The Gastrointestinal System and Dental 4

Practice

Diseases of the gastrointestinal (GI) system can be relevant to the dental surgeon for

several reasons. The mouth may display signs of the disease itself, for example, the

cobblestone mucosa, facial or labial swelling of Crohn’s disease or the osteomata of

Gardner’s syndrome. These are well-covered elsewhere and not discussed further

here. The sequelae of GI disease, for example, gastric reflux producing dental erosion,

iron deficiency anaemia and treatment such as corticosteroid therapy, may all

have a bearing on management and choice of anaesthesia.

Relevant Points in History

Lethargy, dyspnoea and angina may all occur secondary to anaemia from a gastrointestinal

cause, but cardiorespiratory causes should also be borne in mind. The cause of

an anaemia should always be investigated. The possibility of blood loss from the GI

tract should be considered. Weight loss may be due to reduced nutritional intake secondary

to anorexia, nausea or vomiting. There may be loss of protein from diseased

bowel, e.g. in ulcerative colitis. Cancer of the GI tract is the most significant potential

cause of weight loss. The quantity and time course of the weight loss are both important.

Enquiry with regard to appetite and any changes should also be made.

Heartburn and indigestionare vague terms often used by patients and may be

used to describe upper abdominal pain, gastro-oesophageal regurgitation, anorexia,

nausea and vomiting. Oesophageal reflux or ‘heartburn’ causes epigastric pain, i.e.

abdominal pain, around the lower end of the sternum, which radiates to the back and

is worse on stooping and drinking hot drinks. It can have implications for general

anaesthesia (see below) and can be a cause of dental erosion [1] especially on the

palatal/lingual surfaces of the teeth [2] due to the acidity of the gastric fluid. Factors

promoting gastro-oesophageal reflux are shown in Table 4.1.

Dysphagia, or difficulty in swallowing, is a symptom which should always be

taken seriously. Plummer-Vinson syndrome is the name given to dysphagia associated

with webs of tissue in the pharynx and upper oesophagus. Other components

of the syndrome include glossitis, iron deficiency anaemia and koilonychia (spoon-shaped

fingernails suggesting iron deficiency but may also occur in ischaemic heart

disease). A patient with koilonychia is shown in Fig. 4.1. Some other causes of

dysphagia are listed in Table 4.2.

Vomiting may be due to extra-intestinal causes such as meningitis and migraine or

as a result of drug therapy, e.g. morphine. In children, vomiting can be a sign of infection

of various body systems. Nausea or vomiting in the morning may be seen in pregnancy,

alcoholism and anxiety. Haematemesis, or vomiting of blood, may arise from

bleeding oesophageal varices. The relevance to dentistry is mainly related to the fact

that these varices may occur secondary to chronic liver disease with its attendant possible

implications for blood clotting and drug metabolism due to hepatic impairment.

A current or past history of peptic ulcer may be of relevance, particularly when

non-steroidal anti-inflammatory drugs (NSAIDs) are being considered. These ulcers

are common, affecting around 10% of the world population [3]. Men are affected

twice as much as women. The incidence is declining in developed countries; this

may be due to dietary changes [4]. Peptic ulcers may affect the lower oesophagus,

stomach and duodenum. The pendulum has swung away from surgery for these

conditions since the advent of effective drug therapy. Helicobacter pylori (a microaerophilic

Gram-negative bacterium) can be identified in the gastric antral mucosa

in 90% of cases of duodenal ulcers and in the body or antral mucosa of about 60%

of cases of gastric ulcer and is a common aetiological factor in peptic ulcer disease.

Triple therapy regimens are used for treatment, e.g. a proton pump inhibitor such as

omeprazole, a broad spectrum antibiotic, e.g. amoxicillin, and metronidazole, when

H. pylori is involved (see later).