for dental student

1. RESOURCE FACULTY PRESENTED BY
 DR.ASHISH SHRESTHA
ASSOCIATED PROFESSOR
AND HOD
DR.TARAKANT BHAGAT
ASSISTANT PROFESSOR
(DEPARTMENT OF
PUBLIC HEALTH DENTISTRY)
BPKIHS,NEPAL
 PAPULAR CHAUDHARY
ROLL NO:491
4everpapular@gmail.com
 SANTOSH PANDIT
ROLL NO:502
bless288maniac@gmail.com
BATCH 2011
ORAL MANIFESTATIONS OF SYSTEMIC DISEASE
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2. Oral Manifestations of Systemic Diseases
 Many systemic diseases are reflected in the oral mucosa,
maxilla, and mandible.
 Mucosal changes may include ulceration or mucosal bleeding.
 Immunodeficiency can lead to opportunistic diseases such as infection
and neoplasia.
 Bone disease can affect the maxilla and mandible.
 Systemic disease can cause dental and periodontal changes
 Drugs prescribed for a systemic disease can affect oral tissue.
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3. Oral Manifestations of Systemic Diseases
(cont.)
 Local factors may be involved in the manifestation of
systemic disease in oral mucosa.
 The mucosa may be more easily injured due to a systemic disease,
and mild irritation and chronic inflammation may cause lesions
that otherwise would not occur.
 These may include
 Endocrine disorders, disorders of red and white blood cells,
disorders of platelets and other bleeding and clotting disorders,
and immunodeficiency disorders
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4.  Auto immune diseases
 AIDS
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5. Systemic lupus erythematous
 Lupus characterized by acute and chronic inflammation of various tissues of the body.
 When the skin is involved, the condition is called lupus dermatitis or cutaneous lupus
erythematosus.
 A form of lupus dermatitis that can be isolated to the skin, without internal disease, is
called discoid lupus.
 When internal organs are involved, the condition is referred to as systemic lupus
erythematosus (SLE)
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6. CRITERIA FOR diagnosis of SLE
 MALAR RASH: fixed erythema over the
malar eminences(butterfly rash)
 DISCOID RASH: erythematous raised
patches with adherent keratotic scaling &
follicular plugging.
 PHOTOSENSITIVITY: Skin rash
 ORAL ULCERS: oral or nasopharyngeal
ulceration,usually painless
 ARTHRITIS: Non erosive arthritis
 SEROSITIS: pleuritis & pericarditis
 RENAL DISORDER: persistent proteinuria
 NEUROLOGIC DISORDER: seizures,
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7.  HEMATOLOGICAL DISORDER: hemolytic anemia, leucopenia, lymphopenia,
thrombocytopenia.
 IMMUNOLOGIC: anti- ds DNA, anti Sm & antiphospholipid antibodies
 ANTINUCLEAR ANTIBODY: abnormal
 (for the diagnosis of SLE four or the above criteria should either be present
simultaneously or serially)
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8. Oral aspects
 Characteristic oral lesions, non
specific ulceration, salivary gland
disease, TMJ disorders.
 Angular cheilosis, mucositis,
glossitis, glossodynia, dysgeusia,
dysphagia, dry mouth.
 Lip lesion: central atrophic &
occasionally ulcerated area with
small white dots surrounded by
keratinized border composed of
small radiating white striae.
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9. INTRA ORAL LESION:
composed of a central depressed red atrophic area surrounded by 2-4
mm elevated keratotic zone that dissolve into a white line.
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10. Discoid lupus erythematus
 DLE is a chronic, scaring, atrophy producing, photosensitive
dermatosis.
 DLE may occur in patients with SLE.
 <5% DLE progress to SLE .
• PATHOPHYSIOLOGY
 Suggested that heat shock protein is induced in
keratinocyte followed by UV light exposure or stress, and
this protein act as target for T-cell mediated epidermal cell
cytotoxicity.
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11. Clinical features
 Age: 3rd -4th decade.
 Sex female>male.
 Common sites:
• Face, oral mucous membranes, chest, back and extremities.
• Cutaneous lesion are slightly elevated red of purple macules that are often covered by
grey or yellow adherent scales.
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12. Contd…
• Forceful removal of scale result in “carpet track” extension .
• Typical “butterfly” distribution on malar region and across the bridge of
the nose.
• Epidermoid carcinoma and less commonly basal cell carcinoma is reported
in healed ulcer.
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13. Oral manifestation
 Oral mucous membrane involvement rate is 20-50%.
 Oral lesion in discoid form begin as erythematous area, some times slightly
elevated but more often depressed.
 No induration.
 Occasionally superficial ,painful ulceration may occur with crusting or
bleeding.
