ADVICE SHEET BRITISH ORTHODONTIC SOCIETY

NICKEL ALLERGY IN ORTHODONTICS

Introduction

Nickel is a common component of many orthodontic materials, including stainless steel

archwires and brackets, representing approximately 8% of the total composition. In nickel
titanium (Ni-Ti) archwires the concentration of the alloy can be 50% or more.

The use of nickel containing jewellery and the increased popularity of body piercings, in
particular intra-oral piercings means that many patients may have been sensitiTed to nickel
by the time they visit an orthodontist. As a result, this allergy may become an increasingly
common presentation to the orthodontist.

This advice sheet is written to provide more information about nickel allergy. It contains
information on the diagnosis, signs and symptoms of the allergy and advice on the
orthodontic materials that can be used in nickel sensitive patients presenting for
orthodontic treatment.

Occurrence of nickel allergy

In orthodontics, nickel allergy occurs more commonly than allergy to all other metals
combined 1. Currently, it is estimated that nickel allergy is more common in girls (30%),
than in boys (3%) and in adolescents with pierced ears (31%) than those without ear
piercings (2%) 2. Nickel hypersensitivity has also been found to be higher in asthmatic
patients 3.

The possibility of sensitising patients to nickel by the use of oral orthodontic appliances
has also been a concern. However, evidence would suggest that early orthodontic
treatment preceding piercing reduces the risk of nickel allergy by a factor of 1.5 to 2.0 4.

Once sensitiTed to nickel, re-exposure to nickel can elicit a response, which normally
develops over a period of days or even weeks. An immediate response is generally not a
feature of nickel allergy.

Once sensitiTation has been detected, individuals are advised to avoid contact with objects
that contain the metal. Fortunately, most individuals who have nickel sensitivity on their
skin can wear orthodontic appliances without difficulty. This is because it is thought that a
much greater concentration of nickel in the oral mucosa is required to provoke an allergic
reaction than the skin5,6.
What are the signs and symptoms of nickel allergy?

Nickel induces a contact dermatitis, which is a Type IV delayed hypersensitivity immune

response, cell-mediated by T lymphocytes. The diagnosis of a response to nickel in the
oral mucosa can be more variable and difficult to diagnose than on the skin.

Oral signs and symptoms associated with the release of nickel from orthodontic appliances
can include the following:

Gingivitis in the absence of plaque

Gingival hyperplasia
Labial desquamation
Burning sensation in the mouth
Metallic taste
Angular cheilitis
Numbness/tingling sensation
Labial swelling
Soreness of the side of the tongue

Extra-oral signs and symptoms can include localised dermatitis in sites of prolonged skin
contact with nickel-containing objects, for example, headgear studs. This can present as a
maculopapular rash or vasculitis-like skin lesions.

Note: The BOS monitors adverse incidents in orthodontics. An adverse reaction to

orthodontic materials should be reported on the BOS website under the Research and
Audits section (www.bos.org.uk). Alternatively the form can be downloaded as a word
document for submission to BOS.

How to diagnose nickel allergy

Correct diagnosis of nickel allergy is important. A previous allergic response after wearing
earrings or a metal watchstrap would suggest nickel allergy. In case of doubt, a trial
appliance can be placed which may include two to four brackets with a Ni-Ti archwire and
the patient monitored carefully to assess a reaction.

Before the diagnosis of nickel allergy can be made, other lesions should also be eliminated
including, herpetic stomatitis, candidiasis, ulcers due to mechanical irritation and allergies
to other materials including acrylic 7.

If a nickel allergy is still in question, a diagnosis can be confirmed by referring the patient
to a dermatologist for a cutaneous sensitivity (patch) test using 5% nickel sulphate in a
petroleum jelly substrate.

Alternatives for nickel sensitive patients

Most research has determined that all intra-oral orthodontic components made of stainless
steel are safe to use in nickel sensitive patients. This is thought to be due to the molecular
structure of stainless steel, which prevents the release of nickel and makes it unreactive 8.
Stainless steel brackets are also available with a much lower content of nickel and therefore
less allergic potential.
However, in the rare event that the patient continues to show signs and symptoms of
nickel allergy, all stainless steel brackets and arch wires should be removed until the
adverse reaction subsides. Once the lesions have healed, nickel-free appliances can be
placed.

Wide ranges of nickel-free appliances are available, up-to-date information can be

obtained from manufacturers’ catalogues and websites. Examples include:

Nickel free brackets

Ceramic brackets
Polycarbonate brackets
Titanium brackets
Gold brackets
Plastic aligners

Nickel free archwires

Titanium Molybdenum alloy (TMA) archwires

Fibre-reinforced composite archwires
Pure Titanium archwires
Gold plated archwires

Extra oral appliances

For nickel sensitive patients, exposed metalwork should be covered with tape or plasters
or headgear use discontinued. Plastic coated headgear studs are also available.

Conclusion

Currently an intra-oral allergic response to nickel from orthodontic appliances is less

common than an extra-oral response. If intra-oral signs of an allergic reaction are seen,
the orthodontist should be able to continue treatment with orthodontic components
containing stainless steel. However, high content nickel containing wires should be
avoided. If nickel-free alternatives are required, other choices of materials are available as
alternatives.
 References and further reading

1. Lowey MN. Allergic contact dermatitis associated with the use of interlandi
headgear in a patient with a history of atopy. Br Dent J 1993; 17: 67-72
2. Kerosuo H, Kullaa A, Kerosuo E, Kanerva L, Hensten-Pettersen A. Nickel allergy in
adolescents in relation to orthodontic treatment and piercing of ears. Am J Orthod
Dentofac Orthop 1996; 109: 148-154
3. Gul U, Cakmak S K, Olcay I, Kilic A, Gonul M. Nickel sensitivity in asthma patients.
J Asthma 2007; 44: 383-384
4. Fors R, Stenberg, Stenlund H, Persson M. Nickel Allergy in relation to piercing and
orthodontic appliances – a population study. Contact Dermatitis 2012 May 28, Epub
head of print.
5. Bass J K, Fine H, Cisneros G J. Nickel sensitivity in the orthodontic patient. Am J
Orthod Dentofac Orthop 1993; 103: 280-285
6. Dunlap C L, Vincent S K, Barber B F. Allergic reaction to orthodontic wire: report of
a case. J Am Dent Assoc 1989; 118: 449-450
7. Rahilly G K and Price N. Nickel allergy and orthodontics. JO 2003; 30: 171-174
8. Toms AP. The corrosion of orthodontic wire. Eur J Orthod. 1988; 10: 87-97

Produced by the Clinical Governance Committee of the British Orthodontic Society 2012.
Reviewed in 2019. Recommendations may change in the light of new evidence.

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