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PATHOPHYSIOLOGY OF ORAL CAVITY. Roman Benacka, MD, PhD Department of pathophysiology LF UPJŠ. Content. Oral manifestations of systemic disease Oral manifestations of drug reactions Contact stomatitis (irritation & allergy)
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PATHOPHYSIOLOGY OF ORAL CAVITY Roman Benacka, MD, PhD Department of pathophysiology LF UPJŠ
Content • Oral manifestations of systemic disease • Oral manifestations of drug reactions • Contact stomatitis (irritation & allergy) • Bacterial & viral oral infections as focuses for systemic spreading • Nutritional defects - avitaminoses
Topic 1 Oral manifestation of systemic diseases • Gastrointestinal diseases • Haematological disorders • Connective tissue disorders • Pulmonary disorders • AIDS & Immunodeficiencies • Cutaneous disorders • Endocrine disorders
Gastrointestinal diseases Topic 1A • Crohn disease • transmural inflammation, noncaseating granulomas, and fissures in bowels • manifests systemically as arthritis, clubbing of the fingers, sacroiliitis, and erythaema nodosum • intraoral signs occur in 8-9% of cases and may precede intestinal involvement: • diffuse labial, gingival, or mucosal swelling; • cobblestoning of the buccal mucosa; • apthous ulcers, mucosal tags and angular cheilitis • Ulcerative colitis • oral lesions coincide with exacerbations of the colonic disease occur in 5-10% of patients • aphthous ulcerations or superficial hemorrhagic ulcers, angular stomatitis • Gastroesophageal reflux disease (GERD) • regurgitation causes acidic environment (pH 1-2) in the oral cavity • dissolving and errosion of enamel differing from caries;Caries is not increased • commonly seen on the palatal surfaces exposing underlying dentin,
Gastrointestinal diseases Topic 1A • Hepatopathia and bilirubin metabolism and secretion disorders • jaundice (yellow pigmentation) - deposition of bilirubin (25-30 mg/l) in the submucosa - mucosa on the soft palate and in the sublingual region • Chronic liver disease • excessive gingival bleeding with minor surgery - liver synthesizes clotting factors, vitamin K requires proper liver functioning to be adequately absorbed • Hepatitis C • leading infectious cause of chronic liver disease worldwide • association between hepatitis C and erosive oral lichen planus • transmission from patientto dentist
Haematological disorders Topic 1B • Anaemias • oral mucosa exhibit pallor • decreased resistance to infection - glossitis, recurrent aphthae, candidal infections, and angular stomatitis • glossitis, tongue is reddened, the papillae are atrophic (first sign of folate or vitamin B-12 deficiency anaemia) • angular stomatitis caused by a candidal infection (iron deficiency anaemia) • Langerhans histiocytosis (histiocytosis X) • abnormal histiocytic and eosinophilic proliferation - most common form is the eosinophilic granuloma in young adults. may present as a localized proliferation, or it may present with extensive systemic involvement. • Oral sy.: • a) ulcerations on the gingiva (destructive gingivitis), palate, and floor of the mouth. • b) progressive alveolar bone loss with dental extrusion and characteristic floating teeth
Connective tissue disorders Topic 1C • Sjögren syndrome • Def.: second most common autoimmune disease (90% are female; 3% of women over 50 years) manifested by thick and mucinous, or absent secretes (saliva, tears) -> sicca syndrome - keratoconjunctivitis sicca, xerostomia, etc.; lymphocytic • Oral sy.: • xerostomia (dry, red, and wrinkled mucosa) • tongue has a cobblestone like appearance (atrophy of the papillae), • difficulty in swallowing and eating, increased dental caries (sugar is not washed away by saliva), predisposition to infection (common is candidiasis) • Kawasaki disease (mucocutaneous lymph node syndrome) • Def.: vasculitis in medium and large arteries with a corresponding cutaneous lymph node syndrome; replaced rheumatic fever as the primary cause of childhood (< 5 years) heart disease • Symptoms: acute cervical adenopathy, oedema & erythema, desquamation of the hands and feet, fever, polymorphous exanthema - rash; acute cervical adenopathy; aneurysm and myocardial infarction, myocarditis • Oral sy.: • papillae swelling on the surface of the tongue (strawberry tongue) • intense erythema of the mucosal surfaces, labia are cracked, cherry red, swollen, and hemorrhagic
