self-study
course
2013
course
three
The Ohio State University College of Dentistry is a
recognized provider for ADA, CERP, and AGD
Fellowship, Mastership and Maintenance credit. ADA
CERP is a service of the American Dental Association
to assist dental professionals in identifying quality
providers of continuing dental education. ADA CERP
does not approve or endorse individual courses or
instructors, nor does it imply acceptance of credit
house by boards of dentistry. Concerns or complaints
about a CE provider may be directed to the provider or
to ADA CERP at www.ada.org/goto/cerp.
The Ohio State University College of Dentistry is
approved by the Ohio State Dental Board as a
permanent sponsor of continuing dental education
ABOUT this
COURSE…
contact
us
phone
614-292-6737

READ the MATERIALS. Read and
review the course materials.

COMPLETE the TEST. Answer the
eight question test. A total of 6/8
questions must be answered correctly
for credit.

SUBMIT the ANSWER FORM
ONLINE. You MUST submit your
answers ONLINE at:

Who can earn FREE CE credits?
A:
EVERYONE - All dental professionals
in your office may earn free CE
credits. Each person must read the
course materials and submit an
online answer form independently.
Q:
What if I did not receive a
confirmation ID?
A:
Once you have fully completed your
answer form and click “submit” you
will be directed to a page with a
unique confirmation ID.
RECORD or PRINT THE
CONFIRMATION ID This unique ID is
displayed upon successful submission
of your answer form.
Q:
Where can I find my SMS number?
A:
Your SMS number can be found in
the upper right hand corner of your
monthly reports, or, imprinted on the
back of your test envelopes. The SMS
number is the account number for
your office only, and, is the same for
everyone in the office.
Q:
How often are these courses
available?
A:
FOUR TIMES PER YEAR (8 CE credits).
ABOUT your
FREE CE…
fax
614-292-8752

web
www.dent.osu.edu/
sterilization
Q:
http://dent.osu.edu/sterilization/ce
toll free
1-888-476-7678
e-mail
smsosu@osu.edu
FREQUENTLY asked
QUESTIONS…
TWO CREDIT HOURS are issued for
successful completion of this selfstudy course for the OSDB 2012-2013
biennium totals.

CERTIFICATE of COMPLETION is
used to document your CE credit and
is mailed to your office.

