Advertisement

BMC Oral Health

, 19:250 | Cite as

Hawley retainer and lichenoid reaction: a rare case report

  • Mahmoud Ahmed ElhadadEmail author
  • Yasmine Gaweesh
Open Access
Case report
  • 193 Downloads
Part of the following topical collections:
  1. Clinical oral healthcare research

Abstract

Background

Oral lichenoid reaction (OLR) is a type IV cell-mediated immune response in the oral cavity. There is an established relationship between various dental materials and OLR, but few cases reports reported the occurrence of a lichenoid reaction in association with the use of a Hawley retainer.

Case presentation

A female patient (twenty years of age) has been complaining of a reddish painful area on the tongue, which started one year ago and has been increasing in size over time. The patient completed orthodontic treatment two years ago and has been using a Hawley retainer for orthodontic retention since then. After performing histological analysis and patch test, the lesion was diagnosed as a lichenoid reaction to the Hawley retainer. Topical corticosteroids were prescribed, and the patient was asked to stop using the retainer and followed for six months.

Conclusions

It is difficult to diagnose lichenoid lesions and even more challenging to differentiate between OLP and OLR, therefore it is essential to do a full intraoral and extraoral examination. OLL can occur in association with Hawley retainer, which we believe could be because it is made of an acrylic based material. Generally, OLL resolves after removal of the cause.

Keywords

Oral lichenoid reaction Lichen planus Hawley retainer 

Abbreviations

OLDR

Oral lichenoid drug reaction

OLL

oral lichenoid lesion

OLP

oral lichen planus

OLR

oral lichenoid reaction

Background

Oral lichenoid reaction (OLR) or oral lichenoid lesion (OLL) is a condition, which is similar clinically and histologically to oral lichen planus (OLP). This term is used to describe eruptions of the oral cavity having an identifiable etiology [1].

The term OLR was first proposed by Finne et al. [2] in 1982 to designate clinically indistinguishable lesions of OLP. Furthermore, Laine et al. [3] in 1997, correlated OLL to contact allergy triggered by various dental materials.

Clinically, OLR may appear in any of the forms of OLP, namely reticular, plaque-like, erythematous, erosive, bullous, or ulcerative form [3] . Moreover, histologically, OLR and OLP are indistinguishable from one another. The main histological features of both lesions are damage of the basal keratinocytes and Inflammatory cell infiltration of the lamina propria that could extend into the epithelium [4].

When the previously mentioned clinical and histological features are present in a unilateral distribution in the oral cavity, OLL is the most probable diagnosis. Furthermore, the presence of dysplastic changes on the histological examination favors the diagnosis of OLL [5].

The following case-report presents full clinical and histological analyses of an oral soft tissue contact reaction to acrylic resin-based Hawley retainer in the form of an erosive area on the left and a keratotic area on the right dorsolateral surface of the tongue.

Case presentation

A twenty-year-old female presented to the oral medicine clinic at the Faculty of Dentistry, Alexandria University. The patient complained of a reddish painful area on the tongue, that started one year ago and has been increasing in size over time (Fig. 1). The patient reported completing an orthodontic treatment two years ago after which she has been using a Hawley retainer for orthodontic retention (Fig. 2).
Fig. 1

A photograph of the tongue showing fiery red lesion on the left side and white keratotic lesion on the right side

Fig. 2

A photograph showing the acrylic-based Hawley retainer for the lower arch used by the patient

No specific findings were found on medical history taking and extraoral examination. Intraoral examination revealed a reddish patch on the left dorsolateral surface of the tongue surrounded by whitish lines. The lesion measured 2 × 3 cm, had normal consistency, smooth surface texture, and normal surrounding tissues (Fig. 3). Another lesion in the form of a white keratotic plaque on the right dorsolateral surface of the tongue was found upon clinical examination. It was of 1 cm in size with normal consistency and normal surrounding tissues (Fig. 4).
Fig. 3

A photograph of the left dorsolateral side of the tongue showing a 2*3 cm erosive lesion surrounded by a keratotic line

Fig. 4

A photograph of the right dorsolateral surface of the tongue showing a one cm circumferential white keratotic lesion

The initial differential diagnoses included erythroplakia (because of the fiery red color), lichenoid contact reaction (because of the Hawley retainer), and geographic tongue (because of the location and age). An incisional biopsy was taken and subjected to histopathological examination to aid in reaching a conclusive diagnosis.

