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The first piece of the systemic puzzle

The clues about systemic health often appear FIRST to the oral-health provider
BY Jamie Collins, RDH, CDA

The oral cavity can be a gateway to our body systems and provide us a picture of potential risk factors and systemic diseases. We have all learned about the oral manifestations of particular systemic diseases and the link concerning overall health. Heart disease, diabetes, and cardiovascular disease are the most commonly named conditions that we repeat to our patients. We should be consistently performing oral cancer exams, but, other than screening for cancer, do you know what you are looking for? Oral manifestations often precede the appearance of other symptoms for many systemic health conditions.

Anemia — Anemia is a fairly common condition, especially in women of childbearing age. Often, some of the first symptoms appear in the oral cavity. Oral manifestations may include glossitis, recurring aphthous ulcers, mucosal pallor, angular cheilitis, and candida infections. Glossitis is often one of the first signs of vitamin B complex and/or folate deficiency. The tongue may appear red and “bald” due to the atrophic papillae and the patient may complain of burning or pain.

Crohns’s diseae — The mouth is the entrance to the GI tract, and underlying issues or problems concerning the GI system may affect the tissues. There is a long list of potential gastrointestinal problems that may have symptoms appearing in the mouth, including Crohn’s disease, which, according to Crohn’s and Colitis Foundation of America, affects as many as 700,000 Americans. If we broaden the category to irritable bowel diseases, of which Crohn’s and ulcerative colitis are two major categories, this will include 1.4 million Americans.
Oral manifestations may be present in up to 29% of people suffering from Crohn’s disease, and, for many, the oral symptoms may precede the intestinal symptoms. Some of the symptoms a patient may present with can include cobblestoning of the gingival and buccal mucosa, angular cheilitis, aphthous ulcers, and gingival, mucosal, and labial swelling. The swelling and ulcerations of the oral cavity can be reflective of what is happening in the intestinal tract. Other effects that may be present can include increased dental caries and possible nutritional deficiencies due to malabsorption of nutrients in the GI tract. Ulcerative colitis can be similar to Crohn’s disease. However, it is limited to the mucosa and submucosa of the digestive tract. It is characterized by ulcerations, hemorrhage, and abscesses of the colon that go into periods of remission and active disease, which often correlates with oral lesions. An estimated 5% to 10% of patients experience aphthous ulcers or angular cheilitis as manifestations of ulcerative colitis.

GERD — Gastroesophageal reflux disease, GERD, affects an estimated 20% of American adults according to the American Society for Gastrointestinal Endoscopy. Many adults are not aware of the increased risk of developing esophageal cancer if GERD is not treated and controlled. Providers may see oral symptoms such as erosion of the enamel, especially on the palatal surfaces of maxillary molars. Erosion can appear as a dished out area or “pothole” where the enamel has eroded and exposed the dentin of the tooth. Many patients may complain of heartburn or a bad taste especially after lying down. One of the most common complaints from patients is halitosis, no matter how often they brush. I have had many patients in which I have seen evidence of GERD. Upon further questioning of the patient, they indicate experiencing other symptoms including heartburn. A referral to a physician is recommended for a confirmed diagnosis and treatment of GERD.
Sjogren’s syndrome — Sjogren’s syndrome is the second most common autoimmune disease. It affects an estimated 3% of women over the age of 50, and 90% of individuals affected by Sjogren’s are female. Oral manifestations include difficulty in swallowing, changes in taste and speech, increased caries rate, and increased risk of infection all due to a decreased salivary flow. The patient may experience thick, ropy saliva, or a lack of salivary flow. Xerostomia causes the changes in mucosa including dry, red, and wrinkled tissue. Sjogren’s syndrome is characterized by inflammation and hyperplasia around the salivary and lacrimal gland ducts, restricting them and thus blocking the ducts. Symptoms are irreversible; however, medications may help induce salivary flow. Good oral hygiene and regular dental visits are important since Sjogren’s patients are more susceptible to caries.

HIV — HIV-infected individuals often experience the first signs of disease as an oral candidiasis infection, which, presents in an estimated 90% of HIV-infected patients. The most common form is Pseudomembranous candidiasis, most often on the buccal mucosa, palate, or vestibule. Herpes simplex lesions are often more prevalent in HIV-infected individuals. They may appear intra- or extraorally. The HIV lesions tend to be more aggressive and prevalent in the immunocompromised patient vs. non-HIV individuals. Hairy leukoplakia can appear as corrugated lesions on the lateral borders of the tongue. It is caused by the Epstein-Barr virus, and it is more common as a precursor to the AIDS diagnosis for those who have HIV. Kaposi sarcoma is the most common malignant diagnosis in HIV-positive individuals. The lesion appears as a brown, blue, or purple patch often appearing on the hard palate, mucosa, and gingiva. Over a period of time, the patches may ulcerate and bleed. Kaposi sarcoma progression can lead to death due to involvement in the lungs. HIV-immunocompromised patients may also exhibit an increased prevalence of human papillomavirus lesions and aphthous ulcers.

