Int. J.

Oral Surg, 1982: 11: 21-29

(Key words: sarcoidosis: granuloma, epithelioid)

Oral involvement in sarcoidosis

A. C. M. TH. VAN MAARSSEVEEN, I. VAN DER WAAL, J. STAM, R. W. VELDHUIZEN AND

W. A. M. VAN DER KWAST

Departments of Pathology, Pulmonology and Oral Surgery, Free University, Amsterdam, The Netherlands

ABSTRACT - The general aspects of sarcoidosis are presented, as well as some

concepts derived from experimental work. Thereafter, a review of the literature
on oral involvement insarcoidosis isgiven, including thepossible value of an oral
biopsy in the case of suspected sarcoidosis. Finally, 3 patients - 2 with known
sarcoidosis and I with unsuspected sarcoidosis - are presented as a brief
illustration.

(Received for publication 3 March, accepted 21 August 1981)

Sarcoidosis is more common in the third and

fourth decades oflife than in other decades and
has no predilection for sex or races. Figures of
the exact incidence are not available. The
diagnosis is in many cases made as an incidental
finding on the chest film. Sarcoidosis is a
multisystem granulomatous disorder of un-
known etiology. The disease may actually affect
any organ or part of the body. In the past a
relation with tuberculosis was often suggested,
but that hypothesis is nowadays abandoned.
Sarcoidosis is one of the diseases which are
characterized by an abnormal immune re-
sponse, mostly expressed by an impaired cell-
mediated delayed-type hypersensitivity, the
humoral immunity being normal or even
increased. It is most likely that different factors
evoke the response, which is expressed in a
sarcoid granuloma. However, a variety of other
diseases and conditions can cause more or less
similar histopathological findings. A sarcoid
granuloma in the absence of generalized disease
is commonly due to some local condition.
General aspects of sarcoidosis
Organs affected in sarcoidosis
Cutaneous manifestations of sarcoidosis, orig-
inally named "lupus pernio", were first de-
scribed by Besnier in 1889.The first histological
description of the disease was given by Boeck in
1899. In 1914 Schaumann expressed the view
that "lupus pernio" and Boeck's cutaneous
sarcoids were part of the same disease and that
nasal mucosa, tonsils, lymph nodes, con-
junctiva, the lungs and the bones of the hands
could also be affected. Ever since, the disease
sarcoidosis is also known as Besnier-Boeck-
Schaumann disease. Mainly through the work
of LOfgren has bilateral involvement of the
pulmonary hilar lymph nodes been proven to be
an early manifestation of the disease, sometimes
accompanied by erythema nodosum, subfebrile
temperature and general malaise".
Uveoparotitis, as described by HEERFoRDT in
1909, is at present known as a rare manifes-
tation of sarcoidosis". The complete

