10-oral manifestations of systematic diseases

7/30/2019 10-Oral Manifestations of Systematic Diseases

1/11

Oral manifestations of systematic diseases

Khalid Mortaja

29/4/13

10


2/11

Page 2

Oral Manifestations of systematic diseases

We can divide the oral cavity in terms of keratinization into 2 groups:

Keratinized: e.g.: masticatory mucosa (hard palate, gingiva and posteriortongue)

Non-keratinized: e.g.: lining mucosa (buccal mucosa, labial mucosa, alveolarmucosa, floor of the mouth, ventral tongue and soft palate)

Additional group we call it:

Specialised: such as dorsum of the tongue which has taste buds

We have several diseases and situations that could lead to several manifestations

of the oral cavity, they might be local or systematic diseases leading to loss of

teeth, discoloration of teeth, connective tissue alterations or epithelial

alterations, and well talk about them one by one.

1-Diseases and manifestations affecting

Teeth:

1) Leading to loosening and early loss of teeth: Local causes: chronic gingivitis Systemic cause: Diabetes Mellitus, low immunity such as HIV and

Leukopenia, diseases of the connective tissue

2) Leading to discoloration of teeth:


3/11

Page 3

External factors: poor oral hygiene and smoking Internal factors: drugs such as Tetracycline during pregnancy, flurosis,

porphyria, jaundice


Gingiva:

1) Leading to bleeding of gingiva: Local causes: acute and chronic gingivitis, periodontitis, acute necrotizing

gingivitis which is usually associated with an autoimmune disease affecting

the skin, such as: bullous pemphegoid, pemphigus vulgaris, mucous

membrane pemphigoid and lichen planus

Systemic causes: Leukaemia, neutropenia, HIV, drugs (anti-coagulants). Inother words: any disease that affect platelets or the coagulation system,

will easily lead to bleeding of the gingiva

2) Leading to swelling of gingiva: Local cause: bad dentures, acute and chronic gingivitis, Hyperplastic

(Mouth breathers), Tumors

Systemic causes: pregnancy, drugs such as Phenytoin and cyclosporine,infiltrative, tumors

3) Leading to redness of gingiva: Local causes: chronic gingivitis


4/11

Page 4

Systemic causes: Desquamative gingivitis (its caused by systemicdermatological disease), Herpes Simplex Virus, Vascular abnormalities,

Bullous diseases

4) White Patches (Leukoplakia): this type can be premalignant Local causes: friction (not premalignant), smoking (premalignant) Systemic causes: candidiasis, lichen planus, lupus erythematous, chronic

renal failure

5) Leading to pigmentation of gingiva: Racial: usually darker races have darker gingivae Local causes: amalgam tattoo, melanocytic macules ) ( Systemic causes: endocrine diseases (such as Addisons disease), Kaposi

sarcoma, melanoma (malignant tumor of melanocytic nevus), drugs (such

as Hydroxychloroquine and minocycline)

6) Leading to ulceration of gingiva: Local causes: any trauma can cause ulcer (most common) Systemic causes: Hematologic diseases: anaemia, leukaemia, neutropenia Gastro Intestinal diseases: celiac disease, inflammatory bowel disease Connective tissue diseases: systemic lupus erythematous, Behcets

disease, Sweetssyndrome

Infections: herpes simplex virus Immunological diseases: bullous pemphigoid, pemphigus vulgaris Drugs: Cytotoxics (used for chemotherapy)

7) Leading to blistering of gingiva:


5/11

Page 5

Local causes: burn (drinking hot beverages), mucoceles (cyst fused to themucin)

Systemic causes: pemphigus vulgaris, lichen planus, mucous membranepemphigoid (these 3 are the most common causes of blistering of gingiva)

Desquamative Gingivitis vs. Gingivitis

Gingivitis by itself can be caused by systematic or local disease, in contrast to

Desquamative Gingivitis which is caused mainly by a dermatological disease.

Most common causes for Desquamative gingivitis: mucous membrane

pemphigoid, lichen planus, bullous pemphigoid, linear IgA pemphigoid.

Treatment for Desquamative Gingivitis: we can leave it to heal by itself.

Sometimes we use topical steroids + tacrolimus.


6/11

Page 6

As you can see in the figure above, the major difference between Desquamative

gingivitis and chronic gingivitis is that in the first (DG) there is no involvement of

interdental papillae (spared), while the latter (CG) shows involvement of

interdental papillae.

Drug induced gingival swelling

Some drugs cause gingival swelling such as: Phenytoin, Cyclosporine, Nifedipine

and Ca++

channel blockers. Usually their effects increase with prolonged use and

with bad oral hygiene.

