Review article: orofacial granulomatosis

Wenn es kein Angioödem ist, was dann? Diagnostisches Vorgehen bei Gesichtsödemen

Gesichtsödeme sind ein relativ häufiges Symptom bei Patienten allergologischer und dermatologischer Kliniken. Die Differentialdiagnose ist breit gefächert und die endgültige Diagnose kann manchmal eine Herausforderung für den Kliniker sein. Das faziale Angioödem selbst umfasst verschiedene Ätiopathologien (histaminerg, bradykinininduziert und weitere), die von anderen Ursachen des Gesichtsödems differenziert werden sollten, etwa allergischer Kontaktdermatitis, granulomatösen Erkrankungen, inflammatorischen Ursachen, Infektionen, Neoplasmen oder paraneoplastischen Syndromen, Autoimmunerkrankungen und anderen Entitäten, die hier als „Sonstige“ bezeichnet werden. Um die richtigen Untersuchungen anzuordnen und eine gezielte Therapie zu verordnen, ist ein angemessener diagnostischer Ansatz ausschlaggebend. Diese Übersicht konzentriert sich auf Entitäten, die mit Gesichtsödem einhergehen, und fasst ihre klinischen Charakteristika zusammen.

If not angioedema, what is it? Diagnostic approach to facial edema

Facial edema is a relatively frequent clinical presentation encountered in patients seen in allergology and dermatology clinics. The differential diagnosis is broad, and sometimes the definitive diagnosis can be a challenge for the clinician. Facial angioedema itself encompasses different etiopathologies (histaminergic, bradykinergic, etc.) that must be distinguished from other causes of facial edema, such as allergic contact dermatitis, granulomatous conditions, inflammatory causes, infections, neoplasms or paraneoplastic syndromes, autoimmune diseases, among other entities hereby referred as miscellanea. A proper diagnostic approach is essential to order the appropriate tests, as well as to prescribe a targeted treatment. This review focuses on entities that present with facial edema and summarize their characteristic clinical features.

Orofacial Granulomatosis Associated with Crohn's Disease: a Multicentre Case Series

BACKGROUND

Orofacial granulomatosis [OFG] is a rare syndrome that may be associated with Crohn's disease [CD]. We aimed to characterise this relationship and the management options in the biologic era.

METHODS

This multicentre case series was supported by the European Crohn's and Colitis Organisation [ECCO], and performed as part of the Collaborative Network of Exceptionally Rare case reports [CONFER] project. Clinical data were recorded in a standardised collection form.

RESULTS

This report includes 28 patients with OFG associated with CD: 14 males (mean age of 32 years, ±12.4 standard deviation [SD]) and 14 females [40.3 years, ±21.0 SD]. Non-oral upper gastrointestinal tract involvement was seen in six cases and perianal disease in 11. The diagnosis of OFG was made before CD diagnosis in two patients, concurrently in eight, and after CD diagnosis in 18. The distribution of OFG involved the lips in 16 cases and buccal mucosa in 18. Pain was present in 25 cases, with impaired swallowing or speaking in six. Remission was achieved in 23 patients, notably with the use of anti-tumour necrosis factors [TNFs] in nine patients, vedolizumab in one, ustekinumab in one, and thalidomide in two. A further five cases were resistant to therapies including anti-TNFs.

CONCLUSIONS

OFG associated with CD may occur before, concurrently with, or after the diagnosis of CD. Perianal and upper gastrointestinal [UGI] disease are common associations and there is a significant symptom burden in many. Remission can be obtained with a variety of immunosuppressive treatments, including several biologics approved for CD.

Association between cheilitis granulomatosa and odontogenic infections: A case-control study

The association between cheilitis granulomatosa and dental infections (dental caries and apical periodontitis) is still not well understood. Herein, we aimed to investigate the association in large hospital cases with cohort controls. Cheilitis granulomatosa cases (n = 181) were retrieved from Peking University Hospital of Stomatology and age- and sex-matched to controls (n = 181). The χ² -test, Student's t-test, and Mann-Whitney U-test were used to compare the differences between groups. The χ² -test and odds ratio were used to verify if there was an association and risk relationship. The results showed that both dental caries and apical periodontitis were associated with cheilitis granulomatosa (p < 0.001). Individuals with cheilitis granulomatosa had approximately a twofold increased frequency of dental caries than those without cheilitis granulomatosa (104/181, 57.5% vs. 53/181, 29.3%) (p < 0.001). The odds ratio of dental caries occurring in the case group compared to the control group was 3.211. The frequency of apical periodontitis in patients with cheilitis granulomatosa was significantly greater than in those without cheilitis granulomatosa (109/181, 60.2% vs. 28/181, 15.5%) (p < 0.001). The odds ratio was 8.272. Moreover, apical periodontitis was also locationally related to cheilitis granulomatosa (p < 0.001). Collectively, our study showed that the foci of dental infections are associated with cheilitis granulomatosa, suggesting that proper treatment of focal teeth may be important in the management of cheilitis granulomatosa.

