Stomatitis or systemically-induced contact dermatitis from metal wire in orthodontic materials

Oral and Extra-Oral Manifestations of Hypersensitivity Reactions in Orthodontics: A Comprehensive Review

Although rare, oral manifestations of hypersensitivity reactions in orthodontic patients pose a significant clinical challenge due to their heterogeneous presentations, and can cause discomfort and pain, possibly impacting patients' quality of life and orthodontic treatment duration and outcomes. This comprehensive review aimed to elucidate the oral, perioral, and systemic manifestations of hypersensitivity reactions in orthodontic subjects, focusing on patients with fixed appliances, removable appliances, and clear aligners, and detailing their epidemiology, macroscopic and microscopic features, allergy testing, clinical implications, and specific management strategies. Oral and extra-oral manifestations of (immediate and delayed) hypersensitivity reactions occur rarely and are due to the release of metal and non-metal ions from orthodontic appliances. They typically present as erythema, erosive-ulcerative lesions, and gingival hyperplasia, with histopathological findings showing inflammatory infiltrates. Nickel is a significant allergen, and diagnostic tests like patch tests are essential for managing these reactions. Likely due to prolonged contact with oral tissues, fixed orthodontic appliances pose a higher risk compared to removable appliances and clear aligners. Early identification and removal of allergenic materials, combined with effective treatments, can resolve symptoms and prevent recurrence. Keeping dental and medical records updated and knowing family and personal medical histories helps clinicians choose appropriate materials and counsel patients about potential risks. Proper patient education, regular monitoring, and using hypoallergenic materials are key strategies for managing these reactions.

Effect of air abrasive polishing on nickel release, stainless steel corrosion, and nickel-titanium archwires

Background

Orthodontic treatment is becoming more and more popular. However, using fixed orthodontic devices for treatment affects oral hygiene and raises the risk of corrosion, plaque-related illnesses, and dental discoloration-related issues. Air abrasive polishing has a superior effect over the conventional method in removing dental deposits. Using fixed orthodontic appliances affects oral hygiene and raises the risk of diseases caused by plaque, tooth discoloration, and corrosion, as well as corrosion by ions. This study evaluated the impact of air polishing on nickel ion release and corrosion from stainless steel, nickel-titanium, coated stainless steel, and coated nickel-titanium.

Methods

A total of 288 (stainless steel, coated stainless-steel, nickel-titanium, and coated nickel-titanium rectangular archwires) of one brand were subjected to varying air abrasion polishing times (5, 10, and 20 seconds). Then, they were submerged in artificial saliva with a pH of 6.75 and incubated for 28 days at 37 °C. The release of nickel ions (Ni2+) was measured using an atomic absorption spectrophotometer at 7, 14, and 28 days to estimate the cumulative effect. The corrosion of the test-selected samples and surface alterations was evaluated using scanning electron microscopy (SEM).

Results

Prolonged polishing significantly increased Ni2+ release and corrosion. Archwires made of coated stainless steel exhibited the least amount of Ni2+ release.

Conclusion

The air polishing process increased the Ni2+ release at a subtoxic level and could be used on adult patients with long gaps between visits with a polishing period of 5 seconds.

Determination of metal ions release from orthodontic archwires in artificial saliva using inductively coupled plasma-optical emission spectrometer (ICP-OES)

Over the last decades many concerns have been raised regarding the migration of potentially toxic metals from the orthodontic appliances to the oral environment due to the dynamic dominant conditions. The current study aimed to investigate the effect of the oral environment acidity and aging time on the ion release from orthodontic archwires. For this purpose, dental archwires consisted of three different alloys were immersed in artificial saliva of varied pH values for 7 and 30 days at 37±1°C. The liquid extracts were then analyzed with inductively coupled plasma-optical emission spectrometer (ICP-OES). It was found that the released ion species and the measured concentrations were not in accordance with manufacturers’ data. Furthermore, the leachates were mainly enriched with Cr and Ni ions by decreasing the saliva pH, while most of the archwires released the highest amounts of Ni, Mn and Cr ions after 30 days aging at pH = 3.5. Independent of the material type or the aging conditions, the total release of Ni and Cr ions was within the considered average dietary intake levels.

