2013 self-study course three course

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ABOUT this FREQUENTLY asked COURSE… QUESTIONS… Q: Who can earn FREE CE credits? . READ the MATERIALS. Read and review the course materials. A: EVERYONE - All dental professionals in your office may earn free CE contact . COMPLETE the TEST. Answer the credits. Each person must read the eight question test. A total of 6/8 course materials and submit an questions must be answered correctly online answer form independently. for credit. us . SUBMIT the ANSWER FORM Q: What if I did not receive a ONLINE. You MUST submit your confirmation ID? answers ONLINE at: A: Once you have fully completed your p h o n e http://dent.osu.edu/sterilization/ce answer form and click “submit” you will be directed to a page with a 614-292-6737 . RECORD or PRINT THE unique confirmation ID. CONFIRMATION ID This unique ID is displayed upon successful submission Q: Where can I find my SMS number? of your answer form. t o l l f r e e A: Your SMS number can be found in the upper right hand corner of your

1-888-476-7678 monthly reports, or, imprinted on the back of your test envelopes. The SMS number is the account number for ABOUT your your office only, and, is the same for f a x FREE CE… everyone in the office. 614-292-8752 Q: How often are these courses . TWO CREDIT HOURS are issued for available? successful completion of this self- A: FOUR TIMES PER YEAR (8 CE credits). e - m a i l study course for the OSDB 2012-2013 [email protected] biennium totals. . CERTIFICATE of COMPLETION is used to document your CE credit and is mailed to your office. w e b . ALLOW 2 WEEKS for processing and www.dent.osu.edu/ mailing of your certificate. sterilization Page 1 GASTROINTESTINAL DISEASE 2013 WITH ORAL INVOLVEMENT course This self-study covers a few gastrointestinal diseases that present with three characteristic oral findings. The objective is to introduce healthcare professionals to some of the more common oral manifestations of gastrointestinal diseases.

INTRODUCTION It is not uncommon to find oral manifestations of systemic diseases. Skin, hematopoietic and gastrointestinal diseases show frequent oral involvement. Systemic disorders may present with dental and oral mucosal changes (see Table 1). In rare instances, these changes may be the only or initial presentations of an underlying systemic disease. Accurate identification and diagnosis of these alterations by oral health professionals can allow them to assist their patients in seeking Source: virtualmedicalcentre.com appropriate medical care. Since the oral cavity constitutes the proximal end of the INFLAMMATORY gastrointestinal tract, diseases of the BOWEL DISEASE gastrointestinal system may exhibit Inflammatory bowel disease is a oral manifestations. group of idiopathic conditions that Gastroenterologists receive cause chronic of the inadequate training in evaluating gastrointestinal tract. The two the oral cavity, thus disabling them major subtypes of the condition are from recognizing changes in oral Crohn’s disease and ulcerative written by mucosal and mineralized tissues. colitis. In the United States the Oral health professionals have a amber kiyani, dds disease involves over 2% of the closer association with the oral population affecting people in any cavity and are adept at identifying age group. pathological changes in the mouth. edited by In order to assist the patient to seek The oral manifestations of taylor eiford appropriate medical attention, it is inflammatory bowel disease are not mei-ling shotts, bs essential for the oral health rare and in some instances may be professional to familiarize the first presentations of the karen k. daw, mba, cecm themselves with some of the more disease. Oral involvement with common changes seen in the oral Crohn’s disease is reported to range cavity in patients with between 40 and 60% while gastrointestinal disease. ulcerative colitis may be present in up to 6% of the patients. Page 2

TABLE 1 Type of Disorder Diseases that may involve oral cavity 1. Granulomatous Sarcoidosis, Crohn’s Disease 2. Immunologic Vesico-bullous processes (, , , , erythema migrans, chronic ulcerative , psoriasis, lupus, systemic sclerosis), Lichenoid mucositis, , Wegener’s granulomatosis, Behcet’s syndrome, Aphthous ulceration

3. Hematologic , Cyclic , Thrombocytopenia, Leukemia, Langerhans Cell Histiocytosis, , Mycosis fungoides, Plasmacytoma, Plasminogen deficiency

