Oral lichenoid lesions (OLL) or lichen-planus-like lesions are often idiopathic (arising spontaneously or from an obscure or unknown cause). Oral lichen planus (OLP) is a chronic inflammatory disease that causes bilateral white striations, papules, or plaques on the buccal mucosa, tongue, and gingivae. Lichen planus is a common disorder of unknown aetiology. It has been proposed that in some cases it represents a form of allergic reaction to the metals contained in dental amalgam, particularly mercury. Three decades worth of studies overwhelmingly show that lichenoid lesions healed in patients who removed their mercury fillings.
Oral lichen planus (OLP) may present in one of three forms.
- The reticular form is the most common presentation and manifests as white lacy streaks on the mucosa (known as Wickham's striae) or as smaller papules (small raised area). The lesions tend to be bilateral and are asymptomatic. The lacy streaks may also be seen on other parts of the mouth, including the gingiva (gums), the tongue, palate and lips.
- The bullous form presents as fluid-filled vesicles which project from the surface.
- The erosive form presents with erythematous (red) areas that are ulcerated and uncomfortable. The erosion of the thin epithelium may occur in multiple areas of the mouth, or in one area, such as the gums, where they resemble desquamative gingivitis. Wickham's striae may also be seen near these ulcerated areas. This form may undergo malignant transformation.
Oral Lichen Planus Typical Featutes
- Females account for atr 65% of patients
- Patients usually over 40 years
- Untreated disease persists for 10 or more years
- Lesions in combination or isolation comprise Striae,Atropic areas and Erosion Plaques
- Common Sites are buccal mucosa,Dorsum of tongue and Gingiva
- Lesions usually occur bilaterally ansd symmetrically
- Cutaneous lesion only ocassionlly associates .
- Usually good responce to corticosteroids
Amalgam-related oral lichenoid reaction.
Scand J Dent Res. 1986 Oct;94(5):448-51.
Lind PO, Hurlen B, Lyberg T, Aas E.
In 52 patients with oral lichen planus topographically related to amalgam restorations, the fillings were replaced by other materials in 18, 16 of whom experienced complete remission of the lesions within 1-12 months. These results are discussed in relation to the results of epicutaneous patch tests for possible allergy to a number of mercury compounds. The term "oral lichenoid reaction", is suggested to describe these lesions.
Oral lichenoid reactions related to mercury sensitivity.
Br J Oral Maxillofac Surg. 1987 Dec;25(6):474-80.
James J, Ferguson MM, Forsyth A, Tulloch N, Lamey PJ.
Department of Oral Surgery, Glasgow Dental Hospital and School.
Lichen planus is a common disorder of unknown aetiology. It has been proposed that in some cases it represents a form of allergic reaction to the metals contained in dental amalgam, particularly mercury. Twenty-nine consecutive dentate patients who had lichen planus of the oral mucosa were patch-tested to the range of metals contained in dental amalgam. Ten out of 29 (34%) showed an allergic reaction to mercury and all of these patients had amalgams greater than 5 years old. The amalgams were poorly contoured and had corroded, resulting in continued release of mercury ions. Six patients had their amalgams replaced with composite or glass ionomer materials resulting in resolution of ulcerated lesions. In a follow-up of 3-24 months, one patient had a recurrence of ulcerated areas and another, despite resolution of the oral lesions had persistent discomfort.
Mucosal reactions to amalgam restorations.
J Oral Rehabil. 1990 Jul;17(4):293-301.
Jameson MW, Kardos TB, Kirk EE, Ferguson MM.
Department of Restorative Dentistry, School of Dentistry, University of Otago Dunedin, New Zealand.
Amalgam restorations have been implicated both in contact sensitivity reactions and in lichenoid reactions. This appears to be related principally to the mercury content, although other metals cannot be discounted. The cases of two patients are reported who showed features of lichenoid reactions of the oral mucosa, in addition to features of a contact hypersensitivity to mercury. The mucosal lesions resolved following replacement of the amalgams with non-metallic restorations. Consideration is given to the selection of materials and procedures currently available for treatment of these patients. This paper supports the view that sensitivity to heavy metals must be considered as a possible cause of erythematous and lichenoid reactions of the oral mucosa.
Resolution of oral lichenoid lesions after replacement of amalgam restorations in patients allergic to mercury compounds
JUHANI LAINE1, KIRSTI KALIMO2, HELI FORSSELL1, RISTO-PEKKA HAPPONEN1,*
British Journal of Dermatology
Volume 126, Issue 1, pages 10–15, January 1992
The significance of contact allergy in patients with various oral symptoms was studied. Positive patchtest reactions to mercury compounds were found in 21/91 patients. Of these, 18 had lichenoid lesions in oral mucosa in close contact to amalgam fillings, and three patients with contact allergy had neither amalgam fillings in their teeth nor visible oral lesions. Amalgam replacement was carried out in 15/18 symptomatic patients. The fillings were replaced with gold in three cases, composite resin fillings in six, glass ionomer in three and both gold and composite materials in three cases. In 10 patients there was complete replacement and in five it was restricted to the fillings adjacent to the mucosal lesions. After a mean follow-up period of 3.2 years a complete cure was seen in seven patients, each of whom had had all their fillings changed. A marked improvement occurred in six patients, and there was no change in two.
