Abstract Migratory stomatitis is a rare recurring condition of - - PDF document

Romanian Journal of Oral Rehabilitation

• Vol. 10, No. 4 October- December 2018

54

MIGRATORY STOMATITIS – CASE PRESENTATION

Ana Maria Filioreanu¹, Cristina Popa¹*, George Alexandru Maftei¹,Ioanina Parlatescu², Carmen Larisa Nicolae², Eugenia Popescu³

1Oral Medicine Discipline, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and

Pharmacy Iasi

2 Oral Medicine Discipline, Faculty of Dental Medicine, “Carol Davila” University of Medicine and

Pharmacy Bucuresti

3 Oral Surgery Discipline, Faculty of Dental Medicine, “Grigore T. Popa” University of Medicine and

Pharmacy Iasi

*Corresponding author.Email: dr.cristinapopa@gmail.com

Abstract

Migratory stomatitis is a rare recurring condition of unknown etiology that mainly involves lingual mucosa, with a typical appearance of geographic tongue. Factors such as heredity, nutritional deficiencies or stress may be the contributing factors to the appearance of lesions. Clinically, they appear as circular, multiple, erythematous lesions with red spots surrounded by a white, narrow, hyperkeratotic aspect with irregular, slightly elevated appearance modifying its form in 24 hours.The condition may have spectacular clinical signs when the lesions are localised on the tongue, and may involve other areas of oral mucosa, such as labial or floor of mouth

• mucosa. The aim of this study is to present a clinical case of a patient with two localisations of lesions

corresponding clinically to migratory stomatitis. The anatomopathological examination confirmed the migratory stomatitis diagnosis, so we could begin the specific treatment, to which the patient responded positively.

Key words:migratory stomatitis, geographic tongue, geographic stomatitis Introduction Migratory stomatitis is a tissue modification

• f the oral mucosa that usually starts in

childhood, with autosomal dominant transmission and benign evolution[1, 2]. It clinically manifests in spikes. The reactivation is conditioned by stress, emotional states, neighbouring infections (dento-gingival, pharyngeal), or related to general pathology diseases. [1,3,4]. In most cases, lesions begin on the dorsal face of the tongue and then coexist with the lesions located in other topographical areas

• f the oral mucosa. Hume divided migratory

stomatitis into types: Type 1: lesions on the dorsal face, edges and tip of the tongue, with their possible extension to the ventral lingual face; lesions could migrate over time and go through active and remission phases (geographic tongue - with no manifestations in other areas of oral mucosa); Type 2: geographic tongue, accompanied by lesions also located in other areas of oral mucosa; Type 3: lesions involving lingual mucosa, with unusual appearance accompanied by depapillations of oral mucosa in different localisations; Type 4: circinate lesions with a typical appearance and unusual localisation (involving different areas of oral mucosa, but less the tongue surface), clinical signs vary and it is difficult to recognize the lesion [5]. This study presents a case of migratory stomatitis, in which, due to atypical distribution of the lesions, it could be easily confused with other pathological entities. Clinical case

Romanian Journal of Oral Rehabilitation

• Vol. 10, No. 4 October- December 2018

55 The patient MZ, male, aged 37, visited the Maxillofacial Surgery Outpatient Clinic of “Sf Spiridon” County Emergency Hospital in Iasi, complaining of fatigue and discomfort in the dorsal face of tongue and palatine mucosa, with mastication and swallowing functional disorders. From an anamnestic and symptomatic point of view, the patient reported that he had not observed earlier any lesions

• r

subjective pain (burning sensation). Fig.1 Migratory glossitis. 3 days from onset Fig.2 Migratory glossitis. 4 days from onset. Fig.3 Migratory stomatitis, 3 days from

• nset.

Romanian Journal of Oral Rehabilitation

• Vol. 10, No. 4 October- December 2018

56 Fig.4 Migratory stomatitis, palatine mucosa. A detail. Intraoral clinical examination showed the presence of multiple erythematous lesions, which have the appearance of red spots surrounded by a hyperkeratotic narrow white edge, with irregular, slightly elevated appearance.The lesions are located in the mucosa of the dorsal face of the tongue, hard and soft mucosa palate. In the tongue mucosa, the lesions have the appearance typical for migratory glossitis (geographic tongue, marginal exfoliative glossitis or annulus migrans) that appear as complex circinate patterns modifying their appearance in 24 hours [Fig.1,2]. Palatine mucosa presents the same lesional pattern but with slightly less shaped and faded appearance [Fig.3,4]. Most often, in case of localization of dorsal face lesions such as a geographical tongue, the diagnostic certainty is based

• n

anamnesis and clinical examination. Due to rare presence of lesions in oral mucosa areas (palatine mucosa), we considered it necessary to confirm the diagnosis using the histopathological examination. Therefore, we are able to establish the differential diagnosis of these lesions by using the diagnoses for other conditions with similar clinical signs. The differential diagnosis includes: psoriasis,

