Oral mucosa: Manifestations and Gastrointestinal and Haematological Disease

Question 1

What causes the primary effects with GIT disorders?

Answer 1

Part of the disease process

e.g. crohn’s disease

Question 2

What causes the secondary effects with GIT disorders?

Answer 2

Malabsorption, blood loss

= Most oral effects

Question 3

What GIT conditions can impact the oral mucosa?

Answer 3

GORD
Coeliac disease
Idiopathic inflammatory bowel disease
- Crohn's disease (and oro-facial granulomatosis - OFG)
- Ulcerative colitis
Intestinal polyposis syndromes

Question 4

GORD features?

Answer 4

Common
Risk factors: obesity, smoking, alcohol
Symptoms of dyspepsia (heart burn)
Risk of Barrett’s oesophagus (pre-malignant)
Oral effects - erosion and halitosis
Tx - proton pump inhibitors e.g. omeprazole

Question 5

Coeliac disease?

Answer 5

Intolerance to alpha-gliadin peptides in gluten found in wheat, rye, barley
Any age
Genetically susceptible
Prevalence 0.5-1%

Question 6

Pathogenesis of coeliac’s disease?

Answer 6

Exposure to gluten
Proliferation of lymphocytes
Oedema 
Crypt hyperplasia and sub-total villous atrophy 
Mostly in duodenum and jejunum

Question 7

Effects of coeliac disease?

Answer 7

Malabsorption

• Iron (anaemia)
• Ca and Vitamin D
• Folic acid
• Vitamin C
• Vitamin B12

As smaller SA to absorb as much

Question 8

Clinical features of coeliac disease?

Answer 8

Diarrhoea and steotorrhoea
Wasting, loss of appetite
Abdominal discomfort/pain
Tiredness/weakness
Peripheral neuropathy and CNS disturbances
Tetany and osteomalacia = softening of bones
Dermatitis herpetiformis = skin rash
Increased risk of intestinal neoplasms (lymphoma)

Question 9

Oral manifestations of coeliac disease?

Answer 9

Malabsorption gives anaemia resulting in:

• Oral ulceration
• Glossitis
• Candidiasis
• Angular cheilitis
• Hypoplasia of enamel of permanent teeth - often generalised and symmetrical (secondary to malabsorption)

Question 10

Diagnosis of coeliac disease?

Answer 10

History and clinical signs
Blood tests
- FBC and haematinics
- Anti-endomysial antibiotics, tissue transglutaminase antibodies anti-gliadin antibodies, anti-reticulin
- Endoscopy and jejunal mucosal biopsy

Question 11

Coeliac disease tx?

Answer 11

Remove gluten from diet
Replacement of haematinics (iron and folate)
Increased risk of T cell lymphoma and other bowel malignancies)

Question 12

Idiopathic inflammatory bowel disease types?

Answer 12

Crohn’s

Ulcerative colitis

Question 13

Crohn’s disease features?

Answer 13

Young adults
Any part of GIT
- May affect several separate areas (skip lesions)
- Mostly terminal ileum and ascending colon
- Can also affect extra-gastrointestinal sites e.g. skin

Transmural inflammation

• Granuloma formation - cobblestone appearance
• Wall is thickened, lumen narrowed
• Apthous-like ulceration and fissuring
• Fistulae and absceses

Chronic inflammation
Lymphoid hyperplasia

Question 14

Clinical features of Crohn’s disease?

Answer 14

Abdominal pain
Diarrhoea
Weight loss
Malabsorption - B12, bile salts
Variable presentation, depends on severity and site, often intermittent

Question 15

Crohn’s disease oral manifestations?

Answer 15

Ulceration (may be RAS like)
Glossitis = loss of papillae on tongue 
Lip swelling
Cobblestone mucosa
Tissue tags = folds in mucosa
Fissures and ulcers
Angular cheilitis
Mucosal inflammation esp attached to gingiva

Question 16

What diseases can show granulomatous inflammation from a biopsy?

Answer 16

Crohn’s
TB
Sarcoidosis - can also cause lip swelling

Question 17

Crohn’s disease management?

Answer 17

Symptomatic relief
Topical measures for oral manifestations
Immunosuppressants e.g. methotrexate and azathioprine - candidiasis more common
Replacement therapy 
Anti TNF antibodies, infliximab
Elemental diets
Surgery - colonostomy

Question 18

Crohn’s diagnosis?

Answer 18

History 
Oral biopsy - include muscle 
Blood test
- FBC and haematinics
- Gut antibodies, ACE (to exclude sarcoid)
Onward referral

Question 19

Oro-facial granulomatosis - OFG presentation?

Answer 19

Oral features of Crohn’s disease with no clinical features of gut involvement
Can get midline fissures in the lip

Question 20

Causes of lip swelling?

