Crohns Disease

Crohn's disease (CD) is an inflammatory disease of the small or large intestine. The inflammation involves all the layers of the bowel. Oral lesions may be either symptomatic or asymptomatic and affect 6 to 20% of patients afflicted with CD. Most oral manifestation occur in patients with active intestinal disease and their presence frequently correlates with disease activity. Recurrent aphthous-like ulcers are the most common oral manifestation of CD. It is uncertain whether the oral manifestations are a true expression of CD, preexisting and/or coincidental findings, a direct result of medical intervention, or a manifestation of an associated problem such as anemia. Certainly, minor salivary gland duct pathology, cobblestone mucosal architecture, and pyostomatitis vegetans represent granulomatous changes that are characteristic of CD. Biopsies of these small, nonhealing, multiple aphthous-like ulcers reveal granulomatous inflammation. Less frequently, CD patients develop inflammatory hyperplasia of the oral mucosa with a cobblestone pattern, diffuse swelling of the lips and face, indurated polypoid tissue tags in the vestibule and retro-molar pad area, and persistent deep linear ulcerations with hyperplastic margins. Granulomatous lesions have also been observed in the salivary glands, where they may cause rupture of the ducts and mucus retention cyst formation.

Various medications have been reported to cause oral lichenoid (lichen planus-like) drug reactions, including anti-inflammatory and sulfa-containing preparations, which are commonly used to manage IBD patients. Superinfection with Candida albicans may represent a reaction to the bacteriostatic effect of sulfasalazine, a primary manifestation of the disorder, or an impaired ability of neu-trophils to kill this granuloma provoking fungus (Curran et al, 1991). This underscores the sometimes subtle intraoral clinical signs and symptoms of CD that may render a dentist invaluable to the physician working up a patient with previously undiagnosed CD.

IBD patients often complain of pain associated with ulcerative lesions in the oral cavity. palliative sodium bicarbonate mouth rinses (one-half teaspoon of baking soda in eight ounces of water) may be rinsed and expectorated. Moderate potency topical steroid preparations, such as 0.05% fluocinonide, desoximetasone, and triamcinolone, or ultrapotency preparations such as clobetasol and halobeta-sol can be topically applied to the lesions, 4 times daily (not to exceed 2 continuous weeks). Ointments and creams are useful when the lesions are localized and direct topical application is possible. In cases when lesions are disseminated or oropharyngeal in distribution, dexamethasone elixir 0.5 mg/5 mL can be used as a rinse or gargle for 1 minute, 4 times daily and expectorated. The patient must be advised that prolonged use of topical steroids will result in mucosal atrophy, systemic steroid absorption (especially with the ultrapotency preparations), and an increased incidence of mucosal candidiasis.

IBD patients appear to be at an increased risk of dental caries as well as bacterial and fungal infections. These are multifactorial in etiology but appear to be related to either the patient's altered immune status or diet (Benvenius, 1988; Malins et al, 1991; Muerman et al, 1994; Rooney, 1984; Sundh and Emilson, 1989; Sundh et al, 1993). Oral manifestations of anemia such as pallor, angular cheilitis, and glossitis may occur, particularly in undi-agnosed or poorly controlled disease has been reported in patients with active ulcerative colitis (UC).

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