Oral Manifestations of Systemic Diseases

Diseases of the Heart

Cardiac conditions such as ischemic heart disease, myocardial infarction, and hypertension have remained the number one cause of death for the past five decades. Given that these diseases are common chronic ailments that affect the elderly, any oral manifestations of the conditions, as well as their treatments, will become more common in the future with the expansion of the older population.

Some cardiovascular conditions and their subsequent treatment have orofacial signs and symptoms and therefore have oral treatment considerations. Anginal pain can appear as referred pain to the neck, clavicle, and mandible, and it can be localized to the mandible and teeth. A comprehensive differential diagnosis must include consideration of dental-alveolar origin (e.g., caries, periodontal disease), temporomandibular joint (TMJ) disease, referred musculoskeletal pain, central or peripheral nervous system pain, and myocardial infarction.

Several epidemiologic studies have demonstrated an association, but not a causal relationship, between heart disease and dental/periodontal diseases. There is a theory that periodontal pathogens and certain serologic proteins found in the gingival sulcus (particularly C-reactive protein) have also been found in carotid atheromas. Intensive periodontal treatment resulted in acute, short-term systemic inflammation (increased levels of C-reactive protein, interleukin-6, and the endothelial-activation markers soluble E-selectin and alpha1-antitrypsin), as well as mild endothelial dysfunction. However, to this date, a direct linkage between the microbes found in periodontal disease and the onset of coronary artery disease has not been identified. Although a biologic association is plausible, recommendations relating to therapeutic intervention based upon current studies are still unwarranted.

The treatment of cardiovascular diseases with drugs also has deleterious oral consequences. For example, antihypertensive medications have been shown to cause salivary dysfunction (as in the cases of diuretics, calcium channel blockers, and β-blockers), gingival enlargement (calcium channel blockers), lichenoid mucosal reactions (thiazide diuretics), and disturbances in taste (angiotensin-converting enzyme inhibitors, calcium channel blockers). Consideration of possible alteration of drug regimens is appropriate.

Patients who have undergone cardiac transplantation and are receiving postoperative immunosuppressive medications must be evaluated for potential oral complications. Immunosuppressive therapy increases the prevalence of oral opportunistic infections, such as reactivation of herpes simplex virus (HSV) and overgrowth of Candida albicans. Cyclosporine, a frequently used antirejection drug, has been reported to cause gingival enlargement in up to 13% to 85% of patients. That being said, the most common oral finding in patients who are on immunosuppressive medication continues to be mucositis.

Consideration must be given to cardiac conditions before dental treatment is undertaken. Patients who receive anticoagulation therapy may come to medical attention with hemorrhagic lesions of oral mucosal tissues (see “ Cerebrovascular Diseases ” later). Patients at high risk for bacterial endocarditis are listed in Box 12.1 . A Cochrane review of this topic reports that there is no evidence that antibiotic prophylaxis prevents the onset of bacterial endocarditis. In the United States, it is considered standard of care to administer antibiotic prophylaxis in patients undergoing dental procedures that involve manipulation of gingival tissue, the periapical region of teeth, or perforation of the oral mucosa. The regimen for antibiotic prophylaxis recommended by the American Heart Association is provided in Table 12.3 .

The use of local anesthetics with epinephrine can be a concern in the treatment of cardiac patients because of the effect of increased heart rate, stroke volume, and cardiac output. However, at low doses, epinephrine has been found to have few of these systemic effects, and in stable cardiovascular patients, it can be safely used. For patients with a questionable cardiac history, 0.04 mg of epinephrine should be the maximum dose given (approximately two 1.8-mL ampules of local anesthetic with 1 : 100,000 epinephrine), whereas unstable cardiac patients should receive epinephrine only if needed.

Malignant Neoplasms

Oropharyngeal cancer involves the soft palate, tonsil, base of the tongue, and vallecula, and is diagnosed in approximately 50,000 men and women in the United States in 2017. Cancers of the oral cavity and pharynx, which represent 2.9% of all neoplasms in the United States, have a direct and frequently permanent deleterious effect on oral health and function. Although men had a much greater likelihood of developing oropharyngeal cancer in the past, the male/female ratio is now 3 : 1. The prevalence and mortality of oral cancers increase with age, and the major preventable risk factors are tobacco use and excessive alcohol consumption.