ALLOW 2 WEEKS for processing and
mailing of your certificate.
Page 1
2013
course
three
GASTROINTESTINAL DISEASE
WITH ORAL INVOLVEMENT
This self-study covers a few gastrointestinal diseases that present with
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
appropriate medical care.
written by
amber kiyani, dds
edited by
taylor eiford
mei-ling shotts, bs
karen k. daw, mba, cecm
Since the oral cavity constitutes
the
proximal
end
of
the
gastrointestinal tract, diseases of the
gastrointestinal system may exhibit
oral
manifestations.
Gastroenterologists
receive
inadequate training in evaluating
the oral cavity, thus disabling them
from recognizing changes in oral
mucosal and mineralized tissues.
Oral health professionals have a
closer association with the oral
cavity and are adept at identifying
pathological changes in the mouth.
In order to assist the patient to seek
appropriate medical attention, it is
essential for the oral health
professional
to
familiarize
themselves with some of the more
common changes seen in the oral
cavity
in
patients
with
gastrointestinal disease.
Source: virtualmedicalcentre.com
INFLAMMATORY
BOWEL DISEASE
Inflammatory bowel disease is a
group of idiopathic conditions that
cause chronic inflammation of the
gastrointestinal tract. The two
major subtypes of the condition are
Crohn’s disease and ulcerative
colitis. In the United States the
disease involves over 2% of the
population affecting people in any
age group.
The
oral
manifestations
of
inflammatory bowel disease are not
rare and in some instances may be
the first presentations of the
disease. Oral involvement with
Crohn’s disease is reported to range
between 40 and 60% while
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 (lichen planus, pemphigus,
pemphigoid, erythema multiforme, erythema migrans,
chronic ulcerative stomatitis, psoriasis, lupus, systemic
sclerosis), Lichenoid mucositis, Orofacial granulomatosis,
Wegener’s granulomatosis, Behcet’s syndrome, Aphthous
ulceration
3.
Hematologic
Anemia,
Cyclic
neutropenia,
Thrombocytopenia,
Leukemia, Langerhans Cell Histiocytosis, Lymphoma,
Mycosis fungoides, Plasmacytoma, Plasminogen deficiency
4.
Microbial
Actinomycosis, Diphtheria, Syphilis, Tuberculosis, Leprosy,
Noma, 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, White sponge nevus, 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
Linear vestibular ulceration is seen along the lower
buccal vestibule. The ulcers are persistent in nature
and characteristically deep and ragged in
appearance. The ulcers usually occur bilaterally and
are symmetrical. They may result in significant
discomfort forcing the patient to seek medical
attention.
Oral Crohn’s Disease
Source: gastrolab.net
Mucosal Tags
Mucosal tags resembling denture related fibrous
hyperplasia, or epulis fissuratum, may be
identified in patients with Crohn’s disease. The
size of the lesions can vary considerably.
Aphthous Ulceration
Mucogingivitis
Major and minor aphthae are a reported oral
finding in patients with Crohn’s disease. The ulcers
involve mucosa that is not firmly bound to the
underlying bone, buccal and labial mucosa, tongue,
soft palate and the floor of the mouth. They range
in size from 0.2 to 3 cm and appear as round to oval
lesions with a red halo around them. The ulcers
cause significant discomfort, especially in
association with consumption of acidic or spicy
foods. The ulcers heal over a period of 2-3 weeks.
Mucogingivitis appears as diffuse, erythematous
macules involving the gingiva. In some instances,
it may present as hyperplastic plaques involving
attached and unattached gingiva.
Aphthous ulcers are not specific to Crohn’s disease.
Their significance in this context remains uncertain
since they may also be seen in the healthy
population.
Mucosal Swelling
Granulomatous cheilitis is a term used to refer to an
uncommon condition resulting in chronic indurated
swelling of the lips that may be seen in patients
with Crohn’s disease. The swelling is persistent and
is usually not associated with pain. Patients tend to
seek medical attention for cosmetic reasons.
Cobblestoning, or nodular swelling of the gingiva
and buccal mucosa, is another feature attributed to
Crohn’s disease.
ULCERATIVE COLITIS
Ulcerative colitis is a disease of the colon
characterized by the presence of large ulcers. The
most common symptom includes a progressively
increasing bloody diarrhea. Oral involvement with
ulcerative colitis is rare, and may be seen in less
than 2% of the patients.
Pyostomatitis Vegetans
Pyostomatitis vegetans is commonly linked to
ulcerative colitis. It presents in the mouth as
multiple white or yellow, “serpentine” pustules
that rupture easily to form snail track ulcers. While
the lesions are more frequent on the palate and
gingiva, any site in the oral cavity may be
involved. The eruptions develop quickly over a
period of days and may coincide with a flare of
the bowel disease.
Page 4
DIAGNOSIS
erosion that is localized to the inner surface of the
anterior maxillary dentition.
Crohn’s Disease
A prior history of disease and the characteristic
appearance of the lesions may be sufficient for
diagnosis in some instances. In cases where
gastrointestinal disease is not present or not
identified, a biopsy of the oral lesions is necessary.
Identification
of
granuloma
formation
on
histopathology is highly suggestive of Crohn’s
