Oral mucosa: manifestations of gastrointestinal & haematological disease

Question 1

Oral manifestations of GIT disorders - primary effects (2)

Answer 1

Part of the disease process e.g. Crohn’s disease

Question 2

Oral manifestations of GIT disorders - secondary effects (2)

Answer 2

Malabsorption, blood loss

Question 3

Conditions of interest (4)

Answer 3

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

Question 4

Risk factors for GORD (3)

Answer 4

obesity, smoking, alcohol

Question 5

Symptoms of GORD (1)

Answer 5

Dyspepsia (heart-burn)

Question 6

Risk from GORD (2)

Answer 6

Barrett’s oesophagus (pre-malignant)

Question 7

Oral effects of GORD (2)

Answer 7

Erosion and halitosis

Question 8

Treatment of GORD (2)

Answer 8

PPIs e.g. omeprazole

Question 9

Features of coeliac disease (4)

Answer 9

Intolerance to α-gliadin peptides in gluten found in wheat, rye and barley
Any age
Genetically susceptible individual and families
Prevalence 0.5-1% in general population (probably under-diagnosed)

Question 10

Pathogenesis of coeliac disease (5)

Answer 10

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

Question 11

Coeliac disease - malabsorption (5)

Answer 11

Iron (anaemia)
Calcium and vitamin D
Folic acid    	}
Vitamin C	}   more advanced disease
Vitamin B12    }

Question 12

Clinical features of coeliac disease (9)

Answer 12

Diarrhoea and Steatorrhoea
Wasting, (failure to thrive), loss of appetite
Abdominal discomfort / pain
Tiredness and weakness
Peripheral neuropathy and CNS disturbances
Tetany and osteomalacia
Dermatitis herpetiformis
Oral ulceration
Increased risk of intestinal neoplasms (lymphoma

Question 13

Oral manifestations of coeliac diease (6)

Answer 13

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 14

Diagnosis of coeliac disease (3)

Answer 14

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

Question 15

Treatment for coeliac disease (2)

Answer 15

Exclusion diet to remove gluten from diet

Replacement of haematinics (iron and folate)

Question 16

Increased risk from coeliac disease (1)

Answer 16

Increased risk of T-cell lymphoma and other bowel malignancies

Question 17

Features of Crohn’s disease (5)

Answer 17

Young adults; Western world
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 and lumen narrowed
-aphthous-like ulceration and fissuring
-fistulae and abscesses.
Chronic inflammation
Lymphoid hyperplasia

Question 18

Clinical features of relapsing and remitting Crohn’s disease (5)

Answer 18

Abdominal pain
Diarrhoea
Weight loss
Malabsorption – B12, bile salts
Variable presentation, depends on severity and site(s) and often intermittent

Question 19

Oral manifestations of Crohn’s disease (8)

Answer 19

Ulceration (may be RAS-like)
Glossitis
Lip swelling
Cobblestone mucosa
Tissue tags
Fissures and ulcers
Angular cheilitis
Mucosal inflammation esp attached gingiva

Question 20

Management of Crohn’s disease (7)

Answer 20

Symptomatic relief
Topical measures first for oral manifestations
Immunosuppressives e.g.methotrexate and azathioprine
Replacement therapy
Anti-TNF antibodies, infliximab etc
Elemental diets
Surgery

Question 21

Diagnosis of Crohn’s disease (4)

Answer 21

History
-may have known diagnosis – if not then….
Oral biopsy – include muscle
Blood tests:
-FBC and haematinics
-gut anti-bodies, ACE (to exclude sarcoid)
Onward referral

Question 22

Features of oro-facial granulomatosis (4)

Answer 22

Oral features of Crohn’s disease with no clinical features of gut involvement
Separate entity or Crohn’s disease?
May have an allergic aetiology
Responds to exclusion diet (not all cases)

Question 23

Other cause of lip swelling need excluding (5)

Answer 23

Crohn’s
Sarcoidosis
Foreign-body reactions
Melkerson-Rosenthal syndrome e.g. triad of lip swelling, fissured tongue and facial palsy
Infections (rare): TB, syphilis, leprosy

Question 24

Management of oro-facial granulomatosis (4)

