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Oral Signs of Systemic Disease CDA 2015 Lecture Notes

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Oral Signs of Systemic Disease CDA 2015 Lecture Notes 2015-08-28 Oral Signs of Oral Signs of Systemic Disease Systemic Disease Why do you need to know? ! AHA! I diagnosed your systemic disease – less likely ! Helping your patients with known Karen Burgess, DDS, MSc, FRCDC systemic diseases - more likely Oral Pathology and Oral Medicine, Faculty of Dentistry, University of Toronto Department of Dentistry, Princess Margaret Hospital Department of Dentistry, Mt Sinai Hospital 2015-08-29 2015-08-29 2015-08-29 2015-08-29 2015-08-29 2015-08-29 Normal or Abnormal? Clinical description ! Type of abnormality (shape) ! The hardest part of oral pathology ! Number ! Colour ! Consistency ! Size - measure accurately ! Surface texture ! Location 2015-08-29 2015-08-29 2015-08-29 1 2015-08-28 Vocabulary Clinical description ! Ulcer ! Type of abnormality (shape) ! Vesicle/Bulla ! Number ! Macule ! Colour ! Patch ! Consistency ! Plaque ! Size - measure accurately ! Polyp- sessile or pedunculated ! Surface texture ! Location 2015-08-29 2015-08-29 2015-08-29 Description 2015-08-29 2015-08-29 2015-08-29 Differential Diagnosis Differential Diagnosis Differential Diagnosis ! Erythema multiforme ! Mucous membrane pemphigoid ! Primary herpes ! Erythema multiforme –"Any genital or eye lesions –"How long has it been present? ! Mucous membrane pemphigoid –"Any blisters? –"Any skin lesions? ! Pemphigus vulgaris ! Pemphigus vulgaris –"any skin lesions? ! Lichen planus ! Primary herpes –"Any blisters? –"How long has it been present? ! Lichen planus What information will help you narrow down –"Any other symptoms – malaise, fever? –"any skin lesions? – itchy red bumps? this list? –"Have you ever had a cold sore? –"any lacy white lines? 2015-08-29 2015-08-29 2015-08-29 2 2015-08-28 Most likely diagnosis Pemphigus Vulgaris ! Autoimmune vesiculobullous (blistering) ! Pemphigus vulgaris condition of mucous membranes and skin ! Rare, but important ! Average age – 50-60 ! Women = men ! Chronic condition 2015-08-29 2015-08-29 2015-08-29 To Diagnose To Diagnose Treatment ! Need 2 biopsies ! Usually refer to Oral Path/Oral Med, or ! Usually systemic treatment needed by –"One in formalin for regular histo exam Dermatologist or Oral Surgeon to biopsy Dermatologist –"One in Michel’s medium for and do blood tests –"Systemic steroids immunofluoresence (IF) histological examination –"Steroid sparing medication (mycophenolate, azothiaprine) –"Need blood test for pemphigus (IF) –"Maybe Rituximab (monoclonal Ab against B ! The IF tests can only be done at some lymphocytes) labs ! Topical steroids not very effective, but may help a little 2015-08-29 2015-08-29 2015-08-29 Differential Diagnosis of atrophic Description glossitis ! Entire tongue ! Red (erythematous) ! Iron deficiency anemia ! Smooth surface (loss of papilla) ! Vitamin B deficiencies ! Fissures (may have been before) –"B12, B9 (folate) ! 2-3 small ulcers? or ! Atrophic candidiasis erosions? ! Xerostomia? ! Variation of normal? ! Burning tongue syndrome? 2015-08-29 2015-08-29 2015-08-29 3 2015-08-28 Differential Diagnosis of atrophic How to diagnose? glossitis ! Iron deficiency anemia ! Iron deficiency anemia ! Vitamin B deficiencies ! Vitamin B deficiencies –"B12, B9 (folate) –"B12, B9 (folate) ! Atrophic candidiasis ! Atrophic candidiasis ! Xerostomia? ! Variation of normal? ! Burning tongue syndrome? NO tongue appears normal looking 2015-08-29 2015-08-29 2015-08-29 How to diagnose? Anemia vs Candidiasis? Anemia ! Iron deficiency anemia ! Ask patient to see MD to rule out anemia ! Decrease in # of red blood cells or ! Vitamin B deficiencies ! Treat with nystatin oral suspension decrease in hemoglobin –"B12, B9 (folate) –"Rinse for 1 minute with 5 mls of nystatin ! Many causes, eg. ! Atrophic candidiasis suspension, and then spit out. –"Blood loss – Use four times a day for 1 week. " –"Iron deficiency –"Dispense 200 mls –"B12 deficiency –"Other B vitamins (eg. folate) deficiency 2015-08-29 2015-08-29 2015-08-29 Oral signs of Anemia (iron def) Diagnosis Iron Deficiency Anemia ! Usually none ! Generally diagnosed by MD ! Causes ! Occasionally (rare in North America) ! If you think it is possible from oral –" Pale mucosa –"Excessive blood loss (menstr, ulcer) appearance and symptoms ! Up to 11% of women of childbearing age –" Bald tongue (loss of papilla) also known as atrophic glossitis, diffuse or patchy –"Suggest pt see MD and get blood tests for –"Decreased iron intake anemia, -CBC (includes hemoglobin), iron, –" Sore tongue or burning tongue –"Decreased absorption of iron TIBC, ferritin –" Angular cheilitis ! Trmt ! Covered by provincial health insurance if –" Candidiasis –"MD to find out cause and treat done by MD ! Other Symptoms – none or fatigue, –"Dietary iron supplements usually reverse the lightheaded, headaches, palpitations, SOB ! Most dentists cannot order blood tests anemia, may take months 2015-08-29 2015-08-29 2015-08-29 4 2015-08-28 Angular chelitis - trmt ! Nystatin ointment ! Dispense: 30 gms ! Apply small dab to corners of mouth qid (after meals and before bedtime). 