Granulomatous Sarcoidosis Mimics

Many granulomatous diseases can mimic sarcoidosis histologically and in terms of their clinical features. These mimics include infectious granulomatous diseases, granulomatous reactions to occupational and environmental exposures, granulomatous drug reactions, vasculitides and idiopathic granulomatous conditions. It is important to distinguish sarcoidosis from these mimics, as a misdiagnosis of these diseases may have serious consequences. This manuscript reviews numerous sarcoidosis mimics and describes features of these diseases that may allow them to be differentiated from sarcoidosis. Distinguishing features between sarcoidosis and its mimics requires a careful review of the medical history, symptoms, demographics, radiographic findings, histologic features, and additional laboratory data. Understanding the clinical characteristics of sarcoidosis and its mimics should lead to more accurate diagnoses and treatment of granulomatous disorders that should improve the care of these patients. As the diagnostic criteria of sarcoidosis are not standardized, it is possible that some of these sarcoidosis mimics may represent varied clinical presentations of sarcoidosis itself.

Orofacial granulomatosis: Clinical and therapeutic features in an Italian cohort and review of the literature

BACKGROUND

Orofacial granulomatosis (OFG) is characterized by granulomatous inflammation of the soft tissues of maxillofacial region. We explored OFG patients from 10 different Italian centers and summarized the most recent literature data.

METHODS

A review of patients with OFG was carried out. An extensive online literature search was performed to identify studies reporting diagnosis and management of OFG.

RESULTS

Thirty-nine patients were recruited between January 2018 and February 2020. Most of them (97.4%) displayed involvement of the lips, and 28.2% suffered from Melkersson-Rosenthal syndrome. Two patients received diagnosis of CD and one patient of sarcoidosis, suggesting secondary OFG. Oral aphthosis and cervical lymphadenopathy were also described. The mean diagnostic delay was 3.4 years. Histological evaluation was performed in 34/39 patients (87.2%); non-caseating granulomas were found in 73.5% of them. Neurological symptoms (28.2%), gastrointestinal symptoms in absence of overt inflammatory bowel disease (IBD) (20.5%), and atopy (35.9%) were also identified. Therapeutic approaches varied among the centers. Steroids (51.3%) were used with good or partial results. Anti-TNF-α and anti-IgE monoclonal antibodies were used in 6 (15.4%) and 1 (2.6%) patients, respectively, with variable results. Surgery was the choice for 2 patients with good response.

CONCLUSIONS

OFG is a rare and neglected disease showing multiple clinical phenotypes. While early diagnosis is crucial, management is difficult and highly dependent on the expertise of clinicians due to the lack of international guidelines. There is a need to establish registry databases and address challenges of long-term management.

Orofacial granulomatosis: a questionnaire study among Norwegian dental clinicians

Aims

To evaluate awareness on orofacial granulomatosis (OFG) and oral Crohn disease (oral CD) among Norwegian dental clinicians.

Methods

A precoded questionnaire (QuestBack) was sent electronically to dentists and dental hygienists treating children and adolescents in the public dental service (PDS) in Norway. Data on the clinicians’ knowledge of OFG and oral CD related to working experience were analysed by Chi square tests and bivariate logistic regression analyses.

Results

A total of 1097 clinicians were invited to participate, 778 dentists and 319 dental hygienists; 48.2% returned the completed form. Fifty-four percent of the participants had ≥ 10 year experience of clinical practice. Two-thirds (68.4%) of the dentists and all but one of the dental hygienists graduated in Norway. Approximately half of the respondents were aware of OFG (41.2%) and oral CD (57.8%). One-quarter (24.6%) reported that they most likely had seen a patient with OFG and 20.6% with oral CD. Recently graduated dentists (≤ 10 years ago) were more aware of OFG and oral CD than those who graduated > 10 years ago (p ≤ 0.001). Regarding dental hygienists, this difference was observed for OFG only (p < 0.05). Country of education did not affect the clinicians’ reported knowledge. Approximately 90% would refer a patient suspected of having OFG or oral CD either to a dental specialist or to a physician.

Conclusion

The high prevalence of clinicians observing OFG and oral CD in this study may indicate that OFG and/or oral CD are under-reported and that OFG in particular is more common than hitherto believed. The high frequency of awareness was promising for the benefit of the patients.