Histopathologically

The soft tissue section showed keratinized stratified squamous epithelium of variable thickness. Atrophic areas were predominantly present, other areas showed hyperplasia or epithelial proliferation in the underlying lamina propria. Degeneration of the basal epithelial cells and the basement membrane was evident. There was a dense, band-like lymphocytic infiltrate in the lamina propria that obscured the epithelial-connective tissue junction. Additionally, numerous dysplastic criteria such as hyperchromatism, pleomorphism, prominent nucleoli and mitotic figures were evident (Fig. 5).
Fig. 5

a: Microscopic examination of the lesion at (× 200) showing lichen planus with subepithelial lymphocytic infiltration and basal cell degeneration (red arrow). b: Higher magnification at (× 400) of the previous photomicrograph revealing the basal cell degeneration (red arrows) and prominent nucleoli (black arrows). c: Higher magnification at (× 400) of the epithelium showing different dysplastic criteria basilar hyperplasia (red arrows), apoptotic nuclei (blue arrows) as well as hyperchromatism and pleomorphism. d: Another higher magnification at (× 400) of the epithelium showing drop shaped rete pegs. Loss of the basal cells and subepithelial lymphocytic band. e: Higher magnification at (× 400) confirming the Loss of the basal cells and the existence of subepithelial lymphocytic band

Management

Histopathological results suggested the diagnosis of OLR. In an attempt to confirm this diagnosis, we performed a patch test by applying grinded acrylic resin, similar to that used in the construction of the Hawley retainer, on the forearm for 72 h and instructed the patient to report any kind of discomfort. After 72 h, there was desquamation, erythema and pigmentation of the skin suggesting a positive patch test, which confirmed our diagnosis (Fig. 6).
Fig. 6

A photograph of the site of the hypersensitivity test showing delayed hypersensitivity reaction in the form of erythema, pigmentation and desquamation

We instructed the patient to discontinue using the Hawley retainer, replaced it by a vacuum retainer, and prescribed topical corticosteroids to decrease patient’s discomfort. Three weeks later, partial resolution of the lesion was evident. We followed the patient for six months with no signs of lesions recurrence (Fig. 7).
Fig. 7

A photograph of the tongue demonstrating partial healing after six months with depapillation at the original site

Discussion and conclusion

In the presented case a definitive diagnosis was difficult to establish, therefore multiple diagnostic tools were implemented, namely clinical examination, histopathological analysis, and patch testing, which is useful whenever a dental material allergy is suspected [6].

Upon clinical examination, three entities were included in the differential diagnosis; erythroplakia, atrophic LP, and OLR, none of which could be excluded outright based solely on clinical appearance. Using histopathological examination, erythroplakia was excluded as the histopathological features matching those of LP and OLR were evident. Subsequently, the patch test demonstrated a positive result making the diagnosis of OLR more probable.

According to the diagnostic criteria proposed by van der waal [7]; the presented case can be considered “clinically and histopathologically compatible with OLP” but “not typical OLP”. Clinically, this is due to the lack of bilateral and symmetric distribution while histopathologically this is due to the presence of dysplastic changes.

According to Shirasuna et al. [8], Dudhia et al. [5], and several other studies [6, 9, 10, 11]: dysplasia is a possible feature of OLR and consequently OLRs might be liable to malignant transformation. On the other hand, OLP pre-malignancy is debatable [12, 13, 14, 15]. Moreover, even though OLP and OLR appear clinically similar, OLR is usually unilateral in distribution. According to Kamath et al. [15], OLR is more frequently seen in sites with high risk for malignancy like; the tongue, floor of the mouth, and mandibular lingual alveolar ridge. Based on all the above-mentioned evidence, the most probable diagnosis for the presented case was OLR provoked by the acrylic resin material.

