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ORAL MANIFESTATION OF SYSTEMIC DISEASE......
1. RESOURCE FACULTY PRESENTED BY
DR.ASHISH SHRESTHA
ASSOCIATED PROFESSOR
AND HOD
DR.TARAKANT BHAGAT
ASSISTANT PROFESSOR
(DEPARTMENT OF
PUBLIC HEALTH DENTISTRY)
BPKIHS,NEPAL
PAPULAR CHAUDHARY
ROLL NO:491
4everpapular@gmail.com
SANTOSH PANDIT
ROLL NO:502
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BATCH 2011
ORAL MANIFESTATIONS OF SYSTEMIC DISEASE
6/17/2015
1
2. Oral Manifestations of Systemic Diseases
Many systemic diseases are reflected in the oral mucosa,
maxilla, and mandible.
Mucosal changes may include ulceration or mucosal bleeding.
Immunodeficiency can lead to opportunistic diseases such as infection
and neoplasia.
Bone disease can affect the maxilla and mandible.
Systemic disease can cause dental and periodontal changes
Drugs prescribed for a systemic disease can affect oral tissue.
6/17/20152
3. Oral Manifestations of Systemic Diseases
(cont.)
Local factors may be involved in the manifestation of
systemic disease in oral mucosa.
The mucosa may be more easily injured due to a systemic disease,
and mild irritation and chronic inflammation may cause lesions
that otherwise would not occur.
These may include
Endocrine disorders, disorders of red and white blood cells,
disorders of platelets and other bleeding and clotting disorders,
and immunodeficiency disorders
6/17/20153
5. Systemic lupus erythematous
Lupus characterized by acute and chronic inflammation of various tissues of the body.
When the skin is involved, the condition is called lupus dermatitis or cutaneous lupus
erythematosus.
A form of lupus dermatitis that can be isolated to the skin, without internal disease, is
called discoid lupus.
When internal organs are involved, the condition is referred to as systemic lupus
erythematosus (SLE)
6/17/2015
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6. CRITERIA FOR diagnosis of SLE
MALAR RASH: fixed erythema over the
malar eminences(butterfly rash)
DISCOID RASH: erythematous raised
patches with adherent keratotic scaling &
follicular plugging.
PHOTOSENSITIVITY: Skin rash
ORAL ULCERS: oral or nasopharyngeal
ulceration,usually painless
ARTHRITIS: Non erosive arthritis
SEROSITIS: pleuritis & pericarditis
RENAL DISORDER: persistent proteinuria
NEUROLOGIC DISORDER: seizures,
psychosis 6/17/2015
6
7. HEMATOLOGICAL DISORDER: hemolytic anemia, leucopenia, lymphopenia,
thrombocytopenia.
IMMUNOLOGIC: anti- ds DNA, anti Sm & antiphospholipid antibodies
ANTINUCLEAR ANTIBODY: abnormal
(for the diagnosis of SLE four or the above criteria should either be present
simultaneously or serially)
6/17/2015
7
8. Oral aspects
Characteristic oral lesions, non
specific ulceration, salivary gland
disease, TMJ disorders.
Angular cheilosis, mucositis,
glossitis, glossodynia, dysgeusia,
dysphagia, dry mouth.
Lip lesion: central atrophic &
occasionally ulcerated area with
small white dots surrounded by
keratinized border composed of
small radiating white striae.
6/17/2015
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9. INTRA ORAL LESION:
composed of a central depressed red atrophic area surrounded by 2-4
mm elevated keratotic zone that dissolve into a white line.
6/17/2015
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10. Discoid lupus erythematus
DLE is a chronic, scaring, atrophy producing, photosensitive
dermatosis.
DLE may occur in patients with SLE.
<5% DLE progress to SLE .
• PATHOPHYSIOLOGY
Suggested that heat shock protein is induced in
keratinocyte followed by UV light exposure or stress, and
this protein act as target for T-cell mediated epidermal cell
cytotoxicity.
6/17/2015
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11. Clinical features
Age: 3rd -4th decade.
Sex female>male.
Common sites:
• Face, oral mucous membranes, chest, back and extremities.
