Download - Oral manif of system dis
Oral Manifestations of Systemic diseases
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A wide array of systemic diseases produce oral manifestations
• Congenital/developmental disorders• Nutritional disorders• Haematological diseases• Gastrointestinal diseases• Endocrine disorders • Dermatological disorders • Immunological disorders etc
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•Oral manifestation may herald the onset of some diseases or may be late manifestations•May be seen in oral soft tissues including the tongue•May occur in the jaw bones and/or the teeth•Both soft and hard tissue manifestations may
arise in some systemic diseases•A manifestation based approach is presented•Not comprehensive
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Angular cheilitis• Iron deficiency
anaemia• Folic Acid deficiency• Vit B12 deficiency• Vit B2 (riboflavin)
deficiency• Vit B6 (pyridoxine
deficiency)
• Malabsorption states (eg: Crohn’s disease)
• AIDS • Other immune defects
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A wide array of systemic diseases produce oral manifestations
• Congenital/developmental disorders• Nutritional disorders• Haematological diseases• Gastrointestinal diseases• Endocrine disorders • Dermatological disorders • Immunological disorders etc
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Glossitis including lingual mucosal atrophy
• Iron deficiency• Folate deficiency• Vit B12 deficiency• Vitamin B2
(riboflavin) deficiency• Vitamin B3(Niacin)
deficiency(pellagra)
• Vitamin B6 (pyridoxine) deficiency
• Tertiary syphilis
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Glossitis in deficiency states
in Iron deficiency Vitamin B complex
deficiency Vit B12 deficiency
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Enlarged tongue (macroglossia)
• Down’s syndrome• Hypothyroidism of infancy (Cretinism)• Mucopolysaccharidoses• Neurofibromatosis• Amyloidosis (multiple myeloma and others)• Acromegaly
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Fissured tongue
• Down’s syndrome• Sjogren’s syndrome and chronic xerostomic
states• Melkersson-Rosenthal syndrome• Multiple hamartoma and neoplasia
syndrome (Cowden’s syndrome)• Orofacial digital syndrome (sometimes cleft
tongue only)
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Macroglossia and fissured tongue in Down’s syndrome
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Tongue in severe xerostomia (Sjogren’s syndrome)
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Strawberry tongue
Hyperplastic fungiform papillae on a white or red background
• Scarlet fever• Mucocutaneous lymphnode syndrome
(Kawasaki disease)
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Erythema migrans
• Psoriasis• Reiter’s syndrome (may affect buccal
mucosa too)
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Erythema migrans
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White patches on oral mucosa• White sponge naevus• Dyskeratosis congenita• Pachyonychia congenita• Primary immuno-
deficiency diseases (Chronic Mucocutaneous Candidosis-CMC)
• Candidosis- endocrinopathy syndrome
• Chronic renal failure• AIDS and other
immunodeficiency states
• SLE• Pystomatitis vegetans• Syphilis, tertiary
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Some white lesions of systemic origin
White sponge naevus
Pachyonychia congenita Dyskeratosis
congenita
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Hairy leukoplakia in AIDS or other immunocompromised states
Pyostomatitis vegetans presenting as white patches
Eg. Ulcerative colitis
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CMC in Primary immunodeficiency disorders
eg. Congenital thymic aplasia (Di George syndrome)
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Burning sensation in the mouth
• Iron deficiency• Folate deficiency• Vitamin B12 deficiency• Vitamin B complex deficiency• Diabetes mellitus• Xerostomia of systemic causes• States of anxiety and depression• Hypothyroidism
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Numbness of orofacial areas (including lips)
• Intracranial neoplasia• Trotter’s syndrome• Leukaemia• Metastatic disease of the jaws• Diabetes mellitus• Sarcoidosis• Amyloidosis• Sickle cell disease
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Dry mouth
• Diabetes mellitus• Sjogren’s syndrome• Sarcoidosis • Ectodermal dysplasia• Drugs (anticholinergic, sympathomimetics, tricyclic
antidepressants)• Chronic renal failure• AIDS• Bone marrow transplantation (GVHD)
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Desquamative gingivitis
• Erosive lichen planus• Benign mucous membrane pemphigoid• Pemphigus• Dermatitis herpetiformis• Linear IgA disease
