Care of celiac patients by hygienists in the dental office: Research paper
The dental office is one area that hygienists can help celiac patients. Being aware of the signs and symptoms of celiac and knowing ingredients of dental products, hygienists can help patients manage their disease while at the office
By America Lince and Linda Tran
Celiac disease, an autoimmune disease, has caused more than only gastrointestinal symptoms. Manifestations of symptoms occur extraintestinally as iron deficiency anemia, osteoporosis, or recurrent aphthous stomatitis and enamel defects within the oral cavity.
Celiac disease shares a wide range of symptoms with several other disorders, often being misdiagnosed with illnesses such as chronic fatigue syndrome or inflammatory bowel disease. However, this disease has also been known to present itself with no signs or symptoms. Being an autoimmune disease, celiac has been linked to other autoimmune diseases such as thyroiditis, diabetes, and Addison’s disease.
Implementation of a gluten-free diet had shows improvement in the symptoms of celiac and its associated diseases. But in regards to autoimmune diseases, a gluten-free diet does not guarantee the non-development of other autoimmune diseases. Celiac patients need to be constantly aware of gluten-containing products on a daily basis.
The dental office is one area that hygienists can help celiac patients. Being aware of the signs and symptoms of celiac and knowing ingredients of dental products, hygienists can help patients manage their disease while at the office.
Care of Celiac Patient in the Dental Office
Advances in technology and science allowed new discoveries in health care that improve the understanding of widely unrecognized diseases. With this knowledge, many syndromes and diseases that used to go undiagnosed are identified and patients are able to find an answer to what has been happening to them. One example is the relatively new discovery of celiac disease. Before awareness about celiac disease was raised, patients were misdiagnosed for months or years, suffering the same symptoms that did not get better with the treatment they received. According to Rashid, Zarkadas, Anca, and Limeback (2011) “the mean duration of symptoms in adults before diagnosis was 11.7 years” (p. 2).
Researchers found that celiac disease (CD), an autoimmune disorder also called Coellic disease, disturbed multiple systems and organs and was potentially life-threatening. Until recently, it was the only autoimmune disease that had a known trigger: gluten (Lugg, 2010).
Gluten, a protein found mainly in wheat, can be also found in barley, brewer’s yeast, rye, and malt. The presence of gluten affects different kinds of food. It provides a chewy texture to products such as bread, pasta, and many more. The main components of gluten contain glutenin and gliadin. Glutenin provides gluten’s stickiness and elasticity while gliadin triggers an immune reaction (Logsdon, Komasinski, Wess, and Holt 2015).
As of 2010, it was estimated that one in 133 people in the United States suffered from this disease (Glynn, 2014). In patients with first-degree relatives, the prevalence increased to one in 22 with the median age of diagnosis at 45 (Glynn, 2014).
The symptoms are very complex. Some people did not experience any at all or it varied in intensity. It was once believed that CD was only a gastrointestinal disorder with individuals who experienced bloating, diarrhea, vomiting, secondary lactose intolerance, and loss of appetite. But it was discovered that GI symptoms were the least likely to appear. The most distinctive mark of CD, the affection of duodenal villi, affected the production of digestive enzymes and absorption of nutrients.
According to Lugg (2010), patients experienced chronic fatigue, osteoporosis, iron or folate deficiencies, muscle or joint pain, general weakness, recurrent canker sores, reproductive system disorder, liver abnormalities, neurological disorders, depression, and dermatitis herpetiform. CD had also been associated with other autoimmune disorders (Lugg, 2010).
From all these symptoms, CD has been classified into four different forms according to the disease’s clinical manifestations and age of onset. Erriu et at. (2011) categorizes the disease into classical, atypical, subclinical, and latent forms. The classical form include growth deficits and GI disturbances while a combination of other symptoms determined the atypical, subclinical, and latent forms. Atypical pattern often presented only by lesions in the oral mucosa or by defects in dental enamel (Erriu et al., 2011).
Due to the great array of symptomatology that patients experience, it is very difficult to diagnose CD based solely on patients’ manifestations. Several methods are combined to make a definitive diagnosis. Laboratory findings, clinical medical history, and duodenal biopsies are needed to differentiate between an autoimmune disorder, which was called CD, an allergic reaction called wheat allergy (WA), or a non-celiac gluten sensitivity (NCGS) (Elli et al., 2015).
When a patient is suspected of having one of these disorders, in order to have a trustworthy diagnosis, it is best that patients stay on a gluten inclusive diet. Otherwise, false negatives are given and further time and effort from patients are needed (Rashid et al., 2011).
Presence of dental disease
The oral cavity is an area of the body where manifestations of celiac disease possibly appear. According to Costacurta, Maturo, Bartolino, and Docimo, (2010) “enamel hypoplasia, atrophic glossitis, recurrent aphthous stomatitis, and delay in dental eruptions had been described among the clinical oral manifestations of CD” (p.13). Rashid et al. (2011) mentioned that the occurrence of cheilosis and oral lichen planus are the most common along with enamel hypoplasia and recurrent aphthous stomatitis.
