32 Oral Mucosal Immunotherapy
32.1 Becoming Part of the Routine
One major factor in successful immunotherapy is patient compliance. Regardless of how well subcutaneous immunotherapy (SCIT) works, if the patient doesn’t come to receive their injections then SCIT will not work for that patient. Similarly with aqueous sublingual immunotherapy (SLIT) drops, if the patient doesn’t take the drops as directed then SLIT will not work for them. Incorporating patients’ allergy treatment in their daily routine may make it easier for them to be compliant with therapy. Take allergy toothpaste, for example. Most people brush their teeth every day as part of their routine, and recommendations are to do so for 2 minutes—the same amount of time a patient has to hold aqueous SLIT drops under their tongue. Why not take advantage of that?
32.2 Allergy Toothpaste—Say What?
Oral mucosal immunotherapy (OMIT) is a different way to deliver antigen to the immune system using a glycerin-based toothpaste vehicle that does not contain fluoride. It involves taking advantage of the density and characteristics of oral Langerhans cells. Langerhans cells in the oral cavity possess high affinity immunoglobulin E (IgE) receptors, are able to bind and present processed antigens to local T-cells, and induce an inhibitory T-helper (Th2) response. While both SLIT and OMIT use these cells, it has been discovered that the sublingual mucosa (where SLIT is placed) has the lowest density and buccal and vestibular region (of which OMIT takes advantage) have the highest density of these cells.
32.3 A Word Before We Start
This is a relatively new allergy therapy that does not have much literature behind it yet, but is currently under further investigation. There are a few studies in the literature that demonstrate its effectiveness, but it has not been studied nearly as extensively as SCIT or SLIT. However, it is currently being used in practice. If a practitioner chooses to use this therapy as part of their treatment, they should make sure to advise patients that, similar to SLIT drops, OMIT is not covered by insurance and the patient has to bear the expenses.
32.4 Who Is a Candidate for OMIT?
Anyone who brushes his/her teeth at least once a day is candidate for OMIT. As discussed in the immediately preceding chapters, anyone who has symptoms of allergic disease, has positive allergy testing that correlates to their symptoms, does not have medical comorbidities which would reduce the chance of survival in the event of anaphylaxis, is not pregnant at initiation, does not have uncontrolled or poorly controlled asthma, and is not on any medications which would complicate treatment in the event of anaphylaxis.
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