A comprehensive summary of disease variants implicated in metal allergy

Allergic disease represents one of the most prominent global public health crises of the 21^st century. Although many different substances are known to produce hypersensitivity responses, metals constitute one of the major classes of allergens responsible for a disproportionately large segment of the total burden of disease associated with allergy. Some of the most prevalent forms of metal allergy - including allergic contact dermatitis - are well-recognized; however, to our knowledge, a comprehensive review of the many unique disease variants implicated in human cases of metal allergy is not available within the current scientific literature. Consequently, the main goal in composing this review was to (1) generate an up-to-date reference document containing this information to assist in the efforts of lab researchers, clinicians, regulatory toxicologists, industrial hygienists, and other scientists concerned with metal allergy and (2) identify knowledge gaps related to disease. Accordingly, an extensive review of the scientific literature was performed - from which, hundreds of publications describing cases of metal-specific allergic responses in human patients were identified, collected, and analyzed. The information obtained from these articles was then used to compile an exhaustive list of distinctive dermal/ocular, respiratory, gastrointestinal, and systemic hypersensitivity responses associated with metal allergy. Each of these disease variants is discussed briefly within this review, wherein specific metals implicated in each response type are identified, underlying immunological mechanisms are summarized, and major clinical presentations of each reaction are described.Abbreviations: ACD: allergic contact dermatitis, AHR: airway hyperreactivity, ASIA: autoimmune/ autoinflammatory syndrome induced by adjuvants, BAL: bronchoalveolar lavage, CBD: chronic beryllium disease, CTCL: cutaneous T-cell lymphoma, CTL: cytotoxic T-Lymphocyte, DRESS: drug reaction with eosinophilia and systemic symptoms, GERD: gastro-esophageal reflux disease, GI: gastrointestinal, GIP: giant cell interstitial pneumonia, GM-CSF: granulocyte macrophage-colony stimulating factor, HMLD: hard metal lung disease, HMW: high molecular weight, IBS: irritable bowel syndrome, Ig: immunoglobulin, IL: interleukin, LMW: low molecular weight, PAP: pulmonary alveolar proteinosis, PPE: personal protective equipment, PRR: pathogen recognition receptor, SLE: systemic lupus erythematosus, SNAS: systemic nickel allergy syndrome, Th: helper T-cell, UC: ulcerative colitis, UV: ultraviolet.

Systemic Contact Dermatitis: The Routes of Allergen Entry

Systemic contact dermatitis (SCD) is a generalized reactivation of type IV hypersensitivity skin diseases in individuals with previous sensitization after a contact allergen is administered systemically. Patients with SCD may consider their dermatitis unpredictable and recalcitrant since the causative allergens are difficult to find. If a patient has a pattern of dermatitis suggestive of SCD but fails to improve with conventional treatment, SCD should be taken into consideration. If doctors are not familiar with the presentations of SCD and the possible routes of allergen sensitization and exposure, the diagnosis of SCD may be delayed. In this work, we summarized all of the routes through which allergens can enter the body and cause SCD, including oral intake, local contact (through skin, inhalation, nasal spray and anal application), implants, and other iatrogenic or invasive routes (intravenous, intramuscular, intraarticular, and intravesicular). This will provide a comprehensive reference for the clinicians to identify the culprit of SCD.

