1 elsevier items and derived items © 2009 by saunders, an imprint of elsevier inc. chapter 9 oral...

1Elsevier items and derived items © 2009 by Saunders, an imprint of Elsevier Inc.

Chapter 9

Oral Manifestations of Systemic Diseases


OutlineOutline Endocrine DisordersEndocrine Disorders Blood DisordersBlood Disorders ImmunodeficiencyImmunodeficiency Oral Manifestations of Therapy for Oral CancerOral Manifestations of Therapy for Oral Cancer Effects of Drugs on the Oral CavityEffects of Drugs on the Oral Cavity Oral Manifestations of Systemic DiseasesOral Manifestations of Systemic Diseases


Oral Manifestations of Systemic Oral Manifestations of Systemic DiseasesDiseases

(pg. 288)(pg. 288) Many systemic diseases are reflected in the oral Many systemic diseases are reflected in the oral

mucosa, maxilla, and mandible.mucosa, maxilla, and mandible. Mucosal changes may include ulceration or mucosal Mucosal changes may include ulceration or mucosal

bleeding.bleeding. Immunodeficiency can lead to opportunistic diseases Immunodeficiency can lead to opportunistic diseases

such as infection and neoplasia. such as infection and neoplasia. Bone disease can affect the maxilla and mandible.Bone disease can affect the maxilla and mandible. Systemic disease can cause dental and periodontal Systemic disease can cause dental and periodontal

changes.changes. Drugs prescribed for a systemic disease can affect oral Drugs prescribed for a systemic disease can affect oral

tissue.tissue.


Oral Manifestations of Systemic Oral Manifestations of Systemic Diseases (cont.)Diseases (cont.)

Local factors may be involved in the Local factors may be involved in the manifestation of systemic disease in oral manifestation of systemic disease in oral mucosa.mucosa. The mucosa may be more easily injured due to The mucosa may be more easily injured due to

a systemic disease, and mild irritation and a systemic disease, and mild irritation and chronic inflammation may cause lesions that chronic inflammation may cause lesions that otherwise would not occur.otherwise would not occur.

These may includeThese may include Endocrine disorders, disorders of red and white Endocrine disorders, disorders of red and white

blood cells, disorders of platelets and other blood cells, disorders of platelets and other bleeding and clotting disorders, and bleeding and clotting disorders, and immunodeficiency disordersimmunodeficiency disorders


Endocrine DisordersEndocrine Disorders

HyperpituitarismHyperpituitarism HyperthyroidismHyperthyroidism HypothyroidismHypothyroidism HyperparathyroidismHyperparathyroidism Diabetes MellitusDiabetes Mellitus Addison DiseaseAddison Disease


Endocrine DisordersEndocrine Disorders

(pg. 288)(pg. 288) The endocrine system consists of a group The endocrine system consists of a group

of integrated glands and cells that secrete of integrated glands and cells that secrete hormones.hormones. The secretion is controlled by feedback The secretion is controlled by feedback

mechanisms.mechanisms. The amount of hormone circulating in blood The amount of hormone circulating in blood

triggers factors that control production.triggers factors that control production. Diseases may result from conditions Diseases may result from conditions

where too much or too little hormone is where too much or too little hormone is produced.produced.


HyperpituitarismHyperpituitarism

(pgs. 288-289)(pgs. 288-289) Excess hormone production by the Excess hormone production by the

anterior pituitary glandanterior pituitary gland Caused most often by a benign tumor (pituitary Caused most often by a benign tumor (pituitary

adenoma) that produces growth hormoneadenoma) that produces growth hormone Giantism results if it occurs before the closure Giantism results if it occurs before the closure

of long bones.of long bones. Acromegaly results when hypersecretion Acromegaly results when hypersecretion

occurs during adult life.occurs during adult life.


Clinical Features and Oral Clinical Features and Oral Manifestations of HyperpituitarismManifestations of Hyperpituitarism

(pgs. 288-289)(pgs. 288-289) Affects both men and women, most commonly Affects both men and women, most commonly

during the fourth decade of lifeduring the fourth decade of life Patients experience poor vision, light sensitivity, Patients experience poor vision, light sensitivity,

enlargement of hands and feet, and an increase in rib enlargement of hands and feet, and an increase in rib size.size.

Facial changesFacial changes Enlargement of maxilla and mandible may cause Enlargement of maxilla and mandible may cause

separation of teeth and malocclusion.separation of teeth and malocclusion. Frontal bossing and an enlargement of nasal bones may Frontal bossing and an enlargement of nasal bones may

lead to deepening of voice.lead to deepening of voice. Mucosal changesMucosal changes

May have thickened lips and macroglossiaMay have thickened lips and macroglossia


Clinical Features and Oral Manifestations Clinical Features and Oral Manifestations of Hyperpituitarism (cont.)of Hyperpituitarism (cont.)


Diagnosis and Treatment of Diagnosis and Treatment of HyperpituitarismHyperpituitarism

Diagnosis involves measurement of Diagnosis involves measurement of growth hormone.growth hormone.

Treatment often includes pituitary gland Treatment often includes pituitary gland surgery.surgery.


Hyperthyroidism (Thyrotoxicosis)Hyperthyroidism (Thyrotoxicosis)

(pg. 289)(pg. 289) Excess production of thyroid hormoneExcess production of thyroid hormone

More common in women than menMore common in women than men The most common cause is Graves diseaseThe most common cause is Graves disease

• Graves diseaseGraves disease Appears to be due to an autoimmune disorder in which Appears to be due to an autoimmune disorder in which

a substance is produced that abnormally stimulates a substance is produced that abnormally stimulates the thyroid glandthe thyroid gland

Other causes include hyperplasia of the gland, Other causes include hyperplasia of the gland, benign and malignant tumors of the thyroid, benign and malignant tumors of the thyroid, pituitary gland disease, and metastatic tumors.pituitary gland disease, and metastatic tumors.


Clinical Features of Clinical Features of HyperthyroidismHyperthyroidism

Rosy complexion, erythema of the palms, Rosy complexion, erythema of the palms, excessive sweating, fine hair, softened excessive sweating, fine hair, softened nailsnails The patient may have exophthalmos.The patient may have exophthalmos. Anxiety, weakness, restlessness, and cardiac Anxiety, weakness, restlessness, and cardiac

problems may also be associated.problems may also be associated.


Oral Manifestations of Oral Manifestations of HyperthyroidismHyperthyroidism

May lead to premature exfoliation of May lead to premature exfoliation of deciduous teeth in children and premature deciduous teeth in children and premature eruption of permanent teetheruption of permanent teeth Osteoporosis may affect alveolar bone.Osteoporosis may affect alveolar bone. Caries and periodontal disease may appear Caries and periodontal disease may appear

and develop more rapidly in these patients.and develop more rapidly in these patients. Burning tongue also has been reported.Burning tongue also has been reported.