Common signs include nonhealing crusting and ulcerated leukoplakic and erythemic lesions. Pain is not necessarily a symptom of oral cancers, and patients should be advised to see their dentists or physicians for definitive diagnosis if a lesion or swelling has not resolved within a 2- to 3-week period.

Most of the remaining 10% of head and neck malignancies are salivary gland tumors or lymphomas; furthermore, approximately 1% of all tumors originate below the clavicles and metastasize to the head and neck. Accordingly, visual inspection and palpation of the head and neck region must include lymph nodes, muscles of mastication and facial movement, and salivary glands. A biopsy is required of all nonhealing head, neck, and oral lesions.

Early detection of oral cancer is critical, because patients with early-stage tumors have significantly better survival rates than those with late-stage cancers that have already metastasized. For example, 5-year survival rates for small and localized tongue cancers, stage I, as opposed to those tongue cancers with lymph node involvement and metastasis, stage IV, are 76% and 27%, respectively. Accordingly, since 1980, the American Cancer Society has recommended a cancer-related checkup every 3 years for individuals aged 20 to 39 years and an annual checkup for those 40 years and older. This is particularly relevant for the elderly population and, in particular, for older edentulous adults; they see their dental practitioner less frequently than their younger counterparts.

The treatment of most cancers will indirectly or directly affect oral health and function. Chemotherapy causes reversible mucositis, stomatitis, salivary hypofunction, smell and taste dysfunction, diminished appetite, and increased susceptibility to oral microbial infections. Clinically significant nutritional deficiencies and dehydration can occur in the presence of severe oral and pharyngeal mucositis and recurrent microbial infections. Because of the significant morbidity and mortality of antineoplastic therapies, these patients require frequent and long-term follow-up by dental professionals.

Treatment of oropharyngeal neoplasms includes surgery, radiation therapy, and chemotherapy, depending on the tumor stage and extent of regional spread. Extensive removal of the cancerous growth and affected lymph nodes can result in significant facial disfiguration, dysphagia, altered speech and mastication, trismus, paresthesia, salivary gland dysfunction, and diminished neck and shoulder mobility. Head and neck radiation is frequently used after surgery for the treatment of residual and microscopic disease; however, it also has significant adverse effects. Sequelae include mucositis, stomatitis, dysphagia, permanent salivary gland dysfunction, smell and taste alteration, oral microbial infections (e.g., reactivation of HSV, varicella-zoster virus [VZV], and C. albicans infections), and the risk of developing osteoradionecrosis.

Importantly, these patients must undergo preoperative dental evaluation prior to definitive therapy so as to minimize oral sequelae caused by surgery, chemotherapy, and radiotherapy. Both dentate and edentate postoperative patients must continue to perform scrupulous oral hygiene and to maintain a regular recall schedule with oral health professionals to reduce the risk of developing osteoradionecrosis, oral microbial infections, and other oral pathologies. Prior to radiation treatment, fluoride trays should be fabricated.

Bisphosphonates

Oral bisphosphonates are given for the management of osteoporosis and as a component of chemotherapy regimens. A listing of these medications is found in Table 12.2 . Although highly effective for both uses, the adverse effect of osteonecrosis of the jaws (ONJ) needs to be addressed.

Currently, this effect/disease process, which is termed medication-related osteonecrosis of the jaws (MRONJ), ranges from small areas of exposed bones to complete necrosis of the mandible or maxilla or both ( Fig. 12.1 ). The oral bisphosphonates, when used for osteoporosis, rarely causes necrosis of the bone, with an incidence of 0.4%. The intravenous form has a significantly higher incidence of 5% to 20%. Although the exact mechanism of this effect is not known, our empiric knowledge indicates that bisphosphonates affecting osteoclast function is the underlying causative factor. Treatment spans local debridement to complete resection of the necrotic bone. Nonvascularized grafting is not recommended, although there are no contraindications for the use of vascularized flaps.

Cerebrovascular Diseases

The motor, sensory, and cognitive alterations that accompany cerebrovascular diseases have deleterious effects on oral health and function. A cerebrovascular accident can cause permanent oral sensory and motor deficits that often result in poor tongue function and lip seal, difficulty eating and drinking, impaired use of dentures, and visuospatial problems with adverse social and psychologic consequences. Nutritional deficiencies and diminished quality of life can result from impaired food and fluid intake.

