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The Gastrointestinal System

Terms in this set (104)

Anatomy of digestion
Digestion is the process by which food and drink are broken down into their smallest parts so that the body can use them to build and nourish cells and to provide energy
Conditions of the GI track
1) Inflammatory Bowl Syndrome (Crohn's Disease; Ulcerative colitis)
2) Celiac Disease
3) Gastroparesis
4) Ulcers
5) Helicobacter Pylori
Conditions of GI continued
6) Bulimia Nervosa
7) Anorexia Nervosa
8) Obesity (Stomach Banding)
Analgesic use
Avoid NSAIDS with clients that have ulcers or Inflammatory bowel disease
Antibiotics
Avoid long-term use in elderly and those susceptible to pseudomembrane colitis. Certain antibiotics can cause flare up of ulcers
Bleeding
Acid-blocking drugs and protein pump inhibitors can potentiate bleeding if on warfarin
Chair position
Possibly cannot lay all the way back
Potential Issues: Drug interactions with common dental drugs and acid-blocking drugs-lidocaine, diazepam
Tx modification: Smaller dosage due to enhanced duration
Potential Issues: Appointments
Need to schedule during remission
Inflammatory Bowl Syndrome (IBS)
-A disorder that affects the normal function of the colon
2) Symptoms are cramping, pain, bloating, diarrhea, and constipation
3) Affects 1 in 5 Americans, more often women
Inflammatory Bowel Syndrome
4) This syndrome is often precipitated by stress, some medications, large meals, caffeine, and alcohol
5) Important to dental hygiene because of high stress of dental appointments and high number of Americans affected by this syndrome
6) Treated through reducing stress, changing diet, using laxatives and/or anti-diarrhea medications as needed
Inflammatory Bowel Disease
1) Broad term that encompasses Ulcerative colitis and Crohn's Disease
2) Marked by abnormal response to body's immune response
IBD continued
The immune system mistakes food, bacteria, and other materials in the intestine for foreign substances and it attacks the cells of intestines. In the process, the body sends which blood cells into the lining of the intestines where the produce chronic inflammation
Impact of IBD as a chronic disease
1) One of top 4 GI disorders in US
2) Yearly cost of 1.7 billion dollars for health care
3) Lifetime care required
General Considerations in the dental office
1) Clients with IBD will need to avoid aspirin and NSAIDS
2) Recommended acetaminophen or celecoxib in combination with proton pomp inhibitor or misoprostol
General considerations w/ IBD
1) Chair positions-must make client comfortable-may need to sit chair up more
2) Appointments during periods of remission (Symptoms and fever are indicative of active period)
Drug interactions
-If client is taking acid-blocking meds:
-May need less diazepam if sedating
-May need to lower dose of lidocain
-Decreases metabolism and enhances duration
Drug interactions continued
Proton pump inhibitors may reduce some antibiotics and antifungals
Crohn's Disease
1) A chronic, severe inflammatory disorder of the GI tract
2) Occurs most often in the ileum (part of the small intestines) but can occur anywhere along the tract ; from the oral cavity to the anus
Crohn's continued
Causes pain in inflamed areas, diarrhea, fever, rectal bleeding and impaired absorption of nutrients
2) Unknown cause; theories point to heredity; possibly due to abnormalities of the immune system
3) Men and women 1:1 ratio
Crohn's in relationship to dental hygiene
1) The same ulcerations in intestine can manifest in the oral cavity.
2) Relationship with Vit. D deficiency (unsure of exact relationship)
3) Osteoporosis can be common in these patients due to vit. D deficiency and malabsorption and chronic corticosteroid use. (Think Panorex for these clients to monitor bone density)
Impact of Crohn's on the oral cavity
1) A cobblestone appearance of the oral mucosa
2) Persistent tip swelling
3) Erythema around the mouth
4) Cervicofacial lymphadenopathy
5) Recurrent oral stomatitis
Impact of crohns on the oral cavity
6) Epithelial folds
7) Gingival entar gement
8) Gingival erythema
More on the oral impact of Crohns
-These symptoms can occur years before a diagnosis of Crohns is made
-These lesions are identical to the lesions in the ileum
Oral cavity and Crohns
-Drug therapy (steroids) can control the symptoms to a degree but are not used for maintenance
-Usually combined with sulfasalazine
-Anyone on sulfasalazine long term must take supplement of Folic Acid
-Maybe on immune suppressants
-Severe complications in the intestines results in the removal of the infected portion.
