Oral manifestations of systemic diseases

This presentation provides overview of oral manifestations of systemic diseases for undergraduate dentistry students

1. Oral Manifestations of Systemic Diseases Dr. Tahmasub Faraz Tayyab BDS, FCPS (OMFS)

2. Outline Cardiovascular Diseases Respiratory Diseases Renal Diseases Diabetes Mellitus GIT Diseases Blood Disorders HIV

3. The oral cavity is a mirror that reflects many of the human body's internal secrets. Some of these manifestations are disease specific and may be accompanied by many systemic diseases. It is very important to recognize them and provide correct diagnosis.

4. Cardiovascular Diseases Angina Pectoris Congestive Heart Failure (CHF) Cyanotic and non cyanotic valvular heart diseases Arthrosclerosis The classical risk factors - hypertension - hyper- cholesteroleamia - cigarette smoking

5. Two biological mechanisms that explain the relationship between cardiovascular disease and periodontal disease: – Bacteria from periodontal disease may enter the circulation and contribute directly to the atheromatous or thrombotic processes. – Systemic factors alter the immune inflammatory process involved in both periodontal and cardiovascular diseases.

6. Cardiovascular disease Oral manifestations Periodontal disease Lichenoid stomatitis Xerostomia Gingival hyperplasia Hemorrhagic complication

7. Periodontal disease Cardiovascular patients with active periodontal disease are 1.5-2.7 more likely to experience a fatal cardiovascular event Increased inflammation Increased bacteremia risk Lichenoid stomatitis Various cardiovascular drugs may induce lichenoid lesions – oral discomfort Diuretics B1-adrenergic blockers ACE- inhibitors ( angiotensin -converting-enzyme inhibitors)

8. Dry mouth Numerous cardiovascular drugs may reduce salivary function: Diuretics B1-adrenergic blockers Centrally acting sympathetic agonists Synergistic affect with other medications

9. Gingival hyperplasia: Calcium-channel blockers are commonly prescribed Gingival enlargement usually apparent within 1-2 months of therapy Tissue usually firm and painless Overlying inflammation may occur

10. Hemorrhagic complication Antithrombotic/anti-coagulant agents increase the risk of petechia (<2mm) purpura (>2mm-<1cm) ecchymosis(>1cm) hemorrhage

11. PATIENTS WITH RENAL DISORDERS

12. INTRA ORAL FINDINGS Soft tissue changes Oral ulcers – Blood urea nitrogen increases > 150mg/dl, it gets secreted through saliva – uremic crystals – burn mucosa becomes red Uremic stomatitis - Burning sensation

13. UREMIC STOMATITIS Urea secreted in saliva Urease enzyme produced by oral microflora Liberates free ammonia Damages oral mucosa

14. Soft tissue changes Ulcers secondary to anemia, viral infections (immunosupressed) Gingival hyperplasia - cyclosporine & nifedepine

15. Soft tissue changes Salivary glands - enlarged, xerostomia Gingival bleeding, petechiae, ecchymosis due to platelet changes Candidal infection – immunosupression Halitosis – uremic odor, ammonical smell Dysesthesia of lower lip

16. Hard tissue changes Staining in teeth – due to iron supplements Reduced caries due to urea in saliva Delayed tooth eruption Enamel hypoplasia Tooth Mobility

17. Mainly in cases with hyperparathyroidism Tooth appear more radiopaque in background of osteoporotic bone Loss of trabeculations of bone Ground glass appearance Total/ partial loss of lamina dura Loss of cortical outlines of inferior alveolar sinus, cortex of mandible Pulpal calcifications

18. Mainly in cases with hyperparathyroidism Multilocular radiolucency – osteitis fibrosa cystica / browns tumor Arterial & oral calcifications

19. Diseases of Respiratory tract 9/5/2016 20

20. UPPER - AIRWAY INFECTIONS ALLERGIC RHINITIS AND CONJUNCTIVITIS SINUSITIS PHARYNGITIS &TONSILLITIS LOWER - AIRWAY INFECTIONS ASTHMA CYSTIC FIBROSIS ACUTE BRONCHITIS TUBERCULOSIS

21. ORAL HEALTH CONSIDERATIONS of allergic rhinitis ORAL DRYNESS ORAL CANDIDIASIS (CORTICOSTEROIDS)

22. Tooth Pain - Differentiate Between An Odontogenic Infection And Sinus Pain. Sinus Infections Usually Present With Pain Involving More Than One Tooth. Chronic Sinus Infections Are Often Accompanied By Mouth Breathing -Gingivitis. Prolonged Use Of Antibiotics - The Potential Development Of Bacterial Resistance .