Oral mucosa and skin reactions related to amalgam.
Adv Dent Res. 1992 Sep;6:120-4.
Department of Periodontology, Royal Dental College, Copenhagen, Denmark.
Documented cases of oral mucosa and skin affections related to amalgam restorations are rare, although the exact incidence is unknown. Lesions of the oral mucosa may be due to specific immunologic or non-specific toxic reactions toward products generated from restorations. The immunologic reaction most probably involved in mucosal affections related to amalgam is the delayed or cell-mediated (type IV) reaction. Such reactions are seen in contact allergy, and the term "contact lesions of the oral mucosa" has been used. There is a much lower tendency of sensitization through mucous membranes than through skin, and it is questionable whether mercury released from amalgam restorations is able to sensitize a patient. A chronic toxic reaction may be established due to repeated or constant influence to toxic agents in low concentrations over long periods. Such reactions are most frequently localized to the contact zone with the toxic agent. Chronic toxic reactions may possibly be seen in areas of the oral mucosa in direct contact with amalgam fillings. Since the clinical features of these lesions do not differ from those of lesions due to contact hypersensitivity, the diagnosis is obtained by exclusion based on a negative patch test.
Patch test reactions to metal salts in patients with oral mucosal lesions associated with amalgam restorations.
Contact Dermatitis. 1992 Sep;27(3):157-60.
Nordlind K, Lidén S.
Department of Dermatology, Karolinska Hospital, Stockholm, Sweden.
Patch testing with various metal salts was performed in patients with oral mucosal lesions associated with amalgam restorations, by using polypropylene-coated aluminium discs. Positive reactions to mercuric chloride were obtained in 5/12 (42%) of these patients, but only in 1/11 patients (9%) with oral mucosal lesions unassociated with amalgam restorations and in 3/36 patients (8%) in a control group without mucosal lesions. The difference between the former group and the control patients is statistically significant (p less than 0.05). In addition, a positive test reaction to copper sulfate was obtained in 2 patients (16%) with amalgam-associated mucosal lesions and negative reactions to mercuric chloride. 2 of the 5 positive test reactions to mercuric chloride, in the patients with lichenoid mucosal lesions associated with amalgam, became lichenoid and persisted for at least 3 weeks. The patients with these reactions were also positive at a concentration of 0.05% mercuric chloride, but were negative to metallic mercury, in contrast to 2 other patients in the same group. This indicates the necessity of including mercuric chloride when patch testing such patients.
Oral lichenoid lesions and mercury sensitivity.
Contact Dermatitis. 1993 Nov;29(5):275-6.
Bircher AJ, von Schulthess A, Henning G.
Department of Dermatology, University Hospital, Basel, Switzerland.
Healing of lichenoid reactions following removal of amalgam. A clinical follow-up.
J Clin Periodontol. 1995 Apr;22(4):287-94.
Henriksson E, Mattsson U, Håkansson J.
Department of Oral and Maxillofacial Surgery, Central Hospital, Karlstad, Sweden.
174 patients referred to the Department of Oral and Maxillofacial Surgery, Central Hospital, Karlstad, Sweden during 1987 to 1989 for lichenoid lesions and evaluation of a possible connection with amalgam restorations were invited to a clinical re-examination. 159 of the patients were re-examined with the purpose of evaluating the long-term effect upon performed substitution therapy. Partial or total removal of amalgam had been recommended according to a set of given criteria. The re-examination showed that 62 patients had performed partial and 69 patients total removal of amalgam fillings. 28 patients had not performed any substitution therapy. There was a difference between recommended and performed therapy. The results demonstrated that 92% of patients with lichenoid lesions only in contact with amalgam fillings healed or improved clinically following removal of amalgam. No statistical difference was found in healing between patients who only removed fillings in contact and those who had removed all amalgam restorations. More than 60% of buccal lichenoid lesions without contact with amalgam at time of referral disappeared following amalgam substitution. Gingival lichenoid lesions did not respond to substitution of amalgam to another material. 3 out of 17 patch-tested patients demonstrated a hypersensitivity reaction to mercury. All lichenoid lesions in these patients healed following total substitution. Partial or total removal of amalgam fillings was also performed on 10 patients with completely negative patch-tests. 6 out of these patients demonstrated complete healing of their lichenoid reactions at re-examination.
The histopathology of oral mucosal lesions associated with amalgam or porcelain-fused-to-metal restorations.
Oral Dis. 1995 Sep;1(3):152-8.
Larsson A, Warfvinge G.
Department of Oral Pathology, Centre for Oral Health Sciences, Lund University, Malmö, Sweden.
To analyse the interface stomatitis patterns of oral lichenoid lesions in contact with amalgam and to compare these with the histologic changes in oral lesions clinically associated with porcelain-fused-to-metal (PFM) restorations. To relate these features to the presence of tissue-bound mercury (Hg).
A retrospective analysis of tissue biopsies, with clinical data collected via a complementary questionnaire.
SUBJECTS AND METHODS:
479 biopsies diagnosed in 1987 as 'lichenoid reactions'. From these, we retrieved all with amalgam contact and without candida or medication. From 1990-91, all mucosal lesions stated to be associated with PFM restorations were then retrieved for comparative analysis. The biopsies were examined with routine histologic and autometallographic methods.
