Celiac Disease

Celiac disease is an immune-mediated disease of the small intestine caused by exposure to gluten and related prolamines in genetically susceptible individuals.^{1, 2} It affects an estimated 0.7% of the U.S., or 2 million Americans,³ and can develop at any age after solid foods are introduced into the diet.⁴ Celiac disease occurs more often in women than men, and more often in non-Hispanic whites than those of other races or ethnicities.³ People with celiac disease are at greater risk of having other autoimmune diseases, including Sjögren disease.⁵ The only evidence-based treatment is a gluten-free diet.⁵ For many people, adherence to a gluten-free diet relieves symptoms, prevents further damage to the small intestine, and can heal some existing damage.⁵

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.^{2, 6} The dental enamel defects are often a result of hypoplasia, and most commonly occur in the permanent dentition.^{2, 5} 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.^{2, 7} Teeth may be discolored with white, yellow, or brown spots.^{2, 7} 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).^{2, 8}

A small study found that 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.^{9, 10} Malabsorption of calcium and immunological issues are hypothesized to be factors that hinder amelogenesis in patients with celiac disease^{,2, 11} but there is no current consensus regarding the mechanism behind the association between celiac disease and hypoplasia.⁹

Dental enamel defects are not seen as frequently in adults with celiac disease,¹² which may be due to tooth development having been completed prior to disease onset or to adults having had affected teeth extracted or cosmetically treated.^{4, 7} A number of other oral problems may be related to celiac disease,⁷ 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

It is unclear whether celiac disease affects caries risk² as some studies find evidence of increased risk of caries^{13, 14} while others do not.^{11, 15}

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.⁴ Gluten-free diets should not be recommended to patients without confirmation of a diagnosis.⁴ In patients with a confirmed diagnosis of celiac disease, 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.¹⁶

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.¹⁷ 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 is applied inside the mouth.^{5, 17} If wheat gluten is unintentionally included as a contaminant, the FDA estimates it would be at levels less than 0.5 mg gluten per unit dose of oral drug, which is significantly less than the range at which gluten is estimated to be present in a gluten-free diet (5-50mg).¹⁷

A study testing oral hygiene and cosmetic products found that only 4 out of 66 (6%) contained gluten in concentrations greater than 20 ppm, which is the threshold concentration for a product to be considered gluten-free.¹⁸ Many polishing pastes, fluoride gels and varnishes, and most toothpastes are gluten-free, however not all gluten-free products are labeled as such. A listing of gluten-free dental products is available from the ”Beyond Celiac” website.¹⁹

1. Rubio-Tapia A, Ludvigsson JF, Brantner TL, Murray JA, Everhart JE. The prevalence of celiac disease in the United States. Am J Gastroenterol 2012;107(10):1538-44; quiz 37, 45.
2. Wieser H, Amato M, Caggiano M, Ciacci C. Dental Manifestations and Celiac Disease-An Overview. J Clin Med 2023;12(8).
3. Choung RS, Unalp-Arida A, Ruhl CE, et al. Less Hidden Celiac Disease But Increased Gluten Avoidance Without a Diagnosis in the United States: Findings From the National Health and Nutrition Examination Surveys From 2009 to 2014. Mayo Clinic Proceedings 2017;92(1):30-38.
4. Rashid M, Zarkadas M, Anca A, Limeback H. Oral manifestations of celiac disease: a clinical guide for dentists. J Mich Dent Assoc 2011;93(10):42-6.
5. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Celiac Disease. National Institutes of Health. http://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/celiac-disease/Pages/facts.aspx. Accessed December 8, 2023.
6. de Carvalho FK, de Queiroz AM, Bezerra da Silva RA, et al. Oral aspects in celiac disease children: clinical and dental enamel chemical evaluation. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119(6):636-43.
7. National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Dental Enamel Defects and Celiac Disease. National Institutes of Health. https://www.niddk.nih.gov/health-information/professionals/clinical-tools-patient-management/digestive-diseases/dental-enamel-defects-celiac-disease. Accessed December 8, 2023.
8. Aine L, Maki M, Collin P, Keyrilainen O. Dental enamel defects in celiac disease. J Oral Pathol Med 1990;19(6):241-5.
9. Jericho H, Guandalini S. Extra-Intestinal Manifestation of Celiac Disease in Children. Nutrients 2018;10(6).
10. Majorana A, Bardellini E, Ravelli A, et al. Implications of gluten exposure period, CD clinical forms, and HLA typing in the association between celiac disease and dental enamel defects in children. A case-control study. Int J Paediatr Dent 2010;20(2):119-24.
11. Pastore L, Carroccio A, Compilato D, et al. Oral manifestations of celiac disease. J Clin Gastroenterol 2008;42(3):224-32.
12. Cheng J, Malahias T, Brar P, Minaya MT, Green PH. The association between celiac disease, dental enamel defects, and aphthous ulcers in a United States cohort. J Clin Gastroenterol 2010;44(3):191-4.
13. Cantekin K, Arslan D, Delikan E. Presence and distribution of dental enamel defects, recurrent aphthous lesions and dental caries in children with celiac disease. Pak J Med Sci 2015;31(3):606-9.
14. Costacurta M, Maturo P, Bartolino M, Docimo R. Oral manifestations of coeliac disease.: A clinical-statistic study. Oral Implantol (Rome) 2010;3(1):12-9.
15. Priovolou CH, Vanderas AP, Papagiannoulis L. A comparative study on the prevalence of enamel defects and dental caries in children and adolescents with and without coeliac disease. Eur J Paediatr Dent 2004;5(2):102-6.
16. Cervino G, Fiorillo L, Laino L, et al. Oral Health Impact Profile in Celiac Patients: Analysis of Recent Findings in a Literature Review. Gastroenterol Res Pract 2018;2018:7848735.
17. U.S. Food and Drug Administration. Gluten in Drug Products and Associated Labeling Recommendations: Guidance for Industry. U.S. Department of Health and Human Services,, December 2017. https://www.fda.gov/downloads/drugs/guidancecomplianceregulatoryinformation/guidances/ucm588216.pdf. Accessed December 8, 2023.
18. Verma AK, Lionetti E, Gatti S, et al. Contribution of Oral Hygiene and Cosmetics on Contamination of Gluten-free Diet: Do Celiac Customers Need to Worry About? J Pediatr Gastroenterol Nutr 2019;68(1):26-29.
19. Malahias T. Celiac Disease and Dental Care: Dental Materials. https://www.beyondceliac.org/living-with-celiac-disease/dental-care/. Accessed December 8, 2023.

• Search JADA for information on celiac disease
• ADA Library Resources

• Celiac Disease Foundation: What is Celiac Disease?
• Mayo Clinic: Overview—Celiac Disease
• National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases: Dental Enamel Defects and Celiac Disease