CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2005;3:886 – 891
A Prospective Study of the Oral Manifestations of Crohn’s
Disease
SINEAD HARTY,* PADRAIG FLEMING,‡ MARION ROWLAND,* ELLEN CRUSHELL,*
MICHAEL MCDERMOTT,* BRENDAN DRUMM,* and BILLY BOURKE*
*Children’s Research Centre, Our Lady’s Hospital for Sick Children, Department of Paediatrics, Conway Institute for Biomolecular and
Biomedical Research and Dublin Molecular Medicine Center, University College Dublin, Dublin; and ‡Dublin Dental Hospital, Trinity College
Dublin, Dublin, Ireland
Background & Aims: Recent studies suggest that the
mouth may be involved frequently in patients with
Crohn’s disease (CD). The aim of this study was to
document prospectively the proportion of children with
oral lesions at diagnosis of CD, to describe the type of
lesions found, and to examine the ability of gastroenter-
ologists to identify correctly oral Crohn’s manifestations.
Methods: In a prospective 3-year study, systematic den-
tal examinations were performed on all children with
suspected inflammatory bowel disease. Each child un-
derwent upper endoscopy, colonoscopy, and barium fol-
low-through radiography. Results: Forty-eight of 49 chil-
dren with CD were examined by the dentist. Oral CD was
found in 20 patients (41.7%). Oral findings included
mucogingivitis (12 patients), mucosal tags (4 patients),
deep ulceration (4 patients), cobblestoning (3 patients),
lip swelling (3 patients), and pyostomatitis vegetans (1
patient). Noncaseating granulomas were found in all 8
oral biopsy specimens from oral CD lesions (100%). Two
patients with granulomas in oral biopsy specimens had
no granulomas found in any other biopsy specimens.
The presence of oral manifestations was associated
with perianal disease. In only 9 patients (45%) with oral
CD was the mouth found to be abnormal by the consul-
tant gastroenterologists. Only nonspecific oral changes
were seen in children with ulcerative colitis and indeter-
minate colitis. Conclusions: More than one third of all
children presenting with CD had involvement of the
mouth. The ability of physicians to recognize oral lesions
was poor. Expert dental evaluation may be useful during
the investigation of patients with suspected inflamma-
tory bowel disease.
lthough it is recognized widely that Crohn’s disease
A (CD) can affect any site in the gastrointestinal tract
from the mouth to the anus, the recognition of oral
lesions in patients with CD and their potential clinical
relevance has evolved only recently.1,2 Patients with CD
often suffer from aphthous ulceration of the oral cavity.
However, because these ulcers also occur commonly in
patients with ulcerative colitis and in the general popu-
lation, they are not specific for CD.3 In contrast, a
number of characteristic oral lesions have been described
in patients with CD. These include swelling of the lips,
buccal mucosal swelling or cobblestoning, deep linear
ulceration, mucosal tags, and mucogingivitis.4 –12
The prevalence of oral lesions in CD has varied widely
in previous studies.8,13,14 In a recent retrospective study
performed at our centre8 we found a particularly high
prevalence of disease-specific oral lesions in children with
CD. In that study of 25 children who had been examined
by a pediatric dental surgeon at the time of initial
presentation, 48% had disease-specific oral lesions. In
addition, granulomas were found in 75% of 8 oral biopsy
specimens in that study, suggesting that the mouth may
provide an important site for obtaining diagnostic tissue
in children with symptoms of inflammatory bowel dis-
ease (IBD).8
Therefore, the aim of the present study was to docu-
ment prospectively the proportion of children with evi-
dence of oral CD at initial evaluation for suspected IBD
and to describe the spectrum of lesions found. We also
explored whether the presence of oral lesions correlated
with markers of disease severity at diagnosis, and if oral
CD was associated with a particular distribution of dis-
ease elsewhere in the gastrointestinal tract. In addition,
we compared the results of oral examination by consul-
tant gastroenterologists in the clinic setting with formal
oral examination by a pediatric dental surgeon.
Methods
Over a 3-year period between January 1999 and De-
cember 2001 we prospectively recorded the oral manifestations
in children presenting with suspected CD to the gastroenter-
ology department of Our Lady’s Hospital for Sick Children.
Abbreviations used in this paper: CD, Crohn’s disease; CI, confidence
interval; IBD, inflammatory bowel disease.
© 2005 by the American Gastroenterological Association
1542-3565/05/$30.00
PII: 10.1053/S1542-3565(05)00424-6
September 2005
More than 75% of Irish children and adolescents with pedi-
atric IBD undergo diagnostic evaluation at our institution
(Irish Paediatric Surveillance unit data 1998 –1999, unpub-
lished data).
Information was recorded prospectively on each patient
before endoscopy including age, sex, presenting symptoms,
