Oral Manifestations of Systemic Diseases

Oral Manifestations ofOral Manifestations of
Systemic DiseasesSystemic Diseases
Dr.Ramesh Parajuli MS(Otorhinolaryngology,Head and Neck surgery)Dr.Ramesh Parajuli MS(Otorhinolaryngology,Head and Neck surgery)
Chitwan Medical College Teaching Hospital, Bharatpur-10, Chitwan, NepalChitwan Medical College Teaching Hospital, Bharatpur-10, Chitwan, Nepal

 Oral cavity- window to the bodyOral cavity- window to the body
 Lesions of oral mucosa, tongue,Lesions of oral mucosa, tongue,
gingiva, dentition, periodontium,gingiva, dentition, periodontium,
salivary gland, facial skeleton, &salivary gland, facial skeleton, &
extraoral skinextraoral skin
 Appropriate diagnosis &Appropriate diagnosis &
treatmenttreatment

ClassificationClassification
1.Systemic Infectious diseases1.Systemic Infectious diseases
2.Connective tissue disorders2.Connective tissue disorders
3.Granulomatous diseases3.Granulomatous diseases
4.Gastrointestinal diseases4.Gastrointestinal diseases
5.Respiratory diseases5.Respiratory diseases
6.Haematological diseases6.Haematological diseases
7.Endocrine diseases7.Endocrine diseases
8.Neurologic diseases8.Neurologic diseases
9.Nutritional deficiency9.Nutritional deficiency
10.Immunodeficiency diseases10.Immunodeficiency diseases
11.Drug reactions/radiotherapy11.Drug reactions/radiotherapy
12.Dermatological diseases12.Dermatological diseases
13.Metabolic disorders13.Metabolic disorders
14.Neoplastic diseases14.Neoplastic diseases

Infective diseasesInfective diseases
1.Viral infection1.Viral infection
2.Bacterial infection2.Bacterial infection
3.Fungal infection3.Fungal infection
4.Protozoal infection4.Protozoal infection

Viral infectionsViral infections
1.Herpes Simplex Stomatitis1.Herpes Simplex Stomatitis
2.Herpes Zoster2.Herpes Zoster
3.Herpangina3.Herpangina
4.Hand Foot Mouth Disease4.Hand Foot Mouth Disease
5.Cytomegalovirus Infection5.Cytomegalovirus Infection
6.Measles6.Measles
7.Infectious Mononucleosis7.Infectious Mononucleosis
8.Mumps8.Mumps
9.HIV9.HIV

Herpes Simplex StomatitisHerpes Simplex Stomatitis
 HSV-1HSV-1:: Primary herpetic GingivostomatitisPrimary herpetic Gingivostomatitis
Recurrent herpes labialisRecurrent herpes labialis
 HSV-2HSV-2::
 Primary herpetic Gingivostomatitis:Primary herpetic Gingivostomatitis:
-most frequent cause of acute stomatitis in-most frequent cause of acute stomatitis in
childrenchildren
-varies in severity, many infections-varies in severity, many infections
-subclinical-subclinical
-misdiagnosed as “teething”-misdiagnosed as “teething”
-malaise, anorexia, irritability, fever,-malaise, anorexia, irritability, fever,
anterior cervical lymphadenopathy, diffuse,anterior cervical lymphadenopathy, diffuse,
purple, boggy gingivitispurple, boggy gingivitis
-multiple vesicles-multiple vesicles scarred ulcers(1-3mm)scarred ulcers(1-3mm)
-occasionally in adults-occasionally in adults

 Diagnosis:Diagnosis:
-clinically-clinically
-scrapping or smears from the lesion-scrapping or smears from the lesion
-immunofluorescent staining-immunofluorescent staining
-exfoliative cytology- typical-exfoliative cytology- typical
multinucleated giant cellsmultinucleated giant cells
 Treatment:Treatment:
-symptomatic-symptomatic
-acyclovir (systemic)-severe cases-acyclovir (systemic)-severe cases

 Recurrent Intraoral Herpes Simplex InfectionRecurrent Intraoral Herpes Simplex Infection::
-may affect healthy individual-may affect healthy individual
-persistent lesions in immunocompromised-persistent lesions in immunocompromised
--chronic ulcer, raised, white borderchronic ulcer, raised, white border
-esp. at sites of trauma-esp. at sites of trauma
-acyclovir-acyclovir

Herpes zoster (Shingles)Herpes zoster (Shingles)
 Reactivation of Varicella –Zoster virusReactivation of Varicella –Zoster virus
 Predisposing factor:Predisposing factor:
Immunocompromised statusImmunocompromised status
 One dermatome affected (trigeminalOne dermatome affected (trigeminal
nerve)nerve)
 UnilateralUnilateral
 Ulcers in the distribution of dermatomeUlcers in the distribution of dermatome
 Mandibular nerve: ulceration of one sideMandibular nerve: ulceration of one side
of tongue, floor of the mouth, lower labialof tongue, floor of the mouth, lower labial
& buccal mucosa& buccal mucosa
 Maxillary nerve: one side of palate, theMaxillary nerve: one side of palate, the
upper gingiva, buccal sulcusupper gingiva, buccal sulcus
 Lesions persists for 2-3 wksLesions persists for 2-3 wks
Lesions on lips and chin

 Herpes Zoster Oticus (RamsayHerpes Zoster Oticus (Ramsay
Hunt Syndrome)Hunt Syndrome)
 Ophthalmic Herpes ZosterOphthalmic Herpes Zoster
 Post Herpetic NeuralgiaPost Herpetic Neuralgia
 DiagnosisDiagnosis: clinically: clinically
 TreatmentTreatment::
-Analgesics-Analgesics
-Antivirals(within 72 hrs of onset of-Antivirals(within 72 hrs of onset of
the lesions):acyclovir, famciclovir,the lesions):acyclovir, famciclovir,
valacyclovir, & gabapentinvalacyclovir, & gabapentin

HerpanginaHerpangina
 Common in childrenCommon in children
 Coxsackie virus group A,Coxsackie virus group A,
Enteroviruses(30 & 71)Enteroviruses(30 & 71)
 Self limiting vesicular eruptions inSelf limiting vesicular eruptions in
the oropharynx eg. soft palate,the oropharynx eg. soft palate,
uvula, tonsillar pillars, posterioruvula, tonsillar pillars, posterior
pharyngeal wallpharyngeal wall
 Similar to herpes simplex exceptSimilar to herpes simplex except
the lesions more commonly inthe lesions more commonly in
oropharynx rather than oral cavityoropharynx rather than oral cavity
 Diagnosis:Diagnosis: ClinicallyClinically
 Treatment:Treatment: SupportiveSupportive

Hand, Foot and Mouth DiseaseHand, Foot and Mouth Disease
 Enterovirus 71,Coxsackie viruses,Enterovirus 71,Coxsackie viruses,
some untypeable enterovirusessome untypeable enteroviruses
 Young childrenYoung children
 Vesicular eruption in the oral cavity &Vesicular eruption in the oral cavity &
oropharynxoropharynx dysphagia, dehydrationdysphagia, dehydration
 Vesicles on the hands & feetVesicles on the hands & feet
 Pyrexia, malaise, vomitingPyrexia, malaise, vomiting
 Short lived(5-8 days)Short lived(5-8 days)
 Diagnosis:Diagnosis: clinicallyclinically
 Treatment:Treatment: supportivesupportive

Infectious MononucleosisInfectious Mononucleosis
 Acute, self limiting, systemic viralAcute, self limiting, systemic viral
infectioninfection
 Epstein-Barr VirusEpstein-Barr Virus
 Typical presentation: acute soreTypical presentation: acute sore
throat & tender cervicalthroat & tender cervical
lymphadenopathylymphadenopathy
 Glandular diseaseGlandular disease
 Kissing diseaseKissing disease
 Children & young adultsChildren & young adults
 Prodromal symptoms:Prodromal symptoms:
4-5 days, anorexia, malaise,4-5 days, anorexia, malaise,
fatigue, headachefatigue, headache

 Clinical features:-Clinical features:-
Oral manifestationsOral manifestations - early and common- palatal- early and common- palatal
petechiae, uvular edema, tonsillar exudate, gingivitis,petechiae, uvular edema, tonsillar exudate, gingivitis,
& rarely ulcers& rarely ulcers
-Generalized lymphadenopathy, hepatosplenomegaly,-Generalized lymphadenopathy, hepatosplenomegaly,
maculopapular skin rashmaculopapular skin rash
 Laboratory testsLaboratory tests::
Heterophile antibody(Paul Bunnel test, Monospot test)Heterophile antibody(Paul Bunnel test, Monospot test)
-Mild to moderate cases: Symptomatic-Mild to moderate cases: Symptomatic
-Severe disease: Famciclovir-Severe disease: Famciclovir
 Anti-EBV compounds: MaribavirAnti-EBV compounds: Maribavir
 Ampicillin based antibiotics should be avoidedAmpicillin based antibiotics should be avoided

