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New Zealand dental practitioners' experience

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Article in The New Zealand dental journal · June 2010

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55
56 New Zealand Dental Journal June 2010
reports
New Zealand dental practitioners’ experience of patient allergies to
dental alloys used for prosthodontics
Joe Zhou, Andrew Paul, Vincent Bennani , W. Murray Thomson and Norman A. Firth
New Zealand Dental Journal 106, No. 2: 55-60; June 2010
Abstract
The biocompatibility of metal alloys has generated much
concern for practitioners and patients alike over recent years.
Objectives: To investigate dentists’ experience of patient
allergies to metal alloys used in prosthodontic restorations.
Design: Cross-sectional survey of New Zealand practising
general dentists.
Methods: A random sample of 700 was taken from the
New Zealand dental register. The questionnaire asked
dentists whether any of their patients have encountered any
allergic reactions to metal alloys. It also sought information
on what alloys were being prescribed for use in different
types of prosthodontic restorations.
Results: A response rate of 71.4% was obtained (N =
476). Some 83 dentists (17.4%) reported having encountered
suspected metal allergies in patients; of those, 70 had had
the allergies confirmed with a biopsy. Of the entire sample,
327 dentists (72.2%) were aware of the metals used in their
restorations, and 201 (44.8%) specified the alloys used
in their restorations. For cast removable prosthodontic
restorations (such as removable partial dentures), base metal
alloys were the most preferred choice; for full cast crowns,
high noble alloys were the most favoured; noble alloys were
the most favoured for both porcelain-fused-to-metal crowns
and fixed-bridge restorations.
Conclusion: As many as one in six general practising
dentists have encountered allergic reactions to metal alloys
in their patients. General practising dentists’ awareness of the
indications for the various metal alloys used in prosthodontic
restorations should be raised, and biocompatibility issues
should be clarified, so that dentists prescribe the optimum
metal alloy for each type of restoration.
Introduction
The biocompatibility of an alloy is defined as its ability
to exist in harmony with the surrounding biological
environment (Rosenstiel et al，2006). It is an important
factor to consider when selecting an alloy for a prosthodontic
restoration. Biocompatibility is determined (in part) by
corrosion, which is the electrochemically-induced loss of
elemental constituents to the adjacent environment. Noble
metals such as gold and platinum are considered to be
inert in the mouth. While materials such as palladium are
considered to be corrosion-resistant, metals such as copper
can readily corrode in an alloy even if present only in small
amounts. Alloys are a mixture of two or more metals that
are mutually soluble in a molten state. They are used in
dentistry because a single metal does not give the desired
physical properties. Technological advances have seen the
production of different types of metal alloys, and, with the
Peer-reviewed paper. Submitted December 2009; accepted March
2010.
continuing enhancement of properties, those advances have
provided considerable assistance for clinicians to fabricate
optimum restorations for their patients (Roberts et al 2009).
Other factors—such as phase composition, environment,
and micro-environments—also play a major role in a given
alloy’s corrosion resistance. For each of the metals in the
alloy, it is important to consider the atomic weight percentage
and ratio. For example, while a noble alloy may have 10%
copper by weight, 89% of the atoms released through
corrosion in the mouth will be copper (Wataha, 2000). Thus,
even small amounts of undesired metals have the potential to
cause a problem with biocompatibility.
Metals which have been reported to be associated with
suspected biocompatibility problems include nickel,
beryllium, palladium, copper, gallium, chromium, and
even titanium in rare instances. These metals can cause
a varying range of clinical signs. A review by Wataha and
Hanks (1996) mentioned studies indicating possible allergic
effects of high-palladium alloys. Clinical symptoms which
have been documented include erythematous vesicular
lesions in the neck and forearms, and lichen-planus-like
reactions in response to palladium restorations. However,
investigators could not exactly identify which metals were
responsible, and considerable speculation exists with respect
to other causes. Raap et al (2009) analysed positive patch
test reactions to metals in patients. Palladium-, nickel- and
cobalt-containing compounds were among those implicated.
There is widespread concern about the safety of nickel
chromium (Ni-Cr) alloys. Occupational exposure of refinery
workers to nickel has been associated with lung cancer and
nasal cancer. Acute effects of exposure to nickel include skin
sensitisation that can lead to chronic eczema (Rosenstiel et
al, 2006). Alloys which contain beryllium are also under
scrutiny because of its toxicity. The acute effects of beryllium
include contact dermatitis, skin and conjunctival ulcers,
and corneal burns (Moffa et al, 1973). The consequence of
beryllium exposure to dental technicians has been described
in the literature (Kotloff et al, 1993). Fireman et al (2006)
conducted lung testing in 24 dental technicians who all
had past occupational exposure to beryllium. Twelve of
the dental technicians were diagnosed as suffering from
chronic beryllium disease (CBD). Of the 12 who tested
negative to CBD, seven were diagnosed as suffering from
another pulmonary pathology (such as sarcoidosis or chronic
obstructive pulmonary disease).
Such metals can cause local toxicity and/or local allergic
reactions. Allergic reactions result from the formation of a
metal ion complex that immune cells recognise as foreign,
creating a type IV hypersensitivity reaction. Toxicity
responses are due to a direct interference with a cell’s ability
to function. For example, copper will cause an allergic
