The mouth and Systemic Disease

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					 The mouth and
Systemic Disease
   Mike Pemberton
           Dental Disease
• Two main dental diseases

• Dental Caries

• Periodontal Disease
Dental Caries
     • To prevent caries
       – Less sugar, less often
       – Strengthen teeth with
         fluoride (toothpaste)


     • To treat caries
       – Treat (remineralise or
         excise and reconstruct)
         early to prevent pulp
         exposure (root canal
         work or extraction)
Periodontal disease
          • Reflection of
            inflammation due to
            – Build up of biofilm
              (plaque) on teeth
            – Host response


          • To prevent need good
            oral hygiene
Periodontal disease
          • Periodontal disease
            associated with
            – Type II Diabetes
              mellitus
            – Ischaemic heart
              disease
            – Low birth weight and
              premature babies
   The mouth and Systemic
          Disease
• Endocrine
  – Diabetes mellitus
  – Acromegaly
  – Cushing’s syndrome
Diabetes Mellitus – Oral effects
• Susceptibility to infection
    - Candida
    - Periodontal disease
• Sialosis
• Xerostomia
• Burning mouth
        Acromegaly - Orofacial
•   Mandibular prognathism
•   Posterior open bite
•   Spacing of teeth
•   Macroglossia
•   Thickening of facial soft tissues
      Oral Soft Tissues and
       Systemic Disease
• Gastro-intestinal
  – Granulomatous conditions
  – Coeliac disaese
  Oro-facial Lymphoedema

Non-caseating giant-cell granulomas
   causing lymphatic obstruction
    Oro-facial Lymphoedema - Signs
•   Facial swelling
•   Lip swelling
•   Angular cheilitis
•   Mucosal tags/cobblestoning
•   Ulceration
•   Aphthae
•   Full thickness gingivitis
Oro-facial Lymphoedema - Causes

•   Crohn’s disease
•   Sarcoidosis
•   Granulomatous infections
•   Oro-facial granulomatosis
•   Melkersson – Rosenthal syndrome
     R.A.S. – Minor aphthae

• 80% cases
• Crops of 1-5
• Non-keratinised
  mucosa
• 5 - 10 mm diameter
• 7 – 14 day duration
• No scarring
       R.A.S. – Major aphthae
•   15% cases
•   Usually solitary
•   Soft palate, lips
•   > 10 mm diameter
•   >14 days
•   Scarring occurs
 R.A.S – Herpetiform aphthae
• 5% cases
• Crops of 20 –100
• Non-keratinised
  mucosa
• 1-3 mm diameter
  (coalesce)
• 10 -14 days
• No scarring
           R.A.S – systemic
             associations
• Haematinic deficiency state
• Gastrointestinal disease (Crohn’s, coeliac,
  ulcerative colitis)
• Behcet’s syndrome
• Immune disturbances
  – HIV, neutropenia, myelodysplasia
• Others
  – PFAPA (periodic fever, aphthae, pharyngitis and
    adenitis syndrome)
         R.A.S. – systemic
           associations
• Coeliac disease (1 in 100 UK population)
• approximately 4% of patients with classical
  R.A.S.
• R.A.S. remits in patients with coeliac
  disease on a gluten free diet.
• serological tests evolving
             R.A.S. – Behcet’s
• VIIth international conference 1996 agreed
  new diagnostic criteria:
  – Recurrent aphthous ulcers AND
  – any two of
     •   genital aphthous ulceration
     •   typical eye lesions (uveitis etc)
     •   typical skin lesions (erythema nodosum, folliculitis)
     •   Positive pathergy test
     •   Others – musculoskeletal, CNS, GI, vascular
     Oral Soft Tissues and
      Systemic Disease
• Haematological
  – Dyscrasia’s
  – Anaemia
Acute leukaemia – Full blood count
• Anaemia
• Thrombocytopenia
• White cell changes
     - Malignant overproduction of abnormal
  white cells
     - Lymphoblastic/Myeloblastic
     Dyshaemopoietic anaemia -
                  Oral effects
•   Recurrent Aphthous stomatitis
•   Glossitis
•   Candidal infection
•   Burning Mouth Syndrome
•   Plummer – Vinson Syndrome
     Oral Soft Tissues and
      Systemic Disease
• Rheumatological
  – Sjogren’s syndrome
  – Behcet’s
  – Systemic lupus erythematosis
     Xerostomia - Aetiology
•   Developmental
•   Iatrogenic
        - Drugs
        - Irradiation
•   Dehydration
        - Diabetes mellitus
        - Renal failure
•   Salivary gland disease
        - Sjogren’s syndrome
•   Psychogenic
  Sjogren’s Syndrome – Orofacial
           management
 Dry Mouth
• stimulation of residual saliva production
  – Local
     • Sugar-free chewing gum/ SST/ Salivix pastilles
  – systemic
     • Pilocarpine
• Replacement products
     • Artificial saliva’s/ gels
• Caries control
• Candidal infection control
Systemic Lupus Erythematosus
• Multi-system autoimmune disease
• Antibodies produced against variety of
  autoantigens (e.g ANA including dsDNA)
• Orally can mimic many conditions
  – Oral ulceration
  – Lichenoid type lesions
     Oral Soft Tissues and
      Systemic Disease
• Muco-cutaneous disease
  – Lichen planus
  – Vesiculo-bullous disease
    • Pemphigus vulgaris
    • Mucous membrane pemphigoid
    • Erythema multiforme
   Mucocutaneous disease
• Oral
• Other mucosal surfaces
  – Nasal, pharyngeal,
  – Genital
  – Ophthalmic
  – Oesophageal
• Skin and appendages
    Vesiculo-bullous Disease
• Pemphigus vulgaris
• Mucous membrane pemphigoid
• Erythema multiforme
        Pemphigus vulgaris
• Rare disease
• Middle aged, elderly females
• Antigen is desmoglein 3 – a constituent of
  desmosomes forming ‘epithelial
  intercellular cement.’
• Genetic background
• Classical autoimmune disorder
         Pemphigus vulgaris
• Management
• Historically a fatal disease
• Immunosuppresion
  – Systemic steroids
  – Azathioprine
  – Mycophenylate mofetil
  – ? Infliximab
Mucous membrane pemphigoid
•   Uncommon
•   Middle aged and elderly females
•   Classical Autoimmune disorder
•   Various antigens, all at the basement
    membrane zone
    – Bullous pemphigoid – affects skin
    – MMP – affects mucosa (cicatricial pemphigoid)
       • Oral pemphigoid
       • Ocular pemphigoid
Mucous membrane pemphigoid
• Management
• Occular complications important
• Treatment
  – Mild cases
    • topical steroids
    • Improve oral hygiene
  – Severe cases
    • Dapsone
    • Steroids/ Azathioprine / Mycophenylate
     Oral Soft Tissues and
      Systemic Disease
• Immunosuppresion
  – HIV
  Acquired Immune Deficiency Syndrome
                    A.I.D.S.

• 2009 in UK
  – 86,000 living with HIV
  – >1 in 1000 in UK
    • Regional variation
  – 22,000 unaware (25%)
  – 6000 new cases diagnosed but incidence
    falling
  – Encouragement for more widespread testing
                        H.I.V.
                     Treatment 3
• Average age of patient in developed world clinic
  getting older

• Patients who achieve durable suppression of the
  HIV virus have increased risk of several ‘non-
  AIDS’ complications
  –   Cardiovascular disease
  –   Liver disease
  –   Cancer
  –   End-stage renal disease

				
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