Granulomatous disease

Question 1

What are granulomas?

Answer 1

Collection of macrophages due to the inflammatory process

Question 2

What are idiopathic, non-infectious granulomatous disorders of the OC associated with histologically?

Answer 2

Non-ceasating epithelioid granulomas and multinucleated Langerhans type giant cells

Question 3

What type of granulomas are typically associated with infectious granulmatous lesions

Answer 3

Caesating granulomas

Question 4

What is tuberculosis

Answer 4

Chronic bacterial infection caused by mycobacterium tuberculosis

Question 5

Symptoms of tuberculosis

Answer 5

Malaise, anorexia, weight loss, fever,night sweats, cough with purulent or blood strained sputum

Question 6

Compare primary and secondary oral tuberculosis

Answer 6

Primary oral TB occurs alone, very rare and usually in children, often asymptomatic
Secondary oral TB is more common (2nd to pulmonary) and seen in elderly pts, often painful

Question 7

Describe oral tb lesions

Answer 7

• Location - tongue, gingiva, FOM, hard palate
• May present as an ulcer with indurated edges (Appears malignant) which replicates (chronic ulcerations)
• Additional - parotid gland involvement, lesions on bone, cervical/submental/submandibular lymphadenopathy

Question 8

IX of tuberculosis

Answer 8

Blood tests are quicker and more accurate

Biopsy to show mycobacterium or infectious granulomatous infiltrate

Question 9

Tx of tuberculosis

Answer 9

• 3/4 antibiotics for 2 months - isoniazid, rimfapicin, pyrazinamide and ethambutol
• 4 months - isoniazid and rimfapicin

Question 10

What is granulomatosis with polyangiitis?

Answer 10

Rare, multisystem chronic granulomatous disease chracterised by granulomatous lesions of the respiratory tract, systemic vasculitis of small arteries and veins and necrotising glomerulonephritis

Question 11

Describe the systems affected by granulomatosis with polyangiitis

Answer 11

• Lungs - pulmonary nodules, infiltrates, cavities, haemoptysis
• Kidney - necrotising glomerulonephritis, CKD
• Joints - arthritis, arthralgia or swelling
• ENT issue - rhinitis, hearing loss, conjunctivitis
• Cutaneous - nodules and purpura
• Nervous system - sensory neuropathy, facial nerve palsy

Question 12

Describe the oral lesions associated with granulomatosis with polyangiitis

Answer 12

• Oral ulcerations on the tongue, BM, gingiva or palate
• Strawberry gingiva
• Tooth mobility and exfoliation
• Poor post op xla healing
• Cranial nerve palsy
• Parotid gland swelling
• Palatal swelling

Question 13

Describe the ulcerations in granulomatosis with polyangiits

Answer 13

• Ulcer-like apthae or diffuse ulcerative stomatitis

Question 14

What is strawberry gingiva?

Answer 14

Type of gingival hyperplasia where the gingiva looks like strawberry skin

Question 15

Ix and diagnosis of granulomatosis with polyangiitis

Answer 15

Biopsies showing granulomatosis infiltrate
CXR showing nodules, fixed infiltrates or cavities
Urine showing RBC
Nasal discharge or oral swellings

Question 16

Tx of granulomatosis with polyangiitis

Answer 16

Initial - cyclophosphamide and prednisolone +/- methotrexate, ritixumab or mycophenolate
Maintainence - methotrexate or azathioprine alongisde prednisolone
Relapse - cyclophosphamide or rituximab with increased prednisolone dose

Question 17

What is oro-facial granulomatosis?

Answer 17

Condition characterised by granulomatous enlargement of the area around the mouth and jaws, in the absence of a recognised systemi condition causing granulomas

Question 18

What is the aetiology of OFG?

Answer 18

Unknown - possibly genetics, microbiome, hypersensitivity, many have atopic background (asthma, hayfever, eczema)

Question 19

Presentation of oro-facial granulomatosis

Answer 19

• Lip enlargement (upper lip, may be unilateral, redness, angular chelitis or lip fissuring due to dryness)
• Intraoral swelling - BM may be thick and lumpy with reduced mouth opening
• Mucosal tags
• Oral ulcerations
• Atypical gingivitis

Question 20

Describe the gingival lesions in oro-facial granulomatosis

Answer 20

• Extends from the free gingival margins to the full depth of the sulcus
• Red or orange (orange peel)
• Maxilla > mandible
• Poor OH, burning and profuse bleeding

Question 21

Ix of oro-facial granulomatosis

Answer 21

• Biopsy (full thickness gingiva OR areas adjacent to ulcerations)
• Clinical activity score - site, activity, type of lesion

Question 22

Link between OFG and crohn’s

Answer 22

Controversial if OFG is its own disorder or just a manifestation of crohns - increased risk of those with OFG developing crohns in their lifetime

Question 23

What is Crohn’s disease

Answer 23

Chronic, inflammatory bowel disease (IBD) that may affect any area of the gastrointestinal tract from the mouth to the anus

Question 24

List the oral manifestations of Crohn’s disease

Answer 24

Aphthous ulcers (linear ulcers in the sulcus are diagnostic)
Cobblestoning of the buccal mucosa 
Fibrous banding scarring 
Mucosal tags 
Erythema 
Xerostomia 
Gingivitis/mucogingivitis 
Inflammation and or abscess in salivary ducts

Question 25

Tx of crohns disease

Answer 25

• Dietarty restrictions
• topical lesions for ulcerations
• intralesional corticosteroids
• DRUGS - immunosuppressants (prednisolone, azathioprine, methotrexate and infliximab) and immunomodulatory (anti-TNFalpha 2,3)