Systemic diseases and the mouth Flashcards
What are the ways in which a dental manifestation of systemic disease can present?
- Affects tooth structure formation
- Affects Tooth structure components
When does disruption affecting primary teeth occur?
Pre-natal/Peri-natal period
When does disruption affecting secondary teeth occur?
Perinatal/early childhood
What are the systemic causes of dental abnormalities?
Congenital conditions/infections
-> Syphilis,TORCH
-> Ectodermal Dysplasia
Illness/metabolic disorder
-> Severe childhood illness
-> Cancer treatments
Pigmentation from substances in the blood
-> Bilirubin, tetracycline
What are some of the features of ectodermal dysplasia?
- Hypoplasia- cone shaped teeth
- Hypodontia
- Abscess of sweat and salivary glands
What are the dental features of syphillis?
Bulbous crown- Hutchison’s teeth
What occurs to teeth as a result of jaundice and hyperbilirubinaemia?
They become green
What can occur if tetracycline is used during period of tooth formation?
Can become incorporated into tooth structure
- Linear banding
- Significant cosmetic deformity- especially if taken over years
- No longer given to children (don’t use if better drug available)
- May be seen in unerupted third molars- if patient taken tetracycline in early teens
What is the effect of porphyria on dental development?
Changes amount of haem and haem products in blood which may be incorporated into tooth structure
-> Dark pink appearance
What systemic issues can present as change in oral mucosa?
Giant Cell Granuloma
Orofacial Granulomatosis
Recurrent Aphthous Stomatitis
Dermatoses
Immune Deficiency/Disease
Drug reactions
What are the features of Giant cell granulomas?
- Peripheral or central
- Often osteoclast related
- Can be due to irritation- giant cells produced to remove stubborn pathogen
- Central lesion extending into ST- seen on radiographs (essential to take)
- May be due to hormonal changes- PTH excess (not being inhibited by negative feedback control)
What are the causes of excess PTH?
Gland adenoma
Reactive
-> renal failure (dialysis)
-> hypocalcaemia
What are some of the effects of hyperparathyroidism?
- Loss of cortical bone- highest calcium and highest density (preferentially removed when PTH is trying to raise Ca)
- Can be seen as resorption at terminal flanges of the hand
- Can affect lamina dura- lost (do not mistake for PA lesion)- this will reform after disease is corrected
What are the causes of raised ACTH?
Addison’s
Cushing’s (pituitary adenoma)
Small cell carcinoma in lung can also produce excess ACTH
What are the results of raised ACTH?
Stimulates melanocytes
-> Reactive melanosis
-> Widespread brown patches in mouth and skin
How does OFG present?
- Perioral redness/swelling, lip swelling, angular cheilitis
- Can spread to any part of the face
- Fissures can occur
- Proliferative erythematous fill thickness gingivitis in all quadrants (plaque not responsible)
- Stag horning- oedema in floor of mouth
- Linear fissured ulcer in sulcus- between attached gingivae and reflected mucosa
What phenotype of patients in Scotland commonly get OFG?
People with red hair and freckles
What is OFG called if the patient also has Crohn’s?
Oral Crohn’s
Why may children be diagnosed with OFG?
May be diagnosed as OFG in children as at this point they have no gut symptoms yet
-> Find out from parents about bowel habits, abdominal pain and issues with growth (related to malabsorption)
Why is a faecal calprotectin assay useful when screening for crohns?
FC- suggests active IBD (also happens with adeno virus of the gut)
Why may a FCA be less reliable in younger kids?
In young children the raised FC may be attributed to the fact that they are coming into contact with many new pathogens
-> when they are over 10, raised FC levels is more reliable sign of inflammation
When would an endoscopy for Crohns’s be carried out?
Only if clinicians were highly suspicious the patient had Crohns after screening tests
-> requires GA
How are growth charts utilised in Crohn’s screening?
Child should follow predictive centile
-> Blue chart for boys, pink for girls
If growth moves across lines it suggests a malabsorption or GH issue
-> Fairly accurate at predicting patient’s final height
What are common triggers for OFG?
Benzoic acid (found in fizzy drinks)
-> Limiting intake of these beverages can limit symptoms
Sorbic acid
cinnamon derivatives
chocolate
E numbers
What is the best way of determining the trigger for OFG?
