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CDHO Advisory: Celiac Disease

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with celiac disease.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Celiac Disease, 2024-08-13

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Celiac disease

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have celiac disease, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Keeping records.
  9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Male
Female
Parents, guardians, and family caregivers of children, young persons and adults with celiac disease.

MAJOR OUTCOMES CONSIDERED

For persons who have celiac disease: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Resources consulted

  1. Aphthous stomatitis, canker sores, a type of stomatitis that presents with shallow, painful ulcers.
  2. Atrophic glossitis, a condition in which papillae are lost from the dorsum of the tongue, resulting in a sore and highly sensitive surface that makes eating difficult.
  3. Celiac disease, celiac sprue, sprue, gluten intolerance, gluten-sensitive enteropathy,  non-tropical sprue, which
    1. damages the absorptive surface of the small intestine 
    2. leads to malabsorption.
  4. Cholesterol, is
    1. a waxy fat called a lipid produced naturally in the body
    2. essential for the body to make
      1. cell membranes
      2. vitamin D
      3. hormones
    3. of two types 
      1. low-density lipoprotein (LDL), the ‘bad’ cholesterol 
      2. high-density lipoprotein (HDL), the ‘good’ cholesterol because it carries LDL away from the arterial walls where the atherosclerosis accumulates.
  5. Dermatitis herpetiformis, an intensely itchy, blistering skin rash that affects persons with celiac disease.
  6. Gluten, a protein which
    1. is found in wheat, rye, barley and possibly oats (the latter if contaminated with gluten from wheat, rye, or barley)
    2. may also be present in manufactured products such as medications, vitamins, and lip balms.
  7. Gluten-free diet, chiefly includes
    1. cereals without wheat or barley malt
    2. fruits and vegetables
    3. meat, poultry, and fish
    4. milk-based foods
    5. potatoes, rice, corn, beans
  8. Malabsorption, impaired ability to absorb nutrients, such as
    1. carbohydrates
    2. fat
    3. protein
    4. vitamins and minerals
  9. Malnutrition, inadequate nutrition resulting from
    1. inadequate or unbalanced diet
    2. malabsorption
    3. particular medical conditions
    4. problems with digestion or absorption
  10. Villi, microscopic finger-like projections that line the epithelium of the small intestine through which nutrients are absorbed.

