CLINICIANS CORNER

Allergy to auto-polymerized acrylic resin

in an orthodontic patient
Tatiana Siqueira Gonalves,a Mrio A. Morganti,b Lus C. Campos,c Susana M. D. Rizzatto,d and
Luciane M. Menezese
Porto Alegre, Brazil
This article reports on a 60-year-old woman who had an allergic reaction to methylmethacrylate self-curing
acrylic resin during orthodontic treatment. A localized hypersensitive reaction appeared on the palate after
an orthodontic retainer was placed. Samples of the acrylic were removed and analyzed with gas
chromatography to evaluate the residual monomer level. The residual monomer content was between
0.745% and 0.78%, which did not exceed international standards for this material. Patch tests were
performed with several methylmethacrylate resin samples and processed with various techniques; they
showed positive reactions. Despite the many alternative products available, self-curing acrylic resin remains
widely used because of its low cost, ease of use, and diversity of indications. Orthodontists should be aware
that allergic reactions can occur. (Am J Orthod Dentofacial Orthop 2006;129:431-5)

n the last few decades, many substitutes for methylmethacrylate acrylic resins have been developed.
Nevertheless, they remain one of the most used
materials in dentistry because of their low cost, ease of
use, and many applications. Because biocompatibility
plays a central role in the development of safe dental
materials, allergic reactions, especially to acrylic resins,
have been a concern in the dental literature. In contrast,
the orthodontic literature contains little information about
allergic reactions to this material, although it is widely
used.
Nealey and Del Rio1 described stomatitis venenata,
a contact allergy caused by a prosthesis constructed of
self-curing acrylic resin. McCabe and Basker2 reported
2 cases of sensitivity to acrylic and linked these reactions
to the levels of residual monomer (0.233% and 0.186%,
analyzed by gas chromatography). Likewise, allergic
reaction to methylmethacrylate was shown by Giunta
and Zablotsky,3 confirmed by patch testing and histopathologic evaluations.
Devlin and Watts4 cited Fisher, who stated that
From the Pontifical Catholic University of Rio Grande do Sul-PUCRS, Porto
Alegre, Brazil.
a
Postgraduate student, Department of Orthodontics.
b
Postgraduate, Department of Orthodontics.
c
Dermatologist, Department of Internal Medicine.
d
Assistant professor, Department of Orthodontics.
e
Professor, Department of Orthodontics.
Reprint requests to: Tatiana Siqueira Gonalves, Pontifcia Universidade
Catlica do Rio Grande do Sul, Faculdade de Odontologia-Prdio 6, Secretaria
de Ps-Graduao, Av. Ipiranga, 6681Sala 209, Porto Alegre, RS, Brasil;
e-mail, tatianasgoncalves@terra.com.br.
Submitted, September 2005; revised and accepted, October 2005.
0889-5406/$32.00
Copyright 2006 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2005.10.017

patch tests in which pressure or trauma is applied to the

skin provide false-positive results. The authors also
discussed allergic reactions to acrylics, affirming that
these are usually type IV allergic reactions, which
happen after re-exposing a subject to the allergen.
According to those authors, these reactions are normally caused by compounds of low molecular weight
called hamptons, which can initiate a response only
when carried by a protein. For acrylic resins, these
would be formaldehyde, benzyl peroxide, methylmethacrylate, and plasticizers such as dibutyl phthalate.
The authors also pointed out the importance of a
complete evaluation of medical history, because diseases such as anemia and diabetes can render the oral
mucosa more susceptible to pathologic effects.
Generally, allergic reactions to acrylic are local
manifestations, but there are different clinical presentations. Ruiz Genao et al5 mentioned labial edema in a
case of allergy to methylmethacrylate confirmed by
patch test. Lunder and Rogl Butina6 reported that
chronic urticaria was the only symptom of the allergic
reaction and considered it the first case of isolated
systemic involvement developed by acrylics.
Many authors agree that residual monomer leaching
into the oral environment is a main cause of allergic
reactions; therefore, its concentrations have been widely
investigated. Stafford and Brooks7 verified that residual
monomer contents are usually about 1.5% to 4.5% in
self-curing acrylic resins and about 0.3% in heat-curing
resins when submitted to the cycle proposed by Hugget
et al.8 Harrison and Hugget9 referred to British Standard Specifications for self-curing orthodontic resins;
those specifications establish 3.5% as a limit for resid431

432 Gonalves et al

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Fig 1. A, Acrylic retainer in place; B, palatal erythema after retainer was removed.

ual monomer concentration. Yilmaz et al10 mentioned

the international patterns of ISO 1567 as a reference. It
limits the levels of residual monomer to 2.2% for
heat-cured and 4.5% for self-curing acrylic resins.
In this article, we report an allergic reaction to the
self-curing methylmethacrylate acrylic resin of an orthodontic retainer base plate. Although the content of the
residual monomer, verified by gas chromatography,
was well below international standards, a localized
reaction occurred and was confirmed by skin patch test.
CASE REPORT

