DENTAL MANAGEMENT OF DISEASES OF THE GASTROINTESTINAL SYSTEM
DENTAL MANAGEMENT OF DISEASES OF THE GASTROINTESTINAL SYSTEM
INDEXIntroductionCommon gastrointestinal symptoms.
Investigations in GastroenterologyGastrointestinal diseases of
dental interest: Gastro-oesophageal reflux diseaseGastritisHiatus
hernia Peptic ulcer disease: Gastric Ulcer and Duodenal ulcerCeliac
diseaseInflammatory Bowel Disease (IBD): Crohns disease and
Ulcerative colitisIrritable bowel syndrome (IBS)MalabsorptionEating
Disorders: Anorexia and Bulimia Gardners Syndrome Plummer-Vinson
Syndrome Peutz-Jeghers Syndrome Cowdens Syndrome
INTRODUCTION
The primary structures of the gastrointestinal system include
the mouth, pharynx, oesophagus, stomach, small intestine (duodenum,
jejunum and ileum), large intestines (caecum, ascending colon,
transverse colon, descending colon and sigmoid colon) and rectum
.
Common Gastrointestinal Symptoms.
Abdominal Pain Change In Bowel PatternsWeight ChangeHeart
BurnNausea And VomitingDifficulty In SwallowingJaundiceChest
PainDiarrhoeaAbdominal SwellingConstipationLoss Of AppetiteRectal
Bleeding Bruising TendenciesIntestinal
Bloating,WeaknessInvestigations In Gastroenterology.
A detailed health history and physical examination of the
abdomenEndoscopy: This is performed to visualize of parts of the GI
tract and also to take biopsies of the involved
tissues.Gastroscopy: Oesophagus, stomach and proximal duodenum can
be investigated with the gastroscopeColonoscopy: The large bowel
and terminal ileum can be investigated using the colonoscope.
Sigmoidoscopy: Diseases of the rectum can be investigated with
sigmoidoscopeLaparoscopy: This is a method of inspecting the
abdominal organs directly using a fibreoptic system through one or
more small incisions.
Investigations In Gastroenterology.
Radiology: The whole of the GI tract can be investigated
radiologically using a contrast medium such as barium swallow,
barium meal or enema.Crosby capsule: A device used for obtaining
biopsies of small bowel mucosa. This is used for jejunal biopsies
in celiac disease.Faecal fat collection: Faeces collected for 3-5
days to quantitate the fat content ( in the diagnosis of
malabsorption)Faecal occult blood: Simple bed-side methods are used
to detect haemoglobin in blood in faeces.Breath tests: Urea breath
test is used for the detection or absence of H. Pylori. Lactose
Hydrogen breath test is used for the detection of disaccharide
deficiency.
Investigations In Gastroenterology.
Pancreatic function tests: Tests are available to assay
pancreatic exocrine function tests.Intestine motility tests: These
involve the use of radio-opaque markers along the GI
tract.Oesophageal manometry: Oesophageal manometry is a test used
for assessing motor function of the upper oesophageal sphincter,
oesophageal body and lower oesophageal sphincter. This test
measures intra- oesophageal pressure during swallowing.pH
monitoring: pH monitoring is carried out using portable pH probes
positioned above the gastro-oesophageal junction and connected to a
24 hour recording system (used in Gastro-oesophageal reflux
disease).
GASTRO-OESOPHAGEAL REFLUX DISEASE (GERD)
Definition/Description Gastro-oesophageal reflux disease(GERD)
is a condition characterised by inflammation of oesophagus usually
due to reflux of acid from stomachETIOLOGY / Predisposing
FactorsObesitybig mealstight clothingfatty mealsalcohol Smoking
pregnancy hiatus herniadrugs such as tricyclics (antidepressants)
and anticholinergic agents (Buscopan for example). Anticholinergic
agents are parasympathetic nerve impulse inhibitors which inhibit
involuntary movements of the smooth muscles of the GIT and other
sites.SymptomsDull retrosternal ache (heart burn) is often
triggered by food, coffee, or alcohol and aggravated by bending,
lying flat, lifting weight or straining. Pain may radiate to the
throat and to the back.These symptoms often mimic angina.
Regurgitation of stomach contents into the mouth, and transient or
permanent dysphagia to solids are common.
