• No.

Is medical consult advised?

• No (assuming patient/client is already under medical care for sarcoidosis and has no oral lesions).

• Possibly, but not typically.

Is medical consult advised?

• Possibly (depends on severity and level of control of the disease, including the presence/absence of oral lesions).

Is medical clearance required?

• Possibly (e.g., if the disease is poorly controlled or worsening and/or there are active oral lesions). Also, medical clearance may be required if patient/client is being treated with medications associated with immunosuppression¹ +/- increased risk of infection (e.g., corticosteroids [e.g., prednisone], azathioprine, methotrexate, leflunomide, cyclophosphamide, mycophenolate, cyclosporine, biologic response modifier drugs [e.g., rituximab and anti-tumour necrosis factor drugs — anti-TNFs — such as infliximab and adalimumab], etc.).

Is antibiotic prophylaxis required?

• No, not typically (although extended use of corticosteroids may warrant consideration of antibiotic prophylaxis).

Is postponing treatment advised?

• Possibly, but not typically (depends on severity and level of control of disease, including presence/absence of oral lesions, as well as medical clearance for patients/clients on medications associated with immunosuppression).

• While oral involvement is relatively rare, the dental hygienist should be alert for mouth lesions (and salivary gland swelling) in patients/clients with previously diagnosed sarcoidosis. Oral involvement generally appears in patients/clients with chronic multisystem sarcoidosis and seldom occurs in the acute stage, although occasionally oral lesions are the first, or only, manifestation of disease.
• Chronic and/or high dose use of corticosteroids by patients/clients with sarcoidosis can lead to suppression of adrenal function and reduce ability to withstand stress.

• Oral soft tissue lesions may closely resemble granulomatous oral lesions of Crohn’s disease.
• Oral lesions may appear as non-tender, well circumscribed brownish red or violaceous swellings; as papules; or as submucosal nodules that occasionally show superficial ulceration and/or may be symptomatic. They may be solitary or multifocal, involving one or more of the buccal mucosa, gingiva, hard palate, floor of mouth, tongue, and lips. The tongue and lips tend to be affected most often.
• Gingival involvement tends to present as erythematous hyperplasia, although gingival recession also occurs.
• Tongue involvement may be associated with discomfort during eating or drinking.
• The salivary glands — parotid, submandibular, and sublingual — are sometimes affected by granuloma formation, and the parotid glands in particular may be swollen². Swelling may be unilateral or bilateral.
• Xerostomia may result from salivary gland involvement.
• Interosseous manifestations of the mandible and maxilla usually present as lytic lesions, which can lead to tooth mobility, localization of pain to ears, or non-healing sockets.
• Dysphagia can result from oropharyngeal/laryngeal involvement.

• Sarcoidosis is a disease of autoimmune or hypersensitivity etiology that affects about 1 in every 10,000 persons. It usually manifests in persons between the ages of 20 and 40 years³, and it is rare in childhood. It is more common in women than men, and it occurs at an elevated rate among persons of African and northern European descent. While the specific cause(s) are unknown, some persons appear to have a genetic predisposition to the disease, which may be triggered by dust, chemicals, bacteria, or viruses. There is no cure, although spontaneous remission is common and more than half of affected persons eventually appear to rid themselves of the disease.
• Similar to other autoimmune conditions, the body’s immune system attacks its own tissues and organs. While sarcoidosis can attack any organ or tissue, it most frequently begins in the lungs (with > 90% of patients/clients ultimately having pulmonary involvement), lymph nodes (especially in the chest cavity), and/or the skin (with about 25% of patients/clients ultimately having dermatologic involvement).
• Sarcoidosis causes non-necrotizing granulomas (i.e., patches or nodules of red, swollen tissue caused by inflamed cells) to develop in the organs of the body. General signs/symptoms include fatigue, fever, and weight loss. Characteristic signs/symptoms include shortness of breath; persistent dry cough; chest pain; tender, swollen lymph nodes in face, neck, armpits, or groin; tender, red, and sometimes warm, bumps or patches on the skin (particularly the shins and ankles)⁴; and scaly rashes on the upper body. Nodules may occur around scars or tattoos. Sarcoidosis may also affect the eyes⁵ and liver and, less frequently, the heart, spleen, nerves, brain, tear glands, joints, bones, and larynx.
• Depending on the degree of organ involvement beyond the lungs, lymph nodes, and skin, signs/symptoms might also include: painful joints; cardiac dysrhythmias; syncope of cardiac origin; bone pain; kidney stones (which can cause back pain); headache; and nasal blockage or stuffiness.
• Hoarse voice and/or dysphagia are harbingers of laryngeal sarcoidosis.
• Nervous system effects include hearing loss, seizures, and psychiatric disorders (e.g., dementia, depression, or psychosis).
• Most patients/clients with sarcoidosis develop signs/symptoms suddenly. However, affected persons usually improve and achieve remission without treatment within several months to years. (More than half of persons who have sarcoidosis have remission within 3 years of diagnosis.) This is known as acute sarcoidosis.
• For a minority of affected persons, symptomatology worsens over time as they develop chronic sarcoidosis.
• Some affected persons are asymptomatic, with diagnosis of pulmonary sarcoidosis only occurring after a chest X-ray for an unrelated reason.
• Lofgren’s syndrome is a classic set of signs and symptoms that is typical of some persons who have sarcoidosis; namely, fever, enlarged lymph nodes, arthritis (usually in the ankles), and/or erythema nodosum.
• Children younger than 4 years old may have a distinct form of sarcoidosis. It is characterized by enlarged lymph nodes in the chest (which can be seen on a chest X-ray), skin lesions, and eye swelling or redness.
• Management options range from lifestyle changes⁶ and over-the-counter analgesics (such as acetaminophen and ibuprofen) to prescribed corticosteroids (which reduce inflammation and scarring of affected organs) to antimalarial drugs (e.g., chloroquine and hydroxychloroquine) to immunosuppressant therapy.
• Sarcoidosis leads to organ damage in about 1/3 of patients/clients diagnosed with the disease. Long-term complications include pulmonary fibrosis (permanent scarring of the lungs)⁷, chronic renal failure, paralysis (for example, of the face due to inflammation of the facial nerves), lupus pernio (a serious skin condition in which disfiguring sores affect the nose, nasal passages, cheeks, ears, eyelids, and fingers), and, rarely, death (usually the result of lung, heart, or brain involvement).
• Osteoporosis is a complication of prolonged corticosteroid use.

