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CDHO Advisory: Ulcerative Colitis

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with ulcerative colitis.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Ulcerative Colitis, 2023-11-10

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Ulcerative colitis

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have ulcerative colitis, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Keeping records.
  9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Male
Female
Parents, guardians, and family caregivers of children, young persons and adults with ulcerative colitis.

MAJOR OUTCOMES CONSIDERED

For persons who have ulcerative colitis: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory 

Resources consulted

Terminology varies among centres; the following is used for the purposes of this Advisory.

Ulcerative colitis, an inflammatory bowel disease in which

  1. inflammation occurs in the lining of the rectum and colon.
  2. ulcers form when the cells that normally line the rectum and colon are killed by the inflammation and then bleed and produce pus.
  3. inflammation in the colon causes the colon to empty frequently, causing diarrhea.
  4. abnormalities of the immune system may be involved.

Other terminology used in this Advisory is as follows.

  1. Aphthous stomatitis, a recurring condition characterized by the eruption of painful ulcers, commonly called canker sores, on the mucous membranes of the mouth.
  2. Autoimmune system disorder, a condition
    1. in which the immune system 
      1. erroneously attacks and destroys healthy body tissue
      2. creates chronic inflammation
    2. of which there are more than 80 different types. 
  3. Cecum, a pouch that forms the first few centimeters of the large intestine.
  4. Cheilitis, angular cheilitis, perlèche, inflammation of the mouth, which may
    1. resemble chapped lips 
    2. be caused by
      1. bacteria
      2. candidiasis
      3. malnutrition (CDHO Advisory)
  5. Crohn’s disease, Crohn disease (CDHO Advisory), an inflammatory bowel disease that 
    1. may affect any area of the gastrointestinal tract from the mouth to the anus including the
      1. ileum, the most commonly affected part of the small intestine
      2. ileocecal region
      3. colon
      4. small intestine
    2. is also called 
      1. granulomatous ileocolitis
      2. IBD-Crohn’s disease
      3. ileitis
      4. regional enteritis
  6. Episcleritis, irritation and inflammation of the episclera, the thin layer of tissue covering the white (sclera) of the eye, which occurs without an infection.
  7. Fistula, an abnormal connection between an organ, vessel, or intestine and another structure; which in inflammatory bowel disease such as ulcerative colitis or Crohn’s disease creates links between
    1. one loop of intestine and another 
    2. the intestine and the abdominal wall, particularly after surgery
    3. the skin of the buttocks outside the anus and an anal gland just inside the anus, which 
      1. is almost always the result of a previous abscess in the gland
      2. may cause draining of pus, mucus, or stools around the rectal area.
  8. Ileocecal region consists of the
    1. ileum, which moves digesting food to the beginning portion of the large intestine
    2. cecum.
  9. Ileum, the last few centimeters of the small intestine.
  10. Incidence, a measure of the rate of occurrence of new cases of a disease or condition.
  11. Inflammatory bowel disease (IBD) which 
    1. is not the same condition as irritable bowel syndrome (CDHO Advisory)
    2. becomes a chronic, enduring condition, marked by flare-ups and remissions
    3. refers to a group of diseases that includes
      1. ulcerative colitis
      2. Crohn’s disease (CDHO Advisory)
  12. Immunosuppression (CDHO Advisory), suppression of the body’s immune system and its ability to fight infections and other diseases
    1. deliberately induced with medications
    2. caused by diseases such as AIDS (CDHO Advisory) or lymphoma (CDHO Advisory).
  13. Limited or distal colitis, when only the left side of the colon is affected.
  14. Pancolitis, when the entire colon is affected.
  15. Pyostomatitis vegetans, general term for pustules and ulcers in the mouth that are seen in association with ulcerative colitis and other wasting diseases.
  16. Pyoderma gangrenosum, a condition of unknown origin that 
    1. causes large, painful ulcers to develop on the skin, most often on the legs 
    2. may be related to a disorder of the immune system 
    3. is associated with an underlying chronic health condition in about half of the population with pyoderma gangrenosum.
  17. Tenesmus, the sensation 
    1. of constantly needing to pass stools, even though the bowels are already empty
    2. that may involve straining, pain, and cramping.
  18. Thromboembolism, a condition in which a blood vessel is obstructed by a blood clot (thrombus) carried in the bloodstream from its site of origin.  
  19. Toxic megacolon, a severe life-threatening complication of inflammatory bowel disease,  such as ulcerative colitis and Crohn’s disease, which causes rapid dilation of the large intestine and which is associated with inflammation and gastrointestinal infection.
  20. Ulcerative proctitis, when the inflammation occurs in the rectum and lower part of the colon.
  21. Uveitis, inflammation in the pigmented part of the eye, with symptoms such as 
    1. blurred vision
    2. headache
    3. sensitivity to light.

