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Contact stomatitis due to palladium in dental alloys: A clinical report
Contact stomatitis due to palladium in dental alloys: A clinical report Valentino Garau, DDS, MS, PhD,a Maria Giulia Masala, DDS,b Maria Cristina Cortis, DDS, PhD,c and Roberta Pittau, DDSd School of Dentistry, University of Cagliari, Cagliari, Italy A patient was treated with a maxillary gold-palladium alloy fixed partial denture (FPD). Shortly after placement, the patient contracted severe contact mucositis. Patch-testing revealed a positive reaction to palladium chloride (PdCl2, 1% petrolatum) but not to any other component of the prosthesis. After removal of the FPD and placement of a provisional acrylic resin restoration, all signs and symptoms disappeared. A definitive metal-ceramic (titanium-porcelain) prosthesis was placed, and no signs of lesions appeared. This clinical report demonstrates that titanium may be a satisfactory alternative for patients who require prostheses and are sensitive to other metals. (J Prosthet Dent 2005;93:318-20.)
I
n the last 3 decades, the development of technology and the rising cost of gold have led to the introduction of other precious metals into gold dental alloys. Palladium (Pd) has emerged as a suitable component of casting alloys due to its lower price compared to gold.1 Because of its chemical and mechanical properties of corrosion resistance, hardness, ductility, and malleability, it is also used in dentistry and fine jewelry, and as a catalyst in the production of electrical contacts and telecommunications systems.2-4 Since Pd intolerance has been reported in the literature primarily in conjunction with nickel (Ni), chromium (Cr), cobalt (Co),2,4 and platinum (Pt) sensitization,1,3 sensitivity reactions only to Pd (monoallergy) are rare,3,5,6 and the rate of Pd mono-allergy has not yet been established. Oral contact mucositis is the typical local manifestation. Clinical signs include swelling, erythema, blisters, papules or ulcerative lesions, gingival bleeding, and wounds within the mouth. The most common symptoms are metal taste, tender teeth, facial pain, a burning tongue, dryness and a burning mouth, jaw pain and tiredness, and toothache.1,3,4,6-8 Oral lichen planus,4,7,9,10 oral lichenoid changes,1,10 and burning mouth syndrome6,9 are also frequently reported. It has been reported that intraoral exposure to allergens may even be linked to cutaneous manifestations such as contact dermatitis,5 eczema,1,2,8 and chronicle urticaria.4,6,8,9 Systemic symptoms that involve joints and muscles, such as chronicle fatigue syndrome, or central nervous system disorders including tiredness, concentration difficulties, vertigo, sleep disturbance, headache, and depression are noted by some authors6 as more frequently observed than local symptoms. Porphyria, an uncommon metabolic disease, has also been reported.11 Similar clinical lesions observed in
patients with no previous contact may be explained by cross-reactivity between Pd and Ni or other transition metals (Group VII of the Periodic Table).2-4,9,12 Titanium, because of its biocompatibility, is an ideal substitute in patients with allergy to other metals.13 A patient’s allergic sensitivity to palladium, identified after the placement of an FPD that was subsequently replaced with a titanium FPD, is reported in this article.
CLINICAL REPORT
Associate Professor, Department of Oral Surgery. Instructor, Department of Prosthetic Dentistry. c Assistant Professor, Department of Oral Pathology. d Instructor, Department of Prosthetic Dentistry.
