Oral Pathology: Systemic Diseases

Oral Pathology for the Dental Hygienist Introduction

• This study guide is for Oral Pathology for the Dental Hygienist, 8th Edition, Chapter 9, Student Handout.
• The chapter discusses oral manifestations of systemic diseases.

Oral Manifestations of Systemic Diseases

• Many systemic diseases manifest in the oral mucosa, maxilla, and mandible.
• Immunodeficiency can cause infection and neoplasia.
• Systemic diseases and drugs used to treat them can impact oral tissue.
• Local factors can exacerbate the oral manifestation of systemic disease.
• Mild irritation and chronic inflammation may cause lesions.
• Systemic diseases discussed include endocrine disorders, blood cell and platelet disorders and immunodeficiency disorders.

Endocrine Disorders

• Involve integrated glands and cells secreting hormones
• Hormone levels in blood trigger factors that control production
• Diseases may result from too much or too little hormone production, gland dysfunction or problems with hormone control

Hyperpituitarism

• Excess hormone production happens in the anterior pituitary gland
• Benign tumors often cause it
• Gigantism happens before the closure of long bones
• In adult life acromegaly happens when hypersecretion occurs

Clinical Features and Oral Manifestations of Hyperpituitarism

• Poor vision and light sensitivity are signs
• Hands and feet enlarge and rib size increases
• Facial features change
• Enlargement of the maxilla and mandible may cause teeth separation and malocclusion
• Frontal bossing and nasal bone enlargement is possible
• Enlargement of the maxillary sinus leads to voice deepening
• Mucosal changes can include thickened lips and macroglossia

Diagnosis and Treatment of Hyperpituitarism

• Diagnosis involves measurement of growth hormone
• Normal: Decrease in growth hormone
• Acromegaly: Growth hormone will not decrease
• Treatment includes pituitary gland surgery, medical management and radiation therapy
• Diabetes, cardiovascular and respiratory diseases, and colon cancer can arise if untreated

Hyperthyroidism

• Excess thyroid hormone production is also called thyrotoxicosis
• More common in women in their 30s and 40s
• Graves is the most common cause of hyperthyroidism
• Graves is an autoimmune disorder where antibodies stimulate thyroid cells to produce too much thyroid hormone, enlarging the thyroid gland

Clinical Features of Hyperthyroidism

• Thyroid enlargement (goiter)
• Rosy complexion, erythema
• Excessive sweating and fine hair is possible
• Softened nails and exophthalmos can occur
• Anxiety, weakness, restlessness, and cardiac problems may also be associated

Oral Manifestations of Hyperthyroidism

• Premature exfoliation of deciduous teeth and eruption of permanent teeth may happen in children
• Osteoporosis may affect alveolar bone, and burning tongue is also a symptom
• Caries and periodontal disease may appear and develop rapidly in these patients

Treatment of Hyperthyroidism

• Treatment includes surgery
• Medications to suppress thyroid activity
• Administration of radioactive iodine
• Clinical mismanagement may lead to hypothyroidism

Hypothyroidism

• A decreased the output of thyroid hormone
• Cretinism occurs in infancy and childhood
• Myxedema occurs in older children and adults
• Causes iodine deficiency and developmental disturbances
• Autoimmune destruction of thyroid: Hashimoto thyroiditis
• Drugs and treatment for hyperthyroidism can cause this

Hypothyroidism: Oral Manifestations

• Infants get thickened lips and tongue and delayed eruption of teeth
• Enlarged tongue in adults

Hyperparathyroidism

• Excessive secretion of parathyroid hormone (PTH) from the parathyroid glands
• PTH roles include calcium and phosphorus metabolism
• Elevated blood calcium levels, hypercalcemia
• Low levels of blood phosphorus, hypophosphatemia
• May be due to hyperplasia of parathyroid glands, benign or malignant tumor
• More common in women than men and found in middle-aged adults

Clinical Features of Hyperparathyroidism

• Mild cases may be asymptomatic, or may cause joint pain or stiffness
• Lethargy, coma, kidney stones and can affect the skeletal and gastrointestinal system

Oral Manifestations of Hyperparathyroidism

• Bone changes, and loosening of teeth
• Well-defined unilocular or multilocular radiolucencies
• "Ground glass" appearance, loss of lamina dura
• Central giant cell granulomas (CGCGs) on a microscopic level

Diagnosis and Treatment of Hyperparathyroidism

• Measurement of PTH blood levels, include serum calcium and phosphorus measurements
• Treatment can correct increased hormone production due to tumors, renal disease, kidney failure, vitamin D deficiency

