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Review article  7

Hazards of prosthodontic devices and materials

Safa’a A. Asal, Fadel EI-Saeed Abdel Fattah

Department of Prosthodontics, Faculty of
Dentistry, Tanta University, Tanta, Egypt
Correspondence to Safa’a A. Asal, MD, PhD,
Department of Prosthodontics, Faculty of
Dentistry, Tanta University, El‑Geish Street,
Tanta 31527, El‑Gharbia, Egypt
Tel: 002 01017033344;
e‑mail: std2mster@gmail.com
Received 12 November 2016
Accepted 21 January 2017
Tanta Dental Journal
2017, 14:7–11
The intent of this review is to highlight the hazards and risks associated with prosthodontic
practice and briefly discusses their diagnosis in routine practice with the intention to enhance
awareness, and take preventive measures to reduce the risks among professionals.
Keywords:
biological hazards, chemical hazards, ergonomic hazards, physical hazards prosthodontics,
psychological hazards
Tanta Dental Journal 14:7–11
© 2017 Tanta Dental Journal
1687‑8574

biodegradation in the oral environment may lead to

Introduction
A hazard can be defined as a source of potential
damage, harm, or adverse health effects on something
or someone at work.
Hazards are generally labeled as one of five types. Physical
hazards: are conditions or situations that can cause the
body physical harm or intense stress. Chemical hazards:
are substances that can cause harm or damage to the
body, property, or the environment. Biological hazards:
are biological agents that can cause harm to the human
body. Psychological hazards: are conditions created
during work related stress, or a stressful environment.
Ergonomic hazards: are commonly referred to physical
occupational conditions that may pose risk of injury to
various parts of the musculoskeletal system.
Prosthodontics may be defined as ‘the branch
of dentistry pertaining to the restoration and
maintenance of oral function, comfort, appearance
and health of the patient by the restoration of natural
teeth and/or the replacement of missing teeth and
craniofacial tissues with artificial substitutes’. In other
words prosthodontics includes a variety of branches
including complete dentures, removable partial
dentures (RPDs), or implant assisted prostheses.
There are a lot of debates about the safety of the
compositions of widely used materials such as
impression materials, resin‑based synthetic polymers,
cements, alloys, and dental ceramics.
Currently, there are no substantial scientific data, nor
robust evidence warning against the continued use
of any of these materials. Oral release of compounds
from prosthodontic biomaterials remains a major
concern with the likelihood of adverse reactions
that could result from their intraoral use. There
have been also increased concerns regarding the
safe clinical application of these materials as their
harmful effects. Many signs of the noted reactions were
asymptomatic and may even remain unnoticed for a
long period of time. A  questionnaire survey among
prosthodontists indicated adverse patient reactions in
one out of 300 patients, or one patient in ∼2 years per
prosthodontists [1].
Prosthodontic hazards may affect the patient, the
dentist, the dental laboratory technician, or the dental
assistant.
Prosthodontic hazards are labeled as:
• Hazards affecting patients, which may be either:
• Hazards because of the material composition
and manipulation (chemical hazards)
• Hazards caused by of the dentist  (iatrogenic
hazards)
• Hazards affecting dental personnel  (occupational
hazards).
Hazards affecting patients
Chemical hazards
A wide variety of materials such as resin‑based
synthetic polymers, metals, cements, impression
materials, and dental ceramics are used for construction
of dental prosthesis. Polymerization of resin‑based
materials may be initiated by heat, light, or by chemical
activators, which initiates the reaction at room or
mouth temperature. These resin‑based materials
contain accelerators such as amines, copolymers,
such as butylmethacrylate, plasticizing agents such as
dibutylphthalate, and inhibitors such as hydroquinone.
In addition, cadmium salts‑based coloring agents
may also be used. It should be kept in mind that
This is an open access article distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows
others to remix, tweak, and build upon the work non‑commercially, as
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the identical terms.