Contact Dermatitis: Classifications and Management

Contact dermatitis (CD) is a common inflammatory skin disease caused by exposure to contact allergens and irritants. It is also the most common reason of occupational dermatitis and contributes greatly to hand dermatitis and facial dermatitis. Besides the two major forms of contact dermatitis: allergic contact dermatitis and irritant contact dermatitis, other subtypes of CD have been recognized including immediate skin reactions, photoinduced contact dermatitis, systemic contact dermatitis, and non-eczematous contact dermatitis. CD is a great imitator which can mimic many kinds of skin diseases, such as atopic dermatitis, lichen planus, and angioedema. For the diagnosis of CD, a complete medical history, including occupational history, is very important. It can give a clue of CD and provide a list of suspected substances. Besides the well-known diagnostic test, patch testing, there are many other diagnostic tests can be used to help diagnosis of CD and identify the causative allergens, including photopatch test, skin tests for detecting of immediate contact reactions, serum allergen-specific IgE test, and qualitative and quantitative testing of allergen in the suspected materials patients exposed to and challenge test. Before the treatment, the suspected irritants or allergens should be avoided completely. This includes both the removal of the patient from the environment that contains those substances and the promotion of the metabolism and expulsion of the allergens that have been absorbed by the body. In addition, it is also important to restore the skin barrier and reduce skin inflammation through multiple treatments, such as emollients, topical corticosteroids, and antihistamines, as well as systemic corticosteroids and immunosuppressants. Early and appropriate treatments are important to prevent further deterioration and persistence of the skin condition.

Physiochemical characterization and toxicity assessment of colloidal mercuric formulation-'Sivanar amirtham'

The study aims to characterize and understand the toxicological effects of colloidal mercuric formulation. The physiochemical characterization was carried out using Fourier transform infrared spectroscopy (FTIR), X-ray photoelectron spectroscopy (XPS), Energy dispersive X-ray microanalysis system (EDS), Inductively coupled plasma optical emission spectrometry (ICP-OES), X-ray diffraction (XRD), Zeta potential, Brunauer-Emmett-Teller (BET) and electron microscopy. Based on the physiochemical characterizations, the pairwise relationship between the parameters such as size, surface area, surface charge, reactivity and band gap energy were described. The biological effects of the sample were studied by both in vitro and in vivo assays. The in vitro cytotoxicity assay confirmed that the colloidal mercuric formulation was effective against cancer cells (MCF-7) and less toxic to normal cells (Hek 293). The formulation was effective against MCF-7 with more than 85% of apoptotic and necrotic cells, positive for PI staining when treated with 100 μg/mL. The inflammatory response on the macrophage cell lines was studied. The colloidal mercuric formulation upregulated the expression of TGF-β, IL-6 and TNF-α, due to the presence of arsenic and other organic compounds such as piperine. The in vivo developmental toxicity was observed in Zebrafish hampered growth and survival in a dose and time dependent manner. The formulation was safe at lower concentration and exhibit a dose and time dependent toxicity. Based on the results obtained, it is confirmed that the selective toxicity towards MCF-7 cells is promising to develop an effective formulation for the treatment of cancer, provided more such proofs obtained from in vivo experiments.

Comparison of changes in irregularity and transverse width with nickel-titanium and niobium-titanium-tantalum-zirconium archwires during initial orthodontic alignment in adolescents: A double-blind randomized clinical trial

OBJECTIVES

The purpose of this prospective, double-blind, randomized clinical trial was to compare the clinical efficiency of nickel-titanium (NiTi) and niobium-titanium-tantalum-zirconium (TiNbTaZr) archwires during initial orthodontic alignment.

MATERIALS AND METHODS

All subjects (ages between 12 and 20 years) underwent nonextraction treatment using 0.022-inch brackets. All patients were randomized into two groups for initial alignment with 0.016-inch NiTi archwires (n = 14), or with 0.016-inch TiNbTaZr archwires (n = 14). Digital scans were taken during the course of treatment and were used to compare the improvement in Little's Irregularity Index and the changes in intercanine and intermolar widths.

RESULTS

There was approximately a 27% reduction in crowding during the first month with the use of 0.016-inch TiNbTaZr (Gummetal) wire, and an additional 25% decrease in crowding was observed during the next month. There was no significant difference between the two treatment groups in the decrease in irregularity over time ( P = .29). There was no significant difference between the two groups in the changes in intercanine and intermolar width ( P = .80).

CONCLUSIONS

It can be concluded that Gummetal wires and conventional NiTi wires possess a similar ability to align teeth, and Gummetal wires have additional advantages over conventional NiTi, such as formability and use in patients with nickel allergy.

