Dermatologic manifestations in pediatric patients with inflammatory bowel disease

BACKGROUND

Despite studies of dermatologic manifestations in adults with inflammatory bowel disease (IBD), little is known about the prevalence of IBD-associated skin lesions and their correlation with IBD severity in children. We aimed to address these knowledge gaps in our single-center cohort of children with IBD.

METHODS

Retrospective chart review of 528 children and adolescents (≤18 years old) with IBD and seen at Mayo Clinic (Rochester, MN) between 1999 and 2017 was conducted. The Chi-Square/Fischer's exact test (with p ≤ .05 to signify statistical significance) was applied to compare categorical outcomes between Crohn's disease (CD) and ulcerative colitis (UC) patients.

RESULTS

In total, 425 IBD patients (64.9% CD, 53% males) and ≥1 dermatologic diagnosis were included. Presence of ≥1 cutaneous infection was recorded in 42.8% of participants. Acne was the most common non-infectious dermatologic condition (30.8%), followed by eczema (15.8%) and perianal skin tags (14.6%). Angular cheilitis (p = .024), keratosis pilaris (KP, p = .003), and perianal skin complications (i.e., skin tags, fistula, and abscesses; all p < .001) were more frequently diagnosed among children with CD, while fungal skin infections (p = .017) were more frequently diagnosed in UC patients. Severity of IBD correlated with higher prevalence of perianal fistula (p = .003), perianal abscess (p = .041), psoriasis (p < .001), and pyoderma gangrenosum (PG, p = .003).

CONCLUSIONS

Both IBD-specific and IBD-nonspecific dermatologic conditions are very prevalent in childhood IBD, the most common being infectious. Children with CD are more likely to experience angular cheilitis, KP, and perianal skin findings than those with UC. Perianal disease, psoriasis, and PG are associated with more severe IBD.

Pantoprazole-induced Stevens-Johnson Syndrome: A Case-report

INTRODUCTION

Pantoprazole is a proton pump inhibitor mainly used to treat conditions causing excess stomach acid. Stevens-Johnson syndrome (SJS) is a rare bullous disease. The main etiologic factors are drugs, especially antibiotics, anticonvulsants, oxicam and allopurinol. Proton pump inhibitors have been rarely reported as a causative agent in SJS, and only sporadic cases secondary to pantoprazole have just been mentioned in the literature.

CASE REPORT

A 49-year-old woman was referred to the dermatology department for a pruritic generalized eruption, associated with erosive cheilitis. The patient reported self-medication by pantoprazole for two weeks. Physical examination revealed target-like lesions with bullous center in some areas. A skin detachment on the left breast and the neck affecting 10% of the total body surface area was observed. Mucosal examination revealed erosive, painful cheilitis covered by large hemorrhagic crusts and erosions of the nasal cavity. The lesions cleared completely few days after pantoprazole withdrawal and local corticosteroids. Further investigations ruled out infectious etiologies.

CONCLUSION

This case highlights the possible occurrence of hypersensitivity reactions due to the use of a PPI, which is a widely used medication and a generally well-tolerated drug.

Zinc Deficiency with Cheilitis: A Report of Five Cases

Zinc deficiency has long been known as acrodermatitis enteric dermatitis (congenital zinc deficiency). On the other hand, acquired zinc deficiency has attracted attention as a familiar disease in recent years. Epidemiological studies in Japan have shown that acquired zinc deficiency is more common than expected. It is also known that serum zinc levels fall markedly with age. In this report, several cases of acquired zinc deficiency that caused cheilitis are described. In all cases, the only symptom was cheilitis, the serum zinc level was low, and all cases were relieved by zinc supplementation. Zinc deficiency is associated with a range of pathological conditions, including mucocutaneous symptoms, delayed wound healing, dysgeusia, anemia, impaired immunity, and retarded growth development disorders. However, zinc deficiency may be overlooked even in cases of cheilitis alone. Especially in intractable cases, it is important to suspect zinc deficiency as one at the differential diagnoses.

Chronic granulomatous disease as a risk factor for cutaneous lupus in childhood

Chronic granulomatous disease (CGD) is a primaryimmunodeficiency disorder that affects the phagocyticcells of the innate immune system. It is characterizedby recurrent or persistent infections with granulomaformation. Lupus-like lesions have been reported incarriers of CGD and less frequently, in patients withCGD. Immunological study in these patients areusually negative. We describe the case of an 8-yearoldboy with CGD who developed chronic and acutecutaneous lupus erythematous with angular cheilitis,oral ulcers, Raynaud phenomenon, and positiveserologies for antinuclear, anticentromere, and anti-Saccharomyces cerevisiae antibodies.

