Stomatitis areata migrans of the gingiva a rare case report



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Title page

Name: Radhika Arjunkumar

Degrees: BDS (Bachelor of Dental Surgery), MDS (Master of Dental Surgery), Diploma in Laser Dentistry (Indian Academy of Laser Dentistry)

Department: Department of Periodontics

Address: Saveetha Dental College

162,PH road, Vellappanchavadi

Poonamallee

Chennai- 600077

Mobile number-9884281681

Email address- radhikaarjunkumar@gmail.com

Key words: geographic tongue, gingiva, stomatitis areata migrans
Corresponding author *:

Name: Radhika Arjunkumar

Department: Department of Periodontics

Address: Saveetha Dental College

162,PH road, Vellappanchavadi

Poonamallee

Chennai- 600077

Email address- radhikaarjunkumar@gmail.com


Address for correspondence: radhikaarjunkumar@gmail.com
Abstract:

A 28 year old male pateint presented to the hospital with a no medical history and intra oral lesions consistent with stomatitis areata migrans of the gingiva (SAM). Gingival involvement with Stomatitis areata migrans was rare, with two purported instances. This paper presents, with clinical and histologic documentation of a patient having SAM with gingival involvement.



Key words: geographic tongue, gingiva, stomatitis areata migrans

Introduction

Cooke in 1955 first described Stomatitis areata migrans (SAM) 1. It is considered a more extensive involvement of the same process found in the geographic tongue. Geographic tongue is an interesting lesion of unknown etiology, although often related to emotional stress. Geographic tongue is also known as wandering rash of tongue, benign migratory glossitis, glossitis areata exfoliativa and erythema migrans. The condition comprises multiple areas of desquamation of the filiform papilae of the tongue in an irregular circinate pattern. The central part of the lesion sometimes appears inflamed, while the border may be outlined by a thin, yellowish white line or band. Stomatitis areata migrans is known by various other names such as erythema migrans, ectopic geographic tongue, geographic stomatitis, Cooke ‘s disease, erythema circinata migrans migratory stomatitis and migratory mucositis


Case report

A 28-year-old male patient complained of pain in the right lower back tooth for the past 2 days. History revealed that the pain was insidious in onset dull intermittent pain aggravated by mastication and relieved by rest. There was no significant medical history. Intraoral examination revealed dental caries with apical periodontitis in 46, which warranted extraction. Gingival examination showed erythematous areas in marginal and attached gingiva in upper and lower anteriors and premolar region (Figure 1).



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Figure 1: Intra oral view: The anterior view showing erythematous areas in marginal and attached gingiva in the anterior and premolar region
Examination of buccal mucosa, palatal mucosa, dorsum aof tongue and floor of mouth for abnormalities revealed none. On examination of the flexor and extensor surfaces of the arms and legs for any dermatological involvement, no abnormalities were found. The differential diagnosis for this patient’s condition was either desquamative gingivitis or plasma cell gingivitis (history of change of tooth paste 2 weeks back). Routine hematological investigations yielded apparently normal reports.

Histopathology

The site of biopsy was the attached gingiva of the right upper first premolar tooth and H&E staining of the tissue was done. Soft tissue section showed a parakeratinised stratified squamous epithelium and fibro vascular connective tissue with an overlying hyperplastic and acanthotic epithelium. The epithelium shows narrow, elongated rete ridges with only a thin layer of epithelium overlying the connective tissue papillae and the underlying connective tissue comprised dense, irregularly arranged collagen fiber bundles lined by spindle shaped fibroblasts. A moderate chronic inflammatory cell infiltrate is present, comprising predominantly of lymphocytes, macrophages and plasma cells (Figures 2 and 3). Corellating clinical features and histopathology a diagnosis of stomatitis areata migrans of the gingiva was given.

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Figure 2: Histopathology: The section shows a parakeratinised stratified squamous epithelium with narrow, elongated rete ridges;the epithelium was hyperplastic and displayed acanthosis.

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Figure 3: Histopathology (100x magnification): The connective tissue shows dense, irregularly arranged collagen fiber bundles lined by spindle shaped fibroblasts and a mixed cell infiltrate is present, comprising predominantly of lymphocytes, macrophages and plasma cells.

