Oral Manifestation of Systemic Disease


Presented by Jeff Burgess DDS MSD

Boarded in Oral Medicine

Director – Oral Care Research Associates


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 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 Pathol Oral Radiol Endod 2001:34


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%


Liver disease

Amyloidosis

Sarcoidosis

Vitamin deficiency

Anemias

Pituitary disease

Allergy

Autoimmune disease

Conditions

To Be

Covered


Thyroid disease

Adrenal abnormality

Diabetes

Crohn’s disease / IBD

Wegener’s Granulomatosis

Renal failure

Drug reaction

Infectious Disease

The Geriatric patient


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)


Jaundice

Clinical findings - jaundice

Diffuse uniform mucosa yellowing

With specific diseases – other signsand symptoms

Not to be confused with vitamin Aexcess


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


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


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)


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


Amyloidosis

Clinical features

Macroglossia from amyloid deposits (waxy papules and plaques forming nodules)

Tongue and lips Hemorrhagic bulla


Amyloidosis

Clinical features

Xerostomia secondary to salivary gland destruction


Sarcoidosis

Cause – not knownDepression of cell-mediated immunity

Overactivity of B cells

EpidemiologyWomen 20-50/blacks

Noncaseating granulomas Lymph nodes and lungs


Sarcoidosis

Head and Oral Manifestation Intra Oral Lesions

Cervical Adenopathy

Jaw Bone Destruction

Sinus Pathology

Dermal lesions

Facial Palsy

Salivary Gland Abnormality


Sarcoidosis

Intra Oral Lesions Tongue

Buccal mucosa / vestibule

Gingiva with periodontitis

Abnormal healing of extraction sites

Minor salivary glands


Sarcoidosis

Jaw bone destruction Maxilla

Mandible including TMJ

Premaxillary/premolar region

Poorly defined lucency without cortical expansion

Teeth vital

No tooth resorption


Sarcoidosis

Maxillary Osseous Lesion


Sarcoidosis

Osseous Lesions

Pre-treatment (A)

Post-treatment (B)A

B


Sarcoidosis

Sinus and Salivary Gland Destruction

Sarcoid sinusitis

Para nasal sinuses

Parotid enlargement (bilateral, firm, painless)


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


Sarcoidosis

Dermal lesions typically

symmetric

Lip

Nose

Cheeks

Ears

Sarcoidosis

Perioral Lesions


SarcoidosisSymptoms

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


SarcoidosisMucosal Lesion Quality Generally: multiple firm nodules or

papules, raised with irregular borders


SarcoidosisMucosal 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


SarcoidosisMucosal Lesion Quality

Tongue: broad elevated masses with indurations


Sarcoidosis

Gums: papillae redness or nodular mass

Lip: erythematous raised lesion / fixed to mucosa


SarcoidosisDental Treatment

depends on staging of disease Tooth extraction

Medication

Surgical excision

Management of Secondary effectsPain, Oral Dryness, periodontal disease,

caries


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


Vitamin deficiency

B2 (riboflavin):

ariboflavinosis

C (ascorbic acid):

scurvy


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


Anemia

Iron-deficiency anemia

Plummer-Vinson syndrome

Pernicious anemia


Anemia

Iron-deficiency anemia

Clinical features: angular cheilitis, atrophic glossitis and generalized oral mucosal atrophy, burning sensation, with Plummer-Vinson - dysphagia

Causes: Excessive blood loss

Increased demand for red blood cells

Decreased iron intake

Decreased absorption of iron

General symptoms: fatigue, tiring, palpitations, lightheadedness, lack of energy


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


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


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)


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


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


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


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


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


Adrenal abnormality

Cushing’s syndrome (increased glucocorticoid

levels)

Young adult women

Moon facies, girsutism, poor healing, osteoporosis, muscle wasting


Adrenal abnormality

Causes:Autoimmune, infection (tuberculosis, Aids), metastatic tumors, sarcoid, hemochromatosis, or amyloidosis

Addison’s diseaseInsufficient adrenal corticosteroid hormones


Adrenal abnormality

Clinical features: hyperpigmentation of skin – patchy brown macular pigmentation of the oral mucosa (may preceed other pigmentation)


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


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


Diabetes mellitus

Oral features

Periodontal disease

Delayed healing post surgery

Infection (candidiasis)

Nontender, bilateral parotid enlargement

Benign migratory glossitis

Xerostomia

Diabetes Care

From: Dentistry

Today, March 2001


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


Diabetes mellitus

Infection

Alters glucose metabolism (increased insulin resistance/glycemic control)

Concurrent risk factors

Presence of other systemic diseases


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


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)


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


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


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


Diabetes mellitus

Practice management systems:

Multiple appointments and shorter appointments

Consider possibility of complications


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


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


Crohn’s Disease

Lip swelling

Cobblestone

appearance of buccal

mucosa; also gingival

erythema and swelling

Differential: cheilitis

granulomatosa, sarcoidosis


Crohn’s DiseaseHyperplastic fold lower

labial vestibule +

generalized cobblestone like

appearance of gingiva

In: Neville, Damm, White:

Color Atlas of Clinical Oral

Pathology


Inflammatory Bowel Disease

Multiple yellowish pustular

lesions, 2-3 mm, on facial

gingiva, vestibule and

buccolabial mucosa

In: Neville, Damm, White:

