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Necrotizing sialometaplasia--a practical approach to the diagnosis.

To the Editor.--I read with great interest the recent case reported by Carlson (1) on a bulimic patient presenting with necrotizing sialometaplasia (NSM) in the hard palate.

It should be emphasized that NSM has also been reported in association with other upper gastrointestinal disorders such as hiatal and umbilical hernia, gastric and duodenal ulcers, esophagitis, dysphagia, and vomiting after silastic ring vertical gastroplasy. (2) One explanation may be attributed to the lowered mucosal pH due to ascending gastric contents. Indeed, the mucosal pH in the oral cavity in 1 case reported was 5.09 6 0.77 compared with 6.72 6 0.22 in a control group. (2,3) Moreover, the use of hands and fingers to provoke gag reflex in bulimia nervosa may also damage the delicate oral mucosal lining. (4)

Carlson (1) also describes the problematic differential pathologic diagnosis of NSM vis-a-vis malignancy. In this respect, I wish to call attention to a recent report by Lee et al (5) that describes a case of NSM accompanied by adenoid cystic carcinoma.

Consequently, in the case of suspected pathology in the palate, particularly in the presence of delayed healing, 3 pivotal steps should be accomplished: (1) complete medical history concerning vomiting (1); (2) imaging techniques, preferably magnetic resonance imaging, (5) to visualize the margins of the lesion; and (3) multiple serial sections and properly oriented tissue section of the specimen accompanied by specific immunohistochemistry markers as mentioned by Carlson. (1)

Doron J. Aframian, DMD, PhD

Salivary Gland Clinic

Department of Oral Medicine

The Hebrew University-Hadassah School of Dental


Jerusalem, Israel 12272

(1.) Carlson DL. Necrotizing sialometaplasia: a practical approach to the diagnosis. Arch Pathol Lab Med. 2009;133(5):692-698.

(2.) Aframian D, Milhem I, Kirsch G, Markitziu A. Necrotizing sialometaplasia after silastic ring vertical gastroplasty: case report and review of literature. ObesSurg. 1995;5(2):179-182.

(3.) Aframian DJ, Davidowitz T, Benoliel R. The distribution of oral mucosal pH values in healthy saliva secretors. Oral Dis. 2006;12(4):420-423.

(4.) Daluiski A, Rahbar B, Meals RA. Russell's sign: subtle hand changes in patients with bulimia nervosa. Clin Orthop Relat Res. 1997;343:107-109.

(5.) Lee DJ, Ahn HK, Koh ES, Rho YS, Chu HR. Necrotizing sialometaplasia accompanied by adenoid cystic carcinoma on the soft palate. Clin Exp Otorhinolaryngol. 2009;2(1):48-51.

The authors have no relevant financial interest in the products or companies described in this article
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Title Annotation:Letters to the Editor
Author:Aframian, Doron J.
Publication:Archives of Pathology & Laboratory Medicine
Article Type:Letter to the editor
Geographic Code:7ISRA
Date:Jan 1, 2010
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