Jewellery: alloy composition and release of nickel, cobalt and lead assessed with the EU synthetic sweat method

An investigation into the present levels of contamination in children's toys and jewelry in different countries: a systematic review

Contamination by heavy metals and toxic elements in children's toys and jewelry is an ongoing challenge in different countries. These contaminants can enter the children's body via oral, dermal, and respiratory routes, leading to adverse health effects. This study aimed to investigate the present levels of contamination in children's toys and jewelry in 15 countries, including UK, Saudi Arabia, Cambodia, China, Kosovo, Nigeria, North American, Kazakhstan, UAE, Pakistan, Iraq, Israel, West Bank/Palestine, Czech Republic, and Turkey. In this review, the legislation and recommendation of the United States (U.S.), the Bureau of Indian Standards (BIS), Turkish Standards Institute (TSE), Canada, and the European Union (E.U.) on toxic elements in toys and jewelry are introduced. Plastic or metallic toys and children's jewelry still have the most severe toxic elements pollution and the existence of lead (Pb), nickel (Ni), cadmium (Cd), arsenic (As), mercury (Hg), chromium (Cr), copper (Cu), selenium (Se), barium (Ba), Zinc (Zn), cobalt (Co), manganese (Mn), bisphenol A, phthalates, parabens, azo dyes, and flame retardants has been regarded as an ongoing challenge in these articles. Finally, this review offers benchmarking of the concentrations of toxic elements in all types of children's toys and jewelry in different nations.

An autonomous wearable biosensor powered by a perovskite solar cell

Wearable sweat sensors can potentially be used to continuously and non-invasively monitor physicochemical biomarkers that contain information related to disease diagnostics and fitness tracking. However, the development of such autonomous sensors faces a number of challenges including achieving steady sweat extraction for continuous and prolonged monitoring, and addressing the high power demands of multifunctional and complex analysis. Here we report an autonomous wearable biosensor that is powered by a perovskite solar cell and can provide continuous and non-invasive metabolic monitoring. The device uses a flexible quasi-two-dimensional perovskite solar cell module that provides ample power under outdoor and indoor illumination conditions (power conversion efficiency exceeding 31% under indoor light illumination). We show that the wearable device can continuously collect multimodal physicochemical data - glucose, pH, sodium ions, sweat rate, and skin temperature - across indoor and outdoor physical activities for over 12 hours.

Environmental assessment in fine jewelry in the U.S.-Mexico's Paso del Norte region: A qualitative study via X-ray fluorescence spectroscopy

Heavy metal contamination in raw materials has spread widely in the United States. The high increased number of recalls in consumer products and the lack of stricter regulations in the raw materials to be used in the jewelry industry have raised concerns among consumers. Studies in low-cost jewelry have shown the presence and high content of heavy metals; this environmental problem led to a child's death after swallowing a charm containing elevated levels of lead (Pb). Exposure to heavy metals, through inhalation, mouth, and skin contact, causes adverse health effects in children and adults. Exposure to lead affects mainly the nervous system and brain development; exposure to cadmium (Cd) causes damage to liver, kidneys, and lungs, and potentially leads to cancer; exposure to nickel (Ni) causes severe dermatitis. Thus, the importance and impact of studies of this nature cannot be overstated. As heavy metal contamination has increased in the United States, this research fills an important knowledge gap between previous studies conducted on low-cost jewelry and fine jewelry. In this study, conducted in the Paso del Norte region, one hundred and forty-three pieces of fine jewelry were evaluated for the presence of heavy metals using X-ray fluorescence (XRF) spectroscopy. Our study showed that 61 samples (42.7 %) exhibited the presence of Ni in the metal alloy, prevailing in jewelry pieces with lower percentage of gold. Eighteen samples showed the presence of Pb in gemstones, 11 pieces of these samples (7.7 % total) had <33.3 % gold (≤10 K); however, none of the samples showed the presence of Pb in the metal alloy. Further research is needed to evaluate the bioaccessibility of Pb in these gemstones, which may pose a potential health hazard to children and adults in the US Paso del Norte region and throughout the world.

