GOOD

MORNING

ORAL MANIFESTATIONS OF GASTROINTESTINAL DISORDERS

- H.K.AJEYA RANGANATHAN IV B.D.S G D C R I

Guided by :Dr.MubeenDr.VijayalakshmiDr.Suman

Contents

• Introduction • Need for knowledge regarding oral manifestations of

gastrointestinal disorders• Inflammatory bowel disease• Peptic ulcer disease• Gastro Esophagial Reflux Disorder• Malabsorption • Eating disorders • Genetic disorders • Metastatic disorders of jaws• Conclusion

Gastrointestinal diseases

Gastrointestinal diseases refer to diseases involving the gastrointestinal tract, namely the oesophagus, stomach, small intestine, large intestine and rectum, and the accessory organs of digestion, the liver, gallbladder, and pancreas.

Typ

es

of

GI

dis

ord

ers

IMPAIRED DIGESTION AND ABSORPTION

ALTERED SECRETION

IMMUNE DYSREGULATION

IMPAIRED GUT BLOOD FLOW

NEOPLASTIC DEGENERATION

GENETIC INFLUENCES

NEED FOR THE KNOWLEDGE REGARDING GASTROINTESTINAL DISORDERS AND ITS ORAL MANIFESTATION:-

Dentist’s role in monitoring patient compliance with recommended medical therapy for gastrointestinal conditions

Recognize, diagnose, and treat oral conditions associated with gastrointestinal diseases.

Proper medical referral for management of systemic symptoms

Inflammatory bowel diseases• Crohn’s disease• Ulcerative colitis

Gastro-oesophageal reflux disorder

Malabsorption• Pernicious anemia• Folic acid deficiency anaemia

Genetic disorders• Gardner’s syndrome• Peutz-Jegher’s syndrome

Metastatic diseases to the jaw • Malignant neoplasm of liver and GIT

Peptic ulcer disease

Eating Disorders • Bulimia• Anorexia

GASTROINTESTINAL DISEASE MANIFESTING ORAL LESIONS

Ulcerative colitis Crohn’s Disease

INFLAMMATORY BOWEL DISEASES

IBD is currently considered an inappropriate immune response to the endogenous commensal microbiota within the intestines, with or without some component of

autoimmunity.

Ulcerative colitis

Ulcerative colitis is an inflammatory reaction of large intestine characterized by remission and exacerbations.

Etiology:-

Ulcerative colitis

Psychological and

Immunological factors.

Allergy, Bacterial and viral infections

Idiopathic

General symptoms of Ulcerative colitis

The hallmark of ulcerative colitis is rectal bleeding and diarrhoea with crampy pain bilaterally in the abdomen which aggravates before to bowel movement.

Extra intestinal signs • Erythema nodosum• Retinitis• Microcytic hypochromic anaemia• Leucocytosis

Oral Manifestation of ulcerative colitisMajor and minor Aphthous ulcers• Commonly seen on buccal mucosa and mucobuccal fold

Pyostomatitis vegetans : A purulent inflammation of the mouth may occur• Most commonly seen on buccal and labial mucosa. Tongue is

usually spared

Ulcerative colitis patients also can develop hairy leukoplakia, a lesion more commonly associated with human immunodeficiency virus (HIV) disease

Crohn’s disease

Crohn’s disease is the inflammation of small and large intestine involving all layers of gut

Crohn’s disease

Genetic

Smoking, Stress

Excessive immune reaction

Etiology

General symptoms of Crohn’s disease

The clinical presentation of Crohn's disease depends on the extent of inflammation and on the site of intestinal involvement.

Inflammation of the small intestine may impair absorption of vital nutrients.

Involvement of terminal ileum interferes with the absorption of bile salts and vitamin B12

Anaemia, Abdominal pain, Nausea, Vomiting, Weight loss

ORAL MANIFESTATION OF CROHN’S DISEASE

Persistent linear and deep ulcer

Cobblestone

mucosal architectur

e,

diffuse swelling of the

lips and face,

Indurate

d polypoid tag-like

lesions in the

vestibulePyostomatitis vegetans, cobblestone mucosal architecture and minor salivary gland duct pathology represent granulomatous changes that constitute the hallmark of Crohn's disease.

