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Contact stomatitis to rubber products
Contact stomatitis to rubber products Donald M. Cohen, D.M. D.,* and Melvin Hoffman, M.D.,** UNIVERSITY
OF NEBRASKA
MEDICAL
CENTER
COLLEGES
Lincoln, Neb.
OF DENTISTRY
AND
MEDICINE
The literature is reviewed with respect to reported cases of rubber-induced contact stomatitis. In the case reported here, a 25-year-old woman had redness and swelling of the buccal mucosa in an area contacted by orthodontic rubber bands. Standardized epicutaneous patch tests using a specific test series for rubber components were carried out to confirm clinical suspicion of allergic contact stomatitis to rubber.
I
n a recent study’ the results of patch tests on 1,385 patients with suspected contact dermatitis were analyzed. The most important contact allergens in this series were found to be rubber, nickel, and chromate. Facial contact dermatitis has been precipitated by the use of rubber dam materiaP 3 or rubber headrests’ for sensitive persons. Labial reactions have occurred in patients who chewed on pencil erasers or the rubber tip of a toothbrush.5 The lips have a modified epidermis in which contact hypersensitivity is more likely to occur than in the oral mucosa proper.’ Judging from the paucity of case reports in the literature, the rarest type of hypersensitivity to rubber involves the oral mucosa. Several cases of hypersensitivity to rubber dentures have been reported.5 A number of these have even been documented by nonstandard patch test with scrapings or the whole denture. Crissey” states that rubber sore mouth is more likely due to “schmutz” and a poor fit than to contact hypersensitivity. Coppes? describes an allergic reaction to rubber dam material occurring on the lips and buccal mucosa, and Everett and Hice’ report a hypersensitivity to orthodontic rubber elastics, also occurring in the buccal mucosa. These last two cases were not confirmed with patch tests, although the case descriptions would appear to indicate that these were hypersensitivity and not irritant reactions. Four cases of mucosal hypersensitivity to Impergum, a poly-ether rubber impression material, have also been reported.8 At least one case was documented with *Assistant Professor, Department of Oral Diagnosis. Pathology. and Radiology. **Clinical Assistant Professor of Pediatrics (Allergy).
0030-4220/S I / 11049 1 + 04$00 40/O 0 198 I The C. V Mosby Co
cutaneous patch testing of the base and catalyst. The following represents, to our knowledge, the first case of contact stomatitis to rubber confirmed by patch testing with a specific standardized test series for chemicals used in rubber manufacturing. CASE
REPORT
A 25year-old woman undergoing orthodontic treatment had rubber interarch elastics placed as part of her therapy. After the elastic had been in place for 2 weeks. she complained of a burning sensation in both cheeks. Examination revealed redness and swelling of the buccal mucosa in an area contacted by the rubber bands (Fig. 1). Epicutaneous patch testing was used to confirm the clinical suspicion of contact hypersensitivity to rubber. Materials
and Methods
The standardized patch-testing technique was developed in the 1960’s in Scandinavia.’ Patch-testing kits containing the most common current sensitizers are available through Holister-Stier Laboratories and the North American Contact Dermatitis Group. Our patient was first tested with a rubber orthodontic elastic band. She was then screened with a rubber test series and a control. The tested materials were numbered and consisted of the following (Fig. 2): 17, mercaptobenzthiazole; 18, tetramethylthiuram; 36, mercapto mix; 48, thiuram mix; 38. naphthyl mix; 44. PPD mix; 22, carba mix; 30, ethylenediamine: 3 1, formalin; 42, paraphenylenediamine; RB. rubber band; C. control. Results
The patient reacted positively to chemicals 48, 18, and 22 (Tables I and II). She had to remove one patch (No. 48) after 30 hours and another (No. 18) within 45 hours because of severe burning and itching. At 72 hours the patient showed a strong cutaneous reaction (vesicles, edema, and erythema, (Fig. 3) to the thiuram mix (No. 48) 491
492 Cohen and Hofman
Oral Surg. November, 198I
I. Patch test results at 72 hours
Table 17 = 18 = 36 = 48 =
Table
0 (2+) 0 (2+)
38 = 0 44=0 22 = (l-2+) 30 = 0
31 =o 42 = 0 RB= I+ Control = 0
II. Interpretation key used by North American
Contact Dermatitis Group
Fig. 1. Wide zone of spreading erythema located in the buccal mucosa. Note central excoriation indicating contact area of the rubber band.
