Systemically induced contact dermatitis from dental rosin

Rosin is a ubiquitous contact sensitizer which may be present in dental materials such as periodontal dressings, impression materials, cements, and cavity varnishes. When a hypersensitive person is exposed to a sensitizer, allergic contact dermatitis/stomatitis may develop, most commonly after direct skin/mucosa contact with the sensitizer. However, widespread dermatitis may develop after systemic administration of the sensitizer, and this paper reports the case of a rosin-hypersensitive man who developed widespread eczematous dermatitis after dental treatment with a rosin-containing product.     

Allergic contact dermatitis associated with the use of facemask on a patient with a history of atopy

Allergic contact dermatitis (ACD) is a skin inflammation caused by an allergic reaction after contact with small external substances capable of being absorbed by the skin. There are several studies describing allergic reactions to intraoral orthodontic appliances, especially those containing nickel. Allergic reactions due to extraoral appliances are not as frequent, and there are relatively few studies about them. Extraoral eactions are attributed to metallic, elastic, or textile parts of the extraoral appliances. This article's purpose was to report the appearance of an allergic contact dermatitis reaction in a 9-year, 2-month-old female patient, with a history of atopic dermatitis, after an orthodontic facemask was fitted. Rapid maxillary expansion was also performed with a Hyrax appliance while a facemask was used. Early diagnosis of this pathology is essential in order to achieve a total regression of the reaction. Orthodontists should be aware that ACD can be caused by facemasks in predisposed patients.     

Atypical pattern of (meth)acrylate allergic contact dermatitis in dental professionals

(Meth)acrylates in dental bonding agents are a common source of allergic contact dermatitis in dental professionals. The distribution of the contact dermatitis is commonly on finger tips, but is determined by individual habits as demonstrated by the two case reports in this article. Despite the site of contact dermatitis, the bonding agents are often not suspected as a source of contact allergy due to misconception regarding the protective effect of natural rubber latex gloves. With these case reports, we endeavour to emphasize the inadequacy of the latex gloves in protecting against the (meth)acrylate induced contact allergy and also list the measures a dental professional needs to incorporate in order to minimise the risks of sensitisation to (meth)acrylates.     

Skin problems associated with routine wearing of protective gloves in dental practice

Guidelines on cross-infection control recommend the wearing of operating gloves by dental practitioners whilst carrying out routine examinations and treatment on all patients. However, there are a number of dermatological problems that may be associated with the routine wearing of protective gloves in dental practice. This paper describes the aetiology and clinical features of three types of contact dermatitis, ie irritant contact dermatitis, allergic contact dermatitis and contact urticaria. The management of these skin conditions is discussed. Advice is given concerning routine handcare for all dental practitioners.     

Contact dermatitis: clinics and pathology

Contact dermatitis or eczema is a polymorphic inflammation of the skin. It occurs at the site of contact with irritating or antigenic substances. In the acute phase there is occurrence of itching erythema, papules, and vesicles, whereas in the chronic phase there is dryness, hyperkeratosis, and sometimes fissures. Contact dermatitis can be divided into irritant and allergic types. Allergic contact dermatitis is a type-IV T-cellmediated reaction occurring in a sensitized individual after contact with the antigen/allergen. Such antigens are usually low molecular weight substances (MW ~500), called haptens; 3000 contact allergens are known. The diagnosis of contact allergy is made on the basis of the history, clinical findings, and a positive epicutaneous test result. Allergic, but not irritative, contact dermatitis can spread beyond the area of contact to other body parts. Eczematous lesions are characterized by a mononuclear infiltrate consisting mainly of T cells in the dermis and epidermis, together with an intercellular epidermal edema—that is, spongiosis. In allergic contact dermatitis, skin-applied antigen is taken up by epidermal Langerhans cells and transported with the afferent lymph to the regional lymph nodes. Here, naive T lymphocytes are sensitized to become antigen-specific effector T cells, which then leave the lymph node, enter the circulation, and are recruited to the skin by means of specific cell surface molecules, to form the infiltrates. Cytokines released by infiltrating T cells eventually cause keratinocyte apoptosis.     

