case report

Allergic Contact Stomatitis: A Case Report and

Review of Literature
P Lokesh, T Rooban, Joshua Elizabeth, K Umadevi, K Ranganathan

Abstract
Allergic contact stomatitis is a well-recognized entity, which may be easily overlooked by the clinician since its signs and
symptoms are similar to various other oral lesions. Accurate diagnosis warrants adequate treatment that will help in providing
prompt relief and will also prevent further recurrences. We present a case report of a 27-year-old South Indian male student,
who presented with multiple erythematous erosions involving much of the nonkeratinized oral mucosa. History revealed that
there was a previous episode of a similar lesion, associated with intake of food with flavoring agents. Based on the history
and clinical features, we arrived at a diagnosis of allergic contact stomatitis and successfully treated the lesions with topical
and systemic antihistamines.
Keywords: Allergic contact stomatitis, oral mucosa, antihistamines

llergic contact stomatitis is a rare disorder,

which most clinicians are not familiar with.
A wide variety of substances are known to
elicit adverse oral mucosal reactions. Flavoring agents,
preservatives and dental materials are the most common
causes of allergic/hypersensitivity reactions related to
oral mucosa. Flavoring agents and preservatives have
been used widely in commercially available personal
hygiene products and foods, thereby increasing the risk
hypersensitivity reactions.
Previous exposure with an allergen is essential for
diagnosis of allergic contact stomatitis. Sensitization
usually occurs through contact of allergen with the oral
mucosa. Rarely, sensitization may also occur by contact
of allergen with skin. Memory T cells are activated soon
after the initial exposure. On re-exposure to the same
allergen, a type IV hypersensitivity reaction occurs. This
reaction may be delayed by at least 48 hours and the
clinical presentation may vary depending on the severity
of the reaction.
Case report
A 26-year-old dental postgraduate student presented
with a complaint of pain and diffuse intraoral
erythematous lesions for the past three days. The patient
first experienced roughness and discomfort in the left

Dept. of Oral and Maxillofacial Pathology,

Ragas Dental College and Hospital, Chennai

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Indian Journal of Clinical Practice, Vol. 22, No. 9, February 2012

buccal mucosa four days ago. The following day he

developed erythematous lesions and pain in the left
buccal mucosa, followed by lesions on the anterior part
of ventral tongue, soft palate, right buccal mucosa and
lower labial mucosa. Difficulty in brushing, speech and
burning sensation while eating were experienced, for
which 2% benzocaine gel was applied 3-4 times every
day before food intake.
Intraoral examination revealed carious 26, glass
ionomer cement (GIC) Class I restoration in 46,
buccally inclined 18 and 28. Diffuse erythema involving
the whole of soft palate, without extension on to the
hard palate was seen (Fig. 1). Ventral surface of anterior
tongue was bright red in color with few small
whitish plaques, suggestive of necrosis (Fig. 2).
Lower labial mucosa exhibited irregular zones
of erythema. Large oval to irregular bright red
patches surrounded by whitish edematous zones
were seen on buccal mucosa, extending some
distance into the vestibule on both right (Fig. 3) and left
side (Fig. 4). The keratinized mucosa of the hard palate,
gingiva and dorsum of the tongue was not involved.
Further questioning did not reveal history of any
change or use of oral hygiene products, recent dental
treatment or drug intake. Eventually, patient did recall
an episode of having food at a restaurant 2-3 days
before developing the lesions. Patient also gave a
history of episodes of recurrent minor aphthous ulcers.
One such episode occurred about two years ago and
was characterized by multiple painful oral lesions,

case report

Figure 1. Diffuse erythema of soft palate.

Figure 3. Erythematous lesions on right buccal mucosa.

Figure 2. Erosive lesions on ventral surface of tongue.

Figure 4. Erythematous lesions on left buccal mucosa.

which developed soon after intake of specific food,

which the patient has been avoiding since then. Based
on the history and clinical features, a provisional
diagnosis of allergic stomatitis was made.

(Figs. 5-8). A mild increase in the pigmentation was

seen on the buccal mucosa. Two new lesions, which
were not present during the initial examination, were
seen on both the left and right sides of buccal mucosa,
adjacent to the upper canine and premolars (Figs. 9
and 10). These lesions were erythematous areas,
2 1 cm in size with whitish necrotic plaques. Patient
was advised to continue the same medications for three
more days, following which all the oral lesions healed
completely.

Management
Patient was advised to avoid foods with preservatives
and flavoring agents. Cetirizine hydrochloride 10 mg
tablet hs, 5 ml of diphenhydramine hydrochloride
syrup mixed with equal amount of an antacid
liquid in a swish and swallow method 3-4 times
daily were prescribed to alleviate the symptoms.
During the follow-up visit, four days later, most of
the initial lesions had healed without any scarring

Discussion
Contact stomatitis is an inflammation of the oral mucosa
caused by external substances. It can be caused by a

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Figure 5. Soft palate - 4 days after therapy.