77 amalgam-associated lesions were found and could be subdivided into five pre-defined interface stomatitis types. We found 22 lesions associated with PFM and 20 showed histopathologic features similar to those associated with amalgam. Hg accumulations were detected in the majority of amalgam-associated but only in part of the PFM-associated lesions.
Amalgam-associated lichenoid lesions present a wide spectrum of histopathologic patterns, corresponding to similar patterns in dermatopathology but with no evidence of association with specific disease. PFM-associated lesions tend to display similar lichenoid features, suggestive of common pathogenetic mechanisms. Hg accumulations may play a role to maintain the chronicity of such lichenoid lesions.
Oral lichenoid lesions, mercury hypersensitivity and combined hypersensitivity to mercury and other metals: histologically-proven reproduction of the reaction by patch testing with metal salts.
Contact Dermatitis. 1995 Nov;33(5):323-8.
Koch P, Bahmer FA.
Hautklinik der Universität des Saarlandes, Homburg/Saar, Germany.
We report 11 patients seen between 1991 and 1994 with oral lichenoid lesions (OLL). In 10 cases, there was contact with dental amalgam fillings, and in patient no. 10 with both amalgam restorations and a gold crown. The last patient had, in addition to her OLL, lichen planus of the skin and genital mucosa. In 5 cases, combined sensitization to mercury and other metal salts, particularly gold sodium thiosulfate (GST) and palladium chloride (PDC), was observed. In 10 patients, the lesions considerably improved or totally cleared within 1 to 9 months of replacement of restoration materials. Histological examination of biopsies from the test sites of amalgam, mercuric chloride, GST and PDC, taken 10 or 17 days after application of patch tests, showed lichenoid changes in 7 patients with at least 1 of the allergens. As at least 2 patients had inflammatory lesions of the oral mucosa related to both amalgam and gold restorations, combined sensitization to inorganic and organic mercury derivatives, GST and, in 1 case, PDC, a "dental restoration metal intolerance syndrome" is proposed.
Oral lichenoid lesions caused by allergy to mercury in amalgam fillings.
Contact Dermatitis. 1995 Dec;33(6):423-7.
Pang BK, Freeman S.
Contact & Occupational Dermatitis Clinic, Skin & Cancer Foundation, NSW, Australia.
Contact Dermatitis 1996 Jul;35(1):70.
Oral lichenoid lesions (OLL) or lichen-planus-like lesions are often idiopathic. Our aim was to determine whether OLL can be caused by allergy to mercury in amalgam fillings, and whether resolution of OLL occurs after replacement of amalgam with other dental fillings. Patients with only OLL (except for 1 case with cutaneous lichen planus) referred for patch testing during 1985-1994 to the Contact and Occupational Dermatitis Clinic of the Skin & Cancer Foundation, Darlinghurst, were reviewed. Patch tests were performed with 1% mercury, 1% ammoniated mercury, 0.1% thimerosal, 0.1% mercuric chloride, 0.05% phenylmercuric nitrate and an amalgam disc, using Finn Chambers occluded for 2 days, 19 patients (17 women and 2 men; age range: 28-72 years) had OLL in close contact with amalgam fillings and showed positive patch test reactions to mercury compounds, 16 out of 19 patients had their amalgam fillings replaced. In 13 patients, the OLL healed. 1 patient had marked improvement. 1 patient had no improvement and developed multiple oral squamous cell carcinoma. In conclusion, OLL can be caused by allergy to mercury in amalgam fillings. Replacement of amalgam with other dental fillings usually results in resolution of OLL and is recommended for cases with positive patch test reactions to mercury compounds.
The relevance and effect of amalgam replacement in subjects with oral lichenoid reactions
S. H. IBBOTSON1, E. L. SPEIGHT1, R. I. MACLEOD2, E. R. SMART2, C. M. LAWRENCE1
British Journal of Dermatology
Volume 134, Issue 3, pages 420–423, March 1996
In this study we examined the prevalence of mercury hypersensitivity in patients with oral lichenoid reactions (OLR) and the effect of amalgam replacement in subjects with amalgams adjacent to OLR irrespective of their mercury sensitivity status. One hundred and ninety-seven patients with oral problems were examined: 109 with OLR. 22 with oral and generalized lichen planus. and 66 with other oral diagnoses, including aphthous ulcers and orofacial granulomatosis. Nineteen per cent of patients with OLR reacted to mercury on patch testing, significantly more than in those with generalized lichen planus (0%) and in those with other oral diagnoses (3%). Twenty-two patients with OLR and adjacent amalgams had amalgam replacement and. in 16 of 17 mercury-positive subjects and three of four mercury-negative subjects, the OLR resolved after amalgam removal. In conclusion, we found a significantly increased prevalence of mercury hypersensitivity in patients with localized OLR in comparison to subjects with other oral problems. Amalgam replacement resulted in resolution of OLR in the majority of patients with amalgams adjacent to OLR irrespective of their mercury sensitivity status.
Amalgam-associated oral lichenoid reactions. Clinical and histologic changes after removal of amalgam fillings.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996 Apr;81(4):459-65.
Ostman PO, Anneroth G, Skoglund A.
Department of Oral Pathology, University of Umea, Sweden.
