Australasian Journal of Dermatology (2001) 42, 203–206


Allergic contact stomatitis caused by acrylic
monomer in a denture
Dennis Koutis and Susanne Freeman
Skin and Cancer Foundation, Sydney, New South Wales, Australia

dentures that would satisfy him. In the process of doing so,
SUMMARY he was fitted with a diagnostic denture that was relined using
a clinical reline material (Kooliner). Other adaptations to the
A 71-year-old edentulous man developed a severely denture were changes to the occlusion and the denture con-
painful red mouth at sites of contact with a new den- tours, which were made with self-curing acrylic resin (GC
ture. Patch testing showed allergy to samples of the Unifast). The patient wore this provisional denture for several
denture material and to 2-hydroxyethyl methacrylate. weeks and was very happy with it. Therefore, the fit and shape
Patch testing to methyl methacrylate was negative. of this denture were used as a blueprint to construct a new
Prolonged boiling of the denture resulted in reversal of denture that was constructed of artificial plastic teeth and
his symptoms and samples of this fully cured denture heat-cured resin. The patient was comfortable when the
material produced negative patch tests. While allergy denture was issued and, immediately afterwards, left for a
to acrylates is a rare cause of stomatitis, this possibility prolonged holiday. Upon his return, he stated that a few days
must be considered in patients presenting with oral after issue of the new denture he developed a painful red
symptoms. Material safety data sheets are unreliable mouth at sites of contact with the denture.
in providing information regarding the type of acrylate At presentation, examination revealed an edentulous mouth
present in the material. Hence, patch testing should be with erythema in the upper and lower gingival sulci bilaterally
performed with a battery of acrylate allergens as well and also in the upper and lower gingivae and palate. Whitish
as with small samples of the denture material. scaling was evident in both upper gingival sulci.
Key words: burning mouth syndrome. Patch tests were applied for 2 days, but readings could be
performed only at 4 and 16 days because of intercurrent illness
in the patient. The standard series were Trolab Hermal aller-
gens in petrolatum. The acrylates were Chemotechnique, also
INTRODUCTION in petrolatum. Patch testing with the European Standard
Series was negative. However, the patient showed a positive
Patients with burning of the oral mucosa often present a diffi- patch test to 2-hydroxyethyl methacrylate and an equivocal
cult diagnostic and therapeutic problem. Many causes have positive patch test to ethylene glycol dimethacrylate (EGDMA)
been postulated, but rarely proven. Allergy to dental materials in the dental series. He was also patch tested with samples of
is often suspected but, again, is rarely proven. We present a denture material sent by the dental hospital. All showed posi-
case in whom the stomatitis was proven to be due to allergic tive results, with an especially strong response to a sample
contact stomatitis to the acrylic monomer in the subject’s known as Kooliner (Table 1; Fig. 1). Controls were not tested
dentures. with the denture materials, but because the positives, ranging
from  to , were noted as late as day 18, irritant reactions
were very unlikely.
The patient had worn the denture lined with Kooliner and
A 71-year-old man was referred by the dental hospital he was containing GC Unifast for several weeks without any trouble,
attending because there was concern that he may have allergic yet he had a strongly positive patch test to a sample of the
contact stomatitis from his dentures. He gave a history of intol- Kooliner and a less strongly positive patch test to the GC
erance to four sets of dentures over a period of 4 years, all of Unifast. Hence, one must assume that he became sensitized
which had given him pain and did not fit properly. As a result, to a residual monomer of these acrylates during the time he
considerable effort was taken at the dental hospital to make was wearing this denture. The material safety data sheet
(MSDS) of GC Unifast stated that it contains polymethyl
methacrylate; however, MSDS on acrylates are notoriously
Correspondence: Dr S Freeman, Skin and Cancer Foundation, 277
unreliable. It is almost impossible to discover the exact
Bourke Street, Darlinghurst, NSW 2010, Australia. Email: methacrylate present in a product.