NT ? I+ 2+ 3+ IR 0
= = = = = = =
Not tested Doubtful Weak (nonvesicular) reaction, macular edema Strong (edematous or vesicular) reaction Extreme (spreading bullous or ulcer) reaction Irritant reaction Negative
icals can be leached from the finished rubber materials in the presence of perspiration or saliva.R The main group of offending chemicals consists of the rubber accelerators, usually organic sulfur compounds. Wilson I1 found that 104 of 106 casesof rubber sensitivity were due to thiuram accelerator or to mercaptobenzthiazole. Occasionally, other chemicals, such as antioxidants or peptizers (softeners), can cause the sensitization.12 McCarthy and Shklar13 state that there is no Fig. 2. Al test strips with cellulose disks placed on the upper back in vertical rows. Each constituent is numbered and recorded on a separate piece of paper.
and to tetramethylthiuram disulfide (No. 18), a component of the thiuram mix. Less dramatic results (edema, erythema, and only mild vesiculation, Fig. 4) occurred with the rubber band and carba mix (No. 22). Both mixes are composed of accelerators used in the manufacture of rubber to speed the vulcanization process. The patient was nonreactive to the other chemicals and the petrolaturn control. The patient complained of a reactivation of the pruritus
in the area of the original patch test with the rubber elastic and a renewed burning sensation in the buccal mucosa. In
addition, a diffuse macular-papular eruption with pruritus of the entire upper back developed (Fig. 5). Symptoms subsided within 36 hours after institution of therapy with a topical steroid and a short course of oral prednisone. DISCUSSION
Although
a case of allergy to natural rubber has
been reported, lo the vast majority of incidences of contact hypersensitivity to rubber are due to the chemicals used in rubber manufacture. These chem-
typical clinical reaction that immediately suggests an allergic stomatitis. All that is seen is a nonspecific
inflammatory reaction. Patients may complain of a loss of taste, numbness, a burning sensation, and soreness of the involved area. Itching is not a frequent symptom. Often the subjective symptoms of contact stomatitis are more prominent than the physical signs. According to Eversole,” occurrence of oral lesions heralding the onset of a hypersensitivity reaction to some foreign chemical is relatively common. Most instances go unreported because the conditions are usually mild and transient in nature and are not recognized as instances of allergic stomatitis. In contrast, Fisher” and McCarthy and
Shklar’” state that the oral mucosa is extremely resistant to topical sensitization. The reasons given are that the period of contact with sensitizers is brief and that saliva dilutes and removes the antigens. The probable conclusion is that the oral mucous membranes are less reactive to provocative materials and, although many sensitivities still may develop, they are often so mild, nonspecific in nature, and transient
as to go undiagnosed.
A person can develop a positive reaction to an
Volume 52 Number5
Fig. 3. A 2 + reaction consists of multiple small vesicles on a spreading edematous and erythematous base.
Contact stomatitis to rubber products
493
Fig. 4. A I + reaction to orthodontic elastic .band. Note spreading erythema and swelling.
allergen and be nonsensitive to the same material in
the oral mucous membrane.13 With rare exceptions.” however, when the mucous membrane is first sensitized, then the skin is usually involved also. Skin tests should be done first to confirm allergic stomatitis. If negative results are obtained and suspicion still exists, the allergen can be tested directly in the oral cavity. Rosenberg and FischerI describe an excellent intraoral patch-testing technique in which Orabase is used as the vehicle. Sometimes it is impossible clinically to tell a true allergen from an irritant. In these cases it can be assumed that if patch tests with the offending chemical produce no reaction in a series of control subjects, then the chemical is a significant allergen in the test patient. Chemicals contained in standard patch-test kits are generally used in a concentration that is nonirritating. Finally, there must be a correlation between the patch-test results and the clinical history to establish a definitive diagnosis.
I am indebted to Dr. Frank Went2 for his help in preparing the manuscript, Dr. Bob Glenn for providing us with the patient, and Miss Margo Nielsen for typing the manuscript.
SUMMARY
REFERENCES
A case, documented by standardized epicutaneous path testing, of hypersensitivity to an orthodontic rubber elastic band is reported. More specifically, the patient was sensitive to two types of sulfur-containing chemicals used to accelerate the vulcanization process, thiuram sulfides (thiuram mix) and salts of thio-acid (carba mix). Skin hypersensitivity to rubber products is very commonly encountered and poses a hazard to dental personnel and to patients. The symptoms of contact stomatitis are subtle, and this reaction is probably far more common than reports indicate. Standardized patch testing of the skin is a thorough, safe, reliable, and easy method of determining the presence of allergic contact stomatitis.
Fig. 5. Generalized dermatitis due to hypersensitivity with diffuse macular-papular eruption of upper back.
