Oral Manifestations of
Systemic Diseases in Older
Patients
Ali R. Rahimi, MD, FACP, AGSF
RTR Medical Group, Savannah, GA
Objectives
• Review pertinent oropharangeal
structure and function.
• Examine the relationships
between oral symptoms and
systemic conditions.
• Discuss clinical decisions
pertaining to the topic.
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.
Background
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Drug Reactions
Fungal infections
Viral infections
Leukemia
Behcet’s Disease
Diabetes Mellitus
Nutritional Deficiencies
Amyloidosis
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
Drug Reactions- SJS and TEN
• Stevens-Johnson syndrome and toxic
epidermal necrolysis are rare, lifethreatening, 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.
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.
Drug Reactions
Radiation, immunosuppressant
and chemotherapeutic
medications are the major
treatments associated with
stomatitis. Allergic reactions to
materials or certain metalloids
may also contribute.
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.
Fungal Infections
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.
Viral Infections-Herpes
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.
Viral Infections-HIV
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.
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.
Behcet’s Disease
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 antiinflammatory drugs may be used to treat
musculoskeletal symptoms. Corticosteroids or
immunosuppressive drugs may be considered in
severe cases.
Sjögren’s Syndrome
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.
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.
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.
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.
Nutritional Deficiencies
Pernicious Anemia
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.
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.
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.
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/amyloid
osis/DS00431>.
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.
Questions
1.
2.
3.
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?
Describe the possible etiologies of oral
ulcerations that are whitish in color.
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?
Questions
4.
5.
6.
7.
What work up would help determine the
correct cause of iron deficiency anemia?
Replenishment of cyanocobalamine is
accomplished by more than one route.
Describe the appropriate regimens and the
attributes and detriments of each.
Autoimmune diseases often appear with
accompanying conditions. Patients that
suffer Sjodgren’s disease often also
present with what other diseases?
What group of commonly used medications
are associated with gingival
hyperplasia/dysfunction?
Questions
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•
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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?