oral manifestation of systemic disease
DESCRIPTION
This lecture was delivered to multiple dental study groups, hospital rounds, and the AGD of HawaiiTRANSCRIPT
Oral Manifestation of 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
Design: review article with data analyzed from Health and
Nutrition Examination Surveys, the National Center for Health
Statistics, National Health Interview Survey Series 94-97,
American Cancer Society, National Cancer Institute,
Morbidity and Mortality Weekly Reports and peer reviewed
articles from PubMed and Medline
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
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
Most common diseases among 5-17 year-olds, 1996:
* Caries 58.6%
* Asthma 11.1%
* Hay fever 8.0%
* Chronic Bronchitis 4.2%
Oral Manifestation of Systemic Disease
Liver disease
Amyloidosis
Sarcoidosis
Vitamin deficiency
Anemias
Pituitary disease
Allergy
Autoimmune disease
Conditions
To Be
Covered
Oral Manifestation of Systemic Disease
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 -
Liver Disease -Jaundice
Cause Excess bilirubin
Increased production (autoimmune hemolytic anemia or sickle cell anemia)
Liver dysfunction
– Hepatocyte necrosis or disturbance bile canaliculi (gallstones, stricture from cancer, etc)
– Viral infection
– Toxins (alcohol)
Oral Manifestation of Systemic Disease -
Jaundice
Clinical findings - jaundice
Diffuse uniform mucosa yellowing
With specific diseases – other signsand symptoms
Not to be confused with vitamin Aexcess
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 -
Primary Biliary Cirrhosis
Autoimmune disease, women 40+
Jaundice, pruritus, cutaneous xanthomas
Late stage: portal hypertension and sequelae of cirrhosis
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 knownDepression of cell-mediated immunity
Overactivity of B cells
EpidemiologyWomen 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
Gingiva with periodontitis
Abnormal healing of extraction sites
Minor salivary glands
Oral Manifestation of Systemic Disease -
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
Para nasal sinuses
Parotid enlargement (bilateral, firm, painless)
Oral Manifestation of Systemic Disease -
Sarcoidosis
Facial Palsy
Associated with Neurosarcoidosis
Affects the 7th cranial nerve
Results in abnormality associated with muscles of facial expression
Signs include a drooping of the face on side of involvement
Oral Manifestation of Systemic Disease -
Sarcoidosis
Dermal lesions typically
symmetric
Lip
Nose
Cheeks
Ears
Sarcoidosis
Perioral Lesions
Oral Manifestation of Systemic Disease -
SarcoidosisSymptoms
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 -
SarcoidosisMucosal Lesion Quality Generally: multiple firm nodules or
papules, raised with irregular borders
Oral Manifestation of Systemic Disease -
SarcoidosisMucosal 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 -
SarcoidosisMucosal 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 -
SarcoidosisDental Treatment
depends on staging of disease Tooth extraction
Medication
Surgical excision
Management of Secondary effectsPain, 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
Clinical features: angular cheilitis, atrophic glossitis and generalized oral mucosal atrophy, burning sensation, with Plummer-Vinson - dysphagia
Causes: Excessive blood loss
Increased demand for red blood cells
Decreased iron intake
Decreased absorption of iron
General symptoms: fatigue, tiring, palpitations, lightheadedness, lack of energy
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
Hypertrophy of the soft palate with sleep apnea
Coarse facial appearance (mandible prognathism with anterior open bite
Oral Manifestation of Systemic Disease -
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
Causes:Autoimmune, infection (tuberculosis, Aids), metastatic tumors, sarcoid, hemochromatosis, or amyloidosis
Addison’s diseaseInsufficient adrenal corticosteroid hormones
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 %)
Associated with obesity
Most Type II cases do not need insulin
Onset is slow and complications less likely
Oral Manifestation of Systemic Disease -
Diabetes mellitus
Oral features
Periodontal disease
Delayed healing post surgery
Infection (candidiasis)
Nontender, bilateral parotid enlargement
Benign migratory glossitis
Xerostomia
Diabetes Care
From: Dentistry
