Oral Pathology

ORAL MANIFESTATIONS IN PULMONARY DISEASES – TOO OFTEN A

NEGLECTED PROBLEM

Doina-Clementina COJOCARU1, Andrei GEORGESCU2, Robert D. NEGRU3

1
Lecturer, Ist Medical Department, Faculty of Medicine , “Gr. T. Popa” UMPh of Iaşi, Romania
2
Assist. Prof., Department of Odontology, Faculty of Dental Medicine, “Gr. T. Popa” UMPh of Iaşi, Romania
3
Assist. Prof., Ist Medical Department, Faculty of Medicine, “Gr. T. Popa” UMPh of Iaşi, Romania
Corresponding author: andgeorgescu@yahoo.com

Abstract action, fewer systemic adverse effects and faster

Careful examination of the oral cavity in respiratory
medicine is often neglected, although it represents
sometimes a clue for clinical diagnosis and it is important
in completely addressing the patient. On the other hand,
the dental practitioner who treats a patient with unusual
oral lesions should observe correct guidance and medical
advice. Oral manifestations are of polymorphic nature,
being associated with a variety of pulmonary diseases and
specific therapies. Respiratory obstructive diseases,
systemic diseases with pulmonary involvement, lung
cancer, cystic fibrosis or tuberculosis all have clinical and/
or therapeutic involvement of the oral cavity, which
underlines the necessity of regular dental services and
careful oral cavity exam, as well as an active collaboration
between dental practitioners and pulmonologists or
somnologists, for patient’s ultimate benefit.
Keywords: oral cavity, pulmonary disease, diagnosis
1. INTRODUCTION
Careful examination of the oral cavity in
respiratory medicine is often neglected, although
it represents sometimes a clue for clinical
diagnosis and it is important in completely
addressing the patient. On the other hand, the
dental practitioner who treats a patient with
unusual oral lesions should observe correct
guidance and medical advice. The oral
manifestations in this context are polymorphic,
being associated with a variety of pulmonary
diseases and specific therapies.
2. INHALED MEDICATION
Nowadays, inhaled medication represents the
mainstay of therapy in asthma and COPD, due to
its major advantages, including delivery of
pharmacological agents directly to the site of
onset of action. Several drug categories are used:
β2-agonists, corticosteroids, anti-cholinergic
agents and their combinations. The increased use
of inhaled drugs and the fact that a large ratio of
the inhaled substances remains in the oro–
pharyngeal region has raised attention to the oral
consequences of this type of medication:
xerostomia, mucosal changes, ulcerations, dental
cavities, halitosis, taste disturbances,
oropharyngeal candidiasis, gingivitis,
periodontitis, and signs of gastro-esophageal
reflux [1].
It is now proven that prolonged use of
β2-mimetic agents is associated with an increased
rate of dental cavities [2], which can be explained
by the various actions of these agents: reduced
salivary production and secretion, alongwith
increased Lactobacillus sp. and Streptococcus mutans
populations in the oral cavity [2]. Also, β2-agonists
favor relaxation of the smooth muscle of the lower
esophageal sphincter, followed by gastro-
esophageal reflux [3] and a lower pH in the mouth,
a pH < 5.5 being correlated with enamel
demineralization. Inhaled drugs, especially dry-
powders, contain fermentable carbohydrates and
sugar as carriers, further increasing the rate of
tooth decay [4].
Inhaled corticosteroids (ICS) are widely used
in asthma and COPD treatments, a significant
percent of the administered dose remaining in the
oro-pharyngeal region and being associated with
several topical effects: oral candidiasis, dysphonia,
perioral dermatitis, pharyngitis, reflex cough,
sensation of thirst, tongue hypertrophy [5].
These local side effects are not as important as
the systemic secondary effects, yet they can affect