 No scale formation .
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14.  Margin are not well demarcated but frequently show narrow zone of keratinization.
 Central healing may result in depressed scarring
 In case of tongue atrophy of papilla and severe fissuring may be seen.
 Erythematous, artophic plques , surrounded by kertotic border, may involve the entire
lip.
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15. Sjogren Syndrome
 an autoimmune disorder in which immunocytes damage the salivary and
lacrimal glands, and other exocrine glands.
-primary Sjogren syndrome(SS-1)-dry mouth and dry eyes are seen in the
absence of connective tissue disease. Also termed as SICCA Syndrome. Less
common
-Secondary Sjogren syndrome(SS-2)-Dry mouth dry eyes along with the
connective tissue disease and is more common.
 Common connective tissue disorder are
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16. incidence
 Can affect any age, but onset is more common 40-60 yrs
 F>M
etiology
 Specific antigen in SS is unknown
 Possible etiological factors may be
 Genetic association to HLA class II antigens
 connective tissue disease
 Viruses such as EBV, Hep C, HIV
 Graft versus Host disease
 Liver disease
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17. Clinical presentations
A)oral signs and symptoms
 Dry mouth
and erythematous mucosa
 Cracker sign
 Burning sensation
 Salivary gland swelling and
 sialedinitis
 Caries
 Candidiasis
 Abnormal taste and malodour
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18. B) Ocular Signs and Symptoms
 Keratoconjuctivitis sicca
 Foreign body sensation
 Inability to tear
 Light intolerance
C)Others
 Fatigue
 Fever
 Kidney, muscle, nerve, liver, joint, thyroid
involvement
 Connective tissue disease
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19. SYSTEMIC SCLEROSIS
 Autoimmune collagen vascular disease characterized by fibrosis,
vascular alterations
 Systemic sclerosis describes the multisystem nature.
 Clinical types:
1)circumscribed plaques or bands
2)linear morphea
3)fronto parietal lesion with or without hemiatrophy of face
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20.  Incidence
 Greatest incidence in 30-50 years of age.
 F:M = 3-6:1
 Etiology
 Genetic predisposition
 Microchimerism.
 Cytomegalovirus
 Organic solvent and other chemicals
 Chronic renal failure.
 Drugs such as Bleomycin
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21. Oral manifestations
 Difficulty in opening mouth and loss of tongue movement
due to perioral and lingual fibrosis
 Lips become thin, rigid & fixed producing microstomia
 Maxillary anterior teeth are exposed due to retraction of lips
 Crenations of buccal mucosa and tongue has been reported
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22.  Tongue, soft palate & larynx are usually involved
causing mild edema followed by atrophy & induration of
mucosal & muscular tissues.
 Tongue becomes stiff & border like causing difficulty in
eating & speaking.
 Gingival tissues are pale & firm.
 Dysphagia, limited mouth opening, Trismus
 Salivary changes similar to Sjogren syndrome
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23.  Classic radiographic finding is generalized symmetric widening of
periodontal ligament space(2-4 times) which is seen in almost all the
patient.
 Bone resorption at the angle of mandible
 And may destroy condylar and coronoid process of mandible
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24. Dental aspect
 Dysphagia and pulmonary, cardiac or renal disease as
potential C.I for G.A
 Constriction of oral orifice leading to limited mouth
opening(fish mouth)
 Tongue become stiff and less mobile due to
submucosal tissue involvement(chicken tongue)
 Involvement of peri-articular tissue of TMJ together with
microstomia limits assess to the mouth.
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25.  The mandibular angle may be resorbed of rarely there is
resorption of TMJ.
 Penicillamine therapy may cause loss of taste, oral
ulceration, lichenoid reaction and other complications
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26. pemphigus
 Derieved from Greek word; pemphix: bubbleblister)
 Refers to group of auto immune disease characterized by
development of vesiculobullous lesion in the skin and
mucous membrane.
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27. Clinical features
 Vesiculo – bullous lesions
 Oral mucosa involvement (50-70%)
 Nikolsky’s sign (+)
 Bulla spread sign (+)
 Sites – scalp, face, trunk, groin
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28. Oral manifestation
 About 90% of the patients show oral lesion whereas 60% of the patients present as the first
sign in oral mucosa.
 May occur anywhere in the oral mucosa however common sites are palate, buccal, mucosa,
gingiva
 In gingiva may give rise to desquamative gingivitis
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29. Oral manifestation
Highly painful, bleed easily
Filled with clear watery fluid which may become hemorrhagic or
purulent with ragged borders.
Size varies from few millimeters to several centimeters.
