**Oral manifestations of systemic conditions** Bobby Joseph Associate Professor # **Oral manifestations of systemic conditions** **Lecture objectives** After completing this lecture you should have a basic knowledge on: - the oral manifestations of gastrointestinal, liver, kidney, haematological, endocrine and immunological disorders - the effects of these diseases on the oro-facial complex - when you should refer a patient to a medical or specialist practitioner # **Lecture objectives** After completing this lecture you should have a basic knowledge on: - the oral manifestations of gastrointestinal, liver, kidney, haematological, endocrine and immunological disorders - the effects of these diseases on the oro-facial complex - when you should refer a patient to a medical or specialist practitioner # Introduction - 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 # **Introduction** - 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 Title slide with the text "Gastrointestinal disease" **Gastro-oesophageal reflux (healthy individuals)** Term used to describe a **backflow of acid from the** stomach into the oesophagus # **Gastrointestinal Disorders** > [!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)** - Increased frequency and duration of reflux - Damage caused to oesophageal mucosa by regurgitation of gastric contents ## **Gastro-oesophageal reflux disorder (GORD)** - 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)** **GI disorders** - High acidity of gastric contents - Impaired gastro-oesophageal motility **Extra-GI conditions** - Obesity - Large meals - Smoking - Excessive alcohol consumption ### **GORD (predisposing factors)** **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 aspects** - Gastric contents pH as low as 1 cause dental erosion - Seen on the palatal aspects of upper anterior teeth and premolars - Worse if impaired salivation ### **GORD: Dental aspects** - 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: management ## Diagnosis: confirmed by oesophageal pH monitoring ## Symptoms relieved: - Losing weight - Raising the head of bed at night - Frequent small meals with **antacids** ## Drugs ### H₂ blockers - cimetidine - ranitidine ### Proton-pump inhibitors - omeprazole - lansoprazole ### **GORD: management** #### **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: GORD ## 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 - Examples: **cimetidine**, **ranitidine** ## Proton pump inhibitors - Reduce the amount of acid made by stomach - Block a chemical system: **hydrogen-potassium adenosine triphosphatase** - Examples: **omeprazole**, **lansoprazole** ### **Drug therapy: GORD** #### **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 Oesophagus** - Premalignant condition - Normal squamous epithelium replaced by metaplastic columnar epithelium - Consequence of chronic gastro-oesophageal reflux - Common, under diagnosed entity - Incidental finding at endoscopy Endoscopic image showing Barrett's Oesophagus ## **Barrett’s Oesophagus** - 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)** - 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 ## **Pseudomembranous Colitis (antibiotic associated colitis)** - 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)** *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 Colitis (PC)** *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 colitis** - 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 ### **Pseudomembranous colitis** - 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 Consideration** - 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 - No elective treatment until resolution of PC - Oral candidiasis following PC therapy ### **Dental Consideration** - 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 disease** - Not uncommon - Ethnic group-Celts - Not recognised, if not severe - Genetically determined hypersensitivity to gluten - Affects the jejunum ## **Coeliac disease** - 