Rashid et al. [16] reported that acrylic based dental materials can lead to contact allergy manifesting as OLR. OLR should resolve after removal of acrylic based material and OLL would mostly involve contact sites; most frequently, lateral borders of the tongue, labial or buccal mucosa, and vestibular areas [5, 7, 13].

Numerous cases of lichenoid reactions or allergy due to self-curing resin were reported, however, lichenoid reactions linked to Hawley retainers were found to be extremely few. Case reports reporting allergic reactions to self-curing resin reported similar clinical presentations as most of them reported unilateral lesions, swelling and redness of the contact area [16, 17].

Tatiana et al. [18] reported an orthodontic case with allergy due to auto-polymerizing acrylic resin with a clinical presentation of a hypersensitivity reaction in the palate after using an orthodontic retainer. On the other hand, this did not occur when the residual monomer was analyzed with gas chromatography and was not above the international standards.

Furthermore, Alferdo et al. [19] reported a case of allergic reaction in a 33-year-old male. The patient reported discomfort and pain caused by an erythematous lesion located on the free and attached gingiva at the upper left first premolar site after the placement of an acrylic resin temporary restoration. Biopsy revealed a chronic inflammatory process. Notably, after cementation of the final crown, the inflammatory signs and symptoms disappeared.

Hawely retainer is the gold standard appliance for fixation and retention after orthodontic treatment. In addition, Hawely retainers are more favorable and more commonly used than vacuum retainers [20].

The presented case had some limitations. Most importantly, the patch test wasn’t performed using commercially available kits which would have given more precise results [21, 22]. Also, the use of topical corticosteroids in tandem with discontinuation of the use of the retainer confused the effect of each separately.

In conclusion, acrylic resin-based Hawley retainers should be used with caution watching out for possible similar adverse reactions. Further studies are required to explain and emphasize the existence of Hawley retainer-associated OLR in orthodontic patients. Establishing the possibility of such an association would necessitate the performance of a patch test for patients receiving this appliance after orthodontic treatment termination.

Notes

Acknowledgments

The authors would like to acknowledge Mohamed Elhadad (PhD student, Helmholtz Zentrum München, Neuherberg, Germany) and Inas Magdy (PhD, Alexandria university) for their contribution in the professional writing.

Authors’ contributions

ME performed the initial examination, patient assessment, patch test, prescribed treatment, followed up the patient for 6 months and wrote the manuscript. YG performed biopsy, histological analysis and reviewed the literature and reviewed the manuscript. Authors have read and approved the manuscript.

Funding

No funding was obtained for this study.

Ethics approval and consent to participate

not applicable

Consent for publication

Written informed consent was obtained from the patient for publication of this case report.

Competing interests

The authors declare that they have no competing interests.

