Oral Signs of Systemic Diseases

Oral Signs of Systemic Diseases American Academy of Dermatology San Diego, California February 17, 2018

Oral Signs of Gastrointestinal Diseases Roy S. Rogers, III, M.D. Professor of Dermatology Mayo Clinic College of Medicine

Oral Signs of Systemic Diseases "The copyright for this material is held by Mayo Foundation for Medical Education and Research. All requests for reuse of this material must be requested in writing from the author and Mayo Foundation for Medical Education and Research."

Disclosure Statement Roy S. Rogers, III, MD Professor of Dermatology Mayo Clinic College of Medicine Consultancy Research grants Financial interests None None None CP1164245-2

Disclosure Statement Roy S. Rogers, III, MD Professor of Dermatology Mayo Clinic College of Medicine This presentation involves discussion of off-label use of drugs. CP1164245-2

Oral Signs of Diseases of the Gastrointestinal Tract Orofacial granulomatosis Complex aphthosis Pyostomatitis vegetans Inflammatory bowel disease Oral lichen planus Peutz-Jeghers syndrome

Orofacial Granulomatosis Practice Gaps Chronic inflammatory disorder presenting in oral and facial tissues with non-caseating granulomata. Oral lesions resemble those associated with Crohn disease both clinically and histologically in patients without GI involvement. One form is recognized as the Melkersson- Rosenthal syndrome, a trisymptom complex of orofacial edema, facial palsy and a fissured tongue. Therapy to reduce the granulomata and improve the cosmetic deformity is a problem.

Orofacial Granulomatosis Learning Objectives The learner will be able to describe the 3 components of orofacial granulomatosis (OFG) as exemplified by the Melkersson- Rosenthal syndrome. The learner will be prepared to evaluate the patient for associated non-caseating granulomatous diseases. The learner will be able to manage the condition effectively with corticosteroids and non-steroidal anti-inflammatory agents.

Orofacial Granulomatosis References, I 1. Greene RM, Rogers RS III: Melkersson- Rosenthal Syndrome : A review of 36 patients. J Am Acad Dermatol 21: 1263-1270, 1989. 2. Zimmer WM, Rogers RS III, Reeve CM, Sheridan PJ: Orofacial manifestations of Melkersson- Rosenthal syndrome. Oral Surg Oral Med Oral Pathol 74: 610-619, 1992. 3. Rogers RS III: Melkersson-Rosenthal syndrome and orofacial granulomatosis. Dermatol Clin 14: 371-379, 1996. CP1166089-51

Orofacial Granulomatosis References, II 4. Rogers RS III: Granulomatous cheilitis, Melkersson-Rosenthal syndrome, and orofacial granulomatosis. Arch Dermatol 136: 1557-1558, 2000. 5. Lynde CB, Bruce AJ, Orvidas LJ, Rogers RS III, Depry JL: Cheilitis granulomatosa treated with intralesional corticosteroids and anti-inflammatory agents. J Am Acad Dermatol 65: e101-102, 2011. CP1166089-51

Orofacial Granulomatosis References, III 6. Miest R, Bruce AJ, Rogers RS III: Orofacial granulomatosis. Clin Dermatol 34:505-513, 2016. 7. Miest RY, Bruce AJ, Comfere NI, et al: A diagnostic approach to recurrent orofacial swelling: A retrospective review of 104 patients. Mayo Clin Proc 2017; 92:1053-1060. CP1166089-51

Orofacial Granulomatosis Definition Oral lesions resembling oral Crohn disease both clinically and histologically in patients without GI involvement Biopsies of oral mucosa show noncaseating granulomas CP1166089-4

Oral Crohn Disease CP1164271-28

Dramatic Oral Diseases Orofacial granulomatosis Chronic inflammatory disorder presenting in oral and facial tissues May be associated with chronic granulomatous diseases (secondary OFG) or may remain idiopathic (primary OFG) CP1166089-2

