Oral Manifestations of Systemic Diseases V. Žampachová I. ÚP Risk assessment nCan we provide dental treatment to this patient without endangering his/her (or our) health and well being? n Yes. No problems are anticipated, and treatment can be delivered in the usual manner. n Yes. The potential for problems exists, however, modifications can be made in the delivery of treatment that reduces risk to an acceptable level. n No. Potential problems exist that are serious enough to make it inadvisable to provide elective dental treatment. n Most common medical emergencies in dental practice nSyncope nPostural hypotension nHyperventilation nMild allergic reaction nAsthmatic attack nAnaphylaxis nCardiac arrest nMyocardial infarction nAngina pectoris nSeizures nEpinephrine reaction nInsulin shock n Many of these events are preventable, or at least the chances of them occurring can be lessened Oral and systemic diseases nPrimary oral diseases influence on systemic/other organs conditions (i.e. periodontitis → bacteremia → endocarditis) nSymptoms/manifestations of systemic diseases in oral cavity (i.e. anaemia → pale mucosa) nSequels of systemic therapy on oral cavity (i.e. chemotherapy – mucositis) Oral health-related quality of life nNutrition: Oral dysfunction can seriously impact nutritional status nEdentulous patients (fully or partially) favor diets higher in carbohydrates, lower in protein content (! maintaining muscle mass), fibre (!constipation). nEating and chewing - missing teeth qualitatively linked to a poorer diet nChewing ability declines as tooth loss increases, regardless of denture replacement n n Oral health-related quality of life nSleep issues: 3 to 5% percent of the population reported trouble sleeping because of pain or discomfort from dental problems nMostly chronic pain + insomnia are exacerbated by depression and vice versa Oral examination nMany diseases (systemic or local) have signs that appear on the face, head + neck or intraorally nComplete examination can help to provide differential diagnoses in cases of abnormal findings + event. treatment recommendations based on accurate assessment of the signs + symptoms of disease Selected symptoms in dentistry nOedema: inflammatory (local, part of systemic infl., allergic, traumatic, toxic) ncongestive (venostatic) nlymphostatic noncocytic - hypoproteinemia (malnutrition, renal, hepatic) npossible combined etiology, i. e. in tumors (local vessel blockage + inflammation + malnutrition), endocrinopathy (hypothyreosis → myxedema, Cushing sy → moon face) n Focal oedema nUsually part of local reactive changes n nLocal inflammation nCysts incl. retention cyst (salivary) nTumors Bad taste - dysgeusia nAging nHeavy smoking nPoor oral hygiene nDental caries nPeriodontal disease nDry mouth nIntraoral malignancies nDiabetes nHypertension nMedication nOesophageal diseases (reflux, diverticulum, tumor) nStomach diseases (vomiting, bleeding) nRespiratory tract dis. (cough+ sputum, tumors) nUremia nNeurogenic disorder nPsychosis n Local problems Distant/systemic problem Too much saliva nMay be related to psychosomatic problem nNew denture insertion, increased or decreased vertical dimension n n Xerostomia nSymptom: feeling of oral dryness, ↓ amount of saliva in the mouth, commonly + hyposialism nPhysiologic: excessive speaking , during sleep, old age nPathologic causes: local inflammation, incl. infection, atrophy + fibrosis of salivary gland (i.e. autoimmune Sjorgen’s syndrome, HIV-associated salivary gland disease, …) nDehydration state, alcoholism, psychic disturbances nDiabetes, hyperthyroidism nIatrogenic: medications (antihypertensive, tricyclic antidepressants, antihistamines, sympathomimetics), chemotherapy or radiation Dry mouth n 19835048 涂李和娣 930908 xerostomia A From: Oral pathology dept KMUH Xerostomic mucositis nClinical manifestation of salivary gland