• Cutaneous lesion are slightly elevated red of purple macules that are often covered by
grey or yellow adherent scales.
6/17/2015
11
12. Contd…
• Forceful removal of scale result in “carpet track” extension .
• Typical “butterfly” distribution on malar region and across the bridge of
the nose.
• Epidermoid carcinoma and less commonly basal cell carcinoma is reported
in healed ulcer.
6/17/2015
12
13. Oral manifestation
Oral mucous membrane involvement rate is 20-50%.
Oral lesion in discoid form begin as erythematous area, some times slightly
elevated but more often depressed.
No induration.
Occasionally superficial ,painful ulceration may occur with crusting or
bleeding.
No scale formation .
6/17/2015
13
14. Margin are not well demarcated but frequently show narrow zone of keratinization.
Central healing may result in depressed scarring
In case of tongue atrophy of papilla and severe fissuring may be seen.
Erythematous, artophic plques , surrounded by kertotic border, may involve the entire
lip.
6/17/2015
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15. Sjogren Syndrome
an autoimmune disorder in which immunocytes damage the salivary and
lacrimal glands, and other exocrine glands.
-primary Sjogren syndrome(SS-1)-dry mouth and dry eyes are seen in the
absence of connective tissue disease. Also termed as SICCA Syndrome. Less
common
-Secondary Sjogren syndrome(SS-2)-Dry mouth dry eyes along with the
connective tissue disease and is more common.
Common connective tissue disorder are
6/17/2015
15
16. incidence
Can affect any age, but onset is more common 40-60 yrs
F>M
etiology
Specific antigen in SS is unknown
Possible etiological factors may be
Genetic association to HLA class II antigens
connective tissue disease
Viruses such as EBV, Hep C, HIV
Graft versus Host disease
Liver disease
6/17/201516
17. Clinical presentations
A)oral signs and symptoms
Dry mouth
and erythematous mucosa
Cracker sign
Burning sensation
Salivary gland swelling and
sialedinitis
Caries
Candidiasis
Abnormal taste and malodour
6/17/2015
17
18. B) Ocular Signs and Symptoms
Keratoconjuctivitis sicca
Foreign body sensation
Inability to tear
Light intolerance
C)Others
Fatigue
Fever
Kidney, muscle, nerve, liver, joint, thyroid
involvement
Connective tissue disease
6/17/201518
19. SYSTEMIC SCLEROSIS
Autoimmune collagen vascular disease characterized by fibrosis,
vascular alterations
Systemic sclerosis describes the multisystem nature.
Clinical types:
1)circumscribed plaques or bands
2)linear morphea
3)fronto parietal lesion with or without hemiatrophy of face
6/17/2015
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20. Incidence
Greatest incidence in 30-50 years of age.
F:M = 3-6:1
Etiology
Genetic predisposition
Microchimerism.
Cytomegalovirus
Organic solvent and other chemicals
Chronic renal failure.
Drugs such as Bleomycin
6/17/201520
21. Oral manifestations
Difficulty in opening mouth and loss of tongue movement
due to perioral and lingual fibrosis
Lips become thin, rigid & fixed producing microstomia
Maxillary anterior teeth are exposed due to retraction of lips
Crenations of buccal mucosa and tongue has been reported
6/17/2015
21
22. Tongue, soft palate & larynx are usually involved
causing mild edema followed by atrophy & induration of
mucosal & muscular tissues.
Tongue becomes stiff & border like causing difficulty in
eating & speaking.
Gingival tissues are pale & firm.
Dysphagia, limited mouth opening, Trismus
Salivary changes similar to Sjogren syndrome
6/17/2015
22
23. Classic radiographic finding is generalized symmetric widening of
periodontal ligament space(2-4 times) which is seen in almost all the
patient.
Bone resorption at the angle of mandible
And may destroy condylar and coronoid process of mandible
6/17/2015
23
24. Dental aspect
Dysphagia and pulmonary, cardiac or renal disease as
potential C.I for G.A
Constriction of oral orifice leading to limited mouth
opening(fish mouth)
Tongue become stiff and less mobile due to
submucosal tissue involvement(chicken tongue)
Involvement of peri-articular tissue of TMJ together with
microstomia limits assess to the mouth.
