The Release of Ions from Metallic

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.

here is increasing concern about the biocompatibility of dental materials1 and,

therefore, this topic has been widely investigated
during recent years. The metals that are released
from biomaterials in various sites of the human
body have attracted the interest of many investigators because it is believed that the degradation
products can elicit a foreign-body reaction or
induce pathologic processes. Particularly in
orthodontics, there is interest in investigating
reactions secondary to the use of metals that are
known allergens.1 Major emphasis has been
placed on the levels of nickel and chromium in
fluids, such as saliva,2-4 blood,5 or urine.1 However, studies on these issues have given rise to
questions without answers, confirming the need
to learn more about the biocompatibility of dental materials.2

Department of Orthodontics, Pontifical Catholic University of

Rio Grande do Sul (PUCRS), Porto Alegre, Brazil.
Department of Orthodontics, State University of Rio de Janeiro
(UERJ), Rio de Janeiro, Brazil.
Address correspondence to Luciane Macedo de Menezes, DDS,
MS, PhD, Assistant Professor, Department of Orthodontics, Pontifical Catholic University of Rio Grande do Sul (PUCRS), Av. Ipiranga, 6681Predio 6, Sala 209, Porto Alegre, Brazil. E-mail:
luciane@portoweb.com.br
2010 Elsevier Inc. All rights reserved.
1073-8746/10/1604-0$30.00/0
doi:10.1053/j.sodo.2010.06.006

282

Most orthodontic appliances are made from a

stainless-steel alloy, containing approximately
6% to 12% nickel and 15% to 22% chromium,6
and, because they are continuously exposed to
saliva, the metals must exhibit corrosion resistance.7 All metals and alloys are subject to corrosion. The alloys ability to be biocompatible
appears to be related to its pattern and mode of
corrosion.
Corrosion is an electrochemical process that
results in the loss of the essential metallic properties of a metal. Metal destruction by corrosion
occurs either through loss of metal ions directly
into solution or by progressive dissolution of a
surface film, typically an oxide or sulfide, on the
metal.7 The resulting products might trigger inflammatory responses of the soft tissues and
cause irritation or dermatitis.8

The Relationship Between Corrosion

and Biocompatibility
The resistance to corrosion is a fundamental
aspect of biocompatibility and may be affected
by several factors, such as the manufacturing
process, type of alloy, surface characteristics of
the piece,6 environment in which the piece is
inserted,9 and use of the alloy (aging).2
Corrosion releases metallic ions into solution,
either directly or through dissolution or destruc-

Seminars in Orthodontics, Vol 16, No 4 (December), 2010: pp 282-292

Release of Ions from Metallic Orthodontic Appliances

tion of surface oxide or other films and, in the

clinical setting, such metallic ion release may
elicit adverse patient reactions, many of which
have been reported in the literature.7 One of the
most common reactions is the hypersensitivity to
nickel, due to 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.
However, some questions remain to be answered. How much of the corrosion products are
actually absorbed by the organism?5 Is the
amount of metal released sufficient to sensitize a
person or to maintain a reaction in a previously
sensitized person?

The Role of Corrosion on the Release

of Ions
The microstructure of a metal is a basic parameter that affects both its mechanical properties
and, in particular, its corrosion behavior. Variations in manufacturing technique and postmanufacturing finishing and polishing operations might
affect the corrosion behavior of orthodontic appliances.7,10 Three principal methods are used to
manufacture brackets, namely casting, machining
or milling, and powder metallurgical (sintering)
techniques. Cast and sintered brackets are manufactured in a near-finished condition, but with
milled brackets, the slots and wings are machined into lengths of rolled strip that is then
cut into individual brackets. With regard to
wires, manufacturers are well aware of the susceptibility of orthodontic alloys to the various
forms of corrosion and have taken some steps to
combat this potentially destructive process: alloy
substitution or addition (the addition of certain
metals to an alloy can reduce its susceptibility to
corrosion), coatings (orthodontic archwires and
brackets can be coated with either titanium nitride or an epoxy resin) and modification of the
production process.
Mechanical or chemical disruption of the
protective film, or exposure to a medium that
dissolves the film and prevents its reformation,
will result in corrosion. Corrosion involves two
concomitant reactions, an oxidation reaction at
the anode and a reduction reaction at the cathode. Commonly, the anodic reaction will continue until there is total consumption of the
metal, unless the metal can form a protective

