Earn 2 CE credits This course was written for dentists, dental hygienists, and assistants.

Oral Manifestations of Systemic Disease A Peer-Reviewed Publication Written by Jeff Burgess, DDS, MSD

Abstract Educational Objectives: Author Profile Mucosal ulceration, dental disease and other tooth At the end of this educational activity, Jeff Burgess, DDS, MSD, (Retired) Clinical Assistant abnormalities, oral soft tissue tumors, , participants will be able to: Professor, Department of , University bone pathology, and orofacial pain may be directly related 1. Discuss the complexity of the relationship of Washington School of Dental Medicine; (Retired) to or confounded by underlying systemic disease. An between systemic disease and various oral Attending in Pain Center, University of Washington understanding of the relationship between systemic disease conditions. Medical Center; (Retired) Private Practice in Hawaii and oral pathology is important with respect to establishing 2. Identify the different oral manifestations and Washington; Director, Oral Care Research the diagnosis and determining the complexity of subsequent associated with specific systemic diseases. Associates. He can be reached at jeffreyaburgess@ management. For example, dental caries that is confounded by 3. Differentiate between potential systemic hotmail.com . nutritional deficiency or psychological problems such as bulimia diseases associated with some specific oral Author Disclosure or anorexia, or a medical problem that directly or indirectly conditions such as ulceration. Jeff Burgess, DDS, MSD, has no commercial ties (via medication use) causes xerostomia or dry mouth, or a 4. Have improved diagnostic skills in relation with the sponsors or providers of the unrestricted medical condition that alters the patient’s ability to maintain to the connection between systemic disease educational grant for this course. appropriate oral hygiene may need to be managed using a and oral pathology. comprehensive strategy that takes into account the underlying medical issue as well as the dental issues. This course reviews such problems and their impact on oral conditions.

Publication date: July 2013 Supplement to PennWell Publications Expiration date: June 2016 This educational activity was developed by PennWell’s Dental Group with no commercial support. This course was written for dentists, dental hygienists and assistants, from novice to skilled. Educational Methods: This course is a self-instructional journal and web activity. Provider Disclosure: PennWell does not have a leadership position or a commercial interest in any products or services discussed or shared in this educational activity nor with the commercial supporter. No manufacturer or third party has had any input into the development of course content. Requirements for Successful Completion: To obtain 2 CE credits for this educational activity you must pay the PennWell designates this activity for 2 Continuing Educational Credits required fee, review the material, complete the course evaluation and obtain a score of at least 70%. CE Planner Disclosure: Heather Hodges, CE Coordinator does not have a leadership or commercial interest with Dental Board of California: Provider 4527, course registration number CA# 02-4527-13079 products or services discussed in this educational activity. Heather can be reached at [email protected] “This course meets the Dental Board of California’s requirements for 2 unit of continuing education.” Educational Disclaimer: Completing a single continuing education course does not provide enough information to result in the participant being an expert in the field related to the course topic. It is a combination of many The PennWell Corporation is designated as an Approved PACE Program Provider by the educational courses and clinical experience that allows the participant to develop skills and expertise. Academy of General Dentistry. The formal continuing dental education programs of this Scientific Integrity Statement: Information shared in this CE course is developed from clinical research and program provider are accepted by the AGD for Fellowship, Mastership and membership represents the most current information available from evidence based dentistry. maintenance credit. Approval does not imply acceptance by a state or provincial board of Registration: The cost of this CE course is $49.00 for 2 CE credits. dentistry or AGD endorsement. The current term of approval extends from (11/1/2011) to Cancellation/Refund Policy: Any participant who is not 100% satisfied with this course can request a full (10/31/2015) Provider ID# 320452. refund by contacting PennWell in writing. Educational Objectives A very complex relationship exists between these factors At the end of this educational activity, participants will with respect to caries initiation in both primary and adult be able to: teeth. It is known that any perturbation of the oral environ- 1. Discuss the complexity of the relationship between ment can increase the potential for the development of dental systemic disease and various oral conditions. caries. For example, in a study on the relationship between 2. Identify the different oral manifestations associated dental caries and nutritional status, snack foods, and the with specific systemic diseases. consumption of sugar-sweetened beverages in schoolchil- 3. Differentiate between potential systemic diseases dren in Thailand, it was found that malnutrition as well as associated with some specific oral conditions such as food intake habits at bedtime were