disease.
TREATMENT
Once the diagnosis of erosion is made, it is
pertinent for the dentist to determine the reason
for it. Referral to a gastroenterologist may be
required to address this concern. In the event that
the patient is already under the care of a
gastroenterologist, the dentist needs to make sure
that the physician is made aware of the situation.
MALABSORPTION
Ulcerative Colitis
History of disease and biopsy of the affected tissue
with direct immunofluorescence testing is sufficient
to establish diagnosis.
Gastrointestinal diseases and elective gastrectomy
may lead to nutritional imbalances that impair the
hematopoietic system and have an effect on oral
tissues.
ORAL PRESENTATION
Iron deficiency anemia and pernicious anemia
may manifest themselves as atrophic glossitis, 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
vitamin B12 levels.
TREATMENT
Treating the bowel disease usually leads to complete
resolution of the oral lesions for both Crohn’s disease
and ulcerative colitis.
GASTRIC REFLUX
Acid regurgitation is a common symptom in patients
with gastroesophageal reflux disease (GERD), hiatal
hernia, alcoholism and bulimia that may produce
identifiable changes in teeth.
ORAL PRESENTATION
Acid regurgitation may result in enamel erosion in
patients with these conditions. The enamel is lost
from the areas exposed to the acid producing shiny
and hard surfaces. In chronic cases, the enamel is
completely eroded to expose the underlying dentin,
making the teeth sensitive to temperature changes.
Bulimic patients exhibit a characteristic pattern of
…..
TREATMENT
Restoration of iron and vitamin B12 levels results
in regeneration of the tongue papilla and
complete resolution of the condition.
BEHCET’S SYNDROME
Behcet’s syndrome is a multisystem autoimmune
disorder that primarily involves the orogenital and
ocular regions. Cutaneous lesions, arthritis and
involvement of the central nervous system have
also been reported with this condition. The
affected population may frequently have a
Mediterranean or Japanese lineage. The condition
is commonly diagnosed in young adults.
Page 5
ORAL PRESENTATION
The oral lesions of Behcet’s syndrome may be an
initial presentation and are noted in over 99% of the
affected population. The lesions bear a close
resemblance to aphthous ulceration. Soft palate and
the oropharynx are common sites of involvement.
Six or more ulcers may be seen at one time. The
ulcers may vary in size, have a ragged border and
may be surrounded with a larger erythematous ring.
DIAGNOSIS
There is no definitive test available for diagnosis of
Behcet’s syndrome. A diagnostic criterion has been
put forward by the International Study Group.
Premolar and molar regions are rarely affected.
Supernumerary teeth impede the eruption
pathway for normal dentition resulting in multiple
un-erupted incisors and canines.
Osteomas
Osteomas are benign, slow growing bony tumors
composed of well differentiated and densely
sclerotic compact bone that are common to the
skull and facial bones. In patients with the
syndrome, multiple osteomas are seen in the jaws
and the sinuses. When gnathic lesions are seen,
they commonly affect the angle of mandible. They
cause focal expansion of the bones that can be
palpated through the skin or oral mucosa.
Osteomas can grow large enough to cause
significant deformity and interfere with function.
Surgical removal is the treatment of choice.
Epidermoid cysts
Ulcer due to Behcet’s Syndrome
Source: Dr. Kiyani
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
concern. They can be removed surgically.
GARDNER SYNDROME
PEUTZ-JEGHERS SYNDROME
Gardner syndrome is an autosomal dominant
disease characterized by multiple intestinal polyps
and a high risk of adenocarcinoma. Extracolonic
manifestations of the disease are seen in multiple
organs including skin, skeleton and soft tissues.
Peutz-Jeghers Syndrome, or hereditary intestinal
polyposis, is a genetic disease characterized by
development of multiple benign polyps in the
intestines and melanin deposition.
ORAL PRESENTATION
Enostoses
An enostosis is a bony growth within a bone cavity
or on the internal surface of the bone cortex.
Patients with Gardner syndrome show multiple
enostoses in the jaws that can be identified on
radiographs. Alveolar bone serves as a common site
for occurrence. These bony lesions are painless and
produce no expansion. The condition usually
requires no medical or surgical intervention.
Supernumerary Teeth:
Patients with Gardener syndrome tend to have
multiple supernumerary teeth in the anterior portion
of the jaws.
ORAL PRESENTATION
Flat, painless, black or brown macules are seen on
the lips, oral mucosa, perioral skin, dorsa of fingers
and toes. The lesions appear shortly after birth and
range in size from 1-5mm. Labial mucosa, buccal
mucosa, gingiva and hard palate serve as common
sites for occurrence intraorally.
DIAGNOSIS
Diagnosis is primarily made clinically on the basis
of a positive medical history, presence of the
characteristic pigmentation and hamartomatous
polyps. Over 90% of patients with clinical disease
present with a genetic mutation that can now be
identified using molecular testing.
…………..
Page 6
TREATMENT
ORAL PRESENTATION
The lesions require treatment for cosmetic reasons.
Laser ablation has shown promising results in
