**6.2 Case 2: 62-year-old male who requested dental implant treatment**

This patient had no past history of drug or food allergies and did not have allergic rhinitis. He became aware of his dermatitis symptoms on general skin in 1999 and was given external steroid medications at the dermatology clinic. Since he did not recover from his symptoms, he visited a general hospital in 2000 and was diagnosed with photodermatosis. At the hospital he was administered steroids, but exhibited no remarkable recovery. In 2002, he visited another dermatological clinic and was given external steroids and anti-allergic drugs, however, his symptoms remained. In 2005, he visited Tokushima University Hospital to ask for dental implant treatment. After examination by a dentist, the patient was referred to the Dental Metal Allergy Clinic.

### Prognosis

Results of the patch test revealed that the patient had allergy-positive reactions to various kinds of metal reagents. An ultraviolet light test exhibited erythema with more than 5 minutes exposure to ultraviolet A (2.1 J/cm2) and 50 seconds to ultraviolet B (35 J/cm2). The

(a) Before dental treatment (b) After dental treatment

Fig. 15. Intraoral picture, and photos of the ear and back before and after the dental treatment.

Dental Metal Allergy 107

specialists who can take over these treatment regimens. Current data indicate that practicing dentists need obtain further specialized knowledge about dental metal allergy in order to

All treatments that employ dental metal materials have the potential to cause allergic symptoms, and thus, proper preventive measures and treatment plans are required for these allergy patients. The results of our current research demonstrate the necessity for educating

Akyol, A.,A. Boyvat,Y. Peksari & E. Gurgey (2005). Contact sensitivity to standard series

Davies, R. J.,B. T. Butcher & J. E. Salvaggio (1977). Occupational asthma caused by low

Davis, M. D.,K. Bhate,A. L. Rohlinger,S. A. Farmer,D. M. Richardson & A. L. Weaver (2008).

Fleischmann, P. (1928). Zur Frage der Gefährlichkeit Kleinster Quecksilbermengen, *Dtsch* 

Gawkrodger, D. J. (2005). Investigation of reactions to dental materials, *Br J Dermatol* (153):

Geurtsen, W. (2002). Biocompatibility of dental casting alloys, *Crit Rev Oral Biol Med* (13): 71-

Hamano, H.,K. Uoshima,W. P. Miao,T. Masuda,M. Matsumura,H. Hani,H. Kitazaki & M.

Hosoki, M.,E. Bando,K. Asaoka,H. Takeuchi & K. Nishigawa (2009). Assessment of allergic

Hosoki, M.,E. Bando,M. Nakano,K. Nishigawa,K. Okura & Y. Yamazaki (2002). A clinical

Hubler, W. R., Jr. & W. R. Hubler, Sr. (1983). Dermatitis from a chromium dental plate,

Inoue, M. (1993). The Status Quo of Metal Allergy and Measures Against it in Dentistry,

Ishii, N.,H. Ishii,H. Ono,Y. Horiuchi,H. Nakajima & I. Aoki (1990). Genetic control of nickel

Jean-Marie Lachapelle & H. I. Maibach (2009). *Patch Testing and Prick Testing: A Practical* 

sulfate delayed-type hypersensitivity, *J Invest Dermatol* (94): 673-6.

*Guide Official Publication of ICDRG*, Springer, Heidelberg.

hypersensitivity to dental materials, *Biomed Mater Eng* (19): 53-61.

Inoue (1998). [Investigation of metal allergy to constituent elements of intraoral

investigation for the patients with dental metal allergy, *Journal of Dental Research*

molecular weight chemical agents, *J Allergy Clin Immunol* (60): 93-5.

allergens in 1038 patients with contact dermatitis in Turkey, *Contact Dermatitis* (52):

Delayed patch test reading after 5 days: the Mayo Clinic experience, *J Am Acad* 

all dental practitioners in the recognition and treatment of dental metal allergy.

ensure the correct treatment of patients in their clinics.

**8. Conclusion** 

**9. References** 

333-7.

479-85.

(81): 412.

84.

*Dermatol* (59): 225-33.

*Med Wochen scher* (54): 304

*Contact Dermatitis* (9): 377-83.

*J.Jpn.Prosthodont.Soc* (37): 1127-1138.

Fisher, A. A. (1973). *Contact Dermatitis,Second Ed.*, NY.