References

  1. 1.
    Juneja M, Mahajan S, Rao NN, George T, Boaz K. Histochemical analysis of pathological alterations in oral lichen planus and oral lichenoid lesions. J Oral Sci. 2006;48:185–93.CrossRefGoogle Scholar
  2. 2.
    Finne K, Göransson K, Winckler L. Oral lichen planus and contact allergy to mercury. Int J Oral Surg. 1982;11(4):236–9.CrossRefGoogle Scholar
  3. 3.
    Laine J, Kalimo K, Happonen RP. Contact allergy to dental restorative materials in patients with oral lichenoid lesions. Contact Dermatitis. 1997;36(3):141–6.CrossRefGoogle Scholar
  4. 4.
    Van Der Waal I. Potentially malignant disorders of the oral and oropharyngeal mucosa; terminology, classification and present concepts of management. Oral oncology. 2009;45(4–5):317–23.CrossRefGoogle Scholar
  5. 5.
    Dudhia BB, et al. Oral lichen planus to oral lichenoid lesions: Evolution or revolution. Journal of oral and maxillofacial pathology: JOMFP. 2015;19(3):364.CrossRefGoogle Scholar
  6. 6.
    Ismail SB, Kumar SK, Zain RB. Oral lichen planus and lichenoid reactions: etiopathogenesis, diagnosis, management and malignant transformation. J Oral Sci. 2007;49(2):89–106.CrossRefGoogle Scholar
  7. 7.
    van der Meij EH, van der Waal I. Lack of clinicopathological correlation in the diagnosis of oral lichen planus based on the presently available diagnostic criteria and suggestion for modifications. J Oral Pathol Med. 2003;32:507–12.CrossRefGoogle Scholar
  8. 8.
    Shirasuna, Kanemitsu. Oral lichen planus: malignant potential and diagnosis. Oral science international, 2014, 11.1: 1–7.Google Scholar
  9. 9.
    Patil S, Rao RS, Sanketh DS, Sarode SC, Sarode GS. A universal diagnostic criteria for oral lichen planus: an exidency. Int J Contemp Dent Med Rev. 2014:1–4.Google Scholar
  10. 10.
    Ditrichova, Dagmar, et al. Oral lichenoid lesions and allergy to dental materials. Biomedical Papers of the Medical Faculty of Palacky University in Olomouc, 2007, 151.2.Google Scholar
  11. 11.
     Van der Meij EH, mast H, van der Wall I. the possible premalignant character of oral lichen planus and oral lichenoid lesions: a prospectivefive-year followup study of 192 patients. Oral Oncol. 2007;43:742–8.Google Scholar
  12. 12.
    Epstein JB, Wan LS, Gorksy M, Zhang L. Oral lichen planus: Progress in understanding its malignant potential and the implications for clinical management. Oral Surg Oral Med Oral Pathol Oral Radiol Endol. 2003;96:3237.Google Scholar
  13. 13.
    Gonzalez-Molis MA, Scully C, Gil-Montoya JA. Oral lichen planus: controversies surrounding malignant transformation. Oral Dis. 2008;14:229–43.CrossRefGoogle Scholar
  14. 14.
    Sousa FACG, et al. Oral lichen planus versus epithelial dysplasia: difficulties in diagnosis. Brazilian journal of otorhinolaryngology. 2009;75(5):716–20.PubMedGoogle Scholar
  15. 15.
    Kamath VV, Setlur K, Yerlagudda K. "Oral lichenoid lesions-a review and update." Indian journal of dermatology 60.1 (2015): 102.Google Scholar
  16. 16.
    Rashid H, Sheikh Z, Vohra F. Allergic effects of the residual monomer used in denture base acrylic resins. European journal of dentistry. 2015;9(4):614.CrossRefGoogle Scholar
  17. 17.
    Hashimoto K-i, et al. A case of mucositis due to the allergy to self-curing resin. Oral Science International. 2014;11(1):37–9.CrossRefGoogle Scholar
  18. 18.
    Gonçalves TS, et al. Allergy to auto-polymerized acrylic resin in an orthodontic patient. Am J Orthod Dentofac Orthop. 2006;129(3):431–5.CrossRefGoogle Scholar
  19. 19.
    Mesquita AM, Silva JH, Kojima AN, Moura RV, Giovani EM, Özcan M. (2017). Allergic reaction to acrylic resin in a patient with a provisional crown: Case report. Brazilian Dental Science. 20. 115.  https://doi.org/10.14295/bds.2017.v20i1.1303.
  20. 20.
    Pratt MC, et al. Evaluation of retention protocols among members of the American Association of Orthodontists in the United States. Am J Orthod Dentofac Orthop. 2011;140(4):520–6.CrossRefGoogle Scholar
  21. 21.
    Suter VGA, Warnakulasuriya S. The role of patch testing in the management of oral lichenoid reactions. Journal of oral pathology & medicine. 2016;45(1):48–57.CrossRefGoogle Scholar
  22. 22.
    KIM T-W, et al. Patch testing with dental screening series in oral disease. Ann Dermatol. 2015;27(4):389–93.CrossRefGoogle Scholar

Copyright information

© The Author(s). 2019

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors and Affiliations

  1. 1.Oral Medicine and Periodontology DepartmentFaculty of Dentistry, Alexandria UniversityAlexandriaEgypt

Personalised recommendations