Even if your surgeon does not think this is needed because they have never seen a metal allergy before – it is still needed. Tell them to join facebook groups where there are stories of people receiving the normal TMJ concepts joints and having allergies to them!

The process

Most recommended in the ICR circles is the Orthopedic Analysis Panel 2 LTT test. It is a blood test that you will need to probably order for yourself, some surgeons offices might order it for you.

• I had my primary care physician draw my blood for it and ship it off. A doctor is required to sign off on the documents before sending it off.
• Read the directions in the kit, I think they might want you to draw the blood at a certain time during the day so it is not sitting for too long (or you might just want to do this anyways whether they say to or not).
• Be sure to drop off the package by the correct time for them to overnight it to Orthopedic Analysis! When I did it in 2021, it was shipped off by FedEx and you have to call them to see when their last pickup is.

Ordering process:

1. Go to the Orthopedic Analysis website: https://www.orthopedicanalysis.com/order-testing-panel?fbclid=IwAR0UDo_xc4DgbU4R49pYg1bbxdqiGx2_MpXgXrfMgfsO3T6ISzHXW7vo9c8
2. Select the Orthopedic Panel 2, and make sure “Kit and Service” is selected and add to cart. It is about $608.

Will insurance cover the cost?: I have not yet heard of someone’s insurance covering this cost, you can make your own claim and submit to insurance after ordering it for the cost to be on your deductible and maybe for it to get reimbursed.

There are also other options for metal allergy testing, which include:

1. Skin patch testing
   • Still the “gold standard” according to my allergist, and also what research online suggests. I don’t personally buy into it because it is not an in-body test/ no T-cells to test with and I would think doesn’t perfectly portray how your tissues under your skin will react
   • I did this as well for good measure and was allergic to nothing. IMO, there are many things that can mess up the patch test, like sweating. But I know cheap earrings and rings itch. So I went with my gut and did the Orthopedic Analysis test too.
2. Leukocyte migration inhibition test (LMIT)
3. Lymphocyte transformation tests (LTT)
   • Orthopedic Analysis is this type
4. Temporary metal implantation into your arm
   • I don’t know much about this, I just know that Dr. Movahed has done this for one patient before to see if they reacted.
   • Eric at TMJ concepts recommended the LTT test saying, “Dermal nickel is different from implanted…completely different. Don’t have T-cells on your skin. Completely different.”

Results

You will get your results back within a few weeks and can send the report to your surgeon if you find that you have an allergy to any of the metals. Here is an example of the report below (my personal report):

I tested “Reactive” to nickel. Some still get the normal TJR implants with mild to mid-reactive, but it was not worth it to me. A nickel allergy can also “develop at any time” ¹ so I was personally rooting for the titanium implants, even though they are technically not as strong. My diet has been soft for so long too that I don’t think I personally put too much force or wear on my joints over time.

What is is like to have an allergy and have the normal TMJ concepts prosthesis?

From the people I have talked to online who didn’t know they had an allergy to one of the metals and got the normal joints, they have symptoms such as hives, itching, and it can even lead to aseptic loosening of the prosthesis.²

My allergist who wanted me to do the skin patch test acted like metal allergies were not a big deal, that he had only ever seen about 5 knee replacement people that had allergies and they were doing ok and could manage. I think there are varying degrees of allergies, and they should always be taken seriously. Scholarly articles online seem to hum this tune as well, but I have heard otherwise from patients online who are allergic to their TJ prosthesis.

I hope metal allergies are taken more seriously in the medical field in the future.

Why order panel 2 over panel 1?

You could also order panel 1, it tests for most of the metals in the TMJ concepts joints, but not 2 of them:

1. Titanium
2. ASTM F1537-11 Alloy 1, Wrought Co -28Cr-6Mo Low Carbon Alloy (the cobalt alloy particles on panel 2)

You would save $185 ordering panel 1 instead, but I wanted to know everything I could going into this surgery. This price was a drop in the bucket compared to all the other costs that have gone towards my health related to my jaw.

Why test for titanium if the only other joint option is all titanium? Honestly, just to know if you do start having problems with the joints and have a titanium allergy – it is probably that. You will probably have to work with an allergist from then on – I know 2 people with titanium allergies, one is reactive to her joints and the other has not been.