Dennis Koutis, MB, BS. Susanne Freeman, FACD. One month after initial presentation, the patient reported
Submitted 30 June 2000; accepted 4 January 2001. that his mouth was much better after the dentist had boiled

syndrome or stomatitis. most sufferers of these conditions were women.1–5 Oral can. or considered the several positive patch test form that is non-sensitizing. . with a higher probability of allergic con- boiled) and ‘Luxon’ (a new material).20 However. BIS- GMA. capable of inducing sensitization and causing allergic contact reactions13. the first reading was on day 4. combined tact stomatitis. In fact.204 D Koutis and S Freeman Table 1 Results of patch testing with acrylate allergens and denture samples First reading Second reading Substance/material tested (day 4) (day 16) Methyl methacrylate 2% Negative Negative Bisphenol A 1% Negative Negative Triethylene glycol dimethacrylate 2% Negative Negative BIS-GMA 2% Negative Negative Ethylene glycol dimethacrylate 2% /– /– Dimethyl-p toluidine 2% Negative Negative 2-hydroxy ethyl methacrylate 1%  /– Denture sample-regular  /– GC Unifast  /– Kooliner   Rapid Cure  /– Regular Negative Negative Luxon Negative Negative Figure 1 Positive patch tests to samples of denture material (day 4): denture sample-regular polished (No. with or without oedema.3%) and. strong (oedematous or vesicular) reaction. (3) Cell-mediated immunity is less efficient in the oral cavity Some of these studies9. weak (non-vesicular) reaction: erythema. Most often 0. (No. so that the contact time is short.6. particularly as much of the residual monomer with poor oral hygiene and trapped food particles. to substances of various dental screening series. this is rare.23. This explains why the reac. erythema only.1. may be encountered in mally very low in properly prepared dentures (approximately denture-wearing patients for a variety of reasons. Inadequately mild erythema in the gingival sulci and palate. but erosions may be seen. levels of acrylic monomer for the development of allergic reac- tions is underlined by the fact that patients shown to be allergic to acrylic monomer are able to tolerate dentures containing DISCUSSION fully polymerized acrylate. highly unlikely to produce irritant con- the cause is irritation from poorly fitting dentures. There are several published studies that have evaluated the (2) Prolonged contact of substances with the oral epithelium incidence of contact allergy in patients with burning mouth is further avoided by the high mucosal vascularization. The second reading unpolished (No. with or without visible to be an irritant. ished samples of the material. . GC Unifast- was made on day 16 because the patient was unable to attend at the polished (No. The importance of the presence of significant patch tests. signs are confined to the area ment:2.12 in contact with the denture. Kooliner-unpolished (No.7–9 diabetes. burning sensation and soreness in the involved area. short curing cycles14–16 or the use of certain autopolymerizing sequently patch tested with two samples of fully cured dental resins17–19 may be associated with excessive residual monomer acrylic.13 Acrylic monomer is also known Burning or soreness in the mouth. 37). Both produced negative tact stomatitis. denture sample-regular In this patient.24.2-bis[4-(2-hydroxy-3-methacryloxypropoxy)phenyl] propane. such as nickel and cobalt. in all these which leads to rapid absorption of the substances. However.2. Interpretation of the patch tests is out- /–. All the studies. 38). stomatitis.2 The mucous membrane appearance varies from However. Kooliner-polished usual time due to an intercurrent illness.21. others13.11 and xerostomia1. but a similar pattern may be seen (1) Saliva dilutes and washes away substances introduced into with cases due to irritation.25–28 have reported a significant because of a relatively low density of Langerhans cells and incidence of positive patch tests. with . it was found tions at the second reading were weaker than would reasonably have that similar patch test results were obtained for polished and unpol- been expected. 39). 43). infiltration. from any cause. T cells. hence. whereas acrylic monomer is reactions unlikely to be clinically relevant. Allergy to denture materials. This Vesiculation is uncommon. . Rapid Cure (no. ‘Regular’ (the previous material after it had been content and. Examination now revealed only the use of autopolymerizing (cold cured) resins. it is believed that allergy to acrylates is rare as to metals. a factors in some denture wearers.9. therefore.29–32 a cause of stomatitis in dental patients because dental pros. Polymerization is achieved by heat curing or by his dentures prior to reuse. 42). is leached out within approximately the first 12 hours of use.22. residual monomer levels are nor- mucosal inflammation and ulceration. either reported a very low incidence or no incidence at all of theses and fillings contain acrylates present in a polymerized contact allergy. but usu- such as acrylates. 40). studies.21–32 Interestingly. ulcerative) reaction. lined in Table 1.8. irritant and allergic contact minor erythema to a fiery red colour. extreme (spreading. are generally rare conditions.12 In rarity is due to a variety of factors unique to the oral environ. particularly In addition.7 psychogenic factors.13. possibly papules. symptoms are often more prominent disorders9. may also be a cause of such symptoms. He was sub. allergic contact stomatitis. bullous.3 didiasis.2 the mouth. numbness. 2.10 haematological In contact stomatitis. GC Unifast-unpolished (No.6 may be possible underlying than physical signs and include loss of taste. 41).2 ally no itch. For each denture material. believed to be of relevance.

