oral manifestations

1. ORAL MANIFESTATIONS
OF SYSTEMIC DISEASES

2. CONTENTS
 Infections
 Hematologic Diseases
 Cardiovascular Disease
 Rheumatologic Conditions
 Mucocutaneous Disorders
 Gastrointestinal Disorders
 Endocrine Disorders

3. Introduction
 Diagnosing and treating mucosal lesions of the mouth and gums may be
challenging for many clinicians because of the wide variety of conditions that
can present with similar-appearing lesions.
 Oral manifestations are symptoms or conditions in the mouth that can
occur as a result of diseases affecting other organs.

4. Infections
Disease site Oral manifestation
Acute necrotising
ulcerative gingivitis
Gingiva Painful,bleeding gingiva
characterised bynecrosis
and ulceration of gingival
papillae, halitosis
Tuberculosis Tongue, tonsillar area,
soft palate
Painless, solitary 1-5cm
irregular ulcer covered
with persistent exudate,
ulcer has firm ,
undermined border

5. Infections
Type of
syphilis
site Oral manifestation
Prenatal
syphilis
Palate, jaws,
tongue and teeth
Gummatous involvement of palate,
jaws and facial bones,
Hutchinson’s incisors,
mulberry molars,
fissures at corner of mouth

6. Infections
Type of
syphilis
site Oral manifestation
Primary
Syphilis
Lips, tongue or
tonsils
Small papule developing rapidly into
large painless ulcer with indurated
border, chancres and lymph nodes
containing spirochetes

7. Infections
Type of
syphilis
site Oral manifestation
Secondary
Syphilis
Oral mucosa,
palate,
commisures of lip
Maculopapular lesions of oral mucosa
Tertiary
syphilis
Palate and tongue Gummatous infiltration of palate and
tongue followed by ulceration and
fibrosis

8. Infections
Disease site Oral manifestation
Chicken pox Gingiva and oral mucosa Small vesicles that rupture to
form shallow ulcers in oral
mucosa, may coalesce to form
large bullous lesions when they
ulcerate.

9. Infections
Disease site Oral manifestation
Recurrent herpes
labialis
Mucocutaneous junction
of lip, perioral skin
Vesicles that may coalesce ,then
rupture and crusr, painful to
pressure or spicy foods
Recurrent oral
herpes simplex
Palate and gingiva Small vesicles on keratinized
epithelium that rupture and
coalesce ;painful

11. Infections
Disease site Oral manifestation
Histoplasmosis Gingiva, tongue or palate
and all areas of mouth
Nodular, verrucuous, or
granulomatous lesions, ulcers are
indurated and painful,

12. Heamatologic diseases
WHITE BLOOD CELL DISORDERS
 Bacterial infections are predominant adverse sequelae of agranulocytosis.
 Bacterial infections involving the periodontium and/or oral mucosa are thus
the oral sites most typically involved.
 As with comparable patients with substantially reduced number and function
of neutrophils, risk for bacterial infection increases as the depth and duration
of the neutropenia increases.
MANAGEMENT
(i) localized wound care (e.g., oral rinses with chlorhexidine digluconate 0.12%
q.i.d.) as well as
(ii) antibiotic therapy based on antibiotic sensitivity to the cultured organism.

13. WHITE BLOOD CELL NEOPLASMS
 Hematologic cancers such as leukemia and lymphoma can involve the oral soft
tissues either as a metastatic lesion (e.g., leukemic infiltrate) or a primary
malignancy of the oral cavity (e.g., lymphoma).
 Metastatic tumor infiltrate to the gingiva may occur in acute leukemia
patients , producing engorged, inflamed interdental papillae that are prone
to secondary infection due to impaired mucosal immune surveillance as well
as difficulty for the patient to maintain oral hygiene.
 Lymphoma may present as solitary or multiple soft tissue infiltrates involving
mucosal and/or lymphoid structures.
 These masses may involve oropharyngeal structures (e.g., Waldeyer’s Ring)
and/or cervical node lymphadenopathy that is firm and often painless to
palpation.

14.  While the oral mucosa is often affected by stomatotoxic cancer
treatment, the dentition, periodontium, and/or salivary glands can also
be compromised.
 The reduced white blood cell homeostasis contributes to a shift in
subgingival microflora that can cause localized gingival and potentially
systemic infection.
 Oral mucositis occurs in virtually all patients receiving high dose head
and neck radiation
 Osteoradionecrosis (ORN) occurs in approximately 10% of patients
receiving high dose head and neck radiation

15. RED BLOOD DISORDERS
ANEAMIA
 Anemia, regardless of etiology, can result in clinically significant oral
manifestations including oral mucosal pallor, angular cheilitis,
opportunistic infection, glossodynia, and delayed wound healing.
 decreased mandibular trabeculation based on radiographic examination,
consistent with increased mandibular bone marrow activity
 Glossodynia can develop secondary to both neuropathic sensory
disturbances as well as secondary Candida infection in setting of reduced
levels of filiform papillae, as well as impaired mucosal immune
surveillance.