Intact bulla is rarely seen, most of the time its eroded lesion
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30. Mucosal lesions heal without scarring. However, oral mucosa often
shows the formation of keratotic lesion following healing
In addition, there will be foul smell, excessive salivation and difficulty
in taking food
The course of the disease is very rapid, one either terminating in
death or recovery within few days or weeks.
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31. Pemphigus vegetans
 Benign variant of PV because the patient demonstrate the ability to
heal the denuded areas.
 Two types:
 Neumann type:similar to PV
 Hallopeau type: pustules rather than bullae
 Gingival lesions may be lace-like ulcers with purulent surfaces on a red
base or have a granular or cobblestone appearance
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32. Pemphigoid
 Two major types of pemphigoid
I. Bullous pemphigoid.
II. Mucous membrane pemphigoid.
 Though in contrast to pemphigus, lesion are larger and leave denuded area while
they brust, do heal and rarely fatal.
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33. Bullous pemphigoid (BP)
 Age- 60 – 80 years
 Sex - M : F = 2 : 1
 Pathogenesis:
Interaction of auto-antibody with BP antigen on the lamina lucida
of the basement membrane
Complement activation and attraction of neutrophils and
eosinophils
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34. Clinical features
 Bullous lesions
 Sites - Axillae, acral region, trunk
 Oral mucosa - usually not often
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35. 6/17/2015
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36. Mucous membrane pemphigoid(cicatricial pemphigoid)
 Skin involvement is less common, oral mucosa being the most common
site i.e 90% and 2nd being the conjuctiva
 Age 60-80 years
 Male=female
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37. Clinical presentations
– Common sites: limbs, abdomen, axilla, face and groin
– Urticaria or eczema may persist for several weeks to several months before
vesico-bullous lesion appear.
– These vesicles and bullae are thick-walled and tensed and may remain for some
days. Rupture doesn’t always occur.
– Oral, eye and skin lesions are present.
– Bulla spread sign and Nikolsky’s sign are negative.
– Lesions heal with milia formation.
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38. Oral manifestations
 Seen in 30-50% of patients
 However oral lesions are smaller, less painful and form more slowly
then pemphigus vulgaris
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39. Oral manifestations
 Desquamative gingivitis most common oral manifestations and may be
the only site
 Gingival lesions consists of generalized edema, inflammation, and
desquamation with localized areas of discrete vesicle formation
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40. Lichen planus
 It is a rather common chronic mucocutaneous disease, which probably arises due to an
abnormal immunological reaction.
 Disease presented with characterstic volaceous polygonal puritic papules.
 Malignant tranformation potential = 0.4-2%.
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41. Etiology
 Exact etiological cause is unknown.
 Predisposing factors:
I. Emotional stress.
II. Trauma and infection.
III. Grinspan’s syndrome.
IV. Hereditary.
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42. Clinical feature
I. Age >40 years.
II. Female to male ratio 1.4:1.
III. Skin lesions.
 Small angular flat-topped only few mm in diameter. On course of disease they may
be discrete or gradually coalesce into larger plaque cover by fine glistening scale.
 Initially disease lesion appears red, but they soon take reddish , purple and
violaceous hue. Later on dirty brown colour develops.
 Wickham’s straie.
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43. Oral manifestations
- Commonly occurs in mucosal surface of buccal mucosa , vestibules, tongue,lips, floor
of the mouth, palate.
 Appears weeks or months before the skin
lesions.
 Lesions are bilaterally symmetrical.