An ICP-MS Study for Quantitation of Nickel and Other Inorganic Elements in Urine Samples: Correlation of Patch Test Results with Lifestyle Habits

Nickel (Ni) is a frequently used metal in the production of many products, and Ni exposure occurs in humans through food, inhalation, and skin. Studies reported Ni as the most common allergen diagnosed in the serial patch test. The main purpose of our study was to determine the concentration of Ni and other elements in the urine samples of individuals with Ni-sensitivity and to determine the effect of lifestyle habits on these variables. This study was conducted with 388 participants; additionally, both Ni patch test and inorganic analysis (for 24 elements) method in urine with inductively coupled plasma-mass spectrometry (ICP-MS) were applied to all participants. Ninety-two (23.7%) of the participants were found to have nickel sensitivity with a mean urine concentration of 4.475 μg/g creatinine (median=4.260; SD=2.527). The urine nickel concentration was significantly different between female and male participants (p =0.001). We found a significant correlation between Ni and other metals alongside various element pairs. The mean urine Ni concentration of the individuals with a positive Ni sensitivity test result was not different from that of the participants without Ni sensitivity (4.475 vs 4.256 μg/g creatinine, respectively; p = 0.068). The high accuracy, recovery, and repeatability data obtained from the analyses indicate that this study is efficient and appropriate for the quantitative determination of nickel and other elements in urine samples. Ni-containing objects and Ni-rich foods should be of concern for individuals with hypersensitivity reactions to the element.

Gold-silver nanoparticles modified electrochemical sensor array for simultaneous determination of chromium(III) and chromium(VI) in wastewater samples

The oxidation state of ions is a crucial aspect that often has been overlooked when determining the toxicity of chromium (Cr) species in environmental samples. In this study, a novel electrochemical sensor array based on gold-silver nanoparticles modified electrodes was developed for simultaneous determination of the two main chromium species (Cr(III) and (VI)). Specifically, the working electrodes of screen-printed carbon electrodes (SPCEs) were modified with silver-gold bimetallic nanoparticles through electrochemical deposition for detection of Cr(VI). The silver-gold bimetallic nanoparticles were further oxidized to form stable silver-gold bimetallic oxide nanoparticles for the detection of Cr(III). The results showed that the addition of silver with a theoretical value of 1% of gold could contribute to the formation and stabilization of oxides on the surface of gold nanoparticles. After characterization, the two kinds of electrodes were integrated as an electrochemical sensor array for selective and sensitive detection of Cr(VI) and Cr(III). The linear range and limit of detection (LOD, identified by three times of signal-to-noise ratio) were found to be 0.05-5 ppm and 0.1 ppb for Cr(VI), and 0.05-1 ppm and 0.1 ppb for Cr(III), respectively. Finally, the electrochemical sensor array was proven for successful detection of Cr(VI) and Cr(III) in tap water, artificial saliva and artificial sweat samples, and monitoring of Cr(VI) and Cr(III) in chromium-containing wastewater treatment process. Combined with a handheld dual-channel electrochemical device, the simultaneous determination of Cr(VI), Cr(III) and total chromium contents can be easily achieved for various samples.

Chromium and cobalt release from metallic earrings from the Danish market

BACKGROUND

Chromium and cobalt are important skin sensitizers. It has, however, been difficult to identify causative exposures. Studies on nickel allergy have demonstrated piercing as critical for both sensitization and elicitation. It may be speculated that the same applies for chromium and cobalt.

OBJECTIVE

To examine the content and release of chromium and cobalt from earrings randomly purchased in Denmark.

METHODS

Three hundred four earrings were examined with x-ray fluorescence (XRF) spectrometry. Earrings with measured content of chromium or cobalt were spot tested with diphenylcarbazide spot test (n = 166) or Nitroso-R spot-test (n = 99), respectively. Chromium and cobalt release were quantified in a selected subsample (n = 100) with the artificial sweat test (EN 1811).

RESULTS

Chromium was present in 54.6% (166/304) of earrings and cobalt was present in 72.0% (219/304),- measured by XRF. All chromium spot tests for chromium VI were negative. The cobalt spot test was positive for one component. Chromium release was found from 59/100 (median concentration = -0.06 μg/cm² /week) and cobalt release from 29/100 (median concentration = -0.06 μg/cm² /week) of earrings in tested subsample.

CONCLUSION

Earrings for piercing release chromium and cobalt and may on a case basis be a source of chromium and cobalt allergy.

