1. INTRODUCTION:

Allergic reactions are very common nowadays. Anything and everything under the sun including the sun can cause allergy to some individuals. A variety of dental materials ranging from diagnosis to rehabilitation for the management of oral diseases are capable inducing allergic reactions to the dentist, patient and the technician.^[1]Dental materials have been reported as etiologic agents for both local and systemic allergic reactions.^[2]Dental materials should satisfy the biocompatibility specifications because most of them indicated for a longer period of time.^[3] This article aims to give an insight about the allergies caused due to dental materials like dental amalgam restoration, latex gloves, zinc oxide eugenol, composite restoration, local anesthesia along with its management and diagnosis.

Allergy due to amalgam restoration

Amalgam is used as a dental restorative material since 19th century for people all over the world, with few adverse effects. ^[4]

The first case of dental metal allergy resulted in stomatitis and dermatitis around the anus due to amalgam restorations in the oral cavity. ^[5] Amalgam is excellent for dental use because it is well fitting, very strong, easy to handle, cheap and long lasting. Conventional amalgam fillings consist of approximately 50% mercury and about 50% alloy powder containing silver, copper, zinc and tin.^[4,6]

Mercury and its compounds are the most common allergens in amalgam, while the other metals rarely cause allergic reactions. ^[7] The metal ions which is released due to corrosion of Amalgam in the oral cavity is responsible for sensitization and allergy (T Cell dependent, Type IV).^[8] A patient developed urticaria followed by a blistered weeping eruption on the face, anterior trunk and limbs along with systemic effects, following silver amalgam restoration. Patch tests confirmed hypersensitivity to mercury. ^[9]Oral lichen planus is a common allergic reaction caused due to amalgam restoration.

Contact allergy to mercury compounds is an important aspect in the pathogenesis of oral lichen planus especially if it is in close contact with amalgam filling. ^[10] Sensitization to mercury is an important cause of oral lichen lesions, either all the lesions or only a part of it is adjacent to the fillings. ^[11] Many authors have reported that signs and symptoms in oral lichen planus has subsided after the replacement of amalgam, especially if there was a positive patch test result to mercury.^[12] Another manifestation of allergy to mercury is burning mouth syndrome (BMS). ^[13]Air conditioners, proper ventilation of the operating rooms and proper handling of amalgam scraps under sulphide solution can avoid mercury vapor production. ^[14]

Allergy due to zinc oxide eugenol

Eugenol constitutes of many essential oils like oil of carnation (80 %), oil of bay (60 %) and pimento oil (80 %). Eugenol is a pale yellow fluid with a burning taste and strong smell of carnation. Oil of cloves or eugenol is mixed with zinc oxide to form zinc oxide-eugenol, which exhibits therapeutic and physical properties making it useful as a temporary restorative material, palliative base material, and root canal filling material. ^[15] Zinc oxide and eugenol reacts to produces zinc eugenolate, which readily undergoes hydrolysis with the release of free eugenol that is initially rapid and then decreases exponentially, as all the surface eugenol is hydrolyzed .

This eugenol can cause adverse allergic reaction in few individuals if it contacts the soft tissue. ^{[16] [17]}It can produce both local irritation and cause cytotoxic effects, as well as hypersensitivity reactions due to the release. ^[15] Allergic contact stomatitis is a rare disorder, Eugenol is one such material known to cause such reactions. ^[18] Because eugenol can react directly with proteins to form conjugate and reactive haptens. ^[17] Treatment generally consists of eliminating the causal agent. ^[18]

Allergy due to latex gloves

Latex refers to natural rubber which is an extract from Hevea brasilienesis. Natural rubber latex glove use is widespread in dentistry. ^[19] Latex sensitization in general population ranges from 5.4-7.6%. In the late 1980s latex rubber allergy was identified as an increasingly significant health care problem. ^[20]Patients with history of multiple surgery, post-surgery, spina bifida, healthcare workers and allergy to various fruits (latex fruit allergy), congenital urinary tract abnormalities are more prone to latex allergy. ^{[21] [22]} Allergic reactions range from contact dermatitis to potentially life-threatening hypersensitivity. ^[23]

The clinical manifestations of latex allergy are irritant contact dermatitis (most common), allergic contact dermatitis (Delayed type4 hypersensitivity reaction) and immediate type 1 hypersensitivity reaction. The risk of latex hypersensitivity increases with repeated exposure and prolonged use. First step in diagnosis of latex allergy is recording the clinical history of the patient. ^[24] Many in-vitro and in-vivo tests are available for testing latex allergy. But the most reliable test is the skin patch test. ^[25] The only way to treat latex allergy is to avoid the exposure to latex.^[24] Low-protein, powder-free natural rubber latex gloves, or latex-free gloves should be widely adopted, along with other preventive measures. ^[19] Alternative for latex gloves are vinyl, Nitryl or silicone gloves. Alternative for rubber damps are non-latex (poly vinyl chloride damps). ^[26]

Allergy due to local anesthesia

Local anesthetics are used commonly in dentistry. Usually these drugs are well-tolerated but at times they can provoke adverse reactions of various types and severity. ^[27] Local anesthetic agents can be categorized into two classes: ester (benzocaine, cocaine, procaine and tetracaine) amide (lidocaine, bupivacaine, prilocaine, ropivacaine, articaine, mepivacaine). ^[28]These hypersensitivity reactions are mostly due to ester anesthetics as antigenic agent p-amino benzoic acid is one of its breakdown products. ^[29]

