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Systemic allergic contact dermatitis associated with allergy to intraoral metals

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Contact (allergic) dermatitis is a skin disorder related to natural exposure to various allergens. Systemic contact dermatitis (SCD) describes a cutaneous eruption in response to systemic exposure to an allergen. The exact pathologic mechanism remains uncertain. Herein we describe a 36-year-old woman with symmetric systemic allergic contact dermatitis, unresponsive to conventional treatment, associated with dental alloy-contact hypersensitivity. We did skin patch testing and the blood lymphocyte transformation test (LTT) from the dental allergen series to assess contact allergy to restorative dental materials. On patch testing, positive allergic contact dermatitis reactions to metals occurred (nickel, potassium dichromate, and gold). Nickel hypersensitivity was confirmed by LTT, which also revealed silver-amalgam sensitization. Our case report highlights the need to consider adverse reactions to base-metal dental alloys in the differential diagnosis of cases of systemic allergic contact dermatitis.
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Dermatology Online Journal
UC Davis
Peer Reviewed
Title:
Systemic allergic contact dermatitis associated with allergy to intraoral metals
Journal Issue:
Dermatology Online Journal, 20(10)
Author:
Pigatto, Paolo D, IRCCS Galeazzi Hospital, University of Milan
Brambilla, Lucia, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico
Ferrucci, Silvia, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico
Zerboni, Roberto, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico
Somalvico, Francesco, Alpha Search sas
Guzzi, Gianpaolo, 4Italian Association for Metals and Biocompatibility Research – A.I.R.M.E.B.
Publication Date:
2014
Permalink:
http://escholarship.org/uc/item/74632201
Keywords:
adverse events, amalgam dermatitis, contact hypersensitivity reaction, delayed/chemically
induced, delayed-type hypersensitivity, dermatitis/allergic contact hypersensitivity, heavy metals
adverse events, mercury dermatitis, mercury exanthema
Local Identifier:
doj_24253
Abstract:
Contact (allergic) dermatitis is a skin disorder related to natural exposure to various allergens.
Systemic contact dermatitis (SCD) describes a cutaneous eruption in response to systemic
exposure to an allergen. The exact pathologic mechanism remains uncertain. Herein we describe
a 36-year-old woman with symmetric systemic allergic contact dermatitis, unresponsive to
conventional treatment, associated with dental alloy-contact hypersensitivity. We did skin patch
testing and the blood lymphocyte transformation test (LTT) from the dental allergen series
to assess contact allergy to restorative dental materials. On patch testing, positive allergic
contact dermatitis reactions to metals occurred (nickel, potassium dichromate, and gold). Nickel
hypersensitivity was confirmed by LTT, which also revealed silver-amalgam sensitization. Our
case report highlights the need to consider adverse reactions to base-metal dental alloys in the
differential diagnosis of cases of systemic allergic contact dermatitis.
Copyright Information:
eScholarship provides open access, scholarly publishing
services to the University of California and delivers a dynamic
research platform to scholars worldwide.
Copyright 2014 by the article author(s). This work is made available under the
terms of the Creative Commons Attribution-NonCommercial-NoDerivs4.0 license, http://
creativecommons.org/licenses/by-nc-nd/4.0/
Volume 20 Number 10
October 2014
Case Presentation
Systemic allergic contact dermatitis associated with allergy to intraoral metals
Paolo D. Pigatto,1 Lucia Brambilla,2 Silvia Ferrucci2, Roberto Zerboni2, Francesco Somalvico3, Gianpaolo
Guzzi4
Dermatology Online Journal 20 (10): 6
1Department of Biomedical, Surgical and Dental Sciences, Unit of Oral Pathology and Medicine, IRCCS
Galeazzi Hospital, University of Milan, Milan, Italy
2Operative Unit of Dermatology, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milano,
Italy
3Alpha Search sas, Milan, Italy
4Italian Association for Metals and Biocompatibility Research – A.I.R.M.E.B., Milan, Italy
Correspondence:
Dr. Gianpaolo Guzzi, DDS
Italian Association for Metals and Biocompatibility Research – A.I.R.M.E.B.