Evaluation of determinants for the nickel release by the standard orthodontic brackets

AIM

The study was aimed to assess the effect of different pH and immersion time on the amount of nickel release from simulated orthodontic appliance of 3M Unitek company.

MATERIAL AND METHOD

Nickel ion release was evaluated after subjecting the brackets to the simulated artificial oral environment. In this study, 90 stainless steel brackets of 3M Unitek Company were tested by immersing them in artificial saliva of pH 4.2, pH 6.5 and pH 7.6 for a time interval of 1hour, 1 week and 1 month (T1 - 1h, T2 - 7 days, T3 - 30 days) respectively. The data was subjected for the one-way ANOVA and the post-hoc test for the statistical comparison.

RESULTS

Means of 2.99±0.77, 9.53±4.26 and 12.65±2 .52 ppb (parts per billion by volume) of nickel were released for 4.2 pH at a time interval of 1hour, 7 days and 1 month respectively. Means of 5.37±2.26, 10.94±1.51 and 16.92±1.69 ppb of nickel were released for 6.5 pH at a time interval of 1hour, 7 days and 1 month respectively. A mean of 2.13±0.92, 0.74±0.54 and 18.83±1.02 ppb of nickel was released for 7.6 pH at a time interval of 1 hr, 7 days and 1 month respectively.

CONCLUSION

pH of the artificial saliva significantly affected the amount of nickel release. Acidic pH was found to increase the amount of nickel release in the artificial saliva. Time duration of bracket immersion significantly affected the amount of nickel release.

Benign reactive lymphadenopathy associated with submandibular gland enlargement during orthodontic treatment

Lymphadenopathy may be caused due to various reasons, most common being infections, neoplasms and immunologic disorders. Considering the frequent use of biomaterials in dentistry, it is not uncommon to find allergic reactions in the oral mucosa. Delayed-type hypersensitivity is one mechanism of allergy, which may manifest as either contact stomatitis or rarely present as only lymphadenopathy. An unusual case of unilateral submandibular gland swelling with associated lymphadenopathy during orthodontic treatment is reported. The processes followed in the differential diagnosis of the condition have been elucidated. Delayed hypersensitivity as a possible causative factor has been discussed. The article highlights the possibility of such conditions manifesting at any time during orthodontic therapy.

The effect of orthodontic therapy on periodontal health: a review of the literature

Objectives. This review aims to evaluate the effect of orthodontic therapy on periodontal health. Data. Original articles that reported on the effect of orthodontic therapy on periodontal health were included. The reference lists of potentially relevant review articles were also sought. Sources. A literature search was conducted using the databases, Medline, EMBASE, Cochrane Library, Web of Science, Google Scholar, and Scopus databases for relevant studies. The search was carried out by using a combined text and the MeSH search strategies: using the key words in different combinations: “periodontal disease,” “orthodontics” and “root resorption.” This was supplemented by hand-searching in peer-reviewed journals and cross-referenced with the articles accessed. Articles published only in English language were included. Letters to the Editor, historical reviews and unpublished articles were not sought. Conclusions. Within the limitations of the present literature review, it was observed that there is a very close inter-relationship between the periodontal health and the outcome of orthodontic therapy.

PIXE ANALYSIS OF BLOOD SAMPLES OF ORTHODONTIC PATIENTS TO DETECT Ni POISONING

The present study was carried out with the aim to determine if, orthodontic patients accumulate measurable concentration of Ni in blood or not, since the recent evidences shows the allergenic actions of Ni in various forms and orthodontic appliances have been reported to produce Ni allergy. In our experiment, the blood samples were taken before the insertion of appliance and at an interval of 6 months over a total time period of 18 months (four sets) from the Oral Health Department of Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India. In all the four sets of blood samples the common trace elements were detected viz. S , K , Ca , Cr , Fe , Cu , Zn and Br . Our result shows the complete absence of Ni in the blood.

