Oral manifestations

of systemic disease

Oral manifestations of systematic disease

are signs and symptoms of disease
occurring elsewhere in the body detected
in the oral cavity and oral secretions. High
blood sugar can be detected by sampling
saliva.[1] Saliva sampling may be a non-
invasive way to detect changes in the gut
microbiome and changes in systemic
disease. Another example is tertiary
syphilis, where changes to teeth can
occur.[2] Syphilis infection can be
associated with longitudinal furrows of the
tongue.

Mineral and vitamin deficiencies can

cause the tongue to appear beefy red and
feel sore. Those deficiencies are iron,
folate, and vitamin B12. A hairy tongue
may be an indication of Epstein Barr virus
infection and is usually seen in those
infected with HIV. Other systemic
diseases that can cause the tongue to
form aphthous ulcers are: Crohn's disease
and ulcerative colitis, Behcet's Syndrome,
pemphigus vulgaris, herpes simplex,
histoplasmosis, and reactive arthritis.[3]

Cardiovascular and
haematological system
A heart attack is a blood vessel in the
heart being constricted either by a blood
clot or atherosclerosis formation. A heart
attack can cause pain the chest;
sometimes this pain can radiate up to the
jaw. (Malik et al., 2013)[4]

Calcium channel blockers (CCBs) are

medications prescribed for the treatment
of a number of heart conditions and
primarily to treat high blood pressure. They
can cause gingival hypertrophy
(overgrowth), particularly dihydropyridine
and nifidipine. Poor dental hygiene and
inflamed gums are a risk factor. The
overgrowth is not permanent, it is
suggested that if the medication is
stopped then the overgrowth can reduce[
however, this is a decision that would have
to be made in conjunction with the
patient’s dentist and cardiologist as the
risk of stopping some medications
outweigh any advantage gained (Livada
and Shiloah, 2013)[5]

Nicorandil is a medication that is

prescribed for the treatment of angina. It
can cause major apthous-like ulcer
formation (BNF, 2020).[6]

Iron, folate and Vitamin B12 deficiencies –

The most commonest cause of iron
deficiencies is low ferritin; this can cause
the tongue to appear beefy red and appear
sore. It can also present in the mouth as
angular chelitis, which is an infection
caused by either staphylococcus or
candidiasis, and can make the corners of
the mouth appear red and crispy.

Sickle cell disease is a hereditary genetic

condition that results in deformed red
blood cells to be formed. Sickle patients
can suffer from sickle crisis, these are
painful events in which if in the jaw can
mimic dental pain and facial swelling can
also occur during a crisis. The dental pulp
can be affected by sickling and there may
be a delayed eruption and hypoplasia of
the dentition. Sickle patients are also at an
increased risk of developing infection.

Thalasseamias is a group of inherited

genetic disorders that affect the
haemoglobin synthesis; it can result in
either a reduced or absent globin chain
production. If beta thalassaemia major is
left untreated or under transfused, there is
expansion of ineffective bone marrow, this
leads to bony deformities resulting in
dental malocclusion. Beta thalassaemia
major patients may also be on
bisphosphonates and are therefore at risk
of developing osteonecrosis of the jaw.  

Thrombocytopenia is a deficiency of
platelets in the blood. It can present as red
blood blisters in the mouth.

Respiratory system
Patients suffering from respiratory
conditions like asthma and COPD can be
prescribed steroidal inhalers to help
strengthen their lungs. They must ensure
after use that they rinse their mouths,
otherwise there is an increase of dental
caries, xerostomia, candidiasis, ulceration
and gingivitis/periodontitis (Godara et al.,
2011).[7]

Renal System
There are a number of oral complications
following renal transplantation.
Ciclosporin is an immunosuppressant
medication that is used to help prevent
patients from rejecting the transplanted
kidney (BNF, 2020). Due to the
immunosuppression (suppressed immune
system), these patients are more likely to
suffer from gingival hyperplasia, apthous
ulceration, herpes simplex virus, oral
leucoplakia; which may transform into
squamous cell carcinoma, candidiasis
infection or Kaposi’s sarcoma (BNF,
2020).[6]

Digestive System
There are many specific diseases of the
gastrointestinal (GI) tract which have an
impact on oral health. Systemic disease
can affect the upper GI tract such as
Dysphagia, Dysmotility, Gastro-
oesophageal reflux (GORD) and Peptic
Ulcer's; or lower in the tract such as
Coeliac’s, Crohn’s disease, Ulcerative
Colitis and Familial Adenomatous
Polyposis (FAP).[8]

Dysphagia is defined as a difficulty in

swallowing. Structurally it worsens when
eating solids and neurologically it is worse
with fluids.[9] Structural problems may
include malignancy, stricture and
pharyngeal pouching which can lead to
halitosis, regurgitation of undigested food
and high feeling of dysphagia.
Neurological problems may be related to
the patient having Multiple Sclerosis (MS),
Motor Neurone Disease (MND) or having
suffered from a Stroke.[10] Dysphagia may
present as a barrier to care in the dental
setting as the patient may require high
volume suction in order to maintain
patient comfort and reduce the risk of
aspiration of dental material/ fluids.

