Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

September 16, 2017

I have a titanium allergy and think I have a titanium post in my tooth


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Dr. Hall,
I have recently been diagnosed with a titanium allergy. I have two crowns on my left side, upper and lower. I have various odd symptoms that have been addressed with my dentist. They have been checked out and I’ve been told everything “looks” fine. The dull ache surrounding my upper remains. I’m wondering if I have a titanium post and if this is possibly contributing to this dull ache and possibly other unexplained ailments throughout my body. Where do I go from here?
– Jennifer from Kentucky

Jennifer,
Titanium allergy used to be considered very rare, but with the increasing use of dental and orthopedic implants, which almost always use titanium, there are increasing reports of titanium allergy. The MELISA Medica Foundation, which conducts the MELISA test for metal sensitivities, estimates that as many as 4% of the population could be allergic to titanium. However, this test has been criticized as generating false positives, and my guess would be that titanium allergy is less prevalent than that.

Titanium is a very biocompatible metal, apparently due to its high corrosion resistance. Given this corrosion resistance, I would not think that the presence of titanium in a post inside of a tooth would affect tissues outside of the tooth, but I guess that would be possible. If you want to investigate that, I would just go to the dentist that put the post in your tooth and ask if it is titanium. Your dentist should have a record of the type of post that was inserted. I will add that there should only be a post in your tooth if the tooth has had a root canal treatment.

Metal posts are often used in root canal teeth to help retain the buildup that is placed in the tooth and the buildup in turn helps retain the crown on the tooth. For many years, stainless steel posts were the standard. Stainless steel contains nickel, and it is estimated that 10 to 20% of people are allergic to nickel. It was assumed that this wasn’t an issue, because the post was sealed inside the tooth and not in contact with living tissue. Then, about 30 years ago, it was discovered that corrosion products from the stainless steel could leach through the teeth and many dentists, including me, switched to using titanium posts.

Could your dull ache be from a metal sensitivity? I would say that it could. I would wonder if there is any metal in the crowns you have—that is something worth checking also. There could also be a problem with the occlusion of the crowns. In any of these scenarios, everything would “look fine,” but that doesn’t mean that everything actually is fine.
– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

April 24, 2017

I have metal allergies and want a dental implant


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Dear Dr. Hall,

I completely love your web site and enjoy reading so much of the wisdom you pass on to worried people.

I am in the UK and want to ask your opinion. I am 61 so an old bird now however, I have always tried to look after my teeth. Over the past few years I have lost the teeth at the farthest back on both sides. I would love to think that if I managed to get a nest egg, I could have implants to make my teeth whole again. However, I have the severest metal allergy I think possibly doctors have ever encountered. I am proven allergic to nickel, cobalt, and a flutter to mercury. I cannot wear jeans, sandals with buckles and have to avoid all clothing with any form of metalised thread or adornments. Therefore, I know that implants may be a problem. Can you please advise me is there anything on the market whereby posts are made of some material which is not metal based. If there was I could perhaps start saving for my two implants and when I am really old, not fly into a panic when I lose a front tooth. I would be so grateful for your advice. Sorry to have gone on.

Hugely grateful.
Jane from Essex, UK

Jane,
Yes, there is a good solution for you. You actually have a couple of choices.

First, nickel allergies are not all that uncommon, and many people have problems with cobalt. That shouldn’t scare you away from a titanium dental implant. I advise avoiding nickel in particular in any dental restorations or appliances because there are so many people with sensitivities to it. When you say you have a “flutter to mercury,” I’m not sure what that means, but it shouldn’t be an issue with dental implants because practically all of them are pure titanium and titanium is an extremely biocompatible material. If you’re uneasy about it, it shouldn’t be difficult to get an allergist to test you for titanium allergy.

I wouldn’t assume that because you are allergic to some metals, even if those allergies are severe, that you can’t have any contact with metals. After all, there are metals known as minerals that are essential to our diet–iron, zinc, and calcium are all metals.

