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Review Article
Allergy and orthodontics
Sunitha Chakravarthi, Sridevi Padmanabhan and Arun B. Chitharanjan

ABSTRACT
The aim of this paper is to review the current literature on allergy in orthodontics and to identify
the predisposing factors and the implications of the allergic reaction in the management of patients
during orthodontic treatment. A computerized literature search was conducted in PubMed for articles
published on allergy in relation to orthodontics. The MeSH term used was allergy and orthodontics.
Allergic response to alloys in orthodontics, particularly nickel, has been extensively studied and
several case reports of nickel‑induced contact dermatitis have been documented. Current evidence
suggests that the most common allergic reaction reported in orthodontics is related to nickel in
orthodontic appliances and allergic response is more common in women due to a previous sensitizing
exposure from nickel in jewellery. Studies have implicated allergy in the etiology of hypo‑dontia. It
has also been considered as a high‑risk factor for development of extensive root resorption during
the course of orthodontic treatment. This review discusses the relationship and implications of
allergy in orthodontics.

Key words: Allergy, nickel, orthodontics

INTRODUCTION in orthodontics and to provide clinical implications based on

scientific evidence on the topic.
Allergic reactions are of increasing concern to practitioners in
health‑related fields. As patient susceptibility increases, the SEARCH STRATEGY
need for basic understanding and successful management
of these conditions are of primary importance. An allergic A search was conducted on PubMed to retrieve all available
response is one in which certain components of the immune literature on allergy and orthodontics. The search revealed a
system react excessively to a foreign substance. Allergy in total of 114 articles on the topic. A total of 106 articles were
patients undergoing orthodontic treatment can be seen due to retrieved in nickel allergy and orthodontics. Of these, 14 articles
several reasons and these include nickel allergy, allergy to the were reviews on nickel allergy and 92 were case reports. Four
acrylic resins that are used during treatment, latex products, reviews were in languages other than English. These articles
etc.[1] A large variety of metallic alloys are routinely used in were eliminated and 10 articles were studied. Five articles
dentistry. Allergy as a possible factor has also been implicated were in relation to allergy and root resorption, and three were
in root resorption and hypo‑dontia. in relation to allergy and hypo‑dontia.

Gold was used in orthodontics for fabrication of accessories NICKEL ALLERGY IN ORTHODONTICS
until the 1930s and 1940s. In 1929, stainless steel was
used for the first time to replace gold. Several metallic Nickel is a powerful sensitizer metal and a common allergen.
alloys are used in orthodontics, such as cobalt‑chromium, Dermatitis due to contact with nickel was first reported among
nickel‑titanium, b‑titanium, among others; the majority of workers in the nickel plating industry and was recognized as
an allergic response in 1925.[2,3] Nickel has often been pointed
these alloys have nickel as one of their components. The
out as a biological sensitizer capable of causing short‑ and
percentage of this metal in the alloys varies from 8%, as in
long‑term sensitivity reactions. An increased risk of nickle
stainless steel, up to more than 50%, as in nickel‑titanium
alloys. The aim of this paper is to review and analyze
Access this article online
critically the current available literature in the field of allergy
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Website:
Department of Orthodontics, Faculty of Dental Sciences, www.jorthodsci.org
Sri Ramachandra University, Porur, Chennai, Tamil Nadu, India
Address for correspondence: Dr. Sunitha Chakravarthi, DOI:
Department of Orthodontics, Faculty of Dental Sciences,
Sri Ramachandra University, Porur, Chennai ‑ 600 116, Tamil Nadu, 10.4103/2278-0203.105871
India. E‑mail: drcsunitha@gmail.com

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Chakravarthi, et al.: Allergy and orthodontics

sensitization in potential orthodontic patients could possibly PREVALENCE OF NICKEL ALLERGY