response in only a small number of susceptible people,
but it can cause a local toxic response by accumulating
June 2010 New Zealand Dental Journal 57
in high concentrations in the gingival crevice around a
crown. Its presence can then cause oxidative stress on the
cells in the gingival crevice through its ability to accept
electrons. Its toxicity in cell culture has been demonstrated
at concentrations as low as 50micromoles per litre (Wataha,
2000).
With the increasing price of noble alloys, greater use of
new technologies such as CAD CAM (Tay et al, 2008), and
a changing economic climate, the pattern of dental alloy
use is changing. High noble alloys appear to be being used
less, and base metal alloys are coming more into favour.
Unfortunately, the greater use of base metal alloys is likely
to be associated with more allergic reactions. The aim of this
study was to determine the usage of dental alloys by New
Zealand dentists, and to report on their experience of alloy-
associated reactions among patients.
Materials and Methods
The study was a cross-sectional survey of a random sample
of 700 general dentists drawn from the New Zealand Dental
Register in 2009. Specialists were excluded the rationale
for this was that only a few prosthodontists are registered
in New Zealand, and their greater knowledge in alloy usage
meant that their inclusion could distort the results of this
survey, The questionnaire sought details of respondent’s
sociodemographic and dental practice characteristics, and
asked them about their awareness and use of the types of
metals for their prescription restorations. The ‘no metal’
option was not included as this was outside the scope of this
study. They were also asked about their experience (in the
previous two years) of patients with suspected mucosal or
skin reactions to fixed restorations.
A participation incentive was offered in the form of a
prize draw, generously sponsored by Whitehaven Winery.
The prize winner was randomly selected from those who
completed and returned the survey. The questionnaire was
posted with a covering letter explaining the study’s purpose,
and a freepost envelope was included for returning completed
forms. One month later, a second wave of forms was sent to
those who had not yet responded. This was accompanied by
an amended covering letter.
The returned questionnaires were coded and data entered
into a spreadsheet before analysis, using SPSS. Associations
between categorical variables were tested for statistical
significance using the Chi-square test, with the alpha level
set at 0.05.
Results
Of the original random sample of 700 general dental
practitioners, 33 were outside the sampling frame, either
because they were retired, deceased, or because their
questionnaires had been returned due to incorrect address
details. The 476 questionnaires returned from the remaining
667 general dental practitioners yielded a response rate of
71.4%. Comparison of the characteristics of the responders
with those of the dental profession as a whole (using the
Dentist’s Register of the Dental Council of New Zealand)
showed that there were no significant differences, with the
Register data falling within the 95% confidence intervals for
all of the survey estimate (Table 1).
Alloys used in prosthodontics
Data on respondents’ use of alloys in prosthodontics
are presented in Table 2. Base metal alloys were the most
popular for cast removable prosthodontics, followed by
56
Table 1 – Comparison of respondents’ sociodemographic and degree
characteristics with those of the actively-practising NZ dental
profession as a whole (data are percentages)
Respondents (95% CI) The NZ dental
professiona
Females 28.6 (24.5, 32.7) 29.9
Age group
Lowest to 29 11.8 (8.9, 14.7) 12.1
30 to 39 21.2 (17.5, 24.9) 23.4
40 to 49 25.8 (21.9, 29.7) 29.0
50 to 59 25.2 (21.3, 29.1) 22.4
60 and over 16.0 (12.7, 19.3) 14.1
Overseas-
24.6 (20.7, 28.5) 24.0
1qualified
a
Source: Dental Council of New Zealand (2007 workforce analysis)
titanium, and noble alloys. High noble alloys were the most
commonly prescribed alloy for single-unit cast crowns, with
noble alloys the next most commonly used. For porcelain-
fused-to-metal-crowns, noble alloys were used by over half
followed by high noble alloys, base metal and titanium. For
fixed bridges, noble alloys were the most popular, followed
by high noble, base metal, and titanium alloys.
Almost three-quarters of respondents were aware of
the type of metals in their cast restorations (Table 3). Just
under half of respondents reported that they prescribe a
specific alloy for their fixed restorations. Dentists who
graduated before the year 2000 were more likely than those
who graduated later to prescribe the metals in their fixed
restorations..
Health aspects of alloys
Almost one in five respondents (19.1%) reported having
had patients ask for specific alloys because of health reasons.
The number of patients doing so was relatively small, with
an average 6.1% of patients doing so.
About one in six dentists (83, or 17.4%) reported that they
had encountered a suspected metal allergy. Of those, 70
(84.3%) had confirmed their suspicions with a biopsy. The
majority of dentists who had encountered a suspected alloy
allergy reported that it had happened only once (in 57 % of
the cases) or twice (18%).
The most common clinical sign was redness, with 81.9%
of respondents reporting it. Swelling and mucosal ulceration
were mentioned by 16.9% followed by ulceration (15.7%),
pruritis (12.0%), and a rash (10.8%).
Discussion
The aim of this study was to determine New Zealand
general dentists’ pattern of metal alloy usage in their
prosthodontic restorations, and to report on their experience
of allergies to these metal alloys in their patients. The study
showed that as many as one in five dentists have observed
allergic reactions to alloys in their patients, and close to one-
third are not aware of the types of metals present in their
restorations.
The 17.4% prevalence estimate for dentists encountering
an allergy with the two-year period should be interpreted
carefully. The survey findings depend to an extent on the
57
58 New Zealand Dental
NZJournal experience of patient allergies to alloys – ZJhou
dentists’ 2010
une et al