Treatment of HyperthyroidismTreatment of Hyperthyroidism

May include surgery, medications to May include surgery, medications to suppress thyroid activity, or administration suppress thyroid activity, or administration of radioactive iodine of radioactive iodine


HypothyroidismHypothyroidism

(pg. 289)(pg. 289) A decreased output of thyroid hormoneA decreased output of thyroid hormone

Causes include developmental disturbances, Causes include developmental disturbances, autoimmune disease, iodine deficiency, drugs, autoimmune disease, iodine deficiency, drugs, and pituitary diseaseand pituitary disease

CretinismCretinism• When it occurs in infancy and childhoodWhen it occurs in infancy and childhood

MyxedemaMyxedema• When it occurs in older children and adultsWhen it occurs in older children and adults


Hypothyroidism (cont.)Hypothyroidism (cont.)

Oral manifestationsOral manifestations In infantsIn infants

• Thickened lips, enlarged tongue, and delayed Thickened lips, enlarged tongue, and delayed eruption of teetheruption of teeth

In adultsIn adults• Enlarged tongueEnlarged tongue


HyperparathyroidismHyperparathyroidism

(pgs. 289-290)(pgs. 289-290) Due to excessive secretion of parathyroid Due to excessive secretion of parathyroid

hormone from the parathyroid glandshormone from the parathyroid glands The four parathyroid glands are located near The four parathyroid glands are located near

the thyroid gland.the thyroid gland. Parathyroid hormone plays a role in Parathyroid hormone plays a role in

calcium and phosphorous metabolism.calcium and phosphorous metabolism. Hyperparathyroidism is characterized by Hyperparathyroidism is characterized by

elevated blood levels of calcium elevated blood levels of calcium (hypercalcemia) and low levels of blood (hypercalcemia) and low levels of blood phosphorous (hypophosphatemia).phosphorous (hypophosphatemia).


Hyperparathyroidism Hyperparathyroidism (cont.)(cont.)


Hyperparathyroidism (cont.)Hyperparathyroidism (cont.)

May be the result of hyperplasia of May be the result of hyperplasia of parathyroid glands, a benign tumor of one or parathyroid glands, a benign tumor of one or more parathyroid glands, or a malignant more parathyroid glands, or a malignant parathyroid tumorparathyroid tumor Found in middle-aged adultsFound in middle-aged adults Much more common in women than menMuch more common in women than men

Parathyroid hormone increases the uptake of Parathyroid hormone increases the uptake of dietary calcium from the gastrointestinal tract dietary calcium from the gastrointestinal tract and is able to move calcium from bone to and is able to move calcium from bone to circulating blood when necessary.circulating blood when necessary.


Clinical FeaturesClinical Featuresof Hyperparathyroidismof Hyperparathyroidism

Mild cases may be asymptomatic, or may Mild cases may be asymptomatic, or may have joint pain or stiffness.have joint pain or stiffness. Lethargy and coma may occur with severe Lethargy and coma may occur with severe

disease.disease.


Oral Manifestations of Oral Manifestations of HyperparathyroidismHyperparathyroidism

Well-defined unilocular or multilocular Well-defined unilocular or multilocular radiolucenciesradiolucencies Microscopically, they appear to be CGCG Microscopically, they appear to be CGCG

(central giant cell granulomas).(central giant cell granulomas). Bone may have a mottled appearance.Bone may have a mottled appearance.


Diagnosis and TreatmentDiagnosis and Treatmentof Hyperparathyroidismof Hyperparathyroidism

Measurement of parathyroid hormone Measurement of parathyroid hormone blood levelsblood levels May include serum calcium and phosphorous May include serum calcium and phosphorous

measurementsmeasurements Treatment is directed at correcting the Treatment is directed at correcting the

cause of increased hormone production.cause of increased hormone production. Causes may include tumors, renal disease, Causes may include tumors, renal disease,

and vitamin D deficiency.and vitamin D deficiency.


Diabetes MellitusDiabetes Mellitus

(pgs. 290-294)(pgs. 290-294) A chronic disorder of carbohydrate A chronic disorder of carbohydrate

metabolism characterized by abnormally metabolism characterized by abnormally high blood glucose levelshigh blood glucose levels These result from a lack of insulin, defective These result from a lack of insulin, defective

insulin that does not work to lower blood insulin that does not work to lower blood glucose levels, or increased insulin resistance glucose levels, or increased insulin resistance due to obesity. due to obesity.


Diabetes Mellitus Diabetes Mellitus (cont.)(cont.)


Diabetes Mellitus (cont.)Diabetes Mellitus (cont.)

Glucose normally signals beta cells of the Glucose normally signals beta cells of the pancreas to make insulin.pancreas to make insulin. The hormone is then secreted into the The hormone is then secreted into the

bloodstream to facilitate the uptake of glucose bloodstream to facilitate the uptake of glucose into fat and skeletal muscle.into fat and skeletal muscle.

In the presence of insulin, fat and skeletal In the presence of insulin, fat and skeletal muscle cells can use glucose as an energy muscle cells can use glucose as an energy source.source.


Diabetes Mellitus (cont.)Diabetes Mellitus (cont.)

Without insulin, tissue is broken down to Without insulin, tissue is broken down to provide energy and weight loss occurs.provide energy and weight loss occurs. A severe hyperglycemia can lead to diabetic A severe hyperglycemia can lead to diabetic

coma.coma. Ketone can be produced by the breakdown of Ketone can be produced by the breakdown of

fatty acids.fatty acids.• Ketoacidosis lowers the pH of blood.Ketoacidosis lowers the pH of blood.

Phagocytic activity of macrophages is Phagocytic activity of macrophages is reduced and neutrophil chemotaxis is reduced and neutrophil chemotaxis is delayed.delayed.

Collagen production is abnormal.Collagen production is abnormal.


Types of DiabetesTypes of Diabetes

Insulin-dependent diabetes mellitusInsulin-dependent diabetes mellitus Type 1Type 1

Non–insulin-dependent diabetes mellitusNon–insulin-dependent diabetes mellitus Type 2Type 2


Insulin-Dependent Diabetes Insulin-Dependent Diabetes MellitusMellitus

(pgs. 291-292)(pgs. 291-292) Thought to be an autoimmune diseaseThought to be an autoimmune disease

Insulin-producing cells of the pancreas are Insulin-producing cells of the pancreas are destroyed.destroyed.

3% to 5% of all diabetic patients have this type.3% to 5% of all diabetic patients have this type. Can occur at any age, the peak is at 20Can occur at any age, the peak is at 20 Acute onset with polydipsia (excessive Acute onset with polydipsia (excessive

thirst and intake of fluid), polyuria thirst and intake of fluid), polyuria (excessive urination), and polyphagia (excessive urination), and polyphagia (excessive appetite)(excessive appetite)


Insulin-Dependent Diabetes Insulin-Dependent Diabetes Mellitus (cont.)Mellitus (cont.)

