Nonpainful swelling of the palate and loosening of the maxillary incisors

A Rare Presentation of Intraosseous Sarcoidosis of the Mandible Presenting as Peri-Implantitis: A Case Report and Literature Review

PURPOSE

We describe a rare case of intraosseous sarcoidosis initially presenting as peri-implantitis, perform a review and analysis of 27 cases of intraosseous sarcoidosis, and provide a clinical review of this condition.

METHODS

We searched the literature for patients presenting with intraosseous sarcoidosis of the jaw through June 2020 using key phrases. Additional papers were included via a search of references and citing papers. Data including patient demographic characteristics and diagnostic tests were manually extracted from the cases and then qualitatively coded by the authors. Descriptive statistical analysis was performed to elucidate general themes and characteristics.

RESULTS

A total of 27 cases, dating as early as 1943 and as recent as this case, were identified in the literature, including our case. The average age of these patients was 39 years old, with a range of 16 to 75 years. Eighteen (67%) cases were identified as female and nine (33%) as male. Fourteen cases were reported with localized mandibular involvement. Ten had maxillary disease; 3 cases were generalized to both regions. Nine cases presented anteriorly, 12 posteriorly, and 6 extended across both regions. Eight patients received surgical interventions, such as tooth extractions or lesion removal. Five patients received nonsurgical interventions, such as steroids. Ten patients received combination therapy, often involving surgical intervention and steroid therapy.

CONCLUSION

Our patient had an unusual presentation of intraosseous sarcoidosis mimicking peri-implantitis. To our knowledge, no case in the English literature describes a patient with sarcoidosis presenting with peri-implantitis. Based on the literature review and analysis of our patient's experience, sarcoidosis should be considered on the differential diagnosis for patients with persistent, nonhealing bony lesions in the maxillofacial region, particularly when patients have not been exposed to osteoclast inhibitory therapy or radiation. Pathologic analysis of bone and surrounding tissue in these scenarios is essential.

Orofacial granulomatosis: clinical signs of different pathologies

Orofacial granulomatosis (OFG) is an uncommon disease characterized by persistent or recurrent soft tissue enlargement, oral ulceration and a variety of other orofacial features. It could be an oral manifestation of a systemic disease. For a correct differential diagnosis, local and systemic conditions characterized by granulomatous inflammation should be excluded using appropriate clinical and laboratory investigations. In fact, the diagnosis of OFG may be confirmed only by histopathological identification of noncaseating granulomas. The literature from 1943 to 2014 was reviewed with emphasis on the etiology of OFG and on clinical manifestations of systemic pathologies associated with OFG. The precise cause of OFG is still unknown, although several theories have been suggested, such as infection, hereditary factors and allergy. OFG is a disease that has a wide spectrum of presentation, which may include the oral manifestation of a systemic condition such as Crohn's disease, sarcoidosis, granulomatosis with polyangiitis and Melkersson-Rosenthal syndrome.

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 involvement in sarcoidosis: report of 12 cases

AIM

To assess the clinical features, treatment and outcome of oral sarcoidosis and to determine whether oral involvement is associated with a particular clinical phenotype of sarcoidosis.

DESIGN

Multicentric retrospective study.

METHODS

Retrospective chart review. Each patient was matched with four controls.

RESULTS

Twelve patients (9 women, 3 men) were identified. Their median age at sarcoidosis diagnosis was 38 years. Oral involvement was the first clinical evidence of sarcoidosis in seven cases and was a relapse symptom in five cases. Clinical presentations were nodules (n = 7) or ulcers (n = 5) and were mostly solitary. The tongue was the commonest site affected (n = 4), followed by lips (n = 3), oral mucosa (n = 2), palate (n = 2) and gingiva (n = 1). Patients with oral sarcoidosis were significantly younger and had more frequent lacrimal or salivary glands and upper airway tract clinical involvement than the controls; increased angiotensin-converting enzyme was less frequent in oral sarcoidosis. Multiple treatments of oral sarcoidosis were used: no treatment (n = 3), surgery (n = 2), corticosteroids (n = 7), hydroxychloroquine (n = 3), methotrexate (n = 2), doxycycline (n = 1). Methotrexate was efficient in one patient, hydroxychloroquine showed benefit in only 1 out of 3 patients. Three patients presented oral relapses. After a mean follow-up of 6 years, 10 patients experienced a complete (n = 7) or partial (n = 3) remission of oral sarcoidosis; stability was observed in the remaining two cases.

CONCLUSION

Although oral manifestations of sarcoidosis are unusual, physicians should be aware that this specific localization is frequently the first manifestation of the disease. Treatment modalities range from observation in asymptomatic patients to immunosuppressants for severe involvement.

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.

Oral sarcoidosis: a review of literature

Sarcoidosis is a common systemic granulomatous disease affecting multiple organs. Oral involvement is relatively rare and, to our knowledge, there have been only 64 cases reported in the English literature. Most cases of oral sarcoidosis present with mobility of the teeth due to rapid alveolar bone loss. Other oral manifestations include asymptomatic swelling of the involved mucosa, gingivitis and ulcers. Diagnosis of sarcoidosis is by exclusion as no specific test is available. Radiographic, biochemical and histological findings are non-specific, but helpful. All cases of sarcoidosis do not require treatment. Corticosteroids are the treatment of choice in patients requiring treatment. Other drugs such as chloroquine, methotrexate, infliximab and thalidomide are also used in the treatment of sarcoidosis. In most of the oral cases reported, systemic steroids and surgery were the preferred treatment.

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.

Intraosseous sarcoidosis of the jaws mimicking aggressive periodontitis: a case report and literature review

BACKGROUND

Sarcoidosis is a relatively common systemic granulomatous disease of unknown etiology. The skeletal system is affected in up to 39% of patients, but intraosseous sarcoidosis affecting the maxilla and mandible is rare. Only 20 cases have been reported previously in the English literature. This paper presents a case of generalized intraosseous sarcoidosis of the jaw bones that mimicked rapidly progressive periodontitis.

METHODS

A 46-year-old male patient presented with loose teeth for assessment of implants. He had been gradually losing his teeth since 1999. His past medical history was significant, with sarcoidosis diagnosed in 1998. A panoramic radiograph showed a bilateral cotton-wool appearance of the mandible. A soft tissue and bone biopsy was performed and sent for histological examination.

RESULTS

Microscopic examination of hematoxylin and eosin-stained sections revealed non-caseating granulomatous inflammation consistent with skeletal sarcoidosis.

CONCLUSIONS

Intraosseous sarcoidosis of the jaw bones is rare and presents commonly as progressive and rapid alveolar bone loss similar to periodontitis. Therefore, it is important for periodontists to be knowledgeable and able to diagnose this condition, as rapid alveolar bone loss may be the first sign of sarcoidosis.