REVIEW ARTICLE

Effects of Systemic Diseases on Oral Health

Mayank Agrawal1, Sugandha Agarwal2, Sonam Agrawal3

Abstract
Systemic autoimmune and inflammatory diseases often manifest oral lesions in their earliest
stages, and early diagnosis, which may be spurred by a dental examination, is key for improved
outcomes. After systemic diagnosis, oral lesions benefit from specialized care by dentists in
collaboration with the medical team. An understanding of the relationship between systemic
disease and oral pathology is important with respect to establishing the diagnosis and determining
the complexity of subsequent management.
Oral involvement precedes the appearance of other symptoms or lesions at other locations.
These oral manifestations must be properly recognized if the patient is to receive appropriate
diagnosis and referral for treatment.
Thus oral cavity is an important diagnostic area not just because it contains derivatives of all
of the primary germinal layers, and includes tissues not demonstrable anywhere else in the body,
but also because of its role played in diagnosing a number of systemic diseases just because of
their oral manifestations.
(Agrawal M, Agarwal S, Agrawal S. Effects of Systemic Diseases on Oral Health.
www.journalofdentofacialsciences.com, 2014; 3(2): 5-10.

Key words: oral, diseases, systemic, manifestation

Introduction to the body, a constant barrage of invaders like

bacteria, viruses, parasites, and fungi, challenges
The mouth is a mirror of health or disease, a
the mouth. Many systemic diseases have oral
sentinel or early warning system. As the gateway
manifestations.1 A wide array of systemic diseases
1
encountered in internal medicine have
Assistant Professor, Dept of Public Health Dentistry,
manifestations in the oral cavity. Most of these
Rajasthan Dental College and Hospital. Jaipur; 2Senior
3
Lecturer, BBDCODS, Lucknow; Lecturer, Rajasthan manifestations are nonspecific but should alert the
Dental College and Hospital. Jaipur. surgeon to the possibility of concurrent systemic
Address for Correspondence:
disease or latent systemic disease. Some diseases
Dr Mayank Agrawal identified in the oral cavity may be specific.3
e-mail: mayank400@yahoo.co.in These lesions develop on the oral mucosa,
6 Agrawal et al.

tongue, gingiva, dentition, periodontium, salivary meat and liner, peanuts, yeast. Niacin deficiency
glands, facial skeleton, extraoral skin and other syndrome - pellagra. The clinical syndrome is
related structures. These oral manifestations must identified as dermatitis, diarrhea, dementia.
be properly recognized if the patient is to receive Oral manifestations are:
appropriate diagnosis and referral for treatment.1
1. Stomatitis (redness, thickening, roughening,
Vitamin Deficiencies1 scaling, fissures and chronic inflammation)
Vitamin A 2. Glossitis (tongue red, swollen and beefy)
It is a vitamin that is needed by the retina of 3. Oral mucosa becomes fiery red and painful.
the eye, that is necessary for both low-light and
4. Glossitis, pain, redness and ulceration begin
color vision.
at the interdental papillae and spread rapidly.
Oral manifestations are-
Pyridoxine (Vitamin B6)
1. Tooth Eruption rate is retarded
Participates in aminoacid synthesis. Occurs in
2. Retarded alveolar bone formation, animal and vegetable food. A deficiency is
3. Hyperplastic gingival epithelium followed by unusual.
keratinization Oral manifestations are:
Riboflavin (Vitamin B2) 1. Cheilitis
Participates in a wide range of oxidation- 2. Glossitis
reduction reactions in the form of coenzymes.
Vitamin C deficiency (Scurvy)
Ariboflavinosis is associated with number of
Necessary for the proper synthesis of
oral alterations: Initially glossitis involving the tip
collagen. Occurs mainly in citrus fruits. A
and/or the lateral margins of the tongue,
deficiency is known as Scurvy. Hemorrhage
followed later by complete atrophy of all
(purpura and ecchymoses) of skin and gingival
papillae. The tongue has a magenta color. Pallor,
mucosa, subperiostal hematomas are common.
involving oral mucosa followed by cheilosis and
Skeletal changes in infants and children.
fissuring at the angles of the mouth.
Oral manifestation are:
Oral manifestations are:
1. Gingival swelling with spontaneous
1. Sore throat
hemorrhage, ulceration, tooth mobility,
2. Swelling and erythema of the oral mucosa. secondary periodontal infection and
3. Cheilosis- Changes at the angles of the periodontal bone loss. The gingival lesions are
mouth. called Scorbutic gingivitis.
4. Initially there is hyperkeratosis of the 2. Wound healing and localization of focal
epidermis, inflammation in the dermis. infections are impaired because of the
5. Later occur fissures radiating from the corners derangement of collagen synthesis.
of the mouth which become secondarily 3. There is inflammation of the inter dental and
infected. marginal gingiva followed by bleeding,
6. Glossitis- Tongue is atrophic, glazed with red- ulceration, halitosis.
blue coloration resembled to cyanosis. 4. Hemorrhages and swelling of the periodontal
Niacin deficiency (Vitamin B3) membranes occur, followed by loss of bone
and loosening of the teeth, which eventually
Acts as a coenzyme for oxidation reduction
exfoliate.
reactions. Foods containing niacin include lean
5. Scurvy