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 features** - Patients may appear healthy - Manifestations of malabsorption - 3% of patients with aphthae have coeliac disease - Diarrhoea, weight loss, weakness ### **Coeliac disease-clinical features** - 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 features** - Ulcers - Angular cheilitis - Glossitis or burning mouth syndrome - Dental hypoplasia ### **Coeliac disease-oral features** - 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 granulomatosis** | Not a disease entity | | --- | | Regarded as a provisional diagnosis | | Condition includes: | | 1. Localised disorders affecting mouth and face | | 2. Oral manifestations of systemic disease | | 2a. Sarcoidosis | | 2b. Crohn’s disease | | 2c. Melkersson-Rosenthal syndrome | | 2d. Cheilitis granulomatosa | ## **Orofacial granulomatosis** - 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 - 2. Oral manifestations of systemic disease - 2a. Sarcoidosis - 2b. Crohn’s disease - 2c. Melkersson-Rosenthal syndrome - 2d. Cheilitis granulomatosa **Crohn’s disease** - Mucosal inflammation with ulceration & fistulae formation - Lymph node hyperplasia- obstructive oedema - Granulomatous lesions - Abdominal pain, diarrhoea and malaise Endoscopic and histological images showing mucosal inflammation, ulcers, and granulomatous lesions in Crohn’s disease. ## **Crohn’s disease** - 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’s** - Swelling of lips & face - Lip fissures - Perioral erythema and scaling of skin ### **Clinical manifestations-oral crohn’s** - Swelling of lips & face - ==One or both lips can become significantly enlarged.== - Lip fissures - Perioral erythema and scaling of skin **Crohn’s disease** - Mucosal tags or cobblestoning - Oral ulceration - Angular cheilitis - Persistent lymphadenopathy - Full-width gingivitis ### **Crohn’s disease (Oral Manifestations)** - 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. **Sarcoidosis** - 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 ## **Sarcoidosis** - 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: sarcoidosis** - Heerfordt’s syndrome (salivary and lacrimal glands swelling, facial palsy, uveitis) - Xerostomia - Mucosal nodules - Gingival swelling - Labial swelling ### **Orofacial features: sarcoidosis** - 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 syndrome** - Lip or facial swelling - Fissured tongue - Lower motor neurone facial palsy ## **Melkersson-Rosenthal syndrome** - Lip or facial swelling - Fissured tongue - Lower motor neurone facial palsy > [!NOTE] > This is considered a classic triad of features. **Ulcerative colitis** - Widespread ulceration of the colon - Complicated by- haemorrhage, perforation, malignancy - Oral lesions- severe aphthae, candida also seen - Secondary to nutritional deficiency resulting from malabsorption ## **Ulcerative colitis** - 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 vegetans** - 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 - Topical steroids successful - Management of associated IBD—improvement of oral lesions ## **Pyostomatitis vegetans** - 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** Clinical images showing oral lesions characteristic of pyostomatitis vegetans. **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. Title slide with text "Liver disease" # Signs of liver disease: clinical examination - Dupuytren’s contracture - Finger clubbing - Parotid swelling - Jaundice - Spider naevi - Gynaecomastia - Ascites - Scratch marks (itching) # **Liver Disease** ## **Signs of liver disease: clinical examination** - Dupuytren’s contracture - Finger clubbing - Parotid swelling - Jaundice - Spider naevi - Gynaecomastia - Ascites - Scratch marks (itching) - ==The oral mucosa may appear yellow due to jaundice.