Earn

2 CE credits
This course was
written for dentists,
dental hygienists,
and assistants.

Oral Manifestations of
Systemic Disease
A Peer-Reviewed Publication
Written by Jeff Burgess, DDS, MSD

Abstract Educational Objectives: Author Profile

Mucosal ulceration, dental disease and other tooth At the end of this educational activity, Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant
abnormalities, oral soft tissue tumors, periodontal disease, participants will be able to: Professor, Department of Oral Medicine, University
bone pathology, and orofacial pain may be directly related 1. Discuss the complexity of the relationship of Washington School of Dental Medicine; (Retired)
to or confounded by underlying systemic disease. An between systemic disease and various oral Attending in Pain Center, University of Washington
understanding of the relationship between systemic disease conditions. Medical Center; (Retired) Private Practice in Hawaii
and oral pathology is important with respect to establishing 2. Identify the different oral manifestations and Washington; Director, Oral Care Research
the diagnosis and determining the complexity of subsequent associated with specific systemic diseases. Associates. He can be reached at jeffreyaburgess@
management. For example, dental caries that is confounded by 3. Differentiate between potential systemic hotmail.com .
nutritional deficiency or psychological problems such as bulimia diseases associated with some specific oral Author Disclosure
or anorexia, or a medical problem that directly or indirectly conditions such as ulceration. Jeff Burgess, DDS, MSD, has no commercial ties
(via medication use) causes xerostomia or dry mouth, or a 4. Have improved diagnostic skills in relation with the sponsors or providers of the unrestricted
medical condition that alters the patient’s ability to maintain to the connection between systemic disease educational grant for this course.
appropriate oral hygiene may need to be managed using a and oral pathology.
comprehensive strategy that takes into account the underlying
medical issue as well as the dental issues. This course reviews
such problems and their impact on oral conditions.