significantly related to ulceration. the development of dental caries in the primary dentition.1 4. Have improved diagnostic skills in relation to the con- In addition to malnutrition, other conditions impacting nection between systemic disease and oral pathology. diet are also cited in the literature as associated with the development of caries. These include medical (e.g. diabetes) Abstract and psychological (e.g. drug abuse, bulimia, etc.) problems. Mucosal ulceration, dental disease and other tooth ab- The following subsections detail some of the specific sys- normalities, oral soft tissue tumors, periodontal disease, temic problems that are suspected of impacting the develop- bone pathology, and orofacial pain may be directly related ment of caries. to or confounded by underlying systemic disease. An un- derstanding of the relationship between systemic disease Diabetes and oral pathology is important with respect to estab- In animal models, a number of studies suggest that rapid lishing the diagnosis and determining the complexity of progressive caries is associated with chemically induced subsequent management. For example, dental caries that hyperglycemia.2,3 In contrast to the animal studies, at is confounded by nutritional deficiency or psychological least one systematic review of the literature questions the problems such as bulimia or anorexia, or a medical prob- scientific validity of a causative link between caries and lem that directly or indirectly (via medication use) causes diabetes in humans.4 The authors of this review suggest that xerostomia, or a medical condition that alters the patient’s because multiple studies report variable caries experiences ability to maintain appropriate oral hygiene may need to between subjects with and without diabetes (e.g. increased, be managed using a comprehensive strategy that takes into decreased, and similar experiences), that the evidence is, at account the underlying medical issue as well as the dental present, insufficient to determine if a true risk-relationship issues. This course reviews such problems and their impact actually exists in humans. on oral conditions. Drug Abuse Introduction Multiple studies have linked the abuse of drugs to the devel- Numerous orofacial conditions are associated with system- opment of dental caries.5-8 The problem has been identified ic disease. The most serious problems of concern to dental in many countries throughout the world.9-12 professionals include caries, oral ulcers, mucosal One of the drugs that has been most recently studied in and sloughing, gingival bleeding and hypertrophy, soft tis- relation to caries is methamphetamine.13 The street descrip- sue exophytic masses, dry mouth, facial pain, movement tion of ‘’ is not without merit as this particular disorders, tooth abnormalities, abnormal dental wear, drug and its abuse appears to be associated with considerable tooth/mucosal discoloration, developmental and bone as well as other oral problems such as periodon- pathology. This review focuses on the systemic conditions tal disease. Some evidence suggests that salivary pH may be that may cause or contribute to the above oral problems. the reason the drug contributes to dental caries.14 The abuse of narcotics and alcohol has also been associ- Caries ated with an increased risk of caries. However, in at least one Dental caries may be caused or aggravated by a number comparative study, alcohol abuse was less likely than ‘drug’ of systemic diseases via their impact on the three primary abuse to lead to the development of caries. The combination factors that are thought to contribute to dental caries: the of alcohol and drug abuse (which included self-reported use presence of bacteria and biofilm known to cause caries, the of not only heroin and methadone but also cannabis, benzo- availability of a consistent food source (e.g. sugar) for these diazepines, and cocaine) led to the greatest caries risk (38% bacteria, and oral hygiene. Other factors such as genetics increased risk).15 (e.g. tooth development, matrix metalloproteinases) and The authors of this study speculate that the lower rate the use of medications in the treatment of systemic disease in persons abusing alcohol, and particularly those that drink (e.g. affect on salivation) may also play a role in the devel- beer may be related to the effect of increased fluoride con- opment of caries. sumption which is an ingredient in beer.

2 www.ineedce.com The caries risk from narcotics is not just related to of dental caries. Diseases which reduce coordination, limit street use. A recent case report describes the development cognitive activity, or involve significant physical or mental of rampant caries from the abuse of oral transmucosal fen- disability have the potential to facilitate dental disease, tanyl citrate lozenges which are used for the oral manage- including caries, and subsequent .24 Finally, there ment of breakthrough cancer pain.16 Presumably caries risk is limited evidence that genetic factors such as a mutant associated with drug use is behavioral in nature and relates allele for MMP13 (one of the genes that is responsible for to neglect of oral hygiene. producing a matrix metalloproteinase) may contribute in Smokeless tobacco use has also been linked to dental some manner to the etiology of dental caries.25 caries, specifically root caries.17 With respect to cannabis use, one study found that subjects using this drug exces- Oral Ulcers sively had significantly greater smooth surface caries than The systemic conditions that can cause oral