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Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 42-45

Oral lichenoid reaction to dental amalgam and its association with desquamative gingivitis “a diagnostic conundrum”: A case report

Department of Periodontics and Oral Implantology, DY Patil School of Dentistry, Navi Mumbai, Maharashtra, India

Date of Submission23-Jan-2021
Date of Acceptance03-Feb-2021
Date of Web Publication04-Mar-2021

Correspondence Address:
Dr. Poonam Rai
Department of Periodontics and Oral Implantology, DY Patil School of Dentistry, Sector 7, Highway Road, Nerul, Navi Mumbai, Maharashtra.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INJO.INJO_4_21

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Oral lichenoid lesions (OLLs) are chronic inflammatory lesions of the oral cavity, and they can hardly be distinguished from oral lichen planus (OLP). Various terms have been used in the literature, including lichenoid contact lesions, lichenoid contact stomatitis, and oral lichenoid reactions. The concept of contact allergy to dental restorative materials in OLLs has been widely recognized but somewhat controversial. The most common causative allergen is mercury in dental amalgam, with a few reported cases from other materials. These lesions are most often seen in direct topographic relation to the causative agent. The possible correlation between the presence of desquamative gingivitis (DG) associated with autoimmune diseases and the worsening of periodontal parameters has been discussed in the literature, since both conditions can share immuno-inflammatory mechanisms in their pathogenesis. The DG may indirectly worsen the accumulation of plaque in the affected sites, since pain and bleeding may inhibit the patient’s oral hygiene. The aim of this report is to present a clinical case of OLLs associated with amalgam restoration and its association with DG for a three-month follow-up period.

Keywords: Contact hypersensitivity, dental amalgam, desquamative gingivitis, oral lichenoid reaction

How to cite this article:
Pande A, Rai P, Shetty D, Dharmadhikari S. Oral lichenoid reaction to dental amalgam and its association with desquamative gingivitis “a diagnostic conundrum”: A case report. Int J Oral Care Res 2021;9:42-5

How to cite this URL:
Pande A, Rai P, Shetty D, Dharmadhikari S. Oral lichenoid reaction to dental amalgam and its association with desquamative gingivitis “a diagnostic conundrum”: A case report. Int J Oral Care Res [serial online] 2021 [cited 2021 Aug 6];9:42-5. Available from: https://www.ijocr.org/text.asp?2021/9/1/42/310725

  Introduction Top

The oral lichen planus (OLP) and lichenoid lesions comprise a group of disorders of the oral mucosa that likely represent a common reaction pattern in response to extrinsic antigens, altered self-antigens or super antigens. Lichenoid lesions have been frequently used to refer to oral lesions that have clinical and histopathological features similar to OLP but no risk of malignant transformation, or to indicate an uncertain diagnosis of OLP. However, definitive clinical and histological diagnostic criteria that are able to distinguish OLP from lichenoid lesions are still lacking.[1] “Oral lichenoid contact lesion” is a term used to describe oral lesions that resemble OLP both clinically and histopathologically but that are believed to be caused by a localized (contact) hypersensitivity reaction to dental restorative materials, mainly amalgam.[2] Materials such as amalgam, polymethylmethacrylate, and resin composites have for long been identified as allergens in a dental setup. Amalgam is the most widely used dental restorative material. However, because of the continuous low-level release of mercury, its safety and wide-scale use have been questioned. In their immunological studies, Laine et al. observed true allergy to mercury. The allergic response is either toxic/ irritative or allergic in nature. The clinical appearance of the oral lichenoid contact lesion has been rarely described in detail. In this case report, we present a patient who presented with DG associated with an oral lichenoid reaction with her clinical findings.

  Case Report Top

A female patient aged 18 years reported to the outpatient department of Periodontics with the chief complaint of bleeding and swollen gums in the lower front region of the jaw. She also complained of burning sensation on eating spicy food. She gave a history of amalgam restorations done in the lower right and left back region of the jaw one year ago. She had a noncontributory medical history and presented with no known allergies.