283

surface film (a process known as passivation) or

the cathodic reactant is consumed. An alternative and industrially important means of controlling or preventing corrosion is to add to the
solution an inhibitor, a substance that reacts
with the metal to form a protective film on its
surface. Although adding a corrosion inhibitor
to the oral environment is generally not possible, there are indications that certain naturally
occurring proteins in saliva are corrosion inhibitors. Depending on the thermodynamics and
kinetics of the overall reaction, corrosion may
proceed slowly or rapidly and occur as a general
or localized attack.7
Chromium ions provide an electrochemically
formed passive film that offers protection
against aggressive ions in the oral environment
and prevents corrosion. This effect increases as
the chromium content increases. As a result,
stainless-steel and chromium-containing alloys
do not corrode easily. The mechanism occurs by
creating a thin oxide film, which delays corrosion. Integrity of chromium oxide on a metal
surface is very important and chromium oxide
must be maintained and kept stable throughout
the entire material.11 However, when stainless
steel is heat-treated or when bends or welds are
made in wires, surface oxidation might occur,
and an uneven oxide film may cause localized
corrosion. Each heat treatment environment
and cooling method can affect the thickness and
form of the uneven oxide film on the wire surface, which can create various degrees of corrosion.
The level of corrosion of any metal and the
release of ions depends on the chemistry of
the solvent in which it is immersed, the pH of
the solution, and the length of immersion. To
evaluate some of these parameters (pH value,
length of immersion and type of archwire) on
release of metal ions from orthodontic appliances, simulated fixed orthodontic appliances
were immersed in artificial saliva of different pH
values during a 28-day period. Three types of
archwires were used: stainless steel, nickel-titanium (NiTi), and thermo NiTi. The quantity of
metal ions was determined using a high-resolution mass spectrophotometer. The release of six
different metal ions was observed: titanium,
chromium, nickel, iron, copper, and zinc. Results showed that the appliances released measurable quantities of all ions examined; the

284

Macedo de Menezes and Cardoso Abdo Quinto

change in pH had a very strong effect (up to

100-fold) on the release of ions; and the release
of ions was dependent on wire composition, but,
it was not proportional to the content of metal in
the wire. The largest number of ions was released during the first week of appliance immersion. All three observed parameters (chemical
composition of the archwire, pH value of the
artificial saliva, and time of exposure to the solution) influenced ion release.12 The greatest
release of ions occurred during the first 7 days
with a gradual decline thereafter. This finding
cannot be ascribed to saturation of the solution
with metal ions because the solution was
changed for every time period. This kinetics of
ion release can be explained by an initial surge
of ion release from the metal surface or by formation of a stable oxide layer that slows down
further ion release.13 Decreasing the pH from
6.75 to 3.5 increased the release of ions on average 37-fold, with the largest increase for chromium (1:106) and the smallest for titanium (1:7).
These results confirm the hypothesis that low pH
values reduce the resistance of dental alloys to
corrosion.12,14

