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Crohn's disease and oral implications.

Introduction

Crohn's disease (CD) is a chronic, autoimmune inflammatory disorder of the gastrointestinal (GI) tract. (1) Anan-thakrishnan described CD, a form of ulcerative colitis (UC), as "chronic immunologically mediated diseases that are due to a dysregulated immune response to intestinal flora in a genetically susceptible host." (2) Individuals diagnosed with CD experience symptoms including chronic diarrhea, severe abdominal pain, nausea, vomiting and fistulas.'

Etiology of CD consists of genetics, environmental factors and an "inappropriate inflammatory response to intestinal microbes in a genetically susceptible host."' Environmental triggers such as smoking, low levels of vitamin D, medications including oral contraceptives, hormone replacement therapies (HRT), aspirin and non-steroidal anti-inflammatory drugs (NSAIDS) contribute to the pathogenesis of CD. (2) These environmental triggers increase risk of disease flares. (2) Non-environmental factors including antibiotics, stress, depression and diet also contribute to pathogenesis of CD and increase flare ups. (2)

CD involves the ileum and large bowel in most cases, but can affect any part of the GI tract from the mouth to the anus. (1) Patients with CD may experience halitosis, xerostomia from medications, nausea and vomiting, weight loss, malnutrition and bone loss, all of which affect the oral cavity. (3), (4) In addition, Katz et al. discussed how candidiasis, dysphagia, dental erosion and changes in salivary gland function are related to an autoimmune response in patients with CD. (4) Other oral effects of CD include aphthous ulcerations, gingival hyperplasia, diffuse gingival swelling, mucosal hyperplasia, fissuring cheilitis and pyostomatitis vegetans. (5) Although orofacial granulomatosis (OFG) is rare, Saalman, Mattsson and Jontell reported the condition in children with CD. (6) OFG was an oral manifestation of CD prior to diagnosis of the condition. (6) 0FG is a generalized term used to encompass all of the above listed oral conditions. (6) Mergulhao et al. discovered a relationship between gingival hyperplasia/OFG as an early manifestation of CD prior to actual diagnosis of the condition. (5) Oral mucosal involvement with CD was discovered in 1969 when a patient with known gut disease presented with oral mucosal tags. (7)

These oral implications signify the importance of collaborative practice between dental professionals and other medical health care professionals (e.g., primary care physicians, gastroenterologists, dieticians) when assessing for oral disorders. Dental care providers may assist other medical professions with early diagnosis and treatment by providing a record of oral manifestations prior to diagnosis.

Evidence-Based Literature Review

Incidence and Prevalence

"The incidence of [irritable bowel disease] reported in North America ranges from 2.2 to 14.3 cases per 100,000 persons for UC and from 3.1 to 14.6 cases per 100,000 persons for CD. In Europe, respectively, the incidence ranges from 8.7 to 11.8 (UC) and from 3.9 to 7.0 (CD) cases per 100,000 persons. (1) UC is more prevalent than CD, irrespective of the geographical area. (1) Boirivant and Cossu estimated 780,000 individuals with UC compared to 630,000 individuals with CD in the United States. (1) The incidence of both diseases follows a bimodal age distribution manifesting in early adulthood and up to 50 to 70 years of age. (1) The incidence of UC and CD is rising in areas such as southem Europe, Asia and developing countries. (1) A possible reason for this incidence is a strong relationship between CD and people of German and Jewish ethnicity, documented in early studies. This relationship was found due to a polymorphism in the IL23R gene.3

Etiology and Pathophysiology of Disorder

CD is an autoimmune disease. (1) The exact cause of CD is unknown; however, genetics, microbial, immunologic, environmental, dietary, vascular and psychosocial factors have been associated with the development of the condition. (3) In addition, smoking, oral contraceptives, HRT, NSAIDS, low levels of vitamin D, stress, antibiotics and depression all contribute to symptoms of CD. (2), (3) Individuals who are hypersensitive to food, food additives and dental materials may have a positive relationship to CD. (7) Associated food substances and additives include wheat, dairy products, chocolates, eggs, peanuts, cinnamaldehyde, carbone piperitone and monosodium glutamate. (7) Toothpaste has been implicated due to the active ingredients of cinnamaldehyde and carbone piperitone. (7)

