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Relationship of Systemic Diseases to Conditions in the Oral Cavity*
RELATIONSHIP OF SYSTEMIC DISEASES TO CO NDITIO NS IN T H E ORAL CAVITY* By GEORGE L. LAMBRIGHT, M.D., Cleveland, Ohio H E mouth is frequently the channel of disabling and sometimes fatal dis ease. Therefore, the physician and dentist must make a careful examination of this region. T h eir studies are not lim ited to the power of observation, but often
T
dentist’s observation. T h e teeth are only p art of the organism, and some knowl edge of disease is necessary on the part of the dentist.
ENDOCRINES Before proceeding to the description of some of the diseases, it should be of value
Fig. 2.— L eukoplakia of the tongue. Fig. 1.— H e r e d i t a r y s y p h ilis ; s h o w i n g hutchinsonian teeth, saddle nose and bosses on the fro n ta l bones.
include bacteriologic and roentgenologic examinations. A ll of us are convinced of the importance of preventing access of in fection through the mouth by intelligent care of the oral cavity. M y purpose, on this occasion, is to describe some of the lesions in the mouth that come under the *Read before N o rth ern Ohio D ental Asso ciation, Ju n e 5, 1929. J o u r. A . D . A ., M a rc h , 1930
to refer to the effect of the various gland ular secretions on the oral structures. All of us represent some glandular type, in which one may expect to find certain types of teeth, tongue and mandible, corre sponding to the development of the long and short bones. T h e preadolescent hypopituitary patient who has premature ossi fication of the epiphyses with shortening of the long bones has a small retroussé nose, small spadelike hands, small feet, and very often, in the female, undevel
512
L a m b rig h t— System ic Diseases arid O ra l Conditions
oped breasts. T h e teeth are also small, and are widely spaced and irregular in placement. In contrast to this picture, we have the hyperpituitary case, w ith large hands, long legs, large feet, widely spaced teeth, which are large and broad and pearly white, w ith overdeveloped man dible and large tongue. T h e case show ing ovarian insufficiency usually presents large incisors, which are also broad and pearly white, as the underfunctioning of this gland allows the anterior lobe of the pituitary gland to become too active, and hence the mouth is very much like that in the hyperpituitary case.
513
the gums, the salivary secretions are dim inished, and the tongue becomes coated and, in some cases, so thick th at speech is interfered with. D uring pregnancy, the function of this gland is impaired, and there is active decay and pyorrhea. In cretinism, the thick tongue and changes in the teeth are well known. In over activity of the thyroid gland, the mouth is again affected and the secretions are increased, but other changes are less marked. Frequently, severe herpetic stomatitis appears w ith menstruation, closely connected w ith some improper adjustm ent of the glands which affects the secretions and circulation in the
Fig. 4.— H utchinsonian teeth. Fig. 3.— C hild w ith m yxedem a; show ing edem a of eyelids and m alocclusion of the teeth.
In infancy and young adult life, mal functions of the above mentioned glands are, no doubt, the reason for faulty erup tion of teeth, and delay in the appearance of the teeth at normal age periods. T his is the explanation of the presence of a tooth at birth. In the functional activity of the thyroid gland, it is observed that when the gland becomes inactive, after the teeth have obtained full development, the resultant metabolic changes affect the function of the mouth. T h e teeth decay easily, ta rta r accumulates readily around
mouth. Failure of glandular activity is the chief reason for the procession of ex tractions and the almost constant dental care which becomes necessary after the age of 40 years. N ature abandons us in maintaining health in the mouth, as she does in other parts of the body in main taining adequate circulation, and it may well be said th at we are as old as our glands instead of our arteries. I t has been shown by several investigators that cholesterol degeneration begins early after the failure of the thyroid gland, and from here it is only another step to cal cium degeneration.
