Lenette Sparacino has had dental issues for as long as she can remember. “I’ve probably had at least 30 cavities over my lifetime, if not more,” she says. “I remember as a child getting seven cavities filled at one time.” She also remembers being plagued by mouth ulcers and gum inflammation. Years later, she started experiencing digestive symptoms, and was ultimately diagnosed with Crohn’s disease in 2014.
Her official diagnosis inspired her to learn more about her condition from online resources. “I started understanding that Crohn’s could affect your dental health,” she says. That’s when it all clicked: Years of untreated inflammation had been at the root of both her digestive problems and her dental problems.
It may not be immediately obvious, but your mouth is a key part of your gastrointestinal tract. “Crohn’s disease in particular involves any part of the GI tract, anywhere from the oral cavity down to the colon and the anus,” says Dr. Shirley Cohen-Mekelburg, a spokesperson for the American Gastroenterological Association and assistant professor and gastroenterologist focusing on IBD at Michigan Medicine.
You can think of it all as one long pipeline, adds Dr. Earl Campbell, a gastroenterologist at Wellstar Health System. And your mouth and your intestines aren’t just linked physically, but also chemically. “They’re anatomically continuous, and saliva and digestive enzymes are passing from the mouth through the gut,” he says.
This is commonly referred to as the “oral-gut axis,” a communication pathway from the mouth to the anus, along which inflammation can spread its effects. And that inflammation is especially perilous in the case of the inflammatory bowel diseases (IBD) Crohn’s disease and ulcerative colitis. People with IBD are more likely to have gum inflammation than people without these conditions. And vice versa: Those with oral inflammation and various dental health symptoms are likelier to have gut trouble, too.
In fact, as many as 35% of people with IBD have some kind of oral manifestation of the condition, such as canker sores, the gum disease gingivitis, cavities, and angular cheilitis, which causes painful sores at the corners of the mouth. Oral symptoms are slightly more common in people with Crohn’s disease than in those with ulcerative colitis.
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Oral symptoms can crop up before, at the same time, or after intestinal symptoms arise. But people with Crohn’s disease may be more likely to notice oral lesions before any other symptoms appear.
Sparacino, who now shares about her experience with IBD on Instagram and Tiktok @_lifewithcrohnsdisease_, had to come to that realization on her own. She never had a gastroenterologist explain that dental hygiene can be related to IBD or a dentist who asked her about any oral symptoms, even knowing she has Crohn’s disease. “I feel like there’s a big gap between doctors and dentists either not knowing or not sharing this information and patients not knowing this information,” she says. She estimates it took her about four to five years after her Crohn’s diagnosis to discover the link with oral health symptoms.
Ideally, a care provider will help you navigate this relationship. Pointing out that canker sores are a common manifestation of Crohn’s disease, especially during a flare-up of symptoms, for example, helps empower patients to understand their experiences, Cohen-Mekelburg says. She makes sure to explain this link to newly diagnosed patients.
Research supporting this relationship has gained more traction in the last 10 years or so, says dentist and periodontist Andre Paes, a tenured associate professor at Case Western Reserve University, who has researched the link between gastrointestinal disorders and gum diseases. “There are potential inflammatory mediators…in the mouth that could affect other parts of the body and vice versa,” he says.
For example, IBD-related inflammation has also been associated with higher risks of diabetes and heart disease, he says. In addition, there’s been a growing appreciation for the way an imbalance of bacteria in the gut—a common marker of IBD called dysbiosis, which can spark inflammation—may also affect the balance of bacteria in the mouth, he says.
It makes a certain amount of intuitive sense: “If you’re worsening systemic inflammation [anywhere] in the body, you’re going to worsen IBD as well,” Campbell explains. Plus, “more than half of the bacteria in the human body resides in the GI tract and the oral cavity,” Campbell says. In fact, 29% resides in your gut and 26% resides in your mouth. But there’s still a lot to be discovered about how those major hubs of bacteria might be influencing each other along the oral-gut axis, he says.