ulceration controls. The authors speculate that this was related to include infection (e.g. syphilis,26, 27 ,28 HIV/ the drugs effect on salivation (hyposalivation during use) AIDS,29,30 viral infection including and primary and on subsequent post-smoking sugar intake (from the herpetic including virus causal- ‘munchies’).18 ity (HSV-1 or 2),31 candida and other fungal organisms In addition, as noted previously, any medication that (e.g. mucormycosis or histoplasmosis,32-35 autoimmune reduces salivation has the potential to increase the risk of disease (e.g. lupus,36,37 and paraneoplastic pem- caries, particularly if it is used over a prolonged period of phigus,38,39 ,40 inflammatory bowel disease,41 time.19 However, other than anecdotes, there is little docu- thyroid disease,44 malignancy/haematologic disease,45,46 mented research assessing the link between the commonly ,47 and other drug reactions,48-50 used drugs that cause xerostomia and caries progression. In and vascular inflammatory disease.51 Oral ulceration may one animal study chronic administration of clonidine20 and also be associated with organ transplants and the medica- propranolol21 was found to increase caries in rats. Other tions used to manage rejection or treat other diseases (e.g. drugs causing dry mouth that are utilized by patients that thyroid disease),52 liver transplant,53 or renal transplant.54 could cause caries include antihistamines, anti-depressants Nutritional deficiencies are also associated with intraoral such as Elavil® (amitriptyline), Asendin® (amoxapine), ulceration.55,56 Oral ulceration has also been reported with Anafranil® (clomipramine), Remeron® (mirtazapine) and hypogammaglobulinemia.57 Aventyl® or Pamelor® (nortriptline), and Detrol® which is Generally the clinical presentation of oral ulcers is not commonly used to treat incontinence. specific enough to allow identification of the underlying pa- thology in cases involving systemic disease. There are, how- Bulimia and Anorexia ever, several clinical features that may be helpful in guiding Bulimia, a condition associated with repeated vomiting, has the clinician with respect to the differential diagnosis in these been connected to the development of dental caries in both cases. These include ulcer location, duration, reoccurrence, men and women.22 This is presumed to be related to the depth, number, size, scarring, and non-healing. fact that patients who chronically vomit, bathe their teeth in stomach acid during this purging behavior. In addition Lesion Location to bulimia, anorexia is another psychological condition that Lesions associated with primary herpetic stomatits occur may include vomiting and has also been associated with an not only on the intraoral mucosa of the cheek, tongue, pal- increase in dental caries. ate, and posterior pharynx, but also on the attached gingiva. However in a recent systematic review of the literature This is not a typical presentation that is associated with most assessing the orofacial manifestations of these conditions, other oral ulcerative diseases and thus can be used to help including caries, the authors suggest that the development differentiate between non-viral and viral etiology. of caries in patients with eating disorders may not be an automatic sequalae of these abnormalities.23 Lesion Duration Nonetheless, in otherwise healthy patients with good Viral lesions and aphthous ulcers typically persist for 10-14 oral hygiene but with unusual smooth surface lesions or days and heal with complete resolution. In contrast, lesions rampant caries, eating disorders should be considered as a associated with Behcet’s disease may persist for up to four to potential cause of the disease. Caries activity in this group six weeks. Ulcers related to underlying neoplasm, a compro- of patients may also be confounded by general diet and oral mised immune system, or nutritional deficiency persist for a hygiene as well as salivary gland disturbance. much longer period of time.

Medical Conditions Reducing Hygiene Behavior Lesion Reoccurrence Any medical condition that contributes to a reduction in Ulceration reoccurring on the attached gingiva is likely to oral hygiene can increase the potential for the development represent secondary (or reoccurring) HSV-1 or HSV-2. www.ineedce.com 3 Lesion Depth oral-side-effects-of-medications?page=2. Non-steroidal Deep cratering of the is typical of the ulcers anti-inflammatory drugs, including aspirin may also cause associated with Behcet’s disease and HIV/AIDS. However, gingival bleeding if used over a prolonged period of time. A lesions associated with major aphthous, tuberculosis and number of herbal medicines may interact with non-herbal syphilis may also be relatively deep. Deep tongue lesions medications (e.g. the anticoagulants) to increase the po- may also be associated with amyloidosis58 and malignancy. tential for gingival bleeding including ginkgo biloba, dong quai, and danshen.69 Other herbal preparations associated Number of Lesions with gingival bleeding include ginger, ginseng, garlic, and Multiple ulcers clustered throughout the mouth suggest vi- papaya.70 ral etiology (e.g. herpes zoster, primary herpetic stomatitis, or herpangina). Gingival Hyperplasia Specific classes of drugs including the immunosuppressants, The Size of the Lesion calcium channel blockers, and anticonvulsants that are used Large (>1cm or greater) oral ulcers are most typically seen in the treatment of a variety of medical conditions can induce with erythema multiforma, allergy, benign mucous mem- gingival