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Contact Allergy in Oral Disease

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Contact Allergy in Oral Disease ARTICLE IN PRESS REPORT Contact allergy in oral disease RochelleR.Torgerson,MD,PhD,MarkD.P.Davis,MD,AlisonJ.Bruce,MBChB, Sara A. Farmer, MS, and Roy S. Rogers, III, MD Rochester, Minnesota Background: The role of contact allergy in oral cavity disease processes is unknown. Objective: We sought to determine the prevalence of contact allergy to flavorings, preservatives, dental acrylates, medications, and metals in patients with oral disease. Methods: Patients were tested with an 85-item oral antigen screening series. Data were analyzed retrospectively. Results: We evaluated 331 patients with burning mouth syndrome, lichenoid tissue reaction, cheilitis, stomatitis, gingivitis, orofacial granulomatosis, perioral dermatitis, and recurrent aphthous stomatitis. Positive patch test results were identified in 148 of the 331 patients; 90 patients had two or more positive reactions. Allergens with the highest positive reaction rates were potassium dicyanoaurate, nickel sulfate, and gold sodium thiosulfate. Of the 341 positive patch test reactions, 221 were clinically relevant. Limitations: No follow-up data were available in this retrospective analysis. Conclusion: The positive and relevant allergic reactions to metals, fragrances, and preservatives indicated that contact allergy may affect oral disease. ( J Am Acad Dermatol 10.1016/j.jaad.2007.04.017.) ral disease is prevalent in the general pop- or orthodontic devices.1-11 However, few studies ulation, and its symptoms can disrupt a have used larger oral allergen screening series that, person’s daily activities. The spectrum of in addition to metals, included flavorings, preserva- O 12-16 signs and symptoms of oral disease is broad. Patients tives, and dental acrylates. We report the results with no clinically evident lesions may experience of patch tests to the 85 allergens in our oral screening burning or paresthesias, whereas other patients may series. have pain attributable to lichenoid tissue changes or frank oral ulceration. Because clinical findings do not METHODS always account for presenting symptoms, treatment Patient selection of these patients can present both diagnostic and In this retrospective study, 620 patients who therapeutic challenges. underwent patch testing to allergens in an oral The use of patch testing to evaluate patients with antigen screening series were identified from a oral diseases and symptoms has been controversial. clinical database. Allergen patch testing was per- Numerous studies have addressed the effects of formed between May 1, 2000, and April 30, 2004, at metal allergies in patients with dental restorations Mayo Clinic (Rochester, Minn, and Scottsdale, Ariz). Medical histories of the patients were reviewed, and records of 331 eligible patients with a presenting From the Department of Dermatology and the Division of Biostatistics (S.A.F.), Mayo Clinic. symptom of oral disease or oral symptoms were Funding sources: None. retained for the study. Patient demographics were Conflicts of interest: None declared. also obtained from the database. Patients who de- Accepted for publication April 23, 2007. nied research authorization were excluded from the Reprints not available from the authors. analysis. This study was approved by our institu- Correspondence to: Mark D. P. Davis, MD, Department of Dermatology, Mayo Clinic, 200 First St SW, Rochester, MN tional review board. 55905. E-mail: [email protected]. Published online May 24, 2007. 0190-9622/$32.00 Allergen patch tests ª 2007 by the American Academy of Dermatology, Inc. Allergens analyzed in this study were those in our doi:10.1016/j.jaad.2007.04.017 oral screening series. For each patient, the specific 1 ARTICLE IN PRESS 2 Torgerson et al JAM ACAD DERMATOL allergens tested were determined by the treating Table I. Patient demographics (N = 331) physician’s judgment of relevant contactants. Patch Patients testing was conducted using Finn Chambers on Characteristic No. % Scanpor tape (Alpharma Inc, Vennesla, Norway). Allergens were purchased from Chemotechnique Patient sex Female 268 81 Diagnostics (Vellinge, Sweden) or compounded in Male 63 19 our pharmacy. Allergens were applied to the skin of Race the back, torso, extremities, or a combination of the White 220 96 above and left in place for 48 hours. Readings were Black 5 2 obtained at 48 and 96 hours. Hispanic 3 1 Patch test reactions were evaluated using criteria Asian 2 1 similar to the North American Contact Dermatitis Not disclosed 101 ... Group criteria17: negative reaction, macular ery- Age, y thema, weak reaction (nonvesicular erythema, infil- Mean 58 tration, and possibly papules), strong reaction Range 12-90 (edematous or vesicular lesions), extreme reaction 25th