Oral manifestations of systemic disease Flashcards
Which lymph nodes should you always examine extra-orally?
Remember extra-oral examinations begins the moment the patient walks through the door.
- Submental
- Submandibular
- Cervical chain
- Supraclavicular
- Occipital
- Post auricular
- Pre auricular
slide 7 and 8
Which areas should you always examine intra-orally?
-Gingiva
-Mucosa
-Lips
-Vestibule
-Hard palate
-Floor of mouth
- Ventral and lateral border of the tongue
Why might teeth be abnormally coloured?
- Tetracycline used in odontogenesis might make them yellow, brown or grey
- Fluorosis (opaque white or brown patches)
- Severe long term/childhood jaundice (yellow or greenish)
- Porphyria, a rare hereditary disorder of Hb metabolism (purplish red colour)
- Dentinogenesis & osteogenesis imperfecta, hereditary conditions influencing mineralised tissues can manifest in mouth (purplish/brownish discolourations)
What is dental hypoplasia?
When enamel has not formed properly/correctly
When might dental hypoplasia occur and what would the classic manifestations of ongoing disease be?
In congenital syphilis
Once the child is born, the manifestations would include notched & peg-shaped permanent incisors & molars may also be deformed (Moon’s molars
What can cause enamel/dental hypoplasia?
- Severe childhood fevers
- Horizontal grooves or pits
-Especially in the incisors - Severe fluorosis
- Rough pitting, white/brown
- Opacities - Severe rickets
- Grooving or pitting of the enamel
- Due to low vitamin D so calcium absorption is affected - Hypoparathyroidism
- Ectodermal defects (grooving/pitting of enamel)
Which systemic conditions can abnormal loss of tooth surfaces reflect?
- Erosion (due to intrinsic or extrinsic acids)
- Attrition - bruxism
- Abrasion - components of diet
(Look at picture)
How might anaemia present orally in terms of discolouration?
Pallor, bleeding to palate of mucosa, red beefy sore tongue
What might unusual pigmentation on the oral mucous membrane, usually that of a brown melanin type pattern represent?
Either ethnicity or Addison’s disease
How might CVD & respiratory disease present orally?
Blue pigmentation due to cyanosis
How might jaundice present orally?
Yellow tint (have to take it seriously because it might be haemolytic, obstructive hepatic or viral, infectious hepatitis)
Why might the oral mucosa go white?
Keratosis (maybe because of trauma, mucosal disease, candida or cancer)
What can blue/brown tinges at the gingival margin indicate?
Heavy metal poisoning (lead/bismuth)
What might a blue/brown patch elsewhere on the oral mucosa represent?
Melanoma, amalgam tattoo or silver sulphide from degradation products of an old silver point RCT
What conditions might purpura or gingival/mucosal bleeding be indicative of?
Purpura:
-Acute leukaemias and HIV/AIDS
Iatrogenic – Steroids,
-May be subcutaneously and sub-mucosally
-Excessive gingival bleeding may be a feature
-Myelodysplasias – megakaryocytes fail in dysplastic marrows – low platelets
Disorders of clotting…
-Excessive gingival bleeding may be a feature
-Anticoagulant excess
-Purpura is not present
-(haemophilia A is the most important cause) - Don’t forget HaemophiliaB & von Willebrand’s Disease
What conditions might acute gingivitis reflect?
Acute leukaemia
immunodeficiencies
AIDS
Agranulocytosis
Uncontrolled diabetes
Scurvy (vitamin c deficiency)
Pellagra (Vit B3 deficiency, v rare)
What 3 main drug causes is gingival hyperplasia usually related to?
Nifedipine
Cyclosporin
Phenytoin
(always consider leukaemias)
What can stomatitis (ulcerations) be indicative of?
Apthous Ulceration:
-RAS – Major – Minor – Herpetiform
-Fe, Folate, B12- Diet, GI malabsorbtion / metabolic issues
Beçhet’s Disease:
>3 episodes ROU per annum (HLA B51 link)
Genital ulceration Eye lesions
+’ve Pathergy test Skin lesions
CNS involvement (Headache, brain fog etc)
Musculo-skeletal involvement
Reactive Arthritis (Reiter’s syndrome):
Urethritis Uveitis/Conjunctivitis Arthritis & Apthous Ulceration
What are some disorders with haematological associations that could present as stomatitis?
Haematinic deficiencies
Cyclic neutropenias
Leukaemias
Which drug therapies can result in mucosal breaches and therefore stomatitis/ulcerations?
Cardiovascular- beta blockers, nicorandil
Oral hypoglycaemics (DM2)
Chemotherapy cytotoxins
Sulphonamides
Barbiturates
Gold
Urea
What systemic infections can manifest in the oral mucosa & perioral tissues?
Measles (small white spots known as Koplick’s spots produced, not to be confused with fordyce granules which are completely normal)
Chicken pox (cutaneous rash)
Syphilis:
(primary: ulcer at innoculation site)
(secondary: snail track ulcer, widespread rash, generally feeling unwell)
(tertiary: gumma, can lead to nasal speech, Holmes Adie pupil, leucoplakia)
Herpes zoster
Herpes simplex
TB (painful, hiding ulcer)
Actinomycoses (following wisdom teeth removal, fistula forms, yellow sulphur granules)
Which GI tract conditions could present with stomatitis?