514
T h e Jou rn a l of the A m erican D en ta l Association
NUTRITION AL DISEASES N utrition is an im portant factor in maintaining a healthy mouth, and is a problem regarding which there is much inaccurate information, except as regards rickets. T his condition delays dentition and softens the teeth. Scurvy manifests itself early in the disease in swelling, red ness, bleeding and tenderness of the gums. It is not common, but appears sometimes in the most unexpected manner. M y most recent case, seen a short time ago, was in a child who had been severely ill with
fined more to the margins. Pellagra is seen occasionally in this climate. In sprue, there is still some question as to w hether the nutrition is at fault or an infection is present. A grayish white, tenacious de posit appears on the tongue. T h e stools are pultaceous and greasy, and there is marked anemia of the pernicious type. In some cases, M onilia psilosis, a yeast like organism, can be obtained from tongue scrapings. N utritional deficiency, w ith chronic disease, affects the normal function of the mouth as well as the min eral and vitamin content of the body. T he mouth becomes dry, secretions are
Fig. 5.— V incent’s infection of the tonsils.
Fig. 6.— K oplik’s spots; show ing sm all yel low ish pinpoint eruptions on the buccal m em brane.
whoopingcough, which rendered it diffi cult to maintain a sufficient diet. T h e child took milk, but no orange juice or fresh fruits. T h e first symptom was tenderness in the muscles of the legs. W ithin a few days, the gums were characteristically swollen and red. T h e ir normal condition returned within a few days when orange juice was given. Pellagra produces red dening of the tongue, which resembles that associated w ith scurvy and pernicious anemia, except that the redness is con
changed and the teeth decay readily. T he tongue becomes coated and the breath fetid, from changes in the body metabo lism.
INORGANIC M INERAL POISONING Laad poisoning can be discovered by the dentist who is familiar with the lead line around the gum margins, which is present in approximately 40 per cent of the cases. T he line is bluish black, and if
L a m b rig h t— System ic Diseases and O ra l Conditions
a magnifying glass is used to examine it, the line w ill be found to be composed of many fine blacks deposits. A somewhat similar line can be produced by other minerals, but other changes in the gums, such as swelling and hyperemia, w ill help in recognition of the effect of other min erals, such as mercury poisoning. Phos phorus poisoning produces necrosis of the jaw , called “phossy jaw .” I t may be en countered in those persons who are en gaged in the m anufacture of fireworks and matches.
INFECTIOUS DISEASES T h e contagious diseases have their on-
515
the pharnyx which is in the nature of a local anaphylaxis w ith edema, pain and redness. T h e systemic evidence in the form of an erythematous rash is found from twenty-four to forty-eight hours later. A child may have a slight cold and small vesicles may be noted in the mouth. T h e finding of vesicular eruption on the face and body may lead one to suspect chickenpox. Vincent’s infection is well known to all dentists, and is easily diag nosed by staining a slide of the exudate w ith dilute carbolfuchsin solution. Some times, a deposit occurs on the tonsils as well as the gums, and, when on the ton sils alone, may resemble diphtheritic mem-
Fig. 8.— L ead poisoning; show ing m etallic deposits in the gum s.
small
Fig. 7.— Phosphorus necrosis of the jaw .
set in most cases through the mouth, and occasionally the dentist may have the op portunity of observing the first signs. Measles produces a small reddish yellow papule in the buccal membrane and soft palate which is diagnostic from twentyfour to forty-eight hours before the erup tion appears. T h e papules were described by Koplik of N ew York, and are called Koplik’s spots. Scarlet fever and other streptococcus infections of the pharnyx cause a reaction on the part of the cells of
brane. T hrush probably is not seen by the dentist. Once seen, it is never forgot ten. T he child’s tongue is covered by a milky white deposit, which is easily scraped off. Cure is promptly obtained w ith boric acid solutions applied regu larly to the tongue. Chronic infections of the tonsils and sinuses may aggravate gingival infections. One frequently finds an ameba in the secretions from the gums. Its role as a pathogenic organism has not been proved, as it is usually Endameba coli. T h e effects, on the general health, of
516
T h e jo u r n a l o f the A m erican D e n ta l Association
chronic infection at the roots of the teeth and in the gums is a subject in itself and cannot be discussed in this review. Both the physician and dentist should be familiar w ith the lesions of syphilis in the mouth. T h e most common sign is the mucus patch, which is a small superficial ulceration, sometimes w ith small whitish deposit, appearing on the side of the tongue and cheek. I t follows the initial lesion, and is a secondary manifestation. If it is accompanied by eruption on the skin, it is readily diagnosed. Chronic or tertiary lesions may destroy the pillars over the tonsils or the soft palate. T h e tongue may show dense scars. T h e teeth
a secondary manifestation of the disease, the lesion may be more easily suspected. T h e diagnosis is made by microscopic section. Tuberculosis is also fairly com mon as a primary infection in the tonsil.
