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

The ventral surface of the healthy tongue is covered with a smooth, pink mucous membrane and lymphoid follicles. On the dorsal surface, the filiform, fungiform, and circumvallate papillae (which contain the organs of taste) produce a rough, grayish red appearance. The thick epithelial tufts of the filiform papillae give the tongue its characteristic grayish white coating, whereas the globular, pale red fungiform papillae give it a speckled pink appearance. Furrows are not characteristic of the healthy tongue.

The buccal mucosa has a grayish red color and may be crossed by fine grayish ridges where it touches the closed teeth.

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 teeth ²:

• 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

TABLE 25-1 Oral Signs of Nutrient Deficiency

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