Estomatitis Asociada a Metotrexato: Un Reto Diagnóstico / Methotrexate Associated Stomatitis: A Diagnostic Challenge

RESUMEN: Las úlceras orales (UO) son uno de los signos de toxicidad por metotrexato (Mtx) aún en pacientes con esquemas de dosis bajas para el control de artritis reumatoide (AR). En estos casos establecer un diagnóstico correlacionando UO con el medicamento puede ser un reto. Presentamos 2 casos clínicos de pacientes con AR en tratamiento con Mtx, las cuales desarrollaron UO. En los dos casos, interesantemente los pacientes fueron evaluados tanto por especialistas del área médica y oral sin tener un resultado satisfactorio después de múltiples tratamientos. Las UO resolvieron posterior a la suspensión del medicamento. Se estableció el diagnóstico de Estomatitis por Metotrexato (EMtx) por un especialista en medicina oral. El manejo multidisciplinario en estos casos es clave para el establecimiento de un diagnóstico y tratamiento oportuno.

ABSTRACT: Oral ulcers (OU) are a sign of methotrexate (Mtx) toxicity, even in patients with rheumatoid arthritis (RA) that are under a low-dose regime. In those cases, establishing a diagnosis correlating OU with the medication can be quite a challenge. Here we present 2 clinical cases of RA patients under Mtx treatment that developed OU. Interestingly, in both cases the patients were evaluated by two specialists in the medical and dentistry area, and following multiple treatments there was no satisfactory result. However, oral ulcers resolved after stopping the treatment. A diagnosis of Metotrexato stomatitis was established (SMtx) by a specialist in oral medicine. Multidisciplinary management in these cases is key for the establishment of an opportune diagnosis and treatment.

Ulceración por trauma crónico: una lesión simuladora. Informe de un caso clínico / Oral traumatic ulceration: a mimic lesion. Report of a case

Objetivo: Describir la importancia del reconocimiento oportuno del trauma crónico de la mucosa bucal producido por un elemento dentario que generó una lesión erróneamente diagnosticada como neoplasia maligna. Caso clínico: Una paciente de sexo femenino, de 79 años de edad, realizó una consulta estomatológica por una lesión lingual con un diagnóstico presuntivo de cáncer. Tras la inspección de la cavidad bucal y el estudio anatomopatológico se diagnosticó úlcera asociada a trauma dentario. La intervención terapéutica odontológica (eliminación del trauma) resolvió el cuadro cínico. Conclusión: El trauma crónico en la mucosa bucal puede generar lesiones sobre mucosa sana o bien complicar una patología preexistente. En el presente caso, la inspección de la cavidad bucal con la identificación y la eliminación del trauma lograron la reparación de la lesión. El estudio anatomopatológico precisó el diagnóstico de ulceración asociada a trauma dentario (AU)

Aim: The aim of this case report is to show the importance of the early diagnosis of a traumatic lesion of the oral mucosa arising from a posterior broken tooth that was initially misdiagnosed as oral cancer. Case report: A 79-year-old female attends an appointment with the oral medicine specialist for a lesion on the lateral side of the tongue with a presumptive diagnosis of oral cancer. The examination of the oral cavity and the anatomopathological diagnosis confirmed the presence of an ulcer associated with dental trauma. The lesion healed completely with the elimination of the trauma. Conclusion: Chronic trauma in the oral cavity can produce lesions in the oral mucosa or exacerbate preexisting lesions. In this case report a thorough oral examination showed a broken tooth as the cause of trauma and after its removal the lesion healed completely. The result of the biopsy confirmed the diagnosis of an oral ulcer associated with dental trauma (AU)

Manifestación oral del pénfigo vulgar. Reporte de un caso / Oral manifestation of vulgar pemphigus. A case report

RESUMEN El pénfigo es una enfermedad autoinmune potencialmente mortal, que causa ampollas y erosiones en la piel y en la membrana mucosa. Las lesiones epiteliales son el resultado de autoanticuerpos que reaccionan con las glicoproteínas desmosomales y están presentes en la superficie celular del queratinocito. La reacción autoinmune contra estas glicoproteínas causa una pérdida de adhesión celular, resultando en la formación de ampollas intraepiteliales. Del 80 al 90 % de los pacientes con pénfigo vulgar, desarrollan trastornos cutáneos y en el 60 % de los casos alteraciones en la mucosa que es el primer o único signo. El diagnóstico de las lesiones en cavidad bucal es fundamental, ya que pueden prevenir su afectación a la piel. Si se establece el tratamiento en su etapa inicial, la enfermedad es más fácil de controlar y aumenta la posibilidad de una remisión temprana del trastorno y mejor calidad de vida. Este reporte de caso mostró a una paciente de 35 años, la que comenzó a presentar lesiones ulceradas en toda la orofaringe, con sensación de ardor e incapacidad para la ingestión de alimentos. El diagnóstico fue pénfigo vulgar (AU).