Management of orofacial granulomatosis: a case report

Introduction: Orofacial granulomatosis is characterized by recurrent swelling affecting the lips, cheeks, and tongue. The rarity of this pathology and the lack of consensus in therapeutic management make the reporting of this clinical case relevant. Observation: A 48-year-old man consulted for labial and gingival orofacial granulomatosis. The treatment consisted of 40 mg/L injections of triamcinolone acetonide once weekly for 3 weeks. The symptoms improved after 1 week of treatment. Comments: The usual treatment for this condition targets the inflammation caused by the lesion. Corticosteroids (clobetasol, triamcinolone acetonide, prednisolone), monoclonal antibodies (infliximab, adalimumab), or TNF-α inhibitors are commonly used. Symptom recurrenceis frequently observed after treatment with corticosteroids. Biotherapies are often used as a second-line treatment. Conclusion: Orofacial granulomatosis symptoms are rare and difficult to diagnose due to its varying manifestations. Common treatments target one of the steps of the inflammatory response. The detection of specific cellular markers is a way to enable a more precise etiological diagnosis and allows for a more targeted therapy.

Clinicopathological diagnosis of orofacial granulomatosis

Orofacial granulomatosis is a rare chronic inflammatory disorder characterized by persistent or recurrent soft tissue swellings, oral ulceration, and other orofacial features in the absence of an identifiable granulomatous disease. We report a case of a 61-year-old woman with recurrent ulcerations and swellings in her oral mucosa. She was diagnosed as orofacial granulomatosis based upon clinicopathological correlation after exclusion of other granulomatous diseases and showed a favorable response to systemic corticosteroid treatment.

Melkersson-rosenthal syndrome: a case report

Melkersson-Rosenthal Syndrome (MRS) is a rare disorder consisting of a triad of persistent or recurrent orofacial edema, relapsing facial paralysis and fissured tongue. It is rarely possible to observe all aspects of the classical triad at the same time, since these symptoms may appear in different times of life cycle. The most common symptom is orofacial edema. Although etiology of MRS is unclear, various factors such as infections, genetic predisposition, immune deficiency, food intolerance and stress have been held responsible. MRS is diagnosed based on clinical features. This case report describes a 39 years old male patient with recurrent swelling of the upper lip. Clinical examinations showed classical triad of MRS. The diagnosis and treatment procedures were presented with special emphasis to the clinical features of this rare condition.

The role of exclusive enteral nutrition in the management of orofacial granulomatosis in children

BACKGROUND

Orofacial granulomatosis (OFG) is a term used to describe a persistent, painless swelling of lips and orofacial region. It can be associated with ulceration, gingival hypertrophy and cobble stone appearance of the buccal mucosa. OFG is commonly associated with Crohn's disease and can precede the intestinal manifestation of the disease. Exclusive enteral nutrition (EEN) is a recognized treatment for induction of remission for Crohn's disease. The aim of this study was to review the use of EEN in the management of OFG in children.

METHODS

Retrospective review of medical records of all children diagnosed with OFG between 2007 and 2012 was conducted. Presence of comorbidities, progression to inflammatory bowel disease (IBD) and response to EEN was evaluated.

RESULTS

Twenty-nine children were included, mean age at diagnosis was 9 years (standard deviation 3.9) years. Ten children had isolated OFG and 19 had OFG and IBD, of which 12 presented with OFG and IBD and 7 developed IBD later. Median time to progression to IBD was 33 months (inter quartile range: 9.8-85.5). Twenty-two children completed 6 weeks of EEN, and 19 showed clinical improvement in the OFG appearance.

CONCLUSION

EEN appears to be an effective treatment option for children with isolated OFG or OFG and IBD.

Orofacial Granulomatosis: Report of Two Cases with Gingival Onset

Orofacial granulomatosis is a unifying term comprising a variety of clinical conditions involving the face and the oral cavity and histologically characterized by the presence of chronic granulomatous inflammation. Lip swelling and erythema are the most frequent clinical signs. We report on the clinical-pathological features and the management of two cases of orofacial granulomatosis characterized by gingival onset, without other local and systemic manifestations. The diagnosis of orofacial granulomatosis with gingival onset is made by the exclusion of other conditions exhibiting gingival inflammation and/or enlargement. Detailed medical history, haematological investigations and gingival biopsy are fundamental for the definitive diagnosis. Though infrequent, orofacial granulomatosis with gingival involvement should be considered in the differential diagnosis of hyperplastic gingivitis of uncertain origin.

Oral mucosa lesions and oral symptoms in inflammatory bowel disease patients

BACKGROUND

Inflammatory Bowel Disease is known for its extra intestinal manifestations, the oral cavity is no exception.

OBJECTIVES

The aim of this study was to evaluate the association between Inflammatory Bowel Disease and oral mucosa lesions and symptoms, and complementary to evaluate their possible relation with oral hygiene, smoking habits, drug therapy, duration and activity of the disease.

