Professional Documents
Culture Documents
Systemic Disease
Oral Manifestation of
Systemic Disease
Presented by Jeff Burgess DDS MSD
Boarded in Oral Medicine
Director – Oral Care Research
Associates
Oral Manifestation of Systemic
Disease
Miller CS, et al: Changing oral care needs
in the United States: The continuing need
for oral medicine. Oral Surg Oral Med
Oral Pathol Oral Radiol Endid 2001;91:34
Results:
•Millions of Americans with medical conditions affecting oral
health
•Age, medical health and treatment, institutional settings
•Orofacial pain, soft tissue lesions, salivary gland and
chemosensory disorders
Oral Manifestation of Systemic
Disease
Miller CS, et al: Changing oral care needs
in the United States: The continuing need
for oral medicine. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2001:34
Oral Manifestation of Systemic
Disease
Evans C, Dushanka K: The surgeon
general’s report on America’s oral health:
opportunities for the dental profession;
JADA, 2000
Thyroid disease
Adrenal abnormality
Diabetes
Crohn’s disease / IBD
Wegener’s Granulomatosis
Renal failure
Drug reaction
Infectious Disease
The Geriatric patient
Oral Manifestation of Systemic
Disease
References
Color Atlas of Clinical Oral Pathology;
Neville, Damm, White; Lippincott Williams
and Wilkins, 1999
Oral and Maxillofacial Pathology; Neville,
Damm Allen Bouquot; W.B. Saunders
Co.,1995
Color Atlas of Oral Diseases; Laskaris;
Thieme Medical Publishers, 1994
Oral Manifestation of Systemic Disease -
Jaundice
Clinical findings - jaundice
Diffuseuniform mucosa yellowing
With specific diseases – other signs
and symptoms
Not to be confused with vitamin A
excess
Oral Manifestation of Systemic Disease -
Lupoid Hepatitis
Active hepatitis of autoimmune origin
Affects young women; rare
Typically renal, arthritic, lung, bowel problems,
hemolytic anemia, amenorrhea
Differential includes
BMMP and plasma
cell gingivitis
Oral Manifestation of Systemic Disease -
Differential: Lupus
erythematosus,
scleroderma and Crest
syndrome
Oral Manifestation of Systemic Disease -
Amyloidosis
A rare metabolic disorder with extracellular
deposition of fibrillary proteinaceous
substance
Divided into primary, secondary, senile,
familial; P and S may involve systemic as well
as local forms; P = men > 50; S follows
neurologic disease, RA, Hodgkin’s, TB, etc
Causes
Multiple causes (secondary - infection, primary -
multiple myeloma, hemodialysis-associated)
Oral Manifestation of Systemic Disease -
Amyloidosis
Diagnosis
Medical workup with serum electrophoresis – for
multiple myeloma
Symptoms
Fatigue, weakness, weight loss, edema, dyspnea,
hoarseness, bleeding, pain, carpal tunnel
syndrome
Signs
Oral: petechiae, papules, nodules, ulcers, tongue
and salivary gland changes
Oral Manifestation of Systemic Disease -
Amyloidosis
Clinical features
Macroglossia from amyloid deposits (waxy papules
and plaques forming nodules)
Tongue and lips Hemorrhagic bulla
Oral Manifestation of Systemic Disease -
Amyloidosis
Clinical features
Xerostomia secondary to salivary
gland destruction
Oral Manifestation of Systemic Disease -
Sarcoidosis
Cause – not known
Depression of cell-mediated immunity
Overactivity of B cells
Epidemiology
Women 20-50/blacks
Noncaseating granulomas
Lymph nodes and lungs
Oral Manifestation of Systemic Disease -
Sarcoidosis
Head and Oral Manifestation
Intra Oral Lesions
Cervical Adenopathy
Jaw Bone Destruction
Sinus Pathology
Dermal lesions
Facial Palsy
Salivary Gland Abnormality
Oral Manifestation of Systemic Disease -
Sarcoidosis
Intra Oral Lesions
Tongue
Buccal mucosa / vestibule
Sarcoidosis
Jaw bone destruction
Maxilla
Mandible including TMJ
Premaxillary/premolar region
Poorly defined lucency without cortical
