Quartz 4

14. Systemic Manifestations

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Oral manifestations of systemic conditions12

Introduction3

  • Oral disease maybe the first sign of an underlying systemic disorder
  • Trigger further investigations or referral to a medical practitioner
  • Enable early diagnosis and appropriate clinical care

Gastrointestinal Disorders45

NOTE

Many conditions affecting the gastrointestinal (GIT) system have corresponding oral manifestations, as the oral cavity is the beginning of the GIT.

Gastro-oesophageal reflux (healthy individuals)

Term used to describe a backflow of acid from the stomach into the oesophagus

  • It often occurs after a large, spicy, or acidic meal.

Gastro-oesophageal reflux disorder (GORD)6

  • Increased frequency and duration of reflux

  • Damage caused to oesophageal mucosa by regurgitation of gastric contents

  • GORD (or GERD in the US) occurs when reflux becomes excessive in frequency and duration, going beyond the normal physiological limit.

GORD (predisposing factors)7

GI disorders

  • High acidity of gastric contents
  • Impaired gastro-oesophageal motility

Extra-GI conditions

  • Obesity

  • Large meals

  • Fatty meals

  • Smoking

  • Excessive alcohol consumption

GORD: Dental aspects8

  • Gastric contents pH as low as 1 cause dental erosion

  • Seen on the palatal aspects of upper anterior teeth and premolars

  • Erosion is also seen on the lower anterior teeth.

  • Dental management involves addressing the resulting tooth sensitivity and wear.

  • Worse if impaired salivation

GORD: management9

Diagnosis:

  • confirmed by oesophageal pH monitoring

  • The monitoring will show a very low pH.

Symptoms relieved:

  • Losing weight
  • Raising the head of bed at night
  • Frequent small meals with antacids

NOTE

Patients are typically referred to a gastroenterologist for pharmacological management.

Drugs

  • H₂ blockers
    • cimetidine
    • ranitidine
  • Proton-pump inhibitors
    • omeprazole
    • lansoprazole

Drug therapy: GORD10

H2 Blockers

(histamine H2 receptor antagonist)

  • Histamine stimulates parietal cells to release acid

  • H2 blockers stop parietal cells from responding to histamine

  • Reduces acid production

  • They work by preventing histamine from stimulating parietal cells in the stomach.

  • Examples: cimetidine, ranitidine

Proton pump inhibitors

  • Reduce the amount of acid made by stomach

  • Block a chemical system: hydrogen-potassium adenosine triphosphatase

  • This enzyme system is also known as the 'proton pump'.

  • Examples: omeprazole, lansoprazole

Barrett’s Oesophagus11

  • Premalignant condition
  • Normal squamous epithelium replaced by metaplastic columnar epithelium

NOTE

This process is called metaplasia.

  • Consequence of chronic gastro-oesophageal reflux
  • Common, under diagnosed entity
  • Incidental finding at endoscopy

Pseudomembranous Colitis (antibiotic associated colitis)12

  • Inflammation of the colon associated with overgrowth of Clostridium difficile

  • Overgrowth of C. difficile related to recent antibiotic use

  • Production of enzymes and toxins A and B

  • This is typically caused by broad-spectrum antibiotic use.

Pseudomembranous Colitis (PC)13

Clostridium difficile

  • Gram+, spore-forming anaerobic rod, seen in the soil, sand and faeces
  • Spores formed are implicated in spread of infection
  • Colonizes 2-3% of asymptomatic adult and up to 50% of the elderly

Pseudomembranous colitis14

  • Symptoms usually begin after a few days of antibiotic therapy or as long as several weeks after finishing taking the antibiotic

  • Abdominal cramps, pain or tenderness

  • Pus or mucous in stool

  • Watery diarrhea (5 to 10 times per day) or even bloody

  • Severe abdominal pain, tenderness, and cramps.

  • Pus, mucus, or blood in the stool.

Dental Consideration15

  • Have a good knowledge of frequently used antibiotics that predisposes to PC in elderly, debilitated and those with previous history of PC
  • PC following short-term use of Clindamycin has not been reported after use of AHA prophylactic regimen

NOTE

Clindamycin is commonly used in dentistry; however, short-term use has not been reported to cause PC.