Figure 7. Right buccal mucosa - 4 days after therapy.

Figure 6. Ventral surface of tongue - 4 days after therapy.

Figure 8. Left buccal mucosa - 4 days after therapy.

variety of substances, which can either act as irritant

or allergic agents. These substances include dental
materials, preservatives and flavoring agents in foods
or oral hygiene products. Oral mucosa is less commonly
prone to contact allergic reactions, when compared to
skin, though the latter is exposed to a wide variety of
antigenic stimuli. This can be attributed to the various
biologic and physiologic differences between the two.
Saliva acts as a solvent that solubilizes, dilutes and
also starts digesting potential allergens and helps
to wash them there by limiting the duration and
number of molecules that contact oral mucosa. Limited
keratinization makes hapten binding more difficult
and the limited number of antigen presenting cells

in the oral mucosa decreases the chance of antigen

recognition. Irritants and allergens that do contact the
oral mucosa are removed more quickly because of
higher vascularity and faster epithelial renewal rates
than in keratinized skin.

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Indian Journal of Clinical Practice, Vol. 22, No. 9, February 2012

Balsam of peru, cinnamon, cinnamic aldehyde,

menthol, peppermint and eugenol are some of the
common oral flavoring allergens.
These reactions can be either acute or chronic.
Clinical presentations vary based on the nature of
reaction, type of allergen site and duration of contact.
Patients with acute lesions may present with burning
or redness. Vesicles are rarely seen and if present
rupture in a short while after formation. Some patients

case report
Table 1. Differential Diagnoses

Pemphigus

Lupus erythematosus

Pemphigoid

Syphilis

Lichen planus

Friction-induced

Drug reactions

Contact stomatitis

Erythema multiforme

Erythematous candidiasis

lesions during clinical examination. Erosions can also

be caused by trauma arising from friction between
the teeth or irregular dental restorations. Burns from
hot foods, radiation and caustic chemicals also cause
similar erosions.
Figure 9. Lesions on right buccal mucosa, during review
visit.

Figure 10. Lesions on left labial vestibule, during review

visit.

may experience edema, itching or stinging sensation.

Contact allergy lesions occur directly at the site of
exposure to the causative agent. Acute lesions develop
soon after antigenic exposure; diagnosis of these may
be straightforward since a cause-and-effect relationship
can be easily established.
Chronic lesions typically present as areas of erythema,
edema, desquamation and occasionally ulceration. In
addition, allergic contact stomatitis can also present
as erosions with rough surface and irregular borders,
often surrounded by a red halo. These lesions may
be indistinguishable from aphthous ulcers and other

Hence, it is essential to elicit a thorough history and

exclude other pathosis presenting with similar lesions
clinically (Table 1). Patch testing of oral mucosa is
difficult and may yield false-negative results. Some
common conditions which can present as erosive
lesions in the oral mucosa are listed in Table 1.
Identification and elimination of the allergen that
initiated the reaction is essential to treat the condition,
as well as to prevent recurrences. If an association is
not established, cutaneous patch testing may be useful.
Lesions respond well once the antigenic stimulus
is eliminated. Antihistamines, topical anesthetics
and topical corticosteroids are the commonly used
pharmacological agents. Use of antihistamine
suspensions in a swish and swallow method provide
the advantage of both local and systemic action. Some
of these agents may not be tolerable when there is a
mucosal breach. Hence, a well-tolerated, flavored
antacid was included in the prescription.
Conclusion
Allergic contact stomatitis is a well-recognized entity,
the incidence of which could be far more than that
reported. Clinical presentation and histopathologic
features are not always specific. Hence, a high-degree
of suspicion and careful history taking to establish
a cause-and-effect relationship is essential. Biopsy
findings may be confirmatory but not always essential.
Health practitioners should consider contact allergic
stomatitis in the differential diagnosis of nonspecific
oral lesions so as to provide proper treatment and
avoid recurrences.

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case report
Consent

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Written informed consent was obtained from the

patient for publication of this case report and
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Competing Interests
The authors declare that they have no competing
interests.

Acknowledgments
We thank our Principal, Dr S Ramachandran, for
encouraging the publication of this case report and
Dr Yakob Martin, for the images.

suggested reading
1.

LeSueur BW, Yiannias JA. Contact stomatitis. Dermatol

Clin 2003;21(1):105-14, vii.

2.

Tosti A, Piraccini BM, Peluso AM. Contact and irritant

stomatitis. Semin Cutan Med Surg 1997;16(4):314-9.

3.

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Ophaswongse S, Maibach HI. Allergic contact cheilitis.

Contact Dermatitis 1995;33(6):365-70.

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10. Torgerson RR, Davis MD, Bruce AJ, Farmer SA, Rogers
RS 3rd. Contact allergy in oral disease. J Am Acad
Dermatol 2007;57(2):315-21.