These patients will require insulin their These patients will require insulin their entire lives.entire lives. The current approach to management of these The current approach to management of these

patients involves multiple insulin injections and patients involves multiple insulin injections and proper diet, exercise, and frequent proper diet, exercise, and frequent determination of blood glucose levels.determination of blood glucose levels.

But multiple injections of insulin can more But multiple injections of insulin can more readily lead to low blood sugar (hypoglycemia) readily lead to low blood sugar (hypoglycemia) and insulin shock (severe hypoglycemia).and insulin shock (severe hypoglycemia).


Insulin-Dependent Diabetes Insulin-Dependent Diabetes Mellitus (cont.)Mellitus (cont.)

New methods of treatmentNew methods of treatment Nasal spray rather than injectionNasal spray rather than injection Insulin pumpInsulin pump

• A backup may be necessary in case the pump failsA backup may be necessary in case the pump fails• Low insulin can lead to ketoacidosis, resulting in Low insulin can lead to ketoacidosis, resulting in

nausea, abdominal cramps, disorientation, and nausea, abdominal cramps, disorientation, and fatiguefatigue


Non–Insulin-Dependent Non–Insulin-Dependent Diabetes MellitusDiabetes Mellitus

(pgs. 292-294)(pgs. 292-294) Characterized by insulin resistanceCharacterized by insulin resistance

95% of all diabetic patients have this type of 95% of all diabetic patients have this type of diabetes.diabetes.

Usually occurs in patients 35 to 40 years of Usually occurs in patients 35 to 40 years of age or olderage or older

Many of these individuals are obeseMany of these individuals are obese Obesity probably decreases the number of Obesity probably decreases the number of

receptors for insulin binding in sensitive tissues receptors for insulin binding in sensitive tissues like fat or muscle.like fat or muscle.

Diet and weight reduction may control it in Diet and weight reduction may control it in some individuals; others require oral some individuals; others require oral hypoglycemic agents. hypoglycemic agents.


Clinical Features of Non–Insulin-Clinical Features of Non–Insulin-Dependent Diabetes Mellitus Dependent Diabetes Mellitus

(pg. 293)(pg. 293) Atherosclerosis, a thickening of the blood vessel Atherosclerosis, a thickening of the blood vessel

wall from fibrofatty plaques, can lead to impaired wall from fibrofatty plaques, can lead to impaired circulation, causing impaired oxygenation and circulation, causing impaired oxygenation and nutrition in tissue.nutrition in tissue. This increases the risk of ulceration and gangrene of the This increases the risk of ulceration and gangrene of the

feet, high blood pressure, kidney failure, and stroke.feet, high blood pressure, kidney failure, and stroke. Diabetic retinopathy in the eye can lead to Diabetic retinopathy in the eye can lead to

blindness.blindness. The nervous system may be affected. The nervous system may be affected. The person may have decreased resistance to The person may have decreased resistance to

infection.infection.


Clinical Features of Non–Insulin-Clinical Features of Non–Insulin-Dependent Diabetes Mellitus (cont.)Dependent Diabetes Mellitus (cont.)


Oral Complications of Non–Insulin-Oral Complications of Non–Insulin-Dependent Diabetes Mellitus Dependent Diabetes Mellitus

(pgs. 293-294)(pgs. 293-294) Patients may have an increased prevalence of Patients may have an increased prevalence of

oral candidiasis.oral candidiasis. Mucormycosis, a rare oral fungal infection that affects Mucormycosis, a rare oral fungal infection that affects

the palate and maxillary sinuses, may be seen in the palate and maxillary sinuses, may be seen in uncontrolled or poorly controlled diabetes.uncontrolled or poorly controlled diabetes.

Bilateral asymptomatic parotid gland enlargement Bilateral asymptomatic parotid gland enlargement may occur.may occur. Xerostomia may be associated with uncontrolled Xerostomia may be associated with uncontrolled

diabetes mellitus.diabetes mellitus. Patients may have an accentuated response to plaque.Patients may have an accentuated response to plaque. Patients may have slow wound healing and increased Patients may have slow wound healing and increased

susceptibility to infection.susceptibility to infection.


Oral Complications of Non–Insulin-Oral Complications of Non–Insulin-Dependent Diabetes Mellitus (cont.)Dependent Diabetes Mellitus (cont.)


Addison DiseaseAddison Disease

(pg. 294)(pg. 294) Primary adrenal cortical insufficiencyPrimary adrenal cortical insufficiency

In most cases, the cause of destruction of the In most cases, the cause of destruction of the adrenal gland is unknown – it may be an adrenal gland is unknown – it may be an autoimmune disease.autoimmune disease.

It may be due to a tumor or tuberculosis.It may be due to a tumor or tuberculosis. To compensate, the pituitary gland increases To compensate, the pituitary gland increases

production of ACTH.production of ACTH.


Addison Disease (cont.)Addison Disease (cont.)

Clinical featuresClinical features This hormone causes stimulation of This hormone causes stimulation of

melanocytes.melanocytes. Bronzing of the skin may occur, as well as Bronzing of the skin may occur, as well as

melanotic macules on oral mucosa.melanotic macules on oral mucosa. TreatmentTreatment

Steroid replacement therapySteroid replacement therapy


Blood DisordersBlood Disorders

Disorders of Red Blood Cells and Disorders of Red Blood Cells and HemoglobinHemoglobin

Disorders of White Blood CellsDisorders of White Blood Cells Bleeding DisordersBleeding Disorders


Blood Disorders (cont.)Blood Disorders (cont.)

(pg. 294) (Box 9-1)(pg. 294) (Box 9-1) The complete blood count examines red The complete blood count examines red

blood cells, white blood cells, and blood cells, white blood cells, and platelets.platelets. It provides information about the number of It provides information about the number of

each type of cell, the ratio of types, and the each type of cell, the ratio of types, and the appearance of the cells.appearance of the cells.


Disorders of Red Blood Cells Disorders of Red Blood Cells and Hemoglobinand Hemoglobin

AnemiaAnemia Iron Deficiency AnemiaIron Deficiency Anemia Pernicious AnemiaPernicious Anemia Folic Acid and Vitamin BFolic Acid and Vitamin B1212 Deficiency Deficiency

AnemiaAnemia ThalassemiaThalassemia Sickle Cell AnemiaSickle Cell Anemia Celiac SprueCeliac Sprue Aplastic AnemiaAplastic Anemia PolycythemiaPolycythemia


AnemiaAnemia

(pgs. 294-295)(pgs. 294-295) A reduction in the oxygen-carrying A reduction in the oxygen-carrying

capacity of bloodcapacity of blood Most often related to a decrease in the number Most often related to a decrease in the number

of circulating red blood cellsof circulating red blood cells• Nutritional anemiasNutritional anemias

A deficiency in a substance required for the normal A deficiency in a substance required for the normal development of red blood cells, commonly vitaminsdevelopment of red blood cells, commonly vitamins

• Suppression of bone marrow stem cellsSuppression of bone marrow stem cells


Anemia (cont.)Anemia (cont.)