Cytomegalovirus InfectionCytomegalovirus Infection
 Relatively rareRelatively rare
 Cytomegalovirus (CMV)Cytomegalovirus (CMV)
 HIV infection and immunocompromisedHIV infection and immunocompromised
 Clinical features:Clinical features: asymptomaticasymptomatic
Oral lesionsOral lesions -nonspecific painful-nonspecific painful
ulcerations- gingiva & tongueulcerations- gingiva & tongue
-Enlargement of parotid &-Enlargement of parotid &
submandibular glands, dry mouth,submandibular glands, dry mouth,
fever, malaise, myalgia, headachefever, malaise, myalgia, headache
 Laboratory tests:Laboratory tests:
HPE/ImmunochemistryHPE/Immunochemistry
-Resolve spontaneously-Resolve spontaneously
-Ganciclovir (Persistent case)-Ganciclovir (Persistent case)

Measles (Rubeola)Measles (Rubeola)
 ParamyxovirusParamyxovirus
 Highly contagiousHighly contagious
 Coryza, conjunctivitis & generalisedCoryza, conjunctivitis & generalised
cutaneous erythematous rashescutaneous erythematous rashes
 Oral cavity lesions:Oral cavity lesions: PharyngotonsillitisPharyngotonsillitis
Koplik’s spot:Koplik’s spot: small, spotty,small, spotty,
exanthematous lesions on buccalexanthematous lesions on buccal
mucosamucosa
 Vaccination programVaccination program

MumpsMumps
 Common viral illnessCommon viral illness
 Incubation period: 2-3 weeksIncubation period: 2-3 weeks
 Fever, malaise, myalgia, headache, &Fever, malaise, myalgia, headache, &
painful parotid gland swellingpainful parotid gland swelling
 Self limitingSelf limiting
 Complications: SNHLComplications: SNHL
 Diagnosis:Diagnosis: ClinicalClinical
 Treatment:Treatment: SupportiveSupportive

Bacterial InfectionsBacterial Infections
1.1. TuberculosisTuberculosis
2.2. SyphilisSyphilis
3.3. LeprosyLeprosy

TuberculosisTuberculosis
 Chronic, granulomatous, infectiousChronic, granulomatous, infectious
diseasedisease
 Mycobacterium tuberculosisMycobacterium tuberculosis
 Clinical featuresClinical features:: Oral lesions – rareOral lesions – rare
secondary tosecondary to pulmonary tuberculosispulmonary tuberculosis
 Pharynx- not commonPharynx- not common
Primary infection (Tonsils, Adenoids)Primary infection (Tonsils, Adenoids)
Secondary to coughing heavily ofSecondary to coughing heavily of
infected sputuminfected sputum
 UlcerUlcer: multiple, painful, irregular,: multiple, painful, irregular,
undermined borderundermined border, granulating floor,, granulating floor,
usually covered by a gray-yellowishusually covered by a gray-yellowish
exudate, inflamed & induratedexudate, inflamed & indurated
surrounding tissuesurrounding tissue

 Dorsum of the tongue - most commonlyDorsum of the tongue - most commonly
affected- lip, buccal mucosa, & palateaffected- lip, buccal mucosa, & palate
 TB Esophagitis:TB Esophagitis:
-swallowed sputum or direct spread from-swallowed sputum or direct spread from
adjacent lymph nodesadjacent lymph nodes
-stricture, fistula, mucosal irregularities-stricture, fistula, mucosal irregularities
 Granulomatous Cheilitis-Granulomatous Cheilitis- rarerare
 Laboratory tests:Laboratory tests: Sputum culture, HPE,Sputum culture, HPE,
CXRCXR
 Treatment:Treatment: ATTATT

SyphilisSyphilis
 Treponema pallidumTreponema pallidum
-Acquired-Acquired
-Congenital-Congenital
1.1. Primary SyphilisPrimary Syphilis
2.2. Secondary SyphilisSecondary Syphilis
3.3. Tertiary SyphilisTertiary Syphilis

Primary SyphilisPrimary Syphilis
 Lips, tongue, buccal mucosa, & tonsilsLips, tongue, buccal mucosa, & tonsils
 Site of inoculation- 3 weeks after theSite of inoculation- 3 weeks after the
infection, Papule, breaks down to forminfection, Papule, breaks down to form
an ulcer (chancre)an ulcer (chancre)
 Oral chancre:Oral chancre: painless ulcer with apainless ulcer with a
smooth surface, raised borders, &smooth surface, raised borders, &
indurated marginindurated margin
 Non tender cervical lymphadenopathyNon tender cervical lymphadenopathy
 Spontaneous healingSpontaneous healing

Secondary SyphilisSecondary Syphilis
 Most infectiousMost infectious
 Secondary stage – after 6–8Secondary stage – after 6–8
weeks & lasts for 2-10 weeksweeks & lasts for 2-10 weeks
 Clinical features:Clinical features:
Malaise, low-grade fever,Malaise, low-grade fever,
headache, lacrimation,headache, lacrimation,
sore throat, weight loss,sore throat, weight loss,
myalgia,arthralgia, &myalgia,arthralgia, &
generalized lymphadenopathygeneralized lymphadenopathy
Mucous patches

 Hyperemia and inflammation ofHyperemia and inflammation of
pharynx & soft palatepharynx & soft palate
 Snail Track ulcer :-Snail Track ulcer :-
-Oral cavity & oropharnyx-Oral cavity & oropharnyx
-Ulcerated lesion covered with-Ulcerated lesion covered with
grayish white membranegrayish white membrane
which when scraped has pink basewhich when scraped has pink base
with no bleedingwith no bleeding

Syphilitic PharyngitisSyphilitic Pharyngitis
 May be congenital or acquired byMay be congenital or acquired by
sexual intercoursesexual intercourse
 Secondary stage most likelySecondary stage most likely
 HIV positive patientsHIV positive patients

Tertiary SyphilisTertiary Syphilis
 Tertiary syphilis - after a period of 4–7 yearsTertiary syphilis - after a period of 4–7 years
 Typically painlessTypically painless
 No lymphadenopathy unless secondaryNo lymphadenopathy unless secondary
infectioninfection
 Gumma:Gumma:
-Characteristic lesion-Characteristic lesion
-Hard palate, Nasal septum, Tonsil, PPW, or-Hard palate, Nasal septum, Tonsil, PPW, or
LarynxLarynx
 VDRL may be negativeVDRL may be negative

Congenital SyphilisCongenital Syphilis
Early:Early:
first 3 months of life, manifest asfirst 3 months of life, manifest as
snufflessnuffles nasal discharge purulentnasal discharge purulent
Late:Late:
Manifest at pubertyManifest at puberty
Gummatous lesionGummatous lesion
 Oral lesions:Oral lesions: high-arched palate,high-arched palate,
short mandible, Hutchinson’s teeth,short mandible, Hutchinson’s teeth,
and Moon’s or mulberry molarsand Moon’s or mulberry molars

Diagnosis:Diagnosis:
1.Immunoflurorescence or dark field microscopy1.Immunoflurorescence or dark field microscopy
2. Biopsy2. Biopsy
3.Serology3.Serology
Non-treponemal antibody testsNon-treponemal antibody tests::
-VDRL, RPR-VDRL, RPR
-For screening and treatment follow up-For screening and treatment follow up
Treponema specific antibody tests:Treponema specific antibody tests:
-FTA-ABS test, TPHA-FTA-ABS test, TPHA
-For confirmation-For confirmation
-Usually remains positive for life-Usually remains positive for life
Treatment:Treatment: Penicillin( DOC)Penicillin( DOC)
Ceftriaxone, Erythromycin, or DoxycyclineCeftriaxone, Erythromycin, or Doxycycline

LeprosyLeprosy
 Mycobacterium LepraeMycobacterium Leprae
 Optimum temperature growth-less thanOptimum temperature growth-less than
body tempbody temp preference for skin, mucosa &preference for skin, mucosa &
superficial nervesuperficial nerve
 Transmission- nasal dischargeTransmission- nasal discharge
 Both Humoral & cellular immune responseBoth Humoral & cellular immune response
 Clinically- Chronic granulomatousClinically- Chronic granulomatous
diseasedisease skin, peripheral nerve & nasalskin, peripheral nerve & nasal
mucosamucosa

