oral manifestations of systemic disease

Dentistry – beyond teeth

skin, GI tract, musculoskeletal conditions 

mouth is the gateway to the rest of your body 

• Thorough intraoral examination can reveal the first signs of an underlying systemic disease.

• Be aware of the relationship between oral lesions and systemic diseases

• Recognition of abnormal, review and refer when appropriate

• Prompt discussion with other healthcare professionals, who may not understand oral presentations.

• Can lead to an early diagnosis and treatment if recognised.

• Be inquisitive

Example – Gingival Swelling 

• 29 year old female Medically well, takes no regular medications Complaining of bleeding and gums

• Dental clinic receptionist

• Seen by one of the dentists, who notes significant generalised gingival swelling

• Reasonably good plaque control

• Pocket depths 3-4mm in all quadrants

• Radiographs – no bone loss

• ask questions - have you noticed anything? weight loss without trying? difficulty swallowing? fever?

• New rash on her arms

• Clinician suspected something systemic, as there did not appear to be a clear local cause 

Example – Gingival Swelling - answers

• Discussed with the GP who undertook screening bloods

• FBC (full blood count)

• Diagnosis of Leukemia – Referred to haematology urgently for treatment and successfully treated

• But the outcome could have been very different

what to look for when patients ‘ walk through the door’ 4

1. are they looking pale

2. do they look well

3. are they short of breath walking a short distance

4. any signs of self neglect 

extra-oral examination 7

1. Facial symmetry

2. Skin abnormalities - rashes, pale, jaundice 

3. TMJ - sounds such as crepitus 

4. Salivary glands - soft, full, firm 

5. Lymph nodes: Submental, Submandibular, Cervical chain, Supraclavicular , Occipital , Posterior auricular , Anterior auricular → early clues for cancers and haematological malignancies , lymph adenopathies 

6. Lips and peri-oral region - crusting - peri-oral erythema 

7. Neck examination

intra-oral examination 10 

1. Oral Mucosa

2. Tongue

3. Floor of mouth

4. Salivary gland ducts

5. Frenum attachments

6. Gingivae

7. Tonsils and oropharynx

8. Teeth

9. Occlusion

10. Prosthesis

start by looking at lips - mucosa buccal - tongue - ventral surface last, back of the throat and hard palate 

Examination - Lymph nodes

if you have a dental infection - the first place the infection will drain is the submental and submandibular NODES 

cervical lymph nodes

Head & Neck infection is the commonest cause of enlargement 

May also be the first sign of systemic disease:

• with infection you tend to get bilateral enlargement of lymph nodes - tenderness

• with malignancies - unilateral and non tender

Glandular Fever,Lymphomas (hodgkins / non-hodgkin) ,Leukaemias ,HIV infection (Seroconversaion illness, or advanced HIV disease), Metastatic disease (usually from drainage)

what is shown here?

• enamel hypoplasia → not the same as hypo-mineralisation 

• Ameloblasts affected during development – less enamel formed Pits, grooves, thinning

enamel hypoplasia vs hypomineralisation

hypo-mineralisation is when you get the correct thickness of enamel but its softer and wears away faster 

hypoplasia - structure is okay - but thinner, incomplete or pitted

what could be the causes of enamel hypoplasia? 6

1. Nutritional deficiencies

   • Vitamin D / Calcium deficiency

2. Pre/Perinatal issues

   • Maternal infections e.g. rubella and syphilis

   • Prematurity / Low birth weight

3. Infectious diseases

   • Febrile illnesses in early childhood

   • Measles, chickenpox, scarlet fever

4. Endocrine

   • Hypoparathyroidism (abnormal calcium/phosphate

   • regulation)

   • Hypothyroidism – delayed tooth eruption

   • Chronic Renal Disease – disrupting calcium/phosphate

5. Coeliac Disease – nutrient malabsorption

6. genetics 

   • amelogenesis imperfecta 

   • down syndrome 

what is this an example of?

abnormally shaped teeth

what causes teeth abnormalities and how can it be presented?

congenital Syphilis → vertically transmitted from the mother 

• Hutchinson’s incisors

• Mulberry molars

abnormal colour of teeth - what causes banding?

tetracycline (antibiotic) during odontogenesis (pregnancy/ very young children)

abnormal colour of teeth - what causes mottling?

fluorosis - excess fluoride

abnormal colour of teeth - what causes olive green teeth?

childhood jaundice/liver disfunction  - through its very rare 

abnormal colour of teeth - what causes purple/red teeth?

prophyria - rare inherited condition where you get porphyrin build up in the body - translucent looking red/purple teeth 

porphyrin is needed to make red blood cells - build up in the body 

abnormal colour of teeth - what causes translucent brown/purple teeth ?