dysfunction, not a disease entity. nClinical features: nDiffuse erythema. nPain particularly on the gingiva. nMajor salivary glands → no salivary flow. nProgessive dental caries, periodontal diseases, secondary candidiasis. n n Selected symptoms in dentistry nBleeding: acute local causes (injury, teeth extraction, gingivitis), local vessel problems, tumors, … nSystemic causes: coagulopathy (haemophilia, liver insufficiency…), nthrombocytopenia/-pathy (bone marrow disorders incl. haemathological malignancies, therapy…) nvasculopathy (inborn; acquired incl. vitamin C deficiency, …) Bleeding 16726628 廖清安 921101 periodontitis A hematoma erythema multiform03 Periodontitis Hematoma Erythema multiforme 12735883 林郭秋玉 930310 AML ANUG E leukemia 12735883 林郭秋玉 930317 AML ANUG E From: Oral pathology dept KMUH HIV Haematological disorders - haemorrhagic diseases nbleeding after tooth extraction > 1 day n1. coagulopathy - clotting disorders nlong severe bleeding after short delay n2. platelet disorders npurpura, petechiae, ecchymoses nimm. following trauma ® commonly spontaneous stop n3. vascular disorder n vessel rupture after minor trauma, pressure Haematological disorders - coagulopathy nHaemophilia A (X inheritance) nmost common nFVIII deficiency nchildhood nbleeding into muscles or joints (haemarthros) nAcquired disorders nliver diseases (common, may be unknown to the patient) nvitamin K deficiency nanticoagulant treatment – heparin, warfarin, aspirin n Haematological disorders - thrombocytopenia/pathy nIdiopathic thrombocytopenic purpura nantibodies x platelets ® low number in periph. blood nchildren, young women natypical combination of thrombocytopenia + thrombosis, immune mediated, possible reaction postvaccination, in heparin therapy, very rare nvon Willebrand´s disease (AD inheritance) nthrombocytopathy + low level of vW factor (part of FVIII) ndrug associated naspirin n Selected symptoms in dentistry nMucosal surface colour changes nnonspecific inflammatory hyperemia nspecific colour changes in viral/bacterial infections (Koplik spots, …) nintoxication (cherry tint in carbon monoxide i., cyanosis in methemoglobinemia – nitrates i.) nsystemic cyanosis (cardiac and/or respiratory insufficiency) npigmentations – endogenous (jaundice, graphite spots in Addison‘s disease); exogenous Selected symptoms in dentistry nSoreness - presence of mucosa inflammation or ulcers nBurning sensation - thinning or erosion of the surface epithelium; n Burning mouth syndrome: in xerostomia, anemia, vitamin deficiencies (esp. on tongue), psychic disturbances, infections (viral, fungal, chron. bacterial). Selected symptoms in dentistry nContracture (difficulty in mouth opening) nLocal oral causes (inflammation - molars, myogenic, arthrogenic – temporomandibular joint, neurogenic, traumatic) nExtraoral local causes (parotitis, peritonsillar abscess, scarring) nSystemic causes (paralysis, tetanic spasm –trismus) Oral health and diabetes mellitus nType I – periodontal disease frequent + rapidly progressive nI + II – diabetic sialodenosis (bilateral parotid enlargement), mycotic infections: oral candidiasis, zygomycosis; benign migratory glossitis; xerostomia (1/3 of diabetic p.) Oral health and diabetes mellitus nDiabetes mellitus + smoking – risk of periodontitis with loss of tooth-supporting bone 20x higher. nChronic periodontal disease possibly can disrupt diabetic control nIncreased susceptibility to infection, impaired host response, excessive production of collagenase found in periodontal disease – possible important roles in periodontitis n DM associated gingivitis n Oral health and heart disease nOral bacteria → bacteremia → attaching to fatty plaques in the coronary arteries contributes to clot formation. nRisk of fatal heart disease double for persons with severe periodontal disease. nComplete dental treatment incl. extraction prior to