 Nasopharynx to oropharynx:Nasopharynx to oropharynx:
Granulomatous lesion, ulcers, healingGranulomatous lesion, ulcers, healing
with fibrosiswith fibrosis
 Larynx:Larynx:
-Lesion like TB & Syphilis-Lesion like TB & Syphilis
-Supraglottic- mainly epiglottis,-Supraglottic- mainly epiglottis,
aryepiglottic foldsaryepiglottic folds
-Epiglottis : hollow rod, mucosa studded-Epiglottis : hollow rod, mucosa studded
with tiny nodules- laryngeal stenosis &with tiny nodules- laryngeal stenosis &
airway obstructionairway obstruction
Punch biopsy, nasal scrapings (skinPunch biopsy, nasal scrapings (skin
lesions & ear lobules)lesions & ear lobules)
Treatment:Treatment: Dapsone, Rifampicin &/orDapsone, Rifampicin &/or
ClofazimineClofazimine

Protozoal infectionProtozoal infection
1.1. ToxoplasmosisToxoplasmosis
2.2. LeshmaniasisLeshmaniasis

ToxoplasmosisToxoplasmosis
 Toxoplasm gondiiToxoplasm gondii
 ZoonosisZoonosis
 Self limitingSelf limiting
 Immunocompetent: asymptomaticImmunocompetent: asymptomatic
 Immunocompromised:Immunocompromised:
sore throat, malaise, fever, cervicalsore throat, malaise, fever, cervical
lymphadenopathylymphadenopathy
Multiple organs involvementMultiple organs involvement
(lungs, liver, skin, spleen, myocardium,(lungs, liver, skin, spleen, myocardium,
eyes, skeletal muscles, braineyes, skeletal muscles, brain

 Transplacental infection:Transplacental infection:
about 45 %about 45 %
subclinical infection- intrauterine deathsubclinical infection- intrauterine death
 DiagnosisDiagnosis:: serologicalserological
-usually unnecessary-usually unnecessary
-combination of pyrimethamine &-combination of pyrimethamine &
sulphadiazinesulphadiazine

Fungal infectionFungal infection
1.1. CandidiasisCandidiasis
2.2. HistoplasmosisHistoplasmosis
3.3. CryptococcosisCryptococcosis
4.4. AspergillosisAspergillosis
5.5. MucormycosisMucormycosis
6.6. ParacoccidomycosisParacoccidomycosis
7.7. BlastomycosisBlastomycosis

Systemic MycosesSystemic Mycoses
 Chronic fungal infectionsChronic fungal infections
 Histoplasmosis (Histoplasmosis (HistoplasmaHistoplasma
capsulatum)capsulatum)
 Blastomycosis (BlastomycesBlastomycosis (Blastomyces
dermatitidis)dermatitidis)
 Cryptococcosis (CryptococcusCryptococcosis (Cryptococcus
neoformans)neoformans)
 ParacoccidioidomycosisParacoccidioidomycosis((ParacoccidioidParacoccidioid
es brasiliensis)es brasiliensis)
 Aspergillosis (Aspergillus species)Aspergillosis (Aspergillus species)
 Mucormycosis (Mucormycosis (Mucor, Rhizopus)Mucor, Rhizopus)

 PredisposingPredisposing conditionsconditions::
-Immunocompromised status-Immunocompromised status
eg. HIV infectioneg. HIV infection
 Oral lesions – rareOral lesions – rare
 chronic, irregularchronic, irregular ulcerulcer
 Candidiasis rarely produces ulcersCandidiasis rarely produces ulcers
 Deep mycosis: chronic lumps &Deep mycosis: chronic lumps &
ulcersulcers

 Rhinocerebral Mucormycosis:Rhinocerebral Mucormycosis:
-typically commences in the-typically commences in the
nasal cavity or paranasalnasal cavity or paranasal
sinusessinuses invade the palateinvade the palate
(black necrotic ulceration)(black necrotic ulceration)
 Laboratory tests:Laboratory tests: Smear andSmear and
histopathological examinationhistopathological examination
 Treatment:Treatment: Amphotericin B,Amphotericin B,
Itraconazole, Ketoconazole, &Itraconazole, Ketoconazole, &
FluconazoleFluconazole

Collagen-Vascular & Granulomatous DisordersCollagen-Vascular & Granulomatous Disorders
1.1. Sjogren’s SyndromeSjogren’s Syndrome
2.2. Systemic Lupus Erythematous (SLE)Systemic Lupus Erythematous (SLE)
3.3. SclerodermaScleroderma
4.4. Dermatomyositis-PolymyositisDermatomyositis-Polymyositis
5.5. SarcoidosisSarcoidosis
6.6. Wegner’s GranulomatosisWegner’s Granulomatosis
7.7. Behcet’s SyndromeBehcet’s Syndrome
8.8. Reiter’s SyndromeReiter’s Syndrome
9.9. Sweet SyndromeSweet Syndrome
10.10. Cogan’s SyndromeCogan’s Syndrome
11.11. AmyloidosisAmyloidosis
12.12. Kawasaki DiseaseKawasaki Disease
13.13. Rheumatoid Arthritis (RA)Rheumatoid Arthritis (RA)
14.14. Polyarteritis Nodusa (PAN)Polyarteritis Nodusa (PAN)
15.15. Sturge- Weber SyndromeSturge- Weber Syndrome
16.16. Ehlers-Danlos SyndromeEhlers-Danlos Syndrome
17.17. Cowden’s DiseaseCowden’s Disease

Sjogren’s SyndromeSjogren’s Syndrome
 AutoimmuneAutoimmune
 FemaleFemale
 Primary Sjogren’s Syndrome:Primary Sjogren’s Syndrome:
 Secondary Sjogren’s SyndromeSecondary Sjogren’s Syndrome::
associated with RA, SLE, Scleroderma,associated with RA, SLE, Scleroderma,
Polymyositis, Polyarteritis NodusaPolymyositis, Polyarteritis Nodusa
 Presents with xerostomia & parotidPresents with xerostomia & parotid
enlargementenlargement
 Oral findings:Oral findings:
-Due to decreased saliva-Due to decreased salivadysphagia,dysphagia,
disturbances in taste & speech, burningdisturbances in taste & speech, burning
pain of mouth & tongue, increasedpain of mouth & tongue, increased
dental caries, increased predispositiondental caries, increased predisposition
to infection (candidiasis)to infection (candidiasis)

 Mucosal changes: dry, red & wrinkledMucosal changes: dry, red & wrinkled
mucosamucosa
 Fissured tongue, atrophy of tongueFissured tongue, atrophy of tongue
papillae and redness of tongue, crackedpapillae and redness of tongue, cracked
& ulcerated lips& ulcerated lips
-Minor salivary gland biopsy (mucosa of-Minor salivary gland biopsy (mucosa of
lower lip)lower lip)
-Periductal lymphocytic infiltrate-Periductal lymphocytic infiltrate
-Serum: Autoantibodies (ANA, antilacrimal-Serum: Autoantibodies (ANA, antilacrimal
& antithyroid antibodies, RA factor)& antithyroid antibodies, RA factor)
Treatment :Treatment :
-Steroid & immunossuppresive drugs-Steroid & immunossuppresive drugs
-Artificial saliva-Artificial saliva
-Constant dental evaluation-Constant dental evaluation

Systemic Lupus Erythematosus(SLE)Systemic Lupus Erythematosus(SLE)
 Approx. one quarter of SLEApprox. one quarter of SLEoraloral
lesionslesions
 Oral lesions: superficial ulcersOral lesions: superficial ulcers
with surrounding erythemawith surrounding erythema
 Lips & all oral mucosal surfacesLips & all oral mucosal surfaces
 Periodontal diseases, xerostomiaPeriodontal diseases, xerostomia

SclerodermaScleroderma
 Deposition of collagen in the tissuesDeposition of collagen in the tissues
or around nerves & vesselsor around nerves & vessels
 Difficulty in opening mouth(due toDifficulty in opening mouth(due to
fibrosis of masticatory muscles),fibrosis of masticatory muscles),
immobility of tongue, dysphagia,immobility of tongue, dysphagia,
xerostomiaxerostomia
 Telangiectasia: lips, oral mucosaTelangiectasia: lips, oral mucosa
 Association with Sjogren’s SyndromeAssociation with Sjogren’s Syndrome
& CREST Syndrome(Calcinosis,& CREST Syndrome(Calcinosis,
Raynaud’s phenomena, EsophagealRaynaud’s phenomena, Esophageal
hypomotility, & Sclerodactly)hypomotility, & Sclerodactly)

Kawasaki diseaseKawasaki disease
 Mucocutaneous lymph node syndromeMucocutaneous lymph node syndrome
 Vasculitis- medium & large arteriesVasculitis- medium & large arteries
 Children <5 yrs of ageChildren <5 yrs of age
 High grade feverHigh grade fever
 Cardiovascular complicationsCardiovascular complications
 Oral findings:Oral findings: swelling of papillae on theswelling of papillae on the
surface of tongue(strawberry tongue),surface of tongue(strawberry tongue),
erythema of the buccal mucosa & lipserythema of the buccal mucosa & lips
Lips are cracked, cherry red, swollen &Lips are cracked, cherry red, swollen &
hemorrhagichemorrhagic