  • No elective treatment until resolution of PC
  • Oral candidiasis following PC therapy

Coeliac disease16

  • Not uncommon

  • Ethnic group-Celts

  • Not recognised, if not severe

  • Genetically determined hypersensitivity to gluten

  • Gluten is a protein found in grains like wheat and rye.

  • It is becoming more common and is frequently seen in individuals of Scottish descent.

  • Affects the jejunum

Coeliac disease-clinical features17

  • Patients may appear healthy

  • Manifestations of malabsorption

  • 3% of patients with aphthae have coeliac disease

  • These are specifically Recurrent aphthous stomatitis (ulcers).

  • Diarrhoea, weight loss, weakness

  • Patients may exhibit typical signs of malabsorption.

  • Dehydration can occur as a result of diarrhoea.

Coeliac disease-oral features18

  • Ulcers

  • Angular cheilitis

  • Glossitis or burning mouth syndrome

  • The tongue appears red, smooth, and 'beefy' or 'bald' due to the loss of papillae.

  • Dental hypoplasia

  • Enamel hypoplasia is less common.

Orofacial granulomatosis19

  • Not a disease entity

  • Regarded as a provisional diagnosis

  • It represents a spectrum of localized granulomatous disorders affecting the mouth and face.

  • Condition includes:

      1. Localised disorders affecting mouth and face
      1. Oral manifestations of systemic disease
      • 2a. Sarcoidosis
      • 2b. Crohn’s disease
      • 2c. Melkersson-Rosenthal syndrome
      • 2d. Cheilitis granulomatosa

Crohn’s disease20

  • Mucosal inflammation with ulceration & fistulae formation

  • Lymph node hyperplasia- obstructive oedema

  • Granulomatous lesions

  • It is an inflammatory bowel disease that can affect the entire GI tract.

  • Abdominal pain, diarrhoea and malaise

Clinical manifestations-oral crohn’s21

  • Swelling of lips & face

  • One or both lips can become significantly enlarged.

  • Lip fissures

  • Perioral erythema and scaling of skin

Crohn’s disease (Oral Manifestations)22

  • Mucosal tags or cobblestoning
  • Oral ulceration
  • Angular cheilitis
    • ==This often involves cracks at the corners of the mouth caused by a secondary Candida infection.==
  • Persistent lymphadenopathy
  • Full-width gingivitis

NOTE

This is a distinct form of gingivitis where inflammation extends from the marginal gingiva all the way up the attached gingiva.

Sarcoidosis23

  • Multi-system granulomatous disorder of unclear aetiology
  • Affects young adult females, especially Afro-Caribbeans
  • Granulomas form in lungs, lymph nodes, salivary glands, mouth
  • Causes bilateral hilar lymphadenopathy
  • Erythema nodosum

Orofacial features: sarcoidosis24

  • Heerfordt’s syndrome (salivary and lacrimal glands swelling, facial palsy, uveitis)

NOTE

Heerfordt’s syndrome is a specific manifestation of sarcoidosis.

  • Xerostomia
    • This is due to salivary gland involvement.
  • Mucosal nodules
  • Gingival swelling
  • Labial swelling

Melkersson-Rosenthal syndrome25

  • Lip or facial swelling
  • Fissured tongue
  • Lower motor neurone facial palsy

NOTE

This is considered a classic triad of features.

Ulcerative colitis26

  • Widespread ulceration of the colon
  • Complicated by- haemorrhage, perforation, malignancy
  • Oral lesions- severe aphthae, candida also seen
    • The oral lesions are typically aphthous-like ulcers.
  • Secondary to nutritional deficiency resulting from malabsorption

Pyostomatitis vegetans27

  • Rare disorder
  • Bowel symptoms precede oral involvement by several months or years
  • Pustular lesions on the oral mucosa & gingiva
  • Pustular lesions rupture—lead to erosions & ulceration—snail track ulceration
    • The lesions have a characteristic appearance described as 'snail track' ulcerations.
  • Topical steroids successful
  • Management of associated IBD—improvement of oral lesions

Pyostomatitis vegetans is an important oral marker for inflammatory bowel disease

NOTE

This condition is considered an important oral marker for inflammatory bowel disease (IBD), such as ulcerative colitis or Crohn’s disease.