METHODS

Patients were selected from the Gastroenterology Clinic of a Portuguese tertiary referral hospital. This sample consisted of 113 patients previously diagnosed with ulcerative colitis or Crohn's disease along with a control group of 58 healthy individuals that were accompanying the study group patients to their appointments. Clinical interviews and clinical examinations were performed for data collection.

RESULTS

The patients in the study group were more affected by oral symptoms (P=0.011), and showed a trend towards a higher incidence of oral mucosal lesions, even though statistical significance was not reached (8.8% versus 3.4% in the control group; P=0.159). Patients in active phase were the most affected. No differences were detected between Crohn's disease and ulcerative colitis, or concerning smoking habits. The corticosteroid and immunosuppressant therapy seemed to increase the incidence of oral symptoms (P=0.052). The oral mucosa lesions increased and the oral symptoms decreased over the course of the disease, however without statistical significance.

CONCLUSION

Oral mucosa's lesions and oral symptoms were positively associated with Inflammatory Bowel Disease, mainly during disease activity periods and conceivably, associated with corticosteroid and immunosuppressant therapy.

A new approach to the management of caliber-persistent artery: A case report and analysis of previously reported cases

A caliber-persistent labial artery (CPLA) is an incipient arterial branch that penetrates near the submucosal tissue of the lip without dividing or reducing in diameter and often appears as a palpable lesion on the lip. It occurs at an incidence of approximately 3%. This study investigated the causes of swelling of the lips, focusing on CPLA, and reviewed the literature for past cases in order to inform the treatment of a 32-year-old man presenting with an asymptomatic, solitary, elevated lesion on the vermilion of the upper lip of seven months duration. Biopsy resulted in abundant bleeding. Histopathology showed fragments of connective tissue composed of spindle-shaped cells, fibroblasts, collagen fibers and sections of small blood vessels with lymphocytic infiltration of chronic inflammatory cells around the small vessels. A thick-walled section reminiscent of a major artery was apparent. In view of the size of the lesion and concern over the functional and esthetic impairment that might result from surgery, the patient was treated with triamcinolone (40 mg/ml) injected at low pressure into the lesion, which caused the formation of deposits of colloidal particles within the lesion. The procedure was repeated twice at 2-week intervals. Subsequently, the lesion was found to have completely regressed. The favorable therapeutic results achieved, and the findings of the present review, support the intralesional injection of triamcinolone as a first-line conservative treatment in CPLA rather than a surgical approach that can result in inordinate hemorrhaging.

Review article: non-malignant oral manifestations in inflammatory bowel diseases

BACKGROUND

Patients with inflammatory bowel diseases (IBD) may present with lesions in their oral cavity. Lesions may be associated with the disease itself representing an extraintestinal manifestation, with nutritional deficiencies or with complications from therapy.

AIM

To review and describe the spectrum of oral nonmalignant manifestations in patients with inflammatory bowel diseases [ulcerative colitis (UC), Crohn's disease (CD)] and to critically review all relevant data.

METHODS

A literature search using the terms and variants of all nonmalignant oral manifestations of inflammatory bowel diseases (UC, CD) was performed in November 2014 within Pubmed, Embase and Scopus and restricted to human studies.

RESULTS

Oral lesions in IBD can be divided into three categories: (i) lesions highly specific for IBD, (ii) lesions highly suspicious of IBD and (iii) nonspecific lesions. Oral lesions are more common in CD compared to UC, and more prevalent in children. In adult CD patients, the prevalence rate of oral lesions is higher in CD patients with proximal gastrointestinal tract and/or perianal involvement, and estimated to range between 20% and 50%. Oral lesions can also occur in UC, with aphthous ulcers being the most frequent type. Oral manifestations in paediatric UC may be present in up to one-third of patients and are usually nonspecific.

CONCLUSIONS

Oral manifestations in IBD can be a diagnostic challenge. Treatment generally involves managing the underlying intestinal disease. In cases presenting with local disabling symptoms and impaired quality of life, local and systemic medical therapy must be considered and/or oral surgery may be required.

Long-term effectiveness of intralesional triamcinolone acetonide therapy in orofacial granulomatosis: an observational cohort study

Summary

What's already known about this topic?

What does this study add?

Orofacial Granulomatosis

Orofacial granulomatosis (OFG) is an uncommon chronic inflammatory disorder of the orofacial region. It is characterized by subepithelial noncaseating granulomas and has a spectrum of possible clinical manifestations ranging from subtle oral mucosal swelling to permanent disfiguring fibrous swelling of the lips and face. Etiopathogenesis is unknown. A range of systemic granulomatous disorders, including Crohn disease and sarcoidosis, may cause orofacial manifestations that cannot be distinguished from those of OFG. Treatment of OFG has proven difficult and unsatisfactory, with no single therapeutic model showing consistent efficacy in reducing orofacial swelling and mucosal inflammation.