23. ORAL MANIFESTATIONS of Asthma Candidiasis Decreased Salivary Flow Increased Calculus Increased Gingivitis Increased Periodontal Disease Increased Incidence Of Caries

24. CONSIDERATION FOR DENTAL CARE Fluoride Supplements - Particular Those Taking Β2-agonists. The Patient Should Be Instructed To Rinse His Or Her Mouth With Water After Using Inhalers. Oral Hygiene Should Be Reinforced To Reduce Gingivitis And Periodontitis .

25. ORAL MANIFESTATION of TB RARE MAINLY SEEN IN MIDDLE AGED & OLDER PEOPLE SEX-MALES MOST COMMONLY-TONGUE

26. ORAL MANIFESTATION of TB ORAL LESION Ulcer, nodule, vesicle, granuloma , fissure Ulceration: Ragged Border, minimal Induration , granular Base Sentinal Tubercle; nodules Seen Around Ulcer

27. Diabetes Mellitus Periodontal diseases Increased risk of dental caries Xerostomia Sialosis Candidiasis BMS Lichnoid Reaction Peripheral neuropathies

28. ORAL MANIFESTATIONS IN DIABETICS More severe periodontal disease Patients with multiple abscesses should be referred for blood sugar estimation

29. ORAL MANIFESTATIONS IN DIABETICS Sialosis – swelling of salivary glands due to autonomic neuropathy Xerostomia may result from hyperglycemia and subsequent polyuria that depletes the extracellular fluids

30. Oral candidiasis & angular chelitis Oral mucosal lichenoid reactions - hypoglycaemics

31. Burning tongue - associated with candidiasis or peripheral neuropathies

32. Salivary Dysfunction & Xerostomia Salivary Hypofunction / Dry mouth Dry mouth (xerostomia) occurs when the salivary glands are not functioning properly resulting in decreased saliva. Saliva not only aids in digestion, but is a necessary factor in oral health because it also helps to keep your mouth moist and prevent tooth decay. Diabetic neuropathy can also affect the salivary glands. Polyuria Topical treatments: fluoride containing mouthrinses salivary substitutes

33. Salivary Dysfunction & Xerostomia

34. Burning Mouth Syndrome Burning mouth syndrome is a condition with no determined cause and is characterized by a chronic burning pain in your mouth. This burning sensation can be severe, feeling much the same as scalding and can affect the overall areas of your mouth such as your tongue, gums, lips, inside of your cheeks, and the roof of your mouth. Although BMS has no known cause and finding treatment may by difficult, most people can bring it under control by working with an oral health specialist.

35. GIT diseases GASTROESOPHAGEAL REFLUX DISEASE Ulcerative colitis Crohn’s disease Peutz-Jegher’s Syndrome

36. GASTROESOPHAGEAL REFLUX DISEASE Most common disease of upper GI tract gastric contents passively move up from the stomach into the esophagus Symptoms/signs Heart burn (pain/burning sensation extending from epigastrium to the neck) – commonly felt after a meal esophagitis , esophageal ulceration & stricture Chest pain (mimics anginal pain) Dysphagia

37. Oral Manifestations & Dental Considerations erythema and mucosal atrophy dysgeusia , sensitivity & erosion (palatal aspects of upper anteriors and premolars) erosion leads to dentin sensitivity & irreversible pulpal involvement (gastric content pH – as low as 1) Treatment: Head elevation, small meals, H2 blockers

38. Inflammatory Bowel Disease Ulcerative colitis Crohn’s disease (regional enteritis, ileitis) Ulcerative colitis: Inflammatory process usually extends from rectum proximally in a continuous fashion involving variable lengths of large intestine but confined to mucosa & superficial submucosa . Destructive oral ulceration due to immune mediated vasculitis Polystomatitis Vegetans : microabscess on lips, palate, ventral tongue May manifests as aphthous ulcers Bloody diarrhea – cardinal symptom

