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