Oral Manifestations of Systemic Diseases in Older Patients

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Oral Manifestations of Systemic Diseases in
Older Patients

• Ali R. Rahimi, MD, FACP, AGSF

RTR Medical Group, Savannah, GA
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Objectives

• Review pertinent oropharangeal structure and
  function.
• Examine the relationships between oral symptoms
  and systemic conditions.
• Discuss clinical decisions pertaining to the
  topic.

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Background

• The mouth (buccal cavity) is the reservoir for
  the chewing and mixing of food with saliva. It
  is the primary site of digestion and respiration
  as well as the primary communication structure.

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Background

• Drug Reactions
• Fungal infections
• Viral infections
• Leukemia
• Behcets Disease
• Diabetes Mellitus
• Nutritional Deficiencies
• Amyloidosis

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Background Definitions

• Gingivitis-inflammation of the gums
• Xerostomia-abnormal dryness of the mouth due to
  insufficient secretions
• Mucositis-inflammation of a mucous membrane
• Stomatitis-inflammation of the mouth having
  various causes (as mechanical trauma, allergy,
  vitamin deficiency, or infection)
• Cheilitis-inflammation of the lip
• Glossitis-inflammation of the tongue

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Drug Reactions- SJS and TEN

• Stevens-Johnson syndrome and toxic epidermal
  necrolysis are rare, life-threatening, drug
  induced reactions.
• 7 to 21 days after exposure purpuric and
  erythematous macules evolve to skin necrosis and
  epidermal detachment.
• Oral mucous membrane involvement occurs in up to
  50 of cases and may impair ingestion of
  nutrition.
• Most commonly implicated in these reactions are
  sulfonamides, penicillins, phenytoin, and
  phylbutazone.

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Drug Reactions

• Drug-induced neutropenia is typically
  characterized by circular reddish ulcer on the
  gingivae or areas of frequent trauma.
• Gingivitis and oral ulcers often occur with
  chronic neutropenia also.
• Discontinuation of the inducing drug usually
  results in resolution.

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Drug Reactions

• Radiation, immunosuppressant and
  chemotherapeutic medications are the major
  treatments associated with stomatitis. Allergic
  reactions to materials or certain metalloids may
  also contribute.

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Fungal Infections

• Thrush
• Candida albicans infection is most commonly found
  in children. The infection is characterized by
  white plaques or spots in the mouth that lead to
  ulcers or painful cracking at the corners of the
  mouth.
• The patient may experience dysphagia or
  odynophagia as the first symptoms.
• Candidiasis therefore is a common indicator of
  impaired immune function whether as in HIV or for
  other reasons.
• Treatment includes topical nystatin or oral
  fluconazole as indicated by site or causative
  organism of infection.

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Fungal Infections
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Viral Infections- Herpes

• The herpes simplex viruses are categorized as
  type 1(oral) and type 2 (genitoanal).
• The presentation of cold sores around the mouth
  is usual but the viruses can occur any place in
  the body that has broken skin or mucosal
  surfaces.
• As high as 75 of adults will contract oral
  herpes by the time they reach their 40s.
• Oral antivirals and pain medications are
  recommended for treatment of overly painful
  expressions of this condition.

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Viral Infections-Herpes
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Viral Infections-HIV

• As previously discussed, often oral candidiasis
  is the initial symptom with which HIV patients
  present.
• However, hairy leukoplakia, named for its
  corrugated appearance, is also seen as white
  lesions or plaques in the oral cavity. The
  epithelium is thickened, appears white, but is
  generally asymptomatic.
• Treatment may be complicated by comorbidites and
  these should be considered when determining a
  treatment regimen with antivirals.

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Viral Infections-HIV
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Leukemia

• Infections, bruising, or hemorrhage of the oral
  cavity may be caused by thrombocytopenia or
  leukopenia.
• Rarely, diffuse non-tender gingival enlargment,
  overall pallor of tissues due to anemia or
  ulcerative gingivitis may be exhibited.

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Behcets Disease

• Behcets disease is a rare disorder mainly
  affecting young men.
• While the disease affects multiple organ systems,
  oral ulcerations reselmbling canker sores present
  in 99 of patients.
• The oral lesions are the herald of this disease
  and are usually 6mm or smaller and resolve within
  1-3 weeks.
• Treatment is symptomatic and supportive.
  Medication may be prescribed to reduce
  inflammation and/or regulate the immune system.
  Immunosuppressive therapy may be considered.

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Behcets Disease
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Sjögrens Syndrome

• Sjögrens syndrome is the 2nd most common
  autoimmune disease with women in their mid-60s
  being the primarily afflicted.
• Initial symptoms include dry eyes and dry mouth
  due to gradual glandular dysfunction.
• In some cases, dysphagia, increased dental
  caries, increased susceptibility to oral
  candidiasis, and difficulty wearing dental
  prostheses will develop.
• Treatment is generally symptomatic and
  supportive. Moisture replacement therapies may
  ease the symptoms of dryness. Nonsteroidal
  anti-inflammatory drugs may be used to treat
  musculoskeletal symptoms. Corticosteroids or
  immunosuppressive drugs may be considered in
  severe cases.