International Journal of Medical Dentistry 117

Doina-Clementina COJOCARU, Andrei GEORGESCU, Robert D. NEGRU
patient’s compliance to treatment. Among ICS,
beclomethasone dipropionate has a more
favorably profile, being inhaled as an inactive
form, activated in the lung by esterases, with
little activation in the oropharynx, in contrast to
fluticasone propionate and budesonide, which
are inhaled in the pharmacologically-active form
and have an increased incidence of oral side
effects. The “paradoxical” local inflammatory
effect associated with the use of an anti–
inflammatory drug is caused by the various
components of the inhaled substances: the
propellant, lubrication components, and lactose,
which can all be the cause of the direct
inflammatory reaction [5,6].
Corticosteroids are weak acids with little effect
on oral pH, however patients undergoing
treatment with ICS experience overgrowth of
Candida species at oropharyngeal level, often self-
limiting, as due to the inhibition of the immune
system. Clinical aspects of such lesions include
whitish papulaes and plaques, inflamed or
bleeding tissue under the lesions. Also, an
increased prevalence of gingivitis has been
noticed [7,8].
For pneumologists and dentists, monitoring,
early recognition, and appropriate management
of these oral lesions are requested, in order to
improve the life quality of chronic respiratory
patients, while the task of dentists is to carefully
ask patients about their pulmonary conditions
and treatment, paying increased attention to the
characteristic lesions in the mouth. Using a
spacer, decreasing frequency of administration,
and properly rinsing the mouth are simple and
effective measures to prevent oral corticosteroid-
related pathology.
3. PULMONARY OBSTRUCTIVE
DISEASES
Pulmonary obstructive diseases represent the
main spectrum of chronic respiratory maladies
in the modern world, due to increased exposure
to risk factors, such as smoking, obesity, diabetes,
air pollutants, and other noxious environmental
factors. Such diseases share an obstructive
syndrome located in the inferior or upper
airways, also impacting oral cavity health.
118
Chronic obstructive pulmonary disease
(COPD). Smoking is one of the major risk factors
for both COPD and oral pathology as a
periodontal disease. Epidemiological studies are
suggesting an association between COPD and
periodontal disease [9] but, most probably, the
common link between these two conditions is
exposure to tobacco smoke. Some studies are
indicating that COPD is associated with marginal
bone loss [10]. Other common issues are thrush
- the most frequent mucosa ailment, and
worsening of the dental status: gingival bleeding
and pocket depth, reduced teeth number or even
toothlessness, increased incidence of dental
plaque [10-12]. Data are controversial due to the
different periodontal disease variables involved:
pocket depth or attachment loss, while the
endpoint used in the trials - tooth loss - is not due
only to periodontal diseases, but can be the result
of dental cavities. Some authors suggest that
chronic airways obstruction is not associated
with significant increase in pocket depth or a
decreasing number of the remaining teeth,
comparatively with smokers with normal
spirometry, when adjusted to age [13]; on the
opposite side, Wang et al. [12] found out in COPD
patients fewer remaining teeth compared to the
control group, even if one third of it was
represented by current or former smokers. In
addition, these patients have a denture plaque
biofilm that acts like a reservoir of pathogens in
the upper and lower airways, the lower respiratory
tract being colonized with aspirated pathogenic
bacteria [14].
As to malignancy, a cohort study evaluating
the risk of cancer in first-time hospital-diagnosed
COPD patients concluded that these patients are
exposed to a considerably increased risk of
developing tobacco-related cancers, including
cancers of the oral cavity, larynx, and tongue,
alongside lung cancer [15].
Asthma. The most frequent oral health
conditions associated with asthma are dental
cavities and erosions, periodontal disease and
oral candidiasis [16]. The salivary secretion is the
main protective factor involved in oral health. In
asthmatic patients, the use of β2-agonists reduces
the salivary secretion rates by 26 to 36%,
compared to non-asthmatics, affecting
composition, and altering this important
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defensive barrier [2,17]. Furthermore, such
patients, particularly those of pediatric age,
have a prominent oral breathing pattern,
contributing to gingivitis, due to dehydration of
alveolar mucosa, alongwith various
immunological factors which increase gingival
inflammation. Several elements – e.g., excessive
thirst, the attempt to wash away the taste of
inhaled medication, to counterbalance the
desiccating effect of mouth breathing, and the
reduced salivary flow induced by β2-agonists -
are related with an excessive consumption of
cariogenic drinks [18].
An interesting issue is the influence of oral
pathogens over allergy, a prominent feature in
asthma. Several recent studies speculated that
exposure to oral pathogens associated with
periodontal diseases, such as gingivitis or
periodontitis, might play a protective role
against development of asthma and allergy,
although large prospective birth cohort studies
are still missing [19]. Previous results of the
Third National Health Nutrition Examination
Survey (NHANES) [20] highlighted the
importance of oral colonization with
Porphyromonas gingivalis, reflected by the higher
titers of Ig G antibodies against P. gingivalis,
associated with a lower prevalence of asthma.
Card et al. [21] confirmed that allergen-induced
hyperresponsiveness of the airways is
significantly decreased when infection with P.
gingivalis is established after sensitization to
allergen.
Obstructive sleep apnea syndrome (OSAS).
In patients with OSAS, oral inflammation could
play an important pathogenic role, the
inflammatory process of the pharynx, uvula,
soft palate, and oral cavity being associated
with increased production of nitric oxide (NO);
measurement of oral exhaled NO, as a marker
of airway inflammation, appears increased in
OSAS, being related to hypoxemia severity and
obstructive episodes [22]. However, the highest
levels of nitric oxide are found in asthma, even
if, in these patients, the NO sources are the
bronchi and alveoli [23].
Dental services are also very helpful in the
therapeutic management of these patients,
preparing and fitting oral devices for mandible
advancement (ODMA), aimed at relieving
International Journal of Medical Dentistry
