Porphyria induced by palladium-copper dental prostheses: A clinical report

ia induced al report

by palladium-copper

avce Downey, DMDa Oregon Health Sciences University, School of Dentistry, Portland, Ore.

orphyria is an uncommon metabolic disease characterized clinically by neurologic, cutaneous, and gastrointestinal manifestations .l Various practitioners may see the affected patients, depending on their predominant symptoms. The condition develops when there is a deficiency of one of many enzymes needed to produce porphyrins. The porphyrins are needed in the biosynthesis of heme. In some instances this deficiency may be inherited. Patients have been observed in whom drugs? or heavy metals2 triggered the development of clinical symptoms, whereas in others an initiating agent is not identified. This report and discussion is of a patient with acute intermittent porphyria that was identified after placement of dental prostheses having a high content of palladium and copper.

ATIENT

REPORT

A 45”year-old woman was referred to the Oral Pathology Clinic, Oregon Health Sciences University, because of a bad metal taste and systemic problems of a vague etiology that developed soon after placement of dental prostheses. She had worked steadily for 24 years and was married and raising two children, ages 9 and 4. Before this time, the patient had manic depressive illness with two suicide at-

aAssistant Professor, Department of Oral Pathology. 10/1/26622

Fig. THE

JOURMAL

OF PROSTHETIC

DENTISTRY

tempts as a teenager. At one time, she wore large pieces of copper and silver jewelry. Eventually she developed rashes and sensations of “ill-being” when wearing this type of jewelry and discontinued wearing any such jewelry many years ago. Soon after placement of mandibular posterior fixed partial dentures, described to her as composed of palladiumgold alloy, she developed widespread skin rashes that faded with time, severe stomach pain of approximately 3 months’ duration, and 5 weeks of diarrhea, drooling, and an unremitting, disagreeable, metallic taste. As time passed, her feet and arms became swollen, and vomiting ensued. Weight gain was noted and lymph nodes could be palpated in the neck. By 2 weeks postinsertion, loss of coordination, short-term memory loss, hyperventilation, and visual hallucinations were noticed. Eventually the patient was no longer able to work and during the summer of 1988, was bedridden. Epileptic episodes occurred. Various psychiatric and medical evaluations were conducted and therapies tried with little, if any, success.Magnetic resonance imaging revealed a defect in the brain that was compatible with a storage disease. There was no evidence of Wilson’s disease, and blood and urine studies were negative for heavy metals. The patient was thought to have chronic fatigue syndrome. During her dental evaluation, no oral lesions were noted, electrogalvanic measurements were unremarkable, and “a bad metallic taste” was present as described above. As part

1. Erythematous papules near and under copper bracelet.

DOWNEY

Fig.

2. Erythematous

rash associated with a sterling silver necklace.

of the evaluation, the patient wore copper-containing jewelry for several days. Skin manifestations followed, which were noted and recorded. These changes are depicted in Figs. 1 and 2. The dental laboratory that made the prostheses reported that the alloy contained 76% palladium, 2 % gold, and 10 % copper. At this juncture, removal of the fixed partial dentures was suggested. Almost immediately after their removal, the pain, vomiting, metallic taste, and mood swings disappeared. Supplemental therapy by her physician included vitamins C, B-12 injections, and oral B-6 and zinc. Ultimately the patient was diagnosed as having acute intermittent porphyria by blood studies at the Mayo Clinic, Rochester, Minnesota.

ISCUSSION This case represents a rare instance of copper-induced porphyria. Heavy metals, including copper, are well documented in the literature as having a role in the development of porphyria.2 The amount of copper needed to induce the described symptoms is not known. This patient had numerous medium- to large-sized amalgam restorations in her maxillary posterior teeth that had been present for many years. Apparently, she had various neurologic and other ‘“vague” ongoing systemic problems before the acute episode. Amalgam restorations available for use may contain 22 % to 30 70 copper.3 Even though the patient is getting along better than she has in years, it has been recommended that the amalgam restorations be replaced with materials not containing copper. Some consideration was given to the possibility that the galvanic forces developed by the high-palladium prostheses may have lead to increased corrosion of the amalgams.4-6 Heavy metals used in the oral cavity are capable of causing a variety of conditions including allergic, irritant, galvanic, metabolic, and toxic responses.2, 5,7-1s Dentists are responsible for selecting the materials used in restorations

6

and prostheses. Their knowledge should incfude alloy composition and precious metal content. The fact that patients cannot tolerate various types of jewelry should signal the dentist of the possibility of a metal intolerance. In this patient, the acute and debilitating effects caused by the dental prosthesis might have been avoided.

CONCLUSION Systemic symptoms of a condition ultimately, diagnosed as acute intermittent porphyria developed following placement of dental prostheses having high-palladium and copper content. These symptoms remitted following removal of the restorations.

REFERENCES 1. Bissell D. Disorders of porphyrins or metals. New York: WB Saunders, 1985:1153-a. 2. Peters HA, Cripps DJ, Reese HH. Porphyria: theories of etiology and treatment. Int Rev Neurobiol1974;16:301-55. 3. Craig RG. Restorative dental materials-amalgam. St Louis: CV Mosby, 1989:227-54. 4. American Dental Association Council on Dental Materials. Instruments and equipment. J Am Dent Assoc 1984;109:838-49. 5. Marek M. The corrosion of dental materials. Treatise on materials science and technology. vol 23. Scully JC. London: Academic Press, 1983:331-94. 6. Arvidson K, Johansson EG. Galvanic series of some dental alloys. Stand J Dent Res 1977;85:485-91. 7. Leirsker J. On the mechanism of cytotoxicity of silver and copper amalgams in a cell culture system. Stand J Dent Res 1974;82:74-81. 8. Trachtenberg DI. Allergic response to copper and its possible gingival implications. J Periodontol 1972;43:‘705-7. 9. Cohen SR. A review of the health hazards from copper exposure. J Occup Med 1974;16:621-4. 10. Fisher AA. Contact stomatitis and cheilitis: contact dermatitis. Philadelphia: Lea & Febiger 1986:773-800. Reprint requests to: DR. DAVE DOWNEY SCHOOL OF DENTISTRY OREGON HEALTH SCIENCES UNIVERSITY 611 S.W. CAMPUS DR. PORTLAND, OR 97201

JANUARY

1992

VOLUNIE

67

NUMBER

1