• ral lichen planus, acute oral candidiasis,

erythroplakia, discoid or systemic lupus erythematosus, reactive ulcerative lesions and drug allergies. To perform the anatomopathological examination, bioptical samples were taken from the dorsal face of the tongue. Histopathological results showed in the epithelial tissue: parakeratosis and absence

• f granulous layer, acantosis of the spinous

layer especially in suprabasal upper layer and pseudoepiteliomatous hyperplasia; in the superficial chorion, presence

• f

inflammatory infiltration rich in lymphocytes, macrophages and neutrophils. The white area of the lesion presents on the surface of necrotic epithelial cells and an inflammatory infiltration predominantly composed of neutrophils in the superficial

• chorion. The erythematous area of the lesion

was characterized by loss of filiform papillae in association with a subepithelial mononuclear inflammatory infiltrate, suprapapillary hypertrophy and vascular

• ectasia. The clinical examination and the

results of the histopathological examination confirmed the diagnosis of Type 2 Migratory Stomatitis (Hume classification). As the patient suffered from burning sensation, pain, and functional disorders, we recommended a symptomatic treatment with: anesthetic mouth rinse, Vitamin A – topical, antihistamine and zinc-based supplements applications. We also recommended avoidance of contact with local irritants, as well as a diet avoiding acidic and spicy foods. Discussion Migratory stomatitis (MS) was first described in 1955 under the term migratory erythema that may occur in any area of the mucosa[6]. It also has been known as geographic stomatitis, ectopic geographic tongue, Cooke’s disease

• r

migratory mucositis [2,7,8].

Romanian Journal of Oral Rehabilitation

• Vol. 10, No. 4 October- December 2018

57 Main sites are: mucosa of the dorsal face of the tongue, jugular mucosa, and mucosa of the inner versant of the lips. Gingiva, alveolar mucosa and soft palate are rarely involved topographic areas [9,10,11]. Van der Wal N et al described the presence

• f lesions in the palatine mucosa as a form of

manifestation of oral psoriasis and, to a lower extent, as a form of manifestation of geographic stomatitis [12]. The main location is the lingual mucosa with the appearance

• f

geographic tongue. Described for the first time by Reiter in 1831, geographic language (GT) is a chronic, inflammatory disease that appears as an individual pathological entity, or in the context of migratory stomatitis. It is an immunologically mediated and of unknown aetiology condition[4, 5,13]. It affects between 0.6% and 4.8% of the world’s population, and

• ccurs

more frequently in children, and in adults, it is predominant in females [14, 15]. The lesions change over time their location, shape and size, affecting mainly two-thirds

• f distal dorsal faces and the lateral edges of

the tongue, as well as other areas of the oral mucosa in case of migratory stomatitis, in the way the cycle of lingual lesions ocurred in the case presented above. The literature in the field reports a low number of cases of migratory stomatitis. However, some authors believe that the incidence of this condition is much higher, but the cases have not been always statistically assessed as the evolution of the condition is asymptomatic also due to the appearance of migratory glossitis, which is easy to diagnose [4,16]. Although the etiology is unknown, the presence of migratory stomatitis may be associated with general disorders, such as

• ral

psoriasis, the Reiter’s syndrome, atrophic acute candidiasis, lichen planus, or lupus erythematosus [1,17]. In the Reiter’s syndrome, the history of the disease and the clinical examination can be useful for differentiating the lesions as the appearance of geographic stomatitis is associated with the triad of conjunctivitis, urethritis, arthritis [3]. In case of psoriasis, oral mucosal lesions have a similar appearance, and Weathers et

• al. in 1974 described the three types of

clinical entities: geographic tongue, geographic stomatitis and intraoral psoriasis. It characterized migratory stomatitis through the following pathognomonic signs: migratory character, lack

• f

painful symptoms and chronicity of lesions [18]. Ralls and Warnock even argued that migratory stomatitis is a form of incomplete manifestation of psoriasis and Reiter’s syndrome [19]. In terms of lesion evolution, they tend to change their appearance and location in a few minutes or hours. The condition is characterized by periods of exacerbation and remission. In some patients, a lesional spike heals in two weeks, and in other patients, it develops over several months [19]. Regardless of the time frame, injuries are healed without any scars, and when recurrent, they have a new localization describing its migratory effect [14]. Weathers et al divided the geographic lesions into two sub-groups: erythema circinate perstans and erythema circinate migrans[18]. Brooks and Balciunas showed that 34% of patients have a history of migratory lesions [5]. When lesions have an atypical localization, the histopathological examination is useful for the diagnosis, although tissue appearance is somewhat similar to that of psoriasiform lesions. As tissue changes may vary depending on the clinical stage of the lesion, and on the area where the biopsy was taken, the fragments of collected tissue should cover all three characteristic areas: the periphery, the white line and the erythematous region. Because it is generally an asymptomatic benign condition, the migratory stomatitis does not require treatment. If the patient suffers a burning sensation and pain, or functional impairment, there may be recommended:anesthetic mouth rinse, Vitamin A – topical, antihistamine and zinc- based supplements applications. The patient

