Periodontal bleeding and inflammation
Visible indicators of age
Surgical intervention


General practitioners are seeing an increasing number of patients with oral and dental symptoms. It is therefore important to have an appreciation of the various oral manifestations, which may be early signs of underlying medical conditions, as well as encouraging appropriate assessment and review with a dental health professional. 

Periodontal bleeding and inflammation

Poor pregnancy outcomes

Periodontal disease begins with gingivitis (inflammation of the gingiva; often secondary to infection), which can progressively spread to involve the tissues surrounding the tooth (periodontitis) and the supporting alveolar bone. Eventual sequelae can include gingival and alveolar bone recession, with loosing and loss of unstable teeth. The hormonal changes associated with pregnancy can increase the risk of gingivitis and periodontal disease.

A number of studies have investigated the possible association between maternal periodontal disease and increased risk of preterm birth, low birth weight and preeclampsia.1,2 

Around 40% of pregnant women have some form of periodontal disease,3 with higher rates experienced among various racial groups and women of low socioeconomic status, although research has been distorted through work mainly among such subject groups. 

Theories include the dissemination of microorganisms and pro-inflammatory mediators from areas of periodontal infection throughout the body, including the placenta, foetal membranes, and amniotic cavity, to induce pathological processes leading to adverse pregnancy outcomes. However, the evidence is ambiguous and various investigations have produced conflicting results. Certain studies seem to support an association between maternal periodontal disease and the adverse pregnancy outcomes of low birth weight, preterm birth, foetal growth restriction and preeclampsia.4-7 

One particular study demonstrated that pregnant women with severe periodontal disease are 7.5 times more likely to go into labour prematurely – meaning it carries a greater risk for preterm birth than alcohol consumption or smoking.8 However, other work has not demonstrated such an association, and most randomized trials have failed to demonstrate improved perinatal outcomes following treatment of maternal periodontal disease.9-13 Although we can only comment on the need for ongoing research into periodontal disease and preterm birth or low birth weight, an association has been demonstrated (and not disproven or contradicted) between poor periodontal health in pregnancy and late miscarriage (between 12 and 24 weeks gestation).9, 14-15 Reasons for the association remain unclear, and there has been no research as to whether treating periodontal disease in pregnancy can reduce the risk of miscarriage.


The oral features typically associated with leukaemia can include petechiae, ulceration, mucosal bleeding, and diffuse, or localized gingival enlargement; due to infiltration of the gingiva by leukaemic cells, characteristically in acute monocytic and acute myelomonocytic leukaemia.16 The gingiva may appear haemorrhagic with or without ulceration, and feel boggy on palpation. Impaired immunity can cause secondary oral complications, including herpes simplex virus infection, candidiasis and periodontal bone loss. Further complications and opportunistic infections are recognised to develop during treatment, including chemotherapy-related oral mucositis, and it is not uncommon for general practitioners to be involved with the prescription of preventive regimes, such as acyclovir, nystatin and chlorhexidine.17-21


Thrombocytopaenia should be considered during the investigation of oral lesions that appear secondary to minor oral mucosal trauma sustained during normal physiological function, such as mastication and swallowing. These insidious insults can produce various types of hemorrhagic lesions, including petechiae, purpura, ecchymosis, hemorrhagic bullae, and hematoma formation. Gingival bleeding can also occur from minor trauma, including tooth brushing, or occur spontaneously. A low platelet count should also be considered when there is a delay in the expected healing process or with evident oral lesions.22-23

Dental erosion

Anorexia and bulimia

The oral stigmata associated with anorexia and bulimia correspond with the physical intraoral changes due to acidic gastric vomitus and include dental erosion, xerostomia (dry mouth), increased rate of caries, and sialadenosis (benign salivary gland enlargement). The enamel erosion on exposed teeth characteristically affects the lingual (facing toward the tongue) surfaces of the maxillary anterior teeth and, in severe cases, the buccal (facing toward the cheek) surfaces of the posterior mandibular teeth.24 Consequently patients can develop dental sensitivity to extremes of temperature or sweet stimuli. Xerostomia can be secondary to medications used by patients with anorexia or bulimia (laxatives, diuretics, antidepressants), as well as through vomiting and excessive exercise and undue mouth breathing.25

