Celiac disease is an immune-mediated disease of the small intestine caused by exposure to gluten and related prolamines in genetically susceptible individuals.

It can develop at any age after solid foods are introduced into the diet. Celiac disease occurs more often in women than men, and more often in non-Hispanic whites than those of other races or ethnicities. People with celiac disease are at greater risk of having other autoimmune diseases, including Sjögren disease. The only evidence-based treatment is a gluten-free diet. For many people, adherence to a gluten-free diet relieves symptoms, prevents further damage to the small intestine, and can heal some existing damage.

Oral Manifestations of Celiac Disease

Oral manifestations of celiac disease identified in children may include delay in dental eruption, reduction of salivary flow. Recurrent aphthous stomatitis, angular cheilitis, and dental enamel defects in primary and permanent teeth.

Dental enamel defects are often a result of hypoplasia, and most commonly occur in permanent dentition. These defects tend to occur symmetrically and chronologically in all four quadrants. With the most defects seen in the maxillary and mandibular incisors and molars. Teeth may be discoloured with white, yellow, or brown spots. 

Other specific defects may include poor enamel formation, pitting or banding of teeth, and mottled or translucent-looking teeth. A system devised by Aine provides a classification by grade (ranging from Grade 0 through IV). And a description of each (ranging from no defects to severe structural defects).

A small study found the percentage of new pediatric patients with celiac disease who have dental enamel hypoplasia. May be as high as 40-50% compared to about 6% in patients without celiac disease.

Malabsorption of calcium and immunological issues are hypothesized to be factors that hinder amelogenesis in patients with Celiac disease. Moreover, t there is no current consensus regarding the mechanism behind the association between celiac disease and hypoplasia.

Dental enamel defects are not seen as frequently in adults with celiac disease. This may be due to tooth development having been completed prior to disease onset or to adults having had affected teeth extracted or cosmetically treated. 

Other Oral problems that are related to Celiac Disease

A number of other oral problems may be related to celiac disease, such as:

• recurrent aphthous stomatitis, or canker sores or ulcers that recur inside the mouth
• atrophic glossitis, a condition characterized by a red, smooth, shiny tongue
• dry mouth syndrome (xerostomia)
• squamous cell carcinoma of the oropharynx

Dental Patient Management

If celiac disease is suspected (based on oral or other clinical symptoms, the presence of other autoimmune diseases, or first-or second-degree relatives with celiac disease) referral for screening by the patient’s primary care physician could be considered. Gluten-free diets should not be recommended to patients without confirmation of a diagnosis.

Patients with a confirmed diagnosis of celiac disease, and strict gluten-free diets are not likely to improve existing dental enamel defects; clinical conditions would need to be managed and treated by the dentist as appropriate. However, soft tissue oral manifestations such as recurrent canker sores can be expected to improve after implementing a gluten-free diet.

  For patients with celiac disease, oral care products, drugs administered to or via the oral cavity, and any other materials used should be gluten-free. The FDA encourages, but does not require, drug manufacturers to state whether any ingredients come from a gluten-containing grain on drug product labels.

Wheat gluten is very rarely included as an ingredient or as an impurity in oral drug products, which include any drug that is orally ingested, applied to or near the lips, or applied inside the mouth. 

Suppose wheat gluten is unintentionally included as a contaminant. In that case, the FDA estimates it would be at levels less than 0.5 mg gluten per unit dose of an oral drug, which is significantly less than the range at which gluten is estimated to be present in a gluten-free diet (5-50 mg).