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Cobalt-based dental alloy, allergy to cobalt, and palmoplantar pustulosis—reply
LETERS TO THE EDITOR
OOOO February 2012
154 inflammation is driven by leukocyte infiltration with associated pustular lesions caused and/or exacerbated by metals.7 In this regard, it is well known that mercury-containing dental amalgam filling releases elemental mercury (Hg°) that may induce systemic adverse events or contact dermatitis.3 Furthermore, mercury dental amalgam contains trace amounts of metallic cobalt, ⬃0.8 g/g.8 In light of these considerations, could the authors clarify whether the patient had mercury dental amalgam fillings? Considering that PPP has been associated with active smoking history,9,10 it would also be interesting to know whether the patient was a current or a former cigarette smoker. This interesting report by Song et al. adds evidence supporting the notion that chronic exposure to metals could be implicated as a potential cause of PPP and as a consequence that the removal of dental metal contact allergen should be considered as a treatment option. Paolo D. Pigatto, MD Galeazzi Hospital, University of Milan Milan, Italy Gianpaolo Guzzi, DDS Italian Association for Metals and Biocompatibility Research Milan, Italy REFERENCES 1. Song H, Yin W, Ma Q. Allergic palmoplantar pustulosis caused by cobalt in cast dental crowns: a case report. Oral Surg Oral Med Oral Pathol Oral Radiology Endod 2011;111(6):e8-10. 2. Pigatto PD, Guzzi G. Systemic contact dermatitis from nickel associated with orthodontic appliances. Contact Dermatitis 2004;50:100-1. 3. Pigatto PD, Guzzi G, Persichini P, Barbadillo S. Recovery from mercury-induced burning mouth syndrome due to mercury allergy. Dermat 2004;15:75-7. 4. Yiannias JA, Winkelmann RK, Connolly SM. Contact sensitivities in palmar plantar pustulosis (acropustulosis). Contact Dermat 1998;39:108-11. 5. Dantzig PI. A new cutaneous sign of mercury poisoning. Ann Intern Med 2003;139:78-80. 6. Dantzig P. The role of mercury in pustulosis palmaris et plantaris. J Occup Environ Med 2003;45:468-9. 7. Nakamura K, Imakado S, Takizawa M, Adachi M, Sugaya M, Wakugawa M, et al. Exacerbation of pustulosis palmaris et plantaris after topical application of metals accompanied by elevated levels of leukotriene B4 in pustules. J Am Acad Dermatol 2000;42:1021-5. 8. Pigatto PD, Guzzi G. Oral lichenoid lesions: more than mercury. Oral Surg Oral Med Oral Pathol Oral Radiology Endod 2005;100:398-400.
9. Palmoplantar pustulosis and smoking. Br Med J (Clin Res Ed) 1985;291:1278-9. 10. Michaëlsson G, Gustafsson K, Hagforsen E. The psoriasis variant palmoplantar pustulosis can be improved after cessation of smoking. J Am Acad Dermatol 2006;54:737-8. doi:10.1016/j.tripleo.2011.05.048
Cobalt-based dental alloy, allergy to cobalt, and palmoplantar pustulosis—reply In reply: Thank you for allowing us to respond to the Letter to the Editor appearing in this journal. The writers’ suggestion regarding the potential relationship between tobacco smoking and palmoplantar pustulosis (PPP) is reasonable.1 The patient was a cigarette smoker for ⬎20 years. However, he could not recall any hypersensitivity reactions or symptoms of PPP during that 20year history of smoking. He ceased smoking because it was suggested that he take some traditional Chinese medicine prescribed by his physician; however, the symptoms of PPP were not eliminated until the chromium-cobalt alloy casting crowns were removed. The patient had no mercury dental amalgam restorations in his oral cavity. Therefore, we think the findings suggest that the cobalt in the alloy casting crowns is most likely related to the PPP in this case.2 Hong Song, PhD, DDS Qin Ma, PhD, DDS School of Stomatology, Fourth Military Medical University Xi’an, China Yin Wen, MD Xijing Hospital, Fourth Military Medical University Xi’an, China REFERENCES 1. Just-Sarobé M. Smoking and the skin. Actas Dermosifiliogr 2008;99:173-84. 2. Song H, Yin W, Ma Q. Allergic palmoplantar pustulosis caused by cobalt in cast dental crowns: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111(6):e8-10. doi:10.1016/j.tripleo.2011.08.008
