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Oral Manifestations of Patients with Inflammatory Bowel Disease

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Oral Manifestations of Patients with Inflammatory Bowel Disease ANNALS OF GASTROENTEROLOGY 2004, 17(4):395-401 Original article Oral manifestations of patients with inflammatory bowel disease Flora Zervou1, A. Gikas2, E. Merikas2, G. Peros3, Maria Sklavaina2, J. Loukopoulos2, J.K. Triantafillidis2 SUMMARY tivariate analysis, age and IBD were the only factors signif- icantly related to the existence of oral lesions (OR 1.07, 95% Background: Crohns disease (CD) is considered to be a CI: 1.02 1.13, P=0.009). No correlation between activity disease involving the whole gastrointestinal tract, while and duration of disease, sex and smoking habit, with the ulcerative colitis (UC) is a disease exclusively located in presence of oral manifestations, was noticed. No signifi- the large bowel. The aim of this study was to examine whe- cant differences between patients and controls in the inci- ther patients with either CD or UC are at increased risk for dence of other lesions, including leukoplakia, and aphthous- developing oral manifestations. Patients-Methods: A wide like ulcers were found. No cases of pyostomatitis vegetans spectrum of oral lesions was carefully sought by the same in either patients with IBD or controls were found. Conclu- oral dentist in a consecutive series of 30 patients with in- sion: Although the number of patients included in the study flammatory bowel disease (IBD) (15 with CD and 15 with is small we can conclude that oral manifestations in pa- UC). Forty-seven healthy individuals (matched for age and tients with IBD (especially in those with CD), is a frequent sex), attendants of our dental clinic served as controls. Re- and underestimated event that needs further clinical vali- sults: 93% of UC and 87% of the CD group had at least one dation. lesion compared to 55% of the control group (P<0.005). Significantly more patients with CD had mandibula lym- Key words: Inflammatory bowel disease, Crohns disease, phadenopathy (P<0.0001), ulcers (P=0.011), angular Ulcerative colitis, Oral manifestations cheilitis (P<0.0001), hair tongue (P=0.011), periodontitis (P=0.011), gingival bleeding (P<0.0001), gingivitis INTRODUCTION (P=0.002), cobblestone appearance of the mucosa (P=0.002), polypoid tags (P=0.002), buccal trauma Oral manifestations is a well-documented clinical fea- (P<0.0001) and lip swelling (P=0.002) as compared to ture in patients with inflammatory bowel disease (IBD) healthy controls. Ulcerative colitis patients had in a signif- especially in those suffering from Crohns disease (CD). icantly higher proportion of involvement of salivary glands The spectrum of these lesions described so far in the (P<0.0001), as well as lymphadenopathy (P=0.002), buc- medical and dental literature is quite wide and includes 1 cal trauma (P<0.0001) and angular cheilitis (P<0.0001), oral ulceration , labial, buccal and gingival swelling, buc- 2,3 compared to healthy controls. Significantly more patients cal abscesses, mucosal inflammatory hyperplasia, mu- 4 with CD or UC had concurrently 3 or more oral manifesta- cosal tags and fissuring, gingivitis, granulomatous inflam- tions as compared to normal controls (P<0.0001). On mul- mation of minor salivary glands, granulomatous cheili- tis,5 candidiasis, angular cheilitis, lichen planus, pyosto- matitis vegetans,6,7 lymphadenopathy, perioral erythema, 1Department of Oral Medicine, 2Gastroenterology, Saint Panteleimon orofacial granulomatosis, midline lip fissuring, cobble- 8 9 General State Hospital, Nicea, Greece, and 34th Surgical Department, stone appearance of the mucosa, and dental caries. University of Athens, Athens, Greece The prevalence of oral lesions in newly diagnosed 10 Author for correspondence: patients has been estimated at 48% in some reports. John K. Triantafillidis MD, 8, Kerasountos Street, 12461, Haidari, Mucosal tags constituted the most frequent lesion. It is Athens, Greece, Tel (+)210-5819481, Fax: (+)210-5810970, of interest that, like other extraintestinal manifestations, e-mail: [email protected] oral lesions may precede the onset of the underlying intes- 396 F. ZERVOU, et al tinal inflammatory disorder.11 However, it is difficult to (F.Z.), who is director of the oral clinic of the dental determine exactly which oral manifestation is definitely department of our hospital. Careful oral examination related to IBD. It is logical to hypothesize that some of included the following parameters: i) Gingivae: gingivi- these lesions are in fact consequence of the disease or tis, periodontitis, and gingival bleeding ii) Other lesions: secondary reaction to medical treatment. So, pyostoma- cobblestoning, polypoid tag, swelling (labial, buccal or titis vegetans, cobblestone appearance of the mucosa and gingival), angular