|Year : 2016 | Volume
| Issue : 4 | Page : 274-277
Oral lichenoid contact reaction to a complete denture: A rare case report
SK Rath, Mukherji Arnav
Department of Periodontology, Army Dental Centre Research and Referral, New Delhi, India
|Date of Web Publication||15-Nov-2016|
Dr. Mukherji Arnav
15/202, Heritage Apartments, On DBP Road, Yelahanka, Bengaluru - 560 064, Karnataka
Source of Support: None, Conflict of Interest: None
Various restorative materials used in dentistry may cause contact allergy reactions in mouth. The pathogenic relationship between oral lichenoid reaction (OLR) and dental materials has been confirmed many times. This case reports occurrence and management of OLR to acrylic material.
Keywords: Contact allergy, oral lichen planus, oral lichenoid reaction
|How to cite this article:|
Rath S K, Arnav M. Oral lichenoid contact reaction to a complete denture: A rare case report. Int J Health Allied Sci 2016;5:274-7
|How to cite this URL:|
Rath S K, Arnav M. Oral lichenoid contact reaction to a complete denture: A rare case report. Int J Health Allied Sci [serial online] 2016 [cited 2022 Sep 30];5:274-7. Available from: https://www.ijhas.in/text.asp?2016/5/4/274/194133
| Introduction|| |
Oral lichenoid reaction (OLR) or oral lichenoid lesion (OLL) is a term that represents a common end point in response to extrinsic agents (materials, allergens), altered self-antigens, or superantigens. OLL is thus used to describe eruptions of the oral cavity having an identifiable etiology, which are clinically and histologically similar to oral lichen planus (OLP).
In the literature, different terms are used to refer to these lesions. OLRs have sometimes been considered as the part of OLP, and have also been described as contact allergies, OLL,, or contact lesions. The term OLR was proposed by Finne et al. in 1982 to designate clinically indistinguishable lesions of OLP. OLRs may also result from systemic drug exposure, termed as oral lichenoid drug reaction (OLDR), or local allergic contact hypersensitivity, termed as oral lichenoid contact reaction (OLCR). OLL share common clinical and histological features to OLP, which is an autoimmune disorder exaggerated in the oral cavity.
Since this concept was proposed, these lesions have been described as a response to a wide variety of triggering factors and said to involve several clinical types. OLR presenting as contact stomatitis relates to immune-mediated hypersensitivity. These have been discovered to be in direct topographic relation with dental restorative materials, most commonly with amalgam. Although OLRs related to nonmetallic dental materials are notably less frequent than those to metallic materials, cases presenting the reaction to denture base materials, dental cements, endodontic irrigants have been documented.
Here, is a report that presents such an exceptional case of oral soft tissue contact reaction to acrylic base denture material in the form of a soft tissue enlargement occupying the vestibule.
| Case Report|| |
A 56-year-old female patient, wife of a retired personnel, reported to the Department of Periodontology, with the chief complaint of swelling in the upper front gums for the past 3 months and difficulty in wearing dentures due to the same reason. The history of present illness revealed that the patient was asymptomatic 3 months back and the present complaint started with mild pain in the upper front gums, following which the patient noticed redness in the region. A painless growth appeared in the region which grew to the present size over the past 3 months.
On eliciting the medical history, the patient reported no underlying disease or conditions for which she is seeking, or has undergone any medical consultation. She was not on any medications, no admissions to hospital or a day care facility in the last 6 months, and reported to be otherwise systemically healthy. She gave a history of uneventful childbearing and delivery twice, and attainment of menopause at the age of 45 years.
Dental history revealed multiple tooth extractions over the past 20 years. The prime reason for the extractions was dental caries and tooth mobility. She had been using dentures for the past 2 years.
Family history was noncontributory. On general physical examination, she was moderately built, adequately nourished, and with erect posture. There were no clinical signs of anemia, cyanosis, or icterus. Extraoral examination revealed a bilaterally symmetrical face with no sinus, swelling, or scar. A convex lateral facial profile, 5 cm of mouth opening and competent lips at rest were noted. Temporomandibular joint was normal on palpation and visual examination.
Dental examination revealed completely edentulous maxillary arch and partially edentulous mandibular arch with the presence of anteriors and first premolars bilaterally. The patient wore upper a complete denture and a partial lower denture for the past 2 years. On examining the dentures, it was noticed that the maxillary dentures were slightly overextended at the labial vestibular area.
The buccal and labial mucosa was normal in color, contour, and consistency. A mucosal overgrowth was observed in the upper anterior vestibular area on either side of the labial frenum [Figure 1]a and b. The lesion was pink and in confluence with the adjoining mucosa, the size measured at approximately 2 cm in length, 1 cm in width, and 0.5 cm in breadth. The lesion was pedunculated, nontender, nonpulsatile, and firm in consistency on palpation. The mucosal attachment was free from the underlying bone and freely movable with the mucosal retraction. Radiographic analysis was performed using orthopantomogram and intraoral periapical radiograph of the involved site. No osseous lesions or pathology was noted [Figure 2].
|Figure 1: (a) Mucosal overgrowth in the upper anterior vestibular area, (b) mucosal overgrowth in either side of frenum|
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Based on the patient's history, clinical and radiographical examination, a provisional diagnosis of a soft tissue fibroma due to chronic denture irritation was arrived at. A unilateral excisional biopsy of the lesion of the right side, followed by histological examination was planned to arrive at a correct diagnosis. Initially, only one lesion was undertaken for biopsy to diagnose the lesion and to avoid additional postoperative morbidity and discomfort to the patient.