OBJECTIVE AND STUDY DESIGN:
Forty-nine consecutive patients with clinically diagnosed oral lichenoid reactions in contact with amalgam fillings were studied clinically and histologically. The long-term effect of replacement of these fillings was also examined.
Seventeen (35%) patients showed positive reactions to mercury at the epicutaneous patch test that was carried out before treatment. After treatment, total regression of the lesions was found clinically in 33 (69%) and histologically in 26 (55%) patients. Most of the remaining lesions changed clinically and histologically to a less pronounced tissue reaction. Lesions in direct contact with amalgam fillings (group I) showed significantly better healing results than lesions that exceeded the contact area (group II). No difference in healing capacity was noted in the two groups between patients with positive patch reactions to mercury compared with those with negative reactions. Lesions that histologically were classified as benign oral keratosis showed a similar healing pattern as those classified as oral lichen planus.
In group I all lesions changed histologically and clinically to a normal mucosa or to a less affected tissue reaction. In group II this change was less pronounced, which suggests that the fillings themselves were not the only factor involved in the cause of these lesions. The results suggest that various etiologic factors are involved in lichenoid reactions and that the effect of removal of amalgam fillings cannot be predicted by epicutaneous patch testing and biopsies.
In vitro lymphocyte proliferation test in the diagnosis of oral mucosal hypersensitivity reactions to dental amalgam.
J Oral Pathol Med. 1997 Sep;26(8):362-6.
Laine J, Happonen RP, Vainio O, Kalimo K.
Department of Oral Diseases, University Central Hospital of Turku, Finland.
Patch testing was carried out in 23 patients with oral lichenoid lesions (OLL) topographically related to dental amalgam fillings. Twelve patients displayed positive reactions to several mercury compounds, whereas 11 patients were negative. An in vitro lymphocyte proliferation (LyPro) test was carried out using different mercury compounds and other metal salts. Mercuric chloride and phenyl mercuric acetate caused positive proliferation in 3/12 patch test-positive and in 5/11 negative patients. One out of seven healthy control subjects had a positive LyPro result. The mean stimulation index (SI) values between the patient groups or compared with the control subjects did not differ significantly. Zinc, tin, copper or silver salts caused in vitro lymphocyte stimulation in most of the patients and in healthy control people. Total (14) or partial (4) replacement of amalgam fillings was carried out in 18 patients. Complete healing of lichenoid lesions was seen in 4/6 LyPro test-positive and in 5/10 patch test-positive patients at follow-up examinations 12 months after the replacement of amalgam fillings. The in vitro proliferation assay seems not to be a specific test for identifying the patients who would benefit from amalgam replacement.
Contact hypersensitivity to mercury in amalgam restorations may mimic oral lichen planus.
Cutis. 1999 Mar;63(3):189-92.
Camisa C, Taylor JS, Bernat JR Jr, Helm TN.
Section of Clinical Dermatology, Cleveland Clinic Foundation, Ohio, USA.
Oral lichenoid lesions caused by hypersensitivity to mercury in amalgam fillings may mimic oral lichen planus on clinical and histologic examination. A positive patch test reaction to more than one mercurial allergen increases confidence in the diagnosis and justifies the removal and replacement of all amalgam fillings with those made of other materials. A complete remission may be expected about 3 months after the last amalgam filling is removed.
Immunocompetent cells in amalgam-associated oral lichenoid contact lesions.
J Oral Pathol Med. 1999 Mar;28(3):117-21.
Laine J, Konttinen YT, Beliaev N, Happonen RP.
Department of Oral Diseases, University Central Hospital of Turku, Finland.
Inflammatory cells in amalgam-associated, oral lichenoid contact lesions (OLL) were studied in 19 patients by immunocytochemistry using monoclonal antibodies. Ten of the patients displayed allergic patch test (PT) reactions to several mercury compounds and nine were negative. The immunocytochemical quantification showed a uniform composition of the inflammatory mononuclear cells in the two study groups. The number of HLA-D/DR-positive dendritic cells (P<0.001) and CD1a-positive Langerhans cells (P=0.035) was significantly lower in the PT-negative than PT-positive patients. HLA-D/DR expression on keratinocytes varied from negative to full thickness staining of the epithelium. HLA-D/DR expression in the full thickness of epithelium (3) or through the basal and spinous cell layers (2) was seen in 5 of 8 PT-positive patients, whereas none of the PT-negative patients had this staining pattern (P=0.045). These patients also showed a good clinical response after amalgam removal. Consequently, OLL may represent a true delayed hypersensitivity reaction with a trans-epithelial route of entrance of the metal haptens released from dental restorative materials.
Oral lesions and symptoms related to metals used in dental restorations: a clinical, allergological, and histologic study.
Journal of the American Academy of Dermatology. 1999 Sep;41(3 Pt 1):422-30.
Koch P, Bahmer FA.
Department of Dermatology, University of the Saarland, Homburg/Saar, Germany.
Allergy to mercury as a cause of oral lichenoid lesions (OLL) remains controversial. Some authors reported high frequency of sensitization to mercury and beneficial effect from removal of amalgam fillings in such patients, whereas others state that this procedure affects favorably all OLL, whether patients are sensitized to inorganic mercury or not.