Overview of ulcerative colitis

Resources consulted

Ulcerative colitis

  1. is of uncertain origin; it may be 
    1. a comorbidity of an autoimmune system disorder
    2. or an autoimmune system disorder.
  2. occurs at any age, but 
    1. usually in persons in the age range 15 to 30 years
    2. also peaks in the age range 50 to 70 years.
  3. affects men and women equally.
  4. appears to run in families, with reports that up to 20 percent of persons with ulcerative colitis have a family member or relative with ulcerative colitis or Crohn’s disease.
  5. has a higher incidence in whites and persons of Jewish descent.
  6. in about 25 to 40 percent of instances eventually requires surgical removal of the colon because of 
    1. massive bleeding
    2. severe illness
    3. rupture of the colon
    4. risk of cancer.
  7. varies in incidence throughout the world though 
    1. the incidence has increased in recent years
    2. Canada has
      1. among the highest incidences of ulcerative colitis and Crohn’s disease in the world, with prevalence of inflammatory bowel disease estimated at 0.8% of the population (or more than 322,000 persons with IBD).
  8. consists of chronic inflammation which 
    1. usually begins in the rectal area
    2. throughout life
      1. exhibits episodes of remission, lasting months or even years, which alternate with flare-ups
      2. is marked by return of symptoms for most persons. 
  9. is manifested by symptoms of
    1. anemia (CDHO Advisory)
    2. diarrhea, which occurs in 80 percent of persons
    3. fatigue
    4. growth failure in children 
    5. joint pain
    6. loss of appetite
    7. loss of body fluids and nutrients
    8. rectal bleeding
    9. skin lesions
    10. weight loss.
  10. is of mild symptomatology for about half of the persons diagnosed with ulcerative colitis; others suffer 
    1. bloody diarrhea
    2. frequent fevers
    3. nausea
    4. severe abdominal cramps.
  11. is unrelated to ulcers that occur elsewhere in the gastrointestinal tract, such as stomach or duodenal ulcers.
  12. develops into colon cancer in about 3 to 5 percent of instances. 
  13. possesses many similarities with Crohn’s disease but differs from it because, in Crohn’s disease, the inflammation
    1. lies deeper within the intestinal wall
    2. can occur in other parts of the digestive system, such as
      1. esophagus
      2. mouth 
      3. small intestine
      4. stomach.
  14. develops because of inflammation that 
    1. may be an abnormal immune reaction to the normal intestinal bacteria 
    2. thickens gastrointestinal tract wall 
    3. consists of swelling and dilated blood vessels
    4. results in loss of fluid into the tissues.
  15. is characterized by symptoms that
    1. vary in severity
    2. may start slowly or suddenly
    3. may
      1. be mild in about half of persons with the condition
      2. occur as attacks that are
        1. severe and frequent 
        2. provoked by various factors including
          1. respiratory infections
          2. physical stress
    4. include, typically
      1. abdominal pain, which
        1. may be cramping
        2. usually disappears after a bowel movement
      2. diarrhea that 
        1. is bloody 
        2. varies from a few episodes to frequent throughout the day
    5. also may include various of the following signs and symptoms
      1. abdominal sounds experienced as gurgling or splashing 
      2. anemia (CDHO Advisory)
      3. aphthous stomatitis 
      4. blood and pus in the stools
      5. fatigue
      6. fever
      7. gastrointestinal bleeding
      8. growth failure in children
      9. joint pain
      10. loss of appetite 
      11. loss of body fluids and nutrients 
      12. nausea and vomiting
      13. rectal bleeding
      14. skin lumps, ulcers 
      15. tenesmus
      16. weight loss.
  16. in course and prognosis is variable because persons with ulcerative colitis 
    1. that is limited to the rectum or is limited to the end of the left colon 
      1. usually do quite well 
      2. rarely experience serious complications
      3. often need only periodic treatments using oral medications or enemas 
    2. with more extensive disease, may experience blood loss from the inflamed intestines which can
      1. lead to anemia (CDHO Advisory)
      2. require treatment with iron supplements or even blood transfusions
    3. may develop serious comorbidity, complications and associated conditions, especially colon cancer
      1. which occurs in 3 to 5 percent of persons with ulcerative colitis