Oro-facial granulomatosis
Crohn’s disease
Coeliac disease
Ulcerative colitis
Which different conditions do oro-facial granulomatoses comprise?
Oro-facial granulomatoses : swelling and irritation in the mouth and face
Melkersson-Rosenthal syndrome - Labial & peri-oral swellings + facial nerve paralysis + pilcated tongue
Meischer’s syndrome - Lip swelling only
Foodstuffs hypersensitivity (type IV)
What is coeliac disease and how can it present?
- Allergy to gluten
- Oral ulceration
-Small bowel malabsorption of many vitamins, minerals and micro-nuitrients
-Angular cheilitis (sore cracked corners of the mouth)
-Burning of the mouth
-Glossitis (inflammation of the tongue)
What is ulcerative colitis and how can it present orally?
Mural inflammation in colon wall primarily
Features shallow non-granulomatous mural ulcerations & they don’t tend to form fistulas (unlike Crohn’s disease)
Oral manifestations included
Which diseases that affect the skin can also affect the oral mucous membrane?
Pemphigus
Mucous membrane pemphigoid
Epidermolysis bullosa
Erythema multiforme
Lichen planus (most common)
Linear IgA disease
Dermatitis herpetiformis
Which lupus conditions can manifest in and around the mouth?
The 2 images are manifestations of discoid lupus, not systemic lupus.
What is keratosis?
White patch changes on the oral mucosa, can be attributed to lichen planus, lupus, immunosuppression, candidosis, renal failure, tertiary syphilis
What might cause glossitis (inflamed/sore tongue)
-Anemia
-Vitamin deficiency
What is macroglossia & what can it be associated with?
Enlarged tongue, can be associated with:
Hypertrophy/hyperplasia from use e.g. filling extracted tooth sites to maintain chewing
Acromegaly (late pituitary growth hormone excess)
Amyloidosis
Neurofibromatosis
Haemangioma & Hamartomas
Lymphangiomas
Neoplasia
What is important to note about the clinical presentation of macroglossia?
That the tooth imprints on dorsum of tongue suggesting enlargement (white arrows) unlike lateral margin indentations (crenulations) suggesting a tongue thrusting habit
What is amyloidosis?
Protein deposition in soft tissues- often tongue & renal involvement
How do you prove a diagnosis of amyloidosis?
Positive staining to congo-red
You can also expect birefringence on cross polarised light microscopy
What diagnostic criteria would prove that dry mouth is Sjogren’s syndrome?
-Subjective & objective Dry occular, oral & genital mucosae
-ENA (Ro60+ve) auto-antibody positive (watch for bradycardia in neonates-O&G)
-Lip gland biopsy – peri-ductal inflammation pattern
-Classical Utrasound pattern
-Watch for Lymphoma developement over time
-Manage consequences of dry mucosae – infection, caries, tooth wear, discomfort, candida overgrowth etc
What else can cause dry mouth?
Drugs: beta blockers, anti-depressants, etc
Obligate mouth breathers
Anxiety states
What is the Challacombe scale?
Measures clinical oral dryness
slide 55
What variety of effects can viral immunodeficiency cause?
Common: Cervical lymphadenopathy, candidosis, Kaposi’s sarcoma, hairy leucoplakia
Less common: angular cheilitis, herpes simplex/zoster, venereal warts, recurrent ulcers, rapidly progressive periodontitis, histoplasmal ulcers, cytomegalovirus, lymphoma, parotitis, etc.
What could be some symptoms of oral cancer?
-A sore, lump or ulcer on the lip or in the mouth that does not heal after 2 weeks
-A lump in the neck
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 period?)
-Bad breath
-Sensory & / motor loss of the face (V &/ VII involved)
-Abnormal taste in the mouth
-Swallowing difficulty (dysphagia)
-Tongue mobility / stiffness problems (hot potato dysarthria)
What do we mean by changes in the jaw and what could this be attributed to?
Areas of resorption or patchy resorption & sclerosis in the jaws, which may be due to skeletal diseases & associated with changes in the blood chemistry.
Might be Paget’s disease, widespread metastases, hyperparathyroidism, Gardner’s syndrome
What is Gardner’s syndrome?
GI polyps and associated findings of SOD:
-Sebaceous cysts
-Osteomas
-Desmoid tumors
polyps have higher malignancy potential
What is the most common cause of cervical lymph node enlargement?
Oral sepsis
Why else might the cervical lymph node be enlarged?
It may be the first sign of diseases of the reticuloendothelial system:
-Glandular fever
-Hodgkin’s disease
-Non-Hodgkin lymphoma
-Lymphocytic leukaemia
-AIDS & its prodromes
-Or metastatic disease (e.g. oral squamous cell carcinoma)
What manifestations of the hands and arms can show signs of other conditions?
Rheumatoid arthritis:
2°Sjogren’s Syndrome..
Clubbing:
-chronic suppurative disease (often chest)
-liver disease
-cyanotic heart disease
CNS:
-Parkinsonism
-intention tremor – worsens when try move
-cogwheel rigidity on flex / extend
elbows
Liver disease:
-liver palms & tremor
-coagulopathies – drug handling
