Oral Manifestations of Systemic Diseases in Older Patients

Dr shabeel pn

Objectives• Review pertinent

oropharangeal structure and function.

• Examine the relationships between oral symptoms and systemic conditions.

• Discuss clinical decisions pertaining to the topic.

BackgroundThe mouth (buccal cavity) is

the reservoir for the chewing and mixing of food with saliva. It is the primary site of digestion and respiration as well as the primary communication structure.

Background• Drug Reactions• Fungal infections• Viral infections• Leukemia• Behcet’s Disease• Diabetes Mellitus• Nutritional Deficiencies• Amyloidosis

Background DefinitionsGingivitis-inflammation of the gumsXerostomia-abnormal dryness of the

mouth due to insufficient secretions

Mucositis-inflammation of a mucous membrane

Stomatitis-inflammation of the mouth having various causes (as mechanical trauma, allergy, vitamin deficiency, or infection)

Cheilitis-inflammation of the lipGlossitis-inflammation of the tongue

Drug Reactions- SJS and TEN• Stevens-Johnson syndrome and toxic

epidermal necrolysis are rare, life-threatening, drug induced reactions.

• 7 to 21 days after exposure purpuric and erythematous macules evolve to skin necrosis and epidermal detachment.

• Oral mucous membrane involvement occurs in up to 50% of cases and may impair ingestion of nutrition.

• Most commonly implicated in these reactions are sulfonamides, penicillins, phenytoin, and phylbutazone.

Drug Reactions• Drug-induced neutropenia is

typically characterized by circular reddish ulcer on the gingivae or areas of frequent trauma.

• Gingivitis and oral ulcers often occur with chronic neutropenia also.

• Discontinuation of the inducing drug usually results in resolution.

Drug ReactionsRadiation,

immunosuppressant and chemotherapeutic medications are the major treatments associated with stomatitis. Allergic reactions to materials or certain metalloids may also contribute.

Fungal InfectionsThrush• Candida albicans infection is most

commonly found in children. The infection is characterized by white plaques or spots in the mouth that lead to ulcers or painful cracking at the corners of the mouth.

• The patient may experience dysphagia or odynophagia as the first symptoms.

• Candidiasis therefore is a common indicator of impaired immune function whether as in HIV or for other reasons.

• Treatment includes topical nystatin or oral fluconazole as indicated by site or causative organism of infection.

Fungal Infections

Viral Infections- Herpes • The herpes simplex viruses are

categorized as type 1(oral) and type 2 (genitoanal).

• The presentation of cold sores around the mouth is usual but the viruses can occur any place in the body that has broken skin or mucosal surfaces.

• As high as 75% of adults will contract oral herpes by the time they reach their 40s.

• Oral antivirals and pain medications are recommended for treatment of overly painful expressions of this condition.

Viral Infections-Herpes

Viral Infections-HIV• As previously discussed, often oral

candidiasis is the initial symptom with which HIV patients present.

• However, hairy leukoplakia, named for its corrugated appearance, is also seen as white lesions or plaques in the oral cavity. The epithelium is thickened, appears white, but is generally asymptomatic.

• Treatment may be complicated by comorbidites and these should be considered when determining a treatment regimen with antivirals.

Viral Infections-HIV

Leukemia• Infections, bruising, or

hemorrhage of the oral cavity may be caused by thrombocytopenia or leukopenia.

• Rarely, diffuse non-tender gingival enlargment, overall pallor of tissues due to anemia or ulcerative gingivitis may be exhibited.

Behcet’s Disease• Behcet’s disease is a rare disorder mainly

affecting young men. • While the disease affects multiple organ

systems, oral ulcerations reselmbling canker sores present in 99% of patients.

• The oral lesions are the herald of this disease and are usually 6mm or smaller and resolve within 1-3 weeks.

• Treatment is symptomatic and supportive. Medication may be prescribed to reduce inflammation and/or regulate the immune system. Immunosuppressive therapy may be considered.

Behcet’s Disease

Sjögren’s Syndrome• Sjögren’s syndrome is the 2nd most common

autoimmune disease with women in their mid-60’s being the primarily afflicted.

• Initial symptoms include dry eyes and dry mouth due to gradual glandular dysfunction.

• In some cases, dysphagia, increased dental caries, increased susceptibility to oral candidiasis, and difficulty wearing dental prostheses will develop.

• Treatment is generally symptomatic and supportive. Moisture replacement therapies may ease the symptoms of dryness. Nonsteroidal anti-inflammatory drugs may be used to treat musculoskeletal symptoms. Corticosteroids or immunosuppressive drugs may be considered in severe cases.

