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Allergic contact stomatitis



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Allergic Contact Stomatitis
Arash Akhavan, Khalid Alghaithi, Morgan Rabach,
Nina Mirchandani, and Steven R. Cohen
Case Report
A65-year-old women presented for evaluation of painful
mouth lesions 8 days after the repair of a dental bridge.
She had been instructed to apply a local anesthetic, Orabase
paste with benzocaine 20% (Colgate-Palmolive, New York,
NY), to the painful upper and lower gingivae for relief
of discomfort immediately following the dental procedure.
On the morning of the fifth day of applying Orabase
paste, painful blisters developed on the right side of the
mouth. A trial of oral prednisone (40 mg per day for 3 days)
was initiated by her internist; however, the painful uni-
lateral mouth blisters persisted. When she was referred to
one of the authors (S.R.C.), the physical examination re-
vealed blisters and erosions on the right buccal mucosa
(Fig 1) and right lingual mucosa (Fig 2). The lesions were
tender to palpation. No other signs or symptoms of disease
were identified. A suspected diagnosis of contact stomatitis
prompted the withdrawal of the topical anesthetic. The pain
subsided, and all erosions reepithelialized within 72 hours.
Subsequently, patch testing was carried out with a broad
range of chemicals, including chemical allergens of the
European Standard series; dental, preservative, medica-
ment, fragrance, and miscellaneous allergens (from Chemo-
technique Diagnostics, Malmo¨, Sweden); and commercial
Orabase Paste. Patch tests used Finn Chambers (Epitest Ltd
Oy, Tuusula, Finland) under occlusion for 48 hours. The
patches were removed and evaluated at 48 and 96 hours,
according to the following interpretation scheme: nega-
tive () or doubtful reaction (macular erythema of the
contact area), weak (+) reaction (erythema, edema, and
possible papules), strong (++) reaction (erythema, edema,
papules, and vesicles [< 50% of contact area]), and extreme
(+++) reaction (intense erythema and bullae or ulceration
[> 50% of contact area]). At the reading at 48 hours, there
was a + reaction to benzocaine 5% in petrolatum (pet) and
a ++ reaction to Orabase paste (Figs 3 and 4). At 96 hours,
strong reactions to both Orabase paste (+++) and benzo-
caine 5% pet (++) were evident. Positive reactions were
also seen at the sites of nickel sulfate (++) and bacitracin
(++). Allergic contact stomatitis from the benzocaine-
containing Orabase paste was considered the cause of the
painful oral blisters because the condition resolved when
use of the product was discontinued. The dental appliance
was never removed.
What Is Your Diagnosis?
From the Department of Dermatology, Mount Sinai School of Medicine,
New York, NY, and the Department of Medicine/Dermatology, Albert
Einstein College of Medicine, New York, NY.
Address reprint requests to Steven R. Cohen, MD, Department of Medicine/
Dermatology, Albert Einstein College of Medicine, 111 East 210th Street,
Bronx, NY 10467-2490. E-mail:
DOI 10.2310/6620.2006.05063
Figure 1. Buccal and lingual mucosa with blisters.
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Contact Puzzle features brief case reports that illustrate
dramatic and/or unusual examples of contact derma-
titis. Submitted manuscripts should be a maximum
of six pages printed in 12-point font, double spaced.
Format includes Case Report, Diagnosis, Discussion,
and References (six or less). A color photograph(s) of
the clinical problem is required; color photograph(s)
of patch-test results or ancillary test is optional.
Dermatitis, Vol 17, No 2 (June), 2006: pp 88–9088
Allergic contact stomatitis from benzocaine in Orabase
Despite being a well-recognized sensitizer, benzocaine
remains one of the most effective topical anesthetics for
painful disorders of the skin and mucous membranes. A
common medicament, benzocaine is formulated in nu-
merous over-the-counter oral products for pain relief
(Table 1). Allergic contact dermatitis from benzocaine is
well described in the literature.
Marked inflammation
and blisters of the mucosa are characteristic manifestations.
Positive patch-test reactions attributed to benzocaine in
North America from 1994 to 2000 range from 1.7 to 2.6%.
We describe a case of allergic contact stomatitis from
benzocaine in Orabase paste. Our patient presented with
unilateral mucosal pain associated with blisters that ap-
peared 5 days after she started using a commercial anes-
thetic paste containing benzocaine. Withdrawal of the
Figure 3. Benzocaine patch test showing a positive (+) result at
48 hours.