© 2017 Tanta Dental Journal | Published by Wolters Kluwer - Medknow DOI: 10.4103/tdj.tdj_51_16
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8  Tanta Dental Journal, Volume 14 No. 1, January-March 2017
prosthodontic materials are manufactured with the
aim of being inert and insoluble. Thus, the amounts
of leachable components should be very small, which
makes the development of toxic reactions unlikely to
occur. Meanwhile, some of the metals used in dental
alloys are known to be biologically active or potentially
hazardous, such as nickel, cobalt–chromium, cadmium
and beryllium. Unexpected adverse reactions to
prosthodontic materials may occur as a result of their
direct contact with soft tissues [2]. A wide variety of
materials have been used in dental implants. Numerous
investigations have been performed to assess the
biological properties of dental implants. Pure titanium
implants do have an inert nature towards the tissues.
Literature has reported some of the adverse reactions
associated with prosthodontic treatment such as:
• Burning mouth syndrome’ which is one of the
annoying patient complaints which are characterized
by diffused or localized burning sensation in the
mouth. In fact the burning sensation may result
from direct mucosal irritation, intraoral manipulation
of resin or because of the presence of residual
monomer [3,4]
• Contact allergic reactions  (type  IV reactions)
are another adverse reaction associated with
prosthodontic treatment  [5–7]. It appears in
the form of redness and swelling of the affected
mucosa that could be perplexed with the signs
of mechanical irritation caused by overextended,
poorly‑fitting dentures, or poor oral hygiene [8,9].
It may either be caused by formaldehyde, which is
a degradation product of several monomers used in
dentistry, residual monomer especially in chemical
cured prosthetic appliances [1] or to an ethylene
amine activator used in several polymeric materials,
including impression materials and temporary crown
materials [10]. Hildebrand et al. [11] have concluded
that mucosal reactions to metal‑based partial
dentures are rare, while remote reactions occurred
in almost 25% of patients.
Literature has pointed out that allergic reactions to
gold‑based restorations were more common than
to nickel‑containing alloys  [12]. This finding is in
agreement with the findings of a survey of mucosal
reactions to more than 1000 prosthetic units [13].
One of the common reasons of allergic reactions
may be attributed to the use of the denture cleansers
containing persulfate [14]. Symptoms of these allergic
reactions are more severe. It takes the form of tissue
irritation, tissue damage, rash, hives, gum tenderness,
breathing difficulties, and low blood pressure. Other
possible reactions as a result of the misuse of denture
cleansers include damage to the esophagus, abdominal
pain, tissue burn, breathing difficulties, seizures,
bleaching of the oral tissues, internal bleeding, and
vomiting [14].
Recurrent facial dermatitis was observed with
dental work using of epoxy acrylate bisphenol‑A
glycidildimethacrylate [15].
Root fractures after post and core restorations was
documented with different metal combinations and
was attributed to the galvanic corrosion. Therefore, it is
important not to combine two different alloys for the
cast post and core/crown restorations when preparing
post retained crowns [16].
Diagnosis of allergy
Whenever, there is an adverse reaction to any prosthetic
material or treatment, a number of information should
be gathered. Among these are: detailed history of the
adverse reaction, its nature, detailed examination of
the prosthesis, any medication used by the patient, as
well as the salivary flow rate. Thorough investigations
should be carried out to achieve an accurate diagnosis
of allergy. Oral mucosal tests based on adverse reactions
to materials in contact with the hamster‑cheek pouch
is considered to be a short‑term test for prosthodontic
materials and is relatively less invasive or traumatic
than suturing the material in contact with the mucosa.
If a holding device is used, uncertainty exists regarding
the position and amount of pressure exerted by the test
specimen. Specially designed appliances for testing
prosthodontic materials have not received widespread
use, probably because of the inherent problems
associated with the test or the cost involved  [17].
Development of tests for prosthodontic materials
should therefore receive greater attention. While
skin patch test is of limited value because a distinct
difference exists between material reactions intraorally
and extraorally, in addition to the irrigating effect of
saliva which is difficult to assess [18,19].