Early diagnosis of lip cancer preceded by a persistent actinic lesion in a kidney transplant patient: a case report

Lip cancer is 65 times more likely to occur in kidney transplant patients than in members of the general population. Immunosuppression drugs taken by the transplant patients have been associated with this increased occurrence. This case report shows the progression from actinic cheilosis to squamous cell carcinoma (SCC) in the lower lip of a 58-year-old man receiving immunosuppressive therapy 9 years after undergoing a kidney transplant. Earlier incisional biopsies had resulted in a histological diagnosis of actinic cheilosis. However, the last incisional biopsy showed histological results compatible with SCC, and oncological surgery was performed. Eight months post-surgery, the patient was free of cancer and metastasis. Frequent dental follow-up visits allowed for the early diagnosis, proper treatment, and an improved prognosis for this patient.

Plasma cell gingivitis associated with inflammatory chelitis: a report on a rare case

BACKGROUND

Plasma cell gingivitis (PGC) is a rare disease of gingival tissues which is difficult to treat. It has a higher rate of reoccurrence and needs a detailed and careful analysis of etiology. Further, its association with chelitis is rare, only few cases have been reported and the condition with this presentation poses a diagnostic dilemma.

CASE REPORT

This paper reports a 16 year old male with a complaint of bleeding and swelling of gingiva since 3 years. The gingival enlargement occurred on facial aspect of upper and lower anterior teeth involving attached gingival. He also presented with swelling of both lips which was recurrent and for the same duration of 3 years.

DISCUSSION

Based on clinical features and histopathological findings, a diagnosis of plasma cell gingivitis with inflammatory chelitis was made. A detailed history of possible allergen exposure was taken and patch test was conducted to identify any such allergens. Other conditions were ruled out by blood investigation, detailed medical and drug history.

CONCLUSION

A close collaboration between Periodontist and Dermatologist is essential to manage such a case.

Candida-associated denture stomatitis in type 2 diabetes mellitus

OBJECTIVE

To describe the clinical appearance of Candida-associated denture stomatitis (DS) in subjects with type 2 diabetes (T2DM). The relationships between the types of DS, oral complaints and associated conditions were assessed in terms of glycemic control as determined by glycated hemoglobin (HbA1c) measurements.

MATERIALS AND METHODS

Demographic and clinical data were obtained from questionnaires and oral examinations of 110 edentulous patients with T2DM and 50 control subjects.

RESULTS

Type II DS commonly occurred in diabetics (57.3% vs 30%; p=0.002) together with DS related oral complaints (60.9% vs 24%; p<0.001) compared with controls. Burning sensation of the mouth (BS) was the most common complaint. Dryness of the oral mucosa (DOM) (50.9% vs 6%; p<0.001), angular cheilitis (26.4% vs 8%; p=0.01) and glossitis (27.3% vs 6%; p=0.003) occurred more frequently in diabetics. Oral complaints and associated conditions of DS coincided with elevated HbA1c levels (p<0.001). Diabetics with extensive type of inflammation had higher HbA1c levels than type I/III DS subjects (p<0.001).

CONCLUSIONS

Diffuse type of inflammation was associated with T2DM. BS and DOM were the most common oral complaints. Inadequately controlled diabetes with Candida-associated DS was linked to a high incidence of an extensive type of inflammation, oral complaints and associated conditions.

[Manifestations of gastroesophageal reflux disease in the oral cavity]

Were examined clinical and laboratory examined 138 patients: 93 people with gastroesophageal reflux disease (GERD) in whose mouth there were changes in the periodontal tissues, and 45 people without a concomitant GERD with help of clinical and laboratory methods. All patients were conducted to clinical examination of the oral cavity with the establishment of periodontal status on the basis of "Florida Proub" system and evaluation index. During the study was analyzed the major dental complaints as "extraesophageal" symptoms in patients with reflux esophagitis, as well as evaluation of the inflammatory process in periodontal tissues, depending on the stage of GERD.

Actinic cheilitis adjacent to squamous carcinoma of the lips as an indicator of prognosis

Many studies have shown an association between actinic cheilitis and squamous carcinoma of the lips.

AIM

The aim of the study was to observe the relation between actinic cheilitis and the prognosis of squamous carcinoma of the lips. MATERIALS AND METHODS This is a retrospective cross-sectional cohort study of squamous carcinoma of the lips. Histological sections of squamous carcinoma tumors done at the the Department of Pathology of the Sao Paulo Federal University between 1993 and 2000 were reviewed for evidence of actinic cheilitis in the lip vermillion adjacent to the tumor. Patient reports were reviewed to find information about exposure to sun, metastases and relapses. The occurrence or absence of relapses and metastases was correlated with the presence or absence of actinic cheilitis in the lip vermillion. Data was analyzed by Fisher's Exact test.

RESULTS

Of the 31 selected patients, most were caucasian, males and with lower lip involvement. Statistical analysis demonstrated independence between the occurrence of metastases and relapse and gender, skin color and site (lower or upper lips). There was dependence between actinic cheilitis and solar elastosis, and between the absence of actinic cheilitis and the occurrence of metastases. There was no dependence between the absence of actinic cheilitis and the occurrence of relapses.