Buyer beware: Inexpensive, high cadmium jewelry can pose severe health risks

The use of cadmium to produce inexpensive jewelry has recently been documented. Governments have adopted varying standards, with US states focused on either total cadmium content or extractable cadmium from children's jewelry, while the European Union has adopted a limit of 100 mg/kg cadmium for all jewelry. This study evaluated 80 items purchased at a discount jewelry store. The objective was to determine prevalence of cadmium in this jewelry, the amount of cadmium released by simulated mouthing or ingestion, and to confirm previous reports that damage to jewelry can increase cadmium release. Finally, a modified toxicity characteristic leaching procedure (TCLP) assessed the potential for jewelry to release cadmium after disposal. Thirty-two (40%) items showed detectable cadmium by X-ray fluorescence. Nine high‑cadmium pendants and rings with cadmium content ranging from 31.3 to 89.2% were subjected to extractions simulating mouthing or ingestion. Seven of nine items extracted in dilute saline to simulate mouthing released more than the US recommended maximum of 18 micrograms. Damaged jewelry released more cadmium for most items tested, with one ring yielding an average of 10,600 micrograms. Two pendants small enough to be swallowed were tested using dilute HCl to simulate ingestion. While one pendant did not release cadmium in excess of the US recommended maximum of 200 micrograms even when damaged, the other released an average of 63,100 micrograms after being damaged. Fourteen of fifteen samples of two high cadmium charms extracted using a modified TCLP extraction exceeded the 1.0 mg/L TCLP limit for cadmium, averaging 13.1 and 9.6 mg/L respectively for the two charms. These results demonstrate that high‑cadmium jewelry may pose a serious hazard if mouthed or ingested, and that regulatory standards that do not take into account the potential for increased release of cadmium resulting from damage to jewelry electroplating are inadequate.

Nickel release from metallic earrings: A survey of the Danish market and validation of the nickel spot test

BACKGROUND

Exposure to nickel-releasing ear-piercing jewellery may explain the persistently high prevalence of nickel allergy in Europe. While nickel release from earrings is regulated, field studies show that the regulation is not always respected. More knowledge is needed regarding the risk of piercing exposure including suitable screening methods.

OBJECTIVE

To examine the proportion of earrings on the Danish market that release more nickel than allowed, and to validate the use of the dimethylglyoxime (DMG) test as a screening tool.

METHODS

A total of 304 earrings were purchased and tested with the DMG test and X-ray fluorescence spectrometry. The level of nickel release was quantified in a selected subsample of 100 earrings by the European reference test EN 1811. The DMG spot test was validated against EN 1811 at different thresholds.

RESULTS

Excessive nickel release according to the European regulation was found in 45 (14.8%) tested earrings. The sensitivity of the DMG test decreased with reduced levels of nickel release (sensitivity of 45.2% at ≥0.2 μg/cm2 /week vs 61.1% at >0.5 μg/cm2 /week).

CONCLUSION

Excessive nickel release is common in earrings on the Danish market. Because of low sensitivity, the DMG test has limited use in screening of earrings for research but may still be used clinically.

Potentially toxic elements in toys and children's jewelry: A critical review of recent advances in legislation and in scientific research

Contamination by potentially toxic elements (PTEs) in children's toys and jewelry is an ongoing problem where PTEs can become bioavailable especially via oral pathway (ingestion as a whole or of parts, and mouthing) and may cause adverse health effects for children. In the present review, legislation updates from the last decade in the United States (U.S.), Canada, and the European Union (E.U.) on PTEs in toys and jewelry are presented. Then, a literature review mostly covering the last decade on the total concentration, bioavailability, children's exposure, and bioaccessibility of PTEs in toys and jewelry is provided. The U.S. and Canadian legislations mainly focus on lead (Pb) and cadmium (Cd) total/soluble concentration limits to prevent exposure and have received several updates within the last decade, extending particularly the covered span of children's products. It seems that the introduction, subsequent enforcement, and update of regulations in developed countries have shifted the problem towards developing countries. In terms of categories, metallic toys and children's jewelry still have the most severe PTE contamination and the presence of Pb and Cd in these articles is an ongoing issue. Some studies suggest that color can be used as an indicator for the potential presence of PTEs (linked to chemicals such as lead chromate, cadmium sulfide) but the evidence is not always clear. Another concern is vintage/second-hand toys and jewelry as those items might have been produced before the legislation was present. As total and bioaccessible concentrations of PTEs in toys and jewelry do not always correlate, approaches considering bioaccessibility (e.g. of the E.U.) are more scientifically appropriate and help with better estimation of risk from exposure. Studies on toy and jewelry contamination using in vitro bioaccessibility techniques has become more common, however, there is still no in vitro test specifically designed and validated for toys and jewelry.

