I would like to thank Dr. Hamann, Dr. Rodgers and Ms. Sullivan for their eloquent letter and the very kind comparison to Sherlock Holmes. I could not agree more wholeheartedly with their comments. In fact, I mentioned to the parents of the child described in my article the need for patch or radioallergosorbent testing (RAST) by a dermatologist.
However, having previously seen a dermatologist without result—and because this process had been ongoing for more than 18 months—they were satisfied with the identification of the mouthwash as the "culprit." The letter writers are absolutely correct that, without definitive testing, the diagnosis of a contact cinnamon reaction in this case is presumptive, at best. They are also correct in pointing out that many of the agents found in oral care products other than flavoring agents, such as sunscreens, can also cause hypersensitivity reactions in both children and adults.
Four weeks before receiving this letter to the editor, I treated an 11-year-old girl with recurrent, unilateral, irregularly bordered ulcerations of the hard palate. Results of extensive routine blood testing by the pediatrician were within normal limits and served to rule out viral and neoplastic etiologies.
Careful history-taking and a food diary revealed that this child consistently ate chocolate within 48 hours of the recurrence of the unilateral palatal lesions. Referral to a dermatologist was accepted by the parents, and, after RAST testing, a true immunoglobulin E–mediated allergy to chocolate was definitively diagnosed.
I have held appointments in medical school and hospital dermatology departments for the past 10 years, so I would be remiss if I did not strongly reinforce the comment made by Dr. Hamann, Dr. Rodgers and Ms. Sullivan that frequent collaboration between dentists and physicians forges a synergy that greatly enhances the care received by our mutual patients. Dentists like to consider themselves "physicians of the mouth." So, as we move through the 21st century, we must change the paradigm by which we have practiced in the past and work more closely with our medical colleagues.
I would like to thank our dermatology colleagues for taking the time to read and comment on my case report. Their comments are accurate and instructive and show that, whether we are dentists or physicians, striving for excellence in patient care is of paramount importance to us all.