upper airway obstruction by forward
displacement of the mandible, tongue and other
oro-pharyngeal structures, indirectly moving
the suprahyoid and genioglossus muscles in
anterior direction [24-26]. This therapy is
frequently associated with several oro-facial
side effects, usually acceptable: teeth and jaw
tenderness, myofascial pain, gum irritation,
increased salivation or xerostomia. Nevertheless,
there are some reports of exaggerated gag reflex,
periodontal lesions or fractures of teeth or dental
fillings, while long term use of these devices is
associated with temporo-mandibular joint
disease and temporary bite change in the
morning after the removal of the device in
almost all patients [27]. Moreover, some authors
report permanent occlusal alteration after long-
term treatments [28], evidencing the importance
of regular follow-up and dental examination of
the patients using this type of devices.
4. SYSTEMIC DISEASES WITH ORAL
AND PULMONARY INVOLVEMENT
Sarcoidosis is a systemic disease with
granulomas in the lungs and adenopathies,
affecting almost all organs. The oral cavity
lesions in sarcoidosis are localized swelling or
nodules, painless ulcerations of the gingiva,
buccal and labial mucosa, palate, and gingival
inflammation, hyperplasia or recession,
diagnosis being made through biopsy, that
reveals non-caseating granulomas. Involvement
of the tongue is very rare, including swelling,
enlargement and ulcerations, as well as of the
salivary gland, which leads to a tumor-like
appearance [29]. Parotid gland impairment
appears in 6% of patients, especially in women,
the clinical picture including a painless tumor-
like appearance, sometimes with xerostomia. A
rare but very suggestive clinical presentation
associated with glandular involvement is the
Heerfordt-Waldenström syndrome, which
includes systemic sarcoidosis, xerostomia,
parotid gland swelling – usually bilateral -
uveitis, and facial nerve palsy [30,31]. The jaw
bone involvement affects equally the maxilla
and mandible, the symptoms being due to the
lytic character of the lesion: teeth loosening,
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Doina-Clementina COJOCARU, Andrei GEORGESCU, Robert D. NEGRU
radiating pain, nasal obstruction, mandible
tumefaction or maxillary bone loss [29].
Wegener granulomatosis, a necrotizing
granulomatous vasculitis of the small-to-
medium vessels, has a common oral involvement,
expressed as ulcerations on oral mucosa or
palate, tooth mobility and loss. The
pathognomonic finding is granular hyperplastic
gingivitis or the so-called “strawberry
gingivitis”, with red interdental papillae
covered with hyperplastic purple petechiae.
This clinical sign is essential for an early
suspicion of diagnosis, and oral biopsy is
mandatory for preventing a serious multiorgan
involvement of the respiratory airways and
kidneys [7, 32-33].
5. OTHER PULMONARY DISEASES
Lung cancer causes more than 25% of the oral
metastases, the jawbones being more frequently
affected, compared to the soft tissue of the oral
cavity. The mandible is the most exposed bone,
more than 55% of the metastases being located
here, while some studies report that oral
metastases could be the first manifestation of this
type of cancer, announcing unfortunately an
advanced stage of neoplastic pulmonary disease
[34]. When located in the soft tissue, the
metastases appear as a submucosal mass, highly
vascularized, frequently hemorrhagic, rarely
ulcerated, or, more frequently, as a hyperplastic
reactive lesion [35]. When the mandible is
interested, insidious paresthesia of the lower lip
on the affected side, rapidly progressing local
swelling and pain appear, as tumor invades the
inferior alveolar nerve, bone, and soft tissue [36].
Clinical profile of the patient with oral metastases
also includes male sex, and age > 50 years [34].
Pulmonary tuberculosis can lead to oral
lesions in both primary and secondary stages.
Mouth involvement in secondary tuberculosis
is usually a result of reactivation and
hematogenous spread from the primary
infection of the lung, the lesions being very
similar to those of a squamous cell carcinoma:
irregular ulcerations with peripheral thickening
and dirty-appearing base, biopsy and culture
being necessary to confirm the granulomatous
120
inflammation. Secondary oral tuberculosis
usually leads to the diagnosis of asymptomatic
pulmonary tuberculosis. Therefore, all cases of
incidentally discovered oral tuberculosis, even
in asymptomatic patients, should be submitted
to investigations for identifying its primary site
[37-39].
Cystic fibrosis is a genetic disorder caused
by mutations in the gene for the cystic fibrosis
transmembrane conductance regulator (CFTR)
protein, affecting mostly the respiratory tract,
with chronic cough and sputum, dyspnea,
recurrent infections, and associated pancreatic
insufficiency and malnutrition [40]. Oral
manifestations of the disease are generated by
the effects on the salivary glands, the sublingual
ones being the most affected, followed by
submandibular glands, due to the presence - at
that level - of mucous acinar cells; parotid
glands are less affected because of their serous
structure. The affected glands are enlarged and
can be easily palpated; disturbances in the
composition of saliva could lead to xerostomia
and require artificial saliva to keep oral mucosa
moist. The calcium content, mean pH, and
buffering capacity of the saliva are elevated.
Patients with cystic fibrosis can also present
cheilosis from vitamin deficiency, tooth
discoloration, and hypoplastic defects of
permanent dentition, the latter associated with
tetracycline use during the period of tooth
formation; replacing tetracycline with other
antibiotics was followed by a reduction of this
type of dental defects [41]. Data provided by
various studies are conflicting, however, it
seems that the incidence of dental cavities in
pediatric patients with cystic fibrosis is lower
than in age-matched healthy control population,
although these patients display a higher
incidence of enamel defects. This could be
related to an increased calcium content,
buffering capacity of saliva, and prolonged
treatment with antibiotics. Some of these
patients may also suffer from chronic nose and
sinuses obstruction, associated with oral
breathing pattern and anterior open bite [40-42].
The main findings in clinical exam of the oral
cavity and the different therapeutic options of
various pulmonary diseases involving the mouth
are summarized in Table 1.
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Table 1. Pulmonary conditions and the corresponding oral cavity involvement

