- Email: [email protected]
Allergic response to stainless steel wire
Allergic response to stainless steel wire Williana R. Schriver, Colonel, DC, USA,* Richard H. Shereff, Major, MC, TJSA,‘” Jefrey M. Domnitz, Major, MC, lJSA,**” Edward P. Xwintak, Lieutenant Colonel, DC, USA,“*** a,nd Simon Civ jan, Colonel, DC, USAL**** SECOND REPUBLIC
GENERAL OF
HOSPITAL,
LANDSTUHL,
RHEINLAND-PFALZ,
FEDERAL
GERMASY
Stainless steel wire is widely used in oral surgery practice and has excellent properties for routine use. Allergic reaction, although usually not a clinical problem, can occur as a result of the nickel constituent, which is a common allergen. A ease is presented to report the occurrence of a clinically significant stainless steel allergy.
N
ickel is one of the most common causes of allergic contact dermatitis, especially in w0men.l Exposure to this metal is virtually inescapable. Once nickel hypersensitivity occurs in the individual, it usually lasts for many years. The type of sensitization is that of a thymus-derived lymphocyte-dependent cellular immunity (Cell and Coombs Type IV hypersensitivity reaction) .’ Persistence of this type of cellular or delayed hypersensitivity appears to be due to the long-lived “memory” lymphocyte in the circulation, capable of recognizing the specific antigens many years after initial exposure. Although attempts to hyposensitize patients with severe allergic contact dermatitis to some substances have been partially successful, multiple graduated doses of injections with nickel salts have failed to desensitize patients to nickel.‘! 3 Despite the use of nickel in producing stainless steel alloys, most nickelsensitive patients are able to tolerahe these materials without difficulty. The crystal lattice of the alloys generally binds the nickel so that it is not free
The opinions and assertions contained herein are not to be construed as official or as reflecting or the Department of Defense. *Chief, Oral Surgery. **Chief, Dermatology. ***Assistant Chief, Dermatology. ****Assistant Chief, Oral Surgery. *****Chief, Department of Dentistry.
578
are the private views of the authors and the views of the Department of the Army
Allergic Table
I. Analysis of wire’ Element Iron Chromium Nickel
response
to stninless
steel wire
579
(case report) Content (%I 67.6 16.9 15.7 100.2t
*Method: Atomic Absorption Spectrophotometry (Tenth Medical Laboratory, J. Yates Dental Manufacturing Germany, APO N. Y. 09180). Manufacturer: (Ihicago, ill. tExcesx due to experimental error.
Landstuhl, Company,
to react1 The Director of Medical Affairs of a stainless steel suture manufacturer has stated that from 1961 to 1973 no allergic reaction to their stainless steel suture has been reported despite a 10 per cent nickel content.4 CASE REPORT A 23.year-old white woman was seen in the Oral Surgery Service for diagnosis and treatment of pain of the right temporomandibular joint region. History revealed multiple episodes of trauma to her face related to interest and activity in sports. She had had increasing symptoms over the last 9 years; these were treated periodically with analgesics, without adequate relief of her subjective complaints. At the time of history she was not on any medication and gave a history of an allergic reaction to penicillin. Physical examination revealed a well-nourished, well-developed 23-year-old female patient, alert, oriented, and cooperative, without distress, with an intermaxillary opening to 55 mm. without deviation and an exaggerated protrusive and lateral range of motion of her mandible. Her neuromuscular examination leas grossly intact. Radiographic examination revealed bilateral hypermolulity of the trmporomandihular joints on opening, extending anterior to the articular tubercles. No osseous disease was noted. Laboratory examination included a complet,e blood count and tests of calcium, phosphorus, alkaline phosphatase, rapid plasma reagin, rheumatoid antigen, all of which were negative or within normal limits. An impression of temporomandibular joint arthritis secondary to hypermobility of the TMJ was made. The patient was counseled as to the indications for immobilization of her mandible and concomitant physiotherapy, and on Nov. 19, 1975, Oliver loops