Enamel defects are present in 51% of patients with CD, which include hypoplasia and hypomineralization. The dental enamel defects are more prevalent in children where celiac disease appeared before 7 years of age. In adults, those defects are not common because CD manifestation started at an older age or the affected teeth were extracted. Permanent teeth are affected, especially incisors and molars, and the changes usually appeared symmetrically and chronologically in all four quadrants (Rashid et al., 2011).
The intensity and variation of enamel defects in CD are classified by Aines as:
- Grade I defects in color of enamel, single or multiple cream, yellow, or brown opacities.
- Grade II slight structural defects, rough enamel surface, horizontal groves, and shallow pits.
- Grade III evident structural defects, deep horizontal grooves, large vertical pits.
- Grade IV severe structural defects, and change of tooth shape (Krzywicka, Herman, Kowalczyk-Zając, and Pytrus, 2014).
A clinical oral manifestation of CD has been the appearance of recurrent aphthous stomatitis (RAS). Manifestations of RAS are found in 52% of diagnosed celiac patients with the labial mucosa and lateral margins of the tongue being the most common sites. RAS are more often found in silent celiac patients who show no typical gastrointestinal symptoms before being diagnosed with CD (Bramanti, Cicciù, Matacena, Costa, & Magazzù, 2014).
The relation between CD and RAS is explained by looking at RAS’s etiology. Even though it remains unclear, it is believed that many underlying disorders had predisposed patients to develop oral aphthous ulcers. Disorders include iron deficiency anemia, neutropenia, and folic acid or vitamin B12 deficiency, as well as a selective vitamin B12 absorption defect (Altenburg et al., 2014). All of these deficiencies are observed in patients with celiac disease due to the villi affection that produces low absorption of nutrients.
Delayed tooth eruption is another problem found among young celiac patients in comparison to healthy children. This delayed eruption has been linked to the failure to thrive, as a sign of malnutrition, and requires a diagnosis toward gluten intolerance (Krzywicka et al., 2014). Delayed tooth eruption is any tooth not visible in the dental arch after eight months of the usual phase of eruption. Around 20% of celiac patients had shown a delay (Costacurta et al., 2010).
Atrophic glossitis (AG), an inflammatory disorder of the tongue’s mucosa, show a smooth glossy appearance with a red or pink background. The surface appears smooth, which was due to the atrophy of filliform papilla. This causes lesions that mimic ulcers on the dorsum and lateral border of the tongue. Atrophic glossitis is linked to other conditions such as chemical irritations, amyloidosis, and local infections as candidiasis, drug reactions, malnutrition, pernicious anemia, systemic infections, Sjogren syndrome, psoriasis, and celiac disease (Erriu et al., 2012). Patients with AG present difficulty swallowing, chewing, or spend less time speaking. AG is present in 14% of ascertained celiac patients and in 23% of those, celiac is suspected (Bramanti et al., 2014).
According to Lucendo et al. (2015), oral lichen planus (OLP), an autoimmune disease of mucous membranes or skin, is a manifestation of CD first mentioned back in 1993. In a study by Cigic, Gavic, Simunic, Ardalic, and Biocina-Lukenda in 2014, it was discovered that the prevalence of CD in patients with OLP was 14.28% compared with matching healthy controls. It was also noted that only 5.36% of the patients had gastrointestinal symptoms.
In a study by Bramanti et al. in 2014, it was found that angular cheilitis was present in 9.5 % of potential celiac patients and in 6% of celiac patients. Angular cheilitis, presented as minor and mild in size, has diffuse redness, eroded, fissured, ulcerated or encrusted surface, and symptoms of burning, pain, or tenderness. Patients with these manifestations recalled having spontaneous appearances without any previous suspected trauma.
Overlapping symptoms result in misdiagnoses, confusion, and prolonged discomfort. Symptoms that had been known to be shared between CD and other health disorders were the feeling of fatigue, vomiting, diarrhea, bloating, and irritability (Pascual et al., 2014). Knowing the signs, symptoms, and the association of CD with other disorders help determine whether or not CD and oral health are related.
Fatigue is a common symptom among many different diseases causing a wide range of illnesses to be misdiagnosed with chronic fatigue syndrome. Along with chronic fatigue, frequent feeling of being tired all the time is shared with CD being one of the most constant complaints (Siniscalchi et al., 2005). Those with suspected cases of chronic fatigue syndrome should have been considered for CD testing.
Those suffering from chronic disorders have been found to obtain lesser hours of sleep and sleep tends to have little restorative abilities. A study by Zingone et al. (2010) suggested the addition of sleep disturbances to the many signs and symptoms of CD considering how common sleep disorders were in celiac patients, even for those maintaining a gluten-free diet.
