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Oral Disease > Oral mucosa: Manifestations and Gastrointestinal and Haematological Disease > Flashcards

Oral mucosa: Manifestations and Gastrointestinal and Haematological Disease Flashcards

1
Q

What causes the primary effects with GIT disorders?

A

Part of the disease process

e.g. crohn’s disease

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2
Q

What causes the secondary effects with GIT disorders?

A

Malabsorption, blood loss

= Most oral effects

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3
Q

What GIT conditions can impact the oral mucosa?

A 
GORD
Coeliac disease
Idiopathic inflammatory bowel disease
- Crohn's disease (and oro-facial granulomatosis - OFG)
- Ulcerative colitis
Intestinal polyposis syndromes
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4
Q

GORD features?

A

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

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5
Q

Coeliac disease?

A

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

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6
Q

Pathogenesis of coeliac’s disease?

A 
Exposure to gluten
Proliferation of lymphocytes
Oedema 
Crypt hyperplasia and sub-total villous atrophy 
Mostly in duodenum and jejunum
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7
Q

Effects of coeliac disease?

A

Malabsorption

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

As smaller SA to absorb as much

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8
Q

Clinical features of coeliac disease?

A

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)

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9
Q

Oral manifestations of coeliac disease?

A

Malabsorption gives anaemia resulting in:

  • Oral ulceration
  • Glossitis
  • Candidiasis
  • Angular cheilitis
  • Hypoplasia of enamel of permanent teeth - often generalised and symmetrical (secondary to malabsorption)
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10
Q

Diagnosis of coeliac disease?

A 
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
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11
Q

Coeliac disease tx?

A

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

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12
Q

Idiopathic inflammatory bowel disease types?

A

Crohn’s

Ulcerative colitis

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13
Q

Crohn’s disease features?

A

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

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14
Q

Clinical features of Crohn’s disease?

A 
Abdominal pain
Diarrhoea
Weight loss
Malabsorption - B12, bile salts
Variable presentation, depends on severity and site, often intermittent
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15
Q

Crohn’s disease oral manifestations?

A 
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
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16
Q

What diseases can show granulomatous inflammation from a biopsy?

A

Crohn’s
TB
Sarcoidosis - can also cause lip swelling

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17
Q

Crohn’s disease management?

A 
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
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18
Q

Crohn’s diagnosis?

A 
History 
Oral biopsy - include muscle 
Blood test
- FBC and haematinics
- Gut antibodies, ACE (to exclude sarcoid)
Onward referral
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19
Q

Oro-facial granulomatosis - OFG presentation?

A

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

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20
Q

Causes of lip swelling?

A 
Crohn's 
Sarcoidosis
Foreign body reactions
Melkerson-rosenthal syndrome e.g. triad of lip swelling, fissured tongue and facial palsy 
Infecs - TB, syphilis, leprosy
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21
Q

Management of OFG?

A 
Surgery in severe cases
Topical and intralesional steroids (temp relief)
Systemic drugs e.g. azathioprine
Exclusion diet:
- Chocolate
- Crisps
- Carbonated drinks 
- Carvone
- Cinnamon
- Benzoates
22
Q

What is ulcerative colitis?

A

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

23
Q

UC clinical and oral manifestations?

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

Oral manifestations

  • Oral ulcers
  • Pyostomatitis vegetans = yellow areas on gingivae
24
Q

Oral effects of drugs used to treat GIT disorders?

A

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

25
Q

Intestinal polyposis syndrome - gardener’s syndrome?

A 
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
26
Q

Intestinal polyposis syndrome - Peutz jeghers syndrome?

A 
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)
27
Q

What is anaemia?

A

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

28
Q

Anaemia by morphology of RBC?

A

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)

29
Q

Iron deficiency anaemia?

A 
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)

30
Q

Macrocytic anaemia?

A

Macrocytosis
- Rise in mean cell volume above normal range in adults

Causes

  • Dietary deficiency of B12/folate
  • Alcohol
  • Malabsorption
  • Liver disease
  • Hypothyroidism
31
Q

Vitamin B12 deficiency?

A

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
32
Q

Folate deficiency?

A

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

33
Q

Systemic features of iron deficiency anaemia?

A

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

34
Q

Systemic features of megaloblastic anaemia?

A 
Pallor
Jaundice
Neurological changes
Neural tube defects
Mucosal changes
CV disease
Risks with GA
35
Q

Oral manifestations of megaloblastic anaemia?

A 
None
Pallor
Oral ulcerations and exacerbation of RAS
Mucosal stomatitis/glossitis
Smooth tongue
Altered taste
Oral candidosis
Burning mouth syndrome
Dysphagia (oesophageal web_
36
Q

What is leukaemia?

A

Malignant diseases of blood forming cells in bone marrow

One type of WBC produced in excess at detriment of others

37
Q

Types of leukaemias?

A

Acute

  • Lymphoblastic - children (85%) and late middle age
  • Myeloid - older adults and children (15%)

Chronic

  • Lymphocytic - adults
  • Myeloid - adults
38
Q

Acute leukaemia symptoms?

A

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
39
Q

Chronic leukaemia clinical features?

A 
Anaemia
Bleeding
Infec
Splenomegaly
Weight loss
Fatigue
Sweating
40
Q

Oral manifestations of leukaemia?

A

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

41
Q

Graft versus host disease / stem cell transplant

A 
Chemo or chemo-radiotherapy 
Transplant of own or donor stem cells 
May lead to GVHD
- Lichen planus = soreness, white striations
- Sjogren's like syndrome
42
Q

What is multiple myeloma?

What can it cause?

A

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
43
Q

Amyloidosis?

A

Fibrillar protein

44
Q

Leucopenia?

A

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

45
Q

Cyclic neutropenia?

A 
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
46
Q

Management of cyclic neutropenia?

A

Supportive

Self limiting

47
Q

Angina bullosa haemorrhagica (ABH)?

A 
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
48
Q

What is the significance of haematological disease with dental care?

A

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

49
Q

Anaemia and dentistry

A

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
50
Q

Sickle cell

A

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
51
Q

Acute lymphoblastic leukaemia

A

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

52
Q

Chronic lymphocytic anaemia

A

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

Oral Disease (42 decks)

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