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Agrawal et al. 7

Vitamin D 1. Icterus of the oral mucosa in the palatal and

Developmental anomalies of dentin and the sublingual region.
enamel, delayed eruption, and misalignment of 2. In severe cases patient may present with
the teeth in the jaws, there is often peri-apical spontaneous bleeding in the oral cavity.
involvement of grossly normal appearing Gastroesophageal Reflux Disease
deciduous or permanent teeth, followed by the
Dental erosion is the loss of tooth structure due
development of multiple gingival fistulas and
to chemical (usually acids) exposure. Sources of
Rickets. Radiographically there is abnormal
acids include diet (soft drinks, juices), gastric
alveolar bone pattern. Cementum, and lamina
secretions or industrial chemicals. Additionally
dura around the teeth is absent or poorly defined.
hyposalivation, the use of acidic medicaments
Vitamin K intra-orally and improperly performed oral
A deficiency or inhibition of syntheses of hygiene procedures have all been associated with
vitamin K leads to coagulopathy (inadequate dental erosion. Patients with dental erosion are
synthesis of prothrombin and other clotting more susceptible to attrition and may complain of
factors). Most common oral manifestation is dental sensitivity, Dental erosion.
gingival bleeding. Prothrombin levels below 35% Aquired Immuno Deficiency Syndrome (AIDS)
result in bleeding after tooth brushing; and when
Defination by WHO- “One or more
below 20% result in spontaneous gingival
oppurtunistic infections listed in clinical feature
hemorrhages, Gingival bleeding.
that are atleast moderately indicative of
Diseases of Gastrointestinal Tract underlying cellular immune deficiency. Absence of
Hepatitis all known underlying causes of cellular immune
The hepatitis C virus (HCV) is an enveloped, deficiency and absence of all other causes of
single-stranded, positive-sense RNA virus whose reduced resistance reported to be associated with
primary target organ is the liver. 16 Hepatitis is an alteast one of those opportunistic diseases.“ 95%
acute inflammatory and infective infection causing of AIDS patients have head and neck lesions and
the inflammation of the liver. HCV infection mainly about 55% have important oral manifestations.
targets the liver, causing hepatitis, cirrhosis, and The oral signs of HIVD/AIDS are categorized
hepatocellular carcinoma.16 The pathogenesis of as:
HCV infection has become increasingly linked to 1. Fungal Infections
multiple organs, not just limited to the liver.16 The
2. Viral Infections
symptoms include high grade fever with
3. Bacterial Infections
tenderness, enlargement of liver, vomiting,
malaise etc. 4. Neoplasms
Oral manifestations are Icterus of the oral 5. Others
mucosa in the palatal and the sublingual region.  FUNGAL LESIONS
Jaundice i) Candidiasis
ii) Histoplasmosis
It is the yellowish discoloration of the skin and iii) Cryptococcus Neoformans
mucosa resulting from accumulation of bilirubin in
 VIRAL LESIONS
the tissue. It occurs when bilirubin is elevated in
the blood. i) Herpes Simplex
ii) Herpes Zoster
Oral manifestations are: iii) Human Papillomavirus Lesions
iv) Cytomegalovirus

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8 Agrawal et al.

v) Hairy Leukoplakia and Epstein-Barr Virus lower ipsilateral face and lip, ulcers and pain in
 BACTERIAL LESIONS tongue, soft tissues and mandibular teeth.
-Periodontal Disease Sialadenitis (mumps)
 NEOPLASTIC LESIONS An acute infectious viral infection of salivary
i) Kaposi's Sarcoma glands. Mainly affected are children with no
ii) Lymphoma gender disparity.
 OTHER ORAL LESIONS ASSOCIATED Oral findings: Parotitis and trismus. Acute onset of
WITH HIV DISEASE painful, usually bilaterally, enlarged parotids,
i) Oral Ulceration although in the early stages only one parotid
ii) Idiopathic Thrombocytopenic Purpura gland may appear to be involved. The
iii) Salivary Gland Disease and Xerostomia submandibular glands may also be affected.
VIRAL INFECTIONS Bacterial Infections
Herpers simplex Tuberculosis
Herpes simplex virus (HSV) infection is Rarely does tuberculosis manifest itself as an
common and affects mainly the mouth or genitals. oral lesion, occurring in less than 5% of patients
Initial oral infection presents as primary herpetic with Tuberculosis.
stomatitis (gingivostomatitis). All herpes virus
Oral lesions are almost always the result of
infections are characterized by latency and can
contact between the oral tissue and infected
be reactivated. Primary stomatitis presents with a
sputum or hematogenous dissemination in an
single episode of multiple oral vesicles which may
elderly patient (secondary oral Tuberculosis).
be widespread, and break down to form ulcers
Primary oral TB is exceedingly rare as intact oral
that are initially pinpoint but later fuse to produce
tissues along with saliva provide an adequate
irregular painful ulcers. Gingival edema,
barrier against direct mycobacterial invasion.
erythema and ulceration are prominent. The
Traumatized oral tissue, leukoplakias and recent
tongue is often coated and there may be oral
dental extractions have been implicated in
malodor.
predisposing patients to oral Tuberculosis. Oral
Chickenpox tubercular lesions appear as irregular, indurated,
A centripetal (concentrated mainly on trunk ulcerations, fissures or swellings. Lesions may be
and head and neck) rash which passes through solitary or multiple and are often painful. Affected
macular, papular, vesicular and pustular stages. sites include the dorsal tongue, mucosa, palate
Oral findings: Vesicles, especially in the palate, and gingiva. Due to their variable clinical
rupture to produce painful, round or ovoid ulcers, appearance the differential diagnosis should
with inflammatory haloes. include fungal and bacterial infection, sarcoidosis,
Zoster (shingles) chronic aphthous ulcerations as well as
malignancy. Other oro-facial manifestations of
A painful unilateral rash in a dermatome
Tuberculosis include macroglossia, Parotid gland
(distribution of a sensory nerve)
enlargement, facial nerve dysfunction and
Oral findings: Unilateral, severe, pain and /or tubercular osteomyelitis.
paresthesia occurs before, during and sometimes
Syphilis
after (post-herpetic neuralgia, PHN) the rash.
Maxillary zoster – rash over ipsilateral cheek, It is also known as Lues. It occurs most
ulcers and pain in ipsilateral palate and maxillary exclusively by venereal contact, in over crowded
teeth. Mandibular zoster – rash and pain over living and primitive housing condition. Classified

