This document provides an overview of oral aspects of metabolic diseases. It discusses disturbances in mineral, protein, carbohydrate, lipid, and hormone metabolism. Specific conditions summarized include calcium and phosphorus disturbances, protein-energy malnutrition, amyloidosis, porphyria, Gaucher's disease, Niemann-Pick disease, Letterer-Siwe disease, hypervitaminosis A, rickets, osteomalacia, and hypophosphatasia. For each condition, it describes etiology, clinical features, oral manifestations, and histopathology where relevant, providing a comprehensive review of how metabolism can impact oral health.

2. Oral Aspects of
Metabolic
Diseases
BY
C N V Akhila
PG 2nd Year

3. Contents :
• Introduction
• Disturbances in mineral metabolism
• Disturbances in protein metabolism
• Disturbances in carbohydrate metabolism
• Disturbances in lipid metabolism
• Avitaminosis
• Disturbances in hormone metabolism

4. Introduction
▪“Metabolism is the sum total of tissue activity as considered
in terms of physicochemical changes associated with and
regulated by the availability, utilization and disposal of
protein, fat, carbohydrate, vitamins, minerals, water, and the
influences which the endocrines exert on these processes.” –
Duncan
▪Each tissue or organ has properties not restricted to it, but
common to all parts of the organisms, and it is these
common properties which bind the tissues and organs well
together into a unit.
▪Alterations from these normal metabolic processes
constitute the disturbances of metabolism.

5. Disturbances in mineral metabolism
▪Minerals are inorganic elements essential for life and
provide both the structural and regulatory functions of
body.
▪There are 29 different elements in our body constituting
4% of the body weight, concentrated mostly in skeleton.
▪The elements considered essential for normal growth and
development are Ca, P, Mg, K, Na, Cl, S, I, Cu, Fe, Zn,
Mn, Co, Cr, Se and F.
▪Minerals present in high amounts relatively in the body
are referred as macrominerals and those that are less than
0.005% of the body weight are called microminerals.
▪Macromolecules are nutritionally important, whose daily
requirement is more than 100 mg.

6. CONTD.
▪They constitute basic structure of bones and teeth.
▪Help maintain osmotic relations of the body fluids;
regulate acid-base equilibrium of tissues; form part of
hormones; are an integral part of some enzymes and they
are an essential part of oxygen carrying pigments.

7. Calcium
▪Calcium is the fifth most abundant element in the body.
▪Total calcium in body is 100-170 gm.
▪The normal serum calcium level is about 9-11 mg/dl.
▪Vitamin D increases absorption of calcium from intestine.
▪Under normal metabolic conditions for fat splitting and fat
absorption the ingestion of fat has been found to aid in
calcium absorption except in conditions like steatorrhea.
▪Lowering intestinal Ph by citrates also aids in absorption of
calcium.
▪High protein diets also aid in absorption of calcium by
formation of soluble compounds with aminoacids.
▪Lactose or milk sugar increases absorption of calcium.

8. Contd.
▪Excretion – feces, urine and perspiration
▪Functions- formation of bones and teeth, in the
maintenance of skeletal structure, normal membrane
permeability, muscle contraction, etc.
▪A low concentration of ca ions produces hyperirritability and
tetany.
▪Hypocalcaemia- serum levels of ca less than 8.5 mg/dl.
▪Hypercalcaemia- serum levels exceed 11.0 mg/dl.
▪Causes of hypo- hypoparathyroidism
▪Causes of hyper- primary hyperparathyroidism, malignancy
and endocrine causes.

9. Contd.
▪Osteoporosis and calcium deficiency
▪Osteoporosis is due to long term negative calcium balance.
phosphorus
▪ Total body phosphorus is approximately 500-800 gm
▪ 85-90% is in skeleton

10. Disturbances in protein metabolism
▪Proteins are complex biologic compounds of high
molecular weight containing nitrogen, oxygen, carbon and
small amounts of Sulphur.
▪The third principal group of organic compounds and have a
larger range of functions than carbohydrates or lipids.

11. Contd.
▪Proteins have an important bearing on the pre-eruptive and
post-eruptive effects on teeth.
▪They help in formation of the matrix of hard tissues of teeth.
PEM
▪PEM is a spectrum of diseases with kwashiorkor whose
essential feature is protein deficiency and nutritional
marasmus, due to severe and prolonged restriction of all
types of food.
▪In the middle of spectrum there is marasmic kwashiorkor in
which clinical features of both disorders occur.