ABSTRACT Pemphigus is a potentially deadly autoimmune disease causing blisters and erosions in the skin and the mucous membrane. The epithelial lesions are the result of antibodies reacting to desmosomal glycoproteins, and are present in the keratinocytes cellular surface. The autoimmune reaction to these glycoproteins causes a cellular adhesion loss resulting in the formation of intraepithelial blisters. From 80 to 90 % of the patients with vulgar pemphigus develop skin disorders, and 60 % of the cases show mucosa changes as the first or unique sign. The diagnosis of the lesions in oral cavity is essential because it could prevent the skin damage. If the treatment begins in an initial stage, it is easier to control the disease and the possibility of the disorder's early remission and a better life quality increases. This is the report of the case of a female patient, aged 35 years, who presented ulcerated lesions in the entire oropharyngeal region, with itching sensation and inability for food consumption. The diagnosis was vulgar pemphigus (AU).

Deterioro neurológico progresivo como forma de presentación inusual del neurobehçet / Progressive neurological deterioration as unusual form of neuro-behçet presentation

La enfermedad de Behçet puede afectar a varios órganos y tiene dentro de sus características la presencia de úlceras recurrentes genitales, orales y la uveítis. El neurobehçet es una de las manifestaciones clínicas más serias e infrecuente de la enfermedad de Behçet y debe ser considerado en el diagnóstico diferencial con enfermedades inflamatorias, infecciosas o desmielinizante del sistema nervioso central. Este reporte de caso describe a una paciente con manifestaciones neurológicas aguda severas, lo cual es inusual en esta enfermedad(AU)

Behçet's disease can affect several organs and the presence of recurrent genital, oral and uveitis ulcers characterize it. Neuro-Behçet's is one of the most serious and uncommon clinical manifestations of Behçet's disease, so it should be taken into account in the differential diagnosis with inflammatory, infectious or demyelinating diseases of the central nervous system. This case report describes a female patient with acute severe neurological manifestations, unusual in this disease(AU)

Frequency of Oral Manifestation in Patients with Inflammatory Bowel Disease in Chile / Frecuencia de Manifestaciones Orales en Pacientes con Enfermedad Inflamatoria Intestinal en Chile

SUMMARY: Inflammatory bowel disease (IBD) is an autoinflammatory chronic disorder of the gastrointestinal tract with a dysregulated immune response, being Crohn's Disease (CD) and Ulcerative Colitis (UC) the two main conditions. In literature the extra intestinal manifestations associated with IBD have been well documented. However, in our country, there are no studies about the oral manifestations. Having this information, is fundamental in order to optimize resources involved in diagnosis and treatment in a multidisciplinary level. Descriptive observational cross-sectional study, with a non-probabilistic sample for convenience with patients diagnosed with IBD belonging to the "CD-UC Group". In a period of four months the intraoral exam, diagnosis, and description of the lesions according location, type of illness, age, and sex were carried out. Thirty (30) patients (23 UC and 7 CD) filled the criteria of inclusion, 30 % men and 70 % women. 11 patients presented at least one oral lesion, being recurrent oral ulcer the most frequent, and two more specific lesions (macrocheilia and corrugated lesion). Of these patients, 37 % presented at least one oral lesion, being the most frequent one recurrent oral ulcer (ROU).

RESUMEN: La Enfermedad Inflamatoria Intestinal (EII) es un desorden inmunitario autoinflamatorio crónico del tracto gastrointestinal, siendo la Enfermedad de Crohn (EC) y la Colitis Ulcerativa (CU) sus dos condiciones principales. Se ha documentado en la literatura acerca de las manifestaciones extraintestinales asociadas a EII. Sin embargo, en nuestro país, no existen estudios acerca de las manifestaciones orales. Contar con esta información es fundamental para optimizar los recursos involucrados en el diagnóstico y tratamiento a nivel multidisciplinario. Se realizó un estudio observacional descriptivo de corte transversal, con un muestreo no probabilístico por conveniencia con pacientes diagnosticados de EII pertenecientes a la "Agrupación EC-CU". En un periodo de 4 meses se realizó el examen intraoral, diagnóstico y descripción de lesiones según localización, tipo de enfermedad, edad y sexo. Resultados: 30 pacientes (23 CU y 7 EC) cumplieron con los criterios de inclusión, 30 % hombres y 70 % mujeres. De los sujetos, 11 pacientes presentaron al menos una lesión oral, la úlcera recurrente oral fue la lesión más frecuente y se encontraron dos lesiones específicas (macroqueilia y lesión de aspecto corrugado). Un 37 % de los pacientes presentaron al menos una lesión oral, en donde la lesión más frecuente fue la úlcera recurrente oral.

