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Multiple, annular, erythematous lesions of the oral mucosa
D I A G N O S I N G
ORAL
DISEASE
Multiple, annular, erythematous lesions of the oral mucosa T h om as R. R hyne, DDS Steven W. Sm ith, DDS Am y L. M inier, DDS
60-year-old white male was re ferred to the dental clinic for a denture adjustment. An oral ex am ination showed m ultiple, erythema tous, well-defined, annular lesions with a raised yellow-white border on the lateral borders of the tongue, buccal mucosa, and buccal vestibules (Fig 1-4), with m ul tiple deep grooves and fissures on the dorsum of the tongue (Fig 5). T he patient first noticed the lesions several years ago, but because they were not painful he was not concerned. His medical history included adult onset diabetes mellitus, congestive heart failure, two myocardial infarctions, chronic ob structive pulmonary disease, hypertension, and C rohn’s disease in remission. T he medications he was taking included in sulin; digoxin (Lanoxin, Burroughs Well come); furosemide (Lasix, Hoechst-Roussel); haloperidol (Haldol, McNeil Pharm a ceutical); and isosorbide dinitrate (Isordil, Wyeth). H e reported having personal problems for the past 10 years and is cur rently undergoing psychological treat ment.
A
Because of the characteristic presentation of this case, a biopsy was not performed. Discussion
In 1955, Cooke1 was the first to report
Diagnosis
On the basis of clinical appearance, his tory, and location, the diagnosis of benign m igratory stom atitis (BMS) was made.
Fig 1, 2 ■ M ultiple erythematous lesions with raised yellow-white borders on the m axillary and m andibular vestibules.
erythem a m ig ran s a ffe ctin g the oral mucosa. Subsequent reports by Brooks and Balciunas,2 Warnock and others,3 and S apiro and S h k lar4 described sim ilar lesions occurring on the lip, soft palate, uvula, floor of the m outh, buccal and la bial mucosa, mucobuccal fold, vestibule, and gingiva. These lesions are asympto m atic an d often go u n n o ticed by the patient. Several names synonymous with BMS have appeared in the literature. These include stomatitis areata migrans, geo grap h ic stom atitis, erythem a m igrans, migratory mucositis, ectopic geographic tongue, and Cooke’s disease.2,4 The name benign m igratory stom atitis is derived from the periods of exacerbation and re mission that the lesions exhibit, as they g enerally reappear a t a new location w ithout residual scar formation.2 Clinically, the lesions of BMS vary in size and appear as flat, annular, erythem atous areas surrounded by a raised yel low-white border. Fissured tongue and geographic tongue are often noted in patients with BMS5,6 and in individuals experiencing em otional stress.4 Brooks and Balciunas2 recently described the male to fem ale occurrence ratio of BMS at nearly 3:1. BMS is clinically and histologically sim ilar to benign m igratory glossitis JADA, Vol. 116, February 1988 ■ 217
DIAGNOSING
ORAL
DISEASE
Fig 3 ■ Involvement of the buccal mucosa with m ultiple, discrete, annular lesions.
(BMG), also known as geographic tongue, which was first described by Rayer7 in 1831 and has been well documented in the literature. Both conditions involve desquamation of the epithelium followed by healing and subsequent reappearance in another location giving the appearance of “m igration.” T he time over which this occurs varies considerably. T he diagnosis of BMS is usually made w ithout biopsy. Medical history and physical exam ination m ay be h e lp f u l in d i f f e r e n t ia t in g BMS from the oral lesions of psoriasis and Reiter’s syndrome, which have sim ilar appearances. It is interesting to note that in several previous reports of BMS and BMG, the patients have also had gastrointestinal disturbances8 or pyoderma gangrenosum ,9 which is significant for its association w ith ulcerative colitis or C rohn’s disease. As the case presented here also involves a patient w ith Crohn’s disease, it can be speculated about the possible existence of a relationship between BMS and ulcera tive diseases of the gastrointestinal tract. Histologically, BMS (and BMG) show peripheral hyperparakeratosis and acan thosis corresponding w ith the yellowwhite border. T he central erythematous areas reveal desquam ation of the parakeratin and exocytosis of polymorphonuclear leukocytes and lym phocytes in to the
218 ■ JADA, Vol. 116, February 1988
Fig 4 ■ Lesions of benign migratory glossitis on the lateral border of the tongue.
e p ith eliu m , degeneration of epithelial cells, and the formation of microabscesses near the surface.10 A mixed inflammatory infiltrate of lymphocytes, plasma cells, and neutrophils is seen in the underlying connective tissue. S u m m a ry
Benign migratory stomatitis is a relatively rare entity, but because of its benign nature and clinical characteristics, it should be easily recognized by the general practitioner. Biopsy is usually not indi cated and treatment consists of reassuring the patient that the lesions are benign even though they may disappear, reap pear, and change location; the patient should report back for periodic follow-up.
-------------------- JliO A --------------------T he authors thank Dr. Robert M. Craig for his assistance in preparation of the m anuscript.