Discussion

Several cases are reported under the term geographic tongue or erythema circinata in which patients have reddish lesions usually with well - defined borders that appear clinically like the lesions of geographic tongue but are on other sites of the oral cavity 2. They may or may not occur in a given patient in association with typical tongue lesions. Apart from the tongue erythema migrans is said to occur in the buccal mucosa, gingiva, palate, lips and floor of the mouth. A close association among psoriasis, Reiter’s syndrome, and SAM has been reported in literature 2. SAM may represent an incomplete form of either psoriasis or Reiter’s syndrome 2. Hume in 1975 3 described four types on the basis of clinical distribution: (i) lesions that migrate with time and with periods of activity and remission on the dorsum, lateral borders, and tip of the tongue with possible extension to the undersurface (ii) similar to type 1 but with lesions elsewhere in the mouth (iii) tongue lesions that are not typical of type 1 and that may be accompanied by lesions elsewhere in the mouth (two subtypes: fixed forms and abortive forms); and (iv) no tongue lesions but lesions elsewhere in the mouth.

Gingival involvement with SAM was rare, with two such instances reported in literatue 3. The absence of the condition on the gingiva is both conspicuous and noteworthy 4,5,6. This case is rare and does not appear to have been documented either histologically or clinically (with photographs) often in literature. Kuffer et al 7 described multiple lesions on the buccal mucosa, tongue, lip, and two examples on lower gingival tissues. In addition, this patient had a recurring ulcerative gingivitis. Stephen A. Rails, Gary R. Warnock in 1985 8 reported a 62-year-old male patient who had a varied medical history and oral lesions consistent with stomatitis areata migrans. The stomatitis areata migrans affected essentially all oral soft tissues, including the gingival tissues which were rarely involved. The gingival involvement was documented by clinical and histologic means. In our case the clinical appearance of the lesions remained consistent with SAM of the gingiva, with no concomitant dermatological problems or systemic diseases.

Management

Since the etiology was unknown the treatment is empirical.The patient was reassured as to the benign nature of the process. Heavy doses of vitamins have been used, but in general all types of treatment have been unsuccessful. A 10 -year study of patients with geographic tongue treated in a variety of ways concluded that treatment influenced neither the lesions nor the subjective complaints of the patients 9.


Conclusion

Stomatitis areata migrans of the gingiva is a rare clinical condition, which has been reported sparingly in literature. Knowledge about the occurrence of such a benign lesion in the gingiva is important as it prevents the clinician from misdiagnosing the case and instituting unnecessary treatment. The asymptomatic nature of the patient regarding the gingival lesions can help in the diagnosis of this condition and empirical treatment is preferred.



References

  1. Cooke BED: Erythema migrans affecting the oral mucosa. Oral Surg Oral Med Oral Pathol 8: 164-167, 1955.

  2. Weathers DR, Baker G, Archard HO, Burkes EJ Jr: Psoriasiform lesions of the oral mucosa (with emphasis on “ectopic geographic tongue”). Oral Surg Oral Med Oral Pathol 37: 872-888, 1974.

  3. Hume WJ: Geographic stomatitis: A critical review. J Dent 3: 25-43, 1975.

  4. Sapiro SM. Shklar G: Stomatitis areata migrans. Oral Surg Oral Med Oral Pathol 36: 28-33, 1973.

  5. Zingale JA: Migratory stomatitis: A case report. J Periodon- tol 48: 298-302, 1977.

  6. Kogon SL. Stakiw JE: Stomatitis areata migrans. Dent J 44: 26-21. 1978.

  7. Kuffer R, Broch&iou C, Cernta P: Exfoliatio areata linguae et mucosae oris. Rev Stomatol Chir Maxillofac 72: 109- I 19, 1971.

  8. Ralls SA,Warnock GR: Stomatitis areata migrans affecting the gingiva. Oral Surg, Oral Med, Oral Pathol 1985 Aug;60(2):197-200

  9. Bánóczy J, Szabó L, Csiba A: Migratory glossitis. A clinical-histologic review of seventy cases. Oral Surg Oral Med Oral Pathol. 1975 Jan; 39(1):113-21


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