Management of allergy: when diagnosis of the lesion
is confirmed to be allergy to residual monomer,
researchers recommend reduction of the amount of
residual monomer in the dentures by soaking them in
water before insertion, and instructing the patient not
to wear the newly made dentures overnight, so as to
avoid mucosal irritation caused by leachable residual
monomer molecules. Nowadays, change to denture
base materials which are monomer‑free such as light
activated resin (Eclipse) [20].
Iatrogenic hazards
Proper handling and maintenance of the health and
integrity of the oral tissues is the responsibility of the
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dentist. A careful and meticulous diagnosis, treatment
planning and treatment procedures should be carried
out properly. It has been shown that fixed and RPDs
that were constructed using the principles generally
followed did not harm the oral structures  [21].
However, the dentist may be implicated in accidentally
producing an oral problem as a result of inadvisable/
careless dental therapy which may cause patients to
suffer physically, mentally, as well as financially. Such
damage caused by the dentist is called an iatrogenic
damage/hazard [22].
Some of the documented iatrogenic adverse effects of
prosthodontics include:
• Local mechanical irritation; epulis fissuratum is a
reactive lesion arising from excessive and chronic
mechanical pressure on the vestibular oral mucosa.
It may be due to an overextended denture borders,
poor denture fit, or faulty occlusion
• RPDs may increase the incidence of caries, damage
the periodontium, and increase the amount of stress
on natural teeth [23]. This may be explained by the
fact that the insertion of RPD creates potential
for quantitative and qualitative changes of plaque
formation on the remaining teeth and thereby
increases the risk for development of gingivitis and
periodontitis [24]
• Regarding fixed partial dentures, the use of
high‑speed cutting instruments, or the utilization of
retraction cords during impression making procedure
can cause serious and irreversible damage to the
attachment complex if performed without regard to
fragility of the tissues and the small margin for error
that exists [25]
• Overcontoured crowns and restorations tend
to accumulate plaque and possibly prevent the
self‑cleansing mechanism of the adjacent cheeks,
lips, and tongue. The degree and extent of marginal
inflammation depends on failure to maintain the
proper emergence profile, inability to adequately
finish the subgingival crown margins, placement of
margins in an area with no attached gingiva, and
violation of the biologic width [26]
• Materials left in inaccessible areas like subgingival
regions where remainence of elastomeric impression
materials were left behind, thus affecting cell viability.
Therefore, due care should be taken to carefully check
the subgingival areas before disposing the patient
from the clinic
• There was absolute negligence about force distribution
on abutments. The number of teeth replaced far
exceeds the potential supportive ability of the
abutment teeth as dictated by Ante’s law. This will
result in destruction of the periodontal structures
and premature failure of the fixed partial denture
prosthesis
Prosthodontic devices and materials Asal and Abdel Fattah  9
• Implant materials; much attention was focused on the
bone tissue/implant interface and on the ingrowth of
bone into the porous implant fixture.  According to
Branemark, implant failure commonly result from
improper surgical procedures, problems related to
the loading of the implant, and infection [27].
Hazards affecting dental personnel
Occupational hazard is defined as a risk to a person in
his working environment.
According to WHO, the term ‘hazard’ refers to an
inherent property of an agent, or situation having the
potential to cause adverse effects when an organism,
system, or population is exposed to that agent [28].
Dental work set up poses many risks to its employees.
New  Zealand studies found over  40% of dental
professionals were affected with different occupational
hazards, and women dentists experienced double the
chances of allergy occurrence [29].
Biological hazards
Bacterial contamination from splatter and aerosol
dissemination generated by high‑speed instrumentation
pose a significant risk for dental personnel  [30].
Apart from contamination by microorganism, the
composition of aerosol produced during the use of
rotary instruments is of concern.
Contaminated impressions  (soiled with blood
saliva and other infectious material) are another
source of infection in prosthodontic practice. When
plaster/stone is poured into a contaminated impression,
microorganisms from its surface spread into the cast,
and this infected cast is ordinary handled in the dental
laboratory. The plaster dust from the infected casts gets
into the respiratory tract of the laboratory personnel,
settles on clothes and environmental surfaces, and
remains viable for a considerable time  [31]. Other
possible sources of infectious contamination are the
dental unit waterlines  (DUWL), handpieces, saliva
ejectors and suctions as well as other devices attached
to air and waterlines [32].