after they (BMS) or stomatitis. cheilitis.19. without symptoms. This is despite the fact that acrylates have a high monomer is rare as a cause of symptoms in denture wearers. we have presented a case of allergic contact with allergens in the acrylate series. swollen lips. if possible. MMA Resolution after removal and stomatitis use of non-acrylic denture 38 F/49 Upper jaw dental Gingivostomatitis MMA. stated that n-butyl methacrylate symptoms resolved in all patients after either using heat-cured and boiled dentures. allergic contact stomatitis caused by acrylates are few5. patch testing with the initial allergens for detecting dental acrylic allergy (as well as allergy denture material sample was strongly positive. methyl methacrylate. together with caused by allergy to acrylic monomer is demonstrated by the literature reports. but patch to acrylates in sculptured nails and UV-cured inks). dimethacrylate. The monomer occurred during the process of repair of ill-fitting allergens we used for testing are listed (Table 1). In addition. ethylene glycol dimethacrylate. swelling MMA Resolution after removal and prosthesis of lips and eyelids replacement with a porcelain– metal alloy prosthesis 35 F/59 Partial dental Erythema. Indeed. Because it is usually stomatitis produced by acrylic monomer in the patient’s impossible to know which acrylate is present in the product. the patient was able a particularly uncommon cause of burning mouth syndrome to tolerate the same dentures. Stomatitis caused by acrylate allergy 205 one exception. glycol Histories not discussed. 2.2-bis[4-(2-hydroxy- 3-methacryloxypropoxy)phenyl] propane. suggest that these are the most important positive patch tests. . BIS-EMA. Subsequent course not prosthesis 2-hydroxyethyl discussed methacrylate 39 F/46 Drilling work on Stomatitis. approximately 1 week after fillings BIS-GA and EGDMA) cessation of dental drilling work MMA. however. dentures. BIS-GMA. testing with the same denture material after it had been boiled it is preferable to test with a wide range of allergens. or provision of nylon-based dentures M/66 Denture Burning mouth MMA F/62 Denture Burning mouth MMA F/69 Denture Burning mouth MMA 28 F/43 Dental prosthesis Stomatitis Bisphenol A Resolution after removal of dimethacrylate prosthesis F/42 Dental prosthesis Stomatitis Triethylenglycol Resolution after removal of dimethacrylate prosthesis 33 F/71 Denture Stomatitis MMA Follow up not stated 34 F/42 Fixed partial denture Perioral dermatitis.33–39 The present case illustrates that. BIS-GMA (positive patch Spontaneous resolution existing acrylic perioral dermatitis tests also to BIS-EMA.42–45 the wearing of a denture. However. bleeding MMA Resolution after removal of prosthesis erosions prosthesis 36 F/39 Use of acrylic for Mucosal oedema. HEMA (but not to Subsequent course not work on teeth ulceration BIS-GMA) discussed (contained HEMA and BIS-GMA) 37 M/70 Dental prosthesis Perioral dermatitis. published case reports of had been boiled. BIS-GA. Table 2 Published case reports of allergic contact stomatitis due to dental acrylates Type of dental Patient sex/ prosthesis or Acrylate allergen Reference age (years) material used Presentation identified Relevance 5 M/56 Partial denture with Mucosal erythema and MMA 2-hydroxypropyl Resolution with MMA-free MMA base ulceration. HEMA. Furthermore. which were then placed in the patient’s mouth with. These patients should be patch tested In this report. the same as those listed in a recent review of allergic contact out having been fully cured. although allergy to acrylic (Table 2). especially if there appears to be a relationship with in dental workers. oedema.32. sensitizing potential36. erythema.46 Personal experience. EGDMA. 2. 2-bis[4-(2-methacryloxyethoxy)phenyl] propane. Exposure to higher than normal levels of acrylic a broad series of acrylates should be used for patch tests.28.9.9 have found that contact allergy to acrylates is (heat cured) was negative.39–41 and contact dermatitis of the it should be considered in patients presenting with oral com- hands caused by acrylate compounds is well recognized plaints. That the patient’s stomatitis was dermatitis in dentistry. angioedema acrylate polycarbonate prosthesis 9 M/51 Denture Burning mouth MMA Individual patient case M/63 Denture Burning mouth MMA. 2-hydroxyethyl methacrylate. These are dentures. epoxy diacrylate. EGDMA.

