Nevenwerkingen van tandheelkundige vulmaterialen in de klinische praktijk - PowerPoint Presentation

Slide1

Nevenwerkingen van tandheelkundige vulmaterialen in de klinische praktijk

Benoit Nemery, MD, PhD

Omgeving en Gezondheid, Dept. Maatschappelijke Gezondheidszorg en Eerstelijnszorg, KU Leuven

Raapleging Beroeps- en Milieupathologie, Longziekten, UZ Leuven

Slide2

Nevenwerkingen van tandheelkundige vulmaterialen

“Oude” vulmaterialen (Hg/Ag amalgaam)

“Nieuwe” vulmaterialen (composites)

Gevaren voor de tandartsNevenwerkingen voor de patiënt

2

Slide3

Hg

3

Slide4

Hg is één van de meest toxische producten

4

http://www.unep.org/hazardoussubstances/Portals/9/Mercury/Documents/ASGM/

Techdoc

/UNEP%20Tech%20Doc%20APRIL%20

2012

_120608b_web.pdf

Slide5

Hg & the general environment

http://www.unep.org/hazardoussubstances/Portals/9/Mercury/Documents/ASGM/

Techdoc

/UNEP%20Tech%20Doc%20APRIL%202012_120608b_web.pdf

Slide6

Hg & the general environment

http://www.unep.org/hazardoussubstances/Portals/9/Mercury/Documents/ASGM/

Techdoc

/UNEP%20Tech%20Doc%20APRIL%202012_120608b_web.pdf

Slide7

Hg in the general environment

Clarkson

et al

. NEJM 2003, 349, 1731-7

“

Biomagnification

”

Slide8

8

Larson HJ.

Lancet

, 2013, October 10

Slide9

Toxicity of Hg

Clarkson

et al

. NEJM 2003, 349, 1731-7Highly dependent on type of HgHg° (metallic)

Hg ions (Hg

+

or Hg

++

): HgCl

2, Hg(NO3)2

, ...organic Hg: Hg(CH)3, Hg(CH3)2, ...Long chain Hg (insecticides, fungicides, bactericides, …)

Slide10

Toxicity of Hg°

Chronic exposure (inhalation of Hg°):

CNS: tremor, personality changes, psychomotor performance,

PNS: sensorimotor polyneuropathydiscrete renal changes gingivitiseye: mercurialentis

, colour vision

immune dysfunction

teratogenic

Slide11

11

http

://

www.unep.org/hazardoussubstances/Portals/9/Mercury/

AwarenessPack/English/UNEP_Mod4_UK_Web.pdf

2008

Slide12

Hg and dental health care workers

12

Exposure to Hg in dental surgeries

Preparation, insertion, removal of amalgamStorage of Hg, spills, waste disposal Autoclaving contaminated instruments

Slide13

Effects of exposure of dentists to Hg

13

Ngim

et al. Br J Ind Med

1992, 49, 782-90

Singapore: 98 dentists, 54 controls

Ritchie

et al

.

Occup Environ Med 2002, 59, 287-93

= Br Dent J 2004, 197, 625-32Scotland: 180 dentists, 180 controls Thygesen et al. Occup Environ Med 2011, 68, 895-901

Denmark: register-based cohort study

Slide14

Dentists and exposure to Hg

14

Ngim

et al. Br J Ind Med

1992, 49, 782-90

Singapore: 98

dentists

vs

54 controlsMean age: 33.6 y [24-49]Hg in air: geomean 13.6 µg/m

3 [0.7-42]Intelligence tests: better or no differenceNeurobehavioural tests: generally poorer performanceAggression score: higher Related to cumulative dose of Hg (Hg-Air x duration)

Slide15

board (plint) below Hg storage

Dentists and exposure to Hg

15

Ritchie

et al

. 2002/2004

Slide16

Dentists and exposure to Hg

16

Ritchie

et al

. 2002/2004

x 1.77 for µg/g creatinine

Slide17

Dentists and exposure to Hg

17

Ritchie

et al

. 2002/2004

Few differences in neuropsychological functioning, unrelated to Hg

Slide18

Dentists and exposure to Hg

18

Thygesen

et al. Occup Environ Med 2011, 68, 895-901

Denmark: register-based cohort

study (n=122,481)

All Danish workers in employed in dental clinics (5,371 dentists + 33,858 assistants)

vs

GP clinics or lawyers offices between 1964 and 2006

Hospital admissions for neurological diseases, Parkinson’s disease, renal diseases

no indication of associations with Hg exposure

Slide19

Dentists and exposure to Hg

19

Lindbohm

et al. Occup Environ Med 2011, 68,

895-901

Finland

source population: women in dental care jobs + women in pharmacy and health care

case-control study: 222 miscarriages

vs

498 births

Possible increased risk of miscarriage for Hg (but not related to exposure dose)

Slide20

Patients and Hg amalgam?