hyperplasia.71, 72 The medications most frequently brane (BMMP) disease, pemphigus vulgaris, cited as problematic for abnormal gingival growth include;73 erosive lichen planus, radiation mucositis or mucositis immunosuppressants, calcium channel blockers, and anti- associated with chemotherapy and lesions associated with epileptic drugs. severe immunosuppression or uremic stomatits. Large lesions are not typically observed with viral infection al- Gingival Discoloration though sometimes small lesions will coalesce to form larger Gingival discoloration (other than erythema) may be a sign ulcers.59 of Addison’s disease (primary hypoadrenocorticism), silver poisoning, primary or metastatic malignancy (melanoma), Post lesion scarring Kaposi’s sarcoma (with or without associated AIDS), Ulceration occurring with Bechet’s disease occurs with post- hereditary hemorrhagic telangiectasia, and Peutz-Jeghers healing scarring. Typically patients with this condition will syndrome ( lesions). have areas of mucosa that are scarred from past episodes. Intraoral Soft Tissue Tumors Non-healing ulcers General medical conditions that can cause intraoral soft These are most commonly found with malignancy. tissue tumors include parathyroid disease (e.g. primary hyperparathyroidism or hyperparathyroidism secondary to Gingival Bleeding, Hyperplasia, Discoloration an adenoma or carcinoma of a parathyroid gland - Brown’s tumor), malignant acanthosis nigricans (hyperplastic, peb- Gingival Bleeding bly lesions on the ), immunosuppression (squamous Systemic conditions that can cause gingival bleeding papillomas), metastatic neoplasms (typically from the include some of those that also cause ulceration such as breast, prostate, thyroid, lung), amyloidosis secondary to benign pemphigoid (BMMP), pem- multiple myeloma (pebbly lesions of the lip and cheek). phigus, lupus erythematosis, leukemia, and erythema mul- Some of the other systemic conditions that can cause tiforme. Other conditions such as uncontrolled diabetes,60 single or multiple exophytic papules, tissue enlargement, Crohn’s disease (which can cause gingival hyperplasia as or other growths include; chronic granulomatous disease well as erythema and bleeding),61 and idiopathic thrombo- (Crohn’s disease) (which results in granulomatous gingival cytopenia62,63 have also been linked to gingival bleeding. enlargement, cobblestone or corrugated labial mucosa), In addition to the above, what is termed hormonal , syphilis (ulcer plus atypical clinical presenta- , a condition that can occur with pregnancy or tions in AIDS), end stage kidney disease with dialysis disease associated with pregnancy, can also cause general- (causes furred tongue); lymphangioma (results in a pebbly ized gingival erythema and bleeding.64-66 mucosal surface).74-88 Several medications utilized in the management of a number of systemic conditions can cause gingival erythema Dry Mouth and bleeding. These include: Trileptal®,68 anticoagulant Any systemic disease that affects the major or minor sali- drugs such as Coumadin®, warfarin or heparin and chemo- vary glands via direct disease involvement or secondarily as therapeutic agents such as methotrexate and 5-fluorouracil. a consequence of medication use, radiation, or surgical A complete list of the chemotherapy agents that can cause trauma can cause dry mouth or xerostomia. Those systemic mucositis and gingival as well as mucosal bleeding can be conditions capable of impacting the salivary glands in- found at: http://www.webmd.com/oral-health/guide/ clude:89-93 Sjogren’s disease, chronic renal failure (CRF),

4 www.ineedce.com other autoimmune diseases (rheumatoid arthritis, seronega- movement disorders tive spondyloarthritis, connective tissue disease, systemic Jaw movement can be altered by several medical conditions lupus erythematosis), non-Hodgkin lymphoma, diabetes, affecting the musculature, nervous system, vascular system, Parkinson’s disease, HIV/AIDS, psychological problems or the bones of the cranium or . Movement disor- (anxiety disorders and depression), stroke and Alzheimer’s ders include opening stiffness, opening difficulty, painful disease, anemia, cystic fibrosis, and other conditions such movement, and unintentional movement. The conditions as head trauma with nerve damage and chemo or radiation that should be considered in the differential diagnosis relat- therapy for head and neck cancer. ed to systemic disease for the above jaw movement problems Classes of medications used to treat systemic diseases are listed below.98-102 capable of causing dry mouth include:94 antihistamines, an- tipsychotics, diuretics, chemotherapeutic agents, migraine Jaw opening stiffness medications, anticholinergic/antispasmodic agents, antidi- Jaw opening stiffness can be caused by scleroderma, fibro- arrhetics, analgesics – antinflammatory type, narcotic anal- myalgia, muscular dystrophy, and multiple sclerosis (MS). gesics, anti-acne, anti-anxiety medications, anticonvulsants, antihypertensives, anti-nausea and anti-emetic medications, Opening difficulty anti-parkinsonian drugs, bronchodilators, muscle relaxants, Difficulty in opening the jaw may result from infection (in- and other drugs such as cannabis. cluding the cephalic form of tetanus), poisoning, neurologic Dry mouth can occur as a secondary effect of treatment disease, psychogenic abnormality, tumor, substance abuse, in patients using C-pap for sleep apnea and consequent to dystonia, radiation induced , ‘locked-in’ syndrome, the use of COPD inhalers.95 brain stem lesions, idiopathic inflammatory myopathies.