1984. Guerra L. Semin. 24: 57. Helton J. 31: 201–5. Bates JF. for practical purposes. Oral Surg. Dutree-Meulenberg ROG. Clinical evaluation of fifty- six patients referred with symptoms tentatively related to allergic M Jolly from the United Dental Hospital. Devlin H. Dent. Contact Dermatitis 1994. The patient was referred by Dr SK Lechner and Professor 25. 167: 197–200. Estlander T. 30: 80–4. 1986. 153: by epoxy diacrylates in dental composite resins. Oral Surg. Basker RM. 34: 213–15. 1996. Contact Dermatitis 1989. 1977. J. 1980. material series. the range materials in a referred group of patients. Contact Dermatitis 1984. 1998. Dent. J. Tosti A. Contact and irritant stomatitis. The burning mouth due to methyl methacrylate monomer. Dent. Vilaplana J. 68: 187–90. allergy. J. J. Stomatitis and perioral dermatitis caused The effects of varying short curing cycles. Skoglund A. Contact stomatitis and cheilitis. Timmer LH. Contact Dermat. Dent. Riboldi A. Res. Oral medicine in practice: Burning mouth adverse oral mucous membrane reactions related to the use of syndrome. Austin AT. Occupational skin allergy in theses. Acad. 161: 444–7. 1965. Zegarelli DJ. tisers in the burning mouth syndrome. Kurihara 13. 34: 91–8. 24. Am. Dent. Residual monomer levels in denture bases: 39. Sydney. Tissue sensitivity to acrylic resin: 42. Patients with burning methyl methacrylate in a dental prosthesis. Riva F. The MSDS are notoriously unreliable. Sakuraoka K. Occupational contact dermatitis in 2 dental technicians. Jolanki R. the dental profession. 185: 380–4. Rubel D. Kanerva L. 3. Cornellana F. Arch. Contact Dermatitis 1994. Darre E. Alanko K. Timmer LH. materials in the burning mouth syndrome. clinical application. 1976. 156: 238–42. 1980. Venereol. Acrylic ‘allergy’. McCabe JF. in the denture sore mouth syndrome: An investigation of 24 46. 16. allergic contact dermatitis caused by exposure to acrylates during 20. Kanzaki T. Oral Med. diagnosis and management of denture work with dental prostheses. JAMA 1954. Burning mouth syndrome: A possible etiologic role for local contact hyper- REFERENCES sensitivity. Olveti E. 1996. 26: 210–11. Occupational dermatitis due 19. Purpuric patch test reaction and venu- denture base materials with particular reference to a modified litis due to methyl methacrylate in a dental prosthesis. Gasperini M. dermatitis and denture materials. Hypersensitivity reactions to dental materials in patients with lichenoid oral mucosal lesions and in patients with burning mouth syndrome. 4th edn. . Walker DM. 74: supplied helpful information. Contact Dermatitis 1996. Isayama K. 43: 138–42. Austin AT. mucosal diseases investigated by patch testing with a dental 6. 40: 367–73. Stomatitis. Kanerva L. 8: 365–71. Gola M. The burning mouth syndrome: Lack of a role Derm. Br. Peluso AM. Med. 1991. Gebhardt M. Estlander T. van Joost Th. Bergman M. Agner T. 27. 16: 314–19. John S. 1: 337–43. Contact acrylic denture materials. Allergic contact dermatitis in dentistry. Kobayashi T. Konohana A. 26. Contact dermatitis to methyl metha- 21. Groenman NH. patients. Weaver RE. Watts DC. J. 45. Basker RM. Silverman Jr S. sensation related to the wearing of acrylic dentures: An investi. Kassis V. 2. Waakers-Garritsen BG. 1989. Koch P. Allergy 1998. 145: 9–16. of acrylates listed (Table 1) will detect most cases of acrylate 97: 76–83. Dent. Bos JD. J. Invest.39 However. and n-butyl methacrylates and mutual cross-sensitivity in guinea Quintessence Dent. Jolanki R. Kannas L. The effect of different curing cycles on levels 40. They kindly contact stomatitis. Contact dermatitis from an acrylic–metal dental pros- 10. Oral to acrylate. 