20

Slide21

What about patients?

21

no

evidence for significant toxicity resulting from placement of dental amalgams or from their presence (except rare instances of Hg allergy)http://ec.europa.eu/health/archive/ph_risk/committees/04_scenihr/docs/scenihr_o_016.pdf

probably safer not to

place (or remove)

amalgam fillings during pregnancy

[precautionary principle]

Slide22

Nevertheless ...

22

Some patients are convinced that they are “poisoned” by the presence of amalgam fillings

Chronic fatigue syndromeMultiple chemical sensitivity (MCS) = idiopathic environmental intolerance (IEI) ...

Slide23

De Standaard Weekblad 13.12.2013

Slide24

De Standaard Weekblad 13.12.2013

Slide25

Functional somatic syndromes

Gastroenterology

→ irritable bowel syndrome, non-ulcer dyspepsiaGynaecology

→ premenstrual syndrome, chronic pelvic pain

Rheumatology

→ fibromyalgia

Cardiology

→ atypical or non-cardial chest painRespiratory medicine → hyperventilation syndrome

Infectious

diseases

→ chronic (

postviral

) fatigue syndrome

Ear, nose and throat

→

globus

syndrome

Dermatology

→

Morgellons

disease (filaments), …

Dentistry

→

temporomandibular

joint dysfunction, atypical facial pain

Allergy, toxicology

→ multiple chemical sensitivity, “poisoning”

Wessely

et al. Lancet

1999, 354, 936-39

[adapted]

Slide26

Toxicology and functional syndromes

Frequent “

specific

” attributionsMercury, especially dental amalgam

Other

metals

(As, Pb, …)

Formaldehyde and

other indoor

VOCs (solvents)Fungi and mycotoxins (Stachybotrys, …)AsbestosPesticidesNo proof of causation for low

dose

exposure

Careful

epidemiology

Experimental

studies

Well

conducted

therapeutic

interventions

Slide27

Functional somatic syndromes

Wessely

et al. Lancet

1999, 354, 936-39

Large

overlap in

definitions

of

functional

somatic syndromesFatigueHeadache

Patients

with

one

functional

syndrome

often

meet

diagnostic

criteria

for

other

syndromes

Patients

with

different

functional

syndromes

share

non-symptom

characteristics

Sex

:

women

>men (

except

chest

pain)

Emotional

disorder:

anxiety

and

depression

Physiology

:

altered

functioning

of CNS

History

of

childhood

maltreatment

and

abuse

Difficulties

in

doctor-patient

relationship

Slide28

Functional somatic syndromes

Wessely

et al. Lancet 1999, 354, 936-39

All

functional

syndromes

respond

to the same therapiesGeneral: pay attention

,

explain

, limit

investigations

,

rehabilitation

not

cure

Antidepressants

Psychological

therapy

(

cognitive

behavioural

)

Slide29

Toxicology and functional syndromes

Multiple chemical sensitivity, chronic fatigue syndrome, fibromyalgia

Consider/exclude other disease (incl. allergy, irritant-induced asthma, sleep disorders, …)

Exclude real poisoning

History

Clinical syndromes (incl. chronic toxic encephalopathy caused by

heavy

occupational exposure to solvents)

Exposures

Evaluate source of specific attribution

CAVE “clinical ecologists” and other “specialists” (Internet)Limit investigations (immunology, toxicology)Do not (or limit) advice to avoid exposuresExplain and give reassuranceCognitive behavioural therapy

Slide30

Nevertheless ...

30

Some patients are convinced that they are “poisoned” by the presence of amalgam fillings

Chronic fatigue syndromeMultiple chemical sensitivity (MCS) = idiopathic environmental intolerance (IEI) ...

No evidence-based justification

to remove amalgam fillings

to administer chelators to excrete Hg

Slide31

Slide32

Slide33

Conspiracy theories

Slide34

Other agents (composites, ...)