4. Microbial , Diphtheria, Syphilis, Tuberculosis, Leprosy, , Cat-scratch disease, Streptococcal pharyngitis, Candidiasis, Histoplasmosis, Blastomycosis, Coccidioidomycosis, Cryptococcosis, Toxoplasmosis, Aspergillosis, Herpes simplex, Varicella Zoster virus, Infectious mononucleosis, Cytomegalovirus, Enterovirus, Rubeola, Rubella, HIV

5. Gastrointestinal Crohn’s disease, Ulcerative colitis, Gardner syndrome, Peutz-Jegher syndrome, Gastric reflux, Jaundice 6. Skin Ectodermal dysplasia, , Hereditary benign intraepithelial keratosis, Pachyonychia congenita, Dyskeratosis congenita, Xeroderma pigmentosum, Hereditary mucoepithelial dysplasia, Incontinentia pigmenti, Darier’s disease, Hereditary hemorrhagic telangiectasia, Ehler-Danlos syndromes, Tuberous sclerosis, Multiple hamartoma syndrome, Epidermolysis bullosa

7. Endocrine Diabetes mellitus, Hypothyroidism, Addison’s disease, Hyperparathyroidism 8. Metabolic Amyloidosis, Lipoid proteinosis 9. Genetic Crouzon’s syndrome, Apert syndrome, Mandibulofacial dysostosis 10. Nutritional Folic acid deficiency, Iron deficiency Page 3

CROHN’S DISEASE Crohn’s disease or regional enteritis is an idiopathic inflammatory disorder that may involve any part of the gastrointestinal system from mouth to the anus. Abdominal cramps, diarrhea, nausea, weight loss and malnutrition are common symptoms of the disease. Oral lesions may be seen in 40-60% of Crohn’s patients. In about 30% of the cases oral lesions may be the initial presentation of disease. It is important for oral health professionals to recognize these lesions so they can guide their patients to seek appropriate medical care.

ORAL PRESENTATION Linear Vestibular Ulceration Oral Crohn’s Disease Source: gastrolab.net Linear vestibular ulceration is seen along the lower buccal vestibule. The ulcers are persistent in nature and characteristically deep and ragged in Mucosal Tags appearance. The ulcers usually occur bilaterally and Mucosal tags resembling denture related fibrous are symmetrical. They may result in significant hyperplasia, or fissuratum, may be discomfort forcing the patient to seek medical identified in patients with Crohn’s disease. The attention. size of the lesions can vary considerably. Aphthous Ulceration Mucogingivitis Major and minor aphthae are a reported oral Mucogingivitis appears as diffuse, erythematous finding in patients with Crohn’s disease. The ulcers macules involving the gingiva. In some instances, involve mucosa that is not firmly bound to the it may present as hyperplastic plaques involving underlying bone, buccal and labial mucosa, tongue, attached and unattached gingiva. soft and the floor of the mouth. They range in size from 0.2 to 3 cm and appear as round to oval ULCERATIVE COLITIS lesions with a red halo around them. The ulcers Ulcerative colitis is a disease of the colon cause significant discomfort, especially in characterized by the presence of large ulcers. The association with consumption of acidic or spicy most common symptom includes a progressively foods. The ulcers heal over a period of 2-3 weeks. increasing bloody diarrhea. Oral involvement with Aphthous ulcers are not specific to Crohn’s disease. ulcerative colitis is rare, and may be seen in less Their significance in this context remains uncertain than 2% of the patients. since they may also be seen in the healthy population. Pyostomatitis vegetans is commonly linked to Mucosal Swelling ulcerative colitis. It presents in the mouth as Granulomatous is a term used to refer to an multiple white or yellow, “serpentine” pustules uncommon condition resulting in chronic indurated that rupture easily to form snail track ulcers. While swelling of the that may be seen in patients the lesions are more frequent on the palate and with Crohn’s disease. The swelling is persistent and gingiva, any site in the oral cavity may be is usually not associated with pain. Patients tend to involved. The eruptions develop quickly over a seek medical attention for cosmetic reasons. period of days and may coincide with a flare of the bowel disease. Cobblestoning, or nodular swelling of the gingiva and buccal mucosa, is another feature attributed to Crohn’s disease. Page 4 DIAGNOSIS erosion that is localized to the inner surface of the Crohn’s Disease anterior maxillary dentition. A prior history of disease and the characteristic TREATMENT appearance of the lesions may be sufficient for Once the diagnosis of erosion is made, it is diagnosis in some instances. In cases where pertinent for the dentist to determine the reason gastrointestinal disease is not present or not for it. Referral to a gastroenterologist may be identified, a biopsy of the oral lesions is necessary. required to address this concern. In the event that Identification of granuloma formation on the patient is already under the care of a histopathology is highly suggestive of Crohn’s gastroenterologist, the dentist needs to make sure disease. that the physician is made aware of the situation.