(not-for-profit organization)
Via A. Banfi, 4
20122 Milan – Italy
tel. +39-02-782 561
fax. +39-02-367 355 40
email: gianpaolo_guzzi@fastwebnet.it
Abstract
Contact (allergic) dermatitis is a skin disorder related to natural exposure to various allergens. Systemic contact dermatitis
(SCD) describes a cutaneous eruption in response to systemic exposure to an allergen. The exact pathologic mechanism
remains uncertain. Herein we describe a 36-year-old woman with symmetric systemic allergic contact dermatitis, unresponsive
to conventional treatment, associated with dental alloy-contact hypersensitivity. We did skin patch testing and the blood
lymphocyte transformation test (LTT) from the dental allergen series to assess contact allergy to restorative dental materials.
On patch testing, positive allergic contact dermatitis reactions to metals occurred (nickel, potassium dichromate, and gold).
Nickel hypersensitivity was confirmed by LTT, which also revealed silver-amalgam sensitization. Our case report highlights
the need to consider adverse reactions to base-metal dental alloys in the differential diagnosis of cases of systemic allergic
contact dermatitis.
Key words: adverse events; amalgam dermatitis; contact hypersensitivity reaction; delayed/chemically
induced; delayed-type hypersensitivity; dermatitis/allergic contact hypersensitivity; heavy metals adverse
events; mercury dermatitis; mercury exanthema.
Introduction
Systemic contact dermatitis (SCD) is an inflammatory skin disease in response to systemic exposure to an allergen and has
been reported in patients with adverse health effects linked to dental alloy restorations [1-7], but the exact pathologic
mechanism remains uncertain. Herein we report a case of severe systemic allergic contact dermatitis caused by allergy to
metals released by galvanic corrosion between a mercury amalgam tooth filling and an endosseous titanium dental implant.
Case synopsis
A 36-year-old woman reporting severe widespread dermatitis with intractable pruritus was examined in our dermatological
department in April, 2002. The gradual onset of dermatitis developed and persisted several months after she had received 2
endosseous root-formed titanium implants, which were implanted in both her maxillary and mandibular bones (Figure 1 e). On
imaging studies, titanium endosseous implants appeared to be clinically and radiologically well osteointegrated and they were
placed in healed alveolar bone of the maxillary right first molar area (1.6) and mandibular left first molar area (3.6) (Figure 1
a,e), respectively. A single class II mercury amalgam restoration was present on the mandibular left first molar (3.7) (Figure 1
a,e), in close contact to the noble metal-dental alloy implant-supported restoration on 3.6 (Figure 1 a,e). Clinical examination
showed extensive dermatitis with erythema, xerosis, and scaling and crusting on face, neck, and bilateral inguinal areas
(Figure 1 b,c,d). Facial swelling (especially around eyes) was visible but oral mucosa was unaffected.
Her systemic dermatitis was unresponsive to the usual medical therapies. Medications on admission included a topical class 1
glucocorticoid and emollient moisturizing creams. She had no family history of atopic dermatitis and she had no history of
asthma. She did not smoke, drink alcohol, or use illicit drugs; she had no risk factors for occupational and/or non-occupational
exposure to chemical substances. The patient’s dietary fish intake occurred one time per week. Given that the onset of
dermatitis was temporally related to dental work, we hypothesized a hypersensitivity and/or allergic reaction to dental
materials. In particular, we suspected a high-rate release of intraoral metal ions owing to galvanic corrosion between the
mercury amalgam filling on the mandibular left first molar (3.7) and the titanium implant-supported gold/palladium alloy
crown in the mandibular left first molar area, 3.6 area (Figure 1 a). The single metal-ceramic crown restoration was based of
noble alloy, consisting in a gold/palladium-based crown (Figure 1 a,e). A small mercury amalgam tattoo (measuring 2 x 2
millimeters, Figure 1 e) was present in the peri-implant mucosa around the titanium dental implant, which was consistent with
the previous presence of a mercury dental amalgam restoration. No signs of oral pathology were observed on her oral mucosa.
