Crohn's disease / inflammatory bowel disease

Oral health effects

• Cobblestone-like swelling of the inner cheeks (mucosal cobblestoning)

  Deep, transverse and longitudinal ulcerations divide sections of intact mucosa (usually posterior buccal mucosa) into a 'cobblestone' pattern; considered a pathognomonic finding of orofacial Crohn's disease.

  Mechanism: Granulomatous inflammation with coalescing focal ulcers forming serpiginous fissures at the oral mucosal level.

  Clinical management: Biopsy to confirm granulomatous (non-caseating) inflammation and rule out other causes; lesions have responded to biologic therapy or immunomodulators in reported cases.

• Persistent lip and facial swelling (orofacial granulomatosis / granulomatous cheilitis)

  Chronic diffuse swelling of the lips or lower face, oral ulceration, and hyperplastic gingivitis; may occur with or without concurrent bowel disease.

  Mechanism: Non-caseating granulomatous inflammation of orofacial soft tissue, immunopathologically related to intestinal Crohn's granulomas.

  Clinical management: Requires GI referral/workup, since oral lesions can precede intestinal diagnosis; treated with topical/intralesional corticosteroids or systemic biologic/immunomodulator therapy targeting underlying disease activity.

• Canker-sore-like mouth ulcers (aphthous-like ulcers)

  Round or oval, painful ulcers with a yellow pseudomembranous base; the most common oral finding in Crohn's disease, reported in roughly 13% of a large cohort.

  Mechanism: Mucosal immune dysregulation associated with active systemic inflammation, distinct from granulomatous cobblestoning.

  Clinical management: Topical corticosteroids or analgesic rinses for symptom control; flares often correlate with IBD disease activity, so recurrence warrants coordination with the patient's gastroenterologist.

• Nutrient-deficiency-related oral changes

  Malabsorption from ileal Crohn's disease can cause vitamin B12, iron, and folate deficiency, presenting orally as atrophic glossitis, angular cheilitis, mucosal pallor, and recurrent mouth ulcers.

  Mechanism: Terminal ileum involvement/resection impairs B12 absorption; chronic inflammation and GI blood loss drive iron-deficiency anemia; folate malabsorption compounds the effect.

  Clinical management: Screen for anemia/hematinic deficiency when these signs are seen; refer for lab workup (CBC, B12, ferritin, folate) and correct underlying deficiency in coordination with the patient's physician.

• Gum disease and tooth decay (periodontitis and caries)

  People with IBD have about twice the risk of periodontitis, with deeper pockets, more attachment loss and bleeding, and higher caries experience, especially in ulcerative colitis.

  Clinical management: Do a full periodontal charting at baseline and recall, reinforce plaque control, use fluoride (varnish or high-fluoride toothpaste) for caries risk, and keep shorter recall intervals during disease flares or steroid/biologic therapy.

• Pustular mouth lesions (pyostomatitis vegetans)

  A rare oral sign closely associated with inflammatory bowel disease, especially ulcerative colitis. Lesion activity tends to track bowel disease activity.

  Clinical management: Document and photograph; refer to the dentist/oral medicine and the patient's gastroenterologist, since lesions track intestinal disease activity and usually improve when the bowel disease is controlled.