Ulcerative colitis

Ulcerative colitis is an inflammatory condition with some similarities to Crohn disease. However, it is restricted to the colon and is limited to the mucosa and submucosa, sparing the muscularis. Lesions in the colon consist of areas of hemorrhage and ulcerations along with abscesses. Similar lesions may manifest in the oral cavity as aphthous ulcerations or superficial hemorrhagic ulcers. Ulcerative colitis is characterized by periods of exacerbation and remission, and, generally, oral lesions coincide with exacerbations of the colonic disease. Similar ulcerations may arise on the buttocks, abdomen, thighs, and face (Handlers, 1999). Aphthous ulcers or angular stomatitis occurs in as many as 5-10% of patients.

Reflux

Gastroesophageal reflux disease (GERD) is a common condition in the United States. Regurgitation of gastric contents (pH 1-2) reduces the pH of the oral cavity below 5.5; this acidic pH begins to dissolve enamel. It is most commonly seen on the palatal surfaces. Erosion of the enamel exposes the underlying dentin, which is a softer, opaque material. The extent of erosion depends on the frequency and the quantity of exposure along with the duration of disease. Newly exposed dentin is smooth and shiny, while dentin from previous exposures may be stained.

Erosion differs from dental caries in that it is a hard, dished-out area where enamel has dissolved and the underlying dentin is exposed. On the other hand, caries reveals soft, discolored dentin and results from the bacterial breakdown of sugars on the surface of the teeth (Schroeder, 1995). The prevalence of caries is not increased in persons with GERD, possibly because the acidic environment interferes with the formation of the dental biofilm. Good dental care and control of acid helps decrease the prevalence of erosion. However, once the erosion occurs, it is irreversible and can only be treated with surgical restorative procedures. Therefore, early recognition and patient education is the most effective treatment.

Chronic liver disease

Chronic liver disease impacts many systems of the body. The coagulation pathway is one such system. The liver synthesizes many of the clotting factors necessary to stop bleeding. In addition, vitamin K, a fat-soluble vitamin, requires proper liver function to be adequately absorbed from the intestines. In patients with liver disease, the resultant impaired hemostasis can be manifested in the mouth as petechiae or excessive gingival bleeding with minor trauma. This is especially suggestive if it occurs in the absence of inflammation. Therefore, special care must be taken during any type of surgery, oral or otherwise; severe hemorrhage can ensue as a result of the paucity of clotting factors.

The only manifestation of advanced liver disease visible in the oral mucosa is jaundice, which is the yellow pigmentation that results from the deposition of bilirubin in the submucosa. Jaundice may occur following disorders in bilirubin metabolism, production, or secretion. Hepatocellular damage affects secretion, the rate-limiting step in bilirubin metabolism, allowing conjugated bilirubin to leak out of the cells and into the blood stream. This water-soluble substance is loosely albumin bound, and it is deposited in the mucus membranes throughout the body. When jaundice is due to chronic liver disease, the yellow color reflects a direct relation to liver function. Jaundice manifests at serum levels greater than 2.5-3 mg/dL or 2-3 times baseline. Because they are thinner, the mucosae on the soft palate and in the sublingual region are often first to reveal a yellow hue. With time, the yellow changes can be visible at any mucosal site.

Because of its high rate of progression to chronic hepatitis (50%) and cirrhosis, hepatitis C is the leading infectious cause of chronic liver disease worldwide. The association between hepatitis C and oral lichen planus is controversial. This association is greater in Europe and Asia than it is in the United States, where no significant correlation has been noted. The link between the 2 conditions is tenuous and not sufficient to warrant screening for hepatitis C infection in all patients with lichen planus.

HEMATOLOGIC DISORDERS

Anemias

The potential causes for reduction in oxygen-carrying capacity are legion. Fatigue and decreased resistance to infection are common systemic symptoms. The nail beds and oral mucosa exhibit pallor. This pallor is a common and easily recognizable feature of anemia.

Mucosal conditions, such as glossitis, recurrent aphthae, candidal infections, and angular stomatitis, may be more common in patients with anemia. Glossitis may be the first sign of folate or vitamin B-12 deficiency. The tongue appears reddened, and the papillae are atrophic, producing a smooth (“bald”) appearance. Angular stomatitis is commonly caused by a candidal infection, and it has been linked to iron deficiency. If the anemia persists, resistance to infection may be decreased.