Minor salivary gland involvement in sarcoidosis. Report of 3 cases with positive lip biopsies

An update on granulomatous diseases of the oral tissues

With new insights into the pathogenesis of specific granulomatous diseases, and with the advent of high-throughput genetic screening and availability of next-generation biological therapies, clinicians have several options at their disposal to help ensure accurate diagnosis and effective treatment. This article highlights some of the current knowledge about the more common granulomatous systemic diseases that may be encountered in clinical practice.

Oral Crohn's disease: is it a separable disease from orofacial granulomatosis? A review

Symptomatic oral Crohn's disease is comparatively rare. The relationship between orofacial granulomatosis, (where there is granulomatous inflammation and ulceration of the mouth in the absence of gastrointestinal disease) and true oral Crohn's disease is discussed along with the plethora of clinical oral disease presentations associated with both disorders and the differential diagnosis of oral ulceration in patients presenting to a gastroenterological clinic. Specific oral syndromes are outlined including the association between oral manifestations in Crohn's disease and the pattern of intestinal disease and their relationship to other recorded extraintestinal manifestations. The histological and immunological features of oral biopsies are considered as well as the principles of management of symptomatic oral disease. At present, it is suggested that both orofacial granulomatosis and oral Crohn's disease appear to be distinct clinical disorders.

Diagnosis of systemic sarcoidosis prompted by orofacial manifestations

BACKGROUND

Sarcoidosis is a multifactorial systemic inflammatory disorder of unknown origin characterized by many potential signs and symptoms, as well as by the presence of noncaseating granulomas in the organs involved. Sarcoidosis also may manifest in the oral and maxillofacial region.

CASE DESCRIPTION

The authors describe a patient with xerostomia, dysgeusia, oral burning, xerophthalmia and bilateral parotid enlargement. She was diagnosed as having systemic sarcoidosis on the basis of the histologic findings of a biopsy of the labial minor salivary gland, as well as subsequent diagnostic evalutons.

CONCLUSION AND CLINICAL IMPLICATIONS

Enlargement of major salivary glands may be the first sign of sarcoidosis in a patient with few other symptoms or clinical findings suggestive of the disease. This case emphasizes the importance of including sarcoidosis in the differential diagnosis of bilateral parotid swelling associated with xerostomia. It also highlights the dentist's potential role in the diagnosis and dental treatment of patients with systemic sarcoidosis.

Sarcoidosis diagnosed in elderly subjects: retrospective study of 30 cases

STUDY OBJECTIVE

This study investigated the clinical features and disease course of sarcoidosis diagnosed in patients > 70 years of age.

METHODS

A retrospective analysis was made of cases treated at the University Hospital in Nantes, France, between 1986 and 2000. The diagnosis of sarcoidosis was confirmed histopathologically. Cases involving progressive cancer and active tuberculosis were excluded.

RESULTS

Thirty white patients with sarcoidosis diagnosed after age 70 years (mean, 74 years) were included. An alteration of general health (asthenia and/or anorexia and/or weight loss) was frequent (53%) and characteristic of the systemic form of the disease. Dyspnea was a fairly common sign (23%). The intrathoracic form of sarcoidosis was most frequent (43.3%). Diagnosis was difficult and lengthy, and symptomatology was atypical. Accessory salivary gland biopsy was an important contributing factor to diagnosis (70.6% were positive). Oral corticosteroid therapy was often required (60.7%). The disease course was satisfactory overall (81.8% of cases), but only for 50% of patients in intrathoracic stage IV.

CONCLUSIONS

The clinical presentation of sarcoidosis in elderly subjects is mainly characterized by an alteration of general health. Diagnosis is difficult and should include accessory salivary gland biopsy. Therapy frequently involves corticosteroids. Overall prognosis is similar to that for young subjects.

Granulomatous diseases of the oral tissues: differential diagnosis and update

Because of the relatively nonspecific clinical findings associated with a variety of granulomatous diseases, a microscopic diagnosis of granulomatous inflammation often presents a diagnostic dilemma for the clinician. The most common differential diagnosis includes foreign body reactions, infection, Crohn's disease, sarcoidosis, and orofacial granulomatosis. However, a variety of other conditions may be associated with granuloma formation. Often an extensive clinical, microscopic, and laboratory evaluation may be required to identify the source of the granulomatous inflammation. This article highlights the origin, clinical manifestations, current diagnostic modalities, and treatment of specific granulomatous diseases that may be encountered in clinical practice.