A 71-year-old woman was referred to the Prosthetic Dentistry Department, School of Dentistry, University of Cagliari, Italy, for a restoration of the natural dentition for esthetic reasons. The patient reported a previous history of sensitization to common allergens such as dust, pollens, and acari, which caused rhinitis and urticaria, but reported no previous sensitization to metal. The patient had worn a gold-resin FPD, bilaterally in the maxillary posterior region, for several years. After consultation with the patient, the treatment included the placement of a porcelain and Au-Pd alloy FPD from right lateral incisor to the left canine. A few days after placement of the prosthesis, the patient experienced generic discomfort intraorally, characterized by slight swelling and itching in the upper lip, xerostomia, and a burning sensation. Within a month, the patient developed severe mucositis (Fig. 1) at sites in close contact with the FPD, especially on the maxillary gingiva. The mucosa was edematous and erythematous, and periodontal probing depths were estimated to be 3 to 4 mm. Since a contact allergy to some component of the prosthesis was suspected, the composition of the cast metal alloy (Ideor-E; Incomet, Milan, Italy) used to fabricate the prosthesis was obtained from the manufacturer (Table I). Patch testing was performed with a complete dental series (Brial Allergen GmbH, Greven, Germany), in addition to PdCl2 1% petrolatum (Trolab; Hermal, Reinbek, Germany). The potential allergens were applied on a textile vehicle (Leukotest, Beiersdorf, Germany), which was mounted on a hypoallergenic
318 THE JOURNAL OF PROSTHETIC DENTISTRY
VOLUME 93 NUMBER 4
a
b
GARAU ET AL
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Clinical manifestations of severe mucositis with Au-Pd dental alloy.
Fig. 2. Healed mucosa after insertion of titanium-porcelain prosthesis.
Table I. Composition of gold-palladium dental alloy as provided by manufacturer
Table II. Dental series materials tested
Metal
Materials
Au Pt Pd In Ga
Percentage
52% 1% 37% 8.6% 1.4%
coating on the patient’s upper back and fixed with an adhesive bandage (Mefix; Molnlycke, Hilden, Germany). The patch tests were removed at day 2 and read at day 3. Patch testing revealed a strong positive reaction (111) only to PdCl2. The complete materials series, patch-tests results, and reading criteria are reported in Table II. The gold-palladium FPD was immediately removed and replaced by a provisional acrylic resin restoration (SR Ivocron; Ivoclar Vivadent, Schaan, Liechtenstein). The patient was also treated with a topical corticosteroid (Cortifluoral; Schering-Plough, Milan, Italy). The oral lesions improved remarkably in a week, with progressive remission of signs and symptoms. In a month, the oral mucosa and periodontium appeared healthy, xerostomia decreased, and the burning sensation disappeared. Finally, a definitive restoration consisting of ceramic (IPS Opaquer pastes; Ivoclar Vivadent) and commercially pure titanium alloy FPD (Rematitan, Grade I; Dentaurum, Ispringen, Germany) was placed. After insertion of the denture, no lesions were found during recall examinations. The oral mucosa has been healthy for 2 years (Fig. 2).
DISCUSSION Since most patients with Pd-contact allergy are also sensitized to Ni or other transition metals, mono-allergy APRIL 2005
Amalgam Mercury Free mercury (amalgam) Mercury ammonium chloride Thimerosal* Benzyl peroxide Bi-phenol-Ay Bi-phenol-A dimethacrylate Ethylenglycol-dimethacrylate Triethylenglycol-dimethacrylate Methyl-methacrylate Tetracaine chloridrate Gold sodium thiosulfate Potassium dicyanoaurate Ammonium tetrachloroplatinate Copper sulfate Nickel sulfate Palladium chloride Tantalum chloride Gallium oxide Indium nitrate Petroleum jelly
Test concentration / vehicle
Patch-test response
5% Petroleum jelly 0.5% Petroleum jelly 20% Petroleum jelly 1% Petroleum jelly 0.05% Petroleum jelly 1% Petroleum jelly 1% Petroleum jelly 2% Petroleum jelly 2% Petroleum jelly 2% Petroleum jelly 2% Petroleum jelly 1% Petroleum jelly 0.25% Petroleum jelly 0.002% Aqueous 0.25% Petroleum jelly
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
1% 5% 1% 1% 1% 5%
Petroleum Petroleum Petroleum Petroleum Petroleum Petroleum 2
jelly jelly jelly jelly jelly jelly
2 2 111 2 2 – 2
Reading criteria: (2), Negative; (1), erythema; (11); erythema and edema; (111); erythema, edema, vesicles, and papules; (1111); large confluent vesicles. *Organic mercury compound. y Acrylic resin monomer.
