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Many systemic diseases may develop manifestations in the oral cavity, sometimes before it is evident in any other part of the body.


This is an acute, contagious disease caused by a virus. It is transmitted by saliva droplets via the respiratory tract. The disease usually occurs in children and the initial episode provides immunity to further attacks of the disease. Koplik's spots appear several days before the characteristic skin lesions of measles. The spots are bluish-white and surrounded by an inflamed red zone. These spots are formed on the buccal mucosa opposite the molars.

2-22. MUMPS

This condition is an acute, contagious viral infection. It is characterized chiefly by swelling of the salivary glands, usually the parotid gland. Symptoms of the disease include fever, chills, headache, and painful swelling below the ear. Salivation and opening the mouth cause discomfort. The parotid duct opening in the buccal mucosa is usually reddened and swollen. The saliva itself contains the virus.

2-23. SCURVY

This is a rare condition due to a deficiency of vitamin C in the diet. Scurvy is marked by anemia, spongy gums, and a tendency for bleeding by the mucous tissues. The gingiva may have a purplish color.


This condition is a result of a vitamin B12 deficiency in the diet. Symptoms include generalized weakness, numbness or tingling of the extremities, and a sore, painful tongue. The tongue is generally inflamed and often described as beefy-red in color. Treatment consists of the ingestion of vitamin B12 and folic acid.

2-25. EPILEPSY (Figure 2-18)

This disease is discussed here because of the use of Dilantin in its treatment and the marked gingival hyperplasia that may result. (Hyperplasia is rapid growth of the dense, fibrous connective tissue of the gingiva.) In advanced hyperplasia, the teeth may be completely covered by firm, light pink gingival tissue. Normally, bleeding, inflammation, or secondary infection is not a problem in these cases. Treatment of the hyperplastic tissue is surgical removal and strict oral hygiene care to prevent recurrence.

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Figure 2-18. Dilantin hyperplasia.

NOTE: Gingival tissue overgrowth of the clinical crown is caused by Dilantin therapy in some patients. Poor oral hygiene contributes to this development, with the fibrous tissue compounding the hygiene problem.


The causative agent of candidiasis is a yeast-like fungus called Candida albicans. This condition is characterized by lesions that appear on the oral mucosa as white or gray-white patches resembling curdled milk. Limited numbers of this fungus normally occur in the mouths of healthy persons but can cause disease in newborn infants, patients receiving antibiotics, and patients who are debilitated due to alcoholism, leukemia, diabetes, or acquired immunodeficiency syndrome (AIDS).


Leukemias are a group of often-fatal diseases that may show early oral symptoms. They are characterized by marked increases in the number of leukocytes, many of which do not mature. Leukemias may vary from acute to chronic, with the acute form being more common in young persons and the chronic form in older persons. Acute leukemia in a young person responds very well to chemotherapy and five-year cure rates are the rule. Oral symptoms of leukemias include hemorrhaging, ulceration, and enlargement, spongy texture, and magenta coloration of the gingiva. Enlargement of lymph nodes, symptoms of anemia, and hemorrhagic tendencies are also typical. The diseases occur in myelogenous, lymphatic, and monocytic forms. These forms are for the type of white blood cell that is most predominant in the disease.


Diabetes mellitus is a disease in which the body is unable to use carbohydrates (primarily sugar) due to a deficiency in the insulin secretion of the pancreas. This disease is controlled by strict dietary restriction supplemented, as needed, by insulin or other drugs. This metabolic disorder lowers tissue resistance to infection and retards healing. Diabetics also appear to be more susceptible to periodontal disease. This disease may be accompanied by a tendency of gingival tissues to bleed easily.


This disease is characterized by increased deposits of melanin in the tissue. Pigmentation of the lips, mucosa, and gingiva are common. Addison's disease is caused by insufficient secretion of the adrenal glands. Since these patients are very sensitive to minor stresses, dental procedures must be carried out with proper precautions.


Hemophilia is a condition in which bleeding is profuse because of inadequate clotting factors. The lack of the clotting mechanism results in prolonged, uncontrolled bleeding. This condition is a sex-linked hereditary disease confined mainly to males, but it is transmitted by females. The eruption of teeth or extraction or exfoliation of teeth may be accompanied by bleeding possibly lasting days. Since death could result from hemophilia, recognition of it is important before even minor dental procedures are attempted. They should be treated under controlled conditions, such as at a hospital dental clinic.


The dental specialist must be aware of some diseases that can be transmitted in the dental clinic. Being aware of these diseases will make sterilization and disinfection procedures more meaningful.


Influenza, the common flu, is spread by airborne droplet viruses that consist of many different antigenic types. Therefore, it is difficult for a vaccine to be completely effective. New antigenic types are produced by mutation of the viruses. The common cold is caused by many different viruses (possibly hundreds), each of which may have antigenic types.


Hepatitis is a disease caused by a virus that damages the liver. In severe cases, liver necrosis (death of tissue) is common. The two types of distinguishable hepatitis are infectious hepatitis (Type A) and serum hepatitis (Type B). Infectious hepatitis is usually spread by fecal contamination of food or drink. It has an incubation period of about 30 days. Serum hepatitis can be spread by punctures of the tissue with needles and dental scalers that have come in contact with contaminated blood or serum. It has a much longer incubation period (perhaps several months) than infectious hepatitis. The risk of infection is greater between patients than between patient and dental specialist. All dental specialists should be tested and immunized against Type B hepatitis if they are not already immune.