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
Presence of other systemic diseases
Oral Manifestation of Systemic Disease -
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
With implants - success is the same in controlled diabetic as non-diabetic
Oral Manifestation of Systemic Disease -
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
Lip swelling
Cobblestone
appearance of buccal
mucosa; also gingival
erythema and swelling
Differential: cheilitis
granulomatosa, sarcoidosis
Oral Manifestation of Systemic Disease -
Crohn’s DiseaseHyperplastic fold lower
labial vestibule +
generalized cobblestone like
appearance of gingiva
In: Neville, Damm, White:
Color Atlas of Clinical Oral
Pathology
Oral Manifestation of Systemic Disease -
Inflammatory Bowel Disease
Multiple yellowish pustular
lesions, 2-3 mm, on facial
gingiva, vestibule and
buccolabial mucosa
In: Neville, Damm, White:
Color Atlas of Clinical Oral
Pathology
Pyostomatitis
Vegetans
Significance: Oral sign of
inflammatory bowel
disease: Ulcerative colitis
or Crohn’s
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
In: Laskaris, Color Atlas
of Oral Diseases
Differential: lymphoma,
leukemia, squamous cell
carcinoma, tuberculous ulcers,
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
Hematoma of
tongue
Ulcer covered by
necrotic
pseudomembrane
Oral Manifestation of Systemic Disease –
Drug reaction Stomatitis secondary to metal
Stomatitis secondary to antibiotic
Hypersensitivity reactions to medication
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
Oral mucosa with erythema, painful erosions
covered by yellow membrane; Associated burning
and increased salivation
Oral Manifestation of Systemic Disease –
Drug reaction
Stomatitis secondary to antibiotic
Long term use of
antibiotic with difuse
erythema of oral
mucosa; in this case,
possible candidiasis
Differential diagnosis: stomatitis
medicamentosa, erythema multiforme,
pellagra, ariboflavinosis
Oral Manifestation of Systemic Disease –
Drug reaction
Stomatitis secondary to systemic medication
Diffuse erythema of
intra-oral mucosa with
purpuric patches,
vesicles, erosions,
ulcers; follows drug use
Differential diagnosis: EM, pemphigus,
BMMP, erosive LP
Oral Manifestation of Systemic Disease –
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
Pigmentations secondary to drug use
Cheilitis arising from synthetic retinoids
Gingival hyperplasia
Oral Manifestation of Systemic Disease –
Drug reaction
Allergic reaction: inherited
form associated with C1
esterase inhibitor
deficiency
Direct: mast cells or IGE
Sudden onset, lasting 24-48 hours, painless, nonpruritic; can
involve tongue, soft palate, face, hands, feet and glottis
which can be life threatening
Angioedema
Oral Manifestation of Systemic Disease –
Drug reaction
Pigmentation secondary to drug use
Reaction to Chloroquine, an
antimalarial used to treat
rheumatoid arthritis and lupus
Differential: other drug induced discoloration, Peutz-Jeghers
syndrome, Albright’s syndrome and Addison’s disease
Oral Manifestation of Systemic Disease –
Drug reaction
Cheilitis arising from synthetic
retinoidsSynthetic retinoids are used as
therapy for a variety of skin
disorders (e.g. psoriasis, acne
vulgaris, lichen planus,
mycosis fungoides
Other symptoms: hair loss, skin thining, pruritus, epistaxis,
vomiting, paronychia
Clinical signs: cracking of the corners of
the mouth, patchy lip erythema, lip scaling
Risk of teratogenicity high –
avoid in child bearing age women
Oral Manifestation of Systemic Disease -
Infectious Disease
AIDS (HIV)
Tuberculosis
Lyme disease
Viral: Herpes, Varicella/Zoster, Coxsackie/Herpangina
Fungal disease / opportunistic Infection
Acquired Immunodeficiency Syndrome (AIDS)
Oral Manifestation of Systemic Disease - Infectious Disease
Acquired Immunodeficiency Syndrome (AIDS)
HIV effect on CD4+ helper T lymphocytes
Transmission via sexual contact, exposure to infected blood, or perinatally
CD4+ count below 200 cells/ul or with indicator diseases (pneumocystis pneumonia, esophageal candidiases, cytomegalovirus retinitis, disseminated histoplasmosis, Kaposi’s sarcoma, and non Hodgkin’s lymphoma)
Acquired Immunodeficiency Syndrome (AIDS)
Oral problems help to identify the condition
95% of patients with AIDS develop oropharyngeal candidiasis
The presence of Candida suggests profound immunosuppression –correlated with poorer prognosis