Publication date: July 2013 Supplement to PennWell Publications

Expiration date: June 2016
PennWell designates this activity for 2 Continuing Educational Credits
Dental Board of California: Provider 4527, course registration number CA# 02-4527-13079
“This course meets the Dental Board of California’s requirements for 2 unit of continuing education.”
The PennWell Corporation is designated as an Approved PACE Program Provider by the
Academy of General Dentistry. The formal continuing dental education programs of this
program provider are accepted by the AGD for Fellowship, Mastership and membership
maintenance credit. Approval does not imply acceptance by a state or provincial board of
dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to
(10/31/2015) Provider ID# 320452.
This educational activity was developed by PennWell’s Dental Group with no commercial support.
This course was written for dentists, dental hygienists and assistants, from novice to skilled.
Educational Methods: This course is a self-instructional journal and web activity.
Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or
services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or
third party has had any input into the development of course content.
Requirements for Successful Completion: To obtain 2 CE credits for this educational activity you must pay the
required fee, review the material, complete the course evaluation and obtain a score of at least 70%.
CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with
products or services discussed in this educational activity. Heather can be reached at hhodges@pennwell.com
Educational Disclaimer: Completing a single continuing education course does not provide enough information
to result in the participant being an expert in the field related to the course topic. It is a combination of many
educational courses and clinical experience that allows the participant to develop skills and expertise.
Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and
represents the most current information available from evidence based dentistry.
Registration: The cost of this CE course is $49.00 for 2 CE credits.
Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full
refund by contacting PennWell in writing.
Educational Objectives
At the end of this educational activity, participants will
be able to:
1. Discuss the complexity of the relationship between
systemic disease and various oral conditions.
2. Identify the different oral manifestations associated
with specific systemic diseases.
3. Differentiate between potential systemic diseases
associated with some specific oral conditions such as
ulceration.
4. Have improved diagnostic skills in relation to the con-
nection between systemic disease and oral pathology.
Abstract
Mucosal ulceration, dental disease and other tooth ab-
normalities, oral soft tissue tumors, periodontal disease,
bone pathology, and orofacial pain may be directly related
to or confounded by underlying systemic disease. An un-
derstanding of the relationship between systemic disease
and oral pathology is important with respect to estab-
lishing the diagnosis and determining the complexity of
subsequent management. For example, dental caries that
is confounded by nutritional deficiency or psychological
problems such as bulimia or anorexia, or a medical prob-
lem that directly or indirectly (via medication use) causes
xerostomia, or a medical condition that alters the patient’s
ability to maintain appropriate oral hygiene may need to
be managed using a comprehensive strategy that takes into
account the underlying medical issue as well as the dental
issues. This course reviews such problems and their impact
on oral conditions.
Introduction
Numerous orofacial conditions are associated with system-
ic disease. The most serious problems of concern to dental
professionals include caries, oral ulcers, mucosal erythema
and sloughing, gingival bleeding and hypertrophy, soft tis-
sue exophytic masses, dry mouth, facial pain, movement
disorders, tooth abnormalities, abnormal dental wear,
tooth/mucosal discoloration, developmental and bone
pathology. This review focuses on the systemic conditions
that may cause or contribute to the above oral problems.
Caries
Dental caries may be caused or aggravated by a number
of systemic diseases via their impact on the three primary
factors that are thought to contribute to dental caries: the
presence of bacteria and biofilm known to cause caries, the
availability of a consistent food source (e.g. sugar) for these
bacteria, and oral hygiene. Other factors such as genetics
(e.g. tooth development, matrix metalloproteinases) and
the use of medications in the treatment of systemic disease
(e.g. affect on salivation) may also play a role in the devel-
opment of caries.
2 www.ineedce.com
A very complex relationship exists between these factors
with respect to caries initiation in both primary and adult
teeth. It is known that any perturbation of the oral environ-
ment can increase the potential for the development of dental
caries. For example, in a study on the relationship between
dental caries and nutritional status, snack foods, and the
consumption of sugar-sweetened beverages in schoolchil-
dren in Thailand, it was found that malnutrition as well as
food intake habits at bedtime were significantly related to
the development of dental caries in the primary dentition.1
In addition to malnutrition, other conditions impacting
diet are also cited in the literature as associated with the
development of caries. These include medical (e.g. diabetes)
and psychological (e.g. drug abuse, bulimia, etc.) problems.
The following subsections detail some of the specific sys-
temic problems that are suspected of impacting the develop-
ment of caries.
Diabetes
In animal models, a number of studies suggest that rapid
progressive caries is associated with chemically induced
hyperglycemia.2,3 In contrast to the animal studies, at
least one systematic review of the literature questions the
scientific validity of a causative link between caries and
diabetes in humans.4 The authors of this review suggest that
because multiple studies report variable caries experiences
between subjects with and without diabetes (e.g. increased,
decreased, and similar experiences), that the evidence is, at
present, insufficient to determine if a true risk-relationship
actually exists in humans.
Drug Abuse
Multiple studies have linked the abuse of drugs to the devel-
opment of dental caries.5-8 The problem has been identified
in many countries throughout the world.9-12
One of the drugs that has been most recently studied in
relation to caries is methamphetamine.13 The street descrip-
tion of ‘meth mouth’ is not without merit as this particular
drug and its abuse appears to be associated with considerable
tooth decay as well as other oral problems such as periodon-
tal disease. Some evidence suggests that salivary pH may be
the reason the drug contributes to dental caries.14
The abuse of narcotics and alcohol has also been associ-
ated with an increased risk of caries. However, in at least one
comparative study, alcohol abuse was less likely than ‘drug’
abuse to lead to the development of caries. The combination
of alcohol and drug abuse (which included self-reported use
of not only heroin and methadone but also cannabis, benzo-
diazepines, and cocaine) led to the greatest caries risk (38%
increased risk).15
The authors of this study speculate that the lower rate
in persons abusing alcohol, and particularly those that drink
beer may be related to the effect of increased fluoride con-
sumption which is an ingredient in beer.
 The caries risk from narcotics is not just related to
street use. A recent case report describes the development
of rampant caries from the abuse of oral transmucosal fen-
tanyl citrate lozenges which are used for the oral manage-
ment of breakthrough cancer pain.16 Presumably caries risk
associated with drug use is behavioral in nature and relates
to neglect of oral hygiene.
Smokeless tobacco use has also been linked to dental
caries, specifically root caries.17 With respect to cannabis
use, one study found that subjects using this drug exces-
sively had significantly greater smooth surface caries than
controls. The authors speculate that this was related to
the drugs effect on salivation (hyposalivation during use)
and on subsequent post-smoking sugar intake (from the
‘munchies’).18
In addition, as noted previously, any medication that
reduces salivation has the potential to increase the risk of
caries, particularly if it is used over a prolonged period of
time.19 However, other than anecdotes, there is little docu-
mented research assessing the link between the commonly
used drugs that cause xerostomia and caries progression. In
one animal study chronic administration of clonidine20 and
propranolol21 was found to increase caries in rats. Other
drugs causing dry mouth that are utilized by patients that
could cause caries include antihistamines, anti-depressants
such as Elavil® (amitriptyline), Asendin® (amoxapine),
Anafranil® (clomipramine), Remeron® (mirtazapine) and
Aventyl® or Pamelor® (nortriptline), and Detrol® which is
commonly used to treat incontinence.
Bulimia and Anorexia
Bulimia, a condition associated with repeated vomiting, has
been connected to the development of dental caries in both
men and women.22 This is presumed to be related to the
fact that patients who chronically vomit, bathe their teeth
in stomach acid during this purging behavior. In addition
to bulimia, anorexia is another psychological condition that
may include vomiting and has also been associated with an
increase in dental caries.
However in a recent systematic review of the literature
assessing the orofacial manifestations of these conditions,
including caries, the authors suggest that the development
of caries in patients with eating disorders may not be an
automatic sequalae of these abnormalities.23
Nonetheless, in otherwise healthy patients with good
oral hygiene but with unusual smooth surface lesions or
rampant caries, eating disorders should be considered as a
potential cause of the disease. Caries activity in this group
of patients may also be confounded by general diet and oral
hygiene as well as salivary gland disturbance.
Medical Conditions Reducing Hygiene Behavior
Any medical condition that contributes to a reduction in
oral hygiene can increase the potential for the development
www.ineedce.com 3
of dental caries. Diseases which reduce coordination, limit
cognitive activity, or involve significant physical or mental
disability have the potential to facilitate dental disease,
including caries, and subsequent tooth loss.24 Finally, there
is limited evidence that genetic factors such as a mutant
allele for MMP13 (one of the genes that is responsible for
producing a matrix metalloproteinase) may contribute in
some manner to the etiology of dental caries.25
Oral Ulcers
The systemic conditions that can cause oral ulceration
include infection (e.g. syphilis,26, 27 tuberculosis,28 HIV/
AIDS,29,30 viral infection including herpangina and primary
herpetic stomatitis including herpes simplex virus causal-
ity (HSV-1 or 2),31 candida and other fungal organisms
(e.g. mucormycosis or histoplasmosis,32-35 autoimmune
disease (e.g. lupus,36,37 pemphigus and paraneoplastic pem-
phigus,38,39 lichen planus,40 inflammatory bowel disease,41
thyroid disease,44 malignancy/haematologic disease,45,46
cyclic neutropenia,47 allergy and other drug reactions,48-50
and vascular inflammatory disease.51 Oral ulceration may
also be associated with organ transplants and the medica-
tions used to manage rejection or treat other diseases (e.g.
thyroid disease),52 liver transplant,53 or renal transplant.54
Nutritional deficiencies are also associated with intraoral
ulceration.55,56 Oral ulceration has also been reported with
hypogammaglobulinemia.57
Generally the clinical presentation of oral ulcers is not
specific enough to allow identification of the underlying pa-
thology in cases involving systemic disease. There are, how-
ever, several clinical features that may be helpful in guiding
the clinician with respect to the differential diagnosis in these
cases. These include ulcer location, duration, reoccurrence,
depth, number, size, scarring, and non-healing.
Lesion Location
Lesions associated with primary herpetic stomatits occur
not only on the intraoral mucosa of the cheek, tongue, pal-
ate, and posterior pharynx, but also on the attached gingiva.
This is not a typical presentation that is associated with most
other oral ulcerative diseases and thus can be used to help
differentiate between non-viral and viral etiology.
Lesion Duration
Viral lesions and aphthous ulcers typically persist for 10-14
days and heal with complete resolution. In contrast, lesions
associated with Behcet’s disease may persist for up to four to
six weeks. Ulcers related to underlying neoplasm, a compro-
mised immune system, or nutritional deficiency persist for a
much longer period of time.
Lesion Reoccurrence
Ulceration reoccurring on the attached gingiva is likely to
represent secondary (or reoccurring) HSV-1 or HSV-2.
Lesion Depth
Deep cratering of the oral mucosa is typical of the ulcers
associated with Behcet’s disease and HIV/AIDS. However,
lesions associated with major aphthous, tuberculosis and
syphilis may also be relatively deep. Deep tongue lesions
may also be associated with amyloidosis58 and malignancy.
Number of Lesions
Multiple ulcers clustered throughout the mouth suggest vi-
ral etiology (e.g. herpes zoster, primary herpetic stomatitis,
or herpangina).
The Size of the Lesion
Large (>1cm or greater) oral ulcers are most typically seen
with erythema multiforma, allergy, benign mucous mem-
brane pemphigoid (BMMP) disease, pemphigus vulgaris,
erosive lichen planus, radiation mucositis or mucositis
associated with chemotherapy and lesions associated with
severe immunosuppression or uremic stomatits. Large
lesions are not typically observed with viral infection al-
though sometimes small lesions will coalesce to form larger
ulcers.59
Post lesion scarring
Ulceration occurring with Bechet’s disease occurs with post-
healing scarring. Typically patients with this condition will
have areas of mucosa that are scarred from past episodes.
Non-healing ulcers