Skin biopsy was considered but it was not performed. She was patch-tested with a dental allergen series, including mercury
allergens for screening for contact allergy to dental amalgam fillings. The 31 allergens from the dental series are listed in
Table 1. With regard to the timing of patch test readings, patch test strips were removed at day 2 (48 hours) and readings were
performed at day 4 (96 hours). Criteria for scoring of patch test reactions were assessed according to Wilkinson et al [8]. We
observed very strongly positive allergic reactions to nickel sulfate 5 percent (score reaction +++), potassium dichromate 0.5
percent (score reaction +++), and gold sodium thiosulfate 0.5 percent (score reaction ++), all in petrolatum (Chemotechnique
Diagnostics, Vellinge, Sweden) (Table 1). Sensitization to nickel was subsequently confirmed by the lymphocyte
transformation test (LTT-stimulation index, S.I.: 6.7, at a cutoff value of S.I. <2.00 as predictor of response of immune
sensitization to metals) and silver reactivity was evident with an LTT-stimulation index, S.I.: 5.5, (cutoff value of S.I.: <2.00).
Mercury dental amalgam contains silver (30-35 percent by weight) and nickel (Ni2+) in trace amounts (up to 8-9 micrograms
per gram of amalgam metal-matrix alloy) [9]. Both the mercury-containing amalgam filling and the metal-ceramic crown on
the dental titanium implant were removed to reduce considerably her intra-oral electrochemical corrosion process, which
likely released metal ions (mercury, nickel, and silver) into the saliva and the oral mucosa [10-12]. The systemic contact
dermatitis resolved completely within 8 months after the removal of both mercury amalgam tooth filling and a single metal-
ceramic crown restoration (gold/palladium – based crown), which were in close proximity to each other (Figure 1 f,g,h). To
achieve a complete and stable resolution of the patient’s signs and symptoms, it was not necessary to remove her two titanium
dental implants. The patient's systemic contact dermatitis reverted completely and did not recur in 12 years of follow-up
(Figure 1 f,g,h).
Figure 1. Mercury-containing dental amalgam filling (on the mandibular left second molar, 3.7 area) and endosseous titanium implant
placed in the mandibular left first molar area (3.6), at presentation (a,e). Erythema, edema, large scaling, crusting, erosions with oozing on
the neck area, and adjacent right ear (b), neck and submandibular area (c), left and right inguinal region (d). Eight months after the removal
of mercury dental amalgam alloy crown, but with no medications, her signs and symptoms of allergic contact dermatitis completely
resolved (f,g,h), and did not recur. The arrow indicates intraoral mercury amalgam tattoo (measuring 2 x 2 millimeters) in peri-implant
mucosa around dental endosseous titanium implant (e).
Discussion
Adverse events in the skin are considered to be the most common amalgam-related clinical adverse reactions [5,13].
The possibility of acrodermatitis enteropathica was raised because of the symmetric scaly erythematous eruption on her
perineum, but was ruled out. We also excluded the possibility that there was an exposure to aspartame (formaldehyde-
releasing product), a food additive used in the diet, which may cause systemic dermatitis [14]. Our patient was exposed to
elemental mercury (Hg0) released from the mercury amalgam filling. The main route of exposure is by inhalation through the
lungs in which 80 percent of mercury vapor is absorbed and, in part, through ingestion of elemental mercury (Hg0) dissolved
in saliva [5].
Intra-oral wear and corrosion of dental alloy restorations produce a release of an extensive variety of metals and intraoral
metal ions, which are also contact sensitizers. These highly reactive metals are absorbed through the oral mucosa as well as
through the intestinal lumen. In patients who have a positive response (contact sensitivity) to metal allergens (e.g., mercury,
nickel, cobalt, chromium) that are administrated systemically (orally), generalized pruritus and skin eruption may occur.
Nickel, cobalt, palladium, mercury, silver, and gold are contained in mercury amalgam tooth fillings and may create a possible
risk of developing allergic reactions to metals.