Oral manifestations of sarcoidosis

OBJECTIVE

To report two new cases of sarcoidosis of the buccal mucosa and to analyze the literature on oral manifestations of sarcoidosis.

STUDY DESIGN

Oral lesions with histologic features of sarcoidosis were analyzed according to their location and appearance.

RESULTS

Analysis of 45 cases of oral sarcoidosis (43 from the literature and the 2 new presented cases) revealed 12 lesions in the jaws, 10 in the buccal mucosa, 6 in the gingiva, 5 in the lips, 5 in the floor of the mouth, 4 in the tongue, and 3 in the palate. Sarcoidosis in the jaw was located in the alveolar bone and presented as an ill-defined radiolucency. Submucosal nodules were observed in sarcoidosis affecting the buccal mucosa, palate, and lip. Swelling was the main manifestation in the gingiva. In the floor of the mouth, sarcoidosis presented as ranula and that of the tongue as induration. In most of the cases, the lesions in the buccal mucosa, gingiva, and tongue were the first clinical manifestation of the disease.

CONCLUSION

Oral sarcoidosis lesions should be considered in the differential diagnosis of oral soft tissue swellings and jaw lesions.

[Role of biopsy of the accessory salivary glands in Löfgren's syndrome and other forms of sarcoidosis]

The diagnosis of sarcoidosis requires histopathological analysis. Easy accessible site of biopsy is seldom. A systematic labial salivary gland biopsy was performed in 62 suspected sarcoidosis: 22 patients with Löfgren syndrome (group I), and 40 patients with systemic sarcoidosis (group II). Systematic bronchial biopsy was performed in eight patients of group I and ten patients of group II. If systematic biopsies were negative, direct biopsies were performed (lymph node, skin, kidney, liver). In group I, 8/22 labial salivary gland biopsies and 1/8 bronchial biopsies were positive; in group II, 17/40 labial salivary gland biopsies and 5/10 bronchial biopsies were positive. In the other patients, direct biopsies were positive: 27 lymph nodes, eight skin, eight hepatic, four kidney biopsies. In conclusion, labial salivary gland biopsy (even in the absence of sicca syndrome) is more reliable than systematic bronchial biopsies, particularly in Löfgren syndrome and may avoid in 30 to 50% of the cases more aggressive and dangerous biopsies such as liver, kidney or deep lymph nodes biopsies.

Treating oral sarcoidosis

Oral sarcoidosis is rare and can be confused with various other lesions. Two case reports of sarcoidosis involving the lips are presented along with a discussion of sarcoidosis and treatment options.

Sarcoidosis in a patient presenting with clinical and histological features of primary Sjögren's syndrome

A patient presenting with bilateral enlargement of parotid and lacrimal glands, xerostomia, and keratoconjunctiva sicca, whose labial biopsy specimen showed changes consistent with Sjögren's syndrome, is described. The patient was initially misdiagnosed as having primary Sjögren's syndrome (SS). Subsequent investigations, however, performed to exclude an associated lymphoma or sarcoidosis, showed histological changes of the latter. The possibility that early infiltrates of the salivary glands in sarcoid may mimic those of SS is discussed.

Labial salivary gland biopsy in Sjögren's syndrome. Assessment as a diagnostic criterion in 362 suspected cases

Xerostomia is an unsatisfactory diagnostic criterion for the salivary component of Sjögren's syndrome (SS). To determine the diagnostic usefulness of the presence of focal sialadenitis in labial salivary gland (LSG) biopsy specimens, 362 patients suspected of having SS prospectively underwent a unique LSG biopsy procedure. The pattern and severity of LSG inflammation were compared with measurements of parotid flow rate, and the presence or absence of symptomatic xerostomia, major salivary gland enlargement, keratoconjunctivitis sicca (KCS), and other connective tissue diseases (CTD). LSG biopsy focus scores of greater than 1 correlated more closely with the diagnoses of KCS alone and with KCS plus a CTD than did either reduced parotid flow rate or symptoms of xerostomia (P less than 0.0005 and P less than 0.05, respectively). Focal sialadenitis in an adequate LSG specimen is an objective criterion and a more disease-specific feature of SS than xerostomia or any other feature of salivary disease. The salivary component of SS should be redefined as the presence of LSG focal sialadenitis.