Romanian Journal of Oral Rehabilitation

• Vol. 10, No. 4 October- December 2018

58 should avoid contact with local irritants, and adopt a diet avoiding acidic and spicy foods [13]. In more severe forms, we may recommend topical applications based on triamcinolone, local applications

• f

tacrolimus

• r

even

• ral

cyclosporine [10,20,21]. Conclusions Migratory stomatitis is a benign disease of unknown etiology. The correct diagnosis of this condition is essential for the correct management of therapy and removal of any suspicion of the patient regarding possible malignant transformation of the lesions. The presence of these modifications in the

• ral mucosa acts as a barometer of patient’s

immunity, and may also be a symptom in the context of another general pathology. REFERENCES

• 1. Piaccini B., Silva G. Junior, Carneiro S et all.Geographic stomatitis: an oral manifestation of psoriasis? J

Dermatol Case Rep. 2012 Dec 31; 6(4): 113–116.

• 2. Cooke BE. Erythema migrans affecting the oral mucosa. Oral Surg Oral Med Oral Pathol. 1955;8:164–167
• 3. Nursel Akkaya, Seher Karagul, Aydan Kanlı. Geographic Stomatitis · Scientific Symposium of Oral

Diagnosis and Dentomaxillofacial Radiology Society, 2006, Antalya

• 4. Hume WJ. Geographic stomatitis: a critical review. J Dent 1975; 3(1): 25–43
• 5. Brooks JK, Balciunas BA. Geographic stomatitis: review of the literature and report of five cases. J Am Dent

Assoc 1987; 115(3): 421–424.

• 6. Brooks JK, Nikitakis NG. Multiple mucosal lesions. Erythema migrans. Gen Dent. 2007;55:163
• 7. Zadik Y, Drucker S, Pallmon S. Migratory stomatitis (ectopic geographic tongue) on the floor of the mouth. J

Am Acad Dermatol. 2011;65:459–460

• 8. Espelid M, Bang G, Johannessen AC, Leira JI, Christensen O. Geographic stomatitis: report of 6 cases. J Oral

Pathol Med. 1991;20:425–428.

• 9. Picciani BL, Silva-Junior GO, Michalski-Santos B, Avelleira JC, Azulay DR, Pires FR, Dias EP, Cantisano
• MH. Prevalence of oral manifestations in 203 patients with psoriasis. J Eur Acad Dermatol Venereol.

2011;25:1481–1483

• 10. Borrie F, Musthyala R, Macintyre D. Ectopic geographic tongue-a case report. Dent Update 2007; 34(2):

121–122. 11.Warnock GR, Correll RW, Pierce GL, Hatch CL. Multiple,shallow, circinate mucosal erosions on the soft palate and base of uvula. J Am Dent Assoc 1986; 112(4): 523–524. 12.Van der Wal N, van der Kwast WA, van Dijk E, van der Waal I. Geographic stomatitis and psoriasis. Int J Oral

• 13. Assimakopoulos D, Patrikakos G, Fotika C, Elisaf M. Benign migratory glossitis or geogrsphic tongue: an

enigmatic oral lesion. Am J Med 2002; 113(9); 751-755

• 14. Sigal MJ, Mock D. Symptomatic benign migratory glossitis: report of two cases and literature review.

Pediatr Dent 1992; 14(6): 392–396.

• 15. Lucas VS, Challacombe SJ, Morgan PR. Erythema migrans: an unusal presentation. Br Dent J 1993; 175(7):

258–259.

• 16. Rhyne TR, Smith SW, Minier AL. Multiple, annular, erythematous lesions of the oral mucosa. J Am Dent

Assoc 1988; 116(2): 217–218. 17.Yesudian PD, Chalmers RJ, Warren RB, Griffiths CE. In search of oral psoriasis. Arch Dermatol Res.2012;304: 1–5. Maxillofac Surg. 1988;17:106–109 18.Weathers DR, Baker g., Archard HO, Burkes EJ Jr., Psoriasiform lesions of the oral mucosa (with emphasis

• n ,,ectopic geographic tongue’’). Oral Surg Oral Med Oral Pathol 1974; 37(6): 872-888.

Romanian Journal of Oral Rehabilitation

• Vol. 10, No. 4 October- December 2018

59

• 19. Ralls SA, Warnock GR. Stomatitis areata migrans affecting the gingiva. Oral Surg Oral Med Oral Pathol

1985; 60(2): 197-200.

• 20. Ishibashi M, Tojo G, Watanabe M, Tamabuchi T, Masu T, Aiba S. Geographic tongue treated with topical
• tacrolimus. J Dermatol Case Rep. 2010;4:57–59. [PMC free article] [PubMed]

21.Assimakopoulos D, Patrikakos G, Fotika C, Elisaf M. Benign migratory glossitis or geographic tongue: an enigmatic oral lesion. Am J Med 2002; 113(9); 751-755.