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Agrawal et al. 9

as- Primary syphilis, a primary chancre (hard or severe muscle spasm caused by Clostridium
Hunterian chancre) may involve the lip, tongue or tetani.
palate. Oral manifestations are pain and stiffness in
A small, firm, pink macule changes to a the jaw, neck muscles with muscle rigidity
papule which ulcerates to form a painless round producing trismus, dysphagia. Trismus may
ulcer with a raised margin and indurated base. stimulate acute oral infection, trauma, and
They are highly infectious and are associated with temporomandibular dysfunction.
enlarged, painless regional lymph nodes. In Renal Disorders
secondary syphilis, which follows after 6–8
Renal Failure
weeks, about one-third of patients have highly
infectious painless ulcers (mucous patches, split Renal failure (also known as kidney failure or
papule and snail-track ulcers). Rash and renal insufficiency) is a medical condition in which
lymphadenopathy are common. In tertiary syphilis the kidneys fail to adequately filter waste products
a localized granuloma (gumma) that varies in size from the blood.
from a pinhead to several centimeters may arise, Oral manifestation: Ammonic taste and smell is
affecting particularly palate or tongue. Gummas found in mornings. It is caused by high
break down to form deep chronic punched out concentration of urea in saliva and its breakdown
ulcers that are not infectious. More common is to ammonia. Xerostomia is also seen in patients
leukoplakia on the dorsum of the tongue which with renal failure. Enamel hypoplasia, pulpal
has been considered as having a high potential narrowing and calcification, severe tooth erosion
for malignant change. and loss of lamina dura is also found.
Leprosy Uremia
Chronic infectious disease which is mainly It is a clinical condition caused by retention of
seen in skin nerves mucous membrane caused by urinary constituents in the blood.
Mycobacterium leprae. Nodules (lepromas) and Oral manifestations: There is unpleasant taste and
superficial erosions in soft palate .The most varied dryness of mouth. Oral bleeding tendency and
types of lesions. They infiltrate, ulcerate, candidiasis is also observed.
perforate, and are reddish or yellow-reddish Metabolic Disorders
nodules, sessile or pedunculated, varying from 2
Protein Deficiency
to 10 mm, some confluent, and prone to
ulceration. Also seen on tongue, uvula and It mainly includes marasmus and kwashiorkor
gingival. Gingival hyperplasia and loosening of disease. Marasmus is the overall deficit of food
teeth are also found. intake while kwashiorkor is associated with
primary dietary protein deficiency.
Diphtheria
Oral manifestations include bright reddening of
Diphtheria is an upper respiratory tract illness
the tongue with loss of papillae, dry mouth,
caused by Corynebacterium diphtheriae which is
Candidiasis. Edema of the tongue may also
a gram-positive bacterium. It is characterized by
develop with scalloping of the lateral margins.
sore throat, low fever and an adherent membrane
Bilateral angular chelitis, fissuring of the lips,
(a pseudomembrane) on the tonsils, pharynx, and
xerostomia and decreased over all growth of the
nasal cavity.
jaws is seen. There is gingival and periodontal
Tetanus degeneration.
Also called as lock jaw. Is characterized by Disturbances in Mineral Metabolism
intense activity of motor neurons, resulting in

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10 Agrawal et al.

Zinc Deficiency accessibility for visual investigation, and

Oral manifestations include erythematous, examination by palpation.
pustular, moist erosions of the orofacial areas
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