But if you’re even uneasy about titanium, there are dental implants that are made out of zirconia, a super-strong ceramic. This is the only metal-free dental implant I’m aware of. It might take some work to find a dentist who will place zirconia implants, but there are some.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

November 30, 2016

Allergic to her removable partial denture


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Dr. Hall,
I have been sick for over 2 years after having upper and lower partials put in. I’ve had sores in my mouth on my tongue. I complained to my dentist over and over. My dentist just referred me here there and everywhere. I finally went to Mass General Hospital and I am in fact allergic to several metals one being nickel. My questions is, can having these partials in my mouth for this long (I felt better at night when I took them out) however, never feeling quite right as I had to put them back in 7 or so hours later to go to work. Would this make you physically sick?
Thank you in advance for your advice.
Ginger from Massachusetts

Ginger,
I am continually surprised by these cases that come to me about metal allergies and people tell me that their dentist doesn’t have a clue. This is fundamental and important.

To answer your question, yes, you can definitely become physically sick from constant exposure to metals to which you are allergic. Of course I can’t diagnose from here, but it is entirely possible that your sickness from the date of having these removable partial dentures comes from your metal allergies.

I had one rare case in my practice of a woman who was allergic to mercury. While most of my patients didn’t want mercury-containing amalgam fillings in their mouths, for this woman it was imperative to get rid of them because she had a confirmed and very rare allergy to mercury. We had several appointments to take out all of her amalgam fillings and replace them with composites. After the first appointment, she developed a rash on her throat and chest and had some difficulty breathing because of the amalgam dust that we had created during this procedure. From then on we draped her to avoid any additional exposure and gave her a nose mask to breathe through during these appointments. I remember when she came in for her six-month checkup after all of this was completed and I asked her if there was any change in how she felt. She told me that she had been troubled with arthritis, but since the amalgam was removed the arthritis was gone. I am confident that her arthritis was related to her constant exposure to allergens.

Many metallic removable partial dentures are made with an alloy called Vitallium, which is composed of chromium and cobalt and has no nickel in it, but there are less expensive alloys that do have nickel in them. Or they could have other metals that provoke reactions.

About 10% of women and about 1% of men will test positive for nickel allergy. “Are you allergic or sensitive to any metals?” should be a standard question on every dentist’s medical history form, if they use any metals in their restorative materials other than precious metals. But sadly, it isn’t. Most women with these sensitivities will know that they have to wear hypo-allergenic earrings, and the dentist should get this information before treatment. Though there are a growing number of dentists now who only provide metal-free restorations–if that is the case then of course they don’t need to ask this.

Dr. Hall

Do you have a comment or a question or anything else to add? We’d love to hear from you. Enter your comment below.

Click here to ask Dr. Hall a question of your own.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

August 29, 2016

Removing a metal post in a tooth


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Dr. Hall,
I just found out my dentist inserted a stainless steel post into my root canal tooth–my upper molar. A temporary crown is placed over it now and a permanent crown will be placed in a week. My question is can the post be removed and a zirconia or carbon post (I don’t think he does those) be put in instead? I don’t want steel in my mouth even though he said it’s encased. My ears have been pulsating since. Please tell me it’s removable!
– Linda from Brooklyn

Linda,
Yes, a stainless steel post probably can be removed, though there may be some risk involved.

Let me give a little background on this to frame my answer.

stainless steel dental post

A metal post in a lower molar

When a tooth is “bombed out,” needing a root canal treatment and with little tooth structure left, a dental post is often placed in the tooth. This post can serve a couple of purposes. For front teeth and premolars, it can strengthen the tooth against horizontal fracture. For molars and any other teeth, it can also provide additional retention for the crown. If there is little of the original natural crown of the tooth left, the post, anchored in the root of the tooth, will help retain a buildup in the tooth, and the buildup retains the crown.

There is a history to the material out of which the post is made. In the 1970s and earlier, stainless steel was the material of choice for prefabricated dental posts. However, in the 1980s it was discovered that even though a post is cemented inside the tooth and doesn’t come into contact with the bloodstream at all, metal ions were found to leach through the tooth and into the bloodstream. Stainless steel contains nickel, which causes sensitivity reactions in many people (see some of our blog posts on metal allergies). To guard against potential reactions as you seem to be experiencing, many dental practices, including mine, switched to titanium, which is not only very strong but the most biocompatible metal available. In the 1990s, other materials were introduced for posts, including carbon fiber and fiberglass. More recently, zirconia has been used for posts. Zirconia is a ceramic that has high flexural strength and is also very biocompatible.