Table 2. Metal alloys dentists prescribe for different applications (brackets contain column percentages unless otherwise indicated)

Cast removable Full cast crown Porcelain fused to metal Fixed bridge restoration
prosthodontics crown
Base metal alloy 84 (48.6) 9 (4.6) 24 (12.4) 25 (13.1)
Titanium alloy 43 (24.9) 2 (1.0) 15 (7.8) 14 (7.3)
Noble alloy 38 (22.0) 69 (35.6) 101 (52.3) 105 (55.0)
High noble alloy 8 (4.6) 114 (58.8) 53 (27.5) 47 (24.6)

Missing responses 27 6 7 9

Table 3. Awareness of alloys composition and prescribing policy for alloys, by dentist (brackets contain row percentages)

Aware of the types of metal Specify the type of metal to be used in prescribed fixed
present in their fixed restorations restorations
Gender
Male 242 (74.0) 155 (47.4)
Female 85 (67.5) 46 (37.7)
Graduation cohort
Pre-1970 40 (81.6) 24 (49.0)
1970 to 1979 66 (71.7) 42 (46.7)
1980 to 1989 95 (74.8) 66 (52.4)
1990 to 1999 74 (67.9) 45 (40.9)
2000 onwards 52 (68.4) 24 (32.4)
Combined graduation cohort
Pre-2000 275 (71.1) 177 (47.2)*
2000 onwards 52 (68.4) 24 (32.4)
NZ dental graduate
No 82 (71.3) 56 (48.7)
Yes 245 (72.5) 145 (43.4)

All combined 327 (72.2) 201 (44.8)