0300-9785/82/010021-09$02.50/0 © 1982 Munksgaard, Copenhagen

22 VAN MAARSSEVEEN, VAN DER WAAL, STAM, VELDHUIZEN AND VAN DER KWAST
Heerfordt's syndrome consists of uveitis, par-
otitis, fever and facial palsy.
In a review of about 3,700 patients from
different parts of the world suffering from
sarcoidosis, it was observed that the most
frequently affected organs were the lungs and
their lymph nodes, the figure being 80%. The
extra-thoracic lymph nodes were involved in
about 22%, the eyesin 15%,the spleen in 6%, the
central nerve system, the bones and the parotid
glands in about 4% (JAMES et af.2S ) . During the
7th and 8th International Conferences on
Sarcoidosis and Other Granulomatous
Diseases, held in 1976 and 1978 respectively, no
reports of oral involvement in sarcoidosis were
presented, although quite a number of publi-
cations on that subject had been written, mainly
in the literature on oral surgery and oral
pathology.
Histopathologic findings in sarcoidosis
As mentioned before, the sarcoid granuloma is
the histopathologic entity of sarcoidosis. The
sarcoid granuloma consists of a focal collection
of monocyte-derived epithelioid cells (giant
cells) admixed with T-lymphocytes, occasional
plasmacells and fibroblasts (JONES
WILLIAMS'7 ) . At the early stage, the picture
cannot always be distinguished from other local
and generalized chronic granulomatous con-
ditions such as tuberculosis. Occasionally,
central areas with fibrinoid necrosis and a
tendency to hyalinosis are found. In some cases
concentrically or eccentrically laminated
bodies, known as Schaumann bodies, are
found. Also delicate, spidery radiating struc-
tures, known as "asteroid bodies", may be
encountered in sarcoid lesions. These kinds of
structures may also occur in other types of
granulomas and are, therefore, not
pathognomonic",
The first indication of the development of
sarcoidosis may be the appearance of a sarcoid
granuloma in a site where irritatant material has
lain donnant in the tissues. This type of sarcoid
granuloma is not always associated with or
followed by sarcoidosis, but is sufficiently
common to require that every patient with such
a sarcoid reaction be kept under observation for
signs of incipient sarcoidosis.
Sarcoidosis in experimental pathology
The macrophage is part of the mononuclear
phagocytic system. This cell originates as a bone
marrow precursor cell, circulates for a short
time as monocyte, and becomes macrophage
when it enters the tissue, either in a regular way
or by inflammatory stimulation. The suggestion
is made that in sarcoidosis, the mononuclear
cells have an ineffective capacity to react to a
stimulus in a normal way!"!".
There are two categories of granulomas, one
with a high turnover and one with a low
turnover. High turnover granulomas are
characterized by an impressive inflow of mono-
cytes together with an extensive proliferation
rate. The monocytes may disappear quickly by
cell death or by drainage to a lymph node or
may transform ultimately in epithelioid cells,
which may become immobilized in the granu-
loma for months, without proliferation or cell
death. The epithelioid cells orginate from
macrophages, whose capacity for phagocytosis
seems "frustated" 1l.43. There is evidence that
maturation of macrophages into epithelioid
cells is accompanied by a shift from phagocy-
tosis and intracellular digestion to extracellular
secretion of enzymes and mucoproteins. The
multinucleated giant cell, often observed in the
granuloma, has been formed by fusion of
macrophages'":". The suggestion has been
made that young and active macrophages ingest
old and exhausted macrophages, thereby de-
veloping the aspect of giant cells".
Subcutaneous implants in mice showed that
these giant cells are short-lived and disappear
within weeks".
In the low turnover lesions, the macrophage
population is relatively stable and the pheno-
mena just described are much less evident. The
presence of giant cells are scanty in low turnover
and numerous in high turnover granuloma"•.
 ORAL SARCOIDOSIS
To study the pathogenesis of sarcoidosis,
many investigators produced sarcoid-like epi-
thelioid cell granulomas in animals with
"Freund complete adjuvant" with bacteria,
isolated purified cell wall fractions':" or
metals":": Their results suggest that some
components may persist within macrophages
due to ineffective handling, which seems to play
a role in the pathogenesis of the epithelioid cell
granuloma.
Diagnosis and staging
For a long time, biopsy of the subclavicular
lymph node was considered most useful in cases
of suspected sarcoidosis. Nowadays bronchos-
copy is often preferred, since in about 90% of
the patients suffering from sarcoidosis, intra-
thoracal involvement can be demonstrated':'.
The histologic picture of the granuloma is by
itself, as mentioned earlier, insufficient proof of
the diagnosis of sarcoidosis-"; confirmatory
support from the findings of the pulmonologist,
dermatologist or ophthalmologist as well as
from laboratory investigations such as calcium
metabolism (hypercalcaemia) and SACE
(serum angiotensin converting enzyme) is re-
quired", Other supporting evidence includes a
depressed cellmediated immunity, resulting in a
diminished DNCB or negative tuberculin skin
test.
An important diagnostic aid is the Kveim
test, consisting of an intradermal injection of a
reagent prepared from proven sarcoid lym-
phoid tissue. Histological verification for a
positive reaction, consisting of a typical sarcoid
granuloma at the site of inocculation, can be
carried out after 5 or 6 weeks. The value of the
test is dependent upon the quality of the Kveim
antigen and the activity of the disease"-".
A biopsy of apparently healthy oral mucosa
may be of some significance in making a