Clinical featuresClinical features Pallor of skin and oral mucosaPallor of skin and oral mucosa Angular cheilitisAngular cheilitis Erythema and atrophy of oral mucosaErythema and atrophy of oral mucosa Loss of filiform and fungiform papillae on the Loss of filiform and fungiform papillae on the

dorsum of the tonguedorsum of the tongue


Iron Deficiency AnemiaIron Deficiency Anemia

(pg. 295)(pg. 295) An insufficient amount of iron is supplied to bone An insufficient amount of iron is supplied to bone

marrow for red blood cell development.marrow for red blood cell development. May occur as a result of deficient iron intake, blood loss May occur as a result of deficient iron intake, blood loss

from heavy menstrual bleeding or chronic from heavy menstrual bleeding or chronic gastrointestinal bleeding, poor iron absorption, or an gastrointestinal bleeding, poor iron absorption, or an increased requirement for iron in situations such as increased requirement for iron in situations such as pregnancy or infancypregnancy or infancy

Plummer-Vinson syndrome may result from long Plummer-Vinson syndrome may result from long standing iron deficiency anemia.standing iron deficiency anemia. Includes dysphagia, atrophy of the upper alimentary Includes dysphagia, atrophy of the upper alimentary

tract, and a predisposition to developing oral cancertract, and a predisposition to developing oral cancer


Clinical Features and Oral Manifestations Clinical Features and Oral Manifestations of Iron Deficiency Anemiaof Iron Deficiency Anemia

(pg. 295)(pg. 295) Often asymptomatic, may have Often asymptomatic, may have

nonspecific symptoms such as weakness nonspecific symptoms such as weakness and fatigueand fatigue In severe cases may see angular cheilitis, In severe cases may see angular cheilitis,

pallor of oral tissue, and an erythematous, pallor of oral tissue, and an erythematous, smooth, painful tonguesmooth, painful tongue


Clinical Features and Oral Manifestations Clinical Features and Oral Manifestations of Iron Deficiency Anemia (cont.)of Iron Deficiency Anemia (cont.)


Diagnosis and Treatment of Iron Diagnosis and Treatment of Iron Deficiency AnemiaDeficiency Anemia

Laboratory tests show a low hemoglobin Laboratory tests show a low hemoglobin content and reduced hematocrit.content and reduced hematocrit. Red blood cells appear smaller than normal Red blood cells appear smaller than normal

(microcytic) and light in color (hypochromic)(microcytic) and light in color (hypochromic) TreatmentTreatment

Dietary supplementsDietary supplements


Pernicious AnemiaPernicious Anemia

(pgs. 295-296)(pgs. 295-296) Probably an autoimmune disorder in most Probably an autoimmune disorder in most

situationssituations May be caused by removal of the stomach, May be caused by removal of the stomach,

gastric cancer, or gastritisgastric cancer, or gastritis Caused by a deficiency in intrinsic factorCaused by a deficiency in intrinsic factor

Intrinsic factor is secreted by parietal cells in Intrinsic factor is secreted by parietal cells in the stomach; it is necessary for absorption of the stomach; it is necessary for absorption of vitamin Bvitamin B1212


Clinical Features and Oral Manifestations Clinical Features and Oral Manifestations of Pernicious Anemiaof Pernicious Anemia

(pgs. 295-296)(pgs. 295-296) Weakness, pallor, and fatigue on exertionWeakness, pallor, and fatigue on exertion

May see nausea, dizziness, diarrhea, May see nausea, dizziness, diarrhea, abdominal pain, loss of appetite, and weight abdominal pain, loss of appetite, and weight lossloss

Angular cheilitis, mucosal pallor, painful Angular cheilitis, mucosal pallor, painful atrophic and erythematous mucosa, mucosal atrophic and erythematous mucosa, mucosal ulceration, loss of papillae on the dorsum of the ulceration, loss of papillae on the dorsum of the tongue, and burning and painful tonguetongue, and burning and painful tongue


Clinical Features and Oral Manifestations Clinical Features and Oral Manifestations of Pernicious Anemia (cont.)of Pernicious Anemia (cont.)


Diagnosis and Treatment of Diagnosis and Treatment of Pernicious AnemiaPernicious Anemia

Laboratory tests reveal low serum BLaboratory tests reveal low serum B12 12

levels and gastric achlorhydria (lack of levels and gastric achlorhydria (lack of hydrochloric acid)hydrochloric acid) Red blood cells have megaloblastic anemia.Red blood cells have megaloblastic anemia.

• Abnormally large and immature megaloblasts with Abnormally large and immature megaloblasts with nucleinuclei

The Schilling test detects an inability to absorb The Schilling test detects an inability to absorb oral vitamin Boral vitamin B1212

TreatmentTreatment Injections of vitamin BInjections of vitamin B1212


Folic Acid and Vitamin BFolic Acid and Vitamin B1212

Deficiency AnemiaDeficiency Anemia (pg. 296)(pg. 296)

From dietary deficienciesFrom dietary deficiencies Can occur in association with malnutritionCan occur in association with malnutrition May be found with alcoholism or pregnancyMay be found with alcoholism or pregnancy


Oral Manifestations of Folic Acid and Oral Manifestations of Folic Acid and Vitamin BVitamin B1212 Deficiency Anemia Deficiency Anemia

Oral manifestations are indistinguishable Oral manifestations are indistinguishable from those of pernicious anemia.from those of pernicious anemia.


Diagnosis and Treatment of Folic Acid Diagnosis and Treatment of Folic Acid and Vitamin Band Vitamin B1212 Deficiency Anemia Deficiency Anemia

Based upon laboratory tests – serum Based upon laboratory tests – serum assays of folic acid and vitamin Bassays of folic acid and vitamin B1212


Thalassemia Thalassemia (Mediterranean or Cooley Anemia)(Mediterranean or Cooley Anemia)

(pg. 296)(pg. 296) A group of inherited disorders of A group of inherited disorders of

hemoglobin synthesishemoglobin synthesis An autosomal dominant inheritance patternAn autosomal dominant inheritance pattern

• The heterozygous form may be mildly symptomatic The heterozygous form may be mildly symptomatic or asymptomatic.or asymptomatic.

• The homozygous form is associated with severe The homozygous form is associated with severe hemolytic anemia.hemolytic anemia.


