by Cathy Hester Seckman, RDH
We know — although we might not always remember — that the mouth is part of the digestive system. The first step in food digestion is mastication, and the second step involves salivary enzymes that break down food. Even before we swallow, our bodies are at work beginning to utilize the food we eat.
It's an efficient system. But when it malfunctions, repercussions can spread from one end of the digestive tract to the other. Crohn's disease is a particularly damaging digestive disorder that has complicated links to the oral cavity. In many cases, symptoms in the mouth can pre-date symptoms elsewhere.
Crohn's, one of the inflammatory bowel diseases, is characterized by inflammation of the lower part of the small intestine, the ileum. Inflammation can extend deep into the intestinal lining, causing pain, diarrhea, and impaired absorption of nutrients. Other symptoms are weight loss, fever, and rectal bleeding that can lead to anemia. Children suffering from Crohn's can experience delayed development and stunted growth. There is no known cause, although it appears to run in families.
Drug therapy can control Crohn's for years, allowing patients to live normally, but there are many possible complications. Fistulas can develop in different areas of the pelvis, sometimes requiring surgery. Nutritional deficiencies, arthritis, skin problems, eye and mouth inflammation, kidney stones, and gallstones have all been associated with Crohn's. The most serious complication, blockage of the intestine, may require removal of all or part of the intestine, and the temporary or permanent use of an ostomy bag.
An oral appearance
According to the National Institutes of Health, oral manifestations of Crohn's can include:
• A cobblestone appearance of the oral mucosa
• Persistent lip swelling
• Vertical fissures on the lips
• Erythema around the mouth
• Cervicofacial lymphadenopathy
• Recurrent oral stomatitis
• Epithelial folds
• Gingival enlargement
• Linear aphthous ulceration
• Gingival erythema
Since 1969, researchers have known that oral lesions typical of Crohn's are histologically identical to those that occur in the intestinal mucosa. Lesions in both locations are non-necrotizing granulomas in the submucosa, composed of multinucleated Langerhans' giant cells, epitheloid cells, lymphocytes, and plasma cells.
Although they may be identical, the lesions don't necessarily occur at the same time. Oral lesions can exist alone as the only manifestation of Crohn's, or they may precede intestinal lesions by years. Steroids are a common treatment for oral lesions.
In a study of Crohn's patients in West Germany in 1991, the most common types of oral lesions seen were edema, ulcers, and hyperplastic mucosa. Lesions occurred most commonly on the lips, followed by the gingiva, vestibular sulci, and buccal mucosa. Systemic steroids relieved symptoms in half the patients, and topical steroid treatment resolved oral symptoms completely in 7 of 12 patients.
One of the more complicated aspects of Crohn's is the circular effect of the symptoms. An inflammatory bowel disease can cause deficiencies of vitamins B6, B12, folate, iron, zinc, magnesium, and calcium. In the mouth, these kinds of nutritional deficiencies can lead to intraoral burning, glossitis, mucosal irritations, cheilitis, gingivitis, and halitosis. When you add in the painful oral lesions often associated with Crohn's, it's easy to see how a patient might be tempted to avoid eating altogether, or to choose a soft, mild, nutritionally deficient diet.
All of those oral problems can lead to tooth loss and impaired chewing, leading in turn to more nutritional deficiency, which can aggravate Crohn's and its various manifestations. Researchers are almost universal in their call for close cooperation between physicians, dentists, and nutritionists to manage Crohn's disease. One study of children in Ireland in 2001 looked at the usefulness of careful oral examination in diagnosing Crohn's patients.
Forty-five children with newly diagnosed Crohn's disease were evaluated; 25 had previously seen a dentist. Eight of the 25 had mucosal tags, and four had other oral lesions. Those 12 with oral symptoms were more likely to have upper gastrointestinal inflammation, for which they sought treatment sooner than those with no oral symptoms.
Because oral manifestations of Crohn's appear so often in advance of intestinal problems, it has been suggested that patients with oral symptoms typical of Crohn's be monitored for future gastrointestinal symptoms, so diagnosis and treatment can occur at the earliest possible stage of the disease.Resources
• Crohn's and Colitis Foundation of America Inc.
• Pediatric Crohn's and Colitis Association Inc.
• National Digestive Diseases Information Clearinghouse
Cathy Hester Seckman, RDH, is a frequent contributor who is based in Calcutta, Ohio. She can be contacted at cseckman @raex.com.