Vol. 87 No. 1 January 1999
ORAL SURGERY, ORAL MEDICINE, ORAL PATHOLOGY,
MEDICAL MANAGEMENT UPDATE
Editor: James R. Hupp
Inflammatory bowel diseases and the oral cavity Michael A. Siegel, DDS, MS,a and Jed J. Jacobson, DDS, MS, MPH,b Baltimore, Md, and Ann Arbor, Mich UNIVERISTY OF MARYLAND AND UNIVERSITY OF MICHIGAN
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:12-4)
The professions of dentistry and gastroenterology are linked, as both dentists and gastroenterologists have their primary focus within the alimentary canal. Consequently, diseases that initially express themselves in one portion of the alimentary canal can present signs and symptoms in other segments as well. Patients with inflammatory bowel disease (IBD) may present with oral findings that are a manifestation of the underlying disease process. Oral manifestations of IBD may precede the onset of intestinal radiographic lesions by as much as a year or more.1,2 Treatment modalities used to manage IBD can affect the delivery of routine dental care.
GENERAL INFORMATION IBD is a general classification of inflammatory processes affecting the large and small intestines. Ulcerative colitis and regional enteritis (Crohn’s disease) are the most common forms of IBD. Ulcerative colitis is an idiopathic inflammatory disease causing ulceration of the lining mucosa and submucosa of the colon. Crohn’s disease is a chronic granulomatous inflammatory process that occurs throughout the bowel wall but primarily in the ileum. The cause of IBD is unknown, but genetic factors, infectious agents, and immunologic mechanisms appear to play a role in these disorders. Symptoms of IBD include the following: • Abdominal pain, tenderness, and cramping aAssociate Professor, Department of Oral Medicine, School of Dentistry, Univeristy of Maryland at Baltimore. bAssociate Dean for Community and Outreach Programs; Associate Professor, School of Dentistry, University of Michigan. Received for publication Oct. 7, 1998; returned for revision Oct. 12, 1998; accepted for publication Nov. 1, 1998. Copyright © 1999 by Mosby, Inc. 1079-2104/99/$8.00 + 0 7/13/95709
• Food intolerance • Fever • Chronic diarrhea • Weight loss • Rectal bleeding and bloody stools. The combined prevalence of IBD is 1 in 10,000 people. Typically, those affected by the diseases are Caucasian. Askinazi Jews are frequently affected . Age at onset tends to be between 15 and 25 years or between 55 and 65 years.
DIAGNOSIS The diagnostic steps typically needed to arrive at a working diagnosis of IBD include the following: • Imaging/radiographic evaluation, including an upper and/or lower gastrointestinal series enhanced with barium • Sigmoidoscopy or colonoscopy with biopsy • Therapeutic trial of parasympatholytic medications and/or antimicrobial agents to rule out irritable bowel syndrome (functional bowel disease) and/or enteric infections, respectively • Laboratory tests for iron deficiency anemia and low albumin.
MEDICAL MANAGEMENT The medical management of IBD includes the following: • Antidiarrheal/antispasmodic agents (diphenoxylate and atropine)
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• Antiinflammatory agents (sulfasalazine or 5-aminosalicylates)
of IBD treatment, are excreted in saliva and are known to cause aphthous ulcers in some patients.11 Although candidosis is often associated with IBD patients, it probably represents either a reaction to the bacteriostatic effect of sulfasalazine or an impaired ability of neutrophils to kill this granulomaprovoking organism rather than a primary manifestation of the disorder.12 Likewise, some antiinflammatory and sulfa-containing preparations used to manage IBD patients are reported to cause lichenoid drug reactions.13
• Antibiotics (metronidazole) • Corticosteroids (topical by enema and/or systemic) • Surgery in cases of bowel obstruction, fistulae, or perforations • Immunosuppressants (azothiaprine, 6-mercaptopurine).
