READERS FORUM

Letters to the editor*

Allergic reactions to acrylics
I write in response to the article, Allergy to auto-
polymerized acrylic resin in an orthodontic patient
(Gonalves TS, Morganti MA, Campos LC, Rizzatto SMD,
Menezes LM. Am J Orthod Dentofacial Orthop 2006;129:
431-5).
Allergic reactions to acrylic materials are certainly real,
as we witness in our laboratory (Great Lakes Orthodontics);
technicians frequently break out upon exposure to methyl-
methacrylate monomer. Although signicantly less frequent
for cured polymers, these reactions can be serious and require
careful analysis and description. The authors presented a lucid
accounting of their work, which included a good variety of
techniques. I believe a few technical points, unrelated to their
experimental work, should be mentioned.
When discussing immune reactions, Hamptons are
haptens (the English dental lexicon has enough peculiar
words). It is also most unlikely (virtually impossible) for
dental acrylic resins to contain formaldehyde; listing formal-
dehyde as a primary cutaneous antigen in dental acrylics is
absurd, and this type of statement should not be allowed to
capriciously nd its way into the dental literature. Also,
benzyl peroxide is not benzoyl peroxide; they are chemically
distinct. Benzyl peroxide incorrectly appears on the Internet
in regard to acne.
Finally, I nd it disturbing to advocate overcoming
acrylic reactions in sensitive denture patients by intentionally
exposing them to additional acrylic. Should this become
standard practice? Here, light-cured methylmethacrylate is
assumed to be safewith less residual monomer than heat-
cured. The authors also make a point of stating that allergic
reactions are not dose-dependent.
The issue of allergic reaction remains valid with the
increasing number of sensitizing agents surrounding us all.
Such nice clinical work should be married with an equally
careful analysis.
Mark Lauren
Director, Research and Development
Great Lakes Orthodontics, Tonawanda, NY
Am J Orthod Dentofacial Orthop 2006;130:125
0889-5406/$32.00
Copyright 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.06.006
Authors response
We thank Mr Lauren for his interest on our article, in
which we presented a patient with an allergy to auto-
polymerized acrylic resin. We especially appreciated the
considerations on vocabulary, a major drawback when writ-
ing in a foreign language. Even though there are some case
reports of patients who had allergic reactions to auto-poly-
merized acrylic resins, dental staff are much more often
affected by these allergic reactions than patients, including
also respiratory and systemic effects.
1
Orthodontists should
be aware of allergic reactions in patients and be able to work
in a multidisciplinary team capable of formulating a clear
diagnosis and pointing out proper alternatives. The patient
discussed in our article initially showed erythema under her
acrylic resin retainer and some systemic involvement, such as
difculty in swallowing and hypersalivation. She was referred
to a dermatologist, who evaluated her for allergenic responses
(questionnaire and skin patch test, according to the guidelines
of the International Contact Dermatitis Research Group). This
approach is consistent with the literature.
2
Patch testing in
these situations is standard practice in Brazil and also in the
United States, as advocated by the American Academy of
Dermatology.
3
When performed by a qualied professional in
a controlled situation, it is a safe procedure. Eckerman and
Kanerva
4
afrmed that the diagnosis of allergic contact
dermatitis caused by methacrylates is based on patch testing.
Also, as stated by Koutis and Freeman,
5
patients with oral
complaints especially related to wearing dental appliances
should be patch-tested with allergens in the acrylate series. As
seen, patch testing is strongly advocated. A vast amount of
literature is available supporting these authors.
5-15
Regarding formaldehyde in acrylic resins, we do agree
that it is not a chemical in methylmethacrylate resins. It is,
however, found in controlled experiments, leaching from the
cured acrylic.
16-18
The dental literature has enough reports, so
we could have avoided that discussion. It is not yet clear how
it happens, but the possibility of oxidation of methylmetha-
crylate groups into formaldehyde has been considered by
Tsuchiya et al.
17,18
Because formaldehyde has been shown to
be not only allergenic, but also cytotoxic, in the concentra-
tions leached from acrylic resins, we understand Mr Laurens
concerns as a representative from a dental materials corpora-
tion and all that might be involved. We suggest reading the
cited articles as a starting point to elucidate this important
matter.
We believe Mr Lauren misunderstood the brief statement
regarding the aspect of dose-dependency. It is clear in the text
that each patient has a different chemical prole, as suggested
by Kusy,
19
and the allergic reaction depends on the concen-
tration related to each persons tolerance level. For 1 patient,
a small dose can cause an allergic reaction, whereas another
patient might have no reaction, as stated in the text, because
an allergic reaction is not dose-dependent, but related to the
patients sensitivity. As we reported, although there was
little residual monomer on the patients retainer, it was
enough to cause a reaction.
Even though it was not mentioned in our article, Mr
Lauren stated that, in his country, light-cured resin is widely
*The viewpoints expressed are solely those of the author(s) and do not reect
those of the editor(s), publisher(s), or Association.
125
used and considered to be safe, but he seems to question
whether, after cured, it contains less residual monomer than
heat-cured materials. In regard to this, Rose et al
20
conrmed
that heat-cured acrylic resins have, by far, better performance
considering leaching of monomer and cytotoxic prole when
compared with auto- and light-cured materials.
Before we nish, it is proper to mention that, in this time
of evidence-based dentistry, comments should be supported
by scientic ndings and not mere personal opinions. Be-
cause we believe in Mr Laurens good intentions, the oppor-
tunity to elucidate any points that might have been cloudy can
only be well appreciated. Finally, we thank the editor for the
opportunity to respond to the comments about our article
published in the March 2006 issue of the AJO-DO.
