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

Salivary changes in oxidative stress related to inflammation in oral and gastrointestinal diseases

OBJECTIVES

The early diagnosis and monitoring of Crohn's disease (CD) and orofacial granulomatosis (OFG) might be facilitated by assaying potential disease biomarkers in saliva. Markers of oxidative stress and inflammation were assayed in salivas from patients with CD, OFG and concurrent OFG and CD (OFG + CD).

SUBJECTS

Unstimulated whole mouth saliva was collected from 93 subjects, and immunoglobulin A (IgA), lactoferrin (LF) and myeloperoxidase (MPO) were determined by ELISA. Markers of oxidative stress and antioxidant status were assayed spectrophotometrically.

RESULTS

Immunoglobulin A was significantly (p < .03) higher in experimental groups vs the control group. LF was significantly (p < .01) higher in OFG + CD compared to CTRL and CD. Ferric reducing antioxidant power was lower (p ≤ .009) in all experimental groups, and advanced glycation end products were higher (p ≤ .01) in CD and OFG + CD patients.

CONCLUSION

Oxidative stress is increased in saliva in CD and OFG. Although MPO, a product of inflammatory cells, was not significantly increased, the other innate immune markers, IgA and LF, which are also secreted by salivary glands, were increased. This study suggests that saliva might be utilized in monitoring CD and OFG but further longitudinal studies focused on analysing a panel of salivary markers are needed.

Treatments for smell and taste disorders: A critical review

A key concern of both the patient and physician is whether treatment is available that will eliminate or quell a given chemosensory disturbance. In cases where obvious oral, nasal, or intracranial pathology is involved, rational straightforward approaches to treatment are often available. In cases where damage to the sensory pathways is secondary to chronic inflammatory disease, trauma, viral invasion, toxic exposure, or unknown causes, the direction for therapy is more challenging. Indeed, many chemosensory disorders, if present for any period of time, cannot be reversed, while others spontaneously remit without any therapeutic intervention. This review assesses the strengths and weaknesses of more than two dozen approaches to treatment that have been suggested for a wide range of taste and smell disorders.

Oral pathology in inflammatory bowel disease

The incidence of inflammatory bowel diseases (IBD) - Crohn’s disease (CD) and ulcerative colitis (UC) - has been increasing on a global scale, and progressively, more gastroenterologists will be included in the diagnosis and treatment of IBD. Although IBD primarily affects the intestinal tract, extraintestinal manifestations of the disease are often apparent, including in the oral cavity, especially in CD. Specific oral manifestations in patients with CD are as follows: indurate mucosal tags, cobblestoning and mucogingivitis, deep linear ulcerations and lip swelling with vertical fissures. The most common non-specific manifestations, such as aphthous stomatitis and angular cheilitis, occur in both diseases, while pyostomatitis vegetans is more pronounced in patients with UC. Non-specific lesions in the oral cavity can also be the result of malnutrition and drugs. Malnutrition, followed by anemia and mineral and vitamin deficiency, affects the oral cavity and teeth. Furthermore, all of the drug classes that are applied to the treatment of inflammatory bowel diseases can lead to alterations in the oral cavity due to the direct toxic effects of the drugs on oral tissues, as well as indirect immunosuppressive effects with a risk of developing opportunistic infections or bone marrow suppression. There is a higher occurrence of malignant diseases in patients with IBD, which is related to the disease itself and to the IBD-related therapy with a possible oral pathology. Treatment of oral lesions includes treatment of the alterations in the oral cavity according to the etiology together with treatment of the primary intestinal disease, which requires adequate knowledge and a strong cooperation between gastroenterologists and specialists in oral medicine.

Review article: non-malignant oral manifestations in inflammatory bowel diseases

BACKGROUND

Patients with inflammatory bowel diseases (IBD) may present with lesions in their oral cavity. Lesions may be associated with the disease itself representing an extraintestinal manifestation, with nutritional deficiencies or with complications from therapy.

AIM

To review and describe the spectrum of oral nonmalignant manifestations in patients with inflammatory bowel diseases [ulcerative colitis (UC), Crohn's disease (CD)] and to critically review all relevant data.

METHODS

A literature search using the terms and variants of all nonmalignant oral manifestations of inflammatory bowel diseases (UC, CD) was performed in November 2014 within Pubmed, Embase and Scopus and restricted to human studies.

