Oral Manifestation of Systemic

Diseases
Blok Penyakit Sitemik
Drg. Erna Sulistyani, M Kes

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Oral Manifestation of Inflammatory Bowel Disease

Crohn disease
Crohn disease is characterized on pathology by noncaseating granuloma
Oral manifestation : 4 categories
1.
Specific: occur only in association with the bowel disease
and/or show characteristic histology of that condition. In
children with Crohn disease, orofacial Crohn disease can
be an important presentation preceding the bowel
diagnosis
2.
Non-specific : occur more commonly in patient with the
bowel disease than in the general population, but the
pathology is not diagnostic for the bowel disease.

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3. Complications of malabsorption caused

by the bowel inflammation resulting in
deficiencies in vitamins and minerals.
4. Side effects or complications of
medications prescribed to treat the
bowel disease.
The first three of these categories may be
useful in directing the doctor to the bowel
problem and making the specific
diagnosis. The oral changes preceded the
diagnosis of Crohn disease in 60%. There
may be a male predominance.
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1. Orofacial Chrons disease ( spesific)

A cobblestone appearance of the oral
cheek mucosa
Labial and buccal gum swellings with
mucosal tag
Fissuring of the midline of the lip
Aphthous-like ulceration and angular
cheilitis
Enlargement of the attached gums which
are diffuse, red and granular
Severe periodontitis is seen in these
individuals but there is usually a good
response to normal periodontal therapy
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Orofacial Chrons
disease

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2. Nonspecific changes in the mouth and surrounding

facial skin associated with Crohn disease:
Angular Cheilitis
Aphthous Stomatitis has been reported to affect
up to 20-30% of patients with Crohn disease
Recurrent abscesses
Redness and scaling around the lips
Pyostomatitis Vegetans very rare in Crohn disease
Dry mouth
Bad breath (halitosis)
Recurrent vomiting and regurgitation can cause oral

pain and the acid result in dental decay.

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Ulcerative Colitis
Mucosal changes have been reported in some patients
with ulcerative colitis.
1.Specific orofacial changes of ulcerative colitis:
Pyostomatitis vegetans
2.Nonspecific changes of the mouth and surrounding skin
associated with ulcerative colitis:
Minor and major aphthous stoamtitis reported in at least

10%, usually worse with flares of the bowel disease and

improving with treatment of the bowel inflammation.
However this is probably no more common than the
general population.
Glossitis (inflamed tongue)
Cheilitis (inflamed lips)
Bad breath (halitosis)
In children with ulcerative colitis, only nonspecific changes
were seen in one large study.
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b. pyostomatitis
vegetans
redness with multiple
yellow or white
pustules. The pustules
(microabscesses)
easily rupture, to form
superficial ulcers
(erosions) which have
been likened to snail
trails.
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Orofacial signs of malabsorption caused by

inflamatory bowel disease (Chron Disease
and Ulcerative Colitis)
Malabsorption may be due to the chronic
diarrhoea, reduced food intake, overgrowth of
bacteria in the bowel, bowel surgery, the
disease itself, or the drugs used to treat the
bowel disease.
Folic acid deficiency red painful tongue (acute),

becomes shiny and smooth (chronic) (glossitis),

and cheilitis
Iron deficiency atropic glositis, angular cheilitis
Zinc deficiency acrodermatitis redness, scally
skin, oral candidosis, glossitis
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Vitamin A deficiency white patches on oral

mucosa due to keratinization of mucous

membranes
Vitamin B complex deficiency stomatitisglossitis-angular cheilitis
Riboflavin (vitamin B2, Crohn disease as
absorbed from small bowel) cheilosis,
angular cheilitis, glossitis
Niacin (vitamin B3) deficiency

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Acrodermatitis enteropathica

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Vitamin B12 deficiency : glossitis (beefy red tongue

with flat red patches mainly on the sides and top of

the tongue), angular cheilitis, mouth ulcers,
oral candidiasis, diffuse erythematous mucositis,
pale oral mucosa, soreness of the tongue or mouth,
burning mouth, reduced taste sensitivity
Vitamin C deficiency scurvy
Vitamin K deficiency gum bleeding

Orofacial changes due to medications used to

treat inflammatory bowel disease
Many different medications may be used to treat

various aspects of inflammatory bowel diseases

including antibiotics, biologic agents,
immunosuppressants, anti-diarrhoeal agents and for
pain.