diagnosis of sarcoidosis, as will be discussed
later.
Based on the chest film, three stages of
sarcoidosis can be distinguished:
stage I: bilateral enlargement of the
23
hilar nodes without pathologic
changes in the lung fields;
stage II: bilateral enlargement of the
hilar lymph nodes with patho-
logic changes in the lung fields
around the hili;
stage III: no enlargement of the lymph
nodes, but extended, sometimes
patchy or stripy, changes in both
lung fields. The patches can join
together and bullae may be
formed.
Treatment
In general, no treatment for sarcoidosis is
necessary, since the natural tendency is towards
healing I 3.24. In stage I a 65% complete, spon-
taneous remission will occur, while in stage II
this happened in 49%. In about half of the
patients of both stages I and II who did not have
a spontaneous regression, cure was obtained
with drug therapy.
In general, the use of corticosteroids seems
only to accelerate the disappearance of de-
tectable signs of sarcoidosis. After a 3-5 year
period, however, no remarkable difference
could be demonstrated between patients who
had been treated with corticosteroids and those
who had not". In some instances sarcoid
granulomas undergo fibrosis and hyalinosis.
Particularly in the lungs, the tendency to
fibrosis has serious consequences for the
pulmonary function. Therefore, corticosteroids
should be administered in cases of sarcoid
lesions producing lung fibrosis. Steroid treat-
ment is also indicated in cases of cardiac or
neural involvement, in spite of the possible
harmful side-effect of that kind of therapy.
Oral involvement in sarcoidosis;
review of the literature and report of
3 cases
In reviewing the literature on oral aspects of'
sarcoidosis, some reports of extraoral involve-
24 VAN MAARSSEVEEN, VAN DER WAAL, STAM, VELDHUIZEN AND VAN DER KWAST
ment, i.e, affected lymph nodes in the head and
neck area, are included.
Patients with already proven sarcoidosis, who
also had lesions in the oral region
In some of the patients with already proven
sarcoidosis, the oral involvement consisted of
one or more nodules in the oral mucosa,
without preference for any specific site 12 •22,40,45.
A few cases have been reported of involvement
ofthejaw bones 4. 2 1,42. Involvement of glandular
structures in the oral cavity is mentioned by
KALMAN 29 as well as by NARANG & DIXON 37. A
decreased level of a-amylase and increased
levels of albumine and lysozyme have been
observed by BEELEY & CHISHOLM2 in parotid
saliva from a patient suffering from sarcoidosis
with salivary gland involvement. These observ-
ations were interpreted as the result of damage
to the gland. Some years earlier the value of
salivary gland function tests in diagnosing
sarcoidosis and in monitoring the response to
possible therapy was described by CHISHOLM et
al. to •
Patients with already proven sarcoidosis in which
an oral biopsy of apparently healthy tissue was
taken
CAHN et al,' have described a group of 23
patients with known sarcoidosis in which
palatal biopsies of clinically normal areas were
performed. They were able to demonstrate the
presence of sarcoid granulomas in 38% of their
cases, TILLMAN'3 described a 66-year-old man
suffering from sarcoidosis. Oral examination
showed a normal aspect of the gingiva.
Nevertheless, a gingival biopsy was performed
to rule out amyloidosis. More-or-less as a
surprise, the microscopic findings were con-
sistent with sarcoidosis. A biopsy of the labial
glands of the lower lip has been reported
positive in a number of patients suffering from
sarcoidosis'v-":". NESSAN & JACOWAY even
found 58% non-caseating granulomas in bio-
psies of the labial glands in a total number of75
patients with known sarcoidosis".
Apparently healthy patients with one or more
sarcoid granulomas in the oral region, in which
additional examination justified the diagnosis of
sarcoidosis
A number of patients have been described in
which an oral lesion, microscopically diagnosed
as a sarcoid granuloma, led to the detection of
generalized sarcoidosisl.,33,44"7, KERR 30 des-
cribed a 20-year-old man with multiple swollen
lymph nodes in the parotid, submental, sub-
mandibular, superficial and deep cervical area.
Roentgenographs of the chest showed enlarge-
ment of nodes in the upper mediastinum. A
submental node was examined microscopically.
The appearence was that of sarcoidosis.
Apparently healthy patients with one or more
sarcoid granulomas in the oral region, in which
the diagnosis ofsarcoidosis could not be proven or
remained somewhat debatable
SCHROFF 46 has described a 48-year-old female
with a swelling of the whole thickness of the
cheek of 4 weeks duration. The lesion was
biopsied and reported as being of tuberculous
nature. All additional tests, chest films and
other examinations were negative for tubercu-
losis, which led the author to suggest the
diagnosis of sarcoid. Several of such cases have
been reported thereafter J,9,2J,JI,54,56.
NITZAN & AZAR 39 have described a 62-year-
old woman with an indurated submandibular
mass, measuring about 3 em. The radiograph
revealed a sialolith in the submandibular gland.
The clinical diagnosis was sialolithiasis. The
submandibular gland was removed together
with a surrounding lymph node. That lymph
node showed the features of sarcoidosis. No
Kveim test was performed. All other exami-
nations were negative for sarcoidosis. The
Mantoux intracutaneous test was negative. The
patient was suffering from migrating arthritic
pain and swellings, xerophthalmia, dyspnea and
hypertension. Because ofthose symptoms it was
felt that this patient, in spite ofnegative findings
elsewhere in the body, suffered from systemic
sarcoidosis. Nitzan and Azar mentioned that
 ORAL SARCOIDOSIS 25