Diabetes Mellitus

• High blood glucose levels characterize this chronic disorder of carbohydrate metabolism
• High blood glucose levels, hyperglycemia caused by lack of insulin, defective insulin or resistance caused by obesity

Diabetes Mellitus and Glucose

• Insulin is created by glucose signals in pancreas beta cells
• Secreted in the bloodstream to facilitate glucose uptake into fat and skeletal muscle
• Glucose can be used as an energy source
• Cells starved without glucose results in break down of tissues, catabolism
• Ketoacidosis, ketone acid, produced and lowers blood pH

Diabetes Mellitus: Ketoacidosis

• Fatty tissue breaks down and ketone acid lowers blood pH
• Acute condition can cause coma and death
• Macrophages reduced, neutrophils delayed and lymphocytes affected
• Collagen production is abnormal

Other Complications of Insulin-Dependent Diabetes Mellitus

• Complications with organ systems damage blood vessels
• Eyes: Blindness, Kidney: End-stage kidney failure, Nerves: Paresthesia or numbness
• Atherosclerosis of large and medium-size blood vessels: Macrovascular disease
• Abdominal aortic aneurysm, thrombi, stroke or cerebrovascular accident, myocardial Infarction

Diagnostic Criteria of Diabetes

• Fasting blood glucose is equal to or greater than 126 mg/dL
• A random blood glucose is equal to or greater than to 200 mg/dL
• A 2-hour blood glucose level is also equal to or greater than 200 mg/dL after drinking a glucose solution of 75 grams
• A glycosylated hemoglobin level is equal to or greater than 6.5%

Prediabetes

• Fasting blood glucose is between 100 and 125mg/dL
• Two-hour blood is between 140 and 199mg/dL after the OGTT
• Glycosylated hemoglobin level is between 5.7% and 6.4%

Type 1 Diabetes

• Autoimmune disease that destroys insulin-producing cells of the pancreas
• 3% of all diabetic patients have this type, which can happen at any age, but it is more common is at 20 years of age
• The peak age polydipsia- excessive thirst and intake of fluid occurs
• Polyuria is excessive urination and excessive appetite, polyphagia
• Treatment often involves multiple insulin injections and diet, exercise, and blood glucose level tests

Type 1 Diabetes and Hypoglycemia

• Patients require insulin throughout their entire lives and the current approach to management of these patients involves frequent determination of blood glucose levels
• Low blood sugar: Hypoglycemia = insulin shock
• Uncontrolled blood glucose is brittle diabetes

Type 1 Diabetes Alternative Methods of Treatment

• Methods to take in oral hypoglycemic medications and transplantation of pancreatic beta cells into the liver are viable
• People can be treated by transplant of stem cells or usage of an insulin pump

Type 2 Diabetes

• Characterized by insulin resistance
• 97% of all diabetic patients have this type
• Gradual onset that is usually present in patients 35-40 years of age or older, weight gain may contribute
• Dentists and hygienists can play a role to educate patients

NIDDM and Obesity

• Obesity decreases the number of receptors for insulin binding in fat and muscle
• Adipokines are hormones produced from fatty tissue

Gestational Diabetes

• Happens in pregnancy and disappears after pregnancy
• Leads to macrosomia- increase in infant birth weight
• The mother and child have a higher risk of developing type 2 diabetes later in life

Clinical Features of NIDDM

• The vascular system is adversely affected
• Decreased resistance to infection, skin infections, urinary tract infections (UTIs), and tuberculosis
• Atherosclerosis, in blood vessel walls, causes impaired circulation
• This increases the risk of ulceration, gangrene, stroke, high blood pressure and kidney failure

Clinical Features of NIDDM

• Diabetic retinopathy in the eye can lead to blindness
• The nervous system may be affected with decreased resistance to infection

Oral Complications of NIDDM

• Oral candidiasis is possible
• Mucormycosis: A rare oral fungal infection that affects the palate and maxillary sinuses
• Bilateral asymptomatic parotid gland enlargement, xerostomia and periodontal disease can happen
• An accentuated response to plaque formation and slow wound is also an issue

Considerations for Dentists and Dental Hygienists

• Periodontal disease significant complication of diabetes, control is aggravated It poses significant prognostic/ predictive clinical marker for diabetes
• Uncontrolled diabetes produces uncontrolled periodontal Conditions

Addison Diseases:

• Addison disease (Primary Hypoadrenocorticism)- insufficient production of adrenal steroids
• Causes include malignant tumor, tuberculosis, fungal infections, HIV
• Autoimmune disease the pituitary gland increases adrenocorticotropic hormone (ACTH) to compensate
• This may be caused by malignancies, tuberculosis, infections, autoimmunity

Clinical Features of Addison Disease

• Melanocytes are stimulated
• Bronzing of skin, melanotic macules on oral mucosa
• Treatment includes steroid replacement therapy

Hypercortisolism (Cushing Syndrome)

• Caused sustained increase in glucocorticosteroid levels signs will develop slowly
• Weight gain obvious clinical feature
• Hypertension and hyperglycemia is a sign
• Decreased ability to respond to stress and mood alteration

Blood Disorders

• Disorders of red blood cells (RBCs) and hemoglobin
• Disorders of white blood cells (WBCs)
• Bleeding disorders

Anemia

• Reduction in the oxygen-carrying capacity of blood
• Relates to a decrease in RBCs circulating
• Nutritional anemias: Iron, folic acid, B12
• Bone marrow stem cells gets suppressed

Clinical Features of Anemia

• Pallor of skin and oral mucosa
• Angular cheilitis and erythema in oral mucosa
• Filiform and fungiform papillae are lost

Iron Deficiency Anemia

• Insufficient amount of iron is supplied to bone marrow
• Possible causes include deficient iron intake, blood loss, poor iron absorption, an increased requirement
• Plummer Vinson syndrome is a result

Iron Deficiency Anemia: Plummer Vinson Syndrome

• Long-standing iron deficiency anemia
• Symptoms include nonspecific, shortness of breath, cardiac palpitations, and dysphagia
• Tongue gets inflamed, glossitis and angular cheilitis caused by oral candidiasis
• Can cause esophagus and oral cancer

Diagnosis and Treatment of Iron Deficiency Anemia

• Laboratory tests show a low hemoglobin content and reduced hematocrit
• Microcytic: Smaller-than-normal RBCs
• Hypochromic: RBCs are lighter in color
• Hematocrit: The volume of RBCs in blood
• Treatment includes dietary supplements

Pernicious Anemia

• A deficiency in intrinsic factor happens
• Secreted by stomach parietal cells that absorption of vitamin B12
• Autoimmune disorder
• Might be caused by surgical stomach removal, cancer, or gastritis
• B12 must be uptaken for DNA synthesis

Anemia: Clinical Features

• Symptoms include weakness and pallor
• Fatigue on exertion, nausea and dizziness
• Diarrhea, and abdominal pain, loss in appetite and weight loss

Anemia: Oral Manifestations

• Angular cheilitis and mucosal pallor, also atrophic and erythematous
• Mucosal ulceration and loss of papillae on the dorsum of the tongue lead to soreness

Diagnosis and Treatment of Pernicious Anemia

• Low serum B₁₂ levels and gastric achlorhydria (hydrochloric acid deficiency) are findings
• Immature large RBCs,megaloblastic anemia and neutrophils/platelets are immature are all symptoms
• The Schilling test indicates an inability to absorb oral vitamin B12
• Serum antibodies present are directed against the intrinsic factor and vitamin B12 injections are the treatment

Deficiency Anemia

• Folic acid and B12 come both can become dietary deficiencies
• Commonly associated malnutrition; increased metabolic requirements
• Usually found in correlation with alcoholism/pregnancy

Diagnosis and Treatment of Folic Acid and Vitamin B12 Deficiency Anemia

• Labs test serum assays of folic acid and B12 and treatment is made up of dietary supplements
• Megaloblastic anemias- presence of immature and large RBCs

Thalassemia

• Genetic mutation of hemoglobin
• Mediterranean or Cooley Anemia
• Autosomal dominant inheritance pattern
• Heterozygous - mildly symptomatic/asymptomatic
• Homozygous- severe hemolytic anemia

Clinical Features and Oral Manifestations of Thalassemia

• Yellow skin pallor and fever
• Malaise and weakness
• Enlarged spleen and liver, prominent cheekbones
• Depression of the bridge of the nose, prominent maxilla, and circular radiolucencies in alveolar bone
• Protrusion or flaring of maxillary anterior teeth, radiograph may show a salt-and-pepper pattern and thinning of lamina dura

Treatment of Thalassemia

• Experimental and may involve blood transfusions and splenectomy
• Poor prognosis, but getting better
• Hemochromatosis: Deposition of excessive iron throughout body