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Sjögrens Syndrome
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Diabetes Mellitus

• Increased glucose in the patients system implies
  hyperglycemia also in saliva.
• Bacteria find this environment more conducive and
  therefore these patients are more prone to dental
  caries, gingivitis, and periodontal disease.

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Amyloidosis

• Disorder characterized by deposition of insoluble
  proteins in organs that eventually causes
  dysfunction of the organ.
• This condition may present as swollen
  erythematous buccal area if the mucous membranes
  in that area are involved in the disease process.

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Nutritional Deficiencies

• Iron deficiency anemia is the most common cause
  of anemia in older patients and may manifest as
  smoothing, reddening or soreness of the tongue.
• Iron deficiency limits erythropoesis and
  therefore brings about a hypoproliferative
  anemia.
• In older patients anemia associated with chronic
  inflammation is common. Nutritional iron
  deficiency is rare in older adults.

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Nutritional Deficiencies

• Pernicious anemia affects over 2 of the
  population over 60.
• This disorder is clinically characterized by
  megaloblastic hematopoesis and/or neuropathies.
• Oral manifestation possibilities are glossitis
  (beefy red tongue) or stomatitis (generalized
  burning or soreness).
• Treatment with intramuscular or oral Vitamin B12
  should follow diagnosis.

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Nutritional Deficiencies Pernicious Anemia
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Nutritional Deficiencies

• Thiamine (Vitamin B1) and Niacin/nicotinic acid
  (Vitamin B3) are also reported to cause some
  glossitis and cheilitis.
• Folate deficiency leads to a megaloblastic anemia
  that demonstrates many of the same oral
  characteristics of pernicious anemia.
• Cheilitis, glossitis, and mucosal erosions have
  been described.

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Nutritional Deficiencies

• Scurvy caused by vitamin C deprivation may cause
  petechiae to ecchymoses in the submucosa.
• Mucous membrane changes may lead to gingival
  hypertrophy and erosive, bleeding gums.
• Teeth may subsequently become soft associated
  with gingival infection predisposition.
• Replenishment of Vitamin C may prevent further
  degradation of dental integrity.

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Conclusions

• The mucosal surface that is the oral cavity may
  provide insight into the immune function of the
  patient.
• Differential diagnosis is important as many
  disorders may manifest themselves similarly in
  the buccal area.

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References

• Greenspan, JS. "Sentinelsand Signposts the
  Epidemiology and Significance of the Oral
  Manifestations of HIV disease." Oral Diseases May
  1997 S13-17.
• McCance, Kathryn L., and Sue E. Huether.
  Pathophysiology The Biologiv Basis for Disease in
  Adults and Children. 4th ed. St. Louis Mosby,
  2002
• Bologna, Jean L., Joseph L. Jorizzo, and Ronald
  P. Rapini. Dermatology. Spain Mosby, 2003.
• Edwards, Brooks S. Amyloidosis. 2 Aug. 2005. Mayo
  Clinic. 26 Dec. 2005 alth/amyloidosis/DS00431.

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References

• "NINDS Sjogren's Syndrome Information Page."
  National Institute of Neurological Disorders and
  Stroke. 11 Dec. 2005 orders/sjogrens/sjogrens.htm.
• "NINDS Behcet's Disease Information Page."
  National Institute of Neurological Disorders and
  Stroke. 11 Dec. 2005 orders/behcet/behcet.htm.
• Cobbs, Elizabeth L., Edmund H. Duthie, Jr, and
  John B. Murphy. Geriatrics Review Syllabus. 4th
  ed. Dubuque Kendall/Hunt Publishing Company,
  1999.

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Questions

• Many conditions may cause oral discomfort. In an
  older patient with normal immune function, what
  are parts of the work up are the first
  priorities?
• Describe the possible etiologies of oral
  ulcerations that are whitish in color.
• What is the treatment protocol for a patient that
  manifests epidermal irritation following
  initiation of a new regimen? What are the most
  common causes of this reaction?

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Questions

• What work up would help determine the correct
  cause of iron deficiency anemia?
• Replenishment of cyanocobalamine is accomplished
  by more than one route. Describe the appropriate
  regimens and the attributes and detriments of
  each.
• Autoimmune diseases often appear with
  accompanying conditions. Patients that suffer
  Sjodgrens disease often also present with what
  other diseases?
• What group of commonly used medications are
  associated with gingival hyperplasia/dysfunction?

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Questions

• What is the etiology of the majority of
  genitoanal herpes cases? How is this different
  from the etiology of oral herpes found in the
  elderly population?
• A new patient reports with general malaise and
  oral irritation. She is elderly and has many
  comorbidities. What should the workup include?
  What are the possibilities for differential
  diagnoses?
• The patient described in the previous question is
  found to have low Hgb and Hct levels. Her
  transferrin level is within normal limits. What
  other lab(s) should be checked before a diagnosis
  of anemia of chronic disease is made?