CONCLUSION

It may be concluded that tumors originating from actinic cheilitis have a better prognosis.

Mucocutaneous findings in 100 children with Down syndrome

Down syndrome is the most common chromosomal abnormality affecting numerous organs, including the skin. Our aim was to study mucocutaneous findings in this syndrome. To do so, 100 children with Down syndrome attending Schools for Children with Special Educational Needs and centers affiliated to the Welfare and Rehabilitation Organization in two provinces of Iran were thoroughly examined for skin and mucosal lesions. Their mean age was 11.2 years (3-20 years). Mucocutaneous findings were noted in 61. These were as follows (in decreasing order)--fissured tongue 28%, hypertrophy of tongue papilla 22%, premature graying 14%, cheilitis 13%, xerosis 12%, alopecia areata 11%, palmoplantar hyperkeratosis 10%, syringoma 6%, keratosis pilaris 4%, geographic tongue 4%, trichotillomania 4%, vitiligo 3%, seborrheic dermatitis 3%, livedo reticularis 2%. No instances of atopic dermatitis or skin infections and infestations were noted. The lack of atopic dermatitis in our series was in concordance with its low prevalence reported in recent articles. Improved hygiene due to patient care at home may underlie the absence of infections. With the increasing survival rate of those with Down syndrome, physicians should be more aware of the skin findings seen so frequently in this genetic disorder.

Cheilitis granulomatosa associated with melkersson-rosenthal syndrome

Melkersson-Rosenthal syndrome (MRS) consists of persistent or recurrent orofacial edema, relapsing facial palsy and fissured tongue. The complete triad of symptoms is uncommon, varying from 8 to 25%. The presentation of only one symptom is more common. The most frequent complaint is facial edema and enlargement of the lips. We describe a case of a 17-year-old Brazilian girl with limited edema of the lower lip and fissured tongue due to MRS. Her complaints had started two years before. She referred previous clinical treatments without success. We proposed intralesional injection of triamcinolone at 20 mg every 15 days associated with oral clofazimine at 50 mg/day for three months. The lip became normal after four triamcinolone injections. Recent studies have considered MRS a granulomatous disease, and possibly the initial presentation of Crohn's disease in orofacial area of some patients. MRS patients, therefore, should be screened and monitored for gastrointestinal symptoms. Corticosteroid treatment seems to be effective in reducing lip enlargement. We discus the clinical features of this disease, the treatment, and the importance of corticosteroid therapy in cases of MRS-related facial palsy.

Oral mucosa alterations in chronic hepatitis and cirrhosis due to HBV or HCV infection

The aim of the study was to evaluate the character of lesions within oral mucosa in patients suffering from chronic hepatitis and cirrhosis of the liver due to either HBV or HCV infection. A total of 74 patients treated at the Clinic of Infectious Diseases in Wrocław for chronic hepatitis B (20 patients, group I) and for chronic hepatitis C (23 patients group III) and cirrhosis of the liver due to HBV (15 patients , group II) and HCV (16 patients, group IV) infection. The control group comprised 29 healthy subjects. Lesions within the oral mucosa found on clinical examinations were confirmed with a histopathological evaluation. Patients suffering from chronic hepatitis B revealed leukoplakia (1/20), melanoplakia (1/20), petechiae (1/20), 17 patients from this group did not show any changes. Patients suffering from chronic hepatitis C revealed leukoplakia (6/23), Delbanco's disease (2/23), melanoplakia (1/23), lichen planus (1/23), petechiae (1/23), 12 patients from this group did not show any changes. Patients suffering from cirrhosis of the liver due of HBV infection revealed leukoplakia (3/15) petechiae (2/15), Delbanco's disease (1/15), angular cheilitis (1/15), aphthae (1/15), 7 patients from this group did not reveal any changes. Patients suffering from cirrhosis of the liver due of HCV infection revealed petechiae (2/16), melanoplakia (1/16), candidosis (1/16), labial herpes (1/16), 11 patients from this group did not reveal any changes. In control group we observed leukoplakia (3/29), Delbanco's disease (1/29), labial herpes (1/29), petechiae (1/29), and 23 subjects did not present pathological lesions within the oral mucosa. Results indicate the lack of connection between chronic HBV and HCV infection as well as the stage of the disease with the incidence and character of oral lesions in oral mucosa.

Actinic cheilitis: clinical and pathologic characteristics in 65 cases

OBJECTIVE

The purpose of this study was to determine the clinical and histopathologic presentation of actinic cheilitis.

STUDY DESIGN

A retrospective study on 65 patients attending an Oral Medicine clinic in Greece over a 10 year period. For each case the demographic, clinical and histopathologic information were evaluated.