6/17/2015
24
25. The mandibular angle may be resorbed of rarely there is
resorption of TMJ.
Penicillamine therapy may cause loss of taste, oral
ulceration, lichenoid reaction and other complications
6/17/2015
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26. pemphigus
Derieved from Greek word; pemphix: bubbleblister)
Refers to group of auto immune disease characterized by
development of vesiculobullous lesion in the skin and
mucous membrane.
6/17/2015
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28. Oral manifestation
About 90% of the patients show oral lesion whereas 60% of the patients present as the first
sign in oral mucosa.
May occur anywhere in the oral mucosa however common sites are palate, buccal, mucosa,
gingiva
In gingiva may give rise to desquamative gingivitis
6/17/2015
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29. Oral manifestation
Highly painful, bleed easily
Filled with clear watery fluid which may become hemorrhagic or
purulent with ragged borders.
Size varies from few millimeters to several centimeters.
Intact bulla is rarely seen, most of the time its eroded lesion
6/17/2015
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30. Mucosal lesions heal without scarring. However, oral mucosa often
shows the formation of keratotic lesion following healing
In addition, there will be foul smell, excessive salivation and difficulty
in taking food
The course of the disease is very rapid, one either terminating in
death or recovery within few days or weeks.
6/17/2015
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31. Pemphigus vegetans
Benign variant of PV because the patient demonstrate the ability to
heal the denuded areas.
Two types:
Neumann type:similar to PV
Hallopeau type: pustules rather than bullae
Gingival lesions may be lace-like ulcers with purulent surfaces on a red
base or have a granular or cobblestone appearance
6/17/2015
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32. Pemphigoid
Two major types of pemphigoid
I. Bullous pemphigoid.
II. Mucous membrane pemphigoid.
Though in contrast to pemphigus, lesion are larger and leave denuded area while
they brust, do heal and rarely fatal.
6/17/2015
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33. Bullous pemphigoid (BP)
Age- 60 – 80 years
Sex - M : F = 2 : 1
Pathogenesis:
Interaction of auto-antibody with BP antigen on the lamina lucida
of the basement membrane
Complement activation and attraction of neutrophils and
eosinophils
6/17/2015
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34. Clinical features
Bullous lesions
Sites - Axillae, acral region, trunk
Oral mucosa - usually not often
6/17/2015
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36. Mucous membrane pemphigoid(cicatricial pemphigoid)
Skin involvement is less common, oral mucosa being the most common
site i.e 90% and 2nd being the conjuctiva
Age 60-80 years
Male=female
6/17/201536
37. Clinical presentations
– Common sites: limbs, abdomen, axilla, face and groin
– Urticaria or eczema may persist for several weeks to several months before
vesico-bullous lesion appear.
– These vesicles and bullae are thick-walled and tensed and may remain for some
days. Rupture doesn’t always occur.
– Oral, eye and skin lesions are present.
– Bulla spread sign and Nikolsky’s sign are negative.
– Lesions heal with milia formation.
6/17/2015
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38. Oral manifestations
Seen in 30-50% of patients
However oral lesions are smaller, less painful and form more slowly
then pemphigus vulgaris
6/17/2015
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39. Oral manifestations
Desquamative gingivitis most common oral manifestations and may be
the only site
Gingival lesions consists of generalized edema, inflammation, and
desquamation with localized areas of discrete vesicle formation
6/17/2015
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40. Lichen planus
It is a rather common chronic mucocutaneous disease, which probably arises due to an
abnormal immunological reaction.
Disease presented with characterstic volaceous polygonal puritic papules.
Malignant tranformation potential = 0.4-2%.
6/17/2015
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41. Etiology
Exact etiological cause is unknown.
Predisposing factors:
I. Emotional stress.
II. Trauma and infection.
III. Grinspan’s syndrome.
IV. Hereditary.
6/17/2015
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42. Clinical feature
I. Age >40 years.
II. Female to male ratio 1.4:1.
III. Skin lesions.
Small angular flat-topped only few mm in diameter. On course of disease they may
be discrete or gradually coalesce into larger plaque cover by fine glistening scale.