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44.  Usually asymptomatic but patient may complaint of pain, burning sensation
and intolerance to spicy food
 Begins as small white papules that coalesce to form interlacing network of
white lines (Wickham’s striae)
 Erythematous atrophic and erosive (erosive OLP) white lesions are common
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45.  Reticular OLP has classical
features and do not require
biopsy to diagnose
 Hypertrophic white plaques
may occur sometimes and
intact bullae (bullous OLP) are rarely seen
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46.  Common site is buccal mucosa(78-87%),followed by tongue and gingiva
 Koebner’s phenomenon present
 Oral lesions tend to be bilateral and symmetrical
 Erosive lesion on gingiva resembles desquamative gingivitis
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47. Lichen Planus
Reticular, lace-like pattern
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48. Atrophic
Lichen Planus
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49. Lichen Planus
Erythematous LP
with reticular
pattern
From: Eisen: Oral Diseases, 11(6).November 2005.338-349
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50. Lichen Planus
 Erosive
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51. Lichen Planus
Desquamative
gingivitis
From: Eisen: Oral Diseases, 11(6).Novermber 2005.338-349
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52. Recurrent aphthous stomatitis
 Definition: Recurring episodes of small, round or oval ulcers with circumscribe
margin, erythematous halo and a yellow or grey floor, present from childhood or
adolescence and each episode last for 1 to 4 weeks before healing
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53. 6/17/2015
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54. Clinical Features
 Common disease afflicts 20% of the population
 High prevalence: higher socio-economic classes
 Three main clinical types of RAS:
1. Minor aphthous ulcers (Mikulicz ulcers): 80%
2. Major aphthous utcer (Sutton's ulcers): 10%
3. Herpetiform type ulceration: 10%
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55. Main features of recurrent
aphthous
stomatitis
Feature Minor aphthae Major
aphthae
Herpetiform
Age of onset
Symptoms
Ulcer size
Shape of ulcer
Number of u1cers
Sites affected
Duration of each
Ulcer
Other comments
Childhood or adolescence
Minimal
2-4 mm
Round or ovoid
Up to about six
Non-keratinised mobile
mucosae, Vestibule,
Labial, Buccal mucosa
and floor of mouth,
rarely dorsum of. tongue,
Gingiva or palate
Up to 10 days
Heal with little or no scar
Childhood or
adolescence
More painful
May be 10mm or
larger
Round or ovoid
up to about six
Any site
Up to 1 month
May heal with
scarring
Young adult
Extremely painful
Initially tiny, ulcers
coalesce
Ragged
10-100
Any site but often on
ventrum of tongue
Up to I month
Affect females
predominantly
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56. BEHCET’S DISEASE
 Rare multisystem, chronic disease characterized by oral and genital
mucocutaneous ulcerations, skin rashes, arthritis, thrombophlebitis,
uveitis, colitis, and neurologic symptoms.
 Also known adamatiades syndrome.
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57. Reiter’s syndrome
 Disease of unknown etiology.
 Common on age group of 25-35 years.
 Consider as an important complication of non gonococcal urethritis.
 Oral lesion occurs in less than 5% to 50% of patient with disease.
 Consist of tetrad of :
1. Urethritis
2. Arthritis.
3. Conjunctivities.
4. Mucocutaneous lesion.
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58. Oral manifestations
 Lesions are painless, red, slightly elevated areas with a white circinate
border on the buccal mucosa, lips and gingiva.
 Palatal lesions appears as small ,bright red purpuric spots which
darken and coalese. Tongue represents “geographic tongue”.
Note: Clinically similar lesion are seen on the glans penis, producing a circinate
balanitis
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59. Wegner granulomatosis
 Disease of unknown etiology.
 Involve vascular renal and respiratory systems.
 Disease characterize by necrotizing and granulomatous vasculitis.
 Clinical types:
1. Generalize or classic wegener’s granulomatosis.
2. Localized or limited wegener’s granulomatosis.
3. Superficial wegener’s granulomatosis.
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60. Oral manifestations
 Starts with tumor like vegetations in mouth and nose, then inflammatory process
starts in nose and inter dental papilla spreading upto periodontium.
 Ulceration can occur, usually perforating in nature.
 Strawberry gingiva characterized by ulceration, friable granular lesions.
 Mobile teeth .
 Palatal destruction resulting in oro nasal communication.
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61. Oral manifestations of HIV
CLASSIFICATION
Group 1 :
LESIONS STRONGLY ASSOCIATED WITH HIV INFECTIONS
 Candidiasis : Eythematous
Pseudomembranous
 Hairy leukoplakia
 Kaposi’s sarcoma
 Non- Hodgkin’s lymphoma
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62.  Periodontal diseases :
Linear gingiva erythema
Necrotizing ulcerative gingivitis
Necrotizing ulcerative periodontitis
Group 2
LESIONS LESS COMMONLY ASSSOCIATED WITH HIV
 Bacterial infections: M.avium - intracellulare
 M. tuberculosis
 Melanotic hyperpigmentation
 Necrotizing ulcerative stomatitis
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63. LESIONS SEEN IN HIV INFECTION
 Bacterial infections :Actinomyces israeli
Escherichia coli
Kliebsella pneumoniae
Cat scratch disease
 Drug reactions: Ulcerative
 Erythema multiforme
 Lichenoid reaction
 Toxic epidermolysis
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64. • Fungal infections other than candidiasis
 Cryptococcus neoformans
 Geotrichum candidiasis
 Histoplasma capsulatum
 Zygomycosis
 Aspergillus flavus
• Neurologic disturbances : Facial palsy
Trigeminal neuralgia
• Recurrent apthous stomatitis
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65. Oral manifestation can be broadly clasified as
 Fungal lesions
 Viral lesions
 Bacterial lesions
 Neoplastic lesions
 HIV associated other lesions
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66. Fungal lesions
 Candidiasis
 Histoplasmosis
 Cryptococcus neoformans
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67. Viral lesions
 Herpes simplex
 Herpes zoster
 Human papilloma virus
 Cytomegalovirus
 Epstein-Barr Virus(oral hairy leukoplakia)
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68. Bacterial lesion
 Periodontal diseases :
 Linear gingival erythema
 Necrotizing periodontal disease(NUG,NUP)
 Tuberculosis
 Syphilis
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69. Neoplastic lesions
 Kaposi’s sarcoma
 Oral squamous cell carcinoma
 Non –Hodgkin’s lymphoma
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70. Other lesions
 Recurrent apthous ulcer
 HIV associated salivary gland disease
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71. CANDIDIASIS
 The most common opportunistic infection
 CD4 cells counts< 400 cells/mm^3
 4 clinical presentation:
 Pseudomombranous or oral thrush
 Erythematous
 Hyperplastic
 Angular cheilitis
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72. Pseudomembranous candidiasis
 Most common type.