RESULTS

The mean age at the time of diagnosis was 53.1 +/- 11.4 years. Thirty-nine patients (60%) used tobacco in any form. An outdoor occupation was indicated for 43 (66.2%) patients. The location of the lesions of actinic cheilitis was in all cases on the lower lip. Actinic cheilitis appeared in three forms; white non-ulcerated lesions (29%), erosions or ulcers of the lip (48%), mixed white and erosive (23%). The histopathologic characteristics included increased thickness of keratin layer, alterations of the thickness of spinous cell layer, epithelial dysplasia, connective tissue changes, perivascular inflammation and basophilic changes of connective tissue. In 11 cases (16.9%) the presence of squamous cell carcinoma was observed.

CONCLUSIONS

This case-series highlights varied clinical presentation of actinic cheilitis among whom a high proportion developed squamous cell carcinoma.

Salivary flow and its relationship to oral signs and symptoms in patients with dry eyes

OBJECTIVES

The aim of this study was to investigate oral symptoms and clinical parameters in dry eye patients. Subjective reports of the sensation of a dry mouth, salivary flow rates, and clinical parameters of oral disease related to three different types of dry eye patients were examined.

SUBJECTS AND METHODS

There were 224 individuals, including dry eye patients and control subjects. The dry eye patients were classified into three types: patients with Sjögren's syndrome (SS-DE), patients without SS-DE (non-SS-DE), and patients with Stevens-Johnson syndrome (SJS-DE). Salivary flow rates were measured using two kinds of sialometry. Subjective and objective oral symptoms and signs were also examined.

RESULTS AND CONCLUSION

Over half of the dry eye patients complained of a dry mouth. The flow rates of their stimulated whole saliva and parotid saliva were significantly lower than those of the control groups (P < 0.05, P < 0.01). The sensation of a dry mouth and changes in oral soft tissues, dental caries, and oral Candida frequently occurred in dry eye patients.

Acquired immunodeficiency syndrome: manifestations in the oral cavity

Human immunodeficiency virus (HIV) infection is a pandemic disease characterised by impairment of the immune system; the main parameter is a progressive decline in the number of CD4 lymphocytes. This circumstance paves the way for opportunistic infections and the development of neoplastic processes that can lead the patient to a state known as acquired immunodeficiency syndrome (AIDS) and ultimately, results in death. The incorporation of treatment based on a cocktail of different active drugs (highly active antiretroviral therapy) has made it possible to drastically change the panorama of the disease in developed nations; improving quality of life for the patient and delaying the progression of the disease. The oral manifestations of HIV infection have been and continue to be an important component of the disease from the very first descriptions and are indicative of progression. At some point in the course of the disease, nine out of every ten patients will present oral manifestations and, on occasion, these symptoms will be the first sign of the syndrome. It is essential that oral healthcare professionals recognize the hallmarks of the illness. In developed countries, the emergence of new therapies has made it possible to significantly reduce immune deficiency-related oral manifestations, both in terms of frequency, as well as severity. This review analyses the most important oral lesions associated with HIV infection and the current state of affairs in this regard.

Association of dental health parameters with oral lesion prevalence in human immunodeficency virus-infected Romanian children

PURPOSE

This study assessed the association of caries, plaque accumulation, gingival health, and antiretroviral therapy (AT) with oral lesion prevalence in human immunodeficiency virus (HIV)-infected Romanian children.

METHODS

A convenience sample of HIV-infected children who received dental care in 2 hospitals were evaluated for oral lesions, caries (dfs+DFS/total teeth present), plaque (PI, Silness and Löe), and gingival indices (GI, Löe and Silness). Oral lesions were grouped as: (1) extraoral herpetic infections; (2) parotid gland swelling; (3) oral ulcerative lesions; and (4) fungal infections. A standardized operator performed the examinations and photographed the oral lesions for confirmation. Age, gender, and use of AT were documented. Data were analyzed by logistic and multiple regression, Pearson correlation and t test (P<.05).

RESULTS

One hundred four children (mean age=11.7 years) were evaluated. Fungal infections were associated with increased caries rate (P=.002; OR=2.5) and increased GI (P=.01; OR=7.6). Caries, PI, and GI were associated with an increase in oral lesions (r=-0.472, P<.001). AT use was associated with decreased caries (P=.001, t test), but was not associated with decreased oral lesion prevalence.

CONCLUSIONS

Oral lesions, especially candidiasis, are more common in HIV-infected children with higher caries experience, gingival inflammation, and plaque accumulation. In children with limited access to medical care, the role of oral health appears to be important for decreasing the risk of common opportunistic infections.

Cheilitis glandularis: An unusual presentation in a patient with HIV infection

Cheilitis glandularis is a rare disorder of unknown etiology characterized by inflammation of the minor salivary glands of the lower lip. The present report details the features of a patient who presented with cheilitis glandularis and was subsequently found to also have undiagnosed HIV infection.

Down syndrome: lip lesions (angular stomatitis and fissures) and Candida albicans

BACKGROUND

The incidence of angular cheilitis (angular stomatitis, perleche, commissural fissures) appears to be increased in people with Down syndrome (DS). Lip fissures are also (in our clinical impression) a fairly regular feature, yet this is scarcely mentioned in the literature.