Figure 4. Patch test with Orabase paste, showing a positive (++)
result at 48 hours.
Figure 2. Allergic Contact Stomatitis.
Table 1. Commercially Available Oral Topical Medicaments Con-
taining Benzocaine
3 in 1 Toothache Relief (C.S. Dent, Erlanger, KY)
Adult Oral Pain Relief, Topical Gel, 20% (Sheffield
Laboratories, New London, CT)
Anbesol Oral Gel/Liquid (Whitehall-Robbins Healthcare,
Madison, NJ)
Babee Teething Lotion (Pfeiffer, Wilkes Barre, PA)
Baby Gumz (Lee Pharmaceuticals, South El Monte, CA)
Baby Orajel (Del Pharmaceuticals, Uniondale, NY)
Benzodent (Procter & Gamble, Cincinnati, OH)
Dentapaine Buccal Gel (Reese Pharmaceutical)
Dentemp’s Oral Pain Relief Topical Swab (Majestic Drug,
South Fallsburg, NY)
Dent’s Extra Strength Toothache (C.S. Dent)
Double-Action Toothache Kit (C.S. Dent)
Hurricaine (Beutlich, Waukegan, IL)
Little Teethers Oral Pain Relief Gel (Prestige Brands,
Irvington, NY)
Numzident (Block Drugs, Jersey City, NJ)
Orabase, paste and gel (Colgate-Palmolive, New York, NY)
Orafix Medicated (GlaxoSmithKline Consumer, Research
Triangle Park, NC)
Orajel (Del Pharmaceuticals)
Orasept (Pharmakon Labs, Tampa, FL)
Orasol (Clay-Park Labs, Bronx, NY)
Oratect (MGI Pharma, Bloomington, MN)
Otrathol Oral Liquid (multiingredient) (GlaxoSmithKline
Red Cross Canker Sore Medication (Mentholatum, Scoresby,
Victoria, Australia)
Sensogard Gel/Solution (Block Drugs)
Tanac Lipstick/Liquid (Del Pharmaceuticals)
Teething Gel For Babies (Sheffield Laboratories)
Toothache Topical Liquid (Clay-Park Labs, Bronx, NY)
Toothache Gel (Roberts Pharmaceutical, Eaton, NJ)
Zilactin-B Oral Gel (Zila Pharmaceuticals, Phoenix, AZ)
Allergic Contact Stomatitis 89
product resulted in prompt resolution of disease symptoms
and signs. Patch testing revealed strong allergic reactions at
the sites of both benzocaine 5% pet and commercial
Orabase paste, which contained benzocaine 20% in a plas-
ticized hydrocarbon gel with cellulose gum, pectin, xanthan
gum, and unspecified flavorings and preservatives. Testing
with the components of Orabase paste (other than benzo-
caine) was not performed.
Notwithstanding the relatively low overall frequency
of benzocaine allergy
and the rare occurrence of oral sen-
sitivity to the agent, our case illustrates the importance of
maintaining a high index of suspicion for allergic con-
tact dermatitis and allergic contact stomatitis whenever
benzocaine-containing products are used to treat mucosal
or cutaneous pain.
To our knowledge, there has been only one previously
reported case of oral contact allergy to benzocaine.
In that
instance, a 39-year-old man developed blisters and edema
of the oral mucosa after the application of a benzocaine gel.
Here we report, for the first time, a case of allergic contact
stomatitis from Orabase paste with benzocaine 20%.
1. Roos TC, Merk HF. Allergic contact dermatitis from benzocaine
ointment during treatment of herpes zoster. Contact Dermatitis
2. Placucci F, Lorenzi S, La Placa M, Vincenzi C. Sensitization to
benzocaine on a condom. Contact Dermatitis 1996;34:293.
3. Pratt MD, Belsito DV, DeLeo VA, et al. North American Contact
Dermatitis Group patch–test results, 2001-2002 study period
[published erratum appears in Dermatitis 2005;16:106]. Dermati-
tis 2004;15:176–83.