treatment of this condition.
The lesions appearing in the oral cavity resemble
those of the esophagus and vary in size from 2-10
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
JAUNDICE
Excess bilirubin in blood causes accumulation of
bilirubin in tissues.
ORAL PRESENTATION
Jaundice may result in yellow discoloration of the
skin, whites of the eyes, sclera and oral mucosa.
The severity of the yellow discoloration is
dependent on the amount of accumulated
bilirubin and the duration of the disease.
Intraorally, lingual frenum and soft palate are more
severely involved. However, yellow discoloration of
the soft palate is not diagnostic for jaundice, since
similar discoloration patterns may be seen in
people consuming large amounts of vitamin A.
DIAGNOSIS
Liver Function Tests (LFTs) in patients with
jaundice show altered liver enzymes and excess
bilirubin.
TREATMENT
Resolution of liver disease restores oral tissues to
their original colors.
GLYCOGENIC ACANTHOSIS
Glycogenic acanthosis is a benign esophageal
lesion that appears as small, white and raised
plaques. A few reports of intraoral involvement
with this process are available in recent literature.
METASTATIC DISEASE
Malignant neoplasms of the gastrointestinal
system may occasionally metastasize to the oral
cavity through a hematogenous route. The
posterior mandible usually serves as a common
site of involvement. Less commonly the maxilla
and soft tissues may be involved.
ORAL PRESENTATION
The lesions are very rarely asymptomatic. In most
cases the patient complains of pain, paresthesia or
tooth loss. Soft tissue lesions may appear as
exophytic growths exhibiting ulceration in some
instances. Bone involvement presents as an
irregular and poorly circumscribed radiolucency.
Multifocal involvement may occur in some cases.
DIAGNOSIS
A biopsy is necessary to establish diagnosis. The
pathologist performs
immunohistochemistry
staining to trace the origin of the malignancy.
TREATMENT
Metastasis to the jaw is an indicator for poor
prognosis. Palliative care is usually the only choice
of treatment at this stage of the disease.
HEMOCHROMATOSIS
Hemochromatosis is defined as iron overload with
a hereditary or metabolic origin. Oral changes are
observed in 15-25% of patients with this condition.
Bluish gray pigmentation of the palate and gingiva
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
should be equipped with the knowledge and skills to
identify these lesions so they can assist their patients
in seeking appropriate care.
A complete oral examination
comprises the following steps
• An extra-oral inspection of the face and neck
regions to look for any enlargements, lesions or
obvious asymmetries.
• Extra-oral palpation of the salivary glands to feel
for abnormal masses.
• Palpating lymph nodes to rule out
lymphadenopathy.
• Palpating the TMJ for clicking, crepitus, popping
or deviation on opening.
References
1. Neville BW, Damm DD, Allen CM, Bouqout
JE. Oral and Maxillofacial Pathology. 3rd
ed.
2. Daley TD, Armstrong JE. Oral manifestations
of gastrointestinal diseases. Can J
Gastroenterol 2007; 21:241-4.
3. Beitman RG, Frost SS, Roth JL. Oral
manifestations of gastrointestinal diseases.
Dig Dis Sci 1981; 26:741-7.
4. Handlers JP. Oral manifestations of
gastrointestinal diseases. J Calif Dent Assoc.
1999; 27(4):311-7.
• 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.
• Inspecting the floor of mouth for any lesions or
asymmetries, palpate the floor of mouth using
bimanual palpation to feel for any masses.
• Inspecting the gingiva for signs of inflammation,
lesions or asymmetries.
• Inspecting and palpating the alveolar bones for
any protrusions.
ORIGINATING FROM PAKISTAN, DR. KIYANI WENT TO RIPHAH
UNIVERSITY FOR THEIR 5-YEAR DENTAL SCHOOL PROGRAM.
GRADUATING WITH A
4.0 GPA, SHE CAME TO THE OHIO STATE
UNIVERSITY IN ORDER TO FURTHER HER STUDIES FOCUSING ON ORAL
AND MAXILLOFACIAL PATHOLOGY. SHE PLANS TO TAKE THE
INFORMATION SHE LEARNS BACK TO PAKISTAN FOR BOTH
DIAGNOSTIC AND TEACHING PURPOSES.
HER CURRENT RESEARCH STUDIES AS A FELLOW AT OSU
INVOLVE EVALUATING THE ORAL CHANGES ASSOCIATED WITH
GASTROINTESTINAL DISEASES.
DR. AMBER KIYANI CAN BE CONTACTED
• Examining the dentition to complete the exam.
AT: KIYANI.1@OSU.EDU
• 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
1
T
F
Consuming large amounts of Vitamin A could
result in a false positive for Peutz-Jeghers
Syndrome.
2
T
F
GERD stands for gastroesophageal reflux
disease.
F
Multiple enostoses of the jaw associated with
Gardner Syndrome can not be identified on
radiographs.
F
Resolution of oral lesions for Ulcerative Colitis
and Crohn’s Disease is usually a direct result
of treating these diseases.
SUBMIT
ONLINE
SUBMIT
ONLINE
3
4
5
6
7
8
T
T
T
T
T
T
F
F
A complete oral examination includes
palpating salivary glands, alveolar bones, TMJ,
and the lymph nodes.
Hemochromatosis and Jaundice are due to
iron overload with a metabolic or hereditary
origin.
F
Gastroenterologists in the United States do
not receive adequate training in evaluating
the oral cavity.
F
Epidermoid cysts, also referred to as
sebaceous cysts, are connected to the
sebaceous glands.
director
carl m. allen, dds, msd
allen.12@osu.edu
assistant director
karen k. daw, mba, cecm
daw.37@osu.edu
program assistant
rikki hedges, ba
hedges.116@osu.edu
lab technician
mei-ling shotts, bs
shotts.5@osu.edu
Page 9