Oral manifestations of systemic diseases

Oral Manifestations of

Systemic Disorders

Dr. TAREK SHETALecturer of Internal Medicine

Mansoura Faculty of Medicine

Background

- The mouth (buccal cavity)

is the reservoir for the

chewing and mixing of

food with saliva.

- It is the primary site of

digestion and respiration

as well as the primary

communication structure.

Oral manifestations of

Gastrointestinal diseases

Any malabsorption Ulcers, Glossitis, Angular stomatitis

Coeliac disease Ulcers, Glossitis, Angular stomatitis, Dental hypoplasia

Cystic fibrosis Salivary gland swelling

Gardner’s syndrome

(familial colonic polyposis)

Osteomas

GERD Tooth erosion, Halitosis

• Crohn disease– diffuse labial, gingival or mucosal swelling

– “cobblestoning“ of buccal mucosa and gingiva

– aphtous ulcers

– mucosal tags

– angular cheilitis

– oral granulomas

• Ulcerative colitis– oral signs are present in periods of

exacerbation of disease

– aphtous ulceration or superficial hemorrhagic ulcers

– angular stomatitis

– pyostomatitis gangrenosum

cobblestoning of

the gut mucosa

GIT diseases

Oral manifestations of Liver

diseases

Alcoholic cirrhosis Bleeding tendency, Sialosis

Primary biliary

cirrhosis

Sjögren’s syndrome, Lichen planus

Hepatitis C Lichen planus, Sjogren’s syndrome

- jaundice

- petechiae or gingival bleeding (high bleeding tendency)

Dr. TAREK SHETA, M.D

Lichen planus

Poorly defined violaceous plaque with lacy, white pattern on the

buccal mucosa - (70% of oral lichen are HCV associated)

Deficiency of haematinics

(iron, folic acid or vitamin B12)– angular stomatitis

– glossitis

• red colour

• athrophic papilae

• recurrent aphthae

– candidal infection

– Burning mouth

sensation

Oral manifestations Haematological

diseases

• Leukemia

– gingival hypertrophy

– petechiae

– mucosal ulcers

– hemorrhage

Treatment of leukemia

– reactivation of herpes simplex virus

Oral manifestations

Haematological diseases


Gingival hyperplasia: acute monocytic

leukemia

Oral manifestations

Haematological diseasesSickle-cell anaemia Jaw deformities, Osteomyelitis

Aplastic anaemia Gingival bleeding – herpes simplex

lymphoma Infections, Ulcers, Bleeding tendency,

, Gingival swelling

Multiple myeloma Jaw aches, Tooth mobility

Amyloid disease macroglossia, Purpura


• Sjögren syndrome– autoimmune disease

– men : women - 1 : 9, 50 years and older

Main signs

– sicca syndrome

– keratoconjuctivitis sicca

– xerostomia

Oral signs

– decrease in saliva

• xerostomia

– dry, red, wrinkled mucosa

• difficulty in swalloving and eating

• disturbance in taste and speech

• increased dental caries

• infections

• atrophy of the papilae

• candidiasis

Connective-tissue diseases

• Kawasaki disease

– vasculitis of medium and large arteries

Oral signs

– swelling of papilae on the surface of the

tongue (strawbery tongue)

– intense erythema of the mucosal

surfaces

– cracked, cherry red, swolen and

hemorrhagic lips


• Scleroderma

– diffuse sclerosis of the skin, GIT,

heart muscle, lungs, kidney

Oral signs

– pursed lips – dificult to open the

mouth

– esophageal sclerosis

gastroesophageal reflux – damage

of enamel

– pale, rigid mucosa

– teleangiectasias

– decreased mobility of tongue

– salivary hypofunction


Limited mouth opening and decreased

tongue mobility

Gingival retraction

• Lupus erythematosus

– Ulcerations (painless).

