Hypersensitivity to methyl methacrylate: Mode of treatment
Nira Hochman, DMD, and Maya Zalkind, DMD
Hebrew University-Hadassah School of Dental Medicine, Jerusalem, Israel
This article describes the treatment of a patient who experienced a delayed hypersensitivity reaction
associated with acrylic resin. Patch testing revealed an allergy to methyl methacrylate monomer.
Patients with a known or suspected allergy of this type should be treated by alternative methods.
Dental procedures in which negligible contact of the oral mucosa with methyl methacrylate are
presented. (J Prosthet Dent 1997;77:93-6.)
Allergy is a hypersensitive reaction to an allergen,
which is enhanced by repeated exposure. Allergic reactions
fall into two main categories: immediate and delayed.
Whereas immediate allergic reactions to various foods and
drugs are well-lmown, such responses to acrylic resin are
less common and usually of the delayed or contact allergy
~Tpe (stomatitis venenata).>a Fisher 4 found that the methyl
methacrylate monomer can cause an allergic reaction on
contact with sldn or oral mucosa. The products of total
polymerization of methyl methacrylate probably do not
cause such reactions, 4-6 and several researchers have sug-
gested that the allergen in contact stomatitis that is induced
by acrylic resin is the residual monomer formed by incom-
plete polymerization. After the polymerization reaction,
various amounts of the methyl methacrylate monomer re-
main in the acrylic resin. A gas chromatography method
has been described for determhfing the amount of residual
monomer. 6 The residual monomer content in acrylic resin
that had been heat-cured by four different methods ranged
from 0.045% to 0.103%. Autopolymerized acrylic resin
had a residual monomer content of 0.185%. Part of the
residual monomer is gradually leached out, leaxdng a frac-
tion that is tightly bound to the acrylic resin. 7 As the num-
ber and variety of therapeutic agents increase, adverse reac-
tions are also on the rise. Allergies, especially contact
dermatitis, rank high among the occupational hazards with
dental medications and oral agents. 8,9 Howeve~ there are
relatively few reports of hypersensitivity to dental agents in
the literature. It is therefore pertinent to address this prob-
lem, particularly with methyl methacrylate, and to suggest
a mode of treatment for such cases.
This article describes a patient whose medical history
and results of patch tests indicated a cell-mediated or
delayed hypersensitivity to methyl methacrylate mono-
mer. s This article also reports the reactions to patch tests
for three patients with various degrees of sensitivity.
CLINICAL REPORT
A healthy 50-year-old woman underwent crown prepa-
ration in the mandibular left quadrant. Because the prepa-
aAssociate Professor, Department of Prosthodontics.
6Senior Lecturer, Department of Prosthodonfics.
JANUARY 1997
ration was not completed in a single visit, the patient
was fitted with a temporary acrylic resin crown. The
c r o w n was prepared directly in the m o u t h with
autopolymerizing acrylic resin. The patient complained
of pain, swelling, and continuous burning sensations in
her left cheek. The symptoms started approximately 48
hours after the temporary crown was inserted. Clinical
examination revealed severe stomatitis with generalized
redness. The buccal mucosa around the temporary crown
was puffs, red, and erythematous with a grayish-yellow
patch adjacent to the temporary crown. The patient was
treated with Oracort triamcinolone acetonide paste 0.1%,
(Taro Pharmaceutical International, Herzllya Pituah, Is-
rael). A second temporary crown was made by the di-
rect method (described in this article) and with an alu-
minum shell that was relined with GC Unifast LC quick
light-curing acrylic resin (GC Corp., Tokyo, Japan). The
patient experienced no allergic symptoms with this
crown.
Patch testing
Patch testing was done on three subjects by the rou-
tine method described by Maxey m Patient 1 had an al-
lergic reaction to the monomer after an autopolymerizing
temporary crown was inserted. Patient 2 was a dentist
who did not exhibit hypersensitivity after the insertion
of an autopolymerizing temporary crown, but experi-
enced an allergic reaction on the hands after handling
the same acrylic resin. Patient 3 was a dentist who did
not exhibit an allergic reaction to autopolymerizing
acrylic resin either on the skin or the oral mucosa.