Also found is HIV-related gingivitis
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
Major Aphthous characterized by deep, painful, lesions
Acquired Immunodeficiency Syndrome (AIDS)
Herpes Simplex
Viral lesions much different that those seen in
healthy patients with lesions on all surfaces and
coalesced with lateral spreading and circinate
yellow borders
Acquired Immunodeficiency Syndrome (AIDS)
Human
Palpillomavirus
HPV often found in AIDS
Acquired Immunodeficiency Syndrome (AIDS)
Single or multiple non-painful exophytic lesions with broad base, whitened surface
Cytopathologicatypia
Acquired Immunodeficiency Syndrome (AIDS)
Hairy
Leukoplakia
Tongue signs often found in AIDS
Acquired Immunodeficiency Syndrome (AIDS)
Hairy leukoplakia a common finding in HIV infected patients
Demonstration of EB virus required for definitive diagnosis
Differential diagnosis includes: cinnamon-related stomatitis and morsicatio linguarum(chewing/trauma of tongue)
Acquired Immunodeficiency Syndrome (AIDS)
Malignancy
Frequently found in AIDS
Acquired Immunodeficiency Syndrome (AIDS)
Kaposi’s Sarcoma
Lymphoma
Malignancy associated with AIDS
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
Lyme Disease
Oral Manifestation of Systemic Disease - Infectious Disease
Lyme Disease
Primarily associated with TMD
Arthritis
Facial pain localized to the jaw joint
Viral Infection
Oral Manifestation of Systemic Disease - Infectious Disease
•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
Osteonecrosis and tooth devitalization a rare complication
Herpangina
30 enteroviruses can cause ‘herpangina’
Common virus: coxsackie A and B
Primarily effects children and young adults
Occurs spring and fall
Highly contagious
Disease persists 10-12 days
Diagnosis is clinical
Herpangina
Symptoms: sore throat, fever, malaise, headache, occasionally – vomiting and abdominal pain
Multiple isolated well circumscribed oval vesicles with central white core (rice kernal) and adjacent erythema
Hand-foot-mouth disease associated with Coxsackie Virus #16
May be lesions dorsal fingers, toes, palm, soles, buttocks
Red halo more distinct around the lesion
Skin lesions asymptomatic
Lesions begin small but can grow to 1 centimeter
Oral lesions painful
Severity associated with degree of oral involvement
Therapy palliative
Fungal Infection
Oral Manifestation of Systemic Disease - Infectious Disease
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
Histoplasma capsulatum (Histoplasmosis)
Most common systemic infection in the US
Endemic to Ohio and Mississippi regions but also associated with droppings of tropical birds and bats
In healthy adults flu like symptoms; in immunocompromised severe pulmonary manifestations
Oral with disseminated disease: tongue, gingiva, palate, buccal mucosa with ulceration, nodular elevation, erythema with white plaques
Fungal Infection
Histoplasmosis of the palate with ulceration and necrosis of underlying bone
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 -
The Geriatric Patient
Oral Manifestation of Systemic Disease -
The Geriatric Patient
Cardiovascular Diseases
Syncope and orthostatic hypotension
Hypertension
Angina and myocardial infarction (MI)
Bacterial endocarditis
Congestive heart failure
Oral Manifestation of Systemic Disease -
The Geriatric Patient
Liver Diseases
Hepatitis
Cirrhosis
Neoplasm
Oral Manifestation of Systemic Disease -
The Geriatric Patient
Neurologic Diseases
Alzheimer’s disease (AD)
Non-Alzheimer Dementias
Parkinson’s disease (PD)
Oral Manifestation of Systemic Disease -
The Geriatric Patient
Orthopedic DiseasesOsteoporosis
Osteoarthritis (Prosthetic Joint)
Pulmonary DiseasesCOPD
Tuberculosis
Pneumonia
Apnea
Oral Manifestation of Systemic Disease -
The Geriatric Patient
Caries
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:
a) HISTATINS - antifungal peptides
b) CYSTATINS - proteinase inhibitors
c) DEFENSINS - peptide antibiotics
Salivary Peptides - 1
•HISTATINS
•small, cationic proteins in parotid, SM
•multiple roles, e.g. mineralization
•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)
•Human ß defensins (HBD-1, 2)
•36-42 amino acids, ß-sheet
•Permeablize bacterial cell membrane
Xerostomia = Hypofunction
Xerostomia is the symptom of oral dryness
Hypofunction is sign of reduced flow
Questions help predict hypofunction:
1) Amount of saliva is too much, too little,
or, don’t notice it?