So yes, you have a legitimate concern about this stainless steel post. Your dentist should get with current technology. From what you are telling me, he isn’t into any of these newer post materials, most of which have been around for twenty years or more.

Now, as to removing the post that is in there, that could be tricky and, depending on the situation, you may not want to trust your dentist to do this but may want to see a root canal specialist or another dentist who feels comfortable doing this. It depends on how deeply the post goes into the root of your tooth and how well it is cemented. It may be possible to dislodge it with an ultrasonic tip. I remember one patient I had who was adamant about removing several metal posts in his teeth. I don’t remember why his posts were so difficult to remove, but I ended up telling him that I had to drill out all of these posts and I had him sign a paper acknowledging that I had told him there were serious risks in doing this, that I could perforate the roots of any or all of these teeth, leading to the loss of the teeth. He was willing to accept those risks. The good news is that I got out all of the posts without any accidents, but I remember it was very stressful for me.

If you feel that you are experiencing a sensitivity reaction to the post, I would put a halt to the crown procedure until you can have the post removed. Cementing a crown on the tooth will only make it more difficult, as your dentist would have to start by drilling through the crown, possibly ruining the crown.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

January 21, 2016

Allergic to her Maryland bridge

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Dr. Hall,
I have recently had #24 [lower central incisor] pulled due to the gum receding. My dentist had a Maryland bridge made and I am allergic to it. What other options are there? There is not enough room for an implant. The periodontist suggesting removing #25 and replacing with one tooth but I fear I will look more like a side show attraction than I already do. HELP… Am searching for answers.
– Ann from Texas

Ann,
I had to laugh when I heard the suggestion of your periodontist, of taking out the adjacent tooth also and then replacing the two teeth with one large tooth. That sounds so much like a typical dentist and so out of touch with what a patient would want. I agree with you that you could look like a side show. But another option similar to this would be to place one implant supporting two teeth—that can be done also.

A Maryland bridge consists of a porcelain tooth bonded onto a metal framework. The framework has metal wings which are bonded to the lingual side (inside surfaces) of the two adjacent teeth. In order to bond properly, that metal has to be etched. The etching produces microscopic irregularities in the surface that make the metal bond well to dental bonding resins. And there are two ways to make that metal etchable.

One is to use an alloy that contains 1-2% beryllium. Usually that metal also contains nickel and chromium as primary components, but it doesn’t have to. The problem with such an alloy is that about 10% of the population will have an allergy or sensitivity to the alloy. That allergy could be to any of these three components, or all of them, as all are known to provoke sensitivity reactions in some people.

The other way to create an etchable surface on the metal is to plate the metal with tin. When that is done, a semi-precious alloy can be used—one that is made of maybe palladium and silver. Such an alloy is hypoallergenic. The alloy itself isn’t etchable, but the tin plating is. So that is an option for you.

A final option would be to make the bridge out of zirconia. Zirconia is a metal oxide, a compound of the metal zirconium plus oxygen, and is extremely strong. It is a ceramic and is white and translucent, similar to porcelain. Some people call it “ceramic steel.” And it can be etched so that it bonds to dental bonding resin. This, to me, is a better way to go. Not only does it eliminate the sensitivity problem, it is more esthetic since there is no metal to darken the adjacent teeth.

– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

January 5, 2016

Multiple allergies to dental materials

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Dear Dr. Hall,

I have patch tested positive to many metals and chemicals. I had a root canal 5 years ago that got botched and the file was broken. I then went to an endodontist and he tried to go through the top to remove the file, but ending up going through the bottom and cutting. It has never felt right and I went to a dentist who said I had an infection under it. I was diagnosed also by allergist at my local university hospital with TILT, same thing as multiple chemical sensitivity. I know I have allergies to dental cement, formaldehyde, cobalt, chromium, titanium, and many chemicals. Right now I have very bad eczema from all allergies, but I am in pain and just want this root canal tooth pulled and cultured to see what type of infection it is. I am looking for a dentist. I will travel for someone knowledgeable on type IV metal allergies. Could you help me?

Thank you,
Lisa from Mississippi

Lisa,
I’ve been stewing over your question since I first saw it a couple of days ago. That’s quite a tough situation that you have.

I don’t think you necessarily need a dentist trained in your specific allergies, and I don’t know that there is any such dentist. What you need, I think, is a dentist willing to work with you and to work around the list of allergies that you have. And I think for that, you need to call around and ask offices if they are willing to do that.