Contact dermatitis: clinics and pathology.

Contact dermatitis or eczema is a polymorphic inflammation of the skin. It occurs at the site of contact with irritating or antigenic substances. In the acute phase there is occurrence of itching erythema, papules, and vesicles, whereas in the chronic phase there is dryness, hyperkeratosis, and sometimes fissures. Contact dermatitis can be divided into irritant and allergic types. Allergic contact dermatitis is a type-IV T-cell-mediated reaction occurring in a sensitized individual after contact with the antigen/allergen. Such antigens are usually low molecular weight substances (MW approximately 500), called haptens; 3000 contact allergens are known. The diagnosis of contact allergy is made on the basis of the history, clinical findings, and a positive epicutancous test result. Allergic, but not irritative, contact dermatitis can spread beyond the area of contact to other body parts. Eczematous lesions are characterized by a mononuclear infiltrate consisting mainly of T cells in the dermis and epidermis, together with an intercellular epidermal edema that is. spongiosis. In allergic contact dermatitis, skin-applied antigen is taken up by epidermal Langerhans cells and transported with the afferent lymph to the regional lymph nodes. Here, naive T lymphocytes are sensitized to become antigen-specific effector T cells, which then leave the lymph node, enter the circulation, and are recruited to the skin by means of specific cell surface molecules, to form the infiltrates. Cytokines released by infiltrating T cells eventually cause keratinocyte apoptosis.     

Latex glove allergy in dental practice

Skin reactions due to the use of latex examination gloves occur frequently in dental practice. They consist of immediate type I allergy to natural latex protein, type IV delayed hypersensitivity to rubber additives and irritant dermatitis. Type I allergy to latex protein can cause contact urticaria, angioedema, rhinoconjunctivitis and asthma in the dentist, the dental assistant and also in the patient. Exceptionally, latex allergy can cause a life-threatening anaphylactic reaction. Cross reactions to tropical fruit can occur in the latex allergic patient. Type IV allergy causes allergic contact dermatitis. Rubber additives are also present in synthetic rubber. Glove advice for latex allergic patients are presented.     

Occupation-related allergies in dentistry

BACKGROUND: Allergies to natural rubber latex (NRL) were unknown in dentistry until 1987. That changed with the publication of a report documenting NRL-based anaphylaxis in a dental worker. This case and others prompted regulatory and manufacturing changes in rubber products and increased awareness throughout the profession. However, other common dental chemicals cause allergic reactions and irritation and often are handled with insufficient precautions. Although recognition of NRL allergy has improved, awareness of other potential allergens and irritants in dentistry still is limited. OVERVIEW: Recent research indicates that the prevalence of NRL protein allergy may be decreasing. In contrast, occupation-related dermatoses associated with other dental products may be more common. Encounters with bonding agents, disinfectants, rubber, metals and detergents can cause occupation-based irritant contact dermatitis and allergic contact dermatitis. These conditions may be found in more than one-quarter of dental and medical personnel. Therefore, dental-specific information about the recognition and management of allergic and irritant reactions is needed. CONCLUSIONS AND CLINICAL IMPLICATIONS: The prevalence of occupation-related dermatitis may be increasing in dentistry. Reducing exposure to potential irritants and allergens and educating personnel about proper skin care are essential to reversing this trend.     

Contact allergy in and around the mouth

Contact allergic reactions in and around the mouth are not frequent, but they can have very unpleasant consequences. Discussed are the most important materials that can cause reactions in patients and dental personnel. Particulary the enormous increase in the use of latex gloves has caused a rise in latex allergy and contact dermatitis by rubber additives. Acrylates are also important contact sensitizers; they can cause the dentist serious trouble.     

Orthodontic headgear related to allergic contact dermatitis: a case report

A case is reported of a 13-year-old girl who developed a facial rash shortly after orthodontic headgear was fitted. Patch testing revealed that she was strongly allergic to nickel and also allergic to cobalt and chrome. A diagnosis of allergic contact dermatitis was made. Painting the metal buckle of the cervical strap with polyurethane paint prevented further development of her rash, while allowing her orthodontic treatment to progress.     

