Oral manifestations
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This document discusses oral manifestations of systemic diseases in older patients. It provides background on oral structures and functions. It then examines relationships between oral symptoms and conditions like drug reactions, fungal/viral infections, leukemia, Behcet's disease, Sjogren's syndrome, diabetes mellitus, nutritional deficiencies, and amyloidosis. For each condition, it describes common oral presentations and recommendations for treatment and differential diagnosis. The document concludes that the mouth can provide insights into a patient's immune function and that differential diagnosis is important.
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Oral manifestations
- 1. Oral Manifestations of Systemic Diseases in Older Patients Dr shabeel pn
- 2. Objectives • Review pertinent oropharangeal structure and function. • Examine the relationships between oral symptoms and systemic conditions. • Discuss clinical decisions pertaining to the topic.
- 3. Background The mouth (buccal cavity) is the reservoir for the chewing and mixing of food with saliva. It is the primary site of digestion and respiration as well as the primary communication structure.
- 5. Background • Drug Reactions • Fungal infections • Viral infections • Leukemia • Behcet’s Disease • Diabetes Mellitus • Nutritional Deficiencies • Amyloidosis
- 6. Background Definitions Gingivitis-inflammation of the gums Xerostomia-abnormal dryness of the mouth due to insufficient secretions Mucositis-inflammation of a mucous membrane Stomatitis-inflammation of the mouth having various causes (as mechanical trauma, allergy, vitamin deficiency, or infection) Cheilitis-inflammation of the lip Glossitis-inflammation of the tongue
- 7. Drug Reactions- SJS and TEN • Stevens-Johnson syndrome and toxic epidermal necrolysis are rare, life- threatening, drug induced reactions. • 7 to 21 days after exposure purpuric and erythematous macules evolve to skin necrosis and epidermal detachment. • Oral mucous membrane involvement occurs in up to 50% of cases and may impair ingestion of nutrition. • Most commonly implicated in these reactions are sulfonamides, penicillins, phenytoin, and phylbutazone.
- 8. Drug Reactions • Drug-induced neutropenia is typically characterized by circular reddish ulcer on the gingivae or areas of frequent trauma. • Gingivitis and oral ulcers often occur with chronic neutropenia also. • Discontinuation of the inducing drug usually results in resolution.
- 9. Drug Reactions Radiation, immunosuppressant and chemotherapeutic medications are the major treatments associated with stomatitis. Allergic reactions to materials or certain metalloids may also contribute.
- 10. Fungal Infections Thrush • Candida albicans infection is most commonly found in children. The infection is characterized by white plaques or spots in the mouth that lead to ulcers or painful cracking at the corners of the mouth. • The patient may experience dysphagia or odynophagia as the first symptoms. • Candidiasis therefore is a common indicator of impaired immune function whether as in HIV or for other reasons. • Treatment includes topical nystatin or oral fluconazole as indicated by site or causative organism of infection.
- 12. Viral Infections- Herpes • The herpes simplex viruses are categorized as type 1(oral) and type 2 (genitoanal). • The presentation of cold sores around the mouth is usual but the viruses can occur any place in the body that has broken skin or mucosal surfaces. • As high as 75% of adults will contract oral herpes by the time they reach their 40s. • Oral antivirals and pain medications are recommended for treatment of overly painful expressions of this condition.
- 14. Viral Infections-HIV • As previously discussed, often oral candidiasis is the initial symptom with which HIV patients present. • However, hairy leukoplakia, named for its corrugated appearance, is also seen as white lesions or plaques in the oral cavity. The epithelium is thickened, appears white, but is generally asymptomatic. • Treatment may be complicated by comorbidites and these should be considered when determining a treatment regimen with antivirals.
- 16. Leukemia • Infections, bruising, or hemorrhage of the oral cavity may be caused by thrombocytopenia or leukopenia. • Rarely, diffuse non-tender gingival enlargment, overall pallor of tissues due to anemia or ulcerative gingivitis may be exhibited.
