An overview of the current status of national reporting systems for adverse reactions to dental materials

Contact allergies to dental materials in patients

BACKGROUND

Concerns regarding contact allergies and intolerance reactions to dental materials are widespread among patients. Development of novel dental materials and less frequent amalgam use may alter sensitization profiles in patients with possible contact allergy.

OBJECTIVES

To analyse current sensitization patterns to dental materials in patients with suspected contact allergy.

METHODS

This retrospective, multicentre analysis from the Information Network of Departments of Dermatology (IVDK) selected participants from 169 834 people tested in 2005-2019 and registered with (i) an affected area of 'mouth' (and 'lips'/'perioral'), (ii) with the dental material in question belonging to one of three groups (dental filling materials, oral implants or dentures or equivalents) and (iii) with patch-testing done in parallel with the German baseline series, (dental) metal series and dental technician series.

RESULTS

A total of 2730 of 169 834 tested patients met the inclusion criteria. The patients were predominantly women (81.2%) aged ≥ 40 years (92.8%). The sensitization rates with confirmed allergic contact stomatitis in women (n = 444) were highest for metals (nickel 28.6%, palladium 21.4%, amalgam 10.9%), (meth)acrylates [2-hydroxyethyl methacrylate (HEMA) 4.8%] and the substances propolis (6.8%) and 'balsam of Peru' (11.4%). The most relevant acrylates were HEMA, 2-hydroxypropyl methacrylate, methyl methacrylate, ethylene glycol dimethacrylate and pentaerythritol triacrylate. Few men were diagnosed with allergic contact stomatitis (n = 68); sensitization rates in men were highest for propolis (14.9%) and amalgam (13.6%).

CONCLUSIONS

Allergic contact stomatitis to dental materials is rare. Patch testing should not only focus on metals such as nickel, palladium, amalgam and gold, but also (meth)acrylates and the natural substances propolis and 'balsam of Peru'.

Adverse reactions to dental biomaterials: Experiences from a specialty clinic

OBJECTIVES

The Dental Biomaterials Adverse Reaction Unit was initiated by the Norwegian health authorities in 1992 as a response to the public concern regarding the safety of dental amalgam and other dental materials. In this paper, experiences from the Unit are briefly summarized.

METHODS

The Norwegian health authorities' strategy included four main topics: (i) development of a manufacturer-independent system for monitoring adverse reactions related to dental materials, (ii) funding of a specialty unit for clinical examinations of referred patients, (iii) development of official guidelines for examination and treatment of patients with health complaints attributed to dental materials, and (iv) funding of an experimental treatment project for patients with health complaints attributed to dental amalgam.

RESULTS

From the start, more than 2700 adverse reaction reports were received. In the initial years, amalgam was the most frequent material mentioned in the reports. Reports about polymer-based composite materials have not increased after the prohibition of amalgam in Norway. Clinical examination of referred patients is complex and time consuming, and it is important to consider differential diagnoses. There are methodological challenges associated with the design of experimental treatments used on patients with adverse reactions attributed to dental materials. However, the results from the treatment project indicate lower symptom load after replacement of amalgam with other dental restorative materials.

SIGNIFICANCE

Producer independent adverse reaction reporting can provide valuable information about the safety of these materials and could serve as a complement to the mandatory reporting system described in the European medical device regulations (MDR).

General diseases and medications in 687 patients reporting on adverse effects from dental materials

OBJECTIVES

Examination of patients claiming adverse effects from dental materials can be very challenging. Particularly, systemic aspects must be considered besides dental and orofacial diseases and allergies. Therefore, the aim of this study was to investigate a cohort of 687 patients reporting on adverse effects from dental materials focusing on findings related to known general diseases or conditions or medication-related findings with relevance to their subjective complaints.

METHODS

Six hundred eighty-seven patients visiting a specialized consultation on claimed adverse effects from dental materials were retrospectively investigated for their subjective complaints, findings related to known general diseases or conditions, medication-related findings, dental and orofacial findings, or allergies with relevance to their subjective complaints.