Pulmonary disorders Topic 1D • Wegener granulomatosis • Def.: necrotizing vasculitis of small-to-medium arteries and veins + necrotizing granulomas of the upper and lower airways +/- necrotizing glomerulonephritis. Oral and skin manifestations may be correlated with disease progression, thereby serving a prognostic purpose • Oral sy.:in 97% of patients • ulcerations on the buccal mucosa or palate • gingival hyperplasia - is a path gnomonic finding: swollen, reddened, and granular appearance to the gingivae (termed strawberry gums) start as bright red-to-purple friable diffuse papules originate on the labial interdental papillae • tooth and alveolar bone loss are common
Pulmonary disorders Topic 1D • Sarcoidosis • Def.: idiopathic systemic inflammatory disease involving nearly any organ system (liver, heart, spleen, eyes, kidneys), pulmonary manifestations are the most common, cutaneous (5-20% of patients). oral sy presents after systemic symptoms • Oral sy.:multiple painless ulcerations of the gingiva, buccal mucosa, labia, and palate + salivary gland tumorlike swellings. Rarely, sarcoidosis involves the tongue - swelling, enlargement, and ulcerations. Heerfordt syndrome - triade: parotid gland swelling, xerostomia, uveitis, and facial nerve palsy. • Amyloidosis • Def.: deposition of proteins in body tissues leading to tissue damage. Amyloidosis is classified as primary, stemming from multiple myeloma or an idiopathic disease, or as secondary, stemming from a chronic or inflammatory disease process • Symptoms: affects the skin, heart, tongue, and GI tract, while the secondary form, although more common, has no cutaneous manifestations. • Oral sy.:a) macroglossia (the most common; 20% of patients) with lateral ridging due to teeth indentation; b) loss of taste, xerostomia may result from amyloid deposition in the salivary glands Submandibular swelling occurs subsequent to tongue enlargement and may lead to respiratory obstruction.
AIDS and other immunodeficiencies Topic 1E • Candidiasis • repeated oral candidiasis is the first sign in 90% of patients with HIV. • Most common is pseudomembranous type - white plaques on the soft and hard palates, buccal mucosa (most commonly), and tongue that leave a reddened area when scraped. • Herpes simplex virus (HSV) • double-stranded DNA virus that has 2 serotypes: HSV-1 and HSV-2 • Oral sy.: oro-labial vesicles (lips, tongue, gingiva, hard palate) that are rupturing, and leaving a small, irregular, and painful crusted weeping ulceration or fissures on dorsal part of tongue. May extend to esophagus. Stress, fever, and sunlight may precipitate reactivation. Until disproved, all perineal and ulcerations should be considered HSV in patients who are infected with HIV. • Epstein-Barr virus (EBV) - Hairy leukoplakia (HL) • adherent corrugated white plaques most commonly on the lateral portions of the tongue (5% of patients) • Kaposi sarcoma (KS) • - the most common skin or oral malignancy (lymph node enlargement), in patients who are HIV positive • Oral sy.: brown, bluish, purple, or red patches or papules on the hard palate, mucosa, and gingiva that ulcerate, and bleed • Cytomegalovirus (CMV) • double-stranded DNA virus (60% of people being seropositive but asymptomatic) • symptomatic disease - organ or bone narrow transplantation or HIV infection : retinitis (30% ; blindness). pneumonia (5%; lung failure) • Oral sy.: very rare – aphthous-like ulcerations on the lips, tongue, pharynx, or any mucosal site
Primary herpetic gingivostomatitis (HEV 1) affects mostly children or young adults. Inside the oral cavity, herpes simplex typically affects only keratinized tissues, such as the gingiva or the hard palate. Intraoral herpes zoster closely resembles recurrent human herpesvirus 1 (HHV-1) infection
Cutaneous manifestations Topic 1F • Psoriasis • Def.: chronic papulosquamous inflammatory condition of the skin affecting 2% of population (20-30y) • Oral sy.: oral psoriasis rarely manifests without cutaneous involvement: manifest on the lips, tongue, palate, buccal mucosa, and gingiva. Psoriatic tongue involvement appears indistinguishable from geographic tongue • Acanthosis nigricans • Def.: is a cutaneous disorder of hyperpigmentation and papillomatosis that may precede or coincide with a variety of benign, familial, or malignant disorders. Most cases of AN are rare benign congenital (AD) disorder. Malignancy associated AN (MAN) presents commonly with adenocarcinoma of the stomach. • Oral sy.: in 25-50% of MAN patients - cutaneous and oral papillomatosis, gingival hyperplasia hypertrophy of the papillae along the dorsal surface and lateral edge of the tongue.