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Oral Manifestation of Liver Disease

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Dental Management Of Liver disease

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VASCULAR AND HEART DISEASE

Manifestasi oral spesifik tidak ada. Kebanyakan oleh

karena pengobatan ;

Hipertensi :
Manifestasi oral karena obat anti hipertensi meliputi :

xerostomia, lichenoid reactions, burning mouth

sensation, loss of taste sensation or gingival
hyperplasia, sialadenosis.
Dental management:
selalu cek tekanan darah tiap kunjungan.
Perawatan pada pagi hari dan singkat
Pertimbangan pemberian sedative spt diazepam malam

harisebelumnya dan 1 sd 2 jam sebelum perawatan gigi

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Anastesi: hati2 jgn smp masuk pembuluh darah,

max 2 ampul selebihnya hy boleh anastesi tanpa

vasoconstrictor.
Hati-hati adanya orthostatic hipotensi krn obat.

Ischemic Heart Disease

Oral manifestations : anticoagulant or

antiplatelet treatment, bleeding may occur,

manifesting as hematomas, petechiae or
gingival bleeding.
In dental practice a minimum safety period of
6 months after acute infark myocard has been
established before any oral surgical procedure
can be carried out.
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INR :international normalized ratio(INR)

Vc : vasoconstrictor

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ARRHYTHMIAS
Oral manifestations
Many antiarrhythmic drugs have side effects such as
gingival hyperplasia or xerostomia.
Dental management
Evaluate the current condition of the patient and the type of
arrhythmia involved, as well as the medication prescribed.
If important arrhythmia develops during dental treatment,
the procedure should be suspended, oxygen is to be
provided,and the patient vital signs are to be assessed:
body temperature (normal values: 35.5-37C), pulse (normal
values: 60-100 bpm), respiratory frequency (normal values
in adults: 14-20 cycles or respirations per minute), blood
pressure (normal values: systolic blood pressure under 140
mmHg and diastolic blood pressure under 90 mmHg

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Sublingual nitrites are to be administered in

the event of chest pain. The patient should
be placed in the Trendelenburg position,
The dental team should be prepared for
basic cardiopulmonary resuscitation and
initiation of the emergency procedure for
evacuation to a hospital center, if
necessary.

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HEART FAILURE
Oral manifestations
Due to the drug treatments
ACEIs (captopril, enalapril) can produce lichenoid

reactions, burning mouth sensation and a loss of taste

sensation,
Diuretics (furosemide) can produce xerostomia.
Dental Consideration

Consultation with the supervising physician is

advised in order to know the current condition of
the patient and the medication prescribed. Dental
treatment is to be limited to patients who are in
stable condition, since these individuals are at an
important risk of developing serious arrhythmias and
even sudden death secondary to cardiopulmonary
arrest
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PREVENTION OF ENDOCARDITIS
The most widely accepted endocarditis

prevention protocols are those of the

American Heart Association (AHA) and
the British Society of Antimicrobial
Chemotherapy (BSAC).
Antibiotic prophylaxis for dental
procedures is only indicated in patients
with heart disorders related to a very
high risk of developing endocarditis :
Prosthetic heart valves.
Previous infectious endocarditis .
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Congenital heart disease, only in the

following situations:
o Untreated cyanotic congenital heart

disease, including shunts and ducts.

o Congenital heart defects fully repaired with
material or prostheses placed through
surgery or with catheters, during the first 6
months after the operation.
o Repaired congenital heart disease, though
with residual defects associated to
prosthetic materials
Heart transplant patients who develop

cardiacvalve disease.
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Oral Manifestation ofRespiratory disease