Missing responses 24 28

*P <0.05

dentists’ ability to observe and associate adverse reactions
with specific causes, and dentists have little training in
this type of evaluation, as many diagnoses and reaction
mechanisms need to be considered (Dahl et al, 2000). The
signs and symptoms of contact allergic reactions affecting
the oral mucosa may mimic other common oral disorders,
making definitive diagnosis difficult. Contact allergy can
also be mistaken for chronic trauma caused by fractured
teeth and restorations, ill-fitting prostheses, or parafunctional
oral habits, as the lesions have a similar clinical appearance
(De Rossi and Greenberg, 1998). While the study was able
to report on dentists’ experience of allergic reactions among
their patients, a deficiency was that it could not identify the
metals responsible for those allergic reactions. Thus, it is
unable to confirm or refute the evidence in the literature for
certain metals causing allergic reactions to metal alloys.
There seems to be great international variation in the
prevalence of allergies to metals. It has been reported that,
in the USA, 9% of the female population and 0.9% of the
male population are sensitive to nickel (American Dental
Association, 1982), whereas Thyssen et al (2007) estimated
that, in the Danish population, 17% of women and 3% of
men are allergic to nickel and that 1% to 3% are allergic to
cobalt and chromium. For 19,793 patients from 10 European
patch test centres, estimates for the age- and sex-standardised
prevalence of nickel, cobalt and chromium allergies
were 19.7-24.5%, 6.2-8.8%, and 2.4-5.9% (respectively)
during the 2005-2006 period (ESSCA writing group,
2009). It is difficult to make a direct comparison because
of methodological and contextual differences among the
various studies.
For cast full crowns, high noble alloys (HNA) were the most
preferred alloy despite the price. This is a pleasing finding.
HNAs consist of at least 60% by weight noble metals, with
at least 40% gold. They include gold-platinum-palladium
(Au-Pt-Pd), gold-palladium-silver (Au-Pd-Ag), and gold-
palladium (Au-Pd) alloys. These alloys exhibit good yield
strengths at about 73MPa (Vermilyea et al, 1980), which is
high enough to handle the substantial biting forces—ranging
from 485 N in canines to 749 N in second molars (Van
Eijden, 1991)—but low enough that it is not affecting the
workability of the restoration in the laboratory. HNA alloys
also possess good hardness, at around 225VH (Vermilyea et
al, 1980), which gives an indication of how the material will
wear in the mouth. A material with a similar hardness value
to enamel (~350VH) is ideal in order to prevent excessive
wear of the opposing natural teeth. Excessively high
hardness values can also alter the castability of the alloys.
HNA alloys possess excellent corrosion resistance, enabling
good biological compatibility (Rosenstiel et al, 2006).
HNAs also have excellent porcelain adherence, which is
important for the success of metal-porcelain restorations
June 2010 New Zealand Dental Journal 59
58

Table 4. Comparison of different dental alloys (Roberts et al, 2009)

Advantages Disadvantages Clinical Indications
High Noble Good corrosion resistance Price Full cast crown
(HNA)
High yield Strength Elastic Modulus too low for long span PFM crown
Bridges
Appropriate hardness values Short span bridges (3 units)
Porcelain discoloration (silver base
Good castability HNA)

Good bond strength Low sag resistance

to porcelain
Degree of thermal expansion
Easy to solder incompatible with some porcelain
Noble Reduced Cost Porcelain discoloration (Pd-Ag) Full cast crowns
(NA)
Similar physical properties to high Castability not as good as HNA PFM crowns
noble alloys
Short and long span bridges
Good Sag resistance
Base metal Price Poor castability Removable Partial and Complete
Alloys Denture framework
(BMA) High elastic modulus High melting point (oxide layer)
Short span Maryland bridge
High hardness values

Susceptibility to corrosion

Poor biocompatibility (nickel)

Toxic to process (beryllium)

