6 3.4 2.3
11 15 7 14 15 2
1.5
*Severity ratio: All dermatologic “scores” belonging to each particular location divided by relevant number of individuals.
ing tabulation because of the low response rate for the region (32%). About half of the responding SSPD members were occupied solely with prosthodontics or spent more than 75 % of their working hours practicing prosthodontics; about one quarter were so occupied for 50 % of the time; the remainder gave less than 30% of their time to practicing prosthodontics. About 60% of the Scandinavian prosthodontists were affiliated with one of the dental schools, either full or part time. The remainder were occupied in either private practice (20%) or in the public health service (20%).
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Location and assumed cause of nondermatologic complaints among prosthodontists in Scandinavia (18 of 115): Data are arranged in descending order of frequency according to location (horizontally) and assumed cause (vertically) Table VI.
Eyes
Nose
Lungs
Acrylics resin, or other polymer materials, related work Seasonal, “work-related,” or unspecified
5
1
2
1
2
Cyanoacrylate Temporary crown/fixed partial denture material
1
Assumed cause
1
health
6
3
complaints
DENTISTRY
2
2
4 3 3
2
Of the respondents, 48 gave information on occupationrelated health complaints. Women prosthodontists were on the average 6 years younger than their male colleagues, and 55 % of them had health complaints compared with 38 % of the men (Table I). This difference is not statistically significant. Analyses of the individual answers did not reveal any differen.t pattern of reactions between men and women prosthodontists, and occupation-related health complaints were found in all age categories (Fig. 1). All information was therefore treated together. The complaints included dermatoses and nondermatologic reactions. Some persons had both (Table II). Dermatoses. The prevailing occupation-related complaints were dermatoses of the hands and fingers; descriptions ranged from transient or seasonal redness, irritation, or decreased tacttile sensitivity to seriously incapacitating blisters, desquamation, soreness, bleeding fissures, and pain. The dermatoses were evenly distributed to the dorsal sides and insides of hands and fingers (Table III). Sometimes nails and nail borders were affected and occasionally the skin on face, neck, or arms was affected. Frequent causes identified by the prosthodontists were acrylic resin-related work, or acrylic resin allergy, and latex gloves. Also mentioned as causes of the dermatoses were catalyst components of impression materials, eugenol-containing temporary cements, and hand washing procedures. Many dermatoses were not attributed to any specific cause, or were described as varying with temperature and air humidity (winter/summer), vacation periods, etc. (Table III). Attempts to assess the severity ratio specific for each assumed cause indicated that acrylic resin-related work or
OF PROSTBETIC
1
1 6
No. of persons with reactions of specific cause 6
2
1
No. of persons with reactions on specific locations
THE JOURNAL
Ears
2
Epoxy allergy Fungus
Occupation-related
Throat
Systemic symptoms
1 1
2
unspecific allergies and eugenol-containing materials were eliciting the most severe reactions (Table IV). Fingers, particularly the dorsal sides, seemed to be the most common location of severe dermatologic reactions (Table V). In one patient, severe dermatologic reactions to acrylic resin materials were responsible for retirement from dental practice. Nondermatologic health complaints. Nondermatologic complaints were less frequent than dermatoses (Table VI) and included eye reactions together with respiratory reactions attributed to acrylic resin related work, cyanoacrylate, and earlier a temporary crown/fixed partial denture material. Occasionally, headache and nausea were attributed to the use of cyanoacrylates.
Adverse
patient
reactions
Patient reactions are listed in Table VII, Only about one third of the prosthodontists had noticed patient reactions during a a-year period. Calculations based on the total number of patients seen by all prosthodontists indicated a frequency of about 0.3%) or on the average one patient per prosthodontist every second year. Adverse patient reactions were of varying severity, such as redness, swelling, and pain of the oral mucosa, gingiva, and lips, which is sometimes described as “burning mouth syndrome,” or as lichenoid reactions of the oral mucosa and gingiva. In some patients general symptoms such as depressed respiration, palpitation, sweating, or other diffuse general reactions were recorded. Adverse patient reactions were often attributed to acrylic resin-related work, or to contact with other polymer materials, or to eugenol-containing temporary cements. Allergic
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HENSTEN-PETTERSEN
AND
JACOBSEN
Table VII. Patient reactions (N = 147) observed by 45 of 115 Scandinavian prosthodontists during a 2-year period: Data are arranged in descending order of frequency according to location/nature (horizontally) and assumed cause (vertically)
Assumed cause
Acrylic resin-related work/polymer materials Eugenol-containing temporary cement Co/Cr work or Cr allergy Scut.an/Impregum Metal/ceramic-related materials Tissue conditioners Amalgamor mercury allergy Treatment related, unspecified Latex (rubber dam, gloves) Impression materials Gold allergy Nickel allergy Chlorbexidine mouth rinse Flouride mouth rinse No. of patients with
Rubber, swelling, or pain of oral mucosa, gingiva, and lips
OraYgingival lichenoid reactions
Unspecified reactions
54
2
25
1
10 3 5
2 1
Systemic reactions
Strong taste
Dermal symptoms
No. of patients with reactions of specified cause
1
57 26
2 2
3
15 9 6
2
3
7 7
1
4
5
3
7
3 3 1
1
2 1 1 112
11
10
6
3
reactions of specific location/nature
reactions to metals of cobalt/chromium prosthetic castings and to ceramic metals were common, as were reactions to tissue conditioners. Overall, the data indicated that verified allergies to ingredients in prosthetic biomaterials (chromium, MMA, nickel, and eugenol) gave the most severe reactions. One prosthodontist, representing a referring institution for prosthetic patients, recorded 25 patients who were changed from MMA to a polycarbonatebased prostheses because of undesirable reactions to MMA.
