Crohn's disease

Crohn’s disease is a granulomatous chronic inflammatory disease that can affect any region of the gastrointestinal tract. Maria Perno Goldie, RDH, MS, discusses the results of a recent study that tested the theory about whether patients with Crohn’s disease have a higher prevalence and risk for caries as compared to people without the disease.

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Crohn’s disease is a granulomatous chronic inflammatory disease that can affect any region of the gastrointestinal tract from the mouth to anus, although it is usually localized to the small intestine and colon.(1) It can affect any part of the gastrointestinal tract, causing a wide variety of symptoms. It causes abdominal pain, diarrhea, vomiting, and weight loss, but may also cause complications outside the gastrointestinal tract such as anemia, skin rashes, arthritis, inflammation of the eye, tiredness, and lack of concentration.(2)

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There is a genetic association with Crohn’s disease, primarily with variations of the NOD2 gene and its protein, which senses bacterial cell walls. Siblings of affected individuals are at higher risk.(3) Males and females are equally affected. Tobacco smokers are two times more likely to develop Crohn’s disease than nonsmokers.(4)

Crohn’s disease affects between 400,000 and 600,000 people in North America. Current theory is that microorganisms take advantage of the host's weakened mucosal layer and inability to clear bacteria from the intestinal walls, which are both symptoms of Crohn’s.(5)

There is no cure for Crohn’s disease and remission may not be possible or protracted if achieved. In cases where remission is possible, relapse can be prevented and symptoms controlled with: medication; lifestyle and dietary changes; changes to eating habits, such as eating smaller amounts more often; reduction of stress; moderate activity; and exercise. Surgery is generally not indicated and has not been shown to prevent remission, but may be necessary. Adequately controlled, Crohn’s disease may not significantly restrict daily living. Treatment for Crohn’s disease is only when symptoms are active and involves treating the acute problem, then maintaining remission.(6)

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Oral cavity involvement in Crohn’s disease occurs in 8-29% of patients and may precede intestinal involvement.(7) Oral manifestations can prove crucial in diagnosis and can correspond to the intestinal disease course. Orofacial Crohn’s disease is a specific manifestation of Crohn’s disease. There are several clinical presentations in the mouth and facial skin, which histology confirms non-caseating granulomas typical of Crohn’s disease. It is clinically and histologically indistinguishable from orofacial granulomatosis, but occurs only in association with Crohn’s disease of the bowel.

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Signs of orofacial Crohn’s disease include: mucogingivitis; mucosal tags; deep linear ulcers in the fold between the cheek and gingival tissue; cobblestoning of the lining of the inside of the cheeks; lip swelling (macrochelia), with or without fissuring; metastatic Crohn’s disease involving skin of the face may present as ulcers, papules, nodules, plaques or persistent swelling.(8) Treatment options include: cinnamate- and benzoate-free diet; corticosteroid mouthwash; immunosuppressive treatment including systemic steroid; and azathioprine as for bowel disease.(9)

A recent study tested the theory that patients with Crohn’s disease have a higher prevalence and risk for caries compared to people without the disease.(10) Patients with Crohn’s disease were divided into groups among those who have had resective intestinal surgery and those who had not. The patients were compared to 75 controls. DMF-T and DMF-S, Lactobacilli (LB), Streptococcus mutans(SM), salivary flow and dental plaque. (Decayed (D) Missing (M) Filled (F) teeth (T) or surfaces (S).)

The results showed that Crohn’s disease patients who had resective surgery had a higher DMF-S score compared to the control group after adjusting for age, gender and smoking. These patients had higher counts of SM and LB, and more dental plaque. Crohn’s disease patients reported a more frequent consumption of sweetened drinks between meals compared to controls. The authors concluded that patients with Crohn’s disease who had undergone resective surgery had a higher DMFs score, and higher salivary counts of Lactobacilli and Streptococcus mutans compared to the control group.(10)

Risk factors for Crohn’s disease are: being of Jewish heritage (3-6 times more likely than the general population); being of European (particularly Scandinavian) ancestry; family history of inflammatory bowel disease; cigarette smoking; living in an industrialized country (particularly an urban area); eating a diet high in sugar and saturated fat and low in fruit and vegetables; being overweight or obese; and low exposure to sunlight.(11)

A number of tests can help distinguish between ulcerative colitis, Crohn's disease, and other inflammatory conditions. If you or your patients have these risk factors, and medical examination should be obtained.

2. Baumgart, Daniel C; Sandborn, William J (2012). "Crohn’s disease." The Lancet 380 (9853): 1590–605. doi:10.1016/S0140-6736(12)60026-9.
3. Barrett, Jeffrey C; Hansoul, Sarah; Nicolae, Dan L; Cho, Judy H; Duerr, Richard H; Rioux, John D; Brant, Steven R; Silverberg, Mark S et al. Genome-wide association defines more than 30 distinct susceptibility loci for Crohn’s disease. Nature Genetics 40 (8): 955–62. 2008.
4. Cosnes, Jacques (2004). "Tobacco and IBD: Relevance in the understanding of disease mechanisms and clinical practice." Best Practice & Research Clinical Gastroenterology 18 (3): 481–96.
5. Sartor, R Balfour (2006). "Mechanisms of Disease: Pathogenesis of Crohn’s disease and ulcerative colitis." Nature Clinical Practice Gastroenterology & Hepatology 3 (7): 390.
6. Fries, WS; Nazario, B (2007-05-16). "Crohn’s Disease: 54 Tips to Help You Manage." WebMD. Retrieved 2008-02-14.
7. Lourenço SV, Hussein TP, Bologna SB, Sipahi AM, Nico MM. Oral manifestations of inflammatory bowel disease: a review based on the observation of six cases. J Eur Acad Dermatol Venereol. Feb 2010; 24(2):204-7.
9. Rowland M, Fleming P, Bourke B. Looking in the mouth for Crohn’s’s disease. Inflamm Bowel Dis 2010; 16: 332–337.
10. Szymanska S, Lördal M, Rathnayake N, Gustafsson A, Johannsen A (2014) Dental Caries, Prevalence and Risk Factors in Patients with Crohn’s’s Disease. PLoS ONE 9(3): e91059. doi:10.1371/journal.pone.0091059.

Maria Goldie 2013c

Maria Perno Goldie, RDH, MS

To read previous RDH eVillage FOCUS articles by Maria Perno Goldie, click here.

To read more about inflammation and dental hygiene, click here.

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