Oral mucosa: Manifestations and Gastrointestinal and Haematological Disease Flashcards
What causes the primary effects with GIT disorders?
Part of the disease process
e.g. crohn’s disease
What causes the secondary effects with GIT disorders?
Malabsorption, blood loss
= Most oral effects
What GIT conditions can impact the oral mucosa?
GORD Coeliac disease Idiopathic inflammatory bowel disease - Crohn's disease (and oro-facial granulomatosis - OFG) - Ulcerative colitis Intestinal polyposis syndromes
GORD features?
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
Coeliac disease?
Intolerance to alpha-gliadin peptides in gluten found in wheat, rye, barley
Any age
Genetically susceptible
Prevalence 0.5-1%
Pathogenesis of coeliac’s disease?
Exposure to gluten Proliferation of lymphocytes Oedema Crypt hyperplasia and sub-total villous atrophy Mostly in duodenum and jejunum
Effects of coeliac disease?
Malabsorption
- Iron (anaemia)
- Ca and Vitamin D
- Folic acid
- Vitamin C
- Vitamin B12
As smaller SA to absorb as much
Clinical features of coeliac disease?
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)
Oral manifestations of coeliac disease?
Malabsorption gives anaemia resulting in:
- Oral ulceration
- Glossitis
- Candidiasis
- Angular cheilitis
- Hypoplasia of enamel of permanent teeth - often generalised and symmetrical (secondary to malabsorption)
Diagnosis of coeliac disease?
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
Coeliac disease tx?
Remove gluten from diet
Replacement of haematinics (iron and folate)
Increased risk of T cell lymphoma and other bowel malignancies)
Idiopathic inflammatory bowel disease types?
Crohn’s
Ulcerative colitis
Crohn’s disease features?
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
Clinical features of Crohn’s disease?
Abdominal pain Diarrhoea Weight loss Malabsorption - B12, bile salts Variable presentation, depends on severity and site, often intermittent
Crohn’s disease oral manifestations?
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
What diseases can show granulomatous inflammation from a biopsy?
Crohn’s
TB
Sarcoidosis - can also cause lip swelling
Crohn’s disease management?
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
Crohn’s diagnosis?
History Oral biopsy - include muscle Blood test - FBC and haematinics - Gut antibodies, ACE (to exclude sarcoid) Onward referral
Oro-facial granulomatosis - OFG presentation?
Oral features of Crohn’s disease with no clinical features of gut involvement
Can get midline fissures in the lip
Causes of lip swelling?
Crohn's Sarcoidosis Foreign body reactions Melkerson-rosenthal syndrome e.g. triad of lip swelling, fissured tongue and facial palsy Infecs - TB, syphilis, leprosy
Management of OFG?
Surgery in severe cases Topical and intralesional steroids (temp relief) Systemic drugs e.g. azathioprine Exclusion diet: - Chocolate - Crisps - Carbonated drinks - Carvone - Cinnamon - Benzoates
What is ulcerative colitis?
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
UC clinical and oral manifestations?
Bloody diarrhoea Pain Weight loss Tiredness Iritis, ankylosing spondylitis = arthritis affecting spine
Oral manifestations
- Oral ulcers
- Pyostomatitis vegetans = yellow areas on gingivae
Oral effects of drugs used to treat GIT disorders?
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
Intestinal polyposis syndrome - gardener’s syndrome?
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
Intestinal polyposis syndrome - Peutz jeghers syndrome?
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)
What is anaemia?
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
Anaemia by morphology of RBC?
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)
Iron deficiency anaemia?
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)
Macrocytic anaemia?
Macrocytosis
- Rise in mean cell volume above normal range in adults
Causes
- Dietary deficiency of B12/folate
- Alcohol
- Malabsorption
- Liver disease
- Hypothyroidism
Vitamin B12 deficiency?
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
Folate deficiency?
Absorbed in upper small intestine
Dietary insufficiency
Malabsorption
Drugs e.g. anticonvulsants
Systemic features of iron deficiency anaemia?
Lethargy
Dyspnoea
Skin and nail changed - spooning of nails, white lines
Mucosal changes - pale
Oesophageal webbing
Tachycardia/palpitations
Cardiac failure/exacerbation of cardiac diseases
Systemic features of megaloblastic anaemia?
Pallor Jaundice Neurological changes Neural tube defects Mucosal changes CV disease Risks with GA
Oral manifestations of megaloblastic anaemia?
None Pallor Oral ulcerations and exacerbation of RAS Mucosal stomatitis/glossitis Smooth tongue Altered taste Oral candidosis Burning mouth syndrome Dysphagia (oesophageal web_
What is leukaemia?
Malignant diseases of blood forming cells in bone marrow
One type of WBC produced in excess at detriment of others
Types of leukaemias?
Acute
- Lymphoblastic - children (85%) and late middle age
- Myeloid - older adults and children (15%)
Chronic
- Lymphocytic - adults
- Myeloid - adults
Acute leukaemia symptoms?
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
Chronic leukaemia clinical features?
Anaemia Bleeding Infec Splenomegaly Weight loss Fatigue Sweating
Oral manifestations of leukaemia?
Gingival inflammation and swelling
Bleeding
Ulceration (cytotoxic drugs/infection)
Increased susceptibility to oral infections
Graft versus host disease / stem cell transplant
Chemo or chemo-radiotherapy Transplant of own or donor stem cells May lead to GVHD - Lichen planus = soreness, white striations - Sjogren's like syndrome
What is multiple myeloma?
What can it cause?
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
Amyloidosis?
Fibrillar protein
Leucopenia?
Reduction in white cell population
Primary: reduction in haemopoesis
Secondary due to autoimmune disease, infec, drug therapy, HIV
Cyclic neutropenia?
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
Management of cyclic neutropenia?
Supportive
Self limiting
Angina bullosa haemorrhagica (ABH)?
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
What is the significance of haematological disease with dental care?
Approrpriate referral
Risk of infec and bleeding
Importance of good qual care
Anaemia and dentistry
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
Sickle cell
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
Acute lymphoblastic leukaemia
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
Chronic lymphocytic anaemia
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