Orofacial Granulomatosis Primary Conditions Melkersson-Rosenthal syndrome Miescher s cheilitis granulomatosa Monosymptomatic MRS Oligosymptomatic MRS CP1166089-6

Orofacial Granulomatosis Secondary Conditions Sarcoidosis Atopic diathesis Food allergies Tooth root abscess Inflammatory bowel disease Solid facial edema CP1166089-6

Orofacial Granulomatosis Evaluation Biopsy of oral lesion Exclude Crohn disease Exclude sarcoidosis Careful dental evaluation Patch testing (cinnamaldehyde, food coloring) CP1166089-10

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Melkersson-Rosenthal Syndrome Introduction 3 cardinal features Recurrent orofacial swelling Intermittent facial nerve palsy Lingua plicata CP1166089-12

Melkersson-Rosenthal Syndrome History 1928 Melkersson described 35-yr-old woman with facial edema and facial nerve palsy 1932 Rosenthal added lingua plicata 1949 Triad called Melkersson- Rosenthal syndrome CP1166089-13

Melkersson-Rosenthal Syndrome General Information Rare disorder with equal gender distribution No racial predilection More common in women in early adult life Complete triad 18-70% of cases 1 st appearance of symptoms in 2 nd decade CP1166089-14

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Gingival MRS/OFG

Melkersson-Rosenthal Syndrome Clinical Features: Summary Facial palsy Present in 17/36 patients initial symptom 14/36 Bilateral 3 Loss of taste on anterior 2/3 of tongue 2 CP1166089-37

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Melkersson-Rosenthal Syndrome Clinical Features: Summary Lingua plicata Present in 18/36 patients initial symptom 3/36 Positive family history 1 CP1166089-40

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Melkersson-Rosenthal Syndrome Cheilitis Granulomatosa of Miescher Monosymptomatic form of Melkersson- Rosenthal syndrome localized lip lesion Oligosymptomatic form combines any 2 features of classic triad CP1166089-43

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Melkersson-Rosenthal Syndrome Summary Rare disorder of unknown etiology Orofacial edema Characterized by fissured, reddish brown, swollen, nonpruritic lips Facial paralysis Indistinguishable from Bell s palsy Exacerbations and recurrences common CP1166089-49

Melkersson-Rosenthal Syndrome Summary Lingua plicata uncommon component of syndrome but if present aids in Dx Dx difficult because triad often not present simultaneously Always consider syndrome in differential Dx orofacial edema CP1166089-50

Melkersson-Rosenthal Syndrome Summary MRS/OFG is a rare and enigmatic condition Most patients present with a mono- or oligosymptomatic form of MRS There appears to be a relationship between the OFG and gingival pathology Association with Crohn disease is uncommon CP1166089-50

Orofacial Granulomatosis: Relationship to Crohn Disease Three entities: 1. Classical oral CD (GI involvement) 2. OFG with GI involvement (subclinical/ asx/endoscopic only) 3. OFG without bowel involvement Sanderson, et al 2005 CP1166089-10

Melkersson-Rosenthal Syndrome Treatment Modalities Orofacial swelling Intralesional corticosteroids (5-10 mg/ml diluted with lidocaine) Systemic corticosteroids Dapsone Sulfapyridine Other antibiotics Cheiloplastic procedure followed by intralesional corticosteroids and oral antibiotics CP1166089-51

Melkersson-Rosenthal Syndrome Treatment Modalities Orofacial swelling 26/28 recent patients had an excellent response to systemic corticosteroids Dapsone is beneficial in maintaining a remission in 80% of patients Intralesional corticosteroids are also important in gaining and maintaining a remission TNF-alpha inhibitors improve OFG manifestations of patients with Crohn s disease CP1166089-51

Oral Signs of Diseases of the Gastrointestinal Tract Orofacial granulomatosis Complex aphthosis Pyostomatitis vegetans Inflammatory bowel disease Oral lichen planus Peutz-Jeghers syndrome

