By Henry Ehrlich
Brush teeth or get allergy shots–which would your child prefer? Sounds like a slam dunk, although to be fair, some kids hate brushing. Thanks to the inventive mind of Dr. William R. Reisacher this choice is rapidly becoming a reality in the form of oral mucosa immunotherapy, or OMIT. Allergens, not just environmental but also foods, can be introduced to the immune system via oral Langerhans cells (oLC) which are more dense in the gums and cheeks than under the tongue–the induction point for sublingual immunotherapy (SLIT). Toothpaste delivered by normal brushing seemed like an ideal way to ensure compliance–the real bane of allergy shots and SLIT. We wrote about this idea a couple of years ago, but I had never met Dr. Reisacher until the other night at the End Allergies Together [EAT] benefit in Greenwich, Ct. As is my custom, the first thing I did when I met Dr. Toothpaste was to ask him to answer some questions for our readers. — Henry Ehrlich
AAC: Welcome, Dr. Reisacher, to our website. Let me get started. I know that your invention was inspired by your own experience with food allergies. Could you tell us about your allergies and how they found their way into your work? Eureka moments always make for good reading.
Bill: Thanks, Henry, it’s great to be here! It was tough growing up with peanut allergies, and I still have a couple of allergic reactions each year, but the daily struggle has made me stronger and more determined to fight this terrible disease. As an ear, nose and throat doctor who treats allergies, I frequently offer my patients a time-honored treatment to make them less allergic to respiratory allergies called immunotherapy. This often misunderstood and underutilized treatment can give you 20-30 years of benefit after the treatment is done, and helps people who are allergic to things like cats, dust and pollen. Immunotherapy, or desensitization, has been in use for about a century and can be given with weekly shots in the office or drops under the tongue containing concentrated protein extracts, but these techniques are difficult for adults, and particularly children, to maintain for the necessary 3-5 years. My “eureka” moment came when I was brushing my teeth one morning. I was thinking about an article I just read about the immune cells in the mouth and, as I stared into the mirror I realized that the foam was coating all the areas of the mouth where special cells, called Langerhans cells, are in highest numbers. If I could just get these extracts into a great toothpaste, then I could have a really safe and effective treatment for allergies that would also be easy to use every day from home. I almost choked on my toothpaste!
AAC: Could you talk about the functions of the oLCs? What do they do normally and what makes them such a suitable induction point for the allergens? Also, do patients need to use any special brushing technique, apart from brushing thoroughly instead of the rush job kids are known to do. And how long do they have to brush?
Bill: Oral Langerhans cells, or oLCs, are the key to successful allergy treatment. Normally, they collect proteins from the lining of the mouth and brings them back to the lymph nodes in the region, where the body learns how to ignore safe items, such as food. But for people with allergies, that does not happen to the extent it should, so immunotherapy can get those normally hard-working cells off the couch and send your immune system back to college! For the allergy toothpaste treatment, which I call oral mucosal immunotherapy, or OMIT, all it takes is regular tooth-brushing for 2 minutes every day. That’s how long you’re supposed to brush anyway! And if you have a hard time brushing for that long, there are toothbrushes that vibrate or play a song for 2 minutes to help you out.
AAC: What are the mechanics of engaging the immune system and how do they differ from other forms of immunotherapy?
Bill: When proteins enter the mouth, those that are not swallowed right away stick to the lining of the mouth like a magnet. The Langerhans cells gradually pull them underneath the surface just like fish in a tank after you drop the food in, but the proteins are too large to get into the bloodstream. This slow and steady exposure of the proteins to the body’s immune system is why OMIT is safe enough to be done from home. Allergy shots, while very effective, can cause more severe reactions because of the sudden entry of proteins under the skin. This is why shots must be done in the doctor’s office with an observation period of 20-30 minutes afterwards.
AAC: How did you arrive at the formulation for the toothpaste? Did you experiment with different compounds and what went wrong? Was it trial and error or were you guided by basic chemistry?
Bill: The first thing I learned about making toothpaste is that it’s not as easy as it looks. To say that the first attempts were salty would be an insult to salt! The next few versions came out either like mint-flavored soup, or something that could be used to dye the felt on a pool table! Commercially-available toothpaste would mix with the extracts, but the final product was too runny and broke down the proteins. While there certainly was a fair amount of trial and error, this process required a lot of knowledge about which ingredients mix well with others, and how changes in one will affect consistency, taste and foaming action. So, after many months of research, reading and advice from formulation experts and countless tooth-brushing sessions with my partners, the final version was complete! It was an extra thick base paste with all the detergents, abrasives, flavor and color, which became a normal toothpaste only after mixing with a certain amount of liquid allergy extracts. And the best news of all, the proteins were stabilized for over a year!
