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CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 222-226

Localized contact urticaria due to epoxy resin-based endodontic sealer


1 Department of Conservative Dentistry and Endodontics, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
2 Department of Endodontics, Faculty of Dentistry, Atatürk University, Erzurum, Turkey
3 Department of Endodontics, Faculty of Dentistry, Istanbul Medeniyet University, Istanbul, Turkey

Date of Submission29-Dec-2021
Date of Decision25-Jan-2022
Date of Acceptance28-Jan-2022
Date of Web Publication20-Apr-2022

Correspondence Address:
Dr. Afzal Ali
Department of Conservative Dentistry and Endodontics, Pacific Dental College and Hospital, Airport Road, Udaipur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_251_21

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  Abstract 

This case report aimed to report the localized contact Urticaria with epoxy resin-based root canal sealer (AH Plus). Dental materials usually contain chemical that may cause potential allergic reactions to the clinicians as well as patients. Occupational disease in form of contact dermatitis may occur to the dentists. An adolescent postgraduate student in the department of conservative dentistry and endodontics, with an ASA physical status I encountered itching, erythema, and swelling of her left-hand skin with the first-time use of AH Plus sealer in her career. A diagnosis of Contact Urticaria was established by the dermatologist upon examination. Topical steroids and antihistamine drugs were advised to the endodontic postgraduate and within a week the symptoms were resolved. The case report focuses attention on handling of epoxy resin-based root canal sealer. The dentists should exercise care and follow manufacturer's instructions while handling the dental materials.

Keywords: AH Plus sealer, allergic reactions, contact urticaria, dental materials, occupational disease


How to cite this article:
Ali A, Sümbüllü M, İshaq A, Arslan H. Localized contact urticaria due to epoxy resin-based endodontic sealer. Saudi Endod J 2022;12:222-6

How to cite this URL:
Ali A, Sümbüllü M, İshaq A, Arslan H. Localized contact urticaria due to epoxy resin-based endodontic sealer. Saudi Endod J [serial online] 2022 [cited 2022 Nov 30];12:222-6. Available from: https://www.saudiendodj.com/text.asp?2022/12/2/222/343557


  Introduction Top


It has been observed that the most common occupational disease among all health-care professionals is contact dermatitis.[1]

Occupational exposure to chemicals including allergens and irritants poses risks of skin reactions to the dentists.[2],[3] Hand eczema has been reported among the dentists with the incidence ranging between 13.5% and 32.8%.[4],[5],[6],[7]

Epoxy resins are widely used chemicals. They are based on diglycidyl ether of the bisphenol A (DGEBA) at 75% to 90%.[8],[9] Bisphenol F may be used by the manufacturer to increase physical (e.g., heat) and chemical resistance, instead of bisphenol A.[10] Allergic/irritant contact dermatitis, which occur during the production, setting of epoxy resins, or the manipulation, are the most common adverse cutaneous effects caused by epoxy resins.[9],[11],[12] However, contact urticaria with epoxy resin is very rare.[13]

From 1954, since the introduction of first resin-based sealer by Schröeder, over the years, AH Plus® (Dentsply, DeTrey GmbH, Konstanz, Germany), an epoxy resin-based sealer with good physicochemical properties, was developed.[14] It is considered as gold standard for comparing the endodontic sealers and exists in a paste–paste mixture.[15]

Although epoxy resin is known for their potential to cause adverse reactions as well as allergies, only one study has reported an allergy to AH Plus due to epoxy resin components.[16] The present case report aims to describe hypersensitivity reaction that occurred immediately with AH Plus sealer, which was diagnosed as an contact urticaria.


  Case Report Top


Written informed, valid consent was obtained from a 25-year-old Indian female endodontic postgraduate student. She was healthy with the ASA physical score I and she was not aware of any allergies. Her medical history was noncontributory. There was no congenital tooth deficiency or a familial presentation. Prior to wearing gloves, she regularly cleanses her hands with soap and dries it with a paper towel. She totally covers her hands and uses powdered latex gloves for all dental procedures and has not experienced any allergic reactions before. Before the root canal filling, she routinely mixed the root canal sealer over her gloved left hand and applied it to the gutta-percha cones, prior to her enrolment for the postgraduate course.She previously used a root canal sealer containing calcium hydroxide and had not experienced any allergic reaction.