      2. of which the risk increases with the duration of the ulcerative colitis
    4. experience mortality rates, which overall do not differ from those in the general population, that may be increased for particular groups, such as persons with the condition who also 
      1. are elderly
      2. develop complications, such as
        1. anemia (CDHO Advisory)
        2. malnutrition (CDHO Advisory)
        3. shock
      3. undergo various forms of medical or surgical intervention
      4. develop the most severe form, toxic megacolon, which 
        1. is the commonest cause of death
        2. occurs rarely
        3. usually requires surgery to prevent colon rupture.
  17.  is of unknown cause though
    1. a current theory holds that  
      1. genetically susceptible individuals have abnormalities of immunity or otherwise enhanced reactivity against normal intestinal bacteria
      2. the resulting abnormal mucosal immune response predisposes to colon inflammation
    2. biological environmental factors may also play a role; for example
      1. sulfate-reducing bacteria, which produce sulfides, are found in large numbers in persons with ulcerative colitis
      2. sulfide production is higher in persons with ulcerative colitis than in other people
      3. sulfide production is higher during active ulcerative colitis than in remission 
    3. stress and certain foods that trigger symptoms do not cause ulcerative colitis.
  18. is treated 
    1. with the intention of
      1. controlling acute attacks
      2. preventing repeated attacks
      3. helping the colon heal
    2. in hospital when the attack is severe
    3. by methods that 
      1. aim to maintain remission
      2. depend on the severity of the ulcerative colitis, and which chiefly comprise
        1. management of symptoms
        2. control of inflammation
        3. nutritional support including treatment with a special diet or,
        4. severe cases, intravenous feeding 
      3. correction of dehydration
        1. do not affect the disease itself, but are important in helping the person feel and function better; symptoms treated include those of or pertaining to 
          1. anemia (CDHO Advisory)
          2. cramps
          3. diarrhea
          4. pain
    4. with medications that may include immunosuppression (CDHO Advisory)
    5. through diet 
      1. in which nutrition is balanced with adequate calories, protein, and essential nutrients from various food groups
      2. that avoids foods that aggravate diarrhea and gas symptoms especially during flare-ups, a diet which may require
        1. consumption of 
          1. small amounts of food throughout the day
          2. drinking small amounts of water frequently throughout the day
        2. avoidance of 
          1. high-fibre foods, including
            1. beans
            2. bran
            3. nuts
            4. popcorn
            5. seeds
          2. fatty, greasy and fried foods 
          3. gas-inducing foodstuffs, such as beans, spicy food, cabbage, broccoli, cauliflower, raw fruit juices and fruits
        3. limiting milk products when lactose intolerance is evident 
    6. with stress management for events such as
      1. losing a loved one 
      2. losing a job
      3. moving home
      4. worry, embarrassment, sadness or depression about bowel accidents 
    7. with surgery to remove the colon, a procedure which
      1. cures ulcerative colitis
      2. removes the threat of colon cancer
      3. is usually recommended for patients with
        1. ulcerative colitis that is unresponsive to complete medical therapy
        2. changes in the lining of the colon that are thought to be pre-cancerous
        3. serious complications such as
          1. rupture of the colon
          2. severe bleeding 
          3. toxic megacolon
      4. may require one or other of
        1. ileostomy 
        2. a procedure that connects the small intestine to the anus to help the patient gain more normal bowel function.
  19. is investigated with
    1. colonoscopy with biopsy 
    2. follow-up colonoscopy to detect colon cancer 
    3. barium enema
    4. complete blood count 
    5. C-reactive protein test
    6. sedimentation rate. 
  20. cannot be prevented
    1. because the cause is unknown
    2. no methods of prevention are yet available
    3. though colon cancer, the serious complication, is detected early enough for successful surgery by screening with colonoscopy.
  21. relative to its social considerations, is supported by support groups
    1. in Canada
    2. in the US