percentile 47 75th percentile 70 (spreading, bullous, and ulcerative lesions), or irri- tant reaction. For this study, weak, strong, or extreme reactions were considered positive results. For each gold chloride (4.3%). Of the 341 positive reactions patient, the treating physician judged each positive to allergens, 221 (65%) were considered relevant. patch test result to be relevant or irrelevant on the The patients were categorized into 8 disease basis of the patient’s history and clinical examination groups: burning mouth syndrome (145 of 331, findings. The grades of relevance, which included 43.8%), lichenoid tissue reaction (59 of 331, 17.8%), definite and questionable relevance, were recorded cheilitis (54 of 331, 16.3%), stomatitis (27 of 331, in the patient’s medical record when the 96-hour 8.2%), gingivitis (25 of 331, 7.6%), orofacial granu- reading was performed. lomatosis (13 of 331, 3.9%), perioral dermatitis (5 of 331, 1.5%), and recurrent aphthous stomatitis (3 of Statistical analysis 331, 0.9%). The number of positive reactions and Patient data were entered into a clinical database relevant reactions in each disease group are reported (Sybase Incorporated, Dublin, Calif). All statistical in Table III. Patients with burning mouth syndrome analyses were performed using a software package formed the largest disease group and thereby ac- (Statistical Analysis System, SAS Institute, Cary, NC). counted for the largest number of positive reactions. Patients with gingivitis had the highest percentage of positive reactions, and patients with recurrent RESULTS aphthous stomatitis had the lowest percentage of In all, 85 allergens were studied to determine the positive reactions. None of the 13 patients with prevalence of contact allergy to flavorings, preser- orofacial granulomatosis had relevant reactions. vatives, dental acrylates, medications, and metals The most common allergens for each of the 8 in patients with oral disease. Patch testing was disease groups are presented in Table IV. Metals and performed on 331 patients with oral symptoms or flavorings predominated the list. Each of the 5 most evidence of disease during oral examination. The common allergens for patients with gingivitis was a demographics of this population are presented in metal, whereas for patients with cheilitis, only one of Table I. the 5 most common allergens was a metal. Table II shows the number of patients tested with each of the allergens and the percentage of positive and relevant reactions. After 96 hours, 148 of 331 DISCUSSION patients (45%) had at least one positive reaction, and We evaluated 331 patients with oral disease using 90 patients (27%) had two or more positive reactions. an oral screening series with 85 allergens. Our report The 10 allergens with the greatest percentage of emphasizes positive patch test results categorized positive reactions were potassium dicyanoaurate by individual allergens and specific diseases. (19.6%), nickel sulfate hexahydrate (12.5%), gold Our study is unusual because it investigated a sodium thiosulfate (11.6%), fragrance mix (9.8%), large series of allergens and included all patients with palladium chloride (9.7%), balsam of Peru (7.2%), oral disease who underwent patch testing (evalua- beryllium sulfate tetrahydrate (5.4%), cobalt chloride tion was not limited to patients with positive patch (5.2%), 2-hydroxyethyl methacrylate (5.2%), and test reactions). In this work, 45% of patients had at ARTICLE IN PRESS JAM ACAD DERMATOL Torgerson et al 3 Table II. Positive and relevant reactions to oral Table II. Cont’d allergens (N = 331) Reactions, % Reactions, % No. of patients No. of patients Allergentested Positive Relevant Allergentested Positive Relevant Potassium 184 19.6 55.6 Amyl cinnamic aldehyde 2% 298 0.3 100 dicyanoaurate 0.1% Aq* Triethyleneglycol 303 0.3 100 Nickel sulfate 320 12.5 52.5 dimethacrylate 2% hexahydrate 2.5% 1,4-Butanediol 51 0.0 0 Gold sodium 293 11.6 50.0 dimethacrylate 2% thiosulfate 0.5% 1,6-Hexanediol 55 0.0 0 Fragrance mix 8% 264 9.8 84.6 diacrylate 0.1% Palladium chloride 2% 196 9.7 68.4 2-Hydroxypropyl 31 0.0 0 Balsam of Peru 25% 264 7.2 78.9 methacrylate 2% Beryllium sulfate 186 5.4 20.0 Aluminum powder 100% 182 0.0 0 tetrahydrate 1% Aq Ammonium tetra- 183 0.0 0 Cobalt chloride 1% 307 5.2 56.3 chloroplatinate 0.25% Aq 2-Hydroxyethyl 77 5.2 75.0 Bisphenol-A- 302 0.0 0 methacrylate 2% glycidylmethacrylate 2% Gold chloride 0.5% Alc* 186 4.3 62.5 Bisphenol-A- 51 0.0 0 Dodecyl gallate 0.25% 288 4.2 41.7 dimethacrylate 2% Mercury 0.5%y 190 4.2 87.5 Budesonide 0.1% 264 0.0 0 Copper sulfate 2% 79 3.8 33.3 Cadmium chloride 1% Aq 182 0.0 0 Potassium dichromate 0.5% 150 3.3 60.0 Citric acid 1% Aq 289 0.0 0 Benzoic acid 5% 285 3.2 100 Ethyl cyanoacrylate 10% 38 0.0 0 Cobalt sulfate 1% 195 3.1 100 Eucalyptus oil 2% 298 0.0 0 Mercury
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