(Vickery and Badinelli, 1968). For porcelain-fused-to-metal
crowns, the most preferred alloys were noble alloys (NA).
Nobel alloys contain at least 25% noble elements, and there
is no lower limit on the gold content. They include palladium-
silver (Pd-Ag), palladium-copper-gallium (Pd-Cu-Ga),
and palladium-gallium (Pd-Ga) alloys. These alloys have
very similar tensile and yield strength and elastic modulus
to high noble alloys (Huget et al, 1976). This suggests that
NAs are a good compromise (in terms of the cost-to-safety
ratio) between the more expensive high noble alloys and the
relatively inexpensive base metal alloys. Nevertheless, the
presence of silver in Pd-Ag alloys can result in porcelain
greening and furnace contamination during the fabrication
of restorations (Rosenstiel et al, 2006) if the veneering
porcelain is sensitive to silver (most of those in current use
are not).
For full cast metallic crowns, even if NA are suitable, the
best material in these clinical situations remains the HNA,
particularly Type III gold. With its very good castability
and low fusing temperature, Type III gold allows the
fabrication of precisely fitting restorations even in complex
design preparations such as the MOD onlay preparations.
The partial coverage crown involves a more complex tooth
reduction, making well-fitting restorations more difficult
to achieve. NAs would be less satisfactory in this clinical
situation because their castability is inferior to that of HNAs
(Bessing, 1986)
Base metal alloys (BMA) are generally being used by
dentists for cast removable partial dentures. BMA are
defined as having less than 25% noble metal content, and
include nickel-chromium (Ni-Cr) and cobalt-chromium (Co-
Cr). Unfortunately, this study could not identify which of the
two was used by respondents. Co-Cr alloys were developed
in response to the toxic effects of alloys containing nickel
or beryllium (Baran, 1983). Co-Cr is now mainly used in
the construction of the framework for removable partial
dentures (RPD). BMA have a high elastic modulus, making
them very rigid. This is important in removable partial
dentures, where the major connector should be rigid in order
to ensure cross-arch stabilisation: a flexible major connector
may cause damage to the hard and soft tissues of the oral
cavity (Phoenix et al, 2003).
It is worth noting that a high number of dentists are
using titanium for RPD frameworks. Titanium has a high
affinity for oxygen, nitrogen and carbon, along with a high
melting point which makes it difficult to cast. Excessive
contamination would result if conventional casting machines
are used (Donachie 1982). Thus, only casting machines
providing either a vacuum environment or an argon
atmosphere can be used, necessitating the development of
both vacuum/argon pressure and centrifugal dental casting
machines (Rosenstiel, 2006). Selecting a dental laboratory
equipped with such machines and experienced in the casting
of titanium is essential. Such laboratories are uncommon in
New Zealand because few labs are so equipped1. Despite
this, we were surprised by the unusually high proportion
of dentists in the current study who were using titanium in
RPD frameworks. Further investigations of the use of cast
titanium restorations in New Zealand are needed to clarify
this point.
The use of NA for RPD frameworks fabrication was also
relatively high (22.0%). This high proportion suggests that a
large number of hybrid prostheses are being fabricated. These
involve a fixed restoration in combination with a removable
partial denture. To limit corrosion at the interface, the same
metal (generally NA) is used for both parts of the prosthesis.
Again, further investigations are needed to clarify this point.
1
Yellow Pages New Zealand (2010). http://yellow.co.nz/
search/new+zealand/dental+laboratory-1.html Accessed
on 14/3/2010
59
60 New Zealand Dental
NZJournal experience of patient allergies to alloys – ZJhou
Not unexpectedly, the study found that HNA and NA were
preferred by dentists for bridge fabrication. Those alloys
allow good castability and soldering to ensure well-fitting
prostheses without compromising the porcelain-to-metal
bond. For long-span bridges, the uses of NAs provide more
rigidity to the overall structure and so help to minimise the
risk of porcelain fracture. Hence, a compromise has to be
made when selecting an alloy.
The price of the alloys is another factor which has to be
considered in their selection, given the price volatility of
high noble and noble alloys (Rosenstiel et al, 2006). As at
December 2009 in New Zealand, high noble ‘Maxi Gold’
type three was NZ$43.11 per gram and IPS d.SIGN 53 (a
noble alloy) was NZ$17.17 per gram from Ivoclar Vivadent
Ltd. Such relatively high costs are becoming an important
variable in alloy selection (Baumann et al, 2010).
The study also found that one-third of dentists are simply
not aware of the types of metal present in their restorations,
and that fewer than half actually specify the alloys used in their
restorations. The Code of Practice for Dentists and Dental
Technicians (as specified by the Dental Council of New
Zealand) states that “Records should show…a description of
any procedure, including any materials used…” (Baumann
et al, 2010). The wording suggests that dentists are not
obliged to specify the alloys used in their restorations.
The implication of this is that extra responsibility lies with
technicians in selecting the optimum alloy. With a growing
trend for sending laboratory work overseas, there is a risk
of poor alloy selection. The lack of awareness shown by
some dentists (including recent graduates) of the types of
alloys present in prosthodontic restorations indicates a need
for improvement through continuing education in this area.
Given that one in six dentists encountered allergic reactions,
the optimum alloy selection for prosthodontic restorations is
essential.
Conclusion
Allergies to dental alloys in New Zealand are occurring.
As many as one in six general practising dentists have
encountered allergic reactions to metal alloys in their
patients. General practising dentists’ awareness of the
indications for the various metal alloys used in prosthodontic
restorations should be raised, and biocompatibility issues
should be clarified, so that dentists prescribe the optimum
metal alloy for each type of restoration. There is no ideal
alloy for a given case; it is up to the dentist and technician to
select the most appropriate alloys.
Acknowledgment
This study was supported by the University of Otago.
We would like to thank the dentists who participated, and
Whitehaven Winery for donating the incentive for our survey.
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 June 2010 New Zealand Dental Journal 61
60

