Study Title:

Oral Manifestations of Celiac Disease: A Clinical Guide for Dentists

Study Abstract

Celiac disease can develop at any age when solid foods are introduced into the diet; however, if it appears in children while the permanent teeth are developing, i.e., before 7 years of age, abnormalities in the structure of the dental enamel can occur. These defects are seen most commonly in the permanent dentition and tend to appear symmetrically and chronologically in all 4 quadrants, with more defects in the maxillary and mandibular incisors and molars. Both hypoplasia and hypomineralization of the enamel can occur. A band of hypoplastic enamel, often with intact cusps, is common. A hiatus in enamel and dentin formation can occur at a developmental stage corresponding to the onset of gastrointestinal symptoms. Dental enamel defects are common in children who develop symptoms of celiac disease before 7 years of age. Such defects are not seen as frequently in adults with celiac disease, as they may have developed symptoms at a later age or have had severely affected abnormal teeth altered or extracted.11

The exact mechanism leading to these defects is not clear, but immune-mediated damage is suspected to be the primary cause.14,15 Nutritional disturbances, including hypocalcemia, may also play a role.16 Stimulation of naïve lymphocytes by gluten in the oral cavity has also been hypothesized.15

The overall prevalence of systemic dental enamel defects in celiac disease patients with mixed or permanent dentition ranges from 9.5% to 95.9% (mean 51.1%), in patients with deciduous teeth, prevalence is 5.8% to 13.3% (mean 9.6%).14 This difference can be explained by the fact that the crowns of permanent teeth develop between the early months of life and the seventh year (i.e., after the introduction of gluten in the diet) whereas the development of deciduous teeth occurs primarily in utero. The involvement of deciduous teeth in some cases supports the hypothesis that immunologic and genetic factors are more important in the etiology of the defects than nutritional deficiencies. Dental enamel defects are also found in healthy first-degree relatives of patients with celiac disease, further supporting an immunogenetic basis for causation.17

Enamel defects include pitting, grooving and sometimes complete loss of enamel. A classification of these defects in celiac disease was developed by Aine and colleagues7 (Table 1). The various grades of defects are illustrated in Figs. 1, 2 and 3.

The prevalence of dental caries in children with celiac disease varies. It was found to be no different than the general population in 1 study8 but higher in another.11 However, in both these studies, dental enamel defects were more common in patients with celiac disease compared with controls.

Recurrent aphthous ulcers can also occur in celiac disease and may provide another clue to the possible presence of the disorder (Fig. 4). In a large survey of a Canadian population with biopsy-proven celiac disease, 16% of children (< 16 years of age) and 26% of adults reported having recurrent oral ulcers.4,5 The exact cause of aphthous ulcers in celiac disease is unknown; however, it may be related to hematinic deficiency, with low serum iron, folic acid and vitamin B12 due to malabsorption in patients with untreated celiac disease.14

Study Information

Oral Manifestations of Celiac Disease: A Clinical Guide for Dentists
j can dent assoc.
2011 January

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