Clinical Features and Oral Clinical Features and Oral Manifestations of ThalassemiaManifestations of Thalassemia (pg. 296)(pg. 296)

Yellow skin pallor, fever, malaise, and Yellow skin pallor, fever, malaise, and weaknessweakness The face includes prominent cheekbones, The face includes prominent cheekbones,

depression of the bridge of the nose, a depression of the bridge of the nose, a prominent maxilla, and protrusion or flaring of prominent maxilla, and protrusion or flaring of maxillary anterior teeth.maxillary anterior teeth.

Radiographs may show a “salt and Radiographs may show a “salt and pepper” pattern.pepper” pattern. Some trabeculae are prominent, and others Some trabeculae are prominent, and others

are blurred.are blurred.


Treatment of ThalassemiaTreatment of Thalassemia

ExperimentalExperimental May include blood transfusions and May include blood transfusions and

splenectomysplenectomy Poor prognosisPoor prognosis


Sickle Cell AnemiaSickle Cell Anemia

(pg. 297)(pg. 297) An inherited blood disorderAn inherited blood disorder

When someone is heterozygous, it is called sickle cell When someone is heterozygous, it is called sickle cell trait.trait.

When someone is homozygous, they are much more When someone is homozygous, they are much more severely affected.severely affected.

Occurs before age 30 and is more common in Occurs before age 30 and is more common in women than in menwomen than in men

The red blood cells develop a sickle shape when The red blood cells develop a sickle shape when there is decreased oxygen. there is decreased oxygen. This can be triggered by exercise, exertion, This can be triggered by exercise, exertion,

administration of a general anesthetic, pregnancy, or administration of a general anesthetic, pregnancy, or even sleep.even sleep.


Clinical Features and Oral Clinical Features and Oral Manifestations of Sickle Cell AnemiaManifestations of Sickle Cell Anemia (pg. 297)(pg. 297)

The person has weakness, shortness of The person has weakness, shortness of breath, fatigue, joint pain, and nausea.breath, fatigue, joint pain, and nausea.

RadiographicRadiographic There is a loss of trabeculation, and large, There is a loss of trabeculation, and large,

irregular marrow spaces appear.irregular marrow spaces appear. A “hair-on-end” pattern may be seen in the A “hair-on-end” pattern may be seen in the

skull.skull.


Clinical Features and Oral Manifestations Clinical Features and Oral Manifestations of Sickle Cell Anemia (cont.)of Sickle Cell Anemia (cont.)


Diagnosis and Treatment of Sickle Diagnosis and Treatment of Sickle Cell AnemiaCell Anemia

(pg. 297)(pg. 297) The sickle-shaped cells may be seen on a The sickle-shaped cells may be seen on a

blood smear.blood smear. The number of red blood cells is usually low, The number of red blood cells is usually low,

as is the hemoglobin content.as is the hemoglobin content. Treatment is largely supportive, involves Treatment is largely supportive, involves

administration of oxygen and IV and oral administration of oxygen and IV and oral fluid.fluid.


Diagnosis and Treatment of Sickle Diagnosis and Treatment of Sickle Cell Anemia (cont.)Cell Anemia (cont.)


Celiac SprueCeliac Sprue

(pgs. 297-298)(pgs. 297-298) A chronic disorderA chronic disorder

Sensitivity to wheat glutenSensitivity to wheat gluten Ingestion causes injury to intestinal Ingestion causes injury to intestinal

mucosa.mucosa. This injury may cause malabsorption of This injury may cause malabsorption of

nutrients and a resulting anemia.nutrients and a resulting anemia.


Clinical Features and Oral Clinical Features and Oral Manifestations of Celiac SprueManifestations of Celiac Sprue

Symptoms include diarrhea, nervousness, Symptoms include diarrhea, nervousness, and paresthesia.and paresthesia. Painful, burning tongue, atrophy of papillae, Painful, burning tongue, atrophy of papillae,

and ulceration of oral mucosaand ulceration of oral mucosa


Diagnosis and Treatment of Diagnosis and Treatment of Celiac SprueCeliac Sprue

The patient must avoid wheat gluten.The patient must avoid wheat gluten. Oral manifestations resolve when the systemic Oral manifestations resolve when the systemic

disease is controlled.disease is controlled.


Aplastic AnemiaAplastic Anemia

(pgs. 298-299)(pgs. 298-299) A severe depression of bone marrow A severe depression of bone marrow

activity causes a decrease in all circulating activity causes a decrease in all circulating blood cells. – pancytopeniablood cells. – pancytopenia Primary aplastic anemia – the cause is Primary aplastic anemia – the cause is

unknownunknown Secondary aplastic anemia – a result of a drug Secondary aplastic anemia – a result of a drug

or chemical agentor chemical agent


Aplastic Anemia (cont.)Aplastic Anemia (cont.)


Oral Manifestations of Aplastic Oral Manifestations of Aplastic AnemiaAnemia

(pgs. 298-299)(pgs. 298-299) Infection, spontaneous bleeding, Infection, spontaneous bleeding,

petechiae, and purpuric spotspetechiae, and purpuric spots


Diagnosis and Treatment of Diagnosis and Treatment of Aplastic AnemiaAplastic Anemia

(pg. 298)(pg. 298) Leukopenia (decrease in white blood cells) Leukopenia (decrease in white blood cells)

and thrombocytopenia (decrease in and thrombocytopenia (decrease in platelets) occur.platelets) occur.

Primary aplastic anemia is usually Primary aplastic anemia is usually progressive and fatal.progressive and fatal. Secondary aplastic anemia involves removing Secondary aplastic anemia involves removing

the cause. the cause.


PolycythemiaPolycythemia

Polycythemia VeraPolycythemia Vera Secondary PolycythemiaSecondary Polycythemia Relative PolycythemiaRelative Polycythemia


Polycythemia (cont.)Polycythemia (cont.)

(pg. 298)(pg. 298) Characterized by an increase in the Characterized by an increase in the

number of circulating red blood cellsnumber of circulating red blood cells May be absolute or relativeMay be absolute or relative

The three forms of polycythemia areThe three forms of polycythemia are Polycythemia VeraPolycythemia Vera Secondary PolycythemiaSecondary Polycythemia Relative PolycythemiaRelative Polycythemia


Polycythemia Vera Polycythemia Vera (Primary Polycythemia)(Primary Polycythemia)

(pg. 298)(pg. 298) A neoplastic proliferation of bone marrow A neoplastic proliferation of bone marrow

stem cells causes an abnormally high stem cells causes an abnormally high number of circulating red blood cells.number of circulating red blood cells. Unknown causeUnknown cause More common in men than in womenMore common in men than in women Age of onset usually between 40 and 60 years Age of onset usually between 40 and 60 years

of ageof age Clinical featuresClinical features

Headache, dizziness, and itching (pruritus)Headache, dizziness, and itching (pruritus) Thrombi may form.Thrombi may form.


