DENTAL CONSIDERATION IN INFLAMMATORY BOWEL DISEASES

Presented by:Jigyasha

Timsina BPKIHS

Bowel and Bladder habit in history for dental checkup?!! ..,Well.. I will just skip through this and complete history taking faster…

INFLAMMATORY BOWEL DISEASE

General classification of

inflammatory processes that affects the large and small intestines.

Includes: 1)Crohn’s disease 2)Ulcerative colitis

Introduction Ulcerative colitis more prevalent 3.9 to 10 new cases of IBD per

100000 Shows three peak prevalance rates

. 1st peak- 20 to 24 years 2nd peak- 40 to 44 years 3rd peak- 60 to 64 years More commonly affects

Caucasians and Jews

Pathogenesis Considered to be idiopathic.

Increasingly believed to be a result interaction between environmental and genetic factors.

Genetically susceptible individual

Environmental triggers

Genetic susceptibility

Environmental triggers

Ulcerative Colitis a form of colitis, that includes

characteristic ulcers or open sores that attacks only the large intestine

Hallmark - rectal bleeding diarrhea

CROHN’S DISEASE (Crohn syndrome  OR  regional enteritis)

a type of inflammatory bowel disease (IBD) that may affect any part of the gastrointestinal tract from mouth to anus.

Types :1)Non-perforating 2)Perforating or aggressive

type

More commonly affects middle aged women from 20 to 39 years

Clinical features

• Skip lesions

• Granulomas 

• All Layers 

Differentiating features

ORAL MANIFESTATIONS

Can be catagorized as :1. Specific2. Non-specific3. Complications of malabsorption

caused by the bowel inflammation4. Side effects or complications of

medications prescribed to treat the bowel disease.

SPECIFIC NON SPECIFIC

CROHNS Orofacial Crohn disease

•Angular chelitis•Apthous ulcers/ Apthous stomatitis•Dry mouth•Halitosis

ULCERATIVE COLITIS

Pyostomatitis vegetans

•Apthous ulcers/ Apthous stomatitis•Glossitis •Cheilitis•Halitosis

Complications of malabsorption caused by the bowel inflammation

Folic acid deficiency– red painful tongue (Acute)

shiny and smooth (chronic)

Glossitis and Cheilitis

Vitamin A deficiency- hyperkeratosis of oral

mucosa Vitamin B12 deficiency- beefy red

tongue, mouth ulcersVitamin k deficiency- gum bleedingVitamin C deficiency- ulceration of

gums and mucosa

Side effects of therapeutic drugs

Budesonide glossitis, dry mouth

Cyclosporine gum hyperplasia

Ciprofloxacin oral candidiasis, angioedema, Stevens-Johnson syndrome / toxic epidermal necrolysis

Loperamide dry mouth, SJS/TEN, angioedema

Metronidazole unpleasant metallic taste, furry tongue, glossitis, stomatitis, oral candidiasis, dry mouth

Prednisolone  oral candidiasis (thrush)

Sulfasalazine altered taste, stomatitis, oral candidiasis

Oral manifestation of Ulcerative colitis

Pyostomatitis vegetansLarge number of broad

based tiny abscess developing in area of intense erythema

Most commonly affects gingiva and hard palate

Tongue least commonly affected

Histologicaly 1. Hyperplastic

stratified squamous epithelium

2. Intraepithelial or sub epithelial micro abscess

Diagnosis: Biopsy of perilesional tissue with histopathological and immunostaining examinations.

Treatment :1. Topical corticosteroids eg

clobetasol, flucinolone2. Treat the underlying disease.3. Some patient report benefit from

zinc supplementation >1yrs- 10mg OD daily <1yrs – 5mg OD daily4. Antibiotic therapy usually not

beneficial as lesion is refractory.

Recurrent apthous ulcer

Two forms-major apthae

minor apthae

Multiple small (2-4mm, 1cm)round or ovoid ulcer circumscribed

margin, erythematous haloes

with yellow or grey floor

Management Topical , intralesional , systemic

corticosteroids Topical and systemic analgesics eg:

2%lidocaine gel orabaseThalidomide , an immune modulating

and angiogenesis inhibiting drug is effective for refractory cases.-300 mg daily

Colchicines- 0.6mg tds for 2 weeksPentoxyphylline (TRENTAL 400mg) - in

cases where topical steroid do not respond.