DISEASES OF T H E BLOOD T h e beefy redness of the tongue oc curring in pernicious anemia is highly suggestive, and physicians are familiar w ith the importance of observing the tongue when the disease is suspected. It is not absolutely diagnostic, and has been seen w ithout the other diagnostic cri teria. O ne can feel fairly certain w ith its presence that there is an absence of hydro-
Fig. 9.— T ongue in sp ru e ; show ing w hitish deposit over the su rface of the tongue. Fig. 10.— D ip h th eria of the lips.
in hereditary syphilis are notched, and the cuspids are sharply pointed, w ith defec tive enamel. O ne should look for other evidence of syphilis, such as depressed or saddle nose, bosses on forehead and cloudy areas in the cornea of the eyes. Q uite often, the child so afflicted is undersized. T h e dentist cannot diagnose syphilis by the appearance of the teeth alone, but en counters only suggestive evidence. T u b er culous infection of the tongue and mouth is found occasionally. T h e deeply in filtrated and sometimes ulcerating lesion of tuberculosis of the tongue or lip is often mistaken for cancer or syphilis when the condition is primary. If it occurs as
chloric acid in the stomach. O n the other hand, a simple anemia w ill show pallor not only of the tongue, but also of the mucus membrane of the mouth and gums. In leukemia, the most characteristic change in the mouth is marked by severe gingivitis and hemorrhage from the gums. Accompanying the bleeding from the gums, there are other points of bleed ing, as from the nose, eyes or rectum. T he dentist may well suspect leukemia when large hemorrhages occur in the mouth, but it is unlikely th at the dentist w ill en counter the disease first. I t is sufficiently im portant th at the dentist know about it,
L a m b rig h t— System ic Diseases and O ral Conditions
for I have seen the dentist extract teeth in this disease; which only aggravated the condition. Agranulocytosis is a blood condition probably caused by an infection w ith Bacillus pyocyaneus, which is fatal, from paralysis of the hematopoietic sys tem. I t is classed as a blood disease and begins w ith large ulcerating lesions in the throat and mouth, which become gan grenous. T h e leukocytes of the blood w ill fall below 1,000 per cubic millimeter be fore death. Polycythemia is a blood dis ease in which the red blood cells and
517
bowels. T his is seldom the source of the trouble and the tradition is not upheld by experience. Tonsil, adenoid and mouth infections may be local causes, but the source, as a rule, is faulty metabolism, w ith execretion of waste products through the mouth. In chronic heart and kidney disease, the breath is fetid. D ia betic acidosis produces a characteristic odor, peach seeds. Stagnant urine in blad der from prostatic hypertrophy produces a urinous odor of the breath. Certain foods in their process of metabolism pro duce odors on the breath, and the den tist must be fam iliar w ith this. T he tongue is coated in gallbladder and liver disease. T his is often a valuable point in the differential diagnosis of ulcer of the stomach and gallbladder disease, as the tongue in uncomplicated ulcer is clean.
CANCER OF T H E M OUTH T he lesion of cancer is found on the margins of the tongue and the lip. I t is more common on the lower lip. Dentists can assist in the prevention of this condi tion by eliminating points of chronic irri tation and by so placing their crowns and plates as to avoid it.
CONCLUSIONS
Fig. 11.— P h ary n g eal diphtheria.
hemoglobin are greatly increased, the skin is reddish purple, the blood pressure is increased and spleen is enlarged. T h e color of the mouth, lips and tongue, w ith high color in the cheeks, would suggest to the dentist that his patient had an abnormal condition which was affecting the oral cavity. I t is not common.
FETOR ORIS Patients often come to us w ith a chief complaint of bad breath, and they almost invariably attribute it to disorder of the
Im portant factors governing the de velopment, health and diseases of the mouth have been discussed as seen in the practice of medicine with the hope that the dentist’s interest will be aroused and early evidence of systemic disease be elicited. A knowledge of systemic dis ease will give the dentist a much broader insight into conditions within the mouth. T his knowledge w ill prevent the spread of contagious disease, send his patient to his physician when he recognizes evidence of systemic states, and prohibit him from performing operative procedures in the face of serious blood diseases, which may hasten the death of the patient. 628 U nion Building.