Metals That Are Released from

Orthodontic Appliances
The major corrosion products are iron, chromium, and nickel for stainless steel and titanium
and nickel for nickeltitanium alloys.11 The oral
environment is considered hostile and potentially corrosive.10 Among stainless-steel and nickel
titanium corrosion products nickel and chromium have received the most attention because
of their reported adverse effects.11 Nickel is the
most common cause of contact allergy15 and is
known to trigger more allergic reactions than all
other metals combined. In addition to the allergic issue, carcinogenic, mutagenic, and cytotoxic
effects have been assigned to nickel and, to a
lesser extent, chromium.2
Nickel is not a cumulative toxin; it is absorbed
in the gastrointestinal tract and eliminated by its
metabolic route.16 The main route for elimination of nickel is through the kidneys; nearly 90%
is quickly excreted in urine.17 For patients with
no occupational exposure to nickel, the mean
urinary nickel level is about 4.5 g/L (range,
1.9-9.6 g/L) or, according to other authors, up
to 50 g/L. Nickel can also be eliminated in

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.

Signs of Corrosion of the

Orthodontic Appliances
The corrosion processes of the orthodontic appliances, when severe, may be observed by the
naked eye as a discoloration (change of enamel
color around the brackets),19 as the result of the
deposition of corrosion products. Furthermore,
corrosion is a continuous process, and its effects
are cumulative so that in the bracket slot, there
may be a progressive increase in surface rugosity
or a corrosion product buildup over time. This
may cause increased frictional resistance to orthodontic sliding mechanics and adversely affect
the progress of treatment.7 Often, the corrosion
process may be invisible and quantified only by
the concentration of the ions released.

Evaluation of the Ions Released from

Orthodontic Appliances
There are three ways of investigating metal ion
release: in vitro, retrieval (ex vivo investigation
of in vivo aged samples), and in vivo.19 Comparisons with in vitro studies are necessary, yet limited, because of variations in methodology, such
as the immersion solution. The most frequent
solutions used are saline solutions (0.05% or
0.9%) or artificial saliva with different compositions. The storage method may also vary between static and dynamic media according to
changes of solution to avoid saturation.2

Release of Ions from Metallic Orthodontic Appliances

In Vitro Study Evaluations and

Their Usefulness
Several questions are evaluated or answered based
on in vitro studies. What are the ions released from
orthodontic appliances and amount released? Can
the type of alloy used in the fabrication of the
brackets have an influence on the quantity of ions
released? Is the release pattern of new and recycled brackets the same? Do titanium brackets, one
of the alternatives to stainless steel, corrode? Do
these brackets release ions? Studies that address
some of these issues are listed in Table 1.
The quantities of released metal ions measured in some in vitro studies are useful for
relative comparisons and for determination of
the effect of each individual variable on ions
released without the influence of external factors.12 One of the first studies to research this
topic was conducted by Park and Shearer in
1983. They verified that the amount of nickel
released in vitro by a simulated orthodontic appliance was about 40 g per day.20 Because human dietary intake of nickel is reported to be
300 to 500 g per day,21 the release of 40 g of
nickel per day is well below the normal daily
intake and may not be of clinical significance.20
To assess whether the type of alloy used in the
fabrication of the brackets can have any influence on the quantity of ions released, 2 groups
of stainless steel brackets were formed: group A
(American Iron and Steel Institute [AISI] 303)
and group B (AISI 316 L). The specimens (simulated orthodontic appliances) were put in saline solution (0.05%), in a precision shaking
Dubnoff incubator (Precision Scientific Co.,
Chicago, IL), at 36C, for 60 days. The ion release was detected by atomic absorption spectrophotometer. The weight of the brackets was also
measured before and after the test. The results
indicated that group A released more nickel and
chromium ions than group B. Moreover, the
brackets in group A also presented weight loss,
which is considered an indicator of corrosion. It
was concluded that, under the study conditions,
the brackets from group A presented higher biodegradation than group B brackets, which could
be associated with the composition and manufacturing process of these brackets.22
Another issue investigated was the ion release
pattern of new and recycled stainless steel brackets. To evaluate it, new and recycled brackets

