Crohn’s Disease

1. Crohn’s Disease Medically Compromised DEH 26 Tawnya Balla, Ceri Blinsmon, Britney Fernandez, & Ferris Prado

2. Medical History • Name: Tony Hawk • Male • 28 years old • Caucasian • Med student • Single

3. Chief complaint • Occasionally gets canker sores in mouth when Crohn’s Disease is active • Patient states he has constant dry mouth • Patient is here for a cleaning

4. Past dental history • Patient complains he is sensitive to cold on his upper teeth • Patient states he had canker sores throughout his mouth. Last occurrence August 2007 • Patient complains of burning tongue, currently • Patient was seen last by his dentist in January 2007

5. Medical History • Patients states he had persistent diarrhea and ulcers(gastrointestinal) in August 2007 • Patient states the he has frequent canker sores due to Crohn’s disease in August 2007 • Patient states he currently has stress and anxiety and is currently being treated with medication

6. Social History • Patient states that he drinks alcoholic beverages 1 time per week

7. Family History • Patient has a family history of heart disease. His maternal grandfather died of the disease • Patient also has a family history of Crohn’s disease. His mother currently has this disease

8. Medications • Asacol 2.4g 1xdaily taken for maintenance of ulcerative colitis • Ativan 2mg taken as needed for anxiety • Imuran 50mg 1xdaily taken for 14 days for ulcerative colitis • Metronidazole 500mg every 6-8 hrs taken for 14 days for fistula or abscesses

9. Hospitalizations • Patient was hospitalized in October 2007 due to Crohn’s Disease issues

10. ASA status • ASA II- due to systemic illness

11. Vitals • Blood pressure: 110/70 • Respiration: 14 • Pulse: 67

12. What is Crohn’s Disease? • Also known as Regional Enteritis or Inflammatory Bowel Disease • chronic inflammation of the gastrointestinal tract most commonly involving the intestine • it most often affects the end of the small intestine or the beginning of the large intestine

13. What is Crohn’s Disease • It is believed that the disease 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

14. Incidence • Interestingly, the incidence of Crohn’s disease has had a steady increase in the last 50 years • In the US, it is estimated that 7 out of 100,000 people have Crohn’s disease

15. Who is most likely to have Crohn’s disease? • Caucasians are the most likely to develop Crohn’s Disease • Jewish individuals are 2-4 times more likely to have the disease • Hispanics and Asians are among the least likely to develop the disease with a rise in African Americans • taken from www.ccfa.org

16. Etiology • The etiology of Crohn’s disease is unknown, but research has been conducted to determine genetic relationships

17. Etiology- Genetic theory • The first gene for Crohn’s Disease was recently identified and is a result of a mutation or alteration (gene KOD2/CARD) • This mutation affects the bodies ability to recognize bacteria as harmful and has been identified twice as frequently in patient’s with Crohn’s disease as in the general public • taken from www.ccfa.org

18. Etiology- Inflammatory Cell Theory • Another theory implies that the cause may be related to T-cell and/Or macrophage abnormalities and the interaction between both • The result is an anti-inflammatory and pro-inflammatory imbalance • taken from Clinical Advisor

19. More common persistent diarrhea abdominal cramps fever malaise rectal bleeding loss of appetite Less common weight loss anemia obstruction, perforation, or hemorrhage of the intestine fissures abscesses fistula toxic megacolon sepsis Signs and Symptoms

20. Hemorrhage of intestine Ulcerative colitis — a segment of colon showing superficial, hemorrhagic mucosal and submucosal ulceration. Crohn's disease — portion of small intestine showing multifocal areas of thickening of the wall and narrowing of the lumen.

21. More common joint pain skin rash oral ulcers gall stones liver disease eye problems growth retardation in children Other less common anemia blood clots kidney stones nerve damage lung disease pancreatitis pericarditis menstrual irregularities severe gingivitis osteoporosis Crohn’s Disease is a systemic condition causing extraintestinal manifestations effecting 25%

22. Common Oral Manifestations • Hypertrophy and swelling of lips • gingival soft tissue swelling (resembles epulis fissuratum) • cobblestone appearance of buccal mucosa and palate • deep ulcers (yellow/white, appear linear within the vestibule and on the gingiva) • Apthous-like ulcerations • Pyostomatitis vegetans (erythematous, thickened oral mucosa with multiple pustules, and superficial erosions)

23. Crohn's disease — deep crateriform ulcer with rolled border and necrotic center as well as angular cheilitis. Crohn's disease — mucosal hyperplasia and fissuring with linear ulceration (courtesy of Dr. Mark Kernstein).