RESULTS

The most frequent subjective complaints were burning mouth (44.1%), taste disorders (28.5%), and dry mouth (23.7%). In 58.4% of the patients, dental and orofacial findings relevant to their complaints could be found. Findings related to known general diseases or conditions or medication-related findings were found in 28.7% or 21.0% of the patients, respectively. Regarding medications, findings related to antihypertensives (10.0%) and psychotropic drugs (5.7%) were found most frequently. Relevant diagnosed allergies toward dental materials were found in 11.9%, hyposalivation in 9.6% of the patients. In 15.1% of the patients, no objectifiable causes for the expressed complaints could be found.

CONCLUSIONS

For patients complaining of adverse effects from dental materials, findings related to known general diseases or conditions and medications should be given particular consideration, while still in some patients, no objectifiable causes for their complaints can be found.

CLINICAL RELEVANCE

For patients complaining about adverse effects from dental materials, specialized consultations and close collaboration with experts from other medical fields are eligible.

Dental material allergies and oral soft tissue reactions

Dental materials can cause reactions to the oral mucosa and present to the general dental practitioner. These are often referred to as 'allergies' but are frequently lichenoid reactions. Most of these are related to dental amalgam restorations and can be remedied by replacing the restoration with another suitable material. Other metals, including gold, palladium, nickel and chrome, have also been reported to trigger mucosal changes. Less commonly, issues arise from other restorative materials, including denture acrylics, composites and glass polyalkenoates. Reactions are also reported due to endodontic and sealing materials. It is unclear what role skin 'patch' testing has in managing dental material allergies. This article aims to give the practitioner a clearer picture of dental material allergy issues and how they should be approached in primary dental practice.

Investigation of material removal mechanisms and ductile-brittle transition zone of zirconia ceramics sintered at various temperatures

Sintering is a comprehensive process that involves the complex evolution of material microstructures and properties, being recognized as a critical factor to improve the machinability of ceramics. The present work aims to address the evolution of the material removal mechanisms of the 3 mol% yttria-stabilized tetragonal zirconia polycrystal (3Y-TZP) during the sintering process based on the micro scratching tests. The impacts of sintering temperatures on the material removal behaviors, including scratching forces, scratch morphologies, specific scratching energies, and critical transition depths, were rigorously studied. The acquired results indicate that the intergranular bonding strength is a critical factor that determinines the material removal mechanisms of 3Y-TZP, and 1100 °C signifies the transition threshold for the material removal mode. After 1100 °C, the material removal mechanism has gradually converted into the typical ductile-brittle removal regime. Moreover, the critical depth in ductile regime at 1200 °C is about 1.89 times that at 1500 °C, and the critical depth of ductile-brittle transition at 1200 °C is approximately 2.08 times that at 1500 °C.

Methacrylate perspective in current dental practice

OBJECTIVE

To provide a current perspective concerning dental personnel sensitivity to methacrylate materials.

OVERVIEW

Methacrylate related sensitivity and allergies are currently beyond traditional thoughts concerning denture base resins and methyl methacrylate provisional materials. Methacrylates are now ubiquitous in current dental practice and dental personnel should be aware that dental adhesives contain potent sensitizers that may also cross-sensitize individuals to other methacrylates not experienced. The growing sensitivity to 2-hydroxyethyl methacrylate (HEMA) has been described to be epidemic in nature due to the artificial nail industry with dental patients and dental personnel may be more susceptible to dental methacrylate sensitization. While contact dermatitis remains the most prevalent methacrylate-related clinical presentation, respiratory complications and asthma are increasing associated with methacrylate exposure. While additional personal protective equipment (PPE) is thought to be first protective choice, the National Institute for Occupational Safety and Health (NIOSH) considers PPE overall largely ineffective and should be considered only as a last resort.

CONCLUSION

Dental personnel need to be more aware of methacrylate sources and use workplace control measures to limit methacrylate exposures to both dental personnel and patients.