Multimedia and images

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with ulcerative colitis but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

Resources consulted

Comorbid conditions, complications and associated conditions include conditions

  1. occurring within the intestine, such as 
    1. those directly related to the repeated inflammation, which may lead to 
      1. thickening by scar tissue of the intestinal wall and rectum 
      2. death of colon tissue 
      3. systemic inflammatory response syndrome (sepsis) 
      4. extensive colon involvement
    2. bleeding due to ulcers in the colon, which 
      1. increases the risk for 
        1. anemia 
        2. perforation
        3. infection
      2. in some cases, can be massive and dangerous, and require surgery
    3. effects on the colon, including 
      1. narrowing
      2. colon cancer, the risk of which rises with
        1. positive family history of colon cancer
        2. long duration of colitis
    4. intestinal infections, such as those caused by Clostridium difficile, an intestinal bacterium that causes severe diarrhea
    5. rupture, perforation of the intestine
    6. uncomfortable distension of the abdomen.
  2. that occur beyond the intestine, such as
    1. anemia 
    2. aphthous stomatitis
    3. bones and joints
      1. ankylosing spondylitis and similar conditions, which may be associated with low back pain
      2. arthritis of the limbs which with inflammatory bowel disease are experienced by
        1. 15 to 20 percent of adults
        2. 10 to 20 percent of children, which tend to worsen as intestinal symptoms increase
      3. osteopenia (low bone density) and osteoporosis (CDHO Advisory) caused by 
        1. ulcerative colitis
        2. treatment with corticosteroid and other immune-suppressing drugs 
    4. eyes
      1. episcleritis 
      2. uveitis, a common complication
    5. emotion and psychosocial consequences including
      1. fear of abdominal pain before the end of a meal 
      2. humiliation, social isolation and low self-esteem resulting from frequent attacks of diarrhea
      3. serious toll on work, family, and social activities resulting from frequent occurrences of incapacitating symptoms 
      4. for adolescents additional emotional distress from
        1. weight gain from steroid treatments
        2. delayed puberty
    6. growth and sexual development, which may be impaired in children
    7. kidney stones, for which the risk is increased 
    8. liver disease (CDHO Advisory)
      1. liver dysfunction of a minor nature is common
      2. liver disease, gallbladder or bile duct disorders of an inflammatory nature in various degrees of severity 
        1. affect 1 to 3 percent of persons with ulcerative colitis
        2. may be associated with increased cancer risk
        3. may lead to 
          1. recurrent fever
          2. jaundice
          3. cirrhosis 
    9. malabsorption, malnutrition, and dehydration
    10. resulting from
      1. bleeding
      2. diarrhea
      3. side effects of medications
      4. surgery
    11. skin disorders
      1. pyoderma gangrenosum
      2. erythema nodosum, rare
    12. toxic megacolon 
    13. thromboembolism, for which risk is increased
      1. especially for deep venous thrombosis in the legs
      2. for pulmonary embolism, when a blood clot travels from the legs to the lungs. 