1. Jarisch. R.. and Sandor.I.: StandardEpicutaneousTesting: Fwe Year Results and Their Effects on Future Examinations. Z. Hautkr. 53: 462-470. 1978. 2. Coppes. L.: Allergische Reacties of Rubber Dam, Ned. T Tandheek169: 821, 1962. 3. Fisher, A. A.: Contact Dermatitis, ed. 2. Philadelphia, 1973. Lea & Febiger. pp. I-13, 25-70, 163-175,307-337. 4. Fisher, A. A.: Allergic Contact Cheilitis. Dermatology 3: 10-13, 1980. 5. Nyquist, G.: A Study of Denture Sore Mouth, Acta Odontol. Stand. IO: 17-23.88-118, 1952. 6. Crissey, J. T.: Stomatitis, Dermatitis and Denture Materials, Arch. Dermatol. 92: 45-48, 1965. 7. Everett, F. G., and Hice, T. L.: Contact Stomatitis Resulting From the Use of Orthodontic Rubber Elastics: Report of Case, J. Am. Dent. Assoc. 88: 1030-1031.1974. 8. Dahl. B. L.: Tissue Hypersensitivity to Dental Materials, J. Oral Rehabil. 5: 117-120, 1978. 9. Zugerman, C.: Patch-Testing: Technique and Interpretation. Part 2, Derm. pp. 16-20. March 1979.
494
Cohen and HoJman
10. Nutter, A. F.: Contact Urticaria to Rubber, Br. J. Dermatol. 101: 597-598. 1979.
11 Wdson. H. T. H.: Rubber Dermatitrs, Br. J. Dermatol. 81: 175-179. 1969.
12. Gaul, L. E.. Results of Patch-testing With Rubber Antioxrdants and Accelerators, J. Invest. Dermatol. 29: 105, 1957 13. McCarthy, P. L., and Shklar, G.: Dtseases of the Oral Mucosa, ed. 2. Philadelphia, 1980, Lea & Febiger. pp. 256-263. 14. Eversole, L. R.: Allergic Stomatitrdes. J. Oral Med. 34: 93-101. 1979.
Oral Surg. November. 1981 IS. Rosenberg, E. W., and Fischer, R. W.: Improved Method for Intraoral Patch Testing, Arch. Dermatol. 87: 115-l 17. 1963. Reprrnt requests to:
Dr. Donald M Cohen Department of Oral Pathology University of Nebraska Medical Center College of Dentistry 40th and Holdrege Lincoln, Neb. 68583
OF NEBRASKA
MEDICAL
CENTER
COLLEGES
Lincoln, Neb.
OF DENTISTRY
AND
MEDICINE
The literature is reviewed with respect to reported cases of rubber-induced contact stomatitis. In the case reported here, a 25-year-old woman had redness and swelling of the buccal mucosa in an area contacted by orthodontic rubber bands. Standardized epicutaneous patch tests using a specific test series for rubber components were carried out to confirm clinical suspicion of allergic contact stomatitis to rubber.
I
n a recent study’ the results of patch tests on 1,385 patients with suspected contact dermatitis were analyzed. The most important contact allergens in this series were found to be rubber, nickel, and chromate. Facial contact dermatitis has been precipitated by the use of rubber dam materiaP 3 or rubber headrests’ for sensitive persons. Labial reactions have occurred in patients who chewed on pencil erasers or the rubber tip of a toothbrush.5 The lips have a modified epidermis in which contact hypersensitivity is more likely to occur than in the oral mucosa proper.’ Judging from the paucity of case reports in the literature, the rarest type of hypersensitivity to rubber involves the oral mucosa. Several cases of hypersensitivity to rubber dentures have been reported.5 A number of these have even been documented by nonstandard patch test with scrapings or the whole denture. Crissey” states that rubber sore mouth is more likely due to “schmutz” and a poor fit than to contact hypersensitivity. Coppes? describes an allergic reaction to rubber dam material occurring on the lips and buccal mucosa, and Everett and Hice’ report a hypersensitivity to orthodontic rubber elastics, also occurring in the buccal mucosa. These last two cases were not confirmed with patch tests, although the case descriptions would appear to indicate that these were hypersensitivity and not irritant reactions. Four cases of mucosal hypersensitivity to Impergum, a poly-ether rubber impression material, have also been reported.8 At least one case was documented with *Assistant Professor, Department of Oral Diagnosis. Pathology. and Radiology. **Clinical Assistant Professor of Pediatrics (Allergy).