oral symptoms, family history, and medications. Clinical
examination was performed on each patient and findings
including weight and height were recorded. Perianal find-
ings were noted. Blood samples were taken for full blood
count and liver function including albumin and C-reactive
protein levels. Small-bowel contrast studies were performed
routinely after the initial assessment. The oral cavity was
inspected thoroughly by 1 of the 2 consultant gastroenter-
ologists performing the endoscopy before examination by
the dentist and the findings were documented. For this
study, all oral examinations were performed by the same
pediatric dental surgeon (P.F.). Dental examinations were
performed in a dental chair with the use of standard light-
ing. Systematic assessment of the submandibular lymph
nodes, lips, labial mucosa and sulci, commissures, buccal
mucosa and sulci, gingiva, tongue, floor of mouth, and hard
and soft palate were performed and findings were recorded.
Oral biopsy specimens were taken only when clinically
indicated. For example, when a diagnosis of CD was clear
from other findings (eg, perianal disease), an oral biopsy
examination was not performed.
All children underwent upper gastrointestinal endoscopy
as well as colonoscopy. Biopsy specimens were taken from
grossly affected tissue and from unaffected gastric and
colonic mucosa. All biopsy specimens were formalin fixed
and paraffin embedded. Serial H&E-stained 4-␮m sections
were examined in each case. This typically represented 18 to
20 sections per biopsy specimen. When granulomas were
found, periodic acid-Schiff, Grocott, and Ziehl Neelsen
stains were performed on the specimens to rule out fungal
and mycobacterial disease.
Data were analyzed using Epi Info (CDC, Atlanta, GA).
Comparison between groups was made using odds ratios
and 95% confidence intervals (CIs) for categoric variables
and t tests for continuous variables. Statistical significance
was set at the 5% level.
Results
Over the 3-year period, 80 patients were diag-
nosed with IBD. Final diagnoses were CD in 49 (61.3%)
patients, ulcerative colitis in 22 (27.5%) patients, and
indeterminate colitis in 9 (11.3%) patients.
Occurrence of Oral Crohn’s Disease
Forty-eight of the 49 patients with CD were
examined by the dentist. Findings typical of oral CD
were found in 20 patients (41.7%). Nonspecific gin-
givitis (ie, gingival inflammation related to the pres-
ence of dental plaque) was found in 8 (16.7%) pa-
ORAL MANIFESTATIONS OF CD 887
tients, and 20 (41.7%) patients had a normal oral
examination.
Of the 20 patients with oral CD changes, 12 were boys
and 8 were girls (1.5:1) compared with 13 boys and 15
girls in children not found to have oral CD (.86:1; P ⫽
not significant). The mean age for all children with CD
was 11.95 years (SD, 2.7 y; range, 6.6 –17.1 y). The
mean age of children with oral CD was 11.4 years (SD,
2.5 y) and without oral CD was 12.3 years (SD, 2.8 y; P
⫽ not significant). No patient was being treated specif-
ically for oral lesions. Patients with oral CD were signif-
icantly more likely to complain of oral symptoms (odds
ratio, 4.9; 95% CI, 1.20 –20.01; P ⫽ .01) and most
complained of more than 1 symptom (mouth ulcers in 11
patients, angular stomatitis in 5 patients, and cheek/lip
swelling in 8 patients). However, there was no difference
in the duration of oral symptoms between the groups
(mean difference, 2.9 mo; 95% CI, ⫺4.7 to 10.5). The
duration of oral symptoms ranged from 1 to 56 months
(mean, 4.9 mo; SD, 12.7 mo). Oral symptoms did not
precede systemic symptoms in any of the patients with
oral CD.
Manifestations of Oral Crohn’s Disease
More than half the patients (n ⫽ 11) had more
than 1 type of oral lesion (Figure 1). The most common
oral finding was mucogingivitis (n ⫽ 12), followed by
mucosal tags (n ⫽ 4), deep ulceration (n ⫽ 4), cob-
blestoning (n ⫽ 3), and lip swelling (n ⫽ 3). One patient
had pyostomatitis vegetans. Oral biopsy examinations
were performed on 8 patients with oral CD. Noncaseat-
ing granulomas were found in biopsy material from all 8
patients (100%) undergoing oral biopsy examination.
Five patients had biopsy specimens taken from areas of
mucogingivitis, 1 patient from a tag, 1 patient from an
area of cobblestoning, and 1 patient from an ulcer. Most
of the oral biopsy specimens were taken from the buccal
mucosa. Two patients with granulomas in oral biopsy
specimens did not have granulomas present in multiple
biopsy specimens taken from the upper and lower gas-
trointestinal tract.
Clinical and Laboratory Features Associated
With Oral Crohn’s Disease
There was no difference in the frequency of intes-
tinal and systemic symptoms (Table 1) or the severity of
laboratory markers (Table 2) between the 2 groups. The
site of intestinal CD was compared in those with and
without oral CD. Five children were infected with Hel-
icobacter pylori. The presence or absence of Crohn’s gas-
tritis, as opposed to H pylori gastritis, could not be
888 HARTY ET AL CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 3, No. 9