Oral health considerations

Resources consulted

  1. Oral health management 
    1. calls for attention to oral health preventive care to 
      1. avoid
        1. oral infections
        2. hard and soft tissue destruction
      2. recognize and treat or to recommend treatment for 
        1. all inflammatory, infectious or oral lesions
        2. dental caries and oral infections
      3. recognize the
        1. potential importance of 
          1. altered immune status
          2. diet
        2. the risk of adrenal gland suppression in patients receiving corticosteroids 
        3. need to augment the steroid regimen during some oral health treatments, especially for anxious patients for whom
          1. preoperative or postoperative pain management is difficult
          2. a complicated or stressful procedure is anticipated
      4. take account of the risk  of prolonged steroid therapy of
        1. inducing mucosal atrophy
        2. systemic absorption 
    2. may also call for medical advice pertaining to
      1. hypothalamic/pituitary/adrenal cortical function to determine the patient/client’s ability to undergo the Procedures
      2. persistent oral inflammatory, infectious, or granulomatous oral lesions 
      3. use of pain medication to avoid use of non-steroidal anti-inflammatory drugs (NSAID), and other pain relief medications that may trigger a flare-up.
  2. Oral manifestations 
    1. appear to be high in incidence in ulcerative colitis, but the associations with ulcerative colitis, whether causal or predisposing, and the particular manifestations are to varying degrees uncertain
    2. include oral lesions of ulcerative colitis, which  
      1. are sometimes termed pyostomatitis vegetans 
      2. are less common than oral manifestations of Crohn’s disease 
      3. occur 
        1. more often in men
        2. at any age
        3. generally at the same time as intestinal lesions but may precede them 
      4. consist of scattered, clumped or in-line pustules on erythematous mucosa
        1. at multiple oral sites though seldom on the dorsum of the tongue
        2. with variable severity 
        3. which may be accompanied by oral aphthous-like lesions
      5. create discomfort that relates to the
        1. degree of oral ulceration, which may cause pain
          1. on touch
          2. during eating
          3. with acidic, spicy or hot foods
        2. severity of the ulcerative colitis
      6. usually respond to the treatment for ulcerative colitis
      7. may be treated with topical or systemic medications
      8. may indicate need for medical advice
    3. may include
      1. aphthous stomatitis
      2. cheilitis
      3. clinical attachment loss in sites of at least 4 mm 
      4. dentine caries, which are higher in frequency in patients/clients with inflammatory bowel disease 
      5. dry mouth
      6. gastric reflux
      7. gingivitis, which 
        1. may be associated with inflammatory bowel disease, including ulcerative colitis
        2. is considered a bacterial infection of the gums, though why it develops is not fully understood
        3. may result from some combination of an underlying illness, in this instance ulcerative colitis, medications used to treat the illness, and plaque
        4. results in inflammation which, even though it defends against bacterial infection, is nevertheless an abnormal condition whose treatment, given the possibility of an association between gingivitis and ulcerative colitis, should be viewed as a component of the treatment of ulcerative colitis
      8. glossitis
      9. halitosis
      10. periodontitis, which has been observed in high incidence with inflammatory bowel disease
      11. stomatitis.
  3. Non-oral complications with implications for oral healthcare include those involving the
    1. abdomen
      1. abdominal discomfort
      2. digestive disturbance
      3. malabsorption, malnutrition and dehydration (CDHO Advisory)
      4. increased susceptibility to C Difficile infection
      5. intestinal infection
      6. liver disease
    2. blood system
      1. anemia
      2. thromboembolism
    3. bone and joint
      1. osteoporosis (CDHO Advisory)
      2. arthritis
        1. temporomandibular joint in some 10 percent of persons 
        2. limbs
      3. growth impairment
    4. medications, which 
      1. should avoid non-steroidal anti-inflammatory drugs (NSAIDs) because these may aggravate symptoms
      2. may involve immunosuppression (CDHO Advisory) which requires medical advice in advance of the Procedures
      3. may involve prednisone which, during periods of stress such as the Procedures, may need to be temporarily increased
    5. effects of stress and emotional responses
      1. relative to which parents/guardians of children should be advised that 
        1. during periods of stress, such as the Procedures, temporary increases in prednisone medication may be necessary; and 
        2. that they should notify the child’s physician of the occurrence of such bodily stresses
      2. fear.

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications
  4. Information on herbals and supplements 
  5. Complementary and alternative medicine

Types of medications

The goal of medication is to induce and maintain remission, and to improve quality of life and, specifically, to control inflammation.

The initial treatment for ulcerative colitis includes corticosteroids, anti-inflammatory agents, antidiarrheal agents, and rehydration. Surgery is considered if medical treatment fails or if a surgical emergency develops. 