Multinucleate giant cells in sublabial salivary gland tissue in Sjögren's syndrome. A diagnostic pitfall

The presence of multinucleate giant cells in the sublabial salivary gland tissue in Sjögren's syndrome is an unusual phenomenon which can give rise to differential diagnostic problems. We found in 4 cases of 55 patients with Sjögren's syndrome multinucleate giant cells. In 2 of these 4 patients epimyoepithelial islands were also present. The combination of both multinucleate giant cells as epimyoepithelial islands can mimic the histological picture of a non- caseating granulomatous disease. To discriminate between an epimyoepithelial island and an epithelioid granuloma the immunoperoxidase technique with antibodies directed against muramidase appeared an useful tool. The epithelioid cells contain muramidase whereas the cells in the epimyoepithelial island do not contain this enzyme. Thus, multinucleate giant cells are a rare phenomenon in Sjögren's syndrome, therefore restricting its diagnostic significance. When they occur in Sjögren's syndrome staining for muramidase can be of help to avoid a false positive diagnosis of diseases in which non- caseating granulomatous inflammation occur, such as in sarcoidosis.

Sarcoidosis associated with Crohn's disease of ileum, mouth and oesophagus

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Diagnosis of sarcoidosis from oral manifestation

The diagnosis of sarcoidosis may be a matter of complexity. Two cases of sarcoidosis in which oral manifestations were helpful in the diagnosis are presented. Similar cases from the literature are reviewed and discussed, and it seems that sarcoid involvement of clinically normal-appearing oral mucosa occurs with some frequency.

[Morphology of salivary gland diseases]

The human salivary glands represent a functional system with manifold responsibilities and interactions to the organism. The major and minor salivary glands show a common construction schedule consisting of an acinar functional system for the production of an enzyme- and mucin-containing primary saliva and a ductal functional system with manifold secretory, resorptive and regulatory responsibilities for the transport and the definitive composition of the saliva. The cyclic AMP and calcium iones localized in the glandular acini have an exceptional importance for the course of the secretory process. The neurohormonal control of the salivary secretion results by adrenergic and cholinergic transmitter substances. Moreover the secretory process shows a daily cycle combined with morphological alterations of the glandular cells (so called circadian structures). The fluid secretion of the salivary duct system (the output of sodium-, potassium- and chlorine-iones) represents an active energy-consumed transport process which will be regulated by several factors (autonomic nervous system, quantity of perfusion, hydrostatic pressure in the blood capillaries, transepithelial active transport by ATP-consumed pump systems). The striated ducts are the functional most important sector of the duct system for a rapid fluid- and electrolyte excretion. The terminal axons of the postganglionic sympathic and parasympathic neurits are characterized by spindle-shaped enlargements (varicosities) which contain neurosecretory granules. In the region of the acinar and intercalated duct cells a direct synaptic contact exists for the stimulation transmission, in the course of which the terminal axon contacts immediately with the effector cell by penetration of the basement membrane. The salivary glands form a part of the stabil tissues with reversible postmitotic cells in regard of the tissue regeneration. Under pathological conditions (inflammations, impediment of secretion fluid, radiation effects etc.) metaplasias and proliferations of the duct system arise with development of indifferent duct formations analogous to the type of an embryonal salivary gland. The terminal zone between intercalated and striated ducts represents an indifferent zone with large regeneratory potency. A special behaviour shows the myoepithelial cells which are developed as well to the outside of primitive embryonic duct buds as differentiated intercalated and striated ducts. Morphologically three types of diseases can be classified in the salivary glands: sialadenosis, sialadenitis and tumours.(ABSTRACT TRUNCATED AT 400 WORDS)