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How an early diagnosis of a few gastrointestinal disorders can be made using a few oral manifestation
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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
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