Initially disease lesion appears red, but they soon take reddish , purple and
violaceous hue. Later on dirty brown colour develops.
Wickham’s straie.
6/17/2015
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43. Oral manifestations
- Commonly occurs in mucosal surface of buccal mucosa , vestibules, tongue,lips, floor
of the mouth, palate.
Appears weeks or months before the skin
lesions.
Lesions are bilaterally symmetrical.
6/17/2015
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44. Usually asymptomatic but patient may complaint of pain, burning sensation
and intolerance to spicy food
Begins as small white papules that coalesce to form interlacing network of
white lines (Wickham’s striae)
Erythematous atrophic and erosive (erosive OLP) white lesions are common
6/17/2015
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45. Reticular OLP has classical
features and do not require
biopsy to diagnose
Hypertrophic white plaques
may occur sometimes and
intact bullae (bullous OLP) are rarely seen
6/17/2015
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46. Common site is buccal mucosa(78-87%),followed by tongue and gingiva
Koebner’s phenomenon present
Oral lesions tend to be bilateral and symmetrical
Erosive lesion on gingiva resembles desquamative gingivitis
6/17/2015
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52. Recurrent aphthous stomatitis
Definition: Recurring episodes of small, round or oval ulcers with circumscribe
margin, erythematous halo and a yellow or grey floor, present from childhood or
adolescence and each episode last for 1 to 4 weeks before healing
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54. Clinical Features
Common disease afflicts 20% of the population
High prevalence: higher socio-economic classes
Three main clinical types of RAS:
1. Minor aphthous ulcers (Mikulicz ulcers): 80%
2. Major aphthous utcer (Sutton's ulcers): 10%
3. Herpetiform type ulceration: 10%
6/17/2015
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55. Main features of recurrent
aphthous
stomatitis
Feature Minor aphthae Major
aphthae
Herpetiform
Age of onset
Symptoms
Ulcer size
Shape of ulcer
Number of u1cers
Sites affected
Duration of each
Ulcer
Other comments
Childhood or adolescence
Minimal
2-4 mm
Round or ovoid
Up to about six
Non-keratinised mobile
mucosae, Vestibule,
Labial, Buccal mucosa
and floor of mouth,
rarely dorsum of. tongue,
Gingiva or palate
Up to 10 days
Heal with little or no scar
Childhood or
adolescence
More painful
May be 10mm or
larger
Round or ovoid
up to about six
Any site
Up to 1 month
May heal with
scarring
Young adult
Extremely painful
Initially tiny, ulcers
coalesce
Ragged
10-100
Any site but often on
ventrum of tongue
Up to I month
Affect females
predominantly
6/17/2015
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56. BEHCET’S DISEASE
Rare multisystem, chronic disease characterized by oral and genital
mucocutaneous ulcerations, skin rashes, arthritis, thrombophlebitis,
uveitis, colitis, and neurologic symptoms.
Also known adamatiades syndrome.
6/17/2015
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57. Reiter’s syndrome
Disease of unknown etiology.
Common on age group of 25-35 years.
Consider as an important complication of non gonococcal urethritis.
Oral lesion occurs in less than 5% to 50% of patient with disease.
Consist of tetrad of :
1. Urethritis
2. Arthritis.
3. Conjunctivities.
4. Mucocutaneous lesion.
6/17/2015
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58. Oral manifestations
Lesions are painless, red, slightly elevated areas with a white circinate
border on the buccal mucosa, lips and gingiva.
Palatal lesions appears as small ,bright red purpuric spots which
darken and coalese. Tongue represents “geographic tongue”.
Note: Clinically similar lesion are seen on the glans penis, producing a circinate
balanitis
6/17/2015
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59. Wegner granulomatosis
Disease of unknown etiology.
Involve vascular renal and respiratory systems.
Disease characterize by necrotizing and granulomatous vasculitis.
Clinical types:
1. Generalize or classic wegener’s granulomatosis.
2. Localized or limited wegener’s granulomatosis.
3. Superficial wegener’s granulomatosis.
6/17/2015
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60. Oral manifestations
Starts with tumor like vegetations in mouth and nose, then inflammatory process
starts in nose and inter dental papilla spreading upto periodontium.
