Oral Implications of Pernicious Anaemia

Feeling washed-out, tired and fatigued can so easily be dismissed as part of a busy life. Many sufferers endure these symptoms for months indeed years before approaching healthcare.

Oral manifestations of pernicious anaemia often present early in the disease and offers an opportunity for timely intervention. A greater awareness of pernicious anaemia for both the public and dentists alike would keep the disease in the mind’s eye. Unlike with doctors, dental appointments tend to be more frequent and routine, offering a greater potential for detecting anaemias. It takes a keen eye by the dentist to piece together all the signs and therefore do good by the patient in their care.

In my dental clinic, in the town of Hitchin, I have the privilege of providing care for people of all ages. Whilst most have very well-maintained mouths, many have medical conditions that demand special consideration.

Patients are seeing their dentist for their dental concerns, not as a doctor for their systemic health. The mouth, nevertheless, is very much part of the body and can serve as a useful reflection of systemic disease. The title ‘dentist’ places too much weight on the teeth and not the oral cavity as a whole. Perhaps we should re-brand as oral health clinicians as we are not solely trained or concerned with the hard tissues (teeth). The soft tissues are also very much our remit, and the dentist will examine these structures at check-ups to screen for any pathologies of note.

The question is, what causes oral pathology and whether the cause is local in nature or a sign of a broader systemic disease. As a clinician seeing several oral signs and symptoms which lack a local cause, then my thoughts would lean towards the latter and a referral to the GP for further tests may be warranted.

Vitamin B12 plays a key role in cell division and the production of haemoglobin, which in turn is used to carry oxygen in red blood cells. Because of this somewhat compromised cell division, healing is impaired and so too is tissue integrity. This is why oral ulcers can present relatively early in the condition as the gum/mucosa is more friable than that of other tissues such as the skin. It also explains, in some part, why pernicious anaemia shares many of the oral presentations of anaemia. A full blood count as well as vitamin B12 testing is required to differentiate and diagnose.
Insufficient vitamin B12 can have several causes including malnutrition and malabsorption, of which there can be several reasons, or even biological competition such as bacterial gut infections or tapeworms.

Pernicious anaemia is an autoimmune condition which affects the ‘parietal’ cells lining the stomach. These cells release a ‘factor’ which binds to the vitamin B12 to allow it’s absorption later in the ileum. For various reasons, patients with pernicious anaemia unwittingly develop unhelpful antibodies that either attack these parietal cells or the ‘intrinsic factor’ they produce and in doing so compound the absorption of the vitamin B12.

What are the oral signs and symptoms that we sometimes see with Pernicious Anaemia?

Recurrent Oral Ulcers

Exquisitely painful ulcers can frequently come and go and tend to last 1 to 2 weeks. They occur anywhere on the soft tissues, often several at once. They are referred to as aphthous ulcers.

Glossitis

This is one of the most common oral symptoms and causes a swollen beefy red tongue. The upper (dorsal) surface which is usually rough can present as smooth or with smooth patches. A burning or sore sensation is often experienced which can be hypersensitive and precipitated by certain foods. Glossitis can make it difficult to enunciate as well impacting on swallowing and eating.

Burning Mouth Syndrome (BMS)

This is a frustrating and often distressing sensation of persistent pain of tongue, oral mucosa and lips. It can migrate and sometimes causes an altered taste sensation (dysgeusia). Spicy and acidic foods are best avoided.

Ulcerative Gingivitis

The gumline around the teeth becomes inflamed, red and swollen as well as ulcerated. The gums tend to bleed on brushing.

Gum Disease

The tissues which fix the teeth to the bone are more prone to infection and breakdown with pernicious anaemia and as such there is a greater risk of developing gum disease. If untreated this can lead to the progressive loss of tooth support. Gum disease is a painless condition the pace of which is in fits and starts.

