Celiac Disease and Oral Health
Celiac disease (CD) is a hereditary, autoimmune disease induced by a reaction to gluten.
Celiac disease (CD) is a hereditary, autoimmune disease induced by a reaction to gluten. Gluten is found in wheat (breads, soups, pastas, cereals, sauces, and salad dressings); rye (rye breads and beer); and barley (malt products, food colorings, soups, beer, and brewer’s yeast). Nonfood products that may contain gluten, such as Play-Doh, cosmetics, skin and hair products, toothpaste, and mouthrinse, may transfer gluten from hands to the mouth.
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CD affects approximately one in 100 people internationally. The United States, Argentina, Italy, Germany, Denmark, and Finland have a higher prevalence of CD compared with other countries. Found more often in white females, CD is also hereditary. Those with a parent, child, or sibling with CD are at a one in 10 risk of also receiving a CD diagnosis. Environmental factors—such as the introduction of gluten at an early age, absence of breastfeeding, and viral infections during infancy—may increase the risk of CD.
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CD damages the villi of the small intestines, which impedes the body’s ability to absorb nutrients. When individuals with CD are exposed to alpha gliadin, a protein found in gluten, the body creates a T-cell mediated inflammatory response in which IgA antitussive transglutaminase, antiendomysial, and antigliadin antibodies are released. This reaction damages the brush border in the small intestine, which consists of folds of Kerckring that contain villi and microvilli, which are used for nutrient absorption. Through the inflammatory response, the villi are flattened.
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Signs in the Oral Cavity
Children with CD are at increased risk for dental caries. Delayed tooth eruption, mandibular jaw defects, enamel impairments, altered matrix formation, hypocalcification, and burning sensations in the oral cavity are other oral signs of CD. Patients who develop CD before age 7 are at greatest risk of negative effects in their permanent dentition. Dental defects can be used as a warning sign of CD in children and infants. Children with CD may develop patchy white-yellow colorations on their teeth, or enamel hypoplasia, which may cause the dentition to appear ridged and pitted. In some cases, the teeth may present with a distinct groove, a sign of a significant enamel impairment. Patients with CD are at increased risk for xerostomia, which increases the risk of caries; aphthous ulcers; aphthous stomatitis; atrophic glossitis; and, in some cases, oral cancer, especially squamous cell carcinoma of the oropharynx.
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Dental Hygienist on the Healthcare Team
Dental hygienists are often the first point of contact with patients. As such, they must be aware of any dental products that contain gluten, such as prophy paste, toothpaste, and floss, so clinicians must ensure that alternative products for patients with CD are available. Taking diagnostic radiographs, performing a thorough clinical assessment, and gathering a concise medical, dental, and familial history are the foundations of a decisive and complete treatment plan. Dental hygienists must be aware of the possible oral manifestations that can arise in patients with CD. Some adjustments in patient care may be needed to ensure patient comfort. Clinicians can recommend products to soothe aphthous ulcers and an extra soft toothbrush should be suggested, especially if there is irritation in the mouth. In addition, if the patient has xerostomia, moisturizing oral health products are recommended, as well as home fluoride treatment with possible tray fabrication/application. Fluoride varnish is helpful to reduce caries risk due to its viscosity and effective uptake within the tooth structures.
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Patients with CD will need preventive services on 3-month to 4-month intervals so the oral status can be reviewed and evaluated. A thorough dietary analysis may assist with educating patients on how to improve their nutritional intake, especially of calcium and fluoride, which are imperative to oral health. This would be in collaboration with the primary care physician and/or dietitian.