Figure 1. (A) Lip swelling with fissures. (B) Cobblestone appearance of the buccal mucosa. (C) Linear ulceration deep in the mandibular vestibule.
(D) Mucosal tag on the buccal aspect of the gingiva. (E) Mucogingivitis in relation to the maxillary permanent incisors.

distinguished reliably in these patients and, therefore,
they were excluded from this analysis. Among the re-
maining 43 children, those with oral CD were signifi-
cantly more likely to have perianal disease than those
without oral CD (10 of 20 [50%] compared with 4 of 23
[14%]; P ⫽ .023, based on univariate analysis). How-
ever, other sites of disease were affected similarly in both
groups (Table 3).
Ability of Physicians to Recognize Oral
Crohn’s Disease
Forty-six children with CD had oral findings
recorded by both the pediatric gastroenterologist and
the dentist. Agreement between the dentist and gas-
troenterologist was poor (␬, .22; 95% CI, ⫺.06 to
.50). In 8 children without oral CD the gastroenter-
September 2005 ORAL MANIFESTATIONS OF CD 889

Table 1. Comparison of Intestinal and Systemic Manifestations Among Patients With and Without Oral CD
Oral CD Nonoral CD
(total ⫽ 20) (total ⫽ 28)

Symptoms n % n % Odds ratio 95% CI P

Loss of appetite 12 60 19 68 .71 .18–2.8 NS

Oral symptoms 14 70 9 32 4.93 1.2–20.8 0.01
Mouth ulcers 11 55 9 32 2.58 .7–9.9 NS
Angular stomatitis 5 25 4 20 2.00 .4–11.6 NS
Cheek swelling 5 25 0 0a
Vomiting 2 10 7 25 .33 .03–2.10 NS
Epigastric pain 0 0a 1 4
Abdominal pain 17 85 25 89 .68 .08–5.74 NS
Tenesmus 3 15 5 18 .81 .11–4.88 NS
Blood per rectum 14 70 15 53 2.02 .05–8.30 NS
Constipation 3 15 1 4 4.76 .34–259.2 NS
Malena 0 0a 0 0
Perirectal disease 13 65 11 39 1.18 .37–3.8 NS
Arthritis 0 0a 2 7
Clubbing 5 25 9 32 .7 .15–2.98 NS
Erythema nodosum 2 10 2 7 1.44 .1–21.48 NS
Uveitis 0 0a 0 0