39. Treatment Sulfasalazine 5 aminosalicylates Corticosteroids (Topical & Systemic) Immunosuppresents ( Tacrolimus , Cyclosporine, Infliximab ) Surgery

40. CROHN’S DISEASE Affects entire thickness of intestinal wall, in segments forms strictures and scarring Small intestine - 40% Large intestine - 30% Both intestines- 30% Pain & diarrhea Fistulas which connect different sites in GIT, urinary bladder, vagina, prostate and skin Arthritis, uveitis & erythema nodosum of skin are common in both diseases

41. Oral Manifestations ( Crohn’s disease) Oral granulomatous lesions as a nodular mass in the mucobuccal fold Lesions resembling aphthous ulcers Cobblestone appearance on buccal mucosa Linear hyperplastic folds with ulcers in the vestibule

42. Swollen & indurated lips Granular red lesions on gingiva and alveolar mucosa and palatal ulcers (rarely) Pustular lesions Treatment: High fiber diet sulfasalazine Corticosteroids Immunosuppresents Surgery

43. Peutz-Jegher’s Syndrome Autosomal dominant Mucocutaneous pigmentation & intestinal polyposis ( hamartomas ) Black spots ( macule ): perioral skin, lips, buccal mucosa, tongue Treatment: Conservative or local excision

44. Blood Disorders Disorders of Red Blood Cells and Hemoglobin Disorders of White Blood Cells Bleeding Disorders

45. Disorders of Red Blood Cells and Hemoglobin Iron Deficiency Anemia Pernicious Anemia Folic Acid Deficency Anemia Thalassemia Sickle Cell Anemia Aplastic Anemia

46. Anemia A reduction in the oxygen-carrying capacity of blood Most often related to a decrease in the number of circulating red blood cells Nutritional anemias A deficiency in a substance required for the normal development of red blood cells, commonly vitamins Suppression of bone marrow stem cells

47. Anemia (cont.) Clinical features Pallor of skin and oral mucosa Angular cheilitis Erythema and atrophy of oral mucosa Loss of filiform and fungiform papillae on the dorsum of the tongue

48. Iron Deficiency Anemia An insufficient amount of iron is supplied to bone marrow for red blood cell development. May occur as a result of deficient iron intake, blood loss from heavy menstrual bleeding or chronic gastrointestinal bleeding, poor iron absorption, or an increased requirement for iron in situations such as pregnancy or infancy Plummer-Vinson syndrome may result from long standing iron deficiency anemia. Includes dysphagia , atrophy of the upper alimentary tract, and a predisposition to developing oral cancer

49. Clinical Features and Oral Manifestations of Iron Deficiency Anemia Often asymptomatic, may have nonspecific symptoms such as weakness and fatigue In severe cases may see angular cheilitis , pallor of oral tissue, and an erythematous , smooth, painful tongue Treatment Ferrous sulfate 200 mg three times daily (orally) Ferrous Gluconate (250mg/day)

50. Pernicious Anemia Probably an autoimmune disorder in most situations May be caused by removal of the stomach, gastric cancer, or gastritis Caused by a deficiency in intrinsic factor Intrinsic factor is secreted by parietal cells in the stomach; it is necessary for absorption of vitamin B 12

51. Clinical Features and Oral Manifestations of Pernicious Anemia Weakness, pallor, and fatigue on exertion Nausea, dizziness, diarrhea, abdominal pain, loss of appetite, and weight loss Angular cheilitis , mucosal pallor, painful atrophic and erythematous mucosa, mucosal ulceration, loss of papillae on the dorsum of the tongue, and burning and painful tongue Treatment Intramuscular hydroxycobalamine 1 mg 5 times at 3 days interval and than at about 3 monthly intervals

52. Folic Acid and Vitamin B 12 Deficiency Anemia From dietary deficiencies Can occur in association with malnutrition May be found with alcoholism or pregnancy

53. Oral Manifestations of Folic Acid and Vitamin B 12 Deficiency Anemia Oral manifestations are indistinguishable from those of pernicious anemia. Treatment Folic Acid 5mg daily by mouth atlest for 4 months

54. Thalassemia (Mediterranean or Cooley Anemia) A group of inherited disorders of hemoglobin synthesis An autosomal dominant inheritance pattern The heterozygous form may be mildly symptomatic or asymptomatic. The homozygous form is associated with severe hemolytic anemia.