Diagnosis/Investigations Endoscopy With Or Without BiopsyBarium
MealOesophageal Motility Studies Resting ECG Is Helpful To Rule Out
Ischemic Heart DiseaseORAL HEALTH CONSIDERATIONOral adverse effects
of medication for GERD and peptic ulcer disease may include dry
mouth from proton-pump inhibitors (PPI), and sucralfate (a
cytoprotective agent that protects gastric mucosa). Sucralfate
causes constipation; hence the use of codeine should be
avoided.PPIs interfere with calcium absorption. X rays of the jaw
bones for any changes in the bone density should be periodically
checked.Erythema multiforme (a skin or mucocutaneous condition
characterized by multiple pink-red lesions with dark centres;
secondary to drug use or viral infections) from ranitidine,(a
histamine H2-receptor antagonist that inhibits stomach acid
production) and loss of taste from omeprazole (a PPI) are often
reported.If patients are on antacids containing aluminium hydroxide
(Mylanta, Gelusil for example), tetracyclines, metronidazole,
erythromycin and ciprofloxacin should be avoided because they do
not get absorbed adequately
ORAL HEALTH CONSIDERATIONA common condition, regurgitation of
gastric contents (pH 1-2) reduces the pH of the oral cavity below
5.5 & this acidic pH begins to dissolve enamel. It is most
commonly seen on the palatal surfaces of the maxillary dentition.
Erosion of the enamel exposes the underlying dentin, which is a
softer, more yellow, material & sensitive to temperature
changes and secondary to its lower mineral content, develops caries
much more quickly. Erosion is irreversible and can only be treated
with surgical restorative procedures. Early recognition and patient
education is most effective treatmentGASTRITIS
Definition/Description: Gastritis is characterized by acute or
chronic inflammation of the gastric mucosa which is sometimes
accompanied by erosions.ETIOLOGYIn majority of cases
over-indulgence of alcohol or drugs (aspirin or anti- rheumatic
drugs). Chronic form may be caused by H. Pylori infection or from
autoimmune process.Symptoms and signsEpigastric Pain After Eating
VomitingIndigestion Loss Of Appetite Weight Loss. In Autoimmune
Disorder Pernicious Anaemia Is Common.
Diagnosis/InvestigationsNo special investigations are necessary
in majority of cases. When erosions are suspected, endoscopy is
recommended. If pernicious anaemia is present haematological
examination is necessary. Urea breath test, rapid urease test,
culture and histology tests for H. Pylori are recommended
particularly for chronic gastritis.ORAL HEALTH CONSIDERATIONPatient
with gastritis should not be given drugs which directly irritate
gastric mucosa like aspirin ,NSAID s.HIATUS HERNIA
Definition/DescriptionHiatus hernia is a protrusion of the
stomach through a hiatus in the diaphragm. There are two types:
sliding (most common) and paraesophagealhernias. In the sliding
type the gastroesophageal junction and a portion of the stomach are
above the diaphragm where as in paraoesophageal hiatus hernia the
gastroesophageal junction is in the normal location but a part of
the stomach is adjacent to the oesophagusETIOLOGY Exact cause of
hiatus hernia is not known. Stretching of the fascial attachments
between the oesophagus and diaphragm at the hiatus
(aperture)appears to be a feature of its development.
Gastroesophageal reflux disease is associated with hiatus hernia in
a considerable number of patientsSymptoms and signsMajority of
patients with hiatus hernia are asymptomatic. Often hernias are
noted as incidental findings on x-rays. Chest pain may be a feature
in some patients. Strangulation of hernia is a
complication.Diagnosis/investigationsChest x-rays and barium
swallow confirm clinical suspicion of hiatus hernia.