Tuberculosis
Oral lesions are seen in 0.05 to 5% of the patients with TB
Primary forms generally are uncommon and occur in

younger patients with frequently associated caseation of

the draining lymph nodes. usually affects the gingiva and
mucobuccal folds
Secondary lesions are more common and are seen mostly
in older persons.morecommon reflecting oral inoculation
with infected sputum or as a result of hematogenous
spread and involves mainly the tongue and hard palate. [6]
Clinical picture is variable, the typical lesion is an
irregular, superficial, or deep, which tends to increase
slowly in size.
Lesion rarely found on the floor of the mouth, gingiva,
palate, and lips.
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Oral lesions typically consist of a stellate ulcer with

undermined edges with minimal induration and a

granulating floor. Nodules, fissures, tuberculomas,
or granulomas can be found..
.
Skin, cervical lymph nodes, and salivary glands are
also frequently involved.
Lesions may be single or multiple, painful or
painless.
Clinical diagnosis can be difficult because TB can mimic

a variety of other conditions, including malignancy,

HIV, Cicatricial pemphigoid, syphilis, and deep mycotic
infection such as histoplasmosis, Wegener
granulomatosis, and sarcoidosis,
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Primary Oral Manifetation of TB Patient

(female, smoker)

Secondary TB Oral Ulcer in

patient with TB and HIV (+)
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Differential diagnosis :periodontal abscess, syphilitic

ulcer, mycotic ulcer.

Laboratory test :
tuberculin skin test ( positive indicates previous

exposure to the M. Tuberculosis) Mantoux reaction was

scored as positive if the induration was 10 mm in
diameter or 5 mm in BCG-vaccinated subjects, in
patients who had contact with someone with infectious
TB and in those who have a chest X ray with fibrotic
changes consistent with pulmonary TB.
Biopsy for histologic examination,
Ziehl-Neelsen staining with demonstration of acid and
alcohol fast bacilli, and culture should be obtained.

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Dental considerations for the

patient with renal disease
Chronic renal disease (CRD)as a progressive and

irreversible decline in renal function associated with a

reduced glomerular filtration rate (GFR). The most
frequent causes of CRD are diabetes mellitus, arterial
hypertension and glomerulonephritis.
The diminished function of the kidneys results in an
increase in the levels of urea in the blood and also in the
saliva, where it will turn into ammonia
Manifestation: 90 % patient have oral manifestation
Urea in saliva :Halitosis , uremic stomatitis (red mucosa or

ulcer covered by thick exudate or pseudomembrane)

Children low caries activity
Taste disorder, metalic taste
Salivary gland enlarge, hiposalivation,
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Neuropathy :Burning and tenderness

Decrease Imunne system : Candidal

infection, gingival inflamation

Hemostasis disturbances :Prolonged
bleeding, gingival bleesing, petechie,
echymosis
Anemia : Pale mucosa
Urea in saliva : Tooth erosion
Vit D deficiency compensatory with
Hiperparatiroid hormon: enamel hypoplasia,
demineralization of bone, loss of bony
trabeculae, loss of lamina dura, abnormal
bone repair after extraction.

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Dental management :
Dental treatment perform within 24 hours of dyalisis

but consider the presense of heparin(half life 4-6 hr)

Be ware of shunt :avoid the arm with shunt form
blood pressure reading
Protection from HIV /hepatitis because od dyalisis.
Monitor blood pressure before at and after dental
treatment
Anemia and hemorahgia
Osteodystrophy : pathologic or iatrogenic fracture
during dental treatment
Medication : consult with Physician. Be aware of
adverse or synergistic effects.
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Infection : no establish guideline

Nystatin mouth wash 500.0000 units/ml 4 times a

day
Culture for antibioyic sensitivity

Antibiotic prophylaxis
Transplant patient : immunosupressive drug : increase risk
of infection
Steroid Therapy : anticipate hypoadrenal crisis
HAVE FUN

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