Risk Factors

Risk factors include smoking, age (likely as a young adult, also between ages 50 and 70 years), ethnicity (predominantly Eastern European) and family history of CD. (2), (3) Originally, CD was thought to be primarily associated with Jewish ethnicity, but the condition has been identified among those of Eastern European descent. (2), (3)

Methods of Diagnosis

Ghazi suggested a thorough examination including vital signs along with gastrointestinal, genitourinary, musculoskeletal, dermatologic, ophthalmologic, growth delay and hematologic evaluations for diagnosis. (3)Although nonspecific for CD, laboratory tests including complete blood count, chemistry panel, liver function tests, inflammatory markers, stool studies, and serologic tests may be of value for determining vitamin deficiencies, inflammatory markers and nutrition analyses. (3) Imaging modalities for CD include abdominal radiography, barium contrast studies, computed tomography (CT) scan of abdomen, CT enterography or magnetic resonance enterography, magnetic resonance imaging (MRI) of the pelvis, abdominal and/or endoscopic ultrasonography and nuclear imaging. (3)

Characteristics of the Condition/Disease

Ghazi described characteristics of CD, which include abdominal pain and diarrhea, rectal bleeding, fever, weight loss, nausea/vomiting, malnutrition, vitamin deficiencies, fatigue, bone loss, psychosocial issues (depression and anxiety) and growth failure in pediatric patients. (3) These conditions vary depending on severity of CD.

Evidence-Based Methods for Management/Treatment Including Alternative Therapies

Management and treatment of CD includes pharmacotherapy and surgery. (1), (3) Medications used to reduce symptoms of the disease and for treatment of CD are listed in box 1. Although CD has no surgical cure, most patients will require surgical intervention. (3) Surgical interventions for CD are listed in box 2.

Implications for General Health/Well-Being

Implications for general health include nutrition deficiencies, vitamin deficiencies, bone loss and psychosocial issues. (3) These implications can further suppress the immune system of an individual with CD, increasing risk for infection.

Implications for Oral Health and Provision of Dental Care

The presence of aphthous ulcerations, gingival hyperplasia/OFG, diffuse gingival swelling, mucosal hyperplasia and fissuring cheilitis may have implications for dental care if pain is associated with any of these manifestations. (5) Patients with CD may need to reappoint if treatment is intolerable. LIDEX[R] (fluocinonide) cream 0.05 percent may be considered for relief of the inflammatory and pruritic manifestations of corticosteroid-responsive dermatoses. (8)

Studies Measuring Different Management Strategies/ Outcomes

Fan, Chen, Yu, Si and Liu studied the effects of probiotic treatment containing Bifidobacterium, Lactobacillus and Enterococcus species in patients with IBD. (9) Fan et al. reported a pilot study showing an improvement with abdominal pain and stool characteristics as a result of alterations in gastrointestinal flora. (9) Kim et al. tested the efficacy and safety of probiotics and nutrients for individuals with IBD. (10) While individuals reported a decrease in indigestion and less bloating/abdominal discomfort, no conclusive evidence was found in this pilot trial. (10)

Shah discussed alternative medicine as another management strategy used to treat individuals with CD. (11) Modifying the diet has had an impact on celiac disease, colon cancer, and diverticulosis, and may play a role in pathogenesis of IBD. (11)

Clinical Implications

Overview

Clinical manifestations of CD include the presence of aphthous ulcerations, gingival hyperplasia, diffuse gingival swelling, xerostomia, mucosal hyperplasia, cobblestoning of buccal mucosa, mucosal tags, fissuring cheilitis, OFG and orofacial CD. (5), (6), (12), (13), (14) Individuals with CD who are taking NSAIDS may have prolonged bleeding; therefore, caution must be used when performing subgingival scaling.

Treatment Considerations

Quezada et al. recommended that steroids, immunomodulators and biologics should be considered for use in patients with severe oral lesions. (14)

The anti-inflammatory effects from these drugs can mask signs of periodontal inflammation. Individuals with CD are susceptible to bone loss; therefore, a thorough periodontal evaluation should be implemented at the initial appointment and assessed at every continuing care/periodontal maintenance appointment.