"specific treatment for sarcoidosis was of great

benefit" and considered this another support
for their diagnosis.
ORLIAN & BIRNBAUM 4 ! described a 43-year-
old woman with a lesion in the lower left
anterior mucobuccal fold. There was no evi-
-
dence of bony involvement. Lymphadenopathy
was absent. The microscopic appearance was
consistent with sarcoidosis. Additional exami-
nation for sarcoidosis was negative.

Case reports
Case 1. In May 1980, a 23-year-old man was referred
because of multiple nodules on the hard and soft
palate. The nodules were slightly elevated, measured a
few mm and were of a firm elastic consistency. There
was no ulceration (Fig. 1). The patient had his natural
dentition. Possible irritating factors which could have Fig, 2. The chest film showing bilateral enlargement of
played a role in the initiation of the palatal nodules the hilar lymph nodes without pathological changes in
could not be detected, although heavy smoking may the lung fields.
have been of significance. The duration of the
presence of the nodules was unknown to the patient.
This man was known to suffer from sarcoidosis, the
first clinical manifestations being multiple subcu- The patient will be seen at 3-monthly intervals by the
taneous nodules on his legs and arms. The chest film Department of Pulmonology, The nodules of the
had demonstrated bilateral enlargement of the hilar palate have not shown any change during a 6 months
lymph nodes (Fig. 2). follow-up period.
One of the palatal nodules was biopsied, The
histopathology was compatible with a sarcoid granu- Case 2. In June 1977, a 69-year-old woman was
loma (Fig. 3), Healing of the biopsy wound was referred because of a small submucosal nodule on the
uneventful. No treatment has been instituted so far. tip of the tongue of some months duration. On
palpation, a firm, submucosal, somewhat mobile
nodule was felt. The overlying mucosa was intact. The

