Title: Celiac Disease and Pediatric Dentistry: Implications for Oral Health and Dental Management

Introduction :
Celiac disease (CD) is a chronic autoimmune disorder that affects a significant number of individuals, yet
it remains difficult to diagnose. With only a small percentage of affected patients accurately identified,
there is a need for increased awareness and understanding of this condition. In this article, we will
explore the implications of celiac disease on oral health and dental management in pediatric patients.
Understanding Celiac Disease:
Celiac disease is characterized by an intolerance to gluten, a protein found in wheat, barley, and rye.
When individuals with a genetic predisposition to CD consume gluten, it triggers an inflammatory
response in the small intestine, leading to villous atrophy. While the primary effects of CD are
gastrointestinal, it can also have oral manifestations that are of particular importance to pediatric
dentists.
Diagnosing Celiac Disease:
Diagnosing celiac disease requires a comprehensive approach, considering both the gastrointestinal
symptoms and extra-intestinal manifestations. Pediatric patients with CD may present with abdominal
pain, diarrhea, and failure to thrive, along with skin, bone, and oral cavity issues. It is worth noting that
celiac disease is often associated with autoimmune disorders and is twice as common in children with
type I diabetes.
The Role of Breastfeeding and Gluten Introduction:
There is ongoing debate regarding the impact of breastfeeding and the timing of gluten introduction on
the development of celiac disease. Some studies suggest that breastfeeding and a gradual introduction
of gluten starting at four months may offer protection. However, larger-scale studies, such as the
European Multi-center Project Prevent CD, have not found a significant influence of breastfeeding or
early gluten introduction. Likewise, an Italian multi-center trial showed that the timing of gluten
introduction did not affect the risk of disease development.
Environmental Factors and Prevalence:
Changes in food production methods and increased consumption of gluten-rich foods have been
proposed as potential contributors to the rising prevalence of celiac disease. However, the role of
environmental factors in CD development remains a topic of controversy and further research is needed.
Diagnosing celiac disease (CD) can be a complex process due to its wide range of clinical manifestations.
However, there are various tests and markers available that can aid in the diagnosis. One such test is the
human leukocyte antigen (HLA) genotyping, which is often used for high-risk individuals. This test looks
for the presence of HLA-DQ2 and DQ8 haplotypes, which are commonly found in CD patients. While this
test is highly reliable in ruling out CD, it can sometimes produce false positive results.
Another commonly used diagnostic tool is the testing of serum endomysial antibody IgAEME and/or IgA
anti-tissue transglutaminase (tTG) antibodies. These tests are known for their high sensitivity and
specificity in detecting CD. In fact, recent research has found that 71.4 percent of children who tested
positive for anti-tTG in their serum also had it in their saliva. This suggests that a saliva test for anti-tTG
could potentially be developed as a non-invasive and cost-effective screening method for CD.
Celiac disease can affect multiple organs and present with a range of symptoms, both intestinal and
extra-intestinal. In children, common gastrointestinal symptoms include diarrhea, abdominal pain,
bloating, and vomiting. However, it's worth noting that approximately half of CD patients may be
asymptomatic or exhibit atypical symptoms. One such atypical symptom is dermatitis herpetiformis, a
chronic skin rash characterized by burning, itching, and small blisters on the elbows, knees, and
buttocks.
Implications for Pediatric Dentistry:
For pediatric dentists, it is crucial to be aware of the oral manifestations associated with celiac disease.
These may include enamel defects, recurrent aphthous ulcers, delayed tooth eruption, and an increased
risk of dental caries. Early recognition and diagnosis of CD can help dentists provide appropriate dental
management strategies, such as dietary counseling and monitoring for dental complications.
Celiac disease is a complex autoimmune disorder that affects both the gastrointestinal system and oral
health. In pediatric patients, understanding the link between CD and oral manifestations is essential for
dental professionals to provide comprehensive care. Increased awareness, early diagnosis, and
appropriate dental management strategies can significantly contribute to the overall well-being of
children with celiac disease.
Oral manifestations are also common in celiac patients, with dental enamel defects (DED) and recurrent
aphthous stomatitis being often seen. Recurrent aphthous ulcers, although not exclusive to CD, can be a
result of malabsorption of iron, folic acid, and vitamin B12. Atrophic glossitis and aphthous ulcers,
indicating deficiencies in iron, folate, or vitamin B12, can be present in up to 61 percent of CD patients.
