Contact Stomatitis Clinical Presentation

Acute contact stomatitis is easily correlated to the causative agent; however, contact stomatitis most frequently presents as a chronic condition. Tracing the relationship between contact stomatitis and causative factors is difficult. The presence of lip and perioral eczema aids in making the diagnosis. Symptoms of contact stomatitis include the following:

• Burning sensation
• Pain
• Paresthesia
• Numbness
• Bad taste
• Excessive salivation
• Perioral itching

Possible clinical presentations of contact stomatitis include erythematous lesions, erosions/ulcerations, leukoplakialike lesions, oral lichenoid reactions, contact urticaria, burning mouth syndrome, geographical tongue, intense itching of the tongue, and orofacial granulomatosis. The disease may improve after removal of responsible sensitizers.^[4]

• Erythematous lesions of contact stomatitis

  • These lesions are often associated with swelling.
  • They may be localized or diffuse.
  • Common causes include ingredients of mouthwashes and toothpastes, dental materials, and chewing gum flavorings.
  • A burning sensation is a common complaint.
• Erosions/ulcerations of contact stomatitis

  • Erosions/ulcerations are usually painful; they represent the evolution of vesicles and blisters rarely seen in the mouth.
  • Erosions appear as outlined, whitish, rough, macerated areas. Ulcerations are usually covered by a yellow-white exudate and may present with an erythematous halo.
  • Chemical burns are not frequent because the oral mucosa is resistant to heat and acid or alkaline compounds.
  • Possible causes include accidental ingestion of caustic agents, prolonged contact with aspirin or vitamin C tablets, or contact with irritants used for dental care.
  • Allergic contact stomatitis from metal salts or acrylates rarely causes mouth ulcerations.
• Leukoplakialike lesions of contact stomatitis

  • Contact sensitization from nickel and other metals occasionally produces whitish hyperkeratotic lesions that clinically resemble leukoplakia.
  • Leukoplakialike lesions are asymptomatic and are commonly localized in the medial part of the cheek (see the image below).Leukoplakialike lesion in a patient who is allergic to mercury.
• Oral lichenoid reactions of contact stomatitis

  • Lesions that resemble reticular or erosive lichen planus may occur at the site of mucosal contact with amalgam restorations (see the image below).^{[5, 6]} Lichen planus–like lesion adjacent to a dental restoration.
  • These lesions are typically localized.
  • Patients often have a positive patch test result to mercury.^{[7, 8]}
  • Removal of restorations in patients with positive patch test results to mercury usually produces complete regression of the lichenoid lesions, especially when they are in close contact with amalgam fillings. Dental restoration removal occasionally improves the lesions even in patients with negative patch test results, if no cutaneus lichen planus is present.
  • Sensitization to gold, palladium chloride, and copper sulfate has also been associated with oral lichenoid reactions.
• Contact urticaria

  • Swelling of the lips, the tongue, the buccal mucosa, and the gingiva develops suddenly with intense itching.
  • Severe cases may be associated with upper airway obstruction.
  • Contact urticaria from latex occurs in patients undergoing dental treatment due to contact with gloves and dental dams.
  • Latex sensitization is more common in patients with atopy and in children who have had multiple operations (eg, patients with spina bifida).
  • Patients with latex sensitization may experience a severe type I immunoglobulin E–mediated allergy after ingestion of some fruits and vegetables, especially chestnuts, banana, avocado, and kiwi fruit (latex-fruit syndrome), due to cross-reactivity between latex allergens and plant-derived food allergens.
  • Contact urticaria is rarely due to allergy to foods (see the image below).Contact urticaria of the lip due to food allergy.
• Burning mouth syndrome^{[9, 10]}

  • Burning mouth syndrome is characterized by a burning sensation and dryness of the oral mucosa in the absence of objective signs.
  • Symptoms typically improve during meals.
  • Although contact allergy (especially to mercury) has often been implicated, the disorder most likely has a psychogenic basis.
• Orofacial granulomatosis

  • Orofacial granulomatosis can be worsened by contact allergy to mercury, gold, or foods.
  • The disease may improve after removal of responsible sensitizers.

Possible causes of irritant or allergic contact stomatitis include the following:

• Ingredients of dentifrices, mouthwashes, and dental cleaners (rare)^[11]
• Flavoring agents (eg, cinnamon compounds, eugenol, menthol)^[12]
• Colophony in dental floss and denture adhesives^{[13, 14]}
• Antimicrobials (eg, chlorhexidine, quaternary ammonium compounds)
• Ingredients of candies and chewing gums

  • Flavoring agents (rare) (cinnamon compounds, menthol)
  • Propolis (a strong sensitizer often used in the oral cavity because of its antiseptic properties)
• Cosmetic ingredients (fragrance and preservatives) - Common cause of contact cheilitis^[15]
• Ingredients of dental restorations^{[16, 17]}

  • Amalgam fillings contain mercury compounds (45-60%) and often gold, palladium, and platinum.^{[18, 19, 20, 21, 22, 23, 24]}
  • Metallic and ammoniated mercury are common sensitizers.
  • Dental cement used for sealing pulp canals may contain eugenol, balsam of Peru, and colophony.
  • Acrylic fillings rarely cause problems in dental patients because polymerization of the resin occurs without contact between the sensitizing acrylic monomers and the oral mucosa, and the final polymerized acrylate is relatively free of allergens.
• Ingredients of dental prosthesis^[25]

  • Metal prostheses may release nickel, especially when they are poorly made or corroded (see the image below).Allergic contact stomatitis on the gingiva in a patient with a positive patch test result to nickel, palladium, and mercury.
  • Nickel is also present in dental braces, bridges, and crowns (see the image below).Allergic contact reaction due to nickel in a dental brace.
  • Stomatitis from acrylates is rare. Acrylate sensitization is a common occupational problem in dentists and dental technicians. It has been reported in 2-3% of dental patients.^[26]
• Topical drugs, such as antibiotics, anesthetics, antiseptics, and steroids, may cause sensitization.
• Rubber (eg, gloves, dams, orthodontic elastics, bite blocks) may cause sensitization.^[27] Latex allergy is not rare (see the images below). Contact urticaria of the tongue in a patient with latex allergy. Close-up view of contact urticaria of the tongue in a patient with latex allergy.
• Foods^[28]

  • Foods rarely cause contact stomatitis.
  • Children with atopic dermatitis and a food allergy may develop contact urticaria with lip swelling and stomatitis after contact with foods, especially fruits (eg, fruits of the Rosaceae family [eg, apple, peach, pear] in patients with birch pollinosis).
  • Food allergy can worsen granulomatous cheilitis.
• Ingredients in cosmetics, lipsticks, lip balms, and the sunscreens in these products (eg, propolis, ricinoleic acid, colophony derivatives) may cause contact stomatitis (see the images below). Acute allergic stomatitis involving the oral mucosa and the lip due to benzocaine. Allergic contact dermatitis involving the lips and the perioral area due to propolis.
• Tobacco consumption can be responsible for nicotine stomatitis, black hairy tongue, periodontal disease, and contact stomatitis.^{[29, 30]}