Dental/Medical Management of the patient



Crohn’s Disease

Tawnya Balla, Ceri Blinsmon, Britney Fernandez, Ferris Prado

DEH 26- Medically Compromised

Riverside Community College

Definition of Crohn’s Disease

Also known as Regional Enteritis or Inflammatory Bowel Disease, Crohn’s Disease is a chronic inflammation of the gastrointestinal tract most commonly involving the intestine. It can occur in any part of the gastrointestinal tract but it most often affects the end of the small intestine or the beginning of the large intestine. () It’s believed that Crohn’s occurs when the immune system mistakes microbes that are normally found in the intestines for foreign or invading microbes and then activates the immune response to attack these mistakenly invading microbes.

Incidence and Prevalence

The incidence of Crohn’s Disease has had a steady increase in the past 50 years and it may be due to the increased knowledge and understanding of the disease as time continues. In the United States, it is estimated that 7 out of 100,000 people have Crohn’s Disease (Hupp et al, 2006). Caucasians are the most common ethnicity to develop Crohn’s disease with Jewish individuals being 2-4 times more likely to have the disease. Regarding race and ethnicity, the prevalence in Hispanics and Asians is lower with a rise in the prevalence of African Americans ().

Etiology

The etiology of Crohn’s Disease is still largely unknown. Although research is continuous, a few theories have been developed to explain the cause of this disease. Recently, the first gene that is thought to be responsible for causing Crohn’s Disease was identified (gene NOD2/CARD 15). This gene has been identified as having a mutation or alteration twice as frequently in Crohn’s Disease patients as in the general population (). Other theories imply that the cause may be related to T-cell and/or macrophage abnormalities and the interaction between both resulting in an anti-inflammatory and pro-inflammatory imbalance (Hupp et al, 2006).

Signs & Symptoms of Crohn’s Disease

Symptoms of those living with Crohn’s disease range from asymptomatic to symptomatic, and can greatly vary from mild to severe. The most common symptoms include persistent diarrhea, abdominal cramps, fever and tiredness (). Other, less common gastrointestinal symptoms include rectal bleeding, loss of appetite, weight loss, anemia from gastrointestinal bleeding, obstruction, perforation or hemorrhage of the intestine, which may result from inflammation or scar tissue that completely or partially blocks the passage of stool or gas. Fissures or tears, abscesses around the anus or rectum, fistulas, which present as tunnels from the inflamed bowel adhering to the rectum or vagina (Warner and Barto, 2007). Toxic megacolon, which is a life threatening complication, involving distention of the colon with air and sepsis which is the spread of infection through the blood stream, normally from an ulcer in the GI track (Warner and Barto, 2007).

Crohn’s disease is a systemic disease affecting the body as a whole. Extraintestinal manifestations occur in 25% of those diagnosed (Warner and Barto, 2007). The more common extraintestinal symptoms include joint pain from arthritis of central, spinal or peripheral joints, skin rash appearing as reddish purple tender bumps most common on the shins but also on arms and legs. Oral ulcers presenting as multiple clusters of small pustules, ulcers or abscesses, or large irregular apthous ulcers (Warner and Barto, 2007). Also common is gallstones, liver disease from the narrowing of bile ducts, eye problems from the prolonged use of corticosteroids and growth retardation in children (Warner and Barto, 2007).

Medical and Dental Management of the Patient

Presently, there is no cure for Crohn’s disease. The only management that can be done medically or dentally is to cure the symptoms as they come along. The best way that medical professionals do that is by medications. The most common medications are aminosalicylates, which are anti-inflammatory drugs. Corticosteriods are also prescribed and these drugs are sued to suppress the immune system and patients with moderate to severe Crohn’s disease usually are taking these medications. Immune modifiers are used to help heal fistulas, and to help decrease the amount of corticosteroids the patient is taking. One more thing that immune modifiers can do is help maintain the disease’s remission. Antibiotics may be prescribed as needed for infections that may arise. Recently biologic therapies have been approved by the FDA for those patients that have not responded well to the conventional therapies. ()

2/3 of the patients with Crohn’s disease requires surgery. Some of the surgeries required are not too extreme, but depending on how advanced the disease is an ileostomy may be required. An ileostomy is a procedure that is performed when the colon is diseased. The entire colon is removed and the small bowel left over and attaches a pouch to the abdomen so those waste products can be emptied. Minor surgeries maybe required for repairing a fistula or an intestinal obstruction. ()

The patient that suffers from Crohn’s disease should ingest more calories, and eat bland foods that are easily digested. Due to the constant diarrhea, the patient can become very dehydrated and many patients find themselves in the hospitals due to dehydration. The patient that suffers from Crohn’s disease should drink plenty of fluids.

If a patient presents with chronic oral lesions, along with a thorough medical history evaluation the lesions should be biopsied and the patient should be referred for a gastrointestinal evaluation to find out if the cause is Crohn’s Disease. Treatment of the oral Crohn’s lesions include topical corticosteroids, intralesional steroid injections, systemic prednisone therapy, or the use of sulfasalazine; but the lesions will typically respond to systemic therapy when they are from an intestinal disease such as Crohn’s. (Hupp et al, 2006) Because of all of the different medications that the patient may be on it is very important to go over all of the medications to make sure that there are no contraindications to the dental treatment. The patient might also need pre-med because of immunosuppressive medications that they might be on. When prescribing pre-med, the clinician should avoid broad spectrum antibiotics if the patient is on a sulfasalazine, this is because the bacterial flora in the intestines might be diminished leading to a diminishing effect of the sulfasalazine. (Hupp et al, 2006)

Treatment Planning Considerations/Modifications

When planning to treat a patient who suffers from Crohn’s disease there is much to consider. Many patients are on medications that cause xerostomia, biotene or some other supplemental salivary product is recommended. The patient may also be prone to dental caries and should have fluoride treatments at every appointment, and may need a fluoride prescription for at home use. Nutritional counseling would be beneficial for the patient also especially at times when the disease is active. The patient would need a referral to the physician if he hadn’t already been diagnosed with Crohn’s disease and presented with multiple oral lesions and gastrointestinal issues.

References

Warner, A. S., Barto, A. E. (2007). 100 Questions About Crohn’s Disease and Ulcerative Colitis: A Lahey Clinic Guide. Burlington, MA: Jones and Bartlett Publishers

Hupp, J. R., Williams, T. P., Firriolo, F. J. (2006). Dental Clinical Advisor. St. Louis, MO: Mosby Elsivier

Ojha, J., Cohen, D. M., Islam, N. M., Stewart, C. M., Katz, J., & Bhattacharyya, I. (2007). Gingival involvement in Crohn disease. The Journal of the American Dental Association, 138, 1574-1581.

Crohn’s & Colitis Foundation of America (2008). About Crohn’s Disease. Retrieved February 28, 2008, from

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