Fig, 3, Biopsy specimen of one of the palatal nodules

Fig. 1. Multiple nodules on the palate in a 23-year-old showing rather well-circumscribed epithelioid cell
man suffering from sarcoidosis. granulomas compatible with sarcoidosis (H.E. x 200).
26 VAN MAARSSEVEEN, VAN DER WAAL, STAM, VELDHUIZEN AND VAN DER KWAST
lesion of the tongue was excised and histopathologi-
cally reported as compatible with sarcoidosis.
Additional examination by the Department of
Pulmonology showed the presence of pulmonary
sarcoidosis. The Kveim test proved to be positive (Fig.
4). So far, no treatment has been instituted. In the
following 3 years, up to December 1980, no other
lesions or manifestations appeared.
Case 3. In November 1978, a 25-year-old man was
referred because of a rather well-circumscribed
submandibular swelling on the left side. The patient
had noticed this swelling for about 6 months. The
medical history was essentially negative. A clinical
diagnosis of salivary gland tumor, most likely
pleomorphic adenoma, was made. It was not felt
necessary at that time to carry out additional
diagnostic work-up such as sialography, scintigraphy
or aspiration cytology. Pre-operative physical exami-
nation did not reveal any abnormality. In January
1979, a suprahyoidal approach was chosen to remove
the submandibular tumor. At operation, it was clear
that the submandibular salivary gland was of normal
size and consistency, but that a large lymph node,
measuring about 3 em, was lying lateral to that gland.
A fresh frozen section was performed, showing
sarcoid granulomas in the lymph node (Fig. 5).
Nevertheless, it was decided to complete the excision
of the suprahyoidal triangle. In the surgical specimen,
Fig. 4. Skin biopsy of the forearm 5 weeks after
injection of Kveim's reagent. Notice the many giant
cells (H.E. x 80).
b
Fig. 5. Submandibular lymph node with homoge-
neous replacement of lymphoid tissue by many
characteristic confluent epithelioid cell granulomas
(H.E. x 200).
multiple enlarged nodes were found. Also in those
nodes sarcoid granulomas were seen. The patient was
then referred to the Department ofPulmonology. The
diagnosis of sarcoidosis was confirmed by findings on
the chest film and a positive Kveim test. No palpable
lymph nodes elsewhere in the body could be detected.
No treatment has so far been instituted. During the
two-year follow-up period no other lesions or
manifestations have developed.
A very similar experience has been reported by
MANDEL & BAURMASH'4.
Discussion and conclusions
Sarcoidosis may affect any organ or part of the
body .'Sarcoid lesions seem to be the result of an
impaired mechanism of some of the macrop-
hages, The histologic finding of a sarcoid
granuloma is by itself insufficient proof of the
diagnosis of sarcoidosis and may well be due to
some local condition.
In view of the numerous reports on sar-
coidosis, the incidence of oral involvement, as
extracted from the literature, is rather low. In a
number of papers, evidence of the oral sarcoid
being a manifestation of generalized sarcoidosis
is either not presented or remains somewhat
debatable. Some authors have suggested that
oral sarcoid may not be rare, but probably
remains undiagnosed or unreported.
Two of the patients with oral sarcoid
