ORAL MANIFESTATION OF SYSTEMIC DISEASES
1. VITAMIN DEFICIENCY
Riboflavin (vitamin B2)
participates in a wide range of oxidation - reduction reactions in the
form of coenzymes. Riboflavin is widely distributed in meat, liver, diary products
and vegetables and is absorbed in the upper GIT.
Ariboflavinosis is associated with number of oral alterations:
 cheilosis -changes at the angles of the mouth.
Initially there is: hyperkeratosis of the epidermis
inflammation in the dermis
Later occur: fissures radiating from the corners of the mouth
which are from
to become secondarily infected
 glossitis - tongue is atrophic, glazed, skiny with red-blue
coloration resembled to cyanosis.
 sore throat
 swelling and erythema of the oral mucosa
Another extraoral changes:
 eye changes (superficial intersticial keratitis with vascularisation
and inflammatory infiltration of the cornea)
 dermatitis (nasolabial, scrotal and vulvae lesions with atrophy of
the skin).
Niacin (vitamin B3)
acts as a coenzym for oxidation reduction reactions. Foods
containing niacin include lean meat and liner, peanuts, yeast. Niacin deficiency
syndrome - pellagra (refers to rough skin). The clinical syndrome is identified as
dermatitis, diarrhea, dementia.
Oral manifestation
 stomatitis (redness, thickening, roughening, scaling, fissures and
chronic inflammation)
 glossitis (tongue red, swollen and beefy)
Pyridoxine (vitamin B6)
participates in aminoacid synthesis. Occurs in animal and vegetable
food. A deficiency is unusual, but many drugs act as pyridoxin antagenists.
 neuronal dysfunction (seizure, dizziness)
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 cheilitis
 glossitis (simular to pellagra)
Vitamin C
necessary for the proper synthesis of collagen. Occurs mainly in
citrus fruits. A deficiency is known as Scurvy-occurs in the growing child and
erderly men.
-hemorhage (purpura and ecchymoses of skin and gingival mucosa,
subperiostal hematomas.
-skeletal changes in infants and children (disturbance in the formation of
osteoid
matrix)
Oral manifestation:
 gingival swelling with spontaneous hemorrhage, ulceration, tooth
mobility, secondary periodontal infection and periodontal bone loss. The gingival
lesions are called scorbutic gingivitis. Wound healing and localisation of focal
infections are impaired because of the dearangement of collagen synthesis.
Vitamin K
a deficiency or inhibition of syntheses of vitamin K leads to
coagulopathy (inadequate synthesis of prothrombin and other clotting factors).
Intraoral changes:
 gingival bleeding
2. ANEMIAS
A: Iron-deficiency anemia
may results from
- low dietary intake of iron (vegetarian diet etc.)
- decreased absorption of iron (melabsorption)
- increated demands (pregnancy, infancy)
- chronic blood loss
GIT - peptic ulcer,colonic cancer etc.
female genital tract- metrorrhagic, cancers
Oral manifestation
 angular cheilitis
 atrophic glossitis
 generalized oral mucosal atrophy
glossitis - diffuse or patchy atrophy of dorsal tongue papillae (smooth,
glazed appearance)
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Plummer-Vinson syndrom
is rare condition characterized by iron-deficiency anemia, glossitis
accompanied by dysphagia end esophageal webs. This syndrom is considered a
premalignant process (associated with high freguency of both oral and
esophageal atypia, dysplasia and squamous cell carcinoma). It occurs particularly
in midle-aged women in Scandinavia and Great Britain.
esophageal webs = presence of abnormal bands of tissue in the esophageal
B: Pernicious anemia
is megaloblastic anemia caused by poor absorption of cobalamin (vitamin
B12, extrinsic factor) due to lacking of intrinsic factor in autoimune destruction
of the parietal cells of the stomach or after bypass gastrointestinal operations.
Oral manifestation
 focal or diffuse areas of oral mucosal erythema and atrophy
(epithelial atrophy with increased nuclear to cytoplasmatic ratio, prominent
nucleoli and chronic cell infiltrate)
 burning sensation of the tongue, lips, buccal mucosa etc.
