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Lau Yi Ling
Lee Yi Ren
Inflammatory Bowel Disease (IBD)
• Inflammatory process that affect the large and small intestines
• Crohn’s disease
• Ulcerative colitis
• Coeliac Disease
(Burket’s Oral Medicine)
Crohn’s Disease
• Chronic, transmural inflammatory bowel disease
• May affect any part of the bowel system including the oral cavity
• Patchy distribution throughout the gut
• Transmural with inflammation extending the entire thickness of
intestinal wall
• Mucosal ulceration
• Aphthous ulcers within the mucosa that appear normal
• Deep ulcers within areas of swollen mucosa
• Long linear serpiginous ulcers
(Kornbluth et al, 2004)
• Two forms
• Non-perforating -> stenotic obstruction
• Aggressive or perforating -> prone to develop fistulae and abscesses
(Burket’s Oral Medicine)
• Classified based on the bowel segment it affects
• ileitis affecting ileum only
• colitis affecting colon only
• ileocolic affecting both ileum and colon.
(Ruthruff et al, 2007)
Epidemiology
• F>M
• More common between age 20-39 years old
• More common in Caucasian
• Most prevalent in North America, norther Europe and Australia
(Burket’s Oral Medicine)
Causes
• Genetic
• Risk of disease increases when there is an affected family member
• Mucosal immune responses
• Activation of mucosal immunity and suppression of immunoregulation
• Epithelial defects
• Defects in intestinal epithelial tight junction barrier function
• Barrier dysfunction can activate innate and adaptive mucosal immunity and sensitize
subjects to disease
• Microbiota
• Ongoing studies
• Smoking -> increases risk
(Robbins Basic Pathology)
Morphology
• Common sites
• Terminal ileum
• Ileocecal valve
• Cecum
• Skip lesion
• Multiple, separated, sharply delineated areas of disease
(Fatahzadeh, 2009)
Oral Manifestation
• Recurrent aphthous ulcer
• Diffuse soft or tense swelling of the lips, or mucosal thickening
• Cobblestone thickening of the buccal muscosa, with fissuring and
hyperplastic folds
• Gingivae may be erythematous and swollen
• Mucosal tags in sulcus sometimes present
• Glossitis due to iron, folate or vitamin B12 deficiency can result from
malabsorption
• Rupture of salivary ducts and localized mucocele formation with
granulomatous lesion in salivary glands
(Cawson’s Essentials of Oral Pathology and Oral Medicine)
(Odell, 2017)
As a dental practitioner,
• Recognize the orofacial manifestations of patients undergoing
corticosteroid or immunosuppressive therapy
• A complete gastrointestinal work-up is indicated for patients with oral
manifestations suggestive of IBDs and gastrointestinal complaints.
• Even in the absence of intestinal signs and symptoms, pathognomonic
orofacial manifestations should prompt an astute clinician to perform
a tissue biopsy with appropriate staining and closely follow the
patient for potential development of intestinal disease over time.
(Fatahzadeh, 2009)
Management
• Palliation of intestinal symptoms
• Controlling the inflammatory process
• Improving patient's quality of life
• Correction of nutritional deficiencies
• Prevention of complications.
• Medical therapy of IBD is individualized, requires time to work, and is often
associated with serious side effects. In CD, a number of factors including
intestinal location of disease, its phenotypic behavior, and patient's age
also affect decisions on therapeutic approach.
• A variety of anti-inflammatory, immunosuppressive, and biological agents
have been used to induce and/or maintain remission in IBDs.
(Fatahzadeh, 2009)
Ulcerative Colitis
• Disease that causes ulcers and irritation in the inner
lining of the colon and rectum.