expansion
Teeth vital
No tooth resorption
Oral Manifestation of Systemic Disease -
Sarcoidosis
Maxillary Osseous Lesion
Oral Manifestation of Systemic Disease -
Sarcoidosis
Osseous Lesions
Pre-treatment (A)
Post-treatment (B)
A
B
Oral Manifestation of Systemic Disease -
Sarcoidosis
Sinus and Salivary Gland
Destruction
Sarcoid sinusitis
Sarcoidosis
Facial Palsy
Associated with Neurosarcoidosis
Affects the 7th cranial nerve
Sarcoidosis
Dermal lesions typically
symmetric
Lip
Nose
Cheeks
Ears
Sarcoidosis
Perioral
Lesions
Oral Manifestation of Systemic Disease -
Sarcoidosis
Symptoms
Non-painful swelling
Denture soreness
Tongue soreness
Painful / swollen gums
Dental pain / tooth loosening
Lower jaw pain
Transient facial paralysis (facial nerve
palsy)
Dry mouth / taste disturbance
Oral Manifestation of Systemic Disease -
Sarcoidosis
Mucosal Lesion Quality
Generally: multiple firm nodules or
papules, raised with irregular borders
Oral Manifestation of Systemic Disease -
Sarcoidosis
Mucosal Lesion Quality
Generally: multiple firm nodules or
papules, raised with irregular borders
Palate: brownish-red, macular, slightly
ulcerated, non-tender lesions resembling
abscess or tumor, soft swelling
Oral Manifestation of Systemic Disease -
Sarcoidosis
Mucosal Lesion Quality
Tongue: broad elevated masses with
indurations
Oral Manifestation of Systemic Disease -
Sarcoidosis
Gums: papillae
redness or nodular
mass
Lip: erythematous
raised lesion / fixed
to mucosa
Oral Manifestation of Systemic Disease -
Sarcoidosis
DentalTreatment
depends on staging of disease
Tooth extraction
Medication
Surgical excision
Management of Secondary effects
Pain, Oral Dryness, periodontal disease,
caries
Oral Manifestation of Systemic Disease -
Vitamin deficiency
Oral complications
A: none (yellowing of mucosa)
B1 (thiamin): beriberi –
neuropathy/cardiovascular - alcoholics
B2 (riboflavin): ariboflavinosis - glossitis,
cheilitis, sore throat, mucosa erythema;
normocytic, normochromic anemia
Vitamin deficiency
B3 (niacin): pellagra – tongue smooth, red,
raw; dermatitis, dementia, diarrhea; in
populations using corn principally
B6 (pyridoxine): cheilitis and glossitis
Antituberculosis drug isoniazid an antogonist
C (ascorbic acid): scurvy – gingival swelling
and spontaneous bleeding, ulcers, tooth
mobility, delayed wound healing
Oral Manifestation of Systemic Disease -
Vitamin deficiency
B2 (riboflavin):
ariboflavinosis
C (ascorbic acid):
scurvy
Oral Manifestation of Systemic Disease -
Vitamin deficiency
Oral complications
D: rickets – fragile bone structure
E: multiple neural abnormalities
K: coagulopathy (prothrombin and clotting
factors)– with gingival bleeding
Malabsorption syndromes
Microflora problems secondary to long term
antiobiotic use; anticoagulant use
Oral Manifestation of Systemic Disease -
Anemia
Iron-deficiency anemia
Plummer-Vinson syndrome
Pernicious anemia
Oral Manifestation of Systemic Disease -
Anemia
Iron-deficiency anemia
General
Causes:
Clinical symptoms:
features: fatigue,
angular tiring,
cheilitis,
palpitations,
Excessive
atrophic lightheadedness,
blood
glossitis lossgeneralized
and lack of
oral
energy
Increased
mucosal demand
atrophy, for red
burning blood cells
sensation,
withDecreased iron intake
Plummer-Vinson - dysphagia
Decreased absorption of iron
Oral Manifestation of Systemic Disease -
Anemia
Plummer-Vinson syndrome: a rare form
of iron-deficiency anemia - considered
premalignant
Characterized by
combination of iron
deficiency anemia,
dysphagia, and oral
lesions; angular cheilitis
and xerostomia common
Oral Manifestation of Systemic Disease -
Anemia
Pernicious anemia
Results from poor absorption of cobalamin
(vitamin B12 - extrinsic factor) because of lack of