Endocrine diseases Topic 1F • Diabetes mellitus • may increase the prevalence, incidence, or severity of gingivitis and periodontitis. • Oral sy.: the severity and prevalence of periodontitis are increased in persons with diabetes and are worse in persons with poorly controlled diabetes • Periodontitis may exacerbate diabetes by decreasing glycemic control. This effect indicates a degree of synergism and a link between the 2 diseases. • Addison disease • Oral sy.: black tinge of gingivae and teeth
Topic 2 ORAL MANIFESTATION OFDRUGS
Candidiasis after prolonged steroid therapy in reumatism
Minocycline-associated bluish gray hue of the alveolar mucosa pigmentation in a patient who had used the drug for several months to treat severe acne. Gingival enlargement in a man with a several-year history of using calcium channel blockers
Erythema multiforme: multiple erosions on the lips and tongue. Ulcers in buccal mucosa due to coxsackie virus infection
Topic 3 CONTACT WITH FOREIGN MATERAILS
Contact Stomatitis • Def.: inflammatory reaction of the oral mucosa by contact with irritants or allergens. • Pathophysiol.: oral mucosa is resistant to irritants and allergens • High vascularization that favors absorption and prevents prolonged contact with allergens • Low density of Langerhans cells and T lymphocytes • Dilution of irritants and allergens by saliva that also buffers alkaline compounds • Occurence: may occur at any age. Irritant reactions appear to be more common than allergic reactions. Burning mouth syndrome that almost exclusively affects women.
Contact Stomatitis - Causes • Ingredients of candies and chewing gums • cinnamon compounds, menthol, propolis (a strong sensitizer often used in the oral cavity because of its antiseptic properties) • Local use of drugs • antibiotics, anesthetics, antiseptics, and steroids, desinfectives e.g. chlorhexidine, quaternary ammonium compounds) • Rubber and latex • e.g. gloves, dams, orthodontic elastics, bite blocks • Foods (rarely) • Children with atopic dermatitis and a food allergy may develop lip swelling and stomatitis after contact with fruits • Cosmetics • Ingredients (ricinoleic acid, colophony derivatives, sunscreens lipsticks, lip balms)
Contact Stomatitis - Causes • Ingredients of dentifrices, mouthwashes, dental cleaners • Flavoring agents (e.g. cinnamon compounds, eugenol, menthol) • Ingredients of dental restorations • Amalgam fillings contain mercury compounds (45-60%) and often gold, palladium, platinum. Metallic mercury - common sensitizer • Dental cement used for sealing pulp canals (eugenol, balsam of Peru, colophony) • Acrylic fillings (polymerized acrylate is relatively free of allergens) • Ingredients of dental prosthesis • Metal prostheses- may release nickel(present in dental braces, bridges, and crowns), especially poorly made/ corroded • Acrylate sensitization is a common occupational problem in dentists and dental technicians.
Allergic contact reaction due to nickel in a dental brace. Irritant contact stomatitis of the tongue. Leukoplakialike lesion in a patient who is allergic to mercury. Contact urticaria of the lip due to food allergy Acute allergic stomatitis involving the oral mucosa and the lip due to benzocaine. Contact urticaria of the tongue in a patient with latex allergy. Allergic contact stomatitis on the gingiva in a patient with a positive patch test result to nickel, palladium, and mercury. Lichen planus–like lesion adjacent to a dental restoration. Allergic contact dermatitis involving the lips and the perioral area due to propolis
Manifestations of contact stomatitis • Erythema and swelling - may be localized or diffuse, • ingredients of mouthwashes and toothpastes, dental materials, and chewing gum flavorings • Erosions/ulcerations - evolution of vesicles and blisters rarely seen in the mouth. outlined, whitish, rough, macerated areas. • Ulcerations are usually covered by a yellow-white exudate and may present with an erythematous halo. • Chemical burns are not frequent because the oral mucosa is resistant to heat and acid or alkaline compounds. • Prolonged contact with aspirin or vitamin C tablets, or contact with irritants used for dental care. • Allergic contact stomatitis from metal salts or acrylates rarely causes mouth ulcerations. • Contact urticaria • Swelling of the lips, the tongue, the buccal mucosa, and the gingiva develops suddenly with intense itching due to allergy to foods. • Severe cases may be associated with upper airway obstruction.
Chemical burns result in tissue necrosis produced by a chemical agent used by the practitioner or the patient to relieve pain. The lesion takes the aspect of a whitish plaque which can be removed, leaving an erosive, painful surface The bitten mucosa- alteration of normal tissue - whitish multiple erosions, abrasions and slight sloughing of the most superficial layers of the mucosa. It affects the buccal mucosa, lips and tongue wherever they can be reached by the patient´s bite.