What experts still don’t know
It’s unclear exactly why some people have oral IBD symptoms and others don’t, Cohen-Mekelburg says.
We also still need more research on which oral bacteria might contribute to gut symptoms and vice versa, as well as exactly how an imbalance of bacteria in one area affects the balance in another, Campbell adds.
But as future research learns more about how bacteria in the mouth may lead to IBD, addressing an oral bacteria imbalance might help delay or prevent disease progression, Cohen-Mekelburg hypothesizes.
For now, the direction of that relationship isn’t even understood, Paes adds. We still don’t know if changes in oral inflammation and bacteria imbalances happen before or after similar changes in the gut. The answer could one day change the course of treatment.
And if researchers were to identify the specific strains of bacteria involved in oral or gut inflammation, people with IBD might be able to take specific probiotics to help restore balance to their oral or gut microbiomes, Campbell says.
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Common risk factors underlie both
Amid the unknowns, there are some known risks for both IBD and dental health concerns.
For example, “we know that smoking can impact your gum health and your oral health, and it could definitely impact your GI health in general,” Cohen-Mekelburg says. “Patients who have Crohn’s disease who smoke are much more likely to have severe disease.”
IBD may also affect how your body absorbs certain nutrients, and when you’re low in some key vitamins or minerals, you might be more likely to experience oral health symptoms. “Angular cheilitis or glossitis are two manifestations you can get around the mouth or on the tongue that could actually be a sign of a vitamin deficiency with IBD, but not necessarily the IBD itself,” Cohen-Mekelburg says.
Taking care of your oral and your gut health
If you have any concerns about your oral health, it can’t hurt to talk to your dentist and ask if you have signs of inflammation in your mouth, Paes says.
In general, it’s important to discuss any changes in oral or gut symptoms with your doctors, too. “Be aware of what symptoms you’re experiencing and begin to differentiate what the issues are,” Cohen-Mekelburg says. “Talk to your doctor about anything that’s concerning, and then it’s the job of your care team to help build your awareness of what [symptoms] matter most.”
Together, your care providers might help you identify patterns in your symptoms. For example, maybe your oral symptoms worsen around flare-ups of your digestive symptoms. In that case, you want to make sure you’re following your treatment protocol to limit flares as much as possible. “It’s about being proactive, making sure patients are taking medications, that they’re healing,” Cohen-Mekelburg says.
If your IBD treatment protocol involves medications like steroids, which fight IBD-related inflammation, you might also notice reduced inflammation in your mouth, Paes says. When you have IBD, it’s generally a good idea to limit your exposure to factors that can increase inflammation throughout your body—like air pollution, chronic stress, or infections—as they might affect both oral and digestive symptoms, he adds.
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Your gastroenterologist might not always think to mention it (appointments are short, after all), but it’s also important to keep up with general dental hygiene practices, Campbell says. That means “brushing, flossing, and making sure you get regular cleanings.” He acknowledges that’s easier said than done: “My wife is a dentist and it’s been a while since I’ve gone in to get a cleaning, so I think individuals with IBD should be more vigilant on making sure they’re getting in for their routine cleanings with their dentists.”
Sparacino does all she can to ensure her gums and teeth stay as healthy as possible. For example, she uses an extra-strength toothpaste designed for people at higher risk of cavities and tooth decay that a new dentist recommended after she explained her Crohn’s disease and oral health history. “I’ve used that for probably five or six years, since I kind of put the pieces together, and I’ve noticed a lot fewer mouth issues since then. I’m not having cavities at the rate I was having them before.”
Her Crohn’s treatment seems to be helping, too. Ever since starting a type of medication called a biologic, which targets specific proteins to decrease inflammation, she’s rarely had mouth ulcers or gum irritation. “When I would floss, my gums would be so sore. Now, they’re just normal,” she says. She also avoids sticky, chewy sweets like caramel, doesn’t skip dental cleanings, and flosses regularly. “I just try to make a point to take care of my mouth really well.”