3. ENDOCRINOPATHIES
I. PITUITARY GLAND
A: Pituitary dwarfism
the maxilla and mandible of affected patients are smoller than normal;
teeth show a delayed pattein of eruption (several years)
B: Gigantism and agromegaly
Oral manifestation
 enlargement of facial soft tissues (coarse facial appearence)
 mandibular prognathism as a result of the increased growth of the
mandible
(spacing of the teeth - diastema formation)
 macroglossia
II. THYROID GLAND
Hypothyroidism
cretenism, myxedeme
Oral manifestation
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 thickenning of the lips (accumulation of glyosaminoglycans)
 macroglossia (the same reason)
 failing of teeth eruption (childhood)
III. PARATHYROID GLAND
Hypoparathyroidism
Results from surgical removal autoimmune destruction
Oral manifestation are:
 enamel hypoplasia
 failure tooth eruption
caused by hypoparathyroidism early in life
 endocrine – candidiasis syndrome (persistant oral candidiasis)
IV. DIABETES MELLITUS (DM)
is disorder of carbohydrate metabolism usually caused by decreased
production of insulin. DM is divided into two types:
1) Insulin-dependent DM (IDDM)-type I. juvenilní
2) Non-insulin-dependent DM (NIDDM)-type II. adult
Oral manifestation (limited to patients with IDDM)
 periodontal disease (occurs more frequently and progress rapidly
than in
normal patients)
 diabetic sialadenosis (diffuse bilateral enlargement)
 oral candidiasis
 glossitis (migratory)
 xerostomia
4. CROHN DISEASE
is inflammantory disease unknown etiolagy affecting intestine, but may be
seen anywhere in GIT, e.g. oral involvement. Oral lesions are
non-specific orofacial granulomatosis
non-necrotising granulomas in the submucosal connective tissue.
5. UREMIA
Uremic stomatitis
painful disorder with white flaques or crusts distributed on the buccal
mucose, tongue and floor of the mouth.
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6. METABOLIC DISORDERS
Mucopolysacharidosis
Oral manifestations very according to the particular type of
mucopolysacharidosis. the most common changes:
 macroglossic
 gingival hyperplasia
 dental changes (thin enamel)
 impacted teeth with prominent follicular spaces due to
accumulation of glycosaminoglycans
7. JAUNDICE
is the yellow discoloration of the skin and mucosa results from
accumulation of bilirubin in the tissue. It occurs when bilirubin is elevated in the
blood.
8. AMYLOIDOSIS
represents a heterogenous group of conditions characterized by the
deposition of an extracellular proteinaceous material called amyloid. Prognosis of
amyloidosis depends
 on the organ of involvement
 the extention of despositon. (cardiac and renal accumulation
result in faiture)
Forms of amyloidosis:
a)
organ - limited amyloidosis
racely reported in the oral soft tissues
b)
systemic amyloidosis
oral involvevent occurs in primary and myeloma - associated
forms of systemic amyloidosis and is characterized by:
 macroglossia (reported in 12 to 40 percent of patients and
may appear as diffuse or nodular enlargement of the tongue).
 amyloid nodules of the oral mucosa or of the lips (sometimes
associated with ulceration and submucosal hemorrhage). Biopsy of gingival tissue
or labial salivary gland is alternative specimen sources for diagnosis of
amyloidosis.
ORAL MANIFESTATION OF DERMATOLOGIC DISEASES
1. PEMPHIGUS
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represents four related diseases of autoimmune etiology, the most
common of then is Pemphigus vulgaris. Pemphigus is characterized by blistering
due to antibodies agains desmosomes. Immunologic attack on the desmosomes
results in forming of blisters. Pemphigus-like oral eruption may occur in patients
after drug therapy or with lymphoreticular malignantes (paraneoplastic
pemphigus). Oral lesions are often the first sign of the disease. They are
located in tongue, buccal or labial mucose or gingival. Bullae prone to rupture,
leaving hyperemic erosions covered with exudate.
2. BULLOUS PEMPHIGOID
is autoimmune condition characterized by production of antibodies against
a component of the basement membrane. It affects older people (60-80 years
of age).
Oral mucosal involvement is uncommon and begin as bullae, they tend to
rupture and results in large ulceration.
3. ERYTHEMA MULTIFORME
blistering ulcerative mucocutaneous condition of uncertain histogenesis
(probably immunologically mediated process). It affect young adults.
Oral lesions begin as erythematous patches that undergo necrosis and
ulcerations with irregular border (occur the lips, labial and buccal mucosa,
tongue and soft palate). Involving of lips and oral mucosa is reffered to as
Stevens-Johnson syndrome. Treatment by corticoids.
4. LICHEN PLANUS
is relatinely common chronic dermatologic disease that often affects the
oral mucosa. Occurs in the middle-aged adults and presents by skin papulas
Oral lesions
 reticular lichen planus (interlacing white lines involving the
posterior buccal mucosa)
 erosive lichen planus (atrophic areas with central ulceration)
Histology: orthokeratosis and parakeratosis of the epithelium. Destruction of
basal cell layer of the epithelium.
T-lymphocytic infiltrate.
5. LUPUS ERYTHEMATOSUS
imunologically mediated condition in one of several clinicopathologic form:
systemic lupus
erythematosus (SLE)
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is serious multisystem disease with various cutaneous and oral manifestations.
Cause is unknown.
Oral lesions are nonspecific:
appear as lichenoid areas or even granulomatous lesions.
Histology: hyperkeratosis or atrophy spinous cell layer, subepithelial lymphocytic
infiltration.
6. SYSTEMIC SCLEROSIS
immunologically mediated diseases with collagen deposits in the tissues in
extraordinary anounts.
Oral manifestation present as microstomia due to collagen deposition in
the perioral tissues.
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