Answer 24

Surgery in severe cases
Topical and intralesional steroids(temporary relief)
Systemic drugs e.g. azathioprine
Exclusion diet:
-chocolate
-crisps
-carbonated drinks
-carvone
-cinnamon
-benzoates - E210-E219

Question 25

Ulcerative colitis features (3)

Answer 25

Large intestine + rectum –tends to be a continuous region of variable extent Inflammation extends no further than lamina propria -inflamed, bleeds easily – later ulceration develops. -chronic inflammatory infiltrate

Question 26

Ulcerative colitis results in (5)

Answer 26

``` Bloody diarrhoea Pain Weight loss Tiredness Iritis, ankylosing spondylitis etc etc ```

Question 27

Oral manifestations of ulcerative colitis (2)

Answer 27

Oral ulceration | Pyostomatitis vegetans

Question 28

Oral effects of drugs used to treat GIT disorders (6)

Answer 28

Steroids - candidal infection Immunosuppressants e.g. Azathioprine, Methotrexate --> ulceration and infection Antispasmodics - dry mouth H2 receptor antagonists e.g. Ranitidine --> erythema multiforme, discolouration of tongue, dry mouth PPIs e.g. Omeprazole --> taste disturbance, dry mouth, erythema multiforme, angio-oedema Cytokine inhibitors e.g. Infliximab --> oral ulceration, taste disturbance

Question 29

Intestinal polyposis syndromes - Gardener's syndrome - features and causes (3)

Answer 29

AD, APC gene mutation: multiple colon polyps, epidermoid cysts, osteomas, thyroid cancer, fibromas Risk of colon cancer age 21 is 10%, by age 50 it’s 95%! Oral manifestations: osteomas, odontomes supernumerary teeth. Osteomas develop first, often 10-30yrs…early referral!

Question 30

Types of intestinal polyposis syndromes (5)

Answer 30

Peutz Jeghers syndrome AD Hamartomatous polyps (only small risk of dveloping cancer) BUT, have increased risk of cancer in ovaries, pancreas, liver Pigmented macules lips and oral cavity (develop in childhood before anything else)

Question 31

Haematological conditions causing oral manifestations (6)

Answer 31

``` Anaemias -iron deficiency anaemia -macrocytic anaemia Leukaemias Multiple myeloma Neutropenia / agranulocytosis Stem cell transplants / GVHD Angina Bullosa Haemorrhagica ```

Question 32

Anaemia is due to (3)

Answer 32

Decreased numbers of RBC -loss / destruction (Injury, chronic diseases, infections, sickle cell anaemia, hemolytic anaemias e.g. spherocytosis, red cell auto-Abs) -failure of production (low Fe, folate, B12, aplastic anemia, leukaemia, Thalassemia, renal failure gives decreased erythropoetin) Reduction of concentration of haemoglobin e.g. blood loss or hypervolaemia Reduced ability of RBCs to carry oxygen e.g. sickle cell anaemia and Thalassemias

Question 33

Definition of anaemia (2)

Answer 33

A decreased ability of blood to carry O2 Hb concentration below normal range <13.5 g/dl - males <11.5 g/dl - females

Question 34

Anaemia by morphology of RBC (3)

Answer 34

Normocytic anaemia e.g. blood loss Macrocytic anaemia e.g. B12 or folate deficiency Microcytic anaemia e.g. iron deficiency

Question 35

Iron deficiency anaemia features (3)

Answer 35

Most common type world-wide 30% world population -inadequate intake – diet / malabsorption (e.g. Coeliac) -increased loss (e.g.GI bleed) -increased demand (e.g. pregnancy) Hypochromic (less Hb) microcytic anaemia (small)

Question 36

Define macrocytosis (1)

Answer 36

Rise in mean cell volume above normal range 80-95fl in adults – lower in children

Question 37

Causes of macrocyic anaemias (7)

Answer 37

``` Dietary deficiency of B12 / folate Alcohol Malabsorption Liver disease Hypothyroidism Increased demand e.g. pregnancy Drugs e.g. Azathioprin ```

Question 38

How is Vit B12 absorbed (1)

Answer 38

In ileum

Question 39

Vit 12 deficiency - causes (3)

Answer 39

Dietary insufficiency GI disease Pernicious anaemia

Question 40

Pernicious anaemia features (4)

Answer 40