Liver Disease282930

Signs of liver disease: clinical examination

  • Dupuytren’s contracture
  • Finger clubbing
  • Parotid swelling
  • Jaundice
  • Spider naevi
  • Gynaecomastia
  • Ascites
  • Scratch marks (itching)

Hepatitis: causes31

CategoryCauses
InfectionsViral: Hepatitis A,B,C,D,E
Other infections: malaria, yellow fever
DrugsAlcohol
Herbal medications
Paracetamol, statins, anti TB drugs

NOTE

Other causative drugs include Statins and Anti-tuberculosis drugs.

| | Metabolic | Wilson’s disease
Haemochromatosis | | Autoimmune | Autoimmune hepatitis |

Prescribing for patients with liver disease32

  • Discussion with the patient’s physician

  • Hepatic impairment lead to failure of drug metabolism: toxicity

  • Haemostasis may be affected

  • Miconazole, erythromycin, metronidazole, tetracyclines avoided

  • Fluconazole, paracetamol dose reduced

  • NSAID increase risk of GI bleeding: best avoided

  • Miconazole, erythromycin, metronidazole, and tetracyclines should be avoided.

  • Fluconazole dose should be reduced.

  • Paracetamol dose should be reduced, as there is a risk of liver damage if more than 4g/day is taken.

Renal disease3334

Dental aspects of renal diseases

  • Renal function
  • Chronic renal failure-Oral manifestations
  • Renal patient undergoing dialysis-dental management
  • Renal transplant patients-oral complications
  • Pyelonephritis, renal calculi
  • Kidney tumours-Wilm’s tumour, renal cell carcinoma

Chronic renal failure (CRF)35

  • Progressive kidney damage

  • Early CRF: patient notice a need to urinate frequently at night (nocturia)

  • Notice uncharacteristically poor appetite

  • Adult CRF leads to hypertension and uraemia

  • Uraemia is an excess of urea in the blood.

  • CRF can affect diverse body systems

Orofacial manifestations (CRF)36

  • Dry mouth (Xerostomia) is the most common oral manifestation.
  • Mucosal ulceration
  • Bacterial & fungal plaques
  • Pallour of the mucosa
  • The mucosa appears pale and anaemic.
  • Oral purpura
    • These appear as dark red spots on the mucosa.
  • Uraemic stomatitis
  • Ostelolytic lesons in jaws

Oral complications of renal transplantation37

  • Drug induced gingival overgrowth

NOTE

These complications are often related to the immunosuppressive drugs required to prevent organ rejection. Gingival overgrowth is commonly caused by the immunosuppressant cyclosporine.

  • Bacterial & fungal plaques

  • Increased incidence of oral malignancy (cyclosporin) reported

  • Oral candidosis

  • Herpes simplex infections (secondary)

  • There is an increased risk of malignancies, such as squamous cell carcinoma of the gingiva.

Haematological disease383940

  • Anaemia
  • Leukaemia
  • Leukopaenia
  • Lymphomas

Oral signs & symptoms of haematinic deficiencies41

Glossitis

  1. Smooth, depapillated tongue (Fe def.)
  2. Raw, beefy tongue (Vit B₁₂, folic acid def.)

NOTE

A full blood count is often ordered for patients presenting with symptoms like burning mouth syndrome. One of the first oral signs is a depapillated tongue (atrophic glossitis). The tongue is very sore and makes it difficult for the patient to tolerate food, especially spicy food.

Amyloidosis42

  • Rare condition

  • Amyloid deposited in tissues

  • Macroglossia, oral blood-filled bulla

  • Myeloma associated

  • Biopsy-Congo red staining

  • ==It is often associated with multiple myeloma, a malignancy of the bone.==

  • Urine analysis-Bence-Jones proteinuria

  • ==Urinalysis may reveal Bence Jones proteins.==

  • FBC, ESR, marrow biopsy

Human immunodeficiency virus infection4344

  • RNA retrovirus infection

  • Spread through:

    • sexual contact
    • parenteral exposure to blood
    • mother to foetus

  • Transmission can also occur through contaminated blood products.

  • Immune deficiency due to damage to CD4 T-lymphocytes

  • This leads to progressive damage to the cell-mediated immune system.

  • Predisposition to infections with:

    • Viruses and virally induced malignancies
    • Fungi
    • Mycobacteria
    • Autoimmune disease
    • Neurological damage

Oral Lesions in HIV disease45

  • Candidosis

  • HIV-associated Candidiasis is the most common oral lesion. Its presence in a young, otherwise healthy individual should raise suspicion of immunosuppression.