Orofacial granulomatosis as a presenting feature of Crohn's disease

An 11-year-old girl was referred to oral medicine with persistent facial swelling. She was diagnosed with orofacial granulomatosis (OFG) and was treated conservatively for 7 years, with no evidence of systemic illness. Aged 17 she re-presented with a flare up of her OFG, watery diarrhoea and fluctuating febrile episodes. Inflammatory markers were raised and an MR enterogram revealed terminal ileal Crohn's disease. This case highlights that OFG may precede the onset of intestinal Crohn's disease.

Treatment of a Crohn's disease-related cutaneous facial lesion with topical tacrolimus

We report a case of an orofacial lesion in Crohn's disease successfully treated with tacrolimus ointment. A 22-year-old woman with Crohn's disease presented with a discharging lesion on the right side of her face. Intraorally, there was a resultant loss of the sulcal depth. She reported a 1-year history of variable right-sided facial swelling for which she had undergone extraoral incision and drainage, resulting in localized paresthesia and nonhealing of the incision site. Following exclusion tests, a treatment of twice-daily extraoral application of tacrolimus 0.1% ointment was commenced. Upon review, the lesion had reduced in size, with minimal discharge. Further improvement over 12 months of tacrolimus use resulted in a satisfactory cosmetic result as well as resolution of the intraoral features and reestablishment of the full sulcal depth. This case illustrates the successful use of topical tacrolimus to treat a cutaneous manifestation of Crohn's disease.

Recurrent lip swelling: a diagnostic challenge

A Caucasian woman in her late 20s was referred to the allergy/chest clinic by her general practitioner with an 8-month history of recurrent facial angio-oedema. She had no history of urticaria or airways symptoms and denied any similar problems previously. She had no family history of similar illness and was not on any regular medications. There was no history of atopy. Initially, a clinical diagnosis of idiopathic angio-oedema was made. Despite being treated with several antihistamines with doses equivalent to 40 mg of cetirizine/day, her problem had failed to respond satisfactorily. Later on, she also revealed history of intermittent gastrointestinal symptoms such as abdominal pain and diarrhoea. Routine investigations were unremarkable. The patient was referred to a dermatology clinic and a diagnosis of orofacial granulomatosis was suggested: a rare granulomatous disease presenting with lip enlargement, which may or may not be associated with Crohn's disease. A biopsy of the oral mucosa was consistent with this diagnosis.

Unifocal orofacial granulomatosis in retromolar mucosa: surgical treatment with Er,Cr:YSGG laser

Orofacial granulomatosis is defined by permanent or recurrent swelling of orofacial tissues with different multiform and multifocal clinical patterns. An 11-year old boy presented with a 2-month history of mucosa enlargement. Intraoral examination revealed an erythematous, polylobulated, exophytic lesion with a smooth surface located in retromolar mucosa, non-tender and non-infiltratated to palpation. The diagnosis was inflammatory lesion compatible with pyogenic granuloma and laser excision was decided. Haematological parameters were within normal range, as well as chest Xrays. These findings lead to a diagnosis of non-symptomatic orofacial granulomatosis, whose early diagnosis can minimize the impact of systemic-related disorders, like Chron’s disease.

Key words:Laser, orofacial granulomatosis, childhood, oral lesions, diagnosis.

Clinical behaviour and long-term therapeutic response in orofacial granulomatosis patients treated with intralesional triamcinolone acetonide injections alone or in combination with topical pimecrolimus 1%

BACKGROUND

Orofacial granulomatosis (OFG) is a relapsing inflammatory disorder of unknown aetiology and non-standardized treatment protocols. The aim of this study was to assess the clinical behaviour and long-term therapeutic response in OFG patients treated with intralesional triamcinolone acetonide (TA) injections alone or in combination with topical pimecrolimus 1%, as adjuvant, in those patients partially responders to TA.

METHODS

We analysed data from 19 OFG patients followed-up for 7 years. Demographic characteristics, clinical behaviour and long-term therapeutic response were investigated.

RESULTS

Eleven (57.9%) OFG patients treated with intralesional TA injections therapy reached first complete clinical remission in a mean time of 10 ± 2.2 (95% CI, 8.5-11.5) weeks, while eight (42.1%) patients, partially responders to intralesional TA injections, were treated with TA injections plus topical pimecrolimus 1%, as adjuvant, achieving complete clinical remission in a mean time of 29.8 ± 7.8 (95% CI, 23.2-36.3) weeks. Relapses occurred in four TA responder patients with a disease-free time of 35.8 ± 8.7 (95% CI, 21.9-46.4) weeks and in five patients treated with TA and topical pimecrolimus 1% with a disease-free time of 55.8 ± 18.5 (95% CI, 32.8-78.8) weeks. Patients were followed-up for a mean time of 56.3 ± 18.2 (95% CI, 47.6-65.1) months. At last control, all 19 patients were in complete clinical remission.

