This document summarizes various oral manifestations of systemic diseases. It discusses oral signs of gastrointestinal diseases like ulcers and glossitis in celiac disease. It also covers oral signs of liver diseases like bleeding tendency in alcoholic cirrhosis. Further, it outlines oral manifestations of hematological conditions like gingival hypertrophy in leukemia. The document also discusses oral signs of endocrine, pulmonary, renal and nutritional deficiencies. Finally, it examines various oral lesions like aphthous ulcers, changes in tongue coating, and disorders of the salivary glands.

2. Oral Manifestations of
Systemic Disorders
Dr. TAREK SHETA
Lecturer of Internal Medicine
Mansoura Faculty of Medicine

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.

4. Oral manifestations of
Gastrointestinal diseases
Any malabsorption Ulcers, Glossitis, Angular stomatitis
Coeliac disease Ulcers, Glossitis, Angular stomatitis, Dental hypoplasia
Cystic fibrosis Salivary gland swelling
Gardner’s syndrome
(familial colonic polyposis)
Osteomas
GERD Tooth erosion, Halitosis

5. • Crohn disease
– diffuse labial, gingival or mucosal swelling
– “cobblestoning“ of buccal mucosa and
gingiva
– aphtous ulcers
– mucosal tags
– angular cheilitis
– oral granulomas
• Ulcerative colitis
– oral signs are present in periods of
exacerbation of disease
– aphtous ulceration or superficial
hemorrhagic ulcers
– angular stomatitis
– pyostomatitis gangrenosum
cobblestoning of
the gut mucosa
GIT diseases

6. Oral manifestations of Liver
diseases
Alcoholic cirrhosis Bleeding tendency, Sialosis
Primary biliary
cirrhosis
Sjögren’s syndrome, Lichen planus
Hepatitis C Lichen planus, Sjogren’s syndrome
- jaundice
- petechiae or gingival bleeding (high bleeding tendency)
Dr. TAREK SHETA, M.D

7. Lichen planus
Poorly defined violaceous plaque with lacy, white pattern on the
buccal mucosa - (70% of oral lichen are HCV associated)

8. Deficiency of haematinics
(iron, folic acid or vitamin B12)
– angular stomatitis
– glossitis
• red colour
• athrophic papilae
• recurrent aphthae
– candidal infection
– Burning mouth
sensation
Oral manifestations Haematological
diseases

9. • Leukemia
– gingival hypertrophy
– petechiae
– mucosal ulcers
– hemorrhage
Treatment of leukemia
– reactivation of herpes simplex virus
Oral manifestations
Haematological diseases
Dr. TAREK SHETA, M.D

10. Gingival hyperplasia: acute monocytic
leukemia

11. Oral manifestations
Haematological diseases
Sickle-cell anaemia Jaw deformities, Osteomyelitis
Aplastic anaemia Gingival bleeding – herpes simplex
lymphoma Infections, Ulcers, Bleeding tendency,
, Gingival swelling
Multiple myeloma Jaw aches, Tooth mobility
Amyloid disease macroglossia, Purpura
Dr. TAREK SHETA, M.D

12. • Sjögren syndrome
– autoimmune disease
– men : women - 1 : 9, 50 years and older
Main signs
– sicca syndrome
– keratoconjuctivitis sicca
– xerostomia
Oral signs
– decrease in saliva
• xerostomia
– dry, red, wrinkled mucosa
• difficulty in swalloving and eating
• disturbance in taste and speech
• increased dental caries
• infections
• atrophy of the papilae
• candidiasis
Connective-tissue diseases

13. • Kawasaki disease
– vasculitis of medium and large arteries
Oral signs
– swelling of papilae on the surface of the
tongue (strawbery tongue)
– intense erythema of the mucosal
surfaces
– cracked, cherry red, swolen and
hemorrhagic lips
Connective-tissue diseases

14. • Scleroderma
– diffuse sclerosis of the skin, GIT,
heart muscle, lungs, kidney
Oral signs
– pursed lips – dificult to open the
mouth
– esophageal sclerosis 
gastroesophageal reflux – damage
of enamel
– pale, rigid mucosa
– teleangiectasias
– decreased mobility of tongue
– salivary hypofunction
Connective-tissue diseases
Limited mouth opening and decreased
tongue mobility
Gingival retraction

15. • Lupus erythematosus
– Ulcerations (painless).
– oral lesions of lichen planus –
(painfull)
– petechiae
– damage of salivary glands -
xerostomia
Connective-tissue diseases
ulcer
lichen planus lesions

