Mucosal disease series. Number VI. Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS; aphthae; canker sores) is a common condition which is characterized by multiple recurrent small, round or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or grey floors typically presenting first in childhood or adolescence. RAS occurs worldwide although it appears most common in the developed world. The aetiology of RAS is not entirely clear. Despite many studies trying to identify a causal microorganism, RAS does not appear to be infectious. A genetic predisposition is present, as shown by strong associations with genotypes of IL-1beta; IL-6 in RAS patients, and a positive family history in about one-third of patients with RAS. Haematinic deficiency is found in up to 20% of patients. Cessation of smoking may precipitate or exacerbate RAS in some cases. Ulcers similar to RAS may be seen in human immunodeficiency virus disease and some other immune defects, and drugs, especially non-steroidal anti-inflammatory drugs and nicorandil may produce lesions clinically similar to RAS. Topical corticosteroids can often control RAS. However, the treatment of RAS remains unsatisfactory, as most therapies only reduce the severity of the ulceration and do not stop recurrence.

Number 1Epithelial biology

The oral mucous membrane has features similar to skin but also differs in several ways. This paper reviews the aspects of epithelial biology necessary for an understanding of the vesiculoerosive disorders.

Les produits injectables lentement et non résorbables

Products which are non absorbable or slowly absorbable make the correction of facial wasting of any origin possible. These highly efficient products are unfortunately sometimes responsible for complications or even undesirable after effects. In order to avoid this the following are necessary: clinical and histological analysis of facias granulomas, a proposal for guidelines for their use which would predict in situ tolerance.

[Solitary circumscribed neuroma (palisaded encapsulated neuroma) of the oral mucosa]

BACKGROUND

The solitary circumscribed neuroma or "Palisaded Encapsulated Neuroma" is an infrequent benign tumor of the skin of adults, often localised on the face, around the orifices. The involvement of the oral mucosa or of the vermilion border of the lips is rare.

CASE REPORTS

In our 5 cases, a small painless and more or less protruding nodule had been present for years on the mucosa of the hard palate (50 year-old man, 43 year-old woman), the soft palate (63 year-old woman), the vermilion border of the lower lip (48 year-old woman), and the gingiva (26 year-old man). The non specific clinical aspect did not permit a correct diagnosis.

DISCUSSION

Histologically, the solitary circumscribed neuroma is formed by a proliferation of Schwann cells arranged in interlacing bundles, featuring one or several well-limited nodules, sometimes surrounded by a thin capsule. At first sight, this aspect might sometimes mimic schwannoma or neurofibroma. The lesion is interspersed with a variable amount of axons. An association with neurofibromatosis or MEN syndrome type IIb has never been found. Even after incomplete excision the solitary circumscribed neuroma does not recur, a fact supporting a reactive rather than a neoplastic origin.

Polishing-paste-induced silica granuloma of the gingiva

Polishing-paste-induced silica granuloma of the gingiva, an uncommon condition, may mimic various local or systemic pathological entities. A 33-year-old woman and a 42-year-old man were referred for a localised refractory gingival inflammation. Clinical diagnoses included allergy, lichen planus and herpes. Biopsy showed well-demarcated non-caseating granulomas, associating epithelioid and Langhans giant cells. Special bacterial and mycological stains were negative. Systemic examination and laboratory tests ruled out sarcoidosis and Crohn's disease. Polarised light revealed birefringent crystalline foreign material. A diagnosis of silica granuloma was made. Both patients had frequent dental hygiene treatment including polishing with abrasive paste, suggesting an iatrogenic implantation of the foreign bodies. Gingival damage can result from the use of some dental materials containing silica. Often asymptomatic, sometimes producing visible lesions, granulomatous gingivitis may mislead into wrong diagnosis and treatment. Old silica granulomas may become symptomatic if the patient contracts sarcoidosis.

Oral intraepidermal IgA pustulosis and Crohn's disease

A case is reported of a 60-year-old woman with Crohn's disease who developed recurrent oral blisters and erosions. The histopathology of the buccal mucosa showed intraepidermal bullae and clefts with an intense accumulation of neutrophils in the epithelium. Direct immunofluorescence revealed intercellular IgA predominantly in the basal and suprabasal layers and in one biopsy concurrent deposits of IgG. No circulating autoantibodies were detected.