In our experience, after removal of the inciting metal antigens (mercury or nickel), systemic allergic contact dermatitis
resolves within 12 months. Mercury amalgam filling is a well-known contact allergen of local and systemic allergic contact
dermatitis. Usually, mercury amalgam-related contact eczematous dermatitis is caused by delayed-type hypersensitivity
reaction (DTH)/type IV reactions to metals contained in the mercury dental amalgam (i.e.,: mercury, nickel, cobalt,
palladium), according to the Gell and Coombs classification [13,15].
There have been reports of skin disorders associated with exposure to mercury in dental amalgam fillings such as amalgam
dermatitis [2,16-18], baboon syndrome [5,19,20], cheilitis [6,11,13], contact eczematous dermatitis [2-4,7,13,18,20,21],
contact orofacial granulomatosis [5,7], cutaneous and oral lichen planus [5,7,21], dermatitis [3,4,6,7,18], dermographism [5],
edema [18], eczema [3,4,18], erysipelas-like mercury exanthema [22], erythema-multiforme (minor)-like eruption [18,22],
exudative facial dermatitis [17], Grover disease (transient acantholytic dermatosis [23], herpes simplex infection (cold sores)
[24], hyperpigmentation [23], Kawasaki disease (Mucocutaneous Lymph Node Syndrome) [19], lichenoid contact stomatitis
[5,7], mercury amalgam tattoo [19], mercury exanthema [5,16,25], nummular dermatitis (discoid eczema) [5,21], palmo-
plantar pustolosis [23], perioral dermatitis [11], pruritus [2,6], salmon and/or pink exanthema [5,19], scleroderma [26],
systemic allergic contact dermatitis [6,7,20], and urticaria/angioedema[3-7,18].
Adverse events associated with endosseous (titanium) dental implants are yellow nail syndrome [27], facial eczema [1,21],
skin rashes [15,18,25,28], local and peripheral neuropathy [27], burning mouth syndrome (BMS) [11], leukopenia, and
exfoliative cheilitis [11]. Even in this case, it seems highly likely that allergy to chromium could have increased the cutaneous
adverse events caused by either hypersensitivity to dental amalgam alloy and exposure to elemental mercury (Hg0) as
described previously [5]. A number of observations support this hypothesis [5]. In addition, systemic allergic contact
dermatitis has been reported with epidermal hypersensitivity to metals contained in mercury amalgam tooth fillings and the
patients seldom present with oral mucosa involvement [17]. The prevalence of allergy to mercury-containing dental amalgam
is reported to range from 1.4 to 16.5 percent [29].
In our ongoing investigation of 520 case series [11], we have found that the prevalence of systemic contact dermatitis in adult
patients with adverse health effects associated with mercury-containing dental amalgam was 3.5 percent (18 of 520 patients):
95 percent confidence interval, 2.0 – 5.0.
The clinical and biologic relevance of patch testing with dental metal allergens was clear, linking the causative relation
between exposure to dental metal allergens and systemic allergic contact dermatitis in our case. Dermatologists should
consider the possibility of an allergy to metal ions released from dissimilar dental alloy restorations in patients with systemic
allergic contact dermatitis.
Table 1. Patch-Test Allergens Used and Allergic Reactions to Mercury Amalgam Metal-Matrix Alloy of Proven Relevance in
a Patient with Systemic (allergic) Contact Dermatitis (concentrations refer to petrolatum).
Allergen
Concentration
(%) Result
1.
Methyl methacrylate (MMA)
2%
-
2.
Triethyleneglycol dimethacrylate (TREGDMA)
2%
-
3.
Urethane dimethacrylate (UEDMA)
2%
-
4.
Ethyleneglucol dimethacrylate (EGDMA)
2%
-
5.
BIS-GMA
2%
-
Table 2. Skin disorders associated with exposure to mercury-containing dental amalgam fillings.