CLINICAL SIGNIFICANCE

Sensitivity to methacrylate materials is a growing dental workplace major concern and dental personnel should be aware of both the methacrylate content of current materials and the products that contain ingredients with the most sensitization potential.

Factors affecting patient safety culture among dental healthcare workers: A nationwide cross-sectional survey

Background/purpose

Patient safety is a major healthcare challenge. Due to a lack of safety culture knowledge among dental professionals, our objectives were to measure the level of patient safety culture using the Safety Attitude Questionnaire in Chinese (SAQ-C) and identify factors associated with positive attitudes toward patient safety.

Materials and methods

A nationwide cross-sectional survey was conducted within dentistry departments of 20 hospitals and in 40 dental clinics, from which were randomly chosen. The survey (SAQ-C) comprised of 32 items and reflects five dimensions of patient safety culture. The second section collects demographic information that supposedly affects attitudes toward patient safety. Logistic regression analyses were used to identify factors that supposedly influenced positive attitudes toward patient safety.

Results

Mean SAQ-C scores were significantly higher in respondents who were male, older, dentists, supervisors, and working in clinics. Positive attitudes toward patient safety were found in 172 participants (55.7%). Multivariate analyses revealed age and place of work are significantly associated with positive safety attitudes. A limitation of this study is that the association between SAQ-C scores and patient outcomes could not be examined.

Conclusion

With a lack of research in the dental field, our study provides important information on patient safety attitudes for dental healthcare workers. Results from this study present the current status of patient safety culture and help raise awareness of it. Most notably, the study identified several factors associated with positive attitudes toward patient safety. The information can be used to improve patient safety in the future.

Systematic review of patient safety interventions in dentistry

Background

The concept of patient safety in dentistry is in its infancy, with little knowledge about the effectiveness of tools or interventions developed to improve patient safety or to minimise the occurrence of adverse events.

Methods

The aim of this qualitative systematic review was to search the academic and grey literature to identify and assess tools or interventions used in dental care settings to maintain or improve patient safety. All study designs were included from all dental care settings. Outcome measures were: patient safety, harm prevention, risk minimization, patient satisfaction and patient acceptability, professional acceptability, efficacy, cost-effectiveness and efficiency. Quality assessments were performed on the included studies based on CASP tools. Further analysis was undertaken to discover whether any of the tools had been trialled or verified by the authors, or by subsequent authors.

Results

Following abstract screening, and initial qualitative synthesis, nine studies were found to meet the inclusion criteria with 31 being excluded following initial analysis. Tools identified included: checklists (4 studies), reporting systems (3), the use of electronic notes (1) and trigger tools (1). Grey literature searching did not identify any further appropriate studies. In terms of study design, there were observational studies including audit cycles (5 studies), epidemiological studies (3) and prospective cluster randomised clinical trials (1). The quality of the studies varied and none of their outcomes were verified by other researchers. The tools identified have the potential to be used for measuring and improving patient safety in dentistry, with two surgical safety checklists demonstrating a reduction in erroneous dental extractions to nil following their introduction. Reporting systems provide epidemiological data, however, it is not known whether they lead to any improvement in patient safety. The one study on trigger tools demonstrates a 50 % positive predictive value for safety incidents. It is not clear as to what impact the introduction of electronic guidelines has on patient safety outcomes.

Conclusions

This systematic review finds that the only interventions in dentistry that reduce or minimise adverse events are surgical safety checklists. We believe this to be the first systematic review in this field; it demonstrates the need for further research into patient safety in dentistry across several domains: epidemiological, conceptual understanding and patient and practitioner involvement.

Electronic supplementary material

The online version of this article (doi:10.1186/s12903-015-0136-1) contains supplementary material, which is available to authorized users.

