Immediate Hypersensitivity Reaction to Composite Restorations

Restorative materials used in dentistry are constantly exposed to salivary components like enzymes that have a high impact on the degradation of these materials and subsequent leaching of some of their constituents which may be harmful to the oral tissues in some patients. Released triethyleneglycol-methacrylate, bisphenol A-glycidyl methacrylate (Bis-GMA), diurethanedimethacrylate (UDMA) and formaldehyde have been detected from incompletely polymerized composite and are implicated in occurrence of various adverse reactions. We present a case of a 60 year old female who had composite restorations done. She later presented with complaints of several episodes of intermittent gingival and cheek swellings of sudden onset adjacent to the restored teeth. The filling was taken off and patient was placed on anti-allergy medications with a close follow-up.This presentation highlights the occurrence of a typical allergy to composite material in our centre. It serves to educate dental practitioners about the awareness of such adverse reactions to dental resin materials and the need to be prompt in management of the condition.

Introduction composite resin material is hereby presented. Composite resin is currently the preferred choice of restorative material used especially for anterior Case report restorations. Even though resin-based restorative A 50 year old female presented at the conservative materials are considered safe, their constituents can dentistry clinic of Lagos University Teaching Hospital, leach out and induce reactions in patients and dental Lagos, Nigeria for restoration of abrasive cavities on personnel. Documented incidents of adverse several teeth. She was referred to our clinic after reactions in patients caused by resin-based materials extraction of a damaged tooth about 2 weeks earlier. in dentistry are quite few and under reporting is She is a known hypertensive who is well-controlled 1 suspected to be high . on Co-myocardis 40mg daily and Cavedilol 40mg daily for 3years. She was not asthmatic but she Adverse reactions can be either allergic or nonreported a drug allergy to Chloroquine to which she allergic. Allergy to dental resin-based materials is due reacts to by itching. The family history is to a reaction to some of the substances in the resin noncontributory for any medical condition. matrix (e.g. monomers, inhibitors, stabilizers). Common ways of exposure to these substances may On examination, no facial asymmetry was detected. be; pre-polymerization, incomplete polymerization, Intra-oral examination revealed missing 14, Ellis class degradation and leaching of products from 1 fracture of 21, and cervical abrasions on all the polymerized materials by saliva components via premolars and molars excluding the last molars. All passive hydrolysis and enzymatic action.
the abraded teeth were subsequently restored with composite filling material followed by post-operative Reported type of reactions could be cell-mediated instructions and oral hygiene counseling. delayed reactions (type IV) or immediate reactions with humoral antibodies (type I-III). Allergic reactions The patient returned after two weeks with complaints to resin-based materials are normally type IV of chipping off of composite from some of the teeth hypersensitivity reactions while type I reactions are that were restored. She was reviewed and repeat On her third visit, the symptoms still persisted. She composite restorations were done on the affected was reviewed by a Consultant physician and further teeth.
probing revealed that she is atopic with history of reactions to extreme dust, some cosmetics and She reported that on completion of the restorations, some sea foods. She also has early morning allergies she immediately noticed a swelling of the left cheek when she jogs which often results in eruption of and called the attention of the managing dentist. She reddish bumps on her thigh and legs. was reassured that the symptoms would resolve spontaneously and was asked to come again in a week for review if symptoms persisted.
The patient came back 18 days later and complained that she has been having recurrent episodes of swelling of the cheek, tongue and gums with associated temporomandibular joint pain (Figures 1  and 2).

Figure 3:
Sloughing of the oral mucosa adjacent to where the fillings were placed The swollen tongue she reported had resolved but the patient presented pictures that showed the tongue swelling with erythematous areas and picture A tentative diagnosis of an allergic reaction to composite filing material was made subject to further investigation and consultation. The composite restorations were removed and consultation with a dermatologist was proposed with recommendation to do a patch test. She was reviewed by a dermatologist and a diagnosis of allergic reaction to composite resin and specifically, a type I immediate hypersensitivity reaction was confirmed. The proposed patch testing was ruled out on account of the possibility of inducing a severe reaction.
The abrasive lesions were reassessed and all residual resin was removed. She was placed on 5mg Xyzal tablets daily for 4 weeks, 5mg Diazepam tablets daily for 3 days, 1g paracetamol tablets three times daily for 3 days. The patient presented four weeks later and recounted only one or two mild episodes although a There was no associated difficulty in breathing or slight midline shift was still present. She was swallowing. Each episode lasted for about five days, reviewed with an orthopantomograph at the oral resolved and then re-occurred. She was on surgery clinic but no obvious pathology was found. prednisolone tablets prescribed by a doctor during Patient's subsequent recall visits were uneventful with one of the episodes. She was reviewed in the clinic, complaints of occasional mild episodes. reassured and given a week appointment for further review.

