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Dental Manifestations of Dermatologic Conditions

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Dental Manifestations of Dermatologic Conditions REVIEWS Dental manifestations of dermatologic conditions AnatoliFreiman,MD,FRCPC,a Daniel Borsuk, MD,b Benjamin Barankin, MD, FRCPC,c Geoffrey H. Sperber, DMD, PhD,d and Bernice Krafchik, MD, FRCPCa Toronto, Ontario; Montreal, Quebec; and Edmonton, Alberta, Canada Background: Cutaneous disorders can be associated with a wide variety of dental manifestations that should be familiar to dermatologists. Objective: We sought to describe the development of the teeth, explain current dental terms, and review the dental manifestations of some dermatologic conditions. Methods: A MEDLINE search (1966-May 2007) was performed to find relevant articles pertaining to dental manifestations of dermatologic conditions. Results: Dental manifestations are associated with a wide variety of skin diseases that include genetic, infectious, inflammatory, and immune disorders. Limitations: The review is broad and focuses on commonly described manifestations. Conclusions: An appreciation and understanding of dental signs can aid in the diagnosis and treatment of many skin conditions. ( J Am Acad Dermatol 2009;60:289-98.) he common embryologic neural origin of the ectoderm includes the epidermal layer of the Abbreviations used: skin and the amelodentinal (the enamel and CEP: congenital erythropoietic porphyria T EB: epidermolysis bullosa dentine) components of the teeth that result in a ED: ectodermal dysplasia variety of conditions affecting both skin and denti- HI: hypomelanosis of Ito tion. The diseases derived from these components IP: incontinentia pigmenti LCH: Langerhans cell histiocytosis and neuroectodermal mesenchyme are named ‘‘neu- NBCCS: nevoid basal cell carcinoma syndrome rocristopathies,’’ signifying any disease arising from PLS: Papillon-Lefe`vre syndrome maldevelopment of the neural crest. SLS: Sjo¨gren-Larsson syndrome This article provides an overview of the epithelial TS: tuberous sclerosis elements of the mouth and dentition, a glossary of dental terms, and discusses a variety of conditions that affect the teeth and the skin that have been Gardner syndrome, hypomelanosis of Ito (HI), in- reported in the literature from 1966 to 2007. The continentia pigmenti (IP), Langerhans cell histio- diseases include the following: congenital erythro- cytosis (LCH), Naegeli-Franceschetti-Jadassohn poietic porphyria (CEP), congenital syphilis, ecto- syndrome, nevoid basal cell carcinoma syndrome dermal dysplasia (ED), epidermolysis bullosa (EB), (NBCCS), Papillon-Lefe`vre syndrome (PLS), primary immune deficiency syndromes, Sjo¨gren-Larsson syn- drome (SLS), and tuberous sclerosis (TS). a b From the University of Toronto, University of Montreal, The Dermatologists should be aware of dental abnor- Dermatology Centre, Toronto,c and University of Alberta.d Funding sources: None. malities that affect the number, structure, and color Conflicts of interest: None declared. of teeth, as well as the degree of mineralization and Reprint requests: Anatoli Freiman, MD, FRCPC, Division of caries susceptibility of enamel and dentine that are Dermatology, University of Toronto, 131 Bloor St W, Suite present in conditions associated with skin disease. 703, Toronto, Ontario, Canada, M5S1S3. E-mail: anatoli. [email protected]. EPITHELIUM OF THE ORAL MUCOSA, Published online November 25, 2008. 0190-9622/$36.00 AND TOOTH DEVELOPMENT ª 2008 by the American Academy of Dermatology, Inc. The tissue of the oral cavity is lined by a mucous doi:10.1016/j.jaad.2008.09.056 membrane that consists of two layers: epithelium 289 290 Freiman et al JAM ACAD DERMATOL FEBRUARY 2009 and connective tissue. This tissue is extremely enamel as it forms, but are lost as the tooth emerges. mobile, permitting free movement of the cheeks Dentin, which is avascular, forms the bulk of the and lips. In other areas it serves as an organ of taste. tooth, supports the central pulp chamber, and com- The mouth is defined as the area that runs posteri- pensates for its brittleness. The pulp chamber is orly across the roof of the oral cavity in a horizontal enclosed by dentin and is filled with a soft connec- line just beyond the junction of the hard and soft tive tissue. palate, to a corresponding line on the back of the Prenatal development is divided into 3 successive tongue. Histologically the oral mucosa is classified phases; the first begins at fertilization and ends at 4 into 3 types: masticatory, which has a heavily weeks. It is unusual to see congenital defects this keratinized epithelium; a lining mucosa, which is early, as a severe defect would result in loss of the not keratinized and performs the function of pro- embryo. The second phase from 4 to 8 weeks is tection; and a specialized mucosa that covers the