may be rare. In the literature, there are only a few clinical reports of clinical manifestations, undoubtedly related to Pd (positive response only to PdCl2 patch testing).1-3,5,6 It may be difficult to identify patients who are sensitive to some component of a metal alloy before the placement of a prosthesis. As reported in the literature,2,8 patch testing prior to the placement of a prosthesis is not useful because, in absence of previous 319
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GARAU ET AL
contact with the potential allergen, the response may be negative. Because of the increasing incidence of these allergic manifestations, further investigations of the relationship between transition metals and oral or systemic lesions, histopathological processes, and immunological involvement are needed. Based on the clinical observations presented in the literature6,11 and in this report, it has been suggested that patients with allergic tendencies, sensitization to other transition metals, and/or a history of previous exposure to metal allergens, should be considered at high risk of intolerance to prosthetic metallic components. It may be best to avoid metal alloys containing transition metals such as nickel, chromium, cobalt or platinum, for sensitive patients. Also, it may be best to inform patients about the possible problems of metal sensitivity before prosthesis placement. Evidence suggests that a sensitivity reaction may occur only if a metal corrodes in an application environment.13 Titanium, because of its excellent corrosion resistance and biocompatibility in the oral environment, may be an ideal alternative to precious alloys for patients who require prostheses and are allergic to other metals.
2. Todd DJ, Burrows D. Patch testing with pure palladium metal in patients with sensitivity to palladium chloride. Contact Dermatitis 1992;26: 327-31. 3. Camarasa JG, Burrows D, Menne´ T, Wilkinson JD, Shaw S. Palladium contact sensitivity. Contact Dermatitis 1991;24:370-1. 4. van Joost T, Royesanto-Mahadi ID. Combined sensitization to palladium and nickel. Contact Dermatitis 1990;22:227-8. 5. Katoh N, Hirano S, Kishimoto S, Yasuno H. Dermal contact dermatitis caused by allergy to palladium. Contact Dermatitis 1999;40:226-7. 6. Marcusson JA. Contact allergies to nickel sulfate, gold sodium thiosulfate and palladium chloride in patients claiming side-effects from dental alloy components. Contact Dermatitis 1996;34:320-3. 7. Vilaplana J, Romaguera C, Cornellana F. Contact dermatitis and adverse oral mucous membrane reactions related to the use of dental prostheses. Contact Dermatitis 1994;30:80-4. 8. Morris HF. Veterans Administration cooperative studies project No. 147. Part IV: biocompatibility of base metal alloys. J Prosthet Dent 1987;58: 1-5. 9. Fernandez-Redondo V, Gomez-Centeno P, Toribio J. Chronic urticaria from a dental bridge. Contact Dermatitis 1998;38:178-9. 10. Koch P, Bahmer FA. Oral lesions and symptoms related to metals used in dental restorations: a clinical, allergological, and histologic study. J Am Acad Dermatol 1999;41:422-30. 11. Downey D. Porphyria induced by palladium-copper dental prostheses: a clinical report. J Prosthet Dent 1992;67:5-6. 12. Santucci B, Cannistraci C, Cristaudo A, Picardo M. Multiple sensitivities to transition metals: the nickel-palladium reactions. Contact Dermatitis 1996;35:283-6. 13. Kononen M, Rintanen J, Waltimo A, Kempainen P. Titanium framework removable partial denture used for patient allergic to other metals: a clinical report and literature review. J Prosthet Dent 1995;73:4-7.
SUMMARY
Reprint requests to: DR VALENTINO GARAU DIPARTIMENTO DI SCIENZE ODONTOSTOMATOLOGICHE UNIVERSITA` DEGLI STUDI DI CAGLIARI VIA BINAGHI N° 4, 09121 CAGLIARI, ITALY FAX : 139 070-663122 E-MAIL: [email protected]
A patient requiring rehabilitation of the maxillary arch developed a severe contact mucositis due to the Pd-containing alloy of the prosthesis, which was confirmed by a positive patch-test response to PdCl2. After placement of a provisional acrylic resin restoration, the oral mucosa healed. Subsequently, a ceramic and commercially pure titanium alloy FPD was placed, achieving an excellent result for this allergic patient. This study demonstrates that titanium may be an ideal alternative to precious alloys for patients who are allergic to other metals and require a fixed prosthesis.
