Histomorphology of healthy oral mucosa in untreated celiac patients: unexpected association with spongiosis

Background:  The jejunal mucosa is the major site involved in celiac disease, but modifications have also been found in the gastric, rectal and esophageal mucosa. Few studies have focused on the histomorphological features of the oral mucosa in celiac disease patients. Our objectives were: (i) to assess the presence, quality and intensity of lymphocytic infiltrate in clinically healthy oral mucosa and its relation to celiac disease severity (villous height to crypt depth ratio); and (ii) to detect any other histological features connected to celiac disease.
Methods:  Twenty-one untreated celiac disease patients (age range 13–68 years) with clinically healthy oral mucosa were enrolled and compared with 14 controls. Intestinal and oral biopsies were carried out and specimens were evaluated after staining with hematoxylin and eosin.
Results:  Intra-epithelial lymphocyte B and T infiltrates of the oral mucosa were found to be similar in both groups; likewise, intensity of the lymphocytic infiltrate in the lamina propria was similar in both groups and was not related to intestinal damage; important signs of spongiosis were found to be more significantly present in celiac disease patients compared with controls ( P  =   0.0002).
Conclusions:  Our study showed that the healthy oral mucosa of untreated patients does not reflect the intestinal damage by celiac disease, but it is unexpectedly affected by spongiosis, as being detected for the first time in the literature. This latter feature could be related to gliadin ingestion and could contribute to explain the higher susceptibility of celiac disease patients to suffering from oral mucosa lesions.     

Oral pemphigus

A 33-year-old man suffered from spontaneously developing blisters at the oral mucosa. Firstly, the bullous lesions were observed in the third molar region, but they spread progressively over the buccal and palatal mucosa. The bullous lesions ruptured spontaneously, resulting in erosive lesions and pain. Before being referred to an oral and maxillofacial surgeon, the patient consulted his family doctor, his family dentist, as well as an ear-nose-throat-specialist. The oral and maxillofacial surgeon took a biopsy in order to confirm the clinical diagnosis pemphigus vulgaris. The patient was referred to a dermatologist for treatment with systemic corticosteroids and a non-steroid immunosuppressive drug. Subsequently, the mucosal lesions healed.     

Oral manifestations in Cowden's syndrome. Report of four cases

Cowden's syndrome or multiple hamartoma and neoplasia syndrome is a hereditary disorder combining multiple hamartomas of many organs. These hamartomas are derived from ectodermal, mesodermal, and endodermal tissues and may undergo spontaneous malignant changes. Small papular cutaneous lesions and papillomatous outgrowth and papular lesions of the oral mucosa are the most predominant features of the syndrome. Since the orocutaneous lesions often precede the associated malignant degenerations, they may serve as a diagnostic signal for the probably developing neoplasia in other organs. The presence of extensive papillomatous and papular lesions in the oral mucosa combined with skin lesions should therefore alert the clinician to suspect the presence of Cowden's syndrome, the early diagnosis of which is important in order that the concomitant malignant changes might be discovered at the earliest possible moment. Four cases of Cowden's disease are presented, with emphasis on the oral manifestations of this syndrome.     

Immunoelectron microscopic findings in oral mucosa of patients with dermatitis herpetiformis and linear IgA disease

Abstract – Two patients with dermatitis herpetiformis and one with linear IgA disease were examined. Two of the patients had oral lesions and all three showed IgA deposits detected by direct immunofluorescence in apparently normal buccal mucosa. To localize the target structures for IgA deposition, biopsy specimens were taken from normal appearing buccal mucosa for immunoelectron microscopy. The patients with dermatitis herpetiformis had distinct IgA deposits in the upper connective tissue. These were often associated with elastic fibers and occasionally also with capillary walls. In contrast, the patient with linear IgA disease had IgA deposition at the subbasal lamina. Though the clinical expressions may be similar the present immunoelectron microscopic fmdings in oral mucosa clearly differentiate dermatitis herpetiformis from linear IgA disease.     