Angular Cheilitis

This condition affects the corners (commissures) of the mouth causing soreness and inflammation. The skin becomes red and smooth and chapped. It is sore and can lead to secondary infection.

Neurological Effects

In advanced and untreated cases, nerve damage can occur and this can have an impact on tongue and lip movement. This in turn can affect speech and cause tingling and numbness.

How do we treat these conditions?

The good news is that pernicious anaemia can be treated and managed to greatly reduce and overcome many of these symptoms. Early diagnosis will help enormously to prevent any lasting damage.

Just as the causes of these oral conditions can be local or systemic, so too is the treatment.

On the medical side, once a definitive diagnosis has been made with the appropriate blood tests, vitamin B12 injections bypass the gut absorption route and replenish the supply of vitamin B12 to the tissues. Whilst in some cases, high dose oral vitamin B12 supplements can also help, they are rarely sufficient to reverse neurological symptoms. Dietary adjustments including foods high in vitamin B12 also facilitates improvement for those where malabsorption such as pernicious anaemia is not the underlying issue.

These measures alone will often greatly improve the oral symptoms by the very nature that they are a manifestation of the systemic disease.

There are of course more direct and local measures that can be adopted to help from a dental perspective. Often these measures can be very effective alone, which poses the risk of masking these early tell-tale oral signs and unwittingly deferring the diagnosis.

What measures are available to help?

Mouthwash

Aphthous ulcers can be caused by many different reasons and if presenting alone can often be due to lactose intolerance. Lactose free milk in my experience will resolve ulcers for many. This will not help in PA cases, unless of course the patient also has lactose intolerance. For short term and a relatively quick resolution a 2-minute rinse with a Chlorhexidine CHX mouthwash, such as Corsodyl, before retiring for the night, will vastly improve the ulcer in the morning. The problem is that recurrent use of Chlorhexidine rinse quickly leads to an unsightly, albeit harmless, staining of the teeth and tongue. For a chronic condition like pernicious anaemia where there are frequent ulcers CHX it is not ideal. Patients suffering from glossitis and burning mouth syndrome are best avoiding CHX rinses they will greatly exacerbate tongue soreness and numbness.

At the very least a warm saline rinse by mixing 2 teaspoons of table salt and a small tumbler of tap water can help as a mild but very effective anti-septic.

A prescribed mouthwash of sodium bicarbonate and corticosteroid will help reduce the ulcers both in occurrence frequency and intensity.

These measures will also work for ulcerative gingivitis.

Keeping Good Oral Hygiene

An effective toothbrushing and oral care regime at home will help enormously. In the past 10 years I have seen a definite overall improvement in the oral hygiene of patients who use a good electric toothbrush. It is not that a manual toothbrush cannot achieve excellent results, it just takes particular technique and time. Replacing the toothbrush head every 6-8 weeks will also help. Cleaning in between the all the teeth with interdental brushing, such as Tepe’s or Curaprox, will reduce plaque and limit the bacterial load carried in the mouth. This in turn will reduce the bacterial load in the mouth and thereby the risk of oral infection, such as ulcers and gum disease.

Sugar free chewing gum will help address dry mouths by increasing the flow of saliva as well as cleaning off any food from the teeth after a meal.

Angular cheilitis can be treated by a cream prescribed by your dentist or GP. This is applied to the affected area. If you have dentures, it is important to check these are well maintained and are supporting the lower face height as, if too shallow, they will increase the folds at the corners of the mouth increasing the risk of angular cheilitis.

Regular visits with the dentist to check and maintain the oral health as well as seeing the dental hygienist are recommended. If you have recently been diagnosed with PA then inform your dentist so they can tailor their treatment and care accordingly.

I hope this brief synopsis of the oral problems that can arise from pernicious anaemia is helpful. Whilst PA is a serious condition, the good news is that if caught early many of the ill-effects can be managed. Dentists are well placed to spot the early signs and enact prompt treatment. Ask your dentist about what measures they may recommend.