Dental enamel defects, such as grooving, pitting, discoloration, and enamel loss, usually occur
symmetrically and chronologically across all quadrants of the dentition. The exact prevalence of DED in
CD is still unclear, but it is believed to be caused by malabsorption of vitamins D and calcium during vital
tooth enamel formation stages. This is particularly seen in undiagnosed pediatric patients up to 7 years
of age. Another theory suggests that these defects may be immune-mediated, with the anti-tTG
antibodies potentially influencing enamel development in children.
One study found that individuals with CD are 2.83 times more likely to experience dental enamel defects
(DED) compared to those without the disease. However, the occurrence of DED in deciduous teeth, also
known as baby teeth, was relatively low at 2.53%. This can be attributed to the mineralization process of
the crown in deciduous teeth, which usually occurs during a period when individuals are still adhering to
a gluten-free diet. Interestingly, the study also suggested that individuals with CD may experience a dry
mouth sensation even when salivary flow is normal. This indicates that xerostomia, or dry mouth, may
be related not only to the salivary flow rate but also to the organic and inorganic contents of saliva.
Further research is needed to evaluate the quality parameters presented in the saliva of CD patients.
Research studies have shed light on the dental and oral considerations associated with pediatric celiac
disease. A study conducted by Karlin et al. in 2016 emphasized the importance of dental professionals
understanding the specific oral manifestations of celiac disease in order to provide best care. Similarly,
Cruz et al. (2018) highlighted the dental and oral manifestations of the condition and stressed the need
for comprehensive oral care plans.
Beyond the gut, oral manifestations of celiac disease have also been explored in systematic reviews.
Lucchese et al. (2023) conducted such a review, revealing the wide range of oral symptoms that can
occur in individuals with celiac disease. This study emphasized the necessity of dental practitioners being
aware of these manifestations to ensure accurate diagnosis and appropriate treatment.
Green and Cellier (2007) further delved into celiac disease in a comprehensive article published in the
New England Journal of Medicine. Their research provided a thorough overview of the disease, including
its clinical features, diagnosis, and management. This article serves as a valuable resource for dental
professionals seeking a deeper understanding of celiac disease.
In addition to these scholarly articles, case-control studies have also explored the oral and dental
manifestations of celiac disease in children. Alsadat et al. (2021) conducted such a study, which
highlighted the importance of early detection and intervention in managing oral health issues associated
with celiac disease in pediatric patients.
Furthermore, dental practitioners should be aware of the study conducted by Maloney et al. (2014),
which focused specifically on the oral and dental manifestations of celiac disease. This research
emphasized the need for regular oral examinations and the implementation of appropriate preventive
measures for patients with celiac disease.
Lastly, a study by Villemur Moreau et al. (2021) examined the oral manifestations of celiac disease in
French children. This research further contributes to the understanding of the specific oral issues related
to the disease.
In addition to dental enamel defects, other oral manifestations have been associated with CD. These
include recurrent aphthous ulcers (canker sores), atrophic glossitis (inflammation of the tongue),
geographic tongue (a condition characterized by patches on the tongue), angular cheilitis (inflammation
of the corners of the mouth), and oral lichen planus-like lesions. Delayed teeth eruption and glossodynia
have also been reported in some CD patients.
Recognizing these oral manifestations is crucial for pediatric dentists in facilitating early diagnosis and
appropriate management of CD. Children presenting with unexplained dental enamel defects, recurrent
oral ulcers, or other oral mucosal lesions should undergo further evaluation for CD. While serological
testing for specific antibodies can aid in the diagnosis, confirmation typically requires histological
examination of small intestinal biopsies.
Dental management strategies for children diagnosed with CD primarily involve strict adherence to a
gluten-free diet. It is important for dentists to be aware that all dental materials and products used in
affected patients must be gluten-free, including retainers and prescribed medications. Dental materials
may contain excipients derived from food starch, and if derived from wheat, they may contain residual
gluten content. Therefore, caution should be exercised when prescribing medications to CD patients to
ensure they are free from gluten-containing ingredients such as dextrin.
Ensuring the safety of patients with celiac disease (CD) is of utmost importance in pediatric dentistry.
Cross-contamination can occur if gluten-free dental products come into contact with instruments,
equipment, or other products containing gluten. Therefore, dental professionals must take precautions
to prevent such cross-contact and protect the well-being of their patients.
Even if a dental product is labeled as gluten-free, there is still a possibility that it may contain traces of
gluten, which can pose a risk to individuals with CD. Therefore, it is crucial for dental offices to ensure
that all in-office products and medications used are genuinely gluten-free. Pediatric dentists should
familiarize themselves with dental products that are considered safe for children with CD, as even
minimal ingestion of gluten (30 mg) can be harmful to them.