  1. Anti-Inflammation Drugs (5-aminosalicylic Acid Derivative)
    1. balsalazide (Colazal®)
    2. mesalamine (Asacol®, Canasa®, among others), used if sulfasalazine proves ineffective or is poorly tolerated
    3. sulfasalazine (Azulfidine®), often the first treatment.
  2. Immune system suppressors, used to block the immune reaction that contributes to inflammation, and immunomodulators, such as 
    1. azathioprine (Azasan®, Imuran®) 
    2. cyclosporine (Neoral®,  Sandimmune®,  Gengraf®)  
    3. mercaptopurine (Purinethol®)
    4. tacrolimus (Prograf®).
  3. Corticosteroids, used 
    1. in graded doses, high when the disease is at its worst;  dosage is typically reduced once symptoms are controlled 
      1. budesonide (Entocort EC®)
      2. hydrocortisone (Cortef®, Hydrocortone®)
      3. methylprednisolone oral (Medrol®) 
      4. prednisone
    2. for recalcitrant oral lesions of ulcerative colitis2
      1. hydrocortisone topical (with numerous brand names).
  4. Tumor necrosis factor inhibitors, which block the action of TNF-alpha, a substance in the body that causes inflammation, such as
    1. adalimumab injection (Humira®)
    2. certolizumab injection (Cimzia®)
    3. infliximab (Remicade®)
    4. golimumab (Simponi®). 
  5. Monoclonal antibody drugs, such as
    1. ustekinumab (Stelara®)
    2. vedoluzimab (Entyvio®).
  6. Janus kinase (JAK)3 inhibitors, such as
    1. tofacitinib (Xeljanz®)which is a targeted synthetic small molecule
    2. upadacitinib (Rinvoq®), which is a targeted synthetic small molecule.
  7. Selective S1P4 receptor modulators, such as
    1. ozanimod (Zeposia®).
  8. Antibiotics, used to treat bacterial overgrowth in the small intestine caused by stricture, fistulas, or prior surgery
    1. metronidazole (Flagyl®) 
    2. ciprofloxacin (Cipro®, Proquin®). 
  9. Anti-diarrheal and fluid replacements, used when diarrhea and cramp-like abdominal pain are not relieved when the inflammation subsides following treatment, to alter the muscle activity of the intestine to slow the intestinal transit time, taken as needed
    1. codeine 
    2. diphenoxylate and atropine (Lomotil®, Lonox®) 
    3. loperamide (Imodium®, Anti-Diarrheal Formula®).

Side effects of medications

Non-steroidal anti-inflammatory drug (NSAID) use is higher in persons with ulcerative colitis than in control subjects, and one third of patients with an exacerbation of ulcerative colitis report recent NSAID use. This finding leads to some recommendations to avoid NSAID use in patients with ulcerative colitis. 

See the links above to the specific medications.

THE MEDICAL AND MEDICATIONS HISTORY

The dental hygienist in taking the medical  and medications history-taking should 

  1. focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations,  especially immunomodulator medications and prednisone, and other drugs that cause immunosuppression and/or thrombocytopenia (low platelet count)
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions
  2. explore the need for advice from the primary or specialized care provider(s)
  3. inquire about
    1. pointers in the history of significance to ulcerative colitis, such as a recent flare-up 
    2. symptoms indicative of inadequate control of emotional factors, such as stress or fear
    3. the patient/client’s understanding and acceptance of the need for oral healthcare
    4. medications considerations, including over-the-counter medications, herbals and supplements
    5. problems with previous dental/dental hygiene care
    6. problems with infections
      1. generally
      2. affecting the intestines
      3. specifically associated with dental/dental hygiene care
    7. the patient/client’s current state of health
    8. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition.

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2023)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

The dental hygienist 

  1. should not implement the Procedures without prior consultation with the appropriate primary or specialist care provider(s) if the patient/client
    1. is being treated with medications associated with immunosuppression +/- increased risk of infection (e.g., corticosteroids, azathioprine, 6-mercaptopurine, methotrexate, biologic response modifier drugs [e.g., anti-tumour necrosis factor drugs and monoclonal antibody drugs], JAK inhibitors, etc.)
    2. is being treated with medications (e.g., azathioprine, 6-mercaptopurine, and sulfasalazine) associated with thrombocytopenia (low platelet count), which can lead to excessive bleeding5
    3. has recently undergone or is about to undergo surgery
    4. has a history of severe gastrointestinal infection
    5. has a condition or treatment which calls for 
      1. antibiotic prophylaxis
      2. pre-medication 
  2. may postpone the Procedures pending medical advice if the patient/client 
    1. appears debilitated or in a flare-up
    2. is experiencing symptoms suggestive of complications of ulcerative colitis or its treatment 
    3. has not complied with pre-medication, including antibiotic prophylaxis, as directed by the prescribing physician 
    4. has recently changed significant medications, under medical advice or otherwise
    5. recently experienced changes in his/her medical condition such as medication or other side effects of treatment
    6. is unable to provide the dental hygienist with sufficient information about
      1. medications
      2. medical history
    7. has symptoms or signs of 
      1. exacerbation of the medical condition
      2. comorbidity, complication or an associated condition of ulcerative colitis
    8. has not recently or ever sought and received medical advice relative to oral healthcare procedures
    9. is deeply concerned about any aspect of his or her medical condition.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of ulcerative colitis, the dental hygienist should specifically record

