Oral Manifestations

of Gastrointestinal

Disorders

Thilanka Umesh Sugathadasa

Thilanka Umesh Sugathadasa Page 1

Oral Manifestations of Gastrointestinal Disorders

1. Gastro- esophageal reflux disease

2. Crohn’s disease

3. Ulcerative colitis

4. Oro facial granulomatosis

5. Gardner’s syndrome

6. Peutz- jeghers syndrome

7. Malabsorption conditions affecting hematopoiesis

8. Metastatic disease to the jaws

9. Jaundice

Condition Features Clinical/Dental features Diagnosis & Mx

Oesophageal disease(Reflux oesophagitis- Gastro-Oesophageal reflux disease-GORD)

Backflow of acid from stomach in to oesophagus.

One of the most common type of dyspepsia.

Considered to be due to hiatal (diaphragmatic) hernias.

GORD is predisposed by - GI disease like high acidity in stomach content & impaired gastric mobility. - Extra-GI conditions such as obesity, large meals, smoking, alcohol

Can be caused by increased acid production & defect in the sphincters

Symptoms - Heart burns - Burning sensation behind the sternum - Most commonly felt after the meals - Acid taste

Signs - Tooth erosion - Stricture(Acid in oesophagus-Irritation-- Fibrosis-Strictures--Fe absorption)

Dental aspect - Dental erosion typically in palatal aspect of upper anterior teeth & premolars. - Clinically, enamel is lost over broad areas of the teeth that are exposed to the gastric contents. - In bulimics, it is commonly seen & is most severe on the maxillary anterior teeth.(Bulimia- self induced vomiting can see changes in the palatal mucosa also). -Eroded enamel is smooth, shiny & hard. If it become thin enough, yellowish

DD - Candidal oesophagitis(seen in immunocompromised pts or Aplastic anemic pts. ) - Chemical burns from acids/ NSAIDS

General Mx - Reducing weight - Raising head at least 4 inches at night. - Taking frequent meals with antacids.(Aluminium hydroxide) - H2 blockers - Proton pump inhibitors (more effective)

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colour of dentin becomes visible & teeth may become sensitive to temperature changes. - Once enamel has eroded, it is not replaceable physiologically though the patient may need dental restorative Rx. - Because enamel erosion is directly proportional to the contact time with gastric acid, can get some idea of frequency & duration of reflux problem by assessing amount of enamel loss.

Crohn’s disease

See oral Ulceration part

Inflammatory condition of unknown cause.

With UC named as Inflammatory Bowel disease.

Inflammation extends up to lining of the affected organs.

Differences between UC & CD presents in Oral ulceration note.

CD appears to be heterogeneous group of disorders probably caused by commensal bacteria in people with genetically determined dysregulation of mucosal T lymphocytes.

Inflammation mediated by TNF

Sub mucosal chronic inflammation with many mononuclear,

Clinical features - Common in ileoceacal region, but can affects any part of GI tract. - Ulceration, fissuring & Fibrosis os walls. - Manifestations are depend on severity & affected site. - Complication include weight loss, GI obstruction, Internal/ External fistula, Perianal fissures, Abcesses, Arthralgia, Renal damage

Dental features - Ulcers - Facial/ labial swelling - Mucosal tags - Cobblestone proliferation of mucosa(Irregular swelling with fibrosis in between) - Angular cheilitis - May be caused by CD itself or by nutritional deficiencies

Some patients may have asymptomatic intestinal disease or some may develop it later.

Dental Mx may be complicated by Malabsorption & Steroids/immunocompramise therapy.

NSAIDs should be avoided.(Can induce gastric ulceration)

Antibiotics that could aggravate diarrhea should be avoided(Co-amoxiclave & Clindamycine)

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interleukin producing cells.

Non caseating granuloma form in sub mucosa & lymph nodes

Melkerson Rosenthal Syndrome & Cheilitis granulomatosa are incomplete manifestations of CD.

OFG

Group of diseases characterized by noncaseating type granulomatous inflammation affecting soft tissues of Oral & maxillofacial region. - Melkersson-Rosenthal syndrome - Cheilitis granulomatosa (Swelling restricted to the lips,)

Precise cause is unknown but can be infections, genetic predisposition, Allergy

Recently researchers have identified a monoclonal lymphocytic expansion & suggested it could be secondary to chronic antigenic stimulation.

