Systemic Disease and the Mouth Flashcards
(41 cards)
1
Q
3 main groups of Oral manifestation of systemic disease
A
- Dental manifestation of systemic disease
- Mucosal effects of systemic disease
- Oral effects of tx of systemic disease
2
Q
How does systemic disease affect teeth
A
- disruption to tooth structure formation
- disruption of tooth structure content
3
Q
What are the dental manifestations of systemic disease in children?
A
- Usually going to be apparent in children
- primary teeth for pre/ perinatal
- secondary teeth for perinatal/ childhood - Congenital conditions/ infections
- syphilis, TORCH
- ectodermal dysplasia - Illness/ metabolic disorders
- severe childhood illness
- cancer tx - Pigmentation from substances in blood
- Bilirubin, present in high levels in jaundice cna affect teeth
- Tetracycline, administered as an antibiotic
4
Q
Ectodermal dysplasia
A
- typical hypoplasia and hypodontia
- small cone shaped teeth
- missing teeth
- does not have complete ectodermal dysplasia as pt has hair on upper lip
- may have absence of sweat glands and salivary gland
5
Q
Hutchison’s incisors
A
- typical bulbous crown
6
Q
Perinatal illness
A
- show changes to the laying down of cementum and enamel
- affect calcification of the tissues depending on the time of which the illness took place
- same effect happening across many teeth and also affecting diff teeth at diff stages of development
- can see upper incisors formed slightly lower than the incisors here
- but same dark band where there is hypoplastic and hypomineralised enamel and dentine
- extensive perinatal illness as it has gone on for some years, continue up to most of the crown
- the upper area of crown will form at between 4-5 years of age
7
Q
Metabolic disease - Porphyria
A
- change in the amount of haem and haem products in blood
- can be incorporated into dental tissues as they form
8
Q
Tooth substance pigmentation- Bilirubin
A
- significant perinatal jaundice with high bilirubin levels
- leading to yellow green change within dentition
9
Q
Tooth substance pigmentation - Tetracycline
A
- will produce a linear band
- affected development of all of incisor teeth
- producing significant cosmetic deformity
- tetracycline is not recommended to give to children due to this issue
- may sometimes see tetracycline staining of teeth in unerupted 3rd molars due to children taking them during early teenage years when crown of tooth forming
10
Q
Oral Mucosal effects from Systemic disease
A
- Giant Cell Granuloma
- Orofacial Granulomatosis
- Recurrent Aphthous Stomatitis
- Dermatoses, ie: Lichen Planus, Vesiculobullous
- Immune Deficiency/ Disease
- Drug reactions
11
Q
Giant Cell Lesions
A
- can be peripheral/ central
- osteoclast related lesions
- can also be due to local irritation, roducing multinucleate giant cells in order to remove a difficult stubborn pathogen
- if there is central lesion extending into oral ST, usually seen on radiograph
- consider whether they are due to hormonal changes
12
Q
If a child had swelling, what is essential to take?
A
Radiographs
13
Q
Hormonal changes in GCL
A
- peripheral and central lesions
- check parathyroid function
- could be excess of parathyroid stimulation of osteoclasts
- renal failure - reactive hyperparathyroidism
- hypocalcaemia - reactive hyperparahtyroidism
- parathyroid tumour
Pt with renal failure/ on renal dialysis, will possibly have GCL appearing
14
Q
Hyperparathyroidism
A
- loss of cortical bone
- densest bone and has highest calcium content
- preferentially removed when parathyroid hormone is trying to raise plasma calcium level
15
Q
Hyperparathyroidism in dentistry
A
- from dental perspective, this affects the lamina dura
- with ongoing hyperthyroidism, lamina dura is often lost
- don’t mistaken as periapical lesion when lamina dura is absent around apex of tooth but absent all around the tooth
- once hyperparathyroidism corrected, lamina dura will form
16
Q
Raised ACTH - Addison’s
A
- pigmentation due to raised ACTH
- ACTH stimulates hormone for melanocytes
- high ACTH levels will produce a reactive melanosis of the oral mucosa
- widespread pigmentation within mouth and also happen on skin
- increasing of widepsread oral pigmentation should trigger investigation by referral from dentist to GMP
17
Q
Causes of raised ACTH
A
- Addisons
- Cushings, where there is pituitary adenoma producing excess ACTH
- if there is a small cell carcinoma in lung which produce ACTH inappropriately
18
Q
Systemic Illnesses
A
Immune deficiency
- Orofacial Granulomatosis
- SS
- Autoimmune- Addisons, Cushings
- Infection - fungal/ viral
Skin immune disease
- LP
- VB disease: Pemphigoid, Pemphigus
Haematinics deficinecy
- causes: bleeding, diet, increased demand
- effects; oral ulceration, painful tongue
** If pt has low iron, due to internal bleeding into gut/ poor diet/ malabsorption, will cause aphthous type ulceration
19
Q
What is Orofacial Granulomatosis
A
- similar features to Crohns disease
- predominately affecting H&N in children, can develop first time in adults
- children with ginger gene and freckles
20
Q
Clinical photos of OFG
A
- perioral erythema
- perioral swelling
- lip swelling
- angular cheilitis
- active phase of disease: oedema and inflammation going on within perioral tissues
- can spread to any part of the face
- causing dry and cracking surface of lower lip
- proliferative, erythematous, full thickness gingivitis (usually in all 4 quadrant)
- staghorning tooth appearance as they look like antlers (picture 4)
- ## linear fissured ulcer present bottom of labial sulcus: not related to trauma
21
Q
Crohn’s screening
A
- if pt has OFG, then one question to ask if they have Crohn’s disease
- if they have, then normally lesions are termed oral Crohn’s rather than OFG
- OFG normally won’t present with abdominal pain/ problems, but may develop in later time and diagnose as Crohns
22
Q
Best thing to do to determine child presenting with OFG has Crohns?