be due to wearing Ni‑containing jewellery at an early age.[4]
The incidence of Ni‑induced side effects from orthodontic
SALIVARY NICKEL RELEASE FROM FIXED materials in non‑sensitized people is not known. It has also
APPLIANCES been suggested that the risk of sensitization from orthodontically
derived Ni in these patients is extremely low. Nickel allergy is
Park and Shearer[5] reported an average release of 40 µg of the most common contact allergy in industrialized countries;
nickel and 36 µg of chromium from a simulated orthodontic patch test verified data of general populations in several studies
appliance. The release of nickel is not necessarily related have shown that this allergy affects 10%‑30% of females and
to the alloy’s nickel content.[6] The amount of nickel release 1‑3% of males.[18‑22] Two recent surveys from Europe estimated
can increase during stress. The quantities released may incidence of adverse patient reactions in orthodontic practice
be negligible from a toxicological point of view, but might to be approximately 0.3%‑0.4%.[23,24] Kerosuo et al.[25] found
conceivably be of significance for patients with a high prevalence of nickel allergy in Finnish adolescents to be 30%
degree of hypersensitivity to nickel. Fors and Persson [7] in girls and 3% in boys. This is thought to be due to ear piercing
found significantly higher content of nickel in the plaque and being a major cause of sensitization to nickel, as prevalence in
saliva of patients with orthodontic appliances compared with subjects with pierced ears was 31% and those without pierced
non‑orthodontic patients. Moreover, in orthodontic patients, ears was 2%.[25]
significantly higher nickel content was found in plaque
from metal surfaces (band and brackets) than from enamel People with cutaneous piercing were considered a significant
surfaces. risk factor for Ni allergy.[26] Scientific evidence suggests that
orthodontic treatment is not associated with increase of Ni
BIOLOGY OF NICKEL ALLERGY hypersensitivity, unless patients have a history of previous
cutaneous piercing exposure to Ni, usually ear piercing.
Elicitation of an allergic reaction to nickel depends on Previous allergic history has been significantly associated by
the conditions of nickel exposure—for example, hapten several authors to a hypersensitivity response to nickel released
concentration on the contact area, open or occluded exposure, from orthodontic appliances.
presence of an irritant, and degree of contact allergy. The
elicitation threshold varies between patients and also individually NICKEL ALLERGY AND PERIODONTAL
over time.[8,9] Nickel elicits contact dermatitis, which is a type‑IV STATUS
delayed hypersensitivity immune response. This process has two
interrelated, distinct phases:[10] A sensitization phase occurs from Placement of orthodontic brackets influences the accumulation
the moment the allergen enters the body, is recognized, and a of biofilm and colonization of bacteria, thereby making a
response occurs. The elicitation phase occurs after re‑exposure patient more prone to inflammation and bleeding.[27] Pazzini
to the allergen to appearance of the full clinical reaction. There et al. found that nickel can influence inflammatory reactions
may have been no symptoms at the initial exposure, but throughout orthodontic treatment. Such reactions are
subsequent exposure leads to a more visible reaction.[11] characterized by gingival hyperplasia, changes in color and
gingival bleeding upon probing. More than a direct sensitizing
CLINICAL FEATURES ASSOCIATED WITH agent of skin and mucosa, nickel appears to alter the
ALLERGY periodontal status, acting as a modifying factor of periodontal
disease in sensitive patients. Results suggest a cumulative
Clinical abnormalities, such as gingivitis, gingival hyperplasia, effect of nickel throughout orthodontic treatment and that
lip desquamation, multiform erythema, burning sensation in this effect is associated with clinically significant periodontal
the mouth, metallic taste, angular cheilitis, and periodontitis, abnormalities.[28]
may be associated with release of nickel from orthodontic
appliances. [12‑16] These reactions are associated with an Gursoy et al.[29] in 2007 found that low‑dose continuing nickel
inflammatory response induced by corrosion of orthodontic release from orthodontic appliances might be the initiating factor
appliances and subsequent release of nickel. It is manifested as for gingival overgrowth, as it has the capability of increasing
Nickel Allergic Contact Stomatitis (NiACS). A burning sensation epithelial cell proliferation. Pazzini et al. in 2011 found that
is the most frequent symptom. The aspect of the affected patients treated with conventional braces exhibited greater
mucosa is also variable, from slight erythema to shiny lesions, periodontal alterations than those treated with nickel‑free
with or without edema. Vesicles are rarely observed, but when braces. Individuals with an allergy to nickel exhibit better
they are present, they quickly rupture, forming erosion areas. In periodontal health when treated with nickel‑free braces than
chronic cases, the affected mucosa is typically in contact with with conventional braces.[30] Pazzini et al.[31] found that nickel
the causal agent and appears erythematous or hyper‑keratotic can influence the condition of the periodontal and blood
to ulcerated.[17] Other symptoms can also be present, such as cells of allergic orthodontic patients, but with reactions of an
peri‑oral dermatitis and, rarely, orolingual paresthesia. inflammatory, rather than allergic nature.