RESULTS

Oral lesions in IBD can be divided into three categories: (i) lesions highly specific for IBD, (ii) lesions highly suspicious of IBD and (iii) nonspecific lesions. Oral lesions are more common in CD compared to UC, and more prevalent in children. In adult CD patients, the prevalence rate of oral lesions is higher in CD patients with proximal gastrointestinal tract and/or perianal involvement, and estimated to range between 20% and 50%. Oral lesions can also occur in UC, with aphthous ulcers being the most frequent type. Oral manifestations in paediatric UC may be present in up to one-third of patients and are usually nonspecific.

CONCLUSIONS

Oral manifestations in IBD can be a diagnostic challenge. Treatment generally involves managing the underlying intestinal disease. In cases presenting with local disabling symptoms and impaired quality of life, local and systemic medical therapy must be considered and/or oral surgery may be required.

Inflammatory bowel disease

Inflammatory bowel diseases (IBDs) encompass ulcerative colitis, Crohn's disease, and indeterminate colitis, all of which are characterized by remission and exacerbation of gastrointestinal symptoms, and a variety of extraintestinal manifestations including those affecting the oral cavity. Although not particularly a cause for mortality, inflammatory bowel diseases are associated with significant morbidity and impact on the quality of life. This article reviews clinical presentation, diagnostic criteria, and therapeutic modalities for the 2 main types of inflammatory bowel disease and discusses manifestations of these conditions in the oral cavity. The role of the oral health care provider in timely recognition and referral for medical work-up as well as management of oral complaints is also emphasized.

Gingival involvement in Crohn disease

BACKGROUND

Although the oral manifestations of Crohn disease are well-established, there is little specific documentation of the gingival involvement.

CASE DESCRIPTION

The authors describe four patients with significant gingival involvement and identify clinical signs and symptoms of the disease involving the gingivae, along with other oral manifestations. Patients had persistent gingival lesions manifesting as pustular ulcerations, erythema, swelling and cobblestoning. The authors also discuss the differential diagnosis, treatment options and prognostic factors.

CLINICAL IMPLICATIONS

Patients with gingival and/or other oral lesions with or without other constitutional symptoms should be evaluated for Crohn disease. Dentists can play a critical role in the early diagnosis, and they can help prevent complications and improve the prognosis.

Oral signs and symptoms in relation to disease activity and site of involvement in patients with inflammatory bowel disease

OBJECTIVE

An assessment of oral symptoms and signs in patients with inflammatory bowel disease (IBD).

METHODS

Fifty-four patients with IBD, 34 with Crohn's disease (CD) and 20 with ulcerative colitis (UC) participated in the study. Forty-two patients without gastrointestinal disease or complaints attending the orthopedic clinic served as controls. Each patient completed a written questionnaire and was subjected to an oral examination.

RESULTS

The main findings of this study were the higher prevalence of halitosis (50% vs 10% P < 0.0008), nausea (30% vs 7%, P < 0.017) and reflux (regurgitation) (45% vs 17%, P < 0.017) in patients with UC, and nausea (50% vs 7%, P < 0.026), dry mouth and halitosis (29% vs 10%, P < 0.026) and vomiting (41% vs 5%, P = 0.01) in patients with CD, compared with controls. Patients with active CD had a higher prevalence of dry mouth, nausea and vomiting compared with controls (46, 69 and 54% vs 10, 7 and 5%, respectively, P < 0.001) and of reflux compared with non-active CD (46% vs 5%, P < 0.001). Patients with active UC had a higher prevalence of halitosis and regurgitation (50 and 60% vs 10 and 17%, P < 0.001) compared with controls.

CONCLUSIONS

The present study demonstrates increased frequency of oral signs and symptoms in patients with IBD. Patients with active CD had more oral signs compared with non-active CD patients. Manifestations such as nausea, vomiting, regurgitation and dry mouth may have detrimental effects on teeth and soft tissues of the oral cavity. Communication between gastroenterologists and dentists is imperative for success of the overall treatment of their patients.

Orofacial granulomatosis with gingival onset

BACKGROUND, AIMS

Orofacial granulomatosis (OFG) is a descriptive term used for granulomatous disorders of the face and oral cavity that may occur for a variety of reasons, some of which result in significant morbidity and mortality. Although rarely, a granular enlargements of the gingiva may be the first clinical manifestation of OFG, preceding other local or systemic manifestations.

METHOD

We will report a case of OFG that showed an atypical and monosymptomatic onset with a generalized hyperplastic gingivitis that preceded other facial and mucosal features by several weeks.

RESULT

Considering the variable clinical onset of OFG and its apparent increase in incidence, we emphasize that in some cases, the periodontologist, as first consulted health care professional, plays an important role to detect this disorder. Early diagnosis of OFG is a crucial step to prevent and cure its unsightly sequelae and sometimes avoid progression of systemic potentially life-threatening OFG-related diseases.