== <table> <thead> <tr> <th>Hepatitis: causes</th> <th></th> </tr> </thead> <tbody> <tr> <td><strong>Infections</strong></td> <td>Viral: Hepatitis A,B,C,D,E<br>Other infections: malaria, yellow fever</td> </tr> <tr> <td><strong>Drugs</strong></td> <td>Alcohol<br>Herbal medications<br>Paracetamol, statins, anti TB drugs</td> </tr> <tr> <td><strong>Metabolic</strong></td> <td>Wilson’s disease<br>Haemochromatosis</td> </tr> <tr> <td><strong>Autoimmune</strong></td> <td>Autoimmune hepatitis</td> </tr> </tbody> </table> ## **Hepatitis: causes** | **Category** | **Causes** | | :--- | :--- | | **Infections** | Viral: Hepatitis A,B,C,D,E<br>Other infections: malaria, yellow fever | | **Drugs** | Alcohol<br>Herbal medications<br>Paracetamol, statins, anti TB drugs > [!NOTE] > Other causative drugs include Statins and Anti-tuberculosis drugs. | | **Metabolic** | Wilson’s disease<br>Haemochromatosis | | **Autoimmune** | Autoimmune hepatitis | **Prescribing for patients with liver disease** - 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 ## **Prescribing for patients with liver disease** - 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 disease # **Renal disease** # 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 ## **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)** 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 CRF can affect diverse body systems ## **Chronic renal failure (CRF)** - 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)** - Dry mouth - Mucosal ulceration - Bacterial & fungal plaques - Pallour of the mucosa - Oral purpura - Uraemic stomatitis - Ostelolytic lesons in jaws ## **Orofacial manifestations (CRF)** - Dry mouth - ==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 transplantation** - Drug induced gingival overgrowth - Bacterial & fungal plaques - Increased incidence of oral malignancy (cyclosporin) reported - Oral candidosis - Herpes simplex infections (secondary) ## **Oral complications of renal transplantation** - 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.== Four clinical images showing oral conditions: gingival overgrowth, carcinoma of gingiva, herpes simplex, and oral candidosis, with a caption "Oral complications of renal transplantation". Haematological disease # **Haematological disease** # Haematological disease - Anaemia - Leukaemia - Leukopaenia - Lymphomas Oral manifestation of haematological disease showing inflamed gums and bleeding - Anaemia - Leukaemia - Leukopaenia - Lymphomas **Oral signs & symptoms of haematinic deficiencies** **Glossitis** 1. **Smooth, depapillated tongue (Fe def.)** 2. **Raw, beefy tongue (Vit B₁₂, folic acid def.)** ## **Oral signs & symptoms of haematinic deficiencies** **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. **Amyloidosis** - Rare condition - Amyloid deposited in tissues - Macroglossia, oral blood-filled bulla - Myeloma associated - Biopsy-Congo red staining - Urine analysis-Bence-Jones proteinuria - FBC, ESR, marrow biopsy ## **Amyloidosis** - 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 Title slide with the word "Immunodeficiency" # Human immunodeficiency virus infection RNA retrovirus infection **Spread through:** - sexual contact - parenteral exposure to blood - mother to foetus Immune deficiency due to damage to CD4 T-lymphocytes **Predisposition to infections with:** - Viruses and virally induced malignancies - Fungi - Mycobacteria - Autoimmune disease - Neurological damage # **Human immunodeficiency virus infection** - 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 disease** <table> <thead> <tr> <th>Candidosis</th> </tr> </thead> <tbody> <tr> <td>Hairy leukoplakia</td> </tr> <tr> <td>Kaposi’s sarcoma</td> </tr> <tr> <td>Gingival and periodontal disease</td> </tr> <tr> <td>Ulcers</td> </tr> <tr> <td>Other orofacial conditions</td> </tr> </tbody> </table> ## **Oral Lesions in HIV disease** - 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 leukoplakia** **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** **Development may herald onset of AIDS** **Diagnosis: Clinical** **Biopsy: balooned cells with