4. 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
5. Pathogenesis
Considered to be idiopathic.
Increasingly believed to be a result
interaction between environmental and
genetic factors.
7. Ulcerative Colitis
a form of colitis, that includes
characteristic ulcers or open sores that
attacks only the large intestine
Hallmark - rectal bleeding
diarrhea
8. 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
11. ORAL MANIFESTATIONS
Can be catagorized as :
1. Specific
2. Non-specific
3. Complications of malabsorption caused
by the bowel inflammation
4. Side effects or complications of
medications prescribed to treat the
bowel disease.
12. SPECIFIC NON SPECIFIC
CROHNS Orofacial Crohn
disease
•Angular chelitis
•Apthous ulcers/
Apthous stomatitis
•Dry mouth
•Halitosis
ULCERATIV
E
COLITIS
Pyostomatitis
vegetans
•Apthous ulcers/
Apthous stomatitis
•Glossitis
•Cheilitis
•Halitosis
13. 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 ulcers
16. Pyostomatitis vegetans
Large 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
17. Diagnosis: Biopsy of perilesional tissue with
histopathological and immunostaining
examinations.
Treatment :
1. Topical corticosteroids eg clobetasol,
flucinolone
2. Treat the underlying disease.
3. Some patient report benefit from zinc
supplementation
>1yrs- 10mg OD daily
<1yrs – 5mg OD daily
4. Antibiotic therapy usually not beneficial
as lesion is refractory.
18. 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
19. Management
Topical , intralesional , systemic
corticosteroids
Topical and systemic analgesics eg:
2%lidocaine gel orabase
Thalidomide , an immune modulating and
angiogenesis inhibiting drug is effective for
refractory cases.-300 mg daily
Colchicines- 0.6mg tds for 2 weeks
Pentoxyphylline (TRENTAL 400mg) - in
cases where topical steroid do not respond.
20. CATEGORY THERAPEUTIC DOSE
Antimicrobials:
Chlorhexidine
Tetracycline
Penicillin-G
0.2% mouthrinse or 1% gel
5% tetracycline used as
mouthwash
50mg penicillin-G 4 times a day
for 4 days
STEROID
Topical :
Flucinonide
Triamcinolone
acetonide
Systemic:
0.05% gel applied 2-4 times a
day until healing
0.1% gel applied 2-4 times a day
until healing
22. Which of the following antihelminthic drug
shows immunomodulating property??
1) Albendazole
2) Suramin
3) Levamisole
4) Ivermectin
23. • 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
26. 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
27. mucosal tags
cobblestoning of the
lining of the inside of the
cheek
28. Angular cheilitis
Erythema and/or
fissuring of angle of
mouth
Secondary to nutritional
deficiencies following
malabsorption .
Or due to concommitant
infections
29. 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 .
30. Angioedema
Also called lip swelling
It may be allergic or drug
induced.
Mild presentation but require
immediate management if risk
of airway blockage
31. MANAGEMENT
Avoid any known allergen or trigger that causes
the symptoms
Antihistamines -Cetrizine (Alerva 10mg) OD
Fexofanadine(Allegra 120 or
180
mg)
Anti-inflammatory medicines (Corticosteroids)
33. Specific oral manifestation of
Ulcerative colitis is:
A. Angioedema
B. Pyostomatitis vegetans
C. Angular cheilites
D. Glossitis
34. Crohn’s disease differs from
Ulcerative colitis in that it doesnot
show:
A. Granulomas
B. Skip lesions
C. Fistula formation
D. All layers involvement
E. None
(fistula formation requires involvement
of all layers of intestine)
35. Which of the following is a pustular
lesion?
A. Recurrent Apthous Ulcers
B. Pyostomatitis Vegetans
C. Angioedema
D. Angular cheilitis
36. 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)
37. 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.
38. 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
39. If lesions are disseminated ,
Dexamethasone 0.5mg/5ml
(DEXONA) used as rinse for 1 min –
4 times a day and expectorated
40. Dental evaluation of patient with IBD
Determine the history of surgical
therapy.
Determine medications used , with
special attention to steroid therapy in
the past.
Determine the severity of disease
and control
Evaluate the diagnosis of the type of
IBD
41. 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.
42. 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
43. 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
44. 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
For patient on long term steroid therapy, steroid
dosing
45. 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
46. 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
47. 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.
48. 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.
49. 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.
50. 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.
51. 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
52. 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?
53. 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
54. Which of the following drugs are not
avoided in patients with IBD?
A. NSAIDs
B. COX-2 inhibitors
C. Amoxicillin – Clavulanate
D. Clindamycin
55. 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 given
D. None of the above
56. REFERENCES
Medical problems in dentistry
Crispian Scully
BURKET’S oral medicine
Greenberg, Glick, Ship
Shafer’s textbook of Oral pathology
National handbook of medicine
Wikipedia
Clinical Journals by clinics in North
America