Nickel Allergic Contact Dermatitis: Identification, Treatment, and Prevention

Nickel is a ubiquitous metal added to jewelry and metallic substances for its hardening properties and because it is inexpensive. Estimates suggest that at least 1.1 million children in the United States are sensitized to nickel. Nickel allergic contact dermatitis (Ni-ACD) is the most common cutaneous delayed-type hypersensitivity reaction worldwide. The incidence among children tested has almost quadrupled over the past 3 decades. The associated morbidities include itch, discomfort, school absence, and reduced quality of life. In adulthood, individuals with Ni-ACD may have severe disabling hand eczema. The increasing rate of Ni-ACD in children has been postulated to result from early and frequent exposure to metals with high amounts of nickel release (eg, as occurs with ear piercing or with products used daily in childhood such as toys, belt buckles, and electronics).To reduce exposure to metal sources with high nickel release by prolonged and direct contact with human skin, Denmark and the European Union legislated a directive several decades ago with the goal of reducing high nickel release and the incidence of Ni-ACD. Since then, there has been a global reduction in incidence of Ni-ACD in population-based studies of adults and studies of children and young adults being tested for allergic contact dermatitis. These data point to nickel exposure as a trigger for elicitation of Ni-ACD and, further, provide evidence that legislation can have a favorable effect on the economic and medical health of a population.This policy statement reviews the epidemiology, history, and appearances of Ni-ACD. Examples of sources of high nickel release are discussed to highlight how difficult it is to avoid this metal in modern daily lives. Treatments are outlined, and avoidance strategies are presented. Long-term epidemiological interventions are addressed. Advocacy for smarter nickel use is reviewed. The American Academy of Pediatrics supports US legislation that advances safety standards (as modeled by the European Union) that protect children from early and prolonged skin exposure to high-nickel-releasing items. Our final aim for this article is to aid the pediatric community in developing nickel-avoidance strategies on both individual and global levels.

Impact of Heavy Metals on Host Cells: Special Focus on Nickel-Mediated Pathologies and Novel Interventional Approaches

BACKGROUND

Heavy metals [arsenic, aluminium, cadmium, chromium, cobalt, lead, nickel (Ni), palladium and titanium] are environmental contaminants able to impact with host human cells, thus, leading to severe damage.

OBJECTIVE

In this review, the detrimental effects of several heavy metals on human organs will be discussed and special emphasis will be placed on Ni. In particular, Ni is able to interact with Toll-like receptor-4 on immune and non-immune cells, thus, triggering the cascade of pro-inflammatory cytokines. Then, inflammatory and allergic reactions mediated by Ni will be illustrated within different organs, even including the central nervous system, airways and the gastrointestinal system.

DISCUSSION

Different therapeutic strategies have been adopted to mitigate Ni-induced inflammatoryallergic reactions. In this context, the ability of polyphenols to counteract the inflammatory pathway induced by Ni on peripheral blood leukocytes from Ni-sensitized patients will be outlined. In particular, polyphenols are able to decrease serum levels of interleukin (IL)-17, while increasing levels of IL- 10. These data suggest that the equilibrium between T regulatory cells and T helper 17 cells is recovered with IL-10 acting as an anti-inflammatory cytokine. In the same context, polyphenols reduced elevated serum levels of nitric oxide, thus, expressing their anti-oxidant potential. Finally, the carcinogenic potential of heavy metals, even including Ni, will be highlighted.

CONCLUSION

Heavy metals, particularly Ni, are spread in the environment. Nutritional approaches seem to represent a novel option in the treatment of Ni-induced damage and, among them, polyphenols should be taken into consideration for their anti-oxidant and anti-inflammatory activities.

Nickel dermatitis from earrings 15 years after EU directive implementation: a clinical-epidemiological study and a market survey in Rome, Italy

BACKGROUND

Nickel (Ni) dermatitis remains a highly prevalent allergic condition in Italy. There is a continuous need for clinical and epidemiological surveillance to evaluate whether or not European Ni Directive has been effective in contact allergy prevention.

OBJECTIVES

To assess the prevalence of Ni dermatitis among patch-tested patients and self-interviewed school students and to analyse Ni release from earlobe jewellery.

METHODS

Results of patch tests performed in 2006-2007, 2015-2016 and 2017-2018 were retrieved. A questionnaire was compiled by 315 secondary school students. Ni release from earring parts was analysed with the EN1811:2015 method.