Carrying out dietary exclusions is best way of determining dietary trigger
-> must have 100% compliance- difficult as some natural products contain benzoate
Slowly reintroducing food stuffs one at a time after exclusion can help patient single out which ones they must avoid
How is OFG managed?
Topical treatment to angular chelitis/fissure
-> Miconazole/hydrocortisone cream
Topical treatment to lip swelling or facial erythema
-> Tacrolimus ointment 0.03%
-> Intralesional steroids to lip
-> Systemic immune modulation
Why are intrapersonal steroids helpful to treat OFG?
Applying these to oedematous lips may allow drainage if they can break up giant cell lesions in lymphatic system
What does an exclusion diet not prevent?
Children developing Crohn’s in the future
What are the different autoimmune connective tissue diseases?
Systemic lupus erythematosis (SLE)
Systemic sclerosis (Scleroderma)
Sjogrens syndrome
Mixed connective tissue disease (MCTD)
How is SLE distinguished from LP?
- Different results in immunology assays
- SLE lesions can occur in palate
- Histologically- the lymphocytic band is occurring lower down in connective tissue
How does systemic sclerosis present?
- Crest syndrome- BV form haemangiomas on surface of skin (can occur in oral mucosa)
- Ischaemic necrosis of digits
- Oesophagus can lose elasticity- swallowing issues
- Calcinosis- calcification of soft tissue
- Loss of elasticity around mouth (peri-oral fibrosis)- difficulty opening, facial tissues cannot stretch to move bone
What are the dental implications of Systemic Sclerosis?
Dental treatment is difficult- may need to plan 10 years ahead (aim to reduce amount of treatment required)
Dentures are difficult to insert and remove
Posterior extractions are difficult/impossible
Aim for low maintenance dentition, seek advice from restorative consultant
What are the different types of Vasculitic diseases?
Large vessel Disease
-> Giant cell (temporal) arteritis
Medium Vessel Disease
-> Polyarteritis nodosa
-> Kawasaki disease
Small vessel Disease
-> Wegener’s Granulomatosis
Which vasculitic disease is most likely to affect oral cavity and present to dentist?
Wegners- seen on gingivae and palate
-> Ischaemia and necrosis of tissues that can spread throughout upper airway
-> Refer urgently to rheumatologist- will require systemic immunosuppression to control potentially fatal condition
What are the causes of immune deficiencies with oral implications?
Congenital Immune Deficiency- failure of T/B cell development
Acquired Immune Deficiency:
Diabetes
Drug therapy
Cancer therapy
HIV- ulceration/perio
What systemic diseases can be related to candidiasis?
Sjogren’s
HIV related salivary disease
-> both cause dry mouth creating conditions for candida infection
What is a purple change in mucosa caused by?
Kaposi sarcoma (HIV)
-> Unusual to see now due to development of HHART therapy
How does hairy leukoplakia present?
Ridged white lesion on posterior/lateral aspect of tongue
- Can be manifestation of HIV
What is the likely cause of a cluster of blisters appearing on tongue?
Reactivation of HSV
What are the causes of haematinic deficiencies?
Poor intake – dietary analysis/reinforcement
Malabsorbtion
-> GI diseases – Coeliac Disease, Crohn’s Disease
Blood loss
-> Crohn’s Disease, Ulcerative Colitis, Peptic ulcer disease, Bowel Cancer, Liver Disease
Increased Demand
-> Childhood growth spurts
What are the oral effects of haematinic deficiency?
Painful tongue
Ulcers
Oral dysaesthesia
LP
How is ulceration due to increased demand in growth spurt managed?
Iron supplementation- even if iron levels are not low
What are the oral effects of medical therapy?
Dry mouth
Oral Ulceration- Nicorandl
Lichenoid reaction- BB, ACE Inhibitors
Angio-oedema- ace inhibitors
Osteonecrosis- bisphosphonates
What occurs in angio-oedema?
- Rapid swelling of face within an hour, subsides within an hour/day
- Inhibition of complement cascade controlling enzymes
What is nicorandl used for? What are its side-effects
Angina
Shallow painful ulcers with no erythematous halo
Only treatment is to stop drug but this may not be safe systemically
