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Oral Lichen Planus and Allergy to Dental Amalgam Restorations

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Oral Lichen Planus and Allergy to Dental Amalgam Restorations STUDY Oral Lichen Planus and Allergy to Dental Amalgam Restorations Ronald Laeijendecker, MD; Sybren K. Dekker, MD, PhD; Piet M. Burger, MD; Paul G. H. Mulder, PhD; Theodoor Van Joost, MD, PhD; Martino H. A. Neumann, MD, PhD Objectives: To determine contact allergies in patients was replaced in 8 patients of group B, with significant with oral lichen planus and to monitor the effect of par- improvement. In group C, amalgam replacement in 2 tial or complete replacement of amalgam fillings follow- patients resulted in improvement in 1 patient. These ing a positive patch test reaction to ammoniated mer- results were evaluated after 3 months. No positive patch cury, metallic mercury, or amalgam. test reactions to mercury compounds were found in patients with concomitant cutaneous lichen planus and Design: In group A (20 patients), the oral lesions were in group D. confined to areas in close contact with amalgam fillings. In group B (20 patients), the lesions extended 1 cm be- Conclusions: Contact allergy to mercury compounds is yond the area of contact with amalgam fillings. In group important in the pathogenesis of oral lichen planus, es- C (20 patients), the oral lesions had no topographic re- pecially if there is close contact with amalgam fillings and lationship with amalgam fillings. Partial or complete re- if no concomitant cutaneous lichen planus is present. In placement of amalgam fillings was recommended if there cases of positive patch test reactions to mercury com- was a positive patch test reaction to ammoniated mer- pounds, partial or complete replacement of amalgam fill- cury, metallic mercury, or amalgam. Control group D (20 ings will lead to a significant improvement in nearly all patients) had signs of allergic contact dermatitis. patients. Results: Amalgam fillings were replaced in 13 patients of group A, with significant improvement. Dental amalgam Arch Dermatol. 2004;140:1434-1438 RAL LICHEN PLANUS exact cause of OLP remains unknown, but (OLP) has a prevalence an immune-mediated (T-cell dependent) of about 0.5% to 2%. pathogenesis is proposed.1,3,12 Generally, it is a disease The concept of contact allergy to den- of middle-aged and older tal restorative materials aggravating or persons, and the female-male ratio is about inducing OLP is well recognized but O1-4 13-15 2:1. Oral lichen planus can be catego- somewhat controversial. However, rized into several clinical variants. The hy- several authors have reported resolution perkeratotic variant is usually asymptom- atic. The atrophic or erythematous variant For editorial comment and the erosive or ulcerative variant mostly see page 1524 Author Affiliations: have persistent symptoms of pain or sting- Department of Dermatology, ing. The various terms for OLP in the lit- of signs and symptoms in OLP after re- Albert Schweitzer Hospital, erature are oral lichenoid lesions, lichen- placement of amalgam, particularly if Dordrecht (Drs Laeijendecker, oid contact lesions, and lichenoid contact there was a positive patch test result to Dekker, and Burger), and stomatitis and are used interchangeably, mercury, which is the most important al- Departments of Epidemiology which is confusing. In this study, we only lergen in amalgam.6,16-18 and Biostatistics (Dr Mulder) use the term oral lichen planus because The aim of this study was to determine and Dermato-Venereology, there is no difference in clinical practice contact allergies in patients with OLP and University Hospital Rotterdam based on the symptoms of disease, clini- amalgam fillings and to investigate whether (Drs Laeijendecker, Van Joost, cal examination, and histopathologic find- there are specific subgroups of patients with and Neumann), Erasmus 5-9 Medical Centre, Rotterdam, ings. Oral lichen planus is usually a per- OLP, based on differences in the relation- the Netherlands. sistent disorder and may last many years, ship between oral lesions and amalgam fill- 10,11 Financial Disclosure: None. despite several kinds of treatment. The ings. A second objective was to monitor the (REPRINTED) ARCH DERMATOL/ VOL 140, DEC 2004 WWW.ARCHDERMATOL.COM 1434 ©2004 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 10/02/2021 effect of partial or complete replacement of dental amal- gam restorations following a positive patch test reaction to Table 1. Patch Test Antigens ammoniated mercury, metallic mercury, or amalgam. Standard Series Dental Metal Series METHODS Potassium dichromate 0.5% pet Ammoniated mercury 1% pet Neomycin sulfate 20% pet (mercury ammonium Thiuram mix 1% pet chloride)* This prospective nonrandomized control study included 80 white Parapheynlenediamine 1% pet Copper sulfate 2% pet patients who were older than 18 years with 1 or more silver amal- Cobalt chloride 1% pet Potassium dicyanoaurate gam fillings. Sixty patients had the diagnosis of OLP established Benzocaine 5% pet 0.002% aq on the basis of medical history, physical examination, and his- Formaldehyde 1% aq Sodium thiosulfatoaurate