CONCLUSION

Thus, when none of the common causes of gingival enlargement can be detected, OFG diagnosis should be suspected.

Oral staphylococcal mucositis: A new clinical entity in orofacial granulomatosis and Crohn's disease

OBJECTIVE

Orofacial granulomatosis and the oral manifestations of Crohn's disease comprise many clinical features, of which stomatitis is one. The purpose of this study was to establish a role for Staphylococcus aureus in mucositis affecting some patients with orofacial granulomatosis or oral Crohn's disease.

STUDY DESIGN

Four patients (2 with orofacial granulomatosis and 2 with oral Crohn's disease), from a total of 450 patients examined over 10 years, had stomatitis involving the entire oral mucosa, from which S aureus was cultured by the oral rinse technique. These patients were treated with flucloxacillin or erythromycin.

RESULTS

A heavy growth of S aureus was isolated from the mouth of each patient. All 4 patients responded to treatment with flucloxacillin or erythromycin.

CONCLUSIONS

S aureus is a potential cause of panstomatitis in patients with orofacial granulomatosis or Crohn's disease. This infection responds rapidly to antimicrobial treatment.

Treatment of orofacial and ileo-colonic Crohn's disease with total enteral nutrition

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Oral Crohn's disease and pyostomatitis vegetans. An unusual association

Oral features of Crohn's disease include ulcers, lip fissuring, cobblestone plaques, angular cheilitis, polypoid lesions, and perioral erythema. Pyostomatitis vegetans is a rare eruption of the oral mucosa characterized by tiny yellow pustules. It is considered a marker for inflammatory bowel disease. We describe a 45-year-old woman with a 6-month history of painful sores in her mouth, diarrhea, weight loss, and cutaneous lesions. Oral examination revealed cobblestone plaques and indentation on the tongue and friable vegetating pustules on the labial commissures. Staphylococcus simulans was isolated from the pustules. Laboratory studies revealed leucocytosis, eosinophilia, and low hemoglobin and zinc levels. Histologic study of the labial lesions revealed hyperplastic epithelium with intraepithelial clefts that contain eosinophils and neutrophils. Tongue lesions showed chronic inflammation with noncaseating granulomas. Later, colonoscopy and biopsy demonstrated Crohn's disease of the anorectal region. Pyostomatitis vegetans lesions regressed after oral zinc supplementation. Prednisone treatment resulted in healing of the tongue lesions. In our patient, pyostomatitis vegetans appeared to be related to zinc deficiency that may have been caused by malabsorption. The pathogenetic interrelationship between pyostomatitis vegetans and Crohn's disease is discussed.

Granulomatous tonsillitis. A rare extraintestinal manifestation of Crohn's disease

Oral lesions, varying in nature and location, appear to be one of the common extraintestinal manifestation of Crohn's disease. In particular, oral involvement preceding intestinal disease may lead to the diagnosis of Crohn's disease. The present case report of a 17-year-old male patient describes a very rare nonintestinal manifestation of Crohn's disease with severe granulomatous involvement of the tonsils. A sore throat caused by hyperplastic tonsils with granulomatous inflammation as an oral manifestation of Crohn's disease was the leading symptom in this case.

Disorders in taste and smell

Although many conditions and medications have been associated with chemosensory disturbances, data from major chemosensory clinical research centers support three major disorders as being causative: nasal and paranasal sinus disease (21%), post-upper respiratory tract viral infection (19%), and head trauma (14%). Despite extensive evaluation, 22% of patients do not demonstrate identifiable causation.

Cheilitis granulomatosa: report of six cases and review of the literature

Six cases of cheilitis granulomatosa, a rare inflammatory disorder of unknown origin, are reported. The condition produces nontender, persistent swelling of one or both lips and affects primarily young adults. Histologically, nonnecrotizing granulomatous inflammation is seen. The clinical findings and results of therapy in these six cases are presented. One patient was treated with hydroxychloroquine sulfate (Plaquenil) that stabilized the process. One of our patients had vesicular-appearing lesions. Microscopic examination showed the lesions to be dilated superficial lymphatic channels, a finding that to our knowledge has not been previously described.

Pharyngeal perforation during intubation in a patient with Crohn's disease

A case of pharyngeal perforation in a patient with Crohn's disease is described. Crohn's disease may complicate intubation either because of oral lesions changing the local soft tissue architecture, or because chronic corticosteroid therapy has lessened tissue resistance to perforation. Consideration may be given to adjunctive measures when intubating patients with a history of Crohn's disease.