13. Etiology and clinical features of marasmus
▪Rapid succession of pregnancies, and early and often
abrupt weaning followed by artificial feeding of infants in
inadequate amounts.
▪The two features of marasmus are retarded growth and
wasting of subcutaneous tissues, giving the child an aged
appearance.
▪Protein deficiency is common in prolonged febrile illness, in
massive burns and chronic large ulcers, hyperthyroidism
and other hypermetabolic states.
▪Pigment changes in skin with hair loss, hypotension,
weakness and edema. Anemia is common.
▪Decrease in serum proteins, hemoconcentration and
decrease in blood volume.

14. kwashiorkor
▪Some amino acid or protein deficiency arises typically after
prolonged breast feeding and the child is weaned on to a
low protein diet.
▪Insufficient supply of amino acids, leads to inadequate
protein synthesis, reduced synthesis of enzymes and
plasma proteins and impaired development of organs.
▪The child’s weight is less and is masked by edema often
due to hypoalbuminemia.
▪Impaired synthesis of amino acids leads to diarrhea
leading to loss of potassium and magnesium.
▪The child is prone to infections.
▪Oral lesions- bright red tongue, loss of papillae, bilateral
angular cheliosis, fissuring of lips, loss of circumoral
pigmentation.

15. contd
▪Dry, dirty, caries free and easily traumatized with the
epithelium readily becoming deatached from the underlying
tissues, leaving a raw, bleeding surface.
▪In oral cytologic smears- a perinuclear halo or
vacuolization is present with atrophy of epithelium.
▪Early growth retardation, edema, episodes of diarrhea, skin
pigmentation, liver enlargement, alopecia and poor
resistance to infections especially of lungs and intestinal
tract.

16. Amyloidosis
▪An abnormal proteinaceous substance that is deposited
between cells in tissues and organs of the body in a variety
of clinical disorders is referred to as amyloid.
▪Two forms- type A and type B
▪Type A (secondary) amyloid is a fibrillar protein of unknown
origin that is seen in prolonged inflammatory diseases,
genetic diseases.
▪Type B is thought to be of immune origin. It is commonly
seen in patients with multiple myeloma and
macroglobulinemia.
▪Type C includes amyloid of aging, localized nonspecific
amyloid, related to AUPD cell lesions- pheochromacytoma.

18. Contd.
▪The most common diseases predisposing to amyloidosis
are the collagen diseases, particularly rheumatoid arthritis,
chronic infections such as TB and osteomyelitis, and certain
malignant diseases like multiple myeloma, hodgkin disease
▪Any organ may be involved most commonly affected organs
are kidneys, heart, GIT, liver and spleen.
▪Others – skin, eyes, adrenals and nerves and bone.
▪Amyloid deposition in the tongue, resulting macroglossia
and gingiva is also reported.

19. contd
▪Histologically the deposition always begins between cells
and eventually surround and destroy the trapped native cells.
▪The amyloid in the microscopic sections appear as a
hyaline, homogenous material, often perivascular in
distribution especially in the immune associated form.
▪It is best demonstrated by special stains like congo red and
crystal violet or by thioflavin-T fluorescent technique.
▪Under polarized light the congo red stained amyloid shows
green birefringence.

20. Porphyria
▪One of the inborn errors of porphyrin metabolism.
▪Porphyria may appear as a sequel to some infections or
intoxications.
▪2 types- erythropoietic porphyria and hepatic porphyria.
▪Erythropoietic porphyria – early photosensitivity,
splenomegaly and excessive abnormal porphyrin formation
in developing erythrocytes.
▪Hepatic porphyria also a multisystem disorder divided into 4
classes- acute intermittent, porphyria variegata, porphyria
cutanea tarda and heriditary coproporphyria.

21. contd
▪Congenital porphyria or erythropoietic uroporphyria is a non
sex linked recessive disease, both genders are equally
effected.
▪Excretion of red urine containing uroporphyrin is noted at
first year of life.
▪Photosensitivity apparent during first year of life as
exposure to sunlight increases.
▪Vesicles and bullous eruptions appear on face, back of
hands and other exposed parts of body. The vesicles
contain a serous fluid and they heal slowly and leave scars.
▪Teeth may show a red or brownish discoloration.
▪Deposition of porphyrin in the developing teeth and bones
is due to its affinity for calcium phosphate.

23. Disturbances in carbohydrate metabolism
▪Hurlers syndrome is a chromosomal abnormality occurs in
chromosome arm 4p16.3.
▪It is a disturbance in mucopolysaccharide metabolism.
▪Elevated excretion of mucopolysaccharide level.
▪This disease becomes apparent in first two years of life,
progresses during early childhood and adolescence and
terminates in death usually before puberty.
▪Head appears large, prominent forehead, broad saddle
nose wide nostrils, hypertelorism, puffy eyelids, thick lips,
large tongue, open mouth and nasal congestion.
▪Hepatosplenomegaly, short neck and spinal abnormalities,
claw hand. These dwarfed individuals are mentally
retarded.