Overview of celiac disease 

Resources consulted

Celiac disease 

  1. is an incurable condition that can be successfully managed with a gluten-free diet
  2. has numerous comorbidities, complications and associated conditions, which often complicate the clinical picture
  3. is a common genetic disorder that
    1. may or may not run in families
    2. may develop at any point from infancy to late adulthood
  4. is an autoimmune condition 
    1. the exact cause of which is unknown
    2. responds to gluten by damaging or destroying villi in the small intestine, leading to malabsorption which produces
      1. malnutrition (CDHO Advisory)  
      2. complications and associated conditions
  5. causes malabsorption, which results in malnourishment regardless of the amount of food consumed 
  6. is strongly associated with dermatitis herpetiformis
  7. affects 
    1. persons in all parts of the world
    2. about 1 in 133 persons in North America
    3. about 1 in 56 persons who have gastrointestinal symptoms undiagnosed as those of celiac disease
    4. about 1 in 39 persons who have a second-degree relative (grandparent, aunt, uncle, or cousin) with celiac disease 
    5. about 1 in 22 persons who have a first-degree relative (sibling, child, or parent) with celiac disease
  8. may be triggered into activity for the first time by events such as
    1. childbirth
    2. pregnancy
    3. severe emotional stress
    4. surgery
    5. viral infection
  9. is associated with symptoms that 
    1. vary from person to person 
    2. may involve parts of the body other than the digestive system
    3. variously include
      1. abdominal pain, bloating, gas, or indigestion
      2. appetite change, which may be increased or decreased
      3. constipation
      4. diarrhea, persistent or intermittent
      5. lactose intolerance
        1. common at initial diagnosis
        2. normally disappears after the start of the gluten-free diet
      6. nausea and vomiting
      7. stools that float, are foul smelling, bloody, or appear fatty
      8. unexplained weight loss 
    4. result from the malabsorption of key nutrients 
  10. in children, is most commonly experienced as some combination of symptoms which
    1. all reflect malabsorption during the years when nutrition is critical to the child’s normal growth and development
    2. include some combination of problems of
      1. behaviour 
        1. irritability
        2. fussiness
      2. the gastrointestinal system, such as
        1. abdominal bloating and pain 
        2. constipation 
        3. diarrhea
        4. constipation
        5. fatty or pale, foul-smelling stools
        6. nausea
        7. vomiting
      3. growth and development
        1. delayed puberty
        2. weight 
          1. gain below age norms
          2. loss 
        3. height below age norms 
        4. failure to thrive in infants
      4. oral health, including
        1. dental enamel defects
        2. changes in tooth colour 
  11. appears less likely to cause digestive symptoms in adults in whom it may instead produce one or more of the following
    1. amenorrhea
    2. anxiety (CDHO Advisory)  
    3. aphthous stomatitis 
    4. bone or joint pain 
    5. depression (CDHO Advisory)  
    6. fatigue 
    7. infertility or recurrent miscarriage 
    8. neurological effects such as tingling and numbness in the hands and feet 
    9. osteoporosis (CDHO Advisory)  
    10. rheumatoid arthritis (CDHO Advisory)  
    11. seizures
    12. unexplained iron-deficiency anemia (CDHO Advisory)  
  12. even without symptoms, may cause long-term complications
  13. lacks a complete explanation of why the symptomatology is so varied; factors with an apparent role in when and how celiac disease appears include 
    1. age at which consumption of gluten-containing foods began
    2. amount of gluten-containing foods consumed
    3. degree of damage to the small intestine
    4. diagnostic delay: the longer the period prior to diagnosis and the start of the gluten-free diet, the greater is the likelihood of complications
    5. duration of breastfeeding: longer durations are associated with later onset in children
  14. presents difficulty in diagnosis because it resembles other conditions including
    1. anemia of iron-deficiency type caused by menstrual blood loss (CDHO Advisory)  
    2. chronic fatigue syndrome
    3. diverticulitis (CDHO Advisory)  
    4. inflammatory bowel disease, including
      1. ulcerative colitis (CDHO Advisory) 
      2. Crohn’s disease (CDHO Advisory) 
    5. intestinal infections
    6. irritable bowel syndrome (CDHO Advisory)  
  15. is diagnosed with
    1. serology testing, which looks for antibodies to gluten in the blood
    2. endoscopy for biopsy of the duodenum to inspect the villi
    3. capsule endoscopy, which uses a tiny, wireless camera to take pictures of the entire small intestine
    4. genetic testing
    5. ancillary blood tests for
      1. albumin 
      2. alkaline phosphatase, a measure of bone loss
      3. clotting factor abnormalities, such as increased prothrombin time
      4. cholesterol
      5. complete blood count 
      6. liver enzymes
  16. is treated with 
    1. a rigorous gluten-free diet, the only definitive treatment, which
      1. must be strictly maintained throughout the person’s life
      2. can heal existing damage
    2. certain medications
  17. cannot be prevented 
    1. because the exact cause is unknown
    2. is most successfully managed with a combination of
      1. awareness of risk factors
      2. early diagnosis
  18. has an encouraging but mixed prognosis because
    1. a gluten-free diet 
      1. repairs the damage to the intestines
      2. prevents further damage
      3. yields maximal benefits for
        1. children in 3 to 6 months 
        2. adults in 2 to 3 years
    2. long-term damage is only rarely caused to the lining of the intestines before the diagnosis is made
    3. some problems may not improve, such as
      1. below-norm height
      2. dental enamel defects
    4. of the wide range of comorbidities, complications and associated conditions.

Overview of dermatitis herpetiformis  

Resources consulted

Dermatitis herpetiformis

  1. is a chronic skin manifestation of celiac disease that 
    1. affects 10 percent or more of persons diagnosed with celiac disease
    2. usually occurs in early to middle adult life but may also arise in children and later adult life
  2. is characterized by 
    1. a blistered, itchy and burning rash that
      1. may be present in the absence of classic intestinal symptoms of celiac disease
      2. starts with 2-5 mm blisters which develop into erosions that
        1. are most commonly symmetrically distributed on the elbows, knees and buttocks 
        2. occasionally appear on the back of the neck, upper back, scalp, hairline and face 
    2. recovery following the start of the gluten-free diet
  3. is treated with dapsone as required for relief from burning and itching.