described in this report were already known to
 ORAL SARCOIDOSIS
suffer from sarcoidosis. The third patient,
however, was apparently healthy. A sub-
mandibular, rather well-circumscribed swelling
was clinically diagnosed as being most likely a
salivary gland tumor. No sialography or
cytologic puncture, nor any additional exami-
nation was felt necessary at that time. The true
nature of the swelling, being an enlarged lymph
node, first became evident at operation, thus
illustrating the limitation of a provisional
diagnosis by clinical judgement only.
There are several reports mentioning the
presence of sarcoid granulomas in biopsies of
apparently normal oral tissue, especially from
the palate and the lower lip, in patients with
proven sarcoidosis. We hesitate, however, to
advocate the use of such biopsies when
gathering supporting evidence for the diagnosis
of sarcoidosis only, since staging of the disease
is usually based upon the radiographic findings
on the chest films. On the other hand, one
should know that an oral sarcoid granuloma
can be an early manifestation of sarcoidosis and
that such a patient should at least be seen by the
pulmonologist for further evaluation.
Acknowledgement - We thank Mrs. M. Mooijen for
her help in preparing the manuscript and Mr. G. J.
Oskam for photography of the histologic slides.
References
1. AMSDEN, A. F. & BOROS, D. L.: Fe-receptor
bearing macrophages isolated from hypersensi-
tivity and foreign-body granulomas. Am. J.
Pathol. 1979: 96: 457-473.
2. BEELEY, J. A. & CHISHOLM, D. M.: Sarcoidosis
with salivary gland involvement: biochemical
studies on parotid saliva. J. Lab. Clin. Med. 1976:
88: 276-281.
3. BERNIER, L. J. & TlECKE, R. W.: Sarcoidosis. J.
Oral Surg. 1951: 9: 256-257.
4. BETTEN, B. & KOPPANG, H. S.: Sarcoidosis with
mandibular involvement; report of a case. Oral
Surg. 1976: 42: 731-737.
5. BHOOLA, K. D.: Changes in salivary enzymes in
patients with sarcoidosis. Oral Surg, 1965: 20:
877-879.
6. BOROS, D. L. & WARREN, K. S.: The bentonite
27
granuloma: characterization of a model system
for infectious and foreign body granulomatous
inflammation using soluble mycobacterial, his-
toplasma and schistosoma antigens. Immunol.
1973: 24: 511-529.
7. CAHN, L. R., EISENBUD, L., BLAKE, M. N. &
STERN, D.: Biopsies of normal-appearing palates
of patients with known sarcoidosis; a preliminary
report. Oral Surg, 1964: 18: 342-345.
8. CAIN, H. & KRAUS, B.: Mehrkcrnige Riesenzellen
in Granulomen. Neu-ordnung der Binnen-
structur nach Konfluenz von Zellen des
Makrophagensystems. Virchows Arch. A. Path.
Anat. und Histol. 1980: 385: 309-333.
9. CAMPBELL, 1.: Sarcoidosis or tuberculosis? Br,
Dent. J. 1944: 77: 159-163.
10. CHISHOLM, D. M., LYELL, A., HARoON, T. S.,
MASON, D. K. & BEELEY, 1. A.: Salivary gland
function in sarcoidosis: report of a case. Oral
Surg, 1971: 31: 766-771.
II. Corrmn, H., HESS, M. W., KELLER, H. D., RODS,
B. & Tosr, P.: Macrophage kinetics and granu-
loma formation. In: Abstracts Int. Siena
Sarcoidosis Symposium. Siena, Italy, 1979.
12. COVEL, E.: Boeck's sarcoid of mucous mem-
brane; report ofa case. Oral Surg, 1954: 7: 1242-
1244.
13. CRETIEN, J.: Course and treatment of sarcoidosis
in 350 patients. 3rd European Conf. on
Sarcoidosis and other granulomatous disorders.
Novi Sad. Jugoslavia, May 1980.