Dental management of inflammatory bowel diseases

Frequent preventive and routine dental care to monitor oral health

Evaluation of Hypothalamus-pituitary-adrenocortical function

Diagnosis of oral inflammatory or granulomatous lesions

Palliative rinses and topical steroid therapy symptomatic oral lesions • sodium bicarbonate mouth rinses• 0.05% Fluosinonide.• If the lesion is disseminated to oropharynx , dexamethasone elixir

0.5mg/5ml gargle for 1 minute 4 times daily

___________________

Peptic ulcer disease• Peptic ulcer disease is a common benign (non-malignant) ulceration of the epithelial lining of the

stomach (gastric ulcer) or duodenum (duodenal ulcer).

Peptic ulcer disease

GENERAL SYMPTOMS OF PEPTIC ULCER

• Relieved by food (duodenal)• Aggravated by food (Gastric)

Epigastric pain

Gastrointestinal bleeding

Obstruction or Perforation are seen

Peptic ulcer diseaseORAL MANIFESTATIONS OF PEPTIC ULCER DISEASE

Drug induced

Xerostomia

Bacterial disease

Fungal Disease

Altered taste perception

Anaemia

Mucosal pallor

Thrombocytopenia

Gingival bleeding

Agranulocytosis

Mucosal ulcerations

Necrotizing stomatitis

Peptic ulcer diseaseDENTAL MANAGEMENT OF PEPTIC ULCER DISEASE

Minimize stress• Short appointments

Selective usage of analgesics• Avoid Aspirin containing compounds

Check for platelet count before any surgical procedure• Cimetidine may rarely be associated with Thrombocytopenia

Frequent recall and oral prophylaxis is recommended• Anticholinergic associated Xerostomia

Avoidance of tetracycline in patients taking Aluminium antacids

Gastro-esophageal reflux disorderGastroesophageal reflux disease (GERD) is one of the most commonly occurring diseases affecting the upper gastrointestinal tract where in Gastric contents (chyme) passively move up from the stomach into the esophagus

General symptoms of GERD

Heartburn is the cardinal symptom of GERD and is defined as a sensation of burning or heat that spreads upward from the epigastrium to the neck

Esophagitis

Esophagial ulcers, strictures and dysplasia

Dysphagia

Oral manifestations of GERD

Dysgeusia[altered taste]

Erosion Mucosal erythema

Mucosal atrophy Esophagial stricture and Fibrosis Xerostomia

DENTAL MANAGEMENT OF GERD PATIENTSNaHCO3 mouth rinses to minimize disguisia due acid reflux

Topical fluoride application to ensure optimal mineralisation

Salivary substitutes may be prescribed

Patients should be advised to have adequate amount of fluid intake

Note:-Cimetidine • Toxic reaction to IV lidocaine• Inhibits absorption of systemic

antifungal drugs

DISORDERS DUE TO GASTROINTESTINAL MALABSORPTION

PERNICIOUS ANEMIA

Severe deficiency of Vitamin-B12 results in pernicious anemia• Occurs due to atrophy of Gastric mucosa resulting in lack of intrinsic factor• Macrocytic normochromic anemia

Diagnosis• Serum Vitamin B12 levels• Serum methylmalonic acid and homocystien levels• Schilling test

GENERAL SYMPTOMS PERNICIOUS ANEMIANeurological manifestations• Tremors and

palsies• Numbness of

limbs

Tiredness Dizziness

Depression Hair loss

ORAL MANIFESTATIONS OF PERNICIOUS ANEMIA

Burning mouth

Glossitis and glossodyniaInflamed “beefy red" tongue

FOLIC ACID DEFICIENCY ANEMIA

It is a macrocytic anemia caused due to folic acid deficiency• Prevalent in patients whose diet devoid of leafy vegetables.• Alcoholics and drug abusers• Increased requirement of folate – Pregnant women and young children• Anticancer drugs like Methotrexate, Azathioprine and 6-mercaptapurine

leads to folate deficiency • Normal shilling test and serum vitamin B12 but low serum assay of folic

acid• It causes severe anemia but without any neurological abnormalities

ORAL MANIFESTATION FOLIC ACID DEFICIENCY ANEMIA

• Mostly similar to those seen in pernicious anemia

• Angular cheilitis is more common than in pernicious anemia

• Recurrent Aphthous stomatitis {15%}

Angular cheilitis Recurrent Aphthous ulcer

DENTAL MANAGEMENT OF ANEMIA

• Normal dental protocol

Patients at low risk (hematocrit >30%)