She mixed the AH Plus sealer for the first time on her latex gloved left hand in the lab. The paste A and B were mixed until homogeneous consistency was obtained on her totally covered gloved hand instead of a mixing pad. After a few minutes, itching started over the same region of the left hand skin where the root canal sealer (AH Plus) was mixed on gloved hand. Erythema and swelling at the contact site was observed upon removal of gloves [Figure 1]a. No systemic symptoms, including wheezing, dyspnea, or hypotension, were observed. [Table 1] shows composition of AH Plus sealer. The patient reported to the dermatologist and was diagnosed with contact urticaria. Her blood investigation revealed an increased level of IgE immunoglobulin and eosinophils. Oral drugs in the form of Nucort M (steroid), Nexkast (anti-histamine) and Topical application [Figure 1]b of Clonate F, and Utmoist cream were prescribed and she was advised to mix the sealer on the mixing pad or discontinue it. Within a week, the symptoms resolved [Figure 1]c; the timeline of events is shown in [Table 2].
Figure 1: Image (a) representing dentist's skin with localized erythema and swelling (b) Topical steroids application (c) reduction in symptoms

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Table 1: Composition of AH Plus sealer according to the manufacturer

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Table 2: The timeline of events

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  Discussion Top


Allergic reactions can cause urticaria, swelling, rash, and runny nose, as well as dangerous conditions such as laryngeal edema, anaphylaxis, and cardiac arrhythmias.[17] There are various publications on hypersensitivity or allergic reactions during endodontic treatments at patients. These are allergy to rubber dam and gloves – especially involving powdered latex glove and Ledermix paste, anaphylactic shock due to formaldehyde and formocresol, hypersensitivity to sodium hypochlorite and zinc oxide, and skin injury to chloroform.[18],[19],[20],[21],[22],[23],[24] There are a few reported incidents of contact urticaria because of epoxy resin.[13],[25],[26] This case is interesting because the prevalence of contact urticaria in dental practices from epoxy resin seems to be quite low. Only one report has been published regarding a generalized urticaria with anaphylactic shock to the use of epoxy resin-based sealer during root canal treatment.[16]

Contact urticaria is one of the most common skin pathologies and is described by its primary lesion, which appears as wheal. There is transient edema of the dermal tissue and surrounding reflex erythema with itch or sometimes burning sensation at the same time.[27] It occurs within 10 to 60 min at the site of the contact area and completely resolves within 24 h. Clinical presentation is commonly wheal and flare response and urticarial swelling.[28] Direct activation of mast cells, resulting in the release of histamine and possibly the release of other vasoactive substances such as substance A, bradykinin, prostaglandins, and leukotrienes, causes the reaction.[29] Nonprotein substances that cause urticaria are diverse and may include paraphenylenediamine, ethylhexyl acrylate, hexahydrophthalic anhydride, potassium and ammonium persulfate, iridium salts, abietic acid and furfuryl aldehyde, and bisphenol A epoxy resin.[30]

Hand-mixed sealers are mixed on a sterile pad following the manufacturer's recommendations.[31] Although our postgraduate student was aware of this, she applied the mixing procedure on her hand. Topical steroid application and antihistamine drugs were prescribed. It was recommended to mix the sealer on the mixing pad in order to avoid dermal reactions in future. The most effective way to prevent a deterioration of an exacerbation of dermatitis/eczema is to start treatment with an effective anti-inflammatory agent as soon as possible.[32] Topical steroids have strong anti-inflammatory effects to reduce the symptoms and clinical manifestations.[33] Antihistamines also reduce itching by blocking the action of histamine in the skin and help relieve symptoms.[34]

Resin-based sealers are extensively used in endodontics owing to their excellent physical, chemical, and biological properties.[35] AH Plus, an epoxy-based endodontic sealer, offers adequate dimensional stability, low solubility, and micro-retention to dentin.[36] It contains low-molecular weight epoxy resins and amines and sets by the addition reaction between their epoxide groups to form the polymer.[37] Furthermore, bisphenol F compounds may be emerging dental allergens that cross-react with bisphenol A.[38]

Freshly mixed conventional root canal sealer especially demonstrated high cytotoxicity and inadequate biological activity in culture.[39] The primary released monomer from the epoxy-based resin is DGEBA.[40]

In vitro studies reported cytotoxicity with monomers from the uncured material.[41],[42] Zirconium oxide and calcium tungstate are added to promote the radiopacity of AH Plus®.[43] The cytotoxicity and contact reaction might be attributed to the presence of tungsten in AH Plus.[44]

