Chronic symptomatic oral ulcers

Abstract

A 53-year-old woman reported chronic symptomatic gingival and oral lesions exacerbated by spicy and acidic foods of 6 months’ duration. The patient had been evaluated previously for these problems by 8 medical and dental providers and was treated with triamcinolone 0.1% paste, doxycycline, nystatin rinse, clotrimazole troches, valacyclovir, and topical anesthetic rinse, all without benefit. Her medical history was significant for celiac disease and cervical radiculopathy. Surgical, family, and social histories were unremarkable. Medications included ketolorac 0.4% ophthalmic solution and prednisolone acetate 1% ophthalmic solution. The patient reported type 1 allergies to cefaclor and penicillin. The review of systems was pertinent for acid reflux. Extraoral examination revealed a well-nourished woman without evidence of lymphadenopathy, salivary gland enlargement, or thyromegaly. Intraoral examination revealed diffuse erythema, lacelike striae, and ulcerations on the buccal mucosa bilaterally, tongue, and floor of the mouth (Figure 1). In addition, erythema and focal areas of desquamative gingivitis affecting the maxillary and mandibular gingivae were observed (Figure 2). Incisional biopsies of the right buccal mucosa were performed for hematoxylin and eosin staining and direct immunofluorescence analysis (DIF). Routine histology revealed hyperkeratotic, acanthotic, stratified squamous epithelium exhibiting degeneration of the basal cell layer with a dense bandlike infiltrate of lymphocytes immediately subjacent to the epithelium (Figure 3). DIF of perilesional tissue revealed intranuclear immunoglobulin (Ig) G deposition in the basal and parabasal nuclei without specific or significant staining seen with antibodies to IgA, IgM, C3, or fibrinogen (Figure 4). Figure 2Erythema of the maxillary anterior gingiva. View Large Image Figure Viewer Download Hi-res image Figure 3Lichenoid inflammation at the interface between the epithelium and lamina propria (hematoxylin and eosin, magnification X40). View Large Image Figure Viewer Download Hi-res image Figure 4Direct immunofluorescence analysis revealed epithelial cell nuclei in the basal and parabasal region (arrows) demonstrating the speckled pattern of antihuman immunoglobulin G antibody. View Large Image Figure Viewer Download Hi-res image Dr. Kulkarni is the chief resident, Department of Oral Medicine, Penn Dental Medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, PA. Dr. Alawi is a professor of pathology, Department of Basic and Translational Sciences, Penn Dental Medicine, University of Pennsylvania, Philadelphia, PA. Dr. Sollecito is a professor and the chair of oral medicine, Department of Oral Medicine, Penn Dental Medicine, University of Pennsylvania, Philadelphia, PA. Dr. Stoopler is a professor of oral medicine, Department of Oral Medicine, Penn Dental Medicine, University of Pennsylvania, PA.