34

Slide35

Occupational sensitizers in dentistry

35

Hamann

et al. Curr Opinion Allergy Clin Immunol

2004, 4, 403-9

Methacrylates (bonding agents and resins)

Metals (Ni, Co, Pd, ...) in restorations and dental appliances

Antimicrobials and preservatives (biocides)

Natural

rubber latex (NRL) proteins

Synthetic & natural rubber glove allergens (accelerators, ...) Allergic contact dermatitisUpper and lower airway symptoms: rhinitis & asthma

Slide36

Composites

36

Methylmethacrylate (and other methacrylates) are frequent causes of sensitization in dental professionals

Contact dermatitis (including “airborne dermatitis”)Occupational rhinitis and asthma

Type IV allergy (via

haptenization

?) +

potent irritant

effects

Prevalence: 1.3 to 14% of dental workers!

Methacrylates permeate gloves within minutes!Incomplete information in MSDS + impurities !

Slide37

Diagnosing occupational allergy

37

Awareness and high level of suspicion

Temporal relation between symptoms and exposure

Slide38

Occupational allergic asthma

Pitfalls (1)

few symptoms during work

most symptoms after work is common and does

not

exclude occupational allergic asthma !

Slide39

Occupational allergic asthma

Pitfalls (2)

intolerance to irritants outside the workplace

does not exclude occupational asthma !

Slide40

Occupational allergic asthma

Occupational allergic asthma does not necessarily mean asthma AT work, but asthma FROM work

Slide41

Occupational allergic asthma

Practical advice

To detect occupational asthma it is not appropriate, nor sufficient to ask

“is your asthma worse at work?”it is more efficient to ask

“does your breathing get better during the week-end or holiday?”

Burge PS.

Br J Dis Chest

1987, 81, 105-15

Slide42

Occupational allergic asthma

Pitfalls (3)

Repeated absence from work because of

“bronchitis” may be a sign of occupational asthmaeven if these episodes appear to be responsive to treatment with antibiotics, it is the temporary removal from exposure that may be most beneficial

Slide43

Occupational allergic asthma

Pitfalls (4)

Occupational asthma often responds to asthma medication

a satisfactory control of the asthma with medication should not prevent from trying to find the cause of the asthmain advanced cases, it becomes more difficult to discover the cause of asthma

Slide44

Diagnosing occupational allergy

44

Awareness and high level of suspicion

Temporal relation between symptoms and exposure: “improvement during holidays”Document using

Diary with (detailed) exposure, symptoms, medication

Photographs

Pulmonary function tests

sequential peak-flow measurements

Slide45

male, 41 y, operative in polyurethane factory

0

7

14

21

28

35

42

49

56

63

70

TIME (days)

250

300

350

400

450

500

550

PEF (l/min)

Slide46

16/3

19/4

male, 37y, process engineer in plant making car seats (PU)

Slide47

Diagnosing occupational allergy

47

Confirmation of exact causal agent

Skin-prick testing: immediate response (IgE-mediated)Patch tests: delayed response (type IV)

specific “dental” series and own products

needs experienced dermatologist

Specific bronchial provocation testing

complex, time-consuming

only in specialized centre

not always necessary

Slide48

0.0001%

0.001 %

PC

20

1.2 mg/ml

- 35%

8

9

10

11

12

13

14

15

16

17

18

2

3

4

5

6

Time (h)

FEV

1

(l)

male, 26 y, electronic industry, electrolysis bath with Pd

Daenen

et al

.

Eur Respir J

1999, 13, 213-216

Skin Prick Test

Pd(NH

3

)

4

Cl

2

0.001% ++

Pd(NH

3

)

4

Cl

2

NaCl 0.9% 30 min

Slide49

15 min

-26%

male, 51 y, production of “very fine cobalt powder”

histamine PC

20

1.81

→

0.56

mg/ml

Slide50

Management of occupational allergy

50

Avoid/minimize exposure to strong sensitizers

Closed systems, exhaust ventilation, personal protective equipment

Once sensitized,

Completely eliminate exposure to causal agent

Medication as necessary (≠ cure !)

Job change if necessary (socio-economic consequences!)

! airway hyperreactivity and asthma may persist even after complete cessation of exposure

Report to compensation agency, if eligible

Slide51

Dank voor uw aandacht

ben.nemery@med.kuleuven.be

51

Slide52

Toxicity of Hg

Acute poisoning

ingestion (salts): G-I, kidney, shock

inhalation (Hg°): chemical pneumonitis(parenteral Hg°: little toxicity)

Slide53

Slide54

Hoge Gezondheidsraad

Multipele Chemische Intolerantie

+ Intolerantie voor elektromagnetische velden (

Idiopathic Environmental Intolerance attributed

to

Electromagnetic

Fields

, IEI-EMF)

Radiofrequenties en microgolven“electrical/

electromagnetic hypersensitivity” (“electric smog”)

http://www.health.belgium.be/

Slide55

Multiple chemical

sensitivities

Cullen MR. Workers with multiple chemical

sensitivities

.