Tuberculosis is caused by a nonsporeforming bacillus bacteria, Mycobacterium tuberculosis. Cross-infection most likely occurs by droplet transmission. Active tuberculosis infects the individual with a virulent (a strong disease-causing organism) strain of bacteria that the patient cannot ward off by natural means. Inactive tuberculosis occurs when the bacteria are walled off by the fibrous tissue. Even though the Tine and the Mantoux tests detect the presence of circulating antibodies, these tests do not tell whether the infection is active or inactive. A positive test result merely indicates either a present or previous infection with the tuberculous bacteria. A positive test result should always be reported to the dental or medical officer. Tuberculosis of the oral mucosa occurs if wounds or erosions become infected by tubercle bacilli contained in the sputum. The oral lesions vary greatly in their appearance. The tongue is the most frequent site for these lesions. Antibiotics are effective in the treatment of certain types of tuberculosis. However, multi-drug resistant strains have been discovered recently. Outbreaks of tuberculosis have occurred in areas with a high HIV population.


Acquired immunodeficiency syndrome(figures 2-19 and 2-20) is a severe condition caused by infection with the human immunodeficiency virus (HIV). Infected patients may have a variety of manifestations ranging from no symptoms at all to severe immunodeficiency and life-threatening secondary infectious diseases. There are three stages to this disease: asymptomatic infection HIV, AIDS-related complex (ARC), and AIDS. The serum test for the HIV antibody is not necessarily "positive" in all three stages of HIV infection. In stage one (defined here as infection with HIV), the mean conversion time to a positive serum antibody test following introduction of the virus is thought to be about 42 days, but may be longer. (The test will not be positive until sufficient antibodies are present.) Therefore, a patient infected with HIV may not show up as HIV positive even though there is risk of transmission of the virus during an exchange of, or contact with, infected body fluids. The HIV damages both the immune and the neurologic systems. The principal routes of transmission are sexual, blood, and perinatal contacts. Common oral findings in patients with AIDS include candidiasis, herpes, hairy leukoplakia, and Kaposi's sarcoma.

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Figure 2-19. Hairy leukoplakia on the lateral border of the tongue

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Figure 2-20. Kaposi's sarcoma on the dorsal surface of the tongue.


Normally a sexually-transmitted disease, gonorrhea is caused by the gram-negative diplococcus, Neisseria gonorrhoea. Primary infection is by genital contact and secondary infection is possible via the hands.


General. Syphilis is a sexually transmitted disease caused by a spirochete called Treponema pallidum. Oral lesions often are not present with syphilis. However, an active lesion or infective blood may transmit syphilis through a break in the skin or mucosal surface. All oral health providers should be knowledgeable concerning the infectious potential of syphilitic lesions and take necessary precautions (routine use of gloves during treatment, sterilization, and so forth). Syphilis can be classified as acquired and congenital.

Primary Syphilis. Acquired syphilis has three stages -- primary, secondary, and tertiary. The first stage of syphilis is characterized by the appearance of a lesion called the chancre (primary lesion). The chancre is highly infectious and may appear anywhere on the body. Although it is commonly found on the genitalia, its appearance in the mouth is not rare (the site of possible oral-genital contact). A chancre in the oral cavity is characterized by a lesion with a hard, rolled border. Since it is usually painless, the patient is sometimes unaware of its existence. Usually, it is a solitary lesion. Any hard lesion appearing on the lips or in the mouth should be viewed with suspicion. The dentist and the dental specialist should never overlook the possibility of its presence and the attendant danger of infection. The primary lesion will heal spontaneously but, unless treated, will progress to secondary syphilis.

Secondary Lesions. The second stage of syphilis appears from 3 to 8 weeks after the appearance of the primary lesion. Treponema pallidum enter the bloodstream at the site of the primary lesion, multiply, and are carried throughout the body by the circulatory system. Consequently, the secondary lesions may appear anywhere on the body and in large numbers. The secondary lesions on the oral mucosa are known as mucous patches. The mucous patch is usually oval in shape with a moist, glistening, grayish-white, slightly-raised surface. Other secondary lesions may have a radically different appearance. This makes the clinical diagnosis of secondary syphilis difficult. As with the primary lesion, mucous patches are highly contagious. The dental officer and his assistants must be suspicious of any lesions of the mucous membranes of the mouth and throat and should obtain a laboratory diagnosis.

Tertiary Syphilis. The third and terminal stage of syphilis may appear at any time from several months to several years after the initial infection. The lesions of this stage, called gummas, are not very contagious. They rarely contain causative organisms. They appear in the mouth less frequently than secondary lesions. They normally appear as nodules and slowly get bigger, becoming softer and less dense. Eventually the center of the nodule becomes necrotic and a destructive lesion results. The soft tissue and underlying bone are destroyed. When gummas appear in the oral cavity, they often result in perforations of the soft palate.

Congenital Syphilis. A mother having syphilis during pregnancy may transmit the disease to the child. Certain tooth formations are considered typical of congenital syphilis if the child is not treated. In these cases, the incisors are notched on their incisal edges and shaped like a screwdriver. The cusps of the first molars are underdeveloped. The typically notched, screwdriver-shaped incisors are called Hutchinson's incisors. Deformed (mulberry) molars are another diagnostic sign. The presence of these teeth alone, however, should not be considered sufficient reason for making a diagnosis of congenital syphilis.

David L. Heiserman, Editor

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Revised: June 06, 2015