Answer 20

Crohn's 
Sarcoidosis
Foreign body reactions
Melkerson-rosenthal syndrome e.g. triad of lip swelling, fissured tongue and facial palsy 
Infecs - TB, syphilis, leprosy

Question 21

Management of OFG?

Answer 21

Surgery in severe cases
Topical and intralesional steroids (temp relief)
Systemic drugs e.g. azathioprine
Exclusion diet:
- Chocolate
- Crisps
- Carbonated drinks 
- Carvone
- Cinnamon
- Benzoates

Question 22

What is ulcerative colitis?

Answer 22

Large intestine and rectum - tends to be a continuous region of variable extent
Inflammation extends no further than the lamina propria
- Inflamed, bleeds easily - later ulceration develops. Chronic inflammatory infiltrate

Question 23

UC clinical and oral manifestations?

Answer 23

Bloody diarrhoea
Pain
Weight loss
Tiredness
Iritis, ankylosing spondylitis = arthritis affecting spine

Oral manifestations

• Oral ulcers
• Pyostomatitis vegetans = yellow areas on gingivae

Question 24

Oral effects of drugs used to treat GIT disorders?

Answer 24

Steroids
- Candidial infections

Immunosuppressants e.g. methotrexate, azathiorprine
- Ulceration and infection

Antispasmodics
- Dry mouth

H2 receptor antagonists e.g. ranitidine
- Erythema multiforme, discolouration of tongue, dry mouth

Proton pump inhibitors e.g. omeprazole
- Taste disturbance, dry mouth, erythema multiforme, angio-eodema

Cytokine inhibitors e.g. infliximab
- Oral ulceration, taste disturbance

Question 25

Intestinal polyposis syndrome - gardener's syndrome?

Answer 25

``` AD (autosomal dominant) APC gene mutation: multiple colon polyps, epidermoid cysts, osteomas, thyroid cancer, fibromas Risk of colon cancer age 21 is 10% by 50 is 95% Oral manifestations; - Osteomas - Odontomes - Supernumerary teeth - Osteomas develop first - Often 10-30yrs - early referral ```

Question 26

Intestinal polyposis syndrome - Peutz jeghers syndrome?

Answer 26

``` Autosomal dominant Hamartomatous polyps (only small risk of developing cancer) BUT have increased risk of cancer in ovaries, pancreas, liver Pigmented macules lips and oral cavity (develop in childhood before anything else) ```

Question 27

What is anaemia?

Answer 27

A decreased ability of blood to carry O2 Hb concentration below normal range - <13.5g/dl males - <11.5g/dl females Due to: - Decreased number of RBC = Loss/destruction (injury, infec, sickle cell anaemia) = failure of production (low Fe, folate, B12, leukaemia, renal failure) - Reduction of concentration of haemoglobin (blood loss or hypervolaemia) - Reduced ability of RBCs to carry oxygen e.g. sickle cell anaemia

Question 28

Anaemia by morphology of RBC?

Answer 28

Normocytic anaemia e.g. blood loss Macrocytic anaemia e.g. B12 or folate deficiency (cell is larger) Microcytic anaemia e.g. iron deficiency (cell is smaller)

Question 29

Iron deficiency anaemia?

Answer 29

``` Most common 30% of population - Inadequate intake - diet/malabsorption - Increased loss e.g. GI bleed - Increased demand e.g. pregnancy ``` Hypochromic (less Hb) microcytic anaemia (small)

Question 30

Macrocytic anaemia?

Answer 30

Macrocytosis - Rise in mean cell volume above normal range in adults Causes - Dietary deficiency of B12/folate - Alcohol - Malabsorption - Liver disease - Hypothyroidism

Question 31

Vitamin B12 deficiency?

Answer 31

B12 absorbed in ileum Dietary insufficiency GIT disease Pernicious anaemia - Auto-immune gastritis - Parietal cells damaged - Intrinsic factor - secreted by parietal cells - B12 not absorbed in small intestine - absent intrinsic factor

Question 32

Folate deficiency?

Answer 32

Absorbed in upper small intestine Dietary insufficiency Malabsorption Drugs e.g. anticonvulsants

Question 33

Systemic features of iron deficiency anaemia?

Answer 33

Lethargy Dyspnoea Skin and nail changed - spooning of nails, white lines Mucosal changes - pale Oesophageal webbing Tachycardia/palpitations Cardiac failure/exacerbation of cardiac diseases

Question 34

Systemic features of megaloblastic anaemia?

Answer 34

``` Pallor Jaundice Neurological changes Neural tube defects Mucosal changes CV disease Risks with GA ```

Question 35

Oral manifestations of megaloblastic anaemia?

