Cardiovascular diseases

1. Changes of oral mucous membrane in some systemic diseases (gastrointestinal, cardiovascular, endocrine and nervous systems)Lecturer: Matsko N.V.Department of therapeutic Dentistry, TSMU

2. The oral cavity is a mirror that reflects many of the human body's internal secrets. Some of these manifestations are disease specific and may accompanied many systemic diseases. It is very important to recognize them and provide correct diagnosis.

3. The classical risk factors for cardiovascular disease: - hypertension, - hyper-cholesteroleamia, - cigarette smoking Two biological mechanisms that explain the relationship between cardiovascular disease and periodontal disease: – Bacteria from periodontal disease may enter the circulation and contribute directly to the atheromatous or thrombotic processes. – Systemic factors alter the immune inflammatory process involved in both periodontal and cardiovascular diseases. Cardiovascular diseases

4. Cardiovascular diseaseOral manifestations • Periodontal disease • Lichenoid stomatitis • Xerostomia • Gingival hyperplasia • Hemorrhagic complication

5. Cardiovascular diseaseOral manifestations • Periodontal disease Cardiovascular patients with active periodontal disease are 1.5-2.7 more likely to experience a fatal cardiovascular event -Increased inflammation -Increased bacteremia risk

6. Cardiovascular disease Oral manifestations • Lichenoid stomatitis • Various cardiovascular drugs may induce lichenoid lesions – oral discomfort • Diuretics • B1-adrenergic blockers • ACE- inhibitors (angiotensin-converting-enzyme inhibitors)

7. Cardiovascular diseaseOral manifestations Dry mouth • Numerous cardiovascular drugs may reduce salivary function: • Diuretics • B1-adrenergic blockers • Centrally acting sympathetic agonists • Synergistic affect with other medications

8. Cardiovascular diseaseOral manifestations • Gingival hyperplasia: • Calcium-channel blockers are commonly prescribed • Gingival enlargement usually apparent within 1-2 months of therapy • Tissue usually firm and painless • Overlying inflammation may occur

9. Cardiovascular diseaseOral manifestations • Hemorrhagic complication: • Antithrombotic/anti-coagulant agents increase the risk of • -petechia(<2mm) • -purpura(>2mm-<1cm) • -ecchymosis(>1cm) • -hemorrhage

10. Figure 1a: Photograph of a 32-year-old male patient at the time of presentation shows remarkable gingival hyperplasia. The gingival tissue between teeth 11 and 12 resembled an epulis. Extraoral examination showed excessive hairiness of the face. Desquamation was observed on the patient's back . Gingival hyperplasia

11. Endocrine system • Endocrine pathology include: • -thyrotoxicosis; • -hypothyroidism; • -Cushing syndrome; • -Addison disease; • -acromegaly; • -hyperandrogenism; • -hypopituitarism; • -primary hyperparathyroidism; • -hypoparathyroidism; • -pseudohypoparathyroidism; • -manifestations of diabetes mellitus.

12. Type 1 diabetes is usually diagnosed in childhood. Many patients are diagnosed when they are older than age 20. In this disease, the body makes little or no insulin. Daily injections of insulin are needed. The exact cause is unknown. Genetics, viruses, and autoimmune problems may play a role. Type 2 diabetes is far more common than type 1. It makes up most of diabetes cases. It usually occurs in adulthood, but young people are increasingly being diagnosed with this disease. The pancreas does not make enough insulin to keep blood glucose levels normal, often because the body does not respond well to insulin. Many people with type 2 diabetes do not know they have it, although it is a serious condition. Type 2 diabetes is becoming more common due to increasing obesity and failure to exercise. Diabetes

13. Risk factors for diabetes • There are many risk factors for type 2 diabetes, including: -Age over 45 years -A parent, brother, or sister with diabetes -Gestational diabetes or delivering a baby weighing more than 9 pounds -Heart disease -High blood cholesterol level -Obesity -Not getting enough exercise -Polycystic ovary disease (in women) -Previous impaired glucose tolerance

14. Diabetes mellitus presented with an ulcerating rash

15. Patients with type 1 diabetes usually develop symptoms over a short period of time. The condition is often diagnosed in an emergency setting Symptoms of type 1 diabetes: Fatigue Increased thirst Increased urination Nausea Vomiting Weight loss in spite of increased appetite Type 2 diabetes develops slowly, some people with high blood sugar experience no symptoms at all. Symptoms of type 2 diabetes: Blurred vision Fatigue Increased appetite Increased thirst Increased urination Symptoms of diabetes

16. Oral lesions at diabetes FIGURE 1. Lingual view of mandibular incisors of a 60-year-old female with poorly controlled type 2 diabetes. The HbA1c value at initial examination was 13.9%. Multiple periodontal abscesses (teeth 22, 23, 25, 26, and 27) with severe inflammation and bone loss can be seen. Figure 2. Radiograph of the same sextant shown in Figure 1. Severe bone loss can be noted on tooth 2.

17. Complications of Diabetes • 1. Eye Disease • 2. Kidney Disease • 3. Cardiovascular Disease • 4. Neuropathy • 5. Foot Problems • 6. Susceptibility to Dental disease, especially periodontal (gum) infections.