and intermaxillary stainless steel wires were applied in all quadrants in the second premolar and first, molar regions. The content of the wire is indicated in Table I. The patient had relief of her subjective complaint,s and was referred for physiotherapy. On Nov. 11, 1975, she returned with complete remission of her temporomandibular joint complaints, but she mentioned that her “gums felt. raw and sore.” On the evening of Nov. 11, 1975, she again reported to the Oral Surgery Service with moderate distress, complaining of “swelling of the throat, palate, md gums. ” When questioned further, she stated that, as far as she knew, she was allergic to penicillin only; however, she also mentioned that she could not wear earrings in her pierced ears of material other than gold; nor could she wear metal eyeglass frames. The patient stated that stainless steel and silver rings caused “blistering” of her earlobes. At this time, the oral miring was removed and she was treated symptomatically. On Nov. 12, 1975, she returned with marked decrease of edema, and the clinical impression was that of an allergic reaction to the stainless steel wiring. The patient was continued on physical therapy, with marked improvement of her initial subjective complaints. On Nov. 24, 1975, she was skin-tested in the Dermatology Service, which reported a i+ positive patch to nickel and a weakly positive response to silver bromide (as read on Nov. 27, 1975), documenting delayed hypersensitivity response (contact dermatitis) as reported in Table II. She was treated with topical steroids and provided with a nickel-free medic-alert bracelet.
580
Xchriver
Table
Oral Surg. i\joremher, 1976
et al.
II. Skin test (case report)
I. Control 2. Nickel 3. Chromium 4. Silver 5. Manganese 6. Lead 7. Aluminum R. Iron
Skin test metal ions Yellow petrolatum Nickel sulfate (5% aqueoussolution) Potassium dichromate (0.5% aqueous solution) Chromium sulfate (2% aqueoussolution) Silver bromide (2% aqueoussolution) Manganese oxide (pure) Lead acetate (1% aqueous solution) Aluminum acetate (10% aaueoussolution) ’ Ferric chloride (2%.aqueo& solution) Monsel’s solution (as is)
1
Reaction at 72 hr.
0 0
*Weakly positive. Table
Ill. Dimethylglyoxime
(DMG)
spot test*
Solution A--l% dimethylglyoxime in alcoholic solution Solution B-10% ammonium hydroxide solution *A few drops of solution A is applied to metal object followed by a few drops of solution B. Pink to red precipitate signifies the presence of “free” nickel ion. Subsequently, successful intermaxillary fixation was applied with Ethicon 3 mersilene braided suture in the method of Oliver loop-intermaxillary immobilization. DISCUSSION
“Nickel is with you and does things for you from the time you get up in the morning until you go to sleep at night.“5 Our patient probably was sensitized to nickel by ear piercing and rings several years ago. Multiple attempts at allergic history were made before the possibility of stainless steel allergy was considered. This consideration resulted only from her inability to wear earrings with stainless steel posts and metal eyeglasses. The composition of the patient’s “stainless steel” earrings is uncertain and her history is further confused by her positive closed patch tests to two different silver-colored metals. Stainless steel can corrode and release reactive metal salts. The stainless steel wire used for our patient was packaged in 1957. Gross signs of corrosion were not present on other wires from the same package and lot, and dimethylglyoxime spot testing (Table III) for free nickel was negative. Unfortunately, the clinical wire specimens were not tested for corrosion. Analysis of this wire revealed a 15.7 per cent nickel content (Table I). One is cautioned against making an absolute diagnosis of nickel contact dermatitis due to stainless steel in the absence of documentation of corrosion or the presence of free nickel (by the dimethylglyoxime test*, 4). In the light of a strongly positive nickel patch test in a patient who developed marked stomatitis and edema approximately 36 hours after insertion of oral stainless steel wires and with rapid clearing upon removal of the wires, contact dermatitis remains the most likely explanation. The clinician should be aware of delayed hypersensitivity reactions to stainless steel appliances in nickel- or chromate-sensitive individuals. Sensitivity to
