8: Immune-Mediated, Autoimmune, and Granulomatous Conditions

8 Immune-Mediated, Autoimmune, and Granulomatous Conditions

Granulomatous Inflammation

True granulomas are collections of epithelioid histiocytes with variable inflammation and giant cells. Necrotizing granulomas are often seen in infectious processes and diseases of collagen degradation and necrobiosis. Table 8-1 lists the common granulomatous processes affecting the oral cavity; those caused by infections are discussed in Chapter 4.

TABLE 8-1 Types of Granulomatous Inflammation

Granulomatous Inflammation Distinguishing Features
Foreign body granuloma Refractile or nonrefractile foreign material present; sometimes foreign material not identified
Intrinsic (e.g., ruptured hair follicle, cholesterol, keratin) History of trauma or introduction of foreign material
Extrinsic Dermal filler, amalgam
Bacterial infection (e.g., Bartonella henselae) Warthin-Starry stain
Mycobacterial infection (often necrotizing) Acid-fast bacillus or Fite stain
Spirochetal infection (e.g., tertiary syphilis gumma) Warthin-Starry, Dieterle, or modified Steiner stain
Deep fungal infections Methenamine silver or PAS stain; may see pseudoepitheliomatous hyperplasia
Sarcoidosis Hilar lymphadenopathy, elevated ACE levels
Crohn disease Gastrointestinal symptoms, positive endoscopic findings
Orofacial granulomatosis Idopathic or related to Crohn disease
Wegener granulomatosis Upper respiratory or renal findings, c-ANCA positive
Lichenoid granulomatous inflammation Coexisting lichenoid stomatitis
Palisaded granulomas (e.g., rheumatoid nodule) History of rheumatoid arthritis or necrobiotic disease

ACE, Angiotensin converting enzyme; c-ANCA, cytoplasmic antineutrophil cytoplasmic antibodies; PAS, periodic acid–Schiff.

Foreign Body Granulomas

Etiopathogenesis and Histopathologic Features

Extrinsic foreign material introduced accidentally (e.g., glass or amalgam filling material) or intentionally (e.g., dermal fillers) excites a histiocytic response. Though generally resorbed, dermal fillers may migrate to sites, distant from the original injection. Foreign body granulomas also form as a reaction to endogenous substances, such as cholesterol from cell membranes, keratin (ruptured epidermal inclusion cysts), and hair (ruptured hair follicle).

Orofacial Granulomatosis and Crohn Disease

Orofacial granulomatosis may be idiopathic or the first sign of Crohn disease.


Abraham C, Cho JH. Inflammatory bowel disease. N Engl J Med. 2009;361:2068-2078.

Al Johani KA, Moles DR, Hodgson TA, et al. Orofacial granulomatosis: clinical features and long-term outcome of therapy. J Am Acad Dermatol. 2010;62:611-620.

Dupuy A, Cosnes J, Revuz J, et al. Oral Crohn disease: clinical characteristics and long-term follow-up of 9 cases. Arch Dermatol. 1999;135:439-442.

Grave B, McCullough M, Wiesenfeld D. Orofacial granulomatosis—a 20-year review. Oral Dis. 2009;15:46-51.

Harty S, Fleming P, Rowland M, et al. A prospective study of the oral manifestations of Crohn’s disease. Clin Gastroenterol Hepatol. 2005;3:886-891.

Hegarty A, Hodgson T, Porter S. Thalidomide for the treatment of recalcitrant oral Crohn’s disease and orofacial granulomatosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;95:576-585.

Lourenco SV, Hussein TP, Bologna SB, et al. Oral manifestations of inflammatory bowel disease: a review based on the observation of six cases. J Eur Acad Dermatol Venereol. 2010;24:204-207.

Plauth M, Jenss H, Meyle J. Oral manifestations of Crohn’s disease. J Clin Gastroenterol. 1991;13:29-37.

Saalman R, Mattsson U, Jontell M. Orofacial granulomatosis in childhood—a clinical entity that may indicate Crohn’s disease as well as food allergy. Acta Paediatr. 2009;98:1162-1167.

Tabak L, Agirbas E, Yilmazbayhan D, et al. The value of labial biopsy in the differentiation of sarcoidosis from tuberculosis. Sarcoidosis Vasc Diffuse Lung Dis. 2001;18:191-195.

Tilakaratne WM, Freysdottir J, Fortune F. Orofacial granulomatosis: review on aetiology and pathogenesis. J Oral Pathol Med. 2008;37:191-195.

Pyostomatitis Vegetans

Immune-Mediated Conditions

Benign Migratory Glossitis (Migratory Stomatitis; Geographic Tongue, Erythema Areata Migrans)

Jan 12, 2015 | Posted by in Oral and Maxillofacial Pathology | Comments Off on 8: Immune-Mediated, Autoimmune, and Granulomatous Conditions
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