Recurrent Aphthous Stomatitis CLASSIFICATION Simple vs Complex Aphthosis

Recurrent Aphthous Stomatitis Simple Aphthosis Term introduced by Rogers in 1992* Describes patient presentation with RAS in the absence of severe or continuous oral ulcerations, and in the absence of Behcet disease Includes the vast majority of sufferers of RAS Includes 20-50% of the population 5-25 years of age *Postgrad Med 1992;91:141. CP1164271-7

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Complex Aphthosis Concept introduced by Jorizzo et al in 1984 Describes patient presentation of recurrent oral and genital aphthous ulcers or almost constant, multiple oral aphthae, in the absence of Behcet disease Complex aphthosis is a small subset of recurrent aphthous stomatitis (RAS) CP1164271-9

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Vulvar Aphthosis CP1175036-32

Complex Aphthosis The clinician should seek associated conditions in all patients with complex aphthosis 2 of 3 patients have correctable causes for their complex aphthosis condition

Complex Aphthosis Associated Diseases Nutritional deficiencies H. pylori gastritis Chronic ulcerative colitis; Crohn disease Gluten-sensitive enteropathy CP1164271-20

Aphthosis in Pernicious Anemia CP1185684-13

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Complex Aphthosis Hematologic Screening CBC Serum ferritin or iron Zinc Serum or RBC folate Serum vitamin B1, B2, B6 & B 12 CP1164271-53

Complex Aphthosis Hematologic Screening & Response to Therapy in 3 Months Author Year No. % Hutcheon et al 1978 34/39 87.2 Challacombe et al 1978 14/36 38.8 Rogers and Hutton 1986 21/28 75.0 Total 69/103 67.0 CP1164271-51

Hematologic Status in Recurrent Aphthous Stomatitis Compared with Other Oral Disease S. R. Porter, BSc, BDS, FDS, PhD, C. Scully, BSc, BDS, MD, FDS, PhD, MRCPath, and S. Flint, BDS, MBBS, FDS, Bristol, England University Department of Oral Medicine, Surgery, and Pathology, Bristol Dental Hospital and School The hematologic status of 144 consecutive patients in the United Kingdom with oral disease (69 with recurrent aphthous stomatitis; 75 with other disorders) was examined in an attempt to resolve the controversy as to whether levels of hemoglobin, blood cell numbers and indices, and blood film are adequate in the screening of patients with aphthae. Though hemoglobin levels and red blood cell indices were normal in patients with recurrent aphthous stomatitis, there was still a small minority of patients with deficiencies of iron (low serum ferritin), folate (low red blood cell levels), or vitamin B 12 (low serum levels) that would have remained undetected. Full hematologic screening of patients with recurrent aphthous stomatitis thus reveals latent deficiency states, at least in some parts of the world, and there are good reasons for elucidating the underlying cause and correcting these deficiencies, particularly vitamin B 12 deficiency. Therapeutic studies are now required to establish the frequency with which deficiencies actually predispose to recurrent aphthous stomatitis. Oral Surg Oral Med Oral Pathol 1988;66:41-4 CP1175030-111

Recurrent Aphthous Ulceration: Vitamin B1, B2 and B6 Status and Response to Replacement Therapy Nolan A, McIntosh WB, Allam BF, Lamey P-J: Recurrent aphthous ulceration: Vitamin B1, B2 and B6 status and response to replacement therapy. J Oral Pathol Med 1991; 20:389-91 An evaluation of the thiamine, riboflavin and pyridoxine (vitamin B1, B2 and B6) status of 60 patients with recurrent mouth ulcers was performed. Seventeen patients (28.2%) were found to be deficient in one or more of these vitamins. Replacement therapy of these vitamins was given to a study group of deficient patients and a non-deficient group for one month. At the end of therapy and after a follow-up period of 3 months, only those patients who had a B complex deficiency had a significant sustained clinical improvement in their mouth ulcers. Vitamin B1, B2 and B6 deficiencies should, therefore, be considered as another possible precipitating factor in recurrent aphthous ulceration. A. Nolan, W. B. McIntosh, B. F. Allam and P-J. Lamey Department of Oral Medicine and Pathology. Glasgow Dental Hospital and School and Department of Biochemistry, Stobhill Hospital, Glasgow, Scotland Key words: aphthae; mouth, diseases; ulcerations, recurrent aphthous; vitamin B. A. Nolan, University Department of Oral Medicine and Pathology, Glasgow Dental Hospital and School, Glasgow G2 3JZ, Scotland Accepted for publication April 7, 1991 CP1175030-112