-With the use of long term methotrexate (Hepatotoxic- how will this affect our LA choices?)
Ulcerative Colitis
1) Inflammatory reaction of large intestine
2) Life long disease
Signs and symptoms of Ulcerative Colitis
1) Edema
2) Vascular congestion
3) Epithelial erosions
4) Bleeding
UC clinically seen as
1) Attacks of diarrhea
2) Rectal bleeding
3) Abdominal cramps
Medical management of Inflammatory Bowel Disease
1) Never cured
2) Anti-inflammatory meds
3) Steroid therapy
(Watch the clients who are stressed at the dentist or have an infection)
Dental Considerations for IBD
1) If on steroids-may need premedication w/ steroids if stressful appointment
2) PT/INR-especially those taking acid-blocking drugs or proton pump inhibitors AND warfarin
3) Need to know liver and kidney functions-this may affect your anesthetic choices
Dental considerations for IBD continued
4) Schedule appointments during inactive times
5) Ask physician if there is any contraindications to any meds
6) Avoid aspirin and NSAIDS
Clients taking immunosuppressant's
1) A thorough EO/IO must be done due to and increased risk of lymphoma, mononucleosis, herpetic lesions
2) IF present with a fever these clients must go to physician
Avoid
1) Clindamycin and penicillin
2) Increased risk of C. difficile
3) Tell clients to watch for signs-diarrhea
Clients taking sulfasalazine
Any client that is going to have elective surgery will need to a complete blood work panel-including bleeding times
Pseudomembranous Colitis
1) Overgrowth of the gram + anaerobic rod Clostridium difficle
2) Usually in people who had broad spectrum antibiotics
3) Results in altered vascular permeability
4) Diarrhea most common symptom
Also see
1) Sever dehydration
2) Abdominal cramping
3) Fever
4) Hyptension
Dental Considerations
1) Be cautious when prescribing some systemic antibiotics in people susceptible to pseudomembranous colitis
-Cindamycin, Ampicillin, Cephalasporins
2) Treatment can create oral candidiasis
Celiac Disease
1) Unchecked immune reaction to gluten (Wheat, Rye, Barley)
2) Familial
3) Significant morbidity of untreated
4) Estimated 1/100 Americans affected
Common in people with
1) Lupus
2) Type 1 diabetes
3) Rheumatoid arthritis
4) Autoimmune thyroid disease
5) Microscopic colitis
Celiac Disease Symptoms in Children
1) Abdominal bloating/pain/vomiting
2) Constipation/chronic diarrhea
3) Pale, foul-smelling, or fatty stool
4) Weight loss. failure to thrive
Symptoms in children
5) Irritability
6) Delayed growth/puberty/short stature
7) Enamel defects of permanent teeth
Celiac Disease Symptoms in Adults
1) Abdominal distention/chronic diarrhea
2) Malabsorption/Iron deficienty/fatigue
3) Arthritis/bone or joint pain/ osteoporosis
4) Depression/Anxiety
5) Seizures
Symptom in Adults
6) Hand/Foot numbness
7) Irregular menstruation/ infertility/miscarriages
8) Dermatitis herpetiforms
9) Canker sores
Complications of Celiac Disease
1) Lymphoma
2) Osteoporosis
3) Anemia
4) Seizures
Commonly associated with
-Sjogen's syndrome
-Type 1 diabetes
-Thyroid disease
-Recurrent apthous ulcers
-Enamel defects (children)
Oral Implications of Celiac disease
1) Autoimmune disorders:
- Sjorgren's syndrome (most common)
-Type 1 Diabetes-higher rates of CD with Type 1 Diabetics
2) Recurrent Apthous Ulcers-possibly need to use toothpaste without sodium lauryl sulfate
Oral Implications continued
2) Enamel defects in children
-Association is controversial-thought to be from hypocalcaemia due to poor absorption of calcium
-May be diagnostic aid
3) Low bone mass
More oral implications of Celiac disease
4) Iron-deficiency anemia/pernicious anemia
-Loss of filiform/fungiform papilla
-Atrophic tongue
-Glossodynia
-Dysphagia
5) Dematologic manifestations
-Oral Lichen planus
Dental Hygienist's Role in Celiac Disease
1) Assess for early signs of Celiac Disease
-Enamel hypoplasia-in children-when enamel is being formed
-Salivary dysfunction
2) Caution in recommending/ using products containing gluten
-Dentifrices, prophy pastes, fluorides
Products in our clinic that are gluten free