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Desquamative gingivitis
BMMP Pemphigus vulgaris
Linear IgA disease
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Swelling of lips
• Angioedema (allergic/ C1 esterase inhibitor deficiency)
• Crohn’s disease (orofacial granulomatosis)• Sarcoidosis• Ascher’s syndrome (double lip)
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Lip swellings of systemic origin
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Generalized gingival swellings
• Drug induced• Pregnancy• Leukaemia (AMML)• Aplastic anaemia• Hereditary Gingival
fibromatosis and its variants
• Amyloidosis• Mucopolysaccharidosis• A wide array of rare
syndromes
Some generalized gingival swellings
Acute myelomonocytic leukaemia
Hereditary gingival fibromatosis
Pregnancy gingivitisCyclosporin induced gingival
overgrowth
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Localized gingival swellings• Cowden’s syndrome• Sturge Weber angiomatosis• Focal epithelial hyperplasia (Heck’s disease)• Wegener’s granulomatosis (Strawberry gingivitis)• Langerhan’s cell tumours• Sarcoidosis• Crohn’s disease• Tuberous sclerosis
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Some localised gingival swellings of systemic origin
Strawberry gingivitis in Wegener’s granulomatosis
Gingival swellings in Tuberous sclerosis (mental handicap, epilepsy and sebaceous adenomas on skin)
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Spontaneous Gingival bleeding
• Idiopathic thrombocytopenic purpura• Leukaemia, Acute lymphoblastic leukaemia• Lymphoproliferative disorders• Myeloproliferative disorders• Myelodysplastic disorders• Scurvy• Ehlers-Danlos syndrome• Haemophilia, von Willebrandt’s disease
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Bleeding gingivae in leukaemia
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Blood blisters in the mouth
• Any cause of purpura• Mucous membrane pemphigoid• Amyloidosis• (Localized oral purpura- angina bullosa
haemorrhagica)
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Blood blisters
Amyloidosis Localized oral purpura- angina bullosa haemorrhagica
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Conical teeth
• Ectodermal dysplasia• Ellis- van Creveld syndrome
(Chondroectodermal dysplasia)• Incontinentia pigmenti (Bloch-Sulzberger
disease)
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Hypodontia
About 37 syndromes including • Ectodermal dysplasia • Down’s syndrome• Crouzon syndrome• Chondroectodermal dysplasia• Sturge Weber• Incontinentia pigmenti• Goldenhar
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Conical teeth and hypodontia in ectodermal dysplasia
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Delayed eruption of teeth
• Rickets• Hypothyroidism of infancy (Cretinism)• Hypoparathyroidism in early childhood• Hypopituitarism (Pituitary dwarfism)• Cleidocranial dysplasia• Biliary atresia (also green teeth)• Hereditary gingival fibromatosis and associated
syndromes
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Enamel hypoplasia of deciduous teeth
Deciduous dentition:• Intrauterine infection e.g. rubella• Intrauterine metabolic disturbance• Congenital hypoparathyroidism• Pseudohypoparathyroidism (hereditary)
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Enamel hypoplasia of permanent teeth (chronological)
• Severe rickets (disputed)• Childhood fevers• Coeliac disease • Cystic fibrosis• Childhood hypoparathyroidism• Biliary atresia• Gastroenteritis• Radiotherapy• Chemotherapy
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Enamel hypoplasia due to systemic disease
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Supernumerary teeth
About 18 syndromes including• Cleidocranial dysplasia• Gardner’s syndrome• Apert syndrome
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Mandibular prognathism
• Acromegaly• Down’s syndrome• Cleidocranial dysplasia• Gorlin Goltz syndrome• Crouzon syndrome• Apert syndrome
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Bad taste (non-oral causes)• Dry mouth of systemic
causes• Depression and anxiety states• Drugs (Metronidazole, ACE
inhibitors etc)• Nasal/pharyngeal disease
(Chronic sinusitis etc)• Diabetes• Pharyngeal pouch
• Gastric regurgitation• Liver disease• Uraemia• Temporal lobe
tumours • Temporal lobe
epilepsy• Bronchiectasis
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Dysphagia (non oral and oropharyngeal causes)
• Plummer Vinson syndrome
• Pharyngeal pouch• Oesophageal stricture• Oesophageal carcinoma• Scleroderma• Pressure from
mediastinal lymph nodes
• Achalasia of the cardia• Syringobulbia• CVA• Motor neurone disease• Guillain- Barré
syndrome• Myasthenia gravis• Muscular dystrophies