The dental erosion can be irreversible and may require dental restorative treatment. A dry mouth lacks the buffering and cleansing properties of saliva which are important for helping prevent tooth decay, and therefore xerostomia leads to increased risk of dental caries. Sialadenosis is estimated to affect 25% of patients with bulimia, and bilateral parotid enlargement due to the non-inflammatory swelling is the commonest presentation.26 Xerostomia and sialadenosis typically resolve once the patients nutritional status has been restored, and underlying psychiatric issues addressed, although the use of sialagogues, to stimulate salivary gland production, such as pilocarpine, or cevimeline, may be helpful in the interim.27-28

Gastroesophageal reflux disease

Gastroesophageal reflux disease often comprises oral signs and symptoms including xerostomia, burning sensation, halitosis, palatal erythema, water brash, and dental erosion. The reflux of acidic gastric content results in erosion typically affecting the occlusal (the tooth surface in contact with teeth of the opposite jaw) surfaces of the mandibular posterior teeth and the lingual surfaces of the maxillary anterior teeth.

The eroded teeth demonstrate worn, shiny enamel that can appear yellow due to exposure of the underlying dentine, with corresponding symptoms of sensitivity.

The erosive changes can be irreversible, and dental restorative treatment may be required according to the degree of aesthetic damage or symptoms. Appropriate pharmacological treatment of gastroesophageal reflux disease usually brings about resolution of the reversible oral signs and symptoms.29,30

