Cynthia R. Biron, RDH
An 18-year-old female patient with an unremarkable medical history presented in the office of Dr. Anthony Rydell, an oral surgeon. Annie had been referred to Dr. Rydell by her general dentist for the extraction of four impacted third molars. After Annie received a thorough medical and dental history interview, as well as a clinical- and radiographic-oral examination by Dr. Rydell and his staff, Annie was scheduled for the surgery.
After discussing treatment options with Dr. Rydell, Annie decided that she would prefer to have general anesthesia during the extractions. The extractions were uncomplicated and completed within 45 minutes. When Annie returned for her post-operative exam a week later, Dr. Rydell became quite concerned that the normal healing had not occurred.
Dr. Rydell sent Annie for a series of blood tests, which revealed some abnormalities in her immune system. There was no immediate diagnosis, as the test results could be characteristic of many diseases. Several specialists were consulted, and additional tests performed, before Annie was diagnosed with Crohn`s Disease. With proper treatment, Annie`s condition was brought into remission and the surgical sites healed completely.
Crohn`s Disease (CD) is a chronic inflammatory disease of the bowels. The portions of the bowels most commonly affected by the inflammation are the distal ileum (small intestine) and/or the proximal colon. Eighty percent of CD patients have involvement of the inflammatory condition in the rectum. Some cases can be detected during an oral examination, as oral mucosa may have areas of ulceration and inflammation. Other mucosal tissues that may be affected with inflammation are those of the esophagus and stomach. Diagnosis is made by evaluation of symptoms, colonoscopy, biopsy, intestinal radiographs and hematological tests.
Research has not proven a specific cause for CD, but it has led to many theories. Some doctors theorize that a virus or bacterium acts on the body`s immune system by causing an inflammatory response in the intestinal wall. They cannot determine whether the immune response is a cause or a result of the disease process. Research scientists and doctors think that a genetic predisposition is linked to the disease, as specific chromosome markers have been found in patients with CD.
The manifestations of the disease may come on gradually or suddenly and be mistaken for other conditions, such as appendicitis and a myriad of ailments that cause similar symptoms. The symptoms include, but are not limited to, abdominal pain, diarrhea, vomiting, fever, rectal bleeding and weight loss. Ulcerations (aphthous ulcers) and swelling of the intestinal walls can cause bowel obstruction. Severe ulcers can perforate the intestinal wall and cause infections of other organs and tissues. The condition tends to be chronic, with periods of remission and recurrent flare-ups, which are not related to stress, lifestyle or other specific factors. Although diet can contribute to the existing inflammation of the intestines, it is not considered to be the original cause of CD or its recurrence.
The complications include obstruction of the intestine, fistulas of the bladder, vagina or skin. Other bodily systems frequently are affected with inflammation. Arthritis, skin problems, eye and oral inflammation, kidney, gall bladder, liver and biliary-system disorders are complications common to individuals with Crohn`s Disease.
The disease is found in equal numbers of males and females, but more common to specific ethnic groups. A higher incidence of the disease has been noted in people of Jewish descent. They are three to six times more likely to contract the disease than the rest of the population. Twenty to 25 percent of the individuals with CD have immediate blood relatives with some type of inflammatory bowel disorder. The disease is more commonly found in individuals who are between 15 and 55 years of age.
What are the treatments?
Asymptomatic patients usually are not treated with drugs, surgery or prescribed diets. Drug therapy of the mildest form is in the use of salicylate preparations, as they are very effective at managing mild to moderate intestinal inflammation. However, the salicylates have not been effective in preventing recurrence of the disease. The oldest salicylate, sulfasalazine (Azulfidine) is not tolerated by all patients as it has side effects, such as headache and stomach upset, when taken in the high doses necessary for the treatment of CD. The newer salicylates that are being prescribed for CD are Asacol, Dipentum, Rowasa and Pentasa.
The treatment of active CD is corticosteroids, especially Prednisone. The long-term use of corticosteroids is contraindicated due to the well-known side effects that can cause the patient to be immunocompromised and stricken with a host of conditions sometimes termed "Cushingoid" effects. Acute conditions of CD are treated with intravenous forms of cortisone and/or immunosuppressant drugs commonly taken by organ transplant patients. Any drug that provides immunosuppressant effects increases the patient`s risk of infection. Antibiotics, especially metronidazole (Flagyl), have been beneficial in healing lesions, fistulae and fissures of the intestines and rectum. It is most effective for patients whose large intestine is affected by CD.