These are most commonly found with malignancy.
Gingival Bleeding, Hyperplasia, Discoloration
Gingival Bleeding
Systemic conditions that can cause gingival bleeding
include some of those that also cause ulceration such as
benign mucous membrane pemphigoid (BMMP), pem-
phigus, lupus erythematosis, leukemia, and erythema mul-
tiforme. Other conditions such as uncontrolled diabetes,60
Crohn’s disease (which can cause gingival hyperplasia as
well as erythema and bleeding),61 and idiopathic thrombo-
cytopenia62,63 have also been linked to gingival bleeding.
In addition to the above, what is termed hormonal
gingivitis, a condition that can occur with pregnancy or
disease associated with pregnancy, can also cause general-
ized gingival erythema and bleeding.64-66
Several medications utilized in the management of a
number of systemic conditions can cause gingival erythema
and bleeding. These include: Trileptal®,68 anticoagulant
drugs such as Coumadin®, warfarin or heparin and chemo-
therapeutic agents such as methotrexate and 5-fluorouracil.
A complete list of the chemotherapy agents that can cause
mucositis and gingival as well as mucosal bleeding can be
found at: http://www.webmd.com/oral-health/guide/
4 www.ineedce.com
oral-side-effects-of-medications?page=2. Non-steroidal
anti-inflammatory drugs, including aspirin may also cause
gingival bleeding if used over a prolonged period of time. A
number of herbal medicines may interact with non-herbal
medications (e.g. the anticoagulants) to increase the po-
tential for gingival bleeding including ginkgo biloba, dong
quai, and danshen.69 Other herbal preparations associated
with gingival bleeding include ginger, ginseng, garlic, and
papaya.70
Gingival Hyperplasia
Specific classes of drugs including the immunosuppressants,
calcium channel blockers, and anticonvulsants that are used
in the treatment of a variety of medical conditions can induce
gingival hyperplasia.71, 72 The medications most frequently
cited as problematic for abnormal gingival growth include;73
immunosuppressants, calcium channel blockers, and anti-
epileptic drugs.
Gingival Discoloration
Gingival discoloration (other than erythema) may be a sign
of Addison’s disease (primary hypoadrenocorticism), silver
poisoning, primary or metastatic malignancy (melanoma),
Kaposi’s sarcoma (with or without associated AIDS),
hereditary hemorrhagic telangiectasia, and Peutz-Jeghers
syndrome (lip lesions).
Intraoral Soft Tissue Tumors
General medical conditions that can cause intraoral soft
tissue tumors include parathyroid disease (e.g. primary
hyperparathyroidism or hyperparathyroidism secondary to
an adenoma or carcinoma of a parathyroid gland - Brown’s
tumor), malignant acanthosis nigricans (hyperplastic, peb-
bly lesions on the lips), immunosuppression (squamous
papillomas), metastatic neoplasms (typically from the
breast, prostate, thyroid, lung), amyloidosis secondary to
multiple myeloma (pebbly lesions of the lip and cheek).
Some of the other systemic conditions that can cause
single or multiple exophytic papules, tissue enlargement,
or other growths include; chronic granulomatous disease
(Crohn’s disease) (which results in granulomatous gingival
enlargement, cobblestone or corrugated labial mucosa),
lymphoma, syphilis (ulcer plus atypical clinical presenta-
tions in AIDS), end stage kidney disease with dialysis
(causes furred tongue); lymphangioma (results in a pebbly
mucosal surface).74-88
Dry Mouth
Any systemic disease that affects the major or minor sali-
vary glands via direct disease involvement or secondarily as
a consequence of medication use, radiation, or surgical
trauma can cause dry mouth or xerostomia. Those systemic
conditions capable of impacting the salivary glands in-
clude:89-93 Sjogren’s disease, chronic renal failure (CRF),
 other autoimmune diseases (rheumatoid arthritis, seronega-
tive spondyloarthritis, connective tissue disease, systemic
lupus erythematosis), non-Hodgkin lymphoma, diabetes,
Parkinson’s disease, HIV/AIDS, psychological problems
(anxiety disorders and depression), stroke and Alzheimer’s
disease, anemia, cystic fibrosis, and other conditions such
as head trauma with nerve damage and chemo or radiation
therapy for head and neck cancer.
Classes of medications used to treat systemic diseases
capable of causing dry mouth include:94 antihistamines, an-
tipsychotics, diuretics, chemotherapeutic agents, migraine
medications, anticholinergic/antispasmodic agents, antidi-
arrhetics, analgesics – antinflammatory type, narcotic anal-
gesics, anti-acne, anti-anxiety medications, anticonvulsants,
antihypertensives, anti-nausea and anti-emetic medications,
anti-parkinsonian drugs, bronchodilators, muscle relaxants,
and other drugs such as cannabis.
Dry mouth can occur as a secondary effect of treatment
in patients using C-pap for sleep apnea and consequent to
the use of COPD inhalers.95
Orofacial Pain
Pain in the region of the mouth and face may be caused
by a number of systemic problems. It is not within the
purview of this course to extensively review the clinical
pain characteristics of the following conditions. How-
ever several references are listed for additional review.96,
97
Below are several systemic conditions that can cause
orofacial pain:
Cardiac disease (e.g. myocardial infarction, angina)
Thyroid disease (e.g. thyroiditis)
Sinus disease (e.g. acute and chronic sinusitis)
Autoimmune disease (e.g. rheumatoid arthritis, lupus, sclero-
derma)
Secondary trigeminal neuralgia (e.g. from tumors such as me-
ningioma, epidermoid tumor, acoustic neurinoma, metastatic
tumor, brain stem glioma; vascular lesions such as basilar
artery or cavernous sinus aneurysm; connective disease such as
scleroderma; Paget’s disease; syphilis; or toxins; MS)
Craniofacial pain of musculoskeletal origin (e.g. TMD, TMJ
osteoarthritis, bone infection or primary or metastatic tumor)
Infection (e.g. otitis media, infection secondary to immuno-
suppression)
Sickle cell disease (sickle cell arthropathy)
Vascular inflammatory conditions (e.g. giant cell arteritis,
temporal arteritis, Systemic Lupus Erythematosus)
Psychological abnormality (e.g. somatoform disorder, pain of
psychological origin in the head or face)
Medication neurotoxicity (e.g. vincristine)
Suboccipital or cervical nerve or muscle problems
Diabetes
www.ineedce.com 5
Jaw movement disorders
Jaw movement can be altered by several medical conditions
affecting the musculature, nervous system, vascular system,
or the bones of the cranium or mandible. Movement disor-
ders include opening stiffness, opening difficulty, painful
movement, and unintentional movement. The conditions
that should be considered in the differential diagnosis relat-
ed to systemic disease for the above jaw movement problems
are listed below.98-102
Jaw opening stiffness
Jaw opening stiffness can be caused by scleroderma, fibro-
myalgia, muscular dystrophy, and multiple sclerosis (MS).
Opening difficulty
Difficulty in opening the jaw may result from infection (in-
cluding the cephalic form of tetanus), poisoning, neurologic
disease, psychogenic abnormality, tumor, substance abuse,
dystonia, radiation induced trismus, ‘locked-in’ syndrome,
brain stem lesions, idiopathic inflammatory myopathies.
Painful jaw movement
Movement of the jaw may be limited by fibromyalgia, teta-
nus, tumor, and dystonia associated with Behcet’s disease.
Intermittent unintentional movement
Additional jaw movement abnormality including intermit-
tent unintentional movement can result from Parkinson’s
disease, epilepsy, dystonia, nocturnal paroxysmal dysto-
nia, serotonin syndrome, and substance abuse.
Tooth Morphologic Abnormality
Dental problems associated with systemic disease include
excessive tooth wear (from bulimia, anorexia, neurologic
disease, psychological problems, genetic disorders),114-120 de-
velopmental (genetic) abnormalities causing malformed or
excessive or impacted teeth, discoloration (from medication
use), and tooth root resorption (bulimia, gastroesophageal
reflux disease, excessive soft drink consumption associated
with obesity, diabetes, drug abuse, salivary gland agenesis,
and high blood pressure).103-113
Tooth and Mucosal Discoloration
Dental discoloration
Dental discoloration can arise from the treatment of sys-
temic infection with tetracycline and tetracycline-derived
broad spectrum antibiotics. The result is permanent if
the drugs are used during development of the teeth and
bone as they are incorporated into the dental and enamel
structure. Tissues affected include the teeth, bone, and car-
tilage. Both primary and permanent teeth are susceptible
to discoloration which can range from grey to brown or
be yellow. Minocycline hydrochloride application during
growth and development of bone leads to black or green
tooth roots and a blue-gray darkening of the crowns of the
permanent teeth. Staining may also occur in erupted per-
manent teeth from minocycline and within the mucosa of
the palate.121-124
Environmental exposure to a number of elements has
also been associated with discoloration of teeth. These
include silver, iron, and manganese which stain black;
mercury and lead dust which stains the teeth blue-green;
copper and nickel stain blue to blue/green, and chromic
acid which can stain the teeth deep orange.125, 126 Excessive
fluoride during development tends to mottle the color of
enamel.127 In addition to the above causes of tooth dis-
coloration, neonatal sepsis has also been associated with
emergence of ‘green teeth’.128
Mucosal discoloration
Mucosal discoloration can be indicative of systemic
disease. A large number of conditions can cause varying
types of mucosal discoloration. The following are systemic
problems that are known to cause mucosal discoloration
and the specific type of discoloration that has been de-
scribed for each condition.129-131 Minocycline is associated
with a palatal ring. Kaposi sarcoma (KS) is associated with
multiple red lesions within the mucosa, Addison’s disease
results in hyperpigmentation of the mucosa, melanoma re-
sults in a diffuse or more discrete solitary blue black tissue,
thrombocytopenic purpura/leukemia and hemophilia are
characterized by mucosal petechiae, pernicious anemia
causes tongue discoloration, infection (such as infectious
mononucleosis) is associated with petechiae on the palate.
Generalized redness of the oral mucosa is associated
with a number of systemic diseases including: pemphigus,
erosive lichen planus, radiation necrosis, mucositis, candi-
dosis secondary to immunosuppression, allergy, erythema
multiforme, polycythemia, Crohn’s disease, epidermoly-
sis bullosa, viral infection, leukemia, uremic stomatitis,
and vitamin B deficiency
Bone Pathology
Radiolucencies associated with the pericoronal or follicular
spaces adjacent to the teeth are not uncommon. However
systemic disease that can cause this type of bone loss is
rare. Those conditions that have been linked to lesions
associated with unerupted teeth include Ewing’s sarcoma,
histiocytosis X, pseudotumor of hemophilia, and salivary
gland tumors. The diseases that can cause unilocular or
multilocular radiolucency or radiolucency in the maxilla
or mandible not linked to the dentition include metastatic
carcinoma, giant cell tumor resulting from hyperparathy-
roid disease or neurofibromatosis type 1, Burkitt’s lym-
phoma, chondrosarcoma, eosinophilic granuloma, fibrous
dysplasia, cherubism, Ewing’s sarcoma, Langerhan’s cell
disease (idiopathic histiocytosis), malignant lymphoma of
6 www.ineedce.com
bone, multiple myeloma, neuroblastoma, neurosarcoma,
sarcoidosis, tuberculosis, and scleroderma.
For a complete review of disease that can cause bone
pathology the reader is referred to the authoritarian texts
that are provided as references.
The differential diagnosis is refined clinically by the
patient’s gender, age, predominant jaw and region of the
jaw where the lesion is located, the type of lesion (unilocu-
lar or multilocular) and the configuration of the lesion’s
borders (e.g. well defined or diffuse/ill-defined), the pa-
tient’s symptom history (e.g. presence or absence of pain,
dyesthesia/paresthesia,), and examination findings (e.g.
localized swelling, gingival involvement, tooth mobility,
tooth vitality). Other important considerations include
serum chemistries, general symptoms, and bone biopsy.
Another condition involving the jaw bones is osteone-
crosis caused by the use of bisphosphonates as treatment
for advanced forms of cancer.133 Bone resorption of the
mandibular angle has been associated with progressive
systemic sclerosis. A generalized rarefaction of the jaw
bones may also result from nutritional abnormality such as
calcium deficiency (causing osteomalacia or ‘rickets’) or vi-
tamin C deficiency as well as the hereditary hemolytic ane-
mias such as thalassemia and sickle cell anemia. Leukemia
can also cause rarefaction of the skull and jaw ramus. In the
early stages of Paget’s disease (osteitis deformans) rarefac-
tion and bone resorption are associated with radiographic
radiolucency and in the later stage when there is fibrous
deposition the bones take on a ‘cotton-wool’ appearance
when viewed radiographically.
The temporomandibular joints may be affected by con-
nective tissue diseases such as rheumatoid arthritis, juvenile
idiopathic arthritis, psoriatic arthritis, and arthritis associ-
ated with lupus as well as systemic cancer with metastasis.
Gout may also affect the TMJ. Dermatomyositis has been
reported to be associated with condylar resorption.141-146
Conclusion
The effect of systemic health on oral disease is well docu-
mented and includes soft and hard tissue abnormality and
pathology. The diagnosis of oral pathology by dental
professionals may contribute towards the discovery of sys-
temic disease. Regardless of which way the arrow points, the
complexity of management of oral disease associated with
systemic disease is likely to be confounded by the connec-
tion between the two and successful management warrants
an understanding of both problems.
Further Reading
Section on Pain:
1. Surgical management of pain. Editor Kim J Burchiel, Thieme,
New York, 2002. Chapter 20, Jeffrey A Burgess, p 276-287.
2. Neurosurgical management of pain. Editors Richard B North,
Robert M. Levy, Springer, New York, 1996, Chapter 7: Facial
and Cranial Pain; Kim J Burchiel and Jeffrey A Burgess.