Systemic contact dermatitis

Systemic contact dermatitis is an inflammatory skin disease that may occur in persons with contact allergy when they are exposed to the hapten orally, transcutaneously, per rectum, intravesically, intravenously, or by inhalation. The most common causes of systemic contact dermatitis are drugs used both topically and systemically. Other causes are ubiquitously occurring haptens, such as the metals nickel, cobalt, gold, and chromate, and aromatic substances such as spices. Avoidance of the offending hapten is the most obvious treatment. For some haptens, such as nickel, diet treatment may be effective. Chelation therapy with disulfiram is another therapeutic option in nickel-allergic patients with systemic contact dermatitis. Hyposensitization therapy has been attempted with some success in systemic contact dermatitis caused by nickel and Parthenium hysterophorus.

Cytocompatibility of medical biomaterials containing nickel by osteoblasts: a systematic literature review

The present review is based on a survey of 21 studies on the cytocompatibility of medical biomaterials containing nickel, as assessed by cell culture of human and animal osteoblasts or osteoblast-like cells. Among the biomaterials evaluated were stainless steel, NiTi alloys, pure Ni, Ti, and other pure metals. The materials were either commercially available, prepared by the authors, or implanted by various techniques to generate a protective layer of oxides, nitrides, acetylides. The observation that the layers significantly reduced the initial release of metal ions and increased cytocompatibility was confirmed in cell culture experiments. Physical and chemical characterization of the materials was performed. This included, e.g., surface characterization (roughness, wettability, corrosion behavior, quantity of released ions, microhardness, and characterization of passivation layer). Cytocompatibility tests of the materials were conducted in the cultures of human or animal osteoblasts and osteoblast-like cells. The following assays were carried out: cell proliferation and viability test, adhesion test, morphology (by fluorescent microscopy or SEM). Also phenotypic and genotypic markers were investigated. In the majority of works, it was found that the most cytocompatible materials were stainless steel and NiTi alloy. Pure Ni was rendered and less cytocompatible. All the papers confirmed that the consequence of the formation of protective layers was in significant increase of cytocompatibility of the materials. This indicates the possible further modifications of the manufacturing process (formation of the passivation layer).

Cutaneous and systemic hypersensitivity reactions to metallic implants

Cutaneous reactions to metal implants, orthopedic or otherwise, are well documented in the literature. The first case of a dermatitis reaction over a stainless steel fracture plate was described in 1966. Most skin reactions are eczematous and allergic in nature, although urticarial, bullous, and vasculitic eruptions may occur. Also, more complex immune reactions may develop around the implants, resulting in pain, inflammation, and loosening. Nickel, cobalt, and chromium are the three most common metals that elicit both cutaneous and extracutaneous allergic reactions from chronic internal exposure. However, other metal ions as well as bone cement components can cause such hypersensitivity reactions. To complicate things, patients may also develop delayed-type hypersensitivity reactions to metals (ie, in-stent restenosis, prosthesis loosening, inflammation, pain, or allergic contact dermatitis) following the insertion of intravascular stents, dental implants, cardiac pacemakers, or implanted gynecologic devices. Despite repeated attempts by researchers and clinicians to further understand this difficult area of medicine, the association between metal sensitivity and cutaneous allergic reactions remains to be fully understood. This review provides an update of the current knowledge in this field and should be valuable to health care providers who manage patients with conditions related to this field.

Nickel release from new conventional stainless steel, recycled, and nickel-free orthodontic brackets: An in vitro study

INTRODUCTION

The aim of this study was to compare the nickel released from 3 kinds of orthodontic brackets: new conventional stainless steel, recycled stainless steel, and nickel-free brackets.

METHODS

This in-vitro study was performed by using a classic batch procedure. Samples were immersed in artificial saliva at various acidities (pH 4.2, 6.5, 7.6) over an extended time interval (0.25, 1, 24, 48, and 120 hours). The amount of nickel released was determined by using an atomic absorption spectrophotometer and an inductively coupled plasma atomic emission spectrometer. Statistical analysis included a linear regression model for repeated measures, with calculation of Huber White robust standard errors to account for intrabracket correlation of data. For post-hoc comparisons, the Bonferroni correction was applied.