After the initial examination, necessary radiographs should be taken based on the recommendations set by the Council on Scientific Affairs of the American Dental Association (ADA) in collaboration with the Food and Drug Administration. (15) A full-series radiographic exam with posterior bitewings should be taken for new adult patients who have not had recent radiographs. An individualized radiographic exam consisting of selected periapical/oc-clusal views and/or posterior bitewings if proximal surfaces cannot be visualized may be taken on children with CD; however, patients without evidence of disease and with open proximal contacts may not require radiographs. (15) Adult patients of record should have posterior bitewing radiographs at 24- to 36-month intervals if no clinical caries has been detected. (15) Children who are patients of record should have posterior bitewing radiographs at 12- to 24-month intervals if no clinical caries has been detected. (15)

Patients with CD should be instructed to brush with a fluoridated dentifrice twice daily and to drink fluoridated drinking water to decrease risk of caries. (16) For adult patients with CD who have exposed cementum and root caries, an adjunctive topical application of a 1:1 mixture of chlorhexidine/thymol varnish should be applied after prophylaxis to reduce the incidence of root caries if primary methods prove unsuccessful. (16) Children with CD who have an increased risk for caries should have topical fluoride varnish applied every three to six months. (16) Depending on the periodontal status and caries risk of the patient, a three- to six-month interval for prophylaxis is recommended due to oral manifestations of the condition and an increased potential for xerostomia.

Conclusion

In order for dental professionals to collaborate with other medical professionals, they must attain a certain level of knowledge regarding oral manifestations and autoimmune diseases. Clinical implications for individuals with CD include aphthous ulcerations, gingival hyperplasia/OFG, diffuse gingival swelling, xerostomia, mucosal hyperplasia, cobblestoning of buccal mucosa, mucosal tags, fissuring cheilitis and orofacial CD. Dental professionals play an important role with regard to early diagnosis and treatment of individuals with CD. Many patients with undiagnosed CD present with oral manifestations of the disease, while others who have been diagnosed show oral manifestations as the disease progresses. Treatment options for individuals include frequent periodontal risk assessments due to the possibility of bone loss, more frequent continuing care intervals and topical fluoride therapy due to xerostomia caused by medications. Many autoimmune diseases mirror one another in oral manifestations and treatment modalities; therefore, this in-depth study of CD will provide the dental professional with the information necessary to deliver evidence-based treatment for patients with autoimmune diseases.

Oral implications of Crohn's disease signify the importance of collaborative practice between dental professionals and other medical health care professionals when assessing for oral disorders.

Box 1. Medications Used to Treat and Reduce Symptoms of Crohn's Disease (3)

* 5-Aminosalicylic acid derivative agents (e.g., mesalamine rectal, mesalamine, sulfasalazine, balsalazide)

* Corticosteroids (e.g., prednisone, methylprednisolone, budesonide, hydrocortisone, prednisolone)

* Immunosuppressive agents (e.g., mercaptopurine, methotrexate, tacrolimus)

* Monoclonal antibodies (e.g., infliximab, adalimumab, certolizumab pegol, natalizurnab)

* Antibiotics (e.g., metronidazole, ciprofloxacin)

* Antidiarrheal agents (e.g., loperamide, diphenoxylate-atropine)

* Bile acid sequestrants (e.g., cholestyramine, colestipol)

* Anticholinergic agents (e.g., dicyclomine, hyoscyamine, propantheline)

Box 2. Surgical interventions for Crohn's Disease'

* Resection of the affected bowel

* Ileocolostomy or proximal loop ileostomy

* Drainage of any septic foci with later definitive resection

* Strictureplasty

* Bypass

* Endoscopic dilatation of symptomatic, accessible strictures

* Subtotal or total colectomy with end ileostomy (laparoscopic or open approach)

* Segmental or total colectomy with or without primary anastomosis

* Total proctocolectomy or proctectomy with stoma creation

An assignment submitted in partial fulfillment of the requirements for DENT 6610 Special Care Populations, Idaho State University, August 8, 2013.