Several conditions shared by CD and inflammatory bowel disease are periodontitis and aphthous ulcers along with chronic intestinal inflammation. Neither of these diseases were completely understood, but they were known to involve damage to the gastrointestinal tract. (Pascual et al., 2014).
Along with their internal symptoms of intestinal inflammation, diarrhea, and abdominal pain, irritable bowel disease and CD also shared several extraintestinal manifestations. These clinical features included short stature, refractory iron deficiency anemia, and osteoporosis. Patients with irritable bowel disease are symptomatic and show signs of disease whereas CD patients possibly remain asymptomatic. For patients with irritable bowel diseases who did not respond to immunosuppressive or biological treatments it is suggested that CD be considered as a diagnosis (Pascual et al, 2014).
Osteopenia and secondary osteoporosis are diseases that affect many people with CD. Secondary osteoporosis occur from certain medical conditions or treatments, which disturb the completion of peak bone mass, leading to bone loss. The overall increased level of bone loss is caused by an increased percentage of bone remodeling or an increase in the extent of bone that needed remodeling (International Osteoporosis Foundation [IOS], n.d.).
Malabsorption within the intestines causes loss of minerals, fats, and vitamins within the body and affected normal bone metabolism. With CD, it is the “intestinal malabsorption and inflammation that contributed to the pathophysiology of bone damage” (Di Stefano, Mengoli, Bergonzi, & Corazza, 2013). Seventy-five percent of untreated celiac patients suffer from low bone density, increasing their risk of bone fractures. The premenopausal population suffering from CD may reach the age of menopause with an already reduced bone mass (Carroccio et al., 2014).
Clinical detection of osteoporosis and CD is difficult because of the potential absence of any signs or symptoms. Adherences to a gluten free diet have been shown to raise the body’s bone mineral density with significant recovery just after one year (Di Stefano et al., 2013). Unfortunately, the ability to recover from this bone loss is greater in children and lowest in peri- and postmenopausal women. Even without bone mineral density measurements, drug treatment in addition to a gluten free diet are recommended for celiac patients who are at high risk for fractures, are peri- and postmenopausal, or those who do not have enough calcium intake (Di Stefano et al., 2013).
For those suffering from CD, iron is a nutrient that may have been lacking due to the reduced surface absorption in the intestines. In the absence of diarrhea or weight loss in celiac patients, iron deficiency may have been a clinical feature. Many newly diagnosed celiac patients have a tendency to present with iron deficiency anemia. Especially common in children, this deficiency itself may have been the only presenting clinical manifestation of CD leading to its initial recognition (Freeman, 2015).
Although current studies are limited on the relation of iron and CD, previous studies confirm that untreated celiac patients have a limited absorption of iron. Results of Freeman’s (2015) iron regulatory protein study showed that increased intestinal cell proliferation did not have an effect on iron uptake regulation; therefore it was the decrease of the intestine’s ability to absorb iron that affected celiac patients. With proper compliance to a gluten-free diet, however, there is an overall improvement of iron absorption (Freeman, 2015).
Patients with a history of autoimmune disease are more likely to develop additional autoimmune diseases. Health-care providers should be alert and keep watch for the presence of other autoimmune disease of previously diagnosed patients. “In many cases, the presence of one autoimmune disorder helps lead to the discovery of other autoimmune conditions” (Cojocaru, Cojocaru, & Silosi, 2010, p. 132).
Gluten-free diets are shown to decrease the symptoms of celiac and other diseases. Autoimmune diseases seem to be the exception. Despite a strict adherence to a gluten-free diet, many patients still developed autoimmune disorders (Van der Pals et al., 2014). Autoimmune disorders that have been linked to CD are type 1 diabetes, thyroiditis, and Addison’s disease.
Hashimoto thyroiditis and Grave’s disease are two thyroid autoimmune conditions associated with CD. According to Van der pals et al. (2014), with untreated celiac and the consistent inflammation and mucosal injury to the intestine, the risk for developing these thyroid disease increase. Children with CD are three times more likely to develop thyroid disease than those without (Van der Pals et al. 2014).
Addison’s autoimmune disease, also known as adrenal insufficiency, is a rare disease. Patients with Addison’s autoimmune disease are at risk for developing CD, with several studies that also show an increased risk of celiac patients developing Addison’s disease. (Lauret & Rodrigo, 2013). Like CD, Lauret and Rodrigo (2013) agree it can be difficult to diagnose due to shared similar symptoms, which include chronic malaise, fatigue, abdominal cramps, and nausea.
