Often dentists see young children in the office with malformed, decayed, and extreme hypoplastic teeth, and the first assumption is to criticize the lack of home care as a cause of this dental disorder. However, by observing the dental pathology during early development, special considerations should alert us that there maybe a systemic disorder that is causing dental problems.
Dentists, as health professionals, can be key players leading up to the diagnosis of celiac disease (CD), saving the patient from serious health complications that commonly arise when CD is left untreated. The following discusses the etiology, diagnosis and treatment of celiac disease to aid the dental clinician.
Celiac Disease (also referred to as gluten-sensitive enteropathy, gluten intolerance, nontropical sprue) is a permanent auto-immune disease resulting in inflammatory damage to the small-intestinal mucosa. This immune reaction, in response to ingested gluten, causes the intestinal villi (tiny finger-like projections where absorption of nutrients takes place) to become flattened, thus resulting in a decreased absorptive area that can lead to deficiencies of such vitamins as A, B-12, D, E, K folic acid, and minerals such as calcium, iron, magnesium and zinc. These deficiencies, in addition to the body's immune response to gluten, can lead to a wide range of health problems, requiring the patient to seek medical assistance in virtually any specialty of the health care system.
DIAGNOSIS AND TREATMENT
In European countries the incidence of celiac disease is roughly 1: 250. A study in the US by Not et al suggests that the prevalence in North America may parallel this figure.
Blood screening tests (ELISA) which measure IgA anti-gliadin antibodies (AGA), antireticulin (ARA) antibodies and anti-endomysial (EmA) antibodies are available in some Canadian hospitals, however, the small bowl biopsy still remains the gold standard of diagnosis. The biopsy is performed using endoscopy, preferably taking multiple biopsies of the distal duodenum and proximal jejunum, to determine villous atrophy. It is important that the patient does not eliminate gluten from the diet before testing as this will lead to healing of the intestinal mucosa and interfere with diagnosis.
The only treatment for Celiac disease is a strict gluten-free diet for life. Gluten is a storage protein found in many cereals; however, it is only the gluten found in wheat, rye, barley and possibly oats that elicits the inflammatory intestinal reaction seen in CD. This prolamin fraction of gluten that is toxic to those people suffering from CD is glaidin in wheat; hordein in barley; secalin in rye; and avenin in oats.
The dentist by examining the dentition can be instrumental in helping the patient seek proper medical attention. Celiac disease effects the teeth in a characteristic fashion. (Examples of enamel defects are shown in figures 1-5.)
The dentist should refer the patient for possible medical attention if the signs and symptoms follow the patterns outlined. It is crucial that the patient be made fully aware of exactly what a gluten-free diet entails as gluten is hidden in many foods and pharmaceuticals. Following diagnosis, the patient should receive dietary counselling from a professional dietitian. Joining the local chapter of the Canadian Celiac Association offers the advantage of information on diet, current research, news and support groups for those affected by Celiac disease.
SYMPTOMS AND COMPLICATIONS
CD was once considered to be strictly a childhood disease; with failure to thrive, weight loss, distended abdomen and diarrhea as the classic symptoms. In medical history most believed the myth that children would outgrow the traits of CD, but research and improved diagnostic techniques have shown that CD is a life-long condition that can occur anytime during the lifecycle and symptoms can vary significantly among individuals.
Commonly, one or more of the following symptoms may occur from patients suffering from CD:
Abdominal pain, alopecia, anemia (folic acid, iron, vitamin B-12 deficiencies), aphthous ulcers, bloating, bone/joint pain, deficiency of minerals and vitamins, dental abnormalities, depression, diarrhea and/or constipation, easy bruising of the skin, edema of ankles and hands, extreme weakness and lethargy, flatulence, hepatic disease, hypoparathyroidism, hyposplenism, IgA nephropathy, lactose intolerance, nausea and vomiting, osteopenia, steatorrhoea, unexplained neuropathic diseases; severe irritability seizures, short stature and delayed puberty in children.
Conditions more prevalent in individuals with Celiac disease include:
Dermatitis herpetiformis (DH), insulin dependent diabetes, thyroid disease, osteoporosis, miscarriages and infertility, intestinal lymphoma, attention deficit disorder (ADD), neural tube defects in newborns.
Patients with Celiac disease are at high risk of having other autoimmune disorders with a higher than expected prevalence of organ-specific autoantibodies. Like antiendomysium autoantibodies, these organ-specific antibodies (eg. those directed against the thyroid in thyroid disease and the pancreas in diabetes) seem to be gluten-dependant and also tend to disappear during a gluten-free diet.
DISCUSSION & CONCLUSIONS
When dental enamel defects are obvious, it is easy to assume that the patient's lack of proper dental hygiene is the cause, despite his/her insistence that regular brushing and flossing is practiced. The medical history and proper examination may reveal that there is an underlying systemic disorder such as Celiac disease that may have caused these health problems. OH
The Canadian Celiac Association has prepared a 'Medical Facts' sheet to provide further education on CD. If you have a patients who fits the parameters of dental enamel defects as outlined above, this fact sheet can be included in your referral report to the patient's family physician or gastroenterologist. Copies of the 'Medical Facts' sheet can be obtained by contacting: The Canadian Celiac Association, 5170 Dixie Road, Suite 204, Mississauga, ON, L4W 1E3. Tel: 1-800-363-7296 or (905) 507-6208. Fax: (905) 507-4673. www.celiac.ca
Dr. A. R. Hawryluk is a 1973 graduate from the University of Toronto and he practices in Mississauga, ON. He is a fellow of the Pierre Fauchaud Academy. D. Hawryluk is a registered dental hygienist. She has worked at Sick Children's Hospital and is keenly interested in the prevention process of dental disease.
Mrs. M. McCool is a graduate in pharmacy from the University of Calgary. She has aggressively studied Celiac Disease and its related pathology.
Oral Health welcomes this original article.
Aine, L., Dental Enamel Defects and Dental Maturity in Children and Adolescents with Coeliac Disease, pg 1-71, 1986
Canadian Celiac Association Handbook, Celiac Disease needs a Diet for Life. 3rd ed. Toronto: 2000.
Freeman. H.J., Clinical Spectrum of biospy-defined celiac disease in the elderly. Can J Gastroenterol l995:9(l):42-46
Hadjivassiliou M: Gibson A: Davies-Jones GA, Lobo AJ: Stephenson TJ: Milford-Warda A. Does cryptic gluten sensitivity play a pan in neurological illness?, Lancet, 347 (8998):369-71 1996 Feb 10
Murray. JA., The Widening Spectrum of Celiac Disease, American Journal of Clinical Nutrition. Vol 69, 354-65, Mar 99 Pruessner, H, American Family Physician, March 1, 1998
Toscano, V, Conti FG, Anastasi E; Mariani P, Tiberti C; Poggi M; Monti S; Laureti S, Cipolletta E; Gernme G; Caiola S.Di Mario U,' Bonamico M, Am J Gastroenterol, 2000, Jul 97(7):1742-8
Ventura A; Neri E, Ughi C; Leopaldi A, Citta A. Not T, Gluten-dependant diabetes- related and thyroid- related autoantibodies in patients with celiac disease, J Pediatr 2000 Aug, 137(2): 263-5.