– oral lesions of lichen planus –

(painfull)

– petechiae

– damage of salivary glands -

xerostomia


ulcer

lichen planus lesions

• Suppurative lung

syndromes:

– xerostomia

– swelling lips

– gingivitis

Pulmonary diseases


• Sarcoidosis– multiple, nodular, painles ulcerations of

the gingiva, bucal mucosa, labial mucosa and palate

– Tumor like swelling of salivary glans– swelling of the tongue

– xerostomia

– facial nerve palsy

Pulmonary diseases

• Diabetes mellitus

– xerostomia caused decreased

salivation and increased glucosa

level in saliva

• gingivitis

• oral infections

• candidiasis

– higher incidence of caries

– bilateral parotid enlargement

– altered taste

– burning mouth syndrome

gingivitis

hyperplasia

bilateral parotid

gland enlargement

Endocrine diseases

• Hypoparathyroidism

– upper lip twitching

• HyperparathyroidismTeeth rarefaction, Brown tumours

• Gigantism / acromegaly• Spaced teeth, Mandibular prognathism,

• Macroglossia, Megadontia

Endocrine diseases

• Congenital hypothyroidism

• Macroglossia, Retarded tooth eruption

• Pituitary dwarfism

• Microdontia, Retarded tooth eruption

• Pregnancy

• Gingivitis, Epulis

• Cushing´s syndrome

– osteoporosis pathological

fractures of the mandible,

maxilla or alveolar bone

– delayed healing of fractures

and soft tissue injuries

• Addison´s disease

– oral mucosal melanosis –

buccal mucosa, tongue

Endocrine diseases

moon face

hyperpigmentation

• Uremic stomatitis

– in undiagnosed and untreated chronic renal failure

– irritation and chemical injury of mucosa by ammonia or ammonium compounds

Signs

– painful plagues and crusts – bucal mucosa, the floor or dosrum of the tongue, floor of the mouth

– Type I

• generalized or localized erythema

• exudate

• pain, burning, xerostomia, halitosis, gingival bleeding, candidiosis

– Type II

• ulceration

• secondary infection

• anemia

Renal diseases

Renal diseases

Post renal transplant Infections( herpetic, candidal), Bleeding tendency,

Gingival hyperplasia, Kaposi’s sarcoma

Hairy leukoplakia

Renal rickets

(vitamin D resistant)

Delayed tooth eruption, Dental hypoplasia, Enlarged

pulp

Nephrotic syndrome Dental hypoplasia


Nutritional Deficiencies

• Thiamine (Vitamin B1) and Niacin/nicotinic acid

(Vitamin B3) are also reported to cause some glossitis

and cheilitis.

• Folate deficiency leads to a megaloblastic anemia that

demonstrates many of the same oral characteristics of

pernicious anemia.

• Scurvy caused by vitamin C deficiency may cause petechiae to ecchymoses in the submucosa.

• Mucous membrane changes may lead to gingival hypertrophy and erosive, bleeding gums.

Disorders of Teeth

DISORDER FINDINGS

Bulimia Erosion of enamel and loss of dentin

Congenital

cytomegalovirus

Yellow dentin and hypoplastic pitted

enamel

Congenital

porphyria

Erythrodontia of canine teeth and molars

and brown discoloration of incisors

Congenital

syphilis

Hutchinson teeth, mulberry molars

Gardner

syndrome

Supernumerary teeth


Disorders of Teeth

Lepromatous leprosy Reddening of upper teeth (pink spots)

Primary biliary

cirrhosis

Green pigment deposits

Sjogren syndrome Caries, increased plaque accumulation, poor

oral hygiene

GERD Erosion of enamel due to repeated exposure to

gastric acid

Tetracycline staining Permanent gray discoloration

Tuberous sclerosis Pitted enamel of the permanent teeth


PeriodontitisDefinition -chronic infection of connective tissue, periodontal

ligament and alveolar bone

Aetiology: diabetes, heart disease, stroke and preterm birth

birth control pills , steroids, Down syndrome, Langerhans cell

histiocytosis, HIV

Causes of mucosal hyper

pigmentation• Localized• Amalgam, tattoo

• Ephelis / Naevus

• Malignant melanoma

• Kaposi’s sarcoma

• Peutz–Jegher syndrome (search for GI polyps)