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Facial palsy• Bell’s palsy• CVA• Cerebral tumour• Parotid
tumour/malignancy• Diabetes mellitus• HIV infection• Cholesteatoma • Mastoiditis• Melkersson Rosenthal
syndrome• Sarcoidosis (Heerfordt
syndrome)
• Reiter’s syndrome• Multiple sclerosis• Ramsay Hunt
syndrome• Guillain- Barré
syndrome• Lyme disease• Leprosy• Kawasaki disease• Moebius syndrome
(congenital f.p)
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Facial swelling
• Allergic angioedema• C1 esterse inhibitor
deficiency• Systemic
corticosteroid therapy• Cushing’s syndrome• Myxoedema• Acromegaly• Nephrotic syndrome
• Superior vena cava syndrome
• Crohn’s disease• Sarcoidosis• Melkersson-Rosenthal
syndrome• Lymphoma
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Pigmentation• Drugs• Beta thalassaemia• Addison’s disease, Nelson’s syndrome• Biliary atresia• Peutz-Jeghers syndrome• Neurofibromatosis• Albright’s syndrome• Acanthosis nigricans• Laugier- Hunziker syndrome
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Melanotic macules on lip in Peutz Jeghers syndrome
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Ulcerations preceded by blisters
• Viral infections (Herpes simplex, Herpangina, Hand, Foot and mouth disease)
• Pemphigoid (usually BMMP)• Pemphigus vulgaris, Hailey- Hailey disease• Erythema multiforme• Epidermolysis bullosa• Dermatitis herpetiformis• Linear IgA disease
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Ulceration preceded by blisters
Pemphigus vulgaris Benign Mucous membrane pemphigoid
Epidermolysis bullosa
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Ulceration in syphilis
Chancre in primary syphilis
Mucous patches and snail-tract ulcers in secondary syphilis
Gumma in tertiary syphilis
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Ulceration of oral mucosa not preceded by blisters
• Haematinic deficiency • Behcet’s syndrome• Neutropenia (including
cyclic neutropenia)• Leukaemia • SLE• Crohn’s disease • Ulcerative colitis• Coeliac disease
• Drugs (e.g. methotrexate)• Reiter’s syndrome• Tuberculosis• Syphilis (all three stages)
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Ulceration in leukaemia
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Tuberculous ulcer
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Neuromas in the mouth
• Neurofibromatosis• Multiple Endocrine Neoplasia syndrome III
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Halitosis (of non oral/oropharyngeal origin)
• Drugs • Acute febrile illness• Respiratory tract
infections• Hepatic failure• Renal failure• Diabetic ketoacidosis
• Leukaemias• Sinusitis • Neoplasm in the
maxillary sinus• Volatile foodstuff
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Systemic diseases causing radiological abnormalities of the jaws
• Hyperparathyroidism and Hypoparathyroidism• Multiple myeloma• Haemoglobinopathies• Acromegaly• Osteogenesis imperfecta• Albers-Schonberg disease (marble bone dis)• Histiocytosis X• Fibrous dysplasia• Paget’s disease• Systemic sclerosis
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Oral manifestations of internal cancer
• Metastases in jaws or rarely oral soft tissues(Breast, Lung, Prostate, Thyroid, Kidney, Stomach)
• Effects of tumour metabolites– Facial flushing- carcinoid syndrome– Pigmentation (ectopic ACTH-secreting tumours)– Amyloidosis (multiple myeloma)– Oral erosions (glucaganoma)
contd…..
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Oral manifestations of internal cancer (contd..)
• Changes caused by other functional disturbances– Purpura, anaemia, infections (Leukaemia)– Infections (lymphoma, especially Hodgkin’s dis’se)– Bleeding (liver cancer)
• Anaemia (bleeding from gastrointestinal tumours)• Mucocutaneous diseases
– Acanthosis nigricans (gastric Ca)– Erythema multiforme (lymphoma, leukaemia )– Pempigus, pemphigoid (paraneoplastic pemphigus in
lymphomas) contd…..
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Oral manifestations of internal cancer (contd..)
• Inherited disorders with predisposition to internal malignancy and oral lesions– Gardner’s syndrome– Cowden’s syndrome– Multiple endocrine neoplasia syndrome type III– Neurofibromatosis– Gorlin Goltz syndrome– Tylosis– Tuberous sclerosis– Maffuci syndrome
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Conclusion• Oral manifestations of several systemic diseases are of
considerable diagnostic value • By recognizing them the dental clinician can contribute to
early diagnosis of the disease and thereby to the welfare of the patient.
• It is therefore imperative for dental surgeons to be aware of these manifestations
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