SECTION EDITORS

H y p e r s e n s i t i v i t y to t e m p o r a r y soft d e n t u r e liners: A clinical report

H u s s e i n S. Zaki, D D S , MS, a K a t a l i n J. K e t z a n , D M D , b and R i c a r d o L. C a r r a u , MD, FACS c University of Pittsburgh, School of Dental Medicine, Pittsburgh, Pa.

T e m p o r a r y soft lining materials are often used during the healing phases after maxillectomy or mandibulectomy and for routine prosthodontic procedures. They are also indicated when the thickness of the oral mucosa is inadequate or when it exhibits a reduced tolerance to the loads applied to it. 1 The two main disadvantages of temporary soft lining materials are the physical properties of the soft lining materials in clinical use and the effect of the oral environment on those properties. Physical properties such as compliance, resilience, dimensional stability, wettability, adhesion to the denture base, porosity, and growth of Candida albicans on the surface make the use of soft lining materials temporary in nature. 16 Denture stomatitis is believed to be caused by parafunctional habits or trauma from ill-fitting dentures. 5-9 Some authors suggest hypersensitivity to components of the denture material, which leads to an allergic response, infection with Candida albicans, or poor oral or denture hygiene. 911 However, Turrel112,13 suggested that residual monomer and the sorption of fluids such as cleansing agents, food, or drugs by the denture base can cause the denture base to acquire antigenic properties. Uncured plastics are responsible for a growing number of dermatoses. 14 Additives, plasticizers, and ultraviolet-light absorbers are common sensitizers in plastics. 14 Additives such as phthalates, maleates, and dimethylaniline are among the common sensitizers. Dibutyl, diethyl, and dioctyl phthalate in the amount of 10 % or more are used as plasticizers and thought to cause sensitivity reactions in polymers. Ultraviolet-light absorbers such as benzophe-

nones and resorcinol monobenzoate in polymers can also cause allergic reactions. ~4 Temporary soft liner materials are supplied as powder and liquid. 2 The powder is poly(ethyl methacrylate) and the liquid may or may not contain monomers such as ethyl, methyl, or n-butyl methacrylate. All temporary soft liners contain 25% to 60% plasticizers such as ethyl glycolate, butyl phthalyl glycolate, or n-butyl phthalate. Patch testing is currently the best method of finding an offending allergen. Properly applied and correctly interpreted patch tests are at present the only scientific "proof" of allergic contact dermatitis. 14 Two treatment approaches for suspected contact dermatitis should be considered4: identification and elimination of the specific allergen and, if needed, antiallergic therapy. CLINICAL REPORT

aAssociate Professor, Department of Prosthodontics and Director of Maxillofacial Prosthodontics Program. bResident, Maxillofacial Prosthodontics Department. CAssistant Professor, Department of Otolaryngology,University of Pittsburgh Medical Center. J PROSTHETDENT1995;73:1-3. Copyright | 1995 by The Editorial Council of THE JOURNALOF PROSTHETICDENTISTRY. 0022-3913/95/$3.00 + O. 10/1/59078

A 70-year-old white woman was diagnosed with squamous cell carcinoma at the junction of the soft and hard palate, which required excision followed by radiation therapy. The patient was edentulous. After operation the patient's denture flanges were reduced, occlusion was adjusted, and the maxillary denture was extended into the defect for temporary obturation. Both dentures were then relined with a soft liner (Viscogel, Dentsply Int., York, Pa.) The soft liner was changed weekly during the healing process and throughout the radiotherapy period. Three weeks after radiotherapy was completed the patient exhibited minor changes in the consistency of saliva with no visible changes in the oral mucosa. The surgical site was completely healed and the patient was able to function well with the relined dentures. Forty-eight hours after one of the patient's regularly scheduled reline appointments the patient had pain and could not insert her dentures. The patient demonstrated manifestations of edema of the midface and concomitant intraoral ulcerations and edema (Fig. 1). The differential diagnosis included lymphedema, superinfection, candidiasis, and hypersensitivity reaction to drugs, food, or the lining material. The referring physician was consulted, the

J A N U A R Y 1995

THE J O U R N A L OF P R O S T H E T I C D E N T I S T R Y

THE J O U R N A L OF P R O S T H E T I C D E N T I S T R Y

ZAKI, KETZAN, AND CARRAU

Fig. 1. Swelling and ulcerations of maxillary alveolus and palate under relined maxillar obturator.

Fig. 2. Patch test of four soft liners. 1, Flexacryl; 2, Soft Oryl; 3, Coe-Comfort; 4, Viscogel.

patient was prescribed an antimicrobial/antifungal medication, and she was instructed not to wear the dentures except for eating. After 48 hours the swelling and ulcerations in the mouth intensified with the development of mucosal sloughing. A patch test of the soft liner material was performed by placing a sample of Viscogel temporary soft liner material on the forearm with adhesive tape and leaving it in place for 48 hours. Vesicular erythema developed over the forearm

where the Viscogel material had been applied. A second patch test was done with four different soft liners (Table I). Fig. 2 and 3 illustrate the results of the second patch test of all four soft liner materials. The soft liner was consequently changed to Coe-Comfort liner (Coe-Comfort, GC America Inc., Chicago, Ill.), which was the only material that did not provoke an allergic reaction. After complete healing the denture was rebased in heat-processed acrylic resin following customary procedures.