Groot, A. C. d. 2008. Patch Testing. Amsterdam: ELSEVIER.

restoration materials], *Kokubyo Gakkai Zasshi* (65): 93-9.

minimal erythema dose was smaller with ultraviolet A. This patient was diagnosed as having complication dermatitis with photodermatosis, and dental metal allergy.

Subsequently, we then began to remove all metal restorations that contained allergypositive metal elements. After removal of a fixed prosthesis and extraction of some of his teeth, a removable prosthesis with a non-metal clasp (Jeneric/Pentron, Wallingford, CT, USA) was fabricated. Porcelain fused to zirconium crowns were attached to the patient after complete removal of all of his metal restorations. In conjunction with the progress of the dental treatment, the previously exhibited erythema and swelling gradually reduced, and the prurigo in the local region recovered. The figure 15 shows an intraoral picture and the skin symptoms before and after the dental treatment. Clear recovery of the dermatitis was observed except the neck region that was exposed to sunlight. In this case, the exclusion of the intraoral metal restorations resulted in the healing of the patient's chronic and intractable dermatitis.

#### **7. Discussion**

Recently, the number of dental metal allergy patients along with the number of cases that practicing dentists have referred to our special outpatient section have increased. While the cause of this increase is not clear at the present time, suspicions have been raised about the effects of the popularization of pierced earrings as one of the potential causes. In Japan, ear/body piercings since the 1990s have been the cause of nickel allergies in female patients. It is possible that lifestyle choices could be one of the factors responsible for this high prevalence of dental metal allergy. Nickel hypersensitivity is one of the most common metal allergies, and we have documented a high positive reaction rate to nickel reagents. (Hosoki et al., 2009). Larsson-Stymne et al. reported finding a relationship between pierced earrings and nickel allergies (Larsson-Stymne&Widstrom, 1985). Sivertsen et al. also has reported finding the nickel allergy to be associated with pierced ears rather than either local pollution or atopic dermatitis (Smith-Sivertsen et al., 1999). Jensen et al. demonstrated there was a decrease in nickel sensitization in Danish schoolgirls whose ears had been pierced after implementation of the nickel-exposure regulations in 1992 (Jensen et al., 2002). These findings have led to other European countries to regulate exposure to nickel, and in the future, similar regulations may be enacted in Japan. One other study has reported that hypersensitivity reactions to nickel are likely to occur only when there is a prior sensitization from non-dental contacts, and even if this occurs, these sensitizations are still rare (Setcos et al., 2006, Spiechowicz et al., 1999). It is likely that nickel allergens from sources other than dental material will need to be considered in the future, as the use of the nickel alloy in dental materials in Japan is on the wane. Patients with inflammatory swelling due to several types of pierced earrings tend to show positive reactions to both gold and platinum, as well as nickel and palladium. The nickel allergy is known to be an important causative factor of atopic dermatitis (Klas et al., 1996). Therefore, care should be taken when using this material, as nickel allergies often cause serious allergic symptoms. In addition, one of the important results found in the current study was the positive reaction rate to palladium.

Due to the increase of patients with allergies noted over the last few years, practicing dentists need to have sufficient knowledge about dental metal allergies and be able to make these types of clinical diagnoses and then either treat these patients properly or refer them to

minimal erythema dose was smaller with ultraviolet A. This patient was diagnosed as

Subsequently, we then began to remove all metal restorations that contained allergypositive metal elements. After removal of a fixed prosthesis and extraction of some of his teeth, a removable prosthesis with a non-metal clasp (Jeneric/Pentron, Wallingford, CT, USA) was fabricated. Porcelain fused to zirconium crowns were attached to the patient after complete removal of all of his metal restorations. In conjunction with the progress of the dental treatment, the previously exhibited erythema and swelling gradually reduced, and the prurigo in the local region recovered. The figure 15 shows an intraoral picture and the skin symptoms before and after the dental treatment. Clear recovery of the dermatitis was observed except the neck region that was exposed to sunlight. In this case, the exclusion of the intraoral metal restorations resulted in the healing of the patient's chronic and