Diabetes — Diabetes mellitus has been declared a pandemic by the World Health Organization and is characterized by the lack of insulin secretion or insulin resistance, and possibly both. In 2012, over 29 million Americans, roughly 9.3%, have diabetes; of those, an estimated 8.1 million are undiagnosed. Prediabetic Americans over the age of 20 are estimated to be 86 million, with 1.7 million new diabetes cases diagnosed each year. Periodontal disease is the sixth most common complication of diabetes, with diabetes remaining as the seventh leading cause of death. Oral manifestations of diabetes may include reduced salivary flow, changes in taste, candidiasis, bacterial infections, and delayed healing. An individual may also experience lesions such as ulcerations, geographic tongue, migratory glossitis, fissured tongue, lichen planus, and angular cheilitis. The diabetic patient may experience burning mouth syndrome and taste dysfunction or alteration. Patients with diabetes, especially those who are poorly controlled or undiagnosed, have a higher incidence of candidiasis, lichen planus, and aphthous stomatitis. Poorly controlled diabetes increases the risk of severe periodontal disease, and, likewise, severe periodontal disease makes it more difficult to control glucose levels. A sudden negative change in periodontal health not attributed to changes in plaque control may cause concern for undiagnosed or poorly controlled diabetes mellitus. Severe periodontal disease can be a predictor for complications of diabetes, including increased risks of stroke, heart disease, and neuropathy.
Burning mouth syndrome — Burning mouth syndrome can be caused by many systemic conditions, and is characterized by tingling, numbness, soreness, and a dry mouth. It may be a result of candidiasis, menopause, cancer therapy, GERD, or diabetes. If a patient presents with burning mouth syndrome, it may be a result of nerve damage caused by diabetic neuropathy, and the patient should be referred to a physician for testing.

Lupus — Lupus may present orally in an estimated 8% to 45% of patients affected by the autoimmune disease. The individual may display erythema, atrophy, or ulcerations. The lesions may appear similar to erosive lichen planus; in addition, the patient may experience the classic oral presentation of a discoid lupus erythematosus. Often patients will undergo systemic immunosuppression therapy, and oral lesions will diminish or resolve. Painful diffuse ulcerations can be a sign of pemphigus vulgaris; oral manifestations may be the initial symptom in 50% to 80% of patients. Oral symptoms may appear up to a year before a patient experiences skin lesions. Extraoral skin lesions may appear as blisters and crusted skin lesions. Lupus and pemphigus vulgaris both are commonly treated with immunosuppression therapy to relieve symptoms.
Leukemia — A compromised immune system due to acute leukemia can show oral symptoms such as mucosal bleeding, ulcerations, petechiae, and possibly gingival enlargement. The gingiva may feel spongy, and the patient is at a high risk for opportunistic infections due to immunosuppression. Additional risks are infection from candidiasis, herpes simplex, and possibly periodontal disease. Chlorhexidine rinse may be effective for patients undergoing cancer treatments.

Eating disorders — Eating disorders can present with some very identifiable characteristics orally. Bulimia causes the individual to vomit often and exposes the dentition to gastric acid, which causes enamel erosion. The pattern of erosion if often found on the lingual surfaces of maxillary anterior teeth and mandibular molars. The patient may also experience xerostomia due to enlarged parotid glands from frequent vomiting in addition to an increased caries rate. The patient may experience cold and sweet sensitivity as a result of enamel erosion.
As providers, we see patients for a limited amount of time, a few times per year. Each time you get to know your patient and their “normal” health. Do you feel confident in your ability to recognize when a patient expresses a concern, or if you see those ulcerations or abnormalities that the patient states they are suddenly getting, or they may not be aware of?
If you suspect an underlying systemic condition due to either a patient’s concerns about oral conditions or by your own expertise, make the dentist aware and consider referring the individual to a physician for further testing. Thankfully, as clinicians, we see more healthy people than not in practice. Most appreciate our expertise in looking out for the whole person, not just the teeth. As hygienists, we sometimes see the first piece of the puzzle when the human body is changing. RDH
Jamie Collins, RDH, CDA, resides in Idaho with her husband, Cory, and their four children. She currently works as a full-time hygienist as well as an educator at the College of Western Idaho. In addition, she acts as a content expert and contributor in multiple upcoming textbooks. She can be contacted at jamiecollins.rdh@gmail.com.
1. Casiglia JM. Oral Manifestations of Systemic Diseases, 2013. www.emedicine.medscape.com.
2. www.ncbi.nih.gov
3. www.aafp.org

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