RESULTS

The recycled brackets released the most nickel (74.02 +/- 170.29 microg per gram); the new stainless steel brackets released 7.14 +/- 20.83 microg per gram. The nickel-free brackets released the least nickel (0.03 +/- 0.06 microg per gram). All the differences among the groups were statistically significant (P = 0.000).

CONCLUSIONS

Reconditioned brackets released the most nickel. Moreover, the highest nickel release was recorded in the 2 experiments performed at pH 4.2; it was lower at pH 6.5 and 7.6. Conversely, no relevant differences were observed overall between the maxillary and mandibular arches.

Type of archwire and level of acidity: effects on the release of metal ions from orthodontic appliances

OBJECTIVE

To examine the effects of three different parameters-pH value, type of archwire, and length of immersion-on release of metal ions from orthodontic appliances.

MATERIALS AND METHODS

Simulated fixed orthodontic appliances that corresponded to one-half of the maxillary arch were immersed in artificial saliva of different pH values (6.75 +/- 0.15 and 3.5 +/- 0.15) during a 28-day period. Three types of archwires were used: stainless steel (SS), nickel-titanium (NiTi), and thermo NiTi. The quantity of metal ions was determined with the use of a high-resolution mass spectrophotometer (HR-ICP/MS).

RESULTS

The release of six different metal ions was observed: titanium (Ti), chromium (Cr), nickel (Ni), iron (Fe), copper (Cu), and zinc (Zn). Repeated measures statistical analysis of variance (ANOVA) was used. Results showed that (1) the appliances released measurable quantities of all ions examined; (2) the change in pH had a very strong effect (up to 100-fold) on the release of ions; and (3) the release of ions was dependent on wire composition, but it was not proportional to the content of metal in the wire. The largest number of ions was released during the first week of appliance immersion.

CONCLUSION

Levels of released ions are sufficient to cause delayed allergic reactions. This must be taken into account when type of archwire is selected, especially in patients with hypersensitivity or compromised oral hygiene.

Management of contact dermatitis due to nickel allergy: an update

Nickel is the major cause of allergic contact dermatitis in the general population, both among children and adults, as well as in large occupational groups. This metal is used in numerous industrial and consumer products, including stainless steel, magnets, metal plating, coinage, and special alloys, and is therefore almost impossible to completely avoid in daily life. Nickel contact dermatitis can represent an important morbidity, particularly in patients with chronic hand eczema, which can lead to inability to work, a decrease in quality of life and significant healthcare expenses. Therefore, its management is of great importance. This article reviews diagnostic, preventive and therapeutic strategies in this field.

Other Allergic Skin Disorders

In this chapter we discuss allergic skin disorders other than atopic dermatitis (AD): the urticaria-angioedema syndrome, allergic contact dermatitis (ACD), protein contact dermatitis (PCD), phytodermatitis, allergic photodermatitis and allergic vasculitis.

The safety of nickel containing dental alloys

Nickel is a constituent of many dental alloys. This paper reviews mainly papers published after 1985 with regards to biological reactions to nickel in dentistry. Nickel is an allergen, but there is no evidence that individual patients are at a significant risk of developing sensitivity solely due to contact with nickel-containing dental appliances and restorations. Hypersensitivity reactions to nickel are only likely to occur with prior sensitization from non-dental contacts and even these are rare. Clinical evidence has been presented to show that small doses of nickel, e.g. from dental appliances, may induce tolerance to this allergen. The papers reviewed report low rates of release of nickel from dental alloys. Some nickel compounds, which are mildly cytotoxic, have been implicated as carcinogens by inhalation in industrial settings, but these compounds are not present in dentistry-related operations, including dental technology procedures. Nickel-containing alloys and compounds have not been associated with increased cancer risk by oral or dermal routes of exposure. It is concluded that, subject to use according to established techniques, nickel-containing dental alloys do not pose a risk to patients or members of the dental team.