When managing pediatric patients with celiac disease, the focus should be on addressing oral health
issues associated with the condition and promoting overall oral well-being. Restorative procedures like
dental bonding or veneers may be necessary to address dental enamel defects and enhance aesthetics
while protecting tooth structure. Topical analgesics or corticosteroids can be used to alleviate symptoms
and promote healing in cases of recurrent aphthous ulcers.
Moreover, pediatric dentists should emphasize the importance of maintaining a strict gluten-free diet to
manage celiac disease and reduce the risk of oral complications. Collaboration between pediatric
dentists and pediatric gastroenterologists is vital for the comprehensive management of these patients.
Through interdisciplinary communication and shared decision-making, early diagnosis, timely
intervention, and coordinated care can be achieved, leading to improved oral health outcomes.
Patient education plays a significant role in collaborative care. It is essential to educate patients about
the relationship between celiac disease and oral health, provide dietary counseling, and ensure
adherence to gluten-free diet recommendations. By working together, dental and medical professionals
can provide holistic care and optimize the overall well-being of children affected by CD.
In conclusion , celiac disease is an autoimmune disease that often goes undiagnosed, making it a growing
health concern. Pediatric dentists have a crucial role to play as they may be the first to identify oral and
dental manifestations of CD. If the disease is suspected, it is important for the dentist to refer the child
for testing. Early diagnosis is key to avoiding long-term complications such as infertility and
osteoporosis. Additionally, these children have an increased risk of developing gastrointestinal
malignancies, making early detection even more critical. Studies have shown that the mortality rate
among CD patients is higher than that of the general population, highlighting the importance of
proactive management and comprehensive care for these individuals. In the realm of pediatric dental
practices, it is crucial to include inquiries about celiac disease (CD) and other autoimmune diseases in
medical history forms. Celiac disease can have a significant impact on oral health and dental
management for young patients. Pediatric dentists must be able to recognize the oral manifestations of
celiac disease, employ appropriate diagnostic strategies, and provide interdisciplinary care by
collaborating closely with pediatric gastroenterologists and other healthcare professionals, dental
practitioners can make a valuable contribution to enhancing the overall health and quality of life for
children with celiac disease.
The research studies and articles mentioned provide valuable insights and knowledge for dental
practitioners seeking to enhance their understanding of this complex condition. Understanding the
impact of CD on oral health is essential in providing comprehensive care for affected individuals.
Through early recognition of oral manifestations and the implementation of appropriate management
strategies, pediatric dentists play a vital role in improving the overall well-being of CD patients. Further
research is needed to explore the complexities of CD's impact on oral health and identify more targeted
interventions for this patient population. Neutral Tone: "Preventing Cross-Contamination and Managing
Celiac Disease in Pediatric Dentistry"

References:

1. Karlin S, Karlin E, Meiller T, Bashirelahi N. Dental and Oral Considerations in Pediatric Celiac Disease. J Dent
Child (Chic). 2016;83(2):67-70. PMID: 27620516.
2. Cruz IT, Fraiz FC, Celli A, Amenabar JM, Assunção LR. Dental and oral manifestations of celiac disease. Med
Oral Patol Oral Cir Bucal. 2018 Nov 1;23(6):e639-e645. doi: 10.4317/medoral.22506. PMID: 30341262;
PMCID: PMC6260995.
3. Lucchese A, Di Stasio D, De Stefano S, Nardone M, Carinci F. Beyond the Gut: A Systematic Review of Oral
Manifestations in Celiac Disease. J Clin Med. 2023 Jun 6;12(12):3874. doi: 10.3390/jcm12123874. PMID:
37373569; PMCID: PMC10299058.
4. 1.Green, P. H., & Cellier, C. (2007). Celiac disease. New England Journal of Medicine, 357(17), 1731-1743.
5. Alsadat FA, Alamoudi NM, El-Housseiny AA, Felemban OM, Dardeer FM, Saadah OI. Oral and dental
manifestations of celiac disease in children: a case-control study. BMC Oral Health. 2021 Dec 29;21(1):669.
doi: 10.1186/s12903-021-01976-4. PMID: 34965875; PMCID: PMC8715621.
6. Maloney WJ, Raymond G, Hershkowitz D, Rochlen G. Oral and dental manifestations of celiac disease. N Y
State Dent J. 2014 Jun-Jul;80(4):45-8. PMID: 25219065.
7. Villemur Moreau L, Dicky O, Mas E, Noirrit E, Marty M, Vaysse F, Olives JP. Oral manifestations of celiac
disease in French children. Arch Pediatr. 2021 Feb;28(2):105-110. doi: 10.1016/j.arcped.2020.11.002. Epub
2020 Dec 17. PMID: 33341334.