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
Conditions  Anemias
 Pituitary disease
To Be  Allergy
Covered  Autoimmune disease
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
 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 -

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 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

 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 -

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,
withDecreased 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

 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
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 %)

 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
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

 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

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

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
Pyostomatitis
Vegetans
Significance: Oral sign of
inflammatory bowel
disease: Ulcerative colitis
or Crohn’s
In: Neville, Damm, White:
Color Atlas of Clinical Oral
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

Hematoma of Ulcer covered by

necrotic
tongue 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
Angioedema 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
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
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

Other symptoms: hair loss, skin thining, pruritus, epistaxis,

vomiting, paronychia
Oral Manifestation of Systemic Disease -

Infectious Disease
 AIDS (HIV)
 Tuberculosis

 Lyme disease

 Viral: Herpes, Varicella/Zoster,

Coxsackie/Herpangina
 Fungal disease / opportunistic Infection
Oral Manifestation of Systemic Disease - Infectious Disease

Acquired
Immunodeficiency
Syndrome (AIDS)
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)

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)

Hairy leukoplakia a common finding in

HIV infected patients

Demonstration of EB Differential diagnosis includes: cinnamon-related

stomatitis and morsicatio linguarum
virus required for (chewing/trauma of tongue)
definitive diagnosis
Acquired Immunodeficiency
Syndrome (AIDS)

Malignancy

Frequently found in AIDS

Acquired Immunodeficiency
Syndrome (AIDS)

Malignancy associated with AIDS

Lymphoma

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

 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
Hand-foot-mouth disease
associated with Coxsackie
Virus #16
May
be lesions dorsal
fingers, toes, palm, soles,
buttocks
Red halo more distinct
Multiple isolated well
around the lesion
circumscribed oval
Skin lesions asymptomatic

vesicles with central

Lesions begin small but
can grow to 1 centimeter
white core (rice
Oral lesions painful
kernal)
Symptoms: sore throat, fever, and
malaise,
Severity adjacent
associated with
erythema
headache, occasionally – vomiting
degree and
of oral involvement
Therapy palliative
abdominal pain
Oral Manifestation of Systemic Disease - Infectious Disease

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

 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 Diseases
 Osteoporosis

 Osteoarthritis (Prosthetic Joint)

 Pulmonary Diseases
 COPD

 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 •Dehydration
•Dementia (Alz. Type)
•Cancer treatment
•Affective disorders
•irradiation
•GVHD •depression
•anxiety
•Systemic disease •HIV infection
•Sjögren’s Syndrome •Bulimia
•hepatic disease
•thyroid disorders Oral dryness is not a
•sarcoidosis
•diabetes mellitus
normal consequence
of aging
Xerostomia and Medications
MAJOR CLASSES
•ANTI-
CHOLINERGICS
•ANTI-
HISTAMINES
•ANTI-
HYPERTENSIVES
•ANTI-TUSSIVES
•ANTI-
DEPRESSANTS
•DIURETICS
•ANALGESICS
Medications
Causing Dry Mouth
Tricyclic Antidepressants
High Potential
Antihistamines

Benzodiazepine Sedatives
Antiparkinson Medications

SSRI Antidepressants
Low Potential Antihypertensives
Diuretics

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 Candidiasis
Chronic multifocal
or erythematous
type
Enamel Erosion
“The irreversible loss of dental hard tissue due
to a chemical process w/o involvement of
microorganisms”
Additional factors include
•abrasion
•attrition
•salivary factors: low pH?, low buffering
capacity?
Usually caused by:
•intrinsic factors (GERD; vomiting)
•extrinsic (dietary, environmental) acids
Sjögren’s Syndrome
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

•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.
Sjögren’s Diagnosis
1. 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