intrinsic factor in small intestine (arising from
autoimmune destruction of parietal cells in
stomach, atrophy of mucosa, intestinal resection,
gastric bypass or stapling)
Cobalamin necessary for normal nucleic acid
synthesis with cells multiplying rapidly most
effected – e.g. hemotopoietic cells
Oral Manifestation of Systemic Disease -
Anemia
Can arise from
autoimmune destruction of parietal cells in stomach
atrophy of gastric mucosa
intestinal resection or gastric bypass or stapling
Clinical features:
General: fatigue, weakness, pallor, shortness of breath,
headache, palpatation
Oral symptoms: oral burning of tongue, lips, buccal
mucosa; patchy oral mucosa erythema and atrophy
(tongue)
Oral Manifestation of Systemic Disease -
Pituitary abnormality
Acromegaly
Cause: space occupying mass (adenoma)
Clinical features: headache, effects of increased
growth hormone
macroglossia
Arthritis
Tooth spacing
Hypothyroidism
Decreased levels of thyroid hormone
Primary – related to thyroid gland
Hashimoto’s thyroiditis (autoimmune destruction)
Secondary – related to pituitary abnormality
(lack of TSH)
Clinical features
Lip thickening
tongue enlargement
(from glycosaminoglycans)
In childhood – failure of tooth eruption
Oral Manifestation of Systemic Disease -
Hyperthyroidism
Excess production of thyroid hormone
with increased metabolism
Tumor, pituitary adenoma (increased TSH)
Clinical features
Weight loss, tachycardia, increased
perspiration, warm smooth skin, tremor,
eye protrusion
No obvious oral abnormality
Oral Manifestation of Systemic Disease -
Hypoparathyroidism
Abnormal regulation of calcium due to a
reduced production of parathormone from
the parathyroid glands
Can follow surgery or autoimmune disease
Clinical features
Produces a metabolic alkalosis and tentany
Chvostek’s sign – twitching of upper lip with facial
nerve tapped below zygomatic process
Facial pain
If onset early, pitting enamal hypoplasia or failure
of tooth eruption
Oral Manifestation of Systemic Disease -
Hyperparathyroidism
Increased production of parathyroid
hormone from the parathyroid glands
Adenoma or carcinoma or low calcium (renal disease)
Clinical features
Cortical expansion (palate)
Loss of lamina dura
Dense trabecular pattern
of bone (ground glass)
Brown tumor / central giant cell tumor of the jaws
(unilocular or multilocular densities
Oral Manifestation of Systemic Disease -
Adrenal abnormality
Cushing’s syndrome (increased glucocorticoid
levels)
Young adult women
Moon facies, girsutism, poor healing,
osteoporosis, muscle wasting
Oral Manifestation of Systemic Disease -
Adrenal abnormality
Addison’s disease
Insufficient adrenal
corticosteroid hormones
Causes:
Autoimmune, infection (tuberculosis, Aids),
metastatic tumors, sarcoid, hemochromatosis,
or amyloidosis
Oral Manifestation of Systemic Disease -
Adrenal abnormality
Clinical features: hyperpigmentation of skin
– patchy brown macular pigmentation of
the oral mucosa (may preceed other
pigmentation)
Oral Manifestation of Systemic Disease -
Diabetes mellitus
16 million Americans (1 in 17)
25% over 85 with diabetes
5% with insulin-dependent (Type 1)
Teenage onset
Normal body build
Require insulin
Systemic complications
Clinical signs: polyuria, weight loss, loss of
strength, visual disturbance, skin and other
infections, neuropathies, malaise, hypertension
Oral Manifestation of Systemic Disease -
Diabetes mellitus
Non-insulin-dependent diabetes
(Type II)
Onset after the age of 40 (6.7 %)
Diabetes mellitus
Oral features
Periodontal disease
Delayed healing post surgery
Infection (candidiasis)
Xerostomia
Diabetes Care
Dentistry
From:
Today, March 2001
Oral Manifestation of Systemic Disease -
Diabetes mellitus