organ transplantation. nExacerbation of existing heart conditions. Patients at risk for infective endocarditis may require antibiotics prior to dental procedures. Cardiovascular diseases nInfective endocarditis nsource: bacteraemia after tooth brushing dental procedure, mixed flora possible, i.e. viridans strep. group, Staph., HACEK group (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella) nvalve defects: congenital x rheumatic fever nprosthetic valves ncolonisation of cardiac valves ® vegetations ® valve destruction nATB cover in selected patients may be necessary Cardiovascular diseases nantihypertensive drugs ncalcium channel blockers → gingival hyperplasia nanticoagulative therapy → risk of increased bleeding ndiuretics → xerostomia nimplanted pacemakers, defibrillators nrisk of interferention with stomatologic equipment CNS diseases nPossible relationship between periodontal disease and stroke. nPatients with acute cerebrovascular ischemia were found more likely to have an oral infection npossible association of periodontal lesions with increased risk of dementia, esp. Alzheimer‘s ndysbalance in microbiome – dysbiosis - may contribute to chronic systemic inflammation npossible ↓ of nitrite oxide production naccess of the healthy x pathogenic bacterias into blood / brain Respiratory diseases nOral bacteria may be aspirated into the lung → respiratory inflammation (pneumonia), exacerbation of existing respiratory disease (COPD), due to decreased local immunity. nHighly dangerous aspiration pneumonia (purulent – putrid - gangrene) from fragments of carious teeth n n Respiratory tract diseases nOral tuberculosis nrare complication of open lung TBC npainless ulcer on dorsum of tongue ncervical lymphadenopathy nMicro: caseating epithelioid granulomas with multinucleated Langhans‘ cells Respiratory tract diseases nSarcoidosis nchronic granulomatous disease of unknown origin nlungs, LN (hilar), salivary glands; almost any tissue noral: painless swelling – gingivae, lips noral ulcerations possible ndiagnosis: biopsy of labial glands nMi: non-caseating tuberculoid granulomas + fibrosis, possible calcifications Lethal midline granuloma syndrome nclinically: destruction of central facial tissue + fatal outcome possible nGranulomatosis with polyangiitis (Wegener) systemic necrotising vasculitis (ANCA+) ngranulomas of upper and lower RT noral ulceration, „strawberry“ gingivitis – red, granular, swollen; biopsy necessary nglomerulonephritis nAngiocentric NK/T cell lymphoma Gastrointestinal diseases nCrohn´s disease npart of chronic inflammatory bowel diseases, immunologically mediated nileocaecal region – regional intestinal wall thickening and ulceration, fistulae, nMi: mucosal changes, transmural lymphoplasmocytic infiltrate + small granulomas Oral Crohn’s disease n10-20% of Crohn’s patients, commonly prior to the intestinal lesion n90% have granulomas on biopsy nMetallic dysgeusia nGingival bleeding n„Metastatic“ Crohn’s – non-caseating granulomatous skin lesions in patients with Crohn’s. Oral Crohn’s disease nDiffuse labial, gingival, mucosal swelling (pain, cosmetic problems) nCobblestoning of the buccal mucosa and gingiva(inflammatory hyperplasia of oral mucosa), fissuring naphthous ulcers nmucosal tags nangular cheilitis ndeep ulcers – linear, buccal vestibule; n crohns Oral Crohn’s disease copy Pyostomatitis vegetans nInflammatory stomatitis in setting of ulcerative colitis or Crohn‘s disease, uncommon nEdema and erythema with deep folding of the buccal mucosa, pustules, small vegetating projections, erosions, ulcers and fibrinopurulent exudate. nPustules fuse into shallow ulcers resulting in characteristic „snail track“ ulcers n Mixed inflammatory infiltrate, + numerous eosinophils n pyostom1lp Red – oedema Black – perivascular infiltrate Blue – abcess formation with eosinophils pyostom2hp pyostom1clin copy