• Ulcerative: sores or ulcers
• Colitis: inflammation of the colon
(Francis A. Farraye, MD, MSc: Questions and Answers About Ulcerative Colitis)
Severity of ulcerative colitis
• Number of factors: frequency of diarrhoea
• Systemic signs of toxicity: fever, rapid heart rate, abnormal lab tests
1. Mild: having fewer than four diarrhoea daily, with or without blood,
no systemic signs of toxicity (normal temperature and pulse), and a
normal erythrocyte sedimentation rate (ESR)
2. Moderate: having more than four diarrhoea daily but with minimal
signs of toxicity
3. Severe: more than six bleeding diarrhoea daily and evidence of
systemic toxicity as shown by fever (>37.5̊̊C), tachycardia
(>90beats/min), anemia and an elevated ESR and abdominal
tenderness.
(Francis A. Farraye, MD, MSc: Questions and Answers About Ulcerative Colitis)
Pathophysiology
• Cause is unknown
• Autoimmunity may have indirect effect
• Antibodies to epithelial cells in the colon have been found in some
individuals with ulcerative colitis
• Inflammation always starts in rectum and extend upward into the
colon
• Most probably involves the entire colon along the way
(Carie Ann Braun, Cindy Miller Anderson: Pathophysiology: Functinal Alterations in Human Halth pp:
65)
Pathophysiology
• Inflammation invades superficial mucosa
• Mucosa friable, becomes a state where tissue readily bleeds
• Mucosa becomes erythematous and granular
• Lesion in the crypts of Lieberkühn can form into abscesses
• Extensive exudates present in the abscess and ulceration is common
• Overtime, epithelial cells of the mucosa begin to atrophy
(Carie Ann Braun, Cindy Miller Anderson: Pathophysiology: Functinal Alterations in Human Halth pp:
65)
Complications
• Higher risk for colorectal cancer- epithelial cells metaplasia
• Obstruction- granular, abscessess
• Perforation- epithelial mucosal atrophy
• Massive haemorrhage- mucosal friable
(Carie Ann Braun, Cindy Miller Anderson: Pathophysiology: Functinal Alterations in Human Halth pp:
65)
Diagnostic significance in regular dental practice
: Oral and Skin Manifestation
• Pyostomatitis vegetans
-Broad based milliary abscess in area of intense erythema
-Pustular lesion
• Erosion Ulceration
• Fissuring
Common on labial buccal mucosa, labial attached gingiva and hard palate
• Pyoderma vegetans on skin
-Asymmetrical rash most commonly in skin folds (armpit, groin, scalp)
-less common in trunk, face and finger
(Dr. Ayu’s lecture notes: Oral Manifestations of Systemic disease)
Investigation of Ulcerative Colitis
• Plain abdominal X-ray film
• Full blood count
• Liver function tests
• BUSE
• Barium enema (rarely used)-contraindicate for very active colitis and with
toxic megacolon, perforation
• Colonoscopy (most useful)
• Antibody testing
(Nicholas Joseph Tally, Simon O’Connor: Examination Medicine: A guide to Physician Training pp
135)
Management: Mild to Moderate
First line treatment
(Anti-inflammatory, antidiarrheal medication, corticosteroids, fluid for
rehydration)
• Anti-inflammatory drugs: Sulfasalazine, Mesalazine
- Most common using in inflammatory bowel disease
- Effective for both Crohn’s and ulcerative colitis
- Side effect of Sulfasalazine more than Mesalazine
- Allergic skin rash, nausea, headache, folate deficiency, reversible male
infertility
- Decrease relapsed rate but should be administered continuously
(Nicholas Joseph Tally, Simon O’Connor: Examination Medicine: A guide to Physician Training pp
135)
Management: Mild to Moderate
• Corticosteroids
- Budesonide (Entocort, Uceris)
- Orally tablet or capsule or rectally
- Anti-inflammation
- Budesonide less side effects than others corticosteroids
- Weight gain, high blood sugar, acne, increase hair growth, high BP
- Once remission is achieved, reduced gradually and ultimately stop
- Ineffective as maintenance therapy, does not reduce relapse rate
• IV corticosteroid therapy
Management: Acute, moderate to severe
• IV immune suppressors
- Acute UC
- IV corticosteroids not effective
- IV cyclosporine, infliximab, azathioprine
- Cyclosporine and azathioprine: suppress immune system activity
- Infliximab- TNF-alpha inhibitor, blocking inflammatory action
- Raise risk of infection and cancer
(Nicholas Joseph Tally, Simon O’Connor: Examination Medicine: A guide to Physician Training pp
135)
Crohn’s disease vs Ulcerative Colitis
• Involvement of small intestine or upper part of the alimentary canal
• Segmental disease of the colon with ‘skip’ areas of normal rectum
• The appearance of fissures or sinus tracts
• Presence of well-formed sarcoid type granulomas
• In CD, chronic inflammation may affect any part of the
gastrointestinal tract, whereas in UC, mucosal inflammatory changes
are confined to colon.