The patient was a 60-year-old woman who had

undergone orthodontic treatment with a fixed standard
edgewise appliance (3M Unitek, Monrovia, Calif). The
goals of treatment were to correct the posterior vertical
collapse and protrusive incisor position, which were
consequences of missing teeth and severe periodontal
bone loss. Orthodontic treatment took place after the
periodontal issues were under control and the patient
was in a maintenance program. After removal of the
fixed appliance, a removable retainer was constructed
of clear self-curing methylmethacrylate acrylic resin
and stainless steel clasps. It was used to maintain
vertical dimension, thus preventing extrusion of the
posterior teeth until titanium implants could be placed
and while waiting for osseous integration before reconstructive prosthetic work.
Thirty days after placement of the retainer, she returned for a regular appointment, complaining of a burning sensation on the palate, a bitter taste in the mouth,
hypersalivation, and difficulty swallowing when wearing
the appliance. A well-delineated erythema could be seen
on the hard palate, marking the retainer contours exactly
(Fig 1). At this appointment, part of the retainers acrylic

Fig 2. Acrylic appliance.

plate was removed (Fig 2) with a stainless steel bur

under refrigeration to analyze the levels of residual
monomer by using the technique described by Sadamori et al.11
Two portions of acrylic weighing 0.2 g were sampled and stored in test tubes containing 5 mL methylethyl-ketone. The test tubes were sealed and stored in a
dark place at 4C for 48 hours. Then they were centrifuged at 2000 rpm for 15 minutes, and 1 L of the
supernatant was removed with a microsyringe. The sample was immediately injected into an auto-sampling gas
chromatographer (Auto System XL, Perkin Elmer,
[Wellesley, Mass]), equipped with a PE-WAX (Perkin
Elmer) column, 30 m long and 0.25 mm in cross section,
with polyethylene glycol as stationary phase and nitrogen as carrier gas. The device was callipered with

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American Journal of Orthodontics and Dentofacial Orthopedics

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Table I.

Polymerization techniques, surface treatments,

and storage of resin used in patch test

Mass technique, mechanical polishing

Mass technique, chemical polishing
Mass technique, chemical polishing, stored in water for 24 h
Mass technique, chemical polishing, stored in hot water for 1 h
Mass technique, chemical polishing, excessive monomer
Addition technique, mechanical polishing
Addition technique, chemical polishing
Addition technique, mechanical polishing, stored in water for 24 h
Addition technique, mechanical polishing, stored in hot water
for 1 h
Addition technique, mechanical polishing, excessive monomer

different concentrations of a 99% pure grade methylmethacrylate pattern solution (Merck-Schuchardt, Hohenbrunn, Germany), to build a calibration curve used
to calculate the concentrations in the samples and also
as a control. Residual methylmethacrylate monomer
levels were verified at 0.745% and 0.78%.
At the same appointment, the patient was referred
to a dermatologist, who prescribed triancinolone acetonide for oral use. It did not relieve her symptoms and
was replaced by hydrocortisone, which gave partial
relief. A skin patch test was conducted with 10 samples
of the same acrylic resin as in her retainer (JETClssico, So Paulo, Brazil), combining various polymerization and polishing techniques, described in Table
I. These combinations were shown to contain the
highest and lowest concentrations of residual monomer
for self-curing acrylic resin.
With the patch test on her arm, the patient was
instructed not to wet or scratch the area and to call the
physician if a reaction occurred. The first evaluation
was scheduled for 48 hours later. A classification of
clinical signs of reactions to materials was used, as did
Menezes et al12 (Table II).
After 48 hours, the patients reactions were scored
as 2, with erythema alone. No differences were observed
in terms of scores for the samples. Some pressure from the
patch test was noticed on the skin, and the area was left
clear for 24 hours. Another evaluation was made 72
hours after the first application. This time the reaction
was exacerbated, with erythema, edema, and papules,
and rescored as 3. Although variuos techniques were
used to polymerize and polish the acrylic samples, no
differences could be seen in the reactions. The patient
was then instructed to apply flurandrenolide on her
skin, but, after 15 days, signs of the allergic reaction
could still be seen on the patch test site.
The objective of the removable retainer was to
maintain vertical dimension and prevent extrusion of
the posterior teeth while waiting for implant-supported

Table II.