NS, not significant.

aNo calculations were performed for cells with zero values.

ologist classified the mouth as abnormal, and in 11
(55%) children with oral CD the gastroenterologist
failed to identify the oral CD lesions correctly. The
presence of mucogingivitis appeared to be particularly
difficult for the nonoral expert to appreciate with only
4 of 12 cases correctly identified.
Oral Findings in Children With Ulcerative
Colitis and Indeterminate Colitis
Although this study aimed to document the oc-
currence of oral findings in CD, a substantial proportion
of children ultimately diagnosed with ulcerative colitis
or indeterminate colitis also were examined. Of 22 pa-
tients diagnosed with ulcerative colitis during the study
period, a dental examination was performed in 15
(68.2%). Only 2 patients had abnormal oral findings,
comprising nonspecific gingivitis related to periodontal
disease in both. Of these children 1 underwent oral
biopsy examination that revealed the presence of acute
and chronic inflammation without granulomas. Simi-
larly, 7 of 9 patients with indeterminate colitis were
examined by the dentist. Two patients were found to
have nonspecific gingivitis; 1 patient underwent oral
biopsy examination that revealed the presence of acute
and chronic inflammation without granulomas.
Discussion
In this prospective study we confirmed that chil-
dren with CD commonly harbor disease-specific oral

Table 2. Comparison of Clinical and Laboratory Data for Patients With and Without Oral CD
Laboratory value Oral CD, N ⫽ 20 (SD) Nonoral CD, N ⫽ 28 Mean difference 95% CI of mean difference

Hemoglobin 99.9 (34.6) 108.7 (15.6) ⫺8.8 ⫺23.7 to 6.1

Hematocrit 30.6 (11.5) 32.3 (7.8) ⫺1.7 ⫺7.3 to 3.9
MCH 21.1 (8.1) 24.3 (2.8) ⫺3.1 ⫺6.4 to .17
MCV 69.9 (17.4) 75.3 (6.4) ⫺5.4 ⫺12.6 to 1.8
Albumin 32.6 (5.3) 34.4 (6.4) ⫺1.7 ⫺5.4 to 1.8
ESR 37.1 (20.9) n ⫽ 11 36.6 (18.4) n ⫽ 15 .5 ⫺15.5 to 16.5
CRP 39.2 (35.1) n ⫽ 15 30.5 (25.5) n ⫽ 19 8.7 ⫺12.4 to 29.8
Platelets 539.9 (233.8) 543.7 (136.5) ⫺3.8 ⫺111.7 to 104.1
Duration of symptoms 12.7 (17.7) 9.7 (8.1) 2.9 ⫺4.68 to 10.54
Duration of oral 4.2 (12.6) 1.1 (5.1) 3.2 ⫺2.12 to 8.44
symptoms

NOTE. The use of ESR was replaced by CRP at our institution.