The publication of this series is coordinated by the Western Dental Education Center, West Los Angeles VA Medical Center, Los Angeles, R alph W. Correll, DDS, director, and is supported by the Veterans Administration and the American Dental Association. T he opinions and assertions herein are those of the authors and are not to be construed as official or necessarily representing the views of the Veterans Administration.
Fig 5 ■ Deep grooves and fissures on the dorsum of the tongue.
Dr. Rhyne is staff dentist, Audie L. M urphy Memorial Veterans H ospital, and clinical instructor, departm ent of dental diagnostic science, University of Texas Dental School at San Antonio. Drs. Smith and M inier are general practice residents, Audie L. M urphy Memorial Veterans Hospital. Address re quests for reprints to Dr. Rhyne, Dental Service (160), Audie L. M urphy Veterans Hospital, 7400 Merton Minter Blvd, San Antonio, TX 78284. 1. Cooke, B.E. Erythema migrans affecting the oral cavity. Oral Surg Oral Med O ral Pathol 8:164-167, 1955. 2. Brooks, J.K., and Balciunas, B.A. Geographic stomatitis: review of the literature and report of five cases. JADA 115(3):421-424, 1987. 3. Warnock, G.R., and others. Multiple, shallow, circinate m ucosal erosions on the soft palate and base of uvula. JADA 112(4):523-524, 1986. 4. Sapiro, S.M., and Shklar, G. Stomatitis areata migrans. Oral Surg Oral Med Oral Pathol 36(l):28-33, 1973. 5. Correll, R.W.; Wescott, W.B.; and Jensen, J.L. Nonpainful, erythematous, circinate lesions of a pro tean nature on a fissured tongue. JADA 109(1):90-91, 1984. 6. Cooke, B.E. Median rhom boid glossitis and benign glossitis m igrans (geographic tongue). Br Dent J 112(10):389-393,1962. 7. Prinz, H. W andering rash of the tongue (geo graphic tongue). Dent Cosmos 69(l):272-275, 1927. 8. Banoczy, J.; Scabo, L.; and Csiba, A. Migratory glossitis. A clinical-histologic review of seventy cases. Oral Surg Oral Med Oral Pathol 39:113-121, 1975. 9. Ralls, S.A., and W arnock, G.R. Stomatitis areata migrans affecting the gingiva. Oral Surg Oral Med Oral Pathol 60:197-200,1985. 10. Shafer, W.G.; H ine, M.K.; and Levy, B. A text book of oral pathology, ed 4. Philadelphia, W. B. Saunders Co, 1983, pp 28-29.
ORAL
DISEASE
Multiple, annular, erythematous lesions of the oral mucosa T h om as R. R hyne, DDS Steven W. Sm ith, DDS Am y L. M inier, DDS
60-year-old white male was re ferred to the dental clinic for a denture adjustment. An oral ex am ination showed m ultiple, erythema tous, well-defined, annular lesions with a raised yellow-white border on the lateral borders of the tongue, buccal mucosa, and buccal vestibules (Fig 1-4), with m ul tiple deep grooves and fissures on the dorsum of the tongue (Fig 5). T he patient first noticed the lesions several years ago, but because they were not painful he was not concerned. His medical history included adult onset diabetes mellitus, congestive heart failure, two myocardial infarctions, chronic ob structive pulmonary disease, hypertension, and C rohn’s disease in remission. T he medications he was taking included in sulin; digoxin (Lanoxin, Burroughs Well come); furosemide (Lasix, Hoechst-Roussel); haloperidol (Haldol, McNeil Pharm a ceutical); and isosorbide dinitrate (Isordil, Wyeth). H e reported having personal problems for the past 10 years and is cur rently undergoing psychological treat ment.
A
Because of the characteristic presentation of this case, a biopsy was not performed. Discussion
In 1955, Cooke1 was the first to report
Diagnosis
On the basis of clinical appearance, his tory, and location, the diagnosis of benign m igratory stom atitis (BMS) was made.
Fig 1, 2 ■ M ultiple erythematous lesions with raised yellow-white borders on the m axillary and m andibular vestibules.
erythem a m ig ran s a ffe ctin g the oral mucosa. Subsequent reports by Brooks and Balciunas,2 Warnock and others,3 and S apiro and S h k lar4 described sim ilar lesions occurring on the lip, soft palate, uvula, floor of the m outh, buccal and la bial mucosa, mucobuccal fold, vestibule, and gingiva. These lesions are asympto m atic an d often go u n n o ticed by the patient. Several names synonymous with BMS have appeared in the literature. These include stomatitis areata migrans, geo grap h ic stom atitis, erythem a m igrans, migratory mucositis, ectopic geographic tongue, and Cooke’s disease.2,4 The name benign m igratory stom atitis is derived from the periods of exacerbation and re mission that the lesions exhibit, as they g enerally reappear a t a new location w ithout residual scar formation.2 Clinically, the lesions of BMS vary in size and appear as flat, annular, erythem atous areas surrounded by a raised yel low-white border. Fissured tongue and geographic tongue are often noted in patients with BMS5,6 and in individuals experiencing em otional stress.4 Brooks and Balciunas2 recently described the male to fem ale occurrence ratio of BMS at nearly 3:1. BMS is clinically and histologically sim ilar to benign m igratory glossitis JADA, Vol. 116, February 1988 ■ 217
DIAGNOSING
ORAL
DISEASE
Fig 3 ■ Involvement of the buccal mucosa with m ultiple, discrete, annular lesions.