16. PLATELET DISORDERS
 Oral lesions can include petechiae, ecchymoses, or purpura of the oral
mucosa, as well as spontaneous oozing of blood from the gingiva and
periodontium.
 Risk for clinical appearance of oral bleeding due to decreased platelet
number typically becomes clinically significant when baseline circulating
platelet counts are <25,000/mm3.

17. HEAMOPHILIA
 mucosal haemorrhage secondary to trauma as well as gingival and periodontal
bleeding can develop in patients with hemophilia A and hemophilia B.
 Extent of oral bleeding is determined by severity of the respective clotting
factor deficiency in relation to the severity of trauma (e.g., mucosal injury)
or pre-existing inflammation (e.g., chronic inflammatory periodontal
disease).

18. Cardiovascular Disease
HYPERTENSION
DRUGS ORAL MANIFESTATION
Diuretics Dry mouth, lichenoid reactions and taste
changes
Calcium channel blockers gingival hyperplasia,dry mouth, altered taste,
and erythema multiforme
Angiotensin II receptor
blockers
Dry mouth, angioedema, sinusitis, and
altered taste
Alpha blockers Dry mouth and taste changes
Beta blockers dry mouth, taste changes, lichenoid
reactions and oral ulcers
ACE Inhibitors loss of taste, dry mouth, lichenoid reactions,
ulcerations, burning
mouth, and occasional gingival bleeding

19. Cardiovascular Diseases
ANTICOAGULATION
 Oral manifestations of anticoagulant and antiplatelet therapy are rare.
 Minor trauma to the oral mucosa may cause various hemorrhagic lesions,
including petechiae, purpura, ecchymosis, hemorrhagic bullae, and
hematoma formation
 gingival bleeding may result from trauma.

20. Rheumatological disease
BEHÇET’S DISEASE
 Oral ulcers (92–100%) ,genital ulcer (57–93%) , and cutaneous lesions
(38–99%) collectively, with ocular(29–100%) and articular (16–84%)
involvement, are the most frequent features of BD.
 Oral ulcers are recurrent and painful ulcerations with a short duration
of time and
 The lesions start as an erythematous,slightly raised area evolving into
an oval or round ulcer within 2–3 days, with rolled borders and a grayish
yellow necrotic base.

21. Rheumatological disease
SYSTEMIC LUPUS ERYTHEMATOSUS
 The classical oral lupus lesion is a whitish plaque with erythema or erosive
lesion in the center and keratotic striae in the periphery.
 Sometimes with telangiectasia, which can be seen on lips, buccal mucosa, and
gingival tissues .
 Red mucosal macules and plaques, mucosal ulcers, and lesions resembling
lichen-planus or leukoplakia are also reported in patients with SLE.
 Chronic ulcers, or discoid lesions, in lupus carry an additional risk of malignant
transformation into squamous cell carcinoma compared to other ulcerative
lesions with those showing high-risk dysplasia.
 Dysphagia and xerostomia.

22.  Histological characteristics include discoid lesions of the oral cavity showing
hyperkeratosis with keratotic plugs, liquefaction/ vascular degeneration of
the basal epithelial cells,thickening of the basement membrane, atrophy of
rete ridges, edema in the lamina propria, and subepithelial mononuclear
infiltrate.

23. SYSTEMIC LUPUS ERYTHEMATOSUS
Management
 Avoidance of sunlight with at least UVB-15 protective sunblock.
 Topical or intralesional corticosteroids may be considered. Glucocorticoids
should be administered only intermittently and not long term.
 If there is no response to topical therapy, systemic therapies, including
antimalarial agents, prednisone, thalidomide, and methotrexate should also
be considered.
 Secondary infections (e.g., viral and fungal infections) must be addressed for
continued corticosteroids users (topically or systemically).
 Biopsy is required for nonresponding ulcers or discoid lesions in the oral
cavity to ensure that an oral SCC is not developing.

24. Mucocutaneous Disorders
PEMPHIGUS
 PV commonly presents with oral lesions in up to 70% of cases.
 These lesions may be the initial and only sign of disease.
 Cutaneous lesions tend to develop an average of 5 months after oral involvement
 A positive “Nikolsky sign” is often noted in association with both mucosal and
cutaneous lesions, wherein blisters may be induced or expanded when lateral
pressure is applied to the tissue, although this practice should not be encouraged.
 oral mucosal lesions appear as intact fluid filled vesicles and bullae that rupture
easily and form tender irregular mucosal erosions and ulcers
 Desquamative gingivitis is often noted in severe cases where the blisters have
ruptured leaving areas of peeling tissue with red erosions and ulcers

25. Mucocutaneous Disorders
PEMPHIGOID
 The oral manifestations of bullous pemphigoid and MMP are similar.
 Patients commonly present with bleeding, pain, or desquamation of the oral
mucosa.
 Vesicles or bullae may occur anywhere on the oral mucosa, and there may be
a positive Nikolsky sign.
 Blisters eventually rupture leading to irregularly shaped ulcers.
 gingiva is the commonest site of involvement, followed by the palate, buccal
mucosa, and tongue.