OBJECTIVES

To establish the incidence of angular cheilitis and lip fissures in a substantial group of patients with DS and to examine the relationship with Candida albicans.

PATIENTS AND METHODS

The prevalence of orofacial soft tissue lesions was investigated in a group of 77 DS patients. Swabs were taken from lip lesions, palate and tongue and inoculated on Sabouraud's agar discs for the isolation of C. albicans, identified with commercially available kits.

RESULTS

Lip fissures were seen in at least one-quarter of DS patients. Angular cheilitis was also found in a similar percentage.

CONCLUSIONS

C. albicans was isolated from a substantial proportion of lesions tested, and was present more frequently than in those without lip lesions, but it is uncertain whether this represents cause or effect.

Actinic prurigo cheilitis: clinicopathologic analysis and therapeutic results in 116 cases

Objective. This study describes the clinicopathologic features and therapeutic results of 116 patients with actinic prurigo cheilitis seen over an 11-year period. Study Design. A retrospective study was carried out with hospital records and a microscopic slide review from a large dermatology department in Mexico City, Mexico. Results. The study consisted of 42 male (36.2%) and 74 female (63.8%) patients, with a male to female ratio of 1:1.7. Age ranged from 9 to 82 years (mean, 27.9 years; standard deviation, 14.2). Thirty-two cases (27.6%) were found in which cheilitis was the only manifestation of this condition. Pruritus, tingling, and pain of the vermilion were recorded in 96 cases (82.7%). Typical histopathologic findings included in most cases the presence of acanthosis, spongiosis, basal cell vacuolation, ulceration with serohematic crust formation, edema of the lamina propria, lymphocytic inflammatory infiltrate with well-defined lymphoid follicles, and variable numbers of eosinophils and melanophages. Improvement of the symptoms was obtained in 112 cases (96.5%) with sun-protective measures and diverse antiinflammatory agents. However, complete resolution of the labial lesions were more frequently achieved with the combination of topical steroids, thalidomide, and sun-protective measures (42.2%) as compared with topical steroid therapy plus sun-protection measures (16.3%; P <.005). Conclusion. Our findings confirm that lip lesions may appear as the only manifestations of this photodermatosis and that it has typical clinical and microscopic features and should therefore be considered a specific form of cheilitis.

Differences in risk factors among clinical types of oral candidiasis in the Women's Interagency HIV Study

OBJECTIVES

The purpose of this study was to determine the prevalence and concurrence/associations of oral candidiasis types and multiple risk factors in women.

STUDY DESIGN

A cross-sectional analysis of baseline data for 577 human immunodeficiency virus (HIV)-seropositive and 152 HIV-seronegative women from the Women's Interagency HIV Study was conducted. Pseudomembranous candidiasis (PC) and erythematous (EC) candidiasis, angular cheilitis (AC), and denture stomatitis (DS) were studied, and bivariate and multivariate regression analyses were performed.

RESULTS

Prevalences were 8% for PC, 7% for EC, 18% for DS, and 3% for AC; all except AC usually occurred alone. HIV seropositivity was associated with PC, EC, and DS, but not AC. Among HIV-seropositive women, low CD4 cell counts were associated with PC, but not with EC or DS. Heroin/methadone use was associated with PC and EC; salivary hypofunction was associated with PC; high viral load was associated with EC, and poor oral hygiene, with EC and DS.

CONCLUSIONS

Risk factors varied among candidiasis types, suggesting differences in pathogenic mechanisms and usefulness as markers of HIV infection/progression.

Treatment of Miescher's cheilitis granulomatosa in Melkersson-Rosenthal syndrome

Cheilitis granulomatosa is the most frequent dermatological sign in the Melkersson-Rosenthal syndrome. We reviewed 27 cases of this syndrome diagnosed and treated in the last 20 years. All the patients were surgically treated and received intralesional corticosteroids during surgery and tetracycline hydrochloride (500 mg, twice daily) after the operation to prevent recurrence.

Oral manifestations of HIV positive children

Oral manifestations in HIV positive children were observed in thirty-eight HIV infected children that have received care at the Special Care Dentistry Center (SCDC) of the School of Dentistry, University of Sao Paulo. Results have shown that 52.63% of the children presented at least one oral manifestation related with HIV/AIDS. Angular cheilitis occurred in 28.94%, parotid gland bilateral enlargement, pseudomembranous candidiasis and erythematous candidiasis in 18.42%, conventional gingivitis in 13.15%, herpes simplex in 5.26%, hairy leukoplakia, recurrent aphthous ulcer and condyloma acuminatum in 2.63%. Although enamel hypoplasia occurred in 23.68%, this could not be attributed specifically to HIV infection.