characterized by the differentiation of all major surface of the tongue. The latter contains taste buds external and internal structures. It is in this phase and papillae consisting of hyperkeratinized epithe- that many congenital defects develop. From 8 weeks lium. Masticatory mucosa is commonly subdivided to term, growth and maturation take place and the into the orthokeratotic hard palate and the para- embryo is called a fetus. keratotic gingiva, knowledge of which is important During tooth bud development, neural crest-de- when reading histologic slides. The hard palate has rived mesenchyme cells provide the dentine-secret- a keratinized surface and the soft palate and buccal ing odontoblasts and the dental pulp, while discrete mucosa is parakeratinized. The floor of the mouth is segments of the oral epithelium differentiate into the lined by a nonkeratinized mucosa. It is commonly enamel-secreting ameloblasts. The ectodermally de- held that the lining mucosa of the cheeks, lips, floor rived components of the dentition comprise the of the mouth, and undersurface of the tongue are outer enamel cap of teeth and the inner neural nonkeratinized although their stratum superficiale crest-derived dentine. may show a tendency toward parakeratosis depend- In the last 15 years tooth development has been ing on functional and pathological conditions. In increasingly understood at the gene level and the addition, the oral epithelium contains melanocytes, number of recognized genes determining the posi- Langerhans cells, and Merkel cells. tion, shape, and/or number of teeth is increasing Teeth comprise 20% of the surface area of the rapidly. All these genes exhibit important functions mouth with the upper teeth occupying more space in cell communication and are the most important than the lower. They pierce the oral mucosa and are mechanism driving embryonic development. the only structures in the human body that pierce the epithelium. To fulfill their function of chewing, the teeth need GLOSSARY OF DENTAL TERMS to be hard. This is provided by a hard, inert, acellular PERTINENT TO SKIN CONDITIONS enamel, formed by epithelial cells and supported by Amelogenesis: the embryologic production of the less mineralized but more resilient and hard dental enamel by ameloblasts connective tissue dentin. The latter is formed and Anodontia: congenital absence of teeth supported by the soft connective tissue central pulp. Caries: a demineralization of the tooth surface In mammals teeth are anchored to the jaw by caused by bacteria connective tissue supporting tissue consisting of Cementum: the thin layer of calcified tissue cov- cementum, a periodontal ligament, and alveolar ering the roots of teeth and formed by cementoblasts bone. This provides enough flexibility to withstand Crown: the area of the tooth that is visible the forces of mastication. In human beings there are Cuspids (canines): third teeth from the midline two successive rows of teeth to fill the growing Deciduous teeth ( primary teeth or baby teeth): mouth. The first are called primary or deciduous first set of (usually) 20 teeth in childhood; these are teeth followed by the secondary or permanent teeth. replaced later in life with 32 permanent teeth Anatomically the tooth consists of a crown and a Dentine: the major hard tissue component of teeth root, and although teeth vary considerably in shape formed by odontoblasts, positioned between the and size, histologically they are all similar. enamel or cementum, and the pulp Enamel is the covering of the tooth and is the most Enamel: a hard, translucent layer composed of highly mineralized tissue in the body. It consists of inorganic calcium phosphate crystals that covers and 90% inorganic hydroxyapatite crystallites. Cells re- protects the dentine of the crown of the tooth; it is the sponsible for the formation of the enamel are called hardest substance produced by vertebrates and is ameloblasts. They cover the entire surface of the secreted by ameloblasts JAM ACAD DERMATOL Freiman et al 291 VOLUME 60, NUMBER 2 Gingivitis: inflammation of the gums character- ized by redness and swelling induced by bacteria Hypodontia: congenital absence of one or more teeth, also known as oligodontia Impaction: blockage of tooth eruption Incisor: a tooth for cutting or gnawing; located in the front of the mouth in both jaws Macrodontia: enlarged teeth Malocclusion: malposition and/or incorrect rela- tion between the mandibular and maxillary teeth Marginal gingiva: the terminal edge of gingiva Fig 1. Porphyria; red discoloration of teeth. Courtesy of surrounding the teeth in collarlike fashion Marquette University School of Dentistry. Microdontia: decrease in the normal size of teeth Molar: the last 3 upper and lower teeth on both Incisors are almost completely stained, whereas the sides of the mouth canines are colored
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