- 17. Behcet’s Disease • Behcet’s disease is a rare disorder mainly affecting young men. • While the disease affects multiple organ systems, oral ulcerations reselmbling canker sores present in 99% of patients. • The oral lesions are the herald of this disease and are usually 6mm or smaller and resolve within 1-3 weeks. • Treatment is symptomatic and supportive. Medication may be prescribed to reduce inflammation and/or regulate the immune system. Immunosuppressive therapy may be considered.
- 18. Behcet’s Disease
- 19. Sjögren’s Syndrome • Sjögren’s syndrome is the 2nd most common autoimmune disease with women in their mid-60’s being the primarily afflicted. • Initial symptoms include dry eyes and dry mouth due to gradual glandular dysfunction. • In some cases, dysphagia, increased dental caries, increased susceptibility to oral candidiasis, and difficulty wearing dental prostheses will develop. • Treatment is generally symptomatic and supportive. Moisture replacement therapies may ease the symptoms of dryness. Nonsteroidal anti- inflammatory drugs may be used to treat musculoskeletal symptoms. Corticosteroids or immunosuppressive drugs may be considered in severe cases.
- 21. Diabetes Mellitus • Increased glucose in the patients’ system implies hyperglycemia also in saliva. • Bacteria find this environment more conducive and therefore these patients are more prone to dental caries, gingivitis, and periodontal disease.
- 22. Amyloidosis • Disorder characterized by deposition of insoluble proteins in organs that eventually causes dysfunction of the organ. • This condition may present as swollen erythematous buccal area if the mucous membranes in that area are involved in the disease process.
- 23. Nutritional Deficiencies • Iron deficiency anemia is the most common cause of anemia in older patients and may manifest as smoothing, reddening or soreness of the tongue. • Iron deficiency limits erythropoesis and therefore brings about a hypoproliferative anemia. • In older patients anemia associated with chronic inflammation is common. Nutritional iron deficiency is rare in older adults.
- 24. Nutritional Deficiencies • Pernicious anemia affects over 2% of the population over 60. • This disorder is clinically characterized by megaloblastic hematopoesis and/or neuropathies. • Oral manifestation possibilities are glossitis (beefy red tongue) or stomatitis (generalized burning or soreness). • Treatment with intramuscular or oral Vitamin B12 should follow diagnosis.
- 26. Nutritional Deficiencies • Thiamine (Vitamin B1) and Niacin/nicotinic acid (Vitamin B3) are also reported to cause some glossitis and cheilitis. • Folate deficiency leads to a megaloblastic anemia that demonstrates many of the same oral characteristics of pernicious anemia. – Cheilitis, glossitis, and mucosal erosions have been described.
- 27. Nutritional Deficiencies • Scurvy caused by vitamin C deprivation may cause petechiae to ecchymoses in the submucosa. • Mucous membrane changes may lead to gingival hypertrophy and erosive, bleeding gums. • Teeth may subsequently become soft associated with gingival infection predisposition. • Replenishment of Vitamin C may prevent further degradation of dental integrity.
- 28. Conclusions • The mucosal surface that is the oral cavity may provide insight into the immune function of the patient. • Differential diagnosis is important as many disorders may manifest themselves similarly in the buccal area.
- 29. References Greenspan, JS. "Sentinelsand Signposts: the Epidemiology and Significance of the Oral Manifestations of HIV disease." Oral Diseases May 1997: S13-17. McCance, Kathryn L., and Sue E. Huether. Pathophysiology The Biologiv Basis for Disease in Adults and Children. 4th ed. St. Louis: Mosby, 2002 Bologna, Jean L., Joseph L. Jorizzo, and Ronald P. Rapini. Dermatology. Spain: Mosby, 2003. Edwards, Brooks S. Amyloidosis. 2 Aug. 2005. Mayo Clinic. 26 Dec. 2005 <http://www.mayoclinic.com/health/amyloido sis/DS00431>.