Recién nacido con úlcera de Bednar / Bednar's aphthae in newborn

La descripción de la ulcera de Bednar es escasa en la literatura actual. Se ha relacionado con el efecto traumático de la tetina del biberón y/o chupetes no ortodóncicos durante la lactancia. Presentamos a un recién nacido de 20 días de vida que acudió a Urgencias por irritabilidad y se asoció, como único hallazgo al momento de la exploración física, dos úlceras bucales. Describimos la presentación clínica, la evolución y el tratamiento. La normalidad de las pruebas complementarias, las características clínicas y la evolución condujeron al diagnóstico de úlcera de Bednar.

The description of the Bednar's ulcer is uncommon in the current literature. It has been associated with the traumatic effect of the bottle's nipple and/or no orthodontic soothers while breastfeeding. We present a newborn of 20 days of life attended at the emergency room for irritability, with the only finding on physical examination of two oral ulcers. We describe the clinical presentation, evolution and treatment. The normality of the diagnostic test, clinical characteristics and evolution lead to the diagnosis of Bednar's ulcer.

Lesões bucais relacionadas ao uso de próteses dentárias removíveis / Oral lesions related to the use of removable dentures

A prótese dentária visa substituir um ou mais dentes ou tecidos de proteção e sustentação ausentes, reabilitando o equilíbrio neuromuscular do sistema estomatognático, possibilitando o desempenho e manutenção de suas funções, promovendo o bem-estar físico, mental e social. Este estudo teve como propósito verificar os principais tipos de lesões que acometem a cavidade bucal, que são decorrentes do uso de próteses removíveis mal adaptadas ou mal higienizadas pelo paciente, em resposta principalmente a uma orientação inadequada do dentista. Observa-se que as lesões mais citadas pelos autores poderiam ser evitadas se após a instalação da prótese o profissional realizasse um ajuste adequado, orientasse o paciente quanto às técnicas de higienização e o acompanhasse, realizando controles periódicos.

The dental prosthesis aims to replace one or more teeth or tissues for protection and support absent, rehabilitating the balance stomatognathic neuromuscular system, enabling the performance and maintenance of its functions, promoting the physical well-being, mental and social. This study aimed to determine the main types of lesions that affect the oral cavity, which are caused by use of ill-fitting dentures or poorly cleaned by the patient, mainly in response to an incorrect orientation of the dentist. It is observed that the lesions most often cited by the authors could be avoided if after installation the professional conduct of the prosthesis fit properly, orient the patient and the techniques of cleaning and monitoring, conducting periodic controls.

Ulceras dolorosas en la cavidad oral como expresión de leucemia cutis / painful sores in the oral cavity as an expression of leukemia cutis

Objetivo: presentar el caso de una paciente con leucemia cutis en cavidad bucal, con úlceras dolorosas a partir de las cuales se le diagnosticó leucemia mieloide aguda (LMA). Caso clínico: mujer de 30 años de edad con úlceras bucales dolorosas de cinco meses de evolución, acompañadas por fiebre y pérdida de peso. Tras un estudio histopatológico se diagnostica la infiltración de células leucémicas (Leucemia cutis). Conclusión: la leucemia cutis (LC) es la infiltración de células leucémicas en la piel y/o las mucosas. Por lo general surge en un estadio avanzado de una leucemia previamente diagnosticada. Sin embargo, también puede ser un signo de recidiva tumoral, o incluso la primera manifestación de una leucemia hasta ese entonces desconocida. Si bien las manifestaciones clínicas de la LC son proteiformes, la mucosa bucal es una localización frecuente de este tipo de lesiones.

Plasma cell granuloma of lip.