Laboratory tests:Laboratory tests: polymorphonuclear leukocytosis,polymorphonuclear leukocytosis,
thrombocytosis, raised ESR & CRPthrombocytosis, raised ESR & CRP
Diagnosis:Diagnosis: 4 out of 6 clinical features with evidence of4 out of 6 clinical features with evidence of
coronary dilatationcoronary dilatation
1.Fever persisting>5 days1.Fever persisting>5 days
2.Bilateral conjunctival congestion2.Bilateral conjunctival congestion
3.Erythema of lips, buccal mucosa & tongue3.Erythema of lips, buccal mucosa & tongue
4.Acute non-purulent cervical lymphadenopathy4.Acute non-purulent cervical lymphadenopathy
5.Polymorphous exanthema5.Polymorphous exanthema
6.Erythema of palms & soles (edema6.Erythema of palms & soles (edemadesquamation)desquamation)
Treatment:Treatment: Aspirin, IVIgAspirin, IVIg
Steroid avoided- risk of worsening coronary arterySteroid avoided- risk of worsening coronary artery
dilatationdilatation

Dermatomyositis-PolymyositisDermatomyositis-Polymyositis
 Immunologic disease muscleImmunologic disease muscle
 Tongue & the upper portion of theTongue & the upper portion of the
esophagusesophagus
-Difficulty in phonation, chewing &-Difficulty in phonation, chewing &
deglutitiondeglutition
-Stomatitis-Stomatitis
 Difficulty in swallowingDifficulty in swallowingaspirationaspiration
pneumoniapneumonia
 Xerostomia & salivary hypofunctionXerostomia & salivary hypofunction
(2* sjogren’s syndrome)(2* sjogren’s syndrome)

Wegener’s GranulomatosisWegener’s Granulomatosis
 Rare chronic granulomatous diseaseRare chronic granulomatous disease
 ImmunologicalImmunological
 Clinical features:Clinical features: necrotizingnecrotizing
granulomatousgranulomatous lesions of thelesions of the
respiratory tract, generalized focalrespiratory tract, generalized focal
necrotizing vasculitis, and necrotizingnecrotizing vasculitis, and necrotizing
glomerulitisglomerulitis
 Oral lesions:Oral lesions: solitary or multiplesolitary or multiple
irregular ulcers, surrounded by anirregular ulcers, surrounded by an
inflammatory zoneinflammatory zone
 Tongue, palate, buccal mucosa &Tongue, palate, buccal mucosa &
gingivagingiva
 Laboratory tests:Laboratory tests: HPE, c-ANCAHPE, c-ANCA
 Treatment:Treatment: Steroids, Azathioprine,Steroids, Azathioprine, &&
CyclophosphamideCyclophosphamide

SarcoidosisSarcoidosis
 Systemic granulomatous diseaseSystemic granulomatous disease
 Any organAny organ
 Noncaseating granuloma:Noncaseating granuloma:
-characteristic lesion-characteristic lesion
 Oral manifestations:Oral manifestations: multiple, nodular,multiple, nodular,
painless ulceration of the gingiva,painless ulceration of the gingiva,
buccal mucosa, tongue, lips, & palatebuccal mucosa, tongue, lips, & palate
 Salivary gland swellingSalivary gland swelling
 Diagnosis:Diagnosis: BiopsyBiopsy
 Treatment:Treatment: Systemic steroidsSystemic steroids

Heerfordt SyndromeHeerfordt Syndrome
 Uveoparotid FeverUveoparotid Fever
 Rare form of SarcoidosisRare form of Sarcoidosis
 Clinical features:Clinical features: B/L painless, firm,B/L painless, firm,
parotid swelling, ocularparotid swelling, ocular
involvement(uveitis, conjunctivitis,involvement(uveitis, conjunctivitis,
keratitis), facial paralysis, low gradekeratitis), facial paralysis, low grade
fever, sublingual & submandibularfever, sublingual & submandibular
gland may also enlargegland may also enlarge

Behcet’s SyndromeBehcet’s Syndrome
 Chronic, multisystemic inflammatoryChronic, multisystemic inflammatory
disorderdisorder
 Triad of symptomsTriad of symptoms: Aphthous ulcers,: Aphthous ulcers,
Genital ulcers & Ocular lesionsGenital ulcers & Ocular lesions
(uveitis, conjunctivits, keratitis)(uveitis, conjunctivits, keratitis)
 EtiologyEtiology – unclear– unclear
 Immunogenetic basisImmunogenetic basis
 Clinical featuresClinical features -- common in malescommon in males
 Onset -20–30 years ageOnset -20–30 years age

Diagnostic criteria :Diagnostic criteria :
1.1. Recurrent oral ulcers (aphthaeRecurrent oral ulcers (aphthae))
2.2. Recurrent genital ulcersRecurrent genital ulcers
3.3. Ocular lesions (conjunctivitis, iritisOcular lesions (conjunctivitis, iritis
with hypopyon, uveitis, retinalwith hypopyon, uveitis, retinal
vasculitis, reduced visual acuityvasculitis, reduced visual acuity
4.4. Skin lesions (papules, pustules,Skin lesions (papules, pustules,
folliculitisfolliculitis,, erythema nodosum,erythema nodosum,
ulcers, & rarely necrotic lesions)ulcers, & rarely necrotic lesions)
5.5. Positive Pathergy test:Positive Pathergy test:
The test is called positive, when theThe test is called positive, when the
needle puncture causes a sterileneedle puncture causes a sterile
red nodule or pustule that is greaterred nodule or pustule that is greater
than 2mm in diameter at 24 to 48than 2mm in diameter at 24 to 48
hourshours

 For accurate diagnosis, recurrent oralFor accurate diagnosis, recurrent oral
ulcers plus two of the four criteria mustulcers plus two of the four criteria must
be presentbe present
 Mild cases- Topical steroidMild cases- Topical steroid
 Severe cases- Systemic steroid, & otherSevere cases- Systemic steroid, & other
immunosuppressive drugs (Ciclosporin,immunosuppressive drugs (Ciclosporin,
Thalidomide, Colchicine, Dapsone)Thalidomide, Colchicine, Dapsone)

Rheumatoid ArthritisRheumatoid Arthritis
 Progressive destruction of articular &Progressive destruction of articular &
periarticular structure eg. TMJperiarticular structure eg. TMJ
 TMJ pathology: clicking, locking, crepitus,TMJ pathology: clicking, locking, crepitus,
tenderness in the preauricular area, paintenderness in the preauricular area, pain
during mandibular movementduring mandibular movement
 Oral cavity involvement-not commonOral cavity involvement-not common
 Association with secondary Sjogren’sAssociation with secondary Sjogren’s
SyndromeSyndrome
 Immunosuppressive drugsImmunosuppressive drugsacute stomatitis,acute stomatitis,
candidiasis, recurrent HSV infectioncandidiasis, recurrent HSV infection

Reiter’s SyndromeReiter’s Syndrome
 Triggered by infectious agent inTriggered by infectious agent in
genetically susceptiblegenetically susceptible
 Young male (20-30 yrs)Young male (20-30 yrs)
 Characterized by conjunctivitis,Characterized by conjunctivitis,
asymmetric lower extremity arthritis,asymmetric lower extremity arthritis,
non-gonococcal urethritis, circinatenon-gonococcal urethritis, circinate
balanitis, keratoderma blennorrhagiabalanitis, keratoderma blennorrhagia
 Mnemonic : “can’t see, can’t pee, can’tMnemonic : “can’t see, can’t pee, can’t
climb a tree”climb a tree”
 Oral lesions:Oral lesions: papules & ulcerations onpapules & ulcerations on
the buccal mucosa, gingiva, palate, &the buccal mucosa, gingiva, palate, &
lipslips
 Lesions on the tongue mimicLesions on the tongue mimic
geographical tonguegeographical tongue
 Diagnosis:Diagnosis: HPEHPE
 Treatment:Treatment: Systemic steroid, NSAIDSystemic steroid, NSAID

Sweet SyndromeSweet Syndrome
 Acute febrile neutrophilic dermatosisAcute febrile neutrophilic dermatosis
 Etiology:Etiology: unknownunknown
 Fever, leukocytosis, arthralgia,Fever, leukocytosis, arthralgia,
myalgia, & ocular involvementmyalgia, & ocular involvement
 Oral lesions:Oral lesions: painful, aphthous likepainful, aphthous like
ulcer-lips, tongue, buccal mucosa, &ulcer-lips, tongue, buccal mucosa, &
palatepalate
 Skin lesions: nonpruritic,Skin lesions: nonpruritic,
erythematous papules, &erythematous papules, &
vesiculobullous lesionsvesiculobullous lesions
 Diagnosis:Diagnosis: HPEHPE
Systemic Steroid/DapsoneSystemic Steroid/Dapsone