Ulceration can occur, usually perforating in nature.
Strawberry gingiva characterized by ulceration, friable granular lesions.
Mobile teeth .
Palatal destruction resulting in oro nasal communication.
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61. Oral manifestations of HIV
CLASSIFICATION
Group 1 :
LESIONS STRONGLY ASSOCIATED WITH HIV INFECTIONS
Candidiasis : Eythematous
Pseudomembranous
Hairy leukoplakia
Kaposi’s sarcoma
Non- Hodgkin’s lymphoma
6/17/2015
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62. Periodontal diseases :
Linear gingiva erythema
Necrotizing ulcerative gingivitis
Necrotizing ulcerative periodontitis
Group 2
LESIONS LESS COMMONLY ASSSOCIATED WITH HIV
Bacterial infections: M.avium - intracellulare
M. tuberculosis
Melanotic hyperpigmentation
Necrotizing ulcerative stomatitis
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63. LESIONS SEEN IN HIV INFECTION
Bacterial infections :Actinomyces israeli
Escherichia coli
Kliebsella pneumoniae
Cat scratch disease
Drug reactions: Ulcerative
Erythema multiforme
Lichenoid reaction
Toxic epidermolysis
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71. CANDIDIASIS
The most common opportunistic infection
CD4 cells counts< 400 cells/mm^3
4 clinical presentation:
Pseudomombranous or oral thrush
Erythematous
Hyperplastic
Angular cheilitis
6/17/2015
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72. Pseudomembranous candidiasis
Most common type.
Usually asymptomatic.
Usually extensive involving more than one site
Manifests as white or yellowish single or confluent plaque that is scrappable,
exposing erythematous area.
May also extend to oropharynx and esophagus.
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73. Erythematous/ atrophic
Site: dorsum of the tongue,palate and buccal mucosa.
Appears as a reddish macular lesion, or depappilation on the dorsum of the
tongue.
May present alone or in combination with pseudomembranous candidiasis.
Tongue lesion are also referred as central papillary atrophy.
Long standing lesion:mucosal ulceration
Some may complain of occasional burning sensation .
6/17/2015
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74. Hyperplastic
Uncommon and found in severly immunocompromised.
Manifests as white or discolored plaques which cannot be scrapped out
Burning sensation, Dysphagia
Feeling of having large piece of cotton in mouth
6/17/2015
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75. Angular cheilitis
Can be due to mixed infection of candida albicans and staphylococcus aureus.
Manifests as erythema &/or fissuring and/ or scaling of angle of mouth.
May be present with intraoral candidiasis.
6/17/2015
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79. Learning objectives
Be able to enumerate the major oral manifestations of
blood disorders,renal disorders,GI disorder, diabetes,
respiratory diseases
Be able to list the dental considerations and management
of these systemic disorders
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80. Blood Disorders
Disorders of Red Blood Cells and Hemoglobin
Disorders of White Blood Cells
Bleeding Disorders
6/17/201580
81. Disorders of Red Blood Cells
and Hemoglobin
Iron Deficiency Anemia
Pernicious Anemia
Folic Acid and Vitamin B12 Deficiency Anemia
Thalassemia
Sickle Cell Anemia
Aplastic Anemia
Polycythemia
6/17/201581
82. Anemia
A reduction in the oxygen-carrying capacity of blood
Most often related to a decrease in the number of circulating red blood cells
Nutritional anemias
A deficiency in a substance required for the normal development of red blood
cells, commonly vitamins
Suppression of bone marrow stem cells
6/17/201582
83. Anemia (cont.)
Clinical features
Pallor of skin and oral mucosa
Angular cheilitis
Erythema and atrophy of oral mucosa
Loss of filiform and fungiform papillae on the dorsum of the tongue
6/17/201583
84. Iron Deficiency Anemia
An insufficient amount of iron is supplied to bone marrow for red blood cell
development.
May occur as a result of deficient iron intake, blood loss from heavy menstrual bleeding or chronic
gastrointestinal bleeding, poor iron absorption, or an increased requirement for iron in situations such
as pregnancy or infancy
Plummer-Vinson syndrome may result from long standing iron deficiency anemia.