Wataha JC and Hanks CT (1996). Biological effects of palladium Vincent Bennani, DDS, CertAdvPros, CertAdvImpl,
and risk of using palladium in dental casting alloys. Journal of Oral
Rehabilitation 23: 309-320
Doctorate
Sir John Walsh Research Institute, School of Dentistry,
Wataha JC (2000). Biocompatibility of dental casting alloys: a review. University of Otago,
Journal of Prosthetic Dentistry 83: 223-234 PO Box 647,
Joe Zhou, BDS Dunedin 9054
School of Dentistry,
University of Otago, W. Murray Thomson BSc, BDS, MA, MComDent,
PO Box 647, PhD, FICD, FADI
Dunedin 9054 Sir John Walsh Research Institute, School of Dentistry,
University of Otago,
Andrew Paul, BDS PO Box 647,
Oral Health Center, Dunedin 9054
Christchurch Public Hospital,
16 Tuam Street, Norman A. Firth, BDS, MDSc, FRACDS, FFOP(RCPA)
Christchurch 8011. Sir John Walsh Research Institute, School of Dentistry,
University of Otago,
PO Box 647,
Dunedin 9054

Corresponding author: Vincent Bennani, E-mail: vincent.

bennani@otago.ac.nz

The Roya l Australasian

College of Dental Surgeons
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ABOUT THE RACDS Practitioners leads to the award of MRACDS. It is Special Fields with the opportunity to become
based on the successful completion of appropriate Members of the College in a specialist discipline.
The College provides CPD courses and related RACDS assessment
opportunities for new graduates Membership is open to specialists in the fields of
components.
and experienced dentists to Dental Public Health, Endodontics, Oral Medicine,
improve their skills, knowledge FELLOWSHIP Periodontics, Prosthodontics, Special Needs
and understanding. Dentistry, Paediatric Dentistry, and Orthodontics
The FRACDS General Stream comprises a
(holders of the award of MRACDS in a Special
Primary Examination and a Final Examination
Participation in College programs Field may then apply for eligibility to present for
(holders of the award of MRACDS may present
is suited to all career paths in the Final Examination in their Special Field).
directly for the Final Examination).
Dentistry including private FELLOWSHIP
practice, government health The Primary Program has 6 areas of study and
services, academia, armed examination and the aim of the program is to Examinations at an advanced level in the Special
service and university enable candidates to demonstrate an Field Stream provide a pathway to Fellowship in
postgraduate study. understanding of fundamental principles of basic the above specialist fields in addition to Oral and
science and their relationship to clinical practice. Maxillofacial Surgery. The College training
Recognition of the College is program in Oral and Maxillofacial Surgery is
The Final Examination is clinically oriented
widening as closer links and accredited by the Australian Medical and Dental
requiring demonstration of a broad experience in
alliances are developed with Councils.
general dentistry, a maturity of clinical judgement
agencies and institutions within and application of knowledge based on current
Australia, New Zealand, Asia, the
U.K, and the Middle East. BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
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