Sections on Bone, Tooth, and Mucosal Pathology:
1. Differential Diagnosis of Oral Lesions. Editors Norman K
Wood and Paul W Goaz. C.V. Mosby Company, St Louis,
Second edition. 1980.
2. Tumors of the Head and Neck; Clinical and Pathological
Considerations. 2nd Ed. John G Batsakis, Williams and
Wilkins, Baltimore, 1982.
3. Oral and Maxillofacial Pathology. Editors Brad W Neville,
Douglas D Damm, Carl M Allen, Jerry E Bouquot, W.B.
Saunders Company, Philadelphia, 1995.
References
1. Lueangpiansamut J, Chatrchaiwiwatana S, Muktabhant
B, Inthalohit W. Relationship between dental caries status,
nutritional status, snack foods, and sugar-sweetened
beverages consumption among primary schoolchildren
grade 4-6 in Nongbua Khamsaen school, Na Klang district,
Nongbua Lampoo Province, Thailand. J Med Assoc Thai.
Aug 2012;95(8):1090-7. [PMID: 23061315].
2. Nakahara Y, Sano T, Kodama Y, Ozaki K, Matsuura T.
Alloxan-induced hyperglycemia causes rapid-onset and
progressive dental caries and periodontitis in F344 rats. Histol
Histopathol. Oct 2012;27(10):1297-306. [PMID: 22936448].
3. Sano T, Matsuura T, Ozaki K, Narama I. Dental caries and
caries-related periodontitis in type 2 diabetic mice. Vet Pathol.
2011/03;48(2):506-12.
4. Taylor GW, Manz MC, Borgnakke WS. Diabetes, periodontal
diseases, dental caries, and tooth loss: a review of the literature.
Compend Contin Educ Dent. Mar 2004;25(3):179-84, 186-8,
190; quiz 192. [PMID: 15641324].
5. Gupta T, Shah N, Mathur VP, Dhawan A. Oral health status of
a group of illicit drug users in Delhi, India. Community Dent
Health. Mar 2012;29(1):49-54. [PMID: 22482250].
6. Ma H, Shi XC, Hu DY, Li X. The poor oral health status of
former heroin users treated with methadone in a Chinese city.
Med Sci Monit. 2012/04;18(4):1-5.
7. Ravenel MC, Salinas CF, Marlow NM, Slate EH, Evans
ZP, Miller PM. Methamphetamine abuse and oral health:
a pilot study of “meth mouth”. Quintessence Int. Mar
2012;43(3):229-37. [PMID: 22299123].
8. Turkyilmaz I. Oral manifestations of “meth mouth” a case
report. J Contemp Dent Pract. 2010/01;11(1):E073-80.
9. Carter EF. Dental implications of narcotic addiction. Aust
Dent J. Aug 1978;23(4):308-10. [PMID: 282833].
10. Sakki TK, Knuuttila ML, Vimpari SS, Kivelä SL. Lifestyle,
dental caries and number of teeth. Community Dent Oral
Epidemiol. Oct 1994;22(5 Pt 1):298-302. [PMID: 7813180].
11. Scheutz F. Dental health in a group of drug addicts attending
an addiction-clinic. Community Dent Oral Epidemiol.
1984/02;12(1):23-8.
12. Reece AS. Dentition of addiction in Queensland: poor
dental status and major contributing drugs. Aust Dent J. Jun
2007;52(2):144-9. [PMID: 17687962].
13. Morio KA, Marshall TA, Qian F, Morgan TA. Comparing
diet, oral hygiene and caries status of adult methamphetamine
users and nonusers: a pilot study. J Am Dent Assoc. Feb
2008;139(2):171-6. [PMID: 18245685].
14. Ravenel MC, Salinas CF, Marlow NM, Slate EH, Evans
ZP, Miller PM. Methamphetamine abuse and oral health:
a pilot study of “meth mouth”. Quintessence Int. Mar
2012;43(3):229-37. [PMID: 22299123].
15. Dasanayake AP, Warnakulasuriya S, Harris CK, Cooper DJ,
Peters TJ, Gelbier S. Tooth decay in alcohol abusers compared
to alcohol and drug abusers. Int J Dent. 2010;2010:786503.
[PMID: 20379366].
16. Mandel L, Carunchio MJ. Rampant caries from oral
transmucosal fentanyl citrate lozenge abuse. J Am Dent
Assoc. Apr 2011;142(4):406-9. [PMID: 21454846].
www.ineedce.com 7
17. Winn DM. Tobacco use and oral disease. J Dent Educ. Apr
2001;65(4):306-12. [PMID: 11336115].
18. Schulz-Katterbach M, Imfeld T, Imfeld C. Cannabis and
caries--does regular cannabis use increase the risk of caries
in cigarette smokers?. Schweiz Monatsschr Zahnmed.
2009;119(6):576-83.
19. Samec T, Amaechi BT, Battelino T, Krivec U, Jan J. Influence
of anti-asthmatic medications on dental caries in children in
Slovenia. Int J Paediatr Dent. May 18 2012;[PMID: 22607111].
20. Watson GE, Pearson SK, Bowen WH. The effect of chronic
clonidine administration on salivary glands and caries in
the rat. Caries Res. Mar-Apr 2000;34(2):194-200. [PMID:
10773639].
21. O’Connell AC, Van Wuyckhuyse BC, Pearson SK, Bowen
WH. The effect of propranolol on salivary gland function and
dental caries development in young and aged rats. Arch Oral
Biol. 1993/10;38(10):853-61.
22. Roberts MW, Tylenda CA. Dental aspects of anorexia and
bulimia nervosa. Pediatrician. 1989;16(3-4):178-84. [PMID:
2692004].
23. Romanos GE, Javed F, Romanos EB, Williams RC. Oro-facial
manifestations in patients with eating disorders. Appetite. Oct
2012;59(2):499-504. [PMID: 22750232].
24. Chen X, Clark JJ. Tooth loss patterns in older adults with
special needs: a Minnesota cohort. Int J Oral Sci. Jan
2011;3(1):27-33. [PMID: 21449213].
25. Tannure PN, Kuchler EC, Falagan-Lotsch P, et al. MMP13
polymorphism decreases risk for dental caries. Caries
Research 2012; 46(4):401-7)
26. Jones L, Ong EL, Okpokam A, Sloan P, Macleod I, Staines
KS. Three cases of oral syphilis - an overview. Br Dent J.
2012;212(10):477-80. [PMID: 22627222].
27. Czerninski R, Pikovski A, Meir K, Casap N, Moses AE, Maly
A. Oral syphilis lesions--a diagnostic approach and histologic
characteristics of secondary stage. Quintessence Int. Nov-Dec
2011;42(10):883-9. [PMID: 22026003].
28. Chauhan V, Mahesh DM, Panda P, Mahajan S, Thakur S.
Tuberculosis cutis orificialis (TBCO): a rare manifestation
of tuberculosis. J Assoc Physicians India. Feb 2012;60:126-7.
[PMID: 22715564].
29. Sontakke SA, Umarji HR, Karjodkar F. Comparison of oral
manifestations with CD4 count in HIV-infected patients.
Indian J Dent Res. Sep-Oct 2011;22(5):732. [PMID:
22406727].
30. Umoru D, Oviawe O, Ibadin M, Onunu A, Esene H.
Mucocutaneous manifestation of pediatric human
immunodeficiency virus/acquired immunodeficiency
syndrome (HIV/AIDS) in relation to degree of
immunosuppression: a study of a West African population.
Int J Dermatol. Mar 2012;51(3):305-12. [PMID: 22348567].
31. Westley S, Seymour R, Staines K. Recurrent intra-oral herpes
simplex 1 infection. Dent Update. Jul-Aug 2011;38(6):368-70,
372-4. [PMID: 21905349].
32. Terai H, Yamanishi H, Shimahara M. Nicorandil-induced
tongue ulceration with or without fungal infection.
Odontology. Jan 2012;100(1):100-3. [PMID: 21553069].
33. Akin L, Herford AS, Cicciù M. Oral presentation of
disseminated histoplasmosis: a case report and literature
review. J Oral Maxillofac Surg. Feb 2011;69(2):535-41.
34. Garg R, Gupta VV, Ashok L. Rhinomaxillary mucormycosis:
A palatal ulcer. Contemp Clin Dent. Apr 2011;2(2):119-23.
[PMID: 21957389].
35. Bonifaz A, Vázquez-González D, Macías B, Paredes-Farrera F,
Hernández MA, Araiza J, et al. Oral geotrichosis: report of 12
cases. J Oral Sci. 2010/09;52(3):477-83.
36. Khatibi M, Shakoorpour A, Jahromi ZM, Ahmadzadeh A.
The prevalence of oral mucosal lesions and related factors
in 188 patients with systemic lupus erythematosus. Lupus.
2012;21(12):1312-5. [PMID: 22833437].
37. Albilia JB, Lam DK, Clokie CM, Sándor GK. Systemic lupus
erythematosus: a review for dentists. J Can Dent Assoc. Nov
2007;73(9):823-8. [PMID: 18028758].
38. Muñoz-Corcuera M, Esparza-Gómez G, González-Moles
MA, Bascones-Martínez A. Oral ulcers: clinical aspects.
A tool for dermatologists. Part II. Chronic ulcers. Clin Exp
Dermatol. 2009/06;34(4):456-61.
39. Yan Z, Hua H, Gao Y. Paraneoplastic pemphigus characterized
by polymorphic oral mucosal manifestations--report of two
cases. Quintessence Int. Sep 2010;41(8):689-94. [PMID:
20657859].
40. Eisen D. The clinical features, malignant potential, and
systemic associations of oral lichen planus: a study of 723
patients. J Am Acad Dermatol. Feb 2002;46(2):207-14.
[PMID: 11807431].
41. Rowland M, Fleming P, Bourke B. Looking in the mouth for
Crohn’s disease. Inflamm Bowel Dis. Feb 2010;16(2):332-7.
[PMID: 19705418].
42. Xing X, Zhang T, Wang X. Pediatric Wegener’s granulomatosis
with oral ulcers and progressive periodontitis: a case report.
Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Oct
2011;112(4):e1-5. [PMID: 21868265].
43. Noce CW, Gomes A, Copello A, Barbosa RD, Sant’anna S,
Moreira MC. Oral involvement of chronic graft-versus-host
disease in hematopoietic stem cell transplant recipients.
Gen Dent. Nov-Dec 2011;59(6):458-62; quiz 463-4. [PMID:
22313917].
44. Brown AE, Goubran GF. Oral ulceration associated with
hypothyroidism. Report of a case. Oral Surg Oral Med Oral
Pathol. Aug 1978;46(2):216-9. [PMID: 280829].
45. Beena VT, Chauhan I, Heera R, Rajeev R. Oral cancer in
young non-habituè females: a report of four cases and review
of the literature. Aust Dent J. 2011/09;56(3):322-7.
46. {{Ref46} Seoane-Romero JM, Vázquez-Mahía I, Seoane J,
Varela-Centelles P, Tomás I, López-Cedrún JL. Factors related
to late stage diagnosis of oral squamous cell carcinoma. Med
Oral Patol Oral Cir Bucal. Jan 2012;17(1):e35-40. [PMID:
21743390].
47. Porter SR, Scully C, Pedersen A. Recurrent aphthous
stomatitis. Crit Rev Oral Biol Med. 1998;9(3):306-21. [PMID:
9715368].
48. Wardhana, Datau EA. Recurrent aphthous stomatitis caused
by food allergy. Acta Med Indones. Oct 2010;42(4):236-40.
[PMID: 21063045].
49. Basso FG, Boer CC, Corrêa ME, Torrezan M, Cintra ML, de
Magalhães MH. Skin and oral lesions associated to imatinib
mesylate therapy. Support Care Cancer. Apr 2009;17(4):465-
8. [PMID: 19037666].
50. Al-Johani KA, Fedele S, Porter SR. Erythema multiforme and
related disorders. Oral Surg Oral Med Oral Pathol Oral Radiol
Endod. May 2007;103(5):642-54. [PMID: 17344075].
51. Cho SB, Cho S, Bang D. New insights in the clinical
understanding of Behçet’s disease. Yonsei Med J. Jan
