Improving the dietary management of orofacial granulomatosis
Orofacial granulomatosis (OFG) is a rare disfiguring inflammatory disease of the lips, face and oral cavity. The cause is unknown but perhaps involves an allergic component. Management includes immunosuppressant medications or a cinnamon and benzoate free diet which has proven benefit in 72% of patients. The diet is challenging, not all patients respond and symptom recurrence is common. Patients identify chocolate as a problem but are often resistant to long term avoidance. Phenolic acids are among the chemical constituents of cinnamon and benzoates and while the cinnamon and benzoate free diet avoids the highest sources, some dietary exposure remains. Atopy rates are high in patients with OFG and a recent study identified a high rate of pollen sensitisation to pollens associated with oral allergy syndrome (OAS). OAS is an allergic disorder manifesting immediate lip swelling readily resolved by dietary avoidance of raw plant foods containing homologous proteins that cross react with these pollens. The aim of this thesis was to improve the dietary management of patients with OFG. A medical notes review (n=207) outlined the clinical presentation and provided insight into differing phenotypes for patients with OFG. A subsequent study developed and implemented a novel diet low in phenolic acids improving symptoms in 5/10 patients; 4/6 had prior treatment with a cinnamon and benzoate free diet. The next project focused on OAS, examining dietary response to avoidance of cross reactive plant foods in patients with associated pollen sensitisation. Only 2/14 patients responded satisfactorily but a high rate of silver birch sensitisation raises questions about the role this might play in OFG. A final study investigated the reintroduction of chocolate in patients with OFG and found that it can be included cautiously in the diet of some patients with white chocolate being less prone to cause reactions than milk and dark chocolate. This thesis has provided further insight into dietary management that can be translated directly into clinical practice for patients with OFG.
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