ORAL HEALTH CONSIDERATIONS
If a hiatal hernia is treated with medications that cause xero-
stomia (dry mouth), the dose or drug type may need to be altered by
the patients physician.Various treatment modalities for dry mouth
(such as articial saliva, alcohol-free mouth- washes, or increased
uid intake) may need to be prescribed. Class V caries or root
caries are sequelae of dry mouth,even in patients who have been
relatively free of caries prior to developing the disease. If reux
into the oral cavity is present, oral manifestations that are the
same as those of GERD are seen .PEPTIC ULCER DISEASE (GASTRIC AND
DUODENAL ULCERS)
Definition Peptic ulcer disease is characterised by well defined
ulcers in the gastrointestinal mucosa. There are two types: Gastric
ulcers and duodenal ulcers.Etiology
Old No acid no ulcer Idiopathic Stress Spicy food
New Helicobacter Pylori NSAID Crohn s disease Gasrtrinoma
Hyperparthyroidism
Symptoms and signs Epigastric Pain And TendernessPain ASSOCIATED
WITH EATING POINTS TO GASTRIC ULCER. Pain Between Meals And During
The Night Is Suggestive Of Duodenal Ulcer. Pain Tends To Wax And
Wane, Aggravates During Stress And With The Use Of Drugs And
Alcohol. Signs Of Anaemia Due To Bleeding From The Ulcers May Be
Present. Ingestion Of Food, Milk Or Antacids Provides Temporary
Relief. Protracted Vomiting A Few Hours After Meals Is A Sign Of
Gastric Outlet (Pyloric) Obstruction. Black Tarry Stools (Melena)
Due To Gastrointestinal Haemorrhage And Weight Loss Are Other
Features Of The Peptic Ulcer Disease.
Diagnosis/InvestigationsEndoscopy barium meal biopsy (to rule
out gastric malignancy) are recommended diagnostic measuresBiopsy
is not required for duodenal ulcers as duodenum is a rare site of
malignancy. H. Pylori status assessment through urease activity,
histology, serology and urea breath test are useful.ORAL HEALTH
CONSIDERATIONIn peptic ulcer disease, oral signs and symptoms of
anaemia may be present.Aspirin, anti-inflammatory drugs such as
NSAIDs and corticosteroids should be avoided in peptic ulcer
disease. Antibiotics should be taken 2 hours before or 2 hours
after antacids. This is because antibiotics such as ampicillin need
the presence of acid for its absorption. Long term use of
antibiotics taken for peptic ulcers may sometimes promote oral
fungal infections.
CELIAC DISEASE
Definition/Description: Celiac disease is also known as gluten
sensitive enteropathy. It is characterised by the atrophy of the
jejunal mucosa due to its sensitivity to the dietary
glutenETIOLOGYGluten in the diet is the cause of Celiac
disease.Gluten has two components: glutenin and -gliadin. The
latter is antigenic. Genetic predisposition to celiac disease
exists (HLA B8 and BR3).SymptomsDiarrhoea Steatorrhoea Weight Loss
Abdominal Pain Anaemia Muscle WastingOral Mucosal Ulcers Dental
Enamel Hypoplasia Delayed Eruption Skin PigmentationPeripheral
OedemaDermatitis Herpetiformis (Itchy Blistering Skin Disease).
Diagnosis/InvestigationsFull Blood Count May Reveal Anaemia And
Howell-jolly Bodies (Basophilic Nuclear Remnants In Circulating
Erythrocytes).Liver Function Tests For Hypoalbuminaemia, Endoscopy
And Jejunal Biopsy For Atrophic Mucosa With Blunt Villi, Detection
Of Endomysialantibodies (Iga) And Xylose Tolerance Test Are Other
Tests Used In Celiac DiseaseORAL HEALTH CONSIDERATIONIn Celiac
disease oral ulceration, glossitis, angular cheilitis, bleeding
tendencies and anaemia may be encountered. Enamel defects are also
noted in celiac disease.Status of iron levels, bone density and
Vitamin K, folic acid and vitamin B12 should be determined prior to
invasive dental procedures in patients with celiac
disease.Consultation with patients GP is recommended for patients
with Celiac disease prior to the commencement of invasive dental
procedures Inflammatory bowel diseases (IBD)Inflammatory bowel
diseases (IBD) include Crohns disease (CD), ulcerative colitis (UC)
and an ill-defined group of medical conditions known as
indeterminate colitis. These are characterised by the chronic and
recurrent inflammation of different parts of the gastrointestinal
tract.Crohns diseaseUlcerative colitisAny part of the
gastrointestinal tract Rare rectum involvement Common perianal
disease Patchy inflammation Transmural inflammation Common presence
of fistulae and stenotic complication Intraabdominal abscess Deep
ulcerscobblestoning Granulomas Lymphoid follicles
Changes confined to the colon Frequent rectum involvement Rare
perianal disease Continous inflammation Superficial lining mucosa
inflammation Rare presence of fistulae and stenotic complication
Rare presence of abscess Superficial ulcers, friability Cryptic
abscess Crypts distortionETIOLOGYCrohns diseaseUlcerative
colitis
Unknown There is a genetic association with Crohn's
disease.Siblings of affected individuals are at higher risk Males
and females are equally affected. Smokers are two times more likely
to develop Crohn's disease than nonsmokers.Unknown Probable factors
implicated include genetic, immunological, dietary and
psychologicalOral lesions in IBD
Specific Orofacial granulomatosis Cobblestoning Mucosal tags
Deep, linear ulcers with hyperplastic folds Pyostomatitis
vegetans
Nonspecific Aphthous ulcers Angular cheilitis Labial/facial
edema Gingivitis Gingival erythema/edema
Diagnosis/InvestigationsCrohns disease
Ulcerative colitisFull Blood Count (FBC) For Anaemia Elevated
WBC Count,Elevated ESR CountIncreased Platelet Count,Elevated
Levels Of C-reactive Protein ( A Protein In The Blood As A Marker
Of Inflammation)Plain Abdominal X-rayBarium Meal
Endoscopy,Radionuclide ScanningBiopsy For Histology.