Intraoral examination divulged an erythematous and inflamed labial and marginal gingiva with interspersed areas of normal gingiva in relation to 31, 32, 33, 41, 42, and 43. The marginal gingiva was scalloped in outline and had rolled-out margins. There was a diffuse area of desquamation and erythema involving the buccal aspect of marginal and attached gingiva. Faint white striae were seen bordering the areas, showing desquamation. The desquamated area showed loss of stippling [Figure 1]A. Soft tissue examination revealed the presence of a reticular, atrophic, white lesion affecting the buccal mucosa and the gingiva of the left and right mandibular molar side [Figure 1]B. Periodontal examination was carried out with a periodontal probe (UNC15, Hu-Friedy), the probing depth was measured, as well as the presence of bleeding during the probing and the plaque index were recorded. Plaque index gave a score of 1.64, giving a fair inference and bleeding index of 2.67. The maximum probing depth recorded was 4 mm with 34. A provisional diagnosis of DG as a manifestation of chronic mucocutaneous disease was given. So, phase 1 therapy was initiated, which included thorough scaling and root planning; patient education and motivation and specific oral hygiene instructions were given. On referral (oral medicine and radiology), Clobetasol Propionate gel 0.05% was prescribed twice daily for four weeks. After four weeks, the patient was recalled and re-evaluated; however, no difference was noted. There was no disappearance of the lesion, and the gingiva still appeared to be inflamed. Reassessment of diagnosis was necessary and, therefore, further investigation was done to know the causative factor. On cross-examination, the patient gave a history of allergy to metallic ornaments. So, a patch test [alloy + Hg] was done on the forearm to determine contact hypersensitivity. After 48h, the patient returned with the complaint of itching on the mixed patch area. When the patch was removed, a slight erythematous reaction was seen. As the patch test was positive and as the lesion also appeared in direct contact with amalgam restorations with 36 and 47 [Figure 1]C, a diagnosis of a lichenoid reaction to dental amalgam was made.
Figure 1: Preoperative view. (A) Diffuse area of desquamation and erythema involving the buccal aspect of free, marginal, and attached gingiva with faint white striae. (B) Left posterior view showing presence of a reticular, atrophic, and white lesion. (C) Amalgam restoration seen with 36 and 47

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  Treatment Plan Top

The patient was informed, and amalgam restoration was immediately replaced with an interim restorative material with 36 and 47. The patient reported after one week. Complete remission of DG and a reduction in the size of the lesion was seen on both sides. A slight reduction of the lesion was seen on the left side after three months. After six months of removal of amalgam restoration, remission of the DG and lesion was observed [Figure 2].
Figure 2: Postoperative view six months after removal of amalgam restoration showing complete healing of the lesion

