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FACT SHEET: Celiac Disease (also known as “celiac sprue”, “non-tropical sprue”, and “gluten-sensitive enteropathy”; not the same as “non-celiac gluten sensitivity” [NCGS] or “non-celiac gluten intolerance” [NCG1]1; alternative spelling is “coeliac” disease)

Date of Publication: December 11, 2013
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Note: Hematopoietic cell transplantation (encompassing blood stem cell and bone marrow transplantation) is specifically addressed in the Hematopoietic Cell Transplantation Fact Sheet.

Is the initiation of non-invasive dental hygiene procedures* contra-indicated?

  • No.

Is medical consult advised?  

  • No, assuming patient/client is already under medical care for celiac disease and oral, intestinal, and extra-intestinal signs/symptoms are well controlled.
  • Yes, if undiagnosed or poorly controlled celiac disease is suspected.2

Is the initiation of invasive dental hygiene procedures contra-indicated?**

  • No.

Is medical consult advised? 

  • See above.

Is medical clearance required? 

  • No.

Is antibiotic prophylaxis required?  

  • No.

Is postponing treatment advised?

  • Possibly, but not typically (depends on severity and level of control of disease, including presence/absence of oral manifestations such as glossitis and aphthous stomatitis, and degree of anemia).

Oral management implications

  • Dental hygienists play an important role in identifying people — especially children with dental enamel defects — who may have unrecognized celiac disease. In suspected cases, the patient/client should be advised to see a primary care physician for possible serologic (blood) screening3 for celiac disease. A patient/client suspected of having celiac disease should not adopt a gluten-free diet without confirmation of the diagnosis.4 
  • Appropriate medical referral and timely diagnosis can reduce serious complications of this disease. Up to 90% of cases remain undiagnosed, and hence the importance of vigilance by oral health professionals. 
  • Early diagnosis is particularly important for children. Children diagnosed with celiac disease before their adult teeth are fully formed (about seven years) can develop healthy tooth enamel if their disease is treated with a gluten-free diet. 
  • Adherence to a strict gluten-free diet is key to controlling systemic disease, with corresponding improvement of oral manifestations (e.g., aphthous stomatitis and glossitis) other than permanent tooth defects.  
  • Oral care products and dental materials should be as gluten-free as possible for patients/clients with celiac disease.5 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 retainers6 and materials. Products labelled gluten-free should be used whenever possible, and ingredients lists should be checked.
  • Topical fluoride application (e.g., gluten-free varnish) can reduce risk of caries. As well, an extra soft toothbrush may be indicated for patients/clients with enamel wear and/or aphthous ulcers.
  • A diagnosis of celiac disease means that the affected patient/client has an elevated risk of having other autoimmune diseases.

Oral manifestations

  • Dental enamel defects (DEDs, of both primary and permanent dentition) and recurrent aphthous ulcers occur in patients/clients with celiac disease. These conditions may be the only overt manifestations of the disease, occurring in persons without the classic malabsorption syndrome. Therefore, when dental hygienists encounter these features, they should enquire about other clinical symptoms, associated disorders, and family history of celiac disease.
  • Tooth defects that result from celiac disease may resemble those caused by fluorosis, early childhood illness, or maternal/childhood tetracycline use. The tooth defects are irreversible and do not improve after adopting a gluten-free diet, although cosmetic improvement in older children and adults can be achieved with bonding, veneers, etc.
  • Enamel defects, which in North America tend to be seen more frequently in children than adults7, include: tooth discoloration (white, yellow or brown spots); poor enamel formation; pitting or banding of teeth; and mottled or translucent-looking teeth. These imperfections are symmetrical, typically appearing on the incisors and molars.  
  • Delays in dental and skeletal development can result from celiac disease. Children with undiagnosed disease are slow to lose their primary teeth, and their permanent teeth erupt later than usual.
  • Enamel wear tends to be more common in persons with, rather than without, celiac disease. This is possibly related to more frequent bruxism.
  • Dental caries8 and periodontitis may occur at elevated rates in patients/clients with celiac disease. Children may also be prone to angular cheilitis and reduction in salivary flow.
  • Dry mouth syndrome is associated with celiac disease.
  • Glossitis and atrophy of the papillae of the tongue (i.e., red, smooth, shiny tongue) are associated with celiac-related anemia.
  • Squamous cell carcinoma of the mouth and pharynx occur at elevated rates in persons with celiac disease, as does esophageal cancer.
  • Oral lichen planus may occur at an elevated rate.