Many materials used in dentistry are irritants and pose an occupational hazard. It is important to realize the resulting clinical skin symptoms and their reasons to prevent further exposition and to avoid other problems.[45] The sensitizing chemicals such as local anesthetics, acrylics, and antimicrobial agents may cause immediate contact reactions. Diagnosis can be made with a patch test.[46] There is a limitation in the presented case due to the absence of a patch test. In the case of contact urticaria to nonprotein molecules, tests are available for a limited number of allergens.[30] In addition, due to false-negative or false-positive reactions, diagnosis can be difficult.[46] Therefore, the diagnosis was made by the level of IgE in the blood and clinical findings.

The reactions mediated through the amplifying mechanisms of the immune system by a small amount of irritant may lead to allergic contact dermatitis and urticaria. Occupational dermatitis represents a serious problem, especially from the constituents of the resin-based filling materials and adhesives, as they are volatile and penetrate latex and vinyl gloves easily.[47] Leaching and diffusion of these components through gloves is a concern for health-care workers.[48]

Gloves protect against microbes as well as most of the skin irritants, but in susceptible operators, the monomers may leach through the gloves. For this reason, gloves should be changed every half hour. Stretching of gloves overhand could increase resin permeability, and also, the presence of fluids (sweat/water) speeds monomer movement across the glove layer.[49] Nitrile gloves are less permeable than latex gloves.[50] This case report was prepared according to the PRICE 2020 Guidelines [Figure 2].[51]
Figure 2: PRICE 2020 flowchart

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  Declaration of patient consent Top


The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


  Conclusion Top


These allergic instances are quite rare among the dental staffs, considering the number of cases of urticaria with epoxy resin sealer.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Lugović-Mihić L, Ferček I, Duvančić T, Bulat V, Ježovita J, Novak-Bilić G, et al. Occupatıonal contact dermatıtıs amongst dentısts and dental technıcıans. Acta Clin Croat 2016;55:293-300.  Back to cited text no. 1
    
2.
Stoeva IL. Work-related skin symptoms among Bulgarian dentists. Contact Derm 2020;82:380-6.  Back to cited text no. 2
    
3.
Lyapina MG, Stoyanova Dencheva M. Contact sensitization to ingredients of dental materials and cosmetics in dental students: A pilot study. Cent Eur J Public Health 2019;27:73-7.  Back to cited text no. 3
    
4.
Lindberg M, Silverdahl M. The use of protective gloves and the prevalence of hand eczema, skin complaints and allergy to natural rubber latex among dental personnel in the county of Uppsala, Sweden. Contact Dermatitis 2000;43:4-8.  Back to cited text no. 4
    
5.
Wallenhammar LM, Ortengren U, Andreasson H, Barregård L, Björkner B, Karlsson S, et al. Contact allergy and hand eczema in Swedish dentists. Contact Dermatitis 2000;43:192-9.  Back to cited text no. 5
    
6.
Minamoto K, Watanabe T, Diepgen TL. Self-reported hand eczema among dental workers in Japan – A cross-sectional study. Contact Derm 2016;75:230-9.  Back to cited text no. 6
    
7.
Sinclair NA, Thomson WM. Prevalence of self-reported hand dermatoses in New Zealand dentists. N Z Dent 2004;100:38-41.  Back to cited text no. 7
    
8.
Björkner B, Frick-Engfeldt M, Pontén A, Zimerson E. Plastic Materials. Springer, Berlin: Contact Dermatitis; 2011. p. 695-728.  Back to cited text no. 8
    
9.
Amado A, Taylor JS. Contact allergy to epoxy resins. Contact Derm 2008;58:186-7.  Back to cited text no. 9
    
10.
Pontén A, Zimerson E, Bruze M. Contact allergy to the isomers of diglycidyl ether of bisphenol F. Acta Derm Venereol 2004;84:12-7.  Back to cited text no. 10
    
11.
Rietschel RL, Mathias CG, Taylor JS, Storrs FJ, Sherertz EF, Pratt M, et al. A preliminary report of the occupation of patients evaluated in patch test clinics. Am J Contact Dermat 2001;12:72-6.  Back to cited text no. 11
    
12.
Hughes R, Taylor JS. Surveillance of allergic contact dermatitis: Epoxy resin and microscopic immersion oil. J Am Acad Dermatol 2002;47:965-6.  Back to cited text no. 12
    