FBC for anaemia WBCs (increased) ESR(elevated) Liver function
tests (LFTs) may be abnormal. Colonoscopy plain x-ray biopsy for
histology.Dental management of patients with IBD should include the
following:Frequent preventive and routine dental care to prevent
destruction of hard and soft tissue. Evaluation of
hypothalamic/pituitary/adrenal cortical function to determine the
patients ability to undergo extensive dental procedures. Avoid
prescribing non-steroidal anti-inflammatory drugs (NSAID), as they
can trigger a flare-up. The use of paracetamol is recommended,
although it can also adversely affect patients. Early diagnosis and
treatment of oral infections to enhance the gastroenterologists
ability to manage the IBD. Diagnosis (biopsy if necessary) and
treatment of oral inflammatory, infectious, or granulomatous oral
lesions IRRITABLE BOWEL SYNDROME (IBS)
Definition/description: Irritable bowel syndrome (IBS) is
characterized by constipation, diarrhoea, abdominal pain (in the
left iliac fossa) and frequent passage of
stoolsETIOLOGYPsychological and stress related in most
cases.Symptoms and signsPain In Left Iliac Fossa Or Epigastrium
(Aggravated By Eating And Relieved By Defecation)Abdominal
BloatingAlternating Diarrhoea ConstipationPassage Of Mucus In
StoolsAbdominal Tenderness Mucus On Rectal
ExaminationDiagnosis/InvestigationsRectal examination Barium Enema
Sigmoidoscopy.ORAL HEALTH CONSIDERATIONIn irritable bowel syndrome
psychogenic oral symptoms such as facial pain and TMD symptoms may
be present. Routine dental treatment can be offered to patients
with Irritable bowel syndromeMALABSORPTION
Definition/description: Malabsorption syndromes are
characterized by inadequate absorption of dietary substances in
digestion, absorption and transport affecting proteins,
carbohydrates, fats, vitamins and minerals whichcauses nutritional
deficiencies.ETIOLOGYGastrocolic FistulaGastrectomyBiliary
ObstructionChronic Liver FailureChronic PancreatitisAlcohol
AbuseAcute Intestinal InfectionsCeliac Disease AmyloidosisCrohns
Disease Addisons Disease Radiation Enteritis.Symptoms and
signs:Effects of unabsorbed substances include diarrhoea,
steatorrhoea with pale bulky greasy foul smelling stools, abdominal
bloating, and gas. Other symptoms result from nutritional
deficiencies. Weight loss may be a feature in most patients despite
adequate food intake.Diagnosis/investigationsIf history suggests a
specific cause (liver failure, pancreatitis etc) testing should be
directed in that direction.Chronic diarrhoea, weight loss and
anaemia are suggestive of malabsorption. Fecal fat estimation is
helpful in determining steatorrhoea.Fecal fat >6 g/ day is
abnormal. Endoscopy with or without small bowel biopsy reveals
mucosal disease of the small bowel. The Schilling test assesses
malabsorption of the vitamin B12Eating Disorders: Anorexia and
Bulimia Gardners Syndrome Plummer-Vinson Syndrome Peutz-Jeghers
Syndrome Cowdens SyndromeGASTROINTESTINAL SYNDROMES
EATING DISORDERS: ANOREXIA AND BULIMIA
Anorexia involves individuals who intentionally starve
themselves when they are already underweight. People suffering from
this disorder have an intense fear of becoming fat, even when they
are extremely underweight (dened as body weight that is 15% or more
below the recommended levels).Those who suffer from anorexia are
unable to perceive their physical appearance accurately. Persons
with bulimia nervosa consume large amounts of food during binge
episodes in which they feel out of control of their eating. Bulimic
individuals are also not as successful in dieting as are those with
anorexia. They may successfully diet for a short time,but they
often again lose the ability to restrict food intake, often as a
result of some emotional trauma. They then try to prevent weight
gain after such episodes by vomiting, using laxatives or diuretics,
dieting, and/or exercising aggressively. Persons with bulimia,like
those with anorexia,are very dis- satisfied with their body shape
and weight, and their self- esteem is unduly inuenced by their
appearance.DiagnosisThe diagnosis of anorexia or bulimia is not
always clear.For example,some anorexic persons may binge and purge
whereas some bulimic persons may restrict food intake and
overcompensate for overeating by exercising. If an individual eats
through bingeing but is 15% or more below recommended weight,then
anorexia nervosa is the appropriate diagnosis. Both of these
disorders seem to be most prevalent in indus- trialized
societies,particularly where thinness is espoused as the ideal.