4. Sidhu SK, Shaw S, Wilkinson JD. A 10-year retrospective study on
benzocaine allergy in the United Kingdom. Am J Contact Dermat
5. Ryan ME, Davis BM, Marks JG Jr. Contact urticaria and allergic
contact dermatitis to benzocaine gel. J Am Acad Dermatol 1980;
90 Akhavan et al
... Alergiczne kontaktowe zapalenie skóry jest najczêstszym, jednak nie jedynym, objawem narz¹dowym alergii kontaktowej. Alergia kontaktowa mo¿e tak¿e objawiaae siê powstawaniem zmian chorobowych w obrêbie jamy ustnej (allergic contact stomatitis) [3,4], spojówek (allergic contact conjunctivitis) [5,6], pochwy (allergic vaginitis) [7,8], a ponadto mo¿e objawiaae siê w formie reakcji ogólnoustrojowych [9,10]. Alergi¹ kontaktow¹ wyjania siê niektóre przypadki odrzucania implantów ortopedycznych [11,12] i stomatologicznych [12], rozruszników serca [14,15] oraz stentów naczyniowych [16]. ...
Full-text available
The term "contact allergy" is somewhat problematic. Most textbooks and medical (both Polish and foreign-language) dictionaries do not define this term, or consider it synonymous with allergic contact dermatitis (ACD). However, putting equation mark between these terms is not justified: The term "contact allergy" denotes hypersensitivity as the state of altered immune response, whereas the second term describes symptoms of this hypersensitivity in the target organ (the skin). Contact allergy affects 40% adults and 20-30% children and adolescents, whereas the lifetime prevalence of ACD is around 10%. The golden standard in the diagnosis of contact allergy is patch test (epicutaneous test). Using patch tests increases the probability of accurate ACD diagnosis, makes the time to final diagnosis over 20-fold shorter, reduces the cost of treatment and increases chances for achieving complete remission, thus improves patients' quality of life. In the treatment of ACD, in addition to allergen avoidance, corticosteroids and phototherapy are well-established therapeutic modalities. At present, tacrolimus is being implemented into ACD treatment.
Oral mucosal ulceration is a common clinical complaint. Ulceration is often debilitating and affects patients from a wide age group. The clinician confronted with such a patient often feels overwhelmed by the different diagnostic possibilities. Given the wide spectrum of conditions encountered, it is striking that the common use of antibiotics and antifungals to treat oral ulceration, is largely inappropriate. This overview provides general dental practitioners (GDP's) and other general healthcare workers with a broad classification of commonly encountered mucosal ulcerative lesions, a practical approach to reach a diagnosis and basic treatment strategies for each condition.
Full-text available
The aim of the present paper is to review the existing knowledge on the current strategies in food allergy management and propose an integrated approach to management of food allergy and intolerance. Such approach should consist of Standard Operating Procedure (SOPs) addressed to health professionals, food industry and educators, and Dietary Behaviour Principles (DBPs) addressed to different groups of consumers, e.g. breastfeeding mothers, parents and carers of young children. The paper proposes a baseline for this formulation. However, more research is still needed on food allergies, particularly as regards food haptens (small molecular-weight components with sensitizing properties) as opposed to widely-known allergens. KEYWORDS: Food allergy and intolerance; Haptens; Standard Operating Procedures (SOPs); Dietary Behaviour Principles (DBPs).
Full-text available
Contact allergy (CA) is alteration of immune response with readiness to develop an inflammatory reaction against specific substances of low molecular weight (hapten). The prevalence of CA is estimated at 26-40% among adults, and 21-36% children. A proportion of people with CA will remain asymptomatic, among the rest, the most frequent clinical manifestation is allergic contact dermatitis (ACD) with lifetime prevalence estimated at 10%. Less frequent manifestations include allergic contact stomatitis, conjunctivitis, vaginitis, systemic reactions, implant intolerance, and rarely urticaria, asthma, and allergic rhinitis. Patch test (epicutaneous test) is the gold standard in the diagnosis of CA and ACD: Performing the test significantly increases probability of accurate diagnosis, reduces costs of treatment, and leads to improved patients' quality of life. Patch test results may be influenced by patient's medication and health status, and interpretation requires due knowledge and experience. Other diagnostic methods are more laborious and not validated; no in vitro tests are available for routine application at present.
A deterioration in chronic inflammatory ear disease despite topical medication, or failure of the condition to improve with such treatment, should raise the possibility of allergic contact dermatitis. Allergen testing (patch testing) is the ‘gold standard’ method of identifying an agent causing allergic contact dermatitis. We describe an ENT patch test series applied by our department as a screening device for this condition.
