Dissertation committee:
Ελευθερία Ρώμα-Γιαννίκου, Ομότιμη Καθηγήτρια Παιδιατρικής, ΕΚΠΑ
Σουλτάνα Σιαχανίδου, Επίκουρη Καθηγήτρια Παιδιατρικής ΕΚΠΑ
Αλεξάνδρα Τσάμη, Αναπληρώτρια Καθηγήτρια Οδοντιατρικής, ΕΚΠΑ
Βασιλική Συριοπούλου, Ομότιμη Καθηγήτρια Παιδιατρικής, ΕΚΠΑ
Ευδοξία Πεπελάση, Αναπληρώτρια Καθηγήτρια Οδοντιατρικής, ΕΚΠΑ
Αικατερίνη Καββαδία, Αναπληρώτρια Καθηγήτρια Οδοντιατρικής, ΕΚΠΑ
Ιωάννης Καρούσης, Αναπληρωτής Καθηγητής Οδοντιατρική, ΕΚΠΑ
Summary:
Introduction: Previous reports have demonstrated a higher prevalence of dental caries and periodontal disease in adults with inflammatory bowel disease (IBD), but similar data in children and adolescents do not exist.
Aim: The aim of the present prospective case-control study was to evaluate the prevalence of dental caries and periodontal disease, gingivitis or periodontitis and the periodontal treatment needs of children and adolescents with IBD, by a full mouth detailed examination, and to compare them with the findings of an age and sex matched healthy population of a dental practice.
Patients and methods: In this case-control study, were assessed prospectively 55 children and adolescents with IBD in remission (25 boys and 30 girls), aged 4-18 years (mean age: 12.32±3.41), who were followed up at the outpatient IBD clinic of the Gastroenterology Unit, at the Department of Pediatrics of University of Athens, “Agia Sophia” Children’s Hospital. The diagnosis of Crohn (CD) or ulcerative colitis disease (UC) was established according to the Porto criteria. Also, 55 systematically healthy children and adolescents (25 boys and 30 girls), aged 4-18 years (mean age: 12.21±3.96) were assessed as a control group. Patients with IBD and controls were matched according to age, sex and social-economic status, while were derived from the same geographic area.
Patients with IBD or controls were excluded if one or more of the following conditions were observed: systematic conditions or medications with impact on periodontal tissues or gingival overgrowth and previous orthodontic or periodontal treatment within last year and smoking habits.
In children and adolescents with IBD a detailed medical history was obtained and their records concerning disease onset, previous and current medical therapy was reviewed, followed by oral medical history (questionnaire) answered by patient or accompanying parent. A physical examination was performed and the Pediatric Crohn’s Disease Activity (PCDAI) or the Pediatric Ulcerative Colitis Activity Index (PUCAI) was used to assess disease activity in CD and UC patients, respectively. Immediately after assessment by the pediatric gastroenterologist, an oral and dental examination was performed in the IBD clinic. In the control group, a detailed medical history was obtained but a physical examination was not performed.
A questionnaire was filled out for patients with IBD and healthy participants, in order to collect demographic data (age, sex and occupation of their fathers) as well as dental mucosal history including the oral lesions before disease inset or during IBD disease. All participants, patients or controls, were answered closed-ended questions regarding frequency (twice per week, once per day, twice or more per day), method (horizontal, vertical, circular, other) and duration (< 1 min, 1-2 min, >2 min) of toothbrushing, frequency and reason of dental visits (only with dental problem, such as dental pain, abscess or for oral health check-ups every 6 months or 12 months) and symptom of periodontal disease, such as gum bleeding on toothbrushing (yes or no).
An oral examination in both patients with IBD and controls was performed to assess the decayed, missing and filled of deciduous (dmf-t) or permanent (DMF-T) tooth index, the simplified gingival index (GI-S), the plaque control record (PCR) index and the community periodontal index of treatment needs (CPITN). These indices were recorded on all present full-erupted deciduous or permanent teeth.