Our purpose was to determine the frequency of sensitization to metal salts in 194 patients (patients with OLL partly adjacent to amalgam fillings: 19, oral lichen planus (OLP) without close contact to amalgam: 42, other oral diseases: 28, oral complaints: 46, control group: 59). We further studied the histologic changes of biopsy specimens from positive patch tests to metal salts, and investigated the effect of removal of amalgam in OLL, to clarify whether it is possible to identify patients who will benefit from this procedure.
Patch testing was performed with the German standard series, a dental prosthesis series, and a metal salt series including gold, mercury, and palladium salts as well as other salts of metals used in dental restorations. Late readings (10 and 17 days after application of the patch tests) were performed in all patients.
Of 19 patients with OLL adjacent to amalgam fillings, 15 (78.9%) were sensitized to inorganic mercury (INM), significantly more than those with OLL not adjacent to amalgam, other oral diseases or complaints, and the control group. In 5 of 15 (33.3%) of the patients with OLL, a positive patch test to INM was observed only at D10 or D17. Amalgam was removed in 18 patients with OLL (sensitization to INM: 15), and in 11 patients with OLP (sensitization to INM: 2). After removal, the lesions of 13 of 15 of the INM-sensitized patients with OLL (86. 7%) and 2 with OLP healed or improved significantly, but this was not observed with the INM negative patients. Frequency of sensitization to gold sodium thiosulfate (GST) and palladium chloride 1% pet (PDC) was high in all groups. This was partly because readings were performed late. Lesions of 2 patients with allergic contact stomatitis caused by gold and 1 caused by palladium healed completely after removal of these restorations. Histologically, lichenoid changes were observed in 14 of 36 biopsy specimens of positive patch tests from INM (9/21), GST (2/10), and PDC (3/5) in all patient groups, mainly in persistent patch tests at D10 or D17. This was not observed in 12 biopsy specimens taken from persistent patch tests from other substances, including nickel sulfate.
Our results suggest that sensitization to mercury is an important cause of OLL, whether all lesions or only a part of them are adjacent to amalgam fillings. Sensitization to GST may reflect true gold allergy and should be considered as a cause of oral diseases in some patients. Sensitization to PDC is frequent but has yet only little clinical relevance. Patch tests may be positive only at D10 or D17. This suggests the importance of additional readings of GST, PDC, and mercury salts at this time.
Delayed and immediate hypersensitivity reactions associated with the use of amalgam.
Br Dent J. 2000 Jan 22;188(2):73-6.
McGivern B, Pemberton M, Theaker ED, Buchanan JA, Thornhill MH.
University Dental Hospital of Manchester.
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.
Activation of oral keratinocytes by mercuric chloride: relevance to dental amalgam-induced oral lichenoid reactions
M.C. Little1,2, R.E.B. Watson1, M.N. Pemberton2, C.E.M. Griffiths1, M.H. Thornhill3
British Journal of Dermatology
Volume 144, Issue 5, pages 1024–1032, May 2001
chemokines;cytokines;ICAM-1;lichen planus;lichenoid reaction
Despite the benefits of mercury-containing amalgam dental fillings there are growing concerns regarding the potential adverse health effects arising from exposure to mercury released from fillings. In some individuals this process may result in a local lichenoid reaction of the oral mucosa.
The aim of this study was to investigate the possibility that mercury salts released from amalgam fillings might act directly on oral keratinocytes to induce changes that could promote the development of such lesions.
In vitro experiments were performed in which normal oral and cutaneous keratinocytes were cultured in the presence of mercuric chloride (HgCl2). ICAM-1 expression and the release of cytokines was determined by enzyme-linked immunosorbent assay techniques. T-cell binding to HgCl2-pretreated keratinocytes was assessed using a colorimetric method.
Subcytotoxic concentrations of HgCl2 induced a concentration-related increase in ICAM-1 expression and consequent T-cell binding on oral, but not cutaneous, keratinocytes. HgCl2 also stimulated the release of low levels of tumour necrosis factor-a and interleukin-8 (but not RANTES), and inhibited the release of interleukin-1a by oral keratinocytes.
This study provides evidence that oral keratinocytes may play an integral part in initiating the pathogenesis of amalgam-induced lichenoid reactions.
Oral lichenoid reactions associated with amalgam: improvement after amalgam removal
A. Dunsche1, I. Kästel1, H. Terheyden1, I.N.G. Springer1, E. Christophers2, J. Brasch2
British Journal of Dermatology
Volume 148, Issue 1, pages 70–76, January 2003
contact allergy;dental amalgam;oral lichen planus;oral lichenoid reaction;patch test
Background The pathogenetic relationship between oral lichenoid reactions (OLR) and dental amalgam fillings is still a matter of controversy.
Objectives To determine the diagnostic value of patch tests with amalgam and inorganic mercury (INM) and the effect of amalgam removal in OLR associated with amalgam fillings.
Methods In 134 consecutive patients 467 OLR were classified according to clinical criteria. One hundred and fifty-nine biopsies from OLR lesions were histologically diagnosed according to the World Health Organization criteria for oral lichen planus (OLP) and compared with 47 OLP lesions from edentulous patients without amalgam exposure. One hundred and nineteen patients were patch tested with an amalgam series. In 105 patients (357 of 467 lesions) the amalgam fillings were removed regardless of the patch test results and OLR were re-examined within a follow-up period of about 3 years. Twenty-nine patients refused amalgam removal and were taken as a control group.