When I was in practice, I was willing to work with people with multiple sensitivities, and I would have some of them come to me with a list of dental products that they were sensitive to. These were Cliffords tests. They are controversial, and I didn’t want to get into the controversy, but I would honor the findings of the doctor that had run the tests, and we would avoid all of those materials for which the patient tested sensitive. I know from interviewing many dentists that most are not willing to deal with issues like that, but a few are. In the dental marketing that I do, when a dentist is willing to work with those Cliffords tests, we market them as holistic dentists.

I can think of a couple of dentists I know who are within reasonable driving distance (2-4 hours) for you who might be willing to accommodate you. If you’d like me to call and ask, let me know, and I’ll get back to you.

Or another option would be to run a search yourself in Google for dentists who hold themselves out as holistic. And then call the office and tell them about your problems and see if they’re willing to work with you.

Thanks,
Dr. Hall

Do you have a comment? We’d love to hear from you. Enter your comment below.

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

March 1, 2013

Is she allergic to the metal in her crowns?

Dr. Hall,
I am 64 years old…had metal fused porcelain crowns (5 upper front teeth) placed 4 years ago. After countless dentist visits, a nightguard, a guard for my bottom teeth, tensing of the jaw, etc., I cannot stop grinding my teeth. I am constantly aware of these crowns with the sensations I feel in the roof of my mouth. Do you think that maybe I cannot tolerate the metal? Previous to these crowns, I had gold backed crowns for 42 years which I never had a grinding problem. I have no peace and I am ruining my bottom teeth. Could I be allergic to the metal? (only because it actually feels “itchy” at the roof of my mouth.)

– Mae in Pennsylvania

Mae,

I need a disclaimer because of not being able to examine you myself, but just going from what you are telling me, it sounds to me like you have two separate problems.

The itchy feeling around the metal backings to your new teeth could well be from a metal allergy. Here’s what I would do: Ask your dental office for information on the composition of the alloy used in the metal of your porcelain fused to metal crowns. The laboratory would have sent them what is called a “Identalloy” certificate, which lists all the metals in the alloy. If you see “Ni” among the metals listed – this stands for nickel, and nickel allergies are fairly common.

Are you sensitive to any metals in earrings, for example? Women who have nickel allergies need to wear hypoallergenic earrings, and they have to be careful with what metals are put in their mouth.

Let me explain these dental metal allergies. In the medical history that the dentist took before starting any treatment, he or she should have asked if you have any history of metal sensitivities, and if you have anything like that in your history, the dentist should have prescribed metals for use in your mouth that have no nickel in them. The problem is, those metals are more expensive than ones that do have nickel. There are three expense classifications of metals used in crown and bridge work. The highest is called “high noble.” The gold backing you used to have would be in this category. Other alloys have high platinum. This type of metal makes a finer margin and is more malleable, meaning that it can be made to fit the tooth the best. The second highest is called “noble.” These will have a higher silver content, but will have no nickel or beryllium, which are metals that can cause sensitivities in some patients. They are somewhat malleable and make a very nice fit to the tooth, but not as high quality as the high noble.

The lowest category is called “base metal.” These are very stiff alloys and tend to be cast with small gaps between the metal and the tooth, so they don’t fit quite as well and they aren’t malleable at all. They will have some nickel in them and sometimes some beryllium.

Your new crowns may have also disrupted your bite. The metal sensitivity shouldn’t be causing you to grind your teeth, But if you had crowns on five front teeth, that has a strong impact on your bite and your bite could be thrown off to where it is making you want to grind your teeth. If this is happening to you, I would wear a nightguard every night until the bite is adjusted to where you don’t grind any more.

A particular problem if you have porcelain crowns on your front teeth that don’t have a full metal backing is that the porcelain on the upper teeth is highly abrasive to your lower teeth, and you will gradually wear down your lower front teeth. So I would get this fixed.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

September 18, 2010

Allergic to the Metal in her Crowns

This is a follow-up e-mail from Carolyn in New Jersey. She asked about the types of metals that are used in porcelain-fused-to-metal crowns.

Dr. Hall,
Thank you very much for your informative answer.

