Transcript Crohn’s Disease

Crohn’s Disease
Medically Compromised
DEH 26
Tawnya Balla, Ceri Blinsmon,
Britney Fernandez, & Ferris Prado
Medical History
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Name: Tony Hawk
Male
28 years old
Caucasian
Med student
Single
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
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
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
Social History
• Patient states that he drinks alcoholic
beverages 1 time per week
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
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
Hospitalizations
• Patient was hospitalized in October 2007
due to Crohn’s Disease issues
ASA status
• ASA II- due to systemic illness
Vitals
• Blood pressure: 110/70
• Respiration: 14
• Pulse: 67
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
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
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
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
Etiology
• The etiology of Crohn’s disease is
unknown, but research has been conducted
to determine genetic relationships
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
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 proinflammatory imbalance
• taken from Clinical Advisor
Signs and Symptoms
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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
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fissures
abscesses
fistula
toxic megacolon
sepsis
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.
Crohn’s Disease is a systemic condition causing
extraintestinal manifestations effecting 25%
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More common
joint pain
skin rash
oral ulcers
gall stones
liver disease
eye problems
growth retardation in
children
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Other less common
anemia
blood clots
kidney stones
nerve damage
lung disease
pancreatitis
pericarditis
menstrual irregularities
severe gingivitis
osteoporosis
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)
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).
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).
Etiology of symptoms
• Anemia- caused from gastrointestinal
bleeding
• Obstruction, perforation or hemorrhageinflammation 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
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
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
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
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
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.
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
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
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
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
Treatment Planning
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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
Treatment Plan
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Appt. 1
Assessments
FMX
DDS exam
2nd check in
PI
OHI (tell patient about
Biotene and show how
to use)
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Appt. 2
OHI
Nutritional counseling
UR quad scale
Treatment Plan
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Appt. 3
PI
OHI
Nutritional counseling
LR quad scale
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Appt. 4
OHI
Nutritional counseling
UL quad scale
Treatment Plan
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Appt. 5
PI
OHI
Nutritional counseling
LL quad scale
Fluoride tx
Selective Polish
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• 4 week recall
• Review OHI and
Nutritional counseling
Treatment Plan
• Appt. 7
• 3 month recall
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.
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.
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