Results Eleven patients with OLR (8·2%) had skin lesions of lichen planus (LP). Histologically, the lesions in the OLR group could not be distinguished from those seen in the OLP group. Thirty-three patients (27·7%) showed a positive patch test to INM or amalgam. Amalgam removal led to benefit in 102 of 105 patients (97·1%), of whom 31 (29·5%) were cured completely. Of 357 lesions, 213 (59·7%) cleared after removal of amalgam, whereas 65 (18·2%) did not improve. In the control group without amalgam removal (n = 29) only two patients (6·9%) showed an improvement (P < 0·05). Amalgam removal had the strongest impact on lesions of the tongue compared with lesions at other sites (P < 0·05), but had very little impact on intraoral lesions in patients with cutaneous LP compared with patients without cutaneous lesions (P < 0·05). Patients with a positive patch test reaction to amalgam showed complete healing more frequently than the amalgam-negative group (P < 0·05). After an initial cure following amalgam removal, 13 lesions (3·6%) in eight patients (7·6%) recurred after a mean of 14·6 months.
Conclusions Of all patients with OLR associated with dental amalgam fillings, 97·1% benefited from amalgam removal regardless of patch test results with amalgam or INM. We suggest that the removal of amalgam fillings can be recommended in all patients with symptomatic OLR associated with amalgam fillings if no cutaneous LP is present.
Oral lichenoid lesions (OLL) and mercury in amalgam fillings.
Contact Dermatitis. 2003 Feb;48(2):74-9.
Wong L, Freeman S.
Skin and Cancer Foundation, Darlinghurst NSW, Australia.
84 patients with oral lichenoid lesions (OLL) were seen in the contact dermatitis clinic. All these patients had reticulate, lacy, plaque-like or erosive lichenoid changes adjacent to amalgam fillings. Patch testing to metallic mercury, 0.1% thimerosal, 1% ammoniated mercury, 0.1% mercuric chloride, and in some cases 0.05% phenylmercuric nitrate and amalgam discs was undertaken. 33 (39%) patients had positive patch test findings. 30/33 patch test positive patients had replacement of their amalgam fillings, with 28 (87%) patients experiencing improvement of symptoms and signs within 3 months. This confirms that mercury allergy is a factor in the pathogenesis of OLL in some cases. In cases where patch test negative patients improve with amalgam replacement, mercury may be acting as an irritant in the pathogenesis of OLL.
Amalgam-contact hypersensitivity lesions and oral lichen planus.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 Mar;95(3):291-9.
Thornhill MH, Pemberton MN, Simmons RK, Theaker ED.
The purpose of this study was to investigate the relationship between amalgam restorations and oral lichen planus.
Eighty-one patients with oral lichenoid lesions were characterized clinically and skin patch tested for amalgam or mercury hypersensitivity. Thirty-three of these patients had amalgam fillings in contact with oral lesions replaced and were followed to determine the outcome.
Clinically, 2 patient groups were identified: (1) 30 patients with probable amalgam-contact hypersensitivity lesions (ACHLs) and (2) 51 patients with oral lichen planus (OLP) but no clear relationship with amalgam. Seventy percent of ACHL cases were patch test positive for amalgam or mercury compared with only 3.9% of OLP cases (P < .0001). Amalgam replacement resulted in lesion improvement in 93% of ACHL cases. No such improvement was observed in the OLP cases treated (P < .001).
OLP is a heterogeneous condition within which an ACHL subgroup can be identified. ACHLs, but not other OLP lesions, respond favorably to amalgam replacement. A strong clinical association between lesions and amalgam restorations plus a positive patch test result was a good predictor of lesion improvement on amalgam replacement.
Lichenoid reactions of murine mucosa associated with amalgam
A. Dunsche1, M.P. Frank2, J. Lüttges3, Y. Açil1, J. Brasch4, E. Christophers4, I.N.G. Springer1
British Journal of Dermatology
Volume 148, Issue 4, pages 741–748, April 2003
contact allergy;dental amalgam;histology;oral lichen planus;oral lichenoid reaction;patch test
Background In 97% of all patients with oral lichenoid reactions (OLR) associated with dental amalgam a removal of the fillings leads to a decline of the lesions, as a minimum.
The aim of this study was to determine if contact allergic or local toxic effects or both may contribute to OLR using an animal model with mercury-sensitive and non-sensitive rats.
Twenty Brown Norway rats, which have a genetic predisposition for an autoimmune syndrome after exposure to mercury and 20 Lewis rats, not mercury sensitive, were treated as follows: 10 animals of each group were sensitized with a low dose of mercuric chloride. Half of all animals received local exposure of the right buccal mucosa to amalgam (left: control), the others to amalgam alloy free of mercury. All rats were patch tested with an amalgam series.
After 20 days of exposure 96% of all animals showed white mucosal lesions restricted to the contact zone of the alloy on the treated side, but only up to 25% had a positive patch test reaction to amalgam or inorganic mercury (INM). The lesions showed no relation to species, alloy, sensitization or patch test reaction.
While allergic mechanisms may contribute to mucosal contact lesions in Brown Norway rats, this is less probable in Lewis rats. Mercury in general appears to be irrelevant in the development of ORL in this study. If this holds true for humans as well, patch testing with an amalgam series may be helpful in a minor fraction of all patients with OLR.