Skin disorders associated with exposure to mercury-containing dental amalgam fillings
Amalgam dermatitis [2,16-18]
Baboon syndrome [5,19,20]
Cheilitis [6,11,13]
Contact eczematous dermatitis [2-4,7,18,20,21]
6.
N,N-dimethyl-4-toluidine
5%
-
7.
2-Hydroxy-4-methoxy-benzophenone
2%
-
8.
1,4-Butanediol dimethacrylate (BUDMA)
2%
-
9.
BIS-MA
2%
-
10.
Potassium dichromate
0.5%
+++
11.
Cobalt chloride
1%
-
12.
2-Hydroxyethyl methacrylate (2-HEMA)
2%
-
13.
Gold sodium thiosulfate
0.5%
++
14.
Nickel sulfate
5%
+++
15.
Eugenol
2%
-
16.
Colophony
20%
-
17.
N-ethyl-4-toluene sulfonamide
0.1%
-
18.
4-tolyldiethanolamine
2%
-
19.
Copper sulfate
2%
-
20.
Methyl hydroquinone
1%
-
21.
Palladium chloride
2%
-
22.
Aluminum chloride hexahydrate
2%
-
23.
Camphoroquinone
1%
-
24.
N,N-Dimethylaminoethyl methacrylate
2%
-
25.
1,6-Hexanediol diacrylate (HDDA)
0.1%
-
26.
2(2-Hydroxy-5-methylphenyl) benzotriazol
1%
-
27.
Tetrahydrofurfuryl methacrylate
2%
-
28.
Formaldehyde
1%
-
29.
Mercury Ammonium Chloride
1%
-
30.
Mercury (metallic)
0.5%
-
31.
Mercury dental amalgam
20%
-
Contact orofacial granulomatosis [5,7]
Cutaneous and oral lichen planus [5,7,21]
Dermatitis [3,4,6,7,18]
Dermographism [5]
Edema [18]
Eczema [3,4,18]
Erysipelas-like mercury exanthema [22]
Erythema-multiforme (minor)-like eruption [18,22]
Exudative facial dermatitis [17]
Grover’s disease (transient acantholytic dermatosis) [23]
Herpes simplex virus infection (cold sores),[24]
Hyperpigmentation [23]
Kawasaki disease (Mucocutaneous Lymph Node Syndrome) [19]
Lichenoid contact stomatitis [5,7]
Mercury amalgam tattoo [19]
Mercury exanthema [5,16,25]
Nummular dermatitis (discoid eczema) [5,21]
Palmo-plantar pustolosis [23]
Perioral dermatitis [11]
Pruritus (neurogenic), itching [2,6,18]
Salmon and/or pink exanthema [5,19]
Scleroderma [26]
Systemic allergic contact dermatitis [6,7,20]
Urticaria/angioedema [3-7,18]
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... [7,8] Once these cells are sensitized, they return to the skin, ready to act on target cells when the individual is exposed to the allergen either by oral or systemic routes, leading to cutaneous manifestations. [2,7,9] Common routes of exposure include oral, intramuscular, intravenous, inhalation, and subcutaneous. While SCD has been described as a type IV delayed-type hypersensitivity, SCD may also involve a type III immune response, as antigen-antibody complexes have been found in the skin and the blood in such reactions. ...
... Pigatto et al [9] reported 1 case of SCD following oral surgical implantation of titanium on the maxillary bone. Similarly, Darlenski et al [3] also reported 2 cases of SCD following implantation of a metal stabilizing device for foot bone and metacarpal bone fractures. ...
