Oral Manifestations Of Systemic Disease

Question 1

What are the two ways of making a diagnosis?

Answer 1

What we see and hear

Medical history and examination

Question 2

Extra oral examination

Answer 2

Question 3

Extra oral examination inside mouth

Answer 3

Question 4

How do teeth indicate systemic disease ? Abnormal colour

Answer 4

Tetracycline = yellow to brown or grey
Fluorosis = opaque white or brown patches
Severe / childhood jaundice = yellow or green
Porphyria = (rare hereditary disease of haemoglobin metabolism) purplish red
Dentinogenesis Imperfecta / Osteogenesis Imperfecta = purplish or brownish but INCREASED TRANSLUCENCY

Question 5

What can cause Dental Hypoplasia?
(Underdevelopment)
(5)

Answer 5

• Congenital syphilis
• Severe childhood fevers
• Severe fluorosis
• Severe rickets
• Hypoparathyroidism

Question 6

Congenital syphilis - dental hypoplasia?

Answer 6

– Notched and peg-shaped permanent incisors
– Molars may also be deformed (Moon’s molars)

Question 7

Severe childhood fevers - dental hypoplasia?

Answer 7

– Horizontal grooves or pits
– particularly of the incisors

Question 8

Severe fluorosis - dental hypoplasia?

Answer 8

– Rough pitting, white / brown
– opacities (very high fluoride areas
– eg Yemen / Sudan etc)

Question 9

Severe rickets - dental hypoplasia?

Answer 9

– Grooving or pitting of the enamel

Question 10

Hypoparathyroidism - dental hypoplasia?

Answer 10

– Ectodermal defects
– (grooving / pitting of enamel)

Question 11

What causes abnormal loss of tooth surfaces?

Answer 11

1) Erosion - Extrinsic acids – (diet)?
Intrinsic acid – (gastric)?
– risk of oesophageal metaplasia and malignant conversion
– Typical in reflux disease
– heartburn
– Bulimia nervosa… (look for calloses on dorsum of digits)

2) Attrition - bruxism / TMJD / general emotional wellbeing?

3) Abrasion - components of diet / other device intra orally eg mouthpiece of wind instrument etc?

Question 12

Look at reflective qs from PowerPoint 1

Question 13

How does colour of mucous membranes indicate systemic disease?
Anaemia

Answer 13

Anaemia = pallor of mucus membrane + red beefy sore tongue

Question 14

How does colour of mucous membranes indicate systemic disease?
Pigmentation

Answer 14

Ethnicity
Addisons disease

Question 15

How does colour of mucous membranes indicate systemic disease?
Blue due to cyanosis

Answer 15

Cardiovascular disease
Respiratory disease

Question 16

How does colour of mucous membranes indicate systemic disease?
Yellow tint due to jaundice?

Answer 16

haemolytic

obstructive hepatic

infectious

Question 17

How does colour of mucous membranes indicate systemic disease?
White due to keratosis

Answer 17

trauma

mucosal disease

candida

cancer

Question 18

How does colour of mucous membranes indicate systemic disease?
Blue / brown gingival margins

Answer 18

Heavy metal poisoning - lead and bismuth

Question 19

How does colour of mucous membranes indicate systemic disease?
Blue / Brown patch

Answer 19

– melanoma
– Amalgam tatoo
– Silver sulphide – old silver point RCT

Question 20

How does gingival / mucosal bleeding indicate systemic disease?

Answer 20

PURPURA (bleeding under skin)
- HIV/AIDS + acute leukaemias
- iatrogenic - steroids
- Myelodysplasias
- excessive gingival bleeding

DISORDERS OF CLOTTING
- anticoagulant excess
- purpura not present
- HAEMOPHILIA A is the most important cause
- von willebrand disease
- excessive gingival bleeding

EXCESSIVE GINGIVAL BLEEDING

Question 21

Main causes of acute gingivitis

Answer 21

– Acute leukaemia,
– immunodeficiencies,
– AIDS
– Agranulocytosis
– Uncontrolled diabetes

• vitamin deficiencies - vit C - scurvy, vit B3 - pellagra

Question 22

What causes gingival hyperplasia?

Answer 22

– Nifedipine
– Cyclosporin
– Phenytoin

Consider leukaemia

Question 23

Link between stomatitis - ulceration and systemic disease
What might cause the ulcers?

Answer 23

Apthous Ulceration because of :
- Recurrent aphthous stomatitis
- low levels of iron, folate and B12 (haematological associations)
- diet
- GI malabsorption / metabolic issues

Beçhet’s Disease
More than three episodes of oral ulcers per year

Reactive arthritis

Drug therapies
• Cardiovascular – Beta-blockers, niocorandil
• Oral hypoglycaemics (DM2)
• Chemotherapy cytotoxics
• Sulphonamides
• Barbiturates,
• Gold
• Urea

Question 24

Examples of systemic infections that affect mucous membranes - cause stomatitis

Stomatitis (inflammation of mucous membrane in the mouth)

Answer 24

Measles
Chicken pox
Syphilis
Herpes zoster
Herpes simplex
Tuberculosis - hiding painful ulcer
Actinomycoses – Occasionally following removal of wisdom teeth,
– fistula forms, yellow sulphur granules

Question 25

Look at reflective qs from 2 + ANSWERS

Question 26

GI Tract conditions that affect the mucous membranes

Answer 26

• Crohn’s Disease • Coeliac Disease • Ulcerative Colitis

Question 27

Orofacial Granulomatoses

Answer 27

Google def - condition where patients have persistent swelling of lips, face and other areas in the mouth Melkersson - Rosenthal syndrome – neurological -> labial & peri-oral swellings – facial (VII) nerve paralysis & plicated (folded) tongue Meischer’s syndrome – lip swelling only Foodstuffs hypersensitivity (type IV) – eg cinnamon/cinnamaldehydes / benzoates (ie allergy - not from lecture just for understanding ) Crohn’s disease Sarcoidosis

Question 28

What is Coeliac disease ? Oral manifestations?