285

were immersed in buffers of different pH values

over a 48-week period. The release of nickel,
chromium, iron, copper, cobalt, and manganese
ions was analyzed by atomic absorption spectophotometry. The results showed that recycled
brackets released more ions than new brackets.
Brackets immersed in solutions of pH 4 released
more ions than those immersed in solutions of
pH 7, and the total amount of ions released
increased with time over the 48-week period.
This study demonstrates that both new and recycled brackets will corrode in the oral environment. It has been suggested that the microstructural changes after recycling, because of the
cleaning and sterilization procedures involved,
result in an increase in corrosion7 that contraindicates the use of recycling. To avoid clinical
side-effects, metal brackets more resistant to corrosion should be made, and recycled brackets
should not be used.4 These results were later
corroborated and, in some countries, such as the
United Kingdom, the practice of recycling is no
longer recommended.10
Titanium brackets are of interest because their
use is advantageous in the orthodontic treatment
of patients with an allergy to nickel and other
specific substances. However, in an in vivo investigation, performed by Harzer et al,23 that tested
how the surfaces of titanium brackets react to the
corrosive influence of acidic fluoride-containing
toothpaste during orthodontic treatment, the authors observed that significantly more plaque accumulated, and a more marked change of color
occurred on the surface of titanium brackets than
on stainless-steel brackets. The surface of the
rolled wings of titanium brackets was very rough,
and the biocompatibility of titanium supports
plaque adherence, serving as a depot for bacteria
and electrolytic medium for different ions. The
slots of titanium brackets are not as rough as the
wings because the slots are milled and not rolled.
The manufacturer should modify the production
process and mill the entire bracket. Despite this,
the researchers comment that titanium brackets
can safely be used.23

Important Aspects of In Vivo Studies

The administration and elimination routes are
important aspects for understanding the reactions to metals.1 Blood, urine, and hair are the
most accessible tissues for measurement of ex-

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Macedo de Menezes and Cardoso Abdo Quinto

Table 1. Some Research Regarding the In Vitro Release of Ions From Orthodontic Appliances
Author/Year

Study Purpose

Barret,
Bishara
and
Quinn
(1993)43

To compare in vitro the

corrosion rate of a
standard orthodontic
appliance

Park and
Shearer
(1993)20

To evaluate the amount

of nickel and
chromium released
from a simulated
appliance
To evaluate the release
of nickel and
chromium from five
samples consisting of
braces, extraoral and
quad-helix

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

Compare the release of

metal ions from new
and recycled brackets

Tomy, Ormco,
Dentaurum, 3M
Unitek

Artificial saliva
(with different
pH values over
a 48-week
period)

Dolci et al
(2008)22

To evaluate, in vitro, the

biodegradation of
simulated orthodontic
appliances consisting
of stainless steel
brackets and wires

Group A (AISI 303);

and group B (AISI
316 L).

Saline solution
(0.05%), in
shake, at 36C
days 7, 14, 28,
and 60

Sfondrini
et al
(2009)44

To test the hypothesis

that there is no
difference in the
amounts of chromium
released from new or
recycled stainless steel
brackets, and nickelfree brackets.

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

posure or dose to a product or substance, and

are sometimes mentioned as indicator tissues.
Despite this, the most significant method for
measurement of nickel release before and after
onset of orthodontic treatment is salivary analysis because it is the first diluents of the human

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.

Detectable release of nickel and

chromium from orthodontic
appliances seems to occur,
and the amount of nickel
released increases in dynamic
conditions. The authors
commented that the amount
released may be considered
negligible under a toxicologic
point of view, but can be of
considerable importance for
individuals with a high
degree of sensitivity to nckel.
Recycled brackets released
more ions than new brackets.
Brackets immersed in
solutions of pH 4 released
more ions than those
immersed in solutions of pH
7, and the total amount of
ions released increased with
time over the 48-week period.
Brackets from group A
presented a higher
biodegradation than group B
brackets, that could be
associated to composition
and manufacturing process of
these brackets.
The greatest amount of
chromium was released from
new stainless-steel brackets.
The smallest release was
measured with Ni-free
brackets. The difference
between recycled brackets
and Ni-free brackets was not
statistically significant. For all
brackets, the greatest release
was measured at pH 4.2.

