ORAL MANIFESTATIOS OF SYSTEMIC DISEASE

DEPT. OF DERMATOLOGY K.A.U.H

Biology of the mouth

Oral epithelium: - keratinised: masticatory mucosa (hard palate, gingiva and post tongue) - non-keratinised: lining mucosa (buccal, labial, alveolar, floor of the mouth, ventral tongue and soft palate) - Specialised: dorsum of tongue. Taste.

Biology - Immunity

Mechanical: movement of tissue, speech, salivation (Xerostomia) Saliva: enzymes, mucin GALT: B-cell and IgA Cellular: Neutrophils and others WBC. If abnormal: inf ulcers, periodontal disease and gingivitis

*Dis. Affecting teeth

Loosening and early loss:

locals: gingivitis. systemic: DM, low immunity (HIV, Leuckopenia), disease of CT. Extrinsic causes: poor hygiene, smoking, drinks, stains.. Intrinsic: drugs (Tetracyclines), flurosis, porphyria, kernicterius.

Discoloration:

Hypodontia and malformed teeth: Ectodermal dysplasia.

*Dis. Affecting Periodontium 1. Gingival Bleeding

- Locals: gingivitis, periodontitis, acute necrotizing gingivitis (poor hygiene, HIV, Neutropenia, leukemia) - Systemic: Leukaemia, HIV, clotting disease, drugs (anticoagulants), scurvy.

Period. 2. Swelling

Locals:

Chronic Gingivitis. Hyperplastic (Mouth breathers). Tumors and cysts. Pregnancy. Drugs (Phenytoin, ciclosporine, Nifidipine). Sarcoidosis. Leukemia.

Systemic:

Period. Swelling/cont.

Systemic

Infiltartives: Amyloid, Mucopolysaccharides, Mucolipidosis, Lipoid proteinosis.. Crohns dis Wegners granulomatosis

Dis. Period3.Gingival redness

Gingival redness:

local: chronic gingivitis (commonest) systemic: Desquamative gingivitis, HSV, Vascular abnormality (HHT, Haemangioma, KS..), Bullous diseases; esp. Pemphigus, Allergic response.

PERIODO4. WHITE PATCHES (Leukoplakia)

Locals:

Frictional, smokers, ca, burns..

systemic:

Candidiasis, L.P, Lupus, CRF, Hairy Leukoplakia, white-sponge naevus, Syphilitic.

Dis Of Period.5.Pigmentation

This can be seen normally in dark people. Local causes: Amalgam tattoo, melanocytic macules Systemic causes: Addisons dis., K.S, Melanoma and Drugs (Hydroxychloroquine, minocycline).

Pigment. Amalgam tattoo

Period.6. Ulcers

Underlying med dis:

Haematologic: Anaemia, leukaemia, Neutropenia. GI: Coeliac, IBD.

Locals: trauma, Radiotherapy CTD: SLE, Behcets, Sweets, Reiters (E) Infections: HSV, CHICKENPOX, Herpangina, IMN, HIV, TB, Syphilis. Rare: Eosinophilic ulcer, Necrotizing sialometaplasia Skin: ELP, Pemphigus, B.P, Erythema Multiforme, DH, LAD, ..

Cont. Ulcers

Drugs: Cytotoxics, NSAIDS, Alendronate.

Dis Of period. 7 - Blisters

Locals: Burn, Mucoceles Underlying cause: Immunobullous conditions usually present as desqumative gingivitis (Pemphigus, B.P, MMP), HSV.

Desquamative Gingivitis

Persistent red glazed sometimes painful labial gingiva (usually sparing margins) Causes: MMP, LP>>,BP, DH, LAD,.. Treatment: difficult but: improved hygiene, Topical Steroids or Tacrolimus. Severe: Dapsone

Dequ. Gingivitis

Drug induced gingival swelling

Phenytoin, Ciclosporin, Nifedipine and Diltiazem. Increase with prolonged use and poor oral hygiene. Mx: good oral hygiene, removal of plaque prior to initiation of treatment, surgical excision.