Orofacial Pain Painful jaw movement Pain in the region of the mouth and face may be caused Movement of the jaw may be limited by fibromyalgia, teta- by a number of systemic problems. It is not within the nus, tumor, and dystonia associated with Behcet’s disease. purview of this course to extensively review the clinical pain characteristics of the following conditions. How- Intermittent unintentional movement ever several references are listed for additional review.96, Additional jaw movement abnormality including intermit- 97 Below are several systemic conditions that can cause tent unintentional movement can result from Parkinson’s orofacial pain: disease, epilepsy, dystonia, nocturnal paroxysmal dysto- nia, serotonin syndrome, and substance abuse. Cardiac disease (e.g. myocardial infarction, angina) Tooth Morphologic Abnormality Thyroid disease (e.g. thyroiditis) Dental problems associated with systemic disease include Sinus disease (e.g. acute and chronic sinusitis) excessive (from bulimia, anorexia, neurologic Autoimmune disease (e.g. , lupus, sclero- disease, psychological problems, genetic disorders),114-120 de- derma) velopmental (genetic) abnormalities causing malformed or Secondary trigeminal neuralgia (e.g. from tumors such as me- excessive or impacted teeth, discoloration (from medication ningioma, epidermoid tumor, acoustic neurinoma, metastatic use), and tooth root resorption (bulimia, gastroesophageal tumor, brain stem glioma; vascular lesions such as basilar artery or cavernous sinus aneurysm; connective disease such as reflux disease, excessive soft drink consumption associated scleroderma; Paget’s disease; syphilis; or toxins; MS) with obesity, diabetes, drug abuse, salivary gland agenesis, and high blood pressure).103-113 Craniofacial pain of musculoskeletal origin (e.g. TMD, TMJ osteoarthritis, bone infection or primary or metastatic tumor) Tooth and Mucosal Discoloration Infection (e.g. otitis media, infection secondary to immuno- suppression) Dental discoloration Sickle cell disease (sickle cell arthropathy) Dental discoloration can arise from the treatment of sys- Vascular inflammatory conditions (e.g. giant cell arteritis, temic infection with tetracycline and tetracycline-derived temporal arteritis, Systemic ) broad spectrum antibiotics. The result is permanent if Psychological abnormality (e.g. somatoform disorder, pain of the drugs are used during development of the teeth and psychological origin in the head or face) bone as they are incorporated into the dental and enamel Medication neurotoxicity (e.g. vincristine) structure. Tissues affected include the teeth, bone, and car- Suboccipital or cervical nerve or muscle problems tilage. Both primary and permanent teeth are susceptible Diabetes to discoloration which can range from grey to brown or be yellow. Minocycline hydrochloride application during www.ineedce.com 5 growth and development of bone leads to black or green bone, multiple myeloma, neuroblastoma, neurosarcoma, tooth roots and a blue-gray darkening of the crowns of the , tuberculosis, and scleroderma. permanent teeth. Staining may also occur in erupted per- For a complete review of disease that can cause bone manent teeth from minocycline and within the mucosa of pathology the reader is referred to the authoritarian texts the .121-124 that are provided as references. Environmental exposure to a number of elements has The differential diagnosis is refined clinically by the also been associated with discoloration of teeth. These patient’s gender, age, predominant jaw and region of the include silver, iron, and manganese which stain black; jaw where the lesion is located, the type of lesion (unilocu- mercury and lead dust which stains the teeth blue-green; lar or multilocular) and the configuration of the lesion’s copper and nickel stain blue to blue/green, and chromic borders (e.g. well defined or diffuse/ill-defined), the pa- acid which can stain the teeth deep orange.125, 126 Excessive tient’s symptom history (e.g. presence or absence of pain, fluoride during development tends to mottle the color of dyesthesia/paresthesia,), and examination findings (e.g. enamel.127 In addition to the above causes of tooth dis- localized swelling, gingival involvement, tooth mobility, coloration, neonatal sepsis has also been associated with tooth vitality). Other important considerations include emergence of ‘green teeth’.128 serum chemistries, general symptoms, and bone . Another condition involving the jaw bones is osteone- Mucosal discoloration crosis caused by the use of bisphosphonates as treatment Mucosal discoloration can be indicative of systemic for advanced forms of cancer.133 Bone resorption of the disease. A large number of conditions can cause