Oral manifestations in HIV-positive adults from Northern Thailand

Eighty-seven HIV-infected patients in a provincial hospital in Northern Thailand were examined for oral manifestations of HIV disease and AIDS. The median age was 31.3 years. Seventy-four of the patients were women, 13 were men. 96.6% had a history of heterosexual transmission. Sixty-one patients were CDC-category A, 20 were category B and 6 were category C (AIDS). Thirty-eight percent of the patients revealed oral lesions; 23% had one oral lesion and 13.8% had two oral lesions. Common lesions were oral candidiasis (10.3% pseudomembranous candidiasis, 6.9% erythematous candidiasis and 3.4% both forms), oral hairy leukoplakia (11.5%) and exfoliative cheilitis (6.9%). Gingival linear erythema was seen in 8% of the patients; periodontal lesions and necrotising ulcerative gingivitis were not observed. Men were more commonly affected by oral manifestations than women (P < 0.004). The spectrum of oral lesions is comparable to other studies from the region, although most of these reported more men than women. Also, the degree of immunosuppression was more marked (AIDS).

Risk factors associated with oral lesions in HIV-infected heterosexual people and intravenous drug users in Thailand

This study aimed to identify factors associated with the presence of oral lesions in HIV-infected individuals in Thailand, to determine the influence of gender and route of HIV transmission on the prevalence of the lesions, and to investigate whether total lymphocyte cell counts can be used as a serologic marker to predict the occurrence of oral lesions. Two hundred and seventy-eight HIV-infected heterosexual persons and intravenous drug users (IVDUs) were enrolled (230 males, 48 females). Eighty-six HIV-free subjects from the same population were included as controls (61 males, 25 females). Oral candidiasis was the most common oral lesion among HIV-infected individuals (39.6%), followed by hairy leukoplakia (HL) (26.3%), exfoliative cheilitis (18.3%), and linear gingival erythema (LGE) (11.5%). Odds ratios (ORs) for factors associated with the presence of oral lesions were as follows for advanced HIV disease defined by clinical status: symptomatic stage [OR= 18.6; 95% confidence interval (CI) 7.3-47.2], AIDS stage [OR 7.3; 95% CI 3.4-15.7] and laboratory investigation of total number of lymphocyte cell counts of 1,000-2,000 cell/mm3 [OR 2.7; 95% CI 1.4-5.1] and <1,000 cell/mm3 [OR 4.0; 95% CI 2.3-7.0], alcohol consumption [OR 3.4; 95% CI 1.3-9.1], and poor oral health [OR 1.7; 95% CI 1.0-2.9]. Men were significantly more likely to have oral lesions than women. No statistically significant difference in the presence of oral lesions was observed between heterosexuals and IVDUs. This study should help predict the risk of acquiring various types of oral lesions, given that the person is exposed to multiple risk factors compared to another who is not exposed to these factors.

Granulomatous vulvitis, granulomatous cheilitis: a single diagnosis?

We report two cases of labial swelling (oral and vulvar) with a granulomatous histology in patients with a history of Crohn's disease. The differential diagnosis of granulomatous vulvitis and cheilitis, as well as the symptomatology and treatment of vulvar and oral Crohn's disease are further discussed. To our knowledge, reported cases of vulvar and oral Crohn's disease are quite scarce in the literature, but the disease might be underdiagnosed. We hope to contribute to an earlier recognition and a better management of the vulvar and oral mucocutaneous lesions of Crohn's disease.

[Therapy of the Melkersson-Rosenthal syndrome with kenalog]

IA case of Melkersson-Rosenthal syndrome with major and minor symptoms is presented. Clinical diagnosis was established on the basis of the triad: macrocheilia, lingua plicata and facial paralysis and a number of minor symptoms. The upper lip macrocheilia with palpation evident infiltrates corresponded to the diagnosis of granulomatous cheilitis of the upper lip. The upper lip was of intense red color, with the vermilion border effaced causing a marked cosmetic defect. The predominant subjective symptoms were burning and itching sensations with a reduction of movement of the lip. Clinical examination and palpation revealed three granulations enclosed by fissures. A slight exfoliation of the epithelia with serous exudate was dominant feature. The patient was admitted to the Oral Medicine Department of Dental School in Sarajevo on October 8th 1999 for macrocheilia relapses. The therapy using subcutaneous application of kenalog-40 suspension once a week in duration of five weeks showed substantial improvement. According to the prognostic criteria and the control examinations there were no relapses.

Salivary flow and its relation with oral symptoms in terminally ill patients

BACKGROUND

Patients with terminal malignant disease commonly report hyposalivation or xerostomia. This leads to "dry mouth," fungal infection, and mucosal abnormalities. To the authors' knowledge oral symptomatology and findings have not been correlated previously with accurate salivary flow measurements.

METHODS

Measurement of stimulated parotid salivary flow rate and clinical recording of oral symptoms within 24 hours from the time of hospital admission were obtained in 48 terminally ill cancer patients. Subjective reporting of symptoms by patients, parotid salivary flow rate, clinical recording of dental status, presence of candidiasis, angular cheilitis, and dryness of the floor of the mouth were obtained.