2) Mouth dry when eating a meal?
3) Difficulty swallowing any foods?
4) Sip liquids to help swallow dry foods?
Fox et al. (1987)
6 Clinical Signs of Hypofunction
Lips: dryness, redness, etc.
Buccal Mucosa: sticky or dry, red
Dorsal Tongue: patchy erythema, etc.
Major Glands: tender; dry at orifice
Pooling: absent
Caries: increased rate
Navazesh et al. (1992) J. Dental Research
Causes of Hypofunction
•Medications
•Cancer treatment
•irradiation
•GVHD
•Systemic disease
•Sjögren’s Syndrome
•hepatic disease
•thyroid disorders
•sarcoidosis
•diabetes mellitus
•Dehydration
•Dementia (Alz. Type)
•Affective disorders
•depression
•anxiety
•HIV infection
•Bulimia
Oral dryness is not a
normal consequence
of aging
Xerostomia and Medications
MAJOR CLASSES•ANTI-
CHOLINERGICS
•ANTI-
HISTAMINES
•ANTI-
HYPERTENSIVES
•ANTI-TUSSIVES
•ANTI-
DEPRESSANTS
•DIURETICS
•ANALGESICS
MedicationsCausing Dry Mouth
High Potential
Low Potential
Tricyclic Antidepressants
Antihistamines
Benzodiazepine Sedatives
Antiparkinson Medications
SSRI Antidepressants
DiureticsAntihypertensives
NSAIDs
Normal Flow Rates
Secretion rate:
(ml/min) v. low low nrl.
unstim. <0.1 0.1-0.25 0.25-0.5
stim. <0.7 0.7-1 1 - 3
Clinical Aspects
Oral CandidiasisChronic multifocal
or erythematous
type
Enamel Erosion“The irreversible loss of dental hard tissue due
to a chemical process w/o involvement of
microorganisms”
Usually caused by:
•intrinsic factors (GERD; vomiting)
•extrinsic (dietary, environmental) acids
Additional factors include
•abrasion
•attrition
•salivary factors: low pH?, low buffering
capacity?
Sjögren’s Syndrome
•Affects 1 - 2 million Americans (~1%)
•Female : male ratio = 8 : 1
•Onset 35-55 is typical, but any age possible
•Standard criteria improve diagnosis, but
average time to dx is still ~10 yrs.
An autoimmune exocrinopathy with
lymphocytic infiltration of lacrimal and salivary
glands and potential multi-system involvement,
including hepatic, renal, neurological, and malignant
diagnosis
Primary and Secondary Forms
Sjögren’s Diagnosis1. Ocular dryness/symptoms for > 3 months
2. Oral dryness/symptoms > 3 months
3. Ocular signs: Schirmer or Rose-Bengal
4. Positive minor salivary gland biopsy
5. Salivary gland involvement:
scintigraphy with 99Tc
sialography
<1.5 ml whole saliva in 15 min.
6. Autoantibodies
SS-A or SS-B
antinuclear AB's or rheumatoid factor (RF)
Vitali C, et al. (1993) Arthritis Rheumatism
Summary
Oral health and general health are linked inextricably
Many systemic diseases and conditions have oral manifestations
Oral diseases and disorders in and of themselves affect health and well-being throughout life
As reported by Evans et al: The surgeon general’s report on America’s oral health:
opportunities for the Dental Profession; JADA, 131, 2000