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Allergic disease represents one of the most prominent global public health crises of the 21st century. Although many different substances are known to produce hypersensitivity responses, metals constitute one of the major classes of allergens responsible for a disproportionately large segment of the total burden of disease associated with allergy. Some of the most prevalent forms of metal allergy – including allergic contact dermatitis – are well-recognized; however, to our knowledge, a comprehensive review of the many unique disease variants implicated in human cases of metal allergy is not available within the current scientific literature. Consequently, the main goal in composing this review was to (1) generate an up-to-date reference document containing this information to assist in the efforts of lab researchers, clinicians, regulatory toxicologists, industrial hygienists, and other scientists concerned with metal allergy and (2) identify knowledge gaps related to disease. Accordingly, an extensive review of the scientific literature was performed – from which, hundreds of publications describing cases of metal-specific allergic responses in human patients were identified, collected, and analyzed. The information obtained from these articles was then used to compile an exhaustive list of distinctive dermal/ocular, respiratory, gastrointestinal, and systemic hypersensitivity responses associated with metal allergy. Each of these disease variants is discussed briefly within this review, wherein specific metals implicated in each response type are identified, underlying immunological mechanisms are summarized, and major clinical presentations of each reaction are described. Abbreviations: ACD: allergic contact dermatitis, AHR: airway hyperreactivity, ASIA: autoimmune/ autoinflammatory syndrome induced by adjuvants, BAL: bronchoalveolar lavage, CBD: chronic beryllium disease, CTCL: cutaneous T-cell lymphoma, CTL: cytotoxic T-Lymphocyte, DRESS: drug reaction with eosinophilia and systemic symptoms, GERD: gastro-esophageal reflux disease, GI: gastrointestinal, GIP: giant cell interstitial pneumonia, GM-CSF: granulocyte macrophage-colony stimulating factor, HMLD: hard metal lung disease, HMW: high molecular weight, IBS: irritable bowel syndrome, Ig: immunoglobulin, IL: interleukin, LMW: low molecular weight, PAP: pulmonary alveolar proteinosis, PPE: personal protective equipment, PRR: pathogen recognition receptor, SLE: systemic lupus erythematosus, SNAS: systemic nickel allergy syndrome, Th: helper T-cell, UC: ulcerative colitis, UV: ultraviolet.
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Contact dermatitis (CD) is among the most common inflammatory dermatological conditions and includes allergic CD, photoallergic CD, irritant CD, photoirritant CD (also called phototoxic CD) and protein CD. Occupational CD can be of any type and is the most prevalent occupational skin disease. Each CD type is characterized by different immunological mechanisms and/or requisite exposures. Clinical manifestations of CD vary widely and multiple subtypes may occur simultaneously. The diagnosis relies on clinical presentation, thorough exposure assessment and evaluation with techniques such as patch testing and skin-prick testing. Management is based on patient education, avoidance strategies of specific substances, and topical treatments; in severe or recalcitrant cases, which can negatively affect the quality of life of patients, systemic medications may be needed. Contact dermatitis results from the exposure to exogenous allergens or irritants that stimulate immune responses leading to inflammation of the skin.
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Twenty substances among the most common allergens are reported. For each one of them, the general characteristics, sources of exposure, clinical presentation, and specific prevention rules are detailed. Special recommandations concerning the percentages of use and other useful data for patch tests are in addition discussed.
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The term systemic contact dermatitis is used to describe dermatitis in persons with contact sensitivity who are exposed to the hapten orally, rectally, transcutaneously, or intravenously or by inhalation. Well-known examples are eczematous eruptions seen after medicaments which have been administered to persons with contact sensitivity to the specific medicament. Other causes include the ingestion of the metals mercury, nickel, cobalt, and dichromate and plant allergens such as sesquiterpene lactones. Typical clinical features are flare-up reactions of previous dermatitis or previously positive patch test sites, widespread dermatitis, vesicular palmar, and/or plantar dermatitis and flexural dermatitis. Systemic contact dermatitis is rare compared with other types of contact dermatitis.
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Mercury allergy is a clinically relevant condition because it underlies both oral and/or systemic disease caused by a type IV hypersensitivity. Humans are exposed to mercury from mercury-containing dental amalgam filling, fish consumption, and vaccines. There are no safe levels of mercury exposure in humans, and hypersensitivity to mercury, the patient’s clinical condition, and the severity of disease are not related to the dose. Skin patch testing and lymphocyte transformation testing (LTT) are useful to confirm or rule out the presence of mercury hypersensitivity. Avoidance of elemental and inorganic mercury (mercury-based dental amalgam) and organic mercury (fish and seafood) is the first-line treatment for allergy to mercury.