Major mediators – Periodontal disease
Low pro/low high inflamatory mediators
Metabolic dysregulation
Hyperglycemia
Effect on systemic disease
Measurement
HbA1c >6-8 mod to severe (kits available)
Amerihealth
Cytokine measurement
Oral Manifestation of Systemic Disease -
Diabetes mellitus
Infection
Alters glucose metabolism (increased
insulin resistance/glycemic control)
Concurrent risk factors
Diabetes mellitus
Management
Considerations: elevation of blood
glucose/alterations in lipid and protein
synthesis/ insulin control
Uncontrolled diabetes associated with
increased risk of periodontal disease
Increased risk of loss of attachment and bone
loss
? Does periodontal treatment alter glycemic
control
Oral Manifestation of Systemic Disease -
Diabetes mellitus
Management – continued
With periodontal disease Doxycycline +
prophylaxis has effect on disease process (not
with all diabetics)
Clinical:
Thorough history
Hypertension (coronary hypertension)
Get labs (HbA1c) <6 or lower
Number of hypoglycemic instances
Oral complaints/findings (e.g. dry mouth, candidiasis,
dyesthesias, periodontal pain)
Oral Manifestation of Systemic Disease -
Diabetes mellitus
Treat the periodontal disease first
Helps to determine if patient will do well with other
procedures such as extractions, etc.
Antibiotics should not be used routinely
Schedule patients in the AM
Make sure that there is adequate diet consultation
Adequately manage post op pain
Be prepared for medical emergencies
– Confusion, altered conversation, lethargy
– Hunger, nausea, increased mobility
Oral Manifestation of Systemic Disease -
Diabetes mellitus
Management – cont.
Sympathetic involvement
Have orange juice on hand
Water with 75-100mg of sugar
Diabetes mellitus
Practice management systems
Prepare: know the family, diagnosis and plan,
timing of procedures
Patients need more time for evaluation/taking of
history/consultation with medical personnel
Examination must include a complete periodontal
assessment including imaging
More preventative care
Use three appointment schedule (second appointment
strictly to review preventative aspects of disease)
Seen more often for restorative care/assessment
of caries
Oral Manifestation of Systemic Disease -
Diabetes mellitus
Practice management systems:
Multiple appointments and shorter
appointments
Consider possibility of complications
Oral Manifestation of Systemic Disease -
Diabetes mellitus
41 million with pre-diabetes
40% increase last 10 years
Utilize hygenist consultation with
patient
In-office glucometer by hygenist/vital
signs, etc. – pre treatment to assess
control; mention of ancillary measures
such as foot or eye care
Oral Manifestation of Systemic Disease -
Crohn’s Disease
Inflammatory, immune mediated bowel
disease
Oral features
May precede GI lesions in 30% of cases
Diffuse or nodular swelling or oral and perioral tissue with
surface cobblestone appearing
Deep granulomatous ulcers, linear, Buccal mucosa
Soft tissue swellings similar to denture-related fibrous
hyperplasia
Metallic dysgeusia
Oral lesions significant because they may predate GI lesions
Oral Manifestation of Systemic Disease -
Crohn’s Disease
Cobblestone
appearance of buccal
mucosa; also gingival Lip swelling
erythema and swelling
Differential: cheilitis
granulomatosa, sarcoidosis
Oral Manifestation of Systemic Disease -
Crohn’s Disease
Hyperplastic fold lower
labial vestibule +
generalized cobblestone like
appearance of gingiva
Pyostomatitis
Vegetans
Significance: Oral sign of
inflammatory bowel
disease: Ulcerative colitis
Multiple yellowish pustular or Crohn’s
lesions, 2-3 mm, on facial
gingiva, vestibule and In: Neville, Damm, White:
Color Atlas of Clinical Oral