Ulcerative Colitis MALABSORPTION History of disease and biopsy of the affected tissue Gastrointestinal diseases and elective gastrectomy with direct immunofluorescence testing is sufficient may lead to nutritional imbalances that impair the to establish diagnosis. hematopoietic system and have an effect on oral tissues. ORAL PRESENTATION Iron deficiency anemia and pernicious anemia may manifest themselves as atrophic , a condition characterized by loss of papillae from the dorsum surface of the tongue leaving a bald, red tongue. Milder cases are associated with a more patchy distribution on the depapillated areas. In severe cases, persistent ulceration may occur and the red patches may involve other oral tissues. The patients with atrophic glossitis present with a sore and burning sensation of the tongue.

Oral lesions in ulcerative colitis Source Dr. Kiyani DIAGNOSIS

Blood tests are required to measure iron and TREATMENT vitamin B12 levels. Treating the bowel disease usually leads to complete TREATMENT resolution of the oral lesions for both Crohn’s disease Restoration of iron and vitamin B12 levels results and ulcerative colitis. in regeneration of the tongue papilla and GASTRIC REFLUX complete resolution of the condition. Acid regurgitation is a common symptom in patients BEHCET’S SYNDROME with gastroesophageal reflux disease (GERD), hiatal hernia, alcoholism and bulimia that may produce Behcet’s syndrome is a multisystem autoimmune identifiable changes in teeth. disorder that primarily involves the orogenital and ORAL PRESENTATION ocular regions. Cutaneous lesions, arthritis and involvement of the central nervous system have Acid regurgitation may result in enamel erosion in also been reported with this condition. The patients with these conditions. The enamel is lost affected population may frequently have a from the areas exposed to the acid producing shiny Mediterranean or Japanese lineage. The condition and hard surfaces. In chronic cases, the enamel is is commonly diagnosed in young adults. completely eroded to expose the underlying , making the teeth sensitive to temperature changes. Bulimic patients exhibit a characteristic pattern of ….. Page 5 ORAL PRESENTATION Premolar and molar regions are rarely affected. Supernumerary teeth impede the eruption The oral lesions of Behcet’s syndrome may be an pathway for normal dentition resulting in multiple initial presentation and are noted in over 99% of the un-erupted incisors and canines. affected population. The lesions bear a close resemblance to aphthous ulceration. Soft palate and the oropharynx are common sites of involvement. Osteomas are benign, slow growing bony tumors Six or more ulcers may be seen at one time. The composed of well differentiated and densely ulcers may vary in size, have a ragged border and sclerotic compact bone that are common to the may be surrounded with a larger erythematous ring. skull and facial bones. In patients with the DIAGNOSIS syndrome, multiple osteomas are seen in the jaws and the sinuses. When gnathic lesions are seen, There is no definitive test available for diagnosis of they commonly affect the angle of . They Behcet’s syndrome. A diagnostic criterion has been cause focal expansion of the bones that can be put forward by the International Study Group. palpated through the skin or . Osteomas can grow large enough to cause significant deformity and interfere with function. Surgical removal is the treatment of choice.