Gingival swelling-Phenytoin

*Dis of oral mucosa1.Pigmentation

Normal in dark people, Asians and Mediteranians. Bilateral and symmetrical. Melanocytic macules are seen in 3% pop. Other causes:

Melanoma and Ks Addisons disease and ectopic ACTH Drugs (minocycline, antimalarials, occp..) Malignant Acanthosis nigricans Rare causes (NF, Hemochromatosis,IP..)

Mucosal 2. Redness

Infections: HSV, Candidiasis. Inflammatory: LP, MMP, Pemphigus, Allergic. Vascular: Telangiectasia (HHT), KS, PWS. Nutritional: Low B12, Folate, Iron (red tongue). Drugs (mucositis).

Mucosal redness

GT (geographical tongue). MX: Look for signs of underlying dis. check hematenics (B12, Folate , Iron).

Redness- GT

Mucosal 3.Ulcers

Local causes: Trauma, orthodontic applicances, Tumors Recurrent Aphthous stomatitis Systemic causes: Haematological, GI, Dermatological, Infective, Vasculitis, Iatrogenic, ?,drugs

RAS
Recurrent episodes of ulceration each lasting 1-4 weeks. Aetiology: ? But: search for cause Clinical patterns: Minor 80% (<5mm,<1o, <10 days) Major 10% (>5-10mm, <10, >10 days) Herpitiform 10% (<5mm, 10-100, >10 days)

RAS
Investigations: FBC,ESR,IRON, B12,FOLATE,ANTIENDOMYSIAL ab. Treatment: most cases-eventual remession Topical anti Inflammatory agents Systemic agents: Steroids, Colchicine, Dapsone. Thalidomide.

RAS

Mucosal4. White patches (Leukoplakia)

Infective (Candida, Hairy Leukoplakia). Inflammatory (LP.LE..). Liver and Renal diseases. Genetics: White sponge Nevus.

Leukoplakia

Leukoplakia-LP

Mucosal5.Blisters/Erosions

Locals: Burn, Mucocele.. Underlyings: Pemphigus, BP, MMP,EB,EM, Infections: HSV, Chickenpox, Coxackie..

Behcets Syndrome

Major Criteria:

Oral aphthae: 90-100% Genital ulcers: 60-80% Ocular (iridocyclitis, vasculitis..): 10-90% CNS (Meningioencephalitis) Skin (pustules, EN, Pathergy) 50-90%

Minors: proteinuria, thrombophlebitis, Aneurysms, Arthralgias.

Behcets syndrome

Mx of oral ulceration:

Mild: Topical steroids , 5-Aminosalicylic acid, others. Severe: Colchicine, Ciclosporine, Azathioprine

Main Morbidity is related to Ocular Disease so always involve an Ophthalmologist.

Lichen Planus
Aetiology? Cutaneous: itchy papules, violaceous colour. Hair and nails may be involved. Oral: 1. Bilateral white areas- Linear, Reticular, P/P 2. Erosive OLP: Dorsal and Lateral borders of tongue, Buccal Mucosa. 3. Desquamative Gingivitis.

LP-CONT

Mx:

MILD: Topical CS Moderate: topical Tacrolimus +- Top Cs Severe: oral steroids, Ciclosporine, hydroxychloroquine, Azathioprine, Acitretin.

EOLP: Risk of SCC.

Pemphigus

Oral involvement in Various disEndocrine

Addisons: mucosal hyper pigmentation. Congenital hypothyroidism: macroglossia. Acromegaly: macroglossia. DM: Period disease, Xerostomia, candidiasis. Pregnancy: Gingivitis, Epulis.

GIT

Pernicious Anemia: ulcers, glossitis, ang.stomatitis, red lesions Coeliac : ulcers, glossitis, angular stomatitis P-J synd: melanosis Crohns: ging. Hyperplasia, ulcers, golssitis, cobblestoning of mucosa

Hematologic

Hematinic def: Burnning, ulcers, glossitis, angular stomatitis Sickle cell :osteomyelitits of Jaw WBC : Ulcers, infections Hemostsis def: bleeding Leukemias: ging swelling, bleeding, infections and ulcers

Renal

CRF: Xerostomia, Halitosis, Leukoplakia, bleeding

Drugs

CTD

others

END