All these clinical examinations and measurements were taken by the same examiner (VK) throughout the study, using a conventional periodontal probe (PCP-11, Hu-Friedy, Chicago, IL, USA), calibrated to reduce intra-observer variation (Kappa scores were greater than 0.80) and to establish reliability and consistency prior to the beginning of the present study.
For comparison, the distribution of categorical variables, such as oral hygiene habits, bleeding on toothbrushing, frequency and reason of dental visits and CPITN, among the patients with IBD and a control population, was performed the X2 test or Fisher’s exact test for small numbers. Also, for the comparison of existing total or deciduous or permanent teeth or percentages of CIPTN-scores was used z-test, whereas for the comparison of the average of mean values of each index (GI-S, PCR) Student’s t-test was performed. Logistic regression models were used to evaluate the association between personal oral hygiene habits, bleeding on toothbrushing, as well as frequency and the reason of dental visits (as independent variables) and GI-S index or CIPTN, separately for each of group subjects.
Statistical analysis was conducted using the STATA 9.0 software package and the results were considered significant at 1% significant level (p≤0.01).
Results: Oral mucosa history revealed that 23.63% (13 out of 55) patients with IBD had oral lesions. The most common oral lesion was aphthae (8 patients) or aphthae in conjunction with non-specific swellings of mucosa and lips or candidiasis (5 patients). Compared to controls, the mean values of dental caries indices of deciduous (2.95 versus 1.87) and permanent (5.81 versus 2.05) teeth in patients with IBD were 3.2 and 2.8 times higher and this difference was statistically significant (p<0.001).
The mean value of simplified gingival index in patient with IBD (GI-S=40.24%) was statistically significantly higher (p<0.001) than controls (GI-S=24.95%), while there was no respectively significant difference between mean values of plaque control index in patients with IBD (PCR=42.29%) and controls (PCR=41.96%). The mean value of simplified gingival index was higher in patients with Crohn’s disease (GI-S=40%) than in patients with ulcerative colitis (GI-S=39.09%), but this difference was no statistically significant. A statistically significant difference (p<0.001) was found between mean values of simplified gingival index (GI-S=47.23%) and plaque control index (PCR=49.36%) in patients with IBD on immunomodulation compared to those without immunomodulation (GI-S=32.93% and PCR=34.95%).
A statistically significant difference in gum bleeding on toothbrushing in IBD group (54.55%), compared to controls (29.09%), especially in patients on immunomodulation (38.18%).
Among patients with IBD 54.55% had gingivitis (corresponding to CPITN=2), while 36.36% had only gingival bleeding (corresponding to CPITN=1), 9.09% had at least one side with periodontal probing depth between 4 and 5 mm (corresponding to CPITN=3) and none of them was found having healthy periodontium (corresponding to CPITN=0). On the other hand, among the controls, 45.45% had only gingival bleeding, while 40% of the subjects had a healthy periodontium.
Patients with IBD on immunomodulation had increased periodontal treatment needs compared to patients without immunomodulation, especially for simple gingivitis treatment (34.55% versus 20%, corresponding to CPITN=2), or in conjunction with root planning (9.09% versus 0% (corresponding to CPITN=3).
The higher value of simplified gingival index (GI-S) in patients with IBD had a statistically significant positive correlation with mean value of plaque control index (PCR), regardless of immunomodulators, bleeding of gums on toothbrushing and method of toothbrushing, but a negative correlation with duration and frequency of toothbrushing, as well as with the frequency and the reason of dental visits was found.
The increased periodontal treatment needs (CPITN) in patients with IBD had a statistically significant positive correlation with the mean values of simplified gingival (GI-S) and plaque control (PCR) indices, as well as bleeding of gums on toothbrushing, but a negative correlation with the duration of toothbrushing.
Conclusion: Children and adolescents with IBD had higher prevalence of dental caries and periodontal disease, compared to healthy controls. Therefore, they need special dental care not only for management but also for prevention of dental and periodontal problems.