0022-3913/$30.00 Copyright Ó 2005 by The Editorial Council of The Journal of Prosthetic Dentistry.
REFERENCES 1. Koch P, Baum HP. Contact stomatitis due to palladium and platinum in dental alloys. Contact Dermatitis 1996;34:253-7.
320
doi:10.1016/j.prosdent.2005.01.002
VOLUME 93 NUMBER 4
I
n the last 3 decades, the development of technology and the rising cost of gold have led to the introduction of other precious metals into gold dental alloys. Palladium (Pd) has emerged as a suitable component of casting alloys due to its lower price compared to gold.1 Because of its chemical and mechanical properties of corrosion resistance, hardness, ductility, and malleability, it is also used in dentistry and fine jewelry, and as a catalyst in the production of electrical contacts and telecommunications systems.2-4 Since Pd intolerance has been reported in the literature primarily in conjunction with nickel (Ni), chromium (Cr), cobalt (Co),2,4 and platinum (Pt) sensitization,1,3 sensitivity reactions only to Pd (monoallergy) are rare,3,5,6 and the rate of Pd mono-allergy has not yet been established. Oral contact mucositis is the typical local manifestation. Clinical signs include swelling, erythema, blisters, papules or ulcerative lesions, gingival bleeding, and wounds within the mouth. The most common symptoms are metal taste, tender teeth, facial pain, a burning tongue, dryness and a burning mouth, jaw pain and tiredness, and toothache.1,3,4,6-8 Oral lichen planus,4,7,9,10 oral lichenoid changes,1,10 and burning mouth syndrome6,9 are also frequently reported. It has been reported that intraoral exposure to allergens may even be linked to cutaneous manifestations such as contact dermatitis,5 eczema,1,2,8 and chronicle urticaria.4,6,8,9 Systemic symptoms that involve joints and muscles, such as chronicle fatigue syndrome, or central nervous system disorders including tiredness, concentration difficulties, vertigo, sleep disturbance, headache, and depression are noted by some authors6 as more frequently observed than local symptoms. Porphyria, an uncommon metabolic disease, has also been reported.11 Similar clinical lesions observed in
patients with no previous contact may be explained by cross-reactivity between Pd and Ni or other transition metals (Group VII of the Periodic Table).2-4,9,12 Titanium, because of its biocompatibility, is an ideal substitute in patients with allergy to other metals.13 A patient’s allergic sensitivity to palladium, identified after the placement of an FPD that was subsequently replaced with a titanium FPD, is reported in this article.
CLINICAL REPORT
Associate Professor, Department of Oral Surgery. Instructor, Department of Prosthetic Dentistry. c Assistant Professor, Department of Oral Pathology. d Instructor, Department of Prosthetic Dentistry.
A 71-year-old woman was referred to the Prosthetic Dentistry Department, School of Dentistry, University of Cagliari, Italy, for a restoration of the natural dentition for esthetic reasons. The patient reported a previous history of sensitization to common allergens such as dust, pollens, and acari, which caused rhinitis and urticaria, but reported no previous sensitization to metal. The patient had worn a gold-resin FPD, bilaterally in the maxillary posterior region, for several years. After consultation with the patient, the treatment included the placement of a porcelain and Au-Pd alloy FPD from right lateral incisor to the left canine. A few days after placement of the prosthesis, the patient experienced generic discomfort intraorally, characterized by slight swelling and itching in the upper lip, xerostomia, and a burning sensation. Within a month, the patient developed severe mucositis (Fig. 1) at sites in close contact with the FPD, especially on the maxillary gingiva. The mucosa was edematous and erythematous, and periodontal probing depths were estimated to be 3 to 4 mm. Since a contact allergy to some component of the prosthesis was suspected, the composition of the cast metal alloy (Ideor-E; Incomet, Milan, Italy) used to fabricate the prosthesis was obtained from the manufacturer (Table I). Patch testing was performed with a complete dental series (Brial Allergen GmbH, Greven, Germany), in addition to PdCl2 1% petrolatum (Trolab; Hermal, Reinbek, Germany). The potential allergens were applied on a textile vehicle (Leukotest, Beiersdorf, Germany), which was mounted on a hypoallergenic
318 THE JOURNAL OF PROSTHETIC DENTISTRY
VOLUME 93 NUMBER 4
a
b
GARAU ET AL
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Clinical manifestations of severe mucositis with Au-Pd dental alloy.
