Oral Examination: An Important Adjunct to the Diagnosis of Dermatological Disorders

Authors: Sanjay Saraf

Abstract:

The oral cavity can be the site for early manifestations of mucocutaneous disorders (MD) or the only site for occurrence of these disorders. It can also exhibit oral lesions with simultaneous associated skin lesions. The MD involving the oral mucosa commonly presents with signs such as ulcers, vesicles and bullae. The unique environment of the oral cavity may modify these signs of the disease, thereby making the clinical diagnosis an arduous task. In addition to the unique environment of oral cavity, the overlapping of the signs of various mucocutaneous disorders, also makes the clinical diagnosis more intricate. The aim of this review is to present the oral signs of dermatological disorders having common oral involvement and emphasize their   importance in   early detection of the systemic disorders. The aim is also to highlight the necessity of oral examination by a dermatologist while examining the skin lesions. Prior to the oral examination, it must be imperative for the dermatologists and the dental clinicians to have the knowledge of oral anatomy. It is also important to know the impact of various diseases on oral mucosa, and the characteristic features of various oral mucocutaneous lesions. An initial clinical oral examination is may help in the early diagnosis of the MD. Failure to identify the oral manifestations may reduce the likelihood of early treatment and lead to more serious problems. This paper reviews the oral manifestations of immune mediated dermatological disorders with common oral manifestations.

Keywords: Vesiculobullous lesions, Desquamative gingivitis, Nikolsky’s sign, Erythema.

Digital Object Identifier (DOI): doi.org/10.5281/zenodo.1123765

References:

[1] Willberg J, Valimaa H, Gursoy M, Kononen E. Diagnostics of oral mucosae. Nor Tannlegeforen Tid.2015; 125:120-33.
[2] Berkovitz BKB, Holland GR, Moxham BJ. Oral Anatomy, Histology and Embryology.4th Ed. Edinburgh: Mosby Elsevier, 2009.
[3] Scully C, Porter SR. Mouth and Skin. In: Verbov J, (ed). New Clinical Applications in Dermatology: Relationship in Dermatology. UK: Kluwer Academic Publishers; 1998. p. 1-33.
[4] Gartner LP. Oral anatomy and tissue types. Semin Dermatol.1994; 13(2):68-73.
[5] Hovav A-H. Dendritic cells of the oral mucosa. Mucosal Immunology. 2014; 7: 27-37.
[6] Sollecito TP and Stoopler ET. Clinical approaches to oral mucosal disorders. Dent Clin N Am.2013 ix-xi.
[7] Howell FV. Oral mucous membrane lesions. California medicine.1964; 100(3):186-91.
[8] Mustafa MB, Porter SR, Smoller BR and Sitaru C. Oral mucosal manifestations of autoimmune diseases. Autoimmunity Reviews.2015; 14:930-951.
[9] Ramirez-Amador VA, Esquivel-Pedraza L, Orozco-Topte R. Frequency of oral conditions in a dermatology clinic. International Journal of Dermatology.2000; 39:501-5.
[10] Rinaggio J, David M Crossland, Mohamed Y Zeid. A determination of the range of oral conditions submitted for microscopic and direct immunofluorescence analysis. J. Periodontol., 2007; 78: 1904-1910
[11] Scully C, Georgela S. Mucocutaneous disorders. Periodontology 2000, 1998, 18: 81-94.
[12] Goncalves LM, Nogueira da Cruz MCF Junior JRSB. Clinical evaluation of oral lesions associated with dermatologic diseases. Ann Bras Dematol.2009; 84(6):585-92.
[13] Nikitakis NG. Oral soft tissue lesions: A guide to differential diagnosis Part II: Surface alterations. Braz J Oral Sci.2005;4(13):707-715.
[14] Goyal V, Singla R. A clinical and histopathological study on the oral mucosal lesions in common dermatological disorders. Journal of Clinical and Diagnostic Research.2011; 5:1578-1581. Available at: http://www.jcdr.net/back_issues.asp?issn=0973-709x&year=2011&month=December&volume=5&issue=8&page=1578-1581&id=1731
[15] Rameshkumar A, Varghese AK, Dineshkumar T, Ahmed S, Venkatramani J, Sugirtharaj G. Oral mucocutaneous lesions - a comparative clinicopathological and immunofluorescence study. J Int Oral Health. 2015; 7(3):59-63.
[16] Arisawa EAL, Almeida JD, Carvalho YR and Cabral LAG. Clinicopathological analysis of oral mucous autoimmune disease: A 27-Year study. Med Oral Patol Oral Cir Bucal. 2008; 13(2):E94-7.
[17] Suliman NM, Astrom AN, Ali RW, Salman H, Johannessen AC. Oral mucosa lesions in skin diseases patients attending a dermatologic clinic: A cross-sectional study in Sudan. BMC Oral Health. 2011,11:24.
[18] 18.Boorghani M, Gholizadeh N, Zenouz AT, Vatankhah M, Mehdipour M. Oral lichen planus: Clinical features, etiology, treatment and management; A Review of literature. JDent Res Dent Clin Dent prospect. 2010;4(1):3-9.
[19] Edwards CP, Kelsch R. Oral lichen planus: Clinical presentation and management. J Can Dent Assoc.2002; 68(8):494-9.
[20] Farzam Gorouhi, Parastoo Davari, and Nasim Fazel, “Cutaneous and Mucosal Lichen Planus: A Comprehensive Review of Clinical Subtypes, Risk Factors, Diagnosis, and Prognosis,” The Scientific World Journal, vol. 2014, Article ID 742826, 22 pages, 2014. doi:10.1155/2014/742826.
[21] Shirasun K. Oral lichen planus: Malignant potential and diagnosis. Oral science international. 2014; 11(1): 1–7.
[22] Lavanya N, Jayanthi P, Rao UK, Ranganathan K. Oral lichen planus: An update on pathogenesis and treatment. J Oral Maxillofac Pathol. 2011; 15(2):127-32.
[23] Ustaine RP. Diagnosis and treatment of lichen planus. Am Fam Physician. 2011;84(1):53-60.
[24] Sugerman PB and Savage NW. Oral lichen planus: Causes, diagnosis and management. Australian dental journal.2002;47(4):290-297.
[25] Schifter M, Yeoh S-C, Coleman H, Georgiou. Oral mucosal diseases: The inflammatory dermatoses. Australian dental Journal. 2010; 55(1 supp):23-38.
[26] Stoopler ET, Sollecito TP, De Rossi SS. Desquamative gingivitis: Early presenting symptom of mucocutaneous disease. Quintessence International. 2003;34(8):582-586.
[27] 27.Schlosser BJ. Lichen planus and lichenoid reactions of the oral mucosa. Dermatologic therapy.2010; 23 :251-267.
[28] Radochová V, Dřízhal I, Slezák R. A retrospective study of 171 patients with oral lichen planus in the East Bohemia - Czech Republic – single center experience. J Clin Exp Dent. 2014; 6(5):e556-61.
[29] Bornstein MM, Kalas L, Lemp S, Altermatt HJ, Rees TD, Buser D. Oral lichen planus and malignant transformation: a retrospective follow-up study of clinical and histopathological data. Quintessence int. 2006; 37:261-271.
[30] Gondello S, Richiardii L, Carrozo M, Broccoletti R, Carbone M, Pagano M et al. Risk of oral squamous cell carcinoma in 402 patients with oral lichen planus: a follow up study in Italian population. oral oncol 2004; 40:77-83.
[31] Schlosser BJ. Lichen planus and lichenoid reactions of the oral mucosa. Dermatol Ther. 2010; 23(3):251-67.
[32] Scully C, Challacombe SJ. Pemphigus vulgaris: Update on etiopathogenesis, oral manifestations and Management. Crit Rev Oral Biol, Med. 2002;13(5):397-408.
[33] Shiezadeh F, Khadem SS, Golshan A, Mohammadipour HS, Soufizadeh R, Forouzanfar A. Pemphigus vulgaris that was misdiagnosed as diffused gingivitis, a case report and review. American Journal of Oral Medicine and Radiology.2015; 2(4):195-198.