CONCLUSION

These preliminary data suggest that intralesional TA injections still represent a mainstay in the treatment of OFG. It is unclear the role of topical pimecrolimus, as adjuvant, in leading OFG patients, partly responders to intralesional TA injections, to a complete clinical remission.

Orofacial granulomatosis: A case report with review of literature

Orofacial granulomatosis (OFG) encompasses conditions characterized by non-necrotizing granulomatous inflammation of the oral and maxillofacial region that present clinically as labial enlargement, perioral and/or mucosal swelling, oral ulcerations, and gingivitis. The unifying term “OFG” has been introduced to integrate the spectrum of various disorders, including Melkersson-Rosenthal syndrome and granulomatous cheilitis (which is sometimes considered to be a monosymptomatic form of Melkersson-Rosenthal syndrome), and has been shown to be associated with Crohn's disease, sarcoidosis, and infectious diseases such as tuberculosis. Although various etiological agents such as food substances, food additives, dental materials, and various microbiological agents have been implicated in the disease process, its precise pathogenesis is yet to be elucidated. Delayed type of hypersensitivity reaction appears to play a significant role, although the exact antigen inducing the immunological reaction varies in individual patients. However, evidence for the role of genetic predisposition to the disease is sparse. The underlying immunological mechanism appears to show some similarities between OFG and Crohn's disease, emphasizing the need for more comparative studies of the two entities. The aim of this article is to report a case of OFG, along with a detailed literature review of the facts and variations associated with its nomenclature, clinical presentation, and etiology. It also projects the challenges that a professional has to face in the diagnosis and treatment planning of such cases.

Service evaluation of patients with orofacial granulomatosis and patients with oral Crohn's disease attending a paediatric oral medicine clinic

AIM

Presenting features associated with orofacial granulomatosis (OFG) and oral Crohn's disease (OCD) are varied, making successful diagnosis and management difficult. The aim of this service evaluation was to establish a profile of patients with these conditions attending a paediatric oral medicine clinic and to determine their overall satisfaction with the care received.

STUDY DESIGN

A retrospective case note analysis to establish the patient profile and a postal patient satisfaction questionnaire for service evaluation.

METHODS

All patients with OFG and OCD who had attended the joint paediatric dentistry/oral medicine clinic at Charles Clifford Dental Hospital, Sheffield in the previous 14 years were included in the study. Hospital case notes were retrospectively reviewed and patient demographics, clinical features, investigations, diagnosis, treatment and outcomes of treatment were recorded. An anonymous patient satisfaction questionnaire using the Healthcare Satisfaction Generic Module of the Paediatric Quality of Life Inventory (PedsQLTM) was distributed to all patients by mail.

RESULTS

A total of 24 patients (13 females and 11 males) were identified. Median age at presentation was 11 years (SD± 3.79, range 2-15). Fifteen patients (63%) were diagnosed with OCD, and 9 (37%) with OFG. Overall, the most common orofacial feature was oral ulceration (75%) followed by lip/facial swelling (71%), angular cheilitis (67%) and mucosal cobblestoning (67%). Differences in presentation were seen between the two conditions with oral ulceration (87%) and mucosal cobblestoning (80%) being the most frequently observed features of OCD and lip swelling (78%) and angular cheilitis (67%) being the most common features of OFG. 58% of patients reported relief of symptoms through treatment. Thirteen patient satisfaction questionnaires were completed (54%). 85% (n=11) felt the overall care received in the clinic was 'excellent'.

CONCLUSIONS

This service evaluation highlights the variety of presenting features of OFG and OCD. Despite only a moderate response to treatment, patient satisfaction with the service was high, emphasising the importance of good communication when managing children with chronic, debilitating conditions.

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.

Intralymphatic granulomas as a pathogenic factor in cheilitis granulomatosa/Melkersson-Rosenthal syndrome: report of a case with immunohistochemical and molecular studies

Orofacial granulomatosis, an uncommon immunologically mediated disorder, includes cheilitis granulomatosa and Melkersson-Rosenthal syndrome. It is clinically characterized by recurrent or persistent swelling of the orofacial tissues with a spectrum of other orofacial features and sometimes with neurological symptoms. The pathological findings are varied but are often characterized by the presence of noncaseating granuloma. We present a new case of orofacial granulomatosis with unusual histopathological findings, namely, intralymphatic granulomas. These may be the cause of the tissue edema. We demonstrated, by immunohistochemical studies, the lymphatic nature of the vessels affected by the granulomatous process.

