Dig Dis Sci (2010) 55:865–866 DOI 10.1007/s10620-009-1115-7
CORRESPONDENCE
Is Eosinophilic Esophagitis Related to Dental Occlusal Guards? A Case Series Daniel L. Cohen • Manuel Martinez
Published online: 22 January 2010 Ó Springer Science+Business Media, LLC 2010
To the Editor, We read with great interest the recent review article on the subject of eosinophilic esophagitis (EoE) by Moawad et al. [1]. The article described in detail the evidence to support the role of food allergens and aeroallergens in the pathogenesis of EoE. While there has been much interest in the causative role naturally occurring antigens play in the development EoE, there have been no reports of the possible role that artificial antigens may play in triggering the allergic response in susceptible patients. We present a series of cases in which EoE was diagnosed in patients who wore dental occlusal guards. Occlusal guards, also called occlusal splints [2], are common dental devices worn over the teeth, often at night. They are regularly prescribed to treat bruxism and temporal-mandibular joint disorders. While they can be constructed of various materials, most are composed of acrylics and vinyls. Since these materials can erode over time, patients are instructed to replace them after a certain period of time. The first case is a 33-year-old man initially seen 4 years ago by another gastroenterologist for retrosternal chest pain. Esophagogastroduodenoscopy (EGD) with biopsies at that time was notable for esophageal eosinophilic infiltrates. The patient was started on twice daily (BID) proton pump inhibitor (PPI), but remained with eosinophilic infiltrates on two subsequent EGDs. A year ago, he was referred for a second opinion while still on PPI. Allergy testing was unremarkable, and a repeat EGD revealed a
D. L. Cohen (&) M. Martinez Division of Gastroenterology, New York University Medical Center, 423 East 23rd Street, 11 North, GI Lab, New York NY 10010, USA e-mail:
[email protected]
‘‘feline’’ esophagus with congestion, ridges, and furrows. Biopsies revealed greater than 100 eosinophils per high power field (eos/HPF). Swallowed fluticasone therapy was initiated; however a repeat EGD still revealed a ‘‘feline’’ esophagus with greater than 100 eos/HPF. At this point the patient admitted to using an occlusal guard on a nightly basis for 10 years. While his dentist had recommended that he replace it, he had not complied with this request. After discontinuing the occlusal guard, a repeat EGD showed a normal esophagus with biopsies revealing only 3 eos/HPF. The second patient is a 30-year-old man who complained of pyrosis. EGD revealed a ‘‘feline’’ esophagus and biopsies showed 40 eos/HPF. He was started on BID PPI therapy, but a repeat EGD still showed eosinophilia. It was then determined that he used an occlusal guard. After stopping this practice, biopsies revealed only rare eosinophils (less than 1 eo/HPF). The third patient is a 38-year-old woman with a history of asthma and seasonal allergies who complained of bloating. Esophageal biopsies revealed 80 eos/HPF. PPI therapy was initiated, but a repeat EGD still revealed 25 eos/HPF. At this time the patient admitted to wearing an occlusal guard. As the guard had become old, her dentist had already recommended that she replace it, but she could not afford to do so. She has continued using the old guard, and therefore a repeat EGD with biopsies has not been performed. In conclusion, we report a series of EoE patients who were noted to wear dental occlusal guards. Two patients had their esophageal eosinophilia resolve only after discontinuing this practice, while the third patient is delaying the change to a new occlusal guard due to her present economic constraints. These cases point to a potential contributory role for occlusal guards in the pathogenesis of EoE. It is possible that wearing these devices exposes the
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esophagus to their breakdown products and chemicals, thereby stimulating an eosinophilic response in susceptible patients. We feel that clinicians should be aware of this possible association when treating patients with EoE, and that further studies on this relationship are warranted.
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Dig Dis Sci (2010) 55:865–866
References 1. Moawad FJ, Veerappan GR, Wong RK. Eosinophilic esophagitis. Dig Dis Sci. 2009;54(9):1818–1828. 2. Small BW. Occlusal splints. Gen Dent. 2005;53(3):178–179.