Tatiana Siqueira Gonalves
Mario A. Morganti
Luis C. Campos
Susana Maria Deon Rizzatto
Luciane Macedo de Menezes
Porto Alegre, RS, Brazil
Am J Orthod Dentofacial Orthop 2006;130:125-6
0889-5406/$32.00
Copyright 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.06.009
REFERENCES
1. Jacobsen N, Hensten-Pettersen A. Changes in occupational
health problems and adverse patient reactions in orthodontics
from 1987 to 2000. Eur J Orthod 2003;25:591-8.
2. Kanerva L, Rantanen T, Aalto-Korte K, Estlander T, Hannuksela
M, Harvima R.J, et al. A multicenter study of patch test reactions
with dental screening series. Am J Contact Dermat 2001;12:83-7.
3. Allergic contact rashes. http://www.aad.org/public/Publications/
pamphlets/AllergicContactRashes.htm. Accessed on June 5,
2006.
4. Henriks-Eckerman ML, Kanerva L. Gas cromatographic and
mass spectrometric purity analysis of acrylates and methacrylates
used as patch test substances. Am J Contact Dermat 1997;8:20-3.
5. Koutis D, Freeman, S. Allergic contact stomatitis caused by acrylic
monomer in a denture. Australas J Dermatol 2001;42:203-6.
6. Giunta J, Zablotsky N. Allergic stomatitis caused by self-
polymerizing resin. Oral Surg Oral Med Oral Pathol 1976;41:
631-7.
7. Fernstron AI, Oquist G. Location of the allergenic monomer in
warm polymerized acrylic dentures: part I: causes of denture sore
mouth, incidence of allergy, different allergens and test methods
on suspicion of allergy analysis of denture and test casting. Swed
Dent J 1980;4:241-52.
8. Hochman N, Zalkind M. Hypersensitivity to methyl methacry-
late: mode of treatment. J Prosthet Dent 1997;77:93-6.
9. Lunder T, Rogl-Butina M. Chronic urticaria from an acrylic
dental prosthesis. Contact Dermatitis 2000,43:232-3.
10. Saccabusi S, Boatto G, Asproni B, Pau A. Sensitization to methyl
methacrylate in the plastic catheter of an insulin pump infusion
set. Contact Dermatitis 2001;45:47-8.
11. Auzerie V, Mahe E, Marck Y, Auffret N, Descamps V, Crickx B.
Oral lichenoid eruption due to methacrylate allergy. Contact
Dermatitis 2001;45:241.
12. Giroux L, Pratt MD. Contact dermatitis to incontinency pads in
a (meth)acrylate allergic patient. Am J Contact Dermat 2002;13:
143-5.
13. Ruiz-Genao DP, Moreno de Vega MJ, Sanchez Perez J, Garcia-
Diez A. Labial edema due to an acrylic dental prosthesis. Contact
Dermatitis 2003;48:273-4.
14. Kanerva L, Estlander T, Jolanki R, Tarvainen K. Statistics on
allergic patch test reactions caused by acrylate compounds,
including data on ethyl methacrylate. Am J Contact Dermat
1995;6:75-7.
15. Kanerva L, Tarvainen K, Jolanki R, Estlander T. Succesful
coating of an allergenic acrylate-based dental prosthesis. Am J
Contact Dermat 1995;6:24-7.
16. Ruyter IE. Release of formaldehyde from denture base polymers.
Acta Odontol Scand 1980;38:17-27.
17. Tsuchiya H, Hoshino Y, Kato H, Takagi N. Flow injection
analysis of formaldehyde leached from denture-base acrylic
resins. J Dent 1993;21:240-3.
18. Tsuchiya H, Hoshino Y, Tajima K, Takagi N. Leaching and
cytotoxicity of formaldehyde and methyl methacrylate from
acrylic resin denture base materials. J Prosthet Dent 1994;71:
618-24.
19. Kusy RP. Clinical response to allergies in patients. Am J Orthod
Dentofacial Orthop 2004;125:544-7.
20. Rose EC, Bumann J, Jonas IE, Kappert H. Contribution to the
biological assessment of orthodontic acrylic materials. J Orofac
Orthop 2000;61:246-57.
History of orthodontics
I read with interest Norman Wahls recent installment on
the history of orthodontics (Orthodontics in 3 millennia.
Chapter 8: The cephalometer takes its place in the orthodontic
armamentarium. Am J Orthod Dentofacial Orthop 2006;129:
574-80). I noted, however, that Rocco J. DiPaolo was not
included with those who made signicant contributions to
cephalometric radiography.
Approximately 40 years ago, DiPaolo introduced the
quadrilateral analysis, formulated to differentiate between
malocclusions of skeletal and nonskeletal origins and to
identify dysplasias regarding relative size and position of the
lower facial components. Essentially, it is a proportionality
concept that is concerned primarily with the skeletal cong-
uration in a dentofacial complex in both the horizontal and
vertical dimensions, regardless of dentoalveolar relationships.
By detecting any skeletal excess, deciency, or postural
position in both the horizontal and vertical dimensions, this
individualized assessment enables the clinician to institute the
appropriate mechanics but also forewarns of any skeletal
limitation that might compromise treatment.
Quadrilateral analysis became an integral part of orth-
odontic education in the Department of Orthodontics, College
of Dental Medicine, Fairleigh Dickinson University, Ruther-
ford, NJ. Thousands of patients were evaluated cephalometri-
cally, and many research studies were conducted, showing
this analysis to be statistically signicant.
Chris Philip
New York, NY
Am J Orthod Dentofacial Orthop 2006;130:126
0889-5406/$32.00
Copyright 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2006.06.007
American Journal of Orthodontics and Dentofacial Orthopedics
August 2006
126 Readers forum