• Koutrakis NE, Sahu A, Peters SM. Orofacial sarcoidosis: report of three cases. J Oral Med Oral Surg. 2022;28(3):article 29.
  https://www.jomos.org/articles/mbcb/full_html/2022/03/mbcb210228/mbcb210228.html
• Kolokotronis AE, Belazi MA, Haidemenos G, Zaraboukas TK, Antoniades DZ. Sarcoidosis: oral and perioral manifestations. Hippokratia. 2009;13(2):119-121.
  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2683456/
• Iannuzzi MC, Rybicki BA, Teirstein AS. Sarcoidosis. N Engl J Med 2007;(357):2153-2165.
  http://www.nejm.org/doi/full/10.1056/NEJMra071714
• Beegle SH, Barba K, Gobunsuy R, Judson MA. Current and emerging pharmacological treatments for sarcoidosis: a review. Drug Design, Development and Therapy. 2013;7:325-338. doi:10.2147/DDDT.S31064.
  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3627473/
• Canadian Centre for Occupational Health and Safety
  https://www.ccohs.ca/oshanswers/diseases/sarcoido.html
• National Heart, Lung and Blood Institute, National Institutes of Health
  https://www.nhlbi.nih.gov/health-topics/sarcoidosis
• National Institute for Health and Care Excellence
  https://www.nice.org.uk/advice/es2/resources/pulmonary-sarcoidosis-infliximab-pdf-32171319493
• National Health Service
  https://www.nhs.uk/conditions/sarcoidosis/
• Mayo Clinic
  https://www.mayoclinic.org/diseases-conditions/sarcoidosis/symptoms-causes/syc-20350358
• WebMD
  https://www.webmd.com/lung/arthritis-sarcoidosis#1
• Regezi JA, Sciubba JJ, and Jordan RCK.  Oral Pathology: Clinical Pathologic Correlations (7^th edition).  St. Louis:  Elsevier; 2017.

¹ The antimalarial drugs chloroquine and hydroxychloroquine are also sometimes used as immunomodulators in the treatment of sarcoidosis. Their major side effect is retinopathy.
² When parotid gland enlargement is associated with ocular disease, facial nerve palsy, and low grade fever, the condition is referred to as uveoparotid fever or Heerfordt syndrome.
³ Diagnostic tests vary according to which organs are affected. For suspected pulmonary sarcoidosis, a chest X-ray or computerized tomography (CT) scan may be employed along with endoscopic biopsy (i.e., bronchoscopy) and lung function studies. For other organ involvement — such as the skin, heart, or eyes — various examinations, scans, and biopsies will usually be carried out.
⁴ These skin lesions are known as erythema nodosum.
⁵ Eye involvement may be asymptomatic or manifest as eye pain, blurred vision, sensitivity to light, and conjunctival redness. Inflammation can eventually cause blindness, and rarely sarcoidosis can lead to cataracts and glaucoma.
⁶ Lifestyle measures typically recommended include: stopping smoking; avoiding exposure to dust, chemicals, fumes, and toxic gases; eating a healthy diet; and getting plenty of exercise and sleep.
⁷ 20% to 30% of patients/clients experience permanent lung damage.

* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.