AmyloidosisAmyloidosis
 Deposition of amyloid protein (fibrillarDeposition of amyloid protein (fibrillar
protein) in tissuesprotein) in tissues
1.1. Primary:Primary: Idiopathic or Multiple MyelomaIdiopathic or Multiple Myeloma
2.2. Secondary:Secondary: Chronic or InflammatoryChronic or Inflammatory
diseasedisease
Oral manifestations:Oral manifestations: macroglossia,macroglossia,
decreased mobility, yellow nodules ondecreased mobility, yellow nodules on
lateral surfacelateral surface
 Deposition on salivary glandDeposition on salivary gland
hyposalivationhyposalivation
 Submandibular swelling & tongueSubmandibular swelling & tongue
enlargementenlargement respiratory obstructionrespiratory obstruction
 Diagnosis:Diagnosis: HPE (congo red staining)HPE (congo red staining)
 Treatment:Treatment: SymptomaticSymptomatic

Hematological DiseasesHematological Diseases
1.1. Iron Deficiency AnaemiaIron Deficiency Anaemia
2.2. Sickle Cell AnaemiaSickle Cell Anaemia
3.3. Langerhans Cell HistiocytosisLangerhans Cell Histiocytosis
4.4. Osler-Weber-Rendu disease (HHT)Osler-Weber-Rendu disease (HHT)
5.5. Plummer-Vinson SyndromePlummer-Vinson Syndrome
6.6. LeukaemiaLeukaemia
7.7. AgranulocytosisAgranulocytosis
8.8. Myelodysplastic SyndromeMyelodysplastic Syndrome
9.9. Cyclic NeutropeniaCyclic Neutropenia
10.10. Idiopathic Thrombocytopenic PurpuraIdiopathic Thrombocytopenic Purpura
11.11. Multiple MyelomaMultiple Myeloma

Iron Deficiency AnaemiaIron Deficiency Anaemia
 Oral manifestations:Oral manifestations:
Atrophic glossitis, mucosalAtrophic glossitis, mucosal
pallor, angular stomatitis,pallor, angular stomatitis,
flattening of tongue papillae,flattening of tongue papillae,
geographic glossitisgeographic glossitis

Langerhans Cell Histiocytosis (Histiocytosis X)Langerhans Cell Histiocytosis (Histiocytosis X)
 Abnormal clonal proliferation of LangerhansAbnormal clonal proliferation of Langerhans
cells(dendritic cells) & Eosinophilscells(dendritic cells) & Eosinophils
 Etiology:Etiology:UnknownUnknown
1.1. Eosinophillic granulomaEosinophillic granuloma (most common(most common
form)form)
2.2. Hand–Schüller–Christian diseaseHand–Schüller–Christian disease
3.3. Letterer–Siwe diseaseLetterer–Siwe disease

Oral lesions-all formsOral lesions-all forms

solitary or multiple ulceration on the gingivasolitary or multiple ulceration on the gingiva
and the palate usually associated with boneand the palate usually associated with bone
destruction & tooth loosening or lossdestruction & tooth loosening or loss
(“floating teeth”)(“floating teeth”)
Diagnosis:Diagnosis: Biopsy (eg.Skin,lung)-BirbeckBiopsy (eg.Skin,lung)-Birbeck
granules(electron microscopy)granules(electron microscopy)
Treatment:Treatment: Steroids, Vinblastine+/- EtoposideSteroids, Vinblastine+/- Etoposide

LeukaemiaLeukaemia
 EtiologyEtiology-- genetic & environmental factorsgenetic & environmental factors
(viruses, chemicals, radiation)(viruses, chemicals, radiation)
 Clinical features:Clinical features: Leukaemia–Leukaemia– acute &acute &
chronicchronic,, myeloid or lymphocyticmyeloid or lymphocytic
 All forms - Oral manifestationsAll forms - Oral manifestations
 Oral lesions:Oral lesions:
-Ulcerations, spontaneous gingival-Ulcerations, spontaneous gingival
hemorrhage, petechiae, ecchymosis,hemorrhage, petechiae, ecchymosis,
tooth loosening, & gingival hypertrophytooth loosening, & gingival hypertrophy
 Laboratory tests:Laboratory tests:
Peripheral blood smear, bone-marrowPeripheral blood smear, bone-marrow
examinationexamination
 Treatment:Treatment: Chemotherapy, bone-marrowChemotherapy, bone-marrow
transplantation, supportivetransplantation, supportive therapytherapy

Osler-Weber-Rendu DiseaseOsler-Weber-Rendu Disease
(Hereditary Hemorrhagic Telangiectasia)(Hereditary Hemorrhagic Telangiectasia)
 Autosomal dominantAutosomal dominant
 Telangiectasia of dorsum of tongue,Telangiectasia of dorsum of tongue,
oral cavity, buccal mucosa, lips,oral cavity, buccal mucosa, lips,
palate & nasal mucosapalate & nasal mucosa
 Apparent at pubertyApparent at puberty
 Lung, liver, & GI tract arterio-venousLung, liver, & GI tract arterio-venous
malformationsmalformations
 Treatment:Treatment: regular iron therapy,regular iron therapy,
laser therapylaser therapy

Plummer Vinson SyndromePlummer Vinson Syndrome
(Patterson-Brown-Kelly Syndrome)(Patterson-Brown-Kelly Syndrome)
 Oral manifestations:Oral manifestations: Dysphagia, ironDysphagia, iron
def. anaemia, atrophic glossitis, angulardef. anaemia, atrophic glossitis, angular
stomatitis, & koilonychiastomatitis, & koilonychia
 Female, in fourth decadeFemale, in fourth decade
 Barium swallow: web in post-cricoidBarium swallow: web in post-cricoid
regionregion
 Pre-malignantPre-malignant Post-cricoid carcinomaPost-cricoid carcinoma
-Esophageal dilatation-Esophageal dilatation
(if symptoms from web)(if symptoms from web)
-Follow up-developing carcinoma-Follow up-developing carcinoma

Idiopathic Thrombocytopenic Purpura (ITP)Idiopathic Thrombocytopenic Purpura (ITP)
 Oral lesionsOral lesions may be the firstmay be the first
manifestation of this conditionmanifestation of this condition
 Petechiae, ecchymoses,Petechiae, ecchymoses,
& haematoma anywhere on the& haematoma anywhere on the
oral mucosaoral mucosa
 Spontaneous bleeding from theSpontaneous bleeding from the
gingivagingiva
-Systemic steroids, Splenectomy-Systemic steroids, Splenectomy

AgranulocytosisAgranulocytosis
 EtiologyEtiology:: Drug or infectionDrug or infection
Oral lesions -multiple necrotic ulcersOral lesions -multiple necrotic ulcers
covered with dirty pseudomembranecovered with dirty pseudomembrane
 Buccal mucosa, tongue, palate,Buccal mucosa, tongue, palate, & tonsillar& tonsillar
areaarea
 Severe necrotizing gingivitisSevere necrotizing gingivitis
 Laboratory tests:Laboratory tests: White blood countWhite blood count &&
bone-marrow aspirationbone-marrow aspiration
 Treatment:Treatment: Antibiotics, white blood cellAntibiotics, white blood cell
transfusions, granulocyte colony-transfusions, granulocyte colony-
stimulating factor (G-CSF) or granulocyte-stimulating factor (G-CSF) or granulocyte-
macrophage colony-stimulating factormacrophage colony-stimulating factor
(GM-CSF)(GM-CSF)

Cyclic NeutropeniaCyclic Neutropenia
 Regular periodic reduction of theRegular periodic reduction of the
neutrophilneutrophil
 Etiology:Etiology: hereditary autosomalhereditary autosomal
dominantdominant
 Clinical features:Clinical features: childhood,reductionchildhood,reduction
of neutrophils - regularly in a 21-dayof neutrophils - regularly in a 21-day
cycle - low-grade fever, headache,cycle - low-grade fever, headache,
malaise, anorexia, arthralgia, cervicalmalaise, anorexia, arthralgia, cervical
lymphadenopathy, gastrointestinallymphadenopathy, gastrointestinal
disorders, skin & oral manifestationsdisorders, skin & oral manifestations
 Oral lesions -Oral lesions - painful ulcer - whitishpainful ulcer - whitish
membranemembrane
 Localized gingivitisLocalized gingivitis
 Laboratory tests:Laboratory tests: peripheralperipheral bloodblood countcount
 Treatment:Treatment: Supportive, Corticosteroid,Supportive, Corticosteroid,
granulocyte colony stimulating factor(G-granulocyte colony stimulating factor(G-
CSF)CSF)