Plasma cells are medium-sized round-to-oval cells with eccentrically placed nuclei, usually found in the red pulp of the spleen, tonsils, medulla of the lymph nodes, nasal mucosa, upper airway, lamina propria of the gastrointestinal tract, and sites of inflammation. Plasma cell granuloma is a rare reactive tumor-like proliferation composed chiefly of plasmacytic infiltrate. Here, we present a case of plasma cell granuloma of lip in a female patient.

Successful Primary Infliximab Treatment of Orofacial Crohn's Disease without Gastrointestinal Manifestation / 대한소화기학회지

Crohn's disease is a chronic inflammatory bowel disease that can involve the whole gastrointestinal tract. The orofacial manifestation of Crohn's disease, which is rare, can develop irrespective of intestinal involvement. These orofacial lesions are often misdiagnosed as simple oral ulcers. Corticosteroids are the mainstay of therapy for orofacial Crohn's disease. However, infliximab, the chimeric monoclonal antibody to tumor necrosis factor-alpha, is now considered as a primary treatment because of the disease's relatively high rate of steroid resistance. We present a case of deep oral ulcer and periorbital swelling in a 65-year-old woman. She was diagnosed with intestinal Crohn's disease 7 years ago, which was in remission after treatment with an immunosuppressive agent (azathioprine). The patient was given the diagnosed with orofacial Crohn's disease and successfully treated with infliximab.

Pleomorphic adenoma of the soft palate: Myoepithelial cell predominant.

The pleomorphic adenoma is the most common salivary gland tumor. A remarkable morphological diversity can exist from one tumor to the next. We present here a case of pleomorphic adenoma of minor salivary glands of the soft palate which had predominantly myoepithelial cells with minimal stroma, ductal cells, or tubular elements.

Epidemiology of recurrent aphthous stomatitis and co-related factors

Recurrent aphthous stomatitis [RAS] is the most common oral ulcerative disease that affects 20% of general population. The etiology of RAS is unknown and it is due several different mechanisms. The purpose of study was to assess the epidemiology and related factors in its occurrence. In this descriptive -cross sectional study, 1105 persons attending to health centers in Zahedan, selected in a multi-stage random manner, were assessed for abundance and effective factors in development of RAS. The data were gathered as single stage and by interview, completion of a questionnaire and clinical examination. The data were analyzed by Chi-squared test using SPSS software. Among 1105 persons [476 males and 629 females] examined, 199 persons [18%] were affected by aphthea and 168 [84.4%] case had minor, 26 case [13.1%] had major and 5 case [2.5%] had herpetiform aphthea. In this research, there were significant correlations between the abundance of RAS and age [P<0.001], education [P<0.001], job [P=0.002], allergy [P=0.02], kind of allergy [P =0.004], predisposing disease [P =0.005], family history [P< 0.001] and brushing [P<0.001]. No significant differences were found between the abundance of RAS and gender, using snuf, tobacco or mouth wash. RAS is a multifactorial lesion and factors such as age, high-stress job, high education, trauma and allergy are positively co-related with occurrence of the aphthea

Schwannoma of the tongue: An unusual presentation in a child.

Schwannomas are benign tumors of nerve sheath and quite uncommon in the oral cavity. In contrast to the earlier reports in the literature, a confounding case of a lingual schwannoma presenting as a symptomatic and exophytic growth on the ventral surface of the tongue in a 12-year-old boy is discussed here.

Riga-Fede disease: A histological study and case report.

Acute traumatic ulcerations and granulomas of the oral mucosa may result from physical damage via sharp foodstuffs, accidental biting, or talking. Most ulcerations heal within days. Others become chronic, reactive, and exophytic. A histopathologically unique type of chronic traumatic ulceration is the traumatic ulcerative granuloma with stromal eosinophilia (TUGSE). TUGSE exhibits a deep "pseudoinvasive" inflammatory reaction. This lesion may occur under the tongue in infants as a result of chronic mucosal trauma caused by mandibular anterior primary teeth during nursing and is termed Riga-Fede disease (RFD). The clinical presentation many resemble squamous cell carcinoma causing concern. RFD, although not uncommon, is not frequently reported. Thus, dental practitioners are unfamiliar with such lesions. We present a large Riga-Fede lesion in an infant along with the clinical management.