``` Auto-immune gastritis Parietal cells damaged Intrinsic factor – secreted by parietal cells B12 not absorbed in small intestine -achlorhydria -absent intrinsic factor ```

Question 41

Folate deficiency - folate absorption (1) - causes (4)

Answer 41

Absorbed in upper small intestine (100 -200 µg daily) Dietary insufficiency Malabsorption (especially coeliac disease) Excessive use Drugs – e.g. Anticonvulsants, suphasalazine

Question 42

Systemic features of iron deficiency anaemia (7)

Answer 42

``` Lethargy Dyspnoea Skin and nail changes Mucosal changes Oesophageal webbing Tachycardia/papitations Cardiac failure/exacerbation of cardiac diseases ```

Question 43

Systemic features of megaloblastic anaemia (8)

Answer 43

``` Pallor Jaundice Neurological changes Neural tube defects Gonadal dysfunction Mucosal changes Cardio-vascular disease Risks with GA ```

Question 44

Oral manifestations of **megaloblastic??** anaemia (1)

Answer 44

``` None Pallor - Hb < 8g/dl Oral ulceration and exacerbation of RAS Mucosal atrophy /stomatitis / glossitis Depapillated, smooth tongue Altered taste Oral candidosis Worsening of existing mucosal pathology Burning mouth syndrome? Dysphagia (oesophageal web). Look up Plummer-Vinson syndrome ```

Question 45

Leukemia (3)

Answer 45

Malignant diseases of blood forming cells in bone marrow One type of WBC produced in excess at detriment of others -Acute -->lymphoblastic – children (85%) and late middle age -->myeloid - older adults and children (15%) -Chronic -->lymphocytic - adults -->myeloid - adults

Question 46

Acute leukaemia - symptoms due to bone marrow failure or organ infiltration (7)

Answer 46

Signs and symptoms of anaemia Bacterial infections : mouth, throat, chest, skin, peri-anal Delayed healing Bruising and bleeding (including gingival) Bone pain Lymphadenopathy Hepatosplenomegaly

Question 47

Clinical features of chronic leukaemia (7)

Answer 47

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

Question 48

Oral manifestations of chronic leukaemia (3)

Answer 48

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

Question 49

Stem cell transplant / CVHD (3)

Answer 49

Chemotherapy or chemo-radiotherapy Transplant of own or donor stem cells May lead to GVHD - lichen planus - Sjögren's like syndrome

Question 50

Describe multiple myeloma (8)

Answer 50

Tumour of monoclonal plasma cells (B cell origin) Produce and secrete monoclonal protein (Ig) Bence-Jones protein in urine (Ig light chain) Bone pain, osteoporosis, osteolytic lesions Recurrent infection Anaemia Renal failure Amyloidosis

Question 51

What is amyloidosis caused by (2)

Answer 51

Fibrillar protein Ig light chain

Question 52

Leucopenia (3)

Answer 52

Reduction in white cell population Primary: reduction in haemopoesis Secondary: auto-immune disease, infection, drug therapy (e.g. carbamazepine), HIV

Question 53

Cyclical neutropenia features (6)

Answer 53

``` Rare Unknown aetiology Most common in childhood Neutropenia Average cycles of 21 days Infections ```

Question 54

Oral manifestations of cyclical neutropenia (4)

Answer 54

Ulceration -irregular, any surface, may heal with scarring within 2/52 Gingivitis Periodontitis Susceptibility to infection e.g. candidosis

Question 55

Management of cyclical neutropenia (2)

Answer 55

Supportive | Self-limiting

Question 56

Angina bullosa haemorrhagica features and management (5)

Answer 56

Idiopathic Can occur in thrombocytopenia Diagnosis - history and clinical signs FBC and clotting screen Reassure

Question 57

Significance of angina bullosa haemorrhagica for dental care (5)

Answer 57

``` May observe signs suggestive of haematological disease Appropriate referral Risk of infection Risk of bleeding Importance of good quality care ```

Question 58

Typical exam questions - learn

Answer 58

What are the oral effects of Crohn’s disease? What other conditions can share similar features? Describe how you would manage the oral effects of anaemia