body and allows long periods of analyses.19 The

warm and moist condition in the mouth offers
an ideal environment for the biodegradation of
metals, consequently facilitating the release of
metals ions that can cause adverse effects. However, there is little qualitative or quantitative

Release of Ions from Metallic Orthodontic Appliances

data available on the release of metals or metallic salts within the oral cavity.11

The Relationship Between Blood, Urine,

and Ions Release
An important question is whether orthodontic
patients accumulate measurable concentrations
of nickel in their blood during the initial course
of orthodontic therapy. To address this question
blood samples were collected at three different
times: before the placement of orthodontic appliances, 2 months after their placement, and 4
to 5 months after their placement. The study
involved 31 subjects; 18 female and 13 male,
between 12 and 38 years of ageall had malocclusions that required the use of a fully banded
and bonded edgewise appliance. A total of 93
blood samples (3 from each patient) were analyzed by atomic absorption spectrophotometry.
The results obtained from this investigation indicate that orthodontic appliances used, in their
as-received condition, corrode in the oral environment releasing both nickel and chromium,
in amounts significantly below the average dietary intake. Furthermore, the biodegradation of
orthodontic appliances during the initial 5 months
of treatment did not result in significant or consistent increase in the blood level of nickel.5
The pretreatment and treatment levels of
nickel in the urine of 21 orthodontic patients
(12 female, 9 male patients) wearing fixed appliances were evaluated. This was done before
placement of orthodontic appliances and 2
months after placement. Nickel ion analysis was
carried out by the use of atomic absorption spectrophotometry. Urinary nickel levels increased
significantly after the placement of orthodontic
appliances, for both sexes. The biological effect
of a systemic increase in urinary nickel is unknown. Long-term follow-up and larger samples
of patients are needed to validate the results and
to determinate the implications of these findings.1

Concentrations of Metal Ions Released

in Saliva
The large variability in ion concentration among
subjects is a common finding when the release
of metal ions in saliva is examined.24-27 This
variation may be related to several factors be-

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-

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Macedo de Menezes and Cardoso Abdo Quinto

Table 2. Some Research Regarding the In Vivo Release of Ions from Orthodontic Appliances (Saliva)
Author/Year

Ions

Sample

Characteristics

Duration

Results

Before insertion of the

appliance, 2 d 1 wk
and 1 mo
Before insertion of the
appliance, 1 wk, 1
and 2 mo

No differences before
and after
appliance.
No differences
between groups.

Before insertion of the

appliance, 1 wk, 1
mo, 1 year, and 2
years

Reached their highest

levels in the first
mo and decreased
to their initial level
in the rest of the
groups.
No differences
between groups.
Metal levels did not
exceed those of
daily intake.
Increase of ions
during treatment.

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

male, 8 male) with fixed appliances placed in

their upper and lower arches. The second group
consisted of 15 patients (8 female, 7 male) with
a fixed appliance placed only in the upper arch.
The control group consisted of 15 patients (7
female, 8 male) who were not undergoing orthodontic treatment. Four samples of stimulated
saliva were collected from each patient before
insertion of the fixed appliance, 1 week after
insertion of the appliance, 1 month after insertion of the appliance, and 2 months after insertion of the appliance. The same four samples of
saliva were collected from each control patient
at the same time intervals as for the fixed-appliance groups. It was observed that there was a
large variation in the concentrations of both
nickel and chromium in saliva. No significant