Chemical hazards
A variety of materials which are commonly used in
dentistry alloys, polymer materials, acrylic resins,
ceramics, cements, sealers, etchants, hypochlorite,
waxes, and elastomeric impression materials are
generally used in clinical prosthodontic practice as well
as in the laboratory [33]. Ingredients of these materials
do not pose any problem for the patients but may have
deleterious effects on the dental laboratory technicians
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10  Tanta Dental Journal, Volume 14 No. 1, January-March 2017
during laboratory procedures such as packing, grinding,
and finishing the prostheses. A study reported that 53 of
70 dental technicians were affected by pneumoconiosis,
which could be caused by dust from the processing of
dental materials [34].
Irreversible hydrocolloid powder contains about 60%
diatomaceous earth, which could be inhaled and may
prove to be a health risk  (carcinogenic) over a long
time span  [35]. Woody et  al. [36] monitored and
characterized aerosol particles from two alginates and
showed that 10–15% of the particles pose the greatest
risk. With daily utilization of irreversible hydrocolloid
materials in the dental office, improper handling of
these materials could be hazardous to the health of
dental personnel.
Even though the ceramic materials are generally inert,
inhalation of its dust containing free silica in dental
laboratories can lead to silicosis [37].
Regarding the elastomeric impression materials, it is
documented that the polyether materials were found to
be more toxic than polyvinyl siloxanes [38].
Physical hazards
Physical hazards that are commonly encountered
in prosthodontic practice include direct physical
trauma, heat and fire injuries to the face, the scalp and
particularly the eye. Overall, 4.5% of prosthodontists
have percutaneous injuries occurred/year  [39]. The
grinding tools are generally of high frequency and
they can cause direct injury to the face and upper
extremities. The effects of vibration on the hand can
also result in vibration syndrome [40] or vibration
white finger [41,42].
Prosthodontists and dental laboratory technicians
are exposed to noise of different sound levels that are
potentially damaging to hearing which include low
speed handpieces, high‑speed turbine handpieces,
ultrasonic instruments, high velocity suction, and
cleaners, vibrators and other mixing devices, and model
trimmers [43]. These equipments emit sounds, which
are very close to the limit of hearing loss  [43]. Eye
irritations may happen from a variety of laboratory
materials. Painful reactions are elicited when methyl
methacrylate monomer, or when pumice which
contains lime and quartz are accidentally splashed
into the eye; in addition pumice can also cause eye
abrasion [44].
Ergonomic hazards
Ergonomic hazard is a physical factor within the
environment that harms the musculoskeletal system.
Prosthodontists are at high risk of neck and back
problems due to the limited work area and impaired
vision associated with the oral cavity. The symptoms
include low back pain, stiffness, and sciatica with
neurological features such as tingling, paresthesia, and
muscle weakness [45].
Psychosocial hazards
Occupational stress such as coping with patient
demands (75%), practice management/staff issues
(56%), fear of complaints/litigation  (54%) and
nonclinical paperwork  (54%). These physical and
emotional demands may result in physical and mental
burnout [46].
Conclusion
• The use of masks, aspirators, and mechanical removal
of as much resin as possible before using rotary
instruments may reduce the biological exposures
• Decontamination of DUWL includes the state of
art method of using ozone
• Incorporation of ozone generating units into the
dental treatment unit would be the logical extension
of this technology
• The integration of the use of ozone into a dental unit
involves a system of disinfection and sterilization for
DUWL into the clinical management and patient
arena [47].
Recommendations
Measures to combat stress by relaxation, exercise,
meditation, hobbies are also recommended.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
 1 Kallus T, Mjor IA. Incidence of adverse effects of dental materials. Scand
J Dent Res 1991; 99:236–240.
 2 De Melo JF, Gjerdet NR, Erichsen ES. Metal release from cobalt–chromium
partial dentures in the mouth. Acta Odontol Scand 1983; 41:71–74.
 3 Cibirka RM, Nelson SK, Lefebvre CA. Burning mouth syndrome: a review
of etiologies. J Prosthet Dent 1997; 78:93–97.