A case of lichen planus caused by mercury allergy
British Journal of Dermatology
Y. Kato1, R. Hayakawa1, R. Shiraki1, K. Ozeki2
Volume 148, Issue 6, pages 1268–1269, June 2003
Oral lichenoid lesions and contact allergy to dental mercury and gold.
Contact Dermatitis. 2003 Nov;49(5):264-5.
Athavale PN, Shum KW, Yeoman CM, Gawkrodger DJ.
Department of Dermatology, Royal Hallamshire Hospital, Sheffield, UK.
Oral Lichen Planus and Allergy to Dental Amalgam Restorations
Archives of Dermatology. 2004;140:1434-1438.
Ronald Laeijendecker, MD; Sybren K. Dekker, MD, PhD; Piet M. Burger, MD; Paul G. H. Mulder, PhD; Theodoor Van Joost, MD, PhD; Martino H. A. Neumann, MD, PhD
To determine contact allergies in patients with oral lichen planus and to monitor the effect of partial or complete replacement of amalgam fillings following a positive patch test reaction to ammoniated mercury, metallic mercury, or amalgam.
In group A (20 patients), the oral lesions were confined to areas in close contact with amalgam fillings. In group B (20 patients), the lesions extended 1 cm beyond the area of contact with amalgam fillings. In group C (20 patients), the oral lesions had no topographic relationship with amalgam fillings. Partial or complete replacement of amalgam fillings was recommended if there was a positive patch test reaction to ammoniated mercury, metallic mercury, or amalgam. Control group D (20 patients) had signs of allergic contact dermatitis.
Amalgam fillings were replaced in 13 patients of group A, with significant improvement. Dental amalgam was replaced in 8 patients of group B, with significant improvement. In group C, amalgam replacement in 2 patients resulted in improvement in 1 patient. These results were evaluated after 3 months. No positive patch test reactions to mercury compounds were found in patients with concomitant cutaneous lichen planus and in group D.
Contact allergy to mercury compounds is important in the pathogenesis of oral lichen planus, especially if there is close contact with amalgam fillings and if no concomitant cutaneous lichen planus is present. In cases of positive patch test reactions to mercury compounds, partial or complete replacement of amalgam fillings will lead to a significant improvement in nearly all patients.
Healing of oral lichenoid lesions after replacing amalgam restorations: a systematic review.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004 Nov;98(5):553-65.
Issa Y, Brunton PA, Glenny AM, Duxbury AJ.
University Dental Hospital of Manchester, England, UK.
We sought to systematically review the literature related to oral lichenoid lesions (OLLs) and amalgam restorations.
Cohort and case-controlled studies (no randomized controlled trials or controlled clinical trials available) were reviewed with respect to inclusion criteria and data on patients with OLLs, treatment interventions, and the measurement of outcomes.
Fourteen cohort and 5 case-controlled trials met the criteria. The study population consisted of 1158 patients (27% male and 73% female; age range, 23-79 years). From 16% to 91% of patients had positive patch test results for at least 1 mercury compound. Of 1158 patients, 636 had to have their restorations replaced. The follow-up period ranged from 2 months to 9 1/2 years. Complete healing ranged from 37.5% to 100%. The greatest improvements were seen in lesions in close contact with amalgam.
Protocols must be standardized to obtain valid results. The replacement of amalgam restorations can result in the resolution or improvement of OLLs. Patch testing seems to be of limited value. The topographic relationship between an OLL and an amalgam restoration is a useful--but not conclusive--marker.
Lichenoid reaction associated to amalgam restoration.
Med Oral Patol Oral Cir Bucal. 2004 Nov-Dec;9(5):423-4; 421-3.
Segura-Egea JJ, Bullón-Fernández P.
Hypersensitivity to mercury associated with amalgam restorations may occur and present in one of two different ways. Most commonly it presents as an oral lichenoid reaction affecting oral mucosa in direct contact with an amalgam restoration and represents a delayed, type IV, cell mediated immune response to mercury or one of the other constituents of the dental amalgam. We report a case of oral lichenoid reaction associated to amalgam restoration. A 38 year-old woman presented a caries lesion of tooth #37. A Blacks class I preparation was performed and filled with amalgam. After 19 months, intra-oral examination revealed atrophic lesion, lightly erythematous, affecting the left buccal mucous. The lesion contacted directly with the amalgam restoration in the lower first molar. The right buccal mucosa was normal. His medical history was unremarkable, he was taking no medication and had no known allergies. However, the patient had felt certain rare sensation in that zone when eating sharp meals. Biopsy showed histological changes compatible with oral lichen planus. The patient decided not to change again the restoration, because she did not have important annoyances and she did not wish to be treated again. Other restorations were performed with composite resins, and no reaction was evidenced in the mucosa.
Oral lichenoid lesions and allergy to dental materials.
Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2007 Dec;151(2):333-9.
Ditrichova D, Kapralova S, Tichy M, Ticha V, Dobesova J, Justova E, Eber M, Pirek P.
Dental materials, oral hygiene products and food additives may cause contact allergic reactions in the mouth with varied clinical presentation. Oral lichenoid lesions (lichen planus-like lesions) can be induced by hypersensitivity to dental restorative metals, acrylates, flavorings and other substances.