 Usually asymptomatic.
 Usually extensive involving more than one site
 Manifests as white or yellowish single or confluent plaque that is scrappable,
exposing erythematous area.
 May also extend to oropharynx and esophagus.
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73. Erythematous/ atrophic
 Site: dorsum of the tongue,palate and buccal mucosa.
 Appears as a reddish macular lesion, or depappilation on the dorsum of the
tongue.
 May present alone or in combination with pseudomembranous candidiasis.
 Tongue lesion are also referred as central papillary atrophy.
 Long standing lesion:mucosal ulceration
 Some may complain of occasional burning sensation .
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74. Hyperplastic
 Uncommon and found in severly immunocompromised.
 Manifests as white or discolored plaques which cannot be scrapped out
 Burning sensation, Dysphagia
 Feeling of having large piece of cotton in mouth
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75. Angular cheilitis
 Can be due to mixed infection of candida albicans and staphylococcus aureus.
 Manifests as erythema &/or fissuring and/ or scaling of angle of mouth.
 May be present with intraoral candidiasis.
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76. pseudomembranous Erythematous
Hyperplastic
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77. Thank you6/17/2015
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78. Oral Manifestations of systemic
diseases II
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79. Learning objectives
 Be able to enumerate the major oral manifestations of
blood disorders,renal disorders,GI disorder, diabetes,
respiratory diseases
 Be able to list the dental considerations and management
of these systemic disorders
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80. Blood Disorders
 Disorders of Red Blood Cells and Hemoglobin
 Disorders of White Blood Cells
 Bleeding Disorders
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81. Disorders of Red Blood Cells
and Hemoglobin
 Iron Deficiency Anemia
 Pernicious Anemia
 Folic Acid and Vitamin B12 Deficiency Anemia
 Thalassemia
 Sickle Cell Anemia
 Aplastic Anemia
 Polycythemia
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82. Anemia
 A reduction in the oxygen-carrying capacity of blood
 Most often related to a decrease in the number of circulating red blood cells
Nutritional anemias
 A deficiency in a substance required for the normal development of red blood
cells, commonly vitamins
 Suppression of bone marrow stem cells
6/17/201582

83. Anemia (cont.)
 Clinical features
 Pallor of skin and oral mucosa
 Angular cheilitis
 Erythema and atrophy of oral mucosa
 Loss of filiform and fungiform papillae on the dorsum of the tongue
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84. Iron Deficiency Anemia
 An insufficient amount of iron is supplied to bone marrow for red blood cell
development.
 May occur as a result of deficient iron intake, blood loss from heavy menstrual bleeding or chronic
gastrointestinal bleeding, poor iron absorption, or an increased requirement for iron in situations such
as pregnancy or infancy
 Plummer-Vinson syndrome may result from long standing iron deficiency anemia.
 Includes dysphagia, atrophy of the upper alimentary tract, and a predisposition to developing oral
cancer
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85. Clinical Features and Oral Manifestations of Iron Deficiency
Anemia
 Often asymptomatic, may have nonspecific symptoms such as weakness and fatigue
 In severe cases may see angular cheilitis, pallor of oral tissue, and an erythematous,
smooth, painful tongue
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86. Pernicious Anemia
 Probably an autoimmune disorder in most situations
 May be caused by removal of the stomach, gastric cancer, or gastritis
 Caused by a deficiency in intrinsic factor
 Intrinsic factor is secreted by parietal cells in the stomach; it is necessary for
absorption of vitamin B12
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87. Clinical Features and Oral Manifestations of Pernicious Anemia
 Weakness, pallor, and fatigue on exertion
 May see nausea, dizziness, diarrhea, abdominal pain, loss of appetite, and weight loss
 Angular cheilitis, mucosal pallor, painful atrophic and erythematous mucosa, mucosal
ulceration, loss of papillae on the dorsum of the tongue, and burning and painful
tongue
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88. Folic Acid and Vitamin B12
Deficiency Anemia
 From dietary deficiencies
 Can occur in association with malnutrition
 May be found with alcoholism or pregnancy
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89. Oral Manifestations of Folic Acid and Vitamin B12 Deficiency
Anemia
 Oral manifestations are indistinguishable from those of pernicious anemia.