2012;53(1):35-42. [PMID: 22187230].
52. Karincaoglu Y, Esrefoglu M, Aki T, Mizrak B. Propylthiouracil-
induced vasculitic oral ulcers with anti-neutrophil cytoplasmic
antibody. J Eur Acad Dermatol Venereol. Jan 2006;20(1):120-
2. [PMID: 16405633].
53. Savas N, Sevmis S, Karakayali H, Yilmaz U, Haberal M.
Orogenital ulcers in a liver transplant recipient: discerning
between mycophenolate-mofetil-induced complication and
Behcet’s disease. Clin Transplant. 2009/03;23(2):147-9.
54. Garrigue V, Canet S, Dereure O, Panabieres O, Augias
D, Chong G, et al. Oral ulcerations in a renal transplant
recipient: a mycophenolate mofetil-induced complication?.
Transplantation. 2001/09;72(5):968-9.
55. Pontes HA, Neto NC, Ferreira KB, Fonseca FP, Vallinoto GM,
Pontes FS. Oral manifestations of vitamin B12 deficiency: a
case report. J Can Dent Assoc. Sep 2009;75(7):533-7. [PMID:
8 www.ineedce.com
19744365].
56. Garcia BG, Cardoso MF, de Faria O, Gomez RS, Mesquita
RA. A case report of pernicious anemia and recurrent
aphthous stomatitis. J Contemp Dent Pract. 2009;10(2):83-9.
[PMID: 19279976].
57. Fernandes KS, Kokron CM, Barros MT, Kalil J, Gallottini M.
Oral manifestations in patients with hypogammaglobulinemia.
Oral Surg Oral Med Oral Pathol Oral Radiol. Sep
2012;114(3):e19-24. [PMID: 22703644].
58. Al-Hashimi I, Drinnan AJ, Uthman AA, Wright JR, Levine
MJ. Oral amyloidosis: two unusual case presentations. Oral
Surg Oral Med Oral Pathol. May 1987;63(5):586-91. [PMID:
3473379].
59. Brad W. Neville, Douglas D. DAmm, Dean K White. Color
Atlas of Clinical Oral Pathology. second edition. Philadelphia.:
Lippincott Williams and Wilkins; 1991.
60. Tellervo E, Matti K, Pohjamo L, Haukipuro K. Relation
Between Control of Diabetes and Gingival Bleeding. Journal
of Periodontology. 1985/03;56(3):154-157.
61. Chi AC, Neville BW, Krayer JW, Gonsalves WC. Oral
manifestations of systemic disease. Am Fam Physician. Dec 1
2010;82(11):1381-8. [PMID: 21121523].
62. S Cortelazzo, G Finazzi, M Buelli, A Molteni, P Viero, and
T Barbui. High risk of severe bleeding in aged patients
with chronic idiopathic thrombocytopenic purpura.
Available at http://bloodjournal.hematologylibrary.org/
content/77/1/31.short. Accessed 10/24/12.
63. Reebye UN, Ogunrinde OA, Cottrell DA. Idiopathic
thrombocytopenic purpura presenting as gingival bleeding. J
Mass Dent Soc. 2003;52(2):42-3. [PMID: 12886581].
64. Pregnancy Gingivitis (Gum Disease) and Tumors;. Available
at http://www.webmd.com/oral-health/pregnancy-
gingivitis-tumors. Accessed 10/22/12.
65. Wang PH, Chao HT, Lee WL, Yuan CC, Ng HT. Severe
bleeding from a pregnancy tumor. A case report. J Reprod
Med. Jun 1997;42(6):359-62. [PMID: 9219124].
66. Boyarova TV, Dryankova MM, Bobeva AI, Genadiev GI.
Pregnancy and gingival hyperplasia. Folia Med (plovid).
2001;43(1-2):53-6.
67. Singh VP, Sharma A, Sharma S. Papillon-Lefevre syndrome.
Mymensingh Med J. Oct 2011;20(4):738-41. [PMID:
22081200].
68. {{Ref68} Oral Side Effects of Medications. Available at
http://www.webmd.com/oral-health/guide/oral-side-
effects-of-medications?page=2.. Accessed 10.23.12.
69. PDR for Herbal Medicines. 1st. New Jersey: Medical
Economics Company; 1998.
70. Medications that affect oral health. Available at http://www.
cedrugstorenews.com/userapp//lessons/page_view_ui.cf
m?lessonuid=&pageid=EC0E8F0610833E8F8FB741343079
6A37. Accessed 10.23.12.
71. Nohl F, Ferrari P. [Drug-induced gingival hyperplasia]. Ther
Umsch. Sep 1998;55(9):573-5. [PMID: 9789475].
72. {{Ref72} James JA, Marley JJ, Jamal S, Campbell BA, Short
CD, Johnson RW. The calcium channel blocker used with
cyclosporin has an effect on gingival overgrowth. J Clin
Periodontol. Feb 2000;27(2):109-15. [PMID: 10703656].
73. {{Ref73} S Pradhan. Drug induced gingival enlargement – A
review. Available at http://www.pmjn.org.np/index.php/
pmjn/article/view/63/53. Accessed 10/22/12.
74. {{Ref74} Harikishan G, Reddy NR, Prasad H, Anitha S.
Oral Crohn’s disease without intestinal manifestations. J
Pharm Bioallied Sci. Aug 2012;4(Suppl 2):S431-4. [PMID:
23066305].
75. Balci DD, Çelik MM, Çelik E, Demir M, Yaldiz M. A rare
cause of oral papillomatous lesions: Cowden syndrome.
Indian J Dermatol Venereol Leprol. Mar-Apr 2012;78(2):230.
[PMID: 22421679].
76. Hmidi M, Touiheme N, Elboukhari A, Kettani M, Elmejareb
 C, Messary A. Primary B cell lymphoma of the tongue: a case
report. Pan Afr Med J. 2012;12:5. [PMID: 22826730].
77. de-Misa RF, García M, Dorta S, Febles C, Hernández-Machín
B, Serrano S. Solitary oral ulceration as the first appearance of
lymphomatoid papulosis: a diagnostic challenge. Clin Exp
Dermatol. Mar 2010;35(2):165-8. [PMID: 19486068].
78. Lotfi A, Moshref M, Varshosaz M, Jaberi-Ansari S, Ghafouri
A. Maffucci’s syndrome with oral manifestations. Arch Iran
Med. Jul 2009;12(4):421-3. [PMID: 19566364].
79. Alajbeg I, Rogulj AA, Hutinec Z. Orofacial granulomatosis
treated with intralesional triamcinolone. Acta Dermatovenerol
Croat. 2011;19(3):165-9. [PMID: 21933641].
80. Whitaker SB, Wiegand SE, Budnick SD. Intraoral molluscum
contagiosum. Oral Surg Oral Med Oral Pathol. Sep
1991;72(3):334-6. [PMID: 1923422].
81. Sciubba JJ, Niebloom T. Juvenile hyaline fibromatosis
(Murray-Puretic-Drescher syndrome): oral and systemic
findings in siblings. Oral Surg Oral Med Oral Pathol. Oct
1986;62(4):397-409. [PMID: 2430247].
82. van der Beek JM, Cremers CW, van den Broek P. Successful
methotrexate therapy in oral florid papillomatosis. Clin
Otolaryngol Allied Sci. Dec 1980;5(6):365-71. [PMID:
7471503].
83. Al-Azri AR, Logan RM, Goss AN. Oral Lesion as the first
Clinical Presentation in Sarcoidosis: A Case Report. Oman
Med J. May 2012;27(3):243-5. [PMID: 22811777].
84. Kelner N, Rabelo GD, Perez DE, Assunção JN Jr, Witzel
AL, Migliari DA. Analysis of nonspecific oral mucosal and
dermal lesions suggestive of syphilis: a report of 6 cases. Oral
Surg Oral Med Oral Pathol Oral Radiol. Sep 5 2012;[PMID:
22959147].
85. Bjekic M, Markovic M, Sipetic S. Clinical manifestations of
primary syphilis in homosexual men. Braz J Infect Dis. Jul-
Aug 2012;16(4):387-9. [PMID: 22846130].
86. Bardellini E, Amadori F, Flocchini P, Conti G, Piana
G, Majorana A. Oral findings in 50 children with
neurofibromatosis type 1. A case control study. Eur J Paediatr
Dent. Dec 2011;12(4):256-60. [PMID: 22185252].
87. Buchner A, Sandbank M. Multiple fibroepithelial hyperplasias
of the oral mucosa. Oral Surg Oral Med Oral Pathol. Jul
1978;46(1):34-9. [PMID: 277880].
88. Hajheydari Z, Makhlough A. Cutaneous and mucosal
manifestations in patients on maintenance hemodialysis:
a study of 101 patients in Sari, Iran. Iran J Kidney Dis. Apr
2008;2(2):86-90. [PMID: 19377214].
89. Patil S, Khaandelwal S, Doni B, Rahuman F, Kaswan S. Oral
manifestations in chronic renal failure patients attending two
hospitals in north karnataka, India. Oral Health Dent Manag.
Sep 2012;11(3):100-6. [PMID: 22976569].
90. } Liu ZW, Masterson LM, Srouji IA, Musonda P, Scott DG.
Voice Symptoms in Patients with Autoimmune Disease: A
Cross-sectional Epidemiological Study. Otolaryngol Head
Neck Surg. Aug 29 2012;[PMID: 22931896].
91. Leo M Sreebny and Arjan Vissink,. The causes of dry mouth.
In: Leo M Sreebny and Arjan Vissink. Dry Mouth, The
Malevolent Symptom: A Clinical Guide. 1st. Iowa.: Wiley-
Blackwell; John Wiley and sons, inc.; 2010:Chapter 3.
92. Title: Dry Mouth – Causes. mayoclinic. Available at http://
www.mayoclinic.com/health/dry-mouth/HA00034/
DSECTION=causes. Accessed 10/24/12.
93. Dry mouth. Medicinenet. Available at http://www.
medicinenet.com/dry_mouth/article.htm. Accessed
10/14/12.
94. Scully C, Bagan JV. Adverse drug reactions in the orofacial
region. Crit Rev Oral Biol Med. 2004;15(4):221-39. [PMID:
15284187].
95. Asakura Y, Nishimura N, Maezawa K, Terajima T, Kizu
J, Chohnabayashi N. Effect of Switching Tiotropium
HandiHaler(®) to Respimat(®) Soft Mist(™) Inhaler in
www.ineedce.com 9
Patients with COPD: The Difference of Adverse Events and
Usability Between Inhaler Devices. J Aerosol Med Pulm Drug
Deliv. Jun 12 2012;[PMID: 22691112].
96. Jeffrey A Burgess. Craniofacial Pain. In: Kim J Burchiel.
Surgical management of pain. 1st. New York: Thieme;
2002:276-287chapter 20.
97. {Guideline} Kim Burchiel and Jeff Burgess. Facial and Cranial
Pain. In: Richard B North and Robert M Levy. Neurosurgical
Management of Pain. 1. 1. New York: Springer; 1997:83-99/
chapter 7.
98. Gandhi YR. Oro-mandibular dystonia. Natl J Maxillofac
Surg. Jul 2010;1(2):150-2. [PMID: 22442587].
99. Hartl DM, Cohen M, Juliéron M, Marandas P, Janot F, Bourhis
J. Botulinum toxin for radiation-induced facial pain and
trismus. Otolaryngol Head Neck Surg. Apr 2008;138(4):459-
463. [PMID: 18359354].
100. Bakke M, Møller E, Thomsen CE, Dalager T, Werdelin LM.
Chewing in patients with severe neurological impairment.
Arch Oral Biol. Apr 2007;52(4):399-403. [PMID: 17275777].
101. Bakke M, Werdelin LM, Dalager T, Fuglsang-Frederiksen A,
Prytz S, Møller E. Reduced jaw opening from paradoxical
activity of mandibular elevator muscles treated with
botulinum toxin. Eur J Neurol. Nov 2003;10(6):695-9. [PMID:
14641515].
102. Pellecchia MT, Cuomo T, Striano S, Filla A, Barone P.
Paroxysmal dystonia in Behçet’s disease. Mov Disord. Jan
1999;14(1):177-9. [PMID: 9918371].
103. Ferreira-Bacci Ado V, Cardoso CL, Díaz-Serrano KV.
Behavioral problems and emotional stress in children with
bruxism. Braz Dent J. 2012;23(3):246-51. [PMID: 22814694].
104. Alves Mdo S, da Silva FA, Araújo SG, de Carvalho AC, Santos
AM, de Carvalho AL. Tooth wear in patients submitted to