Review article: cinnamon- and benzoate-free diet as a primary treatment for orofacial granulomatosis

BACKGROUND

Orofacial granulomatosis is a rare chronic granulomatous inflammatory disease of the lips, face and mouth. The aetiology remains unclear but may involve an allergic component. Improvements have been reported with cinnamon- and benzoate-free diets.

AIMS

To explore the prevalence of compound and food sensitivity and examine the dietary treatments used in orofacial granulomatosis.

METHODS

A comprehensive literature search was carried out and relevant studies from January 1933 to January 2010 were identified using the electronic database search engines; AGRIS 1991-2008, AMED 1985-2008, British Nursing and Index archive 1985-2008, EMBASE 1980-2008, evidence based medicine review databases (e.g. Cochrane DSR), International Pharmaceutical and Medline 1950-2008.

RESULTS

Common sensitivities identified, predominantly through patch testing, were to benzoic acid (36%) food additives (33%), perfumes and flavourings (28%), cinnamaldehyde (27%), cinnamon (17%), benzoates (17%) and chocolate (11%). The cinnamon- and benzoate-free diet has been shown to provide benefit in 54-78% of patients with 23% requiring no adjunctive therapies. A negative or positive patch test result to cinnamaldehyde, and benzoates did not predict dietary outcome. The most concentrated source of benzoate exposure is from food preservatives. Use of liquid enteral formulas can offer a further dietary therapy, particularly in children with orofacial granulomatosis.

CONCLUSION

Management of orofacial granulomatosis is challenging but cinnamon- and benzoate-free diets appear to have a definite role to play.

Childhood and adolescent orofacial granulomatosis is strongly associated with Crohn's disease and responds to intralesional corticosteroids

We present seven cases of orofacial granulomatosis occurring in paediatric patients aged 6-16 years. All patients were investigated for Crohn's disease and a strong association was found. All patients were treated with intralesional corticosteroid injections with excellent clinical responses. We review the literature and discuss the epidemiological association between childhood orofacial granulomatosis and Crohn's disease, as well as various treatment options, and propose a treatment protocol that was efficacious and well tolerated in all our patients.

Orofacial granulomatosis: clinical features and long-term outcome of therapy

BACKGROUND

Orofacial granulomatosis (OFG) is a chronic inflammatory disorder characterized by persistent or recurrent soft tissue enlargement, oral ulceration, and a variety of other orofacial features. There remain few detailed reports of the clinical features and long-term response to therapy of substantial groups of patients with OFG.

OBJECTIVE

The aim of this study was to determine retrospectively the clinical, hematologic, and histopathological features of a large case series of patients with OFG. In addition the long-term response to therapy was examined.

METHODS

Clinically relevant data of 49 patients with OFG who attended a single oral medicine unit in the United Kingdom were retrospectively examined. The analyzed parameters included diagnostic features, clinical manifestations, and outcomes and adverse side effects of therapy.

RESULTS

Labial swelling was the most common presenting clinical feature at diagnosis (75.5%), followed by intraoral mucosal features other than ulceration such as cobblestoning and gingival enlargement (73.5%). Mucosal ulceration was observed in 36.7% of patients whereas extraoral facial manifestations such as cutaneous erythema and swelling were present in 40.8% of patients. Of the 45 patients who required treatment, 24 (53.3%) were treated with topical corticosteroids/immunosuppressants only, whereas 21 (46.7%) received a combined therapy (topical plus systemic corticosteroids/immunosuppressants and/or intralesional corticosteroids). The long-term outcome analysis showed complete/partial resolution of tissue swelling and oral ulceration in 78.8% and 70% of patients, respectively.

LIMITATIONS

The main limitation of the current study was its retrospective design and methodology including differences in reporting clinical features and outcome.

CONCLUSIONS

OFG can show multiple facial and mucosal clinical features. Long-term treatment with topical and/or combined therapy is needed in the majority of patients. Response to therapy is highly variable even though in the long-term complete/partial disease resolution can be obtained in the majority of patients. Mucosal ulceration tends to be more recalcitrant than orofacial swelling. Adverse side effects of therapy are rare.

Orofacial Granulomatosis due to Tuberculosis

Tuberculosis in a girl with typical features of orofacial granulomatosis is described. The importance of early suspicion and treatment to prevent disfigurement is emphasized.