varying mandibular angle has been associated with progressive types of mucosal discoloration. The following are systemic systemic sclerosis. A generalized rarefaction of the jaw problems that are known to cause mucosal discoloration bones may also result from nutritional abnormality such as and the specific type of discoloration that has been de- calcium deficiency (causing osteomalacia or ‘rickets’) or vi- scribed for each condition.129-131 Minocycline is associated tamin C deficiency as well as the hereditary hemolytic ane- with a palatal ring. Kaposi sarcoma (KS) is associated with mias such as thalassemia and sickle cell anemia. Leukemia multiple red lesions within the mucosa, Addison’s disease can also cause rarefaction of the skull and jaw ramus. In the results in hyperpigmentation of the mucosa, melanoma re- early stages of Paget’s disease (osteitis deformans) rarefac- sults in a diffuse or more discrete solitary blue black tissue, tion and bone resorption are associated with radiographic thrombocytopenic purpura/leukemia and hemophilia are radiolucency and in the later stage when there is fibrous characterized by mucosal petechiae, pernicious anemia deposition the bones take on a ‘cotton-wool’ appearance causes tongue discoloration, infection (such as infectious when viewed radiographically. mononucleosis) is associated with petechiae on the palate. The temporomandibular joints may be affected by con- Generalized redness of the oral mucosa is associated nective tissue diseases such as rheumatoid arthritis, juvenile with a number of systemic diseases including: pemphigus, idiopathic arthritis, psoriatic arthritis, and arthritis associ- erosive lichen planus, radiation , mucositis, candi- ated with lupus as well as systemic cancer with metastasis. dosis secondary to immunosuppression, allergy, erythema Gout may also affect the TMJ. Dermatomyositis has been multiforme, polycythemia, Crohn’s disease, epidermoly- reported to be associated with .141-146 sis bullosa, viral infection, leukemia, uremic stomatitis, and vitamin B deficiency Conclusion The effect of systemic health on oral disease is well docu- Bone Pathology mented and includes soft and hard tissue abnormality and Radiolucencies associated with the pericoronal or follicular pathology. The diagnosis of oral pathology by dental spaces adjacent to the teeth are not uncommon. However professionals may contribute towards the discovery of sys- systemic disease that can cause this type of bone loss is temic disease. Regardless of which way the arrow points, the rare. Those conditions that have been linked to lesions complexity of management of oral disease associated with associated with unerupted teeth include Ewing’s sarcoma, systemic disease is likely to be confounded by the connec- histiocytosis X, pseudotumor of hemophilia, and salivary tion between the two and successful management warrants gland tumors. The diseases that can cause unilocular or an understanding of both problems. multilocular radiolucency or radiolucency in the or mandible not linked to the dentition include metastatic Further Reading carcinoma, giant cell tumor resulting from hyperparathy- Section on Pain: 1. Surgical management of pain. Editor Kim J Burchiel, Thieme, roid disease or neurofibromatosis type 1, Burkitt’s lym- New York, 2002. Chapter 20, Jeffrey A Burgess, p 276-287. phoma, chondrosarcoma, eosinophilic , fibrous 2. Neurosurgical management of pain. Editors Richard B North, dysplasia, , Ewing’s sarcoma, Langerhan’s cell Robert M. Levy, Springer, New York, 1996, Chapter 7: Facial disease (idiopathic histiocytosis), malignant lymphoma of and Cranial Pain; Kim J Burchiel and Jeffrey A Burgess.

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Shah SS, Oh CH, Coffin SE, Yan AC. Addisonian Washington School of Dental Medicine; (Retired) Attend- pigmentation of the oral mucosa. Cutis. Aug 2005;76(2):97-9. ing in Pain Center, University of Washington Medical Cen- [PMID: 16209154]. ter; (Retired) Private Practice in Hawaii and Washington; 132. Lajolo C, Campisi G, Deli G, Littarru C, Guiglia R, Giuliani Director, Oral Care Research Associates. He can be reached M. Langerhans’s cell histiocytosis in old subjects: two rare case reports and review of the literature. Gerodontology. Jun at [email protected] . 2012;29(2):e1207-14. [PMID: 22612839]. 133. Pechalova P, Bakardjiev A, Zaprianov Z, Vladimirov Disclaimer B, Poriazova E, Zheleva A. Bisphosphonate-associated Jeff Burgess, DDS, MSD, has no commercial ties with the osteonecrosis of the jaws -- report of three cases in Bulgaria and review of the literature. Acta Clin Croat. Jun 2011;50(2):273-9. sponsors or the providers of the unrestricted educational [PMID: 22263396]. grant for this course.