16. • Suppurative lung
syndromes:
– xerostomia
– swelling lips
– gingivitis
Pulmonary diseases
Dr. TAREK SHETA, M.D

17. • Sarcoidosis
– multiple, nodular, painles ulcerations of
the gingiva, bucal mucosa, labial mucosa
and palate
– Tumor like swelling of salivary glans
– swelling of the tongue
– xerostomia
– facial nerve palsy
Pulmonary diseases

18. • Diabetes mellitus
– xerostomia caused decreased
salivation and increased glucosa
level in saliva
• gingivitis
• oral infections
• candidiasis
– higher incidence of caries
– bilateral parotid enlargement
– altered taste
– burning mouth syndrome
gingivitis
hyperplasia
bilateral parotid
gland enlargement
Endocrine diseases

19. • Hypoparathyroidism
– upper lip twitching
• Hyperparathyroidism
Teeth rarefaction, Brown tumours
• Gigantism / acromegaly
• Spaced teeth, Mandibular prognathism,
• Macroglossia, Megadontia
Endocrine diseases

20. • Congenital hypothyroidism
• Macroglossia, Retarded tooth eruption
• Pituitary dwarfism
• Microdontia, Retarded tooth eruption
• Pregnancy
• Gingivitis, Epulis

21. • Cushing´s syndrome
– osteoporosis  pathological
fractures of the mandible,
maxilla or alveolar bone
– delayed healing of fractures
and soft tissue injuries
• Addison´s disease
– oral mucosal melanosis –
buccal mucosa, tongue
Endocrine diseases
moon face
hyperpigmentation

22. • Uremic stomatitis
– in undiagnosed and untreated chronic renal
failure
– irritation and chemical injury of mucosa by
ammonia or ammonium compounds
Signs
– painful plagues and crusts – bucal mucosa,
the floor or dosrum of the tongue, floor of the
mouth
– Type I
• generalized or localized erythema
• exudate
• pain, burning, xerostomia, halitosis,
gingival bleeding, candidiosis
– Type II
• ulceration
• secondary infection
• anemia
Renal diseases

23. Renal diseases
Post renal transplant Infections( herpetic, candidal), Bleeding tendency,
Gingival hyperplasia, Kaposi’s sarcoma
Hairy leukoplakia
Renal rickets
(vitamin D resistant)
Delayed tooth eruption, Dental hypoplasia, Enlarged
pulp
Nephrotic syndrome Dental hypoplasia
Dr. TAREK SHETA, M.D

24. 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.
• Scurvy caused by vitamin C deficiency may cause
petechiae to ecchymoses in the submucosa.
• Mucous membrane changes may lead to gingival
hypertrophy and erosive, bleeding gums.

25. Disorders of Teeth
DISORDER FINDINGS
Bulimia Erosion of enamel and loss of dentin
Congenital
cytomegalovirus
Yellow dentin and hypoplastic pitted
enamel
Congenital
porphyria
Erythrodontia of canine teeth and molars
and brown discoloration of incisors
Congenital
syphilis
Hutchinson teeth, mulberry molars
Gardner
syndrome
Supernumerary teeth
Dr. TAREK SHETA, M.D

26. Disorders of Teeth
Lepromatous leprosy Reddening of upper teeth (pink spots)
Primary biliary
cirrhosis
Green pigment deposits
Sjogren syndrome Caries, increased plaque accumulation, poor
oral hygiene
GERD Erosion of enamel due to repeated exposure to
gastric acid
Tetracycline staining Permanent gray discoloration
Tuberous sclerosis Pitted enamel of the permanent teeth
Dr. TAREK SHETA, M.D

27. Periodontitis
Definition -chronic infection of connective tissue, periodontal
ligament and alveolar bone
Aetiology: diabetes, heart disease, stroke and preterm birth
birth control pills , steroids, Down syndrome, Langerhans cell
histiocytosis, HIV

28. Causes of mucosal hyper
pigmentation
• Localized
• Amalgam, tattoo
• Ephelis / Naevus
• Malignant melanoma
• Kaposi’s sarcoma
• Peutz–Jegher syndrome
(search for GI polyps)
• Generalized
• Racial
• Localized irritation, e.g.
smoking
• Drugs, e.g. phenothiazines,
antimalarials, minocycline,
contraceptives, mephenytoin
• Addison’s disease/ Nelson’s
syndrome
• Ectopic ACTH(e.g.
bronchogenic carcinoma)
• Albright’s syndrome
• Haemochromatosis
• Neurofibromatosis,
• Malignant acanthosis nigricans