1) Crosstex Sparkle V fluoride varnish
2) NuPro prophy paste with Novamin-also SLS free
3) D-Lish prophy paste samples
4) ClinPro 5000
Gluten Free toothpaste
1) Tom's of Main- (Simply White toothpaste, Wicked Fresh Toothpaste, Whole Care Fluoride Toothpaste Gel, Children's Toothpaste Gel, Fluoride Free Chilren's Toothpaste)
More Gluten Free toothpaste
2) Crest Pro-Health
2) Aqua-Fresh
3) Arm and Hammer
4) Colgate Great Regular Flavor
5) Oral-B Stages
6) Sensodyne
Gluten Free Mouthwash
-Tom's of Maine is for sure gluten free
-Hard to find
Colgate Products
1) Do not intentionally add gluten by cannot guarantee that they have not been exposed to gluten-no need to be very careful.
2) This includes Prevident!
Gastropariesis
1) Delayed gastric emptying
2) Damages vagus nerve impairs normal stomach/intestine muscle function
3) Food moves slow or stops
4) Chronic condition-treatment manages problem; usually not cured
Causes of Gastroparesis
1) Diabetes-most common
2) Surgery-vagus nerve/stomach
3) Viral infections
4) Anorexia/Bulimia
5) Rx-anticholinergics/narcotics-slow intestinal contractions
More causes of Gastroparesis
6) Gastroesophageal reflux
7) Smooth muscle disorders-amyloidosis and scleroderma
8) Nervous system diseases-abdominal migraine and Parkinson's disease
9) Metabolic disorders-hypothyroidism
Symptoms of Gastroparesis
1) Heartburn/upper abdomen pain
2) Nausea/vomiting of undigested food several hours after ingestion
3) Premature fullness/ lack of appetite
4) Abdominal bloating/stomach spasms/gastroesophageal reflux
5) High and low blood glucose levels
Complications of Gastroparesis
1) Bacterial overgrowth
2) Poorly controlled diabetes
3) Formation of Bezoars (Solid food mass)
-Nausea
-Vomiting
-Stomach obstruction
Treatment of Gastroparesis
1) Medcation: Erythromycin, Metoclopramide (Reglan)
2) Dietary changes
3) Feeding tube
4) Parenteral Nutrition
More treatment of Gastroparesis
5) Gastric Electrical Stimulation
6) Botulinum Toxin
7) Adjustment of Insulin dose
Oral Considerations of Gastroparesis
1) Effects of vomiting
2) More frequent meals
3) Liquid/pureed diet
4) Fluxuations in blood glucose levels
Peptic Ulcer Disease-Etiology
1) H. pylori: Gram- bacillus; African Americans, Latinos
2) Use of NSAIDS: Direct damage to mucosa, Reduce prostaglandin production, reduce mucosa secretion
3) Possible: High acid secretion, Cigarette, Stress, Patients who have osteoporosis and take Bisphosphonates
Medical Management
1) Signs and symptoms: Pain
2) Medication therapy: Drug Cocktail that includes antibiotics to eliminate H. Pylori
3) Recommended thing to avoid: Alcohol, Aspirin, NSAIDS, Corticosteroids, Food causing high acid production, smoking
Dental considerations for PUD
1) Mostly interactions with medications prescribed in the dental office
-Enhance duration of action
-Antacids impair absorption of some commonly used antibiotics (dentistry)-antibiotic needs to be taken 2 hours before antacid
-Many need to adjust medications or anesthetics that are broken down by liver
PUD dental considerations continued
2) If client is on antacids prevents the optimal level of fluoride
-Fluoride is blocked by antacids and better remineralization product nedds to be considered
3) Routine care is avoided during medical therapy for ulcers
Helicobacter pylori (HP)
1) HP is a microorganism implicated in many gastric diseases
-Chronic gastritis; Peptic ulcer; Gastric cancer
2) HP's relationship to oral disease is controversial
-Periodontal disease; Herpes Simplex Virus type 1 (HSV-1)-ongoing studies looking into the relationship of HSV-1 and HP (correlation)
Helicobacter pylori
1) Thought that periodontal pockets and plaque can act as a reservoir and source of infection for H. Pylori
2) This requires working with a physician to reduce the source of HP
Dental Hygiene Considerations with Helicobacter Pylori
1) Consider HP history as risk factor for periodontal disease
2) Include scaling and root planning, patient education, and plaque control in the treatment of HP gastric conditions
Dental implications considered