DISCUSSION Questionnaire investigations dealing with adverse reactions carry intrinsic difficulties with respect tc the respondents’ abilities to observe, evaluate, and describe sometimes poorly understood reactions. Moreover, relevant information can be lost among the nonrespondents. With these reservations, information obtained with questionnaires is important in the total clinical evaluation of dental biomaterials, since only a few, severe reactions are published as case reports and most occupation-related reactions of this kind escape official recording. In the present investigation, the response rate (64 % ) was higher than in most previous questionnaire surveys, and 142
therefore the results were regarded as fairly representative of the Scandinavian prosthodontists in Sweden, Norway, and Denmark.
Dermatologic
reactions
As found in earlier reports, dermatoses were the most frequently related health problem. Dermatoses experienced by the prosthodontists were often of a mild type and were often connected with seasonal variations in air humidity and temperature or were unspecified. This finding is apparently a common trait found also among personnel in orthodontics, periodontics, in dental technicians, and in other clinical personnel in hospitals.16-20 In comparison with Scandinavian orthodontists and dental technicians, the frequency of dermatoses among prosthodontists was somewhat lower (36 % as opposed to 41% to 43 % ), but not as low ss that recorded for the periodontists. The causes of dermatoses among the prosthodontists reflected their occupational activity, and include acrylic resin-related work, hand washing procedures, components of impression materials, and temporary cements as important provoking factors. In addition, dermal reactions to latex gloves were not uncommon. Such reactions are found at an
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increasing frequency among many categories of health personnel as a result of the increasing use of latex gloves.21s22 In contrast to earlier reports, reactions to local anesthetics and drugs were not reported. The factors that provoked the most severe :reactions relevant to dental biomaterials appeared to be acrylic resin-related work, eugenol-containing materials, and impression material compounds. All of these materials contain known allergenic factors capable of eliciting type IV immunoreactions of contact dermatitis. In summary, although dermatoses were frequent, most of them were bearable, and no “new,” particularly risky allergenic group of materials or material brands were revealed. On the other hand, the increased use of gloves, presumably preventing irritant dermatoses from disinfectants, detergents, and hand washing procedures, lead to irritative or hypersensitive reactions to the latex gloves. It should also be kept in mind that gloves are not impenetrable to allergenic components from synthetic resins.23True hypersensitive reactions may occur even with gloves.
Nondermatologic
reactions
Acute, toxic, nondermatologic reactions were experienced by some prosthodontists occasionally following activities such as working with MMA or other synthetic resin materials or with cyanoacrylate liners. The reactions were expressed as eye, respiratory, or general symptoms in connection with exposure to volatile liquids and grinding dust. Such reactions were of a transient nature. Permanent sequelae were not reported and are not known except in the case of MMA exposure among dental technicians.24,25
Patient
IMPLICATIONS
Side effects on dental personnel in contact with biomaterials should be carefully recorded in the same manner as one records adverse reactions in patients. Information of
THE
JOURNAL
SUMMARY
AND CONCLUSIONS
A questionnaire survey of Scandinavian prosthodontists revealed a fairly high frequency of dermatologic ailments located on the hands and fingers. Most dermatoses were bearable and were attributed to seasonal variations in air humidity and temperature, giving irritant reactions in combination with hand hygiene. More severe hand dermatoses were connected with biomaterial-related treatment procedures, including contact with acrylic resins, eugenolcontaining materials, impression materials, latex gloves, or epoxy. One prosthodontist was reported to have retired because of severe reactions to MMA. Nondermatologic reactions occurred in the eyes, respiratory pathways, or occasionally as general symptoms (nausea, headache). Such reactions were of a transient nature and were attributed to vapors from MMA or cyanoacrylate. Patient reactions, assessed to take place in approximately 1 of 300 persons, had been observed by some, but not all prosthodontists, mostly as intraoral reactions to acrylic resins; eugenol-containing temporary cements; cobalt, chromium, nickel, mercury, or gold allergies; and reactions to tissue conditioners or latex gloves.
reactions
The frequency of patient reactions in prosthetic dentistry was low, and most of these were intraoral/gingival reactions related to synthetic resins, eugenol or cobalt/ chromium materials-all materials that are compatible with hypersensitive responses to known allergens. The exact number of reactions was difficult to assess,since the total number of patients reported was obviously an approximation, and since many prosthodontists had not observed any reactions. Tlne uneven observation of patient reactions among the prosthodontists may therefore reflect a real variation of such reactions among dental patients, or may be underestimated for lack of clinical acuity or difficulties in relating treatment procedures and oral reactions. Nonoral reactions among patients (dermal, systemic) were infrequent and were attributed to metal allergy or to allergies to components in impression materials. In some cases,patients also reacted to latex gloves, as was reported in periodontal patients.17
CLINICAL
this kind is important in the general evaluation of side effects of materials. It may also be of clinical significance when dental personnel need treatment of their own dentition. The uneven distribution of observed side effects of dental biomaterials among prosthodontic patients indicates that some reactions may be overlooked or forgotten.