The test was carried out by cleaning the ventral sur-
face of the forearm and placing patches approximately
10 mm square of several test materials on it: (a) liquid
monomer Jet (Lang Dental Mfg. Co. Inc., Wheeling,
ILL); (b) autopolymerized resin made immediately be-
fore application; and (c) GC Unifast LC light quick light-
curing resin. The patches were placed in position with
small gauze pads and hypoallergenic adhesive tape. The
patients were instructed not to bathe the area and to
leave the patch on for 48 hours.
The following results were recorded at 48 hours. With
the liquid monomer, patient 1 had a severe positive reac-
THE JOURNAL OF PROSTHETIC DENTISTRY 93
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 1. Patient 1 had severe positive reaction to monomer.
tion that included a maculopulpar rash, vesicle formation,
and a large zone of erythema (Fig. 1). Patient 2 had a
moderate, positive reaction with a few papules (Fig. 2),
and patient 3 had a negative reaction (no response at all)
(Fig. 3). With the polymerized autopolymerizing resin,
patients I and 2 had mild erythema with a few papules
(Fig. 4,A), which was a less severe reaction than with the
monomer alone. Patient 3 had a negative reaction. The
reaction to light-curing acrylic resin was the mildest
erythema (Fig. 4, B) among the three treatments in pa-
tients 1 and 2 and negative in patient 3. These results are
consistent with a delayed hypersensitivity reaction.
MATERIAL AND METHODS
Dental treatment for patients hypersensitive to me-
thyl methacrylate should be designed to avoid contact
of the material with the skin and oral mucosa. A well-
made provisional fixed partial denture (FPD), similar to
the final prosthesis, should enhance the health of the
abutments and periodontium.n,~2 Various procedures can
be used to facilitate short-term, biologically acceptable,
interim restorations to prevent contact of methyl moth-
acrylate with the skin and oral mucosa. There are three
procedures for the construction of provisional FPDs: di-
rect intraoral, hybrid methods that include both labora-
tory and intraoral phases, and indirect or laboratory
methods. Post and core restorations are also considered.
PROCEDURES
Direct intraoral method
1. Use aluminum shell crowns for molar and premolar
teeth and preformed polycarbonate crowns for ante-
rior teeth. ~-~s
2. Select a shell crown of suitable diameter and trim it
to fit the contour of the gingival crest.
3. Lubricate the patient's lips and oral mucosa with pe-
troleum jelly for protection.
4. Place the Unifast LC acryfic resin in an aluminum shell
crown or preformed polyearbonate anterior crown and
seat it on the appropriate tooth preparation.
94
H O C H M A N AND ZALKIND
Fig. 2. Patient 2 had moderate positive reaction to monomer.
5. Immediately remove the crown from the mouth and
polymerize the resin with visible light. With this
method, contact of the uncured acrylic resin with the
patient's oral mucosa is negligible (Fig. 5).
Hybrid method
1. Have a dental technician make a heat-cured acrylic
resin provisional shell fixed restoration from the di-
agnostic cast of the patient's m o u t h ) 3,14
2. After the teeth are prepared, line the shell intraorally
with GC Unifast LC light quick-curing acrylic resin,
as in steps 3 through 5 of the direct intraoral method.
After curing and polishing, these provisional restora-
tions provide a more esthetic restoration.
Indirect method
This procedure is usually recommended for patients
who require multiple preparations.
1. Reduce the teeth on a second set of mounted diag-
nostic casts to simulate the tooth preparations.
2. Wax the desired occlusal surface, proximal contacts,
and contours on the preparations on the mounted
diagnostic casts. Invest the wax and then melt it off,
pack, process, and heat cure the acrylic resin. Fabri-
cate and polish the interim restorations. Such crowns
only need slight modification and fitting before tem-
porary cementation. 1~,14,~6
Post and core restorations
Post and core restorations may be indicated after
endodontic treatment. There are two commonly used
procedures for these restorations, the immediate and cast
m e t h o d s , i7-19 Immediate post and core restorations are
made from post and amalgam core buildups or post and
composite core buildups} s,2°-22 Composite buildup is
contraindicated for patients hypersensitive to acrylic resin
monomer. An amalgam core may be the solution for
such patients? a In the cast post approach, the pattern is
prepared either in the mouth (direct method) or on the
die (indirect method). 24 In the direct method, a plastic
sprue is fitted to the root canal, and the autopolymerizing
VOLUME 77 NUMBER 1
HOCHMAN AND ZALKIND
Fig. 3. Patient 3 had negative reaction to monomer. Patch
was removed and held to left of patch site for orientation.