3) Consider possibility of HP infection in conjunction with know HSV-1 infection
2) Foster medical collaboration in the treatment of patient with HP-associated gastric conditions
Risks assessment of clients with ulcers
1) Determine if GI disease is: Active, reoccurring
2) What medications is client on: Anti-inflammatory medications can be contraindicated in clients with ulcers
Oral risks for Ulcers
1) Mouth reservoir for H. Pylori-can create reinfection
2) H. Pylori can play role in oral inflammation
3) Potential mucosal burning due to acid secretion
4) Xerostomia-drug induced
5) Enamel erosion
6) Taste alterations-side effect of omeprazole
Role of the hygienist
1) Education on plaque removal
-Source for reinfection
2) Appropriate homecare products
-Mouthriinse (CHX, Essential oils)
3) Toothpaste
4) Xylitol products due to taste alteration
5) Control erosion (Baking soda mouthrinses)
6) DHT
-Tx most effective in combination of DHT/ medical
-monitor for fungal infections if client is on antibiotics
GERD
1) Gastroesopphageal refux disease
2) Occurs when the lower esophageal sphincter (LES) does not close properly and stomach acid (Hydrochloric acid) is allowed to move up the esophagus
GERD Etiology
1) Unknown why some people get GERD
2) LES is not working properly, or
3) They may have a hiatal hernia: a distortion of the upper stomach and diaphragm that distorts the LES causing it to allow acid to move up the espohagus
Impact of GERD on the Oral Cavity
1) Hydrochloric acid cause a decrease in pH of the oral cavity resulting in rapid demineralization
2) These clients should have regularly scheduled re-mineralization therapy through use of topical fluoride varnish
Impact of GERD on the Oral Cavity continued
3) Products such as MI Paste should be used regularly at home
4) Use a neutralizing agent containing sodium bicarbonate
5) In advanced GERD, full coverage restorations are needed, because small restorations will be quickly worn away
GERD medications precautions
1) Long term use can cause low serum magnesium putting client at risk for: Seizures, Arrythmia
2) With prescription medication there is a risk for hip/wrist/spine fracture
-Decreased calcium absorption
-Need to take calcium citrate
3) At greater risk for clostridium difficile infection-Caution with broad spectrum antibiotics
Obesity
1) Classification of weight
2) (US: BMI= lb*703/in^2)
-A BMI less than 18.5 is underweight
-A BMI of 18.5-24 is normal weight
-A BMI of 25-29 is overweight
-A BMI of 30-39 is obese
-A BMI of 40 or higher is severely (or morbidly) obese
More on Obesity
1) Over one-third of US adults-more than 72 million people-were obese in 2005-2006 (this number has stayed relatively level over the last 2 years)
2) Adults aged40-59 had the highest obesity prevalence
3) 16% of children and teens are now considered obese
Classifications of obesity
-Class 1: 30-24.9 BMI
-Class II: 35-39 BMI
-Class III: > or equal to 40 BMI
Obesity in Children
1) The number of obese and overweight children continues to rise steadily every year
2) At this rate, the American life expectancy will fall by and estimated 2-5 years if children do not start managing their weight
3)Children are not getting enough exercise, leading sedentary lives, and eating too much of the wrong food
Risk factors of obesity
1) Lifestyle (70% of total risk)
2) Genetics (30% of total risk)
3) More common in: Females, Minorities, Persons with low socio-economic status
Negative Health Effects of Obesity
1) Hypertension
2) High Cholesterol
3) Type 2 Diabetes
4) Periodontal disease
5) Heart disease and stroke
6) Certain cancers
Relationship of Obesity and Periodontal Disease
1) Obesity is a risk factor for periodontal disease
2) Increases BMI is associated with gingival bleeding
3) Obesity (especially upper body obesity) is associated with deep probing depths
4) Periodontal disease is associated with weight gain
It is about inflammation
1) Thought that obesity changes inflammatory and immune system
2) Potential hyperinflammatory response
