for dental students

1. Oral Manifestations
of Gastrointestinal
Disorders
Thilanka Umesh Sugathadasa

2. Thilanka Umesh Sugathadasa Page 1
Oral Manifestations of Gastrointestinal Disorders
1. Gastro- esophageal reflux disease
2. Crohn’s disease
3. Ulcerative colitis
4. Oro facial granulomatosis
5. Gardner’s syndrome
6. Peutz- jeghers syndrome
7. Malabsorption conditions affecting hematopoiesis
8. Metastatic disease to the jaws
9. Jaundice
Condition Features Clinical/Dental features Diagnosis & Mx
Oesophagea
l
disease(Refl
ux
oesophagitis
- Gastro-
Oesophagea
l reflux
disease-
GORD)
 Backflow of acid from
stomach in to
oesophagus.
 One of the most
common type of
dyspepsia.
 Considered to be due
to hiatal
(diaphragmatic)
hernias.
 GORD is predisposed
by
- GI disease like high
acidity in stomach
content & impaired
gastric mobility.
- Extra-GI conditions
such as obesity, large
meals, smoking,
alcohol
 Can be caused by
increased acid
production & defect in
the sphincters
 Symptoms
- Heart burns
- Burning sensation behind
the sternum
- Most commonly felt after
the meals
- Acid taste
 Signs
- Tooth erosion
- Stricture(Acid in
oesophagus-Irritation--
Fibrosis-Strictures--Fe
absorption)
 Dental aspect
- Dental erosion typically in
palatal aspect of upper
anterior teeth & premolars.
- Clinically, enamel is lost
over broad areas of the
teeth that are exposed to
the gastric contents.
- In bulimics, it is commonly
seen & is most severe on the
maxillary anterior
teeth.(Bulimia- self induced
vomiting can see changes in
the palatal mucosa also).
-Eroded enamel is smooth,
shiny & hard. If it become
thin enough, yellowish
 DD
- Candidal
oesophagitis(seen in
immunocompromised pts
or Aplastic anemic pts. )
- Chemical burns from
acids/ NSAIDS
 General Mx
- Reducing weight
- Raising head at least 4
inches at night.
- Taking frequent meals
with antacids.(Aluminium
hydroxide)
- H2 blockers
- Proton pump inhibitors
(more effective)

3. Thilanka Umesh Sugathadasa Page 2
colour of dentin becomes
visible & teeth may become
sensitive to temperature
changes.
- Once enamel has eroded, it
is not replaceable
physiologically though the
patient may need dental
restorative Rx.
- Because enamel erosion is
directly proportional to the
contact time with gastric
acid, can get some idea of
frequency & duration of
reflux problem by assessing
amount of enamel loss.
Crohn’s
disease
 See oral Ulceration
part
 Inflammatory
condition of unknown
cause.
 With UC named as
Inflammatory Bowel
disease.
 Inflammation extends
up to lining of the
affected organs.
 Differences between
UC & CD presents in
Oral ulceration note.
 CD appears to be
heterogeneous group
of disorders probably
caused by commensal
bacteria in people
with genetically
determined
dysregulation of
mucosal T
lymphocytes.
 Inflammation
mediated by TNF
 Sub mucosal chronic
inflammation with
many mononuclear,
 Clinical features
- Common in ileoceacal
region, but can affects any
part of GI tract.
- Ulceration, fissuring &
Fibrosis os walls.
- Manifestations are depend
on severity & affected site.
- Complication include
weight loss, GI obstruction,
Internal/ External fistula,
Perianal fissures, Abcesses,
Arthralgia, Renal damage
 Dental features
- Ulcers
- Facial/ labial swelling
- Mucosal tags
- Cobblestone proliferation
of mucosa(Irregular swelling
with fibrosis in between)
- Angular cheilitis
- May be caused by CD itself
or by nutritional deficiencies
 Some patients may have
asymptomatic intestinal
disease or some may
develop it later.
 Dental Mx may be
complicated by
Malabsorption &
Steroids/immunocompra
mise therapy.
 NSAIDs should be
avoided.(Can induce
gastric ulceration)
 Antibiotics that could
aggravate diarrhea
should be avoided(Co-
amoxiclave &
Clindamycine)