Immunoelectron microscopic findings in oral mucosa of patients with dermatitis herpetiformis and linear IgA disease

Two patients with dermatitis herpetiformis and one with linear IgA disease were examined. Two of the patients had oral lesions and all three showed IgA deposits detected by direct immunofluorescence in apparently normal buccal mucosa. To localize the target structures for IgA deposition, biopsy specimens were taken from normal appearing buccal mucosa for immunoelectron microscopy. The patients with dermatitis herpetiformis had distinct IgA deposits in the upper connective tissue. These were often associated with elastic fibers and occasionally also with capillary walls. In contrast, the patient with linear IgA disease had IgA deposition at the subbasal lamina. Though the clinical expressions may be similar the present immunoelectron microscopic findings in oral mucosa clearly differentiate dermatitis herpetiformis from liner IgA disease.     

Leprosy-specific oral lesions: a report of three cases

Leprosy is a chronic infection caused by Mycobacterium leprae, a bacillus that presents a peculiar tropism for the skin and peripheral nerves. The clinical spectrum of leprosy ranges from the tuberculoid form (TT) to the disseminative and progressive lepromatous form (LL). Oral lesions are rare but, when present, occur in the lepromatous form. This article describes the clinical and microscopic findings of three cases of LL with oral manifestations. All patients had the lepromatous form and their leprosy-specific oral lesions occurred in the palate. The diagnosis was based on clinical, serological and histopathological findings, and multidrug therapy for multibacillary leprosy was started and continued for 24 months. All patients completed treatment, but developed reaction episodes which were treated with prednisone and/or thalidomide. The authors emphasize the importance of oral mucosa evaluation by a dental health professional during patient care since oral lesions may act as a source of infection.     

Virus-associated dysplasia (bowenoid papulosis?) of the oral cavity

We are presenting a case of multifocal, virus-associated dysplasia of the oral cavity. We believe this case represents bowenoid papulosis, which usually is limited to the genital region. The patient, a 21-year-old white man, had recently completed therapy for Hodgkin's disease. An oral examination revealed multiple red 3 to 6 mm macules scattered over the oral mucosa, involving the buccal and labial mucosa, palate, and gingiva. The favored clinical diagnosis was candidiasis. Histologically, the biopsy specimen showed severe epithelial dysplasia. Three additional oral biopsies of different sites were performed and revealed similar histology. Immunohistochemical stains for human papillomavirus were done, and two of four lesions stained positively. Transmission electron microscopy revealed intranuclear viral particles consistent with human papillomavirus. Further questioning and examination of the patient revealed that he had lesions of the penis that were clinically and histologically bowenoid papulosis. In addition, he admitted to oral-genital sex during the period of therapy for Hodgkin's disease. This is the first reported case of oral bowenoid papulosis, and it supports a viral cause for this disease process.     

Interazione fra amalgama e altri metalli presenti nel cavo orale: caso clinico

ObjectivesThe aim of this study is to demonstrate, through literature review and presentation of an exemplified clinical case, the possibility of treatment of oral mucosal lesions associated with amalgam restorations.Materials and methodsThe clinical case of a patient is reported, who presented with lesions in the lateral borders of the tongue which were erythematous, bilateral and painful on palpation, and with other non-painful lesions in the posterior cheek region. On oral cavity examination, amalgam restorations in several permanent teeth and crowns in gold alloy and ceramic were found. Mucosal lesions affected areas in direct contact with amalgam restorations. The selected treatment consisted of replacing all amalgam fillings with last generation composites.ResultsOne month after the end of amalgam replacement therapies, the patient reported the total disappearance of painful symptoms. At the clinical control two months after treatment, the total disappearance of the lesions was observed.ConclusionsThe removal of amalgams from the oral cavity may represent a first successful therapeutic approach in patients with chronic oral mucosal lesions, especially if located in direct contact with the amalgams. In addition to possible toxico-allergic reactions to amalgams, it should be noted that the simultaneous presence of different types of metal restorations (often amalgam and crowns in gold alloy) may result in the formation of a high electric potential difference that can cause symptoms and lesions in the oral mucosa.     

Traumatic ulcerative granuloma with stromal eosinophilia of the oral mucosa: histological and immunohistochemical analysis of three cases

Traumatic ulcerative granuloma with stromal eosinophilia is an ulcerated oral lesion which pathogenesis is still unclear. Clinically, this disease is characterized by the presence of chronic ulcerative lesions with elevated and indurated borders in the oral mucosa. It usually develops rapidly and persists for several weeks or months, it presents mainly on the tongue but other areas such as gingival, cheek and vestibular mucosa may also be involved. We report three cases showing their clinical, histological and immunohistochemical analysis. In this study the authors underline the importance of a correct differential diagnosis and monitoring of these patients in order to prevent the development of possible serious complications.     