acrylic resin is then inserted into the tooth to make the
core pattern fabrication. 24-26Special care should be taken
to avoid contact of the acrylic resin with the gingival
tissue when this procedure is used. Petroleum jelly should
be applied to all the surrounding tissues. As an alterna-
tive, a wax pattern may be d e v e l o p e d instead o f
autopolymerizing acrylic resin. 27 However, the indirect
method of maldng the post and core may be the treat-
ment of choice for the hypersensitive patient.
DISCUSSION
Various reports in the literature indicate reactions to
methyl methacrylate, 2-6,8,28and the more recent ones im-
plicate excess monomer as the culprit. The allergic reac-
tions were of the delayed general or dermal type among
dental patients, or contact dermatitis among dental per-
sonnel. Sensitization may be caused by repeated contact
with allergy-inducing materials during dental treatment
or prior exposure to components found in jewelry,, per-
fume, or in performing housework. 29 To minimize aller-
gic reactions, the use of heat-cured acrylic resins or re-
lining shell crowns with light autopolymerizing acrylic
resins is recommended whenever possible for fabricat-
ing interim prostheses. Patch testing demonstrated that
there was less of a response with light-cured than with
autopolymerizing acrylic resin. Indirect methods, for
both provisional restorations and post and core fabrica-
tions, are preferable to direct intraoral ones, became they
prevent direct contact of high concentrations of mono-
mer with the oral mucosa. After complete polymeriza-
tion, the cured acrylic resin no longer induces allergic
reactions and, therefore, the provisional crowns should
be placed in a pressure cooker in warm water for 20
minutes to remove unpolymerized monomer, a°
To evaluate possible reactions to acrylic resin, factors
such as oral disease, systemic disorders unrelated to the
prosthesis, and other more c o m m o n causes such as
trauma, poorly adjusted dentures, and chemical injury
must be taken into consideration. The increasing num-
ber of new chemical materials, the biologic effects of
JANUARY 1997
THE J O U R N A l OF PROSTHETIC DENTISTRY
Fig. 4. Stronger reaction to the autopolymerized acrylic resin
than to light-cured acrylic resin. A, Reaction to
autopolymerized resin (Jet) results in mild erythema with few
papules. B, Milder erythema reaction to light-curing acrylic
resin (Unifast).
Fig. 5. Aluminum shell crown relined with rapid polymeriz-
ing light-curing resin.
which are not known, and the increased patient aware-
ness of the health hazards of dental materials are impor-
tant, current issues in dentistry. 3x The newer acrylic res-
ins also contain additives that have not been completely
characterized and may cause such reactions. In addition,
dentists may develop contact allergy by handling dental
resin materials, and vinyl or latex gloves only provide
protection for as long as it takes for the resin monomers
to penetrate the gloves. 32
We thank Professor Chajek-Shaul for her contribution to this study.
REFERENCES
1. Nyquist G. The biological effect of monomeric acrylic, lnt Dent J
1964;14:242-5.
2. Weaver RE, Goebel WM. Reactions to acrylic resin dental prostheses. J
Prosthet Dent 1980;43:138-42.
3. Nea[ey ET, Del Rio CE. Stomatitis venenata: reaction of a patient to acrylic
resin. J Prosthet Dent 1969;21:480-4.
4. Fisher AA. Allergic sensitization of the skin and oral mucosa to acrylic
resin denture materials. J Prosthet Dent 1956;593-602.
5. Giunta J, Zablotsky N. Allergic stomatitis caused by self-polymerizing resin.
Oral Surg Oral Med Oral Pathol 1976;41:631-7.
6. McCabe JF, Basket RM. Tissue sensitivity to acrylic resin. A method of
measuring the residual monomer content and its clinical application. Br
Dent J 1976;140:347-50.
95
THE JOURNAL OF PROSTHETIC DENTISTRY HOCHMAN AND ZALKIND

7. Smith DC, Bains ME. The determination and estimation of residual mono-
mer in polymethyl methacrylate. J Dent Res 1956;35:16-24.