 4 Van Joost T, van Ulsen J, van Loon LA. Contact allergy to denture
materials in the burning mouth syndrome. Contact Dermatitis 1988;
18:97–99.
 5 Rai R, Dinakar D, Kurian SS, Bindoo YA. Investigation of contact allergy
to dental materials by patch testing. Indian Dermatol Online J 2014;
5:282–286.
 6 Gosavi SS, Gosavi SY, Alla RK. Local and systemic effects of
[Downloaded free from http://www.tmj.eg.net on Saturday, March 23, 2019, IP: 182.179.167.76]
unpolymerised monomers. Dent Res J (Isfahan) 2010; 7:82–87.
 7 Lamey PJ, Lewis MA. Oral medicine in practice: burning mouth syndrome.
Br Dent J 1989; 167:197–200.
 8 Crissey JT. Stomatitis, dermatitis, and denture materials. Arch Dermatol
1965; 92:45–48.
 9 Bauer A, Wollina U. Denture‑induced local and systemic reactions to
acrylate. Allergy 1998; 53:722–723.
10 Churgin LS, Payne JC. Sensitized tissue response to an ethylene imine
derivative transitional crown material. J Prosthet Dent 1981; 46:179–180.
11 Hildebrand HF, Veron C, Martin P. Non‑precious metal dental alloys and
allergy. J Biol Buccale 1989; 17:227–243.
12 Gawkrodger DJ. Investigation of reactions to dental materials. Br J
Dermatol 2005; 153:479–485.
13 Usmani N, Wilkinson SM. Allergic skin disease: investigation of both
immediate‑ and delayed‑type hypersensitivity is essential. Clin Exp Allergy
2007; 37:1541–1546.
14 Zarb G, Hobkirk J, Eckert S, Jacob R. Prosthodontic treatment for
edentulous patients. Complete denture and implant‑supported prostheses.
13th ed. St Louis, MO: Mosby, Elsevier Inc.; 2013.
15 Carmichael AJ, Gibson JJ, Walls AW. Allergic contact dermatitis to
bisphenol‑A‑glycidyldimethacrylate  (BIS‑GMA) dental resin associated
with sensitivity to epoxy resin. Br Dent J 1997; 183:297–298.
16 Padmaja S. Biohazards associated with materials used in prosthodontics.
Niger J Clin Pract 2013; 16:139–143.
17 Mjör IA, Christensen GJ. Assessment of local side effects of casting
alloys. Quintessence Int 1993; 24:343–351.
18 Magnusson B, Bergman M, Bergman B, Söremark R. Nickel allergy and
nickel‑containing dental alloys. Scand J Dent Res 1982; 90:163–167.
19 Axell T, Bjorkner B, Fregert S, Niklasson B. Standard patch test series for
screening of contact allergy to dental materials. Contact Dermatitis 1983;
9:82–84.
20 Asal SA, Hassaballa M. Heat‑cure acrylic resin vs light‑activated
resin  (Eclipse): part  1: denture base adaptation. Egypt Dent J 2015;
61:1825–1834.
21 Mackert JR Jr Side effects of dental ceramics. Adv Dent Res 1992;
6:90–93.
22 Carranza NT. Clinical periodontology. 9th ed. Philadelphia, PA:
Philadelphias; 2003. 188,189,191,953,959.
23 Van Noort R, Gjerdet NR, Schedle A, Björkman L, Berglund A. The
current status of national reporting systems for adverse reactions to dental
materials. J Dent 2004; 32:351–358.
24 Scientific Committee on Health and Environmental Risks  (SCHER).
The environmental risks and indirect health effects of mercury in dental
amalgam EU: Health and Consumer Protection. Directorate General
2008; 6:1–18.
25 Block PL. Restorative margins and periodontal health: a new look at an old
perspective. J Prosthet Dent 1987; 57:683–688.
26 Zlataric DK, Celebic A, Valentic‑Peruzovic M. The effect of removable
partial dentures on periodontal health of abutment and non‑abutment
teeth. J Periodontol 2002; 73:137–144.
