Chapter 25 Oral Manifestations of Nutritional Status
Introduction
The structures and lining of the oral cavity offer valuable and easily accessible information on the nutritional status of an individual. Lesions may indicate a nutrient deficiency or may be manifestations of gastrointestinal or other disease.1 Because of the very rapid cell turnover of the oral mucosa, these lesions often may precede other manifestations of nutrient deficiency or systemic disease. Some typical lesions are mucosal ulceration, cheilosis, gingivitis, and glossitis. Between 5% and 10% of the people in the United States are deficient in one or more nutrients, so signs of nutritional deficiency are common.
The Healthy Mouth
Healthy gums have a light reddish appearance and cover the roots of the teeth completely.
The assessment of oral health, obviously, must include the health and status of the teeth. Patients should be asked about their dental history and encouraged to have regular dental checkups. Here are some key nutritional considerations for examination of the teeth2:
• Having fewer than 20 teeth as an adult is associated with a significantly reduced capacity to eat nutritious foods, such as salads, raw fruit and vegetables, nuts, and whole grain products. The same applies even to denture wearers.
• Bulimia may manifest as erosive tooth wear.
• Osteoporosis may manifest initially as changes in jaw structure and/or loose teeth.
• Presence of mercury amalgams may be associated with systemic disease, especially neurologic conditions.
Abnormalities of the Oral Membranes
Table 25-1 summarizes the typical oral manifestations associated with a particular nutrient deficiency, and Table 25-2 summarizes common disorders associated with oral manifestations.1–12
| NUTRIENT | SIGNS OF ORAL DEFICIENCY |
|---|---|
| Vitamins | |
| Biotin | Geographic tongue, atrophy of lingual papillae |
| Folic acid | Gingivitis, glossitis with atrophy, or hypertrophy of filiform papillae, cheilosis |
| Niacin | Intraoral burning, canker sores, halitosis, glossitis, tongue swollen with red tip and sides, swollen red fungiform papillae, filiform papillae becoming inflamed and losing their epithelial tufts (giving the characteristic slick red appearance) |
| Pyridoxine | Intraoral burning, glossitis, mucosal ulcerations and erosions, cheilosis |
| Vitamin B12 | Intraoral burning, mucosal ulcerations and erosions, painful glossitis with a beefy red or fiery appearance, eventually resulting in an atrophic (smooth and shiny) tongue |
| Riboflavin | Soreness and intraoral burning, cheilosis, angular stomatitis, glossitis with a magenta tongue |
| Vitamin C | Sore and bleeding gums, deep blue-red color to gums, loose teeth, follicular hyperkeratosis |
| Vitamin D | Intraoral burning |
| Vitamin E | Glossitis |
| Minerals | |
| Calcium | Periodontal disease, tooth decay |
| Iron | Cheilosis, atrophic glossitis, gingivitis, candidiasis, intraoral burning or pain, mucosal ulcerations and erosions, pallor |
| Zinc | Cheilosis, atrophic glossitis, gingivitis, candidiasis, intraoral burning or pain, mucosal ulcerations and erosions, pallor |
Data from references 1-12.
TABLE 25-2 Common Disorders Associated with Oral Manifestations
| ORAL MANIFESTATION | DISORDER(S) |
|---|---|
| Cheilosis | Crohn’s disease, acrodermatitis enteropathica, alcoholism, celiac disease, malabsorption syndrome |
| Gingivitis | Crohn’s disease, anorexia nervosa, celiac disease, scurvy |
| Erythroplakia | Dysplasia or carcinoma |
| Glossitis | Crohn’s disease, diabetes, alcoholism, celiac disease, malabsorption syndrome, pernicious anemia, iron-deficiency anemia, amyloidosis, carcinoid syndrome, cigarette smoking, anemia |
| Intraoral burning | Menopause, diabetes mellitus, esophageal reflux, Sjögren’s syndrome |
| Leukoplakia | Chronic irritation, dysplasia, early invasive squamous cell carcinoma |
| Ulcerations, erosions | Crohn’s disease, ulcerative colitis, celiac erosions disease, corticosteroid use, acrodermatitis enteropathica, anorexia nervosa, pernicious anemia, iron-deficient anemia, mercury poisoning, nicotine withdrawal |
Data from references 2-12.
In general, ulceration should be considered a nonspecific expression of a disease state. A search for the etiology will usually result in a specific therapy. Aphthous stomatitis is a common example of a mucosal ulceration and is discussed in detail in Chapter 146.
Similarly, cheilosis is a common expression for acquired nutrient deficiency. Gingivitis is associated with the classic signs of scurvy, but other nutrients have now been shown to play a role in gingival health; this subject is discussed in Chapter 199. Glossitis is associated with numerous vitamin deficiency states, each with a characteristic appearance.
Like glossitis, intraoral burning represents a nonspecific expression of a possible nutrient deficiency or systemic disease.3–5 Possible causes in addition to those listed in Table 25-2 are as follows:
• Deficiencies of iron, vitamin B12, folic acid, vitamin B6, and protein
In people who do not wear dentures, nutritional disorders are the most common causative factors.2
Leukoplakia is any white lesion of the oral cavity that cannot be removed by rubbing the mucosal surface. Although lesions are usually only a sign of chronic irritation, 2% to 6% represent either dysplasia or early invasive squamous cell carcinoma.4
Erythroplakia is similar to leukoplakia, except that it has a definite erythematous component. This is a far more serious sign, with 90% of such lesions representing dysplasia or carcinoma.
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5. Ship J.A., Grushka M., Lipton J.A., et al. Burning mouth syndrome: an update. J Am Dental Assoc. 1995;126:843–853.
6. Werbach M.R. Nutritional influences on disease. Tarzana, CA: Third Line Press; 1993.
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