Contact allergy to Duraphat

Skin-sensitizing rosin is present in Duraphat, a fluoride varnish used all over the world. Two cases of hypersensitivity to Duraphat are presented: a dental nurse with dermatitis of the hand and a patient with allergic contact stomatitis.     

Allergic contact stomatitis from colophony

Colophony is an ubiquitous contact sensitizer which may be present in dental materials, such as periodontal dressings, impression materials, cements, fix adhesives and varnishes. Exposure to a sensitizer in a hypersensitive person may initiate an allergic contact dermatitis/stomatitis.This usually occurs after direct skin/mucosa contact with the sensitizer. This paper reports the case of a colophony hypersensitive male who developed contact stomatitis after dental treatment with a colophony-containing product. CLINICAL RELEVANCE: Sensitizing colophony is present in Duraphat 2.26%F varnish, a fluoride varnish used all over the world. A case of hypersensitivity to Duraphat 2.26%F varnish is presented in a patient who, at the initial visit, indicated only an allergy to sticking plasters.     

Management of dental patients with allergies to natural rubber latex

Reports of serious allergic reaction to natural rubber latex (NRL) are not uncommon in dentistry. The prevalence of Type I allergies in high-risk patient groups can range as high as 17% for health care professionals and over 50% in patients with spina bifida. A Type IV allergy to NRL chemical additives, also known as allergic contact dermatitis, is common in health care professions. To safeguard patients and coworkers, dentists must learn to recognize patients and workers at risk for NRL allergies, identify the associated symptoms, implement preventive measures, and encourage thorough diagnostics and management. This article reviews the latest advances in NRL allergies, particularly as they apply in dentistry.     

The prevalence of sensitivity to constituents of dental alloys

Ninety-five participants were epicutaneous patch tested in order to determine the prevalence of sensitivity to components of dental alloys. Seventeen individuals (17.9%) developed allergic reactions, which were caused by mercury (10.5%), copper (2.1%), nickel, cobalt, tin, gold and zinc (1.1%). Eight of 17 allergic responders had a history of dermatitis from metal contact. The results show that there is a need for careful immunological considerations during the selection of suitable alloys, particularly in the case of patients with lesions suspected of being caused by dental alloys.     

Allergic reactions to local anesthetics

In this article type I and type IV allergic reactions evoked by local anaesthetics are discussed. Contact dermatitis (type IV) reactions are mainly caused by local anaesthetics of the ester-type like procaine. Both contact dermatitis and anaphylactic reactions (type I) can be caused by anaesthetics of the amide-type (e.g. lidocaine), but these reactions are rare. Intra- and epicutaneous tests can be useful to prove allergy, but sometimes provocation tests are necessary. Many reactions are not caused by an allergic mechanism.     

Nickel allergy and orthodontics

Nickel is the most common metal to cause contact dermatitis in orthodontics. Nickel-containing metal alloys, such as nickel-titanium and stainless steel, are widely used in orthodontic appliances. Nickel-titanium alloys may have nickel content in excess of 50 per cent and can thus potentially release enough nickel in the oral environment to elicit manifestations of an allergic reaction. Stainless steel has a lower nickel content (8 per cent). However, because the nickel is bound in a crystal lattice it is not available to react. Stainless steel orthodontic components are therefore very unlikely to cause nickel hypersensitivity. This article discusses the diagnosis of nickel allergy in orthodontics and describes alternative products that are nickel free or have a very low nickel content, which would be appropriate to use in patients diagnosed with a nickel allergy.     

The necessity of a test reading after 1 week to detect late positive patch test reactions in patients with oral lichen lesions

Objectives

Establishing the clinical relevance of contact allergy to dental materials in patients with oral lichen lesions (OLL) may be difficult, and tests are often read only on day 3 or day 4; also, concentration of the tested allergens may vary. Several studies on dermatitis patients have shown that additional positive patch test reactions can be found after day 4. Therefore, the aim of the present study was to analyse the frequency of late positive reactions to potential allergens in patients with OLL.