Immunohistochemical staining for vimentin filaments and S-100 protein in myxoma of the jaws

Two jaw myxomas have been analyzed by a panel of antibodies to characterize this tumour type. Vimentin, but not keratin, neuron-specific enolase (NSE), glial fibrillary acidic protein (GFAP), neurofilament (NF), desmin and Factor VIII-related antigen (FVIII-AG), demonstrated positivity in the cytoplasm of the neoplastic cells. Moreover, an antibody against S-100 protein also showed a strong positive reaction in the cytoplasm of the tumour cells examined. Thus directly indicating a mesenchymal derivation for odontogenic myxoma, and is the first demonstration of S-100 protein within the cells of this tumour type.

[Cutaneous-mucous hyalinosis (Urbach-Wiethe disease). Histologic and ultrastructural study of a case]

Hyalinosis cutis et mucosae is a rare genetic disorder, primarily involving skin and mucous membranes, that has been described under various titles as lipoidosis lipoproteinosis and Urbach-Wiethe disease. A 17-year-old girl presented cutaneous macular lesions, skin scars, thickened lips and enlarged firm tongue; hoarseness was known since birth. The labial biopsy specimen was investigated by light and electron microscopy. Histologically there are deposits of amorphous, extra-cellular eosinophilic hyaline material in the upper thickened connective tissue. In the lower part changes are focal with hyaline mantle around the vessels. Histochemical studies have revealed that the deposits were PAS-positive and amylase-resistant, indicating the presence of neutral mucopolysaccharides. Lipid stains were positive, especially in vessel walls. Ultrastructurally hyaline substance is composed of 1 to 2 nm protofilaments, larger ones (5 to 10 nm wide) and amorphous material. Fibroblasts contain in their dilated cisternae amorphous material. A frequent feature is marked multilamination of the capillary basal lamina which is interpenetrated by hyaline substance. Pathogenesis is still unknown but recently it is suggested hyalinosis cutis et mucosae could be a systemic disease of basal lamina.

Different papillomaviruses as the causes of oral warts

We have observed four patients with oral papillomas. Two children had oral mucosal lesions characteristic of focal epithelial hyperplasia, a young man had common, wart-like lesions on his hard palate, and a male immunosuppressed renal allograft recipient had condyloma-like lesions on his gingivae. Papillomavirus-like particles were seen by electron microscopy in lesions from both patients with focal epithelial hyperplasia. No structural antigens for human papillomavirus (HPV) 1, 2, 3, or 5 were found by immunofluorescent microscopy, but further evidence of the presence of a papillomavirus was found by immunoperoxidase microscopy using a cross-reacting sodium lauryl sulfate-disrupted bovine papillomavirus 1 anti-rabbit serum sample. The distinct histologic pattern seen in focal epithelial hyperplasia suggests that a yet undescribed HPV type might be associated with this disease. Histologic, ultrastructural, and immunofluorescent microscopy and restriction endonuclease analysis all gave evidence of HPV 2 in the palatal lesions in patient 3. Evidence of papillomavirus antigen was found by immunoperoxidase microscopy in the oral condylomas from our immunosuppressed patient.

[Cowden disease: report of 8 cases in 2 families (author's transl)]

These 8 cases of multiple hamartoma syndrome are the first reported in Switzerland. Two men aged respectively of 65 and 28 years presented a cobblestone appearance of the gingiva and of the tongue ("pebbly tongue"), which suggested Cowden disease. This diagnosis was confirmed by the discovery of numberous skin lesions, a thyroid goiter, gastrointestinal polyposis, and a mild skelettal dysmorphosis. The older patient had a grade one carcinoma of the bladder; his son and his daughter presented the syndrome, which was also discovered in the family of the second patient (his father, his brother, his sister and one of her daughters). The ultrastructural study of two skin biopsies demonstrated anomalies of the fibroblasts and collagen fibers.

[Stomatodynias]

Stomatodynies are functional manifestations often observed in anxious and depressive individuals, in the form of glosso-, cheilo-, uranodynia. It may show itself in disturbances of the mucosa or of salivary secretion. It is necessary to reassure the patients, to explain the nature of the disease and to prevent them from autotherapy of local or psychic factors.