buccolabial mucosa Pathology
Oral Manifestation of Systemic Disease -
Wegener’s Granulomatosis
Multisystem inflammatory disease
Necrotizing and granulomatous vasculitis
Lung and renal involvement
Insidious onset: wt loss, fatigue, fever
Sinusitis, rhinitis, nasal obstruction, oral
lesions
Granulomatous/bubbly surface; purple/red;
fragile tissue
Skin lesions in 50% cases; lung and salivary
gland
Oral Manifestation of Systemic Disease -
Wegener’s Granulomatosis
Differential: lymphoma,
leukemia, squamous cell In: Laskaris, Color Atlas
carcinoma, tuberculous ulcers, of Oral Diseases
midline lethal granuloma, and
systemic mycoses
Oral Manifestation of Systemic Disease –
Renal failure
Uremic Stomatitis
Metabolic disorder – nitrogenous waste in
blood
Two forms: ulcerative stomatitis,
nonulcerative stomatitis
Xerostomia, uriniferous breath, unpleasant
taste, oral bleeding
Oral Manifestation of Systemic Disease –
Renal failure
Uremic Stomatitis
Drug reaction
Stomatitis secondary to metal
Stomatitis secondary to antibiotic
Stomatitis/ulceration secondary to
antimetabolites
Gingival hyperplasias secondary to
immunosuppressive, antiepileptic and
calcium channel blocking drugs
Oral Manifestation of Systemic Disease –
Drug reaction
Stomatitis secondary to metal
Reaction of gold
compound used in
treatment of
rheumatoid arthritis
Drug reaction
Stomatitis secondary to antibiotic
Drug reaction
Stomatitis secondary to systemic
medication
Diffuse erythema of
intra-oral mucosa with
purpuric patches,
vesicles, erosions,
ulcers; follows drug use
Drug reaction
Stomatitis secondary to antimetabolites
Azathioprine Methotrexate
Lesions typically appear 2-3 weeks post initiation of
drug
Oral Manifestation of Systemic Disease –
Drug reaction
Angioedema
Drug reaction
Allergic reaction: inherited
form associated with C1
esterase inhibitor
deficiency
Angioedema Direct: mast cells or IGE
Drug reaction
Pigmentation secondary to drug use
Reaction to Chloroquine, an
antimalarial used to treat
rheumatoid arthritis and lupus
Drug reaction
Cheilitis arising from synthetic
retinoids Synthetic retinoids are used as
therapy for a variety of skin
disorders (e.g. psoriasis, acne
vulgaris, lichen planus,
mycosis fungoides
Risk of teratogenicity high –
Clinical signs: cracking of the corners of
avoid in child bearing age women the mouth, patchy lip erythema, lip scaling
Infectious Disease
AIDS (HIV)
Tuberculosis
Lyme disease
Acquired
Immunodeficiency
Syndrome (AIDS)
Acquired Immunodeficiency
Syndrome (AIDS)
Candidiasis in
AIDS responds best to
ketoconazole,
fluconazole, and
itraconazole versus
nystatin, clotrimazole
and amphiotericin B
Control for xerostomia
Acquired Immunodeficiency
Syndrome (AIDS)
Histoplasmosis –
5% of AIDS patients in
endemic areas (Ohio
and Mississippi river
valleys)
Nodular, ulcerative,
granular lesions of
mucosal surface
Often disseminated or
pulmonary disease
Acquired Immunodeficiency
Syndrome (AIDS)
Periodontal Conditions
ANUG
Periodontitis
Acquired Immunodeficiency
Syndrome (AIDS)
Aphthous Ulcers
Herpes Simplex
Human
Palpillomavirus
HPV often found in AIDS
Acquired Immunodeficiency
Syndrome (AIDS)
Cytopathologic
atypia
Single or multiple non-painful
exophytic lesions with broad base,
whitened surface
Acquired Immunodeficiency
Syndrome (AIDS)
Hairy
Leukoplakia
Tongue signs often found
in AIDS
Acquired Immunodeficiency
Syndrome (AIDS)
Malignancy
Kaposi’s Sarcoma
Acquired Immunodeficiency
Syndrome (AIDS)
Kaposi’s sarcoma 80%
of all cancers in AIDS
Oral, skin, visceral
lesions (independent
presentation)
Two thirds with oral
lesions
Tumors flat or elevated
and discolored
black/blue
Associated with pain,
dysphagia, bleeding,
mastication problems
Oral Manifestation of Systemic Disease - Infectious Disease