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90. Thalassemia (Mediterranean or Cooley Anemia)
 A group of inherited disorders of hemoglobin synthesis
 An autosomal dominant inheritance pattern
The heterozygous form may be mildly symptomatic or asymptomatic.
The homozygous form is associated with severe hemolytic anemia.
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91. Clinical Features and Oral Manifestations of Thalassemia
 Yellow skin pallor, fever, malaise, and weakness
 The face includes prominent cheekbones, depression of the bridge of the nose, a
prominent maxilla, and protrusion or flaring of maxillary anterior teeth.
 Radiographs may show a “salt and pepper” pattern.
 Some trabeculae are prominent, and others are blurred.
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92. Sickle Cell Anemia
 An inherited blood disorder
 When someone is heterozygous, it is called sickle cell trait.
 When someone is homozygous, they are much more severely affected.
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93.  Occurs before age 30 and is more common in women than in men
 The red blood cells develop a sickle shape when there is decreased oxygen.
 This can be triggered by exercise, exertion, administration of a general anesthetic,
pregnancy, or even sleep.
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94. Clinical Features and Oral Manifestations of Sickle Cell Anemia
 The person has weakness, shortness of breath, fatigue, joint pain, and nausea.
 Radiographic
 There is a loss of trabeculation, and large, irregular marrow spaces appear.
 A “hair-on-end” pattern may be seen in the skull.
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95. Aplastic Anemia
 A severe depression of bone marrow activity causes a decrease in all circulating blood
cells. – pancytopenia
 Primary aplastic anemia – the cause is unknown
 Secondary aplastic anemia – a result of a drug or chemical agent
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96. Oral Manifestations of Aplastic Anemia
 Infection,
 spontaneous bleeding,
 petechiae, and
 purpuric spots
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97. Polycythemia
 Polycythemia Vera
 Secondary Polycythemia
 Relative Polycythemia
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98. Oral Manifestations of Polycythemia
 The oral mucosa may appear deep red to purple; the gingiva may be edematous and
bleed easily.
 Submucosal petechiae,
 ecchymosis,
 hematoma formation may be present.
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99. Disorders of White Blood Cells
 Agranulocytosis
 Cyclic Neutropenia
 Leukemia
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100. Clinical Features and Oral Manifestations of
Agranulocytosis
 Sudden onset of fever,
 chills,
 jaundice,
 weakness,
 sore throat
 Oral infection
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101. Leukemia
 Malignant neoplasms of hematopoietic stem cells
 Characterized by an excessive number of abnormal white blood cells in circulating
blood
 Unknown cause; some are investigating oncogenic viruses
 There are many different types categorized as to whether they are acute or chronic.
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102. Acute Leukemias
 Characterized by very immature cells and a rapidly fatal course if not treated
 Acute lymphoblastic leukemia – involves immature lymphocytes
Primarily affects children and young adults
Good prognosis
 Acute myeloblastic leukemia – involves immature granulocytes
Primarily affects adolescents and young adults.
Prognosis is not as good.
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103. Clinical Features of Acute Leukemias
 Weakness,
 fever,
 enlargement of lymph nodes,
bleeding
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104. Oral Manifestations of Acute Leukemias
 Gingival enlargement
 Oral infection
 Bleeding gums, petechiae and ecchymosis
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105. Chronic Leukemias
 Slow onset
 Primarily affect adults
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106. Clinical Features and Oral Manifestations of
Chronic Leukemias
 Easy fatigability, weakness, weight loss, anorexia
 Pallor of lips and gingiva,
 gingival enlargement,
 petechiae and ecchymosis,
 gingival bleeding
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107. Bleeding Disorders
 Purpura
 Hemophilia
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108. Purpura
 A reddish-blue or purplish discoloration of skin or mucosa from spontaneous
extravasation of blood
 May be due to a defect or deficiency in blood platelets
 Blood may ooze from gingival margins.
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109. Thrombocytopenic Purpura
 A bleeding disorder that results from a severe reduction in circulating platelets
 Idiopathic thrombocytopenic purpura
 If the cause is unknown
 Immune thrombocytopenia
 An autoimmune type of process
 Secondary thrombocytopenic purpura
 Often associated with drugs
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110. Clinical and Oral Manifestations of Thrombocytopenic
Purpura
 Spontaneous purpuric or hemorrhagic lesions on the skin
 Patients bruise easily,
 may have blood in urine,
 have frequent nose bleeds.