Sensitization to nickel: etiology, epidemiology, immune reactions, prevention, and therapy

Nickel is a contact allergen causing Type I and Type IV hypersensitivity, mediated by reagins and allergen-specific T lymphocytes, expressing in a wide range of cutaneous eruptions following dermal or systemic exposure. As such, nickel is the most frequent cause of hypersensitivity, occupational as well as among the general population. In synoptic form, the many effects that nickel has on the organism are presented to provide a comprehensive picture of the aspects of that metal with many biologically noxious, but metallurgically indispensable characteristics. This paper reviews the epidemiology, the prognosis for occupational and non-occupational nickel allergic hypersensitivity, the types of exposure and resulting immune responses, the rate of diffusion through the skin, and immunotoxicity. Alternatives toward prevention and remediation, topical and systemic, for this pervasive and increasing form of morbidity are discussed. The merits and limitations of preventive measures in industry and private life are considered, as well as the effectiveness of topical and systemic therapy in treating nickel allergic hypersensitivity.

Release of elements from retrieved maxillofacial plates and screws

Vitallium appliances and surrounding tissues were investigated to evaluate the release and accumulation of elements. Four microplates, sixteen screws and surrounding tissues were removed from three patients presenting inflammation 4 to 6 years after surgery and were submitted to SEM and X-ray microprobe analysis. Histology was performed on paraffin or PMMA sections of tissues.A continuous release of elements from metallic appliances into soft tissues was observed. Cobalt, chromium, and nickel were detected in soft and boney tissues in close proximity to the appliance. Aluminium, as a component of screw coatings, accumulated in soft tissues, and a remarkable amount of aluminium was detected in the dense lamella of lamellar bone. The results suggest that coatings containing aluminium should be avoided and the time these appliances are allowed to remain in patients should be shortened. Further studies on element release and the fate of aluminium in bone are warranted.

Accumulation of aluminium in lamellar bone after implantation of titanium plates, Ti-6Al-4V screws, hydroxyapatite granules

Titanium plates, Ti6Al4V screws and surrounding tissues, and biopsies of hydroxyapatite (Osprovit) grafts of maxillary sinus lifting were investigated to evaluate the release and accumulation of ions. Optical microscopy, SEM and X-ray microanalysis were carried out to evaluate the plates and screws removed from patients presenting inflammation and biopsies. Ions release from metallic appliances or leaching from granules towards soft tissues was observed. An accumulation of aluminium but not titanium was found in soft tissues. A peculiar accumulation of aluminium in the dense lamella of newly formed bone was recorded. The results seem to indicate that biological perturbations may be related to aluminium release from the tested biomaterials. The aluminium content of these biomaterials, its diffusion and accumulation are discussed. Further studies on ion release from biomaterials and aluminium fate in skeletal tissues are suggested.

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

OBJECTIVES

Since all dental materials pose a potential risk to patients and members of the dental team, the post-market monitoring of adverse reactions caused by dental materials should be considered essential. This article reviews the current status of post-market monitoring of adverse reactions to dental materials and highlights some of the issues that arise in trying to establish an evidence base on the characteristics of adverse reactions to dental materials.

METHODS

Norway, Sweden and more recently the UK have sought to monitor adverse reactions to dental materials systematically and proactively in an effort to add to the evidence base on the safety of dental materials. Their experiences in undertaking post-market surveillance have been combined in preparing this article.

RESULTS

To date the Norwegian, Swedish and the UK projects has received 1268 reports over 11 years, 848 reports over 5.5 years and 1117 reports over 3 years, respectively, relating to adverse reactions seen or experienced by dental personnel and patients. Presently, there are no harmonized criteria for what can be classified as an adverse reaction related to dental materials. Under reporting is a recognised problem and lack of awareness and lack of clarity as to what constitutes an adverse reaction may be contributory factors. A pro-active reporting system takes a considerable time to become established, but can generate a lot of potentially useful information.

CONCLUSIONS

There is a need to raise the awareness among dental professionals of the potential for adverse reactions due to dental materials and to develop an internationally accepted system of data gathering that can produce the evidence that reflect the extent, severity and incidence of adverse reactions to dental materials.