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DENTAL

MANAGEMENT OF
DISEASES OF THE
GASTROINTESTINAL
SYSTEM

INDEX
Introduction
Common gastrointestinal symptoms.
Investigations in Gastroenterology
Gastrointestinal diseases of dental interest:
Gastro-oesophageal reflux disease
Gastritis
Hiatus hernia
Peptic ulcer disease: Gastric Ulcer and Duodenal ulcer
Celiac disease
Inflammatory Bowel Disease (IBD): Crohns disease and Ulcerative colitis
Irritable bowel syndrome (IBS)
Malabsorption

Eating 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 Patterns


Weight Change
Heart Burn
Nausea And Vomiting
Difficulty In Swallowing
Jaundice
Chest Pain
Diarrhoea
Abdominal Swelling
Constipation
Loss Of Appetite
Rectal Bleeding
Bruising Tendencies
Intestinal Bloating,
Weakness

Investigations In

Gastroenterology.

A detailed health history and physical examination of the

abdomen
Endoscopy:
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 gastroscope
Colonoscopy:
The large bowel and terminal ileum can be investigated using the
colonoscope.
Sigmoidoscopy:
Diseases of the rectum can be investigated with sigmoidoscope
Laparoscopy:
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 intraoesophageal 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 Gastrooesophageal 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 stomach

ETIOLOGY / Predisposing
Factors
Obesity
big meals
tight clothing
fatty meals
alcohol
Smoking
pregnancy
hiatus hernia
drugs 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.

Symptoms
Dull 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 Biopsy
Barium Meal
Oesophageal Motility Studies
Resting ECG Is Helpful To Rule Out Ischemic

Heart Disease

ORAL HEALTH
CONSIDERATION
Oral 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
CONSIDERATION
A common

condition, regurgitation of gastric contents (pH 12) 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 treatment

GASTRITIS
Definition/Description: Gastritis is

characterized by acute or chronic


inflammation of the gastric mucosa which
is sometimes accompanied by erosions.

ETIOLOGY
In 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 signs


Epigastric Pain After Eating
Vomiting
Indigestion
Loss Of Appetite
Weight Loss.
In Autoimmune Disorder Pernicious

Anaemia Is Common.

Diagnosis/Investigations
No 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
CONSIDERATION
Patient with gastritis should not be given

drugs which directly irritate gastric mucosa


like aspirin ,NSAID s.

HIATUS HERNIA
Definition/Description
Hiatus 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 oesophagus

ETIOLOGY
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 patients

Symptoms and signs


Majority 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/investigations
Chest 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
artificial saliva, alcohol-free mouth- washes, or
increased fluid 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 reflux 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 Tenderness
Pain 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/Investigations
Endoscopy
barium meal
biopsy (to rule out gastric malignancy) are

recommended diagnostic measures


Biopsy 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
CONSIDERATION
In 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 gluten

ETIOLOGY
Gluten 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).

Symptoms
Diarrhoea
Steatorrhoea
Weight Loss
Abdominal Pain
Anaemia
Muscle Wasting
Oral Mucosal Ulcers
Dental Enamel Hypoplasia
Delayed Eruption
Skin Pigmentation
Peripheral Oedema
Dermatitis Herpetiformis (Itchy Blistering Skin Disease).

Diagnosis/Investigations
Full 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 Disease

ORAL HEALTH
CONSIDERATION
In 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 disease

Ulcerative colitis

Any 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 ulcers
cobblestoning
Granulomas

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

ETIOLOGY
Crohns disease

Ulcerative colitis

Unknown

There is a genetic association with


Crohn's disease.
Unknown

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.

Probable factors implicated include


genetic, immunological, dietary and
psychological

Oral 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/Investigations
Crohns disease

Ulcerative colitis

Full Blood Count (FBC) For Anaemia

Elevated WBC Count,


Elevated ESR Count

FBC for anaemia

Increased Platelet Count,

WBCs (increased)
ESR(elevated)

Elevated Levels Of C-reactive

Protein ( A Protein In The Blood As A


Marker Of Inflammation)

Liver function tests (LFTs) may be


abnormal.

Plain Abdominal X-ray

Colonoscopy

Barium Meal Endoscopy,


Radionuclide Scanning
Biopsy For Histology.

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
stools

ETIOLOGY
Psychological and stress related in most

cases.

Symptoms and signs


Pain In Left Iliac Fossa Or Epigastrium

(Aggravated By Eating And Relieved


By Defecation)
Abdominal Bloating
Alternating Diarrhoea
Constipation
Passage Of Mucus In Stools
Abdominal Tenderness
Mucus On Rectal Examination

Diagnosis/Investigations
Rectal examination
Barium Enema
Sigmoidoscopy.

ORAL HEALTH
CONSIDERATION
In 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 syndrome

MALABSORPTION
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.

ETIOLOGY
Gastrocolic Fistula
Gastrectomy
Biliary Obstruction
Chronic Liver Failure
Chronic Pancreatitis
Alcohol Abuse
Acute Intestinal Infections
Celiac Disease
Amyloidosis
Crohns 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/investigations
If 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 B12

GASTROINTESTINAL SYNDROMES
Eating Disorders: Anorexia and Bulimia
Gardners Syndrome
Plummer-Vinson Syndrome
Peutz-Jeghers Syndrome
Cowdens Syndrome

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 (defined 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 influenced
by their appearance.

Diagnosis
The 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 fingernails 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 process

Plummer-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 anemia

Oral findings
Atrophic glossitis with erythema or fissuring
Angular cheilitis
Thinning of the vermilion borders of the lips
Leukoplakia of the tongue
Inspection 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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