Discussion
• Immediate onset of reaction after prior sensitization Dental composite is a commonly used restorative • Angioedema of lip, cheek, tongue material in dentistry due to its high aesthetic appeal. Composite material however contains methacrylate • Recurrent episodes monomers, such as TEGDMA, Bis-GMA, MMA and 3 EGDMA and these have been reported as allergens .
• History of allergic reactions to other Hypersensitivity can affect patients, dental allergen in the environment including 4 pigs, food items, sunlight professionals, dental technicians and technologists .
A similar case was reported in India where a patient Allergies to methacrylate monomers are being 5 received direct and indirect composite restorations reported in growing frequencies , even though and suffered an upper lip swelling less than an hour experimental data have shown that these monomers after the treatment. Blood tests revealed an increase have only mild to moderate potential to induce in IgE and an absolute eosinophilic count which are allergies. The allergic reactions are usually due to consistent with a type 1 hypersensitivity reaction. It exposure of the oral mucosa or the skin to free was later diagnosed as an acute allergic angioedema monomers as they are unlikely to cause allergy when 3 of the upper lip . fully polymerized.
When a patient is suspected of an allergy, a thorough However, some authours have reported that 6 history taking and clinical examination should be reactions to composite are relatively uncommon .
done. In this case, atopic nature of the patient was They stated that documentations on the risk of such missed by the dentist despite revelation that she has monomers in composites and bonding agents are 1 a specific drug allergy. A further probe to ascertain quite few and this may be due to underreporting .
other allergic items might have established this When the reactions do occur, they most commonly peculiarity of this patient. A high level of suspicion of take the form of delayed Type IV reactions affecting possible allergy to restorative or dental materials oral mucosa in direct contact with the restorations should be aligned with any history of allergy. Prompt (allergic contact dermatitis/ mucositis). Immediate management of cases of allergic reactions to dental Type I reaction to composite restorations is said to be materials must be employed to avoid life-threatening 2 extremely rare . complications. This should include patient education 3 and a personalized treatment plan . All filling Type I reactions involve immunoglobulin E materials containing the suspected allergens or (IgE)-mediated release of histamine and other trigger factors must be eliminated immediately and mediators from mast cells and basophils. Immediate medications should be administered. The important Type I reactions occur within seconds to minutes drugs in management of type 1 hypersensitivity are after allergen exposure following an initial exposure antihistamines, corticosteroids and/or epinephrine. that caused sensitization in genetically predisposed 7 These drugs must be readily available in the dental individuals who are said to be atopic . emergency kit. Patient should be monitored safely till The patient in this case report was probably symptoms subside and followed up with recall visits. sensitized when the composite restorations were Prick method (test) and scratch test are used to first placed. She only reacted when the failed confirm immediate hypersensitivity while the patch restorations were being replaced about two weeks 10 test verifies delayed hypersensitivity Studies in the later. Her reaction was immediate after completion of literature have shown that2-HEMA (2-hydroxyethyl the restorations while still on the dental chair. She methacrylate) and BIS-GMA are the methacrylates reported to the managing dentist that her left cheek that show the greatest percentage of sensitization was swollen even though no anaesthesia was given 11,12 with patch testing . The result of patch testing prior to treatment. must however be correlated with a good history and The clinical presentations of allergic reaction to clinical examination in other to achieve a clinical 13 composite and similar dental materials are not relevance . 8 uniform . These reactions may be allergic Radioallergosorbent Test (RAST) is recommended for angioedema of upper lip, anaphylaxis, urticaria, confirmation of Type I reactions. It detects allergen hereditary atopic eczema, cellulitis, cheilitis granulospecific IgE in the blood. However we were unable to 3,9 matosa, and cheilitis glandularis . perform this test based on non-availability of RAST for In this patient, a diagnosis of Type I hypersensitivity components of resin composite materials in our reaction was made based on the following: centre.