29. Aphthous ulceration
• Acute, recurrent,
painful ulcers on
nonkeratinized
mucosa
• Most common
cause of oral
ulcerations
• Effect up to 30 %
of the population
Dr. TAREK SHETA, M.D

30. Aphthous ulceration
Minor aphthae
(90 -95 %)
Major aphthae
(5-10%)
Herpetiform
ulcers
(1-5%)
Age of onset Childhood or
adolescence
Childhood or
adolescence
Young adult
Ulcer size 2–4 mm 10 mm or larger Initially tiny, but
ulcers coalesce
Number of ulcers Up to about 6 Up to about 6 10–100
Sites Mainly vestibule,
labial, buccal
mucosa &
floor of mouth
Any site Any site but often
on ventrum of
tongue
Duration of each
ulcer
Up to 10 days Up to 1 month Up to 1 month

31. Aphthous
ulcers: minor
Multiple, very
painful, gray-
based ulcers
with
erythematous
halos
on the labial
mucosa.

32. Aphthous
ulcers:
major
52-year-old
female with
advanced
HIV/AIDS with a
5-month history
of painful lesions
on the tongue.

33. Aphthous ulceration
• Systemic Conditions Associated
– Haematologic deficiency (up to 20%)- iron, folic acid
or vitamin B12 deficiency
– Gastrointestinal malabsorption (3%) - Celiac disease,
dermatitis herpetiformis, gluten-sensitive enteropathy,
Crohn disease, pernicious anemia
– Systemic lupus erythematosus, reactive arthritis
– HIV
– Behcet disease
Potential triggers - heredity, food and medication
allergy, decreased mucosal barrier integrity, emotional
stress, and trauma
Dr. TAREK SHETA, M.D

34. Salivary Glands Disorders
• 1-Xerostomia (dryness of mouth)
• Signs and symptoms: diminished or altered taste
and smell,
• halitosis,
• heavy plaque accumulation,
• difficulty in wearing dentures,
• recurrent fungal infections,
• burning sensation,
• dysphagia,
• dry or cracked lips,
• salivary calculi and increased thirst

35. Xerostomia: Causes
• Medications - Antidepressants, antihistamines,
diuretics
• Medical conditions - Parkinson disease, diabetes,
anemia, cystic fibrosis, rheumatoid arthritis
• granulomatous inflammation - tuberculosis,
sarcoid, Sjögren syndrome, HIV, amyloid
• Dehydration - Fever, excessive sweating, vomiting,
diarrhea, blood loss, burns, smoking, consumption
of tea, coffee
• Radiation therapy of head and neck
• Old Age
Dr. TAREK SHETA, M.D

36. 2-Excess salivation (ptyalism):
• Excessive production:
–GERD
–Pancreatitis
–Liver disease
–Serotonin syndrome
–Mouth ulcers
–Oral infections
Dr. TAREK SHETA, M.D

37. Ptyalism (causes)
• Decreased clearance:
–Infections eg tonsillitis, epiglottitis and
mumps.
–Jaw fracture or dislocation
–Radiation therapy
–Neurologic disorders such as myasthenia
gravis, Parkinson's disease, bilateral facial
nerve palsy and hypoglossal nerve palsy.

38. Changes in tongue
coating
Dr. TAREK SHETA, M.D

39. Normal tongue coating is formed of:
1- Tongue papillae.
2- Food debris.
3- Bacteria.
4- Desquamated epithelium.
Dr. TAREK SHETA, M.D

40. The tongue coating
varies in different individuals.
Varies in the same individual during the day
It is continuously formed
it is marked in the morning and is removed by:
1-Mechanical factors: speaking and chewing food.
2-Salivary flow
Dr. TAREK SHETA, M.D

41. Tongue coating is in a continuous
process of removal and formation.
- If removal exceeds formation 
atrophy
- If formation exceeds removal 
increased tongue coating.
Dr. TAREK SHETA, M.D

42. Atrophy of tongue coating

43. 1- Deficient or impaired utilization of
nutrients
1-Iron deficiency anemia.
3-Vitamin B deficiency especially (vitamin B2,
B6, B12, folic acid and nicotinic acid).
Pernicious anemia.
4-Anemia associated with parasitic infection as
ascaris and bilhariziasis.
5-Malnutrition, malabsorption.
6-Chronic alcoholism.
Etiology
Dr. TAREK SHETA, M.D

44. 2- Peripheral vascular disease
1- Angiopathy: Diabetes Mellitus.
2- Vasulitis: systemic lupus
erythematosus.
3- Endarteritis obliterans: syphilitic
glossitis.
4- Obliteration of small blood vessels:
scleroderma, submucous fibrosis.
5- Localized vascular insufficiency in elderly
patients.