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

2-8 wks after placing

the wires

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

Release of Ions from Metallic Orthodontic Appliances

289

appliance. The analysis of saliva was performed

by atomic absorption spectophotometry in a
graphite oven, determining the concentration of
cadmium, copper, zinc, and silver ions. The ion
concentrations in the control group exhibited
low values for cadmium, copper, and zinc,
whereas for the silver ion the values did not
reach the detection limit. In the study group, all
ions presented expressive concentrations at 10
minutes after placement of the appliance, with
higher means for copper, with a tendency for
reduction after 24 hours. Comparison between
groups revealed significant differences for copper (all periods), zinc (10 minutes, 24 hours,
and 7 and 30 days), and for cadmium only at 10
minutes. There was a great release of the ions
analyzed in the study, with high concentrations
measured immediately after placement of the
appliance, but with a tendency to regress within
the study period.18

appliances were higher in orthodontic patients

than in controls and that nickel released from
fixed orthodontic appliances could induce DNA
damage in oral mucosa cells.30 The differences
between the studies of Faccioni et al30 and Westphalen et al,31 regarding the genetic damage,
may be explained by the fact that the study
conducted by Faccioni et al30 was a cross-sectional study associated with a larger number of
patients analyzed using the appliances for a
much longer period (2-3 years).
The paucity of research in this field and the
importance of the issue in health of the orthodontic patients justify further studies with
larger samples and long-term follow-up analysis.
These strategies will yield valuable data to better
understand the genotoxic potential of metals
from orthodontic devices, as well as to assess the
biological risk to which orthodontic patients
may be submitted.31

Genotoxic Effects from the Ions

Released in Oral Cavity

Possible Local or Systemic Effects From

Ions Release

Although the amount of metals released from

orthodontic appliances is significantly below the
average dietary intake and does not reach toxic
concentrations,25,29 it cannot be excluded that it
can be sufficient to induce biological effects in
cells from the oral mucosa.30 Westphalen et al31
assessed the genotoxicity effects from orthodontic appliances by carrying out both micronucleus
(MN) and comet (CA) assays in a group of 20
healthy patients undergoing orthodontic treatment. The combination of MN and CA assay is
recommended because the CA can be used to
detect primary DNA damage (reparable) in a
short period, whereas the MN assay detects chromosomal damage in a further stage. In the study
conducted by Westphalen et al, the time of sampling was 10 days after the placement of the
orthodontic appliance for the CA and 20 days
later (30 days after appliance placement) for
MN assay. The CA results revealed that orthodontic appliances did not induce any genetic
damage. The MN assay showed an increase in
MN cells 30 days after the placement of the
orthodontic appliances.31 By contrast, when the
CA was applied in an in vivo study, conducted by
Faccioni et al,30 with 55 orthodontic patients
and 30 control subjects, it was demonstrated that
metallic ions (nickel) released from orthodontic

The introduction of metal ions into the human

body is an additional risk to health which may
lead to systemic and local effects.5 Hypersensitivity occurs when an adverse reaction follows contact with subtoxic doses of foreign substances.
Three mechanisms comprise hypersensitivity reactions: allergy, intolerance, and hyperreactivity.21 Epidemiologic data demonstrate that the
number of people with sensitivity to nickel has
increased to approximately 20%.15,32 Contact
with nickel by susceptible subjects can yield a
wide range of hypersensitivity reactions.33
Nickel allergies may comprise extraoral and
intraoral reactions though extraoral allergic reactions are more frequent than intraoral reactions. Nickel allergies may comprise intraoral
red zones, blisters, and ulcerations, extending to
the perioral area, and are referred to as allergic
contact mucositis or dermatitis. Intraoral allergic reactions include redness, edema, itching
and dryness of the lips and oral mucosa, burning
sensations, as well as gingival inflammation. All
these reactions are not necessarily limited to the
exposure site. Eczematic and urticarial reactions
of the face or more distant skin areas can occur
with redness, irritation, itching, eczema, soreness, fissuring, and desquamation.21 Occasionally, fever has been reported as a systemic reac-

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tion.34,35 However, much remains to be understood

and studied in terms of nickel, such as its release,
absorption and reactions.