perinuclear vacuoles, swollen cells contain EBV** ## **Hairy leukoplakia** - **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 Sarcoma** **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 Hard palate and gingiva are common sites Presents as a reddish-purple patches** **Presents as a reddish-purple patches Becomes nodular and ulcerate Diagnosis must be supported by biopsy** ## **Kaposi’s Sarcoma** - **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 HIV ## Group I **Lesions strongly associated with HIV infections** HIV associated candidosis ## Group II Lesions less commonly associated with HIV infection HIV associated CMV ulcer ## Group III Lesions possibly associated with HIV infection HIV associated wart # **Classification of oral lesions in HIV** ## **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)** - AIDS is the final stage of HIV disease - CD4 cell count: <200 cells/mm³ - CD4 cell %: <14% - Highly active antiretroviral therapy (HAART) has improved the quality and length of survival for many ## **Acquired immunodeficiency syndrome (AIDS)** - 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 infection** - 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 ## **Key points: HIV infection** - 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 Title slide with the text "Connective tissue disease" **Lupus erythematosus** - Connective tissue disease-systemic & discoid - Females affected more - Both give rise to oral lesions-similar to OLP - SLE-joint pain, rashes, any organ affected - DLE-skin & mucocutaneous # **Lupus erythematosus** - 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 lesions** - Area of erythema or ulceration surrounded by white border - Any part of mucosa involved - Vermilion border of lips affected ## **Lupus erythematosus: oral lesions** - 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 case** Four-panel image showing clinical manifestations: (top-left) erythematous lesions on lower limbs; (top-right) plaque-like lesion on ankle; (bottom-left) oral mucosal lesion with white striae; (bottom-right) histopathological section showing epidermal hyperplasia and inflammatory infiltrate. # **Clinical case** > [!EXAMPLE] 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 planus** Microscopic image of lichen planus histopathology showing hypergranulosis, presence of apoptotic keratinocytes (Civatte bodies) in the basal layer, and lymphocytic infiltrate against the undersurface of the epidermis. # **Histopathology of lichen planus** > [!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.== [[L14 OralManifestationsSystemicDisease.pdf#page=1|L14 OralManifestationsSystemicDisease, p.1]] [[L14 OralManifestationsSystemicDisease.pdf#page=2|L14 OralManifestationsSystemicDisease, p.2]] [[L14 OralManifestationsSystemicDisease.pdf#page=3|L14 OralManifestationsSystemicDisease, p.3]] [[L14 OralManifestationsSystemicDisease.pdf#page=4|L14 OralManifestationsSystemicDisease, p.4]] [[L14 OralManifestationsSystemicDisease.pdf#page=5|L14 OralManifestationsSystemicDisease, p.5]] [[L14 OralManifestationsSystemicDisease.pdf#page=6|L14 OralManifestationsSystemicDisease, p.6]] [[L14 OralManifestationsSystemicDisease.pdf#page=7|L14 OralManifestationsSystemicDisease, p.7]] [[L14 OralManifestationsSystemicDisease.pdf#page=8|L14 OralManifestationsSystemicDisease, p.8]] [[L14 OralManifestationsSystemicDisease.pdf#page=9|L14 OralManifestationsSystemicDisease, p.9]] [[L14 OralManifestationsSystemicDisease.pdf#page=10|L14 OralManifestationsSystemicDisease, p.10]] [[L14 OralManifestationsSystemicDisease.pdf#page=11|L14 OralManifestationsSystemicDisease, p.11]] [[L14 OralManifestationsSystemicDisease.pdf#page=12|L14 OralManifestationsSystemicDisease, p.12]] [[L14 OralManifestationsSystemicDisease.pdf#page=13|L14 OralManifestationsSystemicDisease, p.13]] [[L14 OralManifestationsSystemicDisease.pdf#page=14|L14 OralManifestationsSystemicDisease, p.14]] [[L14 OralManifestationsSystemicDisease.pdf#page=15|L14 