Epidermoid cysts Epidermoid cysts are also referred to as sebaceous cysts, a misnomer since it has no connection to sebaceous glands. These are formed by the implantation of the epidermis into the dermis. They appear as painless, raised, well demarcated, round and subcutaneous bumps. Patients with the syndrome tend to develop multiple epidermoid

cysts on the facial skin and scalp. They can grow to be quite large and may become a cosmetic Ulcer due to Behcet’s Syndrome Source: Dr. Kiyani concern. They can be removed surgically. GARDNER SYNDROME PEUTZ-JEGHERS SYNDROME Gardner syndrome is an autosomal dominant Peutz-Jeghers Syndrome, or hereditary intestinal disease characterized by multiple intestinal polyps polyposis, is a genetic disease characterized by and a high risk of . Extracolonic development of multiple benign polyps in the manifestations of the disease are seen in multiple intestines and melanin deposition. organs including skin, skeleton and soft tissues. ORAL PRESENTATION ORAL PRESENTATION Flat, painless, black or brown macules are seen on Enostoses the lips, oral mucosa, perioral skin, dorsa of fingers An enostosis is a bony growth within a bone cavity and toes. The lesions appear shortly after birth and or on the internal surface of the bone cortex. range in size from 1-5mm. Labial mucosa, buccal Patients with Gardner syndrome show multiple mucosa, gingiva and hard palate serve as common enostoses in the jaws that can be identified on sites for occurrence intraorally. radiographs. Alveolar bone serves as a common site DIAGNOSIS for occurrence. These bony lesions are painless and produce no expansion. The condition usually Diagnosis is primarily made clinically on the basis requires no medical or surgical intervention. of a positive medical history, presence of the characteristic pigmentation and hamartomatous Supernumerary Teeth: polyps. Over 90% of patients with clinical disease Patients with Gardener syndrome tend to have present with a genetic mutation that can now be multiple supernumerary teeth in the anterior portion identified using molecular testing. of the jaws. ………….. Page 6

TREATMENT ORAL PRESENTATION The lesions require treatment for cosmetic reasons. The lesions appearing in the oral cavity resemble Laser ablation has shown promising results in those of the esophagus and vary in size from 2-10 treatment of this condition. mm. Buccal mucosa and tongue have been reported as the most common sites of involvement. DIAGNOSIS A biopsy of the oral lesion is usually sufficient to establish diagnosis. An endoscopy can be carried out to view and biopsy the esophageal lesions. TREATMENT

The lesions are harmless and show no significant growth potential. No treatment is usually necessary.

Peutz-Jeghers Syndrome Source: hshsl.umaryland.edu METASTATIC DISEASE

Malignant neoplasms of the gastrointestinal JAUNDICE system may occasionally metastasize to the oral cavity through a hematogenous route. The Excess bilirubin in blood causes accumulation of posterior mandible usually serves as a common bilirubin in tissues. site of involvement. Less commonly the maxilla ORAL PRESENTATION and soft tissues may be involved. Jaundice may result in yellow discoloration of the ORAL PRESENTATION skin, whites of the eyes, sclera and oral mucosa. The lesions are very rarely asymptomatic. In most The severity of the yellow discoloration is cases the patient complains of pain, paresthesia or dependent on the amount of accumulated . Soft tissue lesions may appear as bilirubin and the duration of the disease. exophytic growths exhibiting ulceration in some Intraorally, lingual frenum and soft palate are more instances. Bone involvement presents as an severely involved. However, yellow discoloration of irregular and poorly circumscribed radiolucency. the soft palate is not diagnostic for jaundice, since Multifocal involvement may occur in some cases. similar discoloration patterns may be seen in DIAGNOSIS people consuming large amounts of vitamin A. A biopsy is necessary to establish diagnosis. The DIAGNOSIS pathologist performs immunohistochemistry Liver Function Tests (LFTs) in patients with staining to trace the origin of the malignancy. jaundice show altered liver enzymes and excess TREATMENT bilirubin. Metastasis to the jaw is an indicator for poor TREATMENT prognosis. Palliative care is usually the only choice Resolution of liver disease restores oral tissues to of treatment at this stage of the disease. their original colors. HEMOCHROMATOSIS GLYCOGENIC ACANTHOSIS Hemochromatosis is defined as iron overload with Glycogenic acanthosis is a benign esophageal a hereditary or metabolic origin. Oral changes are lesion that appears as small, white and raised observed in 15-25% of patients with this condition. plaques. A few reports of intraoral involvement Bluish gray pigmentation of the palate and gingiva with this process are available in recent literature. is noted.