Oral manifestations during chemotherapy for acute lymphoblastic leukemia: a case report.

A 14-year-old, male patient was referred for the treatment of mucositis, idiopathic facial asymmetry, and candidiasis. The patient had been undergoing chemotherapy for 5 years for acute lymphoblastic leukemia. He presented with a swollen face, fever, and generalized symptomatology in the mouth with burning. On physical examination, general signs of poor health, paleness, malnutrition, and jaundice were observed. The extraoral clinical examination showed edema on the right side of the face and cutaneous erythema. On intraoral clinical examination, generalized ulcers with extensive necrosis on the hard palate mucosa were observed, extending to the posterior region. Both free and attached gingivae were ulcerated and edematous with exudation and spontaneous bleeding, mainly in the superior and inferior anterior teeth region. The tongue had no papillae and was coated, due to poor oral hygiene. The patient also presented with carious white lesions and enamel hypoplasia, mouth opening limitation, and foul odor. After exfoliative cytology of the affected areas, the diagnosis was mixed infection by Candida albicans and bacteria. Recommended treatment was antibiotics and antifungal administration, periodontal prophylaxis, topical application of fluor 1.23%, and orientation on and control of proper oral hygiene and diet during the remission phase of the disease.     

Discovery of a patient with strongly suspected bullous pemphigoid in a ward by oral health care providers

To cite this article:
Int J Dent Hygiene 9 , 2011; 159–162
DOI: 10.1111/j.1601‐5037.2010.00448.x
Kanda N, Soga Y, Meguro M, Tanabe A, Yagi Y, Himuro Y, Fujiwara Y, Takashiba S, Kobayashi N. Discovery of a patient with strongly suspected bullous pemphigoid in a ward by oral health care providers. Abstract: Objectives: Oral health care providers may discover systemic diseases incidentally from signs observed in the oral cavity. Here, we report a case in which oral health care providers in a hospital discovered a patient with strongly suspected bullous pemphigoid (BP), which is a relatively rare but important disease, in a ward. Methods: The patient was a 78‐year‐old Japanese woman admitted to our hospital because of severe Alzheimer’s disease. We discovered recurrent ulcers in the oral mucosa and skin when performing oral care in her ward. Biopsy could not be performed safely because of involuntary biting. We performed blood tests for anti‐BP180‐NC16a antibody, which is autoantibody specific for BP. Results: The patient had a very high anti‐BP180‐NC16a antibody titre. We consulted a dermatologist regarding her clinical course and the clinical features of the oral mucosa and skin along with blood test results. BP was very strongly suspected. Discussion: In cases in which oral health care providers suspect their patients may have BP, appropriate examination and provision of information to the doctor are important. Oral health care providers should have knowledge about systemic diseases, the signs of which appear in oral cavity to avoid missing important systemic diseases.     

Diversity of gammadelta T cells in patients with Behcet's disease is indicative of polyclonal activation

OBJECTIVE: Behcet's disease (BD) is a multisystemic disease, with vasculitic lesions in the oral and genital mucosa, eyes, joints, skin and brain. We have previously found that gammadelta T cells are increased in peripheral blood of BD patients. The aim of this study was to investigate the extent of gammadelta T cells in oral biopsies from BD patients with special emphasis on the restriction of Vgamma and Vdelta usage. PATIENTS AND METHODS: Expression of Vgamma and Vdelta chains on peripheral blood gammadelta T cells from 31 BD patients and 19 healthy controls was analysed by flow cytometry and the expression of Vgamma and Vdelta chains in nine ulcerated and eight non-ulcerated oral mucosa from BD patients and non-ulcerated oral mucosa from three healthy controls was analysed by immunohistochemistry. RESULTS: Vgamma9 and Vdelta2 were the predominant chains expressed in peripheral blood of BD patients, although other Vgamma and Vdelta chains were also expressed. The presence of gammadelta T cells was only observed in the ulcerated oral mucosa but not in the non-ulcerated mucosa from the BD patients, and not in the non-ulcerated mucosa from the healthy controls. These gammadelta T cells showed no preferential expression of any of the Vgamma or Vdelta chains. CONCLUSION: These data suggest a polyclonal rather than oligoclonal activation of the gammadelta T cells. This may indicate that during repeated inflammation of the oral mucosa, the gammadelta T cells are responding to a wide variety of antigenic stimuli with consequent expansion of gammadelta T cells expressing various Vgamma and Vdelta chains and that different antigenic stimuli or responses may be responsible for the clinical heterogeneity of the disease.     