55. Clinical Features and Oral Manifestations of Thalassemia Yellow skin pallor, fever, malaise, and weakness The face includes prominent cheekbones, depression of the bridge of the nose, a prominent maxilla, and protrusion or flaring of maxillary anterior teeth. Radiographs may show a “salt and pepper” pattern. Some trabeculae are prominent, and others are blurred. Risk of Infections & liver disease Heamosiderosis & death Treatment Blood transfusion Folic Acid supplements Iron Chelating Agents ( Desferrioxamine ) Ascorbic Acid

56. Sickle Cell Anemia An inherited blood disorder When someone is heterozygous, it is called sickle cell trait. When someone is homozygous, they are much more severely affected. Occurs before age 30 and is more common in women than in men The red blood cells develop a sickle shape when there is decreased oxygen. This can be triggered by exercise, exertion, administration of a general anesthetic, pregnancy, or even sleep.

57. Clinical Features and Oral Manifestations of Sickle Cell Anemia The person has weakness, shortness of breath, fatigue, joint pain, and nausea. Radiographic There is a loss of trabeculation , and large, irregular marrow spaces appear. A “hair-on-end” pattern may be seen in the skull.

58. Sickle Cell Anemia Prevetion of Triggers Dehydration, Acidosis, Hypoxia, Trauma, Stress, Infection Management Of Crisis Analgesics (Morphine, Pethidine ) Hydration Bicarbonate 100% Oxygen PRC Long Term Treatment Hydroxycarbamide Chelating Agents Infections & Liver diseases

59. Aplastic Anemia A severe depression of bone marrow activity causes a decrease in all circulating blood cells. – pancytopenia Primary aplastic anemia – the cause is unknown Secondary aplastic anemia – a result of a drug or chemical agent

60. Oral Manifestations of Aplastic Anemia Infection Spontaneous bleeding Petechiae Purpuric spots

61. Treatment Removal of Cause Antibiotics Hematopoietic stem cell Transplantation Corticosterois Prognosis is poor, 50% of patients die within 6 months usually from hemorrhage or infection Iron Overload may result from repeated blood transfusions

62. Disorders of White Blood Cells Agranulocytosis Cyclic Neutropenia Leukemia

63. Clinical Features and Oral Manifestations of Agranulocytosis Sudden onset of fever chills jaundice weakness sore throat Oral infection

64. Leukemia Malignant neoplasms of hematopoietic stem cells Characterized by an excessive number of abnormal white blood cells in circulating blood Unknown cause; some are investigating oncogenic viruses

65. Acute Leukemias Characterized by very immature cells and a rapidly fatal course if not treated Acute lymphoblastic leukemia – involves immature lymphocytes Primarily affects children and young adults Good prognosis Acute myeloblastic leukemia – involves immature granulocytes Primarily affects adolescents and young adults. Prognosis is not as good.

66. Clinical Features of Acute Leukemias Weakness Fever Enlargement of lymph nodes Bleeding

67. Oral Manifestations of Acute Leukemias Gingival enlargement Oral infection Bleeding gums, petechiae and ecchymosis

68. Chronic Leukemias Slow onset Primarily affect adults

69. Clinical Features and Oral Manifestations of Chronic Leukemias Easy fatigability, weakness, weight loss, anorexia Pallor of lips and gingiva , Gingival enlargement Petechiae and ecchymosis gingival bleeding

70. Bleeding Disorders Purpura Hemophilia

71. Purpura A reddish-blue or purplish discoloration of skin or mucosa from spontaneous extravasation of blood May be due to a defect or deficiency in blood platelets Blood may ooze from gingival margins .

