Oral extension of regional enteritis (Crohn's disease). Report of a case

Unravelling the Oral-Gut Axis: Interconnection Between Periodontitis and Inflammatory Bowel Disease, Current Challenges, and Future Perspective

As the opposite ends of the orodigestive tract, the oral cavity and the intestine share anatomical, microbial, and immunological ties that have bidirectional health implications. A growing body of evidence suggests an interconnection between oral pathologies and inflammatory bowel disease [IBD], implying a shift from the traditional concept of independent diseases to a complex, reciprocal cycle. This review outlines the evidence supporting an 'oral-gut' axis, marked by a higher prevalence of periodontitis and other oral conditions in IBD patients and vice versa. We present an in-depth examination of the interconnection between oral pathologies and IBD, highlighting the shared microbiological and immunological pathways, and proposing a 'multi-hit' hypothesis in the pathogenesis of periodontitis-mediated intestinal inflammation. Furthermore, the review underscores the critical need for a collaborative approach between dentists and gastroenterologists to provide holistic oral-systemic healthcare.

The "Gum-Gut" Axis in Inflammatory Bowel Diseases: A Hypothesis-Driven Review of Associations and Advances

In modern medicine, the oral cavity has often been viewed as a passive conduit to the upper airways and gastrointestinal tract; however, its connection to the rest of the body has been increasingly explored over the last 40 years. For several diseases, the periodontium and gingiva are at the center of this oral-systemic link. Over 50 systemic conditions have been specifically associated with gingival and periodontal inflammation, including inflammatory bowel diseases (IBD), which have recently been elevated from simple "associations" to elegant, mechanistic investigations. IBD and periodontitis have been reported to impact each other's progression via a bidirectional relationship whereby chronic oral or intestinal inflammation can impact the other; however, the precise mechanisms for how this occurs remain unclear. Classically, the etiology of gingival inflammation (gingivitis) is oral microbial dysbiosis in the subgingival crevice that can lead to destructive periodontal disease (periodontitis); however, the current understanding of gingival involvement in IBD is that it may represent a separate disease entity from classical gingivitis, arising from mechanisms related to systemic inflammatory activation of niche-resident immune cells. Synthesizing available evidence, we hypothesize that once established, IBD can be driven by microbiomial and inflammatory changes originating specifically from the gingival niche through saliva, thereby worsening IBD outcomes and thus perpetuating a vicious cycle. In this review, we introduce the concept of the "gum-gut axis" as a framework for examining this reciprocal relationship between the periodontium and the gastrointestinal tract. To support and explore this gum-gut axis, we 1) provide a narrative review of historical studies reporting gingival and periodontal manifestations in IBD, 2) describe the current understanding and advances for the gum-gut axis, and 3) underscore the importance of collaborative treatment and research plans between oral and GI practitioners to benefit this patient population.

Prevalence and severity of periodontal disease in patients with inflammatory bowel disease

Previous reports have demonstrated that oral mucosa and periodontal lesions occur in patients suffering from inflammatory bowel disease (Crohn's disease [CD] and ulcerative colitis [UC]). It is unknown whether periodontal disease is an occasional or regular finding in these patients. The purpose of this study was to assess the prevalence and severity of periodontal disease in patients with inflammatory bowel disease (IBD). The periodontal status of 107 consecutive patients seeking treatment for inflammatory bowel disease was assessed. Examination of the mid- and mesiobuccal aspects of one quadrant on one jaw and the contralateral quadrant of the opposite jaw revealed the 93.5% of the CD patients and 95.1% of UC patients had at least one site with probing attachment loss of 2 mm or greater, and a mean probing attachment loss 1.4 +/- 0.9 mm and 1.5 +/- 1.0 mm, respectively. We found that 28.3% of CD patients and 29.5% of UC patients possessed at least 1 site with a pocket probing depth of 4 mm or greater; the mean pocket probing depth in these patients was 2.4 +/- 0.2 mm and 2.3 +/- 0.2 mm, respectively. Compared with the assessment of Oral Health of United States Adults, IBD patients revealed a 11.9% higher prevalence (P less than or equal to 0.01) but 0.6 mm lower severity (P less than or equal to 0.01) of periodontal disease. The magnitudes of these differences suggest no clinical implications for the management of periodontal disease in IBD subjects.

Oral Crohn's disease: report of two cases in brothers with metallic dysgeusia and a review of the literature

Between 4% and 14% of patients with intestinal Crohn's disease (CD) may manifest the typical oral changes of this disorder. These changes include labial and intraoral inflammatory tissue hyperplasia with fissuring ("cobblestoning") and swelling. In addition, angular cheilitis and regional lymphadenopathy may be present. We report two cases of oral CD in brothers, in whom the unusual symptoms of metallic dysguesia and gingival bleeding were prominent features. Despite the well-recognized familiar incidence of CD, a review of the literature shows that in no previous case reports has familial oral CD been noted. Successful symptomatic and objective treatment results were obtained with a mouthwash preparation of triamcinolone acetonide, tetracycline, and lidocaine.