  • Hairy leukoplakia

  • Kaposi’s sarcoma

  • Gingival and periodontal disease

  • This can present as massive destruction of periodontal and gingival tissues.

  • Ulcers

  • Non-specific ulcers are also seen.

  • Other orofacial conditions

Hairy leukoplakia46

  • White patch which cannot be removed

  • Vertical white folds on the lateral aspects of tongue

  • Associated with EBV

  • Lesion not premalignant

  • Usually superimposed by candida

  • Common in patients with late stage HIV infection

  • It is strongly associated with HIV infection, often in the later stages.

  • Development may herald onset of AIDS

  • Diagnosis: Clinical

  • Biopsy: balooned cells with perinuclear vacuoles, swollen cells contain EBV

  • Histologically, it shows balloon-like cells with perinuclear vacuoles.

Kaposi’s Sarcoma47

  • Most common malignancy in HIV patients,
  • Involves skin and mucosal surfaces
  • Tip of the nose frequent facial site
  • Caused by human herpes type 8
  • Common in homosexuals, can occur in all risk groups
  • Arises from vascular endothelial cells

NOTE

It should be included in the differential diagnosis for any pigmented lesion in the mouth, along with nevi (moles) and malignant melanoma.

  • Hard palate and gingiva are common sites
  • Presents as a reddish-purple patches
  • Becomes nodular and ulcerate
  • Diagnosis must be supported by biopsy

Classification of oral lesions in HIV48

Group I

  • Lesions strongly associated with HIV infections

  • HIV associated candidosis

  • Hairy leukoplakia

  • Kaposi's sarcoma

Group II

  • Lesions less commonly associated with HIV infection

  • HIV associated CMV ulcer

  • Cytomegalovirus (CMV) ulcer infections

Group III

  • Lesions possibly associated with HIV infection

  • HIV associated wart

  • Common warts (verruca vulgaris)

Acquired immunodeficiency syndrome (AIDS)49

  • AIDS is the final stage of HIV disease

  • CD4 cell count: <200 cells/mm³

  • CD4 cell %: <14%

  • A CD4+ cell percentage of <14% is a defining characteristic.

  • Highly active antiretroviral therapy (HAART) has improved the quality and length of survival for many

Key points: HIV infection50

  • Caused by retrovirus
  • Transmitted sexually, IV drug abuse, blood & blood products
  • Progressive deterioration of cell-mediated immunity
  • Oral signs and symptoms may be the initial manifestation
  • Oral candidosis most prevalent oral lesion
  • Hairy leukoplakia may indicate progression to AIDS
  • Kaposi’s sarcoma and lymphomas often in the oral regions
  • Neurological and psychological disorders
  • Death mainly due to opportunistic infections

Lupus erythematosus5152

  • Connective tissue disease-systemic & discoid

  • Females affected more

  • Both give rise to oral lesions-similar to OLP

  • Systemic Lupus Erythematosus (SLE) affects multiple organs, including the kidneys.

  • Discoid Lupus Erythematosus (DLE) is primarily a mucocutaneous disease.

  • Oral lesions from both forms are clinically similar to oral lichen planus.

  • SLE-joint pain, rashes, any organ affected

  • DLE-skin & mucocutaneous

Lupus erythematosus: oral lesions53

  • Area of erythema or ulceration surrounded by white border

  • Any part of mucosa involved

  • Vermilion border of lips affected

  • Lesions are most common in DLE.

  • A small percentage of DLE lesions on the lip have a tendency to undergo malignant transformation.

Clinical case54

Clinical Case: Lichen Planus

A clinical case was presented showing a patient with:

  • ==Skin lesions: Itchy, papular lesions on the flexor aspect of the wrist.==
  • ==Oral lesions: A white, lacy pattern inside the mouth.==

These features are characteristic of Lichen Planus.

Histopathology of lichen planus55

NOTE

The histological features of oral lichen planus include:

  • ==A dense, band-like infiltrate of lymphocytes confined to the superficial part of the connective tissue, just beneath the epithelium.==
  • ==Liquefaction degeneration of the basal cell layer of the epithelium.==
  • ==The presence of apoptotic (dead) keratinocytes, known as Civatte bodies or colloid bodies.==

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