Gastrointestinal DiseasesGastrointestinal Diseases
1.Inflammatory Bowel Disease1.Inflammatory Bowel Disease
(Crohn’s disease & Ulcerative colitis)(Crohn’s disease & Ulcerative colitis)
2.Gastro-esophageal Reflux2.Gastro-esophageal Reflux
3.Peutz-Jegher’s Syndrome3.Peutz-Jegher’s Syndrome
4.Celiac disease4.Celiac disease
5.Chronic liver disease5.Chronic liver disease
6.Malabsorption Diseases6.Malabsorption Diseases

Crohn’s DiseaseCrohn’s Disease
 Diffuse nodular swelling in lipsDiffuse nodular swelling in lips
(painless), angular cheilitis,(painless), angular cheilitis,
cobblestone appearance ofcobblestone appearance of
buccal mucosabuccal mucosa or mucosal tag,or mucosal tag,
Aphthous ulcerAphthous ulcer
 May precede intestinal symptomsMay precede intestinal symptoms
or may be the onlyor may be the only
manifestations in some casesmanifestations in some cases
 Systemic steroidsSystemic steroids

Ulcerative ColitisUlcerative Colitis
 Destructive oral ulceration due toDestructive oral ulceration due to
immune mediated vasculitisimmune mediated vasculitis
 Polystomatitis Vegetans:Polystomatitis Vegetans:
microabscess on lips, palate,microabscess on lips, palate,
ventral tongueventral tongue
 May manifests as aphthous ulcersMay manifests as aphthous ulcers
 Exacerbation & remissionExacerbation & remission

Gastroesophageal Reflux DiseaseGastroesophageal Reflux Disease
 Mucosal & gingival erosionMucosal & gingival erosion
caused by acidcaused by acid
 Erosion of tooth enamelErosion of tooth enamel

Peutz-Jegher’s SyndromePeutz-Jegher’s Syndrome
 Autosomal dominantAutosomal dominant
 Mucocutaneous pigmentation &Mucocutaneous pigmentation &
intestinal polyposis (hamartomas)intestinal polyposis (hamartomas)
 Black spots (macule): perioral skin,Black spots (macule): perioral skin,
lips, buccal mucosa, tonguelips, buccal mucosa, tongue
-Conservative or local excision-Conservative or local excision

Endocrine DiseasesEndocrine Diseases
1.1. Diabetes MellitusDiabetes Mellitus
2.2. Thyroid DisordersThyroid Disorders
3.3. Cushing’s DiseaseCushing’s Disease
4.4. Addison’s DiseaseAddison’s Disease

Diabetes MellitusDiabetes Mellitus
 Oral manifestations-Oral manifestations- variable &variable &
nonspecificnonspecific
 Fungal & bacterial infectionFungal & bacterial infection
 Gingivitis, periodontitis, xerostomia,Gingivitis, periodontitis, xerostomia,
glossodynia, taste changeglossodynia, taste change
 Rx:Rx: Control of DMControl of DM
Antiobiotic/AntifungalAntiobiotic/Antifungal
 Oral hygieneOral hygiene

Thyroid DiseasesThyroid Diseases
 Hypothyroidism:Hypothyroidism: MacroglossiaMacroglossia
 Congenital Hypothyroidism:Congenital Hypothyroidism: Macroglossia,Macroglossia,
pronounced lips, & delayed tooth eruptionpronounced lips, & delayed tooth eruption
with malocclusionwith malocclusion
 Hyperthyroidism:Hyperthyroidism:
Facial & skin manifestations:Facial & skin manifestations: upper eyelidupper eyelid
retraction, exophthalmous,retraction, exophthalmous,
hyperpigmentation, & skin erythemahyperpigmentation, & skin erythema
Oral manifestations:Oral manifestations: early loss of primaryearly loss of primary
teeth with subsequent rapid eruption ofteeth with subsequent rapid eruption of
permanent teeth(young children)permanent teeth(young children)
lymphoid tissue hyperplasia- tonsillar &lymphoid tissue hyperplasia- tonsillar &
oropharynx (Grave’s disease)oropharynx (Grave’s disease)

Cushing’s SyndromeCushing’s Syndrome
 Long term, high dose corticosteroidLong term, high dose corticosteroid
administrationadministration
 Moon or round face, buffalo humps,Moon or round face, buffalo humps,
central obesity, osteoporosis, DM,central obesity, osteoporosis, DM,
HTNHTN
 Oral symptoms:Oral symptoms:
-Increased susceptibility to oral-Increased susceptibility to oral
infections (candidiasis)infections (candidiasis)
-Muscle weakness-Muscle weakness difficulty withdifficulty with
speaking, & swallowingspeaking, & swallowing
Dx:Dx: Dexamethasone suppression testDexamethasone suppression test
RxRx: Depends on the cause: Depends on the cause

Addison’s DiseaseAddison’s Disease
 Primary adrenal insufficiencyPrimary adrenal insufficiency
 Destruction of adrenal cortex eg.Destruction of adrenal cortex eg.
autoimmune, metastasis, infection,autoimmune, metastasis, infection,
haemorrhagehaemorrhage
 Oral manifestations:Oral manifestations: diffuse or patchydiffuse or patchy
pigmentation of the skin & mucouspigmentation of the skin & mucous
membranesmembranes (due to increased ACTH-(due to increased ACTH-
cross reacts with melanin receptors)cross reacts with melanin receptors)
 Buccal mucosa, palate, lips, & gingivaBuccal mucosa, palate, lips, & gingiva
 Diagnosis:Diagnosis: ACTH testACTH test
 Treatment:Treatment: Replace steroidReplace steroid
(glucocorticoid/mineralocorticoid)(glucocorticoid/mineralocorticoid)

Renal DiseaseRenal Disease
(Uraemic Stomatitis)(Uraemic Stomatitis)
 Painful plaques and crust on buccalPainful plaques and crust on buccal
mucosa, dorsum of tongue, & floor ofmucosa, dorsum of tongue, & floor of
mouth covered with graymouth covered with gray
pseudomembrane exudate, & painfulpseudomembrane exudate, & painful
ulcersulcers
 Bleeding diathesis:Bleeding diathesis: inhibited plateletinhibited platelet
aggregation eg. petechiae, ecchymosesaggregation eg. petechiae, ecchymoses
 Irritation & chemical injury of mucosa-Irritation & chemical injury of mucosa-
ammonium compoundsammonium compounds
 Xerostomia, unpleasant taste, burningXerostomia, unpleasant taste, burning
mouth, uriniferous breath odourmouth, uriniferous breath odour
 A/W with acute rise in blood urea nitrogenA/W with acute rise in blood urea nitrogen
 Heal spontaneously after resolution ofHeal spontaneously after resolution of
uraemic state eg. after hemodialysisuraemic state eg. after hemodialysis

Dermatologic ConditionsDermatologic Conditions
1.1. Lichen PlanusLichen Planus
2.2. Pemphigus VulgarisPemphigus Vulgaris
3.3. Mucous Membrane PemphigoidMucous Membrane Pemphigoid
4.4. Erythema MultiformeErythema Multiforme
5.5. Stevens-Jhonson SyndromeStevens-Jhonson Syndrome
6.6. Toxic Epidermal NecrolysisToxic Epidermal Necrolysis

Lichen PlanusLichen Planus
 Chronic, mucocutaneous,Chronic, mucocutaneous,
autoimmune disorderautoimmune disorder
 Precipitating factors: geneticPrecipitating factors: genetic
predisposition, stress, drug, foodpredisposition, stress, drug, food
 Oral manifestations:Oral manifestations: White papulesWhite papules
-coalesce, forming a-coalesce, forming a networknetwork of linesof lines
(Wickham’s striae)(Wickham’s striae)
 Buccal mucosa, gingiva, & tongue,Buccal mucosa, gingiva, & tongue,
lips & palatelips & palate

 Skin lesions: Pruritic papules-flexorSkin lesions: Pruritic papules-flexor
surface of extremitiessurface of extremities
 Malignant transformationMalignant transformation
-Clinically-Clinically
-Histopathological examination-Histopathological examination
-No treatment- asymptomatic-No treatment- asymptomatic lesionslesions
-Topical-Topical steroids & Systemic steroidssteroids & Systemic steroids