AAC: You are working on a novel food allergy diagnostic. Everyone knows we need better diagnostics almost as much as we need better treatments. Can you tell us what this is about and why it represents a leap forward?
Bill: The diagnostic test I am working on is based on a method I patented to isolate and measure the allergy antibodies from the cells that line the internal structures of the body, such as the nose or mouth. This way, the area of the body where the reaction is occurring can be tested, instead of testing antibody levels in the blood or skin. Through research generously funded by the American Academy of Otolaryngic Allergy (AAOA) Foundation, I’ve determined that testing in the symptomatic area can sometimes tell a very different story. Right now, I’m working on a test that can predict whether a person will have swelling or itching in the mouth and throat after eating peanuts. All it takes is brushing the gums in all 4 quadrants of the mouth with a soft brush, which can easily be done from home! In addition to making the diagnosis, this test might also help doctors decide whether it is safe enough for their patients to undergo other types of testing, such as an oral food challenge.
AAC: What are the safety and efficacy records both of environmental and food allergens? Do food allergic patients react to the toothpaste? Any adverse reactions?
Bill: Immunotherapy using environmental allergens is extremely effective with all delivery methods, as long as it’s done consistently for the required amount of time. Safety is also excellent in experienced hands, though severe allergic side effects occur more often with shots. Foods, on the other hand, are more likely to produce severe, life-threatening allergic reactions, particularly when they are swallowed. This is the reason why Intrommune Therapeutics, a NYC-based biopharmaceutical company, has begun the FDA-regulated process of developing an OMIT toothpaste with peanut protein to protect peanut-allergic individuals against accidental exposure. The incidence of this life-threatening (and quality of life-threatening) disease is rising dramatically, and currently there is no FDA-approved product on the market to help control it. Intrommune anticipates that side effects will be minimal because the toothpaste is not swallowed. And it doesn’t smell or taste like peanuts!
AAC: Finally, you mentioned that you do standup comedy. Has standup influenced your clinical skills? Your research? And can you tell us one joke in your act that emanated from your allergies or your work?
Bill: I’ve been doing stand-up comedy in NYC for the past 10 years, and it’s a great way to let off steam after a tough day in the office. When I’m up on the stage, I’m trying to make a special connection with the people in the audience, and I have the same exact goal in my office. When you can find that magical connection, everybody gets a good feeling! One way that comedy has helped me in my research is that it encourages me to try new things and view failure as merely the next opportunity to improve. Comedy and research are also similar in that you have to survive on very little money! Ironically, when I tell people about my allergy toothpaste for the first time, they usually laugh. This guy came up to me the other day and called me a professional nose-picker, so I told him, “That SNOT funny!” Thanks and good night, everybody – I’ll be here all week!
AAC: Thanks for your time.
William Reisacher, MD is a board-certified otolaryngologist, specializing in the diagnosis and treatment of airborne and food allergies in children and adults. Dr. Reisacher graduated from The Mount Sinai School of Medicine in 1994, with Distinction in Research, and completed his Otolaryngology residency at The New York Eye & Ear Infirmary in 2000. He is currently on the full–time faculty of the Otolaryngology – Head and Neck Surgery Department at Weill Cornell Medical College / NewYork-Presbyterian Hospital in New York City, where he is an Associate Professor and the Director of Allergy Services. Dr. Reisacher is a Fellow of the American College of Surgeons and a Fellow of the American Academy of Otolaryngic Allergy (AAOA). He has published numerous chapters and research papers, holds a patent in the area of allergy diagnostics, and has presented his work at both national and international meetings. An Honor Award recipient for the American Academy of Otolaryngology – Head & Neck Surgery, Dr. Reisacher has served on the Allergy & Immunology Committee and Board of Governors, as well as the Board of Directors of the AAOA. He has also been an instructor and mini-seminar moderator for both academies. Dr. Reisacher has appeared on national and local news broadcasts, providing commentary on ENT/allergy topics, and has co-founded companies in both the biopharmaceutical and digital health-tech spaces. He lives in Manhattan with his wife and three children.
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