Prevención del cáncer bucal: lesiones cancerizables de la cavidad bucal / Prevention of oral cancer: cancerous lesions of the oral cavity

El cáncer bucal representa el 3 por ciento de los tumores malignos humanos. En nuestro país, la sobrevida es del 39 por ciento a los 5 años, lo que significa la muerte de la mayoría de los pacientes (61 por ciento) a los cinco años. Mundialmente, existen campañas con el fin de concientizar a la población sobre la existencia y prevención del cáncer bucal. La forma de prevenirlo es reconocer por parte del odontólogo, las lesiones que más frecuentemente pueden transformarse en cáncer, como ser el liquen no reticular en su forma erosiva, atrófica y queratósica, la ulceración traumática, la queilitis crónica y la leucoplasia. En este artículo se darán pautas claras y simples para reconocer, identificar y controlar las mencionadas lesiones, con el objetivo de orientar el diagnóstico precoz.

Tuberculosis of oral cavity.

Tuberculous involvement of oral cavity is very rare. A 34-year-old male presented with non-healing ulcer at upper lip mucosa. Biopsy from ulcer revealed tuberculous lesion. He also had asymptomatic pulmonary tuberculosis diagnosed during work up for primary site of the disease.

Úlceras orales recurrentes: características clínicas y diagnóstico diferencial / Recurrent oral ulcer: clinical characteristic and differential diagnosis

Las úlceras orales recurrentes (UOR), son lesiones inflamatorias frecuentes de la mucosa oral. Generalmente, son redondas u ovaladas, rodeadas por un halo eritematoso de fondo amarillo grisáceo y dolorosas en su mayoría. Las UOR alcanzan una frecuencia de hasta 20% en la población general, afectando a cualquier grupo etario, en especial a adolescentes y adultos jóvenes. La etiopatogenia de las UOR no está completamente dilucidada; algunos factores involucrados incluyen alteraciones inmunológicas, infecciones, déficit nutricional, traumas de la mucosa, alergia alimentaria y de contacto, enfermedades autoinmunes y neo-plasias; junto con factores psiquiátricos, genéticos y medioambientales. En el presente artículo se discuten las características clínicas, factores etiológicos, diagnósticos diferenciales y el estudio de las UOR.

Recurrent aphthous stomatitis (RAS), are common inflammatory lesions of the oral mucous, usually round or ovoid, circumscribed by an erytematous haloes with a yellow-grey floor and mostly painful. The RAS has reach an incidence about 20% in general population, present on any aged group, especially adolescents and young adults. Etiopathogenesis of RAS is not entirely understood. Some factors involved include immune system anomalies, infections, nutritional deficiency, mucous traumatism, food or contact allergy, autoimmunity illness and cancer; together with psychiatric, genetic and environment agents. In this article, main clinical features, etiology related factors, differential diagnosis and initial study of patients consulting for RAS are presented.

Estudo experimental do efeito dos clareadores dentais sobre úlceras induzidas com NaoH na mucosa bucal de ratos / The experimental study tooth-whitening agents effect on ulcers induced with naoh on the oral mucous of mice

Objetivo: Verificar as alterações microscópicas decorrentes da aplicação tópica dos dentrifícios clareadores e dos geis clareadores contendo peróxido de carbamida e carbopol nas concentrações 10 porcento, 16 porcento e 35 porcento, em úlceras no dorso da língua de rato. Método: Foram utilizadas 150 Rattus norvegicus albinus machos com idade de 45 a 50 dias e peso corporal de 250g a 350g, alimentados com ração e água ad libitum. Os mesmos foram divididos em 6 grupos com tratamentos diferenciados e com datas de morte de 2,7,14,21,42 dias. Os grupos de tratamento foram os de gel clareador 10 porcento, 16 porcento, 35 porcento: WHITENESS; o dentrificio clareador 1: COLGATE BICARBONATO DE SÓDIO & PERÓXIDO; dentrificio clareador 2: CONFIDENT, e o Grupo Controle tratado com água destilada. Na mucosa que reveste o dorso da língua de cada animal, na porção mais anterior foram induzidas as lesões ulceradas, por meio da aplicação diária de hidróxido de sódio (NaOH) a 40 porcento, por 7 dias. Após constatada a presença da úlcera foi iniciada a aplicação tópica dos produtos clareadores e a água destilada no grupo controle. Resultados: As úlceras tratadas com os géis clareadores estavam presentes ainda no sétimo dia, porém as tratadas com os dentifrícios clareadores, principalmente o CONFIDENT, persistiam por mais tempo, eram maiores e com o fundo esbranqueçado, havendo maior número de mortes entre os ratos tratados com o CONFIDENT. Conclusão: Pacientes portadores de aftas e outros tipos de úlceras devam ser aletardos sobre o risco de aumentar o período de cicatrização e de ter uma infecção sucundária, quando estiveram utilizando os produtos odontológicos clareadores