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Oral Manifestations of Systemic Diseases in Older Patients

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Title: Oral Manifestations of Systemic Diseases in Older Patients


1
Oral Manifestations of Systemic Diseases in
Older Patients
  • Ali R. Rahimi, MD, FACP, AGSF

RTR Medical Group, Savannah, GA
2
Objectives
  • Review pertinent oropharangeal structure and
    function.
  • Examine the relationships between oral symptoms
    and systemic conditions.
  • Discuss clinical decisions pertaining to the
    topic.

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
(No Transcript)
5
Background
  • Drug Reactions
  • Fungal infections
  • Viral infections
  • Leukemia
  • Behcets Disease
  • Diabetes Mellitus
  • Nutritional Deficiencies
  • Amyloidosis

6
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

7
Drug Reactions- SJS and TEN
  • Stevens-Johnson syndrome and toxic epidermal
    necrolysis are rare, life-threatening, 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.

8
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.

9
Drug Reactions
  • Radiation, immunosuppressant and
    chemotherapeutic medications are the major
    treatments associated with stomatitis. Allergic
    reactions to materials or certain metalloids may
    also contribute.

10
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.

11
Fungal Infections
12
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.

13
Viral Infections-Herpes
14
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.

15
Viral Infections-HIV
16
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.

17
Behcets Disease
  • Behcets 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.

18
Behcets Disease
19
Sjögrens Syndrome
  • Sjögrens syndrome is the 2nd most common
    autoimmune disease with women in their mid-60s
    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
    anti-inflammatory drugs may be used to treat
    musculoskeletal symptoms. Corticosteroids or
    immunosuppressive drugs may be considered in
    severe cases.

20
Sjögrens Syndrome
21
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.

22
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.

23
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.

24
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.

25
Nutritional Deficiencies Pernicious Anemia
26
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.

27
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.

28
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.

29
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 alth/amyloidosis/DS00431.

30
References
  • "NINDS Sjogren's Syndrome Information Page."
    National Institute of Neurological Disorders and
    Stroke. 11 Dec. 2005 orders/sjogrens/sjogrens.htm.
  • "NINDS Behcet's Disease Information Page."
    National Institute of Neurological Disorders and
    Stroke. 11 Dec. 2005 orders/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.

31
Questions
  • 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?

32
Questions
  • 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
    Sjodgrens disease often also present with what
    other diseases?
  • What group of commonly used medications are
    associated with gingival hyperplasia/dysfunction?

33
Questions
  • 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?
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