A pain in the gut: Understanding irritable bowel syndrome and its dental implications

“And what is this new medication for?” I asked my 23-year-old patient while updating the medical history during her prophy appointment. It took a moment for her to respond before she hesitantly replied, “It’s for my irritable bowel syndrome.”

Not surprisingly, many patients don’t want to discuss such personal matters while in the dental chair. My patient seemed much more at ease after I shared with her that I, too, have irritable bowel syndrome (IBS). I then realized the importance of bringing awareness of IBS to the dental community—not because of my own personal journey, but because this common condition can have debilitating symptoms and potentially impact our patients’ oral health.

Often misunderstood and difficult to treat, IBS affects an estimated 5%–20% of the global population.¹ With IBS being one of the most diagnosed gastrointestinal disorders, it’s important for dental professionals to understand the condition and its possible dental implications. Let’s take a closer look at what IBS is, its symptoms, treatments, and what we can do as oral health providers to help our patients who suffer from the disorder.

What is IBS?

IBS is a type of functional gastrointestinal disorder characterized by abdominal pain and distorted bowel function. It is often approached from a comprehensive biopsychosocial standpoint, understanding the interaction between biological, psychological, and social factors that can contribute to the disorder.

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While the exact cause of IBS is unclear, researchers have identified that patients with IBS have a dysregulation in the communication system between the brain and the gastrointestinal tract.¹ Additional underlying reasons for this dysregulation can include stress, altered gut microbiome, genetics, previous history of infectious enteritis, or psychological disturbances (depression, anxiety, somatization).²

IBS vs. IBD: Similar acronyms, different disorders

To fully understand IBS, it’s important to take time to distinguish it from another gastrointestinal condition: inflammatory bowel disease. With similar symptoms and names, IBS (irritable bowel syndrome) and IBD (inflammatory bowel disease) often get confused with each other. IBD is an umbrella term for a group of autoimmune diseases that includes two major forms: ulcerative colitis and Crohn’s disease.³

One of the main distinctions between the two conditions is the cause of symptoms. IBD has an inflammatory component, with observable damage to gastrointestinal (GI) tissues being the source of symptoms.³ With IBS, there’s no physical change in the digestive tract.¹ Because no anatomical cause can be detected during colonoscopies, on x-rays, or from biopsies, IBS is considered a complex disorder with an array of varying symptoms and severity.

Symptoms, diagnosis, and QOL

Common symptoms of IBS include pain or discomfort, cramping, bloating, constipation, and/or diarrhea.¹ Other symptoms associated with IBS include sensations of incomplete defecation during a bowel movement, increased gas, and mucus in the stool. There are four main subtypes based on the consistency of the stool: IBS with predominant diarrhea (IBS-D), predominant constipation (IBS-C), mixed with both diarrhea and constipation (IBS-M), and unclassified with the stool consistency being too irregular to fit into other groups.¹

Since there are no identifiable biological markers or specific diagnostic tests for IBS, patients can go through a long journey to obtain a final diagnosis. Diagnosis is based on the description of symptoms (using Rome IV diagnostic criteria) and ruling out other conditions such as IBD, celiac disease, and colon cancer.¹ Women have a higher prevalence of IBS compared to men, and young adults are the predominant age group (18-39) diagnosed with the disorder.^1,4

IBS is more than just simple tummy trouble. While symptoms and severity can vary from patient to patient, many experience a significant decrease in quality of life (QOL). It has been reported that patients with IBS have lower or similar QOL scores to patients with diabetes, end-stage liver disease, or chronic obstructive pulmonary disease.^5,6 An estimated 50% of those with IBS describe their condition as “very” or “extremely” bothersome.⁷

In an international survey of people with IBS, respondents reported needing to restrict their usual activities an average of 75 days per year due to their symptoms.⁸ Missing work and school, avoiding plans outside the home or far from an accessible bathroom, and avoiding travel are often reported.⁷ Patients with IBS are also at a higher risk for suicidal behavior.⁹ With the potential reduction in QOL so significant, it makes finding solutions for symptom management a priority.

Treatment for IBS

There is no known cure for IBS; however, treatments can help alleviate symptoms. An increase in fiber is often recommended, especially for patients with IBS-C.¹ Probiotics are recommended for those with a suspected altered gut microbiome. For patients who have a psychological or mood disorder component, medications for anxiety and depression may be prescribed. Other medications that are typically prescribed as first-line treatments include an antispasmodic such as hyoscine butylbromide for abdominal pain, osmotic laxative for IBS-C, and loperamide for IBS-D.¹

While medications can be helpful, it has been established that many patients do not find drug therapy to adequately decrease symptoms, leading them to seek alternative treatments.¹⁰ Because of the brain-gut interaction associated with IBS, psychological therapies have been shown to be effective. Cognitive behavioral therapy and gut-directed hypnotherapy are two treatment methods that have been gaining popularity and are backed by research.¹¹

Many individuals with IBS report an increase in symptoms due to certain food triggers. For those patients, a low FODMAP diet may be helpful. A diet low in FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides, and polyols) restricts foods containing higher amounts of these short-chain carbohydrates. The low FODMAP diet has been shown to be effective and safe, with more than 50% of patients with IBS reporting improvement while on the diet.¹² Examples of foods with higher FODMAPs include garlic, onion, apples, and sugar alcohols. There is one specific sugar alcohol that dental professionals are very familiar with: xylitol!

Dental implications

While more research is needed, there are several dental-related associations with IBS that oral health providers should be aware of: sensitivity to xylitol products, temporomandibular disorders (TMD), xerostomia, and a potential oral-to-gut microbial relationship.

Many patients with IBS report sensitivity to foods containing higher FODMAPs. Since xylitol is a polyol, digesting this sugar alcohol may be difficult for some and can cause abdominal discomfort and/or osmotic diarrhea in those with IBS.^13,14 Adverse reactions to xylitol vary from person to person and are dose dependent.¹⁴ A discussion with your patient regarding any known sensitivity to xylitol is warranted, and alternative products may be considered.

Patients with IBS have an increased likelihood of TMDs.¹⁵ In a study by Gollota et al., patients with IBS had more than three times greater risk of having TMD compared to healthy controls.¹⁶ Dental providers should consider screening their patients with IBS for symptoms of TMD.

There is also a recognized correlation between IBS and xerostomia. When exploring the prevalence of sicca complex in IBS patients, Barton et al. found symptoms of dry mouth and dry eyes were 45% more common in the IBS group compared to healthy controls.¹⁷ Another study conducted by Erbasan et al. found an increased prevalence of Sjögren’s syndrome in those with IBS.¹⁸ Checking for xerostomia in patients with IBS is imperative.

It is theorized that having an altered gut microbiome plays a role in the pathogenesis of IBS. Interestingly, it has been established that typical bacteria of the oral cavity are found in higher amounts within the gastrointestinal tracts of patients with IBS. Streptococcus spp. and Veillonellaceae spp. are both found in atypical abundance in the gut of IBS patients.¹⁹ While more research is required regarding the etiology of this oral-gut microbiota relationship, it’s an intriguing concept that needs further study.

How can dental providers help?

Many patients with IBS feel their condition comes with a stigma, making them less likely to discuss their diagnosis. Besides being aware of potential dental effects, providers can show empathy and use motivational interviewing techniques to make patients feel comfortable disclosing and talking about their condition. As health-care professionals, it is vital that we continue to educate ourselves and advocate for comprehensive health. By having a baseline knowledge of IBS and its dental involvement, we can better serve our patients who are struggling with IBS—both in their oral and overall health. 

Editor's note: This article appeared in the June 2023 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

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