T
dentist’s observation. T h e teeth are only p art of the organism, and some knowl edge of disease is necessary on the part of the dentist.
ENDOCRINES Before proceeding to the description of some of the diseases, it should be of value
Fig. 2.— L eukoplakia of the tongue. Fig. 1.— H e r e d i t a r y s y p h ilis ; s h o w i n g hutchinsonian teeth, saddle nose and bosses on the fro n ta l bones.
include bacteriologic and roentgenologic examinations. A ll of us are convinced of the importance of preventing access of in fection through the mouth by intelligent care of the oral cavity. M y purpose, on this occasion, is to describe some of the lesions in the mouth that come under the *Read before N o rth ern Ohio D ental Asso ciation, Ju n e 5, 1929. J o u r. A . D . A ., M a rc h , 1930
to refer to the effect of the various gland ular secretions on the oral structures. All of us represent some glandular type, in which one may expect to find certain types of teeth, tongue and mandible, corre sponding to the development of the long and short bones. T h e preadolescent hypopituitary patient who has premature ossi fication of the epiphyses with shortening of the long bones has a small retroussé nose, small spadelike hands, small feet, and very often, in the female, undevel
512
L a m b rig h t— System ic Diseases arid O ra l Conditions
oped breasts. T h e teeth are also small, and are widely spaced and irregular in placement. In contrast to this picture, we have the hyperpituitary case, w ith large hands, long legs, large feet, widely spaced teeth, which are large and broad and pearly white, w ith overdeveloped man dible and large tongue. T h e case show ing ovarian insufficiency usually presents large incisors, which are also broad and pearly white, as the underfunctioning of this gland allows the anterior lobe of the pituitary gland to become too active, and hence the mouth is very much like that in the hyperpituitary case.
513
the gums, the salivary secretions are dim inished, and the tongue becomes coated and, in some cases, so thick th at speech is interfered with. D uring pregnancy, the function of this gland is impaired, and there is active decay and pyorrhea. In cretinism, the thick tongue and changes in the teeth are well known. In over activity of the thyroid gland, the mouth is again affected and the secretions are increased, but other changes are less marked. Frequently, severe herpetic stomatitis appears w ith menstruation, closely connected w ith some improper adjustm ent of the glands which affects the secretions and circulation in the
Fig. 4.— H utchinsonian teeth. Fig. 3.— C hild w ith m yxedem a; show ing edem a of eyelids and m alocclusion of the teeth.
In infancy and young adult life, mal functions of the above mentioned glands are, no doubt, the reason for faulty erup tion of teeth, and delay in the appearance of the teeth at normal age periods. T his is the explanation of the presence of a tooth at birth. In the functional activity of the thyroid gland, it is observed that when the gland becomes inactive, after the teeth have obtained full development, the resultant metabolic changes affect the function of the mouth. T h e teeth decay easily, ta rta r accumulates readily around
mouth. Failure of glandular activity is the chief reason for the procession of ex tractions and the almost constant dental care which becomes necessary after the age of 40 years. N ature abandons us in maintaining health in the mouth, as she does in other parts of the body in main taining adequate circulation, and it may well be said th at we are as old as our glands instead of our arteries. I t has been shown by several investigators that cholesterol degeneration begins early after the failure of the thyroid gland, and from here it is only another step to cal cium degeneration.
514
T h e Jou rn a l of the A m erican D en ta l Association
NUTRITION AL DISEASES N utrition is an im portant factor in maintaining a healthy mouth, and is a problem regarding which there is much inaccurate information, except as regards rickets. T his condition delays dentition and softens the teeth. Scurvy manifests itself early in the disease in swelling, red ness, bleeding and tenderness of the gums. It is not common, but appears sometimes in the most unexpected manner. M y most recent case, seen a short time ago, was in a child who had been severely ill with
fined more to the margins. Pellagra is seen occasionally in this climate. In sprue, there is still some question as to w hether the nutrition is at fault or an infection is present. A grayish white, tenacious de posit appears on the tongue. T h e stools are pultaceous and greasy, and there is marked anemia of the pernicious type. In some cases, M onilia psilosis, a yeast like organism, can be obtained from tongue scrapings. N utritional deficiency, w ith chronic disease, affects the normal function of the mouth as well as the min eral and vitamin content of the body. T he mouth becomes dry, secretions are
Fig. 5.— V incent’s infection of the tonsils.
