Oral manisfestations of disorders of specific systems Flashcards
How may oral candidosis be related to systemic disease? (what factors can predispose you to oral candidosis?)
Local factors:
- antibiotic therapy
- denture wearing at night time
- high carbohydrate diet
- hyposalivation
- advancing age
Other factors:
- Systemic disease related immunocompromiseDiabetes mellitus, systemic anaemia
- Drug related immunocompromiselocal eg. topical, inhaled steroid therapy
- Drug related immunocompromisesystemic steroid therapy
What is this?
Chronic hyperplastic condition
What are some candida associated lesions?
- Angular Cheilitis
- Median Rhomboid Glossitis (image)
What is this picture of?
Oral warts. A patient which huge warts such as these must consider that they are immunocompromised. Could be caused by HPV.
What is this?
Patient with HHV1 (herpes simplex virus). This shows lots of cold sores and crusting but if a patient just has one cold sore it doesn’t necessarily mean they’re immunocompromised.
What is this?
Recurrent intraoral herpes simplex ulceration. Seen along a nerve distribution, stops in the midline. May indicate patient is immunocompromised.
What is this?
HHV-3 (varicella-zoster) (shingles).
It’s a reactivation of HHV-1. It’s recurrent and much more extensive and painful ulceration than HHV-1.
What is HHV-4?
The Epstein–Barr virus (EBV), also called human herpesvirus 4 (HHV-4), is a virus of the herpes family, and is one of the most common viruses in humans.
It is best known as the cause of infectious mononucleosis (glandular fever). It is also associated with particular forms of cancer, such as Hodgkin’s lymphoma, Burkitt’s lymphoma, nasopharyngeal carcinoma, and conditions associated with human immunodeficiency virus (HIV), such as hairy leukoplakia and central nervous systemlymphomas. There is evidence that infection with the virus is associated with a higher risk of certain autoimmune diseases, especially dermatomyositis, systemic lupus erythematosus, rheumatoid arthritis, Sjögren’s syndrome, and multiple sclerosis.
Infection with EBV occurs by the oral transfer of saliva and genital secretions.
What is this? and how can it be proven?
Oral hairy leukoplakia. To prove it you need to be able to detect the presence of the Epstein Barr Virus by taking a biopsy and looking at the histology. A marker would be used to detect the EBV cells. In the histology slide here you can see them as the blue dots.
What can HIV show as an oral manifestation?
It causes immunosuppression which can lead to HIV gingivitis and periodontitis and other problems like apthous like ulceration (seen in image). So these oral manifestations aren’t directly caused by HIV but are a secondary effect due to its immunosuppression.
How can Hep C (HCV) manifest itself orally?
It is associated with lichenoid reactions which are indistuingishable to other lichenoid reactions (see image). It can also be the secondary cause of Sjogrens like syndrome (lesions and swelling of swelling of salivary glands). leading to dry mouth etc.
What is this?
Snail like ulceration secondary to primary syphilis (a bacterial infection). (so syphilis should be included in differential diagnosis of recurrent oral ulceration.)
Syphilis and HIV increased comorbidity.
How does immunosuppresion affect oral malignancy?
Immunosuppression doesn’t just cause candida etc. it can also increase the risk of oral malignancy such as oral squamous cell carcinoma and also increase the risk of lymphomas.
What is this?
SCC lower lip in a patient with Crohn’s Disease on long term immunosuppression.
What is this?
Could be Systemic/ Discoid Lupus Erythematosus (SLE or DLE) OR could be oral lichen planus type manifestations. Very difficult to distuinguish between them even histologically they are similar.
What is this?
Mumous membrane pemphigoid (MMP). It’s a systemic disease and can show in any mucous membrane. Patients develop desquamative gingivitis orally so should be included in differential diagnosis when desquamative gingivitis is seen.
What is this?
Pemphigus Vulgaris
What is this?
Atrophic glossitis. You should do a full blood count if you see this as should suspect anaemia and anaemia could be secondary to a malignancy eg. a GI malignancy and you’d be the first to spot it.
(all haemotinic deficiencies can cause a smooth tongue)
What could cause this?
You would have to take a history as can’t just say what it is by looking at it as it could be and could be caused by numerous things.
What is this?
Purpura caused by submucosal bleeding.
Differential diagnosis:
- Platelet related eg. thrombocytopaenia
- Clotting related eg. Haemophilia
- Drug related eg. warfarin Rx
Once transplant taken place what can happen and what are the oral complications of this?
Graft vs Host Disease (GVHD). Orally the features are similar to oral lichen planus. Can also affect the salivary glands.
How can cardiovascular disease show itself in oral manifestations?
It doesn’t but the drugs patients take for their cardiovascular disease can lead to oral manifestations such as dry mouth (often seen in patients on diuretics).
People on ACE inhibitors may get sudden idiopathic oedema (see image) which you must beware of as if swelling in neck can lead to blocked airway and death. Swelling often goes down within 24hrs but is recurrent.
How can oral thrush be caused?
Predisposed by systemic immunosuppression. Important local facor = steroid inhaler. often because patient not washing their mouth out after use.
What is this?
Nicorandil induced ulceration. Nicorandil is a drug given to patients with ischaemic heart disease and it can cause oral ulceration (aytypical apthous like ulcer with a greyish base and very little inflammation). No topical treatment works only way to treat it is to reduce the dose of drug or stop it completely.
What is this?
Cyclosporin or Ca2+ channel blocker induced gingival overgrowth.
- Prevalence of 30%
- Higher frequency in adolescents and males
- Effects anterior gingiva
- Changes occur within 3 months of dosing
- High recurrence rate.
Requires gingectomy and periodontal surgery.
What can the drug sulfasalazine induce?
oral lichenoid reactions.
What can bisphosphonates do?
Bisphosphonates have an anti-angiogenic function therefore healing and repair of a necrosed area becomes very difficult. Dental work should be done before patients go on them to prevent bisphosphonate induced oro-necrosis. iv bisphosophates have a worse effect than those taken orally. If there’s a non healing ulcer which is related to bone consider bisphosphonates as the cause.
What is this?
Oral pigmentation. This of Addisson’s disease as a differential diagnosis especially if there are multiple sites of pigmentation.
What is this?
Hereditary Haemorrhagic Telangiectasia. Will also be present in other sites. Talk to GP before doing any extractions or a procedure that can cause a bacteraemia.
What is this?
Cowden’s Syndrome.
- PTEN gene mutation
- High risk breast, uterine, thyroid cancer
- GI abnormalities are present in as many as 72% of patients
- Multiple hamartomas (bumps): skin, mucous membranes, GI tract
- Polyps can occur in any part of GI tract (low malignant potential)
What is this?
Paraneoplastic pemphigus.
Pemphigus related oral ulceration in association with malignancy – known or occult.