Manifestations of contact stomatitis • Lichen planus–like lesions • May occur at the site of mucosal contact with amalgam restorations - lesions are typically localized. • Sensitization to gold, palladium chloride, and copper sulfate • Leukoplakia-like lesions • Contact sensitization from nickel and other metals • commonly localized in the medial part of the cheek. • Burning mouth syndrome • Burning pain and dryness of mucosa improving during meals. • Although contact allergy (especially to mercury) has often been implicated, the disorder most likely has a psychogenic basis. • Other Compliants • Paresthesia, numbness, bad taste, salivation, itching
White-colored findings Leukoplakia- whitish lesion which does not slough off when scraped, histologically presents as a spot, keratosis of wartlike. They are produced by continued chronic irritation in people with some sort of predisposition (smoking habits, the rough and or sharp surfaces of teeth, and or broken or ill-adapted partial and full dentures) Lichen planus - chronic dermatosis which may affect both skin and mucosa. Oral intercrossing white lines that give the appearance of a weave or net (arboriform).In some patients the lesions may disappear spontaneously
Topic 4 BACTERIAL MOUTH INFECTIONS
Bacterial mouth infections • Oral cavity contains some of the most varied and vast flora in the body which - adhere to the teeth, the gingival sulcus, the tongue, and the buccal mucosa. • Number and proportion of florachanges with the ageand systemic changes (pregnancy, drug intake) • Alterations in the flow and composition of salivary fluid and in the levels and activity of defense components (e.g., immunoglobulins, cytokines) in the saliva. • Oral microbiota participate in various systemic diseases. • Foci of infection in the oral cavity arising from chronic periodontitis (inflammation of the periodontal attachment of the teeth and the alveolar bone) or chronic periapical abscesses (i.e., inflammation and abscess of the tissue attached to the apex of the root).
Bacterial infections of the mouth. A 72-year-old man with severe periodontal disease Bacterial infections caused severe alveolar bone loss and periodontitis in X-ray scan
Odontogenic abscess Inflammatory swelling Origin of infection focus
Odontogenic abscess Pathways of spreading
Periodontal disease • The relative risk of cardiovascular disease is doubled in persons with periodontal disease • Periodontal and cardiovascular disease share many common risk and socioeconomic factors, particularly smoking, which is a powerful risk factor for both diseases. • The chronic inflammatory state and microbial burden in persons with periodontal disease may predispose to cardiovascular disease in ways proposed for other infections, such as with Chlamydia pneumoniae.
Bacterial endocarditis due to oral foci of infection • Etiology: Streptococcus viridans; Staphylococci(> 80% of cases) • Dental manipulation 90% (brushing teeth, chewing gum, eating -> transient bacteremia; • 8-10% oral infections - Transient oral bacteremia after tooth extractions lasting less than 15-30 minutes • Occurence: • In developed countries 1-5 cases per 100,000 population per year; mortality rate up to 80% • Patients with congenital or acquired cardiovascular defects are at risk for BE. Mortality rate of 10-80%. • Symptoms: • Septic emboli, congestive heart failure with infection-induced valvular damage, splenomegaly, splenic abscesses. • Neurologic manifestations (delirium, headache, and meningeal irritation) may be caused by mycotic aneurysms.
Cardiovascular diseases due to oral foci of infection • Manifestations: • atherogenesis, thromboembolia • coronary heart disease • cardiomyopathy • Etiology: • Chronic periodontal infections - Streptococcus sanguis oral G-positive bacteria & G -negative Porphyromonas gingivalis found in dental plaque • Mechanisms: • bacterias enter the bloodstream, invade and proliferate within heart and coronary artery endothelial cells (found in carotid and coronary atheromas) • direct effect on atheroma formation & induce platelet aggregation, thrombus formation
Glomerulonephritis due to oral foci of infections • Occurence: • Patients (2-12 years) with poor oral hygiene, twice as common in males as in females • most common primary renal disease in developing countries • Etiology: Streptococcus mitis or Streptococcus mutans bacteremia • Pathology: • In the early phases - diffuse glomerularand endocapillary proliferation + polymorphonuclear infiltration • In later phases - mesangial deposits • Manifestations: • acute nephritic syndrome - abrupt onset of gross haematuria and proteinuria oliguria, oedema, hypertension (80% of cases ) 10-21 days after the onset of bacteraemia. • Non-specific symptoms, such as malaise, weakness, and nausea, are frequent. Dull lumbar pain is present in 5-10% of patients
Topic 5 • Deficiency or excess of vitamins • Deficiency or excess of minerals • Deficiency or excess of main nutrients Oral manifestation of nutrient defects
Scurvy Vitamin B2,B3,B6 deficiency Folic acid, B12 deficiency Iron deficiency periodontal destruction; increased tooth mobility & exfoliation; sore burning mouth; soft tissue ulceration; candidiasis; malformed teeth (inadequate dentine). Scurvy-red swollen gingiva Vitamin C deficiency Angular cheilosis