Fig. 2. Healed mucosa after insertion of titanium-porcelain prosthesis.
Table I. Composition of gold-palladium dental alloy as provided by manufacturer
Table II. Dental series materials tested
Metal
Materials
Au Pt Pd In Ga
Percentage
52% 1% 37% 8.6% 1.4%
coating on the patient’s upper back and fixed with an adhesive bandage (Mefix; Molnlycke, Hilden, Germany). The patch tests were removed at day 2 and read at day 3. Patch testing revealed a strong positive reaction (111) only to PdCl2. The complete materials series, patch-tests results, and reading criteria are reported in Table II. The gold-palladium FPD was immediately removed and replaced by a provisional acrylic resin restoration (SR Ivocron; Ivoclar Vivadent, Schaan, Liechtenstein). The patient was also treated with a topical corticosteroid (Cortifluoral; Schering-Plough, Milan, Italy). The oral lesions improved remarkably in a week, with progressive remission of signs and symptoms. In a month, the oral mucosa and periodontium appeared healthy, xerostomia decreased, and the burning sensation disappeared. Finally, a definitive restoration consisting of ceramic (IPS Opaquer pastes; Ivoclar Vivadent) and commercially pure titanium alloy FPD (Rematitan, Grade I; Dentaurum, Ispringen, Germany) was placed. After insertion of the denture, no lesions were found during recall examinations. The oral mucosa has been healthy for 2 years (Fig. 2).
DISCUSSION Since most patients with Pd-contact allergy are also sensitized to Ni or other transition metals, mono-allergy APRIL 2005
Amalgam Mercury Free mercury (amalgam) Mercury ammonium chloride Thimerosal* Benzyl peroxide Bi-phenol-Ay Bi-phenol-A dimethacrylate Ethylenglycol-dimethacrylate Triethylenglycol-dimethacrylate Methyl-methacrylate Tetracaine chloridrate Gold sodium thiosulfate Potassium dicyanoaurate Ammonium tetrachloroplatinate Copper sulfate Nickel sulfate Palladium chloride Tantalum chloride Gallium oxide Indium nitrate Petroleum jelly
Test concentration / vehicle
Patch-test response
5% Petroleum jelly 0.5% Petroleum jelly 20% Petroleum jelly 1% Petroleum jelly 0.05% Petroleum jelly 1% Petroleum jelly 1% Petroleum jelly 2% Petroleum jelly 2% Petroleum jelly 2% Petroleum jelly 2% Petroleum jelly 1% Petroleum jelly 0.25% Petroleum jelly 0.002% Aqueous 0.25% Petroleum jelly
2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
1% 5% 1% 1% 1% 5%
Petroleum Petroleum Petroleum Petroleum Petroleum Petroleum 2
jelly jelly jelly jelly jelly jelly
2 2 111 2 2 – 2
Reading criteria: (2), Negative; (1), erythema; (11); erythema and edema; (111); erythema, edema, vesicles, and papules; (1111); large confluent vesicles. *Organic mercury compound. y Acrylic resin monomer.