MCH, mean cell hemoglobin; MCV, mean cell volume; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein.
890 HARTY ET AL
Table 3. Disease Location: Comparison of Site of Disease in Children With and Without Oral Lesions Using Single Group
Comparisons
Oral CD Nonoral CD
(total ⫽ 20) (total ⫽ 23)
Site of
disease n % n %
Stomach 19 95 20
Small bowel 9 45 6 26
Ileum 7 35 11
Colon 19 95 16
Perianal 10 50 4 17
NS, not significant.
manifestations at the time of diagnosis. At more than
40% the occurrence of oral CD correlates well with the
findings of a previous retrospective study at our institu-
tion.8 In that study, 48% of 25 children had oral in-
volvement at the time of diagnosis of CD. The slightly
lower proportion of children with oral CD in the present
cohort likely is accounted for by selection bias inherent
in the retrospective design of our previous investigation.
However, taken together, these studies clearly indicate
that the oral cavity is a useful source of diagnostic
material in children presenting with IBD.
Previously8 we have speculated as to the reasons un-
derlying the relatively higher prevalence of oral CD in
our population compared with other studies.4,5,13,14 Fac-
tors such as possible increased involvement of the prox-
imal gastrointestinal tract in younger patients15 and
examination at the time of diagnosis, before the institu-
tion of drug therapy, may have increased the relative
numbers of children with oral CD in our population.
However, routine examination of the oral cavity by an
experienced dental surgeon was perhaps the major factor
underlying the high prevalence of oral CD findings in the
present study. Although our pediatric gastroenterology
group have an established interest in oral CD, the ability
of the physicians in this study to identify and classify
accurately the oral CD findings was poor (␬, .22; 95%
CI, ⫺.06 to .50). Clearly, to be useful, oral examination
in patients with IBD requires involvement of an experi-
enced dentist or oral physician.
The potential usefulness of oral CD findings as a
source of diagnostic material in patients with CD is
underscored by the frequency with which granulomas are
identified in these lesions. In the present study we could
not justify on ethical grounds a routine oral biopsy
examination, especially in children in whom the diagno-
sis of CD was in little doubt (eg, those with perianal
disease at presentation). However, when oral biopsy ex-
amination was performed granulomas were identified in
all 8 lesions pre-identified as those of oral CD. In con-
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Vol. 3, No. 9
Odds ratio 95% CI P
86 2.85 .25–157.35 NS
2.32 .54–10.24 NS
48 .59 .14–2.36 NS
70 8.31 .87–393.89 NS
4.75 1.0–25.35 .023
trast, the 2 biopsy specimens from patients with ulcer-
ative and indeterminate colitis harbored nonspecific in-
flammatory changes without the presence of granulomas.
The type of mouth lesions identified in the present
study covered the spectrum of oral CD manifesta-
tions.4 –11 In our previous study8 mucosal tags and labial
swelling were the most common oral CD findings. How-
ever, in the present study mucogingivitis (Figure 1E) was
the single most common manifestation. This lesion is
particularly difficult for physicians without oral expertise
to identify accurately. When a biopsy examination was
performed we found areas of mucogingivitis to harbor
granulomas commonly, findings that simultaneously
support the contention that these particular lesions are
genuine disease-specific manifestations of CD and also
emphasize their potential contribution toward establish-
ing a diagnosis of CD in an individual patient.
Previous studies have pointed to an apparent associa-
tion between ileocolonic disease and oral CD,2– 4 and in
our original retrospective cohort8 we found that inflam-
mation of the proximal gastrointestinal tract was more
common in children with oral CD. However, in the
present study, apart from an increased prevalence of oral
CD in those with perianal disease, we could not show
that those with oral manifestations differed phenotypi-
cally from children without oral CD. It is noteworthy
that in the present study histologic evidence of inflam-
mation was found very commonly in the stomachs of
children with CD, regardless of the presence or absence
of oral changes (Table 3). This finding is in keeping with
data from a previous retrospective study we published
that showed a very high prevalence of inflammation in
the gastric mucosa of children with IBD.16
It has been suggested that oral CD is a Celtic disease17
and it is possible that the apparent variation in preva-
lence of oral CD reflects ethnic differences in suscepti-
bility to this extraintestinal manifestation of IBD. In this
respect a recent genetic study of Irish and Scottish pa-
tients with CD suggests that NOD2/CARD 15 muta-
September 2005
tions may be less prevalent than in other Caucasian
populations.18 It would be of interest to characterize
NOD2/CARD 15 mutations in patients with oral CD to
ascertain if they differ genotypically from those without
oral involvement.
In summary, we have found that oral manifestations of
CD are common in children presenting with IBD and are
difficult to discern by gastroenterologists in a conven-
tional clinical setting. These lesions commonly contain
granulomas and are accessible easily for diagnostic biopsy
examination. Oral examination by an experienced dental
surgeon or oral physician can be an important adjunct to
the investigation of patients with suspected IBD.
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Address requests for reprints to: Billy Bourke, MD, Children’s Re-
search Centre, Our Lady’s Hospital for Sick Children, Crumlin, Dublin
12, Ireland. e-mail: Billy.Bourke@UCD.ie; fax: (353) 1-455-5307.