Oral Manifestations of Gastrointestinal Diseases - pediagenosis
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Monday, November 25, 2019

Oral Manifestations of Gastrointestinal Diseases

Oral Manifestations of Gastrointestinal Diseases
Inflammatory bowel diseases (IBDs), most notably Crohn disease and ulcerative colitis, are primary intestinal diseases. Both main forms demonstrate a spectrum of oral lesions. These manifestations may be the initial presentation of the disease, and the course of the lesions may be dependent on or independent of bowel disease activity. The incidence of oral lesions in IBD is estimated to be 20% to 50%; lesions are most commonly seen in children with Crohn disease. Oral lesions specific to Crohn disease are histopathologically granulomatous and typically visualized on the buccal mucosa, gingiva, lips, and vestibular and retromolar areas. Four oral lesions specific to Crohn disease have been described: 

(1) White reticular tags, seen most frequently in the labial, buccal, and retromolar regions, form non-caseating granulomas, referred to as indurated taglike lesions. (2) Cobblestoning of the buccal mucosa, most often in the posterior region, is created by hyperplasia and fissuring of the mucosa, primarily in the posterior buccal region and palate; the fissuring results from the formation of mucosa-colored papules that degenerate into firm painful plaques. (3) Mucogingivitis is an edematous, granular, hyperplastic gingiva without ulcerations. (4) Lip swelling occurs, with vertical fissures, deep linear ulcerations in the buccal sulci, and midline labial fissuring. None of these oral lesions vary with disease activity. All can be treated with immunosuppressive medications; topical drugs are most often used, but systemic drugs can be used if disease is severe.
Oral Manifestations of Gastrointestinal Diseases

Nonspecific oral lesions can be seen in IBD patients, as well as in the general population. Aphthous stomatitis is seen in IBD patients, with greater frequency in rheumatologic patients and lesser frequency in the general population. The lesions are round, shallow ulcerations with fibrinous exudate and an erythematous border.
Pyostomatitis vegetans, a chronic mucocutaneous ulcerative condition, presents with multiple miliary white or yellow pustules surrounded by an erythematous, edematous mucosal base; it is most often visible in the labial, gingival, and buccal mucosa. The pustules rupture and coalesce to form a linear, or snail track, ulceration. This type of ulceration has also been described in secondary syphilis. These lesions are non-specific to IBD, but when they are associated with IBD, the type of disease is most frequently ulcerative colitis. Gastroesophageal reflux disease (GERD) results from movement of the gastric contents cephalad, traversing the lower esophageal sphincter, esophagus, and upper esophageal sphincter and moving into the oral cavity. Dental erosions, specifically those occurring on the lingual and palatal surfaces of the teeth, are complications of this condition. Acid is the likely corrosive agent in this process. The critical pH for demineralization is 5.5, but it varies inversely with the concentration of calcium and phosphate in saliva. Several studies have indicated that halitosis could be considered an extraesophageal manifestation of GERD. The etiology of this relationship is less clear but is likely explained physiologically by the degradation of anaerobic bacteria of sulfur-containing amino acids.
Peutz-Jeghers syndrome is an autosomal dominant disease characterized by multiple gastrointestinal tract hamartomatous polyps and mucocutaneous pigmentation. The pigmentation is due to macrophage-filled melanin-pigmented, flat blue-gray or brown spots of 1 to 5 mm located in the dermis of the lips and buccal region. The diagnosis can be made by histologic examination of one of the luminal polyps in an index case or by gross identification of the polyps or noting the presence of mucocutaneous pigmented lesions in an individual who has a first-degree relative in whom the disease was previously diagnosed.
Gardner syndrome is an autosomal dominant disorder characterized by colorectal polyps and extracolonic tumors. Similar to familial adenomatous polyposis (FAP), the genetic mutation responsible for the disease is the adenomatous polyposis gene. The risk of malignant transformation of the colorectal polyps is significant. Unlike FAP, Gardner syndrome is characterized by the presence of multiple osteomas, epidermoid cysts, desmoid tumors, and cutaneous fibromas. The osteomas most often develop in the maxilla and mandible. Dental abnormalities can be seen in about 30% of patients even in the absence of osteomas. The abnormalities seen include supernumerary teeth, compound odontomas, hypodontia, abnormal tooth morphology, and multiple impacted teeth.

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