may be rare. In the literature, there are only a few clinical reports of clinical manifestations, undoubtedly related to Pd (positive response only to PdCl2 patch testing).1-3,5,6 It may be difficult to identify patients who are sensitive to some component of a metal alloy before the placement of a prosthesis. As reported in the literature,2,8 patch testing prior to the placement of a prosthesis is not useful because, in absence of previous 319
THE JOURNAL OF PROSTHETIC DENTISTRY
GARAU ET AL
contact with the potential allergen, the response may be negative. Because of the increasing incidence of these allergic manifestations, further investigations of the relationship between transition metals and oral or systemic lesions, histopathological processes, and immunological involvement are needed. Based on the clinical observations presented in the literature6,11 and in this report, it has been suggested that patients with allergic tendencies, sensitization to other transition metals, and/or a history of previous exposure to metal allergens, should be considered at high risk of intolerance to prosthetic metallic components. It may be best to avoid metal alloys containing transition metals such as nickel, chromium, cobalt or platinum, for sensitive patients. Also, it may be best to inform patients about the possible problems of metal sensitivity before prosthesis placement. Evidence suggests that a sensitivity reaction may occur only if a metal corrodes in an application environment.13 Titanium, because of its excellent corrosion resistance and biocompatibility in the oral environment, may be an ideal alternative to precious alloys for patients who require prostheses and are allergic to other metals.
2. Todd DJ, Burrows D. Patch testing with pure palladium metal in patients with sensitivity to palladium chloride. Contact Dermatitis 1992;26: 327-31. 3. Camarasa JG, Burrows D, Menne´ T, Wilkinson JD, Shaw S. Palladium contact sensitivity. Contact Dermatitis 1991;24:370-1. 4. van Joost T, Royesanto-Mahadi ID. Combined sensitization to palladium and nickel. Contact Dermatitis 1990;22:227-8. 5. Katoh N, Hirano S, Kishimoto S, Yasuno H. Dermal contact dermatitis caused by allergy to palladium. Contact Dermatitis 1999;40:226-7. 6. Marcusson JA. Contact allergies to nickel sulfate, gold sodium thiosulfate and palladium chloride in patients claiming side-effects from dental alloy components. Contact Dermatitis 1996;34:320-3. 7. Vilaplana J, Romaguera C, Cornellana F. Contact dermatitis and adverse oral mucous membrane reactions related to the use of dental prostheses. Contact Dermatitis 1994;30:80-4. 8. Morris HF. Veterans Administration cooperative studies project No. 147. Part IV: biocompatibility of base metal alloys. J Prosthet Dent 1987;58: 1-5. 9. Fernandez-Redondo V, Gomez-Centeno P, Toribio J. Chronic urticaria from a dental bridge. Contact Dermatitis 1998;38:178-9. 10. Koch P, Bahmer FA. Oral lesions and symptoms related to metals used in dental restorations: a clinical, allergological, and histologic study. J Am Acad Dermatol 1999;41:422-30. 11. Downey D. Porphyria induced by palladium-copper dental prostheses: a clinical report. J Prosthet Dent 1992;67:5-6. 12. Santucci B, Cannistraci C, Cristaudo A, Picardo M. Multiple sensitivities to transition metals: the nickel-palladium reactions. Contact Dermatitis 1996;35:283-6. 13. Kononen M, Rintanen J, Waltimo A, Kempainen P. Titanium framework removable partial denture used for patient allergic to other metals: a clinical report and literature review. J Prosthet Dent 1995;73:4-7.
SUMMARY
Reprint requests to: DR VALENTINO GARAU DIPARTIMENTO DI SCIENZE ODONTOSTOMATOLOGICHE UNIVERSITA` DEGLI STUDI DI CAGLIARI VIA BINAGHI N° 4, 09121 CAGLIARI, ITALY FAX : 139 070-663122 E-MAIL: [email protected]
A patient requiring rehabilitation of the maxillary arch developed a severe contact mucositis due to the Pd-containing alloy of the prosthesis, which was confirmed by a positive patch-test response to PdCl2. After placement of a provisional acrylic resin restoration, the oral mucosa healed. Subsequently, a ceramic and commercially pure titanium alloy FPD was placed, achieving an excellent result for this allergic patient. This study demonstrates that titanium may be an ideal alternative to precious alloys for patients who are allergic to other metals and require a fixed prosthesis.
0022-3913/$30.00 Copyright Ó 2005 by The Editorial Council of The Journal of Prosthetic Dentistry.
REFERENCES 1. Koch P, Baum HP. Contact stomatitis due to palladium and platinum in dental alloys. Contact Dermatitis 1996;34:253-7.
320
doi:10.1016/j.prosdent.2005.01.002
VOLUME 93 NUMBER 4