24. Crohn's disease — mucosal edema, aphthaform ulcers and military granulomas (Courtesy of Dr. Mark Bernstein). Ulcerative colitis — similar appearing ulcers of the buccal mucosa (courtesy of University of Oklahoma School of Dentistry). Pyostomatitis vegetans — yellowish, slightly elevated, linear pustules on the gingiva that have the so-called "snail-track" appearance (courtesty of Dr. Mark Bernstein).

25. Etiology of symptoms • Anemia- caused from gastrointestinal bleeding • Obstruction, perforation or hemorrhage- inflammation or scar tissue resulting in little or no passage of stool or gas, sometimes vomiting • Fissure-Cut or tear in the anal canal from persistent diarrhea or hard bowl movements

26. Etiology of symptoms • Abscess-Collection of pus at the anus or rectum • Fistula-Tunnel that forms from the inflamed bowel and adheres to the rectum or vagina, an abscess could also be present • Toxic megacolon-life threatening but rare, distention of the colon with air

27. Etiology of symptoms • Sepsis-Infection (usually in GI track from ulcers) that spreads through the blood stream • Joint pain-arthritis of central, spinal or peripheral joints • Skin rash- can present as reddish purple, tender bumps on the legs and arms

28. Etiology of symptoms • Oral ulcers-Multiple small pustules, ulcers and abscess, or irregular large apthous ulcers • Eye problems-cataracts or glaucoma can be side effects of long-term use of corticoid steroids

29. Etiology of symptoms • Liver disease-Bile ducts narrow due to inflammation and scarring • Pancreatitis-inflammation of the pancreases • Pericarditis-Inflammation around the heart • Osteoporosis-Inflammation of small intestine leads to poor Ca absorption

30. Medical Management • There is no cure • The goal is of medical treatment is to suppress the inflammatory response • Medical therapy is used to decrease frequency of flares • 2/3 of patients with Crohn’s Disease will require surgery at some point during their lives.

31. Medical Management • Surgery is necessary when medications can no longer control the symptoms, it may also be needed to repair a fistula or fissure. • Surgery may also be required if there is intestinal obstruction or another complication such as an intestinal abscess. • Bowel may need to be resected, this procedure is called anastomosis, where 2 ends of a healthy bowel are joined together

32. Medical Management • Another surgical procedure called an ileostomy may be needed also, this is performed when the colon is diseased. The colon is completely removed and a small pouch is attached to the abdomen. This procedure is only done when the rectum can not be used for anastomosis • Patient needs a colonoscopy every 3-5 years

33. Patient Management • Pay special attention to diet (may need to eat soft, bland foods when the disease is active) • Good nutrition is essential • More caloric intake is needed due to the disease • Drink lots of fluids, patients with this disease can become dehydrated due to symptoms

34. Dental Management • Thorough medical history review • If patient presents with chronic oral lesions the lesion should be biopsied and patient should be referred for GI evaluation • Oral lesions have been treated effectively with medium and high potency topical steroids

35. Treatment Planning • Nutritional counseling • Fluoride for caries control • Biotene for xerostomia • Referral to MD (for patients that have not been diagnosed with the disease) • 4 quad scale (medium) • Selective polish

36. Appt. 1 Assessments FMX DDS exam 2nd check in PI OHI (tell patient about Biotene and show how to use) Appt. 2 OHI Nutritional counseling UR quad scale Treatment Plan

37. Appt. 3 PI OHI Nutritional counseling LR quad scale Appt. 4 OHI Nutritional counseling UL quad scale Treatment Plan

38. Appt. 5 PI OHI Nutritional counseling LL quad scale Fluoride tx Selective Polish Appt. 6 4 week recall Review OHI and Nutritional counseling Treatment Plan

39. Appt. 7 3 month recall Treatment Plan

40. References • Crohn’s & Colitis Foundation of America (2008). About Crohn’s Disease. Retrieved February 28, 2008, from http://www.ccfa.org/printview?pageUrl=/info/ • about/crohns • 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. • 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.

41. Answers to Crohn’s Disease quiz • Which ethnic group is most likely to develop Crohn’s Disease? Caucasian, especially Jews. • What is the ultimate cause of Crohn’s Disease? Unknown, research is still being done. • What are 3 of the most common symptoms of Crohn’s Disease? Persistent diarrhea, abdominal cramps, fever, malaise, rectal bleeding, and loss of appetite.

42. Answers to Crohn’s Disease quiz • How often should a patient get a colonoscopy if they currently have Crohn’s disease? Every 3-5 years • Does a patient that presents with Crohn’s disease need a med consult? No, but he should be referred to an MD if he presents with chronic oral lesions and GI issues • What are 2 other names for Crohn’s Disease? Regional Enteritis and Inflammatory Bowel Disease