Oral examination can reveal findings indicative of underlying systemic conditions. Careful oral evaluation includes inspection of the mucosa, periodontal tissues, and teeth. Oral manifestations of anemia may include pallor, glossitis, and candidiasis. Many systemic diseases are reflected in oral changes such as ulceration, bleeding, infections, bone disease, and dental issues. Local factors may also contribute to oral lesions in patients with systemic conditions. Diseases of the endocrine, hematologic, immune, and gastrointestinal systems can all impact the oral cavity. Medications prescribed for systemic illnesses can additionally cause oral side effects.

1. Dr. Suhail S. Kishawi
Consultant in Endocrinology and Diabetes
Oral Manifestations of
Systemic Diseases (I(

2. Oral Manifestations of Systemic Disease
 Careful examination of the oral cavity may reveal
findings indicative of an underlying systemic condition,
and allow for early diagnosis and treatment.
 Examination should include evaluation for mucosal
changes, periodontal inflammation and bleeding, and
general condition of the teeth.
 Oral findings of anemia may include mucosal pallor,
atrophic glossitis, and candidiasis.

3. 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.

4. Oral Manifestations of Systemic Diseases
 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

5. Endocrine Disorders
 Hyperpituitarism
 Hyperthyroidism
 Hypothyroidism
 Hyperparathyroidism
 Diabetes Mellitus
 Addison’s Disease

6. Endocrine Disorders
 The endocrine system consists of a group of
integrated glands and cells that secrete
hormones.
 The secretion is controlled by feedback
mechanisms.
 The amount of hormone circulating in blood triggers
factors that control production.
 Diseases may result from conditions where
too much or too little hormone is produced.

7. Hyperpituitarism
 Excess hormone production by the
anterior pituitary gland
 Caused most often by a benign tumor
(pituitary adenoma) that produces growth
hormone
 GiantismGiantism results if it occurs before the
closure of long bones ( during puberty).
 Acromegaly results when hypersecretion
occurs during adult life ( after puberty).

8. Clinical Features and Oral Manifestations
of Hyperpituitarism
 Affects both men and women, most commonly during theAffects both men and women, most commonly during the
fourth decade of lifefourth decade of life
 Patients experience poor vision, light sensitivity, enlargement ofPatients experience poor vision, light sensitivity, enlargement of
hands and feet, and an increase in rib size.hands and feet, and an increase in rib size.
 Facial changesFacial changes
 Enlargement of maxilla and mandible may cause separation ofEnlargement of maxilla and mandible may cause separation of
teeth and malocclusion.teeth and malocclusion.
 Frontal bossing and an enlargement of nasal bones may lead toFrontal bossing and an enlargement of nasal bones may lead to
deepening of voice.deepening of voice.
 Mucosal changesMucosal changes
 May have thickened lips and macroglossiaMay have thickened lips and macroglossia

9. Pituitary MRI

10. Acromegaly Gigantism

12. Bone and Soft Tissue Manifestations of Acromegaly
Spade hands
Thickened skin

13. A patient with marked macroglossia. This can cause severe
sleep apnea which can be associated with cardiac arrhythmias
and sudden death.

14. Widely spaced teeth

15. Hyperthyroidism (Thyrotoxicosis)
 Excess production of thyroid hormone
 More common in women than men
 The most common cause is Graves’ disease
 Appears to be due to an autoimmune disorder in
which a substance is produced that abnormally
stimulates the thyroid gland
 Other causes include hyperplasia of the gland,
benign and malignant tumors of the thyroid,
pituitary gland disease, and metastatic tumors.

16. ANATOMY OF THYROID GLAND
 The thyroid gland lies over the
thyroid cartilage and upper
trachea.
 It is attached to these
structures by the pretracheal
fascia, which explains why it
moves on swallowing.
 The gland is H-shaped with two
lateral lobes and an isthmus
joining them. In about 15% of
people there is a small
pyramidal lobe arising out of
the upper margin of the
isthmus, usually on the left-
hand side.

17. Clinical Features of Hyperthyroidism
 Cardiac
• Sinus Tachycardia/Atrial Fibrillation
• Congestive heart failure (high-output)
• Angina
• Increased pulse pressure
 Musculoskeletal
• Tremor
• Proximal Muscle Weakness (Myopathy)
 Neurologic/Psychiatric
• Anxiety, Hyperactivity, Mania
• Disorientation, Coma
• Rarely, seizures/convulsions

18. Graves’ Disease
(Toxic Diffuse Goiter)
Clinical Features of Graves’ Disease:

19. Oral Manifestations of Hyperthyroidism
 May lead to premature exfoliation of deciduous teeth in
children and premature eruption of permanent teeth
 Osteoporosis may affect alveolar bone.
 Caries and periodontal disease may appear and
develop more rapidly in these patients.
 Burning tongue also has been reported.