A complete hematological analysis including complete blood count, international normalized ratio, activated partial thromboplastin time, and fasting/postprandial blood glucose estimation was carried out, and results were normal.
The surgical site was prepared with extraoral disinfection by 5% Povidine-iodine scrub and intraoral 0.2% chlorhexidine rinse. Local anesthesia in the form of ring infiltration with 2% lignocain HCL with 1:80000 adrenaline was administered by a 30-gauge needle, circumferentially around the lesion in the healthy mucosa.
A 15c blade was used to give a full thickness incision surrounding the lesion on all sides. The incision included 2 mm of healthy, uninvolved mucosa on the lesion periphery [Figure 3]a. The full thickness incision and the involvement of the healthy tissue in the incision design, assured the removal of the lesion in total [Figure 3]b, failure of which could lead to relapse. The surgical site was sutured with interrupted 3-0 silk, and healing by primary intention was aimed [Figure 3]c. The patient was advised to discontinue wearing dentures and not to brush on the operated site till the removal of the sutures. Analgesics in the form of ibuprofen 400 mg twice daily for 2 days and mouth rinse with 0.2% chlorhexidine gluconate twice daily for 1 week were prescribed. The patient was recalled after 24 h to check for any uneventful morbidity, which was ruled out and suture removal was planned 10 days postoperatively.
|Figure 3: (a) Incision given, (b) complete removal of overgrowth done, (c) sutures placed|
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The excised tissue measuring 1.5 cm by 1 cm [Figure 4]a and b was immediately fixed and transported in 10% formalin solution, to the Department of Pathology, Army Hospital Research and Referral Delhi Cantt, for histological examination.
|Figure 4: (a) The excised tissue measuring 1.5 cm by 1 cm, (b) the excised tissue measuring 1.5 cm by 1 cm|
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The histological analysis of H and E stained section of the lesion revealed squamous cell epithelial lining showing acanthosis and focal elongation of rete pegs in "saw tooth-" shaped pattern. Two distinct patterns of plasma cell infiltration in the dermo-epidermoid junction were seen - one dense and focal and the other scant to moderate diffuse. Dermal edema with no evidence of malignancy was noted. The lesion was identified as a lichenoid reaction [Figure 5]. Based on patient medical and dental history, a diagnosis of OLCR to dental material, that is, acrylic based denture material was arrived at.
|Figure 5: H and E section showing patterns of plasma cell infiltration in the dermo-epidermoid junction. No evidence of malignancy were noted|
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The patient was informed and advised to discontinue wearing dentures till the complete healing of the surgical site. Ten days postoperatively, suture removal was done [Figure 6]a. One month postoperative evaluation revealed satisfactory healing without keloid formation [Figure 6]b.
|Figure 6: (a) Postoperative view after 10 days, (b) postoperative view after 1 month without any keloid formation|
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| Discussion|| |
The etiology of lumbar puncture is still under discussion, with a tendency to self-immunity, whereas the etiology of OLRs is related to the contact with specific agents, such as metallic restorative materials, resins, and drugs, allowing the establishment of a cause-effect relationship.
In this case, the tissue alteration is thought to be caused by the antigen fixation in the keratinocytes, which are recognized and destructed by cells of the immune system., Denture base dental materials play a fundamental role in the appearance of OLCR in the oral mucosa. The reaction to resin materials was reported by Blomgren et al. Ali et al. studied hypersensitivity to acrylic denture base material, and noted the resolution of the lesions of mouth after removal of the prosthesis.
Lesions of OLCR in relation to dental acrylic prosthesis are located in opposition or near proximity to the denture base, and lesions are limited to such sites of contact. Typical sites include the lateral borders of the tongue and buccal/labial mucosa and the buccal/labial vestibular areas. Van der Meij and van der Waal proposed modified WHO criteria according to which OLP could be diagnosed only in cases when both clinical and histopathological criteria are fulfilled, whereas in other cases, the disorder should be considered as OLL.
In the case discussed, the denture flange at the maxillary labial vestibule was evaluated to be a bit overextended. This might have caused repeated impingement of the approximating soft tissue, causing a frank lesion. The lesion with increased vascularity on contact with the denture material might have caused the exuberant lichenoid response as presented. The histological analysis confirmed the typical lichenoid characteristics of the lesion and helped to arrive at the definitive diagnosis.
Not all patients with OLP manifest with the classical bilateral white striae. In such situations, clinicians and pathologists must exercise prudence in blindly branding the lesion as OLL by strict adherence to the 2003 modified criteria. The nonrecurrence of the lesion after the excision of the same and advice of discontinuing the wearing of denture is in accordance to the study by Ali et al.
| Conclusion|| |
Lichenoid lesions of the oral mucosa present a diagnostic challenge. It may be difficult to distinguish OLP, OLDR, and OLCR on the basis of clinical and/or histological findings. It is essential to obtain a thorough history and perform a complete mucocutaneous examination in addition to specific diagnostic testing (i.e., direct immunofluorescence, indirect immunofluorescence, and cutaneous patch testing). In general, OLDR and OLCR resolve once the causative agent has been discontinued.
The authors would like to acknowledge Col (Retd.) MK Mukherji, Mrs. S Mukherji, and Dr. Siddharth Mukherji for their valuable help.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]