• dentinogenesis imperfecta

• blue sclera and brittle bones 

abnormal tooth surface loss 3 

1. Erosion

   • Extrinsic acids (diet) - buccal and labial 

   • Intrinsic acid (gastric) - occlusal and palatal 

   • GORD – risks of oesophageal metaplasia (Barret's oesophagus) and malignant conversation

   • Bulimia nervosa – Eating disorders

2. Attrition - tooth wear 

   • Bruxism

3. Abrasion - mechanical forces 

   • Toothbrushing / musical instruments / pen biting

abnormalities in the oral mucosa- changes in colour - white 4

1. Candidosis (thrush)  

2. Lichenoid lesion

3. Leukoplakia  

4. Linea alba

Candidosis (thrush) - fungal infections - candida is commensal fungus but can overgrow. pseudomembranous - wipes off with gauze - debris - immunocompromised eg cancer treatments 

Lichenoid lesion auto-immune - don’t come off on wiping - infiltration of lymphocytes → lichen planus, lupus 

Leukoplakia smoking or immunosuppression - white patch of unknown aetiology - higher risks of turning into cancers

Linea alba -stress/anxiety - in line of occlusal plane - indentation of the cheek where you are biting - forms a thickened white area

abnormalities of the oral mucosa - changes in colour - red , examples 5

1. (severity of) Periodontitis – Diabetes, Cardiovascular disease

2. Mucous membrane pemphigoid – Autoimmune

3. Pemphigus Vulgaris – Autoimmune

4. Median Rhomboid Glossitis – Candida

5. Erythroplakia - Smoking

(severity of) Periodontitis – Diabetes, Cardiovascular disease

Mucous membrane pemphigoid – Autoimmune

Pemphigus Vulgaris – Autoimmune

Median Rhomboid Glossitis – Candida - smoker or dry mouth

Erythroplakia (red patch) - Smoking but could be a pre cancer/cancer

abnormalities in the oral mucosa - changes in colour - yellow 3

1. Ulceration

2. Bullae (blistering) causing secondary ulceration

3. Drugs

what causes yellow ulcers in the mouth?

ulceration - loss of the full thickness of epithelium

• Inflammatory bowel diseases - ie chrons diseases - Chron’s is the inflammation of the GI tract - it starts with the mouth - tags,ulcers,cobblestoning

• Malnutrition / deficiency states – Fe, Fo, B12

• Coeliac Disease

• Viral reactivations oral ulcers

• Infections – Herpes, Measles etc

• Bechet's Disease

what causes yellow bullae/blistering in the mouth?

blistering - loss of a bit of the thickness in the epithelium. Blister = fluid filled sac

• can be because of a cancer 

• Bullae (blistering) causing secondary ulceration - Paraneoplastic

• Chemotherapies

• Drugs - hypoglycaemics

what could cause a blue/purple colour change in the oral mucosa?  4

1. Purpura – Idiopathic thrombocytopenia purpura and other hematological abnormalities

2. Haematoma – Bleeding disorders, trauma, drugs

3. Kaposi’s Sarcoma – HIV infection

4. Haematological malignancy

Purpura – Idiopathic thrombocytopenia purpura and other hematological abnormalities/clotting conditions - bleeding under the surface of the skin

Haematoma – Bleeding disorders, trauma, drugs

Kaposi’s Sarcoma – HIV infection

abnormalities in the oral mucosa - grey colour changes 2

1. Amalgam Tattoo - deposits of fine flecs of amalgam - radiopacities 

2. Drugs – hydroxychloroquine, imatinib

changes in colour of oral mucosa - black or brown 4

1. Smokers Melanosis - top right - seen in POC - physiological 

2. Melanoma- skin cancer - rare bottom right

3. Addisons Disease - adrenal insufficiency 

4. Peutz-Jeghers Syndrome - dotted - need to be seen by a GI doctor as theu may experience intestinal polyps 

what are some examples of oral swellings? 4

1. Gingival Hyperplasia

   • Nifedipine ,Cyclosporin ,Phenytoin, Leukaemias

2. Lip swelling

   • Crohn’s Disease / Oro-facial granulomatosis (few years later affects the get)

