Oral manifestations of systematic diseases

Khalid Mortaja


‫بســـــــم هللا الرحمــــــن الرحيــــــم‬

Oral Manifestations of systematic diseases
We can divide the oral cavity in terms of keratinization into 2 groups:  Keratinized: e.g.: masticatory mucosa (hard palate, gingiva and posterior tongue)  Non-keratinized: e.g.: lining mucosa (buccal mucosa, labial mucosa, alveolar mucosa, floor of the mouth, ventral tongue and soft palate) Additional group we call it:  Specialised: such as dorsum of the tongue which has taste buds

We have several diseases and situations that could lead to several manifestations of the oral cavity, they might be local or systematic diseases leading to loss of teeth, discoloration of teeth, connective tissue alterations or epithelial alterations, and we’ll talk about them one by one.

1-Diseases and manifestations affecting Teeth:
1) Leading to loosening and early loss of teeth:  Local causes: chronic gingivitis  Systemic cause: Diabetes Mellitus, low immunity such as HIV and Leukopenia, diseases of the connective tissue

2) Leading to discoloration of teeth:
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 External factors: poor oral hygiene and smoking  Internal factors: drugs such as Tetracycline during pregnancy, flurosis, porphyria, jaundice

2-Diseases and manifestations affecting Gingiva:
1) Leading to bleeding of gingiva:  Local causes: acute and chronic gingivitis, periodontitis, acute necrotizing gingivitis which is usually associated with an autoimmune disease affecting the skin, such as: bullous pemphegoid, pemphigus vulgaris, mucous membrane pemphigoid and lichen planus  Systemic causes: Leukaemia, neutropenia, HIV, drugs (anti-coagulants). In other words: any disease that affect platelets or the coagulation system, will easily lead to bleeding of the gingiva

2) Leading to swelling of gingiva:  Local cause: bad dentures, acute and chronic gingivitis, Hyperplastic (Mouth breathers), Tumors  Systemic causes: pregnancy, drugs such as Phenytoin and cyclosporine, infiltrative, tumors

3) Leading to redness of gingiva:  Local causes: chronic gingivitis
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 Systemic causes: Desquamative gingivitis (it’s caused by systemic dermatological disease), Herpes Simplex Virus, Vascular abnormalities, Bullous diseases

4) White Patches (Leukoplakia): this type can be premalignant  Local causes: friction (not premalignant), smoking (premalignant)  Systemic causes: candidiasis, lichen planus, lupus erythematous, chronic renal failure

5)   

Leading to pigmentation of gingiva: Racial: usually darker races have darker gingivae Local causes: amalgam tattoo, melanocytic macules )‫(شامة‬ Systemic causes: endocrine diseases (such as Addison’s disease), Kaposi sarcoma, melanoma (malignant tumor of melanocytic nevus), drugs (such as Hydroxychloroquine and minocycline)

6) Leading to ulceration of gingiva:  Local causes: any trauma can cause ulcer (most common)  Systemic causes:  Hematologic diseases: “anaemia, leukaemia, neutropenia”  Gastro Intestinal diseases: “celiac disease, inflammatory bowel disease”  Connective tissue diseases: ”systemic lupus erythematous, Behcet’s disease, Sweet’s syndrome”  Infections: “herpes simplex virus”  Immunological diseases: “bullous pemphigoid, pemphigus vulgaris”  Drugs: “Cytotoxics (used for chemotherapy)”

7) Leading to blistering of gingiva:
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 Local causes: burn (drinking hot beverages), mucoceles (cyst fused to the mucin)  Systemic causes: pemphigus vulgaris, lichen planus, mucous membrane pemphigoid (these 3 are the most common causes of blistering of gingiva)

Desquamative Gingivitis vs. Gingivitis
Gingivitis by itself can be caused by systematic or local disease, in contrast to Desquamative Gingivitis which is caused mainly by a dermatological disease. Most common causes for Desquamative gingivitis: mucous membrane pemphigoid, lichen planus, bullous pemphigoid, linear IgA pemphigoid. Treatment for Desquamative Gingivitis: we can leave it to heal by itself. Sometimes we use topical steroids + tacrolimus.

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As you can see in the figure above, the major difference between Desquamative gingivitis and chronic gingivitis is that in the first (DG) there is no involvement of interdental papillae (spared), while the latter (CG) shows involvement of interdental papillae.