Complex Aphthosis Associated Diseases Nutritional deficiencies H. pylori gastritis Chronic ulcerative colitis; Crohn disease Gluten-sensitive enteropathy CP1164271-20

Complex Aphthosis Antibiotics & H. pylori gastritis Recent study found increased levels of Vitamin B12 and decreased number of aphthous ulcers after eradication of H. pylori J Oral Pathol Med 42: 89-94, 2013. CP1164271-45

Complex Aphthosis Associated Diseases Nutritional deficiencies H. Pylori gastritis Chronic ulcerative colitis; Crohn disease Gluten-sensitive enteropathy CP1164271-20

Major Aphthous Ulcers with Crohn s Disease CP1175030-22

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Complex Aphthosis Associated Diseases Nutritional deficiencies H. Pylori gastritis Chronic ulcerative colitis; Crohn disease Gluten-sensitive enteropathy CP1164271-20

Aphthous Stomatitis with Sprue CP1175036-40

Complex Aphthosis Prevalence of Associated Celiac Disease No. % Ferguson et al BMJ 1:11, 1975 8/33 24 Wray et al BMJ 2:490, 1975 5/130 4 Wray et al JOP 7:418, 1978 12/330 4 Ferguson et al Gut 21:223, 1980 2/50 4 Tyldesley BDJ 151:81, 1981 6/97 6 CP1185684-4

Recurrent Aphthous Stomatitis References 1. Hutton KP, Rogers RS III: Recurrent aphthous stomatitis. Dermatol Clin 5:761-768, 1987. 2. Rogers RS III: Recurrent aphthous stomatitis: clinical characteristics and associated systemic disorders. Sem Cutan Med Surg 16: 278-283, 1997. 3. Rogers RS III: Complex aphthosis. Adv Exp Biol Med 528: 311-316, 2003.

Recurrent Aphthous Stomatitis References 4. Baccaglini L, Lalla RV, Bruce AJ, Sartori- Valinotti JC, Latortue MC, Carrozzo M, Rogers RS III : Urban Legends: Recurrent Aphthous Stomatitis. Oral Dis Nov 17: 755-770, 2011. 5. Lynde CB, Bruce, AJ, Rogers, RS III: Successful treatment of complex aphthosis with colchicine and dapsone. Arch Dermatol 145:273-276, 2009.

Recurrent Aphthous Stomatitis References, III 6. Lehman JL, Rogers RS III: Acute oral ulcers. Clin Dermatol 34: 470-474, 2016. 7. Cui RZ, Bruce AJ, Rogers RS III: Recurrent aphthous stomatitis. Clin Dermatol 34: 475-481, 2016. 8. Ali NS, Sartori-Valinotti JC, Bruce AJ: Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome. Clin Dermatol 34: 482-486, 2016.