45. 3- Drugs
-Drugs that:
• Interfere with the growth and maturation
of the epithelium e.g cyclosporine.
• Induce candidosis e.g. antibiotic, steroid.
• Induce xerostomia e.g anticholinergic
drugs, radiotherapy.
Dr. TAREK SHETA, M.D

46. 4- Miscellaneous
1- Frictional irritation: atrophy at tip &
lateral borders of tongue.
2- Atrophic lichen planus.
3- Epidermolysis bullosa: ulceration
healed by scar.
4- Long standing xerostomia.
5- Diabetes and chronic candidiasis may
produce a lesion called central papillary
atrophy.
Dr. TAREK SHETA, M.D

47. Increased tongue coating
(white hairy tongue)

48. White hairy tongue
• hypertrophy of filiform papillae resembling hair-
like projections
• Aetiology:- heavy tobacco use, mouth breathing,
antibiotic therapy, poor oral hygiene, general
debilitation, radiation therapy, chronic use of
bismuth containing antacids, lack of dietary
roughage, Febrile illness.
• White, yellow green, brown, or black color is due
to chromogenic bacteria or staining from
exogenous sources

49. Black hairy tongue

50. Etiology
1- Candidal infection in a smoker
2- Topical and systemic antibiotics:
ex: penicillin, tetracycline, aureomycin.
3- Systemic disturbance: anemia,
hyperacidity, peptic ulcer.
4- Sodium perporate and sodium
peroxide mouth wash that stimulate
growth of filiform papillae.
Dr. TAREK SHETA, M.D

51. Geographic tongue (benign migratory
glossitis (wendering rash)
Dr. TAREK SHETA, M.D

52. Geographic tongue
• benign inflammatory condition,
due to Loss of filiform papillae
• Erythematous plaques with well
demarcated white border
• Etiology- diabetes mellitus,
anemia, hormonal disturbances,
psoriasis, Reiter syndrome,
atopic dermatitis,, Down
syndrome, lithium therapy

53. Fissured tongue (furrowed tongue,
scrotal tongue, grooved tongue)
• normal variant in 5-
11% individuals
• Also seen in :
psoriasis, Down
syndrome,
acromegaly, Sjogren
syndrome

54.  Mongolism:
transverse
fissuring of the
tongue
Dr. TAREK SHETA, M.D

55. Sublingual varices
- enlarged tortuous veins in the sublingual area.
- asymptomatic, but trauma may result in bleeding

56. Etiology
 Congential.
 Idiopathic
 elderly people.
 It may be associated with portal
hypertension.
Dr. TAREK SHETA, M.D

57. Macroglossia
• CP: Difficult mastication
and speech and accidental
tongue biting
• CAUSES:
– Down syndrome,
– hypothyroidism,
– neurofibromatosis,
– infection by mycobacteria,
– amyloidosis

58.  The stratified squamous epith. if chronically irritated by:
 Chemical: spices.
 Thermal: smoking.
 Infection: syphilis.
 Mechanical: dental irritation.
 Formed by thickening and hyperkeratinization with the
formation of white patches.
 Precancerous: biopsy
Leukoplakia of the tongue
Dr. TAREK SHETA, M.D

59. Oral hairy leukoplakia
• caused by Epstein-Barr
virus, presents as
asymptomatic,
corrugated, white plaques
with accentuation of
vertical folds along the
lateral borders of tongue
• Mainly seen in HIV
infection, organ transplant
recipients and patients on
chemotherapy
Dr. TAREK SHETA, M.D

60. Glossodynia / Glossopyrosis
Etiology
• Neurologic
– Diabetic neuropathy
– Trigeminal neuralgia
– Acoustic neuroma
• psychiatric
– Anxiety
– Depression
– Cancer phobia
– Somatoform disorder
– OCD
• Systemic disorders
– Anemia (iron deficiency,
pernicious)
– GERD
– Sjogren syndrome
– Hypothyroidism
– AIDS
Dr. TAREK SHETA, M.D

61. THANK
YOU…