Tuberculosis
Tuberculosis
Mycobacterium
tuberculosis spread
through airborn droplets
Less than 5% progress
to active disease
Intraoral manifestation
rare
Most common site is
posterior tongue – as
an ulceration
Slow increase in size
Oral Manifestation of Systemic Disease - Infectious Disease
Lyme Disease
Lyme Disease
Primarily associated with TMD
Arthritis
Facial pain localized to the jaw joint
Oral Manifestation of Systemic Disease - Infectious Disease
Viral Infection
•Herpes I and II
•Herpes Zoster
•Herpangina
Herpes Simplex
Multifocal vesicles that rupture and
coalesce with adjacent erythema
Severe pain with dysphasia,
hypersalivation
Primary and secondary lesions
Herpes Simplex
Type I and II
Type one in 70% of population by
middle age (most cases subclinical)
Initial symptoms fever and
lymphadenopathy – then diffuse
involvement of the intra-oral mucosa
(attached and unattached gingiva)
Malaise, irritability, headache
Herpes Zoster
Reactivation of varicella-zoster (chicken
pox) virus
Primarily effects persons 50 or older
(10-20%)
Intraoral lesions rare but do occur
Initial sensation is tingling/burning
followed by multiple vesicles distributed
unilaterally (V1 and V2)
Herpes Zoster
Oral
Presentation
Herpes Zoster
Vesicles rupture and ulcerate with pain
Healing is without scarring
Post-herpetic neuralgia can be a
complication
Increased prevalence 60+
Most cases resolve within one year
Fungal Infection
Fungal Infection
Opportunistic fungal infection from several
organisms:
Zygomycetes
Advanced malignancy, diabetic acidosis
Lungs, nasal sinuses, GI
Pain, swelling, nasal obstruction, and if palate -
significant necrosis
Aspergillus
Four types; mycetoma can occur in sinus post
endodontic treatment with extrusion of material into the
sinus; invasive also in sinus with bone destruction – post
BMT or chemotherapy
Fungal Infection
Blastomyces dermatitidis
Primairly a lung problem with oral lesions rare
Candida albicans
Variety of clinical manifestations
Will occur in the absence of immunosuppresion
and without dissemination
Local factors may contribute to infection
– Dry mouth
– Poorly fitting dentures
Fungal Infection
Symptoms
Diffuse burning sensation
Cracks at corners of the mouth with
bleeding during full opening
Taste change (metallic)
Dysphagia
Systemic complaints
Fungal Infection
Time to be concerned with I/O fungal
infection:
Young age and otherwise healthy
Old age and otherwise healthy
Pulmonary/sinus involvement
Recurrent and resistant to therapy
Aggressive disease (bone loss, etc)
Consider diabetes mellitus, malignancy, or
immunosuppressive disease
Oral Manifestation of Systemic Disease -
Bacterial endocarditis
Cirrhosis
Neoplasm
Oral Manifestation of Systemic Disease -
Tuberculosis
Pneumonia
Apnea
Oral Manifestation of Systemic Disease -
Xerostomia
Sjogren Syndrome
Xerostomia
Functions of Saliva
• Protection from microbial invasion or overgrowth
•Soft tissue lubrication & hydration
• Buffering
• Remineralization
• Taste
• Speech
• Swallowing
Saliva’s Protective Proteins
Oral Antimicrobial Proteins
1. Adaptive (immune) - sIgA
2. Innate (constitutive) - lactoferrin, lysozyme,
etc.
3. Examples of newer proteins:
•Antifungal properties
•cidal/static activity against 9 Candida sp.
•effective against azole-resistant strains
•possible mouthrinse or gene therapy
Salivary Peptides - 2
•DEFENSINS
•CAPs (cationic antimicrobial peptides)
•Broad spectrum natural antibiotics
•Widespread dermal/epidermal production
(GI, airway, skin, gingivae, saliva)
Benzodiazepine Sedatives
Antiparkinson Medications
SSRI Antidepressants
Low Potential Antihypertensives
Diuretics
NSAIDs
Normal Flow Rates
Secretion rate:
(ml/min) v. low low nrl.