Recently, the number of dental metal allergy patients along with the number of cases that practicing dentists have referred to our special outpatient section have increased. While the cause of this increase is not clear at the present time, suspicions have been raised about the effects of the popularization of pierced earrings as one of the potential causes. In Japan, ear/body piercings since the 1990s have been the cause of nickel allergies in female patients. It is possible that lifestyle choices could be one of the factors responsible for this high prevalence of dental metal allergy. Nickel hypersensitivity is one of the most common metal allergies, and we have documented a high positive reaction rate to nickel reagents. (Hosoki et al., 2009). Larsson-Stymne et al. reported finding a relationship between pierced earrings and nickel allergies (Larsson-Stymne&Widstrom, 1985). Sivertsen et al. also has reported finding the nickel allergy to be associated with pierced ears rather than either local pollution or atopic dermatitis (Smith-Sivertsen et al., 1999). Jensen et al. demonstrated there was a decrease in nickel sensitization in Danish schoolgirls whose ears had been pierced after implementation of the nickel-exposure regulations in 1992 (Jensen et al., 2002). These findings have led to other European countries to regulate exposure to nickel, and in the future, similar regulations may be enacted in Japan. One other study has reported that hypersensitivity reactions to nickel are likely to occur only when there is a prior sensitization from non-dental contacts, and even if this occurs, these sensitizations are still rare (Setcos et al., 2006, Spiechowicz et al., 1999). It is likely that nickel allergens from sources other than dental material will need to be considered in the future, as the use of the nickel alloy in dental materials in Japan is on the wane. Patients with inflammatory swelling due to several types of pierced earrings tend to show positive reactions to both gold and platinum, as well as nickel and palladium. The nickel allergy is known to be an important causative factor of atopic dermatitis (Klas et al., 1996). Therefore, care should be taken when using this material, as nickel allergies often cause serious allergic symptoms. In addition, one of the important results found in the current study was the positive reaction rate to

Due to the increase of patients with allergies noted over the last few years, practicing dentists need to have sufficient knowledge about dental metal allergies and be able to make these types of clinical diagnoses and then either treat these patients properly or refer them to

having complication dermatitis with photodermatosis, and dental metal allergy.

intractable dermatitis.

**7. Discussion** 

palladium.

specialists who can take over these treatment regimens. Current data indicate that practicing dentists need obtain further specialized knowledge about dental metal allergy in order to ensure the correct treatment of patients in their clinics.

#### **8. Conclusion**

All treatments that employ dental metal materials have the potential to cause allergic symptoms, and thus, proper preventive measures and treatment plans are required for these allergy patients. The results of our current research demonstrate the necessity for educating all dental practitioners in the recognition and treatment of dental metal allergy.

#### **9. References**


**Part 5** 

**Contact Dermatitis in Children** 


**Part 5** 

**Contact Dermatitis in Children** 

108 Contact Dermatitis

Jensen, C. S.,S. Lisby,O. Baadsgaard,A. Volund & T. Menne (2002). Decrease in nickel

implementation of a nickel-exposure regulation, *Br J Dermatol* (146): 636-42. Khamaysi, Z.,R. Bergman & S. Weltfriend (2006). Positive patch test reactions to allergens of

Klas, P. A.,G. Corey,F. J. Storrs,S. C. Chan & J. M. Hanifin (1996). Allergic and irritant patch

Lam, W. S.,L. Y. Chan,S. C. Ho,L. Y. Chong,W. H. So & T. W. Wong (2008). A retrospective

Larsson-Stymne, B. & L. Widstrom (1985). Ear piercing--a cause of nickel allergy in

Lundstrom, I. M. (1984). Allergy and corrosion of dental materials in patients with oral

Magnusson, B.,M. Bergman,B. Bergman & R. Soremark (1982). Nickel allergy and nickel-

Minagi, S.,T. Sato,K. Suzuki & G. Nishigawa (1999). In situ microsampling technique for

Nakayama, H. (2002). New aspects of metal allergy, *Acta Dermatovenerol Croat* (10): 207-19. Setcos, J. C.,A. Babaei-Mahani,L. D. Silvio,I. A. Mjor & N. H. Wilson (2006). The safety of

Shanon, J. (1965). Pseudo-atopic dermatitis. Contact dermatitis due to chrome sensitivity

Smith-Sivertsen, T.,L. K. Dotterud & E. Lund (1999). Nickel allergy and its relationship with

Spiechowicz, E.,P. O. Glantz,T. Axell & P. Grochowski (1999). A long-term follow-up of

Suzuki, N. (1995). Metal allergy in dentistry: detection of allergen metals with X-ray