RESULTS

A significant time trend of decreasing Ni positivity from 2006-2007 to 2017-2018 was observed both in the overall population (44.1% in 2006-2007, 33.0% in 2015-2016, 31.6% in 2017-2018, P < 0.0001) and in female patients (P < 0.0001). Conversely, change was not significant in males (P = 0.16). Decrease was significant for all age groups, except for those aged >60 years (P = 0.51). Among 242 students who reported earring use, 130 (54%) reported symptoms at earlobes, mostly associated with jewellery of materials other than gold and silver (59% of those with earlobe symptoms). Ni release exceeded the migration limit in 4/21 (20%) earring parts.

CONCLUSIONS

A high prevalence of Ni dermatitis and earlobe symptoms were found in Rome. A decreasing time trend was noted, with a significant decline in Ni sensitivity compared to the situation observed right after Ni Directive implementation. This most likely represents the consequence of reduced Ni content in earring parts, although a major care in the use of Ni-containing objects could contribute to explain these findings.

Electrochemical Screening Spot Test Method for Detection of Nickel and Cobalt Ion Release From Metal Surfaces

BACKGROUND

Present screening methods to rapidly detect release of nickel and cobalt ions from metallic surfaces involve colorimetric dimethylglyoxime (DMG)- and disodium-1-nitroso-2-naphthol-3,6-disulfonate-based spot tests with a cotton bud. There is a risk of false-negative test reactions because test outcomes are dependent on the pressure, area, and duration of surface wiping.

OBJECTIVE

The aim of the study was to develop a miniaturized electrochemical device that uses a voltage to accelerate nickel and cobalt release from the tested item and perform an initial validation.

METHODS AND RESULTS

A device was built in plastic, and its performance was investigated using 0.5 mL of test solutions of, respectively, DMG and disodium-1-nitroso-2-naphthol-3,6-disulfonate. Cotton buds that had been wetted in test solution were pressed against different metal surfaces at various voltages (0-9 V) and a range of test durations (0-120 seconds). Duplicate testing for nickel and cobalt release was also performed on a sample of 163 jewelry items.

CONCLUSIONS

This novel electrochemical device makes it possible to perform nickel and cobalt ion release testing without rubbing, thereby reducing interindividual differences in testing technique. The nickel testing with the device seemed to be superior to conventional DMG spot testing.

Epidemiology of nickel sensitivity: Retrospective cross-sectional analysis of North American Contact Dermatitis Group data 1994-2014

BACKGROUND

Nickel is a common allergen.

OBJECTIVE

To examine the epidemiology of nickel sensitivity in North America.

METHODS

Retrospective, cross-sectional analysis of 44,097 patients patch tested by the North American Contact Dermatitis Group from 1994 to 2014. Nickel sensitivity was defined as a positive patch test for nickel. We evaluated the frequency of nickel sensitivity and patient demographics. For each positive reaction to nickel, we tabulated clinical relevance, occupational relatedness, and exposure sources.

RESULTS

The average frequency of nickel sensitivity was 17.5% (1994-2014). Nickel sensitivity significantly increased over time (from 14.3% in 1994-1996 to 20.1% in 2013-2014 [P < .0001]). Nickel-sensitive patients were significantly more likely to be female, young, nonwhite, and atopic (have eczema and asthma) and/or have dermatitis affecting the face, scalp, ears, neck, arm, or trunk (P values ≤ .0474). Overall, 55.5% of reactions were currently clinically relevant; this percentage significantly increased over time (from 44.1% in 1994-1996 to 51.6% in 2013-2014 [P < .0001]). The rate of occupational relatedness was 3.7% overall, with a significant decrease over time (from 7.9% in 1994-1996 to 1.9% in 2013-2014 [P < .0001]). Jewelry was the most common source of nickel contact.

LIMITATIONS

Tertiary referral population.

CONCLUSIONS

Nickel allergy is of substantial public health importance in North America. The frequency of nickel sensitivity in patients referred for patch testing has significantly increased over a 20-year period.