Analysis of 415 adverse events in dental practice in Spain from 2000 to 2010

INTRODUCTION

The effort to increase patient safety has become one of the main focal points of all health care professions, despite the fact that, in the field of dentistry, initiatives have come late and been less ambitious. The main objective of patient safety is to avoid preventable adverse events to the greatest extent possible and to limit the negative consequences of those which are unpreventable. Therefore, it is essential to ascertain what adverse events occur in each dental care activity in order to study them in-depth and propose measures for prevention.

OBJECTIVES

To ascertain the characteristics of the adverse events which originate from dental care, to classify them in accordance with type and origin, to determine their causes and consequences, and to detect the factors which facilitated their occurrence.

MATERIAL AND METHOD

This study includes the general data from the series of adverse dental vents of the Spanish Observatory for Dental Patient Safety (OESPO) after the study and analysis of 4,149 legal claims (both in and out of court) based on dental malpractice from the years of 2000 to 2010 in Spain.

RESULTS

Implant treatments, endodontics and oral surgery display the highest frequencies of adverse events in this series (25.5%, 20.7% and 20.4% respectively). Likewise, according to the results, up to 44.3% of the adverse events which took place were due to predictable and preventable errors and complications.

CONCLUSION

A very significant percentage were due to foreseeable and preventable errors and complications that should not have occurred.

Patient safety incidents reported by Finnish dentists; results from an internet-based survey

BACKGROUND

Few data are available on dental patient safety (PS), as most PS studies have focused on other activities in health care.

OBJECTIVE

To detect types and causes of dental PS incidents (PSIs), including adverse events (AEs) and near misses (NMs), in Finnish dental care.

MATERIAL AND METHODS

Altogether 1041 privately or publicly employed dentists in southern Finland completed a structured questionnaire using an internet-based system (Webropol) in 2010.

RESULTS

Nearly one third of the dentists reported some PSI in the previous 12 months. Of the 872 reported events, 53% were classified as AEs, 45% as NMs and 2% remained unclassified. Nearly half of the PSIs had occurred during some form of dental treatment. One third of the AEs were related to dental equipment, devices and supplies. Most of the reported AEs resulted in little or no permanent harm to patients. However, 13% of AEs were considered as serious enough to potentially cause severe harm or did in fact cause permanent harm.

CONCLUSIONS

Reported dental PSIs in Finland are in many respects similar to those reported in other countries. Compared to all annual dental visits in Finland, severe dental AEs seem to be relatively rare. Less severe AEs and NMs are not uncommon, especially in dental surgery, endodontic and restorative treatment. The results of this retrospective study, however, reveal more about incident types than their true prevalence and that further studies on dental PS are needed.

Wear model simulating clinical abrasion on composite filling materials

The aim of this study was to establish a wear model for testing composite filling materials with abrasion properties closer to a clinical situation. In addition, the model was used to evaluate the effect of filler volume and particle size on surface roughness and wear resistance. Each incisor tooth was prepared with nine identical standardized cavities with respect to depth, diameter, and angle. Generic composite of 3 different filler volumes and 3 different particle sizes held together with the same resin were randomly filled in respective cavities. A multidirectional wet-grinder with molar cusps as antagonist wore the surface of the incisors containing the composite fillings in a bath of human saliva at a constant temperature of 37°C. The present study suggests that the most wear resistant filling materials should consist of medium filling content (75%) and that particles size is not as critical as earlier reported.

Biocompatibility of Resin-based Dental Materials

Oral and mucosal adverse reactions to resin-based dental materials have been reported. Numerous studies have examined the biocompatibility of restorative dental materials and their components, and a wide range of test systems for the evaluation of the biological effects of these materials have been developed. This article reviews the biological aspects of resin-based dental materials and discusses the conventional as well as the new techniques used for biocompatibility assessment of dental materials.

