Celiac Disease (CD) is on the rise, so much so that it is becoming a major public health issue. According to the Mayo Clinic, one in 141 Americans living in the U.S. has been diagnosed with CD and an additional estimated two million people have it but are undiagnosed. A study conducted by the Mayo Clinic showed that the prevalence of undiagnosed CD has increased dramatically in the United States over the past 50 years (Rubo-Tapia et al., 2009).
What is Celiac Disease and why is it so hard to diagnose it? CD is a chronic autoimmune disorder that causes damage to the small intestine due to the consumption of gluten, a protein found in wheat, rye, oats and barley. Although CD is a condition that affects both children and adults, the symptoms often manifest differently depending on age. With over 300 symptoms including abdominal pain, irritability and depression, CD is extremely difficult to diagnose. Many people with CD do not present with any malabsorptive symptoms, and therefore, delays in diagnosis are common. In fact, 83% of people with CD are undiagnosed or misdiagnosed with other conditions (National Foundation for Celiac Awareness).
Left untreated, people with CD can develop serious complications such as other autoimmune diseases, osteoporosis, thyroid disease, lymphomas and other GI cancers. For these reasons, undiagnosed CD is associated with a nearly 4-fold increased risk of death (Rubo-Tapia et al., 2009). With no cure, CD is treated one way only: eliminating gluten from the diet altogether. That is why it is extremely important to diagnose CD early on!
The state of one’s teeth and mouth can often alert dentists and other healthcare providers to the presence of CD. CD may damage the enamel of the teeth, creating grooves, bands or pits often symmetrically found on the incisors or molars, may cause discoloration with brown or yellow spots, or cause teeth to have a mottled or translucent appearance. In several severe cases, CD may even deform the shape of the teeth. These changes occur before the age of seven, as children’s permanent teeth are developing.
Recurrent aphthous ulcers, or canker sores, appear as one or multiple round-to-ovoid, shallow, punched-out–appearing, painful oral ulcers. These ulcers are commonly seen in patients with CD and may provide another clue to the possible presence of the disorder. In a large survey of a Canadian population with CD, 16% of children (< 16 years of age) and 26% of adults reported having recurrent oral ulcers (Rashid et al 2011). These ulcers may be due to the malabsorption of certain nutrients, such as folic acid and vitamin B12, in patients with untreated CD disease.
Other, less common, oral health manifestations include:
- atrophic glossitis, a condition characterized by a red, smooth, shiny tongue. This pathological expression is likely due to B12 vitamin deficiency due to celiac nutritional malabsorption (Muggiano et al 2013)
- Oral Lichen Planus, or chronic mouth sores, are a mucocutaneous disease that affect both skin and mucosal sites as oral cavity
- Dry mouth syndrome
- Squamous cell carcinoma—a type of cancer—of the pharynx and mouth
For many people with CD, a dental visit, rather than a trip to the gastroenterologist, is the first step toward discovering their illness. Dentists too should learn about CD and its connection to other diseases to identify patients and refer patients that need follow-up. Working together as a team, healthcare providers can develop a comprehensive care plan for their CD patient, ensuring that they remain healthy, both in the mouth and in the body.
May is Celiac Disease Awareness month. Check out the Celiac Disease Foundation’s Toolkit for a symptoms checklist, a nationwide directory of CD specialists and take the 7 Day Gluten-Free Meal Plan challenge to help individuals diagnosed with Celiac disease and their families ease the transition to a gluten-free diet! If you are a clinician or educator, we challenge you to review our case study of a pediatric patient with Celiac Disease and oral health problems.
Muggiano F, Quaranta A, Giannantoni I. Major dental clinical pathological manifestation of celiac disease. WebmedCentral ORAL MEDICINE 2013;4(11):WMC004448
National Foundation for Celiac Disease Awareness. Celiac Disease Symptoms Can Be Elusive. Available on http://www.celiaccentral.org/Celiac-Disease/Celiac-Symptoms/32/
National Institute of Health. (April 2011).Celiac Disease Awareness Campaign. Available on http://celiac.nih.gov/PDF/Dental_Enamel_Defects_508.pdf
National Institute of Health. (September 2014). A Changing Environment and the Increasing Prevalence of Celiac Disease http://www.celiac.nih.gov/prevalence.aspx
Rashid, M., Zarkadas, M., Anca, A., & Limeback, H. (2011). Oral manifestations of celiac disease: a clinical guide for dentists. J Can Dent Assoc, 77, b39.
Rubio–Tapia, A., Kyle, R. A., Kaplan, E. L., Johnson, D. R., Page, W., Erdtmann, F., … & Murray, J. A. (2009). Increased prevalence and mortality in undiagnosed celiac disease. Gastroenterology, 137(1), 88-93.