Pemphigus VulgarisPemphigus Vulgaris
 Autoimmune diseaseAutoimmune disease
 Antibodies against desmoglein3 (antigen)Antibodies against desmoglein3 (antigen)
 Disassociation of the epithelium atDisassociation of the epithelium at
suprabasal layer with acantholysissuprabasal layer with acantholysis
 Bullous lesionsBullous lesionsrupturesrupturespainfulpainful
bleeding ulcersbleeding ulcers
 Oral, ocular mucosa, & skinOral, ocular mucosa, & skin
 Palate, gingiva, tonguePalate, gingiva, tongue
--Nikolsky’s sign:(+)Nikolsky’s sign:(+)
new lesions develops after pressurenew lesions develops after pressure
applied to asymptomatic oral mucosaapplied to asymptomatic oral mucosa
-HPE-HPE
-Direct immunofluorescence-Direct immunofluorescence

Systemic steroids &Systemic steroids &
immunosuppressive agentsimmunosuppressive agents
(eg. mycophenolate mofetil)(eg. mycophenolate mofetil)
Paraneoplastic Pemphigus:Paraneoplastic Pemphigus:
 Occurs in association withOccurs in association with
underlying neoplasms eg.underlying neoplasms eg.
Lymphoproliferative disease orLymphoproliferative disease or
thymomathymoma
 Often partial response toOften partial response to
systemic steroidssystemic steroids

Mucous Membrane PemphigoidMucous Membrane Pemphigoid
 Antigen: Human alpha-6 integrinAntigen: Human alpha-6 integrin
 Oral manifestations-Oral manifestations- recurrent vesiclesrecurrent vesicles
or bullae (persists longer thanor bullae (persists longer than
pemphigus) that rupture, leaving large,pemphigus) that rupture, leaving large,
superficial painful ulcerssuperficial painful ulcers
 Gingival involvement -Gingival involvement - desquamativedesquamative
gingivitisgingivitis characterised bycharacterised by
erythematous, sore gingivaeerythematous, sore gingivae
 Treatment:Treatment: topical steroid/systemictopical steroid/systemic
immunosuppressive drugsimmunosuppressive drugs

Erythema MultiformeErythema Multiforme
 Skin and mucous membranesSkin and mucous membranes
 Immunologically mediatedImmunologically mediated
 Triggered by: infective agents (eg. HSV),Triggered by: infective agents (eg. HSV),
drugs (sulphonamides, barbiturates), fooddrugs (sulphonamides, barbiturates), food
additives or chemical, immunizationadditives or chemical, immunization
( BCG,HBV)( BCG,HBV)
 Oral lesions:Oral lesions: begins as erythematousbegins as erythematous
areaareablisterblisterrupturesrupturesirregular painfulirregular painful
ulcersulcers
 Lips, buccal mucosa, tongue, soft palate, &Lips, buccal mucosa, tongue, soft palate, &
floor of mouthfloor of mouth
 Skin manifestations:Skin manifestations: erythematous, flat,erythematous, flat,
round macules, papules, or plaques,round macules, papules, or plaques,
usually in a symmetrical pattern-usually in a symmetrical pattern- target ortarget or
iris like lesionsiris like lesions
 HPE & ImmunostainingHPE & Immunostaining
 TreatmentTreatment:: supportive, systemic steroidssupportive, systemic steroids

Stevens–Johnson SyndromeStevens–Johnson Syndrome
 Severe form of erythema multiforme, involving oralSevere form of erythema multiforme, involving oral
mucous membrane, eyes, & genital areamucous membrane, eyes, & genital area
 EtiologyEtiology:: Drugs (salicylates, sulfonamides,Drugs (salicylates, sulfonamides,
penicillin, barbiturates,carbamazepine, phenytoinpenicillin, barbiturates,carbamazepine, phenytoin
etc.)etc.)
 oral lesions -oral lesions - vesicle formation, followed by painfulvesicle formation, followed by painful
erosions - grayish-white or hemorrhagicerosions - grayish-white or hemorrhagic
pseudomembranes - extend to the pharynx, larynx,pseudomembranes - extend to the pharynx, larynx,
and esophagusand esophagus
 Ulceration of skin & mucosal surfaces(eg. mouth,Ulceration of skin & mucosal surfaces(eg. mouth,
urethra, conjunctiva, & lungs)urethra, conjunctiva, & lungs)
 Typical target lesions on palms & soles withTypical target lesions on palms & soles with
blistering in the centreblistering in the centre
 DiagnosisDiagnosis:: Clinical presentationClinical presentation
 TreatmentTreatment::
--self limitingself limiting
-Supportive, & Systemic steroids-Supportive, & Systemic steroids

Toxic Epidermal NecrolysisToxic Epidermal Necrolysis
 Severe skin & mucous membraneSevere skin & mucous membrane
diseasedisease
 Etiology:Etiology: DrugsDrugs
 Clinical features:Clinical features: low-grade feverlow-grade fever,,
malaise, arthralgia, conjunctival burningmalaise, arthralgia, conjunctival burning
sensation, skin tenderness, &sensation, skin tenderness, &
erythemaerythemablisters appear-skin - lifted upblisters appear-skin - lifted up
- whole body surface appears scalded- whole body surface appears scalded
 Nikolsky’s sign –positiveNikolsky’s sign –positive
 Oral manifestations:Oral manifestations: diffuse erythema,diffuse erythema,
vesicles and painful erosions - lips &vesicles and painful erosions - lips &
periorally, buccal mucosa, tongue, &periorally, buccal mucosa, tongue, &
palatepalate
 Diagnosis:Diagnosis: ClinicallyClinically
 TreatmentTreatment: Systemic steroids, antibiotics,: Systemic steroids, antibiotics,
fluids, and electrolytesfluids, and electrolytes

Neurologic DiseasesNeurologic Diseases
1.1. Parkinson’s DiseaseParkinson’s Disease
2.2. Alzheimer’s DiseaseAlzheimer’s Disease
3.3. Bell’s PalsyBell’s Palsy
4.4. Moebius syndromeMoebius syndrome
5.5. Melkersson-Rosenthal SyndromeMelkersson-Rosenthal Syndrome
6.6. Guillain-Barre SyndromeGuillain-Barre Syndrome
7.7. Bulbar palsyBulbar palsy
8.8. Multiple SclerosisMultiple Sclerosis
9.9. Myasthenia GravisMyasthenia Gravis
10.10. Myotonic Muscular DystrophyMyotonic Muscular Dystrophy
11.11. Tuberous SclerosisTuberous Sclerosis

Parkinson’s DiseaseParkinson’s Disease
 Extrapyramidal symptomsExtrapyramidal symptoms
 Loss of facial expressionLoss of facial expression
 Difficulty with mastication, slowDifficulty with mastication, slow
speech, & tremors of head, lips, &speech, & tremors of head, lips, &
tonguetongue
 Esophageal dysmotility &Esophageal dysmotility &
dysphagiadysphagia
 Impaired lip sealImpaired lip seal droolingdrooling
fungal infection of lip commissurefungal infection of lip commissure
(angular cheilitis)(angular cheilitis)

Alzheimer’s DiseaseAlzheimer’s Disease
 DementiaDementia
 Inability to perform self care (oral hygiene)-Inability to perform self care (oral hygiene)-
self neglect & loss of cognitive and motor skillsself neglect & loss of cognitive and motor skills
 Poor oral hygiene- increased prevalence ofPoor oral hygiene- increased prevalence of
dental plaque, dental caries, & gingivaldental plaque, dental caries, & gingival
bleedingbleeding

Multiple SclerosisMultiple Sclerosis
 Demyelination of central nervousDemyelination of central nervous
systemsystem
 Remitting & exacerbating courseRemitting & exacerbating course
 Loss of muscle coordination,Loss of muscle coordination,
weakness of the tongue, & loss ofweakness of the tongue, & loss of
upper extremityupper extremity severely impairsseverely impairs
orodental hygieneorodental hygiene
 Trigeminal neuralgia- also commonTrigeminal neuralgia- also common
characterized by excruciating,characterized by excruciating,
unilateral pain of the lips, gingiva,unilateral pain of the lips, gingiva,
or chin triggered by contact withor chin triggered by contact with
certain areas of the face, lips, orcertain areas of the face, lips, or
tonguetongue

Bell’s PalsyBell’s Palsy
 Idiopathic unilateral lower motorIdiopathic unilateral lower motor
neuron palsy (7neuron palsy (7thth
cranial nerve)cranial nerve)
 Lack of control of the muscles ofLack of control of the muscles of
facial expressionfacial expressiondistortion of facialdistortion of facial
appearanceappearance
 Loss of functional ability of cheek &Loss of functional ability of cheek &
lips (affected side)lips (affected side)poor oro-dentalpoor oro-dental
hygienehygiene

Melkersson-Rosenthal SyndromeMelkersson-Rosenthal Syndrome
 Characterized by -unilateral facial palsy, recurrent facialCharacterized by -unilateral facial palsy, recurrent facial
swelling, & lingua plicata (fissured tongue)swelling, & lingua plicata (fissured tongue)

