Article
A 45-year-old Caucasian housewife had persistent oral soreness in both buccal (cheek) mucosae and palate for at least a year. She also had myalgia, arthralgia and a cutaneous lesion in her scalp but her medical history was otherwise clear. She had no known allergies. The patient was not on any medication apart from Prednisolone given by a physician for a short period. Her social history included no current tobacco use and no alcohol consumption.
Extra-oral examination revealed a scalp lesion showing hair loss in one site (Figure 1a) but otherwise no significant abnormalities, and specifically cervical lymph node enlargement, or cranial nerve, salivary or temporomandibular joint abnormalities. She had no pyrexia or signs of rheumatoid arthritis.
Oral examination revealed a dentition that was heavily restored. There was clinical evidence of some periodontal attachment loss and minimal pocketing. There was no obvious hyposalivation but in both buccal mucosae there were single ulcers. Each had a characteristic border with radiating white striae in a ‘hairbrush’ or ‘hedgehog’ pattern (Figure 1b). She also had bilateral palatal red lesions (Figure 1c).
Q1. What is the probable clinical diagnosis?
A1. The answer to what is the probable clinical diagnosis?
(c) Lupus erythematosus (LE) is the answer; LE, discoid or systematic, is an auto-immune disease which, although rarely affecting the mouth, shows single or multiple lesions with a white reticular network at the periphery and a central erythematous ulcerative area intermingled with small capillaries. It resembles lichen planus. The presence of cutaneous lesions on the scalp and the patient's history of myalgia and arthralgias and oral characteristics suggest systemic lupus erythematosus (SLE). Biopsy of the skin lesion was consistent with lupus erythematosus. In one study of over 180 patients with SLE, 54% had oral mucosal lesions, the most prevalent lesion being ulceration and the most common region involved the buccal mucosa. Palatal involvement is also common. These ulcerations are typically accompanied by white irradiating striae; or erythematous lesions and white plaques. Patients may suffer Sjögren's syndrome.
(a) Lichen planus is a chronic mucocutaneous disease characterized by white and/or other lesions in the mouth.
(b) Cinnamon-induced stomatitis is caused by the continuous, chronic irritation of the oral mucosa by cinnamon or cinnamon products (eg chewing gums, candies, toothpastes or mouthwashes) and is characterized by a burning or tingling sensation and diffuse erythema and, in severe cases, by superficial ulcerations and white scattered lesions on buccal mucosa and tongue. Our patient had no history of using cinnamon products.
(d) Pemphigoid presents orally as bullae that break easily during mastication, leaving ulcerations.
(e) Chronic ulcerative stomatitis mimics lichen planus with oral ulcerations together with white reticular lesions. It is seen in middle-aged women and characterized by the presence of antinuclear antibodies against stratified squamous epithelium, in basal and parabasal layers.