Pulmonary conditions Oral cavity involvement

Deleterious effects on the quantity and quality of saliva,

Inhaled medication decreased oral pH (β2-agonists), candidiasis, dysphonia, tongue
hypertrophy (ICS), xerostomia
Chronic obstructive Periodontitis, thrush, worsening dental status, loss of alveolar
pulmonary disease bone, colonization of airways from denture plaque biofilm

Dental cavities and erosions, periodontal disease, candidiasis,

Asthma
colonization with P. gingivalis (lowers prevalence of asthma)

Obstructive sleep apnea Inflammation (pharynx, uvula, soft palate, oral cavity),
syndrome increased oral exhaled NO, therapy (ODMA)

Jaw metastases (mandible), submucosal mass or hyperplastic

Lung cancer
reactive lesion (soft tissue metastases)

“Strawberry gingivitis”, ulcerations (oral mucosa, palate), tooth

Wegener granulomatosis
mobility and loss

Sarcoidosis Painless ulcerations, gingivitis, localized swelling or nodules

Irregular ulcerations (secondary oral tuberculosis,

Pulmonary tuberculosis
hematogenous spread)
Xerostomia, tooth discoloration and hypoplastic defects
Cystic fibrosis (tetracycline), elevated calcium content, pH and buffering
capacity of saliva

6. CONCLUSIONS 2. Ryberg M, Moller C, Ericson T. Saliva composition

Considering the comprehensive approach to
chronic pulmonary patients, regular dental ser-
vices and careful oral cavity exams are more
than necessary for the management of these
diseases, from diagnosis to therapeutic resour-
ces, favoring an early recognition, lowering the
rate of infectious exacerbations, and increasing
life quality. An active collaboration among den-
tists and pulmonologists or somnologists, for
patient’s ultimate benefit, is absolutely
necessary.
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