Evaluation of a Patient for Sensitivity to

the Metal Ions Released
When there is suspicion of an allergic reaction,
the allergen must be determined. Hypersensitivity is usually diagnosed through patient history,
clinical findings, and biocompatibility testing
(patch tests).36,37
The literature includes some studies in which
patch tests were used to evaluate the hypersensitivity reactions to nickel. Prystowsky et al33 evaluated a sample of 1158 adult volunteers and
found that 5.8% had a positive reaction to 2.5%
nickel sulfate (9% in women and 0.9% in men).
There was a strong correlation between pierced
ears, ear lesions, and areas of contact with jewelry. Among patients referred for clinical evaluation of contact dermatitis, 11% had a positive
reaction to nickel.
Blanco-Dalmau et al36 conducted a patch test
to 5% nickel sulfate in 403 subjects (121 male,
282 female). The incidence of positive reaction
in the study sample was 28.5%, with a remarkable difference between the sexes (31.9% of female subjects, compared with 20.7% of male
subjects).
Stenman and Bergman38 performed patch
tests in 151 patients (119 female, 32 male) with
reported hypersensitivity to the components of
dental materials or trinkets. Positive response to
metals was observed in 42 patients (28% of the
sample), whereas reaction to organic components was observed in 7 patients (4.6%). A positive reaction to nickel was found in 21 patients
(14%), including 20 women and 1 man.
Jones et al17 attempted to determine the incidence of nickel hypersensitivity with patch tests
in 100 patients (50 men, 50 women). The authors investigated the relationship between sex,
age, and previous report of allergy to jewelry
with hypersensitivity to this metal and found
alterations in blood pressure, pulse, or temperature among patients with nickel hypersensitivity.
Furthermore, by placing a removable appliance,
the authors observed that nickel-hypersensitive patients were prone to demonstrate signs of hypersensitivity, at both the area of contact and distant
areas. The authors found an incidence of hyper-

sensitivity to nickel with the patch test of 20% for

women and 2% for men.
Menezes et al39 evaluated hypersensitivity to
eight antigens, some of them components of
bands and brackets used in orthodontic practice. The tested substances were cobalt chloride,
copper sulfate, potassium dichromate, iron sulfate, manganese chloride, molybdenum salt,
nickel sulfate, and titanium oxide. They were
removed after 48 hours and assessed by a dermatologist at 48 and 72 hours after antigen application. The patch tests were carried out before and 2 months after the placement of fixed
orthodontic appliances. Statistically significant
positive reactions were observed for nickel sulfate (21.1%), potassium dichromate (21.1%),
and manganese chloride, 7.9%; reactions to
nickel sulfate had the greatest intensity. No differences were observed between the reactions
before and after placement of the orthodontic
appliances; this indicates that they did not sensitize the patients or affect their tolerance to
these metals during the study period. No statistical difference was observed regarding sex for
any evaluated substance, although a greater tendency to positivity to nickel sulfate was observed
among female patients and to potassium dichromate in male patients.

Procedures Recommended in Cases of

Allergy to Nickel
Firstly, good-quality materials should be used so
that the effects of corrosion are minimized. The
use of recycled brackets should be avoided and
the use of alternative products, such as nickelfree, ceramic, polycarbonate, titanium, or goldplated brackets should be considered. When the
allergic reactions do appear shortly after the
placement of fixed orthodontic appliances,
treatment must be discontinued and any appliances containing nickel removed.19,40,41 After
healing, treatment should resume using alternative alloys.42

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

Release of Ions from Metallic Orthodontic Appliances

nickel in the patients, despite the low amounts

in the composition of orthodontic appliances, is
not easily explained. The differences in the
changes of excretion of these metal ions might
be due to differences in corrosion processes,
solubility coefficients, or excretion mechanisms.
Although increases in metal ion levels have
been detected in some studies after placement
of orthodontic appliances, the levels are not sufficient to cause alarm; however, additional in
vitro and in vivo studies should be performed to
clarify these questions and determine safe levels
of metallic ions.

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