Celiac Disease, Non-Celiac Gluten Sensitivity and Your Dental Patients

Celiac disease (CD) is an autoimmune disorder in which oral exposure to gluten causes damage to the lining of the small intestine. In a healthy patient the lining consists of finger-like projections called “villi” which increase the surface area to allow for the absorption of nutrients.  In a CD patient gluten ingestion causes villous atrophy.  Once the villi are damaged the body is unable to absorb key nutrients such as calcium, folic acid, magnesium, vitamins A, D, E, K, B, B12.  Celiac disease is very much a malabsorption/malnutrition disease.¹

There are various but no conclusive theories at this time as to what causes celiac disease.  Some of the different hypotheses include environmental factors; the composition of the bacteria that make up the gut microbiome; genetically predisposed infants that are delivered via Caesarian section; and possibly even the amount of gluten that a person consumes.²

What is definitely known for sure is that celiac disease: 1) involves the ingestion of gluten, that it 2) has a hereditary component and CD patients possess specific genes, and that 3) it is triggered by a stressful event to the body such as a pregnancy, surgery, or an illness.²

Celiac disease affects more than 3 million North Americans and it affects 91 million people worldwide.  Approximately 1 out of 133 people have CD, which is approximately less than 1 % of the population.^1,3

Celiac disease is more common than Crohn’s, Multiple Sclerosis, and Cystic Fibrosis COMBINED!³

Of the people that have CD more than 83-85% of them do not realize that they have CD. Research demonstrates that it takes approximately 6-10 years for patients to be properly diagnosed.¹

There are a couple of reasons for this.  In general, health professionals may not understand the disease well.^4,5 Lack of awareness also includes the physicians’ difficulty in recognizing the more than 250 various manifestations that surround CD.

CD affects both men and women and patients of all ages.¹ Research demonstrates that the average age of adult presentation is 46.

Celiac disease is considered mostly a disease that affects those of Northern European descent.  However, recent studies show that CD can also affect Hispanic, African American, and Asian cultures.³

A first degree relative (a parent, child, or sibling) of a celiac patient will have a 1 in 22 chance of getting celiac disease.  A second degree relative (a cousin or an aunt, uncle) will have a 1 in 39 chance of getting celiac disease.^1,3,4

Patients possessing one autoimmune disease will have increased chances of having another autoimmune disease. Being diagnosed with BOTH celiac disease and Type I diabetes is common.  Both diseases share similar genetic links.⁶

There are more than 250 manifestations of celiac disease, making it challenging for health professionals to diagnose.  Only approximately 50% of CD patients have classic accompanying gastrointestinal (GI) issues.  Some patients may be asymptomatic, or some might be referred for GI testing because of anemia, thyroid, fatigue, or neurological complaints.  If not recognized celiac disease can lead to serious consequences.⁷

Characterizations and complications from celiac disease can include:  lactose intolerance, fertility issues, osteoporosis, iron deficiency anemia, a rash condition called dermatitis herpetiformis, and possibly,   Non-Hodgkins lymphoma, small bowel cancer, and gluten ataxia.  Children with celiac disease present with complications including enamel defects, short stature, and failure to thrive.^1,2,4,6

Celiac disease patients can present with xerostomia, geographic tongue, atrophic glossitis, angular cheilitis, oral lichen planus, and recurrent aphthous ulcers. Pediatric CD patients will present with enamel defects.^4,7,8

Gluten is a thickener and a binder, that stretchy protein that makes pizza and many other foods so delicious!  It is found in many foods such as breads, pastas, pastries, sauces, and condiments. Gluten is also found in lotions, soaps, shampoos, and make-up.⁹

Gluten is a composite of proteins found in certain grains such as wheat, rye, and barley. Gluten consists of 2 main proteins:  gliadin and glutelin. Of the two, gliadin is responsible for the negative celiac disease effects.

To screen for CD the physician would first order serology tests that will search for specific antibodies. For accurate blood test results the patient must be on a gluten containing diet.  For patients above the age of 2 the Tissue Transglutaminase IgA antibody test is usually ordered along with an IgA antibody test.  An additional Deamidated Gliadin IgA may also be ordered.

