Many systemic conditions can display symptoms through the teeth, mouth and gums. This article, which follows on from our series last year, looks at how these symptoms can manifest in pregnancy, in people with haematological conditions, and in people with gastric reflux or eating disorders
Dr Matthew West
GP, Herts valley CCG
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 mircoorganisms 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 birthweight, 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 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
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 use of sialagogues, to stimulate salivery 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 reflex disease usually brings about resolution of the reversible oral signs and symptoms.29-30
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