A
- look for changes of altered bowel habit/ abdominal pain
- any evidence of growth problems
- if children has small bowel Crohn’s disease, they will fail to absorb nutrients properly and reduce their rate of growth
23
Q
Faecal Calprotectin assay
A
- In young children, when they come across new pathogens for the first time, a raised calprotectin may be due to a variety of causes -> hence unreliable
- older children above 10, calprotectin levels are more associated with gut inflammation
- GA for screening test for endoscopy: based upon good level of suspicion
1. growth failure
2. abdominal pain/ symptoms
3. raised calprotectin levels
24
Q
How to assess growth prediction?
A
- using standardised growth charts
- should follow their own centile group
- blue: boys, pink: girls
25
Causes of OFG without Crohns
- dietary preservatives, ie: benzoic acid in fizzy drinks
- some pts by limiting this can reduce their symptoms
- Dietary allergens, ie: Benzoate, Sorbate, Cinnamon, Chocolate (E210-219)
- skin testing not reliable
- use dietary exclusion to determine trigger
- Benzoates are in tomato and tomato products; all things with tomatoes must avoid
26
Food Maestro app
- parents and pt to enter substances they need to avoid
- when buying stuff, they can scan the bar code of the food in supermarket and the app will tell them any substances they need to avoid
- pt need to comply 100% during trial period
27
Management of OFG
1. 3 month empirical dietary exclusion
- Benzoate/ cinnamon, unless clear of other dietary triggers
2. Topical tx for angular chelitis/ fissure
- Miconazole
- Hydrocortisone cream
3. Topical tx to lip swelling/ facial erythema
- Tacrolimus ointment 0.03%
- Intralesional steroids to lip
** lip swelling is oedema, problem is within lymphatics deep inside lip tissues, medicaments are required to be absorbed and soak into tissues and be carried to lymphatics, drain out
- some cases, need systemic immune modulation
28
CT disease/ autoimmune disease
1. Systemic lupus erythematosis (SLE)
2. Systemic sclerosis (Scleroderma)
3. SS
4. Mixed CT disease (MCTD)
29
Lupus
- similar to LP
- histologically also similar to LP
- changes in mucosa with white striae on erythematous background
- gingival lesions
- difference is found by immunology assays of blood and also unusual pattern
- in histological exam, lymphocytic band is much lower placed within CT in lupus than in LP
30
Systemic sclerosis
Crest syndrome (picture 1)
- telangiectasia/ little BV forming haemangiomas on surface of skin
- may continue through mucosa and cause oral bleeding problems
- problems with oesophagus, no longer has elasticity to stretch and allow bolus to pass
- perioral fibrosis means that mouth cannot be opened as facial tissues will not stretch to move bones
- denture and extraction will be difficult due to limited mouth opening
31
Vasculitic diseases
Large vessel disease
- Giant Cell (temporal) Arthritis
Medium vessel disease
- Polyarteritis nodosa
- Kawasaki disease
Small vessel disease (picture bottom)
- Wegener's Granulomatosis ** most frequently reported
- vasculitic change on gingiva/ palate often cause ischaemia and necrosis of tissue and spread throughout upper airway
- pt must be referred urgently to rheumatologist
- require systemic immunosuppression to control as may become fatal
32
Immune deficiency
Congenital Immune Deficiency
- failure of either B/ T cell development
Acquired Immune deficiency
- diabetes
- drug therapy: immunosuppresive medicines
- cancer therapy
- HIV
33
What is most commonly associated with opportunistic infections?
Immune deficiency
34
This case of SS, may have left pt with a very dry mouth and led to candida infection
- HIV may also produce similar effect and hence more susceptible to candidiasis
- Purple change in mucosa (picture beside), commonly associated with HIV and termed Kaposi sarcoma
35
Hairy Leukoplakia
- ridged white lesion on posterior laterla aspect of the tongue
- uncommonly seen as a manifestation of HIV
36
Herpes simplex reactivating
- viral reactivation on tongue dorsum
- if significant, should be accompanied by immune deficiency investigations
37
What causes haematinic deficencies?
1. Poor intake of diet
2. Malabsorption
- GI disease: Coeliac, Crohns
3. Blood loss
- Crohns disease, Ulcerative colitis, Peptic ulcer disease, Bowel cancer, Liver disease
4. Increased demand
- childhood growth spurts
38
Oral effects of medical therapy
- dry mouth
- oral ulceration
- lichenoid reaction to ACE inhibitors, beta blockers and other drugs
- angio-oedema- ACE inhibitors
- osteonecrosis: bisphosphonates
39
Oral ulceration
- ulcer related to Nicorandil
- although it may look like a major aphthous ulcer, there is no erythematous halo around ulcer
- responds poorly to topical steroids
- only tx is to remove drug causing the problem
Nicorandil- used to treat angina, usually concern to stop the drug as it is for poorly- controlled angina
40
Angio-oedema
- due to por regulation of complement cascade
- caused by inhibition of controlling enzymes as side effect of ACE inhibitor use
41