10 www.ineedce.com Online Completion Use this page to review the questions and answers. Return to www.ineedce.com and sign in. If you have not previously purchased the program select it from the “Online Courses” listing and complete the completeonline purchase. the online Once purchase. purchased Once the purchased exam will bethe added exam willto your be added Archives to yourpage Archives where a pageTake Examwhere link a Take will Exambe provided. link will Click be provided. on the “Take Click Exam” on the link, “Take complete Exam” link, all the complete program all questions the program and ques submit- your tionsanswers. and An submit immediate your answers. grade report An immediate will be provided grade report and upon will bereceiving provided a passing and upon grade receiving your “Verification a passing grade Form” your will “Verification be provided immediatelyForm” will be forprovided viewing immediately and/or printing. for viewing Verification and/or Formsprinting. can be viewed Verificationand/or printed Forms anytime can inbe theviewed future and/or by returning printed toanytime the site, in thesign future in and by return returning to your to Archivesthe site, signPage. in and return to your Archives Page.

Questions

1. Systemic conditions that may result in 21. Heck’s disease is most likely to result in tooth discoloration include: 11. Sarcoidosis is manifested in the mouth what type of oral problem: a. Neonatal sepsis a. Periodontal Disease b. Hemophilia by: a. Fibroepithelial hyperplasia b. Impacted third molars c. Thyroid disease c. Epithelial hyperplasia d. Sinus disease b. Non-caseating c. Deep ulcers d. Gingival discoloration 2. Which systemic disease may be associated d. Blue stained gingiva 22. Which class of medication is not likely to with x-ray follicular space and pericoronal 12. Which of these clinical features of oral cause gingival hyperplasia: radiolucency: ulcers is not helpful in defining a possible a. Tuberculosis a. Corticosteroids b. Progressive systemic sclerosis underlying systemic disease: b. Immunosuppressants c. Paget’s disease a. Ulcer depth c. Calcium channel blockers d. Pseudotumor of hemophilia b. The number of ulcers d. Antiepileptic drugs c. Scaring 3. Name the one systemic condition that is d. Reoccurrence frequency 23. Which systemic disease is most likely to not likely to be associated with temporo- 13. Oral ulcers that persist for a long time result in post-oral ulceration scaring: mandibular joint pathology: a. Tuberculosis a. Juvenile idiopathic arthritis may be most likely to be indicative of b. Syphilis b. Gout which systemic disease: c. Kidney failure c. Dermatomyositis a. Kidney disease d. Behcet’s disease d. Cherubism b. Thyroid disease c. Immune deficiency 24. Sjogren’s disease causes what oral 4. Which systemic condition has NOT been d. Dermatomyositis problem: associated with tooth erosion: a. Periodontal disease a. High blood pressure 14. Which of the following systemic condi- b. Obesity tions has not been associated with the b. Tooth developmental abnormality c. Diabetes development of dental caries: c. Dry mouth d. Liver disease a. Diabetes d. Jaw movement abnormality 5. Which systemic condition is NOT associ- b. Bulimia 25. Large oral ulcers are most likely to be c. Drug abuse ated with mucosal discoloration: d. Dermatologic disease observed with which systemic disease: a. Peutz-Jegher a. Erythema multiforma b. Kaposi sarcoma (KS) 15. Multiple painful punctuate oral ulcers b. Herpes c. Pancreatic cancer occurring on the attached gingiva sug- c. Uremic poisoning d. Laugier’s disease gests which systemic condition: d. Aphthous stomatitis a. Behcet’s disease 6. When a patient presents with jaw muscle 26. Intermittent unintentional jaw move- stiffness which of the following systemic b. Lymphoepithelial disease c. Viral infection ment is not likely to be associated with conditions should be considered in the d. Lichen planus which one of these systemic problems: differential diagnosis: a. Scleroderma 16. Which of these conditions does not cause a. Dystonia b. Thyroid disease oral ulceration: b. Anorexia c. Kidney disease a. Viral infection c. Parkinson’s disease d. Rheumatoid arthritis b. Thyroid disease d. Serotonin syndrome c. Pulmonary disease 27. Which of these intraoral problems is 7. Which of these systemic diseases does d. Inflammatory bowel disease NOT cause unintentional jaw movement: NOT caused by Crohn’s disease: a. Serotonin syndrome 17. Smokeless tobacco has been linked to a. Gingival hyperplasia b. Substance abuse what type of caries: b. Gingival bleeding c. Epilepsy a. Mesial interproximal caries c. Gingival erythema d. Jaw metastatic neoplasm b. Occlusal caries d. Gingival blackening 8. In a study on the relationship between c. Cervical (root) caries d. Distal interproximal caries 28. Gardner’s syndrome results in what oral dental caries and nutritional status, snack problem: foods, and sugar-sweetened beverage 18. A brain tumor such as a meningioma can cause: a. Periodontal bleeding consumption in schoolchildren in b. Gum hyperplasia Thailand it was found that the following