The aim of this study was to demonstrate contact allergy to dental materials in patients with oral lichenoid lesions using patch tests.
PATIENTS AND METHODS:
Routine patch tests with two sets of allergens - "European Standard" and "Dental Screening" (Chemotechnique Diagnostics, Sweden) supplemented with pulverized amalgam, iridium, indium, menthol, sorbic acid and platinum were done on a set of 25 patients with lichenoid lesions located on the buccal mucosa, tongue and lips. Application and interpretation of the tests were conducted according to ICDRG (International Contact Dermatitis Research Group).
15 (60 %) patients showed sensitization to 1 or more allergens, with a total of 31 positive reactions. The greatest frequency of positive reactions was to dental metals, with a total of 27 positive reactions. The order of tested metals according to frequency of positive reactions was mercury (6/25/24 %), amalgam (6/25/24 %), nickel (4/25/16 %), palladium (4/25/16 %), cobalt (3/25/12 %), gold (2/25/8 %), chrome (1/25/4 %), indium (1/25/4 %). The clinical relevance of the results with regard to the material's presence in the mouth was demonstrated in 11 (44 %) patients. In 9 patients, replacement of the positively tested materials led to healing or to significant regression of mucosal changes.
The results of the patch tests showed the possible contribution of contact sensitization in the pathogenesis of lichenoid manifestations in the oral cavity. Due to the premalignant character of these lesions, replacement of positively tested materials and follow up of these patients is advised.
Association between oral lichenoid reactions and amalgam restorations.
Journal of the European Academy of Dermatology and Venereology. 2008 Nov;22(10):1163-7. Epub 2008 Apr 3.
Pezelj-Ribaric S, Prpic J, Miletic I, Brumini G, Soskic MS, Anic I.
This study examined the association between oral lichenoid reactions (OLR) and amalgam restorations in 20 patients with OLR compared to 20 healthy volunteers. Study subjects were skin patch tested and salivary levels of IL-6 and IL-8 were measured. Sixteen out of 20 patients demonstrated a contact allergy to inorganic mercury or amalgam. IL-6 and IL-8 levels were significantly elevated in the OLR group compared to the health volunteer group. The authors did not report exposure to any other drugs which may have caused the localized allergic reaction. All patients with OLR had their amalgam restorations replaced. The authors report that 16 patients experienced complete healing of their lesions, 3 showed a marked improvement and 1 showed no improvement. IL-6 and IL-8 levels reportedly dropped significantly following amalgam replacement. The follow-up was from 3 months to 3.5 years after amalgam replacement. The subjects all had their fillings replaced (there was no control group with OLR and no treatment). Therefore it's possible that the lesions resolved on their own and not as a result of amalgam removal. The authors concluded that OLR is associated with a localized allergic reaction to the mercury in amalgam fillings.
The aim of this study was to perform a clinical assessment of the association between oral lichenoid reactions (OLR) and amalgam restorations and to determine the salivary concentrations of interleukin-6 (IL-6) and IL-8 before and after replacement of the amalgam restorations.
The study included 20 patients with OLR and 20 healthy volunteers, who were examined between 2001 and 2005 at the Oral Medicine Unit of the Medical Faculty University of Rijeka. All patients were skin patch tested by an experienced physician. Saliva samples were collected, prepared and analysed for IL-6 and IL-8 concentrations using enzyme-linked immunosorbent assay.
Sixteen out of 20 patch-tested patients showed a sensitization to inorganic mercury or amalgam. Total replacement of all amalgam fillings was carried out on 20 patients with fillings based on composite resin, gold, porcelain or a combination of these. Sixteen out of 20 patients showed complete healing of OLR; three patients had marked improvement, whereas one patient showed no improvement. Levels of IL-6 detected before replacement were significantly higher than IL-6 levels following the replacement (P = 0.003). The IL-8 levels measured before replacement procedure were significantly higher than the IL-8 levels after replacement of the fillings (P < 0.001).
On the basis of clinical observations, restorative therapy resulted in tissue healing. Following the replacement of amalgam fillings with fillings based on other restorative materials, levels of both IL-6 and IL-8 shifted towards normal, as measured in healthy subjects.
Oral lichenoid reaction associated with tin component of amalgam restorations: a case report.
The American Journal of Dermatopathology 2010 Feb;32(1):46-8.
Aggarwal V, Jain A, Kabi D.
This case report describes a twenty three year old man with bilateral oral lichenoid reaction. Histopathological features were compatible with lichenoid mucositis. Patch test resulted in positive response to amalgam powder and tin. The amalgam restorations were removed and the teeth were restored with a temporary material which was eventually replaced with a light-cured composite resin. The lesion was resolved after one month and was still absent at the six month review.
Amalgam or its components may cause type IV hypersensitivity reactions on the oral mucosa. Majority of the reported cases involved a delayed hypersensitivity to mercury. A case of bilateral oral lichenoid reaction is presented, which was present in relation to amalgam restorations. Histopathological features were compatible with lichenoid mucositis. Patch test was positive with pulverized amalgam and tin. The lesion healed up after replacement of restorations with an intermediate restorative material. The clinician should be aware of all possible pathological etiologies of white lesions. If there is any doubt about the nature or management of an unusual oral lesion, referral to appropriate specialists is mandatory.