ORAL FINDINGS Dentists may encounter oral findings when evaluating and treating patients with IBD. Current dental literature focuses on the oral status of IBD patients with regard to their caries rate, salivary antimicrobial proteins, and infections of bacterial and fungal origin.3-7 These findings include the following: • Aphthouslike ulcerations (1% to 10%) • Pyostomatitis vegetans (present as small, ovoid, erythematous lesions less than 5 mm in diameter with a yellowish gray necrotic surface that rubs off easily, leaving a raw exposed surface; lesions can coalesce and appear papillomatous and are found throughout the oral cavity; biopsy is needed for a definitive diagnosis ) • Chronic granulomatous stomatitis • Cobblestone-appearing gingival architecture • Granulomatous inflammation of minor salivary glands ducts • Persistent lip swelling • Other oral findings: candidosis, lichenoid drug reaction. Unfortunately, some cases reported in the literature are not completely documented, which makes it difficult to determine which oral manifestations are expressions of IBD, which represent preexisting and/or coincidental findings, and which are a direct result of medical treatment of bowel disease. A recent report of 198 consecutive cases of IBD revealed no correlation between clinical disease and frequency of oral lesions.8 If a patient develops IBD during adulthood but has a history of recurrent aphthous ulcerations since adolescence, it is likely that the aphthous ulcers represent a coincident process that may be exacerbated by IBD or its management.9 Aphthous ulcerations are a primary component of Behçet’s syndrome, which has also been implicated in inflammations of the large bowel. 10 In addition, antiinflammatory medications such as 5-aminosalicylates, the mainstay
DENTAL MANAGEMENT Patients with IBD are at increased risk for the development of dental caries and oral infections. The causes of the increased incidence are multifactorial, but they appear to be related to either the patient’s altered immune status or to diet. It is also important to recognize the risk of adrenal gland suppression in patients receiving corticosteroids to manage their IBD (20 mg/day or more of prednisone within the past 9 to 12 months). It may be necessary to augment the steroid regimen during some dental treatments, especially for anxious patients in whom preoperative or postoperative pain management is difficult or when a complicated or stressful procedure is anticipated. Oral inflammatory and granulomatous lesions associated with IBD may respond to topical steroid therapy (fluocinonide 0.05%) but should not be used indefinitely because of the risk of mucosal atrophy and systemic absorption.14 IBD with untreated iron deficiency anemia will benefit from supplemental dietary ferrous sulfate or ferrous gluconate. Intravenous sedation for dental care should be deferred until the anemia is corrected. Consequently, dental management of patients with IBD should include the following: • Frequent preventive and routine dental care to prevent destruction of hard and soft tissue • Evaluation of hypothalamic/pituitary/adrenal cortical function to determine the patient’s ability to undergo extensive dental procedures • Early diagnosis and treatment of oral infections to enhance the gastroenterologist’s ability to manage the IBD • Diagnosis (biopsy if necessary) and treatment of oral inflammatory, infectious, or granulomatous oral lesions. Appropriate referral by both dentist and gastroenterologist will lead to establishment of an accurate diagnosis, treatment of the underlying disorder, and
14 Siegel and Jacobson
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protection of the oral structures. The variation of host factors in any particular patient will determine the oral and gastrointestinal therapy that should be chosen. Coordination and collaboration are essential to highquality care for patients with IBD.
8. Lisciandrano D, Ranzi T, Carrassi A, et al. Prevalence of oral lesions in inflammatory bowel disease. Am J Gastroenterol 1996;91:7-10. 9. Siegel MA. Gastrodontology: a clinical perspective worth consideration. Am J Gastroenterol 1996;91:1-2. 10. Kyle SM, Yeong ML, Isbister WH, et al. Behçet’s colitis: a differential diagnosis in inflammations of the large intestine. Aust N Z J Surg 1991;61:547-50. 11. Dhote R, Bergmann JF, Leglise P, et al. Orocecal transit time in humans assessed by sulfapyridine appearance in saliva after sulfasalazine intake. Clin Pharmacol Ther 1995;57:461-70. 12. Curran FT, Youngs DJ, Allan RN, et al. Candidacidal activity of Crohn’s disease neutrophils. Gut 1991;32:55-60. 13. Vincent SD, Fotos PG, Baker KA, Williams TP. Oral lichen planus: the clinical, historical, and therapeutic features of 100 cases. Oral Surg Oral Med Oral Pathol 1990;70:165-71. 14. Calobrisi SD, Mutasim DF, McDonald JS. Pyostomatitis vegetans associated with ulcerative colitis: temporary clearance with fluocinonide gel and complete remission after colectomy. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995;79:452-4.
REFERENCES 1. Ghandour K, Moneim I. Oral Crohn’s disease with late intestinal manifestations. Oral Surg Oral Med Oral Pathol 1991;72:565-7. 2. Siegel MA. Oral manifestations of gastrointestinal disease: diagnosis and treatment. In: Bayless TM, editor. Current therapy in gastroenterology and liver disease. 3rd ed. Burlington, Ontario, Canada: BC Decker; 1989. p. 1-5. 3. Halme L, Meurman JH, Laine P, et al. Oral findings in patients with active or inactive Crohn’s disease. Oral Surg Oral Med Oral Pathol 1993;76:175-81. 4. Sundh B, Emilson CG. Salivary and microbial conditions and dental health in patients with Crohn’s disease: a 3-year study. Oral Surg Oral Med Oral Pathol 1989;67:286-90. 5. Sundh B, Johansson I, Emilson GC, et al. Salivary antimicrobial proteins in patients with Crohn’s disease. Oral Surg Oral Med Oral Pathol 1993;76:564-9. 6. Meurman JH, Halme L, Laine P, et al. Gingival and dental status, salivary acidogenic bacteria, and yeast counts of patients with active or inactive Crohn’s disease. Oral Surg Oral Med Oral Pathol 1994;77:465-8. 7. Malins TJ, Wilson A, Ward-Booth RP. Recurrent buccal space abscesses: a complication of Crohn’s disease. Oral Surg Oral Med Oral Pathol 1991;72:19-21.
Reprint requests: Michael A. Siegel, DDS, MS Department of Oral Medicine School of Dentistry University of Maryland at Baltimore Baltimore, MD 21201-1586