• Generalized• Racial

• Localized irritation, e.g. smoking

• Drugs, e.g. phenothiazines, antimalarials, minocycline, contraceptives, mephenytoin

• Addison’s disease/ Nelson’s syndrome

• Ectopic ACTH(e.g. bronchogenic carcinoma)

• Albright’s syndrome

• Haemochromatosis

• Neurofibromatosis,

• Malignant acanthosis nigricans

Aphthous ulceration

• Acute, recurrent, painful ulcers on nonkeratinized mucosa

• Most common cause of oral ulcerations

• Effect up to 30 % of the population


Aphthous ulceration

Minor aphthae

(90 -95 %)

Major aphthae

(5-10%)

Herpetiform

ulcers

(1-5%)

Age of onset Childhood or

adolescence

Childhood or

adolescence

Young adult

Ulcer size 2–4 mm 10 mm or larger Initially tiny, but

ulcers coalesce

Number of ulcers Up to about 6 Up to about 6 10–100

Sites Mainly vestibule,

labial, buccal

mucosa &

floor of mouth

Any site Any site but often

on ventrum of

tongue

Duration of each

ulcer

Up to 10 days Up to 1 month Up to 1 month

Aphthous

ulcers: minor

Multiple, very

painful, gray-

based ulcers

with

erythematous

halos

on the labial

mucosa.

Aphthous

ulcers:

major

52-year-old

female with

advanced

HIV/AIDS with a

5-month history

of painful lesions

on the tongue.

Aphthous ulceration

• Systemic Conditions Associated– Haematologic deficiency (up to 20%)- iron, folic acid

or vitamin B12 deficiency

– Gastrointestinal malabsorption (3%) - Celiac disease, dermatitis herpetiformis, gluten-sensitive enteropathy, Crohn disease, pernicious anemia

– Systemic lupus erythematosus, reactive arthritis

– HIV

– Behcet disease

Potential triggers - heredity, food and medication allergy, decreased mucosal barrier integrity, emotional stress, and trauma


Salivary Glands Disorders• 1-Xerostomia (dryness of mouth)

• Signs and symptoms: diminished or altered taste and smell,

• halitosis,

• heavy plaque accumulation,

• difficulty in wearing dentures,

• recurrent fungal infections,

• burning sensation,

• dysphagia,

• dry or cracked lips,

• salivary calculi and increased thirst

Xerostomia: Causes

• Medications - Antidepressants, antihistamines, diuretics

• Medical conditions - Parkinson disease, diabetes, anemia, cystic fibrosis, rheumatoid arthritis

• granulomatous inflammation - tuberculosis, sarcoid, Sjögren syndrome, HIV, amyloid

• Dehydration - Fever, excessive sweating, vomiting, diarrhea, blood loss, burns, smoking, consumption of tea, coffee

• Radiation therapy of head and neck

• Old AgeDr. TAREK SHETA, M.D

2-Excess salivation (ptyalism):

• Excessive production:

– GERD

– Pancreatitis

– Liver disease

– Serotonin syndrome

– Mouth ulcers

– Oral infections


Ptyalism (causes)• Decreased clearance:

– Infections eg tonsillitis, epiglottitis and

mumps.

– Jaw fracture or dislocation

– Radiation therapy

– Neurologic disorders such as myasthenia

gravis, Parkinson's disease, bilateral facial

nerve palsy and hypoglossal nerve palsy.

Changes in tongue

coating


Normal tongue coating is formed of:

1- Tongue papillae.

2- Food debris.

3- Bacteria.

4- Desquamated epithelium.


The tongue coating

varies in different individuals.

Varies in the same individual during the day

It is continuously formed

it is marked in the morning and is removed by:

1-Mechanical factors: speaking and chewing food.

2-Salivary flow


Tongue coating is in a continuous

process of removal and formation.

- If removal exceeds formation

atrophy

- If formation exceeds removal

increased tongue coating.


Atrophy of tongue coating

1- Deficient or impaired utilization of

nutrients

1-Iron deficiency anemia.

3-Vitamin B deficiency especially (vitamin B2, B6, B12, folic acid and nicotinic acid).

