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The Release of Ions From Metallic Orthodontic Appliances
The Release of Ions From Metallic Orthodontic Appliances
Orthodontic Appliances
Luciane Macedo de Menezes and Ctia Cardoso Abdo Quinto
Several metallic alloys used in orthodontics have nickel and chromium as their
components. These metal ions are known to be essential elements for human
beings but are considered one of the most common causes of allergic contact
dermatitis. The allergic reactions are caused by a direct relationship with the
presence of this metal in the environment and may be caused by ingestion or
direct contact with the skin and/or mucosa. The association of different metals
in the oral environment may produce electrogalvanic currents and consequently, corrosion, with different levels of ions being released. The purpose of
this article is to review the release of ions from metallic orthodontic appliances
and its implications, as well as to provide suggestions for the management of
this problem in the orthodontic office. (Semin Orthod 2010;16:282-292.) 2010
Elsevier Inc. All rights reserved.
282
283
284
saliva and sweat; this might contribute to increased excretion in high-temperature areas.1
Studies have demonstrated that other ions
present in the silver solder, such as cadmium,
copper, silver, and zinc, may be released in the
oral cavity, whose exposure may determine several adverse effects with direct toxic alterations
in an acute or chronic manner.18 Such metallic ions are potentially dangerous chemicals,
being included in the list of substances and
processes that pose high risk to human life
because of their carcinogenic potential to the
lung, prostate, and kidneys, in addition to alterations in the hematopoietic, urinary, and
digestive systems.
285
286
Table 1. Some Research Regarding the In Vitro Release of Ions From Orthodontic Appliances
Author/Year
Study Purpose
Barret,
Bishara
and
Quinn
(1993)43
Park and
Shearer
(1993)20
Kerusuo
et al
(1997)24
Solution/Evaluation
Time
Brackets
Bands and brackets
(AISI 305 and 316)
bondable brackets
(AISI 303 and 304)
Artificial saliva
medium at
37C days 1, 7,
14, 21, 28
Sodium chloride
0.05% solution
Sodium chloride
0.9% for 2 h,
24 h, and 7 d
Huang
et al
(2004)4
Tomy, Ormco,
Dentaurum, 3M
Unitek
Artificial saliva
(with different
pH values over
a 48-week
period)
Dolci et al
(2008)22
Saline solution
(0.05%), in
shake, at 36C
days 7, 14, 28,
and 60
Sfondrini
et al
(2009)44
Stainless-steel brackets,
stainless-steel
recycled brackets
and Ni-free brackets
Artificial saliva at
various acidities
(pH 4.2, 6.5,
and 7.6) 15
min, 1 h, 24 h,
48 h, 120 h
Conclusion
Orthodontic appliances release
measurable amounts of nickel
and chromium when placed
in an artificial saliva medium.
For both arch wire types, the
release for nickel averaged 37
times greater than that for
chromium.
Release of 40 g of nickel and
36 g of chromium per day.
data available on the release of metals or metallic salts within the oral cavity.11
287
cause saliva does not present a constant composition and may be different among individuals or
even among periods for the same individual.
The physical properties, amount, and composition of saliva are influenced by factors, such as
diet, period of the day, and psychic conditions.26
The actual amounts of nickel and chromium
released from fixed appliances have been distinct but low, and well below the normal daily
intake of nickel in diet. The literature includes
some in vivo studies evaluating the ion release in
saliva (Table 2).
In an effort to understand the issues on ion
release and its biological effects, in vivo research
was conducted. Saliva from 31 subjects, before
the placement of brackets and 3 weeks after
placement, was collected. The nickel and iron
were quantified by atomic absorption spectroscopy. The only difference observed for the concentration and volume of nickel and iron, was
immediately after placement of the appliance,
when there was a significant increase. So it seems
that there is a high initial release of metals, but
this effect decreases with time.26 In 1997, the
salivary concentrations of nickel and chromium
in patients wearing different types of appliances
were evaluated, by Kerosuo et al.24 The study
sample was composed of 47 patients, and 4 saliva
samples were collected: before placement of the
appliance, after 2 days, after 1 week, and after 1
month. The mean salivary concentration was 55
ng/mL for nickel and 61 ng/mL for chromium,
similar to the values observed before placement
of the appliance.24
The concentration of nickel in the saliva and
dental biofilm in young patients, who wore and
did not wear fixed orthodontic appliances, was
compared. When the saliva samples were taken,
the appliances had been in place an average of
16 months in the group who wore the appliances. A significantly greater content of nickel
was found in the plaque and saliva of patients
with orthodontic appliances (median values for
nickel in the saliva were of 25.3 and 14.9 g/g,
for patients with and without orthodontic appliances, respectively).28
In another study, the alterations in the chromium and nickel concentrations in the saliva of
orthodontic patients treated with fixed orthodontic appliances were evaluated. Forty-five
orthodontic patients were included in this study.
The first group consisted of 15 patients (7 fe-
288
Table 2. Some Research Regarding the In Vivo Release of Ions from Orthodontic Appliances (Saliva)
Author/Year
Ions
Sample
Characteristics
Duration
Results
No differences before
and after
appliance.
No differences
between groups.
Kerosuo et
al 199724
Chromium,
nickel
47 patients
Different types of
appliances
Kocaderelli
et al,
200025
Chromium,
nickel
30 patients
(15
control)
Agaoglu et
al, 200129
Chromium,
nickel
100 patients
Fixed appliance15;
fixed appliance
in maxillary
arch15
Fixed appliance
Eliades et al,
200345
Chromium,
nickel,
ferrous
17 patients
(7 control)
Fixed appliance
Salivary sample
obtained at least 15
mo after appliance
Ramadan
200427
Chromium,
nickel
20 patients
Fixed appliance in
maxillary arch
Fors and
Person,
200628
Souza and
Menezes,
20082
Nickel
17 patients
(24
control)
30 volunteers
Fixed appliance
Initial, 3 and 12 mo
and 1 mo after
debonding
48 h
Freitas,
200818
Cadmium,
copper,
zinc,
silver
30 patients
(30
control)
Petoumenou
et al,
20093
Nickel
17 patients
Chromium,
nickel,
iron
Removable
appliance with
bonded brackets
(AISI 303 and
316 L)
Hyrax appliance
Fixed appliance
and NiTi
archwires
Initial, 10 min 24 h, 7,
30 and 60 d after
placement of the
appliance
Initial, 10 min 24 h, 7,
30 and 60 d after
placement of the
appliance
Increase of ions in
patients with
appliance.
Increase of
chromium and
nickel ions.
Increase of ions, with
high concentrations
immediately after
placement of the
appliance and
tendency of
regression within the
study period.
Increase of ions after
placement of band
and archwire.
differences were found between the nonappliance group and the samples obtained after insertion of the appliances. The results of the
study suggest that fixed orthodontic appliances
do not significantly affect nickel and chromium
concentrations of saliva during the first 2 months
of treatment.25
To test the hypothesis that toxic metallic ions
present in silver solder used in orthodontics are
released in human saliva, 60 subjects were divided into 2 groups (n 30, each): control and
study (in need of maxillary expansion with the
Hyrax appliance). For analysis of the release of
metallic ions, saliva samples were collected from
each patient at 6 periods. For both groups it
consisted of initial, 10 minutes, 24 hours, and 7,
30, and 60 days after placement of the Hyrax
289
290
Conclusions
Several questions remain unanswered concerning the biological effect of a systemic increase in
nickel levels. In addition, there is a lack of information on abnormal accumulation of nickel in
specific tissues of the body. The increase of
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