bariatric surgery. Braz Dent J. 2012;23(2):160-6.
105. Saeves R, Espelid I, Storhaug K, Sandvik L, Nordgarden H.
Severe tooth wear in Prader-Willi syndrome. A case-control
study. BMC Oral Health. 2012;12:12. [PMID: 22639910].
106. Omar R, Johansson A, Johansson AK, Carlsson GE. Tooth
wear. Int J Dent. 2012.
107. Young WG. The oral medicine of tooth wear. Aust Dent J.
Dec 2001;46(4):236-50; quiz 306. [PMID: 11838870].
108. Young WG, Khan F, Brandt R, Savage N, Razek AA, Huang
Q. Syndromes with salivary dysfunction predispose to
tooth wear: case reports of congenital dysfunction of major
salivary glands, Prader-Willi, congenital rubella, and Sjögren’s
syndromes. Oral Surgery, Oral Medicine, Oral Pathology,
Oral Radiology, and Endodontics. 2001;92(1):38–48.
109. Gonçalves GK, Carmagnani FG, Corrêa MS, Duarte DA,
Santos MT. Dental erosion in cerebral palsy patients. J
Dent Child (Chic). May-Aug 2008;75(2):117-20. [PMID:
18647505].
110. Su JM, Tsamtsouris A, Laskou M. Gastroesophageal reflux in
children with cerebral palsy and its relationship to erosion of
primary and permanent teeth. J Mass Dent Soc. 2003;52(2):20-
4. [PMID: 12886578].
111. Dhawan VM, Sziklas JJ, Spencer RP. Localization of Ga-67 in
inflammations in the absence of circulating polymorphonuclear
leukocytes. J Nucl Med. Mar 1978;19(3):292-4. [PMID:
632907].
112. Mulic A, Tveit AB, Songe D, Sivertsen H, Skaare. Dental
erosive wear and salivary flow rate in physically active young
adults. BMC Oral Health. 2012/03;23:12:8.
113. Tantbirojn D, Pintado MR, Versluis A, Dunn C, Delong R.
Quantitative analysis of tooth surface loss associated with
gastroesophageal reflux disease: a longitudinal clinical study. J
Am Dent Assoc. Mar 2012;143(3):278-85. [PMID: 22383209].
114. Mallineni SK, Yiu CK, King NM. Schwartz-Jampel syndrome:
a review of the literature and case report. Spec Care Dentist.
Jun 2012;32(3):105-11. [PMID: 22591433].
115. Campos-Lara P, Santos-Diaz MA, Ruiz-Rodríguez MS,
 Garrocho-Rangel JA, Pozos-Guillén AJ. Orofacial findings
and dental management of Williams-Beuren syndrome. J
Clin Pediatr Dent. 2012;36(4):401-4. [PMID: 23019840].
116. Björksved M, Arnrup K. Homocystinuria and oral health. A
report of 14 cases. Swed Dent J. 2012;36(2):101-8. [PMID:
22876397].
117. Hattab FN. Periodontal condition and orofacial changes in
patients with thalassemia major: a clinical and radiographic
overview. J Clin Pediatr Dent. 2012;36(3):301-7. [PMID:
22838236].
118. Papadaki ME, Lietman SA, Levine MA, Olsen BR, Kaban
LB, Reichenberger EJ. Cherubism: best clinical practice.
Orphanet J Rare Dis. May 24 2012;7 Suppl 1:S6. [PMID:
22640403].
119. Friedrich RE, Giese M, Stelljes C, Froeder C, Scheuer HA.
Size of tooth crowns and position of teeth concerning the
extension of facial plexiform neurofibroma in patients
with neurofibromatosis type 1. Anticancer Res. May
2012;32(5):2207-14. [PMID: 22593511].
120. Brooks JK, Bare LC, Davidson J, Taylor LS, Wright JT.
Junctional epidermolysis bullosa associated with hypoplastic
enamel and pervasive failure of tooth eruption: Oral
rehabilitation with use of an overdenture. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. Apr 2008;105(4):e24-8.
[PMID: 18329564].
121. Fendrich P, Brooke RI. An unusual case of oral pigmentation.
Oral Surg Oral Med Oral Pathol. Sep 1984;58(3):288-9.
[PMID: 6592526].
122. Siller GM, Tod MA, Savage NW. Minocycline-induced oral
pigmentation. J Am Acad Dermatol. Feb 1994;30(2 Pt 2):350-
4. [PMID: 8294596].
123. Sánchez AR, Rogers RS 3rd, Sheridan PJ. Tetracycline and
other tetracycline-derivative staining of the teeth and oral
cavity. Int J Dermatol. 2004/10;43(10):709-15.
124. Cockings JM, Savage NW. Minocycline and oral pigmentation.
Aust Dent J. Feb 1998;43(1):14-6. [PMID: 9583219].
125. Stangel I, Valdes E, Xu J. Absorption of iron by dentin: its role
in discoloration. J Biomed Mater Res. Jun 1996;31(2):287-92.
[PMID: 8731219].
126. Addy M, Moran J, Griffiths AA, Wills-Wood NJ. Extrinsic
tooth discoloration by metals and chlorhexidine. I. Surface
protein denaturation or dietary precipitation?. Br Dent J. Nov
9 1985;159(9):281-5. [PMID: 3864472].
127. Pontes DG, Correa KM, Cohen-Carneiro F. Re-
establishing esthetics of fluorosis-stained teeth using enamel
microabrasion and dental bleaching techniques. Eur J Esthet
Dent. 2012;7(2):130-7. [PMID: 22645728].
128. Swann O, Powls A. Images in clinical medicine. Green teeth
in neonatal sepsis. N Engl J Med. Aug 9 2012;367(6):e8.
[PMID: 22873557].
129. Ciçek Y, Ertas U. The normal and pathological pigmentation
of oral mucous membrane: a review. J Contemp Dent Pract.
Aug 15 2003;4(3):76-86. [PMID: 12937598].
130. Altunay I, Kucukunal A, Demirci GT, Ates B. Variable clinical
presentations of Classic Kaposi Sarcoma in Turkish patients.
J Dermatol Case Rep. Mar 27 2012;6(1):8-13. [PMID:
22514583].
131. Shah SS, Oh CH, Coffin SE, Yan AC. Addisonian
pigmentation of the oral mucosa. Cutis. Aug 2005;76(2):97-9.
[PMID: 16209154].
132. Lajolo C, Campisi G, Deli G, Littarru C, Guiglia R, Giuliani
M. Langerhans’s cell histiocytosis in old subjects: two rare
case reports and review of the literature. Gerodontology. Jun
2012;29(2):e1207-14. [PMID: 22612839].
133. Pechalova P, Bakardjiev A, Zaprianov Z, Vladimirov
B, Poriazova E, Zheleva A. Bisphosphonate-associated
osteonecrosis of the jaws -- report of three cases in Bulgaria and
review of the literature. Acta Clin Croat. Jun 2011;50(2):273-9.
[PMID: 22263396].
10 www.ineedce.com
134. Saranjam HR, Sidransky E, Levine WZ, Zimran A, Elstein D.
Mandibular and dental manifestations of Gaucher disease.
Oral Dis. Jul 2012;18(5):421-9. [PMID: 22251146].
135. El Fares N, El Bouihi M, Zouhair K, El Kabli H, Benchikhi H.
[Maxillary bone sarcoidosis]. Rev Stomatol Chir Maxillofac.
Apr 2011;112(2):121-4. [PMID: 21429541].
136. Ryba F, Rice S, Hutchison IL. Numb chin syndrome: an
ominous clinical sign. Br Dent J. Apr 10 2010;208(7):283-5.
[PMID: 20379242].
137. Orhan E, Erol S, Deren O, Sevin A, Ekici O, Erdogan B.
Idiopathic bilateral central giant cell reparative granuloma
of jaws: a case report and literature review. Int J Pediatr
Otorhinolaryngol. May 2010;74(5):547-52. [PMID:
20219254].
138. Chrcanovic BR, Gomez RS, Freire-Maia B. Neurofibromatosis
type 1 associated with bilateral central giant cell granuloma of
the mandible. J Craniomaxillofac Surg. Oct 2011;39(7):538-
43. [PMID: 21071237].
139. Srinivas C, Gupta T, Rajasekharan P, Munshi A. Bilateral
mandibular metastases in medulloblastoma. J Clin Neurosci.
Feb 2009;16(2):325-8. [PMID: 19056274].
140. Cazal C, Sobral AP, Neves RF, Freire Filho FW, Cardoso AB,
da Silveira MM. Oral complaints in progressive systemic
sclerosis: two cases report. Med Oral Patol Oral Cir Bucal.
Feb 2008;13(2):E114-8. [PMID: 18223527].
141. Stoll ML, Sharpe T, Beukelman T, Good J, Young D, Cron
RQ. Risk factors for temporomandibular joint arthritis in
children with juvenile idiopathic arthritis. J Rheumatol. Sep
2012;39(9):1880-7. [PMID: 22589268].
142. Bracco P, Debernardi C, Piancino MG, Cirigliano MF, Salvetti
G, Bazzichi L. Evaluation of the stomatognathic system in
patients with rheumatoid arthritis according to the research
diagnostic criteria for temporomandibular disorders. Cranio.
Jul 2010;28(3):181-6. [PMID: 20806736].
143. Farronato G, Garagiola U, Carletti V, Cressoni P, Bellintani
C. Psoriatic arthritis: temporomandibular joint involvement
as the first articular phenomenon. Quintessence Int. May
2010;41(5):395-8. [PMID: 20376375].
144. Márton K. [Oral symptoms of immunologic disorders. Part I.
Systemic autoimmune diseases]. Fogorv Sz. 2003/02;96(1):9-
15.
145. Brennan MT, Patronas NJ, Brahim JS. Bilateral condylar
resorption in dermatomyositis: a case report. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. Apr 1999;87(4):446-51.
[PMID: 10225627].
146. Maksimovskiĭ IuM, Grinin VM. [The involvement
of the temporomandibular joints in systemic lupus
erythematosus]. Stomatologiia (Mosk). 1995;74(2):42-5.
Author Profile
Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant
Professor, Department of Oral Medicine, University of
Washington School of Dental Medicine; (Retired) Attend-
ing in Pain Center, University of Washington Medical Cen-
ter; (Retired) Private Practice in Hawaii and Washington;
Director, Oral Care Research Associates. He can be reached
at jeffreyaburgess@hotmail.com .
Disclaimer
Jeff Burgess, DDS, MSD, has no commercial ties with the
sponsors or the providers of the unrestricted educational
grant for this course.
Online Completion
Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the
complete
online purchase.
the online
Oncepurchase.
purchasedOnce
thepurchased
exam will be
theadded
exam will
to your
be added
Archives
to your
pageArchives
where a page
Take Exam
wherelink
a Take
will Exam
be provided.
link willClick
be provided.
on the “Take
ClickExam”
on thelink,
“Take
complete
Exam” link,
all the
complete
programallquestions
the program
andques-
submit your
tions andAn
answers. submit
immediate
your answers.
grade report
An immediate
will be provided
grade report
and upon
will be
receiving
provideda passing
and upon
grade
receiving
your “Verification
a passing grade
Form”your
will“Verification
be providedForm”
immediately
will be provided
for viewing
immediately
and/or printing.
for viewing
Verification
and/orForms
printing.
can be viewed
Verification
and/or printed
Forms
anytime
can be
inviewed
the future
and/or
by returning
printed anytime
to the site,
in the
sign
future
in and
byreturn
returning
to your
to the
Archives
site, sign
Page.
in and return to your Archives Page.