The location of the cerebrovascular accident determines the orofacial deficits. Left cerebral cortex lesions cause right-sided paralysis and difficulty with auditory memory, speech, language, and the oral phase of swallowing. Right cortex lesions cause left-sided paralysis, pharyngeal dysfunction with potential for aspiration, and difficulty with memory and performing simple oral hygiene tasks such as tooth brushing. Orofacial motor and sensory impairments can lead to improper dental and denture hygiene and food accumulation in the dentition, buccal vestibules, and beneath the tongue. Ultimately, this can lead to dental and periodontal diseases and oral microbial infections that can become exacerbated by the lack of sensory detection by the patient. Some patients experience problems with communication, judgment, and memory, and this inhibits accurate solicitation of the patient's pertinent medical history, chief complaint, and compliance with home care instructions.

Anticoagulation therapy, the standard preventive treatment after a stroke, can produce hemorrhage, petechiae, ecchymosis, and purpura of all oral mucosal tissues. Dental treatment can be safely performed on patients on warfarin if the international normalized ratio is 3 or less. However, if excessive dental-alveolar surgery is planned, conversion to low-molecular-weight heparin or heparinization in a hospital setting is recommended. Aspirin use is popular in adults at risk for cardiovascular thrombotic events, and low-dose aspirin is an excellent preventive agent; however, its antiplatelet properties have contributed to a perceived increased risk for bleeding after dental extractions. For most patients who require simple oral surgical procedures, if local hemostatic and conservative surgical techniques are used, the discontinuation of aspirin should not be necessary.

Pulmonary Diseases

A common link between oral health and pulmonary diseases—such as chronic obstructive pulmonary disease (COPD), bronchitis, asthma, and emphysema—is smoking. One of the two preventable causes of oral cancer, smoking is also associated with benign oral mucosal pathology (nicotinic stomatitis, oral fungal infections). Little is known regarding the direct effects of COPD on oral health, yet it is well established that a treatment modality of COPD with corticosteroids has many oral consequences in children and adults, particularly an increase in carious lesions. Chronic use of systemic and inhaled corticosteroids also predisposes patients to oral fungal infections. Finally, nitrous oxide use is contraindicated in those with severe COPD secondary to oxygen-driven respiratory function.

Aspiration pneumonia is caused by the aspiration of gastric or oropharyngeal secretions; it is a common condition, particularly in hospitalized and older adults with compromised immune systems. Oropharyngeal swallowing dysfunction—a consequence of neuromuscular diseases, cerebrovascular diseases, debilitation, salivary hypofunction, and medications—is a frequent risk factor for aspiration pneumonia. Colonization of the oropharynx with gram-negative bacilli predisposes to bacillary pneumonia. A major source of anaerobe infection is the gingival crevice. Furthermore, the prevalence of bacterial colonization increases with poor oral hygiene and periodontal disease; therefore, patients at risk should follow a regular dental hygiene regimen. Broad-spectrum antibiotics are the standard treatment for pneumonia, although extended antibiotic use increases the risk of developing oral fungal infections and antibiotic resistance.

Tuberculosis (TB), a major global health problem caused by the spread of Mycobacterium tuberculosis , manifests infrequently in the oral cavity. The classic oral mucosal lesion is a painful, deep, irregular ulcer on the dorsum of the tongue, with additional sites including the palate, lips, buccal mucosa, and gingiva. M. tuberculosis can also infect the cervical and submandibular lymph nodes (referred to as scrofula ) and can be present in the major salivary glands, particularly the parotid glands. Tuberculosis of the parotid glands is usually discovered following surgical removal.

Oral TB lesions require diagnosis and appropriate antimicrobial management in addition to education on possible transmission via infected oral sites. Positive oral cultures of M. tuberculosis from samples of saliva, caries lesions, and denture plaque collected from TB patients have been reported, demonstrating the possibility of oral infectivity of these patients. As with other diseases, salivary biomarkers are being used to diagnose as well as monitor the response of the organism to the various antituberculosis agents.

Endocrine and Exocrine Disorders

Collagen-Vascular and Granulomatous Disorders

Infectious Diseases