cheilitis, ulcers (aphthous or deep sur- minor salivary duct pathology represent macroscopic rounded by hyperplastic margins), pyostomatitis veget- lesions compatible with CD.12 ans, fissuring (lip: midline, elsewhere and other), vitili- go, erythema migrans, perioral erythema, mandibular There are only scattered systematic descriptions in lymphadenopathy (expressed as palpable mandibular the literature concerning the incidence of oral lesions in nodes that normally are not palpaqble), involvement of IBD patients and none originated from South Europe salivary glands (manifested clinically mainly as xerosto- or Mediterranean basin countries. Therefore, the aim of iii) tongue lesions: this study was to evaluate the incidence of almost all kind mia), and mucosal bleeding, Hairy, of lesions and manifestations described so far in the lit- fissured and geographic tongue. erature in a series of patients with CD and ulcerative Equipment for oral examination included mouth mir- colitis (UC), hospitalized in a gastroenterology IBD re- rors and a suitable high voltage lamp. A standardized ferral center. procedure was carried out in each patient following the WHO recommendations.13,14 PATIENTS AND METHODS In addition to the above mentioned data, details of A total number of 30 consecutive inpatients with a smoking habit were also recorded. definite diagnosis of CD or UC (15 with CD and 15 with Statistical analysis of the results was carried out by UC, aged 40+/-16 years) were enrolled into the study. using Pearsons chi square test, t-test and multivariate Disease activity was assessed by the CDAI for CD pa- analysis. tients and the Truelove and Witts criteria for UC pa- tients respectively. Twenty patients had active disease at the time of examination but none in either group of pa- RESULTS tients had severe disease. The mean duration of disease Eighty-seven percent of patients with CD and 93% was 7+/-5yr (range: 2 months to 19 years). All patients of patients with UC had at least one oral lesion as com- with UC were on maintenance treatment with mesala- pared with 55% of controls (P<0.005). Significantly more zine. Forty-five percent of patients with CD were on patients with CD and UC had concurrently 3 or more mesalazine and 15% on azathioprine as maintenance lesions as compared with controls (P<0.0001) (Table 1). treatment. Table 2 shows the gingival lesions found in patients The control group consisted of 47 people aged 43+/ with IBD and healthy controls. As the table indicates, -12 years, visitors of the outpatient dental clinic. Control significant differences between patients with CD and con- individuals were well matched for sex and age. In fact, trols were found in the incidence of gingivitis, periodon- there were no statistically significant differences between titis and gingival bleeding (P=0.002, 0.011 and <0.0001 patients and controls as far as the parameters age and respectively). Concerning the same parameters, no sig- sex were concerned. nificant differences between patients with UC and con- Oral examination was performed by the first of us trols were noticed. Table 1. Number of lesions concurrently found in patients and controls. Number of lesions Controls Crohns disease P-value Ulcerative colitis P-value None 45% 13% 07% One 38% 7% 40% Two 15% 13% 20% Three or more 2% 67% <0.0001 33% 0.001 Comparisons: Controls vs Crohns disease & Controls vs Ulcerative colitis Oral manifestations of patients with inflammatory bowel disease 397 Table 2. Gingival lesions in patients and controls Parameter Controls Crohns disease P-value Ulcerative colitis P-value Periodontitis 0/47 (0%) 2/15 (13%) 0.011 0/15 (0%) NS Gingivitis 0/47 (0%) 3/15 (20%) 0.002 1/15 (7%) 0.07 Gingival bleeding 0/47 (0%) 4/15 (27%) <0.0001 0/15 (0%) NS NS= No significant differences. Comparisons: Crohns disease vs Controls & Ulcerative colitis vs Controls Table 3 shows the incidence of lesions found in lips, were found. No cases of pyostomatitis vegetans in pa- bucca and tongue. As the table indicates, significant dif- tients with IBD and controls were noticed. ferences between patients with CD and controls were Table 4 shows the results of multivariate analysis. As found in the incidence of a variety of lesions including the table indicates, age and IBD were the only factors mandibular lymphadenopathy (P<0.0001), ulcers significantly related with the presence of oral lesions (OR (P=0.011), angular cheilitis (P<0.0001), hairy tongue 1.07, 95% CI: 1.02 1.13, P=0.009). (P=0.011), periodontitis (P=0.011), gingival bleeding (P<0.0001), gingivitis (P=0.002), cobblestone appear- No correlation between activity and duration of dis- ance of the mucosa (P=0.002), polypoid tags (P=0.002), ease, sex and smoking habit with the presence of oral buccal trauma (P<0.0001) and lip swelling (P=0.002). lesions was noticed. Patients with ulcerative colitis patients
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