Sickle Cell Anemia

• Inherited blood disorder that occurs before a person's 30s
• Common in black individuals, and those of Mediterranean or Asian origin
• RBC's form a sickle shape with decreased oxygen
• Triggered by exercise, exertion, administration of a general anesthetic, pregnancy, or even sleep

Sickle Cell Anemia: Clinical Features

• Weakness, shortness of breath, fatigue, joint pain
• Nausea, severe sickling of erythrocytes
• Acute chest syndrome, kidney dysfunction, issues with the eyes, cardiovascular system, and CNS
• Heart enlargement and cardiac failure are signs

Sickle Cell Anemia

• Bones are characterized by a loss of trabeculation
• Large, irregular marrow spaces appear & changes in skull trabeculae radiate outward

Diagnosis and Treatment of Sickle Cell Anemia

• The sickle-shaped cells are seen on a blood smear
• There is a low number of RBCs with low hemoglobin content
• Oxygen is administered intravenously or orally as supportive treatment

Aplastic Anemia

• Bone marrow severely depressed
• Decrease in all circulating blood cells: Pancytopenia
• Has unknown Primary aplastic anemia cause
• From a drug/chemical agent

Clinical and Oral Manifestations of Aplastic Anemia

• Present in various clinical signs, fatigue and weakness
• Retinal/ cerebral hemorrhages. low platelets
• Bruising, hematomas, ecchymosis
• Predisposed to infections and oral infection
• Spontaneous bleeding can happen, petechiae and purpuric spots

Diagnosis and Treatment of Aplastic Anemia

• Labs show Leukopenia - low WBCs and Thrombocytopenia - Low platelets
• Anemia is fatal and progress when removed
• Aplastic treatment to eliminate cause

Polycythemia

• Increase in the number of circulating RBCs
• Three forms: primary, secondary, and relative

Polycythemia Vera

• Neoplastic bone marrow causes increase RBC
• Cause-unknown, it is commonly found in men
• More known in white folks than in black individuals- aged between the 40-60s

Polycythemia Vera, Signs and symptoms

• Headache, and dizziness are common symptoms
• Disrupted circulation and itching of skin
• vascular stasis and thrombocytopemia

Secondary Polycythemia

• RBC increase, a physiologic reaction. from limited oxygen intake
• High count erythropoietin kidneys
• Caused by smoking, pulmonary cardiac, altitude and elevation in carbon monoxide/

Relative Polycythemia

• Caused by a drop in plasma volume with vomiting, diarrhea, diuretics and profuse sweating
• Middle-aged white men under physical stress are commonly diagnosed
• Overweight, hypertensive with heavy smoking addiction

Polycythemia-Oral

• Mouth show redness coloration between red and purple
• Oral submucosa. with hematoma
• Bleeding easily occur in the gingiva or from scratching

Diagnose-Treat Polycythemia

• Examine hemoglobin measure- then lab test
• Treatment include removing cause, Chemotherapy and Phlebotomy

White blood cell disorders

• WBC disorders: infection-related conditions. bleeding disorder
• Define: clinical aspect and oral manifestations
• Diagnose celiac disease compare between acute and chronic leukemia

WBC disorders, bleeding, and oral cancer

• Bleed. disorder with medication is understood and purpura has oral problems/symptoms
• Medication like chem. and others
• Understand function osteoblasts and osteoclasts

White Blood Cell Disorders

• Group 3 in blood circular/ three groups of WBCs: Granulocytes, Lymphocytes, and Monocytes

Granulocytes in more detailed info:

• Polymorphonuclear Leukocytes (or neutrophilic)
• Eosinophils and basophils

Agranulocytosis

• Decrease to where Neutropenia (low the neutrophil is occurring)
• Primary where cause isn't found and the disorder is immunologic
• Development of granulocytes is problematic, or granulocytes accelerated

Agranulocytosis-oral with signs and symptoms

• Have and see symptoms like sudden chills, and jaundice with fever
• Sore infection in the oral and jaundice
• Destructive tooth, and swelling in the mouth, neck and all that around

Diagnose-Treat Agranulocytosis

• By low WBC count, tests made
• Then they transfuse it, and give antibiotics
• Any procedure will be not needed for dental

Cyclic Neutropenia

• Decrease cycle number neutrophils count
• A condition oral has ulceration and issues

Leukemia

• An issue when have a high WBC, and cancerous signs affect, like blood or body

Acute Leukemias

• They are immature, or happen with a sudden fate, with needed treatment acute lymphoblastic is lymphocytic.