Article
Background/objectives: Distinguishing between oral lichen planus (LP) and lichenoid reactions to dental restorations can be impossible on clinical and histopathological grounds. Epicutaneous patch testing is an investigation that may guide patients and physicians in making timely and costly decisions to replace or cover existing dental restorations. This study aimed to assess the role of epicutaneous patch testing with a battery of dental allergens in patients with undifferentiated oral LP. Methods: A retrospective review of the medical records of patients with biopsy-proven oral LP referred by an oral medicine specialist and who presented for dental epicutaneous patch testing at a dermatology clinic in Perth, Western Australia between 2009 and 2016 was performed. Results: In total, 68 patients were included, of whom 54 (79%) had positive patch tests. Gold 26 (48%), mercury 24 (44%), nickel 22 (41%), copper 19 (35%), potassium dichromate 14 (26%) and methylhydroquinone 13 (24%) were the most common allergens for which patients tested positive. Hypothyroidism and non-steroidal anti-inflammatory drugs were associated with negative patch tests (P = 0.01 and 0.04, respectively). Smoking history, other medications and comorbidities, the location of the dental restorations and unilateral or bilateral disease were not significantly associated with the patch test results. Restorations were removed in 23 patients: 21 of these (91%) had positive epicutaneous patch tests. Of the 20 patients followed up, 19 (95%) experienced some improvement, among whom 11 (58%) had complete remission. Conclusion: Epicutaneous patch testing disclosed a high proportion of relevant positives. This guided the clinical decision to change dental restorations, with high rate of clinical improvement.
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Exfoliative cheilitis is an uncommon chronic inflammatory condition that generally affects the vermilion of the lips. Its cause is still largely unknown an there is no effective treatment. Here we report of a case of exfoliative cheilitis possibly caused by mercury-containing dental amalgam in close proximity to dental titanium implant in a 41-year-old woman. By patch-testing, she was tested positive to thimerosal, palladium, gold, nickel, and copper. There was a strong temporal relation between last titanium dental implant and the onset of exfoliative cheilitis. Clinicians should be aware that exfoliative cheilitis might be associated with an allergy to intraoral dental metals and that titanium dental implant should not be implanted in the vicinity of the mercury-containing dental amalgam filling, even in presence of mercury amalgam as rootend filling material.
Article
Chronic mercury poisoning is becoming a health concern because of extensive pollution of water and fish, and the increasing consumption of fish in the human diet. Mercury is extremely toxic to the body, especially the central nervous system, but diagnosis is difficult because of the lack of specific signs. A total of 11 patients were observed to have a nonpruritic or mildly pruritic discreet papular and papulovesicular eruption that correlated with high blood mercury levels. The mercury evidently came from increased seafood consumption. All of the patients improved when they were placed on either a seafood-free diet or chelation therapy. Physicians should suspect mercury poisoning in patients who eat a high-seafood diet who present with an asymptomatic or mildly pruritic papular or papulovesicular eruption.
Article
Chronic mercury poisoning is becoming a health concern because of extensive pollution of water and fish, and the increasing consumption of fish in the human diet. Mercury is extremely toxic to the body, especially the central nervous system, but diagnosis is difficult because of the lack of specific signs. A total of 11 patients were observed to have a nonpruritic or mildly pruritic discreet papular and papulovesicular eruption that correlated with high blood mercury levels. The mercury evidently came from increased seafood consumption. All of the patients improved when they were placed on either a seafood-free diet or chelation therapy. Physicians should suspect mercury poisoning in patients who eat a high-seafood diet who present with an asymptomatic or mildly pruritic papular or papulovesicular eruption.
Article
Hypersensitivity to the constituents of dental amalgam is uncommon. When it occurs it typically manifests itself as a lichenoid reaction involving a delayed, type IV, cell-mediated hypersensitivity response. Rarely, a more acute and generalised response can occur involving both the oral mucosa and skin. We describe two cases that illustrate the presentation and management of these two types of reaction.