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111. Nonthrombocytopenic Purpura
 Bleeding disorders that can result from either a defect in capillary walls or disorders of
platelet function
 Vitamin C deficiency and infections or chemicals and allergy may be the cause of
alterations in vascular walls.
 Drugs, allergy, and autoimmune disease may cause disorders of platelet function.
 Von Willebrand disease is an autosomal dominant disorder of platelet function.
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112. Oral Manifestations of Nonthrombocytopenic Purpura
 Spontaneous gingival bleeding
 petechiae
 Ecchymoses
hemorrhagic blisters
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113. Hemophilia
 A disorder of blood coagulation
 Results in severely prolonged clotting time
 Due to a deficiency in plasma proteins involved in coagulation
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114. Types of Hemophilia
 The two most common types are type A and type B.
 Transmitted as X-linked diseases through an unaffected carrier daughter to a son
Type A
 Caused by a deficiency of plasma thromboplastinogen or factor VIII
Type B
 Christmas disease
 Less common, the clotting defect is plasma thromboplastin or factor IX
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115. Oral Manifestations of Hemophilia
 Spontaneous gingival bleeding,
 petechiae,
 ecchymosis
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116. PATIENTS WITH RENAL
DISORDERS
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117. INTRA ORAL FINDINGS
Soft tissue changes
 Oral ulcers – Blood urea nitrogen
increases > 150mg/dl, it gets
secreted through saliva – ureamic
crystals – burn mucosa becomes
red
 Uraemic stomatitis - Burning
sensation
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118. UREMIC STOMATITIS
Urea secreted in saliva
Urease enzyme produced
by oral microflora
Liberates free ammonia
Damages oral mucosa
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119. INTRA ORAL FINDINGS
Soft tissue changes
 Ulcers secondary to anaemia,
viral infections
(immunosupressed)
 Gingival hyperplasia -
cyclosporine & nifedepine
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120. INTRA ORAL FINDINGS
Soft tissue changes
 Salivary glands - enlarged, xerostomia
 Gingival bleeding, petechiae, ecchymosis due to
platelet changes
 Candidal infection – immunosupression
 Halitosis – uraemic odor, ammonical smell
 Dysesthesia of lower lip
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121. Hard tissue changes
 Staining in teeth – due to iron
supplements
 Reduced caries due to urea in
saliva
 Delayed tooth eruption
 Enamel hypoplasia
 Tooth Mobility
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122. RADIOGRAPHIC FEATURES
Mainly in cases with
hyperparathyroidism
 Tooth appear more radiopaque in
background of osteoporotic bone
 Loss of trabeculations of bone
 Ground glass appearance
 Total/ partial loss of lamina dura
 Loss of cortical outlines of inferior
alveolar sinus, cortex of mandible
 Pulpal calcifications
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123. RADIOGRAPHIC FEATURES
Mainly in cases with
hyperparathyroidism
 Multilocular radiolucency – osteitis fibrosa
cystica/ browns tumor
 Arterial & oral calcifications
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124. ORAL MANIFESTATIONS IN
DIABETICS
 More severe periodontal
disease
 Patients with multiple
abscesses should be referred
for blood sugar estimation
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125. ORAL MANIFESTATIONS IN
DIABETICS
 Sialosis – swelling of salivary
glands due to autonomic
neuropathy
 Xerostomia may result from
hyperglycemia and subsequent
polyuria that depletes the
extracellular fluids
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126.  Oral candidiasis & angular
chelitis
 Oral mucosal lichenoid
reactions - hypoglycaemics
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127.  Burning tongue - associated with candidiasis or
peripheral neuropathies
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128. Diseases of Respiratory tract
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129. CLASSIFICATION
UPPER - AIRWAY
INFECTIONS
 ALLERGIC RHINITIS
AND
CONJUNCTIVITIS
 SINUSITIS
 PHARYNGITIS &TONSILLITIS
LOWER - AIRWAY
INFECTIONS
 ASTHMA
 CYSTIC FIBROSIS
 ACUTE BRONCHITIS
 TUBERCULOSIS
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130. ORAL HEALTH CONSIDERATIONS for allergic rhinitis
 ORAL DRYNESS
 ORAL CANDIDIASIS
(CORTICOSTEROIDS)
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131. ORAL HEALTH CONSIDERATIONS for
sinusitis
 Tooth Pain - Differentiate Between An Odontogenic Infection And Sinus Pain.
Sinus Infections Usually Present With Pain Involving More Than One Tooth.
 Chronic Sinus Infections Are Often Accompanied By Mouth Breathing -
Gingivitis.