Includes dysphagia, atrophy of the upper alimentary tract, and a predisposition to developing oral
cancer
6/17/201584
85. Clinical Features and Oral Manifestations of Iron Deficiency
Anemia
Often asymptomatic, may have nonspecific symptoms such as weakness and fatigue
In severe cases may see angular cheilitis, pallor of oral tissue, and an erythematous,
smooth, painful tongue
6/17/201585
86. Pernicious Anemia
Probably an autoimmune disorder in most situations
May be caused by removal of the stomach, gastric cancer, or gastritis
Caused by a deficiency in intrinsic factor
Intrinsic factor is secreted by parietal cells in the stomach; it is necessary for
absorption of vitamin B12
6/17/201586
87. Clinical Features and Oral Manifestations of Pernicious Anemia
Weakness, pallor, and fatigue on exertion
May see nausea, dizziness, diarrhea, abdominal pain, loss of appetite, and weight loss
Angular cheilitis, mucosal pallor, painful atrophic and erythematous mucosa, mucosal
ulceration, loss of papillae on the dorsum of the tongue, and burning and painful
tongue
6/17/201587
88. Folic Acid and Vitamin B12
Deficiency Anemia
From dietary deficiencies
Can occur in association with malnutrition
May be found with alcoholism or pregnancy
6/17/201588
89. Oral Manifestations of Folic Acid and Vitamin B12 Deficiency
Anemia
Oral manifestations are indistinguishable from those of pernicious anemia.
6/17/201589
90. Thalassemia (Mediterranean or Cooley Anemia)
A group of inherited disorders of hemoglobin synthesis
An autosomal dominant inheritance pattern
The heterozygous form may be mildly symptomatic or asymptomatic.
The homozygous form is associated with severe hemolytic anemia.
6/17/201590
91. Clinical Features and Oral Manifestations of Thalassemia
Yellow skin pallor, fever, malaise, and weakness
The face includes prominent cheekbones, depression of the bridge of the nose, a
prominent maxilla, and protrusion or flaring of maxillary anterior teeth.
Radiographs may show a “salt and pepper” pattern.
Some trabeculae are prominent, and others are blurred.
6/17/201591
92. Sickle Cell Anemia
An inherited blood disorder
When someone is heterozygous, it is called sickle cell trait.
When someone is homozygous, they are much more severely affected.
6/17/201592
93. Occurs before age 30 and is more common in women than in men
The red blood cells develop a sickle shape when there is decreased oxygen.
This can be triggered by exercise, exertion, administration of a general anesthetic,
pregnancy, or even sleep.
6/17/2015
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94. Clinical Features and Oral Manifestations of Sickle Cell Anemia
The person has weakness, shortness of breath, fatigue, joint pain, and nausea.
Radiographic
There is a loss of trabeculation, and large, irregular marrow spaces appear.
A “hair-on-end” pattern may be seen in the skull.
6/17/201594
95. Aplastic Anemia
A severe depression of bone marrow activity causes a decrease in all circulating blood
cells. – pancytopenia
Primary aplastic anemia – the cause is unknown
Secondary aplastic anemia – a result of a drug or chemical agent
6/17/201595
96. Oral Manifestations of Aplastic Anemia
Infection,
spontaneous bleeding,
petechiae, and
purpuric spots
6/17/201596
98. Oral Manifestations of Polycythemia
The oral mucosa may appear deep red to purple; the gingiva may be edematous and
bleed easily.
Submucosal petechiae,
ecchymosis,
hematoma formation may be present.
6/17/201598
99. Disorders of White Blood Cells
Agranulocytosis
Cyclic Neutropenia
Leukemia
6/17/201599
100. Clinical Features and Oral Manifestations of
Agranulocytosis
Sudden onset of fever,
chills,
jaundice,
weakness,
sore throat
Oral infection
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101. Leukemia
Malignant neoplasms of hematopoietic stem cells
Characterized by an excessive number of abnormal white blood cells in circulating
blood
Unknown cause; some are investigating oncogenic viruses
There are many different types categorized as to whether they are acute or chronic.