For toddlers under the age of 2 the main test would be the Deamidated Gliadin IgA along with IgG antibodies.  It should be noted that very young babies usually start gluten containing diets after approximately 6 months of age making it difficult to obtain accurate blood antibody results in early life.

A positive blood test would still need to be confirmed by the “gold standard” consisting of an endoscopy procedure with 4-6 biopsies of the small intestine lining.  Similar to the serology tests, for accurate histology the patient must be on a gluten containing diet.²

Furthermore, all celiac patients possess either one or both of the following genes:  HLA DQ2 or HLA DQ8. HLA= human leukocyte antigen.  The physician may elect to order tests for HLA typing to exclude celiac disease.^2,10

How much Gluten does it take to make a Celiac Patient Sick?

There is no cure for CD.  Celiac patients must stay on a strict gluten-free diet for life.¹

The World Health Organization defines gluten-free foods as those with 20 parts per million (PPM) or less of gluten.¹⁰ 20 PPM equates to approximately 6 mg.  For a processed food to be allowed “Gluten-Free” labelling Health Canada requires that it contain 20 PPM or less of gluten.¹¹ Some studies demonstrate that consuming 6 mg of gluten per day should not promote villous atrophy.  Regardless, there is variation as to how sensitive various CD patients are to gluten consumptions and it is therefore difficult to define a gluten threshold.¹¹

Gluten-free diets are costly but not an option for celiac patients.  However, the gluten-free trend is also driven by eager consumers hoping to reap purported health benefits.

In 2018 the global gluten-free market size was estimated to be $17.59 billion dollars.  From 2019 to 2025 the gluten-free market is anticipated to expand at a compound annual growth rate of 9.1%.¹²

A cohort of patients experience symptoms similar to those with celiac disease but non-celiac gluten sensitive (NCGS) patients do not test positive for CD. Symptoms include “foggy brain”, abdominal pain, and fatigue after consuming gluten.  There is currently no test available for NCGS. The NCGS population size of patients is estimated to be equal to or exceeds that of CD.¹³

“If the eyes are the window to the soul, then the mouth is the window to the body”.

According to the Academy of General Dentistry more than 90% of all systemic diseases have some clinical connection to the oral cavity.¹⁴

Dental practitioners can play a large role in detecting celiac disease if they learn how to identify associated oral manifestations and pay attention to their patients’ health histories. The dental team should participate with interdisciplinary teams in medicine and nutrition for information integration.

The dental office health history questionnaire should include questions to the patient about gluten sensitivities, celiac disease, GI discomfort, fatigue, and anemia.  In addition, remember to question a suspected CD patient about family history of celiac disease and if they or a relative by chance have another autoimmune disorder such as Type 1 diabetes.

Utilizing gluten-free dental materials creates a safer clinical environment, encouraging celiac patients to present for oral care.  Don’t forget to include gluten-free hand soap and gluten-free hand lotion as these may touch the patients’ mouths.

It is very important that the dental team does NOT diagnose patients or have patients go on a gluten-free diet UNTIL they have seen a celiac disease specialist and a nutritionist.  For patients that are not diagnosed as celiac or designated as non-celiac gluten sensitive by a physician most health experts agree that it is very important that people consume whole grains for a well-balanced diet.

Indeed, the dental team can work together to recognize celiac symptoms, provide safer dental office conditions, and assist patients in prompt referrals to primary care providers and possibly save a life!

Research demonstrates, that by increasing awareness of celiac disease and its manifestations that the  diagnosis rate may reach 50-60% by the year 2019.¹

Since celiac disease is on the rise, researchers are eager to create immunity-tolerant treatments to gluten in people with CD.

Recently in the news, a team of doctors from Northwestern University presented their findings at the United European Gastroenterology Week Conference, in Barcelona Spain. They have spent years developing a technology to enable people with CD to ingest gluten with less inflammation.  Their treatment involves a biodegradable nanoparticle that encapsulates gliadin, “hiding it” so to speak, so that the immune system does not recognize it is the gluten allergen and therefore does not attack it.¹⁵