OF PROSTHETIC
DENTISTRY
REFERENCES Andersen KE, Benezra C, Burrows J, et al. Contact dermatitis. A review. Contact Dermatitis 1987;34:55-78. 2. Forck G, Wingert F. Kontakterkrankungen des Zahnarztes und seiner Helfer. ZWR 1977;7:352-60. 3. Franz G. The frequency of allergy to dental materials. J Dent Assoc S Afr 1982;37:805-10. 4. Ruyter IE, @ysaedH. Analysis and characterization of dental polymers. CRC Crit Rev Biocompatibility 19884247-79. 5. Malmgren 0, Medin L. Overkiinslighetsreaktioner vid anviindning av bonding material inom ortodontivard. Tandllkartidn 1981;73:544-6. 6. Altuna G, Lewis D, Rourke M, Woodside D. Tissue reactions to orthodontic materials. A survey of Canada’s orthodontists [Abstract]. J Dent Res 1986;65:795. Van Groeningen G, Natar JP. Reactions to dental impression materials. Contact Dermatitis 1975;1:373-6. Haugen E, Hensten-Pettersen A. The sensitizing potential of periodontal dressings. J Dent Res 1978;57:950-8. Hensten-Pettersen A, Gjerdet NR, Kvam E, Lyberg T. Nikkelallergi og kjeveortopedisk behandling. Nerd Tannlegeforgen Tid 1984;567-72. 10. Samits MH, Shmunes E. Occupational dermatoses in dentists and allied personnel. Cutis 1969;5:180-4. 11. Calnan CD, Stevenson CJ. Studies in contact dermatitis. XV. Dental materials. St John’s Hosp Dermatol Sot Trans 1963;49:9-26. 12. Djerassi E, Berowa V. Kontakt allergic in der Stomatologie als Berufsproblem. Berufsdermatosen 1966$4:225-80. 13. Wulf S. Das Berufsekzemes der Zahnarztes und seine Problematik. Thesis. Medisinischen Hochschule Hannover, 1975% pp. 14. Irmer J. Kontaktekzeme bai Zahniirzten. Thesis. Westphalischen Wilhelm+ Universitlt zu Miinster 1978:69 pp. 1.
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15. Kanerva L, Estlander T, Jolanki R. Allergic contact dermatitis from dental composite resins due to aromatic epoxy acrylates and aliphatic acrylates. Contact Dermatitis 1989;20:201-11. 16. Jacobsen N, Hensten-Pettersen A. Occupational health problems and adverse patient reactions in orthodontics. Eur J Orthod 1989;ll: 254-64. 17. Jacobsen N, Hensten-Pettersen A. Occupational health problems and adverse patient reactions in periodontics. J Clin Periodontol 1989; 16428-33. 18. Jacobsen N, Hensten-Pettersen A. Yrkesrelaterte helseplager hos tannteknikere. Tenner I focus 1988;48:18-27. 19. Kavli G, Angel1 E, Moseng D. Hospital employees and skin problems. Contact Dermatitis 1987;17:156-8. 20. Lammintausta K. Hand dermatitis in different hospital workers who perform wet work. Dermatosen 1983;31:14-8. 21. Carillo T, Cuevas M, Munoz T, Hinojosa M, Manes I. Contact urticaria and rhinitis from latex surgical gloves. Contact Dermatitis 1986;15:6972. 22. Wrangsjii K, Wahlberg JE, Axelsson JGK. IgE-mediated allergy to nat-
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ural rubber in 30 patients with contact urticaria. Contact Dermatitis 1988;19:264-71. 23. Reitschel RL, Higgins R, Levy N, Pruitt PM. In viva and in vitro testing of gloves for protection against UV-curable acrylate resin systems. Contact Dermatitis 1984;11:279-82. 24. Christiansen ML, Adelhardt M, Kjaergaard Stensen N, Gynthelberg F. Methylmetakrylat-en Lsag til toksisk hjerneskade. Tannlaegebladet 1986;90:759-64. 25. Rajaniemi R. Clinical evaluation of occupational toxicity of methylmethacrylate monomer to dental technicians. J Sot Occup Med 1986:36:56-g. Reprint requests to: DR. ARNE HENSTEN-PE?TERSEN NIOM, SCANDINAVIAN INSTITUTE OF DENTAL MATERIALS POB 70, N-1344 HASLUM NORWAY
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