Nutritional DeficiencyNutritional Deficiency
 Vitamins & trace elementsVitamins & trace elements
1.1. Inadequate intakeInadequate intake
2.2. Impaired digestion & absorptionImpaired digestion & absorption
3.3. Increased lossesIncreased losses

 Vitamin A deficiency:Vitamin A deficiency:
-Dyskeratotic changes of the skin & mucous-Dyskeratotic changes of the skin & mucous
membranesmembranes
-Angular cheilitis-Angular cheilitis
-Defects in the dentin & enamel of-Defects in the dentin & enamel of
developing teethdeveloping teeth
 Vitamin B2 (Riboflavin) deficiency:Vitamin B2 (Riboflavin) deficiency:
-Angular cheilitis-Angular cheilitis
-Burning pain in the lips, mouth, & tongue-Burning pain in the lips, mouth, & tongue
 Vitamin B3 (Niacin) deficiency (Pellagra):Vitamin B3 (Niacin) deficiency (Pellagra):
-Dermatitis, dementia,& diarrhoea-Dermatitis, dementia,& diarrhoea
-Oral manifestations: glossitis (red, swollen) &-Oral manifestations: glossitis (red, swollen) &
stomatitis, burning tonguestomatitis, burning tongue

 Vitamin B6 deficiency:Vitamin B6 deficiency:
-Peripheral neuropathy-Peripheral neuropathy
-Oral lesions-similar to pellagra-Oral lesions-similar to pellagra
(i.e. glossitis & stomatitis)(i.e. glossitis & stomatitis)
 Vitamin C deficiency (Scurvy):Vitamin C deficiency (Scurvy):
-Cofactor for collagen synthesis-Cofactor for collagen synthesis
-Weakened vessels are responsible for-Weakened vessels are responsible for
petechiae, ecchymoses, delayed woundpetechiae, ecchymoses, delayed wound
healinghealing
 Deficiency of Vitamin B12 & Folic acid:Deficiency of Vitamin B12 & Folic acid:
-Megaloblastic anemia-Megaloblastic anemia
-Oral findings: angular cheilitis, recurrent-Oral findings: angular cheilitis, recurrent
aphthous ulcers, & glossitisaphthous ulcers, & glossitis

 Vitamin D deficiency & Calcium deficiency:Vitamin D deficiency & Calcium deficiency:
-Calcium metabolism-Calcium metabolism
-Mandibular osteopenia/osteoporosis, enamel-Mandibular osteopenia/osteoporosis, enamel
hypoplasiahypoplasia
 Vitamin k deficiency:Vitamin k deficiency:
-Haemorrhagic diathesis-Haemorrhagic diathesis
-Oral haemorrhagic bullae-Oral haemorrhagic bullae
 Zinc deficiency:Zinc deficiency:
-Taste changes-Taste changes
-Acrodermatitis Enteropathica: angular cheilitis,-Acrodermatitis Enteropathica: angular cheilitis,
ulcers, glossitis, crusting, scaling of the lips as wellulcers, glossitis, crusting, scaling of the lips as well
as ulcers, erosions & fissuresas ulcers, erosions & fissures

Oral lesions associated with HIVOral lesions associated with HIV
 Early recognition, diagnosis, & treatment ofEarly recognition, diagnosis, & treatment of
HIV associated oral lesions - reduce morbidityHIV associated oral lesions - reduce morbidity
 Oral lesions-Oral lesions-
-Early diagnostic indicator of HIV infection-Early diagnostic indicator of HIV infection
-Stage of HIV infection-Stage of HIV infection
-Predictor of the progression of HIV disease-Predictor of the progression of HIV disease

Oral lesions associated with HIVOral lesions associated with HIV
 Fungal Infection: Bacterial Infection:Fungal Infection: Bacterial Infection:
-Candidiasis -Linear Gingival Erythema-Candidiasis -Linear Gingival Erythema
-Histoplasmosis -Necrotizing Ulcerative-Histoplasmosis -Necrotizing Ulcerative
PeriodontitisPeriodontitis
-Cryptococcosis -Mycobacterium Avium Complex-Cryptococcosis -Mycobacterium Avium Complex
 Viral Infection: Neoplastic:Viral Infection: Neoplastic:
-Herpes simplex -Kaposi’s Sarcoma-Herpes simplex -Kaposi’s Sarcoma
-Herpes zoster -Non-Hodgkin’s Lymphoma-Herpes zoster -Non-Hodgkin’s Lymphoma
-HPV Infection-HPV Infection Others:Others:
-CMV Infection -Recurrent Aphthous Ulcers-CMV Infection -Recurrent Aphthous Ulcers
-Hairy Leukoplakia -Salivary Gland Disease-Hairy Leukoplakia -Salivary Gland Disease

Human Papilloma VirusHuman Papilloma Virus
InfectionInfection
 Oral warts (papillomas), skin warts,Oral warts (papillomas), skin warts,
& genital warts – HPV(types 7,13,&& genital warts – HPV(types 7,13,&
32)32)
Clinical Features:Clinical Features:
 Arises from Stratified squamousArises from Stratified squamous
epithellium, painless, exophytic,epithellium, painless, exophytic,
numerous finger like projections-numerous finger like projections-
cauliflower like appearancecauliflower like appearance
 Tongue, gingiva, & palateTongue, gingiva, & palate
 Biopsy-Biopsy- Histologic diagnosisHistologic diagnosis
 Treatment:Treatment: -Surgical removal-Surgical removal
-Laser (CO2 laser)-Laser (CO2 laser)

Hairy LeukoplakiaHairy Leukoplakia
 Epstein Barr virusEpstein Barr virus
 Common, characteristic lesion-HIV infectionCommon, characteristic lesion-HIV infection
 White, asymptomatic, raised, corrugated,White, asymptomatic, raised, corrugated,
unremovable patch on lateral marigns ofunremovable patch on lateral marigns of
tonguetongue
 The surface is irregular and may haveThe surface is irregular and may have
prominent folds or projections, sometimesprominent folds or projections, sometimes
markedly resembling hairsmarkedly resembling hairs
 Lateral marginsLateral margins may spread to dorsum ofmay spread to dorsum of
tonguetongue
--Usually asymptomatic-Rx not requiredUsually asymptomatic-Rx not required
-Antiviral(Aciclovir/valaciclovir)-Antiviral(Aciclovir/valaciclovir)

Kaposi’s SarcomaKaposi’s Sarcoma
 Most common malignancy in HIV (+Ve)Most common malignancy in HIV (+Ve)
 Human Herpes Virus-8(KSHV)Human Herpes Virus-8(KSHV)
 Derived from capillary endothelial cellsDerived from capillary endothelial cells
 Occur intraorally, either alone or in a/wOccur intraorally, either alone or in a/w
skin & disseminated lesions (lymphskin & disseminated lesions (lymph
nodes, salivary gland)nodes, salivary gland)
 Intraorally-Intraorally- hard palate, buccal mucosa, &hard palate, buccal mucosa, &
gingivagingiva
-bluish, purple or red patches or-bluish, purple or red patches or
papulespapulesnodular, ulcerate & bleednodular, ulcerate & bleed
-Low dose radiation & chemotherapy-Low dose radiation & chemotherapy
(eg.Vinblastine)(eg.Vinblastine)
-Surgical excision (eg.CO2 laser)-Surgical excision (eg.CO2 laser)
-Immunotherapy (Interferon)-Immunotherapy (Interferon)

Non-Hodgkin’s LymphomaNon-Hodgkin’s Lymphoma
 EtiologyEtiology:: Unknown, genetic &Unknown, genetic &
environmental factors (viruses,environmental factors (viruses,
radiation)radiation)

Both sexes - any ageBoth sexes - any age

Lymph nodes involvedLymph nodes involved

Oral lesions - part of a disseminatedOral lesions - part of a disseminated
disease, or the only signdisease, or the only sign
 Oral Lymphoma:Oral Lymphoma: diffuse, painlessdiffuse, painless
swelling, which may or may not beswelling, which may or may not be
ulcerated -soft palate, the posterior partulcerated -soft palate, the posterior part
of the tongue, the gingiva, & theof the tongue, the gingiva, & the
tonsillar areatonsillar area
 HPE & Immunohistochemical examnHPE & Immunohistochemical examn
 TreatmentTreatment:: Radiotherapy &Radiotherapy &
chemotherapychemotherapy

Salivary gland DiseaseSalivary gland Disease
 XerostomiaXerostomia
 Generalised enlargement of parotidGeneralised enlargement of parotid
glandsglands
 Lymphoepithelial cysts-Lymphoepithelial cysts- parotidparotid
glandgland

Oral Manifestations of Systemic Diseases

Oral Manifestations of Systemic Diseases

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