White Tongue Lesions: Candida, Contact Stomatitis, Oral Lichen Planus?

The condition most likely occurred as a result of exposure to cinnamon in chewing gum. The patient was asked to discontinue chewing cinnamon flavored chewing gum.  Following cessation of the gum chewing his lesions resolved (Figure 2) and did not recur.

Discussion
Oral contact stomatitis to cinnamon is not well reported in the literature. Endo and Rees¹ reported clinical findings from 36 patients with suspected cinnamon allergy. The gingival tissue was involved most frequently and the lesions involved general erythema and epithelial sloughing. The apparent cause of the mucosal changes in the reported cases was identified as toothpaste, cinnamon chewing gum, and food.

Another 14 cases were reported by Miller and colleagues.² The histology of these cases ranged from hyperkeratosis to inflammatory change localized primarily to the buccal mucosa in relation to the cinnamon irritant. The lesions in these cases were not ulcerative and mildly symptomatic.

In their review on contact stomatitis, Tosti and associates³ noted that mucosal change in response to metal and other irritants may include erythema, erosions, ulcerations, leukoplakia-like lesions, and lichenoid reactions. For some types of contact stomatitis, the clinical signs may be less pronounced than the subjective symptoms, according to these authors. Functional disturbance can be quite severe. 

Identification of the potential offending irritant and its discontinuance may be all that is necessary to manage a contact stomatitis. However, if symptoms are severe and suggest erythema multiforme,⁴ a short course of systemic corticosteroid (40 to 60 mg initial dose) delivered with taper over 10 to 14 days can produce dramatic improvement. Nonresolution of lesions may necessitate an additional regimen of a systemic or topical corticosteroid, such as fluocinonide(Drug information on fluocinonide) (0.05 gel).

Teaching Points
• Contact stomatitis can occur as a result of cinnamon exposure. 
• The condition can easily be managed by withdrawal of the antigen. 
• A short course of systemic corticosteroid delivered with taper over 10 to 14 days can produce dramatic improvement if symptoms are severe.