Symptoms for Acute and signs

• Suddenness, dramatic or fatigue, or sudden
• Or show sudden fever and lymph swell/enlargement
• Thrombocytopenia means bleeding happens from the lymph

Oral Manifestations of and from Leukemia

• Gums swelling
• Bleeding can be from any area
• Oral/ teeth will be affected

Acute Leuk Diagnose and Treatment

• Blood test to determine to see platelet count and anemia present
• treatment like bone marrow transplant is a possible solution

Chronic Leukemia

• Chronic myeloid leukemia is associate Philadelphia
• Lymphocytic form is familiar for a form-chronic

Leukemias signs/ symptoms

• Symptoms slow to show up or present to show slow
• Fatigueness and weakness show up with weight loss, which can lead to Anorexia

Anorexia-Oral sign- treat it and all its signs/ symptoms

• Look at WBCs high levels
• Transplants are a possible, Chemotherapy is also needed, and some cryotherapy may be recommended from your healthcare professional

Bleeding and Celiac Diseases and Oral Problems, Bleeding Disorder

• Celiac Dis*

• Sensitivity to what have to it, dietary gluten and you cant digestive it

• Mouth will be burned/ affected with ulcer

• Diarrhea can occur or nervousness as well too

Hemostasis, and Terminologies, all its signs, and symptoms/ tests, and disorders

• Hemostats are good, and help with the wound and with clotting (its important that one happen, even if just a few)

• Check-and make sure clot is good

• Check to see platelet count, bleeding disorder will happen if count high

Tests like BLEEDING TIME

• See adequacy of platelet and function
• Make sure no bleeding during, function is adequate
• Has 5 or 10 bleed depending on results

The PT test

• See to make sure clot is good
• Check normal in time frame and all those facts from it check out by second

Partial P-Time tests

• To measure clot forming good
• Used with/for heparin patients
• To see if there is bleeding, a PTT test can show.

What we have Purpura

• This is like when blood flows into the skin
• There could be some issues
• Capillaries weak, might have weakness

Thrombocytopenic Purpura's

• Disorder happens when platelets or anything is really reduced or the amount its suppose to hold is decreased
• Could be autoimmune related

Oral, and the signs from- Thrombocytopenic

• Lesions and spontaneous with no irritation/harm
• Have frequent nose and urination and all
• Ecchymoses are a likely sign and a cause

Thromb thrombocytopenic test and care

• Test how plates are working because important function
• Some capillary test show and could be positive. Some- not good for you
• Transfusions and dental can be good depending the condition

Non -THROMB

• Vessels or plate problems lead here
• Auto disease happen or issue with allergic/ and a chemical problem caused

Non , Oral/ care/ symptom

• Some blisters occur
• All this will be helped by discontinuing agent and taking something
• Plate count to see

What hemophilia do?

• Is when issue with or lack blood coagulation
• From the disorder is that time is prolonged longer, where bleeding has no set time

Some factors with that Cascade and all

• If have factor, that mean and what they mean to you
• Factors are important because responsible for all

Different of Hemophilia

• Daughter issue pass down to son-link from X disease
• The A can have that one protein lacking from plasma, not much can be added. Also some Christmas has factor number.

How is The Mouth. showing oral -Hem

• Shows gum show of it
• Some cuts bleeding when do teeth scale with tool (dental) happens more often, and easily (oral) during

diagnose/ treat what has oral-hem

• Bleed time and is normal
• This to prolong, but the P is treat
• Replace what is lost by finding (what test showed) what the case with oral-hem is for the patient

Therapies related, of those

• Cancer and it’ Oral with radiation, surgery, with chemotherapy, and side too

• Mucositis can occur- hurt and swell: start to happens 2 weeks later. Then over in 6 weeks!

What is a THERAPY? The radiation one? for the oral

• Saliva is destroyed (too bad) and that causes xerostomia and all those issues relating bad

• Care for patients- help the patient understand and fluoride

What is CHEMO? What effect it cause?

• Side effect mucositis and cells affected, and oral ulcers can come

• Some effects on basal epithelium cells

• Complicate when it has Anemia and infections and that oral become hard to treat-for the patient

A drug -effect!

• Blood medication can cause issues later
• Can cause oral (fungal) too
• Is caused by medicine to fix problems with other problems

Medication related or issue-related what is like those can be tested as-

• Medication has the over suppression or infection in all, the parts for now
• It leads bone to be affected when there bone die (more dead than bad)
• There are three stage what happens during them

MRONJ- can form Mucosal discoloration

• All these issues can cause pain and show signs in mouth, where is a good reminder to examine and know for the best care with health coming from.

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