Secondary PolycythemiaSecondary Polycythemia

(pg. 298)(pg. 298) The increase in red blood cells is caused The increase in red blood cells is caused

by a physiologic response to decreased by a physiologic response to decreased oxygen.oxygen. A decrease in blood oxygen causes an A decrease in blood oxygen causes an

increase in erythropoietin by the kidneys.increase in erythropoietin by the kidneys. May be due to pulmonary disease, heart May be due to pulmonary disease, heart

disease, living at high altitude, or elevation in disease, living at high altitude, or elevation in carbon monoxidecarbon monoxide


Relative PolycythemiaRelative Polycythemia

(pg. 298)(pg. 298) Caused by a decrease in plasma volumeCaused by a decrease in plasma volume

Causes may include diuretics, vomiting, Causes may include diuretics, vomiting, diarrhea, or excessive sweating.diarrhea, or excessive sweating.

Most patients are middle-aged white men Most patients are middle-aged white men under physiologic stress, mildly overweight, under physiologic stress, mildly overweight, hypertensive, and heavy smokers.hypertensive, and heavy smokers.


Oral Manifestations of Oral Manifestations of PolycythemiaPolycythemia

(pg. 299)(pg. 299) The oral mucosa may appear deep red to The oral mucosa may appear deep red to

purple; the gingiva may be edematous and purple; the gingiva may be edematous and bleed easilybleed easily.. Submucosal petechiae, ecchymosis, and Submucosal petechiae, ecchymosis, and

hematoma formation may be present.hematoma formation may be present.


Diagnosis and Treatment of Diagnosis and Treatment of PolycythemiaPolycythemia

(pg. 299)(pg. 299) Laboratory testing and measurement of Laboratory testing and measurement of

hemoglobin and hematocrithemoglobin and hematocrit May include removal of causative factors, May include removal of causative factors,

chemotherapy, and phlebotomychemotherapy, and phlebotomy


Disorders of White Blood CellsDisorders of White Blood Cells

AgranulocytosisAgranulocytosis Cyclic NeutropeniaCyclic Neutropenia LeukemiaLeukemia


Disorders of White Blood Cells Disorders of White Blood Cells (cont.)(cont.)

(pgs. 299-301)(pgs. 299-301) Three groups of white blood cells are Three groups of white blood cells are

found in circulation.found in circulation. GranulocytesGranulocytes

• Neutrophils (PMNs), eosinophils, and basophilsNeutrophils (PMNs), eosinophils, and basophils LymphocytesLymphocytes MonocytesMonocytes


AgranulocytosisAgranulocytosis

(pg. 300)(pg. 300) A significant reduction in circulating A significant reduction in circulating

neutrophilsneutrophils Leukopenia – an abnormally low white blood Leukopenia – an abnormally low white blood

cell countcell count Neutropenia – a reduction in the number of Neutropenia – a reduction in the number of

circulating neutrophilscirculating neutrophils


Agranulocytosis (cont.)Agranulocytosis (cont.)

Can result from a problem in development Can result from a problem in development of neutrophils or accelerated destruction of of neutrophils or accelerated destruction of neutrophilsneutrophils Primary – the cause is unknown, may be an Primary – the cause is unknown, may be an

immunologic disorderimmunologic disorder Secondary – a result of chemicals or drugsSecondary – a result of chemicals or drugs


Clinical Features and Oral Clinical Features and Oral Manifestations of AgranulocytosisManifestations of Agranulocytosis

(pg. 300)(pg. 300) Sudden onset of fever, chills, jaundice, Sudden onset of fever, chills, jaundice,

weakness, and sore throatweakness, and sore throat Oral infectionOral infection


Diagnosis and Treatment of Diagnosis and Treatment of AgranulocytosisAgranulocytosis

(pg. 300)(pg. 300) Laboratory testingLaboratory testing Marked reduction in WBC countMarked reduction in WBC count TreatmentTreatment

Transfusions, antibioticsTransfusions, antibiotics Removal of the cause for the secondary formRemoval of the cause for the secondary form


Cyclic NeutropeniaCyclic Neutropenia

(pg. 300)(pg. 300) A cyclic decrease in the number of A cyclic decrease in the number of

circulating neutrophilic leukocytescirculating neutrophilic leukocytes Discussed on pages 208-209Discussed on pages 208-209


LeukemiaLeukemia

(pgs. 300-301) (Box 9-2)(pgs. 300-301) (Box 9-2) Malignant neoplasms of hematopoietic Malignant neoplasms of hematopoietic

stem cellsstem cells Characterized by an excessive number of Characterized by an excessive number of

abnormal white blood cells in circulating bloodabnormal white blood cells in circulating blood Unknown cause; some are investigating Unknown cause; some are investigating

oncogenic virusesoncogenic viruses There are many different types There are many different types

categorized as to whether they are acute categorized as to whether they are acute or chronic.or chronic.


Acute LeukemiasAcute Leukemias

(pgs. 300-301)(pgs. 300-301) Characterized by very immature cells and Characterized by very immature cells and

a rapidly fatal course if not treateda rapidly fatal course if not treated Acute lymphoblastic leukemia – involves Acute lymphoblastic leukemia – involves

immature lymphocytesimmature lymphocytes• Primarily affects children and young adultsPrimarily affects children and young adults• Good prognosisGood prognosis

Acute myeloblastic leukemia – involves Acute myeloblastic leukemia – involves immature granulocytesimmature granulocytes• Primarily affects adolescents and young adults.Primarily affects adolescents and young adults.• Prognosis is not as good.Prognosis is not as good.


Clinical Features of Acute Clinical Features of Acute LeukemiasLeukemias

(pg. 301)(pg. 301) Weakness, fever, enlargement of lymph Weakness, fever, enlargement of lymph

nodes, and bleedingnodes, and bleeding


Oral Manifestations of Acute Oral Manifestations of Acute LeukemiasLeukemias

Gingival enlargementGingival enlargement Oral infectionOral infection Bleeding gums, petechiae and ecchymosisBleeding gums, petechiae and ecchymosis


Diagnosis and Treatment of Acute Diagnosis and Treatment of Acute LeukemiasLeukemias

Laboratory findings include elevated white Laboratory findings include elevated white blood cell count, anemia, and low platelet blood cell count, anemia, and low platelet countcount

Treatment Treatment Bone marrow transplantBone marrow transplant


Chronic LeukemiasChronic Leukemias

(pg. 301)(pg. 301) Slow onsetSlow onset

Primarily affect adultsPrimarily affect adults


Clinical Features and Oral Clinical Features and Oral Manifestations of Chronic LeukemiasManifestations of Chronic Leukemias

Easy fatigability, weakness, weight loss, Easy fatigability, weakness, weight loss, anorexiaanorexia

Pallor of lips and gingiva, gingival Pallor of lips and gingiva, gingival enlargement, petechiae and ecchymosis, enlargement, petechiae and ecchymosis, gingival bleedinggingival bleeding


Diagnosis and Treatment of Diagnosis and Treatment of Chronic LeukemiasChronic Leukemias

High white blood cell countHigh white blood cell count TreatmentTreatment

Bone marrow transplant Bone marrow transplant


Bleeding DisordersBleeding Disorders

HemostasisHemostasis PurpuraPurpura HemophiliaHemophilia


Hemostasis (cont.)Hemostasis (cont.)