13.
Kanerva L, Pelttari M, Jolanki R, Alanko K, Estlander T, Suhonen R. Occupational contact urticaria from diglycidyl ether of bisphenol A epoxy resin. Allergy 2002;57:1205-7.  Back to cited text no. 13
    
14.
Nunes VH, Silva RG, Alfredo E, Sousa-Neto MD, Silva-Sousa YT. Adhesion of Epiphany and AH Plus sealers to human root dentin treated with different solutions. Braz Dent J 2008;19:46-50.  Back to cited text no. 14
    
15.
Kopper P, Figueiredo J, Della Bona A, Vanni J, Bier C, Bopp S. Comparative in vivo analysis of the sealing ability of three endodontic sealers in post-prepared root canals. Int Endod J 2003;36:857-63.  Back to cited text no. 15
    
16.
Stutz N, Hertl M, Löffler H. Anaphylaxis caused by contact urticaria because of epoxy resins: An extraordinary emergency. Contact Dermatitis 2008;58:307-9.  Back to cited text no. 16
    
17.
Karabucak B, Stoopler ET. Root canal treatment on a patient with zinc oxide allergy: A case report. Int Endod J 2007;40:800-7.  Back to cited text no. 17
    
18.
Knowles KI, Ibarrola JL, Ludlow MO, Anderson JR, Newcomb BE. Rubber latex allergy and the endodontic patient. J Endod 1998;24:760-2.  Back to cited text no. 18
    
19.
Sunay H, Tanalp J, Güler N, Bayirli G. Delayed type allergic reaction following the use of nonlatex rubber dam during endodontic treatment. Int Endod J 2006;39:576-80.  Back to cited text no. 19
    
20.
Calişkan MK, Türkün M, Alper S. Allergy to sodium hypochlorite during root canal therapy: A case report. Int Endod J 1994;27:163-7.  Back to cited text no. 20
    
21.
Ding YJ, Song H, Liu JH, Wang GH. Brain injury due to anaphylactic shock as a result of formocresol used during root canal treatment. Int Endod J 2013;46:999-1005.  Back to cited text no. 21
    
22.
Kaufman AY, Solomonov M, Galieva D, Abbott PV. Allergic reaction to the tetracycline component of Ledermix paste: A case report. Int Endod J 2014;47:1090-7.  Back to cited text no. 22
    
23.
Scott A, Gawkrodger DJ, Yeoman C, Egner W, van Noort R, Hatton PV, et al. Adverse reactions to protective gloves used in the dental profession: Experience of the UK Adverse Reaction Reporting Project. Br Dent J 2003;195:686-90.  Back to cited text no. 23
    
24.
Alkahtany SM. Chloroform skin injury after endodontic Chloroform skin injury after endodontic retreatment: Case report. Saudi Endod J 2021;11:100.  Back to cited text no. 24
  [Full text]  
25.
Sasseville D. Contact urticaria from epoxy resin and reactive diluents. Contact Dermatitis 1998;38:57-8.  Back to cited text no. 25
    
26.
Jolanki R, Estlander T, Kanerva L. Occupational contact dermatitis and contact urticaria caused by epoxy resins. Acta Derm Venereol Suppl (Stockh) 1987;134:90-4.  Back to cited text no. 26
    
27.
von Krogh G, Maibach HI. The contact urticaria syndrome – An updated review. J Am Acad Dermatol 1981;5:328-42.  Back to cited text no. 27
    
28.
Vethachalam S, Persaud Y. Contact Urticaria. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021.  Back to cited text no. 28
    
29.
Brancaccio RR, Alvarez MS. Contact allergy to food. Dermatol Ther 2004;17:302-13.  Back to cited text no. 29
    
30.
Bourrain JL. Occupational contact urticaria. Clin Rev Allergy Immunol 2006;30:39-46.  Back to cited text no. 30
    
31.
Uyanik MO, Nagas E, Cubukcu HE, Dagli F, Cehreli ZC. Surface porosity of hand-mixed, syringe-mixed and encapsulated set endodontic sealers. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e117-22.  Back to cited text no. 31
    
32.
Goustas P, Cork MJ, Higson D. Eumovate (clobetasone butyrate 0.05%) cream: A review of clinical efficacy and safety. J Dermatolog Treat 2003;14:71-85.  Back to cited text no. 32
    
33.
Tan CH, Rasool S, Johnston GA. Contact dermatitis: Allergic and irritant. Clin Dermatol 2014;32:116-24.  Back to cited text no. 33
    