topathologic evaluation. They were categorized into 3 equal groups Colophony 20% pet 0.25% pet based on the topographic relationship between oral lesions and Clioquinol 5% pet Ammonium tetrachloroplatinate the amalgam fillings. In group A (20 patients), the oral lesions Balsam of Peru 25% pet 0.25% pet Metallic (elementary) mercury were confined to areas in close contact with amalgam fillings. In N-isopropyl-N- 0.5% pet* group B (20 patients), the lesions extended 1 cm beyond the area phenylparaphenylenediamine 0.1% pet Gold sodium thiosulfate 0.5% pet of contact with amalgam. In group C (20 patients), the oral le- Wool alcohols 30% pet Palladium chloride 1% pet sions had no topographic relationship with dental amalgam res- Mercapto mix 1% pet Cadmium chloride 1% aq torations. A control group (group D; 20 patients) had allergic con- Epoxy resin 1% pet Silver nitrate 1% aq tact dermatitis without any oral pathologic evidence of OLP. Patient Paraben mix 16% pet Gold (tri)chloride 0.5% aq recruitment ended when there were 20 patients in each group. Paratertiary butylphenol Zinc chloride 2.5% pet Six patients (7.5%) (1 each in groups A and B and 2 each in groups formaldehyde resin 1% pet Copper oxide 5% pet C and D) were lost to follow-up prematurely, and another 6 pa- Fragrance mix 8% pet Aluminum chloride hexahydrate tients were substituted. The study was carried out from 1991 to Quaternium-15 1% pet 2% pet 1993 at the Department of Dermato-Venereology, University Hos- Nickel sulfate 5% pet Tin 50% pet pital Rotterdam, and continued from 1994 to 2001 at the Depart- Kathon CG (methyl[chloro]isothiazoli- Thimerosal 0.1% pet ment of Dermatology, Albert Schweitzer Hospital. none) 0.01% aq (Merthiolate)† Patch tests with a standard series (according to the European Mercaptobenzothiazole 2% pet Ferrous sulfate 5% pet standard series) and a dental metal series (Table 1) were oc- Sesquiterpene lactone mix 0.1% pet Gallium oxide 1% pet cluded with Finn chambers on the skin and evaluated after 72 Primine 0.01% pet Titanium oxide 1% pet Zirconium oxide 0.1% pet hours. The reactions were read 30 minutes after removal of the Cocamidopropyl betaine 1% aq Amalgam 5% pet (pulverized patches to minimize false-positive readings. Erythematous and amalgam powder)* indurated test results were regarded as positive. If there was only an erythematous patch test reaction (which was regarded as nega- Abbreviations: aq, aqueous solution; pet, in petrolatum. tive), another evaluation was made after 3 days and, if necessary, *Inorganic mercury compounds. several days or weeks later. Patients were instructed to return if †Organic mercury compound. there was a possible late positive reaction. Replacement of amal- gam fillings was recommended in case of a positive patch test re- action to ammoniated mercury, metallic mercury, or amalgam. erated basal cells, are occasionally seen in the epithelium. If the Alternative dental restorations consisted of composite resins, glass histopathologic changes in the mucosa were less pronounced (es- ionomers, ceramics (porcelain), and gold. pecially the basal cell layer degeneration and the inflammatory If there was a positive patch test reaction to ammoniated mer- infiltrate), the diagnosis of “compatible with OLP” was made. If cury, metallic mercury, or amalgam in groups A and B, the ad- there were more aspecific changes, this was diagnosed as “non- vice was first given to replace the amalgam fillings in close con- specific.” If there were signs of cutaneous lichen planus (CLP), tact with the oral lesions. If there was a significant improvement histopathologic examination of the skin lesions was performed. in the lesions, the patients were advised to replace any remain- The clinical effect of treatment in the patients with OLP was ing part of the amalgam in the dental fillings in the future, but graded as worse (−), unchanged (±), improved (+), and healed only for dental reasons. In group C, all dental amalgam was re- (++). Statistical analysis of the results was performed by means placed if there was a positive patch test reaction to the aller- of the exact ␹2 test for trend, Fisher exact test, 1-way analysis gens. In group D, no advice on replacement of amalgam fillings of variance test, and Kruskal-Wallis test, in which 2-sided P val- was given. In all groups, participants were advised to desist from ues were calculated (with statistical significance set at PϽ.05). new dental amalgam restorations in the future if there was a posi- tive reaction to 1 or more mercury compounds. One or two 3-mm punch biopsy specimens for histopatho- RESULTS logic examination were taken from the hyperkeratotic or ery- thematous lesions and if there was an erosion or ulceration at The basic characteristics, such as sex, age, duration of the the edge of the lesions from all patients in groups A, B, and C. lesions before patch testing, and number of dental amal- The biopsy specimens were fixed in buffered 4% formalin and gam fillings, in groups A, B, C, and D are shown in Table 2 stained with hematoxylin-eosin and the periodic acid–Schiff re- anddidnotdiffersignificantly(PϾ.05).Themostcommonly action.
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