Volume Number
‘42 5
Allergic
response
to stainless
steel wire
581
these substances should not be considered a contraindication to the use of stainless steel in these patients due to the rarity of clinically significant sequelae. Care should be exercised to insure that corrosion has not liberated free nickel or chromium salts from the stainless steel crystal lattice. Reactive nic.kel can be inexpensively and rapidly tested by practitioners with the dimethylglyoxime spot test available in nickel test kits. To date, hyposensitization to metal salts appears fruitless. If allergy to stainless steel wire should occur a.t a time when immobilization is essential, consideration of the use of steroid therapy seems most advisable. Delayed hypersensitivity reactions should be suppressed by these agents. SUMMARY
A review of the literature indicates that an allergic response to stainless steel is rare, although nickel is a common allergen and is encountered continually in daily life. An allergic reaction could occur at a most inopportune time. Rational approaches in management of an allergic response to stainless steel appear to be either : (1) wire removal and symptomatic therapy, (2) application of fixation with other substances, or (3) administration of steroids with necessary stainless steel immobilization left in place. The report suggests the need for research to determine the chromium content or chromium-nickel ratio that would eliminate allergic manifestations to the nickel component in wrought or cast base metal dental appliances. The authors express appreciation to Colonel Gelmar S. Lamb-y, Commander, and to Captain Robert I,. Bamberger, Chief, Laboratory Branch, Tenth Medical Laboratory, APO N. Y. 09180, for their cooperation and analysis of the wire specimens. REFERENCES
1. Fisher, A. A.: Contact Dermatitis, ed. 2, Philadelphia, 1973, Lea & Febiger, Publishers. L’. Gell, P. 0. H., and Coombs, R. R. A.: Clinical Aspects of Immunology, ed. 2, Phila~ delphia, 1969, F. A. Davis Company. 3. Kligman, A. M.: Hyposensitization Against Rhus Dermatitis, Arch. Dermatol. 78: 47, 1958. 1. Rrettlr, J.: Survey of the Literature on Metallic Implants, Injury 2: 26-39, 1970. 5. The Romance of Nickel, New York, 1960, International Nickel Co., Inc.
Ecprint requests to: Dr. William R. Schriver Rox 12 Second General Hospital APO N. Y. 09180
GENERAL OF
HOSPITAL,
LANDSTUHL,
RHEINLAND-PFALZ,
FEDERAL
GERMASY
Stainless steel wire is widely used in oral surgery practice and has excellent properties for routine use. Allergic reaction, although usually not a clinical problem, can occur as a result of the nickel constituent, which is a common allergen. A ease is presented to report the occurrence of a clinically significant stainless steel allergy.
N
ickel is one of the most common causes of allergic contact dermatitis, especially in w0men.l Exposure to this metal is virtually inescapable. Once nickel hypersensitivity occurs in the individual, it usually lasts for many years. The type of sensitization is that of a thymus-derived lymphocyte-dependent cellular immunity (Cell and Coombs Type IV hypersensitivity reaction) .’ Persistence of this type of cellular or delayed hypersensitivity appears to be due to the long-lived “memory” lymphocyte in the circulation, capable of recognizing the specific antigens many years after initial exposure. Although attempts to hyposensitize patients with severe allergic contact dermatitis to some substances have been partially successful, multiple graduated doses of injections with nickel salts have failed to desensitize patients to nickel.‘! 3 Despite the use of nickel in producing stainless steel alloys, most nickelsensitive patients are able to tolerahe these materials without difficulty. The crystal lattice of the alloys generally binds the nickel so that it is not free
The opinions and assertions contained herein are not to be construed as official or as reflecting or the Department of Defense. *Chief, Oral Surgery. **Chief, Dermatology. ***Assistant Chief, Dermatology. ****Assistant Chief, Oral Surgery. *****Chief, Department of Dentistry.