14. DJURIC:, B., MANDl, L. & VEZENDI, S.:
Sarcoidosis in six European cities. In: JONES
WILLIAMS, W. & DAVIES, B. H. (eds.): 81h Int.
Con]. on sarcoidosis and other granulomatous
diseases. Alpha Omega Pub\. Ltd. 1980,527-531.
15. EULE, H., ROTH, 1. & WEIDE, W.: Clinical and
functional results of a controlled clinical trial of
the value of prednisolone therapy in sarcoidosis,
stages I and II. In: JONES WILLIAMS, W. &
DAVIES, B. H. (eds.): Bth Int. Conf. on sarcoidosis
and other granulomatous diseases. Alpha Omega
Publ. Ltd. 1980, 624-628.
16. FRITSCH, P.: Quantification et renouvellement
des cellules des alveoles et bronchioles des
poumon des rats. Thesis. Rapport CEA-R-4947,
1979.
17. GORDON, L. 1., DOUGLAS, S. D. & KAY, N. E.:
Inhibition of neutrophil migration by sarcoid
sera, with partial reversal by trissacharide of N-
acetyl glucosamine, a lysozyme inhibitor. In:
JONES WILLIAMS, W. & DAVIES, B. H. (eds.): 8th
Int. Conf. on sarcoidosis and other granulomatous
diseases. Alpha Omega Publ. Ltd. 1980, 84-88.
18. GREER, R. O. & SANGER, R. G.: Primary intraoral
sarcoidosis. J. Oral Surg. 1977: 35: 507-509.
28 VAN MAARSSEVEEN, VAN DER WAAL, STAM, VELDHUIZEN AND VAN DER KWAST
19. GROSS, N. J. & VALDlMARSON, H.: Ability of a
Iymphokin preparation to mediate delayed hyper-
sensitivity in humans. CUn. Res. 1972: 20: 510.
20. BEERFORDT, C. F.: Ueber eine Febris uveo-
parotidea subchronica an der Glandula parotis
und der Uvea des Auges lokalisiert und haufig mit
Paresen cerebrospinaler Nerven kompliziert.
Arch. Ophth. 1909: 70: 254-273.
21. HILLERUP, S.: Diagnosis of sarcoidosis from oral
manifestation. Int. J. Oral Surg. 1976: 5: 95-99.
22. HOBKIRK, J. A.: Sarcoidosis with oral lesions;
report of case. J. Oral Surg. 1969: 27: 891-894.
23. HOGGINS, G. S. & ALLAN, D.; Sarcoidosis of the
maxillary region. Oral Surg, 1969: 28: 623-627.
24. JAMES, D. G.: Treatment of extra-thoracic
sarcoidosis. 3rd European Conf. on sarcoidosis
and other granulomatous disorders. Novi Sad.
Jugoslavia, May, 1980.
25. JAMES, D. G., NEVILLE, E., SILTZBACH, L. E. &
TURIAF, J.: A worldwide review of sarcoidosis.
In: SILTZBACH, L. E. (ed.): 7th Int. Conf. on
sarcoidosis and other granulomatous disorders.
Ann. New York Acad. of Sci. 1976: 278: 321-334.
26. JONES WILLIAMS, W.: Sarcoidosis -1977. Beitr.
Path. 1977: 160: 325-336.
27. JONES WILLIAMS, W. : The nature and significance
of granulomas in sarcoidosis. In: Abstracts Int.
Siena Sarcoidosis Symposium. Siena, Italy, 1979.
28. JONES WILLIAMS, W., JONES, D. L. & WHITTAKER,
J. L.: Isolated sarcoid-like granulomas in
Hodgkin disease. In: JONES WILLIAMS, W. &
DAVIES, B. H. (eds.): 8th Int. Con! on sarcoidosis
and other granulomatous diseases. Alpha Omega
Pub!. Ltd. 1980,758-763.
29. KALMAN, S. E.: Aberrant gland and sarcoidosis
in the maxillae: report of case. J. Oral Surg. 1954:
12: 63-66.
30. KERR, N. W.: Sarcoidosis. Oral Surg. 1965: 20:
166-173.
31. KOLAS, S. & ROCHE, W. C.: Sarcoidosis lesions
primary in the oral cavity: report of a case. Oral
Surg. 1960: 18: 169-172.
32. LOFGREN, S.: Primary pulmonary sarcoidosis;
early signs and symptoms. Acta Med. Scand.
1953: 145: 424-431.
33. MACDONALD, D. G., ROWAND, R. M. & BLAIR,
G. S.: Sarcoidosis involving the mandible. Br.
Dent. J. 1969: 126: 168-171.
34. MANDEL, L. & BAURMASH, H.: Differentiation of