Material and methods

Eighty-three of 96 consecutive patients with biopsy-verified OLL were patch-tested with a recently developed lichen series. The patches were removed after 48 h and reactions read 3 and 7 days after application.

Results

A total of 129 contact allergies were found, and 26 (20.2 %) of the allergic reactions in 23 patients were seen on day 7 only. The 25.2 % increase in positive test reactions with an additional reading on day 7 in addition to day 3 was statistically significant. Metals were the substances with the highest frequency of late positive reactions.

Conclusions

Patients with OLL cannot be considered properly investigated with regard to contact allergy, unless the testing has been performed with mandatory readings on day 3 (or day 4) and day 7.

Clinical relevance

Late patch test readings are crucial in order to elucidate the role of contact allergy to dental materials in the aetiology of OLL.     

Latex allergy and filaggrin null mutations

Objectives

Natural rubber latex (NRL) contains over 200 proteins of which 13 have been identified as allergens and the cause of type I latex allergy. Health care workers share a high occupational risk for developing latex allergy. Filaggrin null mutations increase the risk of type I sensitizations to aeroallergens and it is possible that filaggrin null mutations also increase the risk of latex allergy. The aim of this paper was to examine the association between filaggrin null mutations and type I latex allergy.

Methods

Twenty latex allergic and 24 non-latex allergic dentists and dental assistants, occupationally exposed to latex, were genotyped for filaggrin null mutations R501X and 2282del4. Latex allergy was determined by a positive reaction or a historical positive reaction to a skin prick test with NRL.

Results

41 individuals were successfully genotyped. Three individuals were filaggrin mutation carriers. One (2.4%) was a 2282del4 heterozygote and two (4.9%) were R501X heterozygote. No homozygote or compound heterozygote carriers were detected. No association between filaggrin null mutations and type I latex allergy was found (p = 0.24). Patients with type I latex allergy more often reported contact dermatitis.

Conclusions

This is the first study to examine a highly plausible association between filaggrin null mutations and type I latex allergy. The study subjects were occupationally exposed to latex but no association between latex allergy and filaggrin mutations were detected. Sensitization to latex in the cases in this study may not have occurred through direct skin contact but through the respiratory organs via latex proteins that are absorbed in glove powder and aerosolized.     

Revised terminology for allergies and related conditions

The European Academy of Allergology and Clinical Immunology has proposed a revised terminology for allergic and allergy-related reactions that can be used independently of target organ of patient age group. The proposed terminology is based on the present knowledge of the mechanisms which initiate and mediate allergic reactions. 'Hypersensitivity' is an umbrella term, 'allergy' involves a hypersensitivity reaction which is initiated by an immunological mechanism, and 'atopy' is an individual or familial tendency to produce IgE antibodies in response to low doses of allergens, and is accompanied by the typical symptoms or asthma, rhino-conjunctivitis or eczema/dermatitis. Each condition should be categorised als 'allergic/not allergic', and the allergic conditions should be further categorised as 'IgE-mediated/non IgE-mediated' (sometimes: 'IgE-associated'). Terms which are no longer in use include: 'idiosyncrasy' (this will now become 'hypersensitivity'); 'pseudo-allergy' ('non-allergic hypersensitivity'); 'extrinsic', 'intrinsic', 'endogenous' and 'exogenous asthma' ('allergic' (possibly 'IgE-mediated') and 'non-allergic asthma'); 'atopic eczema' ('atopic eczema/dermatitis syndrome'; 'allergic (possibly 'EgE-mediated') or 'non-allergic'); 'intrinsic' and 'cryptogenic variants of eczema' (non-allergic atopic eczema/dermatitis syndrom'); 'food intolerance' (non-allergic food hypersensitivity') and 'anaphylactoid reaction' ('non-allergic anaphylaxis').     

Acute allergic reaction to eugenol

Eugenol has been widely used in the dental profession. It is an effective material that is incorporated into many dental products. Contact dermatitis due to this chemical is not unusual. However, true serious allergic reactions are extremely rare. This paper reports on such a case. Careful assessment of patients and of their dental and medical history is necessary to avoid disaster in the office.