Why do some surgeons not order allergy testing?

Many surgeons have not seen a metal allergy in their careers, but when it happens to them for the first time…they usually start asking patients to do the test. I do wish all doctors could be proactive rather than reactive. Metal allergies are generally not taken seriously enough in the medical community imo. The literature suggests that nickel or other allergies do not start occurring until the metal begins to break down and become bioavailable. But this is not the case when you put in an earring that contains nickel and you are allergic – that nickel is not bioavailable, yet cheap jewelry still itches (if you have an allergy to it).

The FDA a couple of years back only allowed 2 PEOPLE to receive the all titanium joints. Just 2!!! I’ve talked to patients online that were years out on the list to receive one so they went ahead with the normal joints and had to have another operation soon after to remove them because of their allergies. It is just not worth it in my opinion to get the normal joints if you have an allergy, such a costly mistake if you do start reacting to the joints! But I know others who do and they do fine. When I talked to the head engineer from TMJ Concepts, he said the people that have reactions to the joints are people that have multiple other allergies or comorbidities as well (see more info below on what he had to say).

Other information to know if you are allergic to any of the metals

If you are allergic to the main metals, your surgeon can apply through the FDA’s compassionate use program to get the all titanium joints. You have to go through this process because the titanium joints are slightly weaker than the standard joints and are less studied, last I heard. I personally called TMJ concepts (when they still allowed that) and they said their titanium joints were put through rigorous testing. The head engineer told me,

• On the standard joints, the wear properties were better and friction is better. Lower friction means less wear.
• Titanium wouldn’t last as long – the material is softer.
• They do different in house tests to assess this – “Pin and disc test – pin on polyetheline. In lab. Bovine serum to mimic fluid.” (whatever this is), “Titanium: 5x to 100xs different dramatic difference. This is in orthopedics. Wear testing for TMJ Concepts: They did articulating in a machine. 75 lb load. Bovine serum. 10 million cycles. Wear measured. Not super meaningful amount of wear. No one knows the true wear scenario in tmj.”
• Lots of research going on here with allergies. These mechanisms sorta understood and not. Some people have reaction to nickel but it’s buried under the chromium. The nickel us VERY low, .5 percent.
• Consensus: no big systemic issues with allergies or compromised immune system. Rheumatoid arthritis can cause more issues, or patients with really bad allergies to multiple things. Some signs to look for: Allergies to silicone, or tattoo that got bright red as soon as you got it. These are the people that are generally sensitive to the cobalt chromium because they got other things going on as well.

Then your surgeon has to sign some of the FDA documents and so does the hospital that the surgery will be performed at! You can try and call the hospital if they are not signing the documents. I think it really pays to go with a surgeon who is very understanding of metal allergies and has experience with the FDA compassionate use process.

Just if you are interested, here are some other interesting things that I learned from TMJ concepts! He talked fast so my notes were terse:

• 30 years out their longest TJRs. No wear. No one ever. Titanium device: 20 yr follow up no one wore out that either.
• Don’t see many retrievals of TJR. Sometimes heterotrophic bone growth in 10-15 years , got to do surgery to clean out bone. Destroy implant trying to get it out. They look for debris… some polyethylene and some scuffing on the head. But titanium will show burnishing. Tissue samples they get back- they just don’t see wear debris like they do hips.
• Divot in polyethylene when wear, how many years to go through? 100 years to wear through (so that plastic fossa is dang strong!!)
• Some patients suffering from material sensitivity. Polyethylene starts to particulate – larger than metals. Activate osteomyelitis. Body tries to eat but can’t. Is usually the failure in a hip replacement. Femurs get eaten.

Also, a big thank you to Caitlin Brown, who I learned most of this information from ❤️ She is writing an article now on metal allergies and I plan to link it here in the future.

---

Citations

1. “What is a nickel allergy?” https://www.healthline.com/health/allergies/nickel#:~:text=Nickel%20allergies%20are%20increasing%20in,is%20unlikely%20to%20go%20away.
2. “Metal allergy in total-joint arthroplasty” https://journals.lww.com/md-journal/Fulltext/2018/09210/Metal_allergy_in_total_joint_arthroplasty__Case.92.aspx