RESULTS

A clinical diagnosis of oral candidiasis was made tentatively in 94% of patients, and 50% of the patients were found to have angular cheilitis. Thirty-one of 45 evaluable patients (68%) reported a sensation of oral dryness. Sixteen of the 48 patients (33%) had no saliva at the floor of the mouth. Analysis of individual salivary flow rates was stratified into 3 levels of secretion: 0, < 0.2, and > or= 0.2 mL/minute. Symptoms were found to correlate with salivary flow rates.

CONCLUSIONS

In the current study, symptoms were found to be most severe in the patients with xerostomia followed by those patients with hyposalivation. Treatment should be directed individually to each group of patients using either salivary substitutes or stimulants. The rate of incidence of oral pathologic findings may be higher than formerly recognized.

Oral findings in pediatric AIDS: a case control study in Brazilian children

A cross-sectional study was performed to verify the oral status in forty-one-children, four months to twelve years old, with antibodies anti-HIV detected by ELISA and Western-blot, in comparison to children with no risk for AIDS. Intraoral and extraoral examinations were performed, and dental and medical history was also obtained. Representative oral findings in AIDS group were cervical lymphadenopathy (53.7 percent), pseudomembranous candidosis (22 percent), angular cheilitis (9.8 percent), parotid enlargement (7.3 percent), erythematous candidosis (4.9 percent), and ulcers (4.9 percent). Control group included only two children with cervical lymphadenopathy. Considering the mean values for dmft and DMFT, there were no statistically significant differences (Student's t test) between the two groups (p < 0.05). While oral soft-tissue lesions were frequently observed in HIV antibodies in seropositive children, dental caries could not be associated primarily with AIDS.

Lip cancer: a review

Dental examinations should routinely include examination of the lips by visual inspection and palpation. The primary risk factor for lip cancer is actinic damage. Squamous cell carcinoma of the lip accounts for about nine per cent of all oral cancers, but there has been a downward trend in the number of cases reported from 1973 to 1984. This trend may be due to the increased use of sunscreens. The clinical presentation and management of lip cancer are discussed.

In-vitro proteinase production by oral Candida albicans isolates from individuals with and without HIV infection and its attenuation by antimycotic agents

In-vitro proteinase production by oral Candida albicans isolates from patients with and without HIV infection (18 isolates from each group) was assessed by image analysis of a plate assay, with bovine serum albumin (BSA) as a substrate. The effect of sub-minimal inhibitory concentrations (sub-MICs) of nystatin, amphotericin B, clotrimazole and miconazole on in-vitro proteinase production by these yeast isolates was also investigated. Proteinase production by C. albicans isolates from patients with HIV infection was significantly greater than production by those from individuals without infection. All 18 isolates from HIV-infected individuals produced proteinase, in comparison to 56% of isolates from uninfected individuals. Pre-exposure of C. albicans isolates (seven proteinase producers from each group) to 1/4 and 1/16 MICs of nystatin, amphotericin B, clotrimazole and miconazole resulted in decreased proteinase production in all isolates tested. However, after exposure to the four antimycotic agents, proteinase production was decreased to a significantly greater extent in isolates from uninfected individuals than in those with HIV disease. Furthermore, when the relative concentration effect of antimycotic agents on proteinase production was compared, C. albicans isolates from the HIV-free group demonstrated a salient dose-response relationship compared with the HIV-infected group. These results indicate that C. albicans from patients with HIV infection are significantly more proteolytic than those from individuals without the infection, and that polyenes and imidazoles curtail the proteolytic activity of all C. albicans isolates, albeit to a lesser extent in those from HIV-infected patients. It appears that HIV disease favours oral colonisation by more proteolytic C. albicans isolates, with resilient proteolytic activity.

Exfoliative cheilitis

Exfoliative cheilitis is an uncommon condition affecting the vermilion zone of the upper, lower or both lips. It is characterized by the continuous production and desquamation of unsightly, thick scales of keratin; when removed, these leave a normal appearing lip beneath. The etiology is unknown, although some cases may be factitious. Attempts at treatment by a wide variety of agents and techniques have been unsuccessful. Three patients with this disease are reported and its relationship to factitious cheilitis and candidal cheilitis is discussed.

Head and neck manifestations of tumoral calcinosis

Intraoral facial and laryngeal features of tumoral calcinosis are reviewed in six patients of Jewish-Yemenite descent. Extraoral features included calcified masses, erythematous patches, and angular cheilitis. Oral soft tissue findings included papillary hyperplasia of the lip vermilion and velvety-red macules on the tongue, palate, and buccal mucosa. Gingival findings included advanced periodontitis and an erythematous marginal gingivitis. In all patients, orthognathic evaluation revealed a concave profile, retruded maxilla, and relative mandibular prognathism. Although previously reported clinical dental abnormalities were not present, extracted teeth demonstrated abnormal dentin. Hoarseness was present in all patients and was the earliest appearing feature in two patients. The appearance of these head and neck findings preceded the classical manifestations of tumoral calcinosis and may be helpful in the early diagnosis of this entity. The varied reported features of tumoral calcinosis support the notion that this disease may present multiple formes frustes with variable clinical expressivity.