Ulcerative colitis nInflamatory bowel disease restricted to colon nOral manifestations (aphthous ulcerations, haemorrhagic ulcers) possible (5-10%), during exacerbations of colonic lesions Gastroesophageal reflux nRegurgitation of gastric content nVery low pH in the oral cavity – enamel dissolution, usually on palatal surfaces of the maxillary dentition – erosion + dentin exposure (temperature changes sensitive) – irreversible, restoration procedures necessary Gastrointestinal diseases nGardner´s syndrome (AD inheritance) n multiple jaw osteomas + polyposis coli multiple adenomas with malignant potential ndental defects, epidermal cysts n nPeutz-Jaeghers syndrome npigmented macules around lips + intestinal non-malignant polyposis (small intestine), but ↑ life-long risk of variable cancers (GIT, genital, ...) Chronic liver disease nJaundice, primary on the soft palate + sublingual region nCoagulopathy (fibrinogen + other coagulation proteins production↓, vitamin K resorption ↓) – oral petechiae, excessive bleeding in minor trauma - !dental surgical procedures nOral lichen planus (white reticular lesions) in chronic hepatitis C, !drug lichenoid reaction – NSAID, antihypertensive drugs Uremic stomatitis npossible complication of renal insufficiency, usually acute nwhite plaques on mucosa (!x leukoplakia) nuremic foetor ex ore Nutritional deficiencies nvitamin A nsquamous metaplasia ® keratinisation (leukoplakias ?), dryness (ocular – ulcers, blindness) nvitamin B2 (riboflavin) nangular stomatitis - painful red fissures at angles nglossitis nswelling and erythema of oral mucosa nvitamin B3 (niacin) n pellagra (dermatitis, dementia, diarrhea); stomatitis + glossitis – red, smooth, raw nvitamin B6 (pyridoxine) deficiency in pyridoxine antagonists drugs, cheilitis + glossitis Nutritional deficiencies nvitamin B12 (cobalamin) + intrinsic factor - pernicious anaemia in autoimmune atrophic gastritis nglossitis, erythema + atrophy nburning sensations Pernicious anemia nPernicious anemia: no absorption of vitamin B12. nMacrocytic anamia (huge red blood cells) nSigns of anemia, weakness, pallor, fatigue during physical activity. nerve degeneration nNausea, diarrhea, abdominal pain, loss of appetite. nOral manifestations of pernicious anemia: angular cheilitis (ulceration and redness at the corners of the lips), mucosal ulceration, loss of papillae on the tongue – atrophic glossitis, commonly early sign!, a burning + painful tongue. Pernicious anemia: red and smooth dorsum of the tongue Haematological disorders - anaemias niron deficiency (microcytic a.) nchronic menstrual blood loss nchronic bleeding from peptic ulcer Haematological disorders - anaemias nnonspecific general changes of anaemia nmucosal and skin pallor + fatigue + breathlessness + tachycardia natrophy of filiform papillae - glossitis nangular stomatitis ncandidiasis Plummer–Vinson syndrome nIron-deficiency anaemia + glossitis + dysphagia nSmooth red painful tongue with atrophy of filiform and the fungiform papillae nAtrophy of mucosa of the mouth pharynx and essophagous and ophagous nAngular cheilitis nDysphagia or feeling of food sticking in the throat nDysphagia due to web in oesophagus (chronic oesophagitis) or stenosis of the esophagal mucosa (early indicator of carcinoma ) nPossible immune dysregulation + metabolic lesions nPremalignant lesions (oral, oesophageal ca) Nutritional deficiencies nvitamin C - scurvy – inadequate collagen synthesis, delayed healing, bleeding ngingival swelling and bleeding, ulcerations ntooth mobility + loss, ↑ periodontal infection nvitamin D – rickets in infancy, osteomalatia in adults – poorly mineralized bone n Nutritional deficiencies nVitamin E (a-tocopherol), deficiency rare, neurologic signs nVitamin K - coagulopathy Gingivitis associated with systemic factors nEndocrine gingivitis: nPuberty nPregnancy nMenstrual cycle n