Sarcoidosis

Jeffrey A Burgess DDS MSD

Clinical Assistant Professor -Department of Oral Medicine
Attending - Pain Center – University of Washington Medical
Center
Director – South Sound Oral Medicine
Federal Way and Redmond
Sarcoidosis
Epidemiology
Head and Oral Manifestation
Symptoms
Mucosal Lesion Location and Quality
Aids in Diagnosis
Differential Diagnosis
Dental Treatment
Epidemiology
Case studies
Oral lesions rare, but may occur initially
Females 3:2
Racial differences
Documented cases in jaw bones rare
Salivary glands involvement (5 - 6%)
Head and Oral Manifestation
Intra Oral Lesions
Cervical Adenopathy
Jaw Bone Destruction
Sinus Pathology
Dermal lesions
Facial Palsy
Salivary Gland Abnormality
Head and Oral Manifestation
Intra Oral Lesions
 Tongue
 Buccal mucosa / vestibule

 Gingiva with periodontitis

 Abnormal healing of extraction sites

 Minor salivary glands

Head and Oral Manifestation
Blinder and coworkers
Analysis of 45 cases of sarcoidosis with oral
involvment
 12 jaw lesions
Blinder et al: Oral manifestations
 10 buccal mucosa of sarcoidosis; Oral Surg, Oral
 6 gingiva Med, Oral Pathol, Oral Radiol,
 5 lips Endod. 1997 83:458-61
 5 floor of the mouth
 4 tongue
 3 palate
In most of the cases – lesions of buccal mucosa, gingiva,
and tongue were the 1st clinical manifestation of the disease
Head and Oral Manifestation
Jaw bone destruction
 Maxilla
 Mandible including TMJ

 Premaxillary/premolar region
 Poorly defined lucency without cortical expansion
 Teeth vital

 No tooth resorption
Maxillary Osseous Lesion
Associated With Sarcoidosis

25 y/o black
female with
history of
sarcoidosis

Rubin et al: Maxillary alveolar bone loss in a

patient with sarcoidosis. J Oral Maxillofac Surg,
1991 49(12):1351-3
Osseous Lesions Associated
With Sarcoidosis
Maxillary and
mandibular anterior
radiographs. Initial
presentation top with
lysis of alveolar bone.
Bottom one year follow-
up with significant bone
regeneration post
treatment

Cohen et al: Systemic

sarcoidosis: report of two
cases with oral lesions. J
Oral Surg 1981 39(8):613-8
Head and Oral Manifestation
Sinus and Salivary Gland Destruction
 Sarcoid sinusitis

 Para nasal sinuses

 Parotid enlargement (bilateral, firm,

painless)
Salivary Gland Anatomy

•Gland type
•Serous
•Mucous
•Glands
•Parotid
•Submandibular
•Sublingual
Minor Salivary Glands

~1000 minor
glands:

•labial, lingual,
palatal, buccal

•10% volume
70% mucins
35% sIgA
Head and Oral Manifestation
Facial Palsy
 Associated with Neurosarcoidosis
 Affects the 7th cranial nerve

 Results in abnormality associated with muscles

of facial expression
 Signs include a drooping of the face on side of
involvement
Head and Oral Manifestation
Dermal lesions typically symmetric
 Lip

 Nose

 Cheeks

 Ears
Sarcoidosis – Perioral Lesions
Sarcoidosis – Lip Lesion
Sarcoidosis – Lip Lesion

28 y/o black female with asymptomatic lesion

of five months duration– slowly enlarging
Symptoms
Non-painful swelling
Denture soreness
Tongue soreness
Painful / swollen gums
Dental pain / tooth loosening
Lower jaw pain
Transient facial paralysis (facial nerve palsy)
Dry mouth / taste disturbance
Mucosal Lesion Quality
Generally: multiple firm nodules or papules,
raised with irregular borders
Palate: brownish-red, macular, slightly ulcerated,
non-tender lesions resembling abscess or tumor,
soft swelling
Tongue: broad elevated masses with indurations
Gums: papillae redness or nodular mass
Lip: erythematous raised lesion / fixed to mucosa
Nodular Lesion of Buccal
Mucosa
Erosive Papular Lesion -Tongue
Diagnosis
Labial salivary gland biopsy
Parotid biopsy
Soft tissue incisional biopsy
 Evidence of non-caseating epitheloid
granuloma; special stains to r/o infectious
disease
Biopsy and the Diagnosis of
Sarcoidosis
Cahn and coworkers
23 patients with sarcoidosis and biopsy of
normal appearing palatal tissue
38% of specimens with sarcoid granulomas
present
 Cahn LR et al: Biopsies of normal appearing palates in patients
with known sarcoidosis. Oral Surg, Oral Med, Oral Pathol, 1964,
18:324-5
Biopsy and the Diagnosis of
Sarcoidosis
Marx and coworkers
Incisional biopsies minor salivary glands/parotid
Minor gland biopsy identified sarcoidosis in 11 of
31 (36%) versus 29 of 31 (93%) with parotid
Authors conclude incisional parotid biopsy
superior to labial minor gland biopsy
 Marx R, et al: Prospective study comjparing incisional labial to incisional parotid
biopsies in the detection and confirmation of sarcoidosis, sjogren’s disease, sialosis
and lymphoma. J Rheumatol, 1988, 15:621-29
Differential Diagnosis of Oral
Lesions
Fibroma
Chronic mucocele (ranula)
Salivary gland tumor
Granular cell tumor
Schwannoma / neurofibroma
Bacterial / viral infection
Foreign body granulomas
Orofacial granulomatosis
Oral carcinoma
Dental Treatment
Depends on staging of disease
Tooth extraction
Medication
Surgical excision
Management of Secondary
Effects

Pain
Oral dryness (xerostomia)
Periodontal disease
Caries
 Effects of Oral Dryness

Caries
Glossitis,
epithelial atrophy
 Oral Candidiasis
Chronic multifocal
or erythematous type
 Management of Oral Dryness
Physical problems Management

discomfort adequate hydration with

sugarfree drinks
mucositis & atrophy
saliva substitutes
difficulty speaking  Oral Balance
decreased taste stimulate flow
 sugarfree gum, etc
 pilocarpine
(Salagen, 5 mg TID)
 Management of Oral Dryness
Infections Prevention & Treatment
candidiasis low sugar diet
dental caries adequate fluids
 cervical scrupulous home care
 incisal frequent professional care
 recurrent antifungal medications
sialadenitis fluoride - gel, toothpaste,
periodontal varnish (Duraphat, etc.)
disease Chlorhexidine / periostat
 Conclusions
Sarcoidosis is a poorly understood granulomatous
disease of uncertain etiology with limited oral
involvement
Clinical presentation varies depending on the site of
the oral lesion(s)
Salivary involvement has oral implications
Intra-oral or salivary gland biopsy may aide in
diagnosis
Symptomatic dental management of oral lesions and
dryness should be initiated if appropriate