 Prolonged Use Of Antibiotics - The Potential Development Of Bacterial
Resistance .
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132. ORAL MANIFESTATIONS of Asthma
 Candidiasis
 Decreased Salivary Flow
 Increased Calculus
 Increased Gingivitis
 Increased Periodontal Disease
 Increased Incidence Of Caries
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133. CONSIDERATION FOR DENTAL CARE
 Fluoride Supplements - Particular Those Taking Β2-
agonists.
 The Patient Should Be Instructed To Rinse His Or Her
Mouth With Water After Using Inhalers.
 Oral Hygiene Should Be Reinforced To Reduce Of
Gingivitis And Periodontitis.
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134. ORAL MANIFESTATION of TB
 RARE
 MAINLY SEEN IN MIDDLE AGED & OLDER PEOPLE
 SEX-MALES
 MOST COMMONLY-TONGUE
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135. ORAL MANIFESTATION of TB
 ORAL LESION –Ulcer,nodule,vesicle,granuloma,fissure
 Ulceration ,Ragged Border,minimal Induration,granular Base
 Sentinal Tubercle; nodules Seen Around Ulceration.
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136. Pregnancy- Oral Manifestations
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137. Dental Considerations
(First Trimester)
 Dental treatment is best avoided
 Assess the current oral health of the patient
 Educate the patient regarding the oral changes
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138.  Nausea and vomiting – caused by increased levels of gonadotropins in the
first trimester
 Enamel erosion- gastric acids present in the vomit erode the inner surface
of anterior teeth
 Pregnancy induced gingivitis
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139. SECOND TRIMESTER
 Organogenesis is complete and the risk to the
foetus is at its lowest
 safest period for any necessary elective dental
treatment
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140. Dental Considerations
Pregnancy Tumor- also
referred to as
Granuloma Gravidarum
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141. Diseases of GIT
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142. GASTROESOPHAGEAL REFLUX DISEASE
 Most common disease of upper GI tract
 gastric contents passively move up from the
stomach into the esophagus
Symptoms/signs
 Heart burn (pain/burning sensation extending from epigastrium to the
neck) – commonly felt after a meal
 esophagitis, esophageal ulceration & stricture
 Chest pain (mimics anginal pain)
 Dysphagia
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143. Oral Manifestations & Dental
Considerations
 erythema and mucosal atrophy
 dysgeusia, sensitivity & erosion
(palatal aspects of upper anteriors
and premolars)
 erosion leads to dentin sensitivity
& irreversible pulpal involvement
(gastric content pH – as low as 1)
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144. Inflammatory Bowel Disease
 Ulcerative colitis
 Crohn’s disease (regional enteritis, ileitis)
Ulcerative colitis
Inflammatory process usually extends from rectum
proximally in a continuous fashion involving
variable lengths of large intestine but confined to
mucosa & superficial submucosa.
 Bloody diarrhea – cardinal symptom
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145. CROHN’S DISEASE
 Affects entire thickness of intestinal wall, in segments
forms strictures and scarring
Small intestine - 40%
Large intestine - 30%
Both intestines- 30%
Pain & diarrhea
Fistulas which connect different sites in GIT, urinary bladder,
vagina, prostate and skin
Arthritis, uveitis & erythema nodosum of skin are common
in both diseases
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146. Oral Manifestations (Crohn’s disease)
 Oral granulomatous lesions as a nodular mass in the mucobuccal fold
 Lesions resembling aphthous ulcers
 Cobblestone appearance on buccal mucosa
 Linear hyperplastic folds with ulcers in the vestibule
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147. Crohn’s disease
 Swollen & indurated lips
 Granular red lesions on gingiva
and alveolar mucosa and
palatal ulcers (rarely)
 Pustular lesions
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148. EATING DISORDERS
 ANOREXIA NERVOSA AND BULIMIA
Anorexia
 individuals who intentionally starve themselves
intense fear of becoming fat
Anorexia usually develops between 14 - 18 years
 Bulimia nervosa
Individuals consume large amounts of food and prevent
weight gain by vomiting, laxatives, diuretics,
dieting, and/or exercising aggressively.
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149. Oral Considerations
 erosion of the enamel on the lingual surfaces of the maxillary teeth
 Parotid enlargement may develop as a sequela of starvation.
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150. REFERENCES
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 BURKETS-ORAL MEDICINE
 TEXT BOOK OF ORAL MEDICINE by Anil Govindrao Ghom
 SHAFER-TEXT BOOK OF ORAL PATHOLOGY
 NEVILLE-TEXT BOOK OF ORAL PATHOLOGY
 CARANZZA’S-CLINICAL PERIODONTOLOGY
 WIKEPEDIA

151. Thank you
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