At this point, my last concern is aesthetics. I seem to be reacting to a metal in my porcelain-fused-to-metal crowns. (Tongue inflammation where the tongue touches the metal parts of my crowns, inflammation in the skin on the lips and around the mouth, and general facial inflammation).

I saw the metal shell underneath each of these porcelain crowns just before they were placed in my mouth. I hadn’t been informed, first, that such a metal shell could or would exist under the porcelain, so there was no time to halt the procedure in order to seriously question the makeup of that shell. It was rough, grainy, and very dull silver-colored. I suppose this is the “black” that is now appearing near the gums. I’m guessing this would have to be a “base” metal. It certainly wasn’t “shiny.” More like the lowest grade of industrial steel.

In addition, I’d asked for a gold surface on top of some of the the porcelain crowns. I had no metal in my mouth prior to this and my goal was to have only gold, if any metal at all. I have a TMJ problem so a forgiving metal was needed on some surfaces.

Understanding completely that there is no “pure gold” for the mouth and that all gold comes as an alloy, I still cannot believe that these surfaces on top of the porcelain crowns are actually gold. They are quite dark silver now, “hot” to my tongue, they burn my tongue, and now the tongue is swollen in those places. I do have an all-gold crown, in the back of my mouth, to compare these dark silver metal surfaces to. The all-gold crown looks, feels, and acts like gold. It’s beautiful and feels good. These “gold” surfaces on top of the porcelain-fused-to-metal crowns, however, look and feel so dark and so hot. I’m suspecting an electrogalvanic reaction between the upper metallic surfaces and the baser metals at the gumline.

I’d questioned the gold content of these upper surfaces (because they looked silver) and received the answer that the colors can be different due to the fact that the gold comes as an alloy. But “this degree of different” is really strange. If my white gold ring began to look this way, I’d take it back to the jeweler for a refund.

So I’m trying to gather intelligent background information, independently, on what I might have received in my mouth that is causing my mouth and tongue to burn, and my facial/lip skin to become so inflamed with scaly red patches around the mouth. I realize that no one but my dentist can give me the chemical composition for sure. I just wanted to have a ballpark idea of what might be happening to me before I approached him on this.

In general terms in the profession: Is it possible for a patient who has paid in full for such crowns to go back, a mere two or three years later, and receive from the lab the exact metallic composition of each crown that they produced for me?

Any further information on any of these points would be greatly appreciated. I understand completely that only my dentist can give me the “bottom line” on my own case. I’m just looking for accurate ballpark info so that I do not permit myself to be led astray.

Does the black at the gumline, therefore, give evidence of a “base metal” having been used for the metal shell under the porcelain crown?

Thank you.
Carolyn

Carolyn,
No, the black line at the gumline doesn’t give any clue as to what metal you have in the crowns, nor does the rough appearance of the metal on the inside of the crown (it is left rough to be more retentive – a shiny surface would slip off the tooth more easily). But your sensitivity gives a strong clue. I would give at least 95% odds, based on your reactions, that nickel was used in your crown, as that is the metal that usually provokes this kind of reaction. That is one of the base metals.

And to answer your previous question, yes, the dentist should retain documentation of what alloy was used and its composition. The dental laboratory is required to send to the dentist what is called an identalloy certificate that lists the composition of the alloy that was used, and the dentist is required to retain this. The dentist bears responsibility for insuring that you don’t have this kind of reaction. Do you have any history of metal allergies, such as a reaction to any metals in earrings? We always asked whether people had any reaction to metals, and flagged the charts of those patients who had metal sensitivities, so I would know when to avoid base metals. Although we got to where we simply didn’t use them on anybody because of the risks involved, except for Medicaid patients, where the government specified that they wanted us to use base metals, because they were cheaper. If your dentist didn’t ask you this, then he or she is responsible for this and should make it right with you.
Dr. Hall

Dr. Hall,
Again, thanks so much. I very much appreciate your insight and your time.

The one overwhelming thing known about me by the dentist and his staff is my multiple chemical sensitivity. That reality looms larger than my name, at this point. I have been my dentist’s “chemical education,” with all the difficulties and humorous moments that implies.

Although mercury made me miserable (all those teeth fell apart and the mercury was incidentally removed before these metal-shelled crowns were installed) I never had a nickel allergy to report! I supposed now I will.

Carolyn

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

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