27 Adell R, Lekholm U, Rockler B, Brånemark PI.A 15-year study of
osseointegrated implants in the treatment of the edentulous jaw. Int J Oral
Surg 1981;10:387–416.
Prosthodontic devices and materials Asal and Abdel Fattah  11
28 International Program on Chemical Safety  (IPCS). Risk assessment
terminology: part 1 and part 2. Geneva, Switzerland: World Health
Organization; 2004. Available from: http://www.inchem.org/documents/
harmproj/harmproj/harmproj1.pdf. [Last accessed on 2012 Feb 17].
29 Sinclair NA, Thomson WM. Prevalence of self‑reported hand dermatoses
in New Zealand dentists. N Z Dent J 2004; 100:38–41.
30 Bentley CD, Burkhart NW, Crawford JJ. Evaluating spatter and aerosol
contamination during dental procedures. J Am Dent Assoc 1994;
125:579–584.
31 Jennings KJ, Samaranayake LP. The persistence of microorganisms
on impression materials following disinfection. Int J Prosthodont 1991;
4:382–387.
32 Bolyard EA, Tablan OC, Williams WW, Pearson ML, Shapiro CN,
Deithman SD. Guideline for infection control in health care personnel,
1998. Hospital Infection Control Practices Advisory Committee. Am J
Infect Control 1998; 26:289–354.
33 Hensten‑Pettersen A, Jacobsen N. Perceived side effects of biomaterials
in prosthetic dentistry. J Prosthet Dent 1991; 65:138–144.
34 Morgenroth K, Kronenberger H, Michalke G, Schnabel R. Morphology and
pathogenesis of pneumoconiosis in dental technicians. Pathol Res Pract
1985; 179:528–536.
35 Choudat D. Occupational lung diseases among dental technicians. Tuber
Lung Dis 1994; 75:99–104.
36 Woody RD, Huget EF, Cutright DE. Characterization of airborne particles
from irreversible hydrocolloids. J Am Dent Assoc 1977; 94:501–504.
37 Kim TS, Kim HA, Heo Y, Park Y, Park CY, Roh YM. Level of silica in
the respirable dust inhaled by dental technicians with demonstration of
respirable symptoms. Ind Health 2002; 40:260–265.
38 Roberta T, Federico M, Federica B, Antonietta CM, Sergio B, Ugo C.
Study of the potential cytotoxicity of dental impression materials. Toxicol
In Vitro 2003; 17:657–662.
39 Siew C, Chang SB, Gruninger SE, Verrusio AC, Neidle EA. Self‑reported
percutaneous injuries in dentists: implications for HBV, HIV, transmission
risk. J Am Dent Assoc 1992; 123:36–44.
40 Szymanska J. Dentist’s hand symptoms and high‑frequency vibration.
Ann Agric Environ Med 2001; 8:7–10.
41 Burke FJ, Jaques SA. Vibration white finger. Br Dent J 1993; 174:194.
42 Szymanska J. Work‑related noise hazards in the dental surgery. Ann Agric
Environ Med 2000; 7:67–70.
43 Mojarad F, Massum T, Samavat H. Noise levels in dental offices and
laboratories in Hamedan, Iran. J Dent (Tehran) 2009; 6:181–186.
44 Scully C, Cawson RA, Griffiths MJ. Chapter 1: mortality and some aspects
of morbidity. In: Occupational hazard to dental staff; 1990. London, British
Medical Journal: 1-21.
45 Harutunian K, Gargallo‑Albiol J, Figueiredo R, Gay‑Escoda C.
Ergonomics and musculoskeletal pain among postgraduate students
and faculty members of the School of Dentistry of the University of
Barcelona (Spain). A cross‑sectional study. Med Oral Patol Oral Cir Bucal
2011; 16:e425–e429.
46 Kay EJ, Lowe JC. A survey of stress levels, self‑perceived health and
health‑related behaviours of UK dental practitioners in 2005. Br Dent J
2008; 204:E19.
47 Puttaiah R, Lin S. Evaluation of ozonated water for controlling dental
treatment water contamination. IADR Abstract 1371; 2006.