(pgs. 301-303) (Tables 9-1, 9-2)(pgs. 301-303) (Tables 9-1, 9-2) A cessation of bleedingA cessation of bleeding

Circulating platelets adhere to a damaged surface and Circulating platelets adhere to a damaged surface and aggregate to form a temporary clot.aggregate to form a temporary clot.

Fibrin binds the plateletsFibrin binds the platelets• Fibrin is converted from fibrinogen by a cascade of Fibrin is converted from fibrinogen by a cascade of

circulating proteinscirculating proteins.. Defects may be caused by abnormalities of either Defects may be caused by abnormalities of either

platelets or coagulation factors.platelets or coagulation factors. These may be determined with laboratory tests.These may be determined with laboratory tests.


Platelet CountPlatelet Count

(pgs. 301-302)(pgs. 301-302) To determine the number of plateletsTo determine the number of platelets

Normal is 150,000 to 400,000/mmNormal is 150,000 to 400,000/mm33

• Spontaneous gingival bleeding may occur if the Spontaneous gingival bleeding may occur if the count is less than 20,000/mmcount is less than 20,000/mm33


Bleeding TimeBleeding Time

(pg. 302) (pg. 302) The adequacy of platelet functionThe adequacy of platelet function Normal is between 1 and 6 minutes.Normal is between 1 and 6 minutes.

Prolonged is greater than 5 or 10 minutes.Prolonged is greater than 5 or 10 minutes.


Prothrombin Time (PT)Prothrombin Time (PT)

(pgs. 302-303) (pgs. 302-303) The ability to form a clotThe ability to form a clot

Normal is usually between 11 and 16 seconds.Normal is usually between 11 and 16 seconds. INR is the ratio of PT to thromboplastin activity.INR is the ratio of PT to thromboplastin activity. Values less than 3 are considered normal.Values less than 3 are considered normal.

• Patients on anticoagulants may have INR values of 4 Patients on anticoagulants may have INR values of 4 to 5.to 5.


Partial Thromboplastin Time (PTT)Partial Thromboplastin Time (PTT)

(pg. 303) (pg. 303) Measures the other way by which clot Measures the other way by which clot

formation occursformation occurs A normal PTT is usually 25 to 40 seconds.A normal PTT is usually 25 to 40 seconds.

Prolongation to 45 or 50 seconds may be Prolongation to 45 or 50 seconds may be associated with bleeding problems.associated with bleeding problems.

Over 50 seconds may be severeOver 50 seconds may be severe


PurpuraPurpura

(pgs. 303-304) (pgs. 303-304) A reddish-blue or purplish discoloration of A reddish-blue or purplish discoloration of

skin or mucosa from spontaneous skin or mucosa from spontaneous extravasation of bloodextravasation of blood May be due to a defect or deficiency in blood May be due to a defect or deficiency in blood

plateletsplatelets Blood may ooze from gingival margins.Blood may ooze from gingival margins.


Thrombocytopenic PurpuraThrombocytopenic Purpura

(pgs. 303-304)(pgs. 303-304) A bleeding disorder that results from a A bleeding disorder that results from a

severe reduction in circulating plateletssevere reduction in circulating platelets Idiopathic thrombocytopenic purpuraIdiopathic thrombocytopenic purpura

• If the cause is unknownIf the cause is unknown Immune thrombocytopeniaImmune thrombocytopenia

• An autoimmune type of processAn autoimmune type of process Secondary thrombocytopenic purpuraSecondary thrombocytopenic purpura

• Often associated with drugsOften associated with drugs


Clinical and Oral Manifestations of Clinical and Oral Manifestations of Thrombocytopenic PurpuraThrombocytopenic Purpura

Spontaneous purpuric or hemorrhagic Spontaneous purpuric or hemorrhagic lesions on the skinlesions on the skin Patients bruise easily, may have blood in urine, Patients bruise easily, may have blood in urine,

and have frequent nosebleeds.and have frequent nosebleeds.


Diagnosis and Treatment of Diagnosis and Treatment of Thrombocytopenic PurpuraThrombocytopenic Purpura

Laboratory tests show a significant Laboratory tests show a significant decrease in platelets.decrease in platelets.

TreatmentTreatment May include transfusions, corticosteroids, and May include transfusions, corticosteroids, and

splenectomysplenectomy


Nonthrombocytopenic PurpuraNonthrombocytopenic Purpura

(pg. 304)(pg. 304) Bleeding disorders that can result from Bleeding disorders that can result from

either a defect in capillary walls or either a defect in capillary walls or disorders of platelet functiondisorders of platelet function Vitamin C deficiency and infections or Vitamin C deficiency and infections or

chemicals and allergy may be the cause of chemicals and allergy may be the cause of alterations in vascular walls.alterations in vascular walls.

Drugs, allergy, and autoimmune disease may Drugs, allergy, and autoimmune disease may cause disorders of platelet function.cause disorders of platelet function.

Von Willebrand disease is an autosomal Von Willebrand disease is an autosomal dominant disorder of platelet function.dominant disorder of platelet function.


Oral Manifestations of Oral Manifestations of Nonthrombocytopenic PurpuraNonthrombocytopenic Purpura

Spontaneous gingival bleeding, petechiae, Spontaneous gingival bleeding, petechiae, ecchymoses, and hemorrhagic blistersecchymoses, and hemorrhagic blisters


Diagnosis and Treatment of Diagnosis and Treatment of Nonthrombocytopenic PurpuraNonthrombocytopenic Purpura

Systemic corticosteroids, splenectomy, Systemic corticosteroids, splenectomy, and discontinuation of the causative agentand discontinuation of the causative agent


HemophiliaHemophilia

(pg. 304)(pg. 304) A disorder of blood coagulationA disorder of blood coagulation

Results in severely prolonged clotting timeResults in severely prolonged clotting time Due to a deficiency in plasma proteins involved Due to a deficiency in plasma proteins involved

in coagulationin coagulation


Types of HemophiliaTypes of Hemophilia

(pg. 304)(pg. 304) The two most common types are type A The two most common types are type A

and type B.and type B. Transmitted as X-linked diseases through an Transmitted as X-linked diseases through an

unaffected carrier daughter to a sonunaffected carrier daughter to a son• Type AType A

Caused by a deficiency of plasma thromboplastinogen Caused by a deficiency of plasma thromboplastinogen or factor VIIIor factor VIII

• Type BType B Christmas diseaseChristmas disease Less common, the clotting defect is plasma Less common, the clotting defect is plasma

thromboplastin or factor IXthromboplastin or factor IX


Oral Manifestations of HemophiliaOral Manifestations of Hemophilia

Spontaneous gingival bleeding, petechiae, Spontaneous gingival bleeding, petechiae, and ecchymosisand ecchymosis


Diagnosis and Treatment of Diagnosis and Treatment of HemophiliaHemophilia

The bleeding time and PT in hemophilia The bleeding time and PT in hemophilia are normal; the PTT is prolonged.are normal; the PTT is prolonged.