VOLUME 73

NUMBER 1

ZAKI, KETZAN, AND CARRAU

THE JOURNAL OF PROSTHETIC DENTISTRY

F i g . 3, R e s u l t s of p a t c h t e s t in Fig. 2 a f t e r 48 hours.

CONCLUSIONS

Table

I. Soft l i n e r p r o d u c t s in s t u d y
Manufacturer Ingredients

1. D e n t u r e s t o m a t i t i s is b e l i e v e d to b e c a u s e d b y p a r a f u n c t i o n a l h a b i t s , t r a u m a f r o m ill-fitting d e n t u r e s , p o o r oral d e n t u r e h y g i e n e , or i n f e c t i o n f r o m C a n d i d a albic a n s . T h e c o n c e n t r a t i o n s of r e s i d u a l m o n o m e r a n d t h e s o r p t i o n of c l e a n i n g a g e n t s , i n g e s t e d food, or d r u g s c a n also b e o f f e n d i n g factors. Allergic s t o m a t i t i s t o m a t e r i a l s u s e d i n d e n t u r e s s h o u l d b e d i f f e r e n t i a t e d f r o m all o t h e r f o r m s of s t o m a t i t i s b y p r o p e r l y a p p l i e d p a t c h tests. 2. P a t c h t e s t s t h a t u s e d i f f e r e n t m a t e r i a l s will likely demonstrate the offending reactant. 3. A c h e m i c a l l y d i f f e r e n t soft l i n e r s h o u l d b e u s e d u n t i l h e a l i n g occurs. T h e d e n t u r e s h o u l d t h e n b e r e b a s e d w i t h h e a t - p r o c e s s e d acrylic r e s i n b e c a u s e u n c u r e d m o n o m e r m i g h t cause a d d i t i o n a l allergic or i r r i t a n t r e a c t i o n s .

Product name

Flexacryl-soft Lang Dental Mfg., Wheeling, Ill.

Viscogel

Dentsply International, York, Pa.

Soft Oryl
REFERENCES

Teledyne Getz, Elk Grove, Ill.

1. Wright PS. Composition and properties of soft lining materia]s for acrylic dentures. J Dent 1981;9:210-23. 2. Craig R. Restorative dental materials. 7th ed. St. Louis, Missouri: CV Mosby, 1985:496. 3. Bergman B, The effects of prosthodontic materials on oral tissues. Oral Sci Rev 1977;10:75-93. 4. Accepted dental therapeutics. J Am Dent Assoc 1979;38:48-9. 5. Zarb GA, Rolender CL, Hickey JC, Carlsson GE. Boucher's prosthodontic treatment for edentulous patients. 10th ed. St. Louis, Missouri: CV Mosby, 1990:33. 6. Heartwell CM, Rahn AO. Syllabus of complete dentures. 2nd ed. Philadelphia: Lea & Febiger, 1974:372. 7. Nyguist G. A study of denture sore mouth. Acta Odontol Scand 1952;10(Suppl):11-154. 8. Bergman B, Carlsson GE, Hedgard B. A longitudinal two-year study of a number of full denture cases. Acta Odontol Scand 1964;22:3-26. 9. Bergendal T. Treatment of denture stomatitis. [Doctoral Thesis]. Stockholm: University of Stockholm, 1982. 10. Kaabar S. Allergy to dental materials with special reference to the use of amalgam and polymethylmethacrylate. Int Dent J 1990;40:35945. 11. Stenman E, Bergman M. Hypersensitivity reactions to dental materials in referred group of patients. Scand J Dent Res 1989;97:76-83. 12. Turrell AJW. Aetiology of inflamed upper denture bearing tissues. Br Dent J 1966;118:542-6.

Coe-Comfort

GC America, Inc., Chicago, Ill.

N = butyl methacrylate, dibutyl phthalate, trimethylolpropane trimethacrylate, dimethyl-ptoluidine Poly(ethyl methacrylate), Butyl phthalyl butyl Glycolate (BPBG), ethanol, peppermint oil, liquid paraffin Poly(ethyl methacrylate), dibutyl phthalate, n-butyl acetate, ethanol Ethyl(methacrylate), Zn undecylenate, ethanol, benzoil benzoate, dibutyl pthalate

13. Turrell AJW. Allergy to denture base materials: fallacy or reality. Br Dent J 1966;120:415. 14. Fisher AA. Contact dermatitis. 3rd ed. Philadelphia: Lea & Febiger, 1986:546.
Reprint requests to:

DR. H. S. ZAKI REGIONALCENTERFOR MkXILLOFACIALPROSTHETICREHABILITATION UNIVERSITYOF PITTSBURGH SCHOOLOF DENTALMEDICINE 3501 TERRACEST. 2059 SALKHALL PITTSBURGH,PA 15261

JANUARY 1995