[34] Sangeetha S, Victor DJ. The molecular aspects of oral mucocutaneous diseases: a review. International journal of genetics and molecular biology. 2011; 3(10):141-148.
[35] Chan PT. Review on pathogenesis of pemphigus. Hong Kong Dermatology & Venerology bulletin. 2002; 2(10):62-68.
[36] Budimir J, Mihic LL, Situm M, Bulat V, Persic S, Tomljanovic-Veselski M. Oral lesions in patients with pemphigus vulgaris and bullous pemphigoid. ActaClin Croat. 2008; (47):13-18.
[37] Diana Kuriachan, Rakesh Suresh, Mahija Janardhanan, and Vindhya Savithri, “Oral Lesions: The Clue to Diagnosis of Pemphigus Vulgaris,” Case Reports in Dentistry, vol. 2015, Article ID 593940, 3 pages, 2015. doi:10.1155/2015/593940.
[38] Neville BD, Damm DD, Allen MC, Bouquot JE. Oral and maxillofacial pathology. 3rd Edition. Philadelphia. Saunders Elsevier; 2011.
[39] Fassmann A, Dvorakova N, Holla IL, Vanek J, Wotke J. Manifestation of pemphigus vulgaris in the orofacial region: Case report. Scripta Medica (BRNO). 2003;76(1):55-62.
[40] Robinson NA, Wray D. Desquamative gingivitis; A sign of mucocutaneous disorders-A review. Australian Dental Journal.2002; 48 (4):206-211.
[41] Gardner, A. F. Differential oral diagnosis in systemic disease. Bristol: Wright. (1970).
[42] Sciubba JJ. Autoimmune aspects of pemphigus vulgaris and mucosal pemphigoid. Adv Dent Res. 1996;10(1):52-6.
[43] Dagistan S, Goregen M, Miloglu, Cakur B. Oral pemphigus vulgaris: a Case report with review of literature. Journal of Oral Science 2008; 50(3):359-362.
[44] Lamoreuk MR, Sternbach MR, Teresa HSU W. Erythema multiforme. AmFam Physician.2006; 74(11)1883-1888.
[45] Popper HA and Greer RO. Pemphigus vulgaris: Primary oral presentation with differential diagnositic guidelines. the international journal of periodontics and restorative dentistry. Int J Periodontics Restorative Dent. 1982;2(2):46-53.
[46] Ata-Ali F, Ata-Ali J. Pemphigus vulgaris and mucous membrane pemphigoid: Update on etiopathogenesis, oral manifestations and management. JClinExp Dent.2011,3 (3):e246-50.
[47] Darling MR, Daley T. Blistering Mucocutaneous diseases of the oral mucosa-a review part I. Mucous membrane pemphigoid. JCDA. 2006, 71(11); 851-854.
[48] Bascones-martinez A, Meurman JH. Immune-mediated diseases: What can be found in the oral cavity? Int J Dermatol.2015; 54(3):258-70.
[49] Bagan J, Muzio Ll, Scully C. Mucosal disease series: Mucous membrane pemphigoid. Number III. Oral diseases.2005;11:197-218.
[50] Sara Babu S, Sunil S, Pratap A, Mathew AL. Mucous membrane pemphigoid. Oral and maxillofacial pathology journal. 2016;7(1):702-705.
[51] Ajjappa BG, Prakash S, Nagur, Karibasappa PN. Desquamative gingivitis in mucous membrane pemphigoid: A rare case report. 2013;3: 117-20.
[52] Osterne RLV, Brito RGDM, Pacheco IA, Alves ANPNN, Sousa FB. Management of erythema multiforme associated with recurrent herpes infection: A case report. JCDA.2009; 75(8):597-601.
[53] Intong LRA, Daniel BS, Murrell D. Erythema Multiforme, Steven-Johnsons syndrome, and Toxic epidermal necrolysis. In: Dedee Murrell, (ed). Blistering diseases: Clinical Features, Pathogenesis, Treatment. Verlag Berlin Heidelberg: Springer; 2015. p. 319-325.
[54] Sokumbi O, Wetter DA. Clinical features, diagnosis and treatment of erythema multiforme: A review for the practicing dermatologist. International Journal of Dermatology.2012; 51: 889-902.
[55] Kempton J, Wright JM, Kerins C, Hale D. Misdiagnosis of erythema multiforme: a literature review and case report. Pediatr Dent. 2012 Jul-Aug; 34(4):337-42.
[56] Farthing P, Bagan J-V, Scully C. Mucosal disease series Number IV: Erythema multiforme. Oral Diseases.2005; 11 :261-267.
[57] Joseph TI, Vergheese G, George D, Sathvan P. Drug induced oral erythema multiforme: A rare and less recognised variant of erythema multiforme. J Oral maxillofac pathol.2012; 169101:145-148.
[58] Avangco L, Rogers RS. Oral manifestations of erythema multiforme. Dermatologic Clinics.2003; 21(1):195-205.
[59] Lopez-Labady J, Villarroel-Dorrego M, Gonzalez N, Perez R, Mata de Henning M. Oral manifestations of systemic and cutaneous lupus erythematosus in a venuzuelan population. Journal of oral pathol med. 2007; 36:524-7.
[60] Crowson NA, Magro C. The cutaneous pathology of lupus erythematosus: A review. J Cutanpathol. 2001;28 :1-23.
[61] Simoes DM, Fava M, Figueiredo MA, Salum FG and Cherubini K. Oral manifestations of lupus erythematosus – report of two cases. Gerodontology. 2013; 30:303-308
[62] Jacobson DL, Gange SJ, Rose NR, Graham NM. Epidemiology and estimated population burden of selected autoimmune diseases in the United States. Clin Immunol Immunopathol. 1997, 84; (3): 223-243.
[63] Leite CA, Galera MF, Espinosa M, et al. Cristhiane Almeida Leite, Marcial Francis Galera, Mariano Martínez Espinosa, et al., “Prevalence of Hyposalivation in Patients with Systemic Lupus Erythematosus in a Brazilian Subpopulation,” International Journal of Rheumatology, vol. 2015, Article ID 730285, 6 pages, 2015. doi:10.1155/2015/730285.
[64] Albilia JB, Clokie CML, Sandor GKB. Systemic lupus erythematosus: A review for dentists. JCDA.2001;73(9):823-828
[65] Nico MM, Vilela MA, Rivitti EA, Lourenco SV. Oral lesions in lupus erythematosus: correlation with cutaneous lesions. Eur J Dermatol. 2008; 18(4):376-8.