24. Oral manifestations
▪Shortening and broadening of mandible, localized areas of
bone destruction in the jaws may be found which appear to
represent hyperplastic dental follicles with large pools of
metachromatic material- polysaccharide.
▪Teeth are widely spaced and misshapen.
▪Gingiva appears enlarged due to poor oral hygiene or
mouth breathing.
▪Tongue is also characteristically enlarged.
▪H/F: there is excessive accumulation of intracellular
mucopolysaccharide in tissues and organs. Abnormal
deposits are also found in many sites with involved
fibroblasts assuming clear cells or gargoyle cells in gingiva.
Large, cresent shaped nuclei, agranular cytoplasm. Cannot
be identified by H & E.

26. Disturbances in lipid metabolism
▪ Gaucher’s disease:
It is a common lysosomal storage disease characterized by
deposition of glucocerebroside in cells of the macrophage-
monocyte system. Lysosomal hydrolase deficiency, it
cleaves glucocerebrocide.
GD type I (non-neuropathic) is the most common and least
severe form of the disease.
GD type II (acute infantile neuropathic) typically begins
within 6 months of birth. Symptoms include an enlarged
liver and spleen, extensive and progressive brain damage,
eye movement disorders, seizures, limb rigidity, and a poor
ability to suck and swallow. Affected children usually die by
age two.

27. Contd.
▪GD type III (chronic neuropathic) can begin at any time in
childhood or even in adulthood. intermediate. Major
symptoms include an enlarged spleen and/or liver, seizures,
poor coordination, skeletal irregularities, eye movement
disorders, blood disorders including anemia, and respiratory
problems. Patients often live into their early teen years and
adulthood.
▪All three types are inherited as autosomal recessive traits.
▪Numerous large, foamy, slightly granular cells with small,
round pyknotic nuclei- gaucher cells in spleen, lymph nodes
and liver.
▪Poor prognosis, enzyme replacement therapy

29. Niemann pick disease
▪is a group of inherited, severe metabolic disorders in
which sphingomyelin accumulates in lysosomes in cells.
▪It is inherited as autosomal recessive trait.
▪here are four types of in two categories. Patients with ASM
deficiency are classified into type A and B. Type A patients
exhibit hepatosplenomegaly in infancy and profound central
nervous system involvement and unable to survive beyond
two years of age.
▪Niemann–Pick disease type A: classic infantile
▪Niemann–Pick disease type B: visceral
▪Niemann-pick disease type C: subacute/juvenile

30. contd
▪Type B patients also show hepatosplenomegaly and
pathologic alterations of their lungs but usually without
the involvement of their central nervous system. Some
can develop significant life-threatening complications
including liver failure, hemorrhage, oxygen
dependency, pulmonary infections, and splenic rupture.
Some develop coronary artery or valvular heart
disease. nearly 20% of the patients died.
▪For those classified into type C, they may have mild
hepatosplenomegaly, but their central nervous system
is profoundly affected

31. Contd.
▪Niemann- pick cells are foamy, lipid laden cells
distributed through out the reticuloendothelial system
▪They are positive for cholestrol

32. Letterer- siwe disease
▪Letterer–Siwe disease is one of the four recognized
clinical syndromes of LCH.
▪Letterer-Siwe is characterized by skin lesions, ear
drainage, lymphadenopathy, osteolytic lesions, and
hepatosplenomegaly. The skin lesions are scaly and may
involve the scalp, ear canals, and abdomen.
▪Oral lesions may consists of ulcerative lesions, gingival
hyperplasia, destruction of bone maxilla and mandible,
loosening, premature loss of teeth.
▪Histiocytic proliferation, they do not contain cholesterol, no
fibrosis.
▪Progressive anaemia and leukopenia

33. contd
▪Langerhans cells are dendritic cells(antigen-presenting
immune cells) of the skin and mucosa, and
contain organelles called Birbeck granules.

35. Hypervitaminosis
▪Hypervitaminosis A refers to the toxic effects of ingesting
too much preformed vitamin A. Toxicity results from
ingesting too much preformed vitamin A from foods (such as
fish or animal liver), supplements, or prescription
medications and can be prevented by ingesting no more
than the recommended daily amount. Symptoms may
include:[1]
▪Abnormal softening of the skull bone (craniotabes—infants
and children),Blurred visionBone pain or
swelling,Bulging fontanelle (infants),Changes in
consciousness,Decreased appetite,Dizziness
▪Loss of hair, dryness of lips and oral mucosa.