According to Kumar, Rajadhyaksha, and Wortsman (2001), Addison’s autoimmune disease has the strongest relation to CD due to their similar backgrounds. The affiliation between these two diseases may not have been coincidental because Addison’s disease is rather uncommon (Kumar, Rajadhyaksha, & Wortsman, 2001). Therefore, Kumar, Rajadhyaksha, and Wortsmans suggest that patients with Addison’s are more prone to develop CD and should be screened.
Due to asymptomatic CD, screening was also recommended for patients with type 1 diabetes (T1DM). The occurrence of CD along with T1DM is more common than celiac alone (Akirov & Pinhas-Hamiel, 2015).
Serena, Camhi, Sturgeon, Yan, and Fasano’s 2015 study show there is a higher occurrence of growth impairment in patients with both CD and T1DM. Patients also show significantly lower body weight and height standard deviation scores (Serena et al., 2015). Patients who adhere to a gluten-free diet show an improvement in growth whereas patients who did not restrict gluten from their diets have continuous growth impairments (Akirov & Pinhas-Hamiel, 2015).
A patient’s health is also more at risk to decline when possessing both diseases. Glycemic control worsens with an increase in retinopathy, nephropathy, peripheral neuropathy, and subclinical atherosclerosis (Akirov & Pinhas-Hamiel, 2015).
Gluten-free diets for T1DM and CD patients have been difficult. Many gluten-free foods affect glucose levels, lipid profiles, and insulin requirements in diabetes patients because of gluten-free food’s high glycemic indices (Akirov and Pinhas-Hamiel, 2015). It is important for T1DM patients to be aware of how a gluten-free diet will affect blood sugar levels and adjust insulin accordingly.
Mental Health Issues
There are conflicting studies regarding the relationship of CD and depression. This could be a result of the varied lifestyles from the different populations where the studies had been performed. A study in the United States came to the conclusion that the number of CD patients with depression was no different than the control groups (Garud et al., 2009). What Garud et al. (2009) did determine was that the occurrence of depression for CD patients was significantly greater in those who also had another autoimmune disorder, especially the ones who already had T1DM.
Besides the impact that celiac disease can have on the overall health of patients experiencing it, it is important not to dismiss the social implications it may involve, especially since society tends to see gluten-free diets as more of an elected lifestyle or just another trend instead of seeing it as a treatment for a chronic disease.
Patients recently diagnosed, primarily adults, have to learn to follow a gluten-free diet for the rest of their lives. This gluten-free lifestyle can interfere with their relationship with others when eating out, diminishing their enjoyment of food, and stopping travel mainly overseas, resulting in frustration (Roos, Hellström, Hallert, & Wilhelmsson, 2013).
Dental Hygiene Appointments
Providing patient care as a hygienist includes more than just cleaning teeth. Hygienists have the opportunity to discuss with patients the intricate connection between systemic health and oral health. Some points to keep in mind while interacting with patients is to consider CD in patients with enamel defects and frequent recurrent aphthous ulcers, especially since enamel defects could be the only sign of CD in children (Krzywicka et al., 2014).
A dental visit can be a quick way to screen for celiac disease in those who have indicatives. Keep close attention if the patient has a disease that may be confused with CD and whose symptoms are not improving with current treatment methods. CD may be difficult to diagnose due to its multitude of varying symptoms, but also bear in mind that CD may also be asymptomatic. Be particularly aware if the patient is already diagnosed with an autoimmune disease, especially T1DM and thyroiditis (Doyle, 2015).
It is important for those with CD or gluten sensitivity to stay attentive in their day-to-day activities to keep from unintentionally ingesting gluten. The dental office is one area where the accidental ingestion of gluten can occur. A common additive in plastic is gluten; dental products containing plastic and dental equipment may have non-dietary gluten and can generate and heighten symptoms of CD (Memon, Baker, Khan, Hashmi, & Gelfond, 2013). Along with toothpaste, mouth rinse, and floss, some other dental products that may contain gluten are prophy paste, fluoride, topical anesthesia, gloves, and orthodontic retainers. It is important for the dental office to know what products may or may not contain gluten and which products are best to recommend for CD patients.
With such a variety of symptoms that are linked to a multitude of different diseases, and even being asymptomatic, the diagnosis of CD had been difficult. Knowledge gained from previous studies revealed commonalities among these diseases and how they influenced one another. Most studies concluded that CD be considered as a diagnosis. As hygienists, increasing our awareness and staying informed about celiac and other diseases and the potential effects they may have on our patients will not only make us a valuable asset in the dental office but in the health-care community.
Linda Tran and America Lince are dental hygiene students at Collin College in McKinney, Texas. They are both active members of the student chapter of the American Dental Hygienists’ Association. America has over 10 years of dental experience from Mexico and in the United States. She would love to work in a community clinic to help those with limited access to care. Linda was a certified dental assistant prior to being accepted into the dental hygiene program. She plans to continue her education with a master's in dental hygiene and hopes to one day become an educator.
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