ORAL MANIFESTATION OF SYSTEM DISEASES - Prime Care Dental Clinic

OVERVIEW:

The mouth is said to be the mirror of the body, this is because:-

Systemic diseases often have oral manifestations e.g. acute leukaemia. Lymphomas etc.
Systemic disease can affect or complicate the management of dental patients e.g. Diabetes.
Systemic diseases can be complicated by dental treatment e.g. patients with prosthetic heart valves.

Certain changes in the mouth/ jaws can be caused by unsuspected systemic diseases and may be of diagnostic importance e.g. Café au lait pigmentation in intestinal polyposis

There are many systemic diseases with oral manifestations, the following groups will be considered:

Blood Diseases
Haemorrhagic diseases
Hormonal diseases
Nutritional diseases
Gastrointestinal Diseases
Dermatological diseases
Infections – Hepatitis, STDs, HIV/AIDS etc
Psychiatric diseases

I. ORAL MANIFESTATIONS OF BLOOD DISEASES

DISEASE	ORAL MANIFESTATION
ANAEMIA	Pallor of the oral mucosa, Atrophic glossitis, Angular cheilitis, poor wound healing, reduced resistance to infection, + oral ulcers, inability to withstand surgery. Note the oral manifestations of severe iron deficiency anaemia as manifested as Plummer-Vinson syndrome
APLASTIC ANAEMIA ACUTE LEUKAEMIA	Pallor, petechiae and purpura of the OM, spontaneous gingival bleeding, Ecchymosis, deep necrotizing ulcers which lack surrounding erythema. Oral infections and opportunistic infections by candida, Generalized gingival swelling 2⁰ to infiltration of the gingivae by leukaemic cells in leukaemia. Cranial nerve palsy due to nerve infiltration by leukaemic cells
LYMPHOMA	Cervical lymphadenopathy (generalized) Painless oral swellings Deep fissuring painful ulcers especially after chemotherapy

2. ENDOCRINE DISORDERS

DIABETES	Uncontrolled or poorly controlled diabetes- Simple chronic Periodontitis. Dry mouth, burning tongue, poor wound healing.
PITUITARY GLANDS	Gigantism/ acromegaly
THYROID GLANDS	Hypothyroid – Cretinism Hyperthyroid – thyrotoxicosis with its implication for dental treatment.
PARATHYROIDS	Hypoparathyroidism – Enamel hypoplasia, retarded new bone formation, tetany Hyperparathyroidism – multiple cystic tumors of the bone.
ADRENAL CORTEX	ADDISONS’S DISEASE – Due to the hypofunction of the adrenal cortex Progressive weakness and fatigue, lassitude, Anorexia and wt loss, GIT disturbances, Abnormal pigmentation of the oral cavity, face and body areas exposed to light or mechanical irritation, Hypotension, vomiting and diarrhea. ADDISONIAN CRISIS- Rapid fall in BP, circulatory collapse (Shock), vomiting, fatal if not quickly treated with hydrocort and fluid replacement.(May follow OS procedures or stressful dental treatment)

NUTRITIONAL DISORDERS

VIT A	Night blindness
VIT B2 (Riboflavin)	Causes inflammatory and degenerative changes in the oral mucosa, angular cheilitis, stomatitis,
NICOTINIC ACID	Severe painful glossitis, stomatitis, oral ulcerations,
FOLIC ACID	Angular cheilitis, ulcerative stomatitis.
VIT B12	Painful glossitis, fiery red tongue, papillary atrophy
VIT C	Markedly enlarged, spongy bluish gingivae which bleeds readily, mobile teeth which can easily exfoliate. Pt prone to ANUG
VIT D	Hypoplastic teeth if occurs early in life, Rickets

GASTROINTESTINAL DISEASES

INTESTINAL MALABSORPTION (COELIAC DISEASE)	Most common cause is gluten enteropathy Many patients have signs of GIT disorder or obvious signs of malabsorption which may lead to the diagnosis although some patients present with minor systemic symptoms but present with oral symptoms the investigation of which may lead to the diagnosis. Diarrhoea is the most common complaint, weight loss, weakness or a failure to grow in children result in malabsorption which also causes anaemia due to iron, vitamin B and folic acid deficiency separately or in combination and these give rise to the oral lesions which are glossitis, fiery red OM, angular cheilitis, minor apthous ulcers,
ULCERATIVE COLITIS	This is an inflammatory disease which affects the mucosa and submucosa of the colon and rectum. The disease is characterized by periods of remission and exacerbations. Disease not characterized by specific oral disease but apthous ulcers and pyostomatitis vegetans may be seen and the severity of these lesions wax and wane with the periods of the disease.
CROHN’S DISEASE (REGIONAL ENTERITIS)	This is a chronic inflammatory disease chiefly affecting the terminal ileum and causing narrowing of it. The patient experiences recurrent episodes of crampy abdominal pain, fever and diarrhoea resulting in malnutrition and anaemia, protein and multivitamin deficiency. Oral ulcers may be the presenting symptoms in !% of cases and may predate other symptoms. Oral lesions may appear on the gingivae, OM, buccal mucosa or the lips Gingival lesions appear as longstanding purplish-red, tender or non tender non-haemorrhagic enlargements occurring in areas of good plaque control. The buccal mucosal lesions have formations of granulation tissue, a general redness or a thickening with folding and ridging. Some patients may have swollen lips. The ulcers on the lips and the buccal sulcus are often linear and may persist for several years and may be the presenting lesion along with diarrhea. Some patients have swollen lips either due to the involvement of the lip itself or chronic lymphatic obstruction as a consequence of the intra-oral disease. The oral lesions are persistent and are resistant to treatment Oral manifestations of anaemia, malnutrition and vitamin deficiencies may also manifest. Biopsy reveal non-caseating granulomas with epithelioid cells, giant cells and peripheral lymphocytes.
INTESTINAL POLYPOSIS	PEUTZ-JENGHERS SYNDROME – consists of mucocutaneous pigmentation arranged in oval, round or irregular brown or black macules which first appear in early childhood. In the mouth, the buccal mucosa and the lips are most affected but the pigmented macules may also be found on the palate, gingiva and rarely on the tongue. Similar pigmentation may be found in the nasal mucosa, conjunctiva and rectal mucosa. The cutaneous pigmentation occurs around the mouth, nostrils or eyes and on the rectal mucosa and are referred to as “café au lait” pigmentation. It occurs intra-orally and it develops in infancy or early childhood and does not fade with age though the skin pigmentation may fade with age. The polyposis occur chiefly in the small intestines although the large bowel is affected in 50% of the cases. The polyps may also occur in the nose and mouth and they are not considered as premalignant. GARGENER’S SYNDROME: Consists of hard and soft tissue tumours. The soft tissues lesions consist of sebaceous cysts, subcutaneous fibromas and other masses of fibrous tissue. The hard tissue masses occur in the skull and facial bones and appear as osteomas in the ramus of the mandible and sinuses. Malignant changes in the lesions are likely unless prophylactic excision of the affected segment of the bowel is done, thus it is important for the dentist to be aware of the condition since he may be able to suggest the diagnosis at a stage when prophylactic surgery will prevent serious complication of the disease.

DERMATOLOGICAL DISEASES

Epidemolysis bullosa
Pemphigus vulgaris
Erythema Multiforme
Lichen Planus
Psoriasis
Systemic Lupus Erythromatosus

NOTE: See previous notes for oral manifestations of infectious diseases eg STDs, HIV oral manifestations of psychiatric disorders.