Fig. 6.— K oplik’s spots; show ing sm all yel low ish pinpoint eruptions on the buccal m em brane.
whoopingcough, which rendered it diffi cult to maintain a sufficient diet. T h e child took milk, but no orange juice or fresh fruits. T h e first symptom was tenderness in the muscles of the legs. W ithin a few days, the gums were characteristically swollen and red. T h e ir normal condition returned within a few days when orange juice was given. Pellagra produces red dening of the tongue, which resembles that associated w ith scurvy and pernicious anemia, except that the redness is con
changed and the teeth decay readily. T he tongue becomes coated and the breath fetid, from changes in the body metabo lism.
INORGANIC M INERAL POISONING Laad poisoning can be discovered by the dentist who is familiar with the lead line around the gum margins, which is present in approximately 40 per cent of the cases. T he line is bluish black, and if
L a m b rig h t— System ic Diseases and O ra l Conditions
a magnifying glass is used to examine it, the line w ill be found to be composed of many fine blacks deposits. A somewhat similar line can be produced by other minerals, but other changes in the gums, such as swelling and hyperemia, w ill help in recognition of the effect of other min erals, such as mercury poisoning. Phos phorus poisoning produces necrosis of the jaw , called “phossy jaw .” I t may be en countered in those persons who are en gaged in the m anufacture of fireworks and matches.
INFECTIOUS DISEASES T h e contagious diseases have their on-
515
the pharnyx which is in the nature of a local anaphylaxis w ith edema, pain and redness. T h e systemic evidence in the form of an erythematous rash is found from twenty-four to forty-eight hours later. A child may have a slight cold and small vesicles may be noted in the mouth. T h e finding of vesicular eruption on the face and body may lead one to suspect chickenpox. Vincent’s infection is well known to all dentists, and is easily diag nosed by staining a slide of the exudate w ith dilute carbolfuchsin solution. Some times, a deposit occurs on the tonsils as well as the gums, and, when on the ton sils alone, may resemble diphtheritic mem-
Fig. 8.— L ead poisoning; show ing m etallic deposits in the gum s.
small
Fig. 7.— Phosphorus necrosis of the jaw .
set in most cases through the mouth, and occasionally the dentist may have the op portunity of observing the first signs. Measles produces a small reddish yellow papule in the buccal membrane and soft palate which is diagnostic from twentyfour to forty-eight hours before the erup tion appears. T h e papules were described by Koplik of N ew York, and are called Koplik’s spots. Scarlet fever and other streptococcus infections of the pharnyx cause a reaction on the part of the cells of
brane. T hrush probably is not seen by the dentist. Once seen, it is never forgot ten. T he child’s tongue is covered by a milky white deposit, which is easily scraped off. Cure is promptly obtained w ith boric acid solutions applied regu larly to the tongue. Chronic infections of the tonsils and sinuses may aggravate gingival infections. One frequently finds an ameba in the secretions from the gums. Its role as a pathogenic organism has not been proved, as it is usually Endameba coli. T h e effects, on the general health, of
516
T h e jo u r n a l o f the A m erican D e n ta l Association
chronic infection at the roots of the teeth and in the gums is a subject in itself and cannot be discussed in this review. Both the physician and dentist should be familiar w ith the lesions of syphilis in the mouth. T h e most common sign is the mucus patch, which is a small superficial ulceration, sometimes w ith small whitish deposit, appearing on the side of the tongue and cheek. I t follows the initial lesion, and is a secondary manifestation. If it is accompanied by eruption on the skin, it is readily diagnosed. Chronic or tertiary lesions may destroy the pillars over the tonsils or the soft palate. T h e tongue may show dense scars. T h e teeth
a secondary manifestation of the disease, the lesion may be more easily suspected. T h e diagnosis is made by microscopic section. Tuberculosis is also fairly com mon as a primary infection in the tonsil.