72. Thrombocytopenic Purpura A bleeding disorder that results from a severe reduction in circulating platelets Idiopathic thrombocytopenic purpura If the cause is unknown Immune thrombocytopenia An autoimmune type of process Secondary thrombocytopenic purpura Often associated with drugs

73. Clinical and Oral Manifestations of Thrombocytopenic Purpura Spontaneous purpuric or hemorrhagic lesions on the skin Patients bruise easily, May have blood in urine, Have frequent nose bleeds.

74. Nonthrombocytopenic Purpura Bleeding disorders that can result from either a defect in capillary walls or disorders of platelet function Vitamin C deficiency and infections or chemicals and allergy may be the cause of alterations in vascular walls. Drugs, allergy, and autoimmune disease may cause disorders of platelet function. Von Willebrand disease is an autosomal dominant disorder of platelet function.

75. Oral Manifestations of Nonthrombocytopenic Purpura Spontaneous gingival bleeding petechiae Ecchymoses Hemorrhagic blisters

76. Hemophilia A disorder of blood coagulation Results in severely prolonged clotting time Due to a deficiency in plasma proteins

77. Types of Hemophilia The two most common types are type A and type B. Transmitted as X-linked diseases through an unaffected carrier daughter to a son Type A Caused by a deficiency of plasma thromboplastinogen or factor VIII Type B Christmas disease Less common, the clotting defect is plasma thromboplastin or factor IX

78. Oral Manifestations of Hemophilia Spontaneous gingival bleeding petechiae ecchymosis

79. Oral lesions associated with HIV Early recognition, diagnosis, & treatment of HIV associated oral lesions - reduce morbidity Oral lesions- -Early diagnostic indicator of HIV infection -Stage of HIV infection -Predictor of the progression of HIV disease

80. Oral lesions associated with HIV Fungal Infection: Bacterial Infection: - Candidiasis -Linear Gingival Erythema - Histoplasmosis -Necrotizing Ulcerative - Periodontitis - Cryptococcosis -Mycobacterium Avium Complex Viral Infection: Neoplastic : -Herpes simplex -Kaposi’s Sarcoma -Herpes zoster -Non-Hodgkin’s Lymphoma -HPV Infection Others : -CMV Infection -Recurrent Aphthous Ulcers -Hairy Leukoplakia -Salivary Gland Disease

81. Human Papilloma Virus Infection Oral warts ( papillomas ), skin warts, & genital warts – HPV(types 7,13,& 32) Clinical Features: Arises from Stratified squamous epithelium, painless, exophytic, numerous finger like projections- cauliflower like appearance Tongue, gingiva & palate Biopsy- Histological diagnosis Treatment: -Surgical removal -Laser (CO2 laser)

82. Hairy Leukoplakia Epstein Barr virus Common, characteristic lesion-HIV infection White, asymptomatic, raised, corrugated, unremovable patch on lateral marigns of tongue The surface is irregular and may have prominent folds or projections, sometimes markedly resembling hairs Lateral margins may spread to dorsum of tongue Diagnosis: Biopsy Treatment: - Usually asymptomatic-Rx not required -Antiviral( Aciclovir / valaciclovir )

83. Kaposi’s Sarcoma Most common malignancy in HIV (+ Ve ) Human Herpes Virus-8(KSHV) Derived from capillary endothelial cells Occur intraorally , either alone or in a/w skin & disseminated lesions (lymph nodes, salivary gland) Intraorally - hard palate, buccal mucosa, & gingiva -bluish, purple or red patches or papules nodular , ulcerate & bleed Diagnosis: Biopsy Treatment: - Low dose radiation & chemotherapy ( eg.Vinblastine ) -Surgical excision (eg.CO2 laser) -Immunotherapy (Interferon)

84. Non-Hodgkin’s Lymphoma Etiology : Unknown, genetic & environmental factors (viruses, radiation) Clinical features: Both sexes - any age Lymph nodes involved Oral lesions - part of a disseminated disease, or the only sign Oral Lymphoma : diffuse, painless swelling, which may or may not be ulcerated -soft palate, the posterior part of the tongue, the gingiva , & the tonsillar area HPE & Immunohistochemical examn Treatment : Radiotherapy & chemotherapy

85. Salivary gland Disease Xerostomia Generalised enlargement of parotid glands Lymphoepithelial cysts- parotid gland