6/17/2015101
102. Acute Leukemias
Characterized by very immature cells and a rapidly fatal course if not treated
Acute lymphoblastic leukemia – involves immature lymphocytes
Primarily affects children and young adults
Good prognosis
Acute myeloblastic leukemia – involves immature granulocytes
Primarily affects adolescents and young adults.
Prognosis is not as good.
6/17/2015102
103. Clinical Features of Acute Leukemias
Weakness,
fever,
enlargement of lymph nodes,
bleeding
6/17/2015103
104. Oral Manifestations of Acute Leukemias
Gingival enlargement
Oral infection
Bleeding gums, petechiae and ecchymosis
6/17/2015104
108. Purpura
A reddish-blue or purplish discoloration of skin or mucosa from spontaneous
extravasation of blood
May be due to a defect or deficiency in blood platelets
Blood may ooze from gingival margins.
6/17/2015108
109. Thrombocytopenic Purpura
A bleeding disorder that results from a severe reduction in circulating platelets
Idiopathic thrombocytopenic purpura
If the cause is unknown
Immune thrombocytopenia
An autoimmune type of process
Secondary thrombocytopenic purpura
Often associated with drugs
6/17/2015109
110. Clinical and Oral Manifestations of Thrombocytopenic
Purpura
Spontaneous purpuric or hemorrhagic lesions on the skin
Patients bruise easily,
may have blood in urine,
have frequent nose bleeds.
6/17/2015110
111. Nonthrombocytopenic Purpura
Bleeding disorders that can result from either a defect in capillary walls or disorders of
platelet function
Vitamin C deficiency and infections or chemicals and allergy may be the cause of
alterations in vascular walls.
Drugs, allergy, and autoimmune disease may cause disorders of platelet function.
Von Willebrand disease is an autosomal dominant disorder of platelet function.
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113. Hemophilia
A disorder of blood coagulation
Results in severely prolonged clotting time
Due to a deficiency in plasma proteins involved in coagulation
6/17/2015113
114. Types of Hemophilia
The two most common types are type A and type B.
Transmitted as X-linked diseases through an unaffected carrier daughter to a son
Type A
Caused by a deficiency of plasma thromboplastinogen or factor VIII
Type B
Christmas disease
Less common, the clotting defect is plasma thromboplastin or factor IX
6/17/2015114
121. Hard tissue changes
Staining in teeth – due to iron
supplements
Reduced caries due to urea in
saliva
Delayed tooth eruption
Enamel hypoplasia
Tooth Mobility
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121
122. RADIOGRAPHIC FEATURES
Mainly in cases with
hyperparathyroidism
Tooth appear more radiopaque in
background of osteoporotic bone
Loss of trabeculations of bone
Ground glass appearance
Total/ partial loss of lamina dura
Loss of cortical outlines of inferior
alveolar sinus, cortex of mandible
Pulpal calcifications
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122
123. RADIOGRAPHIC FEATURES
Mainly in cases with
hyperparathyroidism
Multilocular radiolucency – osteitis fibrosa
cystica/ browns tumor
Arterial & oral calcifications
6/17/2015
123
124. ORAL MANIFESTATIONS IN
DIABETICS
More severe periodontal
disease
Patients with multiple
abscesses should be referred
for blood sugar estimation
6/17/2015
124
125. ORAL MANIFESTATIONS IN
DIABETICS
Sialosis – swelling of salivary
glands due to autonomic
neuropathy
Xerostomia may result from
hyperglycemia and subsequent
polyuria that depletes the
extracellular fluids
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130. ORAL HEALTH CONSIDERATIONS for allergic rhinitis
ORAL DRYNESS
ORAL CANDIDIASIS
(CORTICOSTEROIDS)
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131. ORAL HEALTH CONSIDERATIONS for
sinusitis
Tooth Pain - Differentiate Between An Odontogenic Infection And Sinus Pain.
Sinus Infections Usually Present With Pain Involving More Than One Tooth.
Chronic Sinus Infections Are Often Accompanied By Mouth Breathing -
Gingivitis.
