Celiac Disease’s Toll on Your Teeth
First published in Allergic Living’s Winter 2012 magazine.
After Michelle B. was diagnosed with celiac disease in early 2009, she made sure to tuck all nine of her extracted teeth into her handbag when she was referred to the Celiac Disease Center at Columbia University in New York. She wondered if the dental problems with which she had been plagued since her early twenties – repeated cavities, root canals, infections and extractions – could possibly have something to do with celiac disease.
“I kept all my teeth because I just knew something wasn’t right,” explains the 38-year-old resident of Maplewood, New Jersey.
The clinic examined them and found they all had abnormalities associated with celiac disease, like enamel defects, structural defects and calcium deficiency.
“I knew something bigger was wrong than just my teeth, but I was still shocked by the link.”
Celiac disease and teeth? Really? If that’s news to you, you’re not alone – it’s quite possible that your doctor, dentist and hygienist have never heard of that link either. Among celiac disease’s curious mix of symptoms, oral health problems have only recently been shown to be one of them.
The first American study that looked at a connection between celiac disease, dental enamel defects and canker sores was published in The Journal of Clinical Gastroenterology in 2009. Meantime, the very first clinical guidelines for dentists that outlined celiac disease and dental problems was published in 2011, in the Journal of the Canadian Dental Association.
It’s hard to pin down the number of celiac patients affected by oral health issues – the studies have been generally been small – but the 2009 study found that dental enamel defects were found in 87 percent of the children with diagnosed celiac disease compared to 33 percent of non-celiac kids, and that 42 percent of celiac patients, both adults and kids, had frequent bouts of canker sores, versus 22 percent of the non-celiac patients.
Why is it happening?
Just why celiac disease can do a number on your teeth and mouth is, like so much else associated with the frustrating condition, far from clear. “We don’t know what the exact mechanism is, but there are two theories,” says Dr. Peter Green, a gastroenterologist and director of the Celiac Disease Center, who co-authored the 2009 study.
First, because celiac disease means that the body has trouble absorbing key nutrients, including vitamin D and calcium, that could translate to poor tooth enamel formation in childhood.
The second theory points to the immune system: Celiac patients have a substance in the blood known as tTG antibodies, and those antibodies may have some kind of influence on the development of the enamel, he says. (Non-celiac gluten sensitivity and oral health problems have not been studied, says Green.)
Part of the reason why the celiac-oral health connection isn’t on the radar of many health professionals is that dental enamel defects and canker sores – the two most common ways celiac disease affects the mouth – have a number of other causes, too.
“Dental enamel defects could also could be due to excess fluoride, genetics or certain antibiotics [like tetracycline],” explains Alexandra Anca, a Toronto dietitian who co-authored the Canadian clinical guide for dentists, and is scientific adviser for the Canadian Celiac Association’s professional advisory board. “Because of this, I don’t think many dentists are fully aware that celiac disease might be an issue.”
Unfortunately, medical doctors may not yet be in the know either. Even Green, the medical director of a prominent celiac research and treatment center, only recently recognized the connection. “It’s a big step forward for me to develop insight [into this link,]” he admits.
“The mouth, unfortunately, is a bit of a ‘no man’s land’ for physicians. It’s considered to be in the realm of dentists and oral pathologists, and its place in general medicine and gastroenterology has been forgotten.” He adds: “It’s not often you would look in people’s mouths during an exam. Now my group does. We ask about canker sores now, too.”
Greater awareness of the issue may be on the horizon. When Dr. Ted Malahias, a dentist in Groton, Connecticut, who also co-authored the 2009 paper, talks to fellow dental professionals at conferences, he says they are receptive and excited about finding a new piece to the puzzle for patients with stubborn dental issues. “It gets their curiosity going,” he says.
Your Action Plan
Problems like canker sores and atrophic glossitis (see “Watch Your Mouth,” for an explanation of specific celiac-related mouth troubles) are often related to vitamin and mineral deficiencies or immune response, says Malahias, and will likely improve once the celiac disease is addressed with the gluten-free diet.
Likewise, if a child who has dental enamel defects on his or her baby teeth is diagnosed with celiac disease before age 7 (when the enamel is forming on the permanent adult teeth), following a gluten-free diet should mean that dental enamel defects aren’t part of the adult teeth, he says.
However, if you’re an adult with dental enamel defects stemming from long-term, undiagnosed celiac disease, you are stuck with weakened tooth enamel. “The gluten-free diet can’t change the enamel,” he says.
If you have been diagnosed with celiac disease, you are following the gluten-free diet, and your teeth and mouth are fine, you have nothing to worry about, reassures Anca. (If you are diagnosed but cheat on your diet, oral health problems may be in your future, though.)
But if, like Michelle B., you haven’t been diagnosed with celiac disease but have been battling bad teeth, it’s worth a conversation with your doctor, particularly if you have a close family member with celiac disease, or you have any possible celiac symptoms (classic symptoms include abdominal distension and pain, and chronic diarrhea).
This is especially true for kids. “There are many factors that can cause dental enamel defects, but if the medical history indicates there is something else is going on, or there’s a family history of celiac disease, we recommend parents talk to their family doctor about getting their child tested for celiac disease,” says Malahias.
“In kids, the dental enamel defects can be an early warning sign of celiac.” (Michelle B. is keeping a very close eye on her 8-year-old son’s dental visits, but so far all is well.)
Michelle B.’s advice: “You just have to keep on pursuing the truth. My gut, no pun intended, was telling me there was something else going on. If your doctor or dentist doesn’t want to take the time to help you find an answer, you have to find someone who will. Eventually I put the pieces together, but it was a very long road.”
See also: Celiac Disease: Watch Your Mouth