0030-4220/S I / 11049 1 + 04$00 40/O 0 198 I The C. V Mosby Co
cutaneous patch testing of the base and catalyst. The following represents, to our knowledge, the first case of contact stomatitis to rubber confirmed by patch testing with a specific standardized test series for chemicals used in rubber manufacturing. CASE
REPORT
A 25year-old woman undergoing orthodontic treatment had rubber interarch elastics placed as part of her therapy. After the elastic had been in place for 2 weeks. she complained of a burning sensation in both cheeks. Examination revealed redness and swelling of the buccal mucosa in an area contacted by the rubber bands (Fig. 1). Epicutaneous patch testing was used to confirm the clinical suspicion of contact hypersensitivity to rubber. Materials
and Methods
The standardized patch-testing technique was developed in the 1960’s in Scandinavia.’ Patch-testing kits containing the most common current sensitizers are available through Holister-Stier Laboratories and the North American Contact Dermatitis Group. Our patient was first tested with a rubber orthodontic elastic band. She was then screened with a rubber test series and a control. The tested materials were numbered and consisted of the following (Fig. 2): 17, mercaptobenzthiazole; 18, tetramethylthiuram; 36, mercapto mix; 48, thiuram mix; 38. naphthyl mix; 44. PPD mix; 22, carba mix; 30, ethylenediamine: 3 1, formalin; 42, paraphenylenediamine; RB. rubber band; C. control. Results
The patient reacted positively to chemicals 48, 18, and 22 (Tables I and II). She had to remove one patch (No. 48) after 30 hours and another (No. 18) within 45 hours because of severe burning and itching. At 72 hours the patient showed a strong cutaneous reaction (vesicles, edema, and erythema, (Fig. 3) to the thiuram mix (No. 48) 491
492 Cohen and Hofman
Oral Surg. November, 198I
I. Patch test results at 72 hours
Table 17 = 18 = 36 = 48 =
Table
0 (2+) 0 (2+)
38 = 0 44=0 22 = (l-2+) 30 = 0
31 =o 42 = 0 RB= I+ Control = 0
II. Interpretation key used by North American
Contact Dermatitis Group
Fig. 1. Wide zone of spreading erythema located in the buccal mucosa. Note central excoriation indicating contact area of the rubber band.
NT ? I+ 2+ 3+ IR 0
= = = = = = =
Not tested Doubtful Weak (nonvesicular) reaction, macular edema Strong (edematous or vesicular) reaction Extreme (spreading bullous or ulcer) reaction Irritant reaction Negative
icals can be leached from the finished rubber materials in the presence of perspiration or saliva.R The main group of offending chemicals consists of the rubber accelerators, usually organic sulfur compounds. Wilson I1 found that 104 of 106 casesof rubber sensitivity were due to thiuram accelerator or to mercaptobenzthiazole. Occasionally, other chemicals, such as antioxidants or peptizers (softeners), can cause the sensitization.12 McCarthy and Shklar13 state that there is no Fig. 2. Al test strips with cellulose disks placed on the upper back in vertical rows. Each constituent is numbered and recorded on a separate piece of paper.
and to tetramethylthiuram disulfide (No. 18), a component of the thiuram mix. Less dramatic results (edema, erythema, and only mild vesiculation, Fig. 4) occurred with the rubber band and carba mix (No. 22). Both mixes are composed of accelerators used in the manufacture of rubber to speed the vulcanization process. The patient was nonreactive to the other chemicals and the petrolaturn control. The patient complained of a reactivation of the pruritus
in the area of the original patch test with the rubber elastic and a renewed burning sensation in the buccal mucosa. In
addition, a diffuse macular-papular eruption with pruritus of the entire upper back developed (Fig. 5). Symptoms subsided within 36 hours after institution of therapy with a topical steroid and a short course of oral prednisone. DISCUSSION
Although
a case of allergy to natural rubber has
been reported, lo the vast majority of incidences of contact hypersensitivity to rubber are due to the chemicals used in rubber manufacture. These chem-
typical clinical reaction that immediately suggests an allergic stomatitis. All that is seen is a nonspecific
inflammatory reaction. Patients may complain of a loss of taste, numbness, a burning sensation, and soreness of the involved area. Itching is not a frequent symptom. Often the subjective symptoms of contact stomatitis are more prominent than the physical signs. According to Eversole,” occurrence of oral lesions heralding the onset of a hypersensitivity reaction to some foreign chemical is relatively common. Most instances go unreported because the conditions are usually mild and transient in nature and are not recognized as instances of allergic stomatitis. In contrast, Fisher” and McCarthy and
Shklar’” state that the oral mucosa is extremely resistant to topical sensitization. The reasons given are that the period of contact with sensitizers is brief and that saliva dilutes and removes the antigens. The probable conclusion is that the oral mucous membranes are less reactive to provocative materials and, although many sensitivities still may develop, they are often so mild, nonspecific in nature, and transient
as to go undiagnosed.
