Gastrointestinal Disease States and Associated Oral Cavity Lesions: Assessment, Analysis, and Associated Dental Management Guidelines
Angular cheilitis is associated with cracking at the corners of the mouth, pain, and bleeding in severe cases.
Nutritional anemias, and very particularly iron-deficiency anemia, ill-fitting dentures, improper bite, HIV/AIDS, cold weather, and constant lip-smacking are common etiological factors.
Superinfection with candidiasis is very common at the corners of the mouth. Some patients may have associated esophageal candidiasis and may complain of dysphagia and/or odynophagia.
Prescribe topical antifungal therapy, pain medications in severe cases, and lip balm for those suffering due to the cold weather. Additionally, always treat the underlying cause of angular cheilitis.
Aphthous ulceration is often brought on by stress, local trauma, prolonged fever, or Crohn’s disease (Table 44.1). Of Crohn’s disease patients, 4–15% have aphthous ulcers. Aphthous ulceration is a rare finding with celiac disease. Aphthous ulcers can also occur in patients suffering from immunological conditions such as Sjögren’s syndrome, systemic lupus erythematosus (SLE), and scleroderma.
|Disease||Generic (Trade) Name||Treatment Instructions|
|Mild Disease||1. Topical 0.15 Benzydamine (Difflam or Tantum) oral rinse||Apply to the ulcers four times/day for two weeks or until the ulcers heal.|
2. Protective Bioadhesives:
Topical Carellose (Orabase: pectin plus gelatin)
|Apply to the ulcers four times/day for two weeks or until the ulcers heal.|
3. Topical Corticosteroids, in adhesive base or as a spray/cream/pellet:
a. 1% Triamcinalone dental< ?hsp 1.5em?>paste (Adrortyl or Kenolog in< ?hsp 1.5em?>Orabase)
b. Hydrocortisone, 2.5mg< ?hsp 1.5em?>pellets (Corlan)
c. 0.12% or 0.2% Chlorhexidine< ?hsp 1.5em?>gluconate aqueous mouth< ?hsp 1.5em?>wash (Peridex) or 1%< ?hsp 1.5em?>Chlorhexidine gluconate gel
|With any of the preparations for mild disease: Apply to the ulcers four times/day for two weeks or until the ulcers heal.|
|Severe Disease||1. Systemic Corticosteroids: Tablets/capsules||30–60mg prednisone daily for one week, followed by a one-week dose taper.|
|Severe Disease||2. Thalidomide (Thalomid)||50–200mg daily for four to eight weeks.|
The severity of the ulceration determines the type of treatment provided. Some of the treatment options available are listed in Table 44.1. For a complete list, refer to Chapter 48.
Peutz-Jegher’s syndrome is associated with mucocutaneous hyperpigmentation and gastrointestinal hamatomatous polyps. The polyps can appear throughout the GI tract.
The macules appear in infancy and childhood and fade over time. The macules over buccal mucosa, however, do not fade over time. Occasional macules are seen on the palms, soles, digits, eyes, and mouth; 95% of the lesions occur on the lips and 83% occur on the buccal mucosa.
Complications associated with Peutz-Jegher’s syndrome are intestinal obstruction, abdominal pain, and gastrointestinal (GI) bleeding.
Esophageal cancer can be squamous cell cancer or an adenocarcinoma. However, both have poor prognosis. Squamous cell cancer is not associated with Barrett’s esophagus. The cancer is usually located in the middle to proximal esophagus, and it may coexist with oropharyngeal cancer.
Risk factors for esophageal cancer are smoking and alcohol use. The additional risk factors for adenocarcinoma of the esophagus are GERD, Barrett’s esophagus, and being a Caucasian 40-year-old male patient.
GASTROESOPHAGEAL REFLUX DISEASE
Gastroesophageal reflux disease (GERD) occurs when the lower esophageal sphincter (LES) does not close properly and stomach contents leak back into the esophagus causing heartburn, or the contents go into the back of the mouth, causing a water brash.
A hiatal hernia may contribute to GERD. Hiatal hernia can occur at any age and is not uncommon in people over ages 40–50. Obesity and pregnancy are often aggravating factors for GERD. Heartburn that occurs more than twice per week may be considered GERD.
Patients with GERD experience substernal heartburn associated with burning, belching, water brush (from acid and water), and regurgitation. Heartburn may indicate severe disease. The symptoms occur after a meal and are aggravated by any change in position. The symptoms are also aggravated by certain foods: fatty foods, spicy foods, and tomato-based foods.
Extra-Esophageal Manifestation of GERD
GERD-associated extra-esophageal manifestations can be dental erosions, chronic cough and constant clearing of the throat, atypical chest pain, epigastric pain, and nausea.
Complications associated with GERD are esophagitis associated with linear ulcers seen on endoscopy, strictures caused by partially healed ulcers, and Barrett’s esophagus that is diagnosed by barium swallow.
GERD treatment includes the following medical management:
Adjunct treatment guidelines for GERD are:
PEPTIC ULCER DISEASE
Heliobacter pylorus (H. pylori) is most often implicated as the leading cause of peptic ulcer. H. pylori can reside in the mucosal lining and causes no problem in some patients. When implicated however, it is found to erode the mucosa and cause ulceration.
The next leading cause is chronic NSAIDS use. Peptic ulcers can also be due to ischemia consequent to smoking. Stress and diet are no longer thought to be causative factors.
Peptic ulcers named according to their location in the GI tract are:
- Gastric ulcer: A peptic ulcer found in the stomach
- Duodenal ulcer: A peptic ulcer found in the duodenum
The following are symptoms associated with peptic ulcers:
- Pain: The most common type is a burning pain caused by the stomach acid coming into contact with the ulcer. The pain varies in location and can also be gnawing or hunger-like. The pain can last for a few minutes or a few hours. It is often relieved with food.
- Nausea and vomiting with or without blood.
- Black, tarry stools or dark blood in the stools.
- Indigestion, anorexia, early satiety, and bloating.
Peptic ulcer diagnosis is made using the following tools:
The treatment goal is to promote healing by eradicating H. pylori and decreasing the acid production that aggravates the ulcer. Successful treatment takes only a few weeks; the treatment options are as follows:
Complications associated with peptic ulcer include bleeding, perforation, or obstruction. Note that bleeding ulcers do not perforate and perforated ulcers do not bleed.