Color Atlas of Clinical Oral

Pathology

Pyostomatitis

Vegetans

Significance: Oral sign of

inflammatory bowel

disease: Ulcerative colitis

or Crohn’s



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



In: Laskaris, Color Atlas

of Oral Diseases

Differential: lymphoma,

leukemia, squamous cell

carcinoma, tuberculous ulcers,

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


Renal failure

Uremic Stomatitis

Hematoma of

tongue

Ulcer covered by

necrotic

pseudomembrane


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


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


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


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


Drug reaction

Stomatitis secondary to antimetabolites

Azathioprine Methotrexate

Lesions typically appear 2-3 weeks post initiation of

drug


Drug reaction

Angioedema

Pigmentations secondary to drug use

Cheilitis arising from synthetic retinoids

Gingival hyperplasia


Drug reaction

Allergic reaction: inherited

form associated with C1

esterase inhibitor

deficiency

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

Angioedema


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


Drug reaction

Cheilitis arising from synthetic

retinoidsSynthetic retinoids are used as

therapy for a variety of skin

disorders (e.g. psoriasis, acne

vulgaris, lichen planus,

mycosis fungoides

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

vomiting, paronychia

Clinical signs: cracking of the corners of

the mouth, patchy lip erythema, lip scaling

Risk of teratogenicity high –

avoid in child bearing age women


Infectious Disease

AIDS (HIV)

Tuberculosis

Lyme disease

Viral: Herpes, Varicella/Zoster, Coxsackie/Herpangina

Fungal disease / opportunistic Infection

Acquired Immunodeficiency Syndrome (AIDS)

Oral Manifestation of Systemic Disease - Infectious Disease


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)


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


Candidiasis in

AIDS responds best to ketoconazole, fluconazole, and itraconazole versus nystatin, clotrimazole and amphiotericin B

Control for xerostomia


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


Periodontal Conditions

ANUG

Periodontitis


Aphthous Ulcers

Major Aphthous characterized by deep, painful, lesions


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


Human

Palpillomavirus

HPV often found in AIDS


Single or multiple non-painful exophytic lesions with broad base, whitened surface

Cytopathologicatypia


Hairy

Leukoplakia

Tongue signs often found in AIDS


Hairy leukoplakia a common finding in HIV infected patients

Demonstration of EB virus required for definitive diagnosis

Differential diagnosis includes: cinnamon-related stomatitis and morsicatio linguarum(chewing/trauma of tongue)


Malignancy

Frequently found in AIDS


Kaposi’s Sarcoma

Lymphoma

Malignancy associated with 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


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

Lyme Disease


Lyme Disease

Primarily associated with TMD

Arthritis

Facial pain localized to the jaw joint

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

Symptoms: sore throat, fever, malaise, headache, occasionally – vomiting and abdominal pain

Multiple isolated well circumscribed oval vesicles with central white core (rice kernal) and adjacent erythema

Hand-foot-mouth disease associated with Coxsackie Virus #16

May be lesions dorsal fingers, toes, palm, soles, buttocks

Red halo more distinct around the lesion

Skin lesions asymptomatic

Lesions begin small but can grow to 1 centimeter

Oral lesions painful

Severity associated with degree of oral involvement

Therapy palliative

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


The Geriatric Patient



Cardiovascular Diseases

Syncope and orthostatic hypotension

Hypertension

Angina and myocardial infarction (MI)

Bacterial endocarditis

Congestive heart failure



Liver Diseases

Hepatitis

Cirrhosis

Neoplasm



Neurologic Diseases

Alzheimer’s disease (AD)

Non-Alzheimer Dementias

Parkinson’s disease (PD)



Orthopedic DiseasesOsteoporosis

Osteoarthritis (Prosthetic Joint)

Pulmonary DiseasesCOPD

Tuberculosis

Pneumonia

Apnea



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

•Cancer treatment

•irradiation

•GVHD

•Systemic disease

•Sjögren’s Syndrome

•hepatic disease

•thyroid disorders

•sarcoidosis

•diabetes mellitus

•Dehydration

•Dementia (Alz. Type)

•Affective disorders

•depression

•anxiety

•HIV infection

•Bulimia

Oral dryness is not a

normal consequence

of aging

Xerostomia and Medications

MAJOR CLASSES•ANTI-

CHOLINERGICS

•ANTI-

HISTAMINES

•ANTI-

HYPERTENSIVES

•ANTI-TUSSIVES

•ANTI-

DEPRESSANTS

•DIURETICS

•ANALGESICS

MedicationsCausing Dry Mouth

High Potential

Low Potential

Tricyclic Antidepressants

Antihistamines

Benzodiazepine Sedatives

Antiparkinson Medications

SSRI Antidepressants

DiureticsAntihypertensives

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 CandidiasisChronic multifocal

or erythematous

type

Enamel Erosion“The irreversible loss of dental hard tissue due

to a chemical process w/o involvement of

microorganisms”

Usually caused by:

•intrinsic factors (GERD; vomiting)

•extrinsic (dietary, environmental) acids

Additional factors include

•abrasion

•attrition

•salivary factors: low pH?, low buffering

capacity?

Sjögren’s Syndrome

•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.

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

Sjögren’s Diagnosis1. 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

Oral Manifestation of Systemic Disease

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