Celiac disease affects 1% of the population worldwide and can manifest in the digestive system, as well as in every organ in the body. Common symptoms of celiac disease include diarrhea, vomiting, constipation, and failure to thrive in children, and fatigue, bone or joint pain, depression and anxiety, and migraines in adults. But among the 200 known clinical signs and symptoms associated with celiac disease are also oral manifestations such as dental enamel hypoplasia, aphthous ulcers, and delayed eruption of teeth.
Stefano Guandalini, MD, Celiac Disease Foundation Medical Advisory Board member, and Edgardo Rivera, MD explain why oral symptoms of celiac disease can be so pronounced and why it is vital to educate dentists and oral hygienists about them as oral symptoms can be a useful screening tool for celiac disease. Please review the full report below.
CELIAC DISEASE AND ORAL HEALTH: WHAT DENTISTS NEED TO KNOW
BY STEFANO GUANDALINI, MD AND EDGARDO RIVERA, MD
Celiac disease, with a prevalence around 1% of the general population, is the most common genetically induced food intolerance in the world. Triggered by the ingestion of gluten in genetically predisposed individuals, this enteropathy may appear at any age, and is characterized by a wide variety of clinical signs and symptoms. Gastrointestinal presentations include chronic diarrhea, abdominal pain, weight loss or failure to thrive in children. Extra-intestinal manifestations, including dermatitis herpetiformis, anemia, short stature, osteoporosis, arthritis, neurologic problems, unexplained elevation of transaminases, and even female infertility are also common.
One manifestation that tends to be overlooked is celiac disease’s effects on oral health. In fact, celiac disease can lead to delayed tooth eruption, dental enamel defects, and recurrent oral aphthae. Our last two IMPACT newsletters have outlined typical intestinal and common extra-intestinal manifestations for readers. This article will focus on oral symptoms of celiac disease, by definition extra-intestinal, but generally less common and less discussed in the literature and among physicians.
ORAL MANIFESTATIONS OF CELIAC DISEASE
The long list of clinical signs and symptoms associated with celiac disease includes oral manifestations such as dental enamel hypoplasia, aphthous ulcers, and delayed eruption of teeth. Dental enamel hypoplasia, a nutritionally related defect of the enamel, presents in varying expressions such as pits, lines and grooves on the teeth. Its prevalence has been reported to range from 10% to 97% (Pastore et al., 2008, Wierink et al., 2007, Avsar & Kalayci, 2008, Acar et al., 2012), and it appears to be more prevalent in children with celiac disease, compared with adults. This defect, more common in patients with celiac disease compared to the general population (Rashid et al.), is thought to be secondary to nutritional deficiencies and immune disturbances during the period of enamel formation in the first seven years (Cheng et al.) of life. Another enamel defect that can be associated with celiac disease is partial or complete loss of the enamel. In fact, a large epidemiological study in Italian children (Martelossi et al., 1996) found that dental enamel defects can sometimes be the only symptom of celiac disease in children. Therefore, such defects can be a useful screening tool. Dentists must be made aware of them and should refer children with them for follow up with a pediatrician or pediatric gastroenterologist.
Aphthous ulcers, such as canker sores, can also be present in children and in adults with celiac disease. At this time it is unclear if these are associated with enamel defects— more research is needed on this question—and their prevalence in celiac disease patients is variable (Campisi et al., 2008). Oral ulcers are neither characteristic nor specific to celiac disease since aphthous ulcers can also be associated with other medical conditions such as inflammatory bowel disease and Bechet’s disease. However, it should be noted that in celiac patients, these ulcers often regress once the patients are on a gluten-free diet (Campisi et al., 2007).
Another oral manifestation of celiac disease is delayed tooth eruption. This symptom has been reported in up to 27% of patients with celiac disease (Campisi et al., 2007). However, this is a non-specific sign, possibly related to malnutrition. It needs to be assessed in conjunction with the rest of the oral exam, the dental clinician should be aware and suspicious about the possibility of celiac disease.
A study in Israel assessed oral health, bacterial colonization and salivary buffering capacity of children with celiac disease at diagnosis and on a gluten-free diet (Shteyer et al., 2013). All the children were examined by pediatric dentists, and saliva samples were collected for bacterial and pH analysis. A higher prevalence of enamel hypoplasia (66%) was found in the celiac children. However, the plaque index was significantly lower in the celiac children on a gluten-free diet, which correlated with oral health behavior related to teeth brushing and frequency of eating between meals. In fact, the celiac children on a gluten-free diet brushed their teeth and used fluoride significantly more often than other children in the study.
DIAGNOSING CELIAC DISEASE
The dental symptoms discussed above are certainly not adequate to diagnose celiac disease. The diagnosis of celiac disease should encompass clinical presentation, serological markers, and other relevant data. However, because oral symptoms can be so pronounced, it is vital to educate dentists and oral hygienists about them. If they notice such symptoms in patients, whether pediatric or adult, they should refer to a physician, ideally a gastroenterologist, for further evaluation.
Read the original report here.
Celiac Disease and Oral Health: What Dentists Need to Know