• UC is twice more prevalent than CD and the incidence of both
diseases appears to follow a bimodal age distribution with signs and
symptoms frequently manifesting in early adulthood as well as 50 to
70 years of age.
• The involvement of colonic mucosa is possible with both UC and CD
giving rise to similar symptoms. In this context, differentiation
between the 2 diseases is often difficult leading to a less specific
diagnosis known as indeterminate colitis.
Feature Crohn's disease Ulcerative colitis
Involvement of terminal ileum Commonly Rare
Involvement of colon Usually Always
Rectum involvement Rare Often
Perianal disease Common Rare
Disease distribution Patchy inflammation Continuous inflammation
Depth of mucosal inflammation Deep or transmural Shallow
Presence of fistulae Common Rare
Stenotic complication Common Rare
Etiology Possibly autoimmune Not known
Risk of colorectal cancer Lower than ulcerative colitis Higher than Crohn's disease
Presence of granulomas on biopsy May be present Not present
(http://bestpractice.bmj.com/topics/en-gb/636/investigations#firstOrder)
Dental Aspects
• Patient usually has short stature associated with diarrhea and enamel
defects
• Anemia – glossitis, burning mouth, angular cheilitis and ulcers
• Untreated patients may have bleeding tendency
• Anemia may complicate GA
• Information on oral manifestations of celiac disease helps prepare
dentists for the opportunity to contribute to early diagnosis of celiac
disease and in so doing, may help avoid disease complications.
References
• Francis A. Farraye, MD, MSc: Questions and Answers About Ulcerative Colitis
• Carie Ann Braun, Cindy Miller Anderson: Pathophysiology: Functinal Alterations in
Human Halth pp: 65
• Dr. Ayu’s lecture notes: Oral Manifestation of Systemic disease
• Nicholas Joseph Tally, Simon O’Connor: Examination Medicine: A guide to
Physician Training pp 135
• www.crohnscolitisfoundation.org/info/treatment/antibiotics
• Ulcerative colitis Guide medication-https://www.everydayhealth.com/ulcerative-
colitis/guide/medications
• Antidiarrheal Medicines for Inflammatory Bowel Disease - Topic Overview
WebMD
• Types of ileostomy: MedlinePlus Medical Encyclopedia
• Greenberg, M.S., Burket, L.W. and Glick, M., 2003. Burket's oral medicine:
Diagnosis & Treatment. BC Decker.
• Kumar, V., Abbas, A.K. and Aster, J.C., 2017. Robbins Basic Pathology E-Book.
Elsevier Health Sciences.
• Kornbluth, A. and Sachar, D.B., 2004. Ulcerative colitis practice guidelines in
adults (update): American College of Gastroenterology, Practice Parameters
Committee. The American journal of gastroenterology, 99(7), pp.1371-1385.
• Bernstein, C.N., Blanchard, J.F., Rawsthorne, P. and Yu, N., 2001. The prevalence
of extraintestinal diseases in inflammatory bowel disease: a population-based
study. The American journal of gastroenterology, 96(4), pp.1116-1122.
• Fatahzadeh, M. (2009). Inflammatory bowel disease. Oral Surgery, Oral Medicine,
Oral Pathology, Oral Radiology, and Endodontology, 108(5), pp.e1-e10.
• Odell, E. (2017). Cawson's essentials of oral pathology and oral medicine,
international edition. [Place of publication not identified]: Churchill Livingstone.