Cytokine which produce by the lymphocytic clone could be responsible for the formation of granulomas.

However, immunologic origin(cell- mediated hypersensitivity reaction) is favoured because of presence of activated helper T lymphocytes expressing IL-2 receptors.

Clinical features - Non-tender recurrent labial swelling that eventually becomes persistent. - Swelling may affect one or both lips, causing lip hypertrophy (macrocheilia) - Swelling is initially soft but becomes firmer with time due to fibrosis. - Recurrent facial swelling, may affects chin, cheeks, periorbital region & eyelids. - Rarely may not be associated with lip hypertrophy. - Intraoral involvement may take the form of hypertrophy, erythema or nonspecific erosions involving the gingiva, oral mucosa or tongue.

Diagnostic dilemma may be further complicated by systemic diseases such as crohn’s disease, sarcoidosis,

DD of persistent lip swelling - Angioedema(Idiopathic/ hereditary) - Sarcoidosis - Crohn’s disease - OFG - Specific infections(TB/ leprosy & deep fungal infection) - Amyloidosis - Tumors(Tissue or minor salivary gland tumor)

Diagnosis is mainly by exclusion

Rx is difficult due to absence of etiologic factors.

Rx objectives are to improve pts clinical appearance & comfort

Spontaneous remission possible.

Eliminate the odontogenic infections

1st line Rx - Local or systemic corticosteroids. - intralesional triamcinolone 10mg/ml (Recently higher concentrations -40mg/ml) due to injection volume become less. systemic steroids therapy is limited now due to complications & recurrent nature. - With steroids results are immediate - Relapses are common

Complications - Skin atrophy - Hypopigmentation

Other - Thalydomide - Methotrxate - Metronidazole

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Ulcerative Colitis

Inflammatory bowel disease.

Affecting part or whole large intestine, frequently lower colon & rectum.

Cause inflammation & ulcers in superficial layers of large intestine mucosa followed by pseudo polyp formation.

Diarrhea with mucus +blood +pus

Pain, fever, anorexia

Extra abdominal signs are minimal

Commonest complication is Iron deficiency anaemia.

Skin lesions present like Erythema nodosum.

Carcinoma Dental aspect

Oral manifestations are rare.

Chronic ulceration can be occur. (Polystomatitis gangrenosum)

Polystomatitis vegetans (Multiple intraepithelial micro abscesses)

Lesions related to anaemia

Antibiotics & NSAIDS should be avoided.

Gardner’s syndrome

Autosomal dominant condition

Genetic defect on the chromosome 5

Characterized by the intestinal polyposis with a very high risk of malignant transformation into colonic adenocarcinoma.

Head & Neck manifestations - Multiple enostoses (bone growth within the bony cavity) of the jaws - Supernumerary & or unerupted teeth - Increased risk of odontomas(Compound) - Osteomas of the jaws & paranasal sinuses. - Epidermoid cyst in the skin of Head & Neck.

Peutz- jeghers syndrome

Associate with harmatomatous polyposis, mostly of small intestine

Autosomal dominant.

Intraorally, lesions are usually flat, painless, brown pigmented patches of buccal mucosa, tongue or labial mucosa.

No Rx required to pigmented lesion unless there are cosmetic or social reason.

Malabsorption condition affecting hematopoiesis

GI diseases related to protein- caloric malnutrition or micronutrient Malabsorption may have an effect(Iron)

Atrophic tongue

Ulcer with bright red border

Burning sensation(glossopyrosis)

Angular cheilitis

Candidal infection

Antifungal

Remove the cause.

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Metastatic disease to the jaws

Malignant neoplasms of liver & GI tract occasionally metastasize to oral region commonly posterior mandible, through hematogenous route.

Vertebral plexes of veins considered as primary mechanisms whereby these tumors bypass the right heart- lung capillary bed.

Asymptomatic Pain Paresthesia Loosening of teeth

Radiographs shows irregular, poorly circumscribed & often multifocal radiolucencies

Less commonly metastases may involve the maxilla or oral soft tissues

Jaundice

Excess bilirubin in blood results in accumulation of bilirubin in tissues, including oral mucosa(Yellow)

Lingual frenum & soft palate are higherly affected(which contain elastin)

Careful with persons who eats large amount of Vit A

Yellowish to greenish pigmentation can be seen in the teeth of children with hyperbilirubinemia during calcification