Immunohistological findings in lip biopsy specimens from patients with Crohn's disease and healthy subjects

Biopsies of apparently normal buccal mucosa were taken from 14 patients with Crohn's disease and 13 healthy controls who were matched for dental status. Most patients had an increased number of lymphocytes around vessels in the subepithelial tissue and two showed fibrosis with moderate atrophy of minor glands. Plasma cells which contained immunoglobulin, predominantly IgA, were only found around minor salivary glands in both patients and controls. Quantitative studies showed a significant increase in the number of cells containing IgA in patients compared with controls. No correlation was found between immunoglobulin pattern and disease activity, age, sex, or duration of Crohn's disease. A significant correlation was found between the activity of the disease, as defined by the Crohn's Disease Activity Index, and the number of plasma cells containing IgM.

Lymphoid lesions of the oral cavity

The lymphoid lesions of the oral cavity may be classified into three groups: 1. Benign lesions. 2. Malignant lesions. 3. Other lymphoid-like lesions. 1. Benign lymphoid lesions: In this group the following lesions must be differentiated: reactive lymph node hyperplasia, enlarged follicle of the lingual tonsil, lymphoepithelial cysts, lymphoepithelial lesions, lymphoid polyps, and cystadenolymphomas. The most frequent locations of benign lymphoid lesions are the lingual tonsil, buccal mucosa, tongue, and floor of mouth. 2. Malignant lesions: One subgroup includes the systemic lymphoid diseases, the other subgroup the lymphoid tumors. According to the WHO classification, the following entities belong to systemic lymphoid diseases: acute and chronic lymphoid leukemia, Waldenström's macroglobulinemia, plasma-cell leukemia, heavy-chain disease, Sézary's disease, and chronic lymphoproliferative diseases (unclassified). WHO has classified the lymphoid tumors as follows: lymphosarcoma, mycosis fungoides, plasmacytoma, reticulosarcoma, unclassified malignant lymphomas, Hodgkin's disease. The WHO classification is compared to the Kiel classification. The special cell types and the differences of the two international classifications are interpreted, especially terms such as centroblastic-centrocytic lymphomas, immunoblastic lymphomas, and the different terminology of reticulosarcomas. 3. Other lymphoid-like lesions: The following examples are discussed in relation to the oral cavity: eosinophilic granuloma, sarcoidosis, Melkersson-Rosenthal's syndrome, Wegener's granulomatosis, foreign body granuloma, and other lesions.

Oral lesions in Crohn's disease: report of two cases and update of the literature

A review of twenty-two previously reported cases and two new cases of oral lesions of Crohn's disease shows that there is a predilection for occurrence in certain anatomic sites and that the appearance of lesions is dependent on location. The most frequently affected areas and their respective appearances are the buccal mucosa, showing a cobblestone pattern; the vestibule, demonstrating linear, hyperplastic folds and ulcers; and the lips, appearing diffusely swollen and indurated. Less frequent are lesions of the gingiva and alveolar mucosa, which reveal a granular, erythematous swelling, and the palate, represented by multiple ulcers of the aphthous type. The significance of the clinical lesions and their microscopic features id discussed, as is a differential diagnosis in similar-appearing lesions.

Oral manifestations of Crohn's disease

In a systematic study of 100 patients with Crohn's disease, 100 with ulcerative colitis, and of 100 normal subjects matched for age, sex, and denture status, nine patients with Crohn's disease, two with ulcerative colitis, and one normal control were found to have oral lesions. In Crohn's disease, the macroscopic and histological appearances resembled those encountered elsewhere in the gastrointestinal tract and their incidence was related to the activity of the disorder. The lesions in the other two groups were different macroscopically and histologically. Production of salivary IgA was found to be reduced in Crohn's patients with active bowel disease. It is suggested that the occurrence of oral lesions in patients with Crohn's disease might represent a local immunological reaction to oral antigens.

Oral manifestations of Crohn's disease without demonstrable gastrointestinal lesions

The literature relating to oral manifestations of Crohn's disease is reviewed and a case is reported in which clinical and histopathologic features of oral Crohn's disease are present without demonstrable gastrointestinal lesions. It is suggested that it is reasonable to make a firm diagnosis of the condition on this evidence alone and to monitor the patient for subsequent gastrointestinal symptoms, so that treatment can be instituted at an early stage.