36. Vitamin D
▪Rickets is defective mineralization or calcification of bones
before epiphyseal closure in immature mammals due to
deficiency or impaired metabolism of vitamin D.
▪Osteomalacia is a similar condition occurring in adults,
generally due to a deficiency of vitamin D after epiphyseal
closure.
▪ bone tenderness, bone fractures, craniotabes, skull
bossing, bowed legs, rachitic rosary, Harrison's groove,
pigeon chest, Hypocalcemia, a low level of calcium in the
blood can result in tetany– uncontrolled muscle spasms.
Dental problems can also arise.

37. Contd.
▪Oral manifestations developmental anomolies of dentin and
enamel.
▪Delayed eruption
▪Misalignment of teeth
▪Rachiatic teeth –abnormally wide predentin zone.
▪Much interglobular dentin.
▪Enamel hypoplasia
▪Hypoplastic enamel
▪Eruption rate retarded.

38. osteomalacia
▪The most common cause of osteomalacia is a deficiency
of vitamin D, which is normally derived from sunlight
exposure and, to a lesser extent, from the diet.
▪Long bones – diaphysis
▪Malabsorbtion is also the etiology
▪Remodelling of bone is abnormal.
▪Pelvic deformities seen in women.
▪Oral manifestations severe periodontitis.
▪Histologically inadequate calcification of bone matrix is
seen.

39. Hypophosphatasia
▪Hypophosphatasia (HPP) is a rare genetic disorder
characterized by the abnormal development of bones and
teeth. These abnormalities occur due to defective
mineralization, the process by which bones and teeth take
up minerals such as calcium and phosphorus.
▪Perinatal hypophosphatasia
▪Infantile hypophosphatasia
▪Childhood hypophosphatasia
▪Adult hypophosphatasia
▪Hypophosphatasia is associated with a molecular defect in
the gene encoding tissue non-specific alkaline phosphatase
(TNSALP).

40. Contd,
▪Perinatal hypophosphatasia is the most lethal form.
Profound hypomineralization results in caput
membranaceum (a soft calvarium), deformed or shortened
limbs.
▪Osteomalacia
▪Infantile hypophosphatasia presents in the first 6 months of
life, with the onset of poor feeding and inadequate weight
gain. Clinical manifestations of rickets often appear at this
time. Although cranial sutures appear to be wide, this reflects
hypomineralization of the skull, and there is often
“functional” craniosynostosis.

41. contd
▪Hypophosphatasia in childhood has variable clinical
expression. As a result of defects in the development of the
dental cementum, the deciduous teeth are often lost fore the
age of 5. Frequently, the incisors are lost first; occasionally
all of the teeth are lost prematurely. Dental radiographs can
show the enlarged pulp chambers and root canals that are
characteristic of rickets.
▪Adult hypophosphatasia can be associated with rickets,
premature loss of deciduous teeth, or early loss of adult
dentation followed by relatively good health. Osteomalacia
results in painful feet due to poor healing of metatarsal
stress fractures. Pseudo fractures

42. Vitamin C
▪Swollen gums and spongy gums
▪Scurvy buds are seen at interdental papillae.
▪Hemorrhage, bleeding gums and periodontal problems.
▪Loosening or mobile teeth due to bone loss.

43. Contd.
▪Scorbutic lattice
▪Trummer field zone
▪Immature looking fibroblasts
▪The area beneath the trummer field zone is free of
hematopoietic cells and is made of connective tissue
cells- gerustmark.

44. Vitamin B12
▪Glossitis can mean soreness of the tongue, or more
usually inflammation with depapillation of the dorsal surface
of the tongue, leaving a smooth
and erythematous (reddened) surface, (sometimes
specifically termed atrophic glossitis).
▪smooth tongue, Hunter glossitis, Moeller glossitis, or Möller-
Hunter glossitis, is a condition characterized by a smooth
glossy tongue that is often tender/painful, caused by
complete atrophy of the (depapillation).The dorsal tongue
surface may be affected totally, or in patches, and may be
associated with a burning sensation, pain and/or
erythema. and has a great many causes, usually related
to iron-deficiency anemia, pernicious anemia, B vitamin
complex deficiencies

46. Hypothyroidism
▪Hypothyroidism is defined by a decrease in thyroid
hormone production and thyroid gland function.
▪Childhood hypothyroidism known as cretinisim is
characterized by thick lips, large protruding tongue
(macroglossia), malocclusion and delayed eruption of teeth.
▪Dysgeusia, poor periodontal health, altered tooth
morphology and delayed wound healing.
▪

47. hyperthyroidism
▪The oral manifestations of thyrotoxicosis, includes
increased susceptibility to caries, periodontal disease,
enlargement of extraglandular thyroid tissue (mainly in the
lateral posterior tongue), maxillary or mandibular
osteoporosis, accelerated dental eruption and burning
mouth syndrome.

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