578
are the private views of the authors and the views of the Department of the Army
Allergic Table
I. Analysis of wire’ Element Iron Chromium Nickel
response
to stninless
steel wire
579
(case report) Content (%I 67.6 16.9 15.7 100.2t
*Method: Atomic Absorption Spectrophotometry (Tenth Medical Laboratory, J. Yates Dental Manufacturing Germany, APO N. Y. 09180). Manufacturer: (Ihicago, ill. tExcesx due to experimental error.
Landstuhl, Company,
to react1 The Director of Medical Affairs of a stainless steel suture manufacturer has stated that from 1961 to 1973 no allergic reaction to their stainless steel suture has been reported despite a 10 per cent nickel content.4 CASE REPORT A 23.year-old white woman was seen in the Oral Surgery Service for diagnosis and treatment of pain of the right temporomandibular joint region. History revealed multiple episodes of trauma to her face related to interest and activity in sports. She had had increasing symptoms over the last 9 years; these were treated periodically with analgesics, without adequate relief of her subjective complaints. At the time of history she was not on any medication and gave a history of an allergic reaction to penicillin. Physical examination revealed a well-nourished, well-developed 23-year-old female patient, alert, oriented, and cooperative, without distress, with an intermaxillary opening to 55 mm. without deviation and an exaggerated protrusive and lateral range of motion of her mandible. Her neuromuscular examination leas grossly intact. Radiographic examination revealed bilateral hypermolulity of the trmporomandihular joints on opening, extending anterior to the articular tubercles. No osseous disease was noted. Laboratory examination included a complet,e blood count and tests of calcium, phosphorus, alkaline phosphatase, rapid plasma reagin, rheumatoid antigen, all of which were negative or within normal limits. An impression of temporomandibular joint arthritis secondary to hypermobility of the TMJ was made. The patient was counseled as to the indications for immobilization of her mandible and concomitant physiotherapy, and on Nov. 19, 1975, Oliver loops and intermaxillary stainless steel wires were applied in all quadrants in the second premolar and first, molar regions. The content of the wire is indicated in Table I. The patient had relief of her subjective complaint,s and was referred for physiotherapy. On Nov. 11, 1975, she returned with complete remission of her temporomandibular joint complaints, but she mentioned that her “gums felt. raw and sore.” On the evening of Nov. 11, 1975, she again reported to the Oral Surgery Service with moderate distress, complaining of “swelling of the throat, palate, md gums. ” When questioned further, she stated that, as far as she knew, she was allergic to penicillin only; however, she also mentioned that she could not wear earrings in her pierced ears of material other than gold; nor could she wear metal eyeglass frames. The patient stated that stainless steel and silver rings caused “blistering” of her earlobes. At this time, the oral miring was removed and she was treated symptomatically. On Nov. 12, 1975, she returned with marked decrease of edema, and the clinical impression was that of an allergic reaction to the stainless steel wiring. The patient was continued on physical therapy, with marked improvement of her initial subjective complaints. On Nov. 24, 1975, she was skin-tested in the Dermatology Service, which reported a i+ positive patch to nickel and a weakly positive response to silver bromide (as read on Nov. 27, 1975), documenting delayed hypersensitivity response (contact dermatitis) as reported in Table II. She was treated with topical steroids and provided with a nickel-free medic-alert bracelet.
580
Xchriver
Table
Oral Surg. i\joremher, 1976
et al.
II. Skin test (case report)
I. Control 2. Nickel 3. Chromium 4. Silver 5. Manganese 6. Lead 7. Aluminum R. Iron
Skin test metal ions Yellow petrolatum Nickel sulfate (5% aqueoussolution) Potassium dichromate (0.5% aqueous solution) Chromium sulfate (2% aqueoussolution) Silver bromide (2% aqueoussolution) Manganese oxide (pure) Lead acetate (1% aqueous solution) Aluminum acetate (10% aaueoussolution) ’ Ferric chloride (2%.aqueo& solution) Monsel’s solution (as is)
1
Reaction at 72 hr.