Dr Matthew West
GP, Herts Valley CCG 


  1. Xiong X, Buekens P, Fraser WD, Beck J. Offenbacher S. Periodontal Disease and Adverse Pregnancy Outcomes: a Systematic Review. BJOG. 2006;113(2):135-143
  2. Babalola DA, Omole F. Periodontal Disease and Pregnancy Outcomes. J Preg 2010
  3. Lieff S, Boggess KA, Murtha AP et al. The Oral Conditions and Pregnancy Study: Periodontal status of a cohort of Pregnant Women. J Periodontol. 2004;75:116–6
  4. Dasanayake AP. Poor Periodontal Health of the Pregnant Woman as a risk factor for low Birth Weight. Ann Periodontol. 1998;3:205–211 
  5. Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal Infection and Preterm birth: results of a Prospective study. J Am Dent Assoc.2001;132: 875–880
  6. Goepfert AR, Jeffcoat MK,  Andrews WW, Faye-Petersen O, Cliver SP. Goldenberg RL. Periodontal Disease and Upper Genital Tract Inflammation in early Spontaneous Preterm Birth. Obstetrics and Gynecology. 2004;104:777–783 
  7. Dörtbudak O, Eberhardt R, Ulm M, Persson GR. Periodontitis, a marker of risk in Pregnancy for Preterm Birth. Journal of Clinical Periodontology. 2005;32:45–52
  8. S. Offenbacher, D. Lin, R. Strauss, et al. Effects of Periodontal Therapy during Pregnancy on Periodontal status, Biologic parameters, and Pregnancy Outcomes: a pilot study,” Journal of Periodontology. 2006; 77(12):2011–2024
  9. Moore S, Ide M, Coward PY et al. A Prospective study to investigate the Relationship between Periodontal Disease and Adverse Pregnancy outcome. Br Dent J. 2004;197:251–258
  10. Macones GA, Parry S, Nelson DB et al. Treatment of localized Periodontal Disease in Pregnancy does not reduce the occurrence of Preterm Birth: results from the Periodontal Infections and Prematurity Study (PIPS) Am J Obstet Gynecol. 2010;202:147
  11. Offenbacher S, Beck JD, Jared HL et al. Effects of Periodontal Therapy on rate of Preterm delivery: a Randomized Controlled Trial. Obstet Gynecol. 2009;114:551–559 
  12. Michalowicz BS, Hodges JS, DiAngelis AJ et al. Treatment of Periodontal Disease and the risk of Preterm Birth. N Engl J Med. 2006;355:1885–1894 
  13. Newnham JP, Newnham IA, Ball CM et al. Treatment of Periodontal Disease during Pregnancy: a Randomized Controlled Trial. Obstet Gynecol. 2009;114:1239–1248
  14. Davenport ES, Williams CECS, Sterne JAC, Murad S, Sivapathasundram V, Curtis MA. Maternal Periodontal Disease and Preterm low Birthweight: Case–Control Study. Journal of Dental Research. 2002;81:313–318
  15. Davenport ES. Does Periodontal Disease affect Pregnancy outcome? British Dental Journal 197, 247 (2004)
  16. Dreizen S, McCredie KB, Keating MJ, Luna MA. Malignant Gingival and skin “infiltrates” in adult Leukemia. Oral Surg Oral Med Oral Pathol. 1983;55(6):572-579
  17. Levy-Polack MP, Sebelli P, Polack NL. Incidence of Oral Complications and Application of a Preventive protocol in Children with Acute Leukemia. Spec Care Dentist. 1998;18(5):189-193 
  18. Glenny AM, Fernandez Mauleffinch LM, Pavitt S, Walsh T. Interventions for the Prevention and Treatment of Herpes Simplex virus in patients being treated for Cancer. Cochrane Database Syst Rev. 2009;(1):CD006706 
  19. Worthington HV, Clarkson JE, Eden OB. Interventions for Preventing Oral Mucositis for Patients with Cancer Receiving Treatment. Cochrane Database Syst Rev. 2007;(4):CD000978 
  20. Pereira Pinto L, de Souza LB, Gordón-Núñez MA et al. Prevention of Oral Lesions in Children with Acute Lymphoblastic Leukemia. Int J Pediatr Otorhinolaryngol. 2006;70(11):1847-1851 
  21. Stokman MA, Spijkervet FK, Boezen HM, Schouten JP, Roodenburg JL, de Vries EG. Preventive Intervention Possibilities in Radiotherapy- and Chemotherapy-induced Oral Mucositis: results of meta-analyses. J Dent Res. 2006;85(8):690-700
  22. Gonsalves WC, Chi AC, Neville BW. Common Oral Lesions: Part I. Superficial Mucosal Lesions. Am Fam Physician. 2007;75(4):501-507 
  23. Neville BW, Damm DD, Allen CM, Bouquot JE. Pernicious Anemia. In: Oral and Maxillofacial Pathology. 3rd ed. St. Louis, Mo.: Saunders Elsevier; 2009:829-831
  24. Valena V, Young WG. Dental Erosion patterns from intrinsic Acid Regurgitation and Vomiting. Aust Dent J. 2002;47(2):106-115
  25. Dynesen AW, Bardow A, Petersson B, Nielsen LR, Nauntofte B. Salivary Changes and Dental Erosion in Bulimia Nervosa. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2008;106(5):696-707
  26. Riad M, Barton JR, Wilson JA, Freeman CP, Maran AG. Parotid Salivary Secretory pattern in Bulimia Nervosa. Acta Otolaryngol. 1991;111(2):392-395
  27. Mehler PS, Wallace JA. Sialadenosis in Bulimia. A new Treatment. Arch Otolaryngol Head Neck Surg. 1993;119(7):787-788
  28. Little JW. Eating disorders: Dental Implications. Oral Surg Oral Med Oral Pathol Oral Radio Endod 2002;93:138-43
  29. Moazzez R, Barlett D, Anggiansah A. Dental Erosion, Gastro-Oesophageal Reflux Disease and Saliva: How are they Related? J Dent 2004;32:489-94
  30. Barron RP, Carmichael RP, Marcon MA, Sandor GK. Dental Erosion in Gastroesophageal Reflux Disease. J Can Dent Assoc 2003;69:84-9