Oral lesions, HIV phenotypes, and management of HIV-related disease: Workshop 4A

The workshop considered 5 questions related to oral lesions, HIV phenotypes, and the management of HIV-related disease, with a focus on evidence and challenges in resource-poor settings. First, are oral lesions unique with respect to geographic location or phenotype? Second, how useful would an oral lesion index be to predict HIV in resource-poor countries with no access to CD4 counts or viral load? Third, what are the latest methods and delivery modes for drugs used to treat oral lesions associated with HIV? Fourth, what is the role of the oral health care worker in rapid diagnostic testing for HIV? Fifth, what ethical and legal issues are to be considered when managing the HIV patient? The consensus of the workshop was the need for additional research in 4 key areas in developing countries: (1) additional investigation of comorbidities associated with HIV infection that may affect oral lesion presentation and distribution, especially in pediatric populations; (2) the development of region-specific algorithms involving HIV oral lesions, indicating cumulative risk of immune suppression and the presence of HIV disease; (3) well-designed clinical trials to test new therapies for oral lesions, new treatments for resistant oral fungal and viral diseases, effectiveness of therapies in children, and new drug delivery systems; and (4) the role of the oral health care worker in rapid diagnostic testing for HIV in various regions of the world.     

Darier disease: case report with oral manifestations

Darier disease, also known as keratosis follicularis or dyskeratosis follicularis, is a rare autosomal dominant genodermatosis. It is clinically manifested by hyperkeratotic papules primarily affecting seborrheic areas on the head, neck and thorax, with less frequent involvement of the oral mucosa. When oral manifestations are present, they primarily affect the palatal and alveolar mucosa, are usually asymptomatic, and are discovered in routine dental examination. Histologically, the lesions present suprabasal clefts in the epithelium with acantholytic and dyskeratotic cells represented by corps ronds and corps grains. This paper reports a case of an adult male patient presenting clinical signs of Darier disease in the palatal mucosa and skin on the neck and upper limbs. Intraoral biopsy of the affected area, analysis of family history and evaluation by a multidisciplinary team led to the diagnosis of Darier disease. Dental professionals and pathologists should be aware of these lesions to allow correct diagnosis and proper management of this disease.     

Orale Manifestation einer miliaren Tuberkulose

Case report

We report on the clinical course of a 40-year-old patient with an oral manifestation of miliary tuberculosis. In addition to oral mucosa and lung, the colon and ileum were also infested. The oral lesions may resemble malignant tumors and are difficult to diagnose, especially because tuberculosis has become a rare disease in industrialized countries.

Discussion

Oral lesions and concomitant pulmonary complaints can be a sign for existing tuberculosis. Patients with these problems should undergo a chest X-ray and a biopsy from the oral mucosa. In addition, tests should be conducted to determine if mycobacteria are present in the sputum, gastric fluid, and urine and cultures grown. In cases with negative results PCR may detect DNA of Mycobacterium tuberculosis.     

Resolution of oral lesions after tobacco cessation

Background: Dentists and other health care professionals are familiar with the impact of tobacco on oral and general health. However, oral health care professionals do not often provide tobacco-cessation counseling to their patients, thus reflecting a significant disconnect between research and clinical practice. This report demonstrates the benefits of tobacco cessation in resolving oral lesions and improving overall periodontal and oral health. Methods: A 51-year-old white male presented to the University at Buffalo, School of Dental Medicine clinic requesting an oral and periodontal examination as part of a presurgical protocol prior to cardiac surgery. A review of the patient's history from a health questionnaire revealed that he was using smokeless tobacco every day. An oral examination revealed several white lesions (5 x 10 mm) on the maxillary right and left labial mucosa. The patient was provided with tobacco-cessation counseling as well as oral hygiene instructions and professional dental prophylaxis. Results: An oral examination 2 weeks after tobacco cessation revealed complete resolution of the oral lesions and overall improvement of periodontal and oral health. Conclusion: Although the findings presented in this article are based only on a single case report, the improvement in the patient's oral health after cessation of tobacco use was dramatic and reinforces the belief that tobacco-cessation counseling should be a routine component of the standard of care for tobacco-using patients.     