CATEGORY THERAPEUTIC DOSE

Antimicrobials: Chlorhexidine Tetracycline Penicillin-G

0.2% mouthrinse or 1% gel5% tetracycline used as mouthwash50mg penicillin-G 4 times a day for 4 days

STEROID Topical : Flucinonide

Triamcinolone acetonideSystemic: Prednisolone

0.05% gel applied 2-4 times a day until healing 0.1% gel applied 2-4 times a day until healing

1-2 mg /kg/ day

CATEGORY THERAPEUTIC DOSE

Immunomodulators: Thalidomide Pentoxyphylline Colchichine

300mg daily 400mg tds for 1 month 0.6mg tds for 2 weeks

Others :Dapsone Diphenhydramine with viscous lidocaine

400mg tds 12.5 mg/ml with 2% lidocaine in 1:1 ratio – 5-10 ml swish and spit

Which of the following antihelminthic drug shows immunomodulating

property??1) Albendazole2) Suramin3) Levamisole4) Ivermectin

• Levamisole -Sharada N, Shashikant MC,

Priyanka kant,Manika jain

Case study source :pubmed

Fifty RAS subjects were enrolled in the single-blind randomized placebo-controlled trial. Study medications were administered thrice daily for 3 consecutive days/week for 3 consecutive weeks. Patients in Group 1 received placebo, Group 2 received levamisole (150 mg) and Group 3 received levamisole (150 mg) and low-dose prednisolone (5 mg). Patients were followed up for 60 days after treatment

Result:Levamisole alone or in combination with

low dose prednisolone produced similar results

Glossitis inflammation with

depapillation of the dorsal surface of the tongue 

Cheilitis inflammation of

the lips.

Oral Manifestation of Crohn’s disease

Oro-facial Crohn’s Disease

Signs of orofacial Chrohn disease include:

mucogingivitis

deep linear ulcers in the vestibule

-hyperplastic margins-rolled edge -shows presence of non

caseating granulomas

mucosal tags

cobblestoning of the lining of the inside of the cheek

Angular cheilitisErythema and/or

fissuring of angle of mouth

Secondary to nutritional deficiencies following malabsorption .

Or due to concommitant infections

Management

Treatment of underlying pathology

Maintenance of proper hygiene

Topical antifungal medication as  clotrimazole (0.1% )

amphotericin B, ketoconazole

Topical corticosteroids can help with the inflammation .

AngioedemaAlso called lip swelling

It may be allergic or drug induced.

Mild presentation but require immediate management if risk of airway blockage

MANAGEMENTAvoid any known allergen or trigger that

causes the symptoms Antihistamines -Cetrizine (Alerva 10mg)

OD Fexofanadine(Allegra 120

or 180 mg) Anti-inflammatory medicines

(Corticosteroids) Epinephrine shot

Lets just check if u had

been sleeping or not???

Specific oral manifestation of Ulcerative colitis is:

A. Angioedema B. Pyostomatitis

vegetansC. Angular cheilitesD. Glossitis

Crohn’s disease differs from Ulcerative colitis in that it doesnot show:

A. GranulomasB. Skip lesionsC. Fistula formationD. All layers involvementE. None (fistula formation requires

involvement of all layers of intestine)

Which of the following is a pustular lesion?

A. Recurrent Apthous UlcersB. Pyostomatitis VegetansC. AngioedemaD. Angular cheilitis

Management of IBD Detailed history, physical examination ,

gastrointestinal radiography and endoscopy.

Medical management First line drug

Sulfasalazine- initiate and maintain remission

Sazone 500mg 1-2g 3 to 4 times a day

Corticosteroid –Initiation dose 40 to 60 mg

prednisolone oral daily (Emsolone 5,10,20,40 mg tab)

Maintenance dose- 10 to 20 mg prednisolone oral daily

Second line drug - Antibiotic agents - Immunosuppresive drugs

Azathioprine -Azoran 5omg 1.5 to2.5 mg/kg body weight

Surgical management : in 15 to 20 % cases

proctocolectomy combined with ileostomy

Suppotive therapy bed rest , dietary manipulation ,

and nutritional supplementation.

Management of oral lesions

Chlorhexidine gluconate 0.2% used as swish and expectorate

Moderate potency topical steroid (eg 0.01% fluocinolone FLUCORT-H oint) or ultra potency preparation (eg clobetasol 0.05% LOBATE cream ) can be applied topically – 4 times a day

But should not exceed 2 continuous week

If lesions are disseminated , Dexamethasone 0.5mg/5ml

(DEXONA) used as rinse for 1 min – 4 times a day and expectorated

Dental evaluation of patient with IBDDetermine medications used , with special attention to steroid therapy in the past.