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interleukin producing
cells.
 Non caseating
granuloma form in sub
mucosa & lymph
nodes
 Melkerson Rosenthal
Syndrome & Cheilitis
granulomatosa are
incomplete manifestations of
CD.
OFG
 Group of diseases
characterized by
noncaseating type
granulomatous
inflammation affecting
soft tissues of Oral &
maxillofacial region.
- Melkersson-
Rosenthal syndrome
- Cheilitis
granulomatosa
(Swelling restricted to
the lips,)
 Precise cause is
unknown but can be
infections, genetic
predisposition, Allergy
 Recently researchers
have identified a
monoclonal
lymphocytic expansion
& suggested it could
be secondary to
chronic antigenic
stimulation.
 Cytokine which
produce by the
lymphocytic clone
could be responsible
for the formation of
granulomas.
 However,
immunologic
origin(cell- mediated
hypersensitivity
reaction) is favoured
because of presence
of activated helper T
lymphocytes
expressing IL-2
receptors.
 Clinical features
- Non-tender recurrent
labial swelling that
eventually becomes
persistent.
- Swelling may affect one or
both lips, causing lip
hypertrophy (macrocheilia)
- Swelling is initially soft but
becomes firmer with time
due to fibrosis.
- Recurrent facial swelling,
may affects chin, cheeks,
periorbital region & eyelids.
- Rarely may not be
associated with lip
hypertrophy.
- Intraoral involvement may
take the form of
hypertrophy, erythema or
nonspecific erosions
involving the gingiva, oral
mucosa or tongue.
 Diagnostic dilemma may be
further complicated by
systemic diseases such as
crohn’s disease, sarcoidosis,
 DD of persistent lip swelling
- Angioedema(Idiopathic/
hereditary)
- Sarcoidosis
- Crohn’s disease
- OFG
- Specific infections(TB/
leprosy & deep fungal
infection)
- Amyloidosis
- Tumors(Tissue or minor
salivary gland tumor)
 Diagnosis is mainly by
exclusion
 Rx is difficult due to
absence of etiologic
factors.
 Rx objectives are to
improve pts clinical
appearance & comfort
 Spontaneous remission
possible.
 Eliminate the
odontogenic infections
 1st
line Rx
- Local or systemic
corticosteroids.
- intralesional
triamcinolone 10mg/ml
(Recently higher
concentrations -
40mg/ml) due to
injection volume become
less.
systemic steroids
therapy is limited now
due to complications &
recurrent nature.
- With steroids results
are immediate
- Relapses are common
 Complications
- Skin atrophy
- Hypopigmentation
 Other
- Thalydomide
- Methotrxate
- Metronidazole

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Ulcerative
Colitis
 Inflammatory bowel
disease.
 Affecting part or
whole large intestine,
frequently lower
colon & rectum.
 Cause inflammation
& ulcers in superficial
layers of large
intestine mucosa
followed by pseudo
polyp formation.
 Diarrhea with mucus +blood
+pus
 Pain, fever, anorexia
 Extra abdominal signs are
minimal
 Commonest complication is
Iron deficiency anaemia.
 Skin lesions present like
Erythema nodosum.
 Carcinoma
Dental aspect
 Oral manifestations are
rare.
 Chronic ulceration can be
occur. (Polystomatitis
gangrenosum)
 Polystomatitis vegetans
(Multiple intraepithelial
micro abscesses)
 Lesions related to anaemia
 Antibiotics & NSAIDS
should be avoided.
Gardner’s
syndrome
 Autosomal dominant
condition
 Genetic defect on the
chromosome 5
 Characterized by the
intestinal polyposis
with a very high risk
of malignant
transformation into
colonic
adenocarcinoma.
 Head & Neck manifestations
- Multiple enostoses (bone growth within the bony cavity)
of the jaws
- Supernumerary & or unerupted teeth
- Increased risk of odontomas(Compound)
- Osteomas of the jaws & paranasal sinuses.
- Epidermoid cyst in the skin of Head & Neck.
Peutz-
jeghers
syndrome
 Associate with
harmatomatous
polyposis, mostly of
small intestine
 Autosomal dominant.
 Intraorally, lesions are
usually flat, painless, brown
pigmented patches of
buccal mucosa, tongue or
labial mucosa.
 No Rx required to
pigmented lesion unless
there are cosmetic or
social reason.
Malabsorpti
on
condition
affecting
hematopoie
sis
 GI diseases related to
protein- caloric
malnutrition or
micronutrient
Malabsorption may
have an effect(Iron)
 Atrophic tongue
 Ulcer with bright red border
 Burning
sensation(glossopyrosis)
 Angular cheilitis
 Candidal infection
 Antifungal
 Remove the cause.

6. Thilanka Umesh Sugathadasa Page 5
Metastatic
disease to
the jaws
 Malignant neoplasms of liver & GI tract occasionally metastasize to oral region
commonly posterior mandible, through hematogenous route.
 Vertebral plexes of veins considered as primary mechanisms whereby these tumors
bypass the right heart- lung capillary bed.
 Asymptomatic
Pain
Paresthesia
Loosening of teeth
 Radiographs shows irregular, poorly circumscribed & often multifocal radiolucencies
 Less commonly metastases may involve the maxilla or oral soft tissues
Jaundice
 Excess bilirubin in blood results in accumulation of bilirubin in tissues, including oral
mucosa(Yellow)
 Lingual frenum & soft palate are higherly affected(which contain elastin)
 Careful with persons who eats large amount of Vit A
 Yellowish to greenish pigmentation can be seen in the teeth of children with
hyperbilirubinemia during calcification