(BMG), also known as geographic tongue, which was first described by Rayer7 in 1831 and has been well documented in the literature. Both conditions involve desquamation of the epithelium followed by healing and subsequent reappearance in another location giving the appearance of “m igration.” T he time over which this occurs varies considerably. T he diagnosis of BMS is usually made w ithout biopsy. Medical history and physical exam ination m ay be h e lp f u l in d i f f e r e n t ia t in g BMS from the oral lesions of psoriasis and Reiter’s syndrome, which have sim ilar appearances. It is interesting to note that in several previous reports of BMS and BMG, the patients have also had gastrointestinal disturbances8 or pyoderma gangrenosum ,9 which is significant for its association w ith ulcerative colitis or C rohn’s disease. As the case presented here also involves a patient w ith Crohn’s disease, it can be speculated about the possible existence of a relationship between BMS and ulcera tive diseases of the gastrointestinal tract. Histologically, BMS (and BMG) show peripheral hyperparakeratosis and acan thosis corresponding w ith the yellowwhite border. T he central erythematous areas reveal desquam ation of the parakeratin and exocytosis of polymorphonuclear leukocytes and lym phocytes in to the
218 ■ JADA, Vol. 116, February 1988
Fig 4 ■ Lesions of benign migratory glossitis on the lateral border of the tongue.
e p ith eliu m , degeneration of epithelial cells, and the formation of microabscesses near the surface.10 A mixed inflammatory infiltrate of lymphocytes, plasma cells, and neutrophils is seen in the underlying connective tissue. S u m m a ry
Benign migratory stomatitis is a relatively rare entity, but because of its benign nature and clinical characteristics, it should be easily recognized by the general practitioner. Biopsy is usually not indi cated and treatment consists of reassuring the patient that the lesions are benign even though they may disappear, reap pear, and change location; the patient should report back for periodic follow-up.
-------------------- JliO A --------------------T he authors thank Dr. Robert M. Craig for his assistance in preparation of the m anuscript.
The publication of this series is coordinated by the Western Dental Education Center, West Los Angeles VA Medical Center, Los Angeles, R alph W. Correll, DDS, director, and is supported by the Veterans Administration and the American Dental Association. T he opinions and assertions herein are those of the authors and are not to be construed as official or necessarily representing the views of the Veterans Administration.
Fig 5 ■ Deep grooves and fissures on the dorsum of the tongue.
Dr. Rhyne is staff dentist, Audie L. M urphy Memorial Veterans H ospital, and clinical instructor, departm ent of dental diagnostic science, University of Texas Dental School at San Antonio. Drs. Smith and M inier are general practice residents, Audie L. M urphy Memorial Veterans Hospital. Address re quests for reprints to Dr. Rhyne, Dental Service (160), Audie L. M urphy Veterans Hospital, 7400 Merton Minter Blvd, San Antonio, TX 78284. 1. Cooke, B.E. Erythema migrans affecting the oral cavity. Oral Surg Oral Med O ral Pathol 8:164-167, 1955. 2. Brooks, J.K., and Balciunas, B.A. Geographic stomatitis: review of the literature and report of five cases. JADA 115(3):421-424, 1987. 3. Warnock, G.R., and others. Multiple, shallow, circinate m ucosal erosions on the soft palate and base of uvula. JADA 112(4):523-524, 1986. 4. Sapiro, S.M., and Shklar, G. Stomatitis areata migrans. Oral Surg Oral Med Oral Pathol 36(l):28-33, 1973. 5. Correll, R.W.; Wescott, W.B.; and Jensen, J.L. Nonpainful, erythematous, circinate lesions of a pro tean nature on a fissured tongue. JADA 109(1):90-91, 1984. 6. Cooke, B.E. Median rhom boid glossitis and benign glossitis m igrans (geographic tongue). Br Dent J 112(10):389-393,1962. 7. Prinz, H. W andering rash of the tongue (geo graphic tongue). Dent Cosmos 69(l):272-275, 1927. 8. Banoczy, J.; Scabo, L.; and Csiba, A. Migratory glossitis. A clinical-histologic review of seventy cases. Oral Surg Oral Med Oral Pathol 39:113-121, 1975. 9. Ralls, S.A., and W arnock, G.R. Stomatitis areata migrans affecting the gingiva. Oral Surg Oral Med Oral Pathol 60:197-200,1985. 10. Shafer, W.G.; H ine, M.K.; and Levy, B. A text book of oral pathology, ed 4. Philadelphia, W. B. Saunders Co, 1983, pp 28-29.