OralManifestationsSystemicDisease, p.15]] [[L14 OralManifestationsSystemicDisease.pdf#page=16|L14 OralManifestationsSystemicDisease, p.16]] [[L14 OralManifestationsSystemicDisease.pdf#page=17|L14 OralManifestationsSystemicDisease, p.17]] [[L14 OralManifestationsSystemicDisease.pdf#page=18|L14 OralManifestationsSystemicDisease, p.18]] [[L14 OralManifestationsSystemicDisease.pdf#page=19|L14 OralManifestationsSystemicDisease, p.19]] [[L14 OralManifestationsSystemicDisease.pdf#page=20|L14 OralManifestationsSystemicDisease, p.20]] [[L14 OralManifestationsSystemicDisease.pdf#page=21|L14 OralManifestationsSystemicDisease, p.21]] [[L14 OralManifestationsSystemicDisease.pdf#page=22|L14 OralManifestationsSystemicDisease, p.22]] [[L14 OralManifestationsSystemicDisease.pdf#page=23|L14 OralManifestationsSystemicDisease, p.23]] [[L14 OralManifestationsSystemicDisease.pdf#page=24|L14 OralManifestationsSystemicDisease, p.24]] [[L14 OralManifestationsSystemicDisease.pdf#page=25|L14 OralManifestationsSystemicDisease, p.25]] [[L14 OralManifestationsSystemicDisease.pdf#page=26|L14 OralManifestationsSystemicDisease, p.26]] [[L14 OralManifestationsSystemicDisease.pdf#page=27|L14 OralManifestationsSystemicDisease, p.27]] [[L14 OralManifestationsSystemicDisease.pdf#page=28|L14 OralManifestationsSystemicDisease, p.28]] [[L14 OralManifestationsSystemicDisease.pdf#page=29|L14 OralManifestationsSystemicDisease, p.29]] [[L14 OralManifestationsSystemicDisease.pdf#page=30|L14 OralManifestationsSystemicDisease, p.30]] [[L14 OralManifestationsSystemicDisease.pdf#page=31|L14 OralManifestationsSystemicDisease, p.31]] [[L14 OralManifestationsSystemicDisease.pdf#page=32|L14 OralManifestationsSystemicDisease, p.32]] [[L14 OralManifestationsSystemicDisease.pdf#page=33|L14 OralManifestationsSystemicDisease, p.33]] [[L14 OralManifestationsSystemicDisease.pdf#page=34|L14 OralManifestationsSystemicDisease, p.34]] [[L14 OralManifestationsSystemicDisease.pdf#page=35|L14 OralManifestationsSystemicDisease, p.35]] [[L14 OralManifestationsSystemicDisease.pdf#page=36|L14 OralManifestationsSystemicDisease, p.36]] [[L14 OralManifestationsSystemicDisease.pdf#page=37|L14 OralManifestationsSystemicDisease, p.37]] [[L14 OralManifestationsSystemicDisease.pdf#page=38|L14 OralManifestationsSystemicDisease, p.38]] [[L14 OralManifestationsSystemicDisease.pdf#page=39|L14 OralManifestationsSystemicDisease, p.39]] [[L14 OralManifestationsSystemicDisease.pdf#page=40|L14 OralManifestationsSystemicDisease, p.40]] [[L14 OralManifestationsSystemicDisease.pdf#page=41|L14 OralManifestationsSystemicDisease, p.41]] [[L14 OralManifestationsSystemicDisease.pdf#page=42|L14 OralManifestationsSystemicDisease, p.42]] [[L14 OralManifestationsSystemicDisease.pdf#page=43|L14 OralManifestationsSystemicDisease, p.43]] [[L14 OralManifestationsSystemicDisease.pdf#page=44|L14 OralManifestationsSystemicDisease, p.44]] [[L14 OralManifestationsSystemicDisease.pdf#page=45|L14 OralManifestationsSystemicDisease, p.45]] [[L14 OralManifestationsSystemicDisease.pdf#page=46|L14 OralManifestationsSystemicDisease, p.46]] [[L14 OralManifestationsSystemicDisease.pdf#page=47|L14 OralManifestationsSystemicDisease, p.47]] [[L14 OralManifestationsSystemicDisease.pdf#page=48|L14 OralManifestationsSystemicDisease, p.48]] [[L14 OralManifestationsSystemicDisease.pdf#page=49|L14 OralManifestationsSystemicDisease, p.49]] [[L14 OralManifestationsSystemicDisease.pdf#page=50|L14 OralManifestationsSystemicDisease, p.50]] [[L14 OralManifestationsSystemicDisease.pdf#page=51|L14 OralManifestationsSystemicDisease, p.51]] [[L14 OralManifestationsSystemicDisease.pdf#page=52|L14 OralManifestationsSystemicDisease, p.52]] [[L14 OralManifestationsSystemicDisease.pdf#page=53|L14 OralManifestationsSystemicDisease, p.53]] [[L14 OralManifestationsSystemicDisease.pdf#page=54|L14 OralManifestationsSystemicDisease, p.54]] [[L14 OralManifestationsSystemicDisease.pdf#page=55|L14 OralManifestationsSystemicDisease, p.55]]