Answer 35

``` None Pallor Oral ulcerations and exacerbation of RAS Mucosal stomatitis/glossitis Smooth tongue Altered taste Oral candidosis Burning mouth syndrome Dysphagia (oesophageal web_ ```

Question 36

What is leukaemia?

Answer 36

Malignant diseases of blood forming cells in bone marrow | One type of WBC produced in excess at detriment of others

Question 37

Types of leukaemias?

Answer 37

Acute - Lymphoblastic - children (85%) and late middle age - Myeloid - older adults and children (15%) Chronic - Lymphocytic - adults - Myeloid - adults

Question 38

Acute leukaemia symptoms?

Answer 38

Symptoms due to bone marrow failure or organ infiltration - Signs and symptoms of anaemia - Bac infecs: mouth, throat, chest, skin, peri-anal - Delayed healing - Bruising or bleeding - Bone pain - Lymphadenopathy - Hepatosplenomegaly

Question 39

Chronic leukaemia clinical features?

Answer 39

``` Anaemia Bleeding Infec Splenomegaly Weight loss Fatigue Sweating ```

Question 40

Oral manifestations of leukaemia?

Answer 40

Gingival inflammation and swelling Bleeding Ulceration (cytotoxic drugs/infection) Increased susceptibility to oral infections

Question 41

Graft versus host disease / stem cell transplant

Answer 41

``` Chemo or chemo-radiotherapy Transplant of own or donor stem cells May lead to GVHD - Lichen planus = soreness, white striations - Sjogren's like syndrome ```

Question 42

What is multiple myeloma? | What can it cause?

Answer 42

Tumour of monoclonal plasma cells Produce and secrete monocolonal protein Bence-jones protein in urine ``` Bone pain, osteoporosis, osteolytic lesions Recurrent infec Anaemia Renal failure Amyloidosis ```

Question 43

Amyloidosis?

Answer 43

Fibrillar protein

Question 44

Leucopenia?

Answer 44

Reduction in white cell population Primary: reduction in haemopoesis Secondary due to autoimmune disease, infec, drug therapy, HIV

Question 45

Cyclic neutropenia?

Answer 45

``` Rare Unknown cause Most common in childhood Average cycles of 21 days = large dip in white cell count then it recovers Infections ``` ``` Ulcers - Irregular, any surface, may heal with scarring within 2/52 Gingivitis Periodontitis Susceptibility to infec e.g. candidosis ```

Question 46

Management of cyclic neutropenia?

Answer 46

Supportive | Self limiting

Question 47

Angina bullosa haemorrhagica (ABH)?

Answer 47

``` Blood filled blisters in mouth which burst and cause ulcers Idiopathic Can occur in thrombocytopenia Diagnosis - history and clinical signs FBC and clotting screen Reassure pt ```

Question 48

What is the significance of haematological disease with dental care?

Answer 48

Approrpriate referral Risk of infec and bleeding Importance of good qual care

Question 49

Anaemia and dentistry

Answer 49

Mucosal disease - Glossitis: Sore tongue. May be some inflammation and atrophy of the filiform papillae. - Angular stomatitis - Oral ulceration and worsening of RAS - Infection, particularly candidosis (acute pseudomembraneous and denture stomatitis) (iron deficiency is a predisposing factor for candidosis) Risks from GA - Shortage of O2 can be dangerous as it can result in brain damage or MI if significant anaemia - Highest risk in sickle cell disease Lowered resistance to infection - Candidosis - Other infections when severe anaemia or leukaemia e.g. osteomyelitis after infections

Question 50

Sickle cell

Answer 50

Oral mucosa may be pale or yellow due to haemolytic jaundice Precipitating factors of sickle cell crisis: - Hypoxia - Dehydration - Infections (dental) e.g. acute pericoronitis = prompt ABS tx needed - Fever

Question 51

Acute lymphoblastic leukaemia

Answer 51

Acute leukaemia can result in: Anaemia Raised susceptibility to infection following granulocyte deficiency or abnormalities Bleeding tendency (purpura) as reduction in platelet production Oral signs of acute lymphoblastic leukaemia (children): Osteomyelitis following extraction Gingival swelling, may turn purple, ulcerate and necrose following reduction in healthy white blood cells to fight infections. Mucosal pallor Abnormal gingival bleeding Purpura - purple mucosal areas, blood blisters Anaemia Mucosal ulceration (from cytotoxic drugs e.g. methotrexate and immunodeficiency) Herpes infections Acute pseudomembranous candidosis Cervical lymphadenopathy Feeling unwell, fatigue = Avoid extraction due to risks of infection (osteomyelitis), anaemia and bleeding If essential - blood transfusion and antibiotic cover

Question 52

Chronic lymphocytic anaemia

Answer 52

Slow progressing disease in adults - can be asymptomatic and may not influence life span Oral manifestations mild Mucosal pallor Gingival or palatal swelling Purprua Oral ulceration - from infec or cytotoxic drugs Routine dentistry as normal If significant anaemia, bleeding tendencies or susceptibility to infection take care