Although the causes of sarcoidosis are still unknown, past and current studies have provided evidence that this disease may be associated with occupational exposure to specific environmental agents. We describe a case of sarcoidosis in a dental surgeon with long exposure to inorganic dusts. To the best of our knowledge, this is the first report of this kind in the literature.
Case presentation
At the beginning of 2000, a 52-year-old Caucasian man, who worked as a dental surgeon, presented with shortness of breath during exercise, cough and retrosternal pain. After diagnosis of sarcoidosis, a scanning electronic microscopy with X-ray microanalysis of biopsy specimens was used in order to determine whether the disease could be traced to an occupational environmental agent. Results showed the presence of inorganic dust particles within sarcoidotic granulomas, and demonstrated that the material detected was identical to that found in a powder used by our patient for several years.
Conclusions
Although these results cannot be considered as definitive proof, they do however provide strong evidence that this disease may be associated with material used by dental surgeons.
The instruments used during dental surgical procedures produce intense heat (electrocautery, laser) and such procedures usually produce fumes containing biological material (even partially incombusted). High-speed, air-driven dental handpieces, ultrasonic scalers, the polishing of composite and ceramic restorations and the use of the milling cutter on metallic prostheses disperse a large amount of aerosol and spatter including fine particulate matter. During the polishing and whitening of natural teeth, chemical compounds (composed by particles of sodium di-carbonate and tricalcium phosphate) are sprayed on the tooth surface detaching part of its enamel and dispersing microparticles in the environment, thus exposing patients and operators at risk of inhalation. For example, a standard hygiene procedure involves the use of prophylactic material and ultrasonic and/or manual instrumentation . The prophylaxis phase can be substituted by an artificial bicarbonate aerosol. Artificial cleaning aerosols are formed by a Mini-Clean device (Castellini, Bologna, Italy) with air pressure set at six to seven atmospheres and water flow at one atmosphere. Each individual run lasts 20 to 30 minutes for each patient. It has been reported that 95% of the particles measure less than five micrometers and are mainly concentrated within two meters of the patient where they can be easily inhaled by dental clinicians.
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Occupational and environmental exposures — It has been hypothesized that sarcoidosis is associated with several occupational and environmental exposures. However, only beryllium and its salts have been shown to produce granulomata that are similar to that seen in sarcoidosis. Despite intensive efforts, studies have largely failed to identify an external agent or agents responsible for sarcoidosis .
A case series suggested that exposure to World Trade Center (WTC) dust during the collapse, rescue, or recovery was associated with an increased incidence of sarcoidosis-like granulomatous pulmonary disease during the five years following the disaster . The series reported 26 patients who had pathologic evidence of new onset sarcoidosis following WTC dust exposure. The estimated annual incidence rate was 86 cases per 100,000 population during the first year after the WTC collapse and 22 cases per 100,000 population during the next four years. In comparison, the estimated annual incidence rate was 15 cases per 100,000 during the 15 years prior to the disaster. Eighteen of the 26 patients (69 percent) also developed findings consistent with asthma.
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