Treatment: good oral hygiene, stop drugs withdrawal. In some severe conditions

we might do surgical excision.

This figure shows a drug (phenytoin) induced gingival swelling


7/11

Page 7


oral mucosa:

1) Leading to pigmentation of oral mucosa: Racial: usually darker races have darker oral mucosa Local causes: nevus, melanocytic macule in the oral cavity Systemic causes: tumors such as (melanoma and Kaposi sarcoma),

endocrine disorders such as (Addisons disease and Cushing syndrome),

drugs such as (minocycline and tetracycline)

2) Leading to redness of oral mucosa: Local causes: infections such as herpes simplex virus Systematic causes: Infections: such as candidiasis Inflammatory causes: such as lichen planus, mucos membrane

pemphigoid, pemphigus vulgaris

Vascular causes: telangiectasia, Kaposi sarcoma Drugs: cytotoxic drugs such as mucositis

Other causes: geographical tongue (not related to any disease), nutritionaldeficiencies such as (folate, iron, vitamin B12)

Geographical

tongue

Redness


8/11

Page 8

3) Leading to ulceration of oral mucosa: Local causes: traumas (most common cause) such as (orthodontic

appliances), tumors

Systemic causes: Haematological diseases Gastro Intestinal diseases: such as celiac disease and inflammatory

bowel disease

Dermatological diseases: such as lichen planus and bullous pimphigoid Infections: such as herpes simplex virus Vaculitis Iatrogenic (caused by drugs)

Recurrent Aphtous Stomatitis

Recurrent episodes of ulceration, each lasts 1-4 weeks.

We have 3 types:

Major Aphtous: 10%

Duration: 4 weeks or more

Size: 5-10 mm Number: < 10 ulcers

Minor Aphtous: 80%

Duration: < 10 days Size: < 5mm Number: < 10 ulcers

Herpitiform: usually painful, 10%

Duration: > 10 days Size: < 5mm Number: 10-100 ulcers

Investigations for RAS: CBC, ESR, iron, vitamin B12, Folate.


9/11

Page 9

Treatment for RAS: because they are associated with inflammatory diseases we

will use anti-inflammatory drugs (Steroids and Colchicine).

4) White Patches (leukoplakia): this type can be premalignant Infective leukoplakia: candida, hairy leukoplakia Systemic causes: lichen planus, lupus erythematous, renal and liver diseases Genetic causes: white sponge nevus

5) Leading to blistering of oral mucosa:


10/11

Page 10

Local causes: burn, mucocele Underlying causes: Pemphigus, Bullous Pemphigoid, Mucous Membrane

Pemphigoid

Behcets Syndrome

It is a connective tissue disease. We have major and minor criteria to diagnose it:

Major: Oral aphtous (I cant diagnose Behcets syndrome without it) Genital ulcers Skin diseases Ocular diseases CNS diseases

Treatment for Behcets syndrome depends on the severity, for mild cases we will

use topical steroids, while for severe cases we will use Colchicine and

Cyclosporine.

Main Morbidity is related to Ocular Disease so always involve an Ophthalmologist.

Lichen planus

It is a dermatological disease, manifested by: plaques distributed all over the body

(scalp and mucosa). For mucosa, we have many types of lichen planus and the

most important one is the erosive lichen planus, because it can be associated with

Squamous Cell Carcinoma. Another thing that can be caused by lichen planus is

Desquamative Gingivitis.

Treatment for lichen planus: topical steroids, tacrolimus, cyclosporine.

Endocrine diseases


11/11

Page 11

Addisons disease: usually associated with hyperpigmentation of oral mucosa,

tongue and palate.

Congenital hypothyroidism and acromegaly: associated with macroglossia (big

tongue).

Diabetes mellitus: associated with loosening of teeth, xerostomia, candidiasis

Pregnancy: associated with Gingivitis, Epulis.

Gastro Intestinal Tract diseases

Pernicious Anemia: ulcers, glossitis, red lesions.

Coeliac: ulcers, glossitis, angular stomatitis.

Crohns disease: gingival hyperplasia, ulcers, golssitis.

Hematological diseases

Here we are interested in the involvement of WBCs, either increased or

decreased, with ulcers or infections.

Hemostasis: associated with bleeding.

Renal diseases

Chronic Renal Failure: associated with Xerostomia, Halitosis, Leukoplakia and

bleeding

NOTE: drugs names are for memorization, you have to know the drugs that cause

gingival swelling

Done by: Khalid Mortaja

10-oral manifestations of systematic diseases

Documents