44: Gastrointestinal Disease States and Associated Oral Cavity Lesions: Assessment, Analysis, and Associated Dental Management Guidelines

44

Gastrointestinal Disease States and Associated Oral Cavity Lesions: Assessment, Analysis, and Associated Dental Management Guidelines

ANGULAR CHEILITIS

Angular cheilitis is associated with cracking at the corners of the mouth, pain, and bleeding in severe cases.

Predisposing Factors

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.

Treatment

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 ULCERS

Etiology

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.

Table 44.1 Treatment Options for Aphthous Ulcerations

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.
Mild Disease

2. Protective Bioadhesives:

Topical Carellose (Orabase: pectin plus gelatin)

Apply to the ulcers four times/day for two weeks or until the ulcers heal.
Mild Disease

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.

Treatment

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

Etiology

Peutz-Jegher’s syndrome is associated with mucocutaneous hyperpigmentation and gastrointestinal hamatomatous polyps. The polyps can appear throughout the GI tract.

Clinical Manifestations

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

Complications associated with Peutz-Jegher’s syndrome are intestinal obstruction, abdominal pain, and gastrointestinal (GI) bleeding.

ESOPHAGEAL CANCER

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

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

Etiology

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.

Clinical Features

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

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.

Treatment

Medical Management

GERD treatment includes the following medical management:

1. Proton pump inhibitors (PPIs): PPIs are acid suppressants and they are the most effective drugs prescribed to treat GERD. Esomeprazole (Nexium), lansoprazole (Prevacid), omeprazole (Prilosec), and pantoprazole (Protonix) are the most commonly prescribed PPIs. Side effects: PPIs can interfere with the absorption of calcium because of the hypochlorhydria, and they also reduce bone resorption through inhibition of osteoclastic vacuolar-proton pumps. There is an increased risk of fractures associated with long-term PPI therapy and high doses of PPIs. Short-term PPIs use can prevent these serious adverse side effects.
2. H2 blockers: H2 blockers provide short-term relief and should not be used for more than a few weeks. Cimetidine (Tagamet), famotidine (Pepcid), and ranitidine (Zantac) are the commonly used H2 blockers.

Surgical Management

1. Surgery: The goal with surgery is to tighten the stomach by fundoplication where the top part of the stomach is wrapped around the esophagus. Surgical management is not always efficient.
2. Implant: The FDA recently approved an implant for patients who want to avoid surgery. Enteryx is a solution that becomes spongy and reinforces the lower esophageal splinter (LES), thus preventing the stomach acid from flowing into the esophagus. Enteryx is injected during endoscopy. The implant has been approved for people who have GERD that has responded to PPIs. The long-term effect of the implant therapy is unknown.

Adjunct Treatment

Adjunct treatment guidelines for GERD are:

1. The patient should sleep with the head elevated with blocks. Trying to elevate the head with multiple pillows is not effective.
2. There should be no food consumption for three hours prior to sleeping.
3. The patient should stop smoking and avoid alcohol, caffeine, and mint-containing foods.
4. The patient should also avoid aspirin and NSAIDS to avoid further aggravation of symptoms.

PEPTIC ULCER DISEASE

Etiology

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.

Classification

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

Symptoms

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.

Diagnosis

Peptic ulcer diagnosis is made using the following tools:

1. Barium studies: Barium studies detect the location of the ulcer(s) and identify the ulcer status.
2. Endoscopy: Endoscopy visually detects the location of the ulcer(s) and identifies the ulcer status.
3. Blood test: The blood test is done to detect the presence of H. pylori antibodies. This test has a disadvantage because it cannot differentiate between past exposure and current infection with the bacteria. The test may be positive for several months after the bacterium has been eradicated.
4. Breath test: During the breath test a radioactive carbon atom as a part of urea is consumed as a clear liquid, and 30 minutes later the patient is asked to exhale in a small plastic bag. H. pylori, when present, break down the urea consumed and the radioactive carbon atom is then detected in the form of CO2 in the exhaled air. The advantage of the breath test is its ability to detect bacteria eradication with treatment.
5. Stool antigen test: This test helps identify the presence of H. pylori in the stool. It also helps detect eradication with treatment.

Treatment

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:

1. Antibiotics: H. pylorus is eradicated with antibiotic treatment, and antibiotic treatment reduces the recurrence rate down to 10–20%. Antibiotic treatment options include:

a. Combination antibiotics: Combination antibiotics work best; the ones commonly prescribed for two weeks are amoxicillin (Amoxil), clarithromycin (Biaxin), and metronidazole (Flagyl).
b. Commercial preparations: Commercial preparations containing two of the antibiotics along with a cytoprotective or acid suppressant are available under the names Helidac and Prevpac.
2. Proton pump inhibitors (PPIs): The PPIs shut down the tiny pumps in the acid-secreting cells in the stomach and promote healing. The PPIs are also found to inhibit H. pylori activity.
3. Acid blockers: H2 blockers reduce the amount of acid released in the GI tract and promote healing.
4. Cytoprotective medications: Sucralfate (Carafate), misoprostol (Cytotec), or bismuth subsalicylate (Pepto-Bismol), are often prescribed. These medications protect the tissue lining of the stomach and duodenum, plus they appear to inhibit H. pylori activity.

Complications

Complications associated with peptic ulcer include bleeding, perforation, or obstruction. Note that bleeding ulcers do not perforate and perforated ulcers do not bleed.

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Jan 4, 2015 | Posted by in General Dentistry | Comments Off on 44: Gastrointestinal Disease States and Associated Oral Cavity Lesions: Assessment, Analysis, and Associated Dental Management Guidelines
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