Recurrent oral ulceration: aphthous-like ulcers in periodic syndromes

Recurrent oral ulceration that clinically resembles recurrent aphthous stomatitis but presents atypically, including commencement after adolescence, with fever, with a strong family history, or failing to resolve with age, has been termed aphthous-like ulceration (ALU). It may be seen in some immunodeficiency states, chronic viral infections, rheumatologic disorders, skin diseases, and the periodic syndromes. The periodic syndromes, considered to be the prototypic autoinflammatory diseases, present with recurrent short attacks of myalgia, arthralgia, rashes, abdominal pain, lymphadenopathy, and fever. Several of the syndromes can result in amyloidosis. Genetic studies have enhanced the clinical characterization of these conditions and elucidation of their molecular etiopathogenesis. This paper describes 2 patients with periodic syndromes presenting with ALU and reviews the present understanding of the syndromes.

Local adverse effects of amalgam restorations

Amalgam has been used for the restoration of teeth for well over 100 years, and is the most successful of the direct restorative materials with respect to longevity. Despite the increasing use of tooth-coloured materials, with advantages of aesthetics and adhesion, amalgam is one of the most widely used dental restorative materials. One of the principal disadvantages of amalgam, apart from aesthetics, is that it may have adverse biological effects, both locally and systemically. Locally, it can cause an erythematous lesion on the adjacent oral soft tissues (tongue and buccal mucosa), and systemically free mercury in the amalgam may give rise to a hypersensitivity reaction. The purpose of this paper is to review the literature concerning the local adverse reactions to dental amalgam. The focus will be on the reactions of the oral mucosa, and brief consideration will be given to laboratory cytotoxicity of dental amalgam and its components, and to the 'amalgam tattoo'.

Onset and progression of clinical manifestations of orofacial granulomatosis

BACKGROUND

There remain few studies describing in detail the early occurrence and long-term progression of clinical manifestations of orofacial granulomatosis (OFG) in a substantial number of patients.

OBJECTIVES

The aim of this study was to determine the early and late clinical manifestations of a large case series of patients with OFG.

PATIENTS/METHODS

Clinically relevant data of 49 patients with OFG who attended an Oral Medicine unit in the UK were examined retrospectively. The analyzed parameters included occurrence and typology of initial manifestations at onset and with respect to long-term follow-up.

RESULTS

Five major patterns of disease onset were observed. Recurrent facial swelling with/without intra-oral manifestations was the single most common presentation at onset followed by intra-oral ulcers, and other intra-oral and neurological manifestations. The majority of patients later developed a spectrum of additional features.

CONCLUSIONS

OFG results in multiple manifestations at different time points. The disease onset is characterized by manifestations other than facial swelling in about half of affected individuals. However, patients can develop cosmetically unacceptable lip/facial swelling at a later stage. Nearly all affected individuals ultimately develop lip/facial swelling while about half of all patients develop oral ulceration.

Cutaneous sarcoidosis: differential diagnosis

Sarcoidosis is a multisystem disease with cutaneous lesions present in 20%-35% of patients. Given the wide variability of clinical manifestations, it is one of the "great imitators," making it necessary to consider clinical, epidemiological, radiographic, laboratory, and histopathological criteria to make the diagnosis. Cutaneous lesions have been classified as specific and nonspecific, depending on the presence of noncaseating granulomas on histologic studies. Specific lesions include maculopapules, plaques, nodules, lupus pernio, scar infiltration, alopecia, ulcerative lesions, and hypopigmentation among others. Nail, mucosal, and childhood sarcoidosis represent a distinct subset of the disease process. The most common nonspecific lesion is erythema nodosum. Others include calcifications, prurigo, erythema multiforme, nail clubbing, and Sweet syndrome. The importance of considering cutaneous sarcoidosis in the clinical differential diagnosis of a given skin lesion relies on the association with systemic involvement and the convenience of the skin as a tissue source for histologic analysis.

Orofacial granulomatosis of the lower lip and cheek: report of a case

Orofacial granulomatosis (OFG) is a granulomatous disease of the orofacial region. This clinicopathological entity describes patients with oral lesions characterized by persistent and/or recurrent labial enlargement, ulcers, and a variety of other orofacial features, which on biopsy have lymphedema and noncaseating granulomas. The cause is idiopathic but appears to represent an abnormal immune reaction. This may be a manifestation of Crohn's disease (CD) since some patients with oral lesions develop typical bowel symptoms of CD in ensuing months to years; tooth-associated infections, sarcoidosis, food or contact allergies, and viruses have also been implicated in causing OFG. Clinical features of OFG are highly variable and sometimes so insidious that signs and symptoms are frequently not severe enough to cause alarm. The lips are most commonly involved and demonstrate a nontender, persistent swelling. Because of the relatively nonspecific clinical findings associated with granulomatous diseases, a microscopic diagnosis of granulomatous inflammation often presents a diagnostic dilemma for clinicians. We report a case of OFG of the lower lip and cheek and describe its management to add to the current body of literature on the subject.