From the Guidelines
Patients with Crohn's disease who develop oral lesions should be managed with a combination of treating the underlying Crohn's disease and adding topical or intralesional approaches for symptomatic relief, as the current evidence suggests that systemic treatment of isolated oral lesions should be conserved for disease unresponsive to more limited approaches. The management of oral lesions in Crohn's disease is crucial, as these lesions can affect the quality of life of patients. According to the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1, orofacial granulomatosis (OFG) is a rare disease with similar microscopic appearances to intestinal Crohn’s disease. The guidelines suggest that gastroenterologists often miss oral lesions compatible with oral Crohn’s disease, highlighting the importance of referral to an oral medicine clinic for assessment. Some key points to consider in the management of oral lesions in Crohn's disease include:
- Topical steroids and tacrolimus are often used, but with limited evidence 1
- An 8-week cinnamon and benzoate-free diet has been reported to be effective in 72% of patients with OFG, but the long-term continuation of such a diet is challenging 1
- Exclusive enteral nutrition (EEN) with Elemental 028 has been used successfully to treat children with OFG, with 10/10 of isolated OFG cases and 10/12 cases with OFG and Crohn’s disease responding 1
- Intralesional triamcinolone injection has been shown to be effective in 63.6% of patients with non-Crohn’s disease OFG, with a mean disease-free period of 28.9 months 1
- Systemic treatment with azathioprine or biologics such as infliximab or adalimumab may be considered in patients with Crohn’s disease and OFG who do not respond to topical or intralesional treatments 1.
From the Research
Oral Lesions in Crohn's Disease
- Oral manifestations of Crohn's disease (CD) include non-specific lesions and specific lesions directly related to intestinal inflammation 2.
- Specific oral lesions in CD are associated with active disease and improved with immunomodulators or biologic therapy 2.
- The most frequently observed oral lesions are oedema, ulcers, and hyperplastic lesions on the buccal mucosa, which may be asymptomatic or cause discomfort 3.
Prevalence of Oral Lesions
- The prevalence of oral lesions in patients with Crohn's disease ranges from 0.5% to 37% 3.
- A prospective study found that 12.9% of patients with active CD had indurated tag polypoid lesions, 9.7% had cobblestoning of the mucosa, and 16.2% had diffuse asymptomatic buccal swelling 4.
- Non-specific oral lesions, such as angular cheilitis and atrophic glossitis, were more frequent in patients with active CD 4.
Treatment of Oral Lesions
- Intralesional corticosteroid injections can be an effective treatment for lip swelling associated with oral Crohn's disease 5.
- Biologic therapy and immunomodulatory therapy can improve specific oral lesions in CD 2.
- The management of Crohn's disease involves a comprehensive approach, including patient risk stratification, patient preference, and clinical factors in therapeutic decision-making 6.