26. MANAGEMENT
 Active autoimmune vesiculobullous diseases are generally managed with a
combination of long term topical and/or systemic immunosuppressant
medications.
 The most common group of these medications is corticosteroids.

27. GASTROINTESTINAL DISORDERS
CELIAC DISEASE
 The prevalence of recurrent aphthous ulceration in patients with CD has been reported to be
significantly higher than in the general population.
 permanent teeth enamel defects.
Grade I: Defect in color of enamel Single or multiple creams, yellow or brown opacities with
clearly defined or diffuse margins; a part or the entire surface of enamel is without
glaze
Grade II: Slight structural defects Enamel surface rough, filled with horizontal grooves or shallow
pits; light opacities and discoloration may be found; a part or the entire surface of
enamel is without glaze
Grade III: Evident structural defects A part or the entire surface of enamel rough and filled with
deep horizontal grooves that vary in width or have large vertical pits; large opacities of
different colors or strong discoloration may be in combination
Grade IV: The shape of the tooth changed: the tips of cusps are sharp-pointed and/or the incisal
edges are unevenly thinned and rough; the thinning of the enamel material is easily
detectable and the margins of the lesions are well defined; the lesion may be strongly
discolored.

28. MANAGEMENT
 gluten-free diet is effective management of the ulcers.
 use of topical corticosteroids and systemic medications such as pentoxifylline,
doxycycline, zinc sulfate, colchicine, clofazimine, prednisone, montelukast
sodium, sulfones, thalidomide, methotrexate, cyclosporin, chlorambucil,
infliximab, etanercept, interferon -α, azathioprine, and levamisole.

29. GASTROINTESTINAL DISORDERS
INFLAMMATORY BOWEL DISEASE
 Oral lesions may be the primary presenting signs preceding gastrointestinal
symptoms in 5–10% of affected patients.
 Oral lesions may become more severe during active gastrointestinal disease;
however, up to 30% of patients may continue to manifest oral lesions despite
disease control.
 broadly classified as“specific” or “nonspecific.”

30.  CHRONS DISEASE specific lesions include:
 Mucosal tags, usually noted in the labial and buccal vestibules and in the
retromolar region. Up to 75% of these lesions may show noncaseating granulomas
on histopathology. No direct association of these lesions with intestinal CrD
activity has been reported.
 Cobblestoning of the buccal mucosa with fissured swelling and corrugation, with a
hyperplastic appearance. This is generally noted on the posterior buccal mucosa
 Mucogingivitis, with the gingiva appearing edematous, granular, and hyperplastic,
with or without ulceration . The entire height of the gingiva may be involved.
 Lip swelling with vertical fissures (Fig. 42), deep linear ulcerations (usually in the
buccal sulci with hyperplastic folds), and midline lip fissuring may also occur in
CrD. These lesion also have no clear association with intestinal CrD activity.

31.  Nonspecific oral lesions include:
 Aphthous-like ulceration reported to occur in up to 10% of patients with UC,
and 20–30% of those with CrD
 Pyostomatitis vegetans which may occur in CrD but more frequently in UC
 Angular cheilitis
 Persistent submandibular lymphadenopathy

32.  MANAGEMENT
 Management of the oral manifestations of IBD usually involves treatment of
the underlying intestinal disease.
 In severe cases with local oral symptoms, topical and/or systemic
corticosteroids and immunosuppressive drugs may be indicated.

33. ENDOCRINE DISORDER
DISORDER ORAL MANIFESTATION
Addison’s
disease
Melanotic pigmentation of oral mucosa
oral candidiasis
Hypothyroidism Oral candidiasis
Enlargement of tongue
Delayed eruption of teeth
Diabetes
mellitus
Xerostomia
Compromised periodontal health
Oral candidiasis
Lichenoid drug reactions

34. Renal failure
Condition Oral manifestation
Chronic renal failure Oral purpura
Mucosal ulceration
Pallor of mucosa
White plaques
Giant cell lesions

35. CONCLUSION
 Oral manifestations of systemic diseases are common and diverse.
 They may be the direct result of disease pathology, secondary infiltrative
processes, or treatment-related adverse effects.
 Oral manifestations can be the presenting symptom for many systemic
diseases, and thus a careful medical and social history is critical to ensure
that diagnosis and treatment are not delayed.

36. REFERENCES
 Yeoh, Sue-Ching & Hua, Hong & Yepes, Juan & Peterson, Douglas. (2019). Oral
Manifestations of Systemic Diseases and Their Treatments: A Comprehensive
Approach to Clinical Practice. 10.1007/978-3-319-72303-7_18.
 Harrison’s Principles of internal Medicine

37. THANK YOU