Food labelling

Questions and Answers About the New Regulations to Enhance the Labelling of Food Allergens, Gluten and Added Sulphites: Health Canada

Multimedia and images

Dermatitis herpetiformis photographs
Dermatitis herpetiformis on the knee
Digestive system

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with celiac disease but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

Resources consulted

  1. Because celiac disease is an autoimmune disorder 
    1. other autoimmune conditions may be linked to it in some way; these include
      1. autoimmune liver disease (CDHO Advisory)  
      2. Down syndrome (CDHO Advisory)  
      3. Graves’ disease (CDHO Advisory)  
      4. Hashimoto thyroiditis (CDHO Advisory)
      5. myasthenia gravis
      6. rheumatoid arthritis (CDHO Advisory)  
      7. sarcoidosis (CDHO Fact Sheet) 
      8. Sjögren syndrome (CDHO Advisory)  
      9. systemic lupus erythematosus (CDHO Advisory)  
      10. type 1 diabetes (CDHO Advisory)  
      11. Turner syndrome
    2. other comorbid conditions include
      1. Addison disease (CDHO Advisory)  
      2. fatigue
      3. infertility 
      4. liver disease (CDHO Advisory)  
      5. intestinal lymphoma 
      6. neurological diseases
      7. shortness of stature
  2. Other conditions or complications appear to occur when celiac disease is untreated, and are expected to improve with a gluten-free diet; these include
    1. osteoporosis (CDHO Advisory)  
    2. depression (CDHO Advisory)  
    3. anemia (CDHO Advisory)  
    4. deficiency of iron, folic acid and/or Vitamin B12
  3. Complications and conditions associated with delayed diagnosis include
    1. anemia (CDHO Advisory)  
    2. autoimmune disorders
    3. bone disease
      1. fractures
      2. kyphoscoliosis 
      3. osteoporosis (CDHO Advisory)  
    4. hypoglycemia (CDHO Advisory)  
    5. infertility or repeated miscarriage
    6. intestinal cancer
    7. liver disease (CDHO Advisory)  
  4. Complications and conditions associated with malabsorption
    1. anxiety (CDHO Advisory)  
    2. bruising tendency
    3. depression (CDHO Advisory)  
    4. fatigue
    5. growth delay in children
    6. hair loss
    7. itchy skin (dermatitis herpetiformis)
    8. missed menstrual periods
    9. mouth ulcers 
    10. muscle cramps and joint pain
    11. nosebleeds
    12. seizures 
    13. tingling or numbness in the hands or feet
    14. unexplained below-norm height
  5. Even without symptoms, celiac disease may lead to long-term complications
    1. anemia (CDHO Advisory)  
    2. intestinal cancer 
    3. liver disease (CDHO Advisory)  
    4. miscarriage
    5. osteoporosis (CDHO Advisory)  

Oral health considerations

Adapted from

  1. Dental enamel defects
    1. are one of the manifestations of celiac disease, though not all dental enamel defects are caused by it 
    2. may for some persons be the only presenting sign or symptom of celiac disease
    3. can help dental hygienists identify persons who may have celiac disease
    4. associated with celiac disease involve the permanent dentition and include 
      1. tooth discoloration: white, yellow, or brown spots on the teeth
      2. poor enamel formation
      3. pitting or banding of teeth
      4. mottled or translucent-looking teeth
      5. defects that are symmetrical and often appear on the incisors and molars
      6. defects that do not improve once a diagnosed patient/client adopts a gluten-free diet
    5. appear to be strongly associated with celiac disease in childhood, likely during enamel formation
    6. may be confused with imperfections incorrectly ascribed, for example, to
      1. early childhood illness
      2. excessive fluoride
      3. maternal illness
      4. maternal tetracycline
    7. are disguised with cosmetic treatment, such as bonding and veneers
    8. should be reported to the primary care physician.
  2. Other oral manifestations include
    1. recurrent aphthous stomatitis
    2. atrophic glossitis 
    3. dry mouth syndrome 
    4. Sjögren syndrome (CDHO Advisory)  
    5. squamous carcinoma of the pharynx and mouth (CDHO Advisory). 
  3. Other oral health considerations include severe emotional stress as a trigger for celiac disease.

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 

Gluten is used in some medications. 

Types of medications

A rigorous gluten-free diet is the only definitive treatment, which must be strictly maintained throughout the rest of the person’s life, and which can repair existing damage.

  1. dapsone (diaminodiphenylsulfone)
    1. an antibiotic used to control the rash of dermatitis herpetiformis 
    2. does not treat the intestinal condition, so that persons with dermatitis herpetiformis must maintain a gluten-free diet
  2. vitamin and mineral supplements, as required
  3. corticosteroids, as required
    prednisone (Prednisone Intensol®) 

Side effects of medications

See the links above to the specific medication. 

THE MEDICAL AND MEDICATIONS HISTORY

The dental hygienist in taking the medical  and medications history-taking should 

  1. focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions
  2. explore the need for advice from the primary or specialized care provider(s)
  3. inquire about
    1. pointers in the history of significance to celiac disease, such as dental enamel defects and other oral manifestations
    2. symptoms indicative of comorbidities, complications and associated conditions that should be taken into consideration in decisions about implementing the Procedures
    3. the patient/client’s understanding and acceptance of the need for oral healthcare
    4. medications considerations, including over-the-counter medications, herbals and supplements
    5. problems with previous dental/dental hygiene care
    6. problems with infections generally and specifically associated with dental/dental hygiene care
    7. the patient/client’s current state of health
    8. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition.