Article
We experienced 15 patients with generalized rash, mostly appearing a day or two after breaking a clinical thermometer or during dental treatment. Similar skin manifestations were revealed, suggestive at first glance of mercury exanthem, i.e. diffuse symmetrical erythema predominantly on major fluxural areas. An inverted triangular or V-shaped erythema on both upper antero-medial thighs was a common feature. Severe cases had miliary pustules and/or purpura on erythematous skin. Pruritus or burning sensation was relatively mild. Pyrexia or malaise was a complaint of more than half the patients. Most of the patients had a previous history of contact dermatitis to Mercurochrome, and by patch-testing were found to have contact allergy to several mercurials, especially inorganic ones. Until recently, Mercurochrome had been most widely used as a topical disinfectant in Japan. This seems to be a possible cause of the high incidence of contact allergy to mercurials in this country. From our findings we feel that our patients had developed systemic contact dermatitis due to inhalation of mercury vapor.
Article
A metal worker had repeated episodes of contact dermatitis over a period of years. Patch tests with 5% ammoniated mercury were strongly positive but occupational contact could not be proved. Recurrence of the dermatitis one day after amalgam dental fillings had been made and again one year later, this time without new fillings, raised the possibility that it was due to the old amalgam fillings. Removal of all the amalgam fillings resulted in a new outbreak of severe dermatitis; during the 5 years ensuing there has been no recurrence. This case history suggests that contact dermatitis may be caused by not only the mercury in new fillings but also by that in old fillings.
Article
Background: Dental products contain many allergens, and may cause problems both for patients undergoing dental treatment and for dental personnel because of occupational exposure. Individual patch test clinics may not study sufficient numbers of patients to collect reliable data on uncommon allergens. Objective: To collect information on dental allergens based on a multicenter study. Materials and Methods: The Finnish Contact Dermatitis Group tested more than 4,000 patients (for most allergens, 2,300 to 2,600 patients) with dental screening series. Conventional patch testing was performed. The total number and percentage of irritant (scored as irritant [IR] or doubtful [?]) and allergic (scored as +, ++, or +++) patch test reactions, respectively, were calculated, as well as the highest and lowest percentage of allergic patch test reactions recorded by the different patch test clinics. A reaction index (RI) was calculated, giving information on the irritancy of the patch test substances. Results: The most frequent allergic patch test reactions were caused by nickel (14.6%), ammoniated mercury (13%), mercury (10.3%), gold (7.7%), benzoic acid (4.3%), palladium (4.2%) and cobalt (4.1%). 2-hydroxyethyl methacrylate (2.8%) provoked most of the reactions caused by (meth)acrylates. Menthol, peppermint oil, ammonium tetrachloroplatinate, and amalgam alloying metals provoked no (neither allergic nor irritant) patch test reactions. Conclusion: Patch testing with allergens in the dental screening series, including (meth)acrylates and mercury, needs to be performed to detect contact allergy to dental products.
Article
Yellow nail syndrome is characterized by nail changes, respiratory disorders, and lymphedema. In a yellow nail patient with a skeletal titanium implant and with gold in her teeth, we found high levels of titanium in nail clippings. This study aims to examine the possible role of titanium in the genesis of the yellow nail syndrome. Nail clippings from patients with one or more features of the yellow nail syndrome were analyzed by energy dispersive X-ray fluorescence. Titanium was regularly found in finger nails in patients but not in control subjects. Visible nail changes were present in only half of the patients. Sinusitis with postnasal drip and cough was the most common complaint. The dominant source of titanium ions was titanium implants in the teeth or elsewhere. The titanium ions were released through the galvanic action of dental gold or amalgam or through the oxidative action of fluorides. In other patients the titanium was derived from titanium dioxide in drugs and confectionary. Stopping galvanic release of titanium ions or canceling exposure to titanium dioxide led to recovery. In one patient with a titanium implant, the symptoms recurred after renewed exposure to titanium. Yellow nail syndrome is caused by titanium.