Oral Signs of Diseases of the Gastrointestinal Tract Orofacial granulomatosis Complex aphthosis Pyostomatitis vegetans Inflammatory bowel disease Oral lichen planus Peutz-Jeghers syndrome

Pyostomatitis Vegetans CP1166089-53

Pyostomatitis Vegetans Described by McCarthy in 1949 Related to pyodermite végétante (Hallopeau) Pustular and vegetating eruption of oral mucosa and lips Mucosal marker for inflammatory bowel disease CP1166089-54

Pyostomatitis Vegetans Oral Lesions Buccal, gingival, labial, and sulcular mucosa favored Any oral surface may be involved; dorsum of tongue usually spared Pain is not prominent CP1166089-55

Pyostomatitis Vegetans Oral Lesions Elemental lesion is a 2- to 5-mm pustule on an erythematous base Lesions coalesce into plaques and become vegetating ( snail track ) Later, verrucous or cobblestone tissue changes develop CP1166089-56

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Pyostomatitis Vegetans Oral Lesions 25% of patients with pyostomatitis vegetans have undiagnosed IBD The clever clinician can establish the cause of the condition CP1166089-55

Pyostomatitis Vegetans References McCarthy FP: Arch Dermatol 60:750, 1949 McCarthy P and Shklar G: Arch Dermatol 88:913, 1963 Van Hale H et al: Arch Dermatol 121:94, 1985 Ballo FS et al: J Am Acad Dermatol 21:381, 1989 Ayangco L et al: J Periodontol 73:1512, 2002 Hegarty AM et al: Clin Exp Dermatol 29:1, 2004 CP1166089-68

Pyostomatitis Vegetans References Pyostomatitis vegetans-pyodermatitis vegetans: A clinicopathologic study of 7 cases at a tertiary referral center. Clark LG, Tolkachjov SN, Bridges AG, Camilleri MJ J Am Acad Dermatol 2016; 75: 578-584. Adds primary sclerosing cholangitis to inflammatory bowel disease as associations Confirms peripheral & tissue eosinophilia CP1166089-68

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Oral Signs of Diseases of the Gastrointestinal Tract Orofacial granulomatosis Complex aphthosis Pyostomatitis vegetans Inflammatory bowel disease Oral lichen planus Peutz-Jeghers syndrome

Inflammatory Bowel Disease Inappropriate inflammatory response to intestinal microbes in a susceptible host Bimodal prevalence: youth and late middle-age Half of IBD sufferers have extra-intestinal manifestations Those with CD have more oral manifestations

Inflammatory Bowel Disease Ulcerative Colitis More common in Europe than N. America Large bowel & rectum 24% probability of colectomy in 10 years Increased likelihood of colorectal cancer

Inflammatory Bowel Disease Ulcerative Colitis Stomatitis Glossitis Cheilitis Complex aphthosis Pyostomatitis vegetans

Inflammatory Bowel Disease Crohn Disease Young males > females 10% have oral lesions Oral lesion activity often synchronous with disease activity Gut involvement is discontinous and transmural Perianal fistulas in 20% in 20 years

Inflammatory Bowel Disease Crohn Disease Complex aphthosis Pyostomatitis vegetans Orofacial swelling Orofacial granulomatosis Mucosal nodularity (cobblestoning) Mucogingivitis Deep linear sulcular ulcers Mucosal tags Oral Crohn disease

Oral Crohn Disease CP1164271-28

Inflammatory Bowel Disease Boirivant M, Cossu A: Invited Review: Inflammatory Bowel Disease. Oral Dis 2012; 18:1-15.

Oral Signs of Diseases of the Gastrointestinal Tract Orofacial granulomatosis Complex aphthosis Pyostomatitis vegetans Inflammatory bowel disease Oral lichen planus Peutz-Jeghers syndrome

Oral Lichen Planus Practice Gaps Very common (2%) and underdiagnosed condition. Lesions of oral lichen planus may be premalignant. Lesions of oral lichen planus may be part of a multisite, autoimmune condition involving skin, genitalia, oral, ocular, esophageal mucosae, and nails.

Oral Lichen Planus Lesions of oral lichen planus may be part of a multisite, autoimmune condition involving skin, genitalia, oral, ocular, esophageal mucosae, and nails. Lesions of oral lichen planus may occur in patients with hepatitis C infection.