OOOO February 2012
154 inflammation is driven by leukocyte infiltration with associated pustular lesions caused and/or exacerbated by metals.7 In this regard, it is well known that mercury-containing dental amalgam filling releases elemental mercury (Hg°) that may induce systemic adverse events or contact dermatitis.3 Furthermore, mercury dental amalgam contains trace amounts of metallic cobalt, ⬃0.8 g/g.8 In light of these considerations, could the authors clarify whether the patient had mercury dental amalgam fillings? Considering that PPP has been associated with active smoking history,9,10 it would also be interesting to know whether the patient was a current or a former cigarette smoker. This interesting report by Song et al. adds evidence supporting the notion that chronic exposure to metals could be implicated as a potential cause of PPP and as a consequence that the removal of dental metal contact allergen should be considered as a treatment option. Paolo D. Pigatto, MD Galeazzi Hospital, University of Milan Milan, Italy Gianpaolo Guzzi, DDS Italian Association for Metals and Biocompatibility Research Milan, Italy REFERENCES 1. Song H, Yin W, Ma Q. Allergic palmoplantar pustulosis caused by cobalt in cast dental crowns: a case report. Oral Surg Oral Med Oral Pathol Oral Radiology Endod 2011;111(6):e8-10. 2. Pigatto PD, Guzzi G. Systemic contact dermatitis from nickel associated with orthodontic appliances. Contact Dermatitis 2004;50:100-1. 3. Pigatto PD, Guzzi G, Persichini P, Barbadillo S. Recovery from mercury-induced burning mouth syndrome due to mercury allergy. Dermat 2004;15:75-7. 4. Yiannias JA, Winkelmann RK, Connolly SM. Contact sensitivities in palmar plantar pustulosis (acropustulosis). Contact Dermat 1998;39:108-11. 5. Dantzig PI. A new cutaneous sign of mercury poisoning. Ann Intern Med 2003;139:78-80. 6. Dantzig P. The role of mercury in pustulosis palmaris et plantaris. J Occup Environ Med 2003;45:468-9. 7. Nakamura K, Imakado S, Takizawa M, Adachi M, Sugaya M, Wakugawa M, et al. Exacerbation of pustulosis palmaris et plantaris after topical application of metals accompanied by elevated levels of leukotriene B4 in pustules. J Am Acad Dermatol 2000;42:1021-5. 8. Pigatto PD, Guzzi G. Oral lichenoid lesions: more than mercury. Oral Surg Oral Med Oral Pathol Oral Radiology Endod 2005;100:398-400.
9. Palmoplantar pustulosis and smoking. Br Med J (Clin Res Ed) 1985;291:1278-9. 10. Michaëlsson G, Gustafsson K, Hagforsen E. The psoriasis variant palmoplantar pustulosis can be improved after cessation of smoking. J Am Acad Dermatol 2006;54:737-8. doi:10.1016/j.tripleo.2011.05.048
Cobalt-based dental alloy, allergy to cobalt, and palmoplantar pustulosis—reply In reply: Thank you for allowing us to respond to the Letter to the Editor appearing in this journal. The writers’ suggestion regarding the potential relationship between tobacco smoking and palmoplantar pustulosis (PPP) is reasonable.1 The patient was a cigarette smoker for ⬎20 years. However, he could not recall any hypersensitivity reactions or symptoms of PPP during that 20year history of smoking. He ceased smoking because it was suggested that he take some traditional Chinese medicine prescribed by his physician; however, the symptoms of PPP were not eliminated until the chromium-cobalt alloy casting crowns were removed. The patient had no mercury dental amalgam restorations in his oral cavity. Therefore, we think the findings suggest that the cobalt in the alloy casting crowns is most likely related to the PPP in this case.2 Hong Song, PhD, DDS Qin Ma, PhD, DDS School of Stomatology, Fourth Military Medical University Xi’an, China Yin Wen, MD Xijing Hospital, Fourth Military Medical University Xi’an, China REFERENCES 1. Just-Sarobé M. Smoking and the skin. Actas Dermosifiliogr 2008;99:173-84. 2. Song H, Yin W, Ma Q. Allergic palmoplantar pustulosis caused by cobalt in cast dental crowns: a case report. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111(6):e8-10. doi:10.1016/j.tripleo.2011.08.008