submaxillary lymphadenopathy and submaxil-
lary gland pathology. Oral Surg, 1962: 15: 3-14.
35. MARIANO, M. & SPECTOR, W. G.: The formation
and properties of macrophage polykaryons (in-
flammatory giant cells). J. Path. 1974: 113: 1-19.
36. MEYER, S., STAM, J_, SIRKS, J. L. & Koov, R.:
Reaction to Kveim-test material in sarcoidosis.
Lancet 1975: 1: 808.
37. NARANG, R. & DIXON, R. A.: Sarcoidosis and
ranula ofasublingual gland. Oral Surg, 1975: 39;
376-381.
38. NESSAN, V. J. &JACOWAY, J. R.: Biopsy of minor
salivary glands in the diagnosis of sarcoidosis.
New Engl. J. Med. 1979: 301: 922-924.
39. NITZAN, D. & AZAR, B.: Submandibular lymph
gland manifestation with unsuspected sar-
coidosis. Oral Surg. 1975: 40: 728-731.
40. ORLEAN, S. L. & O'BRIEN, J. J.: Sarcoidosis
manifesting a soft lesion in the floor ofthe mouth.
Oral Surg, 1966: 21: 819-923.
41. ORLIAN, A. & BIRNBAUM, M.: Intraoral localized
sarcoid lesion. Oral Surg. 1980: 49: 341-343.
42. POE, D. L.: Sarcoidosis of the jaw, a new disease
of the mandible. Am. J. Orthod. 1943: 29: 52-56.
43. PAPADIMITRIOU, J. M. & SPECTOR, W. G.: The
origin, properties and fate of epithelioid cells. J.
Path. 1971: lOS: 187-203.
44. ROCHE, W. c.: Sarcoidosis of sublingual glands:
report of case. J. Oral Surg, 1967: 25: 77-79.
45. SAMITZ, M. H., SATANOVE, A. & KIRSHDAUM, B.:
Sarcoidosis involving the mucous membranes.
A.M.A. Arch. of Derm. and Syph. 1953: 58: 473-
474.
46. SCHROFF, J.: Sarcoid of the face (Besnier-Boeck-
Schaumann disease): report of a case. J. Am.
Dent. Ass. 1942: 29: 2208-2211.
47. SCHULE, B.: Zur Diagnostik und Therapie der
Sarkoidose (M. Boeck). Kiefer-Gesichts-Bereich
F ortschr. Kiefer Gesichtschir, 1970: 14: 225-234.
48. SHELLEY, W. B. & HURLEY, H. J.: The immune
granuloma: late delayed hypersensitivity to zir-
conium and beryllium. In: SAMTER, M. (ed.):
Immunologic Diseases. Little-Brown and Comp.,
Boston 1971: 1: 722-734.
49. SILTZDACH, L. E.: Qualities and behaviour of
satisfactory Kveim suspensions. In: SILTZBACH,
L. E. (ed.): 7th Int. Conf on sarcoidosis and other
granulomatous disorders. Ann. New York Acad.
of Sci. 1976: 278: 665-668.
50. SPECTOR, W. G.: Epithelioid cells, giant cells and
sarcoidosis. In: SILTZBACH, L. E. (ed.): 7th Int.
Conf. on sarcoidosis and other granulomatous
disorders. Ann. New York A cad. of Sci. 1976: 278:
3-6.
51. TANNENBAUM, B., ANDERSON, L. G.,
ROSENBERG, E. H. & SHEFFER, A. L.: Diagnosis of
sarcoidosis by lip biopsy ofminor salivary glands.
CMA J. 1974: 111: 1323-1324.
52. TARPLEY, T. M., ANDERSON, L., LIGHTBODY, P.
& SHEAGREN, 1. N.: Minor salivary gland
involvement in sarcoidosis; report of3 cases. Oral
Surg. 1972: 33: 755-762.
53. TILLMAN, B. H.: Sarcoidosis with unsuspected
 ORAL SARCOIDOSIS 29
oral manifestations; report of a case. Oral Surg. Address:
1964: 18: 130-135.
I. van der Waal,
54. TILLMAN, R. R., TAYLOR, R. G. & CARCHIDI, J.
Pathoiogiscli Instituut
E.: Sarcoidosis of the tongue; report of a case.
Vrije Universiteit
Oral Surg, 1966: 21: 190-195.
De Boelelaaen II17
55. WARFEL, A. R.: Macrophage fusion and multi-
Amsterdam
nucleated giant cell formation; surface mor-
Holland
phology. Exp. Mol. Path. 1978: 28: 163-176.
56. WATTS, K. D.: Sarcoid of the gingiva; a case
report. Br. J. Oral Surg. 1968: 6: 108-113.