21. Hypothyroidism
 A decreased output of thyroid hormone
 Causes include developmental disturbances,
autoimmune disease, iodine deficiency, drugs,
and pituitary disease
 Cretinism
 When it occurs in infancy and childhood
 Myxedema
 When it occurs in older children and adults

22. Hypothyroidism in Infants
•Age: 6 mos •4 mos after L-T4

23. Oral Manifestations Of Hypothyroidism
 In infantsIn infants
• Thickened lips, enlarged tongue, andThickened lips, enlarged tongue, and
delayed eruption of teethdelayed eruption of teeth
 In adultsIn adults
• Enlarged tongueEnlarged tongue

24. Hyperparathyroidism
 Due to excessive secretion of parathyroid
hormone from the parathyroid glands
 The four parathyroid glands are located near
the thyroid gland.
 Parathyroid hormone plays a role in calcium
and phosphorous metabolism.
 Hyperparathyroidism is characterized by :
 Elevated blood levels of calcium (Hypercalcemia)
 Low levels of blood phosphorous
(hypophosphatemia).

27. Hyperparathyroidism
 May be the result of hyperplasia of parathyroid glands,
a benign tumor of one or more parathyroid glands, or a
malignant parathyroid tumor
 Parathyroid hormone increases the uptake of dietary
calcium from the gastrointestinal tract and is able to
move calcium from bone to circulating blood when
necessary.
 A generalized mottled appearance of the bone (very
little trabeculation of bone) and partial loss of the
lamina dura. This causes loosening of the teeth.

32. Diabetes Mellitus
 A chronic disorder of carbohydrate
metabolism characterized by
abnormally high blood glucose levels
 These result from a lack of insulin,
defective insulin that does not work to
lower blood glucose levels, or increased
insulin resistance due to obesity.

33. Diabetes Mellitus
 Diabetes effects blood glucose metabolism and vessel
pathology.
 The condition may be the result of absolute insulin
deficiency (Type 1 diabetes), a problem with insulin
function (termed relative or (Type 2 diabetes), or both
conditions. Other types of diabetes include gestational
diabetes and diabetes occurring secondary to other
diseases.
 The prevalence of diabetes is estimated to be
increasing worldwide; with 20% over 65 having the
disease.

34. Diabetes : Impact on physiology
 A deficiency in insulin or a problem with its metabolic activity canA deficiency in insulin or a problem with its metabolic activity can
result in an increased blood glucose level (ie, hyperglycemia).result in an increased blood glucose level (ie, hyperglycemia).
 Hyperglycemia leads to an increase in the urinary volume of glucoseHyperglycemia leads to an increase in the urinary volume of glucose
and fluid loss, which then produces dehydration and electrolyteand fluid loss, which then produces dehydration and electrolyte
imbalance. This later problem, if severe, may result in coma.imbalance. This later problem, if severe, may result in coma.
 The stress of the disease also results in an increase in cortisolThe stress of the disease also results in an increase in cortisol
secretion. It is the inability of the diabetic patient to metabolize andsecretion. It is the inability of the diabetic patient to metabolize and
use glucose, the subsequent metabolism of body fat, and the fluiduse glucose, the subsequent metabolism of body fat, and the fluid
loss and electrolyte imbalance that causes metabolic acidosis.loss and electrolyte imbalance that causes metabolic acidosis.
 It is the hyperglycemia and ketoacidosis coupled with vascular wallIt is the hyperglycemia and ketoacidosis coupled with vascular wall
disease (microangiopathy and atherosclerosis) that alters the body’sdisease (microangiopathy and atherosclerosis) that alters the body’s
ability to manage infection and heal.ability to manage infection and heal.
 Complications in the diabetic patient that can occur during and afterComplications in the diabetic patient that can occur during and after
dental treatment include hypoglycemia, coma, or infection anddental treatment include hypoglycemia, coma, or infection and
delayed healing.delayed healing.

37. NormalNormal DiabetesDiabetes

38. Oral Complications of Type 2 Diabetes Mellitus
 Patients may have an increased prevalence of oral
candidiasis.
 Mucormycosis, a rare oral fungal infection that affects
the palate and maxillary sinuses, may be seen in
uncontrolled or poorly controlled diabetes.
 Bilateral asymptomatic parotid gland enlargement may
occur.
 Xerostomia may be associated with uncontrolled
diabetes mellitus.
 Patients may have an accentuated response to plaque.
 Patients may have slow wound healing and increased
susceptibility to infection.

39. Thrush
Oral thrush is a condition in which the fungus CandidaOral thrush is a condition in which the fungus Candida
albicans accumulates on the lining of mouth.albicans accumulates on the lining of mouth.

40. Mucormycosis is any fungal infection caused by
fungi in the order Mucorales
 A sporangium of
a Mucoralean fungus

41.  Excessive periodontal bone
loss, tooth mobility and early
tooth loss can occur.
 Xerostomia resulting inXerostomia resulting in
dehydration of oral tissuesdehydration of oral tissues
(and Candidiasis).(and Candidiasis).
 Oral changes result in anOral changes result in an
accentuated response toaccentuated response to
plaque.plaque.