GORD can present as retrosternal pain,

acid brash and a hoarse voice. Risk
factors for GORD are obesity, diet,
smoking and hiatus hernia. Complications
of which being oesophagitis, Barrett's
oesophagus, Strictures and ulcers.
Common management of GORD include
lifestyle measures, proton pump inhibitors
and rarely surgery. The is a clear
relationship between GORD and dental
erosion and therefore can be detrimental
to hard tissues i.e. teeth and also soft
tissues of the mouth.[11]

Crohn's Disease is a patchy disease which

can affect any area of the GI tract from the
oral cavity to the anus. The manifestations
depend on the affected area. The oral
manifestations present as Orofacial
Granulomatosis, an inflammatory
condition affecting the oral mucosa. It is
non-caveating granulomas and has a
"Cobblestone" appearance. OFG can be
isolated or a manifestation of Crohn's and
can be treated with local or systemic
corticosteroids. Aggravating factor of
which is cinnamon, therefore a cinnamon-
free diet is recommended.[8]

Eating disorders are a psychological

problem which has an impact on the GI
tract. Two common eating disorders are
Anorexia Nervosa and Bulimia Nervosa.
Anorexia Nervosa is a refusal to maintain
a "normal" body weight with a fear of
weight gain and distorted perception of
body image. Bulimia Nervosa is binge-
eating followed by attempts to restrict
weight gain and can include purging.
Eating disorder oral manifestation is
severe palatal erosion due to vomiting.
There is occlusal erosion of the maxillary
teeth causing the incised edges of the
incisors to be thin and knife-edged.
Occlusal surfaces have a flat to cupped-
out appearance.[12] Extra-orally eating
disorders may present with swollen
parotid glands.

Other oral manifestations of GI disease is

Angular Stomatitis, commonly seen in
iron-deficient anaemia and mouth ulcers in
Crohn's disease.

Endocrine System
Diabetes Mellitus has two main types:
Type 1, autoimmune destruction of beta-
cells leading to reduced insulin production
and Type 2, the body becomes
increasingly resistant to the effects of
insulin leading to the bodies inability to
regulate plasma glucose levels resulting in
a fall in insulin production. Diabetes has
numerous implications on oral health.
Patient with Diabetes have increase extent
and severity of Periodontal Disease,
increased prevalence of Dental Caries due
to Xerostomia, can suffer from Burning
Mouth Syndrome and Candidal infections
as well as experiencing altered taste
sensation, altered tooth eruption and
hypertrophy of the parotid glands. Other
oral health problems include chronic
hyperglycaemia, infection, delayed wound
healing and Lichen Planus/Lichenoid
reactions.[13]

The oral manifestations of Acromegaly

predominate as spacing of the lower
incisor teeth and widening of the
mandible. Other complications include
visual field defects, headaches, Diabetes,
Sleep apnoea, Hypertension, Arthralgia
and Arthritis and Carpal Tunnel
Syndrome.[13] Arthralgia and Carpal Tunnel
Syndrome both have an impact on a
patients’ ability to maintain good oral
hygiene practice and therefore may
predispose them to Dental caries and
Periodontal Disease. It is imperative these
patients are given Enhanced Prevention in
order to reduce the risk of Dental Caries
and Periodontal Disease.

Another endocrine disorder that may

present orally is Addison’s Disease. Signs
include skin hyperpigmentation, alabaster-
coloured pale skin, low blood pressure,
postural hypotension. Skin pigmentation
have increased deposition in the palmer
skin creases, nails and gingiva.[13]
Management of Addison’s is with steroids.
During dental treatment the patient may
require an increased dose of steroids
based on treatment need.
Skeletal System
Osteopgenesis imperfecta, also known as
brittle bone disease, is caused by a gene
mutation affecting the collagen genes,
patients generally present with a large
number of fractures from minor injuries.
Teeth, if affected, are of the appearance of
dentinogenesis imperfecta.  

Osteoporosis is a very common disease

associated with a decreased bone mineral
density, it mainly affects post menopausal
women whose oestrogen levels have
dropped. It is managed with the used of
bisphosphonates. Prior to placement on
bisphosphonates, a dental check must be
done to extract any hopeless teeth as
extractions in patients who have
prolonged used of bisphosphonates are at
risk of MRONJ. (SDCEP,2017)

Immune System
Human Immunodeficiency Virus (HIV)
infects and destroys cells of the immune
system, principally the CD4+ T-Helper
lymphocytes. As well as lymphocytes, CD4
receptors are also present on the surface
of macrophages and monocytes, cells in
the brain, skin, and probably many other
sites.The normal CD4 count is 500-1500
therefore patient’s with HIV have a CD4
count less than 500. Patients that are HIV
positive have increased risk of developing
infections and tumours. The severity of
illness is greater the lower the CD4 count.
A CD4 count less than 200 is a diagnosis
of Acquired Immunodeficiency Syndrome
(AIDS). Oral manifestation of HIV include
candidiasis, Oral Hairy Leukoplakia, oral
ulcers, oral warts, oral lymphoma and
Kaposi Sarcoma.[13] Other presentations
include gingivitis and oral malignancies.
Treatment and management of HIV is
based around highly active anti-retroviral
therapy (HAART). HAART has been proven
to significantly lower prevalence of oral
lesions, particularly oral candidiasis and
oral hairy leukoplakia.[14]

Nervous System

Muscular System

References.
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Yaskell, Tina; Vargas, Jorel; Song, Xiaoqing;
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Osama; Al-Mutawa, Sabiha; Ariga, Jitendra;
Soparkar, Pramod; Behbehani, Jawad;
Behbehani, Kazem (2017). "The salivary
microbiome is altered in the presence of a
 high salivary glucose concentration" . PLOS
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4. Malik, Muhammad Ajmal; Alam Khan,
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. Rolands, ChristeffiMabel (2015). "Oral
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10. Logemann, JA; Curro, FA; Pauloski, B;
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12. Milosevic, A. (1999-02-13). "Eating
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 14. Hamza, Omar JM; Matee, Mecky IN; Simon,
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