Oral cGVHD screening tests in the diagnosis of systemic chronic graft-versus-host disease

To determine the diagnostic properties of oral manifestations and histological features of graft-versus-host disease (GVHD) screening tests in the diagnosis of systemic chronic graft-versus-host disease (cGVHD). Sixty patients having undergone allogeneic haematopoietic stem cell transplantation were selected. The patients were submitted to a clinical oral examination to assess symptoms and clinical changes in the oral mucosa. Histopathologic analysis of the lower lip oral mucosa (LLOM) and salivary glands (SG) was also performed. Systemic cGVHD was used for a comparison to oral cGVHD. The accuracy of oral cGVHD tests was low for all methods (58.4% and 52.6% for white lesions and white/red lesions, respectively, in the clinical analysis; 50.4% for the presence of oral pain; and 66.8% and 55.1% for LLOM and SG histopathologic tests, respectively). However, the presence of oral pain had good diagnostic properties [specificity: 100.0, 95% confidence interval (CI): 88.0–100.0; positive predictive value (PPV): 100.0, 95% CI: 94.4–100.0; and negative predictive value (NPV): 72.0, 95% CI: 57.3–83.3]. Moreover, SG alterations revealed by the histopathological analysis also exhibited good diagnostic properties (sensitivity: 98.6, 95% CI: 81.5–99.8; PPV: 71.1, 95% CI: 62.1–79.7; NPV: 85.9 95% CI: 32.9–99.4). The clinical severity of oral lesions and histophatological changes in the LLOM did not exhibit adequate diagnostic properties, whereas both oral pain and SG histopathological analysis exhibited adequate properties for the diagnosis of systemic cGVHD. Histological changes in lip oral mucosa and salivary glands together with a clinical manifestation of the disease in the oral mucosa can be useful to determining the systemic cGVHD.     

Oral mucosa in children with Prader–Willi syndrome

J Oral Pathol Med (2011) 40 : 778–784 Prader–Willi syndrome is a genetic disorder. Abnormal saliva secretion, emotional and behaviour problems, may affect the health status of the oral mucousa. Objectives: To assess the impact of self‐destructive behaviour and abnormal saliva secretion on the oral mucosa in children with Prader–Willi syndrome (PWS). Materials and methods: Fifteen PWS’s children (mean age 9.8 ± 4.4 years) and 15 healthy children (mean age 11.5 ± 3.5 years) were assessed for self‐destructive behaviours, such as picking at the skin, physical and chemical saliva characteristics, mycology, and the clinical status of the oral mucosa. Results: Picking at the skin was only in children with PWS (n = 12). In contrast to the control group, the moistening rate of the lower lip mucosa was slower, and the mean pH of the resting saliva was reduced in the affected subjects. Sticky frothy or frothy saliva, decreased secretion rate of the stimulated saliva, and a reduced buffer capacity were more frequently in PWS’s children; Candida spp. and oral candidiasis were also more common. Injurious lesions in the oral mucosa were found in one control child, and in eight PWS’s subjects. In affected children, the lesions were concurrent with picking at the skin. A statistical correlation was noted between the presence of Candida spp. and oral candidiasis, and unfavourable saliva properties, and between injurious lesions and a slow moistening rate of the lower lip mucosa, and oral candidiasis. Conclusions: Abnormal saliva secretion and self‐destructive behaviours in children with Prader–Willi syndrome predispose them to injurious lesions in the oral mucosa, and possibly, to oral candidiosis.     

Lichen sclerosus of the oral mucosa: a case report

Lichen sclerosus or lichen sclerosus et atrophicus is a chronic inflammatory disease predominantly affecting the genital mucosa and skin. Clinically, it is characterized by white atrophic plaques in the anogenital region. The lesions are generally asymptomatic, but may cause discomfort with itching and pain. Extragenital mucosal involvement is very unusual, and lesions limited to the oral mucosa are even less frequent. Knowledge of such lesions is important in order to establish a differential diagnosis with other white oral lesions, and histological confirmation is required. We present the case of a 31-year-old woman with a well delimited, pearly white lesion located in the upper gingival mucosa, lip mucosa and adjacent skin. The lesion had led to loss of periodontal attachment of the affected tooth, causing pain in response to tooth brushing. The biopsy confirmed lichen sclerosus, and treatment was provided in the form of intralesional corticoid injections, followed by improvement of the mucosal lesion, though without recovery of the periodontal loss.