The prevalence of oral lesions in HIV-infected homosexual and bisexual men: three San Francisco epidemiological cohorts

To establish the prevalence of HIV-related oral lesions, we performed oral examinations of members of three San Francisco epidemiological cohorts of homosexual and bisexual men over a 3-year period. Hairy leukoplakia, pseudomembranous and erythematous candidiasis, angular cheilitis, Kaposi's sarcoma, and oral ulcers were more common in HIV-infected subjects than in HIV-negative subjects. Among HIV-infected individuals, hairy leukoplakia was the most common lesion [20.4%, 95% confidence interval (CI) 17.5-23.3%] and pseudomembranous candidiasis was the next most common (5.8%, 95% CI 4.1-7.5%). Hairy leukoplakia, pseudomembranous candidiasis, angular cheilitis and Kaposi's sarcoma were significantly more common in patients with lower CD4 lymphocyte counts (P less than 0.05). The prevalence of erythematous candidiasis and Kaposi's sarcoma increased during the 3-year period. Careful oral examinations may identify infected patients and provide suggestive information concerning their immune status.

Angular cheilitis in a group of Sri Lankan adults: a clinical and microbiologic study

The relative importance of various factors in the pathogenesis of angular cheilitis in a population of Sri Lankan adults was studied. Forty-nine patients with cheilitis were examined clinically and microbiologically. Only 5 of 49 patients were full denture wearers. The clinical presentation of the lesions could be categorized as mild (Type I), moderate (Type II) or severe (Type III) and the duration of the lesions ranged from 1 month to more than 4 yr. Hematologic investigations revealed 18 patients with low hemoglobin 8 of whom had hypochromic, microcytic anaemia. Pathogenic organisms were isolated from 59% of the lesions; Candida spp. in 24 patients and Staph. aureus in 11 patients. A significant positive relationship between commissural leukoplakia and an infective etiology of angles was noted. This study confirms the multifactorial etiology of angular cheilitis while highlighting the varied clinical presentation of the lesions in an Asian population.

Melkersson-Rosenthal syndrome

The Melkersson-Rosenthal Syndrome consists of recurrent edema of the lips, intermittent facial edema and a furrowed tongue. This is the classic triad which defines the syndrome, although it is accepted that the presence of two manifestations is sufficient to make the diagnosis. Distribution is universal although the majority of the cases are described in the European literature. The case of a 37 year-old female is presented. She came to consult for persistent edema of the upper lip, of a three-year duration, which started abruptly without any clear etiologic correlation with acute episodes that disappear spontaneously or with corticoid treatment. Associated symptoms included migraine headaches which started years earlier. The complimentary examinations were normal except for a mild elevation of the sedimentary rate, and the biopsy was compatible with granulomatous cheilitis. In conclusion, MRS has to be considered as a diagnostic possibility in a patient who consulted for recurrent edema associated with other dermatologic and neurologic manifestations, although not necessarily having the complete triad.

Concurrent anomalies: cheilitis glandularis and double lip. Report of a case

Double lip and cheilitis glandularis are uncommon anomalies involving the minor salivary glands of the lip. A unique case of concurrent double lip and cheilitis glandularis is presented. The development, diagnosis, and treatment of both lesions are reviewed. Their concurrent development in this patient appears to be unrelated.

Recurrence of angular cheilitis

The incidence of recurrence of angular cheilitis following a successful antimicrobial treatment was studied in 48 patients. Clinical assessments including a microbial examination were carried out 8 months and 5 yr after termination of treatment. Eighty percent of the patients reported recurrence of their angular cheilitis on one or more occasions during the observation period. Patients with cutaneous disorders associated with dry skin or intraoral leukoplakia had an increased incidence of recrudescence. Neither the presence of denture stomatitis nor the type of microorganisms isolated from the original lesions of angular cheilitis, i.e. Candida albicans and/or Staphylococcus aureus, were associated with the number of recurrences. The present observations indicate that treatment of the majority of patients with angular cheilitis should be considered in a longer perspective than previously supposed, due to the short lasting therapeutic effects of the antimicrobial therapy.

Oral inflammatory changes as an initial manifestation of Crohn's disease antedating abdominal diagnosis. Report of a case

The case of a 14-year-old boy who had oral ulcers with histologic proof of granulomatous disease nine months before the diagnosis of intestinal Crohn's disease is presented. Additional extraintestinal manifestations of this case were cheilitis, anal fissures, and "metastatic" disease to the umbilicus. The diagnosis was established after the onset of abdominal symptoms. All manifestations responded rapidly to systemic prednisone, sulfasalazine, and metronidazole.