8. Lui JL. Hypersensitivity to a temporary crown and bridge material. J Dent
1979;7:22-4.
9. Patterson R, Zeiss CR, Kelly JF. Editorial: Classification of hypersensitivity
reactions. New Engl J Med 1976;295:277-9.
10. Maxey LW. Dental allergy patch testing. In: Frazier CA, ed. Dentistry and
the allergic patients. Springfield: Charles C Thomas, Publisher, 1983: chap
11.
11. Goldman MM, Cohen DW. Periodontal therapy. 4th ed. St Louis: CV Mosby
1968:509, 991.
12. Amsterdam M, Fox L. Provisional splinting principles and techniques. Dent
Clin North Am 1959:73-99.
13. Zinner ID, Trachtenberg DI, Miller RD. Provisional restorations in fixed
partial dentures. Dent Clin North Am 1989;33:355-77.
14. Tylman SD, Malone WF. Tylman's theory and fixed prosthodontics. In:
Malone WF, Flacker JE. Oral histologic considerations for treatment resto-
rations. St Louis: CV Mosby Co, 1978:250-63.
15. Miller SD. The anterior fixed provisional restoration: a direct method. J
Prosthet Dent 1983;50:516-9.
16. Antonoff SJ, Levine H. Fabricating an acrylic resin temporary fixed pros-
thesis for an allergic patients. J Prosthet Dent 1981;45:678-9.
17. Trabert KC, Cooney JP. The endodontically treated tooth. Restorative con-
cepts and techniques. Dent Clin North Am 1984;28:923-51.
18. Tylman SD, Malone WF. Tylman's theory and practice of fixed
prosthodontics. In: Caruso JL, Morgorelli JC, Sawyer MF, Young AI, edi-
tors. Coronal radicular stabilization of endodontically treated teeth for re-
storative dentistry. St Louis: CV Mosby Co, 1978:488-500.
19. Shillingburg HT, KesslerJC. Restoration of the endodontical[y treated tooth.
Chicago: Quintessence Pub Co, 1982:45-94.
20. Landwerlen JR, Berry HH. The composite resin post and core. J Prosthet
Dent 1972;28:500-3.
21. Assif D, Aviv l, Himmel R. A rapid dowel core construction technique. J
Prosthet Dent 1989;61:16-7.
22. Christensen LC. Plastic dowel and core systems. J Prosthet Dent
1988;60:673-5.
23. Taleghani M, Morgan RW. Reconstructive materials for endodontically
treated teeth. J Prosthet Dent 1987;57:446-9.
24. Hudis SI, Go[dstein GR. Restoration of endodontically treated teeth: a
review of literature. J Prosthet Dent 1986;55:33-8.
25. Shi[lingburg HT, Jr, Fisher DW, Dewhirst RB. Restoration of endodontically
treated posterior teeth. J Prosthet Dent 1970;24:401-9.
26. Mondelli J, Piccino AC, Berbert A. An acrylic resin pattern for a cast dowel
and core. J Prosthet Dent 197I;25:413-7.
27. Rosen H. Operative procedures on mutilated endodontically treated teeth.
J Prosthet Dent 1961;11:973-86.
28. Stungis TE, Fink JN. Hypersensitivity to acrylic resin. J Prosthet Dent
1969;22:425-8.
29. Hensten-Pettersen A, Jacobsen N. Perceived side effects of biomaterials
in prosthetic dentistry. J Prosthet Dent 1991;65:138-44.
30. Giunta JE, Grauer I, Zablotsky N. Allergic contact stomatitis caused by
acrylic resin. J Prosthet Dent 1979;42:188-90.
31. Kaaber S. Allergy to dental materials with special reference to the use of
amalgam and polymethy[methacrylate, Int Dent J 1990;40:359-65.
32. Munksgaard EC. Permeability of protective gloves to (di)methacry[ate in
resinous dental materials. Scand J Dent Res 1992;100:189-92.
Reprint requests to:
DR. N. HOCHMAN
DEPARTMENTOF PROSTHODONTICS
HADASSAH SCHOOLOF DENTALMEDICINE
HEBREW UNIVERSITY
EO.B. 12272
91120 JERUSALEM
iSRAEL
Copyright © 1997 by The Editorial Council of The Journal of Prosthetic Den-
tistry.
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