42. Bilateral,Bilateral, asymptomatic parotid glandparotid gland
enlargementenlargement

43. Diabetes mellitus
 Acute fulminating
abscess, gingival
erythema, and
hyperplasia may
indicate presence of
diabetes

44. Diabetes mellitus
 It is important to note
that although not an
oral change per say, the
patient with diabetes
mellitus, experiences
slow wound healing
and increased
susceptibility to
infection.

45. Addison’s Disease
 Primary adrenal cortical insufficiency
 In most cases, the cause of destruction of the
adrenal gland is unknown – it may be an
autoimmune disease.
 It may be due to a tumor or tuberculosis.
 To compensate, the pituitary gland increases
production of ACTH.

46. •Cortisol synthesis is
controlled by ACTH
(adrenocorticotrophic
hormone) from the
pituitary, which in turn is
controlled by CRH
(corticotropin-releasing
hormone) from the
hypothalamus.
•negative feedback by
cortisol on both pituitary
and hypothalamus

47.  This disease causes
an increased
production of melanin,
resulting in melanotic
macules in the oral
mucosa due to
elevated levels of MSH
(melanocyte
stimulating hormone)
Addison’s Disease

49. Effects of Drugs on the Oral
Cavity
 Blood pressure drugs, antianxietyBlood pressure drugs, antianxiety
medications, antipsychotic medications, andmedications, antipsychotic medications, and
antihistamines can cause xerostomia.antihistamines can cause xerostomia.
 Prednisone suppresses the immune systemPrednisone suppresses the immune system
and can lead to candidiasis and oraland can lead to candidiasis and oral
infections.infections.
 Antibiotics may increase risk of candidiasis.Antibiotics may increase risk of candidiasis.

50. Effects of Drugs on the Oral
Cavity
 Tetracycline can cause toothTetracycline can cause tooth
discoloration.discoloration.
 Phenytoin and nifedipine can causePhenytoin and nifedipine can cause
gingival enlargement.gingival enlargement.
 Cyclosporine may cause gingivalCyclosporine may cause gingival
enlargement.enlargement.

51. Effects of Drugs on the Oral Cavity
Oral drug-reaction patterns with associated
drugs and drug classes include:
 Xerostomia –
 Antidepressants and antipsychotics,
 Antihypertensives,
 Antihistamines, and decongestants
 Swelling –
 Penicillins, aspirin, sulfa drugs and ACE inhibitors
 Nonspecific ulceration and mucositis –
 Antineoplastics (methotrexate, 5-fluorouracil,)
 Sulfonamides, tetracyclines,
 Nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, indomethacin,
salicylates,)

52. Effects of Drugs on the Oral Cavity
 Lupus erythematosus (LE) – like - Carbamazepine,,
griseofulvin, , hydralazine, isoniazid, lithium,
methyldopa,
 Pigmentation - Amiodarone, antimalarials (chloroquine,
hydrochloroquine),, cyclophosphamide, estrogen,
ketoconazole, minocycline,
 Gingival enlargement - Calcium channel blockers
(amlodipine, diltiazem, nifedipine, ), cyclosporine,
phenytoin, and sodium valproate

53. Minocycline-associated pigmentation in a patient who hadpigmentation in a patient who had
used the drug for several months to treat severe acne. Noteused the drug for several months to treat severe acne. Note
the bluish gray hue of the alveolar mucosa superior to thethe bluish gray hue of the alveolar mucosa superior to the
attached (pink) gingival mucosa.attached (pink) gingival mucosa.

54. Gingival enlargement in a 41-year-old man with a
several-year history of using calcium channel
blockers.

55.  Crohn diseaseCrohn disease
 Diffuse labial, gingival or mucosal swellingDiffuse labial, gingival or mucosal swelling
 CobblestoningCobblestoning of buccal mucosa andof buccal mucosa and
gingivagingiva
 aphtous ulcersaphtous ulcers
 mucosal tagsmucosal tags
 angular cheilitisangular cheilitis
 oral granulomasoral granulomas
 Ulcerative colitisUlcerative colitis
 Oral signs are present in periods ofOral signs are present in periods of
exacerbation of diseaseexacerbation of disease
 Aphtous ulceration or superficialAphtous ulceration or superficial
hemorrhagic ulcershemorrhagic ulcers
 Angular stomatitisAngular stomatitis
•cobblestoning
of the gut
mucosa
GIT diseases
•pystomatitis vegetans

56. GIT diseases
 Gastroesophageal reflux
 Reduction of the pH of the oral cavity below 5,5 – enamel
damage
 Damage of the dentin – higher sensitivity (to temperature..),
caries
 Chronic liver diseases
 Jaundice
 Petechiae or gingival bleeding (hemostasis disorder)

57. THANK YOUTHANK YOU

58. Effects of Drugs on the Oral CavityEffects of Drugs on the Oral Cavity

59. Effects of Drugs on the Oral CavityEffects of Drugs on the Oral Cavity