2015-08-29 2015-08-29 2015-08-29 Description Differential Diagnosis Diagnosis Generalized gingival enlargement ! Med Hist Dark red, and some dark pink areas ! Drug induced gingival overgrowth Smooth surfaced ! Hyperplastic gingivitis –"Drugs –"Current state of health On attached gingiva & onto alv mucosa ! Leukemia Abundant plaque ! Duration of the problem Possibly bleeding ! Other signs and symptoms What information will help you narrow –"Fatigue, easy bruising, unusual bleeding this list down? 2015-08-29 2015-08-29 2015-08-29 Drug induced gingival overgrowth Leukemia ! What would you expect? ! Leukemia - too many WBC ! Leukemic infiltrate in gingiva most often in AML (acute myeloid leukemia) ! Acute – rapidly progressive 2015-08-29 2015-08-29 2015-08-29 5 2015-08-28 AML Leukemia Diagnosis of AML ! Fever ! Acute myelogenous leukemia ! Do not biopsy gingiva ! Lethargy and fatigue –"Can present as swollen red-purple gingiva ! Get patient to a physician quickly to get ! Shortness of breath –"Localized or generalized CBC – complete blood count ! Pale skin –"If present, associated with malaise, fatigue, ! If not sure – could refer to Oral Surgeon, ! Frequent infections and bruising Oral Medicine, Oral Pathologist, or ! Why? ! Easy bruising Periodontist, but quickly ! Gingival enlargement is not common ! Unusual bleeding, such as frequent nosebleeds and bleeding from the gums ! Do you need to diagnose this? 2015-08-29 2015-08-29 2015-08-29 Treatment Treatment ! AML treated by oncologist, admitted, and ! AML treated by oncologist, admitted, and get chemo right away get chemo right away ! AML gingiva – as dentists how can we ! AML gingiva – how do you treat? help? –"“10 foot pole” –"No scaling, no prophy, no touching –"Gentle chlorhexadine (no alcohol) rinse –"The treatment is chemotherapy by the ! Two weeks after chemo started, gingiva oncologist much better, no dental treatment 2015-08-29 2015-08-29 2015-08-29 Description Differential Diagnosis Diagnosis ! Lichen planus •" History to see if patient has a diagnosis of ! Lichenoid reaction to ?? •" Lichen planus •" Lupus ! Lupus •" History to see if pt had a bone marrow ! Graft vs host disease (GVHD) transplant (for GVHD) •" If not, refer for: How can we tell the difference? •" Biopsy (lichen planus vs lupus) •" Blood test for systemic lupus (not usually positive in chronic cutaneous lupus eryth.) 2015-08-29 2015-08-29 2015-08-29 6 2015-08-28 Lupus erythematosis Lupus – oral signs ! Autoimmune condition ! Looks like lichen planus but: ! Mucocutaneous (can affect skin and –"Less common mucous membranes) +/- systemic –"Not common to be the first presenting sign of lupus ! Common –"More common on hard palate than lichen pl ! Average age onset – 30 –"White areas “feathery” rather than “lacy” ! Women much > men –"May be seen on lower lip ! Chronic condition –"Different skin lesions 2015-08-29 2015-08-29 2015-08-29 Treatment ! Oral lesions usually respond to the systemic treatment for systemic lupus ! Oral steroids for oral lesions if ness –"Only if symptomatic –"Start with OraCort –"5 gms tube, apply small dab to sore area tid for 2 weeks and taper off ! Stronger treatment by rheumatologist if needed 2015-08-29 2015-08-29 2015-08-29 Description Description ! Yellow colour of mucosa, more in soft ! Yellow colour of mucosa, more in soft palate palate, lingual frenum ! Shallow ulcer on side of tongue ! Yellow colour to skin What is your differential diagnosis? whs.com What2015-08-29 else do you want to know? 2015-08-29 2015-08-29 7 2015-08-28 Jaundice Differential Diagnosis Differential Diagnosis ! Yellow colour of mucosa, more in soft ! Jaundice ! Jaundice –yellow skin, mucous palate, lingual frenum ! Normal membranes, and sclera ! Yellow colour to skin ! Hypercarotenemia ! Hypercarotenemia – orange skin and ! Yellow colour to sclera of eye mucous membranes ! Bad spray on tan – yellow or orange skin only www.nhs.com chrisbeatcancer.com 2015-08-29 2015-08-29 2015-08-29 Jaundice Jaundice ! Excessive breakdown of RBCs ! Too much bilirubin in the bloodstream ! Hemolytic anemia settles in the tissues. ! Damaged liver can’t process bilirubin ! Bilirubin from breakdown of Hb in RBCs ! Infections (eg. Hepatitis) ! Non-specific – can be due to ! Toxins (alcohol or other drugs) –"Excessive breakdown of RBCs ! Cirrhosis –"Damaged liver can’t process bilirubin ! Blocked bile ducts –"Blocked bile ducts – bilirubin can’t be excreted ! Gall stones, less common – cancer ! Immature liver not processing bilirubin 2015-08-29 2015-08-29 2015-08-29! At birth Diagnosis
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