140: 347–50. Burning mouth: An analysis of 57 patients. 28: 268–75. Cutan. Virgili A. material for patch testing. Estlander T. Occupational Dermatitis 1990. 1978. 34: 191–5. Contact Dermatitis Chemotechnique produces a series of 31 allergens in their 1979. 14. 1989. Arcidiacono A. 30: 249–50. Scand. 29. Menne T. Contact Dermatitis 1991. Sensitisation to dental A method of measuring the residual monomer content and its acrylic compounds. Denture-induced local and systemic reactions 30. 1998. Fisher AA. Dent. J. Alanko K. Davenport JC. Allergic contact stomatitis from 11. Etiological factors crylate. drome. Contact dermatitis due to an acrylic dental prosthesis. J. 35. Prosthet. 12: 517–32. Contact dermatitis and 1. Corazza M. 92: 45–8. Burning mouth syndrome: screening series. Egelrud T. Dent. J. Thulin H. 1987. climacteric and diabetes. J. Contact stomatitis 9. 34: 263–7. 424–6. Dermatol. Bates JF. 15. pigs. 26: 935–40. 5. Contact Dermatitis 1984. 42: 7–9. Role of contact sensi- Contact Dermatitis. Contact method of analysis. Sertoli A. J. Grant-Kels JM. Ali A. J. Huggett R. Martini S. Br. Surg. with a persistent patch mouths: A clinical investigation of causative factors. 22: 282–7. 1982. Am. Evaluation of patch test results with denture Etiologic factors in denture sore mouth syndrome. Skin sensitivity to denture base present in the product. The aetiology. Piraccini BM. 1984. 20: 146–8. 32. 41. 149: 281–6. Prosthet. Tarvainen K. Am. Contact Dermatitis 1975. 34. Contact Dermatitis 1986. Dermatol. Rietschel RL. In: Fisher’s 28.206 D Koutis and S Freeman because it is usually impossible to know which acrylate is 22. ACKNOWLEDGEMENTS 99: 320–8. Jinno T. Wakkers-Garritsen BG. J. Dermatol. Australas. J. Kabasawa Y. 18. Fowler JF. Baum HP. Kaaber S. Altomare GF. for contact urticaria and contact dermatitis. Kanerva L. Contact Dermatitis 1996. 1978. Estlander T. gation. The level of residual monomer in acrylic 38. 5: 90–6. Dermatol. Dermatitis 1996. 38: 116–20. 14: 80–4. Br. Br. Scand. Stenman E. 41: 63–71. Am. dental prostheses. 1994. Baltimore: Williams & Wilkins. 4. Burning mouth 7. 36. Giles Jr AR. Storrs F. 35: 370–1. 58: 34–8. Sensitisation potential of methyl. 1992. J. as well as samples of denture 572–5. 1995. J. Ch. Vincenzi C. Francalanci S. Rothe MJ. Kanerva L. 53: 722–3. Pigatto PD. Bauer A. Br. 76: 488–90. Dermatol. Reynolds AJ. ethyl of residual monomer in acrylic resin denture base materials. Res. 8. Chung CW. Davidson CL. Am. J. Romaguera C. 1993. 2000. Hasegawa Y. Tosti A. 12. 33. Contact Dermatitis 1992. Clin. Lamey PJ. Br. 31. Basker RM. Jolanki R. Br. Acad. 1984. J. Allergic sensitisation of the skin and oral mucosa to S. Nater JP. The burning mouth syn. Trombelli L. A review of 98 cases. Acta Derm. to an epoxy acrylate. Farli M. Gorsky M. J. Reactions to acrylic resin dental pros. Acad. Peluso AM. stomatitis. Sensitisation to acrylates in a dental patient. Virgili A. Dermatol. Goebel WM. Vedel P. Oral Med. 1992. Contact 44. 11: 26–8. Jolanski R. Contact Dermatitis 1993. Oral Pathol. Crissey JT. 157: 272–5. Dent. Chinn H. Technol. J. Sturdee DW. Acad. 43. Nielsen E. 17. 1994. 10: 245. Geier J. 36. 23. Dent. syndrome: The role of contact hypersensitivity. thesis. van Loon LAJ. Kanerva L. Br. Dent. Huang W. Corazza M. Dent. Basker RM. Kozel MMA. Wathorn R. 37. 4: 154–7. 1997. Wollina U. including the test reaction. Dermatitis 1996. Wilson J. Dermatol. Nater JP. Hypersensitivity reactions to dental acrylate battery. Lewis MA.