Pernicious anemia.

4-Anemia associated with parasitic infection as ascaris and bilhariziasis.

5-Malnutrition, malabsorption.

6-Chronic alcoholism.

Etiology


2- Peripheral vascular disease

1- Angiopathy: Diabetes Mellitus.

2- Vasulitis: systemic lupus

erythematosus.

3- Endarteritis obliterans: syphilitic

glossitis.

4- Obliteration of small blood vessels:

scleroderma, submucous fibrosis.

5- Localized vascular insufficiency in elderly

patients.

3- Drugs

-Drugs that:

• Interfere with the growth and maturation of the epithelium e.g cyclosporine.

• Induce candidosis e.g. antibiotic, steroid.

• Induce xerostomia e.g anticholinergic drugs, radiotherapy.


4- Miscellaneous

1- Frictional irritation: atrophy at tip & lateral borders of tongue.

2- Atrophic lichen planus.

3- Epidermolysis bullosa: ulceration healed by scar.

4- Long standing xerostomia.

5- Diabetes and chronic candidiasis may produce a lesion called central papillary atrophy.


Increased tongue coating

(white hairy tongue)

White hairy tongue

• hypertrophy of filiform papillae resembling hair-like projections

• Aetiology:- heavy tobacco use, mouth breathing, antibiotic therapy, poor oral hygiene, general debilitation, radiation therapy, chronic use of bismuth containing antacids, lack of dietary roughage, Febrile illness.

• White, yellow green, brown, or black color is due to chromogenic bacteria or staining from exogenous sources

Black hairy tongue

Etiology

1- Candidal infection in a smoker

2- Topical and systemic antibiotics:

ex: penicillin, tetracycline, aureomycin.

3- Systemic disturbance: anemia, hyperacidity, peptic ulcer.

4- Sodium perporate and sodium peroxide mouth wash that stimulate growth of filiform papillae.


Geographic tongue (benign migratory

glossitis (wendering rash)


Geographic tongue

• benign inflammatory condition,

due to Loss of filiform papillae

• Erythematous plaques with well

demarcated white border

• Etiology- diabetes mellitus,

anemia, hormonal disturbances,

psoriasis, Reiter syndrome,

atopic dermatitis,, Down

syndrome, lithium therapy

Fissured tongue (furrowed tongue,

scrotal tongue, grooved tongue)

• normal variant in 5-

11% individuals

• Also seen in :

psoriasis, Down

syndrome,

acromegaly, Sjogren

syndrome

Mongolism: transverse fissuring of the tongue


Sublingual varices

- enlarged tortuous veins in the sublingual area.

- asymptomatic, but trauma may result in bleeding

Etiology

Congential.

Idiopathic

elderly people.

It may be associated with portal

hypertension.


Macroglossia

• CP: Difficult mastication

and speech and accidental

tongue biting

• CAUSES:

– Down syndrome,

– hypothyroidism,

– neurofibromatosis,

– infection by mycobacteria,

– amyloidosis

The stratified squamous epith. if chronically irritated by:

Chemical: spices.

Thermal: smoking.

Infection: syphilis.

Mechanical: dental irritation.

Formed by thickening and hyperkeratinization with the formation of white patches.

Precancerous: biopsy

Leukoplakia of the tongue


Oral hairy leukoplakia

• caused by Epstein-Barr virus, presents as asymptomatic, corrugated, white plaques with accentuation of vertical folds along the lateral borders of tongue

• Mainly seen in HIV infection, organ transplant recipients and patients on chemotherapy


Glossodynia / GlossopyrosisEtiology

• Neurologic

– Diabetic neuropathy

– Trigeminal neuralgia

– Acoustic neuroma

• psychiatric

– Anxiety

– Depression

– Cancer phobia

– Somatoform disorder

– OCD

• Systemic disorders– Anemia (iron deficiency,

pernicious)

– GERD

– Sjogren syndrome

– Hypothyroidism

– AIDS


THANK YOU…

Oral manifestations of systemic diseases

Health & Medicine

Transcript of Oral manifestations of systemic diseases