Questions
1. Systemic conditions that may result in 21. Heck’s disease is most likely to result in
tooth discoloration include: 11. Sarcoidosis is manifested in the mouth what type of oral problem:
a. Neonatal sepsis a. Periodontal Disease
b. Hemophilia by:
a. Fibroepithelial hyperplasia b. Impacted third molars
c. Thyroid disease c. Epithelial hyperplasia
d. Sinus disease b. Non-caseating granulomas
c. Deep ulcers d. Gingival discoloration
2. Which systemic disease may be associated d. Blue stained gingiva
22. Which class of medication is not likely to
with x-ray follicular space and pericoronal 12. Which of these clinical features of oral cause gingival hyperplasia:
radiolucency: ulcers is not helpful in defining a possible
a. Tuberculosis a. Corticosteroids
b. Progressive systemic sclerosis underlying systemic disease: b. Immunosuppressants
c. Paget’s disease a. Ulcer depth c. Calcium channel blockers
d. Pseudotumor of hemophilia b. The number of ulcers d. Antiepileptic drugs
c. Scaring
3. Name the one systemic condition that is d. Reoccurrence frequency 23. Which systemic disease is most likely to
not likely to be associated with temporo- 13. Oral ulcers that persist for a long time result in post-oral ulceration scaring:
mandibular joint pathology: a. Tuberculosis
a. Juvenile idiopathic arthritis may be most likely to be indicative of b. Syphilis
b. Gout which systemic disease: c. Kidney failure
c. Dermatomyositis a. Kidney disease d. Behcet’s disease
d. Cherubism b. Thyroid disease
c. Immune deficiency 24. Sjogren’s disease causes what oral
4. Which systemic condition has NOT been d. Dermatomyositis problem:
associated with tooth erosion: a. Periodontal disease
a. High blood pressure 14. Which of the following systemic condi-
b. Obesity tions has not been associated with the b. Tooth developmental abnormality
c. Diabetes development of dental caries: c. Dry mouth
d. Liver disease a. Diabetes d. Jaw movement abnormality
5. Which systemic condition is NOT associ- b. Bulimia 25. Large oral ulcers are most likely to be
c. Drug abuse
ated with mucosal discoloration: d. Dermatologic disease observed with which systemic disease:
a. Peutz-Jegher a. Erythema multiforma
b. Kaposi sarcoma (KS) 15. Multiple painful punctuate oral ulcers b. Herpes
c. Pancreatic cancer occurring on the attached gingiva sug- c. Uremic poisoning
d. Laugier’s disease gests which systemic condition: d. Aphthous stomatitis
6. When a patient presents with jaw muscle a. Behcet’s disease
b. Lymphoepithelial disease 26. Intermittent unintentional jaw move-
stiffness which of the following systemic
c. Viral infection ment is not likely to be associated with
conditions should be considered in the d. Lichen planus which one of these systemic problems:
differential diagnosis: a. Dystonia
a. Scleroderma 16. Which of these conditions does not cause
b. Thyroid disease oral ulceration: b. Anorexia
c. Kidney disease a. Viral infection c. Parkinson’s disease
d. Rheumatoid arthritis b. Thyroid disease d. Serotonin syndrome
c. Pulmonary disease 27. Which of these intraoral problems is
7. Which of these systemic diseases does d. Inflammatory bowel disease
NOT cause unintentional jaw movement: NOT caused by Crohn’s disease:
a. Serotonin syndrome 17. Smokeless tobacco has been linked to a. Gingival hyperplasia
b. Substance abuse what type of caries: b. Gingival bleeding
c. Epilepsy a. Mesial interproximal caries c. Gingival erythema
d. Jaw metastatic neoplasm b. Occlusal caries d. Gingival blackening
8. In a study on the relationship between c. Cervical (root) caries
d. Distal interproximal caries 28. Gardner’s syndrome results in what oral
dental caries and nutritional status, snack
18. A brain tumor such as a meningioma problem:
foods, and sugar-sweetened beverage a. Periodontal bleeding
consumption in schoolchildren in can cause:
a. (Secondary) trigeminal neuralgia b. Gum hyperplasia
Thailand it was found that the following b. Burning tongue c. Dental malformations
factor was strongly associated with caries c. TMJ pain d. Mandibular osteomas
development: d. Ear pain 29. Multiple ulcers clustered throughout the
a. Malnutrition
b. Weight 19. Hypogammaglobulinemia has been mouth suggest what type of etiology:
c. A diet of meat associated with what type of oral problem: a. Kidney disease
d. Soft drinks a. Periodontal disease b. Pulmonary disease
b. Caries c. Viral infection
9. Which one of these conditions is not c. Oral tumors d. Cardiac disease
associated with jaw pain: d. Oral ulceration
a. Tetanus 30. In the study of caries activity of school
b. Fibromyalgia 20. In healthy patients with good oral
children in Thailand, what condition
c. Tumor hygiene but unusual smooth surface
d. Pancreatic disease lesions or rampant caries what problem besides malnutrition was found to
10. The term ‘hormonal’ gingivitis is should be considered as a potential cause contribute to the development of dental
associated with: of the oral disease: caries in primary teeth?
a. Thyroid abnormality a. Thyroid disease a. The type of food eaten during the day
b. Adrenal insufficiency b. Pancreatic disease b. Food intake habits at bedtime
c. Pregnancy c. Bulimia c. The number of meals eaten in a day
d. Pituitary disease d. Sarcoidosis d. The amount of food intake