Diagnosis involves identifying the missing Diagnosis involves identifying the missing factor; treatment involves replacing it.factor; treatment involves replacing it.


ImmunodeficiencyImmunodeficiency

(pgs. 304-305)(pgs. 304-305) Can involve the different parts of the Can involve the different parts of the

immune system either alone or togetherimmune system either alone or together May involve a deficiency in cell-mediated or May involve a deficiency in cell-mediated or

humoral immunityhumoral immunity May involve deficiency in phagocytosisMay involve deficiency in phagocytosis

Divided intoDivided into Primary immunodeficiency of genetic originPrimary immunodeficiency of genetic origin Secondary immunodeficiency from another Secondary immunodeficiency from another

underlying disorderunderlying disorder


Primary ImmunodeficienciesPrimary Immunodeficiencies

(pg. 305)(pg. 305) Of genetic originOf genetic origin

May involve B cells, T cells, or bothMay involve B cells, T cells, or both Very rareVery rare

Bruton disease (X linked congenital Bruton disease (X linked congenital agammaglobulinemia)agammaglobulinemia)

DiGeorge syndrome (thymic hypoplasia)DiGeorge syndrome (thymic hypoplasia) Severe combined immunodeficiencySevere combined immunodeficiency


Secondary Immunodeficiencies Secondary Immunodeficiencies (Cont.)(Cont.)


Secondary Immunodeficiencies Secondary Immunodeficiencies (Cont.)(Cont.)

(pg. 305) (Table 9-3)(pg. 305) (Table 9-3) Occur as the result of an underlying Occur as the result of an underlying

disorderdisorder May be malnutrition, viral infection, cancer, May be malnutrition, viral infection, cancer,

renal disease and Hodgkin’s diseaserenal disease and Hodgkin’s disease May occur with immunosuppressive drugs, May occur with immunosuppressive drugs,

drugs used along with radiation, chemotherapydrugs used along with radiation, chemotherapy


Oral Manifestations of Therapy for Oral Manifestations of Therapy for Oral CancerOral Cancer

(pgs. 305-307)(pgs. 305-307) Radiation TherapyRadiation Therapy ChemotherapyChemotherapy


Oral Manifestations of Therapy for Oral Manifestations of Therapy for Oral Cancer (cont.)Oral Cancer (cont.)

(pg. 305)(pg. 305) Oral cancer can be treated with surgery, Oral cancer can be treated with surgery,

radiation therapy, or chemotherapy, or a radiation therapy, or chemotherapy, or a combination.combination.


Radiation TherapyRadiation Therapy

(pgs. 305-306)(pgs. 305-306) The patient often experiences The patient often experiences

mucositis during radiation therapy.mucositis during radiation therapy. Mucositis begins about the second Mucositis begins about the second

week of therapy and subsides a few week of therapy and subsides a few weeks after its completion.weeks after its completion.

It is painful and appears as an It is painful and appears as an erythematous and ulcerated mucosa.erythematous and ulcerated mucosa.

The patients may have difficulty The patients may have difficulty eating, pain on swallowing, and loss eating, pain on swallowing, and loss of taste.of taste.


(pgs. 305-306)(pgs. 305-306) Destruction of major salivary glands may result in Destruction of major salivary glands may result in

xerostomiaxerostomia The patient is prone to rampant caries and oral The patient is prone to rampant caries and oral

candidiasis.candidiasis. They also are prone to osteoradionecrosis.They also are prone to osteoradionecrosis.

Radiation Therapy (cont.)Radiation Therapy (cont.)


Patients should have an oral evaluation Patients should have an oral evaluation before radiation therapy of the head and before radiation therapy of the head and neck.neck. Potential sources for oral infection and teeth Potential sources for oral infection and teeth

with a questionable prognosis should be with a questionable prognosis should be removed.removed.

The hygienist can help withThe hygienist can help with Fluoride applicationFluoride application Patient educationPatient education Frequent follow-up appointments Frequent follow-up appointments

Radiation Therapy (cont.)Radiation Therapy (cont.)


ChemotherapyChemotherapy

(pgs. 306-307)(pgs. 306-307) Drugs used for cancer chemotherapy Drugs used for cancer chemotherapy

affect basal cells of the epithelium.affect basal cells of the epithelium. Mucositis and oral ulceration are common Mucositis and oral ulceration are common

complications.complications. A decrease in all blood cells may occurA decrease in all blood cells may occur

Lowered RBC counts can lead to anemia.Lowered RBC counts can lead to anemia. Lowered WBC counts can lead to infections.Lowered WBC counts can lead to infections. Lowered platelets can lead to bleeding Lowered platelets can lead to bleeding

problems.problems.


Effects of Drugs on the Oral CavityEffects of Drugs on the Oral Cavity

(pgs. 307-308)(pgs. 307-308) Blood pressure drugs, antianxiety Blood pressure drugs, antianxiety

medications, antipsychotic medications, medications, antipsychotic medications, and antihistamines can cause xerostomia.and antihistamines can cause xerostomia.

Prednisone suppresses the immune Prednisone suppresses the immune system and can lead to candidiasis and system and can lead to candidiasis and oral infections.oral infections.

Antibiotics may increase risk of Antibiotics may increase risk of candidiasis.candidiasis.


Effects of Drugs on the Oral Cavity Effects of Drugs on the Oral Cavity (cont.)(cont.)



Tetracycline can cause tooth discoloration.Tetracycline can cause tooth discoloration. Phenytoin and nifedipine can cause Phenytoin and nifedipine can cause

gingival enlargement.gingival enlargement. Cyclosporine may cause gingival Cyclosporine may cause gingival

enlargement.enlargement.


Discussion Questions Discussion Questions

What oral manifestations of systemic diseases What oral manifestations of systemic diseases may be observed within the oral cavity?may be observed within the oral cavity?

What disorders of blood cells may be observed What disorders of blood cells may be observed within the oral cavity?within the oral cavity?

What effects may immunodeficiency have upon What effects may immunodeficiency have upon the oral cavity?the oral cavity?

What oral manifestations may be observed What oral manifestations may be observed during therapy for oral cancer?during therapy for oral cancer?

What effects of drugs may be observed within What effects of drugs may be observed within the oral cavity?the oral cavity?