Anorexia usually develops in adolescence, between the ages of 14
and 18 years, whereas bulimia is more likely to develop in the late
teens or early twenties.ORAL HEALTH CONSIDERATIONS
The cardinal oral manifestation of eating disorders is severe
erosion of the enamel on the lingual surfaces of the maxillary
teeth.Acids from chronic vomiting are the cause.Examination of the
patients ngernails may disclose abnormalities related to the use of
fingers to initiate purging. Mandibular teeth may be affected but
not as severely as the maxillary teeth.Parotid enlargement may
develop as a sequela of starvation. Rarely does one observe
soft-tissue changes of the oral mucosa because of trauma from
gastric acids. Gardners Syndrome
Gardners syndrome consists of intestinal polyposis (which
represents premalignant lesions) and multiple impacted
supernumerary (extra) teeth. This disorder is inherited as an
autosomal dominant trait, and few patients afflicted with this
syndrome reach the age of 50 years without surgical intervention.
In a young patient with a family history of Gardners syndrome,
dental radiography (such as pantomography) can provide the earliest
indication of the presence of this disease processPlummer-Vinson
Syndrome
Plummer-Vinson syndrome, originally described as hysterical
dysphagia, is noted primarily in women in the fourth and fifth
decades of life. The hallmark of this disorder is dysphagia
resulting from esophageal stricture, causing many patients to have
a fear of choking. Patients may present with a lemon tinted pallor
and with dryness of the skin, spoon-shaped fingernails ,
koilonychia , and splenomegaly . The oral manifestations are the
result of an iron deficiency anemiaOral findings Atrophic glossitis
with erythema or fissuringAngular cheilitis Thinning of the
vermilion borders of the lipsLeukoplakia of the tongueInspection of
the oral mucous membranes will disclose atrophy and
hyperkeratinization.These oral changes are similar to those
encountered in the pharynx and esophagus. Carcinoma of the upper
alimentary tract has been reported in 10 to 30% of patients.
Thorough oral, pharyngeal, and esophageal examinations are
mandatory to ensure that carcinoma is not present. Artificial
saliva may reduce the sensation (and thereby, the fear) of
choking.
Peutz-Jeghers Syndrome
Peutz-Jeghers syndrome is characterized by multiple intestinal
polyps throughout the gastrointestinal tract but primarily in the
small intestine. Malignancies in the gastrointestinal tract and
elsewhere in the body have been reported in approximately 10% of
patients with this syndrome. Pigmentation (present from birth) of
the face, lips, and oral cavity is a hallmark of this syndrome.
Interestingly, the facial pigmentation fades later in life although
the intraoral mucosal pigmentation persists. No specific oral
treatment is necessary.Cowdens Syndrome
Cowdens syndrome (multiple hamartoma and neoplasia syndrome) is
an autosomal dominant disease. FEATURES facial trichilemmomas
gastrointestinal polyps breast and thyroid neoplasms oral
abnormalities.Cowdens syndrome is considered to be a cutaneous
marker of internal malignancies.Pebbly papilloma-like lesions and
multiple fibromas may be found widely distributed throughout the
oral cavity.
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