Oral manifestations of inflammatory bowel disease

What is inflammatory bowel disease?

There are two main forms of inflammatory bowel disease – ulcerative colitis and Crohn disease. Both are characterised by abdominal pain and diarrhoea, sometimes with bleeding.

• Ulcerative colitis typically involves only the colon (large bowel)
• Crohn disease can affect any part of the gastrointestinal tract from the lips to the anus with scattered lesions. Crohn disease is characterised on pathology by non-caseating granulomas but these are not always found on bowel biopsy.

Although the two diseases are quite separate, accurate diagnosis can sometimes be difficult especially in the early stages. Therefore involvement of other organs can help to make the distinction.

Involvement of body sites other than the bowel in inflammatory bowel disease

Both forms of inflammatory bowel disease can develop symptoms and signs in addition to the bowel disease. Changes in the skin and oral mucosa can develop with both, but are more commonly seen with Crohn disease. Sometimes these develop before the diagnosis of inflammatory bowel disease, leading the doctor to investigate for bowel problems. In some patients they may appear with flares of the bowel inflammation. Where the association is specific with diagnostic histology, it can be valuable in making the diagnosis.

Oral mucosa signs of inflammatory bowel disease

The changes of the face and oral mucosa associated with inflammatory bowel disease can be divided into four main categories:

1. Specific, meaning these occur only in association with the bowel disease and/or show characteristic histology of that condition.
2. Non-specific, meaning these occur more commonly with the bowel disease than in the general population, but also do occur without bowel disease, and the pathology is not diagnostic for the bowel disease.
3. Complications of malabsorption caused by the bowel inflammation resulting in deficiencies in vitamins and minerals.
4. Side effects or complications of medications prescribed to treat the bowel disease.

The first three of these categories may be useful in directing the doctor to the bowel problem and making the specific diagnosis.

Oral signs of Crohn disease

The oral mucosa is commonly affected in Crohn disease with up to one third of patients reported to have oral changes, and even higher in children. In some studies, the oral changes preceded the diagnosis of Crohn disease in 60%. There may be a male predominance.

1. Specific oral mucosal changes: orofacial Crohn disease

In children with Crohn disease, orofacial Crohn disease can be an important presentation preceding the bowel diagnosis.

2. Nonspecific changes in the mouth and surrounding facial skin associated with Crohn disease:

• Angular cheilitis
• Aphthous ulcers/aphthous stomatitis – has been reported to affect up to 20-30% of patients with Crohn disease, although some studies show no increase in this compared to the general population. These cannot be distinguished clinically from the common aphthous ulcers.
• Recurrent abscesses
• Redness and scaling around the lips
• Pyostomatitis vegetans – very rare in Crohn disease
• Dry mouth – can result in dental decay, denture discomfort and infection
• Bad breath (halitosis)
• Recurrent vomiting and regurgitation can cause oral pain and the acid result in dental decay.

Oral signs of ulcerative colitis

Mucosal changes have been reported in some patients with ulcerative colitis.

1. Specific orofacial changes of ulcerative colitis: pyostomatitis vegetans

2. Nonspecific changes of the mouth and surrounding skin associated with ulcerative colitis:

• Minor and major aphthous ulcers/stomatitis – reported in at least 10%, usually worse with flares of the bowel disease and improving with treatment of the bowel inflammation. However this is probably no more common than the general population.
• Glossitis (inflamed tongue)
• Cheilitis (inflamed lips)
• Bad breath (halitosis)

In children with ulcerative colitis, only nonspecific changes were seen in one large study.

Orofacial signs of malabsorption

Malabsorption may be due to the chronic diarrhoea, reduced food intake, overgrowth of bacteria in the bowel, bowel surgery, the disease itself, or the drugs used to treat the bowel disease.

• Folic acid deficiency (Crohn disease as absorbed from small bowel) – red painful tongue (acute), becomes shiny and smooth (chronic) (glossitis), and cracked lips (cheilitis).
• Iron deficiency
• Zinc deficiency – acrodermatitis enteropathica and acrodermatitis enteropathica-like conditions, oral candidiasis, glossitis
• Vitamin A deficiency – white patches on oral mucosa due to keratinization of mucous membranes
• Vitamin B complex deficiency – stomatitis-glossitis-angular cheilitis
• Riboflavin (vitamin B2, Crohn disease as absorbed from small bowel) – cheilosis, angular cheilitis, glossitis
• Niacin (vitamin B3) deficiency – pellagra
• Vitamin B12 deficiency (Crohn disease as absorbed from small bowel) – glossitis (beefy red tongue with flat red patches mainly on the sides and top of the tongue), angular cheilitis, mouth ulcers, oral candidiasis, diffuse erythematous mucositis, pale oral mucosa, soreness of the tongue or mouth, burning mouth, reduced taste sensitivity
• Vitamin C deficiency – scurvy
• Vitamin K deficiency – gum bleeding

Orofacial changes due to medications used to treat inflammatory bowel disease

Many different medications may be used to treat various aspects of inflammatory bowel diseases including antibiotics, biologic agents, immunosuppressants, anti-diarrhoeal agents and for pain. An alphabetical listing of some of the more common treatments follows, with their oral side effects.

Azathioprine and mycophenolate mofetil, often used to treat inflammatory bowel disease, do not have reported side effects in the mouth.