SarcoidosisSarcoidosisJeffrey A Burgess DDS MSD
Clinical Assistant Professor -Department of Oral Medicine
Attending - Pain Center – University of Washington Medical Center
Director – South Sound Oral Medicine
Federal Way and Redmond
Sarcoidosis
Epidemiology
Head and Oral Manifestation
Symptoms
Mucosal Lesion Location and Quality
Aids in Diagnosis
Differential Diagnosis
Dental Treatment
Epidemiology
Case studies
Oral lesions rare, but may occur initially
Females 3:2
Racial differences
Documented cases in jaw bones rare
Salivary glands involvement (5 - 6%)
Head and Oral Manifestation
Intra Oral Lesions
Cervical Adenopathy
Jaw Bone Destruction
Sinus Pathology
Dermal lesions
Facial Palsy
Salivary Gland Abnormality
Head and Oral Manifestation
Intra Oral Lesions Tongue Buccal mucosa / vestibule Gingiva with periodontitis Abnormal healing of extraction sites Minor salivary glands
Head and Oral Manifestation
Blinder and coworkersAnalysis of 45 cases of sarcoidosis with oral involvment 12 jaw lesions 10 buccal mucosa 6 gingiva 5 lips 5 floor of the mouth 4 tongue 3 palate
In most of the cases – lesions of buccal mucosa, gingiva, and tongue were the 1st clinical manifestation of the disease
Blinder et al: Oral manifestations of sarcoidosis; Oral Surg, Oral Med, Oral Pathol, Oral Radiol, Endod. 1997 83:458-61
Head and Oral Manifestation
Jaw bone destruction Maxilla Mandible including TMJ Premaxillary/premolar region
Poorly defined lucency without cortical expansion Teeth vital No tooth resorption
Maxillary Osseous Lesion Associated With Sarcoidosis
Rubin et al: Maxillary alveolar bone loss in a patient with sarcoidosis. J Oral Maxillofac Surg, 1991 49(12):1351-3
25 y/o black female with history of sarcoidosis
Osseous Lesions Associated With Sarcoidosis
Maxillary and mandibular anterior radiographs. Initial presentation top with lysis of alveolar bone. Bottom one year follow-up with significant bone regeneration post treatment
Cohen et al: Systemic sarcoidosis: report of two cases with oral lesions. J Oral Surg 1981 39(8):613-8
Head and Oral Manifestation
Sinus and Salivary Gland DestructionSarcoid sinusitisPara nasal sinusesParotid enlargement (bilateral, firm,
painless)
Salivary Gland Anatomy
•Gland type
•Serous•Mucous
•Glands •Parotid•Submandibular•Sublingual
Minor Salivary Glands
~1000 minor glands:
•labial, lingual, palatal, buccal
•10% volume 70% mucins 35% sIgA
Head and Oral Manifestation
Facial Palsy Associated with Neurosarcoidosis Affects the 7th cranial nerve Results in abnormality associated with muscles
of facial expression Signs include a drooping of the face on side of
involvement
Head and Oral Manifestation
Dermal lesions typically symmetric Lip Nose Cheeks Ears
Sarcoidosis – Perioral Lesions
Sarcoidosis – Lip Lesion
Sarcoidosis – Lip Lesion
28 y/o black female with asymptomatic lesion of five months duration– slowly enlarging
Symptoms
Non-painful swelling
Denture soreness
Tongue soreness
Painful / swollen gums
Dental pain / tooth loosening
Lower jaw pain
Transient facial paralysis (facial nerve palsy)
Dry mouth / taste disturbance
Mucosal Lesion Quality
Generally: multiple firm nodules or papules, raised with irregular borders
Palate: brownish-red, macular, slightly ulcerated, non-tender lesions resembling abscess or tumor, soft swelling
Tongue: broad elevated masses with indurations
Gums: papillae redness or nodular mass
Lip: erythematous raised lesion / fixed to mucosa
Nodular Lesion of Buccal Mucosa
Erosive Papular Lesion -Tongue
Diagnosis
Labial salivary gland biopsy
Parotid biopsy
Soft tissue incisional biopsy Evidence of non-caseating epitheloid
granuloma; special stains to r/o infectious disease
Biopsy and the Diagnosis of Sarcoidosis
Cahn and coworkers
23 patients with sarcoidosis and biopsy of normal appearing palatal tissue
38% of specimens with sarcoid granulomas present
Cahn LR et al: Biopsies of normal appearing palates in patients with known sarcoidosis. Oral Surg, Oral Med, Oral Pathol, 1964, 18:324-5
Biopsy and the Diagnosis of Sarcoidosis
Marx and coworkers
Incisional biopsies minor salivary glands/parotid
Minor gland biopsy identified sarcoidosis in 11 of 31 (36%) versus 29 of 31 (93%) with parotid
Authors conclude incisional parotid biopsy superior to labial minor gland biopsy
Marx R, et al: Prospective study comjparing incisional labial to incisional parotid biopsies in the detection and confirmation of sarcoidosis, sjogren’s disease, sialosis and lymphoma. J Rheumatol, 1988, 15:621-29
Differential Diagnosis of Oral Lesions
Fibroma
Chronic mucocele (ranula)
Salivary gland tumor
Granular cell tumor
Schwannoma / neurofibroma
Bacterial / viral infection
Foreign body granulomas
Orofacial granulomatosis
Oral carcinoma
Dental Treatment
Depends on staging of disease
Tooth extraction
Medication
Surgical excision
Management of Secondary Effects
Pain
Oral dryness (xerostomia)
Periodontal disease
Caries
Effects of Oral Dryness
Glossitis,epithelial atrophy
Caries
Oral Candidiasis
Chronic multifocal or erythematous type
Management of Oral Dryness
Physical problems
discomfort
mucositis & atrophy
difficulty speaking
decreased taste
Management
adequate hydration with sugarfree drinks
saliva substitutes Oral Balance
stimulate flow sugarfree gum, etc pilocarpine
(Salagen, 5 mg TID)
Management of Oral Dryness
Infectionscandidiasisdental caries cervical incisal recurrent
sialadenitisperiodontal disease
Prevention & Treatmentlow sugar diet
adequate fluids
scrupulous home care
frequent professional care
antifungal medications
fluoride - gel, toothpaste, varnish (Duraphat, etc.)
Chlorhexidine / periostat
Conclusions
Sarcoidosis is a poorly understood granulomatous disease of uncertain etiology with limited oral involvementClinical presentation varies depending on the site of the oral lesion(s) Salivary involvement has oral implicationsIntra-oral or salivary gland biopsy may aide in diagnosisSymptomatic dental management of oral lesions and dryness should be initiated if appropriate