Drug induced gingival swelling
Some drugs cause gingival swelling such as: Phenytoin, Cyclosporine, Nifedipine and Ca++ channel blockers. Usually their effects increase with prolonged use and with bad oral hygiene. Treatment: good oral hygiene, stop drugs withdrawal. In some severe conditions we might do surgical excision.

This figure shows a drug (phenytoin) induced gingival swelling

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3-Diseases and manifestations affecting oral mucosa:
1) Leading to pigmentation of oral mucosa:  Racial: usually darker races have darker oral mucosa  Local causes: nevus, melanocytic macule in the oral cavity  Systemic causes: tumors such as (melanoma and Kaposi sarcoma), endocrine disorders such as (Addison’s disease and Cushing syndrome), drugs such as (minocycline and tetracycline)

2) Leading to redness of oral mucosa:  Local causes: infections such as herpes simplex virus  Systematic causes:  Infections: such as candidiasis  Inflammatory causes: such as lichen planus, mucos membrane pemphigoid, pemphigus vulgaris  Vascular causes: telangiectasia, Kaposi sarcoma  Drugs: cytotoxic drugs such as mucositis  Other causes: geographical tongue (not related to any disease), nutritional deficiencies such as (folate, iron, vitamin B12)


Geographical tongue Page 7

3) Leading to ulceration of oral mucosa:  Local causes: traumas (most common cause) such as (orthodontic appliances), tumors  Systemic causes:  Haematological diseases  Gastro Intestinal diseases: such as celiac disease and inflammatory bowel disease  Dermatological diseases: such as lichen planus and bullous pimphigoid  Infections: such as herpes simplex virus  Vaculitis  Iatrogenic (caused by drugs)

Recurrent Aphtous Stomatitis
Recurrent episodes of ulceration, each lasts 1-4 weeks. We have 3 types: Major Aphtous: 10%  Duration: 4 weeks or more  Size: 5-10 mm  Number: < 10 ulcers Minor Aphtous: 80%  Duration: < 10 days  Size: < 5mm  Number: < 10 ulcers Herpitiform: usually painful, 10%  Duration: > 10 days  Size: < 5mm  Number: 10-100 ulcers

Investigations for RAS: CBC, ESR, iron, vitamin B12, Folate.
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Treatment for RAS: because they are associated with inflammatory diseases we will use anti-inflammatory drugs (Steroids and Colchicine).

4) White Patches (leukoplakia): this type can be premalignant  Infective leukoplakia: candida, hairy leukoplakia  Systemic causes: lichen planus, lupus erythematous, renal and liver diseases  Genetic causes: white sponge nevus

5) Leading to blistering of oral mucosa:
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 Local causes: burn, mucocele  Underlying causes: Pemphigus, Bullous Pemphigoid, Mucous Membrane Pemphigoid

Behcet’s Syndrome
It is a connective tissue disease. We have major and minor criteria to diagnose it:  Major:  Oral aphtous (I can’t diagnose Behcet’s syndrome without it)  Genital ulcers  Skin diseases  Ocular diseases  CNS diseases Treatment for Behcet’s syndrome depends on the severity, for mild cases we will use topical steroids, while for severe cases we will use Colchicine and Cyclosporine. Main Morbidity is related to Ocular Disease so always involve an Ophthalmologist.

Lichen planus
It is a dermatological disease, manifested by: plaques distributed all over the body (scalp and mucosa). For mucosa, we have many types of lichen planus and the most important one is the erosive lichen planus, because it can be associated with Squamous Cell Carcinoma. Another thing that can be caused by lichen planus is Desquamative Gingivitis. Treatment for lichen planus: topical steroids, tacrolimus, cyclosporine.

Endocrine diseases
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Addison’s disease: usually associated with hyperpigmentation of oral mucosa, tongue and palate. Congenital hypothyroidism and acromegaly: associated with macroglossia (big tongue). Diabetes mellitus: associated with loosening of teeth, xerostomia, candidiasis Pregnancy: associated with Gingivitis, Epulis.

Gastro Intestinal Tract diseases
Pernicious Anemia: ulcers, glossitis, red lesions. Coeliac: ulcers, glossitis, angular stomatitis. Crohn’s disease: gingival hyperplasia, ulcers, golssitis.

Hematological diseases
Here we are interested in the involvement of WBCs, either increased or decreased, with ulcers or infections. Hemostasis: associated with bleeding.

Renal diseases
Chronic Renal Failure: associated with Xerostomia, Halitosis, Leukoplakia and bleeding

NOTE: drugs names are for memorization, you have to know the drugs that cause gingival swelling… Done by: Khalid Mortaja

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