a. (Secondary) trigeminal neuralgia b. Burning tongue c. Dental malformations factor was strongly associated with caries c. TMJ pain d. Mandibular development: d. Ear pain 29. Multiple ulcers clustered throughout the a. Malnutrition b. Weight 19. Hypogammaglobulinemia has been mouth suggest what type of etiology: c. A diet of meat associated with what type of oral problem: a. Kidney disease d. Soft drinks a. Periodontal disease b. Pulmonary disease b. Caries 9. Which one of these conditions is not c. Viral infection c. Oral tumors d. Cardiac disease associated with jaw pain: d. Oral ulceration a. Tetanus 30. In the study of caries activity of school 20. In healthy patients with good oral b. Fibromyalgia children in Thailand, what condition c. Tumor hygiene but unusual smooth surface d. Pancreatic disease lesions or rampant caries what problem besides malnutrition was found to 10. The term ‘hormonal’ gingivitis is should be considered as a potential cause contribute to the development of dental associated with: of the oral disease: caries in primary teeth? a. Thyroid abnormality a. Thyroid disease a. The type of food eaten during the day b. Adrenal insufficiency b. Pancreatic disease b. Food intake habits at bedtime c. Pregnancy c. Bulimia c. The number of meals eaten in a day d. Pituitary disease d. Sarcoidosis d. The amount of food intake www.ineedce.com 11 ANSWER SHEET Oral Manifestations of Systemic Disease

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Lic. Renewal Date: AGD Member ID: Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 2 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp. For Questions Call 216.398.7822

Educational Objectives If not taking online, mail completed answer sheet to 1. Discuss the complexity of the relationship between systemic disease and various oral conditions. Academy of Dental Therapeutics and Stomatology, A Division of PennWell Corp. 2. Identify the different oral manifestations associated with specific systemic diseases. P.O. Box 116, Chesterland, OH 44026 3. Differentiate between potential systemic diseases associated with some specific oral conditions such as ulceration. or fax to: (440) 845-3447 4. Have improved diagnostic skills in relation to the connection between systemic disease and oral pathology. For immediate results, go to www.ineedce.com and click on the button “Take Tests Online.” Answer Course Evaluation sheets can be faxed with credit card payment to 1. Were the individual course objectives met? Objective #1: Yes No Objective #3: Yes No (440) 845-3447, (216) 398-7922, or (216) 255-6619. Objective #2: Yes No Objective #4: Yes No Payment of $49.00 is enclosed. (Checks and credit cards are accepted.) Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. If paying by credit card, please complete the 2. To what extent were the course objectives accomplished overall? 5 4 3 2 1 0 following: MC Visa AmEx Discover 3. Please rate your personal mastery of the course objectives. 5 4 3 2 1 0 Acct. Number: ______4. How would you rate the objectives and educational methods? 5 4 3 2 1 0 Exp. Date: ______Charges on your statement will show up as PennWell 5. How do you rate the author’s grasp of the topic? 5 4 3 2 1 0 6. Please rate the instructor’s effectiveness. 5 4 3 2 1 0 7. Was the overall administration of the course effective? 5 4 3 2 1 0 8. Please rate the usefulness and clinical applicability of this course. 5 4 3 2 1 0 9. Please rate the usefulness of the supplemental webliography. 5 4 3 2 1 0 10. Do you feel that the references were adequate? Yes No 11. Would you participate in a similar program on a different topic? Yes No 12. If any of the continuing education questions were unclear or ambiguous, please list them. ______13. Was there any subject matter you found confusing? Please describe. ______14. How long did it take you to complete this course? ______15. What additional continuing dental education topics would you like to see? ______AGD Code 739 PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS. COURSE EVALUATION and PARTICIPANT FEEDBACK Provider Information RECORD KEEPING We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included PennWell is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental association PennWell maintains records of your successful completion of any exam for a minimum of six years. Please with the course. Please e-mail all questions to: [email protected]. to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP contact our offices for a copy of your continuing education credits report. This report, which will list all does not approve or endorse individual courses or instructors, not does it imply acceptance of credit hours credits earned to date, will be generated and mailed to you within five business days of receipt. INSTRUCTIONS by boards of dentistry. All questions should have only one answer. Grading of this examination is done manually. Participants will Completing a single continuing education course does not provide enough information to give the receive confirmation of passing by receipt of a verification form. 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