Answer 28

• Genetic inherited sensitivity to Gliadin component of wheat gluten.... Small bowel villous atrophy & malabsorption of many vitamins, minerals & micro-nutrients - Oral Ulceration - Angular cheilitis - Burning mouth - Glossitis

Question 29

What is Ulcerative Colitis? Oral manifestations?

Answer 29

• Mural inflammation in Colon wall primarily - Shallow non-granulomatous mural ulceration – unlike Crohn’s tends not to fistulate - Haemorrhagic lesion - Pyoderma gangrenosum - Apthous like ulcer - Pyostomatitis vegetans - (small patches across the mucosa)

Question 30

Diseases affecting skin and mucous membranes:

Answer 30

– Pemphigus – Mucous membrane pemphigoid – Epidermolysis bullosa – Erythema multiforme – Lichen planus (more common) – Linear IgA disease – Dermatitis Herpetiformis

Question 31

Lupus - 2 types? Oral manifestations?

Answer 31

DLE + SLE DLE- affects skin and mucosa SLE - Systemic Lupus Erythematosis - Rheumatological condition, ANA positive – Chronic inflammation flattens cheeks (butterfly rash over malar regiuons) – developing wolf-like facial (lupine(-> Lupus) features – Plus reticular pattern oral keratosis v similar to Lichen planus pattern clinically

Question 32

What is keratosis? What causes keratosis ?

Answer 32

White patches (in mouth) Lichen planus Lupus Immunosuppressive Candidosis Renal failure Tertiary syphilis

Question 33

What is glossitis? What causes glossitis?

Answer 33

Inflammation of the tongue • Anaemia – Most common identifiable cause – Most frequently due to iron deficiency (iron is stored in the filliform papillae) diet, malabsorbtion • Vitamin deficiencies - Riboflavin deficiency (B12) and pellagra (B3) - Malabsorption syndromes Eg coeliac

Question 34

What can cause an enlarged tongue?

Answer 34

• Hypertropy / Hyperplasia from use eg filling extracted tooth sites to maintain chewing • Acromegaly • Amyloidosis • Neurofibromatosis • Haemangioma & hamartomas • Lymphangiomas • Neoplasia

Question 35

What is amyloidosis

Answer 35

• Protein deposition in soft tissues – often tongue & renal involvement • Often a monoclonal protein Ig Light / Heavy chain (Multiple myeloma?) Beta pleated sheet protein deposition

Question 36

Primary sjodrens syndrome + Secondary sjodrens syndrome What do you need to watch out for? What are the consequences of dry mucosa? What drugs can cause dry mouth?

Answer 36

Primary - de novo occurrence (first time / no other conditions?? Unsure but googled) Secondary - if preceded by another rheumatological condition eg rheumatoid arthritis, lupus Dry oral, ocular and genital mucosa Watch for lymphoma over time Consequences of dry mucosa : Infection Caries Toothwear Candida overgrowth Discomfort Drugs = beta blockers, Antidepressant, chemotherapy

Question 37

Oral cancer symptoms

Answer 37

Often there are no symptoms but when there are : • A sore, lump or ulcer on the lip or in the mouth that does not heal after 2 weeks • A lump in the neck • A white or red patch on the gums, tongue or lining of the mouth • Unusual bleeding, pain or numbness in the mouth • Oral pain that does not go away or a feeling that something is caught in the throat • Difficulty or pain with chewing or swallowing • Difficulty with jaw opening • Jaw swelling - poor denture fit • Tooth loosening – often rapid (too fast for perio?) • Bad breath • Sensory & / motor loss of the face (V &/ VII involved) • Abnormal taste in the mouth • Swallowing difficulty (dysphagia) • Tongue mobility / stiffness problems

Question 38

How do changes in the jaw indicate systemic disease?

Answer 38

Areas of resorption or patchy resorption: • Paget's disease • Widespread metastases • Hyperparathyroidism

Question 39

How does cervical lymph nodes indicate systemic disease?

Answer 39

Oral sepsis is commonest cause of enlargement May also be first sign of diseases of the reticuloendothelial system: • Glandular fever • Hodgkin's disease • Non-Hodgkin lymphoma • Lymphocytic leukaemia • AIDS Metastatic disease (eg Oral squamous cell carcinoma)

Question 40

How can hands / arms indicate systemic disease?

Answer 40

• Rheumatoid arthritis - 2°Sjogren’s Syndrome • Clubbing – chronic suppurative disease (often chest) , liver disease , cyanotic heart disease • CNS – Parkinsonism • Liver disease - liver palms & tremor , coagulopathies – drug handling