Cobalt toxicity in humans-A review of the potential sources and systemic health effects

Cobalt (Co) and its compounds are widely distributed in nature and are part of numerous anthropogenic activities. Although cobalt has a biologically necessary role as metal constituent of vitamin B₁₂, excessive exposure has been shown to induce various adverse health effects. This review provides an extended overview of the possible Co sources and related intake routes, the detection and quantification methods for Co intake and the interpretation thereof, and the reported health effects. The Co sources were allocated to four exposure settings: occupational, environmental, dietary and medical exposure. Oral intake of Co supplements and internal exposure through metal-on-metal (MoM) hip implants deliver the highest systemic Co concentrations. The systemic health effects are characterized by a complex clinical syndrome, mainly including neurological (e.g. hearing and visual impairment), cardiovascular and endocrine deficits. Recently, a biokinetic model has been proposed to characterize the dose-response relationship and effects of chronic exposure. According to the model, health effects are unlikely to occur at blood Co concentrations under 300μg/l (100μg/l respecting a safety factor of 3) in healthy individuals, hematological and endocrine dysfunctions are the primary health endpoints, and chronic exposure to acceptable doses is not expected to pose considerable health hazards. However, toxic reactions at lower doses have been described in several cases of malfunctioning MoM hip implants, which may be explained by certain underlying pathologies that increase the individual susceptibility for Co-induced systemic toxicity. This may be associated with a decrease in Co bound to serum proteins and an increase in free ionic Co²⁺. As the latter is believed to be the primary toxic form, monitoring of the free fraction of Co²⁺ might be advisable for future risk assessment. Furthermore, future research should focus on longitudinal studies in the clinical setting of MoM hip implant patients to further elucidate the dose-response discrepancies.

The Health Risk of Cd Released from Low-Cost Jewelry

The composition of the surface layer of 13 low-cost jewelry samples with a high Cd content was analyzed using an energy-dispersive X-ray fluorescence spectrometer (ED XRF). The analyzed jewels were obtained in cooperation with the Czech Environmental Inspectorate. The jewels were leached in two types of artificial sweat (acidic and alkaline) for 7 days. Twenty microliters of the resulting solution was subsequently placed on a paper carrier and analyzed by an LIBS (Laser-Induced Breakdown Spectrometry) spectrometer after drying. The Cd content in the jewelry surface layer detected by using ED XRF ranged from 13.4% to 44.6% (weight per weight—w/w). The samples were subsequently leached in artificial alkaline, and the acidic sweat and leachates were analyzed using laser-induced breakdown spectrometry (LIBS). The amount of released Cd into alkaline sweat ranged from 24.0 to 370 µg Cd per week, respectively 3.23–61.7 µg/cm²/week. The amount of released Cd into acidic sweat ranged from 16.4 to 1517 µg Cd per week, respectively 3.53–253 µg/cm²/week. The limit of Cd for dermal exposure is not unequivocally determined in the countries of the EU (European Union) or in the U.S. Based on the US EPA (United States Environmental Protection Agency) approach used to establish the reference dose (RfD) for Cd contained in food and information about the bioavailability of Cd after dermal exposure, we assessed our own value of dermal RfD. The value was compared with the theoretical amount of Cd, which can be absorbed into the organism from jewelry in contact with the skin. The calculation was based on the amount of Cd that was released into acidic and alkaline sweat. The highest amount of Cd was released into acidic sweat, which represents 0.1% of dermal RfD and into alkaline sweat, 0.5% of dermal RfD. These results indicate that the analyzed jewelry contains Cd over the limit for composition of jewelry available within the territory of the EU. The determined amount of Cd in analyzed jewelry does not, however, pose a threat in terms of non-carcinogenic toxic effects.

Titanium: a review on exposure, release, penetration, allergy, epidemiology, and clinical reactivity

Exposure to titanium (Ti) from implants and from personal care products as nanoparticles (NPs) is common. This article reviews exposure sources, ion release, skin penetration, allergenic effects, and diagnostic possibilities. We conclude that human exposure to Ti mainly derives from dental and medical implants, personal care products, and foods. Despite being considered to be highly biocompatible relative to other metals, Ti is released in the presence of biological fluids and tissue, especially under certain circumstances, which seem to be more likely with regard to dental implants. Although most of the studies reviewed have important limitations, Ti seems not to penetrate a competent skin barrier, either as pure Ti, alloy, or as Ti oxide NPs. However, there are some indications of Ti penetration through the oral mucosa. We conclude that patch testing with the available Ti preparations for detection of type IV hypersensitivity is currently inadequate for Ti. Although several other methods for contact allergy detection have been suggested, including lymphocyte stimulation tests, none has yet been generally accepted, and the diagnosis of Ti allergy is therefore still based primarily on clinical evaluation. Reports on clinical allergy and adverse events have rarely been published. Whether this is because of unawareness of possible adverse reactions to this specific metal, difficulties in detection methods, or the metal actually being relatively safe to use, is still unresolved.