3. Cobble stoning – Crohn’s Disease - trauma, endoscopy

4. Pregnancy - epulis

textural changes in the oral mucosa 4

1. keratosis – White patches

   • Lichen planus

   • Lupus

   • Immunosuppression

   • Candidosis

   • Syphilis

   • hyperkeratosis - take a biopsy to make sure its not cancer

2. Glossitis →Anaemia or Vitamin deficiencies (need to regenerate the surface of your mouth)→ B12 – pernicious anaemia→ Malabsorption syndromes – coeliac, short bowel syndrome (post surgical)

GI – Crohn’s Disease

• Oral Manifestations - might be the first signs 

  • Lip swelling - bilateral 

  • Deep linear sulcal ulceration- top 

  • Stag-horning - bottom

  • Cobble stoning of the buccal mucosa

  • Glossitis due to secondary malabsorption

• Melkersson-Rosenthal syndrome – facial nerve paralysis (7th cranial nerve)

Coeliac Disease

• Genetic inherited sensitivity to Gliadin component of wheat gluten Small bowel malabsorption - villus atrophy 

• Oral Ulceration

• Angular cheilitis - candida infection 

• Burning mouth

• Glossitis

Ulcerative Colitis

• Inflammation in the colon - malabsorption 

• Shallow non-granulomatous ulceration

• Pyoderma gangrenosum - skin

• Pyostomatitis vegetans – oral - bottom

Auto-immune

• Pemphigus

• Pemphigoid

• Lichen Planus - can be in other areas of the body 

Auto-immune – Lupus

• Discoid Lupus Erythematosis (DLE) - only affects the mouth/skin - no organ involvement

• Systemic Lupus Erythematosis (SLE)

  • ANA/ENA positive – ds-DNA

  • Rheumatological condition

  • Chronic inflammation flattens cheeks

Sjogren’s Syndrome/disease 

Not all dry mouths are Sjogren’s Syndrome

Primary – de novo occurrence

Secondary – Preceded by another rheumatological condition

• Symptoms – Oral and ocular dryness

• Extra-glandular features

  • MSK (Distal joint pain and myalgia)

  • Skin (Dryness, rashes and vasculitis)

  • Lungs (Interstitial lung disease)

  • GI (Swallowing difficulties, pancreatitis)

  • Nervous system (Peripheral neuropathy, fatigue)

  • Renal (interstitial nephritis)

• Antibodies – Ro60 and La

challacombe scale 

measures dry mouth 

Hands / Arms

1. Rheumatoid arthritis

   • Swan neck deformity, ulnar deviation

2. Finger Clubbing

   • Cardiac (IE, heart disease)

   • Pulmonary (COPD)

   • Gastrointestinal (PBC, IBD)

3.  Central Nervous System

   • Parkinsonism tremors

4. Liver diseases

   • Liver palms / palmar erythema and asterixis

5. Infective Endocarditis

   • Splinter haemorrage

Enlarged Tongue - possible causes

1. Endocrine Disorders

   • Acromegaly – Inappropriate secretion of growth hormone (cause? - pituitary tumour)

   • Hypothyroidism - can cause tissue oedema resulting in tongue enlargement

2. Metabolic Disease

Amyloidosis – build-up of amyloid protein in

organs which results in organ damage

• Tongue deposits

• Histopathology – positive staining red to congo-red and birefringence on cross polarised light microscopy

Inflammatory and Infectious

Sarcoidosis – granulomas build-up in different organs

Other conditions

• Genetic syndromes

• Neurofibromatosis

• Haemangioma / hamartoma

• Lymphangiomas

• Neoplasia

Bone changes as a result of systemic disease

• Areas of resorption or patchy resorption and sclerosis in the jaws may be due to skeletal disease and associated with changes in blood chemistry.

• Paget's disease →Results in excessive breakdown of bone and dysregulated remodelling.

• Bony metastases - mental region in the mandible - radiolucency 

• Hyperparathyroidism