Evaluate the diagnosis of the type of IBD

Treatment planning modification schedule appointments during remission

Minimize stress by shorter appointments and adjunctive sedation techniques.

Evaluation of hypothalamic/pituitary/adrenal cortical

function to determine the patient’s ability to

undergo extensive dental procedures.

Dental management Frequent preventive and

routine dental care to prevent destruction of hard and soft tissue.

If patient under corticosteroid therapy

obtaining blood pressure and blood glucose measurement prior dental treatment highly recommended

Routine dental treatment like oral prophylaxis and simple restorations carried out as normal.

Surgical treatment contraindicated due to collective effect of risk associated with anemia like delayed wound healing , increased risk of infection depression of respiration

Dental Surgical Procedure

Current Systemic Steroid Use

Routine dental procedure

No supplementation required

Minor oral surgery lasting <1 hour , Under LA

Consider supplementation with 25mg hydrocortisone equivalent before the procedure

Oral surgery with or without GA lasting >1 hour

50-100 mg hydrocortisone equivalent on the day of surgery

Major Oral surgery done under GA lasting >1hour with significant blood loss

Usual daily dose and 50 mg hydrocortisone equivalent IV, repeat hydrocortisone equivqlent every 8 hour after initial dose upto 72 hours

For patient on long term steroid therapy, steroid dosing

In patient with history of immunosuppresive agents intake, liver function test recommended

complete blood studies including hemoglobin, hematocrit, red cell count and protrombin time and partial thromboplastin time necessary

Topical steroids should be short termed and monitored because of the side effects of mucosal atrophy and systemic absorption.

NSAIDS should be avoided.

Antibiotics that could aggravate diarrhea should be avoided.

These include :- amoxicillin-clavulanate (AMOXICLAB) and clindamycin

Pain and anxiety control measures

Patient are advised to obtain proper rest the night before treatment.benzodiazepine sedative can be prescribed to be taken the night before treatment.

Appointments are tolerated best when they are scheduled in the morning and in limited in duration.

Patients are advised to reduce business and social obligations the day of the appointment.

Analgesics (COX-2 inhibitor , acetaminophen) alone or in combination with opioid should be provided during postoperative phase when needed.

Conclusion In dental treatment of patients with

IBD, it is important that they undergo frequent dental revisions and preventive care to avoid oral infections and hard and soft tissue destruction.

We should be aware of the risk of infection, drug actions and interactions, the patient’s ability to withstand the stress and trauma of dental procedures and proper medical referral when necessary.

AND FINALLY An Twenty eight-year-old girl presented

with a four-month history of painful mouth ulcers, resulting in decreased oral intake and weight loss, history of intermittent abdominal pain and irregular bowel movements. On examination, she had redness and swelling of the lips as well as tenderness of the right lower quadrant of abdomen.

. Colonoscopy with multiple biopsies revealed multiple areas of the cobblestoning with sharply demarcated areas in-between and invovement of all the layers.

Key points :recurrent painful mouth ulcers

redness and swelling of the lips

cobblestoning with sharply demarcated areas in-

between invovement of all the

layers.

Q. Diagnosis ?? Recurrent apthous ulcer with

Angioedema secondary to Crohn’s disease

Points to be noted in history?? A. History of similar illness in other

family members?

B. Frequency of altered bowel movements ?

C. Medications used with special attention to steroid therapy in the past?

What investigations would you like to conduct before oral procedure??

A. Blood pressure and Blood glucose measurement

B. Complete blood studies including hemoglobin, hematocrit, red cell count and protrombin time and partial thromboplastin time

C. Liver function test

Which of the following drugs are not avoided in patients with IBD?

A. NSAIDsB. COX-2 inhibitorsC. Amoxicillin – ClavulanateD. Clindamycin

Which of the following dental modifications for IBD is false

A. Topical steroids should be short termed and monitored

B. Antibiotics that could aggravate diarrhea should be avoided

C. Aspirin should be givenD. None of the above

REFERENCESMedical problems in dentistry Crispian ScullyBURKET’S oral medicine Greenberg, Glick, ShipShafer’s textbook of Oral

pathologyNational handbook of medicineWikipedia Clinical Journals by clinics in

North America

THANK YOU