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  Discussion Top

DG is a descriptive term, indicating inflamed, peeling gingiva.[3] It is characterized by sloughing of the gingival epithelium as a result of the formation and rupture of a vesicle. The gingiva appears to be erythematous and often edematous. The patient experiences discomfort and pain during mastication and often complains of bleeding gums. It is a clinical, non-pathognomonic term rather than a distinct diagnosis and may represent the oral clinical manifestation of various systemic mucocutaneous diseases. These most often include cicatricial (benign mucous membrane) pemphigoid, lichen planus, or pemphigus vulgaris to allergic reactions to a number of chemical products or allergens[4],[5] Amalgam contact hypersensitivity lesions are most often seen in areas that are partially or completely in contact with amalgams. For a contact allergic reaction to be established, mercury salts and other metal ions that are leached from amalgams have to penetrate the epithelial lining and bind with host keratinocyte surface proteins. In susceptible individuals, this results in a cell-mediated response directed at basal keratinocytes.[6] The lesions are most common on the buccal mucosa and lateral surface of the tongue. Oral lichenoid lesions associated with dental amalgam (OLL-DA) represent a late hypersensitivity response to some components of metal alloys, particularly mercury.[7] Clinically and histologically, OLL may be indistinguishable from OLP and present underlying DG.[8] The diagnosis of our case is based on criteria suggested by Al-Hashimi et al.: (1) Clinical presentation, (2) patch test, and (3) results of replacing suspected material. The lesions are usually seen in close contact to the amalgam restoration and are asymmetrically distributed. The case reported had a reticular, atrophic, white lesion affecting the buccal mucosa and the gingiva of the left and right mandibular molar region. The first step in recognition of allergy-induced diseases is a detailed history of the present complaint and the clinical course. Various reports show the use of the patch test in determining mercury sensitivity. Hypersensitivity reactions that are cell mediated, such as contact dermatitis, are demonstrated by using patch testing.[9] However, Issa et al. proposed that the patch test has limited benefits as a predictor of such reactions. A histological analysis could have given us more accurate diagnosis and, therefore, can be a limitation of this study. On the contrary, in a study correlating the clinical and pathological characteristics of OLP with OLL, Stipetić et al found a coincidence of nearly 50% between histological findings and clinical diagnosis, concluding that histological characteristics themselves may not always be exclusive in the interpretation for diagnosis. In our case report, the initial diagnosis was befuddled with OLP; thus, the treatment was initiated accordingly. No difference was noted in the lesion and DG even after phase 1 therapy and corticosteroid therapy as prescribed. This led us to look into a more detailed patient history and clinical examination. The lesion was seen in close proximity with amalgam restorations, and, therefore, a patch test was carried out. A hypersensitivity reaction was seen after 48h and then, immediate replacement of amalgam restoration with an interim restoration was done. After one week, gingiva appeared to be normal with a reduction in the size of the lesion. According to Larsson and Warfvinge,[10] the structure of this lymphoid organ, similar to that of the secondary follicles, is induced in the peripheral tissue by an antigen that is locally responsible for the maintenance of an abnormal immune response. The removal of such antigens, in this case mercury in organic form present in amalgam restorations, would be responsible for its disappearance. Three months after the replacement of the restorations, there was an improvement of the clinical aspect of the buccal mucosa. Montebugnoli et al. and Pawar et al. observed partial or complete remission of the lesions in the three-month period. In the six-month clinical examination, clinical improvement and disappearance of DG were observed.

  Conclusion Top

After replacement of amalgam restoration, the improvement in healing of the DG, with time, strengthens the certainty that it was related to the development of lichenoid lesions associated with dental amalgam, as a hypersensitive response.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Khudhur AS, Di Zenzo G, Carrozzo M Oral lichenoid tissue reactions: Diagnosis and classification. Expert Rev Mol Diagn 2014;14:169-84.  Back to cited text no. 1
Baccaglini L, Thongprasom K, Carrozzo M, Bigby M Urban legends series: Lichen planus. Oral Dis 2013;19:128-43.  Back to cited text no. 2
McCarthy FP, McCarthy PL, Shklar G Chronic desquamative gingivitis: A reconsideration. Oral Surgery 1960;13:1300-13.  Back to cited text no. 3
Sklavounou A, Laskaris G Frequency of desquamative gingivitis in skin diseases. Oral Surg Oral Med Oral Pathol 1983;56:141-4.  Back to cited text no. 4
Lo Russo L, Gallo C, Pellegrino G, Lo Muzio L, Pizzo G, Campisi G, et al. Periodontal clinical and microbiological data in desquamative gingivitis patients. Clin Oral Investig 2014;18:917-25.  Back to cited text no. 5
Thornhill MH Immune mechanisms in oral lichen planus. Acta Odontol Scand 2001;59:174-7.  Back to cited text no. 6
Cavalla F, Biguetti CC, Garlet TP, Trombone APF, Garlet GP Inflammatory pathways of bone resorption in periodontitis. In: Bostanci N, Belibasakis G, editors. Pathogenesis of Periodontal Diseases. New York: Springer Publishing; 2018.  Back to cited text no. 7
Carbone M, Broccoletti R, Gambino A, Carrozzo M, Tanteri C, Calogiuri PL, et al. Clinical and histological features of gingival lesions: A 17-year retrospective analysis in a northern Italian population. Med Oral Patologia Oral Y Cirugia Buccal2015;17:e555.11.  Back to cited text no. 8
Adams S Allergies in the workplace. Curr Opin related to amalgam. Adv Dent Res, Allergy Clin Immunol2006;19:82-6.  Back to cited text no. 9
Larsson A, Warfvinge G Immunohistochemistery of tertiary lymphoid follicles in oral amalgam associated lichenoid lesions. Oral Dis 1998;4:187-93.  Back to cited text no. 10


  [Figure 1], [Figure 2]


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