Prolonged Use Of Antibiotics - The Potential Development Of Bacterial
Resistance .
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133. CONSIDERATION FOR DENTAL CARE
Fluoride Supplements - Particular Those Taking Β2-
agonists.
The Patient Should Be Instructed To Rinse His Or Her
Mouth With Water After Using Inhalers.
Oral Hygiene Should Be Reinforced To Reduce Of
Gingivitis And Periodontitis.
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134. ORAL MANIFESTATION of TB
RARE
MAINLY SEEN IN MIDDLE AGED & OLDER PEOPLE
SEX-MALES
MOST COMMONLY-TONGUE
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135. ORAL MANIFESTATION of TB
ORAL LESION –Ulcer,nodule,vesicle,granuloma,fissure
Ulceration ,Ragged Border,minimal Induration,granular Base
Sentinal Tubercle; nodules Seen Around Ulceration.
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137. Dental Considerations
(First Trimester)
Dental treatment is best avoided
Assess the current oral health of the patient
Educate the patient regarding the oral changes
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138. Nausea and vomiting – caused by increased levels of gonadotropins in the
first trimester
Enamel erosion- gastric acids present in the vomit erode the inner surface
of anterior teeth
Pregnancy induced gingivitis
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139. SECOND TRIMESTER
Organogenesis is complete and the risk to the
foetus is at its lowest
safest period for any necessary elective dental
treatment
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142. GASTROESOPHAGEAL REFLUX DISEASE
Most common disease of upper GI tract
gastric contents passively move up from the
stomach into the esophagus
Symptoms/signs
Heart burn (pain/burning sensation extending from epigastrium to the
neck) – commonly felt after a meal
esophagitis, esophageal ulceration & stricture
Chest pain (mimics anginal pain)
Dysphagia
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143. Oral Manifestations & Dental
Considerations
erythema and mucosal atrophy
dysgeusia, sensitivity & erosion
(palatal aspects of upper anteriors
and premolars)
erosion leads to dentin sensitivity
& irreversible pulpal involvement
(gastric content pH – as low as 1)
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144. Inflammatory Bowel Disease
Ulcerative colitis
Crohn’s disease (regional enteritis, ileitis)
Ulcerative colitis
Inflammatory process usually extends from rectum
proximally in a continuous fashion involving
variable lengths of large intestine but confined to
mucosa & superficial submucosa.
Bloody diarrhea – cardinal symptom
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145. CROHN’S DISEASE
Affects entire thickness of intestinal wall, in segments
forms strictures and scarring
Small intestine - 40%
Large intestine - 30%
Both intestines- 30%
Pain & diarrhea
Fistulas which connect different sites in GIT, urinary bladder,
vagina, prostate and skin
Arthritis, uveitis & erythema nodosum of skin are common
in both diseases
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146. Oral Manifestations (Crohn’s disease)
Oral granulomatous lesions as a nodular mass in the mucobuccal fold
Lesions resembling aphthous ulcers
Cobblestone appearance on buccal mucosa
Linear hyperplastic folds with ulcers in the vestibule
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147. Crohn’s disease
Swollen & indurated lips
Granular red lesions on gingiva
and alveolar mucosa and
palatal ulcers (rarely)
Pustular lesions
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148. EATING DISORDERS
ANOREXIA NERVOSA AND BULIMIA
Anorexia
individuals who intentionally starve themselves
intense fear of becoming fat
Anorexia usually develops between 14 - 18 years
Bulimia nervosa
Individuals consume large amounts of food and prevent
weight gain by vomiting, laxatives, diuretics,
dieting, and/or exercising aggressively.
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149. Oral Considerations
erosion of the enamel on the lingual surfaces of the maxillary teeth
Parotid enlargement may develop as a sequela of starvation.
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150. REFERENCES
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BURKETS-ORAL MEDICINE
TEXT BOOK OF ORAL MEDICINE by Anil Govindrao Ghom
SHAFER-TEXT BOOK OF ORAL PATHOLOGY
NEVILLE-TEXT BOOK OF ORAL PATHOLOGY
CARANZZA’S-CLINICAL PERIODONTOLOGY
WIKEPEDIA