A person can develop a positive reaction to an
Volume 52 Number5
Fig. 3. A 2 + reaction consists of multiple small vesicles on a spreading edematous and erythematous base.
Contact stomatitis to rubber products
493
Fig. 4. A I + reaction to orthodontic elastic .band. Note spreading erythema and swelling.
allergen and be nonsensitive to the same material in
the oral mucous membrane.13 With rare exceptions.” however, when the mucous membrane is first sensitized, then the skin is usually involved also. Skin tests should be done first to confirm allergic stomatitis. If negative results are obtained and suspicion still exists, the allergen can be tested directly in the oral cavity. Rosenberg and FischerI describe an excellent intraoral patch-testing technique in which Orabase is used as the vehicle. Sometimes it is impossible clinically to tell a true allergen from an irritant. In these cases it can be assumed that if patch tests with the offending chemical produce no reaction in a series of control subjects, then the chemical is a significant allergen in the test patient. Chemicals contained in standard patch-test kits are generally used in a concentration that is nonirritating. Finally, there must be a correlation between the patch-test results and the clinical history to establish a definitive diagnosis.
I am indebted to Dr. Frank Went2 for his help in preparing the manuscript, Dr. Bob Glenn for providing us with the patient, and Miss Margo Nielsen for typing the manuscript.
SUMMARY
REFERENCES
A case, documented by standardized epicutaneous path testing, of hypersensitivity to an orthodontic rubber elastic band is reported. More specifically, the patient was sensitive to two types of sulfur-containing chemicals used to accelerate the vulcanization process, thiuram sulfides (thiuram mix) and salts of thio-acid (carba mix). Skin hypersensitivity to rubber products is very commonly encountered and poses a hazard to dental personnel and to patients. The symptoms of contact stomatitis are subtle, and this reaction is probably far more common than reports indicate. Standardized patch testing of the skin is a thorough, safe, reliable, and easy method of determining the presence of allergic contact stomatitis.
Fig. 5. Generalized dermatitis due to hypersensitivity with diffuse macular-papular eruption of upper back.
1. Jarisch. R.. and Sandor.I.: StandardEpicutaneousTesting: Fwe Year Results and Their Effects on Future Examinations. Z. Hautkr. 53: 462-470. 1978. 2. Coppes. L.: Allergische Reacties of Rubber Dam, Ned. T Tandheek169: 821, 1962. 3. Fisher, A. A.: Contact Dermatitis, ed. 2. Philadelphia, 1973. Lea & Febiger. pp. I-13, 25-70, 163-175,307-337. 4. Fisher, A. A.: Allergic Contact Cheilitis. Dermatology 3: 10-13, 1980. 5. Nyquist, G.: A Study of Denture Sore Mouth, Acta Odontol. Stand. IO: 17-23.88-118, 1952. 6. Crissey, J. T.: Stomatitis, Dermatitis and Denture Materials, Arch. Dermatol. 92: 45-48, 1965. 7. Everett, F. G., and Hice, T. L.: Contact Stomatitis Resulting From the Use of Orthodontic Rubber Elastics: Report of Case, J. Am. Dent. Assoc. 88: 1030-1031.1974. 8. Dahl. B. L.: Tissue Hypersensitivity to Dental Materials, J. Oral Rehabil. 5: 117-120, 1978. 9. Zugerman, C.: Patch-Testing: Technique and Interpretation. Part 2, Derm. pp. 16-20. March 1979.
494
Cohen and HoJman
10. Nutter, A. F.: Contact Urticaria to Rubber, Br. J. Dermatol. 101: 597-598. 1979.
11 Wdson. H. T. H.: Rubber Dermatitrs, Br. J. Dermatol. 81: 175-179. 1969.
12. Gaul, L. E.. Results of Patch-testing With Rubber Antioxrdants and Accelerators, J. Invest. Dermatol. 29: 105, 1957 13. McCarthy, P. L., and Shklar, G.: Dtseases of the Oral Mucosa, ed. 2. Philadelphia, 1980, Lea & Febiger. pp. 256-263. 14. Eversole, L. R.: Allergic Stomatitrdes. J. Oral Med. 34: 93-101. 1979.
Oral Surg. November. 1981 IS. Rosenberg, E. W., and Fischer, R. W.: Improved Method for Intraoral Patch Testing, Arch. Dermatol. 87: 115-l 17. 1963. Reprrnt requests to:
Dr. Donald M Cohen Department of Oral Pathology University of Nebraska Medical Center College of Dentistry 40th and Holdrege Lincoln, Neb. 68583