0 0
*Weakly positive. Table
Ill. Dimethylglyoxime
(DMG)
spot test*
Solution A--l% dimethylglyoxime in alcoholic solution Solution B-10% ammonium hydroxide solution *A few drops of solution A is applied to metal object followed by a few drops of solution B. Pink to red precipitate signifies the presence of “free” nickel ion. Subsequently, successful intermaxillary fixation was applied with Ethicon 3 mersilene braided suture in the method of Oliver loop-intermaxillary immobilization. DISCUSSION
“Nickel is with you and does things for you from the time you get up in the morning until you go to sleep at night.“5 Our patient probably was sensitized to nickel by ear piercing and rings several years ago. Multiple attempts at allergic history were made before the possibility of stainless steel allergy was considered. This consideration resulted only from her inability to wear earrings with stainless steel posts and metal eyeglasses. The composition of the patient’s “stainless steel” earrings is uncertain and her history is further confused by her positive closed patch tests to two different silver-colored metals. Stainless steel can corrode and release reactive metal salts. The stainless steel wire used for our patient was packaged in 1957. Gross signs of corrosion were not present on other wires from the same package and lot, and dimethylglyoxime spot testing (Table III) for free nickel was negative. Unfortunately, the clinical wire specimens were not tested for corrosion. Analysis of this wire revealed a 15.7 per cent nickel content (Table I). One is cautioned against making an absolute diagnosis of nickel contact dermatitis due to stainless steel in the absence of documentation of corrosion or the presence of free nickel (by the dimethylglyoxime test*, 4). In the light of a strongly positive nickel patch test in a patient who developed marked stomatitis and edema approximately 36 hours after insertion of oral stainless steel wires and with rapid clearing upon removal of the wires, contact dermatitis remains the most likely explanation. The clinician should be aware of delayed hypersensitivity reactions to stainless steel appliances in nickel- or chromate-sensitive individuals. Sensitivity to
Volume Number
‘42 5
Allergic
response
to stainless
steel wire
581
these substances should not be considered a contraindication to the use of stainless steel in these patients due to the rarity of clinically significant sequelae. Care should be exercised to insure that corrosion has not liberated free nickel or chromium salts from the stainless steel crystal lattice. Reactive nic.kel can be inexpensively and rapidly tested by practitioners with the dimethylglyoxime spot test available in nickel test kits. To date, hyposensitization to metal salts appears fruitless. If allergy to stainless steel wire should occur a.t a time when immobilization is essential, consideration of the use of steroid therapy seems most advisable. Delayed hypersensitivity reactions should be suppressed by these agents. SUMMARY
A review of the literature indicates that an allergic response to stainless steel is rare, although nickel is a common allergen and is encountered continually in daily life. An allergic reaction could occur at a most inopportune time. Rational approaches in management of an allergic response to stainless steel appear to be either : (1) wire removal and symptomatic therapy, (2) application of fixation with other substances, or (3) administration of steroids with necessary stainless steel immobilization left in place. The report suggests the need for research to determine the chromium content or chromium-nickel ratio that would eliminate allergic manifestations to the nickel component in wrought or cast base metal dental appliances. The authors express appreciation to Colonel Gelmar S. Lamb-y, Commander, and to Captain Robert I,. Bamberger, Chief, Laboratory Branch, Tenth Medical Laboratory, APO N. Y. 09180, for their cooperation and analysis of the wire specimens. REFERENCES
1. Fisher, A. A.: Contact Dermatitis, ed. 2, Philadelphia, 1973, Lea & Febiger, Publishers. L’. Gell, P. 0. H., and Coombs, R. R. A.: Clinical Aspects of Immunology, ed. 2, Phila~ delphia, 1969, F. A. Davis Company. 3. Kligman, A. M.: Hyposensitization Against Rhus Dermatitis, Arch. Dermatol. 78: 47, 1958. 1. Rrettlr, J.: Survey of the Literature on Metallic Implants, Injury 2: 26-39, 1970. 5. The Romance of Nickel, New York, 1960, International Nickel Co., Inc.
Ecprint requests to: Dr. William R. Schriver Rox 12 Second General Hospital APO N. Y. 09180