Extraoral Manifestations of Oral Lichen Planus No. % Patients 584 100 Cutaneous 93 16 Scalp 6 1 Nails 11 2 Vulvovaginal 77/399 19 Male genitalia 8/174 5 Esophagus 4 <1 Ocular 1 <1 Multiple sites simultaneously 33 6 Eisen, 2002 CP1156367-6

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Oral Lichen Planus Hepatitis C Virus Associations Hepatitis C virus (HCV) infections are a global health problem Lichen planus has been associated with HCV infection Recent meta-analysis found a large regional correlation with the Middle East, Southeast Asia and Mediterranean countries HCV patients have an increased risk for developing LP and LP patients have an increased risk of having HCV infection

Oral Lichen Planus HCV Infection and OLP Three recent meta-analyses provide strong evidence of an association in all regions of the world The odds ratio is 2.8-5.4 The risk of cutaneous LP is greater than OLP (10.2 to 5.4) HCV might be associated with the pathogenesis of OLP

Oral Lichen Planus HCV Infection Screening For screening to be valuable, we would need evidence that it would identify undiagnosed cases and that the knowledge would prevent spread or improve health of the OLP patient Estimate prevalence of HCV with LP as 4% in Europe and 24% in the Middle East Screening value increased in high risk patients (IDU, sex with IV drug users, HX blood transfusion, male gender, age 30-49) Practical approach is to take a HX for risk factors and test those persons

Oral Lichen Planus References 1. Rogers RS III, Eisen D: Erosive oral lichen planus with genital lesions. Dermatol Clin 21: 91-98, 2003. 2. Eisen D: The clinical features, malignant potential and systemic associations of oral lichen planus. A study of 723 patients. JAAD 46: 267-214, 2002. 3. Fox LP, et al: Lichen planus of the esophagus. JAAD 65: 175-180, 2011. 4.Shengyuan L, et al: Hepatitis C virus and lichen planus: a reciprocal association determined by a meta-analysis. Arch Dermatol 145: 1040-1047, 2009.

Oral Signs of Diseases of the Gastrointestinal Tract Orofacial granulomatosis Complex aphthosis Pyostomatitis vegetans Inflammatory bowel disease Oral lichen planus Peutz-Jeghers syndrome

Peutz-Jeghers Syndrome Syndrome of mucocutaneous pigmentation and GI polyposis Autosomal dominant genodermatosis Presents in infancy: usually diagnosed in 3 rd decade b/o failure to recognize oral manifestations

Peutz-Jeghers Syndrome Cutaneous lesions may fade but oral lesions persist Early diagnosis permits proper management of potentially malignant transformation of intestinal polyps and evaluation for other cancers

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Oral Signs of Diseases of the Gastrointestinal Tract Orofacial granulomatosis Complex aphthosis Pyostomatitis vegetans Inflammatory bowel disease Oral lichen planus Peutz-Jeghers syndrome

Cutaneous Manifestations of Gastrointestinal Disease JAAD CME review articles. Shah KR, et al. Part I: J Amer Acad Dermatol 2013; 68:189-210. Thrash B, et al. Part II: J Amer Acad Dermatol 2013; 68:211-246.

Oral Dermatology Clinics in Dermatology Volume 34, Number 4, July/August, 2016 Oral Dermatology, Part I Guest Editors: Roy S. Rogers, III, MD and Nasim Fazel, MD, DDS

Oral Dermatology Clinics in Dermatology Volume 35, Number 5 September/ October, 2017 Oral Dermatology, Part II Guest Editors: Roy S. Rogers, III, MD and Nasim Fazel, MD, DDS

Oral Dermatology CME Review Article in JAAD, 2017 Cizenski JD, Watson I, Frieder J, Wilder EG, Wright JM, Menter A: Spectrum of orocutaneous associations. J Am Acad Dermatol 2017; 77: 795-806 & 809-830.

Oral Signs of Gastrointestinal Diseases Roy S. Rogers, III, M.D. Professor of Dermatology Mayo Clinic College of Medicine