Physical Examination

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.^[45]The disease may improve after removal of responsible sensitizers.^[46]

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.

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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).^{[47, 48]}

Lichen planus–like lesion adjacent to a dental restoration.

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These lesions are typically localized. Patients often have a positive patch test result to mercury.^{[49, 50]}

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. A 2015 study suggests that palladium-sensitized patients should always undergo an oral examination, with particular attention to the presence of/exposure to dental crowns.^[51]

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.

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Burning mouth syndrome

Burning mouth syndrome^{[52, 53]}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 can have a psychogenic basis, with anxiety, if present, usually considered an exacerbating factor rather than a cause.

Orofacial granulomatosis

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

Differential Diagnoses

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Media Gallery

Irritant contact stomatitis of the tongue.
Close-up view of irritant contact stomatitis of the tongue.
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.
Allergic contact reaction due to nickel in a dental brace.
Allergic contact stomatitis on the gingiva in a patient with a positive patch test result to nickel, palladium, and mercury.
Leukoplakialike lesion in a patient who is allergic to mercury.
Lichen planus–like lesion adjacent to a dental restoration.
Contact urticaria of the lip due to food allergy.
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.
Positive patch test result to mercury.
Positive prick test result to latex.

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Author

Antonella Tosti, MD Professor of Dermatology, Department of Dermatology and Cutaneous Surgery, University of Miami, Leonard M Miller School of Medicine

Antonella Tosti, MD is a member of the following medical societies: American Academy of Dermatology, International Society of Dermatology, European Academy of Dermatology and Venereology, Women's Dermatologic Society, Canadian Dermatology Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: PharmaDerm<br/>Received income in an amount equal to or greater than $250 from: Valeant; Pharmaderm.

Coauthor(s)

Massimiliano Pazzaglia, MD, PhD Fellow, Department of Dermatology, University of Bologna, Italy

Disclosure: Nothing to disclose.

Bianca Maria Piraccini, MD, PhD Professor, Chief, Dermatology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna; Chief, Department of Medical and Surgical Sciences, University of Bologna, Italy

Bianca Maria Piraccini, MD, PhD is a member of the following medical societies: American Academy of Dermatology, Council for Nail Disorders, European Academy of Dermatology and Venereology

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Dermatologic/Mohs Surgeon, The Surgery Center at Plano Dermatology

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Drore Eisen, MD, DDS Consulting Staff, Dermatology of Southwest Ohio

Drore Eisen, MD, DDS is a member of the following medical societies: American Academy of Dermatology, American Academy of Oral Medicine, American Dental Association

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

Craig A Elmets, MD Professor and Chair, Department of Dermatology, Director, Chemoprevention Program Director, Comprehensive Cancer Center, UAB Skin Diseases Research Center, University of Alabama at Birmingham School of Medicine

Craig A Elmets, MD is a member of the following medical societies: American Academy of Dermatology, American Association of Immunologists, American College of Physicians, American Federation for Medical Research, Society for Investigative Dermatology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: University of Alabama at Birmingham; University of Alabama Health Services Foundation<br/>Serve(d) as a speaker or a member of a speakers bureau for: Ferndale Laboratories<br/>Received research grant from: NIH, Veterans Administration, California Grape Assn<br/>Received consulting fee from Astellas for review panel membership; Received salary from Massachusetts Medical Society for employment; Received salary from UpToDate for employment. for: Astellas.