Occup

Med State Art Rev 1987, 2, 655-62.

“… an acquired disorder characterized by recurrent

symptoms

,

referable

to multiple

organ

systems

,

occurring

in response to

demonstrable

exposure

to

many

chemically

unrelated

compounds

at doses

far

below

those

established

in the

general

population

to

cause

harmful

effects

. No single

widely

accepted

test of

physiologic

function

can

be

shown

to

correlate

with

symptoms

.”

Slide56

Multiple Chemical Sensitivity (MCS)

poorly understood & controversial syndrome

fatigue, difficulty concentrating, anxiety, headache, nausea, dizziness, pounding heart, muscle tension, shortness of breath, ...

in response to exposure to many chemically unrelated

compounds (

odours

, solvents, “pollutants”, ...)

at doses well below accepted toxic levels

Slide57

no toxicological or immunological basis

no demonstrable organic disease

but distressing and may be very disabling

panic reactions, hyperventilation, depression, ...job loss, social isolation, ...frustration, medical shopping (“clinical ecologists”) probably psychogenic origin (“chemophobia”)

Pavlovian

conditioning to odours ?

MCS

Slide58

MCS

Functional

syndromeSomatoform disorder

Slide59

Sweden, Västerbotten Environmental Health Study

Questionnaire – 3406 subjects

Self-reported or MD-diagnosed intolerance to

odorous/pungent chemicalscertain buildingsEMFssounds

2014, 217, 427-34

overlap greater than coincidence

Slide60

Conspiracy theories

JAMA Internal Medicine 2014, March 17

Slide61

Conspiracy theories

JAMA Internal Medicine 2014, March 17

Slide62

Conspiracy theories

JAMA Internal Medicine 2014, March 17

Slide63

Conspiracy theories

JAMA Internal Medicine 2014, March 17

Slide64

Hg & the “personal” environment

dental amalgams

no evidence for significant toxicity resulting from placement of dental amalgams or from their presence

(except rare instances of Hg allergy)http://ec.europa.eu/health/archive/ph_risk/committees/04_scenihr/docs/scenihr_o_016.pdfprobably safer not to place amalgam fillings during pregnancy

[precautionary principle]

Slide65

Hg & the domestic environment

Broken thermometers (

500 mg

Hg) & other medical devicesBroken compact fluorescent lamps (CFL, “energy saving light bulbs”): 5 mg Hg http://www.epa.gov/cfl/cflcleanup.html

http://ec.europa.eu/health/scientific_committees/environmental_risks/docs/scher_o_124.pdf

[SCHER 18.05.2010]: “human health risk for adults unlikely”, children ?

Nance

et al

. Human health risks from mercury exposure from broken compact fluorescent lamps (CFLs). Regul Toxicol Pharmacol

2012, 62, 542-52

Slide66

Hg & the domestic environment

Some

paints may contain Hg

(Agocs et al. NEJM, 1990, 323, 1096-101; Hefflin

et al

.

Appl

Occup Environ Hyg, 1993, 8, 866-70)

Cultural or religious use of HgHg brought home from work, incl. dental offices“cottage industry” (reclaiming of silver and gold from ore or from old amalgams)

Slide67

Acrodynia in a 2 y old child

Casus (2008, UZ Leuven):

- Kind van 2 jaar oud

Acrodynie

(verkleuring vingertoppen), geen andere symptomen

Hg-U

: 15 µg/g

creatinine

(

Nl

< 5)

anamnese: geen evidente kwikblootstelling, maar tijdens de zomermaanden geslapen in een kamer met een recent geplaatste onbedekte cementgebonden dekvloer

hypothese: emissie van Hg uit cement?

Slide68

Hg in cement?

M. De Ceulaer, Thesis

Master

of Safety, 2012Concentratie Hg in cementmonsters (n=6) :mediaan 410 µg/kg

[<LOD - 4166 µg/kg]

Concentratie Hg in luchtmonsters (n=35), na plaatsen van cementvloer:

mediaan

131

ng

/

m³ ([<LOD - 273 ng/m³]