Uo, M. & F. Watari (2004). Rapid analysis of metallic dental restorations using X-ray

Wataha, J. C. (2000). Biocompatibility of dental casting alloys: a review, *J Prosthet Dent* (83):

Wiesenfeld, D.,M. M. Ferguson,A. Forsyth & D. G. MacDonald (1984). Allergy to dental

Yanagi, T.,T. Shimizu,R. Abe & H. Shimizu (2005). Zinc dental fillings and palmoplantar

identification of elements of a restoration with exposed metal to identify potential

local nickel pollution, ear piercing, and atopic dermatitis: a population-based study

allergy to nickel among fixed prostheses wearers, *Eur J Prosthodont Restor Dent* (7):

fluorescence spectroscope and its application toward allergen elimination, *Int J* 

test reactions and atopic disease, *Contact Dermatitis* (34): 121-4.

Kong (1995-99), *Int J Dermatol* (47): 128-33.

schoolgirls? , *Contact Dermatitis* (13): 289-93.

containing dental alloys, *Scand J Dent Res* (90): 163-7.

nickel containing dental alloys, *Dent Mater* (22): 1163-8.

simulating atopic dermatitis, *Dermatologica* (131): 176-90.

scanning analytical microscopy, *Dent Mater* (20): 611-5.

gold, *Oral Surg Oral Med Oral Pathol* (57): 158-60.

from Norway, *J Am Acad Dermatol* (40): 726-35.

lichen planus, *Int J Oral Surg* (13): 16-24.

allergens, *J Prosthet Dent* (82): 221-5.

(55): 216-8.

41-4.

223-34.

*Prosthodont* (8): 351-9.

pustulosis, *Lancet* (366): 1050.

sensitization in a Danish schoolgirl population with ears pierced after

the dental series and the relation to the clinical presentations, *Contact Dermatitis*

study of 2585 patients patch tested with the European standard series in Hong

**7** 

Alena Machovcová

*Czech Republic* 

*University Hospital Motol, Prague* 

**Allergic Contact Dermatitis in Children** 

Contact allergy (CA), a pathologic response after (usually repeated) contact to environmental substances of low molecular weight occurring in a varying proportion of exposed persons, often results in clinical disease, allergic contact dermatitis (ACD), which can be disabling. CA is diagnosed by patch testing, a technique of controlled exposure of patients suspected to have ACD to a standardized set of substances frequently found to be the cause of ACD (Uter, 2004). ACD is an inflammatory reaction of the skin that follows percutaneous absorption of antigen from the skin surface and recruitment of previously sensitized, antigen-specific T lymphocytes into the skin (Rietschel & Fowler, 2001a). Although sensitivity to contact allergens occurs in 10-20% of the adult population, the exact incidence and prevalence of sensitization in children is unknown. ACD in children is not rare. The documented rates of ACD in children are on the increase (Militello et al., 2006; Goossens & Morren, 2006). Sensitization to contact allergens begins in infancy and continues to be more common in toddlers and young children. Infants, even neonates, may be sensitized (Fisher, 1994a; Bruckner et al., 2000). The rate of positive results may vary with referral patterns, selection criteria for patch testing, regional and social variations in allergens exposure and the allergen tested (Militello et al., 2006; Goossens & Morren, 2006;

Previously, ACD was once wrongly considered uncommon in the pediatric population (Hjorth, 1981). It was thought that children had reduced exposure to contact allergens during childhood. The second reason was less susceptibility of the child immune system to contact allergens (Mortz & Andersen, 1999). However, during the last 10-20 years, several reports have described a considerable number of children with CA and ACD (Pevny et al., 1984a; Pevny et al., 1984b; Weston & Weston, 1984; Rademaker & Forsyth, 1989; Barros et al., 1991; Dotterund & Falk, 1995; Motolese et al., 1995; Katsarou et al., 1996; Rudzki & Rebandel, 1996; Stables et al., 1996; Manzini et al., 1998; Brasch & Geier, 1997), confirming that CA and ACD may be frequent in children and may cause significant problems. Prevalence of positive patch tests without clinical correlation (CA) in population-based studies is different from the prevalence of ACD (positive patch test with clinical correlation)

**1. Introduction** 

Wahlberg & Lindgerg, 2006).

in patients referred for patch testing.

**2. Epidemiology (prevalence and incidence)** 