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2024)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

  1. There is no contraindication to the Procedures. 
  2. With an otherwise healthy patient/client whose symptoms are under control and whose treatment is proceeding normally, the dental hygienist should implement the Procedures, though these may be postponed pending 
    1. medical advice, which is likely to be required if the patient/client 
      1. has symptoms or signs of exacerbation of celiac disease
      2. provides a history of comorbidity, complication or associated condition of celiac disease that should be taken into account in decisions about implementing the procedures
      3. has not complied with pre-medication, including antibiotic prophylaxis, as directed by the prescribing physician 
      4. has not recently or ever sought and received medical advice relative to oral healthcare procedures
      5. has recently changed significant medications, under medical advice or otherwise
      6. has recently experienced changes in his/her medical condition such as medication or other side effects of treatment 
      7. is unable to provide the dental hygienist with sufficient information about
        1. medications
        2. bleeding tendency
        3. treatment of comorbidity, complication or associated condition
      8. is deeply concerned about any aspect of his or her medical condition
    2. a pharmacist’s advice if confirmation is required of the absence of gluten from any medications required in the course of the proposed oral healthcare.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of celiac disease, the dental hygienist should specifically record

  1. a summary of the medical and medications history
  2. any advice received from the physician/primary care provider relative to the patient/client’s condition
  3. the decision made by the dental hygienist, with reasons
  4. compliance with the precautions required
  5. all Procedure(s) used
  6. any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The dental hygienists should 

  1. urge the patient/client to alert any healthcare professional who proposes any intervention or test that he or she 
    1. has a history of celiac disease
    2. is taking medication
  2. should discuss with the patient/client, as appropriate 
    1. the risks of gluten in medications and preparations used for oral hygiene self-care (with prudent avoidance of gluten-containing products and use of gluten-free products as much as possible)
    2. the importance of the patient/client’s
      1. self-checking the mouth regularly for new signs or symptoms
      2. reporting to the appropriate healthcare provider any changes in the mouth
    3. the need for regular oral health examinations and preventive oral healthcare 
    4. oral self-care including information about 
      1. choice of toothpaste2 
      2. tooth-brushing techniques and related devices
      3. dental flossing
      4. mouth rinses
      5. management of a dry mouth 
    5. the importance of
      1. an appropriate diet in the maintenance of oral health 
      2. help from a registered dietitian who specializes in celiac disease
    6. comfort level while reclining, and stress and anxiety related to the Procedures
    7. medication side effects such as dry mouth, and recommend treatment
    8. mouth ulcers and other conditions of the mouth relating to  celiac disease, comorbidities, complications or associated conditions, medications or diet
    9. pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promoting health through oral hygiene for persons who have celiac disease.
  2. Reducing the adverse effects of overlooking celiac disease by
    1. recognizing celiac disease at an early stage from dental enamel defects
    2. ensuring that the medical history is appropriately recorded
    3. generally increasing the comfort level of persons in the course of dental-hygiene interventions 
  3. Reducing the risk that oral health needs are unmet.

POTENTIAL HARMS

  1. Causing harm by failing to alert patients/clients to the possibility of gluten in the medications and products they use for oral hygiene self-care.3
  2. Performing the Procedures at an inappropriate time, such as in the presence of comorbidities, complications and associated conditions for which prior medical advice is required.
  3. Disturbing the normal dietary and medications routine of a person with celiac disease.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2009-11-24

DATE OF LAST REVIEW

2011-03-01; 2019-11-14; 2024-08-13

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow
MD, MHSc, MBA, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd

Kyle Fraser
RDH, BComm, BEd, MEd

Carolle Lepage
RDH, BEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2009, 2011, 2019, 2024 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children.
2 Sorbitol — which is used in toothpastes and other products — can either be corn-derived or grain-derived. It is a highly processed sugar that should pose no issue to persons with celiac disease, regardless of derivation. Some authorities, however, state that corn-derived sorbitol is preferable to grain-derived sorbitol. Products with wheat starch should be definitively avoided.
3 Potential sources of gluten exposure include toothpaste, mouth rinse, floss (especially flavoured types), teeth whitening products (including gels, strips, and rinses), prophylaxis/polishing paste, fluoride gels and varnishes, and orthodontic retainers and materials. Products labelled gluten-free should be used whenever possible, and ingredients lists should be checked.