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DIAGNOSIS • Polycarbonate brackets that are produced from plastic

polymers;
Sensitivity to nickel has been evaluated through biocompatibility • Titanium brackets;
tests, [32] including cutaneous sensitivity (patch) tests, [33] • Gold‑plated brackets.
and reactivity to nickel has been evaluated with in vitro cell
proliferation assays.[34] It is important to make correct diagnosis Extra‑oral metal components, including metal studs in
of nickel allergy, symptoms of which may occur either within or headgear, are of greatest concern due to greater sensitivity of
remote to the oral environment. The signs and symptoms of skin. Plastic‑coated headgear studs may be a better alternative
nickel allergy are presented in Table 1. The following patient for such patients.
history would suggest a diagnosis of nickel allergy.[11]
• Previous allergic response after wearing earrings or a ALLERGY AND ROOT RESORPTION
metal watchstrap;
• Appearance of allergy symptoms shortly after initial Root resorption is a common sequel to orthodontic treatment
insertion of orthodontic components containing nickel; and has been recorded in 93% of treated adolescents.[37]
• Confined extra‑oral rash adjacent to headgear studs. Davidovitch et al.[38] hypothesized that individuals who have
medical conditions that affect the immune system may be at a
A dermatologist should confirm the diagnosis by patch testing high level of risk for developing excessive root resorption during
using 5% nickel sulfate in petroleum jelly. the course of orthodontic treatment. In reviewing orthodontic
patient records at the University of Oklahoma, they discovered
MANAGEMENT OF NICKEL ALLERGY that the incidence of asthma, allergies and signs indicative of
psychological stress were significantly higher in patients who
The majority of investigations have found that nickel‑sensitive had experienced excessive root resorption during orthodontic
patients are able to tolerate stainless steel without any treatment as compared with the group of orthodontic patients
noticeable reaction.[35] Most research concludes that stainless who had completed their course of treatment without suffering
steel is a safe material to use for all intra‑oral orthodontic this unfortunate outcome.
components for nickel‑sensitive patients.
McNab et al.[39] reported that the incidence of external apical
Alternatives to Nickel‑Titanium Wires root resorption was elevated in patients with asthma. However,
Alternatives to Ni‑Ti include twistflex stainless steel and both asthmatics and healthy patients exhibited similar amounts
fiber‑reinforced composite archwires. Wires such as TMA, of moderate and severe resorption. Nishioka et al.[40] found that
pure titanium, and gold‑plated wires may also be used without allergy and asthma might be an etiological factor in excessive
risk. Altered nickel‑titanium archwires also exist and include root resorption. The same association was found in earlier
plastic/resin‑coated nickel‑titanium archwires.[36] Ion‑implanted studies.[37‑41] Owman‑Moll and Kurol[41] also suggested that there
nickel‑titanium archwires have their surface bombarded with might be a link between allergy and the extent of root resorption,
nitrogen ions, which forms an amorphous surface layer, but no statistically significant difference was found. Nishioka
conferring corrosion resistance and displacing nickel atoms, et al.[40] strongly supported the hypothesis that allergy and
and decreasing the risk of an allergic response. asthma may be high‑risk factors for development of excessive
root resorption during orthodontic treatment. They concluded
Brackets that allergy, root morphology abnormalities and asthma may
Stainless steel brackets are generally considered safe. However, be considered high‑risk factors for development of excessive
nickel‑free alternative brackets to stainless steel include: root resorption during the course of orthodontic treatment in a
• Ceramic brackets produced using polycrystalline alumina, Japanese population.
single‑crystal sapphire, and zirconia;
ALLERGY AND HYPODONTIA
Table 1: Signs and symptoms of nickel allergy [11]

Intra‑oral Extra‑oral Three articles were retrieved in the search and only one article
Stomatitis from mild‑to‑severe erythema Generalized urticaria dealt with allergy in relation to hypo‑dontia. Third molars are
Papula peri‑oral rash Widespread eczema the most commonly missing teeth followed by the second
Loss of taste or metallic taste Flare‑up of allergic premolars and the maxillary lateral incisors.[42] The etiology of
dermatitis hypo‑dontia is considered to be multifactorial, with genetics and
Numbness Exacerbation of environmental factors playing an important role.[43] Yamaguchi
pre‑existing eczema et al.[44] in 2008 studied 3683 Japanese orthodontic patients
Burning sensation and found positive correlation between allergy and hypo‑dontia.
Soreness at the side of the tongue
They concluded that health problems, especially those related
Angular cheilitis
to allergy, are of importance and could be strongly related to
Severe gingivitis in the absence of plaque
hypo‑dontia.

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CONCLUSION Prevalence of nickel allergy among Finnish university students in 1995.

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44. Yamaguchi  T, Tomoyasu  Y, Nakadate  T, Oguchi  K, Maki  K. Allergy Source of Support: Nil, Conflict of Interest: None declared.

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