Local adverse effects of amalgam restorations

Amalgam has been used for the restoration of teeth for well over 100 years, and is the most successful of the direct restorative materials with respect to longevity. Despite the increasing use of tooth-coloured materials, with advantages of aesthetics and adhesion, amalgam is one of the most widely used dental restorative materials. One of the principal disadvantages of amalgam, apart from aesthetics, is that it may have adverse biological effects, both locally and systemically. Locally, it can cause an erythematous lesion on the adjacent oral soft tissues (tongue and buccal mucosa), and systemically free mercury in the amalgam may give rise to a hypersensitivity reaction. The purpose of this paper is to review the literature concerning the local adverse reactions to dental amalgam. The focus will be on the reactions of the oral mucosa, and brief consideration will be given to laboratory cytotoxicity of dental amalgam and its components, and to the 'amalgam tattoo'.

Do adverse effects of dental materials exist? What are the consequences, and how can they be diagnosed and treated?

OBJECTIVES

All dental biomaterials release substances into the oral environment to a varying degree. Various preclinical biocompatibility test systems have been introduced, aiming at an evaluation of the potential risks of dental materials. Potential pathogenic effects of released substances from dental materials have been demonstrated. For the biocompatibility of a biomaterial, it is not only important that minimal diffusable substances are released when it is in body contact--the material must also fulfill the function for which it has been designed. This is also very much dependent on the material properties and its handling properties. The aim of this review was to generate an overview of the present status concerning adverse reactions among patients and personnel.

MATERIALS AND METHODS

A systematic review was performed using a defined search strategy in order to evaluate all MEDLINE-literature published between 1996 and 2006.

RESULTS

The compilation of the literature available has revealed that the majority of studies have been carried out on patients compared with personnel. Adverse reactions towards dental materials do occur, but the prevalence and incidence are difficult to obtain. The results were essentially based on cohort studies. Clinical trials, especially randomized-controlled trials, are in the minority of all studies investigated, with the exception of composite and bonding studies, where clinical trials, but not randomized-controlled trials, represent the majority of studies. Patients and personnel were treated separately in the manuscript. Amalgam studies show the lowest degree of verified material-related diagnosis. Even if objective symptoms related to adverse reactions with polymer resin-based materials have been reported, postoperative sensitivity dominates reports concerning composites/bondings. Verified occupational effects among dental personnel show a low frequency of allergy/toxic reactions. Irritative hand eczema seemed to be more common than in the general population.

CONCLUSIONS

Patient- and personnel-related studies are of variable quality and can be improved. There is a need for a better description of the content of materials. A registry for adverse effects of dental materials would be useful to detect the occurrence of low-incidence events.

Materials. Consensus report of Working Group 4

The method used by the working group was an iterative process based upon a structured review of the relevant literature by a group of rapporteurs. The literature was searched using common databanks (e.g., Medline, Pubmed, Cochrane Library etc.), and also by performing manual searches in the non-indexed literature. The review papers were circulated to the members of the group before and during a conference that served as the basis for subsequent discussions. Each paper was subject to detailed collective analysis and subsequently modified on the basis of panel's discussion and referred to additional relevant literature where appropriate. The consensus statements were prepared after a detailed consideration of the papers submitted to the workshop by the working group. The papers were scrutinized, amended and approved by the group.

Preferences over dental restorative materials among young patients and dental professionals

Knowledge of the patient's view is necessary, as patients' rights are an issue of increasing importance in dental practice. This study aimed to examine how dentists (n = 42), dental assistants (n = 65), and young dental patients (n = 306) in Norway and Denmark valued three attributes of dental restorations, namely, expected longevity, the appearance, and the risk of an adverse reaction. According to the discrete choice method, participants were presented with several scenarios, describing different levels of the attributes, for comparison of two restorations (A and B). The differences among patients, dentists, and dental assistants were examined by logistic regression analyses. The likelihood of a dentist favoring one restoration over another was very sensitive to the difference in the expected longevity of the restorations, and much less to differences in visibility. The patients had considerable sensitivity to differences in visibility and much less to differences in duration. Danish teenagers attach less importance to visibility of the restoration and greater importance to the risk of an adverse reaction than Norwegian teenagers. All differences were statistically significant. Preferences associated with properties of dental restorations differ between teenage patients and dental professionals and this should be addressed in clinical decision-making.