- 30. References "NINDS Sjogren's Syndrome Information Page." National Institute of Neurological Disorders and Stroke. 11 Dec. 2005 <http://www.ninds.nih.gov/disorders/sjogren s/sjogrens.htm>. "NINDS Behcet's Disease Information Page." National Institute of Neurological Disorders and Stroke. 11 Dec. 2005 <http://www.ninds.nih.gov/disorders/behcet /behcet.htm>. Cobbs, Elizabeth L., Edmund H. Duthie, Jr, and John B. Murphy. Geriatrics Review Syllabus. 4th ed. Dubuque: Kendall/Hunt Publishing Company, 1999.
- 31. Questions 1. Many conditions may cause oral discomfort. In an older patient with normal immune function, what are parts of the work up are the first priorities? 2. Describe the possible etiologies of oral ulcerations that are whitish in color. 3. What is the treatment protocol for a patient that manifests epidermal irritation following initiation of a new regimen? What are the most common causes of this reaction?
- 32. Questions 4. What work up would help determine the correct cause of iron deficiency anemia? 5. Replenishment of cyanocobalamine is accomplished by more than one route. Describe the appropriate regimens and the attributes and detriments of each. 6. Autoimmune diseases often appear with accompanying conditions. Patients that suffer Sjodgren’s disease often also present with what other diseases? 7. What group of commonly used medications are associated with gingival hyperplasia/dysfunction?
- 33. Questions • What is the etiology of the majority of genitoanal herpes cases? How is this different from the etiology of oral herpes found in the elderly population? • A new patient reports with general malaise and oral irritation. She is elderly and has many comorbidities. What should the workup include? What are the possibilities for differential diagnoses? • The patient described in the previous question is found to have low Hgb and Hct levels. Her transferrin level is within normal limits. What other lab(s) should be checked before a diagnosis of anemia of chronic disease is made?
Editor's Notes
- The mouth (also called the buccal cavity) is used for initial digestion. Chewing and mixing of food takes place in this cavity without which a person may not be able to take in enough nutrition to fuel the processes needed for daily life. The other primary use for these structures is communication. With out properly function of the mouth a person is without means of sustenance or interaction with their caretakers and physician.
- Erythema multiforme, Stevens-Johnson Syndrome and toxic epidermal necrolysis is often viewed as a spectrum or progression of dermatologic drug reaction. The reaction is delayed in that the condition is usually noticed one to three weeks after exposure to the medication. Erythema multiforme begins as an undefined rash or reddening of the skin and mucus membranes. This may progress onto purpuric macules and even onto skin necrosis and detachment of the epidermis. The oral mucuos membranes are involved in about half of the cases and anemia may be seen in a third of cases. In the end, these conditions are self limiting with some cases ending in death. Treatment includes withdrawal of the offending agent(s) and supportive care.(Bologna et al.)
- The candida species are normal flora that inhabit the body’s surface, especially in the moist folds. Any lacerations therefore may become infected with candiasis. In the oral cavity, this infection manifests as white areas that may lead to ulceration. The elderly patient may be at increased risk because of poor denture care, comorbidities such as diabetes, or chronic need for antibiotics. The patient usually presents with dysphagia or odynophagia secondary to inflammation. The infection may progress to involve the respiratory tract, lungs, gastrointestinal tract and vagina, indicating the degree of immune dysfunction. Even after successful treatment recurrence is common. Chronic treatment is needed in some cases as well as correction of underlying causes, if possible. (Bologna et al.)
- While the herpes viruses are distinct, it is possible to be coinfected or experience herpes related symptoms in areas other than around the oral cavity. As the elderly person ages the general decline of their immune system is often thought to leave them susceptible to infections. These conditions are associated with severe pain during manifestations. (Cobbs et al.)