Sjögren’s Syndrome

Diabetes Mellitus• Increased glucose in the

patients’ system implies hyperglycemia also in saliva.

• Bacteria find this environment more conducive and therefore these patients are more prone to dental caries, gingivitis, and periodontal disease.

Amyloidosis• Disorder characterized by

deposition of insoluble proteins in organs that eventually causes dysfunction of the organ.

• This condition may present as swollen erythematous buccal area if the mucous membranes in that area are involved in the disease process.

Nutritional Deficiencies• Iron deficiency anemia is the most

common cause of anemia in older patients and may manifest as smoothing, reddening or soreness of the tongue.

• Iron deficiency limits erythropoesis and therefore brings about a hypoproliferative anemia.

• In older patients anemia associated with chronic inflammation is common. Nutritional iron deficiency is rare in older adults.

Nutritional Deficiencies• Pernicious anemia affects over 2%

of the population over 60. • This disorder is clinically

characterized by megaloblastic hematopoesis and/or neuropathies.

• Oral manifestation possibilities are glossitis (beefy red tongue) or stomatitis (generalized burning or soreness).

• Treatment with intramuscular or oral Vitamin B12 should follow diagnosis.

Nutritional DeficienciesPernicious Anemia

Nutritional Deficiencies• Thiamine (Vitamin B1) and

Niacin/nicotinic acid (Vitamin B3) are also reported to cause some glossitis and cheilitis.

• Folate deficiency leads to a megaloblastic anemia that demonstrates many of the same oral characteristics of pernicious anemia.– Cheilitis, glossitis, and mucosal

erosions have been described.

Nutritional Deficiencies• Scurvy caused by vitamin C

deprivation may cause petechiae to ecchymoses in the submucosa.

• Mucous membrane changes may lead to gingival hypertrophy and erosive, bleeding gums.

• Teeth may subsequently become soft associated with gingival infection predisposition.

• Replenishment of Vitamin C may prevent further degradation of dental integrity.

Conclusions• The mucosal surface that is

the oral cavity may provide insight into the immune function of the patient.

• Differential diagnosis is important as many disorders may manifest themselves similarly in the buccal area.

ReferencesGreenspan, JS. "Sentinelsand Signposts: the

Epidemiology and Significance of the Oral Manifestations of HIV disease." Oral Diseases May 1997: S13-17.

McCance, Kathryn L., and Sue E. Huether. Pathophysiology The Biologiv Basis for Disease in Adults and Children. 4th ed. St. Louis: Mosby, 2002

Bologna, Jean L., Joseph L. Jorizzo, and Ronald P. Rapini. Dermatology. Spain: Mosby, 2003.

Edwards, Brooks S. Amyloidosis. 2 Aug. 2005. Mayo Clinic. 26 Dec. 2005 <http://www.mayoclinic.com/health/amyloidosis/DS00431>.

References"NINDS Sjogren's Syndrome Information

Page." National Institute of Neurological Disorders and Stroke. 11 Dec. 2005 <http://www.ninds.nih.gov/disorders/sjogrens/sjogrens.htm>.

"NINDS Behcet's Disease Information Page." National Institute of Neurological Disorders and Stroke. 11 Dec. 2005 <http://www.ninds.nih.gov/disorders/behcet/behcet.htm>.

Cobbs, Elizabeth L., Edmund H. Duthie, Jr, and John B. Murphy. Geriatrics Review Syllabus. 4th ed. Dubuque: Kendall/Hunt Publishing Company, 1999.

Questions1. Many conditions may cause oral

discomfort. In an older patient with normal immune function, what are parts of the work up are the first priorities?

2. Describe the possible etiologies of oral ulcerations that are whitish in color.

3. What is the treatment protocol for a patient that manifests epidermal irritation following initiation of a new regimen? What are the most common causes of this reaction?

Questions4. What work up would help determine the

correct cause of iron deficiency anemia?5. Replenishment of cyanocobalamine is

accomplished by more than one route. Describe the appropriate regimens and the attributes and detriments of each.

6. Autoimmune diseases often appear with accompanying conditions. Patients that suffer Sjodgren’s disease often also present with what other diseases?

7. What group of commonly used medications are associated with gingival hyperplasia/dysfunction?

Questions

• What is the etiology of the majority of genitoanal herpes cases? How is this different from the etiology of oral herpes found in the elderly population?

• A new patient reports with general malaise and oral irritation. She is elderly and has many comorbidities. What should the workup include? What are the possibilities for differential diagnoses?

• The patient described in the previous question is found to have low Hgb and Hct levels. Her transferrin level is within normal limits. What other lab(s) should be checked before a diagnosis of anemia of chronic disease is made?