As many as 70 percent of CD patients must be treated with surgical correction or removal of portions of their intestines. Surgery usually provides a significant improvement in the health of the CD patient, and medications such as Flagyl and the newer salicylates seem to be effective in delaying disease recurrences in these post-surgical cases.
Although vitamin and mineral supplements are recommended for CD patients, megadoses of these supplements are not recommended. Diets low in fiber prevent the worsening of already inflamed and irritated intestinal linings. Patients experiencing active CD usually are limited to liquid diets. Calming and resting irritated bowels frequently is accomplished through the use of IV nutrition. Antispasmodic drugs, such as Lomotil, are beneficial for relief of abdominal cramps and diarrhea.
Risk management of CD patients
We may not know a patient has CD, as he or she may be asymptomatic and the condition may not have been diagnosed, as in the case of Annie. Often, we can thoroughly assess our patients to avoid treatment complications, as well as determine if ailments they describe or oral conditions they have could indicate an underlying, systemic disease that has not been diagnosed. We should refer them to physicians for diagnostic testing whenever their overall health or specific medical-history findings are a concern to us.
When a patient presents with a history of Crohn`s Disease, there are many risk factors that are of concern when providing dental treatment. The assessment of the CD patient is rather complex and requires astute judgment on the part of the clinician treating the patient and all the doctors involved.
A consult with the patient`s physician is mandatory. Patients who appear to be in remission still should have hematological profiles to determine if their immune systems are intact before any invasive procedures, including periodontal debridements, are performed. A consult with the physician should clarify risk factors for drug interactions and adverse effects, adrenal insufficiency, post-operative infection, bleeding problems and impaired wound- healing.
One of the greatest concerns to the dental team is the patient`s corticosteroid therapy. Even when the patient isn`t currently taking a corticosteroid, he or she still can be at risk for infection or adrenal insufficiency. The effects of corticosteroids on the immune system and adrenal glands go on long after corticosteroid therapy has ended. An invasive procedure could become infected and the infection could get out of control, if the immune system hasn`t completely returned to normal after being exposed to corticosteroids. A patient`s adrenal glands that have become less responsive to the pituitary glands stimulation, as a result of long-term exogenous cortisone, will not rise to the occasion and secrete an increased amount of cortisone on demand when a patient in dire stress is in need of it. This means an adrenal crisis could occur, which is a rare, but frequently fatal, emergency. A consultation with the physician and a conservative approach in treatment-planning are required. Dentists adhering to strict, conservative guidelines follow the "Rule of Two`s," which states: "If a patient has taken 20 mg. of cortisone (or its equivalent) per day, for as long as two weeks within the last two years, there is a risk of infection and adrenal insufficiency."
CD patients on other medications may require alterations in the treatment plan. Those taking Flagyl should not be given mouth rinses that contain alcohol, as the interaction of Flagyl and alcohol has an "Atabuse effect;" that is, it causes violent stomach upset with projectile vomiting. Some mouth rinses contain as much as 25 percent alcohol, and inadvertently swallowing such a rinse could cause the patient to experience some degree of stomach upset.
Aspirin and nonsteroidal anti-inflammatory drugs such as ibuprofen (Motrin), Advil, Aleve, etc., should not be prescribed for dental pain in CD patients. Patients taking antispasmodic drugs, such as Lomotil or other opioid agents, would require dental pain control with drugs that would not potentiate the effects of the drugs taken for intestinal pain.
Any other immunosuppressant drugs the CD patient may be taking, or has recently taken, may cause post-operative infection, bleeding problems and/or impaired wound-healing. In addition to the consult with the patient`s physician, careful questioning of the patient can reveal information about his or her body`s ability to resist infection and repair injured tissue. Ask open questions such as:
- "If you get a shallow half-inch cut in your finger, how long does it take for the bleeding to stop?"
- "How long does it take for the same cut to heal completely?"
Patients usually know they have a bleeding problem when what used to stop bleeding, a little direct pressure under a Band-Aid, doesn`t work anymore. They also become aggravated when tiny cuts on the hands take so long to heal.
Because Crohn`s Disease is not seen as frequently as many other diseases, health professionals are less likely to know about the complex problems associated with treating such patients. We commend the oral surgeon and his staff for their thoroughness in caring for "Annie," and for sharing their experiences with us so that others may benefit by knowing more about CD.
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Cynthia R. Biron, RDH, is chair of the dental hygiene program at the Tallahassee Community College. She also is a certified emergency medical technician.
For more information about CD
If you wish to consult with a research professional on the current information about Crohn`s Disease, contact:
Crohn`s and Colitis Foundation of America, Inc.
444 Park Ave. South
New York, NY 10016