18. Main oral health problems People with diabetes are at higher risk for oral health problems, such as 1. gingivitis (an early stage of gum disease), 2. periodontitis (serious gum disease). People with diabetes are at an increased risk for serious gum disease because they are 1. generally more susceptible to bacterial infection 2. have a decreased ability to fight bacteria that invade the gums. Gingivitis in a 19-year-old women with uncontrolled diabetes mellitus

19. thrush, an infection caused by fungus that grows in the mouth, dry mouth which can cause soreness, ulcers, infections and cavities. Other oral problems associated to diabetes include: Inflamed, papulonodular hyperplasia of the gingiva in a diabetic patient

20. Periodontitis Increased rate of dental caries Xerostomia Salivary dysfunction Burning mouth and tongue Candidiasis Cheilosis Glossodynia Lichen Planus Oral changes associated with diabetes include cheilosis, mucosal drying, burning mouth and tongue, diminished salivary flow, alterations in the flora of the oral cavity and increased rate of dental caries. Periodontal changes include enlarged gingiva, sessile or pedunculated gingival polyps, polypoid gingival proliferations, abscess formation, periodontitis, and loosened teeth. Periodontal disease in diabetics follows no consistent or distinct pattern. Oral Complications of Diabetes

21. Salivary Dysfunction & Xerostomia • Salivary Hypofunction/ Dry mouth Dry mouth (xerostomia) occurs when the salivary glands are not functioning properly resulting in decreased saliva. Saliva not only aids in digestion, but is a necessary factor in oral health because it also helps to keep your mouth moist and prevent tooth decay. Diabetic neuropathy can also affect the salivary glands. • Polyuria • Topical treatments: • fluoride containing mouthrinses • salivary substitutes

22. Periodontal Disease • Increased prevalence of PerioDisease • Decreased healing in poorly controlled DM • Management of periodontal disease may help improve glycemic control

23. Dental Caries • Increased prevalence of dental caries • Salivary hyperglycemia

24. Oral Candidiasis • Opportunistic fungal infection commonly associated with hyperglycemia. • Salivary dysfunction compromise immune function. • Salivary hyperglycemia provide substrate for fungal growth

25. Burning Mouth Syndrome Burning mouth syndrome is a condition with no determined cause and is characterized by a chronic burning pain in your mouth. This burning sensation can be severe, feeling much the same as scalding and can affect the overall areas of your mouth such as your tongue, gums, lips, inside of your cheeks, and the roof of your mouth. Although BMS has no known cause and finding treatment may by difficult, most people can bring it under control by working with an oral health specialist.

26. Oral manifestations of patients with hyperthyroidism • -accelerated dental eruption in children, • -maxillary or mandibular osteoporosis, • -enlargement of extraglandular thyroid tissue, • -increased susceptibility to caries and periodontal disease, • -burning mouth syndrome, • -development of connective-tissue diseases such as Sjergen’s syndrome or systemic lupus erythematosus.

27. Oral manifestations of patients with hypothyroidism • -delayed eruption, • -enamel hypoplasia in both dentitions, • -anterior open bite, • -macroglossia, • -micrognathia, • -thick lips, • -dysgeusia, • -mouth breathing.

28. Oral manifestations of patients with hyperparathyroidism • 1. Dental abnormalities: -widened pulp chambers; -development defects; -alterations in dental eruption -weak teeth -maloclussions • 2. Brown tumor • 3. Loss of bone density • 4. Soft tissue calcifications

29. Oral manifestations of patients with hypoparathyroidism • 1. Dental abnormalities: • -enamel hypoplasia in horizontal lines; • -poorly calcified dentin; • -widened pulp chambers; • -dental pulp calcifications; • -shortened roots; • -hypodontia; • -delay or cessation of dental development. • 2. Mandibular tori • 3. Chronic candidiasis • 4. Paresthesia of the tongue or lips • 5. Alteration in facial muscles

30. Addison's disease Addison's disease results from a chronic insufficiency of the adrenal cortex. The first signs of the disease may be: - pigmentation of the skin and mucous membranes due to excessive deposition of melanin in the connective tissue and epithelial cells. Pigmentation of the skin appears in the areas exposed to light (the face, the back surface of the hands). As the disease progresses the skin become light brown or bronze color. -possible fatigue, gastrointestinal disturbances (nausea, vomiting, diarrhea, abdominal pain), headache, memory loss, weight loss.

31. Addison's disease Availability small (one to several square millimeters) grey-black spots or stripes, dark brown or grey-blue color without signs of inflammation on the mucous membrane of the: • mouth in the cheek area, • tongue edges, • palate, • gums. The spots can be oval or take the form of strips or fine grit, above the level of the mucous membrane, they are not separated.

32. Addison's disease The most common symptoms are fatigue, lightheadedness upon standing or while upright, muscle weakness, fever, weight loss, difficulty in standing up, anxiety, nausea, vomiting, diarrhea, headache, sweating, changes in mood and personality, joint and muscle pains.

33. Addison's disease is differentiated from:-multiple melanotic macules, -smoker’s melanosis, -Peutz-Jeghers syndrome, -heavy metal poisoning, -postinflammatory hyperpigmentation, -congenital pigmentation of the oral mucosa, which is observed in some nationsFig. the band-like grayish blue pigmentation of the maxillary and mandibular anterior gingiva after using drugs that include antimalarial agents.      *

34. Addison's disease • Treatment: -replace the missing or low levels of cortisol (hydrocortisone) • Prognosis: -Prognosis for patients appropriately treated with hydrocortisone and aldosterone is excellent. These patients can expect to enjoy a normal lifespan. -Without treatment, or with substandard treatment, patients are always at risk of developing Addisonian crisis.