- This condition not only indicates possibility of HIV, it also may herald infection with the Epstein-Barr virus or declining immune function for any reason. Often in geriatric patients HIV progress more rapidly and early recognition of disease may improve the outcomes. (Greenspan S13-17)
- Leukemia accounts for only 2.5% of malignancies in the US. While elderly patients are often found to have cytopenia of some sort it should not be thought of as the natural progression of age. Often evaluation uncovers a disease process that accounts for a peripheral blood finding. Myelodysplastic syndromes are characterized by abnormal marrow maturation and cytopenia. MDS is most common in men in their 70s to 80s and the incidence is as common as chronic lymphocytic leukemia. Treatment for these disorders in the geriatric patient is a topic of much debate due to fatal complications. (Bologna et al.)
- Behcet&apos;s disease is a rare, chronic inflammatory disorder. An autoimmune disease that results from damage to blood vessels throughout the body, particularly veins the cause of Behcet&apos;s disease is unknown, although there have been reports of a virus found in some individuals with the disease. Behcet&apos;s disease generally begins when individuals are in their 20s or 30s, although it can happen at any age. . Most symptoms of the disease are caused by vasculitis (an inflammation of the blood vessels). (NINDS Behcet&apos;s Disease Information Page)
- Sjogren&apos;s syndrome often accompanies other autoimmune disorders — rheumatoid arthritis, lupus and others. These rheumatic diseases are marked by inflammation of your connective tissues, and it&apos;s common for people with Sjogren&apos;s syndrome to also have a connective tissue disorder. In this particular disorder the healthy tissues of the eyes and salivary glands are attacked resulting eventually in dry mouth, dental caries, dry eyes, and corneal ulcers. (NINDS Sjogren&apos;s Syndrome Information Page)
- Diabetes mellitus is a syndrome in which either not enough insulin is secreted from the pancreas to utilize glucose or the cells do not respond adequately to the presence of insulin to utilize glucose. Therefore the level of glucose is abnormally high in turn causing many long term ill effects. (McCance and Huether)
- Amyloidosis is a heterogenous group of disorders that involve amyloid protein deposition in organs, effectually causing the dysfunction of the organ systems involved. Both types one and two of amyloid may be involved and the patterns that may be seen under inspection may shed some light on tissue distribution. Mixed patterns are common however and may make prediction of involvement may therefore be obscured. (Edwards)
- Iron deficiency is the most common form of anemia. In younger patients, IDA may result from lack of iron in the diet. The elderly patient usually suffers from IDA resulting from chronic inflammation from some comorbidity. When working up a patient for anemia, it is very important to rule out nutritional iron insufficiency. The tests for transferrin or total iron binding capacity may help determine etiology. Occult blood loss or nutritional iron deficit should be ruled out before costly supplementation of erythropoetin. (Cobbs et al)
- The underlying disorder in pernicious anemia is the absence of intrinsic factor, an enzyme necessary for absorption of dietary vitamin B12. Congenital deficiency in secretion of intrinsic factor, gastric bypass, and partial or total gastrectomy are some of the primary causes of pernicious anemia. Pernicious anemia is also associated with autoimmune disorders. Neurologic manifestations may follow neuronal death and these complications cause a serious threat because they are not reversible even with treatment. Untreated pernicious anemia is fatal, usually due to right sided heart failure. Conventionally, oral replenishment of vitamin b12 was ruled out on the basis that there was no intrinsic factor, however it seems that there is a secondary mechanism for absorption. In order to utilize this mechanism it is necessary to give much larger doses than the 100mcg intramuscularly once a month that is recommended. (Cobbs et al)
- Tooth decay
- Folate is necessary for erythrocyte production and maturation. The mechanisms that cause the impaired DNA synthesis and erythrocyte destruction are not fully understood although folate coenzymes the synthesis of purines and pyrimidines of the four DNA and RNA bases. Many of the manifestations of pernicious anemia and folate deficiency are very similar save the neurological symptoms. If neurological symptoms are present they may be attributed to a thiamine deficiency, which frequently accompanies folate deficiency). Treatment of folate deficiency usually requires one milligram per day. The symptoms of this deficiency lasts for about 1 to 2 weeks after treatment begins. (Cobbs et al)
- (McCance and Huether)