Most of the reactions usually attributed to vasovagal or psychogenic reflexes. ^{[30] [31]} A case with IgE-mediated reaction to an amide-type LA with cross- reactivity to an ester-type LA is also reported. ^[31] Predisposing factors are age (below 6 years and above 65 years), underweight patients, patients with liver disorders, kidney disorders, disorder in the presence of serum cholinesterase required for the metabolism of local anesthesia and pregnancy. Most adverse reactions are psychogenic or vasovagal. ^[27] Syncope is the most common adverse effect. Other adverse reactions to LA include from clinical symptoms mimicking anaphylaxis such as itching, hypotension, tachycardia, bronchospasm, nausea, vertigo or collapse. ^{[31] [32]}

Adverse reactions are reported in case of lignocaine, procaine, mepivacaine, tetracaine, prilocaine, carticaine. ^{[33] [34] [35]}These reactions can be due to the LA (allergic reaction/idiosyncratic) or doses of LA (toxic reaction or overdosage) or due to psychogenic factors like anxiety and fear caused by the dental/ anesthetic act. ^{[36] [37]} In a study, 25 adverse reactions were diagnosed (0.25% of study population). Most (22/25) were mild, quickly reversible psychogenic or vasovagal reactions. ^[27] Management of adverse reactions with LA includes prevention by relieving fear and anxiety prior to injection and immediate treatment. ^[38]

Allergy due to resin material composite

Allergy to dental resin-based materials is due to a reaction with substances like methyl methaacrylate (MMA), 2-Hydroxy-ethyl methaacrylate (HEMA), ethylene glycol dimethaacrylate (EGDMA), urethane dimethaacrylate (UDMA), bisphenol A, triethylene glycol dimethaacrylate (TEGDMA), phthalate, formaldehyde. ^[39] To develop an allergy the person has to be sensitized to the specific allergen at an earlier. Methaacrylic monomers often cross-react, so a patient who have been sensitized to one monomer is likely to react to others. ^[40] Allergic reactions to dental resin-based materials are normally type IV hypersensitivity reactions but rarely it can be type I. ^[41] Type IV or delayed- type hypersensitivity reaction, occurs 1-3 days after exposure to the specific antigen.

It is localized to the area in direct contact to the antigen. The amount of antigen required for a type IV reaction is about 100- 1000 times greater than that required for a type I reaction. ^{[42] [43]} Allergic stomatitis with mild erythema in gingiva and buccal mucosa, contact allergy, lichen oil like reactions on lip are seen. ^{[44] [45] [46]} Substances like UDMA, TEGDMA are genotoxic. Genotoxicity is the ability of a material to break down or mutate DNA. A genotoxic material is carcinogenic. ^[47] Xenoestrogen is a chemical substance can bind to estrogen receptors and cause effects similar to estrogen.

This leads to alterations in puberty onset and damages to the fetus. ^[48] This is called Estrogenic effect and Bisphenol-A is a xenoestrogen. ^[49] Clinical intra-oral adverse effects are swelling, sores or necrosis of the oral mucosa. ^{[50] [51]} Extra-orally sores, swelling, rash and itching is seem. General symptoms such as headache, anxiety, vertigo, fatigue and pain from muscles and joints have also been reported. ^[50] Burning mouth syndrome is an adverse reaction to dental polymers. ^[51]To prevent allergy is to lower the possibility of leakage, to prevent unnecessary direct exposure to monomers by using physical barrier like rubber damp sheet.

Allergic reactions due to Titanium

Titanium is considered as a non-allergic metal. It is widely used as dental implants, it is also found as paints, white pigments and photo catalyst. Titanium dioxide is the most commonly used for of titanium. Maki and coworkers in 2016 reported a 69-year-old male with significant pathologic findings around dental implants; he exhibited allergic symptoms like eczema after orthopedic surgery. The screws used in the orthopedic surgery were made up titanium and it was removed 1 year later, but the eczema remained. The eczema disappeared only after the removal of dental implant. ^[52]

Similar case of titanium allergy was reported in which patient had eczema on the face after titanium implants placement in the mandible. ^[53] The estimated prevalence of this allergy is low (0.6%). 9 out of 1500 patients showed positive reactions to Ti allergy tests in a prospective study. ^[54] MELISA test is the validated test to detect titanium sensitization. ^[55] A 19-year-old man was reported with hypersensitivity (DRESS) syndrome after titanium bio prosthesis for a spinal fracture. ^[56]Polytheretherketone (PEEK) is an alternative for titanium which offers similar mechanical properties and bone forming capacity. ^[57]

Nickel- chromium allergy

Nickel chromium is widely used for making orthodontic wires, brackets, crowns etc. Nickel is known to be a common cause of hypersensitivity reactions and contact allergy. ^[58] The signs and symptoms are burning sensation, gingival hyperplasia and numbness on sides of tongue. It is confirmed by using 5% nickel sulphate in petroleum jelly (patch test). ^[59] Chromium and cobalt reactivity is commonly seen in nickel allergy. Patch test was done for 1208 patients with contact dermatitis, 18.5% had positive reactions to 2-3 metals. ^[60]High-nitrogen nickel-free austenitic stainless steel wires, ceramic brackets, polycarbonate brackets and gold brackets are used to avoid nickel allergy. Ni-Ti arch wire can be replaced with titanium molybdenum alloy (TMA) or stainless steel wire. ^{[61] [62]}

CONCLUSION:

For a proper diagnosis and safe treatment, it is very important to take a proper history of the patient related to allergy, clinical examination and confirmatory tests like patch tests due to the rise in the number of patients with allergy. So a dentist should have a sound knowledge about the allergies documented to known materials and thus prevent allergic manifestations.

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Received on 11.07.2016 Modified on 22.07.2016

Research J. Pharm. and Tech 2016; 9(10):1819-1822.

DOI: 10.5958/0974-360X.2016.00370.X