References

(1.) Boirivant M, Cossu A. Invited medical review: inflammatory bowel disease. Oral Dis. 2011: 18, 1-15. doi:10.1111/j.1601-0825.2011.01811.x

(2.) Ananthakrishnan AN. Environmental triggers for inflammatory bowel disease. Curr Gastroenterol Rep. 2013; 15(302): 1-7. doi:10.1007/s11894-012-0302-4

(3.) Ghazi L3. Crohn disease. Medscape Reference: Drugs, Diseases, and Procedures. 2013. Available at: http://emedicine.medscape.com/article/172940-overview#aw2aab6b2b3

(4.) Katz 3, Shenkman A, Stavropoulos F, Melzer E. Oral signs and symptoms in relation to disease activity and site of involvement in patients with inflammatory bowel disease. Oral Dis. 2003; 9(1): 34-40. doi:10.1034/ j.1601-0825.2003.00879.x

(5.) Mergulhao P, Magro F, Pereira P, et al. Gingival hyperplasia as a first manifestation of Crohn's disease. Dig Dis Sci. 2005; 50(10): 1946-9. doi :10.1007/s10620-005-2965-2

(6.) Saalman R. Orofacial granulomatosis in childhood - a clinical entity that may indicate Crohn's disease as well as food allergy. Acta Paediatr, 2009; 98: 1162-7. doi:10.1111/j.1651-2227.2009.01295.x

(7.) Tilakaratne WM, Freysdottir 3, Fortune F. Orofacial granulomatosis: review on aetiology and pathogenesis. 3 Oral Pathol Med. 2008; 37, 1915. doi: 10.1111/j.1600-0714.2007.00591.x

(8.) Medicis Pharmaceutical Corp. Lidex-fluocinonide cream. 2012. Available at: http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=11E81560-9891-4407-A952-171151D9B672

(9.) Fan Y, Chen S, Yu Y, et al. A probiotic treatment containing lactobacillus, bifidobacterium and enterococcus improves IBS symptoms in an open label trial. 3 Zhejiang Univ SCI B. 2006; 7(12): 987-91. doi:10.1631/jzus.2006.130987

(10.) Kim LS, Hilli L, Orlowski 3, et al. Efficacy of probiotics and nutrients in functional gastrointestinal disorders: a preliminary clinical trial. Dig Dis Sci. 2006; 51: 2134-44. doi:10.1007/s10620-006-9297-8

(11.) Shah S. Dietary factors in the modulation of inflammatory bowel disease activity. Medscape Gen Med. 2007; 9(1), 60-82. Available at: www.ncbi.nlm.nih.gov/pmc/articles/PMC1925010/?report=reader#_ffn_sectitle

(12.) Michailidou E, Arvanitidou S, Lombardi T, et al. Oral lesions leading to the diagnosis of Crohn disease: report on 5 patients. Quintessence Int. 2009; 40(7): 5818,

(13.) Pittock S, Drumm B, Fleming P et al. The oral cavity in Crohn's disease. Pediatr. 2001; 138:767-71. doi:10.1067/mpd.2001.113008

(14.) Quezada S, Turner PL, Alexiev B, et al. Severe refractory orofacial Crohn's disease: report of a case. Dig Dis Sci. 2009: 54: 229-5. doi:10.1007/s10620-008-0588-0

(15.) U.S. Department of Health and Human Services, Food and Drug Administration, Public Health Service, American Dental Association, Council on Scientific Affairs. Dental radiographic examinations: Recommendations for patient selection and limiting radiation exposure. 2012. Available at: www.ada.org/sections/professionalResources/pdfs/Dental_Radio-graphic_Examinations_2012.pdf.

(16.) American Dental Association, Council on Scientific Affairs. Non-fluoride caries preventive agents: full report of a systematic review and evidence-based recommendations. 2011. Available at: http://ebd.ada.org/contentdocs/clinical_recommendations_non_fluoride_caries_preven-tive_agents_full_report.pdf.

By Michelle L. Smith, RDH, BSDH, MSDH(c)

Michelle Smith, RDH BSDH, MSDH(c) is ADHA manager of dental hygiene education.
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Title Annotation:clinical feature
Author:Smith, Michelle L.
Publication:Access
Article Type:Report
Date:Apr 1, 2014
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