Reading of patch test

Result
Negative
Positive

Score

Reaction

0
1
2
3
4

Absent
Light erythema
Erythema
Erythema, edema, papules
Erythema, edema, papules, vesicles

prosthetic rehabilitation. When this stage of treatment

was completed, a bonded fixed retainer was placed to
prevent relapse of the periodontally compromised anterior teeth.
DISCUSSION

Acrylic resins are widely used in dentistry, especially in orthodontics and prosthodontics. Increasing
concerns about the biocompatibility of this material
were evident a decade ago, when reactions were described in the literature.1-3 According to Kusy,13 although metal allergies, particularly to nickel, are the
main cause of hypersensitivity reactions in orthodontics, methylmethacrylate is also a key etiologic agent,
especially in women. Although reactions to this kind
of allergen are rare,14 awareness of local and systemic manifestations is important in orthodontic practice when a patients general health is concerned.5,6
This patient had an allergic reaction to a retainer made
of self-curing acrylic resin. Local clinical signs, such as
palatal erythema delineating the contact area, were
evident. Burning sensations and difficulty in swallowing also occurred, raising concerns about systemic
involvement.
Other authors have studied residual monomer contents in heat-cured acrylic resins,15 and many have tried
to determine the most effective polymerization cycle,
reaching very low levels of unpolymerized monomer.8,9
Self-curing resins have a great disadvantage in this
aspect. Without a heat source to provide energy that
could overcome binding forces to a stabilizer, the
material needs a chemical activator. As a result, there
are significantly higher levels of unpolymerized content, which vary among commercial brands and processing techniques.
Samples of the retainer were analyzed by gas
chromatography. The resulting levels were acceptable,
well below international standards.7,9,10 Comparisons
with results of other studies should be made carefully.
Other authors might have used other types of resins
(McCabe and Basker2 experimented with heat-cured
resins) and also because of different extraction methods
(eg, the aforementioned authors use of methanol). We

434 Gonalves et al

used methyl-ethyl-ketone as the solvent in a technique

shown to be the most effective by Sadamori et al.11
When a patient is hypersensitive, removal of the
etiologic agent is always called for. This patient was
also treated with oral medication, triancinolone acetonide, and later with hydrocortisone, which gave only
mild relief. Complete remission of symptoms was
achieved only after the retainer was removed. A skin
patch test for the acrylic resin, with several samples of
the same material processed by various techniques, was
conducted to determine whether altering the processing
method could improve biocompatibility. Methods generally suggested to lower the residual monomer content, such as 24-hour immersion in water and hot-water
baths, were also tested. No difference was noticed in
the reactions to any sample. In this patient, the slightest
amount of unpolymerized methylmethacrylate was sufficient to start a reaction. This agrees with the findings
of Kusy,13 who stated that the effect caused by everyday substances depends on concentration, but, when the
concentration exceeds a specified level, it can become
harmful. Each patient has a different chemical profile,
so that what is optimal concentration for 1 patient might
cause an allergenic response in another; this explains
why such a low level of residual monomer caused the
reaction in this patient.
Fernstrm et al16 suggested that only the unpolished
surface of the resin contained allergenic substances.
However, the patch test verified that even polished
resin samples caused an allergic reaction of the same
intensity. As found by Fowler,17 the allergic reaction
peaked in 72 hours and lasted for more than 2 weeks.
This observation refuted the possibility of a traumatic
reaction to the patch test from pressure or scratching
and confirmed the allergic reaction type IV diagnosis.4
Overcoming allergic reactions in denture patients
sensitized by methylmethacrylate might require, according to Kanerva et al,18 1 of 6 possibilities: cover
the prosthesis with light polymerized methyl methacrylate, cover it with ultraviolet polymerized urethane
acrylate, cover it with ultraviolet polymerized methacrylate, use a polycarbonate prosthesis, use vulcanite, or
use titan associated to ceramic teeth. A patient allergic
to methylmethacrylate was shown to also have positive
patch test results to polysulfone and polycarbonate,
leaving urethane dimethacrylate as the only choice.19
Therefore, the treatment of allergic reactions to dental
materials should be individualized. Suspicious changes
should be investigated by a dermatologist and, whenever possible, confirmed by patch testing. Because an
allergic reaction is not dose-dependent, but related to
the patients sensitivity,13 it could eventually become
life-threatening.20

American Journal of Orthodontics and Dentofacial Orthopedics

March 2006

With hydrocortisone, this patient experienced enough

relief of symptoms to continue supervised use of her
retainer. This was a temporary situation necessary to
maintain the vertical dimension and prevent extrusion
of the posterior teeth until reconstructive implantsupported prosthetic work was finished. The retainer
was then discontinued, and a wire was bonded with a
bis-GMA composite resin to prevent relapse of the
periodontally compromised incisors. No reactions or
discomfort was associated with that appliance.
CONCLUSIONS

Awareness of reactions that can occur with dental

materials is important to the orthodontist. Acrylic resins
based on methylmethacrylate can produce type IV hypersensitivity reactions. Diagnosis and treatment should include a multidisciplinary team. In all instances, the
patients well-being should guide treatment decisions,
and general healthnot just oral healthshould be the
goal.
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