Page 7 CONCLUSION

Many gastrointestinal diseases have been reported to produce very characteristic mucosal or dental alterations in the oral cavity. Dental professionals References should be equipped with the knowledge and skills to identify these lesions so they can assist their patients 1. Neville BW, Damm DD, Allen CM, Bouqout in seeking appropriate care. JE. Oral and Maxillofacial Pathology. 3rd ed.

A complete oral examination comprises the following steps 2. Daley TD, Armstrong JE. Oral manifestations of gastrointestinal diseases. Can J • An extra-oral inspection of the face and neck Gastroenterol 2007; 21:241-4. regions to look for any enlargements, lesions or obvious asymmetries. 3. Beitman RG, Frost SS, Roth JL. Oral

• Extra-oral palpation of the salivary glands to feel manifestations of gastrointestinal diseases. for abnormal masses. Dig Dis Sci 1981; 26:741-7.

• Palpating lymph nodes to rule out 4. Handlers JP. Oral manifestations of lymphadenopathy. gastrointestinal diseases. J Calif Dent Assoc. 1999; 27(4):311-7. • Palpating the TMJ for clicking, crepitus, popping or deviation on opening.

• Examining the lips for any lesions, color changes or masses.

• Inspecting and palpating labial and buccal mucosa for any lesions or obvious masses.

• Inspecting the palatal mucosa and palpating for any obvious masses.

• Inspecting the oropharynx for any asymmetries.

• Inspecting the tongue for any lesions or asymmetries, palpate the tongue to feel for any masses. ORIGINATING FROM PAKISTAN, DR. KIYANI WENT TO RIPHAH UNIVERSITY FOR THEIR 5-YEAR DENTAL SCHOOL PROGRAM. • Inspecting the floor of mouth for any lesions or GRADUATING WITH A 4.0 GPA, SHE CAME TO THE OHIO STATE asymmetries, palpate the floor of mouth using UNIVERSITY IN ORDER TO FURTHER HER STUDIES FOCUSING ON ORAL bimanual palpation to feel for any masses. AND MAXILLOFACIAL PATHOLOGY. SHE PLANS TO TAKE THE INFORMATION SHE LEARNS BACK TO PAKISTAN FOR BOTH • Inspecting the gingiva for signs of inflammation, DIAGNOSTIC AND TEACHING PURPOSES. lesions or asymmetries. HER CURRENT RESEARCH STUDIES AS A FELLOW AT OSU INVOLVE EVALUATING THE ORAL CHANGES ASSOCIATED WITH • Inspecting and palpating the alveolar bones for GASTROINTESTINAL DISEASES. any protrusions. DR. AMBER KIYANI CAN BE CONTACTED • Examining the dentition to complete the exam. AT: [email protected]

• Making a note of any suspicious findings and ensuring that an expert takes a look at the area of concern. Page 8 post-test instructions - answer each question ONLINE - press “submit” - record your confirmation id - deadline is August 2, 2013

Consuming large amounts of Vitamin A could 1 T F result in a false positive for Peutz-Jeghers Syndrome.

GERD stands for gastroesophageal reflux 2 T F SUBMITdisease. Multiple enostoses of the jaw associated with 3 T F Gardner Syndrome can not be identified on radiographs.

Resolution of oral lesions for Ulcerative Colitis 4 T F and Crohn’s Disease is usually a direct result ONLINEof treating these diseases. d i r e c t o r A complete oral examination includes carl m. allen, dds, msd 5 T F palpating salivary glands, alveolar bones, TMJ, [email protected] and the lymph nodes. a s s i s t a n t d i r e c t o r karen k. daw, mba, cecm Hemochromatosis and Jaundice are due to [email protected] 6SUBMIT T F iron overload with a metabolic or hereditary origin. p r o g r a m a s s i s t a n t rikki hedges, ba Gastroenterologists in the United States do [email protected] 7 T F not receive adequate training in evaluating the oral cavity. l a b t e c h n i c i a n mei-ling shotts, bs [email protected] Epidermoid cysts, also referred to as ONLINEsebaceous cysts, are connected to the 8 T F sebaceous glands. Page 9