DISEASES OF T H E BLOOD T h e beefy redness of the tongue oc curring in pernicious anemia is highly suggestive, and physicians are familiar w ith the importance of observing the tongue when the disease is suspected. It is not absolutely diagnostic, and has been seen w ithout the other diagnostic cri teria. O ne can feel fairly certain w ith its presence that there is an absence of hydro-
Fig. 9.— T ongue in sp ru e ; show ing w hitish deposit over the su rface of the tongue. Fig. 10.— D ip h th eria of the lips.
in hereditary syphilis are notched, and the cuspids are sharply pointed, w ith defec tive enamel. O ne should look for other evidence of syphilis, such as depressed or saddle nose, bosses on forehead and cloudy areas in the cornea of the eyes. Q uite often, the child so afflicted is undersized. T h e dentist cannot diagnose syphilis by the appearance of the teeth alone, but en counters only suggestive evidence. T u b er culous infection of the tongue and mouth is found occasionally. T h e deeply in filtrated and sometimes ulcerating lesion of tuberculosis of the tongue or lip is often mistaken for cancer or syphilis when the condition is primary. If it occurs as
chloric acid in the stomach. O n the other hand, a simple anemia w ill show pallor not only of the tongue, but also of the mucus membrane of the mouth and gums. In leukemia, the most characteristic change in the mouth is marked by severe gingivitis and hemorrhage from the gums. Accompanying the bleeding from the gums, there are other points of bleed ing, as from the nose, eyes or rectum. T he dentist may well suspect leukemia when large hemorrhages occur in the mouth, but it is unlikely th at the dentist w ill en counter the disease first. I t is sufficiently im portant th at the dentist know about it,
L a m b rig h t— System ic Diseases and O ral Conditions
for I have seen the dentist extract teeth in this disease; which only aggravated the condition. Agranulocytosis is a blood condition probably caused by an infection w ith Bacillus pyocyaneus, which is fatal, from paralysis of the hematopoietic sys tem. I t is classed as a blood disease and begins w ith large ulcerating lesions in the throat and mouth, which become gan grenous. T h e leukocytes of the blood w ill fall below 1,000 per cubic millimeter be fore death. Polycythemia is a blood dis ease in which the red blood cells and
517
bowels. T his is seldom the source of the trouble and the tradition is not upheld by experience. Tonsil, adenoid and mouth infections may be local causes, but the source, as a rule, is faulty metabolism, w ith execretion of waste products through the mouth. In chronic heart and kidney disease, the breath is fetid. D ia betic acidosis produces a characteristic odor, peach seeds. Stagnant urine in blad der from prostatic hypertrophy produces a urinous odor of the breath. Certain foods in their process of metabolism pro duce odors on the breath, and the den tist must be fam iliar w ith this. T he tongue is coated in gallbladder and liver disease. T his is often a valuable point in the differential diagnosis of ulcer of the stomach and gallbladder disease, as the tongue in uncomplicated ulcer is clean.
CANCER OF T H E M OUTH T he lesion of cancer is found on the margins of the tongue and the lip. I t is more common on the lower lip. Dentists can assist in the prevention of this condi tion by eliminating points of chronic irri tation and by so placing their crowns and plates as to avoid it.
CONCLUSIONS
Fig. 11.— P h ary n g eal diphtheria.
hemoglobin are greatly increased, the skin is reddish purple, the blood pressure is increased and spleen is enlarged. T h e color of the mouth, lips and tongue, w ith high color in the cheeks, would suggest to the dentist that his patient had an abnormal condition which was affecting the oral cavity. I t is not common.
FETOR ORIS Patients often come to us w ith a chief complaint of bad breath, and they almost invariably attribute it to disorder of the
Im portant factors governing the de velopment, health and diseases of the mouth have been discussed as seen in the practice of medicine with the hope that the dentist’s interest will be aroused and early evidence of systemic disease be elicited. A knowledge of systemic dis ease will give the dentist a much broader insight into conditions within the mouth. T his knowledge w ill prevent the spread of contagious disease, send his patient to his physician when he recognizes evidence of systemic states, and prohibit him from performing operative procedures in the face of serious blood diseases, which may hasten the death of the patient. 628 U nion Building.