[Digestive symptoms of scleroderma (author's transl)]

The authors successively study the oral, peri-oral, esophageal, intestinal and anal manifestations of systemic scleroderma. They point out that dental, salivary, and esophageal involvement is of great interest for diagnosis and prognosis. They particularly describe the malabsorption syndrome including anatomical and ultrastructural lesions of the smooth muscle fibers. They present an original study of arrector pili in clinically and histologically non-involved skin of patients undergoing scleroderma. Finally they state that any suspected or diagnosed scleroderma needs a digestive check-up as follows: radiologic examination of the teeth, biopsy of the minor salivary glands of the lower lip, radiologic study of esophageal motility and radioactive C 14 glycocholate test.

[Dominant generalized cortical hyperostosis with multiple involvement of the cranial nerves]

The authors report an observation of dominant generalized cortical hyperostosis with multiple and unilateral involvement of a certain number of cranial nerves. In other members of the family, who present with the same bone disorder, involvement of the cranial nerves was limited to the facial nerve, either uni or bilaterally, with a partially or totally regressive evolution. This cranial nerve involvement, which is classic in the recessive form (first described) of generalized cortical hyperostosis, has until now, never been reported in the dominant form of this disorder.

[Oral aphthoid toxic dermatoses]

In a description of 4 cases (phenindione, 1 case; niflumic acid, 1 case; gold salts, 2 cases), the authors describe a new variety of oral toxicodermatitis characterized by an eruption of painful, infiltrated aphthoid ulcerations, not precededbybull ae, small (less than 1 cm), roundish, with a greyish yellow necrotic centre surrounded by an erythematous halo. Histological investigation reveals a compact, polymorphous inflammatory infiltrate with numerous polynuclear neutrophiles or, less commonly, eosinophiles some of which are in a state of pyknosis of leukocytoclasia, associated with phenomena of spongiosis or necrosis of the epithelium.

[Corticotherapy and mucocutaneous pathology]

The tremendous advances in treatment brought about by corticotherapy applied to cutaneo-mucosal pathology should not be allowed to obscure the fact that its action is merely palliative, that it should only be proceeded with after careful diagnosis and that it may trigger undesirable side-effects. General corticotherapy is definitely indicated in certain serious dermatoses (e.g. pemphigus vulgaris) in large doses at the beginning of the course of treatment which often has to be kept up indefinitely; it is in these patients that the most serious accidents occur. It is also indicated in other dermatoses (e.g. lichen planus) in smaller doses and in separate courses, generally triggering incidents and accidents of a less serious nature which to a certain extent seem to be attenuated by taking the drug on alternate days. It is counter-indicated in one particular condition: psoriasis. Corticotherapy by intra- and sub-lesional local injection is most useful in the treatment of certain localised skin lesions (e.g. cheloids) and of the oral mucosa (e.g. erosive lichen planus). Either a few drops are injected or a larger quantity in a suspension of microcrystals. Complications have sometimes been observed in the skin (leukoderma, dermoepidermatrophia and, particularly, amaurosis), but never so far after sub-mucosal injections. Local corticotherapy by external application, very widely used in the form of ointments, creams and lotions for numerous cutaneous conditions may cause various more or less serious local side-effects, the systemic effects with depression of the hypophyso-adrenal axis, only seem to occur to any extent with occlusive dressings. It can also be used in the treatment of some conditions of the oral mucosa (e.g. some forms of lichen planus, benign mucous membrane pemphigoid) by means of either a corticosteroid incorporated into a special excipient which adheres to the mucous membrane or in tablets of 17-betamethasone valerate which gradually break up in the saliva. With the usual posology of 10 tablets of 0.1 mg per day, even over several months, there are no systemic effects, 17-betamethasone valerate (unlike phosphate) having an action which is primarily topic and being practically unabsorbed as has been shown by assessment of plasmatic cortisol.

[Odontogenic keratocysts]

Keratocysts may develop from cellular multiplication, from recidivating growth of epithelial cells left after curettage, and they have an important potential growth, they can degenerate into malignancies. There are several etiological possibilities: tissues connected with crown formation, invagination of nucous epithelium, degeneration of follicular cysts producing keratin. The most important characteristic of these cysts is the frequent recidivation. Fron a clinical standpoint, they are classified as benign tumors. After enucleation, the walls of healthy tissue should be reduced, particularly in locations where the access of curettes is difficult. If necessary, apicetomy is performed in order to completely eliminate the cyst walls. Histological examination is mandatory. Finally, radiologic controls during at least six years should be made.