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

2. ORAL MANIFESTATIONS OF GASTROINTESTINAL DISORDERS
- H.K.AJEYA RANGANATHAN
IV B.D.S
G D C R I
Guided by :
Dr.Mubeen
Dr.Vijayalakshmi
Dr.Suman

3. 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

4. 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.

6. NEED FOR THE KNOWLEDGE REGARDING GASTROINTESTINAL
DISORDERS AND ITS ORAL MANIFESTATION:-
Recognize, diagnose, and treat oral conditions associated with
gastrointestinal diseases.
Proper medical referral for management of systemic symptoms
Dentist’s role in monitoring patient compliance with recommended medical
therapy for gastrointestinal conditions

7. GASTROINTESTINAL DISEASE MANIFESTING ORAL LESIONS
Inflammatory bowel diseases
• Crohn’s disease
• Ulcerative colitis
Peptic ulcer disease
Gastro-oesophageal reflux
disorder
Malabsorption
• Pernicious anemia
• Folic acid deficiency anaemia
Eating Disorders • Bulimia
Genetic disorders
• Anorexia
• Gardner’s syndrome
• Peutz-Jegher’s syndrome
Metastatic diseases to the jaw • Malignant neoplasm of liver and GIT

8. INFLAMMATORY BOWEL DISEASES
Ulcerative colitis Crohn’s Disease
IBD is currently considered an inappropriate immune response to the endogenous commensal
microbiota within the intestines, with or without some component of autoimmunity.

9. Ulcerative colitis is an inflammatory reaction of large intestine characterized by remission
and exacerbations.
Etiology:-
Idiopathic
Psychological
and
Immunological
factors.
Allergy,
Bacterial
and viral
infections
Ulcerative colitis

10. 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

11. Major 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

12. Crohn’s disease is the inflammation of small and large
intestine involving all layers of gut
Genetic
Smoking,
Stress
Excessive
immune
reaction
Crohn’s disease
Etiology

13. 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

14. Persistent
linear and
deep ulcer
Cobblestone
mucosal
architecture,
diffuse
swelling of
the lips and
face,
Indurated
polypoid tag-like
lesions in
the vestibule
Pyostomatitis vegetans, cobblestone mucosal architecture and minor salivary gland duct pathology represent
granulomatous changes that constitute the hallmark of Crohn's disease.

15. 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

16. Peptic ulcer disease

17. Peptic ulcer disease
GENERAL SYMPTOMS OF PEPTIC ULCER

18. Peptic ulcer disease
ORAL 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

19. Peptic ulcer disease
DENTAL MANAGEMENT OF PEPTIC ULCER DISEASE

20. Gastroesophageal 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

21. 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

22. Dysgeusia
[altered taste]
Erosion Mucosal erythema
Mucosal atrophy
Esophagial stricture and
Fibrosis
Xerostomia

23. NaHCO3 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

24. 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

25. GENERAL SYMPTOMS PERNICIOUS ANEMIA

26. ORAL MANIFESTATIONS OF PERNICIOUS ANEMIA
Inflamed “beefy red" tongue Glossitis and glossodynia
Burning mouth

27. 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

28. 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

29. DENTAL MANAGEMENT OF ANEMIA
Patients at low risk (hematocrit
>30%)
• Normal dental protocol
Patients at high risk( hematocrit <30%)
• Stress reduction protocols
• Shorter appointments
• Sedation techniques
Outpatient intra venous sedation and
general anaesthesia is contraindicated
Hospitalization for moderate and
advanced surgical procedures

30. EATING DISORDERS
Two common eating disorders are Anorexia nervosa and Bulimia nervosa
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
Common intention of either of the disorders is weight loss

31. GENERAL SYMPTOMS OF EATING DISORDERS

32. ORAL MANIFESTATIONS OF EATING DISORDERS
Erosion of lingual
surfaces of maxillary
anterior teeth
Increased risk of
caries and periodontal
disease
Parotid gland swelling
Teeth sensitive to
thermal changes

33. 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

34. GENETIC DISORDERS
Gardner’s syndrome:-
• 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

35. GENERAL SYMPTOMS OF GARDNER'S SYNDROME

36. GARDNER'S SYNDROME

37. MANAGEMENT OF GARDNER’S SYNDROME

38. PEUTZ-JEGHER’S SYNDROME

39. METASTATIC DISEASES OF JAW
Malignant lesion of liver and Gastro intestinal tract occasional
metastasize to oral cavity
• Most commonly seen on posterior mandibular region
• Spread through hematogenous route via vertebral plexus of veins
Symptoms
• May be asymptomatic or may present with jaw pain or tooth ache
• Paraesthesia
• unexplained mobility of tooth
Prognosis
• Only a few patients have survived for up to 5 years after the diagnosis

40. CONCLUSION
It 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