www.ineedce.com 11
 ANSWER SHEET

Oral Manifestations of Systemic Disease

Name: Title: Specialty:

Address: E-mail:

City: State: ZIP: Country:

Telephone: Home ( ) Office ( )

Lic. Renewal Date: AGD Member ID:

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

Educational Objectives If not taking online, mail completed answer sheet to

1. Discuss the complexity of the relationship between systemic disease and various oral conditions. Academy of Dental Therapeutics and Stomatology,
A Division of PennWell Corp.
2. Identify the different oral manifestations associated with specific systemic diseases.
P.O. Box 116, Chesterland, OH 44026
3. Differentiate between potential systemic diseases associated with some specific oral conditions such as ulceration. or fax to: (440) 845-3447
4. Have improved diagnostic skills in relation to the connection between systemic disease and oral pathology.
For immediate results, go to www.ineedce.com
and click on the button “Take Tests Online.” Answer
Course Evaluation sheets can be faxed with credit card payment to
1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No (440) 845-3447, (216) 398-7922, or (216) 255-6619.
Objective #2: Yes No Objective #4: Yes No P ayment of $49.00 is enclosed.
(Checks and credit cards are accepted.)
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.
If paying by credit card, please complete the
2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 following: MC Visa AmEx Discover
3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 Acct. Number: ______________________________
4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 Exp. Date: _____________________
Charges on your statement will show up as PennWell
5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0
6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0
7. Was the overall administration of the course effective? 5 4 3 2 1 0
8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0
9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0
10. Do you feel that the references were adequate? Yes No
11. Would you participate in a similar program on a different topic? Yes No
12. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
13. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
___________________________________________________________________
14. How long did it take you to complete this course?
___________________________________________________________________
___________________________________________________________________
15. What additional continuing dental education topics would you like to see?
___________________________________________________________________
___________________________________________________________________ AGD Code 739
PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
COURSE EVALUATION and PARTICIPANT FEEDBACK Provider Information RECORD KEEPING
We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association PennWell maintains records of your successful completion of any exam for a minimum of six years. Please
with the course. Please e-mail all questions to: hhodges@pennwell.com. to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP contact our offices for a copy of your continuing education credits report. This report, which will list all
does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours credits earned to date, will be generated and mailed to you within five business days of receipt.
INSTRUCTIONS by boards of dentistry.
All questions should have only one answer. Grading of this examination is done manually. Participants will Completing a single continuing education course does not provide enough information to give the
receive confirmation of passing by receipt of a verification form. Verification of Participation forms will be Concerns or complaints about a CE Provider may be directed to the provider or to ADA CERP ar www.ada. participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of
mailed within two weeks after taking an examination. org/cotocerp/ many educational courses and clinical experience that allows the participant to develop skills and expertise.
COURSE CREDITS/COST The PennWell Corporation is designated as an Approved PACE Program Provider by the Academy of General CANCELLATION/REFUND POLICY
All participants scoring at least 70% on the examination will receive a verification form verifying 2 CE Dentistry. The formal continuing dental education programs of this program provider are accepted by the Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing.
credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/ AGD for Fellowship, Mastership and membership maintenance credit. Approval does not imply acceptance
Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact by a state or provincial board of dentistry or AGD endorsement. The current term of approval extends from Image Authenticity
their state dental boards for continuing education requirements. PennWell is a California Provider. The (11/1/2011) to (10/31/2015) Provider ID# 320452 The images provided and included in this course have not been altered.
California Provider number is 4527. The cost for courses ranges from $20.00 to $110.00.
© 2013 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

OMSD713DIG
Customer Service 216.398.7822