nModified inflammatory response to estrogen and progesterone levels within the gingival tissue → greater response to plaque → more inflammation + ↑vascular component n Hormonal disturbances nPyogenic granuloma - overgrowth of granulation tissue. n n n nPuberty gingival enlargement - swollen gingival tissues in adolescents (like pregnancy gingivitis), disappear after normal hormone balance returns. Endocrine disorders nPituitary hyperfunction of growth hormone ngigantism nacromegaly n jaws (condylar growth) + hands + feet Endocrine disorders and pregnancy nPregnancy ngingivitis npregnancy epulis formation nrecurrent aphthae n . Pregnancy gingivitis nhyperplasia + erythema, in 5 % nPossible pseudotumorous polyps. nBoth of these clear up after hormonal balance returns to normal. Endocrine disorders nAdrenocortical diseases nAddison´s disease = cortical insufficiency (autoimmune, infections, tumors) nfailure of cortisol and aldosteron secretion nearly sign – brown oral pigmentations (melanin), diffuse or focal; gingiva, buccal mucosa, lips n Endocrine disorders nCushing‘s syndrome – hypercortisolism (adrenal, ACTH, secondary – therapy) n„moon face“ - round nhirsutism, poor healing, osteoporosis, hypertension nsecondary after prolonged corticosteroid therapy (autoimmune disease, transplantation, …) Endocrine disorders nHyperparathyroidism – excess PTH nstones formation – renal calculi, metastatic calcifications nOsseous changes – loss of lamina dura surrounding teeth roots, brown tumor identical to jaw giant cell granuloma (in bones, + hemosiderin, multinucleated giant cells) nDuodenal ulcers Haematological neoplasia - leukaemias nneoplastic disorder of bone marrow nacute x chronic nlymphoblastic x myeloblastic nALL - children nCLL, CML, AML - adults nanaemia + infection + bleeding tendency nhepatosplenomegaly + lymphadenopathy noral: gingival swelling + mucosal ulcerations + purpura Leukemia associated gingivitis Autoimmune diseases ncommonly middle aged women nantibodies in blood possible n nrheumatoid arthritis nSjögren´s syndrome nlichen planus nsystemic lupus erythematosus nsystemic sclerosis (incl. IgG4 systemic sclerosing disease) Autoimmune diseases nSystemic lupus erythematosus nantinuclear factors n~ 20% patients have oral symptoms nskin rash (butterfly) + arthritis + pleuritis + glomerulonephritis noral: lichenoid lesions, ulceration, cheilitis nSystemic LE ( multisystem disease, systemic manifestation, serological abnormalities; antinuclear “ANA” and anticytoplasmic antibodies ) nDiscoid (localized) LE nMucocutaneous disease, no serological abnormalities n Discoid lupus erythematosus: typical lesion on the buccal mucosa SLE nDiscoid erythematous, central red ulcerated or atrophic lesion – plaque, sm. peripheral white fine lines nButterfly rash: facial erythema nSkin: elevated red, purple macules, scales, ( follicular plugging ) nRaynaud’s phenomenon: pallor or cyanosis and tingling of toes and fingers on exposures to cold or emotion due to paroxymal vasospasm. n n Autoimmune diseases nSystemic sclerosis nsubcutaneous and visceral fibrosis (GIT, lungs, …) nmask-like face + limited oral opening n n n Autoimmune diseases nIgG4 associated systemic sclerosing disease nvariable manifestation – incl. chronic sialoadenitis with Sjögren (sicca) syndrome nsmall salivary gland biopsy n Amyloidosis nDeposition of pathologic fibrillar amyloid proteins nOral manifestation – macroglossia (in 20%), firm, loss of mobility nHistopathology + special methods necessary for diagnosis Oral cavity health in systemic therapy nOral mucositis in chemotherapy nLocal microbiome changes + ↑ risk of mycotic overgrowth in antibiotic therapy n↑ risk of systemic spread of oral infection nVariable problems in HIV/AIDS therapy nXerostomia Drug induced conditions nAphthous stomatitis nXerostomia nLichen planus nGingival hyperplasia nCandidiasis n…