• Stress reduction protocols • Shorter appointments • Sedation techniques

Patients at high risk( hematocrit <30%)

Outpatient intra venous sedation and general anaesthesia is contraindicated

Hospitalization for moderate and advanced surgical procedures

EATING DISORDERS

Anorexia nervosa• Intentional starving

even if the patient is already underweight

• Patients use laxatives and diuretics to lose body weight

Bulimia nervosa• Patients consumes

large amount of food due to lack of control over appetite

• Self induce vomiting , laxatives and diuretics are used to lose body weight

Two common eating disorders are Anorexia nervosa and Bulimia nervosa

Common intention of either of the disorders is weight loss

GENERAL SYMPTOMS OF EATING DISORDERS

Cardiac arrhythmi

aAnaemia Amenorrh

oea

Pubertal delay

Constipation

Osteoporosis

ORAL MANIFESTATIONS OF EATING DISORDERS

Erosion of lingual surfaces of maxillary

anterior teeth

Increased risk of caries and periodontal

diseaseParotid gland swelling

Teeth sensitive to thermal changes

DENTAL MANAGEMENT OF EATING DISORDERS

Support the patient psychologically by demonstrating a caring and compassionate attitude

Avoid elective dental procedures until patient is stable from a cardiac stand point

Complex restorative treatment should be avoided until the purging has been corrected

Emphasis on oral hygiene maintenance

Crowns may have to be placed if thermal symptoms are present in an actively purging patient

GENETIC DISORDERS

• It is an autosomal dominant where in defect is on Adenomatous polyposis Coli tumour suppressor gene chromosome no.5

• It is characterised by intestinal polyps and multiple impaction of supernumerary teeth

• Prevalence 1:8,300-1:16,00,000 live birth

Gardner’s syndrome:-

GENERAL SYMPTOMS OF GARDNER'S SYNDROME

Familial colorectal polyposis

Other general manifestations involve :• Skin (multiple epidermoid cysts)• Soft tissues• Retina• Skeletal system• Teeth

Typical polyps are seen in 2nd decade of life.• The polyps being adenomatous ultimately transform into

adenocarcinoma

GARDNER'S SYNDROMEOral manifestations of Gardner's syndrome

Osteomas-most common skeletal manifestations • Most commonly seen in skull paranasal sinuses and mandible• Occur during puberty and precedes bowel polyps

Impacted teeth

supernumerary teeth

Odontomas Radiographs of two sisters with Gardner syndrome showing

enostosis, unerupted teeth and osteomas of the mandible

MANAGEMENT OF GARDNER’S SYNDROME

Prophylactic colectomy is recommendedExcision of jaw osteomas and epidermoid cysts for cosmetic reasons may be indicated

PEUTZ-JEGHER’S SYNDROME

It is an autosomal dominant condition with a defect in LKB1 gene

Characterised by hamartomatous polyposis

Prevalence: 1:20,000

Oral manifestation :• Oral and perioral pigmentation• Freckling of skin around lips and vermilion zone of lip• Intraoral lesion are usually painless brown patch on buccal mucosa

METASTATIC DISEASES OF JAW

• Most commonly seen on posterior mandibular region• Spread through hematogenous route via vertebral plexus of veins

Malignant lesion of liver and Gastro intestinal tract occasional metastasize to oral cavity

• May be asymptomatic or may present with jaw pain or tooth ache• Paraesthesia• unexplained mobility of tooth

Symptoms

• Only a few patients have survived for up to 5 years after the diagnosis

Prognosis

CONCLUSIONIt is vital to recognize oral manifestation of gastrointestinal diseases as they are useful in development of differential diagnosis for patients with gastrointestinal complaints

The severity or prognosis of the disease can be monitored by the presence or extent of oral manifestation

The success of the management of gastrointestinal diseases may be reflected in response to oral tissues

Hence, the oral physicians play a critical role in recognising , diagnosing and treating oral condition related with gastrointestinal diseases and also to provide dental care to afflicted individuals

Thank you