1. The mouth and Systemic Disease Mike Pemberton

2. Dental Disease • Two main dental diseases • Dental Caries • Periodontal Disease

4. Dental Caries • To prevent caries • Less sugar, less often • Strengthen teeth with fluoride (toothpaste) • To treat caries • Treat (remineralise or excise and reconstruct) early to prevent pulp exposure (root canal work or extraction)

6. Periodontal disease • Reflection of inflammation due to • Build up of biofilm (plaque) on teeth • Host response • To prevent need good oral hygiene

7. Periodontal disease • Periodontal disease associated with • Type II Diabetes mellitus • Ischaemic heart disease • Low birth weight and premature babies

9. The mouth and Systemic Disease • Endocrine • Diabetes mellitus • Acromegaly • Cushing’s syndrome

10. Diabetes Mellitus – Oral effects • Susceptibility to infection - Candida - Periodontal disease • Sialosis • Xerostomia • Burning mouth

12. Acromegaly - Orofacial • Mandibular prognathism • Posterior open bite • Spacing of teeth • Macroglossia • Thickening of facial soft tissues

13. Oral Soft Tissues and Systemic Disease • Gastro-intestinal • Granulomatous conditions • Coeliac disaese

14. Oro-facial Lymphoedema Non-caseating giant-cell granulomas causing lymphatic obstruction

15. Oro-facial Lymphoedema - Signs • Facial swelling • Lip swelling • Angular cheilitis • Mucosal tags/cobblestoning • Ulceration • Aphthae • Full thickness gingivitis

16. Oro-facial Lymphoedema - Causes • Crohn’s disease • Sarcoidosis • Granulomatous infections • Oro-facial granulomatosis • Melkersson – Rosenthal syndrome

17. R.A.S. – Minor aphthae • 80% cases • Crops of 1-5 • Non-keratinised mucosa • 5 - 10 mm diameter • 7 – 14 day duration • No scarring

18. R.A.S. – Major aphthae • 15% cases • Usually solitary • Soft palate, lips • > 10 mm diameter • >14 days • Scarring occurs

19. R.A.S – Herpetiform aphthae • 5% cases • Crops of 20 –100 • Non-keratinised mucosa • 1-3 mm diameter (coalesce) • 10 -14 days • No scarring

20. R.A.S – systemic associations • Haematinic deficiency state • Gastrointestinal disease (Crohn’s, coeliac, ulcerative colitis) • Behcet’s syndrome • Immune disturbances • HIV, neutropenia, myelodysplasia • Others • PFAPA (periodic fever, aphthae, pharyngitis and adenitis syndrome)

21. R.A.S. – systemic associations • Coeliac disease (1 in 100 UK population) • approximately 4% of patients with classical R.A.S. • R.A.S. remits in patients with coeliac disease on a gluten free diet. • serological tests evolving

22. R.A.S. – Behcet’s • VIIth international conference 1996 agreed new diagnostic criteria: • Recurrent aphthous ulcers AND • any two of • genital aphthous ulceration • typical eye lesions (uveitis etc) • typical skin lesions (erythema nodosum, folliculitis) • Positive pathergy test • Others – musculoskeletal, CNS, GI, vascular

23. Oral Soft Tissues and Systemic Disease • Haematological • Dyscrasia’s • Anaemia

24. Acute leukaemia – Full blood count • Anaemia • Thrombocytopenia • White cell changes - Malignant overproduction of abnormal white cells - Lymphoblastic/Myeloblastic

25. Dyshaemopoietic anaemia - Oral effects • Recurrent Aphthous stomatitis • Glossitis • Candidal infection • Burning Mouth Syndrome • Plummer – Vinson Syndrome

26. Oral Soft Tissues and Systemic Disease • Rheumatological • Sjogren’s syndrome • Behcet’s • Systemic lupus erythematosis

27. Xerostomia - Aetiology • Developmental • Iatrogenic - Drugs - Irradiation • Dehydration - Diabetes mellitus - Renal failure • Salivary gland disease - Sjogren’s syndrome • Psychogenic

28. Sjogren’s Syndrome – Orofacial management Dry Mouth • stimulation of residual saliva production • Local • Sugar-free chewing gum/ SST/ Salivix pastilles • systemic • Pilocarpine • Replacement products • Artificial saliva’s/ gels • Caries control • Candidal infection control

29. Systemic Lupus Erythematosus • Multi-system autoimmune disease • Antibodies produced against variety of autoantigens (e.g ANA including dsDNA) • Orally can mimic many conditions • Oral ulceration • Lichenoid type lesions

30. Oral Soft Tissues and Systemic Disease • Muco-cutaneous disease • Lichen planus • Vesiculo-bullous disease • Pemphigus vulgaris • Mucous membrane pemphigoid • Erythema multiforme

31. Mucocutaneous disease • Oral • Other mucosal surfaces • Nasal, pharyngeal, • Genital • Ophthalmic • Oesophageal • Skin and appendages

32. Vesiculo-bullous Disease • Pemphigus vulgaris • Mucous membrane pemphigoid • Erythema multiforme

33. Pemphigus vulgaris • Rare disease • Middle aged, elderly females • Antigen is desmoglein 3 – a constituent of desmosomes forming ‘epithelial intercellular cement.’ • Genetic background • Classical autoimmune disorder

34. Pemphigus vulgaris • Management • Historically a fatal disease • Immunosuppresion • Systemic steroids • Azathioprine • Mycophenylate mofetil • ? Infliximab

35. Mucous membrane pemphigoid • Uncommon • Middle aged and elderly females • Classical Autoimmune disorder • Various antigens, all at the basement membrane zone • Bullous pemphigoid – affects skin • MMP – affects mucosa (cicatricial pemphigoid) • Oral pemphigoid • Ocular pemphigoid

36. Mucous membrane pemphigoid • Management • Occular complications important • Treatment • Mild cases • topical steroids • Improve oral hygiene • Severe cases • Dapsone • Steroids/ Azathioprine / Mycophenylate

37. Oral Soft Tissues and Systemic Disease • Immunosuppresion • HIV

38. Acquired Immune Deficiency SyndromeA.I.D.S. • 2009 in UK • 86,000 living with HIV • >1 in 1000 in UK • Regional variation • 22,000 unaware (25%) • 6000 new cases diagnosed but incidence falling • Encouragement for more widespread testing

39. H.I.V.Treatment 3 • Average age of patient in developed world clinic getting older • Patients who achieve durable suppression of the HIV virus have increased risk of several ‘non-AIDS’ complications • Cardiovascular disease • Liver disease • Cancer • End-stage renal disease