3) Excess adipose tissue increases the excretion of several cytokines, including: Tumor necrosis factor, Interleukin-6, Interleukin-8
Obesity Prevention
1) Reduce caloric intake by 100 calories per day for each passing decade after age 20
2) Balance appetite stimulators and suppressors
3) Increase physical activity
4) Make sensible food choices
Eating Regulators
1) Stimulators: Ghrelin, Empty stomach, sight and smell of food, cold temperatures
2) Suppressors: Leptin, PYY-336, hormone that signals to stop eating, CCK, hormone signals to stop eating and state sleeping, heat
Role of obesity and periodontal disease
1) Previous slide shows the current thought on the role of periodontitis and obesity
2) Obesity and Perio are chronic inflammatory conditions
3) This increases cytokines-IL-1, IL-6 and tumor nercrosis factor-raising the levels of C-reactive Protein produced by liver
-what is the role of IL-1, IL-6 and tumor necrosis factor?
Role of obesity continued
4) This increases insulin, greater fibrinogen production
5) This in turn leads to diabetes, poor glycemic control and cardiovascular disease
6) Since we have more cytokines then we will have greater attachment loss
Obesity and perio
7) The dental hygienist does have a role in educating the client on weight loss and nutritional issues
8) This will decrease the risk of periodontal disease
How can we address obesity?
1) Recognize at-risk clients
2) Prevent-Do a food diary with children to determine their intake levels
3) Inform parents tactfully of findings and recommend changes
4) Determine BMI of child
Addressing obesity
5) Explain significance of BMI to parent
6) Educate on connections between heart disease, diabetes, oral health, and obesity
7) Recommend less TV time and more physical activity
8) Give ideas for healthy food options-fruits, vegetables, whole grains, low fat milk
Gastric Surgery
1) Gastrorestriction (Banding)
2) Gastric bypass (Roux-en Y)-most common
3) Do not guarantee permanent weight loss
4) Usually restricted to most obese but there is a trend for people with less of a problem
More on Gastric surgery
5) Micronutrient deficiencies are a concern (up to 40% of people in one study had a vitamin B12 deficiency)
Nutrition after Roux-en Y
1) Small frequent meals throughout the day
2) Small sips of liquid
3) Liquids and food not to be consumed at the same time-must be 30 minutes apart
4) Frequent eating then increases caries risk
5) Dehydration also a risk-this leads to xerostomia
Eating habits
Literature review shows a decrease in taste after surgery
Who should have bariatric surgery?
1) Class III
2) Class II with co morbidities
3) Conservative treatment needs to be tried first
Stomach banding-How does it work?
-Surgeons make tiny incisions and using laparoscopic techniques, fasten the band around the upper part of the stomach
-The band divides the stomach into a small upper pouch and the rest of the stomach
-Once the patient eats and fills the new upper pouch, the stomach will feel full and the patient will no longer feel the need to continue eating
Stomach Banding continued
-Food gradually moves from the upper stomach to the lower stomach which reduces the chances of mal-absorption found with other stomach altering surgeries
-The band is adjustable so a patient can continue to lose weight with it for a period of years
More on stomach banding
1) Was approved by the FDA in June of 201 for severely obese people (100 pounds or more overweight)
2) One study found that over a three year period, 93% of people lost wieght
Stomach binding continued
3) 89% of people experienced a side effect: most experienced nausea and vomiting
4) Frequent vomiting is likely to cause tooth damage, look for this in people using gastric bands
Nutrition is a priority
1) Increase complex carbohydrates and reduce simple sugars
2) Include cariostatic foods such as protein, chesses
3) Increase water intake
4) Increase fibrous food so it stimulates slaliva
Must include NIT
1) Fluorides
2) Frequent recare due to caries risk
3) OHI is very important
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