34.
Hoare C, Li Wan Po A, Williams H. Systematic review of treatments for atopic eczema. Health Technol Assess 2001;4:1-191.  Back to cited text no. 34
    
35.
Duarte MA, de O Demarchi AC, de Moraes IG. Determination of pH and calcium ion release provided by pure and calcium hydroxide-containing AHPlus. Int Endod J 2004;37:42-5.  Back to cited text no. 35
    
36.
Dias KC, Soares CJ, Steier L, Versiani MA, Rached-Júnior FJ, Pécora JD, et al. Influence of drying protocol with isopropyl alcohol on the bond strength of resin-based sealers to the root dentin. J Endod 2014;40:1454-8.  Back to cited text no. 36
    
37.
Komabayashi T, Colmenar D, Cvach N, Bhat A, Primus C, Imai Y. Comprehensive review of current endodontic sealers. Dent Mater J 2020;39:703-20.  Back to cited text no. 37
    
38.
Aalto-Korte K, Alanko K, Henriks-Eckerman ML, Estlander T, Jolanki R. Allergic contact dermatitis from bisphenol A in PVC gloves. Contact Dermatitis 2003;49:202-5.  Back to cited text no. 38
    
39.
Gandolfi MG, Prati C. MTA and F-doped MTA cements used as sealers with warm gutta-percha. Long-term study of sealing ability. Int Endod J 2010;43:889-901.  Back to cited text no. 39
    
40.
Lodienė G, Kopperud HM, Ørstavik D, Bruzell EM. Detection of leachables and cytotoxicity after exposure to methacrylate- and epoxy-based root canal sealers in vitro. Eur J Oral Sci 2013;121:488-96.  Back to cited text no. 40
    
41.
Miletić I, Devcić N, Anić I, Borcić J, Karlović Z, Osmak M. The cytotoxicity of RoekoSeal and AH plus compared during different setting periods. J Endod 2005;31:307-9.  Back to cited text no. 41
    
42.
Lodiene G, Morisbak E, Bruzell E, Ørstavik D. Toxicity evaluation of root canal sealers in vitro. Int Endod J 2008;41:72-7.  Back to cited text no. 42
    
43.
Marín-Bauza GA, Silva-Sousa YT, da Cunha SA, Rached-Junior FJ, Bonetti-Filho I, Sousa-Neto MD, et al. Physicochemical properties of endodontic sealers of different bases. J Appl Oral Sci 2012;20:455-61.  Back to cited text no. 43
    
44.
Collado-González M, Tomás-Catalá CJ, Oñate-Sánchez RE, Moraleda JM, Rodríguez-Lozano FJ. Cytotoxicity of guttaflow bioseal, guttaflow2, MTA fillapex, and AH plus on human periodontal ligament stem cells. J Endod 2017;43:816-22.  Back to cited text no. 44
    
45.
Meinardi MM, Bruynzeel DP. Skin reactions to dental materials. Ned Tijdschr Tandheelkd 2002;109:233-9.  Back to cited text no. 45
    
46.
Kanerva L, Estlander T, Jolanki R. Occupational skin allergy in the dental profession. Dermatol Clin 1994;12:517-32.  Back to cited text no. 46
    
47.
Hensten-Pettersen A. Skin and mucosal reactions associated with dental materials. Eur J Oral Sci 1998;106:707-12.  Back to cited text no. 47
    
48.
Safadi GS, Safadi TJ, Terezhalmy GT, Taylor JS, Battisto JR, Melton AL Jr. Latex hypersensitivity: İts prevalence among dental professionals. J Am Dent Assoc 1996;127:83-8.  Back to cited text no. 48
    
49.
Sananez A, Sanchez A, Davis L, Vento Y, Rueggeberg F. Allergic reaction from dental bonding material through nitrile gloves: Clinical case study and glove permeability testing. J Esthet Restor Dent 2020;32:371-9.  Back to cited text no. 49
    
50.
Tinsley D, Chadwick RG. The permeability of dental gloves following exposure to certain dental materials. J Dent 1997;25:65-70.  Back to cited text no. 50
    
51.
Nagendrababu V, Chong BS, McCabe P, Shah PK, Priya E, Jayaraman J, et al. PRICE 2020 guidelines for reporting case reports in endodontics: A consensus-based development. Int Endod J 2020;53:619-26.  Back to cited text no. 51
    


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