  1. a summary of the medical and medications history
  2. any advice received from the physician/primary care provider relative to the patient/client’s condition
  3. the decision made by the dental hygienist, with reasons
  4. compliance with the precautions required
  5. all Procedure(s) used
  6. any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The dental hygienists should 

  1. urge the patient/client to alert any healthcare professional who proposes any intervention or test 
    1. that he or she has a history of ulcerative colitis
    2. to the medications he or she is taking
  2. should discuss, as appropriate 
    1. the importance of the patient/client’s
      1. self-checking the mouth regularly for new signs or symptoms
      2. reporting to the appropriate healthcare provider any changes in the mouth
    2. the need for regular oral health examinations and preventive oral healthcare 
    3. oral self-care including information about 
      1. choice of toothpaste
      2. tooth-brushing techniques and related devices
      3. dental flossing
      4. mouth rinses
      5. management of a dry mouth
    4. the importance of an appropriate diet in the maintenance of oral health
    5. for persons at an advanced stage of a disease or debilitation
      1. regimens for oral hygiene as a component of supportive care and palliative care
      2. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves
      3. scheduling and duration of appointments to minimize stress and fatigue
    6. comfort level while reclining, and stress and anxiety related to the Procedures
    7. medication side effects such as dry mouth, and recommend treatment
    8. mouth ulcers and other conditions of the mouth relating to ulcerative colitis, comorbidities, complications or associated conditions, medications or diet
    9. pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promoting health through oral hygiene for persons who have ulcerative colitis.
  2. Reducing the adverse effects (including stress that is excessive for the patient/client) by 
    1. Informed discussion with the person’s prescribing physician, as necessary
    2. obtaining medical advice about the Procedures during a flare-up
    3. obtaining an accurate history, including medications
    4. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    5. using appropriate techniques of communication
    6. providing advice on scheduling and duration of appointments.
  3. Reducing the risk that oral health needs are unmet.

POTENTIAL HARMS

  1. Failing to
    1. recognize the significance of mouth lesions in ulcerative colitis
    2. advise the patient/client to seek medical advice if he or she has not already done so.
  2. Performing the Procedures at an inappropriate time, such as 
    1. during a period of severe debilitation or during a flare-up without obtaining medical advice or when necessary adjustments to medications have not been made
    2. when the patient/client is using prednisone or other medications associated with immunosuppression, and informed advice has not been obtained from the prescribing primary care or specialist provider
    3. when the patient/client is using medications associated with thrombocytopenia, and informed advice has not been obtained from the prescribing primary care or specialist provider
    4. in the presence of acute oral infection without prior medical advice 
    5. when the patient/client has history of severe gastrointestinal infection and medical advice has not been obtained
    6. in the presence of complications for which prior medical advice is required
    7. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person with ulcerative colitis.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2009-11-24

DATE OF LAST REVIEW

2011-04-01; 2019-12-12; 2023-11-10

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow
MD, MHSc, MBA, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd

Kyle Fraser
RDH, BComm, BEd, MEd

Carolle Lepage
RDH, BEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2009, 2011, 2019, 2023 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children.
2 A non-steroid drug used to treat oral lesions of UC is dapsone (DDS), a sulfone antibiotic.
3 JAK = Janus kinase
4 S1P = sphingosine 1-phosphate
5 Flare-ups of the underlying disease itself can rarely be accompanied by thrombocytopenia.