M. Greenwood, J. G. Meechan and C. Stroud
At some stage in clinical practice all dental practitioners will encounter patients with disorders of the immune system. It is therefore important that dental practitioners are aware of the potential implications for safe practice.
Purpose of the Paper
- Provides an overview of clinical immunology and how it interfaces with dentistry.
- Highlights signs of possible immunodeficiency.
- Discusses oral conditions that may be seen in patients with inherited or induced immunodeficiency states.
- Patients with immunodeficiency usually give a history of excess numbers and severity of infections.
- Patients with immunodeficiency are clearly more prone to recurrent or serious infections that may be particularly difficult to treat.
- Patients with immunodeficiency may also present with relatively common infections, for example oral candidiasis, but it is the persistent nature of infection that may be unusual.
- Patients with immunodeficiency are also prone to malignancy and autoimmune disease as they have lost regulatory and surveillance cells that normally keep the immune system in check.
- There may be clinical signs that suggest more widespread immune dysregulation such as autoimmune disease resulting in patches of skin depigmentation, a condition known as vitiligo, or hyperpigmentation can occur as the result of Addison’s disease.
- Patients may give a history of allergy. Hypersensitivity reactions are immune-mediated antigen-specific reactions that are either inappropriate or excessive and result in harm to the host.
- Other examples of specific primary immune-deficiencies:
- C1 esterase inhibitor deficiency: a condition that may be inherited resulting in uncontrolled activation of the complement pathway.
- Chronic mucocutaneous candidosis (CMC): a rare condition presenting with chronic candida infection of the skin and mucous membranes.
- Common variable immunodeficiency (CVID): a form of antibody deficiency disorder that could be the result of multiple gene defects. Treatment is with life-long antibody replacement therapy.
- Chronic granulomatous disease (CGD): usually presents in childhood with recurrent deep seated abscesses, which may be in unusual sites.
- Wiskott-Aldrich syndrome (WAS): associated with eczema, recurrent infections and low platelet counts.
- DiGeorge syndrome: a disorder with variable features, including congenital cardiac defects, cleft palate and abnormal facial features. It is a disorder of T cell function and leads to predisposition to infection.
- Severe Combined Immunodeficiency (SCID) is a genetic disorder leading to impaired function of B and T lymphocytes.
Potential features on clinical examination:
- Oral lichenoid lesions may cause patients to complain of oral soreness and ulceration can occur. Amalgam has been implicated in the production of oral lichenoid reactions in the tissues that contact restorations with this material. (1)
- Oral erythema can also occur secondary to Type IV hypersensitivity. Implicated substances include acrylic.
- Cheilitis is an inflammatory eruption of the lip and may be due to contact allergy or irritation from constant licking of lips, atopic dermatitis, infection, usually with Staphyloccoccus aureus or iron deficiency.
- Candidosis may be seen in immunosuppressed patients. Candidal organisms are highly opportunistic and are present in a dormant yeast phase in a significant proportion of the population.
- Immunosuppressed patients are susceptible to viral infections, in particular those of the herpes group such as herpes simplex and varicella zoster virus. (2)
- Other viral infections include the papilloma virus group and hairy leukoplakia.
- A large number of conditions result from autoimmunity and can be organ-specific, such as hyper or hypo-thyroidism, or non-organ specific, for example rheumatoid arthritis, systemic lupus erythematosus (SLE) and vasculitis.
- Certain autoimmune conditions may present with oral signs, such as Addison’s disease or autoimmune adrenal insufficiency. They could include increased pigmentation of skin folds, buccal mucosa and scars.
- In Type I diabetes mellitus, oral complications include candida infection, dry mouth, sialosis and glossitis. Severe oral infections can upset glycaemic control and patients are prone to increased superficial infections and poor wound healing.
- Patients with celiac disease may present with aphthous ulceration secondary to anaemia. Some may describe a blistering skin rash known as dermatitis herpetiformis.
- Other relatively rare autoimmune diseases include the vesiculobullous disorders pemphigoid and pemphigus. Bullous pemphigoid is seen most commonly in the elderly with subepidermal blisters. Pemphigus vulgaris is often associated with non-healing erosions.
- Scleroderma is a multi-system disorder characterised by fibrosis of connective tissue. Oral manifestations can include peri-articular involvement of the temporomandibular joint and skin involvement around the mouth leads to microstomia. The tongue may become thickened and stiffened with oral telangiectasia and widening of the periodontal membrane space but without associated tooth mobility.
- One of the best known immunological diseases recognised by dental practitioners is that of Sjögren’s syndrome, comprising dry eyes, dry mouth and associated inflammatory arthritis.
- Behçet’s disease, a systemic vasculitis, has significant oral manifestations ranging from a clinical triad comprising aphthous type oral ulceration, genital ulcers and iritis.
Oral manifestations of drugs taken by patients with immunological disease:
- Ciclosporin produces gingival hyperplasia and has been reported to cause this side-effect in up to 30% of patients taking this drug. (3)
- Cyclophosphamide, methotrexate and mycophenylate cause bone marrow suppression, which can lead to oral ulceration (4) as well as a reduced resistance to periodontal disease.
- Corticosteroids have a dual effect on the periodontium. Their anti-inflammatory effects can offer protection against periodontal breakdown. On the other hand chronic use of steroids may produce osteoporosis, which increases the risk of periodontal disease. (5)
- NSAIDs should be avoided in those taking corticosteroids as this combination can lead to peptic ulceration. Similarly NSAIDs interact with methotrexate leading to an increase in methotrexate toxicity. The toxicity of the latter drug may also be increased by the penicillins.
- McParland H, Warnakulasuriya S. Oral lichenoid contact lesions to mercury and dental amalgam — a review. J Biomed Biotechnol 2012; 2012: 569-589.
- Westley S, Seymour R, Staines K. Recurrent intraoral herpes simplex 1 infection. Dent Update 2011; 38: 368–370, 372–4.
- Seymour R A, Smith D G, Rogers S R. The comparative effects of azathioprine and cyclosporine on some gingival health parameters of renal transplant patients. A longitudinal study. J Clin Periodontol 1987; 14: 610–613
- Weng R R, Foster C E 3rd, Hsieh L L, Patel P R. Oral ulcers associated with mycophenolate mofetil use inca renal transplant recipient. Am J Health Syst Pharm 2011; 68: 585–588.
- Wactawski-Wende J, Grossi S G, Trevisan M et al. The role of osteopenia in oral bone loss and periodontal diseases. J Periodontal 1996; 67: 1076–1084.
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