Related signs and symptoms

  • Celiac disease is a common, chronic, genetic9 disorder associated with sensitivity to dietary gluten, a protein present in wheat, rye, barley, and their cross-bred grains (e.g., triticale).10 When gluten is ingested11, autoimmune mediated damage occurs in the mucosa of the small intestine. The resulting atrophy of intestinal villi (small, finger-like projections) can lead to malabsorption of protein, fat, and carbohydrates. Over time, the body becomes unable to absorb nutrients such as iron, calcium, folate, and vitamin B12.
  • Canadian prevalence is about 1% of the population, and the disease is more common in Caucasians and persons with a family history of the disease. Other risk factors include Type 1 diabetes, Sjögren syndrome, and autoimmune thyroid disease.
  • Classic signs and symptoms are abdominal pain, bloating after eating, chronic diarrhea12 (with large, pale, foul stools), and weight loss. However, many persons present with non-gastrointestinal manifestations, such as anemia, weakness, fatigue, short stature, osteoporosis, menstrual irregularities, and infertility. In children, vomiting and/or delayed growth and puberty may occur. In infants, failure to thrive may result from inability to absorb nutrients.
  • Osteomalacia (i.e., softening of bone), osteoporosis, hyposplenism (i.e., reduced functioning of the spleen), headaches, joint pain, nervous system injury (including numbness and tingling in feet and hands), acid reflux, and heartburn are associated with celiac disease.
  • Dermatitis herpetiformis13 is “celiac disease of the skin”, and patients/clients present with a severely itchy, burning, and blistering rash, often on the elbows, knees, torso, scalp, and buttocks.
  • While gene mutations seem to increase the risk of developing the disease, other factors are required to trigger it. Celiac disease may be triggered, or appear for the first time, after surgery, pregnancy, childbirth, viral infection, or profound emotional trauma.
  • There is no cure. Symptoms are managed by adhering to a strict, life-long gluten-free diet (GFD).
  • Complications of untreated celiac disease include malnutrition, lactose intolerance, infertility, and malignancy (intestinal lymphoma and small intestine cancer).

References and sources of more detailed information


Date: August 25, 2013
Revised: November 14, 2019; August 13, 2024


FOOTNOTES

1 Celiac disease is not the same as non-celiac gluten sensitivity/intolerance. The former is an autoimmune-mediated disorder in which gluten damages the villi that make up the lining of the small intestine and for which there are well-defined defects in dentition. The latter does not entail the same intestinal damage, even though some symptoms are similar to those of celiac disease, including abdominal pain, bloating, diarrhea, and fatigue. Emerging evidence suggests that at least some persons with presumed gluten sensitivity/intolerance may be reacting to other proteins or carbohydrates contained in wheat. Thus, the terms “non-celiac wheat sensitivity” [NCWS] and “non-celiac wheat intolerance” [NCWI] are sometimes used to describe persons who have sensitivities to products that typically contain gluten but who do not meet the diagnostic criteria for celiac disease. Of further note, persons with non-celiac gluten sensitivity often experience a complex of extra-intestinal symptoms (including headaches and brain fog) in addition to their gastrointestinal (GI) symptoms. Clinically, NCGS may be difficult to distinguish from functional GI disorders, primarily irritable bowel syndrome (IBS).
2 Patients/clients with celiac disease are typically evaluated and followed by a gastroenterologist (i.e., a physician specializing in gastrointestinal diseases), in addition to their family physician.
3 The IgA tissue transglutaminase (tTG) antibody test is preferred for screening over the IgA anti-endomysial antibody test (EMA).
4 Confirmatory biopsy of the small intestine by a gastroenterologist — should the blood test be positive — requires exposure to gluten. Once the diagnosis has been medically established, referral to a dietitian with expertise in gluten-free diet is indicated.
5 While sorbitol — which may be 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. By contrast, products with wheat starch should be definitively avoided. Of further note, gluten is an additive in some plastics.
6 Gluten is sometimes used as an additive in methyl methacrylate (MMA).
7 This may be due to tooth development having been completed prior to overt disease onset or to adults having had affected teeth extracted or cosmetically treated.
8 The scientific literature is conflicting as to whether patients/clients with celiac disease are more prone to dental caries. Dental decay may be due to a combination of factors, including poor enamel quality, reduced saliva production, and an altered oral microbiome.
9 This genetic disorder may or may not run in families.
10 Dietary sources of gluten include: wheat-containing breads, soups, pastas, cereals, sauces, and salad dressings; rye-containing breads and beer; and barley-containing malt products, food colourings, soups, beer, and brewer’s yeast. Additionally, medications and vitamin or other health supplements may contain gluten. Non-food products that may contain gluten and can be transferred from hands to mouth include: modelling compounds (such as play dough); cos­metics (such as lipstick); and skin and hair products.
11 Even airborne gluten can trigger the body to attack the villi.
12 Constipation may be an atypical (i.e., non-classical) presentation of celiac disease.
13 The vast majority of persons with dermatitis herpetiformis (DH) also have features of villous atrophy (i.e., classical celiac disease). DH can be diagnosed with a biopsy taken from skin adjacent to erosions or blisters.


* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.