A 39-year-ole man developed edema and vesiculation of the oral mucosa following the application of benzocaine (Hurricaine) gel. Open testing demonstrated an immediate urticarial reaction. Closed patch tests were positive after 48 hours. The contact dermatitis was consistent with a delayed-type hypersensitivity. It appears, however, that a nonimmunologic mechanism caused the contact urticaria since passive transfer was negative.
Benzocaine has been labeled a notorious sensitizer. It is thought to be a common and potent sensitizer. It is suggested that such patients should routinely avoid tetracaine and procaine, as cross-reactions between benzocaine and such caines occurred commonly. Benzocaine also currently remains the screening chemical on the European Standard Battery (ESB) for topical caine allergy. To identify the rate of incidence of benzocaine allergy in the United Kingdom, and the level of cross reactivity between other caines in the ESB. Methods: The results from a 10-year retrospective study of 5,464 patients, subjected to patch testing with a modified ESB, which included caine mix III (Chemotechnique Diagnostics, Tygelsjo, Sweden), and the results of caine mix IV (Chemotechnique) reactions in 265 of these patients who complained of anogenital symptoms, are discussed. Majority of allergic reactions occurred with the constituents of caine mix III, with benzocaine reactions being the least common allergen in this group. Cross reactivity between benzocaine and other caines, occurred infrequently. Our data indicate that benzocaine allergy is not common in the United Kingdom. As cross-reactivity between benzocaine and other caines did not occur commonly, a significant number of relevant allergic reactions to other caines may go undetected, as benzocaine remains the screening chemical for topical anaesthetic allergy on the ESB. We suggest benzocaine be removed from the ESB, and be replaced by caine mix III.
Bcakground: Patch testing is the most worthwhile diagnostic tool for the evaluation of patients with suspected allergic contact dermatitis. Objective: This study reports patch-testing results from July 1, 1998, to December 31, 2000, by the North American Contact Dermatitis Group. Methods: Patients were tested with the same screening series of allergens, using a standardized patch-testing technique. The data from these patients were recorded on a standard computer entry form and analyzed. Results: Fifty allergens were tested on over 5,800 patients. Amidoamine, benzophenone-3, and iodopropynyl butylcarbamate were the new allergens. The top 10 allergens in frequency of positive reactions were identical to those of our 1996-to 1998-study period. The incidence of allergic nickel reactions continues to go up, leading all the test substances by 16.2%. Conclusion: Our findings reinforce the need for a more comprehensive group of diagnostic allergens than is found in the T.R.U.E. TEST, which is sold in the United States.
Keywords:allergic contact dermatitis;local anaesthetics;benzocaine;herpes zoster;medicaments
Allergic contact dermatitis is a significant cause of cutaneous disease affecting many individuals in the home and at the workplace. Patch testing is the most worthwhile diagnostic tool for the evaluation of patients with suspected allergic contact dermatitis. This study reports the results of patch testing from January 1, 2001, to December 31, 2002, by the North American Contact Dermatitis Group (NACDG). Patients were tested with an extended screening series of 65 allergens. A standardized patch-testing technique was used. Data from these patients were recorded on a standardized computer entry form and analyzed. Sixty-five allergens were tested on 4,913 patients. The top 10 allergens remain the same in this study period as in the 1999-2000 study period: nickel sulfate (16.7%), neomycin (11.6%), Myroxilon pereirae (balsam of Peru) (11.6%), fragrance mix (10.4%), thimerosal (10.2%), sodium gold thiosulfate (10.2%), quaternium-15 (9.3%), formaldehyde (8.4%), bacitracin (7.9%), and cobalt chloride (7.4%). Of the 4,913 patients tested, 69% had at least one positive allergic patch-test reaction. Of all patients, 15.8% had occupation-related dermatitis; 15.4% were determined to have irritant contact dermatitis, and 11.1% of the 15.4% had a relevant reaction to an occupational irritant. Of all patients tested, 16.7% had a relevant reaction to an allergen not in the NACDG standard series, and 5.5% had a relevant reaction to an occupational allergen not in the standard series. Our findings once again reinforce the need for a more comprehensive group of diagnostic allergens than those found in the standard